3.6.3.30 Guidelines to Table 3 - Lower Limb Function

Summary

Table 3 is used to assess the functional impact of a condition when performing activities requiring the use of lower limbs.

Table 3 specifies that the lower limbs extend from the hips to the toes.

The descriptors in Table 3 refer to a range of activities relevant to a person's ability to move around, including walking, kneeling, squatting, standing, standing up from a seated position, using stairs, using public transport or using a motor vehicle, and (where applicable) their ability to mobilise with the use of wheelchairs or walking aids.

The descriptors in other Tables may also refer to activities relating to a person's mobility but those Tables measure the impact of impairment on other areas of function, not related to lower limbs. For example, some descriptors in Table 1 - Functions requiring Physical Exertion and Stamina, measure the level of difficulty in walking, climbing stairs or mobilising in a wheelchair due to symptoms arising from conditions affecting physical exertion or stamina. Table 4 - Spinal Function, is used to assess activities involving spinal function, that is, bending or turning the back, trunk or neck. Table 3 is used to assess the level of difficulty in performing mobility-related activities arising from conditions affecting the use of lower limbs.

Conditions causing impairment commonly assessed using Table 3

These include but are not limited to:

• lower limb musculoskeletal conditions including degenerative joint disease (osteoarthritis)
• other forms of arthritis
• neurological conditions including peripheral neuropathy and strokes or cerebrovascular accidents (CVAs) causing paralysis or loss of strength or sensation
• cerebral palsy or other condition affecting lower limb coordination
• inflammation or injury of the muscles or tendons of the lower limbs, for example, chronic Achilles tendonitis
• lower limb amputations or absence of whole or part of lower limb
• long-term effects of musculoskeletal injuries
• chronic pain affecting lower limbs
• lymphoedema
• some permanent vascular conditions (for example, chronic venous stasis due to post- deep vein thrombosis (DVT) syndrome or, varicose veins).

Diagnosis & evidence under Table 3

The diagnosis of the condition causing the impairment must be made by an appropriately qualified medical practitioner and supported by corroborating medical evidence. This includes a GP, an orthopaedic surgeon, or other medical specialist such as a rheumatologist or rehabilitation physician.

A PERSON'S SELF-REPORTED SYMPTOMS MUST NOT BE SOLELY RELIED UPON in determining functional impacts of the person's condition (impairment). There must be corroborating medical evidence of the person's impairment.

Examples of corroborating evidence for the purposes of Table 3 include, but are not limited to:

• a report from the person’s treating doctor
• a report from a medical specialist confirming diagnosis of conditions associated with lower limb impairment (such as, arthritis or other condition affecting lower limb joints, paralysis or loss of strength or sensation resulting from stroke or other brain or nerve injury, cerebral palsy or other condition affecting lower limb coordination, inflammation or injury of the muscles or tendons of the lower limbs, chronic pain affecting the lower limbs, amputation or absence of whole or part of lower limb, lymphoedema, or peripheral neuropathy)
• a report from an allied health practitioner (such as physiotherapist, occupational therapist or exercise physiologist) confirming the functional impairment
• results of diagnostic tests (such as X-Rays or other imagery)
• results of physical tests or assessments showing impaired function of the lower limbs.

If the person has and usually uses a lower limb assistive device, the assessment under Table 3 must be undertaken considering what the person can do or has difficulty doing while using this assistive device.

Interpretation & application of relevant terms

Where the descriptors in Table 3 refer to moving around in or using a wheelchair and to transferring to and from a wheelchair, this includes both manually-propelled wheelchairs and powered mobility aids (such as power assist wheelchair, power wheelchair or mobility scooter).

'Public transport' means any mode of transport that runs to a timetable such as buses, trains, trams and ferries. It excludes community transport, taxis, rideshare or hire cars. A person who is able to use any one of these modes of transport, having regard only to the level of impairment to their lower limbs, is considered to be able to use public transport, even if they are precluded from using other modes of public transport. When assessing a person's ability to use public transport it is irrelevant whether the person actually uses public transport, whether public transport is available to the person and whether the person actually receives assistance.

‘Local’ facilities refer to those which are restricted to a particular area or neighbourhood (for example, a corner shop, a shopping centre or supermarket, workplace or education or training campus). Of relevance is the short distance a person would need to travel to such a location.

Similarly, where Table 3 refers to activities such as walking (or mobilising in a wheelchair) to local facilities (it is irrelevant whether such establishments, businesses, buildings or structures actually exist in a person's locality or how they may be labelled. Of relevance is the description of activity involved and impact on the person’s functional impairment.

The 10 and 20-point descriptors in Table 3 use the term 'assistance'. Assistance is defined in the instrument as assistance from another person, rather than any aids, equipment or assistive technology the person may use, unless specified otherwise (3.6.3.05).

When referring to standing from a seated position at the 20-point descriptor, a ‘seat’ is taken to be a standard chair. This is further clarified through the use of an example stating a person has severe difficulty standing after being seated in a dining chair without assistance.

