MINISTRY OF SOCIAL JUSTICE AND EMPOWERMENT 5 NOTIFICATION New Delhi, the 1st June, 2001 {Guidelines for evaluation of various disabilities and procedure for F certification. ‘ No, 16-18/97-NI. I.-In order to review the guidelines for evaluation of various disabilities ‘and procedure for certification as given in the Ministry of Welfare’s O.M. No. 4-2/63-HW.-Ill, ‘ated the 6th August, 1986 and to recommend appropriate modifications/alterations keeping in view the Persons with Disabilties (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995, Government of India in Ministry of Social Justice and Empowerment, vvide Order No, 16-18/97-NI. I, dated 28-8-1998, set up four committees under the ‘Chaiemanships of Director General of Health Services-one each in the area of mental retardation, Locomoter/ Orthopaedic disablity, Visual disability and Speech & Hearing fisablity. Subsequently, another Committee vas also constituted on 21-7-1999 for evaluation, assessment of multiple disablities and categorization and extent of disability and procedures for certifiation. 2. After having considered the reports of these committees the undersigned is directed to Convey the approval of the President to notify the guidelines for evaluation of following ‘isabilties and procedure for certification:- # 4. Visual impairment 2: Locomotor / Orthopaedic disability 3, Speech & hearing disability 4, Mental retardation 5, Multiple Disabilities || 3. The minimum degree of disability should be 40% in order to be eligible for any || aman (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 (1of 1996), q Soe er ce eee Ses Pe gaa a | ‘and the State Government. The State government may constitute a Medical Board consisting | 5. Specified test as indicated in Annexure should be conducted by the medical board and 3 recorded before a certificate ls given, a 6. The certificate would be valid for a period of five years for those whose disability is temporary. For those who acquire permanent disability, the validity can be shown as "Permanent 7 The State Governments/UT Administrations may constitute the medical boards indicated in para 4 above immediately, if not done s0 far. 8 The Director General of Health Services Ministry of Health and iFamily Welfare willbe the final authority, should there arise any Controversy/doubt regarding the interpretation of the definitions/classfications/evaluations tests etc. ANNEXURE Reports of the Committee set UP to review the guidelines for evaluation of various disabilities {and procedure for certication and to recommend appropriate modifications/alternations ‘keeping in view the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act 1995. {In order to review the definitions of various types of cisablity, the guidelines for evaluation of various disabilities and procedure for certification as given in the Ministry of Welfare's (.M.No.6-2/83-HW.III, dated the 6th August, 1986 and to recommend appropriate ‘modifications/aiterations keeping in view the Persons with Disables (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995, five Sub-Committees were constituted in the areas of Mental Retardation, Orthopedic/Locomotor Disability, Visual Disabilty, Speech & Hearing and Multiple Disabilities, under the Chairmanship of Dr S.P.Agarwal, Director General of Health Services, vide the Ministry of Social Justice & Empowerment's Order No.16-18/97- NEAL, dated 28.8.1998 and 21.7.1999. A copy each of the Order is at Appendix.Z. 2. These Sub-Committees, after detalled deliberations, have submitted thelr reports. List of participants of the meetings taken by the Committee is at Appendiscil. The reports ofthe Committees set up to review the guidelines for evaluation of various disabilities and procedure for certification on each of the area of the disabilities are given in Appendi APPENDIX. No 16-18/97-NII Government of India Ministry of Social Justice & Empowerment ‘New Delhi Dated 281h August 1998, ‘ORDER In order to review the definitions of various types of disability, the guidelines for evaluation of Various eisablities and procedure for certification as given in the Ministry of Welfare's (.M.No.4-2/83-HW-III, dated the 6th August. 