3.6.3.20 Guidelines to Table 2 - Upper Limb Function

Summary

Table 2 is used to assess the functional impact of a condition when performing activities requiring the use of the upper limbs.

Table 2 specifies that the upper limbs extend from the shoulder to the fingers.

The descriptors in Table 2 refer to a range of activities relevant to a person's ability to pick up, handle, manipulate and use objects encountered in everyday life, including but not limited to, coins, pencils, cartons of liquid, zippers, computer keyboards, or touchscreens of electronic devices.

Conditions causing impairment commonly assessed using Table 2

These include but are not limited to:

• upper limb musculoskeletal conditions, including degenerative joint disease (osteoarthritis)
• other forms of arthritis
• chronic rotator cuff lesions
• adhesive capsulitis/frozen shoulder
• neurological conditions including stroke or other brain or nerve injury causing paralysis, or loss of strength or sensation
• cerebral palsy or other condition affecting upper limb coordination
• inflammation or injury of the muscles or tendons of the upper limbs for example, chronic lateral epicondylitis/tennis elbow
• upper limb amputations or absence of whole or part of upper limb
• chronic pain affecting the upper limbs
• lymphoedema
• peripheral neuropathy
• ulnar nerve palsies.

Diagnosis & evidence under Table 2

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, or other medical specialist such as, an orthopaedic surgeon, 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 2 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 upper limb impairment (such as, arthritis or other condition affecting upper limb joints, paralysis or loss of strength or sensation resulting from stroke or other brain or nerve injury, cerebral palsy or other condition affecting upper limb coordination, inflammation or injury of the muscles or tendons of the upper limbs, chronic pain affecting the upper limbs, amputation or absence of whole or part of upper limb, lymphoedema, or peripheral neuropathy)
• a report from an allied health practitioner (such as, physiotherapist, occupational therapist or exercise physiologist) confirming the functional impact
• results of diagnostic tests (such as, X-Rays or other imagery)
• results of physical tests or assessments.

The descriptors are to be considered in relation to impairment to a person’s upper limbs. The person may have one or both upper limbs affected, however only a single rating should be applied taking into account the overall level of functional impact. In either circumstance, the descriptors are based on the activities the person can do or has difficulty doing with either of their upper limbs.

If the person has and usually uses an upper limb assistive device/s, the assessment under Table 2 must be undertaken considering what the person can do or has difficulty doing while using the assistive device/s.

If a person has an amputation of an upper limb and does not use an assistive device, consideration must be given to what the person can do or has difficulty doing with their remaining limb. In some cases the person may have made, or able to make adaptations in using their remaining limb and may be able to undertake activities without significant difficulties. Adaptations may also be dependent on the position of the amputation, for example, amputation of an entire arm versus below the elbow amputation.

A person that has a functional impact of their upper limb/s as a result of a cervical spine condition (including nerve pain or weakness) should be assessed under Table 2 – Upper Limb Function.

Interpretation & application of relevant terms

‘Most daily activities’ refers to the usual activities a person would expect to undertake during the normal course of their day. This will vary from individual to individual but may involve things such as, personal care activities, household duties (for example, cooking or cleaning), commuting to and from work, and undertaking work tasks.

‘Above head height’ is intended to measure the level of difficulty the person has in reaching above their head (for example, to carry out a task such as, hanging out washing, changing a ceiling light bulb or obtaining items from an overhead shelf, which requires the person to reach upwards for a period of time).

The 20-point descriptor in Table 2 uses 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).

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.

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 a person meets all 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.

In other cases, a prescribed number of descriptors may be required for that rating to apply (for example, ‘the person has moderate difficulty carrying out at least 4 of the following’).

For example, if a person meets 4 or more of the descriptors at the 10-point rating, but only meets 2 of the descriptors under the 20 point rating, the appropriate impairment rating is 10 points. For a person to be assigned the 20-point descriptor under Table 2, at least 3 of the 5 descriptors must be satisfied.

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. 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 number of 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 be solely 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.

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’).

Impairment Ratings for Table 2

0-point impairment rating level

The 0-point descriptor requires that the person have NO OR MINIMAL functional impact on activities using the upper 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 MILD functional impact on activities using upper limbs.

For this rating to be assigned, the person must be able to manage most daily activities requiring the use of their upper limbs but has MILD DIFFICULTY with at least 3 of the descriptors at (1)(a), (b), (c), and (d).

10-point impairment rating level

The 10-point descriptor requires that the person have MODERATE functional impact on activities using upper limbs.

For this rating to be assigned, the person, must have MODERATE DIFFICULTY in performing at least 4 of the descriptors at (1)(a), (b), (c), (d), (e), (f) and (g).

20-point impairment rating level

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

For this rating to be assigned, the person must have SEVERE DIFFICULTY in performing at least 3 of the descriptors at (1)(a), (b), (c), (d) and (e).

The 20-point descriptor (1)(a) requires that a person either has limited movement or coordination in both upper limbs OR an amputation rendering an upper limb non-functional. Where a person does not have an amputation of 1 upper limb, they may still satisfy descriptor (1)(a) if the severity of the condition renders 1 upper limb completely dormant.

A person is unlikely to satisfy 3 or more descriptors and be assigned a 20-point rating under Table 2 where they have a condition affecting only one upper limb. Consideration must be given to what the person can do, or could be retrained to do, with their unaffected upper limb.

(1)(d) specifies the person has severe difficulty turning the pages of a book without assistance. To meet this point, a person would have severe difficulty turning the pages of a book without assistance from another person, even with any assistive technology they have and usually use. However where the person may not read or have access to books, an alternative example may be an inability to use the touchscreen of an electronic reading device such as a Kindle without assistance.

See Sabeei and Secretary, Department of Social Services (2014) AATA 815.

30-point impairment rating level

The 30-point descriptor requires that a person has no function in both of their upper limbs or the person has no upper limbs.

Consistent with the principle of incremental hierarchy of descriptors, it would be expected that the level of impairment required for 30 points will be higher than that for 20 points. Given that the descriptor point (1)(a) for 20 points requires the person to have limited movement or coordination in both their upper limbs, or have an amputation rendering one of their upper limbs non-functional, in order to meet the 30-point descriptor, the person must have NO FUNCTION in both of their upper limbs or the person has no upper limbs.

Impact of pain

In determining the functional impact on activities under Table 2, 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 upper 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

For conditions where both upper limbs are affected, a single impairment rating under Table 2 should be determined based on the resulting combined functional impairment.

Restrictions on overhead activities under Table 2 are only relevant in applying the 5-point descriptor. If the person has more severe restrictions on overhead activities arising from shoulder injury, they should still be assessed under Table 2 in relation to what they can/cannot do in accordance with the existing descriptors. People with upper limb conditions are not to be assessed under Table 4, which is to be solely used to assess restrictions on overhead restrictions arising from spinal conditions. This avoids double counting (3.6.3.06).

Examples of Table 2 assessment

Impairments that should not be assessed using Table 2

Difficulties handling and manipulating objects due to severe visual impairment should not be assessed under Table 2 if there are no inherent medical conditions affecting the upper limbs. Such impairment should be assessed under Table 12 - Visual Function.