Determining the level of functional impact - rules

When establishing whether a person’s impairment causes no or minimal (0 points), mild (5 points), moderate (10 points), severe (20 points) or extreme (30 points) functional impact, each descriptor and all its paragraphs for an impairment rating level in the Table must be read as a whole.

The structure of the Tables requires that, in assessing the level of functional impact, a comparison must be made of all the descriptors for each level of impairment. This does not necessarily mean all descriptors must be met, but all must be considered to determine which descriptors apply to the person’s impairment.

While every descriptor requires consideration, in order to compare and contrast the descriptors to determine which impairment rating best reflects the level of functional impact resulting from a person’s condition. Each Table provides specific instructions on the number of descriptors to be met in order to assign a particular impairment rating. Determination of a person's impairment level must be based on the corroborating evidence provided by the person, including the person's medical history, investigation results and clinical findings.

The descriptors in each Table follow an incremental hierarchy, which is expressed among other things, by the use of terms indicating increasing levels of difficulty in performing certain activities. These levels are expressed as: no or minimal difficulty, mild difficulty, moderate difficulty, severe difficulty and extreme difficulty. Some Tables also represent an increase in frequency of symptoms, which is reflective of the impairment rating level.

The hierarchy of descriptors in Table 3 also takes into account other factors. These include a person's ability to perform certain activities unassisted or unaided and/or when using devices, equipment or aids such as a lower limb prosthesis, a walking stick, other walking aids (for example, a quad stick, crutches, a walking frame) or a wheelchair.

When determining a person's limitations in relation to conducting 'work tasks', consideration must be given to a person's ability to undertake the task, regardless of whether or not it is part of work they do or have done previously. 'Work' is taken to refer to any work that exists in Australia, even if not within the person’s locally accessible labour market.

An assessment starts by considering descriptors for 0 points and, if a person has more than 'no or minimal functional impact', the descriptors for 5 points are then considered, and so on for the descriptors for higher impairment levels. When it is determined that the person meets all the required descriptors for a certain impairment rating level, but does not meet all the required descriptors for the next impairment rating level, the appropriate impairment rating applicable to the person's circumstances will be the rating at which all the required descriptors are met.

Note 1: Individual descriptors or their parts must not be applied in isolation from one another.

In determining whether the required descriptors for a specific impairment level are met or not, ALL the descriptors for that level must be considered and applied as set out in the descriptor.

In some cases, all descriptors must be met for an impairment rating to be assigned. For example, for a person to be assigned 20 points under Table 3, the person must have severe difficulty performing all activities set out at (1)(a)(i), (ii) and (iii) without assistance, as well as meet descriptor (1)(b).

In some cases a single descriptor from paragraph (1) as well as paragraph (2) are required for an impairment rating to be assigned (for example, for a person to be assigned 10 points under Table 3, the person must meet either (1)(a), (b), (c) or (d) as well as meet paragraph (2)). NO descriptors or their parts are to be disregarded.

Note 2: The descriptors must be applied sequentially to allocate an impairment rating - the incremental hierarchy of descriptors MUST NOT be ignored. As mentioned above, the assessment process involves applying the 0-point descriptors first and continuing to apply the descriptors for higher impairment levels, until all the required descriptors for a certain impairment rating level are met.

Note 3: If the person's impairment does not meet the required descriptors for a certain impairment level, the person's impairment cannot be rated at that or any higher level.

Determination of the descriptor that best fits the person's impairment level must be based on the available medical evidence including the person's medical history, investigation results and clinical findings. A person's self-reported symptoms must not solely be relied on. An impairment rating must not be applied unless the person's self-reported functional impacts are consistent with and supported by the medical evidence available.

In determining the level of functional impact, care should be taken to distinguish between activities that the person does not do as opposed to activities that they have difficulty performing because of their impairment.

An activity listed under a descriptor cannot be taken as being able to be performed if it can only be performed once or rarely - the person needs to be able to usually perform such activity whenever they would normally attempt it or be required to perform it. Where an activity is usually required to be performed repetitively, a person who can only perform such activity once and is then unable to perform the activity again when required will be taken to be unable to perform this activity. Equally, where an activity is normally undertaken infrequently (for example, only once per day or once per week), a person who can perform that activity once per day or once per week, is not unable to perform the activity merely because they are unable to perform the activity repetitively or with greater frequency than would normally be required. For conditions where both lower limbs are affected, a single impairment rating under Table 3 should be determined based on the resulting combined functional impairment.

When assessing episodic or fluctuating impairments and conditions, a rating must be assigned which reflects the overall functional impact of those impairments, taking into account the severity, duration and frequency of the episodes or fluctuations as appropriate (see 3.6.3.08 ‘Assessing impairments caused by episodic or fluctuating medical conditions’).

Assessing impairment for persons using wheelchairs or walking aids

Where a person uses a wheelchair or certain walking aids (a quad stick, crutches or walking frame), the correct impairment rating depends, among other factors, upon the extent to which they are independent or dependent on another person’s assistance to mobilise while using a wheelchair or walking aids, and to transfer to and from a wheelchair. Within each of the 10 and 20-point impairment ratings, the descriptors note that this impairment rating level 'includes' a person who is either independent or who requires assistance to move around in or to transfer to and from a wheelchair (motorised or non-motorised), or to move around using walking aids.

