Chapter 19 - Impairment in Activities of Daily Living

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Table of Contents PDF Version

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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:

Rating Tables

Table	Loss of Function	Other Impairment
Table 19.1	Loss of Function - Activities of Daily Living - Personal Hygiene	This table is used to rate impairment of an activity of daily living, specifically personal hygiene.
Table 19.2	Loss of Function - Activities of Daily Living - Dressing	This table is used to rate impairment of an activity of daily living, specifically dressing.
Table 19.3	Loss of Function - Activities of Daily Living - Eating	This table is used to rate impairment of an activity of daily living, specifically eating.
Table 19.4	Loss of Function - Activities of Daily Living - Transfers/Bed Mobility	This table is used to rate impairment of an activity of daily living, specifically transfers/bed mobility.
Table 19.5	Loss of Function - Activities of Daily Living - Locomotion	This table is used to rate impairment of an activity of daily living, specifically locomotion.
Table 19.6	Loss of Function - Activities of Daily Living - Bowel and Bladder Control	This table is used to rate impairment of an activity of daily living, specifically bowel and bladder control.
Table 19.7	Other Impairment - Chronic Pain	This table is used to rate chronic pain.

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 19.1 - Loss of Function - Personal Hygiene

Rating	Criteria	Examples
Nil	Independent. Can perform bathing and grooming tasks independently.	Preparing for and completing the following activities: cleaning teeth or dentures; clipping nails; combing or brushing hair; shaving or applying make-up; washing, rinsing and drying the face and body either in the tub, shower or via sponge bath.
One	Independent. Can perform bathing and grooming tasks without special equipment, adaptation, or assistance from others, but has difficulty and/or pain carrying out activity.	Pain with reaching to clip toe nails. Difficulty getting the arm overhead and reaching to brush hair. Takes more than a reasonable amount of time to bathe/groom self.
Four	Independent with aids, assistive devices or adaptation of task. Can perform bathing and grooming tasks independently with aids or assistive devices, or with adaptation of the task.	Requires use of a long-handled wash sponge/brush. Needs to use an electric razor for safety.
Nine	The Member/Veteran/Client requires the assistance of another person for bathing and/or grooming tasks with respect to set-up or supervision, or the physical assistance of another person to the extent that the Member/Veteran/Client is able to perform 50% or more of the tasks associated with bathing and grooming.	Requires the personal assistance of another person to prepare shower equipment or set Member/Veteran/Client up for a sponge bath. Requires the personal assistance of another person to supervise shower for safety reasons. Member/Veteran/Client needs help with nail care only. Member/Veteran/Client able to bathe self except for his/her feet. Member/Veteran/Client not able to reach overhead to brush/comb hair.
Thirteen	The Member/Veteran/Client requires the physical assistance of another person to the extent that the Member/Veteran/Client is able to perform less than 50% of bathing and grooming tasks, or the Member/Veteran/Client is dependent on another person for bathing and grooming.	Member/Veteran/Client needs help to bathe self below the knees and perineum/buttock areas and to perform nail care. Member/Veteran/Client able to only minimally assist by helping to position limbs for bathing, etc.

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 19.2 - Loss of Function - Dressing

Rating	Criteria	Examples
Nil	Independent. Can dress and undress independently.	Obtaining clothes from their customary places such as drawers and closets; manages bra, pullover garment or front-opening garment; managing underpants, slacks, skirt, belt, stockings and shoes; manages zippers, buttons or snaps; and applies and removes prosthesis or orthosis when applicable.
One	Independent. Can dress and undress independently, without special equipment, adaptation, or assistance from others, but has difficulty and/or pain carrying out activity.	Multiple attempts to reach feet before socks are removed. Pain with pulling on garments overhead, etc. Takes more than a reasonable amount of time to dress/undress.
Four	Independent with aids, assistive devices or adaptation of task. Can dress and undress independently with aids or assistive devices, or with adaptation of the task.	Wears modified clothing, such as clothing with velcro. Uses one or more assistive devices such as prosthesis or orthosis, a button hook, sock aid, elastic shoe laces, etc. to dress.
Nine	The Member/Veteran/Client requires the assistance of another person for set-up or supervision, or the physical assistance of another person to the extent that the Member/Veteran/Client can still perform 50% or more of the tasks associated with dressing.	Requires the personal assistance of another person to prepare/collect clothing for wear. Member/Veteran/Client needs help with shoes and socks only. Member/Veteran/Client unable to put bra on independently. Member/Veteran/Client able to dress the upper limbs, but requires assistance getting clothing over his/her feet to dress the lower limbs.
Thirteen	The Member/Veteran/Client requires the physical assistance of another person to the extent that the client is able to perform less than 50% of dressing tasks, or the Member/Veteran/Client is dependent on another person for dressing.	Member/Veteran/Client able to help dress one side, but requires assistance with closures, and getting clothing over head and over his/her feet to dress the lower limbs. Member/Veteran/Client able to only minimally assist by helping to position limbs for dressing, etc.