1986 and to recommend appropriate ‘modifications/alterations keeping in view the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995, the following, Sub-Committees are hhereby constituted in the areas of Mental Retardation, Orthopedic/Locomotor Disability, Visual Disabilty and Speech & Hearing disability Sub-Committee on Mental Retardation: 41. Dr. $ P Aggarwal, Chairperson Director General Health Services Ministry of Health and Family Welfare, ‘Nirman Bhawan ‘New Deihi-12 2. Dr.R.Srinivastava Murthy, Co-Chairperson Prof aHead, Depit. of Psychiatry, NIMHANS,Bangalore-22. 3. Dr. G G.Prabhu, Member Workehil Court Mysore. 4. Dr. (Mrs.)NeenaVohra, Member Consultant & HOD, Psychiatry, Dr-R.M.LHospital, New Deth. 5. Dr Anand Pandit, Member Hony. Prof & Director KEM Hospital Pune-11. 6. Dr, D.K Menon, Member-Secretery Director National Instt, for Mentally Handicapped Secunderabad 11, Sub-Committee on Locomotor / Orthopaedic Disability: 1. Dr. SP Aggarwal, Chairperson DGHs. Ministry of Health Nieman Bhavan New Delhi-i1 2, Dr. K.K. Singh, Co-Chairperson Prof, & Head. AHMS, New Delhi. 3, Dr, Balu Sankaran, Member FX-DOHS FX-Chairman ALIMCO. New Delhi 4, Dr. Suranjan Bhattacharl, Member HOD. Dept. of PMR CMC Hospital. Vellore. 5. Dr. RK Srivastava Member Medical Superintendent. Safdarjung Hospital New Delhi. 6. Dr. 8 P Yadav Member Ex-Chairman Rehab Council of India New Delhi 7. Dr. BR Avadhani Member - Secretary Director IPH New Delhi LIL Sub - Committee on visual Disability. 1. Dr. S P Aggarwal Chairperson D.G.its, Ministry of Heaith New Delhi 2. Dr.V.K.Dada. Co-Chalrperson Head. Dr RP.CentreAIMS. New Dai 3. DeHan Mohan. Member Director. Mohan Eve Institute Rajender Nagar. ‘New Dethi 4. Shri Lal Advani Member Consultant ‘Saket. New Delhi 5. Or. Bhushabn Punani Member Blind Men's Association ‘Ahmedabad 6. Shri A Datrange Member National Association for the Blind : Mumbal. 7. Dr. $ R Shukla Member-Secretary Director NIvK, Dehradun, TV, Sub- Committee on Speech & Hi 1. Dr. $ P Aggarwal Chairperson D.GH.S. Ministry of Health. New Delhi 2. Dr.S.K:Kacker. Co-Chairperson Ex-Director. LAIIMS. New Deli 3 DrS Nikam Member Director AlIMS, Mysore. 4. De, JuM.Hans. Member Sr.ENT Surgeon. Dr. RML Hospital. New Delhi 5. Dr. M Raghunath Member Professor In Audiology PGIMER. Chandigarh 6. Dr. (MRS) ReknaRoy Member-Secretary Director AYINIHH Mumbai-400050. 2. The terms of reference for the Committees are as follows: 2) Providing uniform definitions and categorisation of degree and extent of the sisabilty. ') Recommending authorities competent to give certification, ©) The Committees will submit thele report in two months, 3. TAYDA to the members of the Committee will be borne by the concerned Institute whose Director is included as Member-Secretary of the Sub- Committee, (Gaur Chatterjee) Joint Secretary to Govt. of India Tele No. 3381641 sTo. All Members of the Committees. Copy for information to : PSS to Secretary (SIBE)/AS(SI8E),35(0D) ‘ShastriBhavan, New Delhi, Dated 21st uly1999 ‘ORDER thas been decided to constitute @ Sub-Committee inthe sector of Mutiple Disability, in order to have standard definitions and guidelines for evaluation and procedure for certification, aid to ‘make appropriate recommendations. keeping in view the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995. Accordingly, 2 Sub- Committee is hereby constituted in the sector of multiple disability, with the folowing Members: 4. Dr SP Aggarwal, Chairman Director General of Health Services Ministry of Heath & Family Welfare Nirman Bhavan, New Delhi. 2. Smt. Aloka Guha, Member Director, Spastics Society of Tamil Nadu, Opp.TTTI, Taramani Road, Ohennal-{3 3, Dr. H.C. Goyal, Member Constant, Rehabilitation Department Safdarjung Hospital, New Deli 4, Dr. Uma Tull, Member General Secretary ‘Amar 3yotl Charitable Trust, N-192,Greater Kallash -1 New Delhi - 110048. 5. Dr DK. Menon, Member: Secretary Director, National Institute forthe Mentally Handicapped, Manovikasnagar, Secunderabad-500 009, 3. The terms of reference forthe Committee are as folows:- (Providing uniform definitions and categorisation of degree and extent ofthe disablities. (0) Recommending authorities competent to give oertifeation. (©) The Committee will submit its report in two months. 4. TA/DA to the members of the Committee wil be bome by the National Institut forthe Mentally Handicapped, Secunderabad. (Gauri Chatter) Joint Secretary to the Government of India. Tele No.338 1641, To: Al Members of the Committees Copy for information to Ss to Secretary (SIBEY/ AS (SJBE)/ JS(0D).