3.6.3.20 Guidelines to Table 2 - Upper Limb Function

Summary

Table 2 is used to assess functional impairment when performing activities requiring the use of hands or arms.

Consistent with this purpose, 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, computer keyboards etc.

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

The diagnosis of the condition must be made by an appropriately qualified medical practitioner. This includes a general practitioner or medical specialists 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 permanent condition (impairment). There must be corroborating medical evidence of the person's impairment.

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

If a person has an amputation of an upper limb and does not use a prosthesis, 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 with minimal difficulties.

Interpretation & application of relevant terms

The 20-point descriptor in Table 2 uses the term 'assistance'. Assistance means assistance from another person, rather than any aids or equipment the person has and usually uses (refer to 3.6.3.05 'Use of aids, equipment & assistive technology').

Determining the level of functional impact - general rules

As in the other Tables, the descriptors in Table 2 are interlinked in that they follow a consistent incremental hierarchy, which in this Table is expressed, among other things, by the use of terms indicating increasing levels of difficulty in performing certain activities (e.g. without difficulty, some difficulty, difficulty, severe difficulty, unable to).

Consequently, as is the case in applying any other Table, in establishing whether the impairment causes no (0 points), mild (5 points), moderate (10 points), severe (20 points) or extreme (30 points) functional impact, all the descriptors for each impairment rating level in Table 2 should be read as a whole and compared so the descriptors, their relativity and hierarchy in this Table are understood.

When determining a person's limitations in relation to conducting 'work tasks', this is taken to refer to any job available in Australia.

The structure of the Tables requires that, in assessing the level of functional impact, a comparison must be made of all of the descriptors in each level of impairment. An assessment starts by considering descriptors for 0 points and, if a person has more than 'no 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 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 lower of those 2 impairment ratings (i.e. 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. NO descriptors or their parts are to be disregarded.

For example, for a person to be assigned a 20 point rating under Table 2, at least 3 of the 5 descriptors must be satisfied.

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 descriptor for a certain impairment rating level are met.

Note 3: If the person's impairment does not meet all 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 be solely relied on. It would be inappropriate to apply an impairment rating based solely on a person's self-reported functional history if this level of functional impairment is not consistent with 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.

The descriptors are to be considered in relation to impairment to either hands or arms. The person may have one hand or one arm affected or both hands or both arms. In either circumstance, the descriptors are based on the activities the person can do or has difficulty doing with either of their hands or either arm. An activity listed under a descriptor is not taken as being able to be performed if it can only be done once or rarely - the person needs to be able to perform such activity when they would normally attempt it or be required to perform it.

0-point impairment rating level

The 0-point descriptor specifies the person has no functional impact on activities using hands or arms. The person can carry out all activities in descriptor (1).

5-point impairment rating level

The 5-point descriptor requires that for this impairment rating to be assigned to a person, the person must be able to manage most daily activities requiring the use of hands and arms but has SOME DIFFICULTY with most (i.e. at least 3) of the activities in the descriptor points (1)(a), (b), (c), and (d).

10-point impairment rating level

For this rating to be allocated to a person, they must have DIFFICULTY in performing most (i.e. at least 4) of the descriptor points (1)(a), (b), (c), (d), (e) and (f).

20-point impairment rating level

For a person to meet the 20-point descriptor, most (i.e. at least 3) of the descriptor points (1)(a), (b), (c), (d) and (e) must be met.

The 20-point descriptor (1)(a) requires that a person either has an amputation rendering one of their hands or arms non-functional, OR they have limited movement or coordination in both of their arms or both of their hands. Where a person does not have an amputation of 1 hand or arm, they may still satisfy descriptor (1)(a) if the severity of the condition is such that it renders 1 hand or arm completely non-functional, such as to be equivalent to an amputation.

A person cannot satisfy 3 or more descriptors to be assigned a 20 point rating under Table 2 where they have a condition affecting only one arm or one hand. Consideration must be given to what the person can do, or could be retrained to do, with their unaffected arm or hand.

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

30-point impairment rating level

The policy intent of the 30-point descriptor is that a person is totally unable to perform any activities requiring the use of arms or hands.

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 arms or hands, or have an amputation rendering one of their arms or hands non-functional, in order to meet the 30-point descriptor, the person must have NO FUNCTION at all in either:

• both their hands, or
• both their arms.

Note: A person is considered to have no function in both their hands or both their arms, if the person has no movement or coordination in both their hands or both arms or has no hands or no arms. A person will not meet the 30 point descriptor if they have some movement or function in one of their hands or arms.

Avoiding double counting

For bilateral 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 shoulder or 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).

In determining the functional impact on activities using hands or arms, 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 hands or arms on a repetitive basis due to the chronic pain they experience on doing so. This chronic pain could be either a symptom of a permanent condition impacting upper limbs or a permanent condition itself.

When assessing chronic pain under Table 2, refer to 3.6.3.02 'Assessing functional impact of chronic pain'.

Some conditions causing impairment commonly assessed using Table 2

These include but are not limited to:

• upper limb musculoskeletal conditions including specific degenerative joint disease (osteoarthritis)
• other permanent forms of arthritis or chronic rotator cuff lesions
• neurological conditions including cerebrovascular accident (CVA or 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
• upper limb amputations or absence of whole or part of upper limb
• chronic carpal tunnel syndrome
• ulnar nerve palsies.

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.