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P-9.2.1, r. 1 - Regulation respecting the application of the Act to assist persons who are victims of criminal offences and to facilitate their recovery

Full text

In force date

2021-10-13 Show full text at this date

SCHEDULE I

(ss. 18, 24 and 26)

SCHEDULE OF PERMANENT FUNCTIONAL AND ESTHETIC IMPAIRMENTS

FUNCTIONAL UNITS

(1) Mental function

(2) State of consciousness

(3) Cognitive aspect of language

(4) The functions of the visual system are composed of 2 units:

(4.1) Vision

(4.2) Ancillary functions of the visual system

(5) The functions of the auditory system are composed of 2 units:

(5.1) Hearing

(5.2) Ancillary functions of the auditory system

(6) Taste and smell

(7) Skin sensitivity is composed of 7 units:

(7.1) Skin sensitivity of the skull and face

(7.2) Skin sensitivity of the neck

(7.3) Skin sensitivity of the trunk and genital organs

(7.4) Skin sensitivity of the right upper limb

(7.5) Skin sensitivity of the left upper limb

(7.6) Skin sensitivity of the right lower limb

(7.7) Skin sensitivity of the left lower limb

(8) Clinical pictures of balance disorders

(9) Phonation

(10) Mimic

(11) Ability to move and maintain the position of head

(12) Ability to move and maintain the position of trunk

(13) Ability to move and maintain the position of upper limbs is composed of 2 units:

(13.1) Ability to move and maintain the position of right upper limb

(13.2) Ability to move and maintain the position of left upper limb

(14) Manual dexterity (prehension and manipulation) is composed of 2 units:

(14.1) Right manual dexterity

(14.2) Left manual dexterity

(15) Locomotion

(16) Protection provided by the skull

(17) Protection provided by the rib cage and abdominal wall

(18) Nasopharyngeal respiration

(19) The digestive functions are composed of 4 units:

(19.1) Ingestion (chewing and swallowing including prehension and salivation)

(19.2) Digestion and absorption

(19.3) Excretion

(19.4) Hepatic and biliary functions

(20) Cardio-respiratory function

(21) The urinary functions are composed of 2 units:

(21.1) The renal function

(21.2) Micturition

(22) The genito-sexual functions are composed of 3 units:

(22.1) Genital Sexual Activity

(22.2) Procreation

(22.3) Termination of Pregnancy

(23) Endocrine, hematological, immune, and metabolic functions

(24) Clinical pictures of paraplegia and quadriplegia

ESTHETIC UNITS

(25) There are 8 esthetic units:

(25.1) Esthetic of the skull and scalp

(25.2) Esthetic of the face

(25.3) Esthetic of the neck

(25.4) Esthetic of the trunk and genital organs

(25.5) Esthetic of the right upper limb

(25.6) Esthetic of the left upper limb

(25.7) Esthetic of the right lower limb

(25.8) Esthetic of the left lower limb

(1) THE MENTAL FUNCTION

The various dimensions of the mental function have an impact on all activities of daily living.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Evaluation must take into account the following criteria for determining the overall impact of an impairment of the mental function on daily life:

— The degree of independence and social functioning evaluated on the basis of the need to turn to compensating strategies, technical aids, or human surveillance and/or assistance

— The importance of the impact of a cognitive disorder on the performance of activities of daily living

— The importance of the impact of affective or mental disorders on the performance of activities of daily living evaluated using the “Global Assessment of Functioning Scale” proposed by the American Psychiatric Association in American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th Edition, Washington, DC, 1994, p. 32.

GLOBAL ASSESSMENT OF FUNCTIONING (GAF)

100 |
| Superior functioning in a wide range of activities, life’s problems never
| seem to get out of hand, is sought out by others because of his or her many
| positive qualities. No symptoms.
91 |
|
90 |
| Absent or minimal symptoms (e.g., mild anxiety before an exam), good
| functioning in all areas, interested and involved in a wide range of
| activities, socially effective, generally satisfied with life, no more than
| everyday problems or concerns (e.g., an occasional argument with family
| members).
|
81 |
|
80 |
| If symptoms are present, they are transient and expectable reactions to
| psychosocial stressors (e.g., difficulty concentrating after family
| argument), no more than slight impairment in social, occupational, or school
| functioning (e.g., temporarily falling behind in schoolwork).
|
71 |
|
70 |
| Some mild symptoms (e.g., depressed mood and mild insomnia) OR some
| difficulty in social, occupational, or school functioning (e.g., occasional
| truancy, or theft within the household), but generally functioning pretty
| well, has some meaningful interpersonal relationships.
|
61 |
|
60 |
| Moderate symptoms (e.g., flat affect and circumstantial speech, occasional
| panic attacks) OR moderate difficulty in social, occupational, or school
| functioning (e.g., few friends, conflicts with peers or co-workers).
|
|
51 |
|
50 |
| Serious symptoms (e.g., suicidal ideation, several obsessional rituals,
| frequent shoplifting) OR any serious impairment to social, occupational, or
| school functioning (e.g., no friends, unable to keep a job).
|
41 |
|
40 |
| Some impairment in reality testing or communication (e.g., speech is
| sometimes illogical, obscure, or irrelevant) OR major impairment in several
| areas, such as work or school, family relations, judgment, thinking, or mood
| (e.g., depressed man avoids friends, neglects family, and is unable to work;
| child frequently beats up younger children, is defiant at home, and is
| failing at school).
|
31 |
|
30 |
| Behaviour is considerably influenced by delusions or hallucinations OR serious
| impairment in communication or judgment (e.g., sometimes incoherent, acts
| grossly inappropriately, suicidal preoccupation) OR inability to function in
| almost all areas (e.g., stays in bed all day; no job, home, or friends).
|
21 |
|
20 |
| Some danger of hurting self or others (e.g., suicide attempts without clear
| expectation of death; frequently violent; manic excitement) OR occasionally
| fails to maintain minimal personal hygiene (e.g., smears feces) OR gross
| impairment in communication (e.g., largely incoherent or mute).
|
11 |
|
10 |
| Persistent danger of severely hurting self or others (e.g., recurrent
| violence) OR persistent inability to maintain minimal personal hygiene OR
| serious suicidal act with clear expectation of death.
1 |

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent impairment can
be compared with those that would result from the situation with maximum impact
among the following:

If symptoms are present, they have no significant impact on
UNDER THE personal and social functioning. The after-effects of the
MINIMUM permanent impairment are less than those that would result
THRESHOLD from the situations described for category of severity 1.

Affective or mental disorders that affect personal and
social functioning and that are between 71 and 80 on the
SEVERITY 1 “Global Assessment of Functioning Scale”;
2%
or Regular and permanent need to take prescription medication
that may cause side effects.

Affective or mental disorders that affect personal and
social functioning and that are between 61 and 70 on the
“Global Assessment of Functioning Scale”;
SEVERITY 2
5% or Minor cognitive impairment such as shorter attention span
while performing complex tasks, occasionally combined with
fatigability. The difficulties experienced require slight
changes in the organization of activities.

Affective or mental disorders that affect personal and social
functioning and that are between 51 and 60 on the “Global
Assessment of Functioning Scale”;

or Slight cognitive impairment such as attention, memory, or
learning difficulties, occasionally combined with fatigability.
SEVERITY 3 The impairment is severe enough to affect the organization and
15% performance of complex tasks such as making important decisions.

The difficulties experienced require significant changes in the
organization of activities and may necessitate human surveillance
or assistance.

Affective or mental disorders that affect personal and social
functioning and that are between 41 and 50 on the “Global
Assessment of Functioning Scale”;

or Moderate cognitive impairment such as attention, memory or
learning difficulties, or reduced judgment, often combined with
SEVERITY 4 fatigability. The impairment is severe enough to affect the
35% performance of routine tasks such as the planning of daily
domestic activities (meals, housework, purchases).

The difficulties experienced require a reorganization in the
organization of activities and necessitate human surveillance
or assistance.

Affective or mental disorders with major disruption of personal
and social functioning, altered sense of reality;
SEVERITY 5
70%
or Cognitive impairment severe enough to prevent the performance of
simple routine tasks. The person can only be left alone for short
periods.

The person is totally or almost totally dependent on human
assistance for the performance of most activities of daily living.
SEVERITY 6
100%
Protective measures may be necessary such as a protected
environment, confinement, restraint.

(2) STATE OF CONSCIOUSNESS

Consciousness is the faculty that makes a person aware and able to judge his or her own reality. Permanent impairments to the state of consciousness can show up as episodic disorders such as epilepsy, lipothymia, or fainting, or as ongoing disorders such as stupor, coma, or a chronic vegetative state.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Impacts on other functional units, such as incontinence during an epileptic seizure, are taken into account in this unit.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent impairment
can be compared with those that would result from the situation with maximum
impact among the following:

UNDER THE After-effects of the permanent impairment are less than those
MINIMUM resulting from the situation described in Severity 1.
THRESHOLD

Disturbances to the state of consciousness that slightly
interfere with daily activities medication, which may have
SEVERITY 1 possible side effects, is necessary to keep conditions such as
5% epilepsy under control. Response to medical treatment is
adequate and sufficient to allow the patient to drive a car.

Disturbances to the state of consciousness that moderately
interfere with daily activities. Response to medical treatment
SEVERITY 2 is sufficient to allow the patient to remain independent but
15% not to perform tasks that could endanger his or her safety or
that of others, such as driving a car.

Disturbances to the state of consciousness that significantly
interfere with daily activities. The severity of the seizures
in terms of their intensity (type), frequency despite
medication, and circumstances (trigger, timing) justifies the
SEVERITY 3 regular intervention of another person (surveillance or
30% assistance).
However, the patient remains sufficiently independent to retain
a certain level of social interaction.

Impairments to the state of consciousness that severely
SEVERITY 4 interfere with daily activities.
60%
Autonomy and social interactions are reduced to a minimum.

SEVERITY 5 Total absence of interpersonal relationships, such as in a
100% chronic vegetative state, making the person completely
dependent on another person and on medical support.

(3) COGNITIVE ASPECT OF LANGUAGE

The cognitive aspect of language refers to the mental ability to understand and produce oral and written language. Examples of impairments include dysphasia, aphasia, alexia, agraphia and acalculia.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) The evaluation must take into account the following abilities in order to determine the overall impact on daily life:

— Expressing oneself in speech

— Expressing oneself in writing

— Expressing oneself with gestures or expressions

— Naming or describing objects

— Spelling

— Understanding verbal and nonverbal language

— Reading with understanding

— Understanding spoken or written directions

— Repeating

Depending on the circumstances, the evaluation of functional impairments may be documented using any other relevant examination.

(3) Peripheral sensory or motor impairments that may interfere with understanding and/or the mechanical expression of language must not be evaluated using the rules provided under this unit but using the rules provided in the functional units that specifically deal with the observed impacts.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment are less than those
MINIMAL resulting from the situation described in Severity 1.
THRESHOLD

SEVERITY 1 Occasional trouble with word recall in written or
5% spoken language.

Frequent word substitutions or deformations (paraphasia),
SEVERITY 2
20%
or Difficulty in understanding long, complex sentences or
abstract or figurative language.

SEVERITY 3 Serious difficulty with writing (dysgraphia);
40%
or Difficulty in understanding simple sentences.

SEVERITY 4 Major problems in understanding combined with difficulties
70% with expression that make conversation very arduous.

SEVERITY 5 Understanding is virtually or totally nonexistent and the
100% person is completely incapable of expressing thoughts in
language.

(4) FUNCTIONS OF THE VISUAL SYSTEM

The function of the visual system is to put people in contact with the outside world by means of light.

The functions of the visual system are composed of 2 functional units.

(4.1) Vision

(4.2) Ancillary Functions of the Visual System

— Protection

— Eye lubrication

— Light sensitivity, photophobia, accommodation, convergence, colour perception, etc

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Reading difficulties related to a cognitive impairment must not be evaluated using to the rules provided in this unit but using the rules provided in the functional unit “Cognitive Aspect of Language”.

(3) Specific guidelines are given at the beginning of each functional unit.

(4.1) VISION

Specific Guidelines

The evaluation is conducted in 4 steps.

STEP 1: Evaluation of the 3 components required for optimal vision

(A) Procedure to determine the retained percentages of central visual acuity for distance and close-up vision

· Central visual acuity is measured for each eye using the best optical correction that can be comfortably tolerated and that is acceptable for distance and close-up vision.