‘APPENDIX. List of participants of the meeting held on 29.2.2000 under the Chairmanship of Dr. S.P.Agarwal. Director General of Heath Services with the Members of Subcommittee constituted vide Order 'No.16-18/96-NL.I (PWD). dated 28.8,1998 of Ministry of Social Justice & Empowerment 1. Dr. RK. Srivastava, Addl Director General of Health Services. 2. Dr. V.K. Dada, Head, R.P. Centre, AIIMS, New Delhi 3. Dr. RStinivasa Murty, Prof. & HOD, Deptt. of Psychiatry, NIMHANS, Bangalore. 4,Dr. O.K. Menon, Director, NIMH, Hyderabad. 5. Dr. Rekha Roy, Director, NIHH, Mumbai. 6 Dr. S.R, Shukla, Director, NIVH, Dehradun, 7. Dr. Dharmendra Kumar, Offdating Director, NIRTAR, Cuttack, 8. Dr. AS. Bais, Deputy Director General (Medical. 9. Dr. §:Chug, Consultant in Medicine & Chairman, Medical Board, Dr. RML Hospital 10. Dr. LS. Chauhan, ADG (IH), 11. Dr. AN, Sina, CMO (HAY. List of participants of the meeting held on 17.8.2000 under the Chairmanship of Dr. S.P.Agarwal Director General of Health Services with the Members of Sub-Committee constituted vide Order 'No.16-18/96-NI.I (PWD). dated 21.7.1999 of Ministry of Social Justice & Empowerment. 1. Dr. RK, Srivastava, Addl, Director General of Health Services 2. Dr. H.C. Goyal, Consultant & HOD, Rehabilitation, S.J.Hospital. New Delhi 3. Dr. O.K. Menon, Director, National Insitute forthe Mentally Handicapped, Secunderabad. 4, Smt. Aloka Guha, Ditector, Spastic Society of Tamil Nadu, Opp. TTI, ‘Taramani Road, Chennal-13. 5. Dr. AN. Sinha, CMO (HA). ‘APPENDIX.LIL A.MENTAL RETARDATION 1. Definition:- Mental retardation isa condition of arrested or incomplete «development of the mind, which is especially characterised by impairment of ‘kl manifested during the development period which contribute to the ‘overall evel of intligence, Le., cognitive, language, motor and social abilities. 2. Categories of Mental Retardation:- 2.1 Mild Mental Retardation:~ The range of 50 to 69 (standardised 10 test) is indicative of mild retardation. Understanding and use of language tend to be delayed to a varying degree and ‘executive speech problems that interfere with the development of independence may persist into adult life, 2.2 Moderate Mental Retardation: - The IQ is inthe range of 35 to 49. Discrepant profiles of abilities are common in this group with some individuals achieving higher levels in visuo-spatial skis than in tasks dependent on language while others are markedly clumsy by enjoy social interaction and simple conversation. The level of development of languagein variable: some of those affected can take part in simple conversations ‘hile others have only enough language to communicate their basic needs. 2.3 Severe Mental Retardation:- The 1Q is usualy in the range of 20 to 34. In this category, mast of the people suffer from a marked degree of motor Impairment or other associated deficits indicating the presence of clinically significant damage to or mal-development of the central nervous system. 2.4 Profound Mental Retardation: - The 1Q in this category estimated to be Under 20. The ability to understand or comply with requests or instructions are severally imited. Most of such individuals are immobile or severally restricted in mobility, incontinent and capable at most of only very rudimentary forms of non-verbal communication. They posses lite or no ablity to care for their own basic needs and require constant help and supervision, 3, Process of Certifications:- 3.1 A disability certificate shall be Issued by 2 Medical Board consisting of three members duly ‘constituted by the Centra/State Government. At least, one shall be a Specials in the area of, ‘mental retardation, namely. Psychiatrist, Paediatrician and clinical Psychologist. 32 The examination process will consist of three components, namely, clinical assessment, ‘assessment, of adaptive behaviour and intellectual functioning. 8. VISUAL DISABILITY 1. Definition: - Blindness refers to @ condition where @ persons suffers from any ofthe condition, namely, |) total absence of sight; or i) visual acuity nt exceeding 6/60 or 20/200(snellen) in the better eye with best correcting lenses; or i) limitation of field of vision subtencing an angle of 20 degree or worse; 2. Low Vision: - Persons with low vision means a person a with impairment of Vision of less than 6/18 to 6/60 with best correction inthe better eye or impaitment of fed in any one ofthe following categories:- 2) reduction of fields less than 50 degrees ») Heminaopia with macular involvement ©) Attudinal defect involving lower fields. 