Chapter 19 - Impairment in Activities of Daily Living

Introduction

The Activities of Daily Living (ADLs) are a defined set of activities necessary for normal self-care: the activities of personal hygiene, dressing, eating, transfers/bed mobility, locomotion and bowel and bladder control.

For VAC disability assessment purposes, ADL include those activities necessary for self-care. These activities include:

• personal hygiene - includes bathing and grooming tasks. Bathing means washing of face, trunk, extremities and perineum. Grooming means brushing of hair and teeth, shaving and make-up application.
• dressing - means donning and doffing indoor and outdoor clothing.
• eating - means eating and drinking of prepared foods. Includes cutting, buttering bread, etc.
• transfers/bed mobility - means moving between sitting and standing, moving from one seat to another, or sitting in, rising from and moving around in bed.
• locomotion - means walking on level ground, on gentle slopes and on stairs.
• bowel and bladder control - means degree of continence.

This chapter is used when criteria does not exist in the system specific tables, or are inadequate, or for which the application of some tables may be inappropriate.

This chapter is used to rate permanent impairment from conditions that have multi-system effects or global body effects such as: endocrine, metabolic and hemopoietic conditions that do not respond to optimal treatment, inflammatory arthritis (e.g. rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome and psoriatic arthritis), generalized osteoarthritis, fibromyalgia syndrome, chronic fatigue syndrome, amyotrophic lateral sclerosis (ALS), Parkinson's disease, multiple sclerosis, polyneuropathy affecting the function of the upper and lower limbs, spinal cord injury or disease affecting the function of the upper and lower limbs, brain injury or disease affecting the function of the upper and lower limbs and other "syndromes" of undiagnosed physical symptoms.

Many of the conditions rated in this chapter have chronic pain symptoms. These symptoms are rated within Table 19.7 - Other Impairment - Chronic Pain.

Impairment from psychiatric conditions is rated within Chapter 21, Psychiatric Impairment. No additional rating is to be taken from this chapter.

Impairment from malignant conditions is rated within Chapter 18, Malignant Impairment. No additional rating is to be taken from this chapter.

If more than one entitled condition is rated within this chapter, the conditions are bracketed for assessment purposes.

When entitled conditions that are rated within this chapter result in permanent impairment of specific organ systems or have an associated impairment of specific organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

Rating Tables

This chapter contains six "Loss of Function" and one "Other Impairment" table which may be used to rate entitled conditions having multi-system or global body effects.

When a rating is applicable from more than one table, the ratings are added.

The tables within this chapter are:

Loss of Function - ADL

Table 19.1 to Table 19.6 are used to rate entitled conditions that have multi-system or global body effects.

A rating may be applicable from each Table 19.1 to Table 19.6. If non-entitled conditions, or conditions rated within another chapter of the Table of Disabilities, are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this chapter. If applicable, the PCT is applied at each table level.

Other Impairment - Chronic Pain

Only one rating may be selected from Table 19.7. If more than one rating is applicable, the ratings are compared and the highest selected.

A rating from this table is not added to a rating from any other chapter for the same entitled disability.

Pain and chronic pain are defined in many ways.

The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage". The US Commission on the Evaluation of Pain defines it as a "complex experience, embracing physical, mental, social, and behavioural processes, which compromises the quality of life of many individuals".

The American Medical Association defines chronic pain as "an evolving process in which injury may produce one pathogenic mechanism, which in turn produces others, so that the causes of pain change over time".

The perception of pain and its severity is complex and individually based. Pain is highly influenced by emotion, the individual's personality and values, cognitive awareness, experiences, education and ethnic and cultural background. Chronic pain may affect the social and emotional well-being of the individual, and effects are proportional to the duration the pain has been present and to its intensity.

As the perception of pain is highly subjective, and as the study of the evaluation of pain continues to evolve, the objective evaluation of chronic pain is extremely difficult. Therefore, the evaluation of pain behaviour and emotional status and attitude is important in the assessment of chronic pain.