· The retained percentage of visual acuity for each eye, which is entered on the form for calculating the efficiency percentage for each eye in Step 2, is obtained using the following table:

RETAINED PERCENTAGE OF CENTRAL VISUAL ACUITY

Distance
distance Close-up
(meters) Vision 0.4M 0.5M 0.6M 0.8M 1M 1.25M 1.6M 2M 2.5M 3.2M 4M
__________________________________________________________________________
|
6/4.5 | 100* 100 97 95 75 70 60 57 55 52 51
| 50** 50 48 47 37 35 30 28 27 26 25
| _________________________________________________________________
|
6/6 | 100 100 97 95 75 70 60 57 54 52 51
| 50 50 48 47 37 35 30 28 27 26 25
| _________________________________________________________________
|
6/7.5 | 97 97 95 92 72 67 57 55 52 50 48
| 48 48 47 46 36 33 28 27 26 25 24
| _________________________________________________________________
|
6/9 | 95 95 92 90 70 65 55 52 50 47 46
| 47 47 46 45 35 32 27 26 25 24 23
| _________________________________________________________________
|
6/12 | 92 92 90 87 67 62 52 50 47 45 43
| 46 46 45 43 33 31 26 25 23 22 21
| _________________________________________________________________
|
6/15 | 87 87 85 82 62 57 47 45 42 40 38
| 43 43 42 41 31 28 23 22 21 20 19
| _________________________________________________________________
|
6/18 | 84 84 82 78 59 54 44 41 39 36 35
| 42 42 41 39 30 27 22 21 19 18 17
| _________________________________________________________________
|
6/21 | 82 82 79 77 57 52 42 39 37 35 33
| 41 41 39 38 28 26 21 21 18 17 16
| _________________________________________________________________
|
6/24 | 80 80 77 75 55 50 40 37 35 32 31
| 40 40 38 37 27 25 20 18 17 16 15
| _________________________________________________________________
|
6/30 | 75 75 72 70 50 45 35 32 30 27 26
| 37 37 36 35 25 22 17 16 15 13 13
| _________________________________________________________________
|
6/36 | 70 70 67 65 45 40 30 27 25 22 21
| 35 35 33 32 22 20 15 13 12 11 10
| _________________________________________________________________
|
6/45 | 66 66 63 61 41 36 26 23 21 18 17
| 33 33 32 30 20 18 13 12 10 9 8
| _________________________________________________________________
|
6/60 | 60 60 57 55 35 30 20 17 15 12 11
| 30 30 28 27 17 15 10 9 7 6 5
| _________________________________________________________________
|
6/90 | 57 57 55 52 32 27 17 15 12 10 8
| 38 38 27 26 16 13 9 7 6 5 4
| _________________________________________________________________
|
6/120 | 55 55 52 50 30 25 15 12 10 7 6
| 27 27 26 25 15 12 7 6 5 3 3
| _________________________________________________________________
|
6/240 | 52 52 50 47 27 22 12 10 7 5 3
| 26 26 25 23 13 11 6 5 3 2 1

__________

* UPPER VALUE: RETAINED PERCENTAGE OF CENTRAL VISUAL ACUITY IN THE ABSENCE OF MONOCULAR APHAKIA

** LOWER VALUE: RETAINED PERCENTAGE OF CENTRAL VISUAL ACUITY WITH ALLOWANCE FOR MONOCULAR APHAKIA

(B) Procedure to determine the retained percentage of the visual field for each eye

· The extent of the visual field is determined using the usual perimetric methods. The conventional standard is the III-4e kinetic stimulus of the Goldman perimeter. The IV-4e stimulus should be used with a person with an aphakic eye corrected with prescription glasses and not contact lenses.

· The index finger or target is brought from the periphery to the visual field, i.e., from the unseen to the seen. The peripheral field is measured for each meridian. If the measurement differs from the clinical result, a second measurement that agrees with the first within 15° should be obtained. The result is recorded on an ordinary visual field chart for each of the 8 principal meridians separated from one another by 45°. The meridians and the normal extent of the visual field from the point of fixation are recorded on the visual field chart shown in Diagram 1.

Where there is a deficit in a quadrant or a half field, or any other anomaly, the measurement will be the average of the values for the 2 adjacent meridians.

· The retained percentage of the visual field, which is entered on the form for calculating the percentage of visual efficiency of each eye in Step 2, is obtained using the following formula:

Total retained degrees *

_____________________________________________

Number of degrees prior to the criminal offence** × 100 = % retained % of visual field

* SUM OF RETAINED DEGREES FOR THE 8 PRINCIPAL MERIDIANS SHOWN IN DIAGRAM 1 (FOR THE III-4E ISOPTER)

** THE EXTENT OF THE VISUAL FIELD PRIOR TO THE CRIMINAL OFFENCE CAN VARY DEPENDING ON THE PERSON AND ON AGE. FOR THE IMPAIRED EYE, THE EXTENT OF THE VISUAL FIELD PRIOR TO THE CRIMINAL OFFENCE IS DETERMINED BY COMPARISON WITH THE OTHER EYE, IF IT IS HEALTHY. WHERE THE CONTRA LATERAL EYE IS NOT HEALTHY, THE NORMAL VALUE IS PRESUMED TO BE 500.

· The extent of the diplopia when the person looks in various directions is determined using the best correction possible (prism) comfortably tolerated and that is acceptable, but without coloured lenses.

· The evaluation is conducted using a small test light or Goldman perimeter III-4e stimulus at 330 mm or any campimeter at 1 m from the eye of the person.

· Results for image separation when the person looks in various directions are recorded on a visual field chart (Diagram 2) for each of the 8 principal meridians.

· In the case of an impairment outside the central 20°, total percentage loss of ocular motility is calculated by adding the percentages of loss indicated in Diagram 2 corresponding to the separation of the 2 images as evaluated by the examination, up to a maximum of 92%.

· In the case of an impairment inside the central 20°, total percentage loss of ocular motility corresponds to the maximum of 92%.

The retained percentage of ocular motility entered on the form to calculate the efficiency percentage of each eye in Step 2 is obtained by subtracting the percentage of loss from 100%.

The result is applied to the eye with the greatest impairment. The other eye is attributed a normal value, i.e., 100%.

· Loss of ocular motility

· Inside the central 20° equals 92%

· Outside the central 20° equals the sum of the percentages up to a maximum of 92% for the meridians where a separation of images has been noted

STEP 2: Determination of the Percentage of Efficiency of Each Eye

Retained %* Retained %* Retained %* % of Efficiency
of Visual of Visual of Ocular of Eye
Acuity Field Motility**

Right Eye ____________ X ____________ X _______________ = _____________

Left Eye ____________ X ____________ X _______________ = _____________

* THE RETAINED PERCENTAGES ARE THOSE NOTED IN THE EXAMINATION OF THE 3 COMPONENTS AND CALCULATED IN STEP 1.

** FOR CALCULATION PURPOSES, THE RETAINED PERCENTAGE OF OCULAR MOTILITY CALCULATED IN STEP 1 IS ONLY APPLIED TO THE MOST SERIOUSLY IMPAIRED EYE. THE OTHER EYE IS ASSIGNED AN OCULAR MOTILITY VALUE OF 100%.

STEP 3: Determination of the Percentage of Visual Efficiency

% of Efficiency* % of Efficiency* % of Efficiency
of Better Eye of Other Eye of Vision

( X 3 ) + =
__________________________________________________ ___________________
4

* THE EFFICIENCY PERCENTAGES FOR EACH EYE ARE THOSE OBTAINED IN STEP 2.

STEP 4: Determination of the Percentage of Functional Loss of Vision

Normal Vision % of Efficiency % of Functional Loss
of Vision* of Vision

100% - __________________ = _________________________

* THE VISION EFFICIENCY PERCENTAGE IS THAT OBTAINED IN STEP 3.

For financial assistance purposes, the category of severity corresponds to the percentage of functional loss of vision. The result is rounded up to the nearest 0.5% or higher unit, with a maximum of 85%.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment are less than those
MINIMUM resulting from the situation described in Severity 0.5.
THRESHOLD

Inconvenience due to wearing a corrective device to provide
normal vision. Financial aid in this category of severity is
SEVERITY only awarded if the person was not wearing a corrective
0.5% device prior to the criminal offence.

Inconvenience due to a permanent impairment to vision that
SEVERITY cannot be fully corrected with a corrective device (glasses,
1 TO 85 prisms, contact lenses).

The category of severity corresponds to the extent of
1 TO 85% functional loss of vision as determined by an ophthalmologic
evaluation. It varies from 1 to a maximum of 85.

(4.2) ANCILLARY FUNCTIONS OF THE VISUAL SYSTEM

Specific Guidelines

(1) Loss of accommodation and photophobia experienced by a person with an aphakic eye are already included in the visual acuity calculation in Step 1A of 4.1. (see Retained Percentage of Central Visual Acuity) and are not eligible for a category of severity in this section.

(2) Fusion anomalies and convergence insufficiencies experienced by a person diagnosed with ocular motility impairments are already included in the ocular motility calculation in Step 1C of 4.1. and are not eligible for a category of severity in this section.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent impairment
can be compared with those that would result from the situation with maximum
impact among the following:

UNDER THE After-effects of the permanent impairment are less than those
MINIMUM resulting from the situations described in Severity 1.
THRESHOLD

Slight photosensitivity or photophobia requiring, among other
things, the wearing of sunglasses, such as with maculopathy,
or corneal, pupillary or ocular media impairment,

or Slight loss of accommodation;

or colour vision disorder;

SEVERITY 1 or Slight fusion anomaly or slight paralysis of convergence,
1% such as with decompensated, nonreducible, and occasionally
symptomatic anterior heterophoria;

or Slight unilateral or bilateral intermittent lacrimation;

or Slight palpebral ptosis;

or Justification for therapeutic measures resulting in minor
inconvenience such as having to take regular medication.

Moderate photophobia that requires, among other things, the
wearing of sunglasses, such as with maculopathy, or corneal,
pupillary, or ocular media impairment;

or Moderate or significant loss of unilateral or bilateral
accommodation;

or Moderate fusion anomaly or moderate paralysis of convergence,
SEVERITY 2 such as with decompensated, nonreducible, and daily
3% symptomatic anterior heterophoria;

or Paralysis of conjugate upward gaze;

or Frequent unilateral or bilateral lacrimation;

or Marked palpebral ptosis;

or Superficial punctate keratitis.

Significant photophobia, such as with nonreactive mydriasis;

or Complete paralysis of accommodation in one eye, such as with
pseudophakia;
SEVERITY 3
5% or Lacrimation caused by complete stenosis of one inferior
caniculus;

or Moderate keratitis requiring frequent lubrication.

Maximum photophobia, such as with the loss of the iris;

or Complete paralysis of accommodation in both eyes;

or Complete paralysis of convergence;

SEVERITY 4 or Paralysis of conjugate downward or lateral gaze;
10%
or Severe and persistent unilateral or bilateral keratitis
despite treatment;

or Lacrimation caused by complete stenosis of the inferior
caniculi of both eyes.

(5) FUNCTIONS OF THE AUDITORY SYSTEM

The function of the auditory system is to put people in contact with the outside world by means of sound (words, music, background noise, etc.).

The functions of the auditory system are composed of 2 functional units.

(5.1) Hearing

(5.2) Ancillary Functions of the Auditory System

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Balance disorders and understanding difficulties related to a cognitive disorder must not be evaluated using the rules provided in this unit but using the rules provided in the functional units “Clinical Pictures of Balance Disorders” and “Cognitive Aspect of Language”.

(3) Specific guidelines for evaluating auditory impairments are given at the beginning of 5.1.

(5.1) HEARING

Specific Guidelines

The evaluation is conducted in 3 steps:

STEP 1: Determination of the average hearing threshold for each ear (tonal audiometry) and of the factor of severity of the binaural impairment

(A) Determination of the average hearing threshold for each ear (tonal audiometry)

The hearing threshold for each ear is evaluated by tonal audiometry without a hearing aid. The frequencies used are 500, 1,000, 2,000, and 4,000 hertz (Hz).

For calculation purposes, the maximum hearing threshold for a given frequency is set at 100 dB.