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 19.3 - Loss of Function - Eating

Rating	Criteria	Examples
Nil	Independent. Can perform eating tasks without special equipment, adaptation, or assistance from others.	Eating from a dish; using a spoon or fork to bring food to the mouth; food is chewed and swallowed, managing all consistencies of food; and drinking from a cup or glass.
Three	Independent. Can perform eating tasks without special equipment, adaptation, or assistance from others, but has difficulty and/or pain carrying out activity.	Difficulty cutting meat or buttering bread. Pain with moving the upper limb through range of motion required to bring fork or glass to the mouth. Difficulty keeping food on fork or spoon due to unsteadiness. Takes more than a reasonable amount of time to eat.
Nine	Independent with aids, assistive devices or adaptation of task. Can perform eating tasks independently with aids or assistive devices, or with adaptation of the task.	Requires modified table wear, such as a rocker knife, high-sided bowl, flatware with specialty handles, a drinking straw, etc. Requires modified food consistency or blenderized food.
Thirteen	The Member/Veteran/Client requires the assistance of another person for eating tasks for set-up or supervision or the physical assistance of another person to the extent that the Member/Veteran/Client is able to perform 50% or more of eating tasks.	Requires the personal assistance of another person to cut meats, butter breads, open cartons. Requires the personal assistance of another person to apply an orthosis. Member/Veteran/Client is able to eat most of his/her meal independently. Requires assistance with heavy cups and foods, such as peas, which require a steadier hand. Member/Veteran/Client requires supervision and help as the Member/Veteran/Client tends to choke, has swallowing problems, or is quite confused and forgets to eat.
Eighteen	The Member/Veteran/Client requires the physical assistance of another person to the extent that the Member/Veteran/Client is able to perform less than 50% of eating tasks.	Member/Veteran/Client is unable to use utensils. Member/Veteran/Client is able to raise foods such as breads, biscuits, sandwiches, etc. to his/her mouth independently, but requires the physical assistance of another person for all foods for which utensils are to be used.
Twenty-one	Completely dependent. The Member/Veteran/Client is completely dependent on another person to perform all eating tasks.	Member/Veteran/Client is fed. Member/Veteran/Client takes no food by mouth.

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 19.4 - Loss of Function - Transfers/Bed Mobility

Rating	Criteria	Examples
Nil	Independent. Can transfer between surfaces and move around in bed without special equipment, adaptation, or assistance from others.	Able to sit up and move around in bed unaided, and able to move from sitting to standing and standing to sitting unaided.
One	Independent. Can transfer between surfaces and move around in bed without special equipment, adaptation, or assistance from others, but has difficulty and/or pain carrying out activity.	A wide stance, shakiness, etc., when moving from sitting to standing, or from standing to sitting. Multiple attempts before successfully carrying out a transfer or movement in bed. Pain with transfers and bed mobility. May take more than reasonable time to carry out activity.
Four	Independent with aids, assistive devices or adaptation of task. Can transfer between surfaces and move around in bed independently with aids or assistive devices, or with adaptation of the activity. A prosthesis or orthosis is considered an assistive device if used for a transfer.	Needs the use of the upper extremities when moving from sitting to standing, or from standing to sitting. Requires a raised seating/surface. Needs assistive devices such as a bed ladder or similar device, transfer rails or a chair with arm rests, etc.
Nine	The Member/Veteran/Client requires the assistance of another person to transfer between surfaces and/or move around in bed for set-up or supervision only.	Requires that a person be available to prepare the surfaces for transfer (i.e. raise or lower the surface). Uncomfortable moving from sitting to standing or standing to sitting without the presence of another person "in case".
Thirteen	The Member/Veteran/Client requires the physical assistance of another person to the extent that the client can still perform 50% or more of the tasks associated with bed mobility and/or transferring.	Requires some help positioning the lower extremities in bed. Requires the physical assistance of another person to help position the legs to prepare for transfers, etc.
Eighteen	The client requires the physical assistance of another person to the extent that the client is able to perform less than 50% of the tasks associated with bed mobility and/or transferring.	Requires partial lift or support when moving from standing to sitting or sitting to standing. Requires partial lift, or boost, to move from lying to sitting, or to move around in bed.
Twenty-one	Totally dependent. The client is dependent on another person to perform all aspects of transferring between surfaces and/or moving around in bed.	Requires the use of manual or electric lifts. Requires a two-person lift.

