GARP Chapter 5: Neurological Impairment — The Chapter Your Back Claim Is Probably Missing

Chapter 5 covers traumatic brain injury, stroke, peripheral nerve damage, epilepsy, migraine and the progressive neurological diseases. It is unusual in the Guide for one reason: most of it happens somewhere else.

Neurological conditions rarely produce one deficit. A stroke can take your arm, your leg, half your visual field and your speech. So Chapter 5 supplies tables for the functions no other chapter covers — cognition, comprehension, expression, sensation and the cranial nerves — and then sends you out across the rest of the Guide for everything else, combining the results.

This is also the chapter that captures numbness and pins and needles, which is why a back or neck claim is usually incomplete without it.

This is part of our series working through the GARP. Start with what the GARP is, the chapter map, and Chapters 1, 2, 3 and 4.

The structure: combine across functions, compare against prognosis

Four steps:

Rate functional loss on Tables 5.1–5.5 (cognition, comprehension, expression, sensory nerves, cranial nerves).
Rate functional loss under other chapters of the Guide.
Rate the condition on Table 5.6 (the Other Impairment table, based on prognosis and pain).
Combine Steps 1 and 2 through Chapter 18, compare with Step 3, and take the higher.

The governing rule sits behind all of it: ratings from one functional loss table are combined with ratings from other tables for a different loss of function from the same condition — but functional loss ratings are never combined with Other Impairment ratings for the same condition.

The Guide's own example is the clearest illustration. A cerebrovascular accident "may require ratings for hemiparesis of the upper limb, hemiparesis of the lower limb, hemianopia and dysphasia" — four ratings, from Chapter 3, Chapter 3 again, Chapter 8 and Table 5.3, all combined. One condition, four different lost functions, four ratings.

Step 2 routes to Chapter 3 for limb function, Chapter 6 for eating, swallowing and faecal continence, Chapter 7 for hearing, Chapter 8 for vision, Chapter 9 for urinary continence and Chapter 10 for sexual function.

Table 5.1 — cognition

Applied only where an organic brain condition has been diagnosed. It is expressly not for assessing general mental capacity in someone whose condition is unrelated to the brain, and psychiatric conditions go to Chapter 4 instead. The rating must relate only to deficits that were not present before the onset of the condition.

The scale is steep — NIL, 10, 25, 40, 60, 70:

10 — mild but demonstrable memory impairment: misplaces objects, difficulty with names and appointments, can still learn but more slowly, and compensates through written notes, schedules, checklists and spouse.
25 — moderate: frequent difficulty recalling recent experiences, fails to follow through on intentions, gets lost more easily in unfamiliar areas; reduced initiative, spontaneity and capacity for abstract thinking; aids such as lists and diaries are still adequate.
40 — the same but more frequent and severe; partially able to compensate but cannot function with complete independence and needs some supervision.
60 — severe: difficulty sequencing the steps for dressing or preparing meals; unable to work or live independently; needs supervision to avoid harm.
70 — gross: unable to initiate and sustain activities without supervision; prompting required for virtually all daily activity.

The Guide adds an important caution, and it cuts both ways: self-reports of deteriorating mental function must be interpreted with caution, because organic brain disease often comes with a lack of insight or denial of failing abilities — while self-reported poor memory may actually reflect depression rather than a true memory deficit. Where there is doubt, formal psychometric testing may be required.

If you have an accepted brain injury and cognitive symptoms, neuropsychological testing is the evidence that settles this table. Without it, the assessment is working from an impression.

Tables 5.2 and 5.3 — comprehension and expression

Rated separately, and combined where both apply. Neither may include deficits present before the condition began.

Comprehension (5.2) runs NIL, 5, 10, 25, 40, 50 — from difficulty following group discussion or rapid topic changes, through understanding only simple sentences, to being unable to understand simple instructions or yes/no questions even with gesture. It also carries dyslexia criteria at the mild, moderate and severe levels.

Expression (5.3) assesses four things: audibility (speaking loudly enough to be heard), intelligibility (articulating accurately enough to be understood), functional efficiency (speaking quickly enough and sustaining it), and retrieval and manipulation of language. Its 5-point criteria include being permanently hoarse, being unable to shout, needing to repeat yourself at times, or sustaining speech for ten minutes only with hesitation and word-retrieval difficulty.

Note the boundary: where communication is restricted by vision loss, hearing loss or loss of hand function, the rating comes from Chapter 8, Chapter 7 or Chapter 3 respectively — not from these tables.

Table 5.4 — sensory nerves, and why your back claim needs it

This is the table most veterans never hear about, and it is the one that matters for a very common situation.

Chapter 3 assesses the motor function of the spine and limbs. Sensory loss is assessed here instead — and, critically, as well as. If your accepted lumbar condition causes numbness down your leg, that is a rating under Table 5.4 which combines with your spinal rating. It is not counted in the spinal figure.

Ratings are given by dermatome or peripheral nerve, but not both for the same loss, across three columns: partial unilateral loss, total unilateral or partial bilateral loss, and total bilateral loss.