The average hearing threshold for each ear is obtained using the calculation method given below. For results above 25 dB, the average hearing threshold is rounded up or down to the nearest multiple of 5.

CALCULATION OF AVERAGE HEARING THRESHOLDS

___________________________________________________________________________________
| |
500 Hz 1,000 Hz 2,000 Hz 4,000 Hz | Average Hearing | Rounded
| Threshold | Average
| | (dB)
Right | |
Ear ________+________+________+________= | _________÷ 4 = ________ | → _______
| |
Left | |
Ear ________+________+________+________= | _________÷ 4 = ________ | → _______
___________________________________________________________________________________

(B) Determination of the factor of severity of the binaural impairment

The rounded averages obtained for each ear are entered in the table below to obtain the factor of severity.

The rounded average for a given ear must be 25 dB or more to entitle a person to financial assistance.

FACTORS OF SEVERITY FOR BINAURAL IMPAIRMENT

Rounded
Average
(dB)
for
Each
Ear <25 25 30 35 40 45 50 55 60 65 ≥70

<25 NA 0.5 0.5 1 1.5 2.5 4.5 6.5 8 8.5 9

25 0.5 1.5 1.5 2 2.5 3.5 5.5 7.5 9 9.5 10

30 0.5 1.5 3 3.5 4 5 7 9 10.5 11 11.5

35 1 2 3.5 6 6.5 7.5 9.5 11.5 13 13.5 14

40 1.5 2.5 4 6.5 9 10 12 14 15.5 16 16.5

45 2.5 3.5 5 7.5 10 15 17 19 20.5 21 21.5

50 4.5 5.5 7 9.5 12 17 27 29 30.5 31 31.5

55 6.5 7.5 9 11.5 14 19 29 39 40.5 41 41.5

60 8 9 10.5 13 15.5 20.5 30.5 40.5 48 48.5 49

65 8.5 9.5 11 13.5 16 21 31 41 48.5 51 51.5

≥70 9 10 11.5 14 16.5 21.5 31.5 41.5 49 51.5 54

STEP 2: Determination of auditory discrimination for each ear (vocal audiometry) and of the adjustment factor

The percentages of auditory discrimination for each ear are obtained by vocal audiometry and entered in the table below to obtain the adjustment factor.

ADJUSTMENT FACTOR

% of Auditory Discrimination
for Each Ear 90 to 100 70 to 89 50 to 69 <50

90 to 100 0 1 2 3

70 to 89 1 2 3 4

50 to 69 2 3 4 5

<50 3 4 5 6

STEP 3: Determination of the category of severity

The category of severity for auditory impairment is the sum of the factor of severity from Step 1 and the adjustment factor from Step 2.

Factor of Severity Adjustment Factor
(Step 1) (Step 2) Category of Severity

______________________ + _________________________ = _____________________

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment are less than
MINIMUM those resulting from the situation described in
THRESHOLD Severity 0.5.

SEVERITY Inconvenience due to a permanent hearing loss.
0.5 to 60

The category of severity corresponds to the extent of
0.5 to 60% functional hearing loss determined by an audiological
evaluation. It varies from 0.5 to a maximum of 60.

(5.2) ANCILLARY FUNCTIONS OF THE AUDITORY SYSTEM

CATEGORIES OF SEVERITY

Inconveniences experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment are less than those
MINIMUM resulting from the situations described in Severity 1.
THRESHOLD

Frequent or intense tinnitus* but with no significant effect
on sleep;
SEVERITY 1
2% or Medical necessity for preventive, palliative, or therapeutic
measures that cause inconvenience, such as swimming forbidden
because of a tympanic perforation.

Recurring otorrhea due to tympanic perforation;

SEVERITY 2 or Frequent irritation and infections, such as with external
3% auditory canal stenosis;

or Frequent, episodic exacerbations, such as with cholesteatoma.

SEVERITY 3 Tinnitus* sufficiently frequent and intense to compromise
5% sleep on a regular basis.

* TINNITUS BEING A SUBJECTIVE PHENOMENA, IT IS CONSIDERED FOR FINANCIAL ASSISTANCE PURPOSES ONLY IF ITS OCCURRENCE, INTENSITY AND CONSEQUENCES HAVE REGULARLY BEEN DOCUMENTED SINCE THE CRIMINAL OFFENCE.

(6) TASTE AND SMELL

Taste is the sensory function that provides people with information on the physical and chemical characteristics of food. It allows them to determine what is sweet, salty, bitter, or sour.

Smell is the sensory function that lets people distinguish odours. It determines whether odours are pleasant or unpleasant and helps people appreciate the flavour of food. In conjunction with the trigeminal system, it also provides a protection function by detecting potentially dangerous chemical substances.

Since they are closely related, taste and smell are considered as a single functional unit.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Evaluating taste includes semi-objective chemical testing of the 4 basic sensations: sweet, salty, bitter, and sour.

(3) Evaluating smell includes subjective sniff tests complemented by the following semi-objective methods:

— Verification of the olfacto-respiratory reflex by testing the reaction to strong odours that normally cause reflex blockage of inhalation

— Verification of trigeminal sensitivity by testing the reaction to irritating substances (vinegar, ammonia)

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following situations:

UNDER THE After-effects of the permanent impairment, such as partial
MINIMUM loss of taste or smell, are less than those resulting from
THRESHOLD the situation described in Severity 1.

Perception of unpleasant or inappropriate taste or odours
SEVERITY 1 (dysgueusia, cacosmia, parosmia) that may interfere with
3% daily activities.

SEVERITY 2 Total loss of one of both functions with partial or total
5% retention of the other.

SEVERITY 3 Total loss of both functions: taste and smell.
10%

(7) SKIN SENSITIVITY

Skin sensitivity is the sensory function that puts people in contact with the outside world through skin contact. It allows them to explore the outside world and react to changes in the environment (warning and protection function).

Skin sensitivity is composed of 7 functional units, each representing a separate region of the body:

(7.1) Skin Sensitivity of Skull and Face

(7.2) Skin Sensitivity of Neck

(7.3) Skin Sensitivity of Trunk and Genital Organs

(7.4) Skin Sensitivity of Right Upper Limb

(7.5) Skin Sensitivity of Left Upper Limb

(7.6) Skin Sensitivity of Right Lower Limb

(7.7) Skin Sensitivity of Left Lower Limb

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Skin sensitivity impairment resulting from paraplegia or quadriplegia must not be evaluated using the rules provided in this chapter but using to the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia”.

(3) The anatomical boundaries used to separate contiguous parts of the body are the following:

▸ ▸ Skull

Region inside the normal, usual hairline. In the presence of baldness, the anatomical boundary corresponds to what would have been the normal hairline.

▸ ▸ Face

Region defined by the anatomical boundaries of the skull and neck.

Lips area: Upper boundary is the base of the nose defined by the alae of the nose and the columella.

Lateral boundaries are the nasolabial creases

Lower boundary is the labiomental crease

▸ ▸ Neck

Upper boundary: line following the lower part of the body of the mandible, continuing along the vertical rami to the temporomandibular joints and then along the normal usual hairline

Lower boundary: line beginning at the jugular notch, continuing along the upper edge of the clavicle to the mid-point and then to the C7 spinous process

▸ ▸ Trunk and Genital Organs

Region defined by the anatomical boundaries of the neck, upper limbs, and lower limbs

▸ ▸ Upper Limb (upper boundary)

Circular line beginning at the apex of the armpit, extending backwards and forwards, and ending at the mid-point of the clavicle

▸ ▸ Lower Limb (upper boundary)

Line beginning at the median upper edge of the pubic symphysis, continuing obliquely to the antero-superior iliac spine, then along the upper edge of the iliac crest, and ending at the upper vertical boundary of the gluteal fold

(7.1) SKIN SENSITIVITY OF SKULL AND FACE

(Including the buccal cavity, the gums, and the teeth)

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment canbe compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment, such as a
MINIMUM sensitivity impairment affecting an area of skin under
THRESHOLD 1 cm2 on the skull or the face (not including lips area),
are less than those resulting from the situation described
in Severity 1.

Sensitivity impairment affecting an area:

for the entire skull and face: between 1 and 25 cm2;

SEVERITY 1 or for the face: between 1 and 5 cm2;
1%
or for the lips area between: less than 1 cm2;

or corresponding to one subdivision of the principal
branches* of a trigeminal nerve

Sensitivity impairment affecting an area:

for the entire skull and face: more than 25 cm2;

SEVERITY 2 or for the face: greater than 5 cm2 up to 15 cm2;
3%
or for the lips area: between 1 and 5 cm2;

or corresponding to 2 subdivisions of the principal
branches* of a trigeminal nerve

Sensitivity impairment affecting an area:

for the face: greater than 15 cm2 up to 25% of the entire
SEVERITY 3 surface;
6%
or for the lips area: greater than 5 cm2 up to 10 cm2;

or corresponding to more than 2 subdivisions of the principal
branches* of a trigeminal nerve

Sensitivity impairment affecting an area:

for the face: between 25% and 50% of the entire surface;
SEVERITY 4
10% or for the lips area: greater than 10 cm2;

or corresponding to a unilateral impairment of an entire
trigeminal nerve

SEVERITY 5 Sensitivity impairment affecting an area greater than
20% 50% of the entire surface of the face.

* THE 3 PRINCIPAL BRANCHES OF THE TRIGEMINAL NERVE ARE THE OPHTHALMIC, MAXILLARY, AND MANDIBULAR DIVISIONS.

(7.2) SKIN SENSITIVITY OF NECK

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the
situation with maximum impact among the following:

UNDER THE After-effects of the permanent impairment, such as a
MINIMUM sensitivity impairment affecting an area of skin under
THRESHOLD 2 cm2, are less than those resulting from the situation
described in Severity 1.

SEVERITY 1 Sensitivity impairment affecting an area of skin equal to
1% approximately 2 cm2 to 10 cm2.

SEVERITY 2 Sensitivity impairment affecting an area of skin equal to
2% approximately 10 cm2 to 25 cm2.

SEVERITY 3 Sensitivity impairment affecting an area of skin equal to
3% approximately 25 cm2 or more up to 50% of the entire neck
surface.

SEVERITY 4 Sensitivity impairment affecting an area of skin greater
5% than 50% of the entire neck surface.

(7.3) SKIN SENSITIVITY OF TRUNK AND GENITAL ORGANS

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

After-effects of the permanent impairment, such as a
sensitivity impairment affecting an area of skin under
UNDER THE 5 cm2 on the trunk or under 2 cm2 on the breasts (only
MINIMUM applies to women)or genital organs, are less than those
THRESHOLD resulting from the situations described in Severity 1.

Sensitivity impairment affecting an area of skin
approximately equal to
SEVERITY 1
1% 5 cm2 to 25 cm2 on the trunk, not including the breasts
(only applies to women) and genital organs;

or 2 cm2 to 5 cm2 on the breasts (only applies to women)
or genital organs.

Sensitivity impairment affecting an area of skin
approximately equal to

SEVERITY 2 25 cm2 to 100 cm2 on the trunk, not including the breasts
2% (only applies to women) and genital organs;

or 5 cm2 to 25 cm2 on the breasts (only applies to women) or
genital organs.

Sensitivity impairment affecting an area of skin

approximately equal to 100 cm2 or more up to 25% of the
SEVERITY 3 entire surface of the trunk, not including the breasts
4% (only applies to women) and genital organs;
or greater than 25 cm2 on the breasts (only applies to women)
or genital organs.

SEVERITY 4 Sensitivity impairment affecting an area of skin
7% approximately equal to 25% to 50% of the entire surface
of the trunk.

SEVERITY 5 Sensitivity impairment affecting an area of skin greater
10% than 50% of the entire surface of the trunk.

(7.4) SKIN SENSITIVITY OF RIGHT UPPER LIMB

(7.5) SKIN SENSITIVITY OF LEFT UPPER LIMB

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life,
mental suffering, pain, and other consequences - resulting from a
permanent impairment can be compared with those that would result from
the situation with maximum impact among the following:

After-effects of the permanent impairment, such as a
UNDER THE sensitivity impairment affecting an area of skin under
MINIMUM 5 cm2 on the upper limb or under 1 cm2 on the hand, are
THRESHOLD less than those resulting from the situations described
in Severity 1.

