This chapter is used to assess the motor function of the spine and limbs. Sensory loss is to be assessed under Chapter 5 (Neurological Impairment).
Impairment of limbs
When a previously-accepted condition is later removed by an amputation that is also an accepted condition, the rating is to be based on the amputation or the resulting functional deficit, whichever results in the higher impairment rating. The previously accepted condition is not to be given an impairment rating.
PART 3.1: UPPER LIMBS
Functional impairment is to be calculated separately for each upper limb. Thus one functional impairment rating may be calculated for the right upper limb and another for the left upper limb.
Calculation of the impairment rating for conditions of each upper limb
Follow the steps below to calculate the impairment rating for accepted conditions of each upper limb:
(Steps 2–8 are elaborated in the following pages.)
STEP 1
If accepted condition(s) affect only the right upper limb, follow steps 2–8.If accepted condition(s) affect only the left upper limb, follow steps 2–8 substituting “left” for “right” in the instructions.If accepted condition(s) affect both upper limbs, follow steps 2–8 to assess the right upper limb, and then, to assess the left upper limb, repeat steps 2–8 substituting “left” for “right” in the instructions.
STEP 2
Establish which joints in the right upper limb, if any, have some restriction of movement as a result of accepted conditions affecting the right upper limb.
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STEP 3
(Omit this step if is there is no restriction of joint movement in the right upper limb.)Calculate the functional impairment due to restriction of range of movement of joints in the right upper limb as a result of accepted conditions of the right upper limb.
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STEP 4
Calculate the functional impairment rating for the right upper limb as a whole using Table 3.1.2.
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STEP 5
Compare the functional impairment rating for the right upper limb as a whole with the functional impairment rating from any restricted range of movement. Take the higher of these two as the final functional impairment rating for the right upper limb.
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="2" style="width:108pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FigureHeading"><span>Other Impairment Table 12.2.1</span></p></td><td style="width:379.9pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="text-align:right; line-height:14pt"><img src="image.005.png" width="35" height="45" alt=""></p></td></tr><tr><td colspan="3" style="width:498.7pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:6pt; text-align:center; font-size:12pt"><span style="font-weight:bold">THE HAEMOPOIETIC SYSTEM:</span><span style="font-weight:bold"> </span><span style="font-weight:bold">TREATMENT REQUIREMENTS*</span></p></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span style="font-weight:bold">Impairment Ratings</span></p></td><td colspan="2" style="width:415.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span style="font-weight:bold">Criteria</span></p></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>NIL</span></p></td><td colspan="2" style="width:415.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>Symptoms in remission and no active therapy indicated.</span></p></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>TWO</span></p></td><td colspan="2" style="width:415.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>Transfusion requirements: 2–3 units per 12–16 weeks.</span></p></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>FIVE</span></p></td><td colspan="2" style="width:415.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><ul style="margin:0pt; padding-left:0pt"><li class="Bullet" style="margin-left:9.6pt; margin-bottom:3pt; text-indent:0pt; padding-left:4.55pt; font-family:serif; font-size:10pt"><span style="font-family:'Times New Roman', serif">Intermittent combination cytotoxic therapy </span><span style="font-family:'Times New Roman', serif"></span><span style="font-family:'Times New Roman', serif"></span><span style="font-family:'Times New Roman', serif"></span><span style="font-family:'Times New Roman', serif"></span><span style="font-family:'Times New Roman', serif">— one course every 3–4 weeks.</span></li><li class="Bullet" style="margin-top:3pt; margin-left:9.6pt; margin-bottom:3pt; text-indent:0pt; padding-left:4.55pt; font-family:serif; font-size:10pt"><span style="font-family:'Times New Roman', serif">Phlebotomy once every 4 weeks.</span></li><li class="Bullet" style="margin-top:3pt; margin-left:9.65pt; margin-bottom:3pt; text-indent:0pt; padding-left:4.55pt; font-family:serif; font-size:10pt"><span style="font-family:'Times New Roman', serif">Transfusion requirements: 2–3 units per 6 weeks.</span></li></ul></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>TEN</span></p></td><td colspan="2" style="width:415.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><ul style="margin:0pt; padding-left:0pt"><li class="Bullet" style="margin-left:9.6pt; margin-bottom:3pt; text-indent:0pt; padding-left:4.55pt; font-family:serif; font-size:10pt"><span style="font-family:'Times New Roman', serif">Phlebotomy more than once every 4 weeks.</span></li><li class="Bullet" style="margin-top:3pt; margin-left:9.65pt; margin-bottom:3pt; text-indent:0pt; padding-left:4.55pt; font-family:serif; font-size:10pt"><span style="font-family:'Times New Roman', serif">Transfusion requirements: 2–3 units per 4 weeks.</span></li></ul></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>TWENTY</span></p></td><td colspan="2" style="width:415.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>Transfusion requirements: 2–3 units per 2 weeks.</span></p></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span style="font-weight:bold; font-style:italic"></span></p></td><td colspan="2" style="width:415.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span style="font-weight:bold; font-style:italic">(*Additional to relevant body system assessment.)</span></p></td></tr><tr style="height:0pt"><td style="width:83.4pt"></td><td style="width:35.4pt"></td><td style="width:390.7pt"></td></tr></tbody></table>
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STEP 6
Make any applicable age adjustment to the final functional impairment rating for the right upper limb by applying Table 3.6.1 in Part 3.6 of this chapter.