For the purpose of Table 3, the term 'includes' means that a person who uses a wheelchair or certain walking aids may be considered under the criteria for these impairment rating levels and may meet the required descriptor for either 10 or 20 points. This term does not mean that a person who uses a wheelchair or walking aids automatically satisfies the overall requirements for 10 or 20 points solely because of their wheelchair or walking aid use.

The use of wheelchairs or walking aids is not in itself an absolute indicator of the level of severity of a person's impairment when performing activities relating to their ability to move around. Individual circumstances do differ, including reasons for which people acquire such devices, frequency of use and the tasks for which they use them. A person may have a number of devices or aids and use different devices or aids for different purposes or not used them at all for certain tasks. While the vast majority of people who use wheelchairs or walking aids do so upon recommendation by appropriate professionals, this equipment can nevertheless be purchased and used in Australia without prescription.

As outlined in 'Determining the level of functional impact - rules' above, in deciding which impairment rating applies, the required descriptors under a specific impairment rating level must be considered and NO descriptors or their parts are to be disregarded. If the Notes(1)(c) in the 10-point rating and point (1)(b) in the 20-point rating were read and applied in isolation, any person who uses a wheelchair or walking aids would qualify for at least 10 points under Table 3. This is not consistent with the policy intent.

The policy intent is that a person is not to be automatically allocated an impairment rating of 10 or 20 points solely on the basis that they use certain aids or equipment. The criteria in the Note for a rating of 10 or 20-point rating are not stand alone and cannot be applied in isolation from the other requirements for these ratings. This intent is reflected in the assessment rule in the Impairment Tables discussed above which stipulates that a person can only be allocated a specific impairment rating if the required descriptors for that impairment level are met.

Impairment Ratings for Table 3

0-point impairment rating level

The 0-point descriptor requires that the person have NO OR MINIMAL functional impact on activities requiring the use of the lower limbs. The person can carry out all activities in descriptor (1).

5-point impairment rating level

The 5-point descriptor requires that the person have a MILD functional impact on activities using lower limbs.

The person must have MILD DIFFICULTY with at least one of the activities in descriptors (1)(a), (b) or (c) AND also meet at least one of the descriptors at (2)(a),(b) or (c).

If the person does not meet at least one descriptor point in both descriptors (1) or (2), they cannot be allocated 5 points and the correct impairment rating is 0 points.

10-point impairment rating level

The 10-point descriptor requires that a person must have a MODERATE functional impact on activities using lower limbs.

For this rating to be assigned, the person must have MODERATE DIFFICULTY with at least one of the activities in descriptors (1)(a), (b), (c), or (d) AND also satisfy descriptor (2).

This impairment rating level includes a person who can move around independently (without assistance) using a wheelchair and can independently transfer to and from a wheelchair, such as moving from a wheelchair into a vehicle seat or using a wheelchair accessible toilet independently.

This rating also includes a person that may require additional time and effort to move around a workplace, may need to use accessible entries, lifts and toilets, and may not be able to access some areas of a workplace or training facility.

20-point impairment rating level

The 20-point descriptor requires that a person have a SEVERE functional impact on activities using lower limbs.

For this rating to be assigned, the person must have SEVERE DIFFICULTY with all of the requirements set out in (1)(a)(i), (ii) and (iii) without assistance AND must also meet descriptor (1)(b).

30-point impairment rating level

The 30-point descriptor requires that a person have an EXTREME functional impact on activities using lower limbs.

For this rating to be assigned, the person must be UNABLE to mobilise independently. To meet this descriptor the person would not be able to mobilise at all without assistance.

In comparison, a person who has some ability to mobilise very short distances without assistance (such as around the home) but is unable to do the activities listed in the 20-point descriptors (1)(a)(i), (ii) and (iii) and requires assistance to use public transport (descriptor (1)(b)) would meet the 20-point descriptor.

Impact of pain

In determining the functional impact on activities under Table 3, consideration should be given to the impact of pain on the person's ability to undertake these activities. For example, a person may have difficulty using their lower limbs other than for very short periods due to the pain they experience when doing so.

For more information about assessing pain, please refer to 3.6.3.02 ‘Assessing functional impact of chronic pain’.

Avoiding double counting

Double counting of impairments must be avoided (see 3.6.3.06 'Rating multiple conditions with common impairments & double counting’). The Table 3 descriptors are to be met only from lower limb conditions.

Table 3 requires that a person have functional impairment when performing activities requiring the use of lower limbs. If a person has difficulty with mobility due to restrictions on physical exertion, this must be assessed under Table 1 – Functions requiring Physical Exertion and Stamina. A person who has difficulty bending or with mobility stemming from a spinal condition must be assessed under Table 4 – Spinal Function.

Examples of Table 3 assessment

Impairments that should not be assessed using Table 3

Difficulties mobilising independently due to severe visual impairment should not be assessed under this Table if there are no inherent medical conditions affecting the lower limbs. Such impairment should be assessed under Table 12 - Visual Function.