Sensitivity impairment affecting an area of skin
approximately equal to
SEVERITY 1
1% 5 cm2 to 25 cm2 on the upper limb, not including the hand;

or 1 cm2 to 5 cm2 on the hand.

Sensitivity impairment affecting an area of skin
approximately equal to
SEVERITY 2
3% 25 cm2 or more up to 25% of the entire surface of the
upper limb, not including the hand;

or 5 cm2 or more up to 25% of the entire surface of the hand.

Sensitivity impairment affecting an area of skin
approximately equal to
SEVERITY 3
5% 25% to 50% of the entire surface of the upper limb, not
including the hand;

or 25% to 50% of the entire surface of the hand.

Sensitivity impairment affecting an area of skin

SEVERITY 4 greater than 50% of the entire surface of the upper limb,
8% not including the hand;

or greater than 50% of the entire surface of the hand.

SEVERITY 5 Sensitivity impairment affecting an area of skin
10% greater than 50% of the entire surface of the palm.

(7.6) SKIN SENSITIVITY OF RIGHT LOWER LIMB

(7.7) SKIN SENSITIVITY OF LEFT LOWER LIMB

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

After-effects of the permanent impairment, such as a
UNDER THE sensitivity impairment affecting an area of skin under
MINIMUM 5 cm2 on the lower limb or under 2 cm2 on the sole of the
THRESHOLD foot, are less than those resulting from the situations
described in Severity 1.

Sensitivity impairment affecting an area of skin
SEVERITY 1 approximately equal to 5 cm2 to 25 cm2 on the lower
1% limb, not including the sole of the foot;

or 2 cm2 to 5 cm2 on the sole of the foot.

Sensitivity impairment affecting an area of skin
SEVERITY 2 approximately equal to 25 cm2 to 100 cm2 on the lower
2% limb, not including the sole of the foot;

or 5 cm2 to 10 cm2 on the sole of the foot.

Sensitivity impairment affecting an area of skin

SEVERITY 3 greater than 100 cm2 but less than 25% of the entire
4% surface of the lower limb, not including the sole of
the foot;
or greater than 10 cm2 but less than 50% of the entire
surface of the sole of the foot.

Sensitivity impairment affecting an area of skin
approximately equal to
SEVERITY 4 25% to 50% of the entire surface of the lower limb,
6% not including the sole of the foot;

or 50% or more of the entire surface of the sole of the
foot.

SEVERITY 5 Sensitivity impairment affecting an area of skin
8% greater than 50% the entire surface of a lower limb.

(8) CLINICAL PICTURES OF BALANCE DISORDERS

Balance is the sensory function that enables a person to keep his or her body in a stable position when in motion or at rest and to maintain a steady gaze with respect to head movements. It is controlled by the central nervous system, which combines and processes the visual, vestibular, and proprioceptive information required for appropriate motor responses.

For financial assistance purposes, all impacts related to balance disorders are presented under this single functional unit.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Impacts on other functional units, such as locomotion impairments due to a balance disorder, are included in the categories of severity of this unit.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment are less than
MINIMUM those resulting from the situation described in Severity 1.
THRESHOLD

Regular but brief bouts of unsteadiness, dizziness, or
SEVERITY 1 vertigo that occur mainly during abrupt movements or changes
2% of position but do not affect the ability to perform tasks
of daily living.

Regular therapeutic measures that may cause side effects are
justified.

Regular bouts of unsteadiness, dizziness, or vertigo that
occur despite therapeutic measures, such as difficulty
walking (sensation of drunkenness), feeling of insecurity
SEVERITY 2 on uneven ground, in a crowd, or in the dark.
5%
The person can perform tasks of daily living but cannot
take part in activities that could endanger his or her
safety or that of others such as activities involving heights
or ladders.

Regular bouts of unsteadiness, dizziness, or vertigo that
SEVERITY 3 occur despite therapeutic measures and whose severity makes
15% it impossible to drive a car safely.

Regular bouts of unsteadiness, dizziness, or vertigo that
occur despite therapeutic measures and whose severity
makes the surveillance or assistance of another person
SEVERITY 4 necessary to perform many tasks of daily living.
30%
The person is still capable of independently performing
simple tasks of daily living such as doing household
chores or taking care of personal hygiene.

Regular bouts of unsteadiness, dizziness, or vertigo that
occur despite therapeutic measures and whose severity
makes the surveillance or assistance of another person
SEVERITY 5 necessary to perform most tasks of daily living.
60%
The person is still capable of taking care of personal
hygiene.

Regular bouts of unsteadiness, dizziness, or vertigo that
occur despite therapeutic measures and whose severity
SEVERITY 6 makes it impossible to stay upright.
100%
The person is confined to bed or a wheelchair, either at
home or in an institution.

(9) PHONATION

Phonation refers to the ability of mechanically producing vocal sounds that can be heard and understood and whose rate and flow can be maintained.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) The evaluation must take into account audibility, intelligibility, and flow quality.

— Audibility: Intensity of the voice

— Intelligibility: Quality of articulation and phonetic links

— Flow: Maintenance of rate and rhythm

(3) Language disorders related to a cognitive impairment must not be evaluated using the rules provided in this chapter but using the rules provided in the functional unit “Cognitive Aspect of Language”.

CATEGORIES OF SEVERITY

UNDER THE After-effects of the permanent impairment are less than
MINIMUM those resulting from the situations described in Severity 1.
THRESHOLD

Minor but perceptible impairment to audibility,
SEVERITY 1 intelligibility, or flow;
1%
or Change in speech timbre.

Audibility: Voice intensity is diminished but is
sufficient to allow normal conversation;

or Intelligibility: Some difficulties and inaccuracies but
SEVERITY 2 articulation is adequate for understanding;
5%
or Fluidity: Verbal flow is slow, hesitant, or interrupted
but is adequate for normal conversation.

Audibility: Voice intensity quickly weakens. Close-up
conversations are possible but difficult in noisy settings;

SEVERITY 3 or Intelligibility: Family and friends understand, but
10% strangers find it difficult to understand and often
ask the person to repeat;

or Fluidity: Verbal flow is slow and hesitant enough to
limit continuous speech to short periods.

Audibility: Voice intensity is very weak, like
whispering. Telephone conversations are impossible;

SEVERITY 4 or Intelligibility: Articulation is limited to
20% pronouncing short, familiar words;

or Fluidity: Verbal flow is very slow and arduous.
Isolated words and short sentences can be spoken but
continuous speech cannot be maintained.

SEVERITY 5 Absence or almost total absence of vocal function.
30%
Speech is inaudible or incomprehensible.

(10) MIMIC

Mimic refers to the ability to produce facial expressions using neuromusculoskeletal structures.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment are less than
MINIMUM those resulting from the situations described in
THRESHOLD Severity 1.

Ability to produce facial expressions is slightly
impaired such as with a partial and minor impairment to a
SEVERITY 1 branch of the facial nerve, or an equivalent impairment
1% resulting from the loss of mimic muscle tissue;

or Occasional involuntary movements, such as facial
synkinesia.

Ability to produce facial expressions is impaired over
an area equal to approximately one-quarter of the face
such with a total impairment to a frontal or mandibular
branch of the facial nerve, or with an equivalent
SEVERITY 2 impairment resulting from the loss of mimic muscle tissue;
3%
or Frequent involuntary movements, such as facial synkinesia;

or Facial spasms.

Ability to produce facial expressions is impaired over an
area equal to approximately one-half of the face such as
SEVERITY 3 with a total unilateral impairment to a facial nerve or a
7% partial bilateral impairment of the facial nerves, or an
equivalent impairment resulting from the loss of mimic
muscle tissue.

Ability to produce facial expressions is impaired over an
area equal to approximately three-quarters of the face
SEVERITY 4 such with a complete unilateral impairment to the facial
12% nerve combined to a partial contra lateral impairment, or
an equivalent impairment resulting from the loss of mimic
muscle tissue.

SEVERITY 5 The ability to produce facial expressions is nonexistent
15% or virtually nonexistent.

(11) ABILITY TO MOVE AND MAINTAIN POSITION OF HEAD

The synergistic actions of anterior flexion, extension, lateral flexion and rotation of the neck make it possible to move and maintain the head in a stable position while performing numerous daily activities.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) The category of severity is determined by the situation with maximal impact, either the result of the overall weighted evaluation or any other situation described, including functional restrictions.

(3) The overall weighted evaluation is performed in the event of a decrease of active mobilization.

(a) The decrease in active mobilization is evaluated by measuring the maximum amplitudes of active movements obtained with optimal effort from the person being evaluated. The result must be consistent with the overall clinical evaluation. In the event of a discrepancy that cannot be explained with medically accepted knowledge, the passive movement measurement is used.

(b) The normal limit of the amplitude of the movement is obtained by comparison with the equivalent contralateral movement, as required. When this cannot be done or when the contralateral movement is faulty, use conventional values generally accepted as normal for the age of the person.

(c) For each movement, the importance of the loss is entered in the table. When, for a given movement, a result falls between 2 values, the closest value is used.

OVERALL WEIGHTED EVALUATION

Active Mobilization of the Cervical Region
___________________________________________________________________
|
| Anterior Flexion Flexion Rotation Rotation
| Flexion Extension to Left to Right to Left to Right
_______________|___________________________________________________________________
Normal Limits |
(Normal ± a |
few degrees |
| 0 0 0 0 0 0
_______________|___________________________________________________________________
|
Loss of |
approximately | 2 2 1 1 4 4
25% |
_______________|___________________________________________________________________
|
Loss of |
approximately | 6 6 3 3 8 8
50% |
_______________|___________________________________________________________________
|
Loss of |
approximately | 10 10 5 5 20 20
75% |
_______________|___________________________________________________________________
|
Loss of 90% |
or more | 15 15 10 10 25 25
_______________|____________________________________________________________________

Total Overall Weighted Evaluation = _________ Points

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent impairment
can be compared with those that would result from the situation with maximum
impact among the following:

After-effects of the permanent impairment, such as the
UNDER THE loss of a few degrees in the amplitude of movements
MINIMAL without significant functional impact, are less than
THRESHOLD those resulting from the situation described in
Severity 1.

The result of the overall evaluation of active
SEVERITY 1 mobilization capacity is between 1 and 10, indicating
2% a slight difficulty with activities requiring moving
and maintaining the position of the head.

The result of the overall evaluation of active
mobilization capacity is between 11 and 20, indicating
a moderate difficulty with activities requiring moving
and maintaining the position of the head;

or Regular and permanent inconveniences due to a medical
SEVERITY 2 necessity to avoid activities requiring
4%
- Extended periods of immobilization of the head and
neck;
or
- Repetitive or frequent efforts that place significant
strain on the neck.

The result of the overall evaluation of active
mobilization capacity is between 21 and 40, indicating
a significant difficulty with activities requiring moving
and maintaining the position of the head;
SEVERITY 3
8% or Regular and permanent inconveniences due to a medical
necessity

- To avoid activities requiring repetitive or frequent
efforts equivalent to handling loads of 5 to 10 kg.

The result of the overall evaluation of active
SEVERITY 4 mobilization capacity is between 41 and 60, indicating
15% a severe difficulty with activities requiring moving and
maintaining the position of the head.

The result of the overall evaluation of active
SEVERITY 5 mobilization capacity is greater than 60.
30%
Capacity to move or maintain the position of the head
is nonexistent or virtually nonexistent.

(12) ABILITY TO MOVE AND MAINTAIN POSITION OF TRUNK

The synergistic actions of anterior flexion, extension, lateral flexion, and rotation of the dorsal, lumbar, and sacral regions make it possible to move and maintain the trunk in a stable position while performing numerous daily activities.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Impacts on the ability to move and maintain the position of the trunk resulting from paraplegia or quadriplegia must not be evaluated using the rules provided in this unit but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(3) The category of severity is determined by the situation with maximal impact, either the result of the overall weighted evaluation or any other situation described, including functional restrictions.

(4) The overall weighted evaluation is performed in the event of a decrease of active mobilization.

(c) For each movement, the importance of the loss is entered in the table. When, for a given movement, a result falls between 2 values, the closest value is used.

