3.6.3.40 Guidelines to Table 4 - Spinal Function

Summary

Table 4 is used to assess the functional impact when performing activities involving spinal function. Spinal function involves bending or turning the back, trunk or neck.

Conditions causing impairment commonly assessed using Table 4

These include but are not limited to:

• spinal cord injury
• spinal stenosis
• cervical spondylosis and radiculopathy
• lumbar radiculopathy
• herniated or ruptured spinal disc
• spinal cord tumours
• chronic pain affecting the spine
• arthritis or osteoporosis involving the spine.

Diagnosis & evidence

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, a rheumatologist, a rehabilitation physician, or other relevant specialist.

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 purpose of Table 4 include, but are not limited to:

• a report from the person’s treating doctor
• a report from a medical specialist confirming diagnosis of conditions commonly associated with spinal function impairment (such as, spinal cord injury, spinal stenosis, cervical spondylosis, lumbar radiculopathy, herniated or ruptured disc, spinal cord tumours, arthritis or osteoporosis involving the spine, or chronic pain affecting the spine)
• a report from an allied health practitioner (such as, a physiotherapist, or occupational therapist), confirming loss of range of movement in the spine or other effects of spinal disease or injury.

Interpretation & application of relevant terms

Where the descriptors in Table 4 refer to ‘moving around independently using a wheelchair’, this includes both manually-propelled wheelchairs and powered mobility aids (such as, power assist wheelchair, power wheelchair or mobility scooter).

‘Overhead’ is intended to measure the level of difficulty the person has in looking up (for example, looking at a bird in a tree), not reaching above head height (for example, to carry out a task, such as hanging out washing or obtaining items from an overhead shelf, which requires the person to reach upwards for a period of time). This clarification is important to ensure it is spinal function, not upper limb function that is being assessed.

In relation to paragraph (1)(c) at the 10-point impairment rating level, a ‘light object’ refers to any object that would weigh no more than a kilogram.

When referring to standing from a seated position at the 10-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.

The 10-point descriptor in Table 4 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 the 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 is the rating at which all the required descriptors are met.

Where several descriptors must apply for a rating the word 'and' links the descriptor. However, one of several descriptors may be sufficient for that rating when the word 'or' links the descriptors, such as that outlined at the 5-point impairment rating level on Table 4 where (1)(a), (b) or (c) must be met for a rating to be assigned. 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’).

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 all required descriptors for a certain impairment level, the person's impairment cannot be rated at that level or at 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.

When determining whether the person is able to undertake the activities listed under the descriptors, consideration must be given to whether the person suffers pain on undertaking the activities. For example, under the 20-point descriptor, if a person is able to remain seated for 10 minutes but suffers severe pain while doing so, it should be considered that the person is unable to remain seated for at least 10 minutes.

Chronic pain can be either a symptom of a condition impacting spinal function or a condition itself. When assessing chronic pain under Table 4, please refer to 3.6.3.02 ‘Assessing functional impact of pain’.

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 (for example, 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 4, 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.

Impairment Ratings for Table 4

0-point impairment rating level

The 0-point descriptor requires that the person have NO OR MINIMAL functional impact on activities involving spinal function.

For this rating to be assigned, the person MUST be able to carry out all activities in descriptor (1)(a), (b) and (c).

5-point impairment rating level

The 5-point descriptor requires that the person have a MILD functional impact on activities involving spinal function.

For this rating to be assigned, the person must have MILD DIFFICULTY in at least one of the descriptors (1)(a), (b) or (c).

10-point impairment rating level

The 10-point descriptor requires that the person have a MODERATE functional impact on activities involving spinal function.

For this rating to be assigned, the person must be able to sit in or drive a car for at least 30 minutes and one of either (1)(a), (b), (c) or (d) must also apply.

In relation to descriptor (1)(a), the reference to 'sustaining overhead activities' is intended to measure the level of difficulty the person has in looking up (for example, looking at a bird in a tree), NOT reaching up (for example, to carry out a task, such as hanging out washing or counting items on an overhead shelf, which requires the person to look upwards for a period of time). That is, it is a measure of spinal function, NOT upper limb function.

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 the person has a SEVERE functional impact on activities involving spinal function.

For this rating to be assigned the person must have SEVERE DIFFICULTY performing at least one of the activities listed at (1)(a), (b), (c), or (d).

In relation to descriptor (1)(b) the person must EITHER have SEVERE DIFFICULTY turning their head without moving their trunk OR SEVERE DIFFICULTY bending their neck without moving their trunk.

Consideration must also be given to whether the person can undertake the activity on a repetitive or habitual basis. If a person is able to bend forward to pick up a light object from a desk or table but after doing this once has to rest their back and is unable to bend forward for the remainder of the day, it should be considered that the person has severe difficulty undertaking this activity.

This impairment level rating includes a person who requires assistance to move around in (mobilise), or transfer to and from a wheelchair, such as requiring assistance to use a toilet.

This rating also includes a person who would not be able to move independently or move around using walking aids, such as a quad stick, crutches or walking frame without assistance and the person requires assistance from another person to walk on some surfaces, even when using a walking aid.

30-point impairment rating level

The 30-point descriptor requires that a person has an EXTREME functional impact on activities involving spinal function.

For this rating to be assigned the person must meet descriptor (1).

This rating can only be applied when the person cannot perform any activities involving spinal function.

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 4 descriptors are to be met only from spinal conditions.

Upper or lower limb impairment resulting from a spinal condition (such as, nerve root compromise) can be additionally assessed under Table 2 - Upper Limb Function or Table 3 - Lower Limb Function only if the Table 4 rating does not fully account for the overall level of impairment. Table 4 requires that a person have functional impact when performing activities requiring the use of the spine. If a person has difficulty with mobility relating to a restricted ability to undertake activities involving physical exertion, this must be assessed under Table 1 – Functions requiring Physical Exertion and Stamina.

Example of Table 4 assessment

Impairments that should not be assessed using Table 4

The introduction to Table 4 makes clear that other Tables should be used in certain circumstances:

• Restrictions on overhead tasks resulting from shoulder conditions should be rated under Table 2 - Upper Limb Function.
• Restrictions resulting from hip conditions should be rated under Table 3 - Lower Limb Function.