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STEP 7
Determine if any Other Impairment rating applies to the right upper limb.
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STEP 8
(Omit this step if no Other Impairment rating applies to the right upper limb.)Compare the final functional impairment rating for the right upper limb with any Other Impairment rating applicable to the right upper limb. Take the higher of these ratings.
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Step 2: Establish which joints in the right upper limb have some restriction of movement as a result of accepted conditions of the right upper limb.
For the purposes of assessment under the Guide, the major joints of the upper limb are the shoulder, the elbow and the wrist.
In addition, the joints of the thumb and fingers are also to be considered. However, only one rating is to be given for the total effect of restrictions in all joints of the thumb and fingers considered together.
Conditions such as painful arc syndrome and fractured neck of radius may affect the range of movement (ROM) of the shoulder. A condition such as fractured scaphoid will be likely to affect the ROM of the wrist. In cases of fractures, the ranges of movements of the joints proximal to and distal to the fracture site should generally be considered as joints the ROM of which may be affected.
Hence, it must be determined which, if any, of
shoulder;
elbow;
wrist; and
thumb and fingers,
potentially have loss of range of movement due to accepted conditions.
Certain vascular conditions or neurological conditions of the upper limb, such as muscle weakness, tremor, apraxia, and loss of co-ordination, may have an effect on the function of the upper limb without restricting the range of movement of any joint of the limb. The assessment of such conditions is to be made under Step 4 of this Part.
Step 3: Calculate the functional impairment due to restriction of range of movement of joints in the right upper limb as a result of accepted conditions of the right upper limb.
Single functional impairment ratings may be obtained for each of the following four joints or sets of joints based on restriction of range of movement due to accepted conditions:
shoulder;
elbow;
wrist; and
thumb and fingers.
These impairment ratings are to be obtained by applying Table 3.1.1. Such functional impairment ratings are referred to as the functional impairment rating of the upper limb based on restriction of range of movement of the shoulder, elbow, wrist, or thumb and fingers respectively.
The loss of range of movement is to be estimated to the nearest quarter of the normal range of movement.
The range of movement relevant to assessment under this Guide is the active range of movement of the joint, that is the range through which the veteran can move the joint by virtue only of those muscles whose normal function it is to do so. The ability of a veteran to flex a joint by use of other, non-affected body parts does not reduce the rating which the impaired joint attracts. (For example, if a veteran cannot flex the right elbow in the normal fashion, by use of the right biceps, but can use the left hand to bend the right elbow, the right elbow should be assessed as having “loss of almost all movement”.)
The loss of range of movement will usually be provided as a fractional loss of range of movement and such data can be related directly to items within Table 3.1.1. However, sometimes, the measured movements of an affected joint will be available in degrees. In such a case the measured movement must be compared with the average range of movement of a normal joint to obtain the fractional loss of range of movement.
The average ranges of movement of various normal joints of the upper limb may be obtained from Table 3.5.1 in Part 3.5. These values are to be used in arriving at the fractional loss of range of movement when the actual movements of a joint are known in degrees.
If non-accepted conditions contribute to the loss of range of movement, Chapter 19 (Partially Contributing Impairment) is to be applied in conjunction with Table 3.1.1.
For the purposes of this chapter:
“position of function” means the position that interferes least with the total function of the limb or the spine; and
“unfavourable position” means a position that is significantly different from the position of function; and
“flail joint” means a joint that is completely unstable in all directions.