C6 & 7 (together) — 5 / 10 / 20
C2-3, C8, L5 & S1, S2&3&4 — 0 / 5 / 10
Median nerve — 5 / 10 / 20
Ulnar, sciatic, tibial, pudendal, posterior femoral cutaneous, greater auricular — 0 / 5 / 10
Radial nerve — 0 / 0 / 0
Central hemianaesthesia — 15 / 30

"Partial loss" means either less than the complete nerve distribution, or altered sensation — and the Guide names peripheral neuropathies with a "glove and stocking distribution" and "happy feet" as examples. That language is worth noticing, because it is exactly how a veteran with diabetic or chemical-exposure neuropathy describes their symptoms.

Under presumptive liability, peripheral neuropathy is attributable where diabetes mellitus is an accepted condition present at onset — so for many veterans this table is now more accessible than it used to be.

Table 5.5 — cranial nerves

Mostly a routing table. Vision and eye movement go to Chapter 8; chewing and swallowing to Chapter 6; hearing to Chapter 7; balance to Chapters 15 or 16; speech to Table 5.3. Where no alternative table exists, Table 5.5 supplies the rating:

Smell (I) — 0 unilateral, 5 bilateral
Taste (VII) — 0 unilateral, 5 bilateral
Facial expression (VII) — 10 unilateral, 20 bilateral
Trigeminal sensory (V), each division — 5 unilateral, 10 bilateral
Shoulder elevation (XI) — 5 unilateral, 10 bilateral

The listed figures are for complete loss; partial losses are reduced proportionately.

Table 5.6 — when there is a condition but little deficit

The Other Impairment table exists for conditions where the functional deficit is minimal but a significant neurological condition is nonetheless present. It rates on prognosis and, in some cases, pain:

NIL — headaches of any type that are infrequent and easily controlled; a history of epilepsy no longer needing medication.
5 — documented cerebrovascular disease (TIAs, a CVA with good return of function, arterial narrowing demonstrated on Doppler or angiography — but not calcification on plain X-ray); aneurysms not surgically corrected; tics or hemifacial spasm; epilepsy requiring daily medication.
10 — progressively deteriorating neurological disorders with significantly reduced life expectancy, such as multiple sclerosis or Alzheimer's disease; intermittent tic douloureux.
20 — rapidly progressive disorders with significantly reduced life expectancy, such as motor neurone disease; frequent tic douloureux.

Two useful observations. A stroke with good recovery still rates 5 — recovery does not reduce it to nothing. And well-controlled epilepsy on daily medication rates 5 even with no seizures, because the criterion is the medication requirement, not the seizure frequency.

The Guide also notes that Chapter 15 (Intermittent Impairment) may be applied where episodes are more frequent or severe. For migraine and epilepsy this usually produces the better figure, and the two should be compared.

What this means in practice

If you have an accepted spinal condition with numbness, that is a separate rating. Chapter 3 handles motor function only. Sensory loss belongs to Table 5.4 and combines with your spinal figure. This is one of the most commonly missed points in the entire Guide.

Get the nerve distribution documented. Table 5.4 is organised by dermatome and named peripheral nerve. "Numbness in the leg" cannot be rated; "altered sensation in the L5 and S1 distribution" can.

For a brain injury, get formal testing. The Guide says psychometric testing may be required where there is doubt, and Table 5.1's steps are large — 10 to 25 to 40. Testing is what moves an assessment off an impression.

Bring an observer for cognition too. Just as with Chapter 4, the Guide expressly recognises that people with organic brain disease often lack insight into their own deficits. A family member's account is evidence.

List every function the condition has affected. This is the chapter where ratings genuinely combine across the Guide. Limb weakness, vision, hearing, swallowing, continence and sexual function are all separately rateable consequences of one neurological condition.

For migraine and epilepsy, compare with Chapter 15. Table 5.6 gives 5 points for epilepsy on daily medication and NIL for infrequent headaches. The intermittent impairment method usually captures a genuinely disabling episodic condition better.

Frequently asked questions

My back is accepted and I get numbness down my leg. Is that included?

No — and it should be rated separately. Chapter 3 assesses motor function; sensory loss is assessed under Table 5.4 in Chapter 5 and combines with the spinal rating.

Is my head injury assessed here or under mental health?

Cognitive deficits from a diagnosed organic brain condition are assessed under Table 5.1. Psychiatric conditions, including PTSD and depression, go to Chapter 4. Someone with both may be rated under both.

Does my epilepsy count if I have not had a seizure in years?

Epilepsy requiring daily medication rates 5 under Table 5.6. A history of epilepsy no longer requiring medication rates NIL.

How is migraine rated?

Infrequent, easily controlled headaches rate NIL under Table 5.6, so migraine is usually better assessed under Chapter 15 (Intermittent Impairment), which rates attack severity, duration and the number of affected days per year. The Guide directs that Chapter 15 may be applied for more frequent or severe episodes.

I had a stroke but recovered well. Is it worth anything?

Yes. "Cerebrovascular accident with good return of function" is expressly a 5-point criterion under Table 5.6, and any residual deficits are separately rated and combined.

How is peripheral neuropathy rated?

Under Table 5.4, by the nerve or dermatome affected and whether the loss is partial or total, unilateral or bilateral. The Guide names glove-and-stocking distribution and "happy feet" as examples of partial loss.

Does age adjustment apply?

No. None of the tables in Chapter 5 permit age adjustment.

Next in this series

Chapter 6: gastrointestinal impairment — reflux, bowel conditions, hernias and obesity.

Talk to us

If you have a permanent impairment assessment coming up and want it done by a doctor who applies this Guide every week, call 0429 146 039 or email reception@vhc.org.au.