APPENDICES TO PART ONE

SCALE FOR ASSESSING THE DEGREE OF DISABILITY OF VICTIMS OF MEDICAL ACCIDENTS, IATROGENIC CONDITIONS OR NOSOCOMIAL INFECTIONS REFERRED TO IN ARTICLE D. 1142-2

I. - NEUROLOGY

Neurological deficits should only be assessed after a sufficiently long period of time (generally around 2 to 3 years and after a longer period in children) in order to assess their permanence and adaptations to disabilities.

It is desirable that the interval between the initial trauma and the final assessment be used to carry out regular reliable medical check-ups.

I. - Sensory-motor deficits of medullary and central origin

A. - Of spinal cord origin

Tetraplegia and paraplegia are always complex clinical entities combining impairment of locomotion (and prehension in the case of tetraplegia), urinary function, genito-sexual function, respiratory function (in the case of the highest lesions) and spinal disorders. These different deficits cannot be dissociated in order to assess the rate of disability by adding them together. In this spirit, the rates proposed below correspond to an overall assessment of the consequences of the injury. However, this overall assessment method should not exempt the expert from describing in detail the nature and importance of the various deficits making up these clinical entities, especially as they depend on the level of injury.

B. - Hemispheric, truncal or cerebellar origin

C. - Cerebrospinal fluid circulation disorders

Rates must be assessed according to the deficits observed, which are essentially cognitive.

The presence of derivation equipment alone does not justify a rate of disability.

II. - Cognitive deficits

Analysis of neuropsychological deficit syndromes must refer to a precise semiology. The so-called "frontal" syndrome in fact corresponds to entities that are now well defined, with associated deficits of varying degrees of severity, resulting in highly polymorphous clinical pictures.

Assessment of the degree of disability must therefore be based on precise and specialised medical assessments, correlating the initial lesions and the data from clinical and paraclinical examinations.

A. - True frontal syndrome

B. - Isolated impairment of certain cognitive functions

C. - Minor cognitive disorders

In the absence of a true frontal syndrome or isolated impairment of a cognitive function, certain cranial traumas, more or less serious, may leave a syndrome combining: lability of attention, slowness of ideation, difficulty in memorising, intellectual fatigue, intolerance to noise, mood instability, persisting beyond 2 years: 5 to 15%.

D. - Dementia

Dementia states are very heterogeneous due to their clinical polymorphism and varied aetiologies.

True post-traumatic dementia is rare and must be documented by major bilateral anatomical lesions. Alzheimer's-type dementia is never post-traumatic. However, a proven and severe traumatic event can accelerate the progression of this degenerative process, an acceleration that cannot be translated into a rate of partial permanent disability. The expert will therefore have to compare the modified evolution with the usual evolution of the condition and try to quantify this difference in time.

III. - Mixed cognitive and sensory-motor deficits

These mixed deficits are the characteristic sequelae of severe cranial trauma. They are most often associated with frontal dysfunction, cognitive deficits, behavioural disorders, pyramidal and/or cerebellar syndromes, sensory disorders (hemianopsia, oculomotor paralysis, etc.) corresponding to lesions visualised by imaging.

These combinations produce clinical pictures that differ from one subject to another, such that no precise rate can be proposed as for perfectly individualised sequelae. These deficits will be the subject of an overall assessment.

However, in the context of medico-legal assessment, it is possible to recognise several levels of severity depending on the overall deficit.

IV. - Sensory-motor deficits of peripheral origin

A. - Face

B. - Upper limbs

In the case of an incomplete form, the rates proposed above should be corroborated with those proposed for deficits in prehension function.

C. - Lower limbs

In the case of an incomplete form, the rates proposed above should be corroborated with those proposed for deficits in locomotor function.

D. - Deafferentation pain

Whether they are isolated or accompany a sensory-motor deficit, they should be taken into account :

E. - Cauda equina syndrome

Depending on the extent of the sensory motor and genital-sphincter disorders: 15 to 50%.