OVERALL WEIGHTED EVALUATION

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent impairment
can be compared with those that would result from the situation with maximum
impact among the following:

UNDER THE After-effects of the permanent impairment, such as the loss
MINIMUM of a few degrees in the amplitude of movements without
THRESHOLD significant functional impact, are less than those
resulting from the situation described in Severity 1.

The result of the overall evaluation of active mobilization
SEVERITY 1 capacity is between 1 and 10, indicating a slight
2% difficulty with activities requiring moving and
maintaining the position of the trunk.

The result of the overall evaluation of active mobilization
capacity is between 11 and 20, indicating a moderate
difficulty with activities requiring moving and maintaining
the position of the trunk;

or Regular and permanent inconveniences due to a medical
necessity to avoid activities requiring
SEVERITY 2
4%
- Extended periods of immobilization of the trunk.
Functional restrictions are sufficient to limit
periods of uninterrupted driving to 1 or 2 hours;
or
- Repetitive or frequent efforts that place significant
strain on the trunk.

The result of the overall evaluation of active mobilization
capacity is between 21 and 40, indicating a significant
difficulty with activities requiring moving and maintaining
the position of the trunk;

or Regular and permanent inconveniences due to a medical
necessity to avoid activities requiring
SEVERITY 3
8%
- Extended periods of immobilization of the trunk.
Functional restrictions are sufficient to limit periods
of uninterrupted driving to less than one hour;
or
- Repetitive or frequent efforts equivalent to handling
loads of 5 to 10 kg.

The result of the overall evaluation of active mobilization
capacity is between 41 and 60, indicating a severe
difficulty with activities requiring moving and maintaining
the 15% position of the trunk;

SEVERITY 4 or Regular and permanent inconveniences due to a medical
15% necessity to avoid activities requiring

- Extended periods of immobilization of the trunk.
Functional restrictions are sufficient to prevent
or limit periods of uninterrupted driving to a few
minutes.

The result of the overall evaluation of active mobilization
capacity is greater than 60.
SEVERITY 5
30% Capacity to move or maintain the position of the trunk is
nonexistent or virtually nonexistent.

(13) ABILITY TO MOVE AND MAINTAIN POSITION OF UPPER LIMB

The function of moving and maintaining the position of an upper limb, especially an hand*, makes it possible to reach and move objects in the pericorporeal space. It also makes it possible to reach various parts of the body, notably for personal care and hygiene.

* In the event of amputations, the distal extremity of the limb

This function is composed of 2 functional units.

(13.1) Ability to Move and Maintain Position of Right Upper Limb

(13.2) Ability to Move and Maintain Position of Left Upper Limb

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Impacts on the ability to move and maintain the position of an upper limb resulting from quadriplegia must not be evaluated using the rules provided in this unit but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(3) In the case of an amputation, “Manuel Dexterity” must also be evaluated.

(4) The dominant limb shall be the limb most frequently used for daily activities, notably for writing.

(5) The category of severity is determined by the situation with maximal impact, either the result of the overall weighted evaluation or any other situation described, including functional restrictions.

(6) The overall weighted evaluation is performed in the event of a decrease of active mobilization.

(b) The normal limit of the amplitude of the movement is obtained by comparison with the equivalent contralateral movement. When this cannot be done or when the contralateral movement is faulty, use conventional values generally accepted as normal for the age of the person.

— When the measure of the loss of amplitude of movement falls between 2 values, the closest value is used.

— When an examination indicates a decrease in both amplitude of the movement and muscle strength, the highest score is used.

OVERALL WEIGHTED EVALUATION

(13.1) ABILITY TO MOVE AND MAINTAIN POSITION OF RIGHT UPPER LIMB

(13.2) ABILITY TO MOVE AND MAINTAIN POSITION OF LEFT UPPER LIMB

Non-dominant Limb: (ND)

Dominant Limb: (D)

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment, such as the loss
MINIMUM of a few degrees in the amplitude of movements without
THRESHOLD significant functional impact, are less than those resulting
from the situation described in Severity 1.

SEVERITY 1 The result of the overall evaluation of active mobilization
capacity is between 0.5 and 3, indicating a very slight
ND 1% difficulty with activities requiring moving and maintaining
D 1% the position of the upper limb.

The result of the overall evaluation of active mobilization
capacity is between 3.5 and 6, indicating a slight difficulty
with activities requiring moving and maintaining the position
of the upper limb;

SEVERITY 2 or Regular and permanent inconveniences due to a medical
necessity to avoid activities requiring repetitive or
ND 2% frequent efforts
D 2.5%

- That place significant strain on the upper limb;
or
- Requiring the moving of heavy objects.

The result of the overall evaluation of active mobilization
capacity is between 6.5 and 16, indicating a moderate
difficulty with activities requiring moving and maintaining
the position of the upper limb;
SEVERITY 3
or Regular and permanent inconveniences due to a medical
ND 4% necessity to avoid activities requiring repetitive or
D 5% frequent efforts

- Equivalent to moving loads of approximately 5 to 10 kg.

SEVERITY 4 The result of the overall evaluation of active mobilization
capacity is between 16.5 and 36, indicating a significant
ND 8% difficulty with activities requiring moving and maintaining
D 10% the position of the upper limb.

SEVERITY 5 The result of the overall evaluation of active mobilization
capacity is between 36.5 and 59, indicating a very
ND 15% significant difficulty with activities requiring moving
D 18% and maintaining the position of the upper limb.

SEVERITY 6 The result of the overall evaluation of active mobilization
capacity is between 60 and 89, indicating a severe
ND 20% difficulty with activities requiring moving and maintaining
D 24% the position of the upper limb.

Active mobilization capacity of the upper limb is
SEVERITY 7 nonexistent or virtually nonexistent.

ND 24% The result of the overall evaluation of active mobilization
D 30% capacity is 90 or more.

(14) MANUAL DEXTERITY (prehension and manipulation)

The manual dexterity function refers to the prehension, manipulation, and release of objects. Fine dexterity allows for the quick or precise manipulation of small objects with the fingers while gross dexterity allows for the manipulation of larger objects with the whole hand.

Manual dexterity is composed of 2 functional units:

(14.1) Right Manual Dexterity

(14.2) Left Manual Dexterity

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Impacts on manual dexterity resulting from quadriplegia must not be evaluated using to the rules provided in this unit but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(3) Impacts resulting from an impairment to skin sensitivity of a hand must also be evaluated using the rules provided in the functional unit “Skin Sensitivity of Upper Limb.”

(4) The dominant limb shall be the limb most frequently used for daily activities, notably for writing.

(6) The overall weighted evaluation is performed in the event of a decrease of active mobilization.

(1) The decrease in active mobilization is evaluated by measuring the maximum amplitudes of active movements obtained with optimal effort from the person being evaluated. The result must be consistent with the overall clinical evaluation. In the event of a discrepancy that cannot be explained with medically accepted knowledge, the passive movement measurement is used.

(2) The normal limit of the amplitude of the movement is obtained by comparison with the equivalent contra lateral movement. When this cannot be done or when the contra lateral movement is faulty, use conventional values generally accepted as normal for the age of the person.

(3) For each movement, the importance of the loss is entered in the tables provided.

(4) The result of the overall weighted evaluation is the sum of the scores obtained in Tables A, B and C.

Table A: Fine and Power Grasp

Table B: Manipulation: Contribution of the Fingers

Table C: Manipulation: Contribution of the Wrist and Elbow/Forearm

— In Table C, when the result falls between 2 values, the closest value is used.

— In Tables B and C, when the examination indicates a decrease in both amplitude of the movement and muscle strength, the highest score is used.

TABLE A

FINE AND POWER GRASP

The quality of the grasp is evaluated on the basis of precision, strength, and speed of execution in grasping, holding, and releasing objects.

TABLE B

MANIPULATION: CONTRIBUTION OF FINGERS

TABLE C

MANIPULATION: CONTRIBUTION OF WRIST AND ELBOW/FOREARM

(14.1) RIGHT MANUAL DEXTERITY

(14.2) LEFT MANUAL DEXTERITY

Non-dominant Limb: (ND)

Dominant Limb: (D)

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment, such as the
MINIMUM loss of a few degrees in the amplitude of movements without
THRESHOLD significant functional impact, are less than those
resulting from the situation described in Severity 1.

The result of the overall evaluation of active mobilization
capacity is between 0.5 and 6.5, indicating a very slight
SEVERITY 1 difficulty for activities requiring manual dexterity;

ND 1% or Regular and permanent inconveniences due to the medical
D 1% necessity to avoid exposure to cold such as with a vascular
impairment like a Raynaud’s phenomenon.

SEVERITY 2 The result of the overall evaluation of active mobilization
capacity is between 7 and 14.5, indicating a slight
ND 2% difficulty for activities requiring manual dexterity.
D 2.5%

The result of the overall evaluation of active mobilization
capacity is between 15 and 29.5, indicating a moderate
SEVERITY 3 difficulty for activities requiring manual dexterity;

ND 4%
D 6% or Clumsiness such as trembling or dysmetria that nevertheless
allows the person to use the hand for personal care.

SEVERITY 4 The result of the overall evaluation of active mobilization
capacity is between 30 and 49.5, indicating a significant
ND 6% difficulty for activities requiring manual dexterity.
D 8%

SEVERITY 5 The result of the overall evaluation of active mobilization
capacity is between 50 and 79.5, indicating a very
ND 12% significant difficulty for activities requiring manual
D 15% dexterity.

SEVERITY 6 The result of the overall evaluation of active mobilization
capacity is between 80 and 129.5, indicating a severe
ND 18% difficulty for activities requiring manual dexterity.
D 22%

The result of the overall evaluation of active mobilization
SEVERITY 7 capacity is between 130 and 199.5, indicating a very severe
difficulty for activities requiring manual dexterity. Manual
ND 28% dexterity is limited to a minimum of useful activities.
D 35%

SEVERITY 8 The result of the overall evaluation of active mobilization
capacity is 200 or more. Manual dexterity is nonexistent
ND 40% or virtually nonexistent. No useful or effective action
D 50% possible.

(15) LOCOMOTION

Locomotion is the capacity to move from place to place. It also allows people to adopt and change body positions. Locomotion is the result of the functional synergy between the 2 lower limbs, the pelvis, and the trunk.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Impacts on locomotion resulting from paraplegia, quadriplegia, or balance disorders must not be evaluated using the rules provided in this unit but using the rules provided in the functional units “Clinical Pictures of Paraplegia and Quadriplegia” or ’Clinical Pictures of Balance Disorders.”

(3) The term “efficiency” used in the categories of severity refers to the time it takes to perform the activity and the quality of the result.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

After-effects of the permanent impairment, such as less
UNDER THE than 1 cm difference in leg length or the loss of a few
MINIMUM degrees of active mobilization with no significant
THRESHOLD functional impact, are less than those resulting from the
situations described in Severity 1.

Locomotion capacity is slightly reduced.

Limitations: Walking at an ordinary pace, walking at
a brisk pace, running, and performing complex
movements are affected but remain efficient(1),
notably by changing certain normal movements.

For example, slight functional impact resulting
from joint instability, patello-femoral syndrome,
or a decrease in the amplitude of one or more
hip, knee, or ankle movements.

SEVERITY 1
2% (1) Efficient: The time it takes to perform the
activity and the quality of the result remain
within normal limits.

Restrictions: The extent compares to such restrictions as
those imposed by the need to wear

- A lift or corrective shoe insert to compensate
for differences in leg lengths of 1 cm to
3.5 cm;

- A custom-fitted shoe to compensate for a
disfigurement of the foot;

- Support stockings to satisfactorily control
of circulatory disorders.

Locomotion capacity is moderately reduced.

Limitations: Walking occurs with a limp, despite the use of
a technical aid like a corrective shoe insert,

or Walking at a brisk pace or running is less
efficient but remains possible;

or Negotiating changes in ground level, stairs, and
uneven ground is less efficient(1), but remains
possible,

or Uninterrupted walking is limited to approximately
300 m to 500 m due to intermittent claudication;

or Complex movements like kneeling and crouching
are less efficient but remain possible, notably
by performing them more slowly and making
changes to normal movements.

(1) Less efficient: Activity remains possible but
SEVERITY 2 takes more time to be performed OR the quality
6% of the result is diminished.