3, Categories of Visual Disability ‘All with correction ~ (age impairment | 20% | ‘6/60 to Nil (uses ed 60 to Wi [2y60 to 1/60 orfield ec at 1 ft. to Ntfield of von 10°F a ‘ il ls cowie om lorfiel of vision 10° 90% jw eetposors Note: F.C, means Finger Count 14, Process of Certification ‘A disabiity certificate shall be issued by a Medical Board duly constituted by the Central/State Government having, at least three members. Out of which, at least one member shall be a specialist in ophthalmology. B, SPEECH & HEARING DISABILITY 1. Definition of Hearing: - A persons with hearing impairment having difficulty of various degrees in hearing sounds isan impaired person, 2. Categories of Hearing Impairment. peice [DB 26t040 (dB in better ear [better ear [41 to 60.08 in [50 to 80%in betereor” beter ear | oe In) [Serve hearing nearing t0 50% in « [Impairment [Impairment |better ear in better ear bs pstana P nearing (71 to 9008 | Impairment | '1 d8 and | \sboverin |O) Total deafness better ear/to hea 1) Pure tone average of learning in 500, and 2000 H2, 4000 HZ by conduction (AC and BC ) ‘should be taken as basis for consideration as per the test recommendations. 1) When there i only a island of hearing present in one or two frequencies in better ear, it should be considered as total lass of hearing. il) Wherever there is no response (NR) at any ofthe 4 frequencies (500, 1000,2000 and 4000 HZ), it should be considered as equivalent to 100 dB loss for the purpose of classification of isablty and in arriving at the average, 3. Process of Certification ‘A disablity certificate shal be issued by a Medical Board duly constituted by the Central and thea * State Government. Out of which, atleast, one member shall be a specialist in the field of ENT. C. LOCOMOTOR DISABILITY 1 Definition - 1) Impairment: An impairment in any oss or abnormality of psychological, physiological or anatomical structure or function in @ human being. i) Functional Limitations: Impalement may cause funtional imitations which are partial or total inability to perform those activites, necessary for motor, sensory or mental function within the range or manner of which @ human being is normally capable. it) Disablity: A disability, i any restriction or lack. ( resulting from an impairment) of ability to perform an actvty in the manner or within the range considered normal fr a human being iv) Locomotor Disabilty: Locomotor disability is defined asa persons inability to execute distinctive actives associated with moving both himself and objec, from place to place and such inability resulting from afficton of musculoskeletal andor nervous system. 2. Categories of Locomotor Disability “The categories of locomotor disables are enclosed at Annexure-A. 3. Process of Certification ‘A disability certificate shal be issued by a Medical Board of three members duly constituted by the Central and the State Government, out of which, atleast, one member shal be a specialist {rom either the field of Physical Medicine and Rehabiltation or Orthopaedics. “Two specimen copies ofthe cisablity certificate for mental retardation and others (visual cisablity, speech and hearing dsabilty ard locomotor dsabiity) ae enclosed at Annexure-8 Twas aso decided that whenever required the Chairman ofthe Board may co-opt other experts induding that ofthe members constituted for the purpose by the Cenval and the State Government On representation by the applicant, the Medical Board may review its decision having regard to all the facts and circumstances ofthe case and pass such order in the matter asi thinks fit. ANNEXURE-A LOCOMOTOR DISABILITY REVISED GUIDELINES FOR EVALUATION OF THE PERMANENT PHYSICAL IMPAIRMENT 41.1 Guidelines for Evaluation of Permanent Physical Impairment of Upper Limb 4. The estimation of permanent impairment depends upon the ‘measurement of functional impairment and isnot expression of a personal opinion, 2. The estimation and measurement should be made when the nical condition has reached the stage of maximum Improvement from the medical treatment. Normally the time period is to be decided by the medical doctor who is evaluating the case for issuing the PPI Certificate as per standard format of the certificate. 