PART 3.1 : UPPER LIMBS
PART 3.1: UPPER LIMBS
PART 3.2 : LOWER LIMBS
PART 3.2: LOWER LIMBS
PART 3.3 : SPINE
PART 3.3: SPINE
PART 3.4 : RESTING JOINT PAIN
PART 3.4: RESTING JOINT PAIN
PART 3.5 : RANGES OF JOINT MOVEMENT
PART 3.5: RANGES OF JOINT MOVEMENT
PART 3.6 : SPINE AND LIMBS AGE ADJUSTMENT
PART 3.6: SPINE AND LIMBS AGE ADJUSTMENT
PART 6.1 : DISEASES OF THE DIGESTIVE SYSTEM
PART 6.1: DISEASES OF THE DIGESTIVE SYSTEM
PART 6.2 : ABDOMINAL WALL HERNIAS AND OBESITY
PART 6.2: ABDOMINAL WALL HERNIAS AND OBESITY
PART 7.1 : HEARING LOSS AND TINNITUS
PART 7.1: HEARING LOSS AND TINNITUS
PART 7.2 : EAR, NOSE, AND THROAT
PART 7.2: EAR, NOSE, AND THROAT
PART 8.1 : IMPAIRMENT OF VISUAL FUNCTION
PART 8.1: IMPAIRMENT OF VISUAL FUNCTION
PART 8.2 : OTHER OCULAR IMPAIRMENT
PART 8.2: OTHER OCULAR IMPAIRMENT
PART 9.1 : RENAL FUNCTION
PART 9.1: RENAL FUNCTION
PART 9.2 : LOWER URINARY TRACT FUNCTION
PART 9.2: LOWER URINARY TRACT FUNCTION
PART 10.1 : SEXUAL FUNCTION
PART 10.1: SEXUAL FUNCTION
PART 10.2 : REPRODUCTION
PART 10.2: REPRODUCTION
PART 10.3 : BREASTS
PART 10.3: BREASTS
PART 12.1 : THE ENDOCRINE SYSTEM
PART 12.1: THE ENDOCRINE SYSTEM
PART 12.2 : THE HAEMOPOIETIC SYSTEM
PART 12.2: THE HAEMOPOIETIC SYSTEM
Conditions of the haemopoietic system include anaemias, leukaemias and polycythaemia.
Haemopoietic conditions usually affect various other body systems, therefore loss of function for the condition is to be established by assessing the effect of the condition on those body systems. Some haemopoeitic conditions are also malignant conditions and may be assessed by applying Chapter 14 (Malignant Conditions). For very severe haemopoietic conditions, where many body systems are affected, Tables 16.1 and 16.2 in Chapter 16 (Activities of Daily Living) are also to be applied to rate the loss of function.
Many anaemias will respond adequately to replacement or supplemental therapy. For example, the hypochromic anaemia of iron deficiency will usually respond to dietary iron supplementation and pernicious anaemia will usually respond to parenteral Vitamin B12.
Calculation of the impairment rating for loss of haemopoietic function
Follow the steps below to calculate the impairment rating due to accepted loss of haemopoietic function:
(Each step is elaborated on the following page.)
STEP 1
Establish which body systems are affected by the accepted haemopoietic condition.
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STEP 2
Determine the impairment rating for functional impairment of the affected body systems.
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STEP 3
Determine the impairment rating for the treatment requirements of the haemopoietic condition by applying Table 12.2.1.
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Step 1: Establish which body systems are affected by the accepted haemopoietic condition.
Haemopoietic conditions may affect the function of other body systems. For example, refractory anaemia may result in reduced effort tolerance.
Step 2: Determine the functional impairment of all body systems affected by the haemopoietic condition.
Apply the appropriate functional impairment table elsewhere in this Guide to assess the functional impairment arising from the haemopoietic condition. For example, in the case of refractory anaemia causing reduced effort tolerance, the reduced effort tolerance is to be assessed by use of the Effort Tolerance protocol in Chapter 1.
If non-accepted conditions have contributed to the impairment rating for any of the affected body systems, Chapter 19 (Partially Contributing Impairment) is to be applied.
The various functional impairment ratings are not combined at this stage but are to be included in the final combining of all impairment ratings.
Step 3: Determine the impairment rating for the treatment requirements of the accepted haemopoietic condition using Table 12.2.1.
The ratings obtained in Steps 2 and 3 are not to be combined at this stage but both are to be included in the final combining of all impairment ratings.