Restrictions: The extent compares to such restrictions as those
imposed by the need

- To wear a lift or corrective shoe insert to
compensate for differences in leg lengths
exceeding 3.5 cm;

- To wear a prosthesis or custom-fitted shoe
because of the amputation of the 1st toe;

- To wear hinged knee brace, which is medically
justified by symptomatic instability of the
knee and necessary for performing demanding
activities such as certain sports;

- To undergo medical or surgical treatments due
to frequent, episodic exacerbations such as
osteomyelitis relapses;

- To reduce locomotion activities due to
circulatory problems that are poorly
controlled despite therapeutic measures like
with some cases of post-phlebitis syndrome.

Locomotion capacity is significantly reduced.

Limitations: Walking at brisk pace or running is only
possible over very short distances such as with
an arthrodesis of one ankle;

or Negotiating changes in ground level, stairs,
and uneven ground is only possible over very
short distances;

or Uninterrupted walking is limited to
approximately 120 m to 300 m due to
intermittent claudication;
SEVERITY 3
12% or Complex movements like kneeling and crouching
are inefficient or impossible.

Restrictions: The extent compares to such restrictions as
those imposed by the need to wear

- A tibial-pedal prosthesis in the case of a
neurological impairment with drop foot for
example;

- A hinged knee brace, which is medically
justified by symptomatic instability of the
knee and permanently necessary for
performing all activities;

- A prosthesis or custom-fitted shoe because
of an amputation at the median point
of a foot.

Locomotion capacity is very significantly reduced.

Limitations: Walking at brisk pace or running is
inefficient or impossible even over very
short distances;

SEVERITY 4 or Uninterrupted walking is limited to
20% approximately 75 m to 120 m due to
intermittent claudication.

Restrictions: The extent compares to such restrictions as
those imposed by the need to wear

- A prosthesis because of an amputation
at the ankle.

Locomotion capacity is severely reduced.

Limitations: Uninterrupted walking is limited to under
75 m due to intermittent claudication,

Restrictions: The extent compares to such restrictions
as those imposed by the need to wear
SEVERITY 5
30% - A femoral-pedal orthesis due to a severe
impairment to the entire limb;

- A prosthesis with patellar support due to
an amputation below the knee;

- A prosthesis due to an amputation at the
median point of both feet or both ankles.

Locomotion capacity is reduced to a minimum of useful activities.

Limitations: Moving about requires the use of 2 canes or
2 crutches.
Moving about out of doors may require the use
of a walker or wheelchair.

SEVERITY 6
45% Restrictions: The extent compares to such restrictions as
those imposed by the need to wear

- A prosthesis due to a disarticulation of a
knee, an amputation of a limb at the thigh
level, or an amputation below the knee not
permitting the wearing of a prosthesis with
patellar support;
- Prosthesis with patellar support due to
amputation below the knee of both limbs.

Locomotion capacity is nonexistent or almost nonexistent.

Limitations: Moving about requires the use of a wheelchair.
SEVERITY 7
60%
Restrictions: The extent compares to such restrictions as
those imposed by the need to wear
- Prosthesis due to amputation at the thigh
of both limbs.

(16) PROTECTION PROVIDED BY THE SKULL

The protection provided by the skull helps maintain the integrity of the brain.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) The evaluation must take into consideration the extent of any inconvenience resulting from preventive restrictions made necessary by a permanent, unrepairable loss of continuity of the skull.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment, such as burr
MINIMUM holes, are less than those resulting from the situation
THRESHOLD described in Severity 1.

SEVERITY 1 Preventive restrictions made necessary by a permanent loss
2% of continuity of the skull such as an unrepaired section
affecting an area equal to or greater than 3 cm2.

(17) PROTECTION PROVIDED BY THE RIB CAGE AND ABDOMINAL WALL

The protection provided by the rib cage and abdominal wall helps maintain the integrity of the contents of the thorax and abdomen.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) When the presence of hernia is noted, it may be incisional, inguinal, femoral, umbilical or epigastric.

(3) Impacts on digestive or respiratory functions must not be evaluated using the rules provided in this chapter but using the rules provided in the functional units that specifically deal with the observed impacts.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

After-effects of the permanent impairment, such as a faulty
UNDER THE consolidation of a rib or ribs with no functional impact or
MINIMUM a repaired nonrecurrent hernia, are less than those
THRESHOLD resulting from the situations described in Severity 1.

Inconveniences resulting from the medical necessity of
functional restrictions or treatments required by

- Defects in the abdominal wall such as a recurrent or
surgically unrepairable readily reducible single hernia;
SEVERITY 1
1%
or

- A limited but surgically unrepairable defect in the rib
cage such as exeresis, pseudoarthrosis, or abnormal
consolidation of one rib.

Inconveniences resulting from the medical necessity of
functional restrictions or treatments required by

- Defects in the abdominal wall such as recurrent or
surgically unrepairable readily reducible hernias;
SEVERITY 2
2%
or

- A significant, surgically unrepairable defect in the
rib cage such as exeresis, pseudoarthrosis, or abnormal
consolidation of several ribs.

Inconveniences resulting from the medical necessity of
functional restrictions or treatments required by
SEVERITY 3
5% - Defects in the abdominal wall such as recurrent or
surgically unrepairable hard to reduce hernia(s).

Inconveniences resulting from the medical necessity of
functional restrictions or treatments required by
SEVERITY 4
7% - Defects in the abdominal wall such as recurrent or
surgically unrepairable non reducible hernias.

(18) NASOPHARYNGEAL RESPIRATION

Nasopharyngeal respiration, which is provided by the nose, sinuses, and pharynx, allows the passage, filtration, moistening, and heating of air.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment are less than
MINIMUM those resulting from the situations described in
THRESHOLD Severity 1.

Partial unilateral decrease in nasal air flow;
SEVERITY 1
1% or Local, unilateral irritant phenomena that may result,
for example, from a perforation of the nasal septum or
damage to the mucosa.

Total unilateral or partial bilateral decrease in nasal
air flow;

SEVERITY 2 or Local, bilateral irritant phenomena that may result,
2% for example, from a perforation of the nasal septum or
damage to the mucosa;

or Need for medical treatments or follow-ups due to chronic,
persistent sinus infections.

SEVERITY 3 Total bilateral nasal obstruction permanently requiring
5% breathing through the mouth.

(19) DIGESTIVE FUNCTIONS

Digestive functions enable people to use food to produce energy, to grow, and to keep their bodies functioning.

Digestive functions are composed of 4 functional units.

(19.1) Ingestion (chewing and swallowing including prehension and salivation)

(19.2) Digestion and Absorption

(19.3) Excretion

(19.4) Hepatic and Biliary Functions

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Impacts on digestive functions resulting from paraplegia or quadriplegia must not be evaluated using the rules provided in this chapter but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(3) The table below specifies the relative degree of the terms used in the descriptions of the categories of severity describing the impairments of the hepatic and biliary functions as “slight”, “moderate”, or “severe”. Depending on the circumstances, the evaluation of the functional impairment may be documented by any other appropriate specific examination.

Specific Evaluation “Slight” Impairment “Moderate” Impairment “Severe” Impairment
Criteria

Bilirubin 0 - 35 > 35 - 100 > 100

Albumin > 35 25 - 35 < 25

Ascites - Medically controlled Uncontrolled

Neurological Signs - Controlled or Poorly controlled,
intermittent severe

Nutritional Status Excellent Good Poor

INR* Normal > 1.5 - 2.5 > 2.5

* International Normalized Ratio

(19.1) INGESTION: Chewing and Swallowing Including Prehension and Salivation

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

After-effects of the permanent impairment, such as dental
UNDER THE impairment or slight malocclusion with no impact on
MINIMUM chewing, are less than those resulting from the situations
THRESHOLD described in Severity 1.

Loss of one or more teeth with the possibility of
correction using a fixed prosthesis or implants;

or Unrepairable dental impairment sufficient to affect
chewing;

SEVERITY 1 or Area(s) of altered sensitivity sufficient to affect
1% chewing;

or Hyposalivation or hypersalivation sufficient to affect
chewing or swallowing;

or Limitations to mouth opening, which nonetheless remains
equal to or greater than 35 mm.

Loss of teeth with the possibility of correction using
a removable prosthesis (including any related
inconveniences), but not technically correctable with a
fixed prosthesis or implants;

or Slight temporo-mandibular dysfunction sufficient to
SEVERITY 2 affect chewing;
2%
or Malocclusion sufficient to affect chewing;

or Limitations to mouth opening, which nonetheless remains
equal to or greater than 30 mm;

or Mild salivary incontinence.

Total edentation of one maxilla with the possibility
of correction using a removable prosthesis (including
any related inconveniences), but not technically
correctable with implants;

or Moderate to severe temporo-mandibular dysfunction;
SEVERITY 3
5% or Limitations to mouth opening, which nonetheless remains
equal to or greater than 20 mm;

or Moderate to severe salivary incontinence;

or Medical necessity on a regular and permanent basis to
follow a restrictive diet combined with medical
treatments.

Total edentation of both maxillae with the possibility
of correction using removable prostheses (including
any related inconveniences), but not technically
correctable with implants;

SEVERITY 4 or Limitations to mouth opening, which nonetheless
10% remains equal to or greater than 10 mm;

or Salivary and alimentary incontinence;

or Sufficient discomfort when chewing or swallowing
to justify a soft diet (purees) on a permanent basis.

Total edentation of both maxillae, technically not
correctable;

or Limitations to mouth opening, which is less than 10 mm;

SEVERITY 5 or Sufficient discomfort on chewing or swallowing to
25% justify a liquid diet on a permanent basis;

or Necessity for artificial feeding on an intermittent
basis combined with ongoing medical treatments or
occasional surgical treatments;

or Medical necessity to perform serial dilations on a
regular basis, which may cause severe functional
discomfort.

SEVERITY 6 The function is nonexistent or virtually nonexistent,
40% making artificial feeding necessary on a permanent
basis.

(19.2) DIGESTION AND ABSORPTION

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment are less
MINIMUM than those resulting from the situation described in
THRESHOLD Severity 1.

SEVERITY 1 Medical necessity on a regular and permanent basis
2% to take medication to facilitate digestion or absorption,
including possible side effects.

SEVERITY 2 Medical necessity on a regular and permanent basis to
5% follow a restrictive diet combined with medical
treatments.

Sufficient functional discomfort to affect nutritional
status. The impairment is confirmed by clinical and
laboratory testing and is associated with permanent
weight loss of approximately 10% in comparison with prior
SEVERITY 3 weight or, according to circumstances, with the
10% recommended weight for the age, sex, and body type;

or Medical necessity to undergo treatments due to episodic
exacerbations such as one or 2 episodes a year of
recurrent chronic pancreatitis.

Sufficient functional discomfort to affect nutritional
status. The impairment is confirmed by clinical and
laboratory testing and is associated with permanent weight
loss of 15 20% to in comparison with prior weight or,
according to circumstances, with the recommended weight
for the age, sex, and body type;
SEVERITY 4
25% or Medical necessity to undergo treatments due to frequent
exacerbations such as 3 episodes or more a year of
recurrent chronic pancreatitis;

or Medical necessity for intermittent artificial feeding
combined with ongoing medical treatments and/or
occasional surgical treatments.

Sufficient functional discomfort to affect nutritional
status. The impairment is confirmed by clinical and
laboratory testing and is associated with permanent
SEVERITY 5 weight loss of 25% or more in comparison with prior weight
40% or, according to circumstances, with the recommended weight
for the age, sex, and body type;
or Medical necessity on a permanent basis for artificial
feeding combined with ongoing medical treatments and/or
occasional surgical treatments.

SEVERITY 6 The function is nonexistent or virtually nonexistent,
50% making intravenous feeding necessary on a permanent basis.

(19.3) EXCRETION

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment, such as the
MINIMUM presence of non urgent diarrhea, are less than those
THRESHOLD resulting from the situation described in Severity 1.

Urgent diarrhea on a regular and permanent basis with
an average frequency of approximately 1 to 2 times
SEVERITY 1 a day;
2%
or Medical necessity on a regular and permanent basis to
take medication to facilitate excretion, including possible
side effects.

Urgent diarrhea on a regular and permanent basis with
an average frequency of approximately 3 to 5 times a day;
SEVERITY 2
5%
or Manifestations of fecal incontinence (soiling) that
justify the constant wearing of protection.