3. The upper limb is divided into two component parts; the arm ‘component and the hand component, 4, Measurement of the loss of function of arm component consists of measuring the loss of motion, muscle strength and co-ordinated activities5, Measurement of loss of function of hand component consists of determining the prehension, sensation and strength. For estimation of prehension opposition, lateral pinch cylindrical ‘rasp, spherical grasp and hook grasp have to be assessed as shown in Hand Component of Form A Assessment Proforma for ‘upper extremity. 6. The impairment ofthe entire extremity depends on the ‘combination ofthe functional impairments of both components 2 ARM COMPONENT Total value of arm component is 90% 1.2.4 Principles of evaluation of range of motion (ROM) of joints 1. The value of maximum ROM in the arm component is 90% 2. Each of the three joints ofthe arm is weighed equally (30 Exampl “The intra articular fractures ofthe bones of right shoulder joint may affect range of motion even after healing, The loss of ROM should be calculated in each arc of motion as. envisaged in the ‘Assessment Form A (Assessment Proforma for Upper Extremity). Arc of ROM Normal value ‘Active ROM Loss of ROM Shoulder Flexion 0-220, 110 50% Rotation 0-180 90 50% Abduction-Adduction 0-180 90 50% Hence the mean loss of ROM of shoulder wil be 50-+50+50/3 =150/3 = 50% ‘Shoulder movements constitute 30% ofthe motion of the arm component, therefore the loss of ‘mation for arm component willbe SO X 0.3d = 15% IF more than one join ofthe arm i involved the los of percentage in each joint is calculated separately as above and then added together, 1.2.2, Principles of evaluation of strength of muscles 1 Strength of muscies can be tested by manual method and graded from 0-5 as advocated by Medical Research Council of Great Britain depending upon the strength of the muscles. 2. Loss of muscle power can be given percentages as follows: Manual muscle Strength grading Loss of Strength in percentage 0 100% 1 80% 2 60% 3 40% 4 20% 5 o%4 3, The mean percentage of loss of muscle strength around 2 joint is multiplied by 0.30. 4, If oss of muscle strength involves more than one joint the mean loss of percentage in each joint is calculated separately and then ‘added together as has been described for loss of mation. 1.23 Principles of evaluation of coordinated activities: 1 The total value for coordinated activities is 90% “Ten different coordinated activities should be tested as given in Form A. (Appendix.I of Annexure-A) 2. Each activity has a value of 99% 1.2.4 Combining values for the Arm Component: “The total value of loss of function of arm component is obtained by combining the value of loss (of ROM, muscle strength and coordinated activities, using the combing formula. atb(ooa) 90 where a = higher value b= lower value Example Let us assume that an individual with an intra articular fracture of bones of shoulder joint in ‘addition to 16.596 loss of motion in arm has 8.3% loss of strength of muscles and 5% loss of Coordination. These values should be combined as follows: Loss of ROM - 16.5% Loss of strength of muscles - 8.3% Toadd Loss of coordination - 59% 23.34+5(90-23.3)=27 0% 0 So the total value of loss of function in Arm component will be 27.0% 1,3 HAND COMPONENT: 1 Total value of hand component is 90% 2 The functional impairment of hand is expressed as loss of prehension, loss of sensation and loss of strength 1.3.1 Principles of evaluation of prehension: 1 Total value of prehension is 30% itincludes 8) Opposition - 89% TTested against - Index finger -296Middle finger-2.% Ring 2% = Little finger - 2% ) Lateral pinch -5% - Tested by asking the patient to bold a key between the thumb and lateral side of index finger. ©) Cylindrical grasp - 6% Tested for 1) Large object of 4 inches size -396 1) Small object of 1 inch size - 3% ) Spherical grasp -6% Tested for 1) Large object of 4 inches size - 39% 1) Small object of 1 inch size - 39% €) Hook grasp - 5% -Tested by asking the patient to lift a beg 1.3.2, Principles of Evaluation of sensation: 4, Total value of sensation in hand is 305% 2. Te should be assessed according tothe distribution given below: |) Complete lass of sensation Thumb ray 9% Index finger 6% Middle finger 59% Ring finger 5% Lil finger 596 li) Partial loss of sensation: Assessment should