V. - Neuro-sensory deficits

Please refer to the relevant specialities, in particular ophthalmology and otorhinolaryngology.

VI. - Epilepsy

A disability rate cannot be proposed without proof of the reality of the cranioencephalic trauma and the reality of the seizures. In these cases, several years' follow-up (4 years minimum) is essential, in order to take into account the spontaneous evolution of the disorders and the adaptation to treatment.

Isolated EEG abnormalities, in the absence of proven seizures, do not lead to a diagnosis of post-traumatic epilepsy.

A. - Epilepsies with impaired consciousness

(Generalised epilepsies and complex partial epilepsies)

B. - Epilepsies without disorders of consciousness

Simple partial epilepsies duly authenticated according to the type and frequency of seizures and according to the side effects of treatment: 10 to 30%.

VII. - Special cases

Post-concussive" syndrome persisting beyond 18 months: up to 3%.

II. - PSYCHIATRY

The diagnosis of psychiatric sequelae requires examination by a confirmed specialist. This examination must include not only a precise semiological analysis of the symptoms presented by the injured person, but also a careful longitudinal study of his biography. In all cases, it is essential to discuss the respective roles of any previous condition, the personality, the trauma and any other pathogenic factors.

I. - Traumatic neuroses

(Post-traumatic stress disorder, fear neurosis) (F43.1 of ICD X (1)).

These follow psychic manifestations provoked by the sudden, unpredictable and sudden intrusion of a traumatic event which overwhelms the individual's defence capacities.

The stress factor must be intense and/or prolonged.

The event must have been memorised.

Symptoms include phobic-type anxiety disorders, avoidance behaviours, a repetition syndrome and personality disorders. Treated very early, traumatic neurosis recovers and returns to its previous state without leaving sequelae constituting a permanent disability. Traumatic neurosis can only be assessed after approximately 2 years.

The determination of permanent disability may be based on the following proposals:

II. - Persistent mood disorders

In cases of multiple orthopaedic and somatic injuries whose evolution is long and complicated (extensive burns with prolonged care, orthopaedic injuries with repeated surgery, osteitis, etc.), a permanent painful psychological state may persist, corresponding to a :

A resistant depressive state that may justify a permanent disability rate of up to 20%.

A transient depressive reaction in the aftermath of a psychological and/or somatic trauma does not constitute a permanent disability and may be assessed on the basis of the suffering endured.

III. - Acute or chronic psychotic disorders

Psychotic disorders are never caused by trauma.

Certain after-effects of cerebral lesions or hydrocephalus at normal pressure may result in deficits or psychotic-like syndromes which are treated as neurological after-effects.

In the immediate aftermath of a traumatic event, when a major depressive state or manic episode occurs in a patient with bipolar mood disorder, it is legitimate to treat the episode, but not the progression of the pathology.

Certain temporal lesions in the minor hemisphere may produce pseudo-manic disorders which are treated as neurological sequelae.

IV. - Specific aspects

A. - Conversion and somatoform disorders

In view of the difficulty in understanding conversion disorders without referring to non-consensual aetiopathogenic theories, it is advisable, for this type of symptom, to refer to the ICD X (F44) which distinguishes: amnesia, fugue, stupor, trance and possession, motor disorders, sensitivity disorders (persistent somatoform pain syndrome, F 45. 4), disorders of the sense organs.

Before assessing them as sequelae, it is important to know that such disorders :

- they do not correspond to the systemic loss of the affected function ;

- that their psychogenesis is accepted insofar as they may occur in close temporal relationship with traumatic events;

- that the loss of function helps the victim to avoid an unpleasant conflict or to express dependence or resentment indirectly;

- they are associated with characteristic features:

- there is sometimes a "beautiful indifference", i.e. a surprising attitude of quiet acceptance of a serious disability ;

- their basic personality is usually histrionic and dependent;

- their evolution is unpredictable (they could be induced or lifted by hypnosis):

- they usually improve in a few weeks or months, particularly when the onset is associated with a traumatic event;

- the course may be more protracted (with a more gradual onset) when they involve paralysis or anaesthesia, or when their onset is associated with intractable interpersonal problems or difficulties ;

- that conversion disorders which have already been evolving for more than one or two years prior to psychiatric consultation are often resistant to any treatment.