Urgent diarrhea on a regular and permanent basis with
an average frequency over 5 times a day;
SEVERITY 3
10%
or Fecal incontinence of formed stools with an average
frequency of 5 times or less a week.

SEVERITY 4 Total fecal incontinence;
35%
or Need for a permanent colostomy.

SEVERITY 5 Need for a permanent ileostomy.
40%

(19.4) HEPATIC AND BILIARY FUNCTIONS

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

After-effects of the permanent impairment, such as the
UNDER THE presence of biochemical anomalies that have no clinical
MINIMUM impact and require no special medical follow-up, are less
THRESHOLD than those resulting from the situation described in
Severity 1.

SEVERITY 1 Medical necessity on a regular and permanent basis to take
2% medication to facilitate hepatic and biliary functions,
including possible side effects.

SEVERITY 2 “Slight” functional impairment according to specific
5% evaluation criteria.

Sufficient functional discomfort to affect nutritional
status. The impairment is confirmed by clinical and
laboratory evaluations and is associated with permanent
weight loss of approximately 10% in comparison with prior
weight or, according to circumstances, with the
SEVERITY 3 recommended weight for the age, sex, and body type;
10%
or Medical necessity to undergo treatments due to episodic
exacerbations like recurrent cholangitis;

or Medical necessity on a permanent basis for serial
dilations due to an impairment to the biliary tree.

“Moderate” functional impairment according to specific
evaluation criteria;

or Sufficient functional discomfort to affect nutritional
status. The impairment is confirmed 4 by clinical and
SEVERITY 4 laboratory testing and associated with permanent weight loss
25% of 15 to 20% in comparison with prior weight or, according
to circumstances, with the recommended weight for the age,
sex, and body type;

or Medical necessity to install an endoprosthesis with regular
changes due to an impairment of the biliary tree.

“Severe” functional impairment according to specific
evaluation criteria;

or Sufficient functional discomfort to affect nutritional
SEVERITY 5 status. The impairment is confirmed by clinical and
40% laboratory testing and is associated with permanent weight
loss of 25% or more in comparison with prior weight or,
according to circumstances, with the recommended weight
for the age, sex, and body type;

or Medical necessity for long-term percutaneous drainage.

(20) CARDIO-RESPIRATORY FUNCTION

The cardiac and respiratory functions act together to oxygenate the blood and eliminate carbon dioxide so that people can produce energy and keep their bodies functioning.

The cardiac and respiratory functions are grouped under one functional unit.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Impacts on cardio-respiratory function resulting from quadriplegia must not be evaluated using the rules provided in this chapter but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(3) Impacts on other functional units resulting from an impairment of the cardio-respiratory function must not be evaluated using the rules provided in this chapter but using the rules provided in the functional units that specifically deal with the observed impacts.

(4) Endurance is the specific preferred criterion for overall evaluation of the cardio-respiratory function. Evaluations must be performed under optimal conditions, i.e., with maximum therapy. Depending on the circumstances, the impairment must be confirmed using one or more of the following tests:

(1) Evaluation of the cardiac function

· Electrocardiogram with Holter if necessary

· Stress test

· Echocardiogram

· Any other specific examination appropriate to the circumstances

(2) Evaluation of the respiratory function

The table below specifies the relative degree of the terms used in the descriptions of the categories of severity describing the impairments of the respiratory function as “moderate” “significant” or “severe.” Depending on the circumstances, the evaluation of the functional impairment may be documented by any other appropriate specific examination.

The VO2MAX measurement is the predominant criterion for evaluating the extent of functional loss. When the actual loss is clinically greater, the evaluation may be documented using the other parameters indicated in the table as well as any other specific examination such as radiological examinations or measurements of other pulmonary volumes by plethysmography.

Parameter Normal Moderate Signifiant Severe
Limits Impairment Impairment Impairment

VO2MAX > 25 ml / 20 to 25 ml / 15 to 19 ml / < 15 ml /
(kg x min) (kg x min) (kg x min) (kg x min)

FVC / predicted ≥ 80% 60% to 79% 51% to 59% ≤ 50%

DLC / predicted ≥ 70% 60% to 69% 41% to 59% ≤ 40%

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment are less than
MINIMUM those resulting from the situations described in
THRESHOLD Severity 1.

Slight functional discomfort. However, endurance remains
normal or almost normal.

Respiratory: Difficulty breathing due to partial pulmonary
exeresis, or a parietal, diaphragm, or pleural
impairment.

SEVERITY 1 Note: For a more significant functional impact,
2% the category of severity is determined by
respiratory function tests.

Cardiac: Functional impairment documented by a positive
maximum stress test at over 7 mets;

or Documented arrhythmia satisfactorily
controlled by medication.

Respiratory: Abnormal and permanent dyspnea with significant
physical effort;

SEVERITY 2 or Difficulty breathing clinically manifested by a
5% permanent stridor.

Cardiac: Functional impairment documented by a positive
maximum stress test at 7 mets.

Limited endurance capacity. Unaccustomed physical
activity or significant physical effort causes excessive
fatigue, palpitations, dyspnea, or angina. The person
remains comfortable at rest and while performing normal
daily physical activities.

Respiratory: Abnormal and permanent dyspnea when walking
uphill at a normal pace;

SEVERITY 3 or “Moderate” impairment of the respiratory function
10% documented by respiratory function tests.

Cardiac: Functional impairment documented by a positive
maximum stress test at 6 mets;

or Documented arrhythmia satisfactorily controlled
by a pacemaker;

or Functional impairment documented by an ejection
fraction of 40% to 50%.

Respiratory: Inconveniences related to the presence of a
permanent tracheotomy.

SEVERITY 4 Cardiac: Functional impairment documented by a positive
20% maximum stress test at 5 met;

or Functional impairment documented by an ejection
fraction of 30% to 39%.

Limited endurance capacity. Performing normal daily
physical activities causes excessive fatigue, palpitations,
dyspnea, or angina. The person remains comfortable at rest.

Respiratory: Abnormal and permanent dyspnea requiring
stopping (after approximately 100 m) when
walking at a normal pace on flat ground;
SEVERITY 5
30% or “Significant” impairment of the respiratory
function documented by respiratory function
tests.

Cardiac: Functional impairment documented by a positive
maximum stress test at 4 mets;

or Functional impairment documented by an ejection
fraction of 25% to 29%.

Respiratory: Abnormal and permanent dyspnea that occurs while
performing daily activities that require little
effort such as walking at a slow pace on flat
ground;

or “Severe” impairment of the respiratory function
documented by respiratory function tests.
SEVERITY 6
60%
Cardiac: Functional impairment documented by a positive
maximum stress test at 2 or 3 mets;

or Functional impairment documented by an ejection
fraction of 20% to 24%.

Very limited endurance capacity. All physical activity
causes an increase in clinical signs. The person is
uncomfortable performing the least physical activity and
is uncomfortable even at rest.

Respiratory: Abnormal and permanent dyspnea with the least
SEVERITY 7 effort;
85% or Need for permanent oxygen therapy
(15-18 hours/day).

Cardiac: Functional impairment documented by a positive
maximum stress test at less than 2 mets;

or Functional impairment documented by an ejection
fraction of less than 20%.

SEVERITY 8 Absence of spontaneous respiration and dependence on
100% a respirator.

(21) URINARY FUNCTIONS

The functions of the urinary tract is to eliminate metabolic waste from the body and control the concentrations of the various components of the blood and other body fluids.

Urinary functions are composed of 2 functional units.

(21.1) Renal Function

(21.2) Micturition

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Impacts on urinary functions resulting from paraplegia or quadriplegia must not be evaluated using the rules provided in this chapter but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(3) Impacts on other functional units resulting from complications due to high blood pressure must not be evaluated using the rules provided in this chapter but using the rules provided in the functional units that specifically deal with the observed impacts.

(4) The measurement of creatinine clearance is the main criterion for documenting an impairment to the renal function. Depending on the circumstances, the evaluation of the functional impairment may be documented by any other appropriate specific examination such as renal scanning.

(21.1) RENAL FUNCTION

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

After-effects of the permanent impairment, such as
UNDER THE biochemical or hematological anomalies with no
MINIMUM significant clinical impacts, are less than those resulting
THRESHOLD from the situation described in Severity 1.

Inconveniences related to the need on a regular and
SEVERITY 1 permanent basis to take medication due to high blood
2% pressure, including possible side effects. Blood pressure
is maintained at 160/90 or less with the treatment.

Persistent high blood pressure, minima between 90 and
120, despite taking medication on a regular and permanent
basis;

or Renal function diminished but remaining greater than
SEVERITY 2 75% of normal;
5%
or Occasional exacerbations caused by high urinary tract
infections (2 to 3 per year) despite treatments and medical
follow-up;
or Preventive restrictions due to the relative risk
represented by the shutdown or the loss of a kidney.

Persistent high blood pressure, minima greater than 120,
despite taking medication on a regular and permanent basis;

or Renal function diminished but remaining between 50% and
SEVERITY 3 75% of normal;
15%
or Frequent exacerbations caused by high urinary tract
infections (6 to 12 per year) despite treatments and
medical follow-up (such as with chronic pyelonephritis);

or Need for immunosuppressive treatments, including side
effects, in the case of a kidney transplant.

SEVERITY 4 Renal function diminished with clinical manifestations
30% and a change in general health. Retained renal function
is less than 50% of normal.

Renal function diminished with clinical manifestations and
SEVERITY 5 a change in general health. Retained renal function is
50% less than 25% of normal;

or Need for dialysis on a permanent basis.

Renal function diminished with a severe change in general
SEVERITY 6 health that is sufficient to confine the person to his
90% or her room. The person is entirely or almost entirely
dependent on others for performing most daily activities.

(21.2) MICTURITION

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

After-effects of the permanent impairment, such as slight
UNDER THE increase in frequency or duration of micturition with no
MINIMUM significant clinical impacts, are less than those resulting
THRESHOLD from the situation described in Severity 1.

SEVERITY 1 Recurrent urinary tract infections despite medical
2% treatments and follow-up.

Trouble with micturition severe enough to justify regular
treatments or quarterly urethral dilations;
SEVERITY 2
5% or Urgent micturition or incontinence during coughing or
exertion sufficient to require protection to be worn on a
regular basis but insufficient to require regular use of
diapers.

Trouble with micturition severe enough to justify monthly
urethral dilations, intermittent catheterization, or
percussion micturition;

or Urinary incontinence in the form of significant daily
SEVERITY 3 leaking between micturitions sufficient to require the
10% regular use of diapers;

or Inconveniences related to the need of an artificial
continence sphincter;

or Inconveniences related to the need to implant a sacral
stimulator.

Total urinary incontinence at the least effort or change
in position, and even at rest;

SEVERITY 4 or Inconveniences related to the need to leave a urethral
20% catheter in place;

or Inconveniences related to the need for an external urinary
derivation such as a subpubic cystostomy or an ileal
bladder.

(22) GENITO-SEXUAL FUNCTIONS

The genito-sexual functions are used to accomplish sex acts for pleasure and/or procreation.

Genital sexual activity and procreation are occasionally complementary, but remain distinct in terms of their purpose. An impairment of one of these functions does not necessarily involve an impairment of the other. Termination of pregnancy is also taken into consideration when evaluating non-pecuniary damage, even when the procreation function is not permanently affected.

The genito-sexual functions are composed of 3 functional units.

(22.1) Genital Sexual Activity

(22.2) Procreation (this also refers to the ability to give birth)

(22.3) Termination of Pregnancy

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Impacts on genito-sexual functions resulting from paraplegia or quadriplegia must not be evaluated using the rules provided in this chapter but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(22.1) GENITAL SEXUAL ACTIVITY

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment are less than
MINIMUM those resulting from the situation described in
THRESHOLD Severity 1.

SEVERITY 1 Trouble performing genital sexual activities that may be
1% attenuated by minor palliative measures such as the use
of a lubricant.

Clinical manifestations such as pain in women during
sexual intercourse (dyspareunia) that make genital sexual
activities more difficult;
SEVERITY 2
5% or Erectile dysfunction. Genital sexual activities remain
possible with oral medication or measures such as
intracavernous injections, intraurethral suppositories,
or vacuum pumps.

SEVERITY 3 Need for a genital prosthesis in order to perform genital
10% sexual activities.

SEVERITY 4 Genital sexual activities are impossible despite all
25% treatment measures.