be made according to percentage of loss of sensation in thumb/finger(s) 1.33. Principles of Evaluation of strength 1. Total value of strength is 30% 2, Ttindudes: 1) Grip strength 20% 1) Pinch strength 10% ‘Strength of hand should be tested with hand dynamo-meter or by cinical method (grip method). ‘Additional weightage - A total of 10% additional weightage can be given to following ‘accompanying factors if they are continuous and persistent despite treatment 1. Pam 21 Infection 3. Deformity 44. Mat-alignment 5. Contractures 6. Cosmetic disiguration1s 7. Dominant extreity-4% 8, Shortening of upper mb Fist 1" - No weightage For each 1” beyond first 1" -2% ‘The extra points should not exceed 10% of the total Arm Component and total PPI should not ‘exceed 100% in any case. 1.3.4. Combining values of hand component: “The final value of loss of function of hand component is obtained by summing up values of loss ‘of prehension, sensation and strength. 1.3.5. Combining values for the Extremity: Values of impairment of arm component and impaitment of hand component should be added by Using combining formula: Example: Impairment of Arm 27% 64+27(90-64) 90 Impairment of hand -64% =71.8% “The total value can also be obtalned by using the Ready Recknoer table for combining formula given at Appendix of Annexure.A. 2. Guldelines for Evaluation of permanent physical Impairment in Lower Limb. ‘The measurement of loss of function in lower extremity Is divided into two components: Mobiity and standing components 2.4 Mobility Component: 1 Total value of mobility component is 90% 2. Itincludes range of movement (ROM) and muscle strength 2.1.1. Principles of Evaluation of Range of Movement: 1. The value of maximum range of movement in mobility component is 80% 2. Each of three joints Le. hi, knee and foot ankle component Is weighed equally - 30%, Example: ‘A fracture of right hip joint bones may affect range of motion of the hip joint. Loss of ROM of theaffected hip indifferent are should be assessed as given in Form B (Assessment Proforma for lower extremity). (Appendix.t of Annexure.A) Affected Joint - Rt. Hip: ‘rc of Mavernent Normal ROM ActiveROM Loss in percentage Flexion-Extension 0-140 70 5086 ‘Abduction-Adduction 0-20 6 33% Rotations 0-0 30 66% Mean loss of ROM of Rt Hip =50+33+66= 50% 3 Since the hip constitute 30% of the total moblity component ofthe lower limb the loss of motion {nreation to the lower limb will be 50 x 0.30=15% If more than one joint ofthe limb is involved the mean loss of ROM in percentage should be ‘luted in relation to individual joint seperately and then added together as follows to calculate the loss of mobiity component in relation to that particular limb, For example. Mean loss of ROM of Rt.Hip 50% Mean lass of ROM Rt. Knee 40% Loss of mobility component of Rt. Lower Limb wil be (60 x 0.30)+(40 x 0.30) = 2796 2.1.2. Principle of Evaluation of Muscle Strength: 1. The value for maximum muscle strength in the limb fs 90% 2. Strength of muscles can be tested by Manual Method and graded (0-5 as advocated by MRC of Great Britain depending upon the residual strength in the muscle group, 3. Manuel muscle grading can be given percentage lke below: Power Grade of Ms Loss of strength in percentage 100% 80% 60% 0% 20% 0% 4, Mean percentage of muscle strength loss around a joint is ‘multiplied by 0.30 to calculate loss in relation to limb 5. If there has been a loss muscle strength involving more than one joint the values are added as has been described for loss of ROM. 2.4.3. Combining values for mobility component: 1. The values of loss of ROM and loss of muscle strength should be combined withthe help ofse Combining formula: 2+b(90-2) 90 (a= higher value, b = lower value) Example: Let us assume thatthe individual with a fracture of right hip bones has in addition to 16% loss of motion, 8% loss of muscle strength also. Combined values Motion-16%6 164819016) 90 Strength-8% 6% 2.2 Stability component: 1. Total value of the stability component is 90% 2. It should be tested by cinical method as given in From B (Assessment Proforma for lower extremity). There are nine activities, which need to be tested, and each activity has 2 value of ‘ten per cent (105). The percentage valued in relation to each activity depends upon the percentage of loss stability in relation to ‘each activity 2.3 Extra points: Extra