Taking all these factors into account, and looking back over a period of two to three years, it is possible in some cases to propose a rate of permanent disability which cannot be based on any particular range, given the diversity of clinical expressions.

This assessment can never reach the same rate as that which would be given for a similar clinical picture reflecting an irreversible organic lesion.

B. - Factitious disorders (F68.1 of ICD X)

Intentional production of symptoms in order to play the role of the patient (pathomimicry). Such disorders are never attributable to a traumatic event.

C. - Simulation

Intentional production of symptoms in order to obtain advantages or avoid obligations. Such disorders are never attributable to a traumatic event.

III. - OPHTHALMOLOGY

I. - Visual acuity

The examination will include a separate eye-by-eye determination of central distance and near acuity using the usual optotypes: Monoyer scale or its equivalents for distance vision, at 5 metres; Parinaud scale at normal reading distance for near vision. If there is a discrepancy between the alleged functional signs and the findings of the clinical examination, visual acuity measurements should be supplemented by control tests and, where appropriate, by the study of visual evoked potentials (VEPs).

A refractive disorder that can be fully corrected by optical means will not be considered as an ocular impairment giving rise to disability.

The disability rates are given in table I :

Table I. - Distance vision

It is accepted that any vision greater than 7/10 corresponds to normal visual efficiency and therefore does not lead to disability.

It is necessary to specify the alterations in visual acuity concerning distance vision on the one hand and near vision on the other.

This is why Table I, which assesses visual disability at a distance, must be supplemented by Table II, which assesses visual disability at close range (quantified at a normal reading distance - after any correction for presbyopia - using the Parinaud scale test).

Table II should only be used in rare cases where there is a significant dissociation between distance and near visual disability. In these cases, the arithmetic mean of the two disabilities should be taken to obtain a rate that corresponds to a more accurate determination of disability.

Table II. - Near vision

A. - Blindness and severe visual impairment

Absolute blindness or total blindness (cannot distinguish between day and night): 85%.

The rate of disability in the case of severe visual impairment results from the reduction in visual acuity (table I) and the impairment of the visual field (diagram 1).

B. - Loss of vision in one eye

Functional loss in one eye (if vision in the other eye is normal): 25%.

In the event of enucleation with the fitting of an ocular prosthesis, the rate of permanent disability remains the same because the purpose of wearing the prosthesis is not to improve function but to improve aesthetics (the mobility and quality of the fitting are assessed as part of the aesthetic loss).

II. - Visual field

The examination will be carried out using the Goldmann dome or equivalent. Only those manifestations that are apparent on the III/4 test will be considered as having a real functional impact and therefore as constituting incapacity. The visual field must be studied binocularly, with both eyes open. Superimposing the tracing on diagram 1 gives the level of disability.

If the central visual field is affected, the examination may be completed by an Amsler test or equivalent, and the disability assessed as mentioned for central and paracentral scotomas.

Diagram 1 shows the level of disability:

Diagram 1: approach to visual field assessment (the broken line represents the limit of the normal binocular visual field for isopter III/4). Each point corresponds to an unperceived gap and 1% PPI. The points are added together. The rectangle in the margin corresponds to the central field.

A. - Hemianopsia

Homonymous lateral hemianopia results in significant disability, much greater than the loss of vision in one eye: the subject actually loses half of his visual field, which is not the case for the one-eyed person. When studied in binocular vision, depending on the value of macular sparing, it justifies rates of 42% or more in the event of an associated drop in visual acuity (whereas monocular blindness does not exceed 25%).

Complete homonymous lateral hemianopia :

- with macular sparing: 42% ;

- with loss of central vision: if macular sparing is partial, calculate the central acuity deficit using table I, then relate it to the remaining post-hemianopic visual capacity (85 - 42 = 43%), and add it to the 42% rate.