The manner in which emotional distress presents is very individual. It may present as withdrawal, anger or unreasonableness, depressive features or bodily complaints.

For VAC purposes, chronic pain is pain that persists beyond the period of time normally required for complete physical healing or pain due to chronic physical disorders such as rheumatoid arthritis. Further, this pain must be in existence for at least 6 months before it is considered to be chronic. This pain is generally expected to persist despite medical attention, although it may wax and wane over the 6-month period and thereafter. Key elements considered in the assessment of emotional distress in relation to pain include overall mood, anxiety, depressive features, and irritability. Symptoms of headache, musculoskeletal pain, fatigue, gastrointestinal distress, memory difficulties and insomnia are common, and will be included in the rating of the condition within this table.

If non-entitled conditions or conditions rated within another chapter of the Table of Disabilities are contributing to the overall impairment, then the PCT must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Table 19.1 - Loss of Function - Personal Hygiene

Each bullet (•) represents one criterion. In order for a rating to be established for Table 19.1, all criteria designated at that rating level must be met.

Table 19.2 - Loss of Function - Dressing

Each bullet (•) represents one criterion. In order for a rating to be established for Table 19.2, all criteria designated at that rating level must be met.

Table 19.3 - Loss of Function - Eating

Each bullet (•) represents one criterion. In order for a rating to be established for Table 19.3, all criteria designated at that rating level must be met.

Table 19.4 - Loss of Function - Transfers/Bed Mobility

Each bullet (•) represents one criterion. In order for a rating to be established for Table 19.4, all criteria designated at that rating level must be met.

Table 19.5 - Loss of Function - Locomotion

Each bullet (•) represents one criterion. In order for a rating to be established for Table 19.5, all criteria designated at that rating level must be met.

Table 19.6 - Loss of Function - Bowel and Bladder Control

Each bullet (•) represents one criterion. In order for a rating to be established for Table 19.6, only one criterion must be met at a level of impairment for that rating to be selected.

Table 19.7 - Other Impairment - Chronic Pain

Each bullet (•) represents one criterion. In order for a rating to be established for Table 19.7, the majority of bullets at a certain rating level must be met.

* Intractable pain is severe, persistent, ongoing pain that is unresponsive to the usual treatment modalities.

Steps to Determine Activities of Daily Living Assessment

Step 1:

Determine the rating from Table 19.1 (Loss of Function - Activities of Daily Living - Personal Hygiene).

Step 2:

Does the Partially Contributing Table apply? If yes, apply to the Step 1 rating.

Step 3:

Determine the rating from Table 19.2 (Loss of Function - Activities of Daily Living - Dressing).

Step 4:

Does the Partially Contributing Table apply? If yes, apply to the Step 2 rating.

Step 5:

Determine the rating from Table 19.3 (Loss of Function - Activities of Daily Living - Eating).

Step 6:

Does the Partially Contributing Table apply? If yes, apply to the Step 5 rating.

Step 7:

Determine the rating from Table 19.4 (Loss of Function - Activities of Daily Living - Transfers/Bed Mobility).

Step 8:

Does the Partially Contributing Table apply? If yes, apply to the Step 7 rating.

Step 9:

Determine rating from Table 19.5 (Loss of Function - Activities of Daily Living - Locomotion).

Step 10:

Does the Partially Contributing Table apply? If yes, apply to the Step 9 rating.

Step 11:

Determine rating from Table 19.6 (Loss of Function - Activities of Daily Living - Bowel and Bladder Control).

Step 12:

Does the Partially Contributing Table apply? If yes, apply to the Step 11 rating.

Step 13:

Determine rating from Table 19.7 (Other Impairment - Activities of Daily Living - Chronic Pain).

Step 14:

Does the Partially Contributing Table apply? If yes, apply to the Step 13 rating.

Step 15:

Add the ratings at Step 2, 4, 6, 8, 10,12 and 14.

Step 16:

Determine the Quality of Life rating.

Step 17:

Add the ratings at Step 15 and 16.

Step 18:

If partial entitlement exists, apply to rating at Step 17.

This is the Disability Assessment.