points have been given for pain, deformities, contractures, loss of sensations and shortening Maximum points to be added are 10% (excluding shortening). Details are as following 1) Deformity In funcional poston 3% In non-functional postion 6% i) Pain Sever(aressly interfering 9% with function) Moderate (moderately inter- 6% fering with function) Mild (mildly interfering with 3% function) il) Loss of sensation Complete Loss 9% Patil Loss o% iv) Shortening First 1/2" Nt Every 1/2" beyond first 1/2" % ¥) Complications ‘Superficial complications 3% Deep complications 3, Guidelines for Evaluation of Permanent Physical Impairment of Trunk (Spine)ts ic guideline 1. As permenanent physical impairment caused by spinal deformity tends to change over the years, the certificate issued in relation to spine should be reviewed as per the standard format of the certificate given at Annexure -B of Appendix.IIT. 2. Permanent physical impairment should be awarded in elation to spine and notin relation to whole body. 3, Permanent physical impairment due to neurological deficit in addition to spinal impairment should be added by combining formula. The local eects ofthe lesions ofthe spine can be ‘conventionally divided into traumatic and non traumatic. The percentage of PPI In relation to ‘each situation should be valued as follows: 3.1 TRAUMATIC LESIONS: 3.4.1 Cervical spine injuries Percentage of PPI In relation to Spine |) 2596 or more compression of one or two adjacent 20% ‘vertebral bodies with No involvement of posterior elements, No nerve root involvement, moderate Neck rigidity and persistent Soreness. li) Posterior element damage with radiological Evidence of ‘moderate parties dislocation/subluxation including whiplash injury. ‘A) With fusion healed, No permanent motor oF 10% sensory changes. b) Persistent pain with radiologically demonstrable 25% Instability. ti) Severe bislocation: 2) Fair to good reduction with or without fusion with 10% 1no residual motor or sensory involvement; ») Inadequate reduction with fusion and persistent radicular pain 15% 3.1.2, Cervical Intervertebral Disc Lesions Percentage of PPI In relation to Spine |) Treated case of disc lesion with persistent pain 10% and no neurological deficit 1) Treated case with pain and instability 15% 3.1.3. Thoracic and Thoracolumbar Spine Injuries: 1) Compression of less than 50% involving one 10% vertebral body with no neurological manifestation i) Compression of more than 50% involving single vertebra 20%‘oF more with involvement of posterior elements,healed, no reurolagical manifestations persistent pain, fusion indicated ii) Same as (b) with fusion, pain only on heavy use of back 15% 'v) Radiologically demonstrable instability with 30% fracture or fracture dislocation with persistent pain, 3.1.3. Thoracic and Thoracolumbar Spine Injuries: 1) Compression of less than 50% involving one 10% vertebral body with no neurological manifestation 1) Compression of more than 50% involving singlevertebra or 20% ‘more with involvement of posterior elements, healed, no neurological manifestations persistent pai, fusion indicated li) Sarne as (b) with fusion, pain only on heavy use of back 15% Iv) Radiologically demonstrable instabilty with fracture or fracture 30% slocation with persistent pain. 3.1.4 Lumbar and Lumbosacral Spine: Fracture | Same STAR oS 9 ae We RE Vee a, W|I ef finite pattern or neurological Deficit 3) | Compression of more then 25% with dsrupion of Posterior dements, pastnt | 30% | ain and stifness, healed With or without fusion, init to ft more than 10 kgs. | Raciclogialy demonstrable irstabity in low lumbar or Lumbosacal spine with | 35% a 3.1 § Dise lesion: a) ‘Treated case with persistent pain 13% by) ‘Treated case with pain and instability 20% 9 Treated case of dise disease with pain activities of lifting | 25% moderately modified eso 4) | Treated case of ise disease with persistent pain and | 30% stiffness, aggravated by heavy lifting necessitating | modification of all activities requiring heavy weight lifting 3.2. NON TRAUMATIC LESIONS: (kz WL 03.24 Scol ist Basic guidelines - following modification is suggested. «The largest structural curve should be accounted for while and not the compensatory curve or both structural curves. 