Incomplete homonymous lateral hemianopia :

- to be assessed according to diagram 1 ;

- take into account partial macular sparing as above.

Altitudinal hemianopia :

- superior: up to 25% (diagram 1) ;

- inferior: up to 60% (diagram 1).

Double complete lateral or bitemporal hemianopia (depending on pattern 1 and central vision): up to 85%.

Neglect-type hemianopsias have a normal visual field at the perimeter. The reality of the visual neglect and the estimation of its functional consequences will be assessed with the neurologist.

B. - Quadranopsia

Superior: up to 12% (diagram 1).

Lower: up to 30% (diagram 1).

C. - Concentric strictures

In traumatology, they are often due to anorganic manifestations and therefore do not justify PPI.

It is necessary to use multiple control tests, and to compare the clinical picture with the imaging and neurological examination.

However, bilateral organic campimetric narrowing resulting from double hemianopsia should not be overlooked.

D. - Central and paracentral Scotomas

In the case of loss of central vision: use tables I and II (visual acuity).

Paracentral and juxtacentral scotomas with preserved visual acuity (to be assessed on the basis of their extent, determined using the Amsler grid for binocular vision, and their impact on near reading):

- if they affect only one eye: up to 5% ;

- if they affect both eyes: 2 to 10%.

Lateral hemianopic scotomas, which are homonymous with occipital lesions, severely impair reading because they are located in the same place in each eye: 15%.

III. - Oculomotricity disorders

A. - Heterophoria

Disability will only be assessed after orthoptic rehabilitation.

Non-reducible decompensation of heterophoria, depending on discomfort: up to 5%.

Complete paralysis of convergence: 5%.

B. - Diplopia

In the case of oculomotor paralysis, the evaluation of the oculomotor deficit should not give rise to a definitive assessment before eighteen months.

In cases of orbital origin, the oculomotor deficit should not be definitively assessed before six months after the end of any surgical treatment.

Disability due to diplopia depends on the sector concerned, the eccentricity of the field of diplopia in relation to the primary position of gaze and the functional result obtained with any prismatic correction, according to the following diagram:

(Diagram not reproduced)

The study of the fields of diplopia and aplopia must be carried out without any dissociation manoeuvre; for example, by asking the subject to stare at an object and noting the double field of vision.

The rate will be reduced if the diplopia is reduced by constant neutralisation of the deviated eye or if prismatic correction is possible.

C. - Paralysis of gaze function

D. - Intrinsic motor deficiencies

E. - Impairment of saccades and pursuits

These do not produce any real functional visual signs but rather sensations of imbalance and should be assessed by the ear, nose and throat specialist.

IV. - Lens lesions

The aphakic eye, i.e. deprived of its crystalline lens, can only regain usable vision after compensation by optical equipment. The degree of disability varies greatly depending on whether this compensation is achieved by glasses, contact lenses or implantation of an artificial lens.

The assessment of the degree of disability will therefore take into account the type of optical equipment used, whether the vision is uni or bilateral, age and any loss of visual acuity.

Optical compensation provided by an artificial crystalline lens (pseudo-phakia): 5%.

In children up to the age of 16, the rate will be increased to 7% to take account of the impact of the loss of accommodation on binocular vision.

To this basic rate resulting solely from the disadvantages of pseudophakia, it may be necessary to add that resulting from the loss of visual acuity and other associated sequelae (lacrimation, photophobia, etc.).

If the optical equipment is glasses or contact lenses (aphakia):

To this rate should be added that resulting from the possible loss of visual acuity and other associated sequelae, without however being able to exceed 25% for a unilateral lesion.

V. - Appendages of the eye

VI. - Multiple visual sequelae

The association of sensory or oculomotor sequelae is not uncommon. Assessment of the overall rate of functional impairment cannot be based on simple arithmetic addition: after assessment of the rate of disability resulting from the most significant deficit, the rate of the second disability will be calculated by reference to the remaining visual capacity (it being understood that the loss of all visual capacity is 85%).