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 19.5 - Loss of Function - Locomotion

Rating	Criteria	Examples
Nil	Independent. Can walk on level ground, on gentle slopes, and on stairs without special equipment, adaptation, or assistance from others.	Walks in a manner normal for age on a variety of different terrains and at varying speeds.
Four	Independent. Can walk on level ground, on gentle slopes, and on stairs without special equipment, adaptation, or assistance from others, but has difficulty and/or pain carrying out activity.	Walks at a normal pace on flat ground but with intermittent difficulty. Caution needed on steps and uneven ground. Intermittent pain with weight bearing.
Nine	Independent with aids, assistive devices or minor reduction of walking distance. Can walk independently on level ground, on gentle slopes, and on stairs with aids or assistive devices.	Walks at a reduced pace in comparison with peers on flat ground. Unable to manage stairs or ramps without rails. Pain restricts walking to 250 m or less at a time. Can walk further after resting.
Eighteen	The client requires minor task adaption or minor physical assistance of another person for locomotion. Walking distance moderately limited.	Requires the physical assistance of another person to hold their arm for stability. Unable to negotiate stairs without personal assistance. Requires routine use of a cane or crutch. Pain restricts walking to 100 m or less at a time. Can walk further after resting.
Twenty-six	The client requires moderate physical assistance of another person to perform some aspects of tasks or moderate adaption of task. Walking distance severely limited.	Client requires the routine use of a walker. Pain restricts walking to 50 m or less at a time. Can walk further after resting.
Thirty-four	Totally dependent. Client is unable to walk or stand. Mobile only in a wheelchair.	Is bed/chair bound.

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 19.6 - Loss of Function - Bowel and Bladder Control

Rating	Criteria
Nil	Continent of bowel; and Continent of bladder but may have occasional symptoms of dysuria, urgency and/or frequency.
One	Lower urinary tract infection 1-2 times per year.
Four	Fecal incontinence associated with occasional staining; no incontinent pad required; or Urinary incontinence requiring 1-2 incontinent pads per day; or Symptoms of dysuria, urgency and/ or frequency and daytime voiding every 3 hours and awake at least once throughout the night.
Nine	Fecal incontinence associated with soiling but less than daily; may need incontinent pad on occasion; or May require 2-4 urethral dilatation per year; or Suffers lower urinary tract infections at least 4 times per year despite long term prophylactic antibiotic drug therapy.
Thirteen	Fecal incontinence necessitating frequent changes of underwear or 1 - 4 incontinent pads per day; or Urinary incontinence requiring more than 2 incontinent pads per day; or Symptoms of dysuria, urgency and/or frequency and daytime voiding every 2 hours and nocturia 2-3 times per night.
Eighteen	Permanent use of condom catheter; or Symptoms of dysuria, urgency and frequency and daytime voiding every hour and nocturia 2-3 times per night; or Obstructed voiding with any one of the following: post-void residuals greater than 150cc; uroflometry - markedly diminished peak flow rate (less than 10 cc /sec.); stricture disease requiring more than 4 dilatation per year.
Twenty-six	Fecal incontinence necessitating use of greater than 4 incontinent pads per day; or Permanent colostomy; or Intermittent daily catheterization required; or Symptoms of dysuria, urgency, and /or frequency with less than 30 minutes between voidings and voiding more than 5 times per night.
Thirty-four	No voluntary control of bladder; or Permanent indwelling catheter; or Fecal incontinence with complete loss of sphincter control.
Forty-three	Permanent suprapubic catheter.

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.

Table 19.7 - Other Impairment - Chronic Pain

Rating	Criteria
Nil	Chronic pain not present.
Two	Pain severity is mild (based on intensity and frequency). Intermittent pain treatment required. Pain occasionally interferes with sleep. No or minimal emotional distress in response to pain.
Four	Pain severity is moderate (based on intensity and frequency), with daily or almost daily symptoms. Requires ongoing medical monitoring and requires medication on a regular basis and has good response to treatment. Up to a total of 120 minutes loss of sleep most nights on an ongoing basis. Subjective memory loss/impaired concentration. Mild emotional distress in response to pain, demonstrated by one or more of the following: occasional depressive symptoms; occasional anxiety symptoms; occasional irritability or anger; coping is adequate, but reacts to stress with some degree of anxiety or agitation; occasional difficulty adapting to stressful circumstances (e.g. some difficulty coping and reacts to stress with worsening of behavioural symptoms).
Nine	Pain severity is moderate most of the time but has daily exacerbations where pain intensity reaches 9 - 10/10. Requires ongoing medication on a regular basis but has only partial or inadequate pain relief with requirement for occasional break through pain medication. Insomnia greater than 120 minutes loss of sleep most nights on an ongoing basis. Moderate emotional distress in response to pain, demonstrated by one or more of the following: frequent depressive symptoms; frequent anxiety symptoms but no physiological concomitants; frequent irritability or anger; frequent difficulty applying usual coping skills in stressful circumstances (e.g. reacts to stress with considerable anxiety, agitation, or marked worsening of behavioural symptoms).
Thirteen	Intractable pain*. Individual demonstrates severe emotional distress in relation to pain, demonstrated by one or more of the following: depressed mood communicated both subjectively (e.g. hopelessness or helplessness) and objectively (e.g. tearfulness); anxiety with physiological concomitants; persistent difficulty applying usual coping skills in stressful circumstances (e.g. reacts to stress with considerable anxiety, agitation, or marked worsening of behavioural symptoms).

* 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.