(22.2) PROCREATION

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

UNDER THE After-effects of the permanent impairment are less than
MINIMUM those resulting from the situation described in
THRESHOLD Severity 1.

Inconveniences related to the relative risk represented
by the loss of a testicle or an ovary.
SEVERITY 1
2% Note: financial assistance is only awarded if procreation
was possible at the time of the criminal offence.

Ovulation difficult but possible with a specific medication
such as a fertility drug;

or Woman’s procreation function affected, but fertilization is
still possible with a specialized medical procedure such as
artificial insemination or in vitro fertilization;

SEVERITY 2 or Man’s procreation function affected (e.g., retrograde
5% ejaculation) but fertilization is still possible with
a specialized medical procedure;

or Inconveniences related to the need for a cesarean section
to give birth.

Note: This situation can only be accepted once, i.e.,
following the first birth.

SEVERITY 3 Procreation is impossible despite all treatment measures.
25%

(22.3) TERMINATION OF PREGNANCY

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

SEVERITY 1 Loss of one embryo or fetus.
8%

SEVERITY 2 Loss of more than one embryo or fetus.
12%

(23) ENDOCRINE, HEMATOLOGICAL, IMMUNE, AND METABOLIC FUNCTIONS

The endocrine, hematological, immune, and metabolic functions play a role that has an impact on the functioning of the entire body.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

After-effects of the permanent impairment, such as biochemical
UNDER THE or hematological anomalies with no significant clinical impact,
MINIMUM are less than those resulting from the situations described in
THRESHOLD Severity 1.

Regular and permanent need

for medication, which may cause side effects;

SEVERITY 1
2% or

to take preventive measures and action due to a risk of
transmission of a viral infection or a risk of infection
such as following splenectomy.

Slight impairment to general health with frequent
exacerbations, fatigability, and a slight reduction
of endurance;

SEVERITY 2 or The regular and permanent need to receive one or
5% several injections once or twice a day;

or The regular and permanent need to follow a restrictive
diet combined with medical treatments.

Moderate impairment to general health with asthenia. The
problem limits the ability to perform unaccustomed
physical activities or physical activities requiring
significant effort such as running or rapidly climbing
SEVERITY 3 a number of stairs. However, the person remains able to
15% perform relatively demanding activities such as walking
long distances or climbing 2 floors at a normal pace;

or Regular and permanent need to receive one or several
injections more than twice a day.

Significant impairment to general health with asthenia. The
problem limits the ability to perform many normal daily
SEVERITY 4 activities but the person remains able to perform moderate
30% activities such as walking at a normal pace or doing
regular household chores, with the exception of heavy work.

Severe impairment to general health with asthenia. Endurance
SEVERITY 5 is limited to light activities such as certain essential
60% daily activities like getting dressed, managing self care,
and moving around the home.

Very severe impairment to general health with asthenia. The
SEVERITY 6 person is totally or almost totally dependent on another
90% person to perform most daily activities and is practically
confined to his or her room.

(24) CLINICAL PICTURES OF PARAPLEGIA AND QUADRIPLEGIA

Paraplegia or quadriplegia resulting from a spinal cord injury has an impact on a number of bodily functions as well as a severe esthetic impact.

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) This chapter deals exclusively with the conditions of paraplegia or quadriplegia (neurological levels C1 to L5). All the impacts on any other functional unit resulting from paraplegia or quadriplegia are included in the categories of severity of this unit.

(3) Esthetic impairment that results from changes to form and contours (e.g., atrophy, contractures) or from the use of technical devices or aids (e.g., orthesis, urethral catheter, wheelchair) are included in the categories of severity of this unit.

(4) The preferred criterion for evaluating the impacts of paraplegia or quadriplegia on the performance of activities of daily living is residual functional potential. Motor level and functional potential are evaluated based on the criteria of the American Spinal Injury Association (ASIA) in “International Standards for Neurological and Functional Classification of Spinal Cord Injury, revised 1996.”

(5) For other medullary or radicular impairments, the impacts must be evaluated using the rules provided in the functional or esthetic units that specifically deal with the observed impacts, for example

— Medullary impairment at a neurological level under L5,

— Brown-Séquard syndrome, central medullary syndrome, anterior medullary syndrome,

— Cerebral impairment (hemiplegia),

— Peripheral nervous system impairment (compression of nerve roots, lumbar plexus impairment)

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental
suffering, pain, and other consequences - resulting from a permanent
impairment can be compared with those that would result from the situation
with maximum impact among the following:

SEVERITY 1 Functional potential is equivalent to a motor level between
75% D8 and L5.

SEVERITY 2 Functional potential is equivalent to a motor level between
80% D2 and D7.

SEVERITY 3 Functional potential is equivalent to a motor level of
85% C8 or D1.

SEVERITY 4 Functional potential is equivalent to a motor level
90% of C7.

SEVERITY 5 Functional potential is equivalent to a motor level
95% of C6.

SEVERITY 6 Functional potential is equivalent to a motor level
100% between C1 and C5.

(25) ESTHETIC

Esthetic prejudice results from a deterioration in general appearance due to an impairment to the skin or to the form or contours of the body.

Esthetic is composed of 8 units:

(25.1) Esthetic of the Skull and Scalp

(25.2) Esthetic of the Face

(25.3) Esthetic of the Neck

(25.4) Esthetic of the Trunk and Genital Organs

(25.5) Esthetic of the Right Upper Limb

(25.6) Esthetic of the Left Upper Limb

(25.7) Esthetic of the Right Lower Limb

(25.8) Esthetic of the Left Lower Limb

EVALUATION RULES

(1) See the provisions of Chapter III of the Regulation.

(2) Esthetic prejudice that becomes apparent when performing a function (such as limping, salivary incontinence), or that results from the use of technical devices or aids (such as orthosis, prosthesis) must not be evaluated using the rules provided in this chapter. This dynamic component is already taken into consideration in the percentages awarded for the categories of severity in each of the functional units that specifically deal with the observed impacts.

(3) In paraplegia or quadriplegia, esthetic prejudice resulting from changes to form and contours (such as atrophy, contractures) or from the use of technical devices or aids (such as orthosis, urethral catheter, wheelchair) must not be evaluated using the rules provided in this chapter. This component is already taken into consideration in the percentages awarded in the categories of severity of the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(4) Permanent esthetic impairment must not only be visible, it must be apparent, that is, it must be clearly visible at 50 cm. Any “apparent” impairment is taken into consideration despite the fact that it is normally hidden by clothing or hair.

(5) The following 4 categories of impairment are the retained criteria for the evaluation:

▸▸ Change in skin colour: hypopigmentation or hyperpigmentation due to damage to the superficial dermis. The deep dermis is not damaged. Suppleness, elasticity, hydration, and pilosity are retained.

▸▸ Flat scars: linear or almost linear, well oriented in the same direction as natural skin creases, at the same level as the adjoining tissue and almost the same colour. They do not cause contractures or distortion of neighboring structures.

▸▸ Faulty scars: linear or plaques, misaligned or cross over a natural skin crease. They may be irregular, depressed, deeply adhering, retractile, keloidal, hypertrophic, or pigmented.

▸▸ Change in shape and contours: disfigurement, tissue loss, atrophy, or amputation.

(6) The anatomical boundaries retained to separate contiguous parts of the body are the following:

▸▸ Skull and Scalp:

Region inside the normal, usual hairline. In the presence of baldness, the anatomical boundary corresponds to what would have been the normal hairline.

▸▸ Face:

Region defined by the anatomical boundaries of the skull and neck.

Fifteen (15) anatomical elements are used for the purposes of evaluating form and contours:

· Right half of forehead

· Left half of forehead

· Right orbit/eyelid

· Left orbit/eyelid

· Nose

· Right eye (visible part of the ocular globe)

· Left eye (visible part of the ocular globe)

· Right cheek

· Left cheek

· Mouth (visible part when open)

· Upper lip

· Lower lip

· Chin

· Right ear

· Left ear

▸▸ Neck:

Upper boundary: line following the lower part of the body of the mandible, continuing along the vertical rami to the temporomandibular joints and then along the normal usual hairline.

Lower boundary: line beginning at the jugular notch, continuing along the upper edge of the clavicle to the mid-point and then to the C7 spinous process.

▸▸ Trunk and Genital Organs:

Region defined by the anatomical boundaries of the neck , the upper limbs and the lower limbs

▸▸ Upper Limb (upper boundary):

Circular line beginning at the apex of the armpit, extending backwards and forwards, and ending at the mid-point of the clavicle.

▸▸ Lower Limb (upper boundary):

(7) For each esthetic unit, the category of severity is determined by the result of the overall weighted evaluation. The evaluation is conducted in 4 steps:

Step 1: Describe all esthetic impairments found during the clinical evaluation.

Step 2: For each category of impairment (permanent changes to skin colour, flat scars, faulty scars, and changes to form and contours), determine the description corresponding to the result of the clinical evaluation. Only one score may be assigned per category of impairment.

Step 3: Add the scores.

Step 4: Determine the category of severity based on the appropriate correlation table.

(25.1) ESTHETIC OF THE SKULL AND SCALP

(25.2) ESTHETIC OF THE FACE

(25.3) ESTHETIC OF THE NECK

(25.4) ESTHETIC OF THE TRUNK AND GENITAL ORGANS

(25.5) ESTHETIC OF THE RIGHT UPPER LIMB

(25.6) ESTHETIC OF THE LEFT UPPER LIMB

(25.7) ESTHETIC OF THE RIGHT LOWER LIMB

(25.8) ESTHETIC OF THE LEFT LOWER LIMB

CATEGORIES OF SEVERITY

Under the Minimum Threshold

After-effects of the permanent impairment, such as a scar that is barely visible and not apparent at 50 cm, are less than those resulting from the situation described in Severity 1.

___________________________________________________________________________________

CATEGORIES OF SEVERITY ACCORDING TO THE RESULT OF THE OVERALL WEIGHTED EVALUATION
___________________________________________________________________________________
| | | | | | |
|Under the| 0,5 to 1 | 1,5 to 5 | 6 to 19 | 20 to 39 | 40 to 79 | 80 and
| Minimum | | | | | | over
|Threshold| | | | | |
| N/A |SEVERITY 1|SEVERITY 2|SEVERITY 3|SEVERITY 4|SEVERITY 5|SEVERITY 6
________|_________|__________|__________|__________|__________|__________|__________
| | | | | | |
25.1. | | | | | | |
Skull | | | | | | |
and | | | | | | |
Scalp | N/A | 0.5% | 1% | 3% | 5% | 8%
________|_________|__________|__________|__________|__________|_____________________
| | | | | | |
25.2. | | | | | | |
Face | N/A | 1% | 3% | 7% | 15% | 30% | 50%
________|_________|__________|__________|__________|__________|_____________________
| | | | | | |
25.3. | | | | | | |
Neck | N/A | 0.5% | 1% | 3% | 5% | 8%
________|_________|__________|__________|__________|__________|_____________________
| | | | | | |
25.4. | | | | | | |
Trunk | | | | | | |
and | | | | | | |
Genital | | | | | | |
Organs | N/A | 0.5% | 1% | 3% | 6% | 9% | 12%
________|_________|__________|__________|__________|__________|_____________________
| | | | | | |
25.5. | | | | | | |
Right | | | | | | |
Upper | | | | | | |
Limb | N/A | 0.5% | 1% | 3% | 6% | 9% | 12%
________|_________|__________|__________|__________|__________|__________|__________
| | | | | | |
25.6. | | | | | | |
Left | | | | | | |
Upper | | | | | | |
Limb | N/A | 0.5% | 1% | 3% | 6% | 9% | 12%
________|_________|__________|__________|__________|__________|__________|__________
| | | | | | |
25.7. | | | | | | |
Right | | | | | | |
Lower | | | | | | |
Limb | N/A | 0.5% | 1% | 3% | 6% | 9% | 12%
________|_________|__________|__________|__________|__________|__________|__________
| | | | | | |
25.8. | | | | | | |
Left | | | | | | |
Lower | | | | | | |
Limb | N/A | 0.5% | 1% | 3% | 6% | 9% | 12%
________|_________|__________|__________|__________|__________|__________|__________

(*) Not applicable

1266-2021O.C. 1266-2021, Sch. I.

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