3.2.2 Measurement of Spine Deformity: Cobb's method for measurement, of angle of curve in the radiograph taken in standing postion should be used. The curves have been divided into following groups depending upon the angle of ‘major structural scoitic deformity. Group. (Cobb's Angle | PP in relation to Spine] t 1 | 0.20 NIL } | Lu {21-50 | 10% 0 = | 20% 101 & above 430% | 7| j {In addition to the above PPI should aso be evaluated in relation the torso imbalance. The torso ‘imbalance should be measured by dropping a plumb tine from C7 spine and measuring the distance of plum line from gluteal crease. Deviation of Plumb line PPr Upto 1.5 cn 4% 1.6 - 30cm 8% 3:1-506m 16% 5.1 and above 32% 3.2.4 Head Tilt over C7 spine PPI Upto 15 4% More than 15 10% 3.2.5 Cardiopulmonary Test In cases with scoliosis of severe type cardiopulmonary function tests and percentage deviation from normal should be assessed by one of the fllowing method whichever seems more reliable clinically a the time of assessment. The value thus obtained may be added by combining formula, Chest Expansion PPI 4-5¢m. Normal Less than 4 om 15% for each om reduction in Chest expansionNo expansion 25% b counting in one breathe: Breathe Count PPr More than 40 Normal 0-40 5% 0-30 10% 0-20 15% 0-10 20% Less than 5 25% 3.2.6 Associated Problems: To be added directly but the total value of PPI In relation to spine should not exceed 100%. 2) Pain mildly interfering with ADL 4% cmoderately restricting ADL 69 severely restricting ADL 1056 ) Cosmetic Appearance: “No obvious disfiguration with clothes on Nil mild disfigurement 29% “severe disfigurement 4% ©) Leg Length Discrepancy. “Firsts * shortening nu “Every'4" beyond firsts" *% 4) Neurological deficit - Neurological deficit should be calculated as per established method of ‘evaluation of PPI in such cases. Value thus obtained should be added telescopically using combining formula, 3.3 KYPHOSIS Evaluation should be done on the similar guidelines as use for scoliosis wth the following ‘modifications: 3.3.1 Spinal Deformity PPL less than 20 Ni 21-40 10% 41-60 20% ‘Above 60 30% 1332 Torso Imbalance - Plumb line dropped from external ear normally falls at ankle level. The ‘evation from normal should be measured from ankle anterior joint line to the plumb ine. Less than 5 em infront of ankle 4% 5 to 10 cm in front of ankle 8% 10 to 15 cm in font of ankle 16% More than 15 om in front of ankle 32% (Ac decay) Miscellaneous conditions: “Those conditions ofthe spine which cause stiffness and pain etc, are rated as follows.T | Conditions Percentage PPI A | Subjective symptoms of pain, no involuntary | -0% muscle spasm, not substantiated by | demonstrable structural pathology B_ | Pain, persistent muscles spasm and stiffness | -20% of spine, substantiated by mild radiological | change. C [Same as B with moderate radiological | 25% changes D | Same as B with severe radiological changes | 30% involving any one of the regions of spine | E Same as D involving whole spine | 40% 4. Guidelines for Evaluation of PPI in cases of Short Stature/Dwarftsm: 41. Recumbent length or longitudinal height below 3rd percentile or less than 2 Standard Deviation from the mean is considered to have short stature. 2, The evaluation of a Short Statured person should be considered only when it is of ‘isproportionate variety and is accompanied by an underiying pathological conditions, e ‘Achondroplasia,Chandrodysplasia Punctata, spandyioepiphysical dysplasia,mucopoly and ‘acchnydosis, etc. 3. The ICMR norms as enclosed at Appendix II of Annexure. A should be used as a guideline for the height 4, Every 1" vertical height reduction should be valued as 4% permanent physical impairment. 5. Associated skeletal deformities should be evaluated, separately and total percentage of both should be added by combining formula, idelines for Evaluation of Permanent Physical Impairment in Amputees: fe Guidelines: 4. In cases of multiple amputees ifthe total sum of permanent physical impairment is above 100%, It should be taken as 100% only. 2. Ifthe stump Is unfit for fting the prosthesis additional weightage of 5% Should be added to the value. 3. In case of amputation in more than one limb percentage of each limb is added by ‘combining formula and another 10% wll be added but when only toes or fingers are involved only 5% will be added 4. Any complication inform of stiffness of proximal jlnt, neuroma infection, etc, should be tiven upto a total of 10% additional weightage.