New Delhi, the 1st June, 2001
Subject - Guidelines for evaluation of various disabilities and procedure for certification.
- 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. 4-2/83-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, Government of India in Ministry of Social Justice and Empowerment, vide Order No. 16-18/97-NI. I, dated 28-8-1998, set up four committees under the Chairmanships of Director General of Health Services-one each in the area of mental retardation, Locomotor/ Orthopaedic disability, Visual disability and Speech & Hearing disability. Subsequently, another Committee was also constituted on 21-7-1999 for evaluation, assessment of multiple disabilities and categorization and extent of disability and procedures for certification.
- 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 disabilities and procedure for certification -
- Visual impairment
- Locomotor / Orthopaedic disability
- Speech & hearing disability
- Mental retardation
- Multiple Disabilities.
- The minimum degree of disability should be 40% in order to be eligible for any concessions/benefits.
- According to the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Rules, 1996 notified on 31.12.1996 by the Central Government in exercise of the powers conferred by sub-section (1) and (2) of section 73 of the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 (1of 1996), authorities to give disability Certificate will be a Medical Board duly constituted by the Central and the State Government. The State government may constitute a Medical Board consisting of at least three members out of which at least one shall be a specialist in the particular field for assessing locomotor/Visual including low vision/hearing and speech disability, mental retardation and leprosy cured, as the case may be.
- Specified test as indicated in Annexure should be conducted by the medical board and recorded before a certificate is given.
- 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'.
- The State Governments/UT Administrations may constitute the medical boards indicated in para 4 above immediately, if not done so far.
- The Director General of Health Services Ministry of Health and Family Welfare will be the final authority, should there arise any controversy/doubt regarding the interpretation of the definitions/classifications/evaluations tests etc.
Reports of the Committee set UP to review the guidelines for evaluation of various disabilities and procedure for certification 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 disability, the guidelines for evaluation of various disabilities and procedure for certification as given in the Ministry of Welfare's O.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, five Sub-Committees were constituted in the areas of Mental Retardation, Orthopedic/Locomotor Disability, Visual Disability, 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-NI.I, dated 28.8.1998 and 21.7.1999. A copy each of the Order is at Appendix.I.
These Sub-Committees, after detailed deliberations, have submitted their reports. List of- participants of the meetings taken by the Committee is at Appendix.ll. The reports of the 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 Appendix.lll.
Government of India
Ministry of Social Justice & Empowerment
New Delhi Dated 28lh August 1998.
In order to review the definitions of various types of disability, the guidelines for evaluation of various disabilities and procedure for certification as given in the Ministry of Welfare's O.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 hereby constituted in the areas of Mental Retardation, Orthopedic/Locomotor Disability, Visual Disability and Speech & Hearing disability:
I Sub-Committee on Mental Retardation:
- Dr. S P Aggarwal, Chairperson Director General Health Services Ministry of Health and Family Welfare, Nirman Bhawan New Delhi-11
- Dr.R.Srinivastava Murthy, Co-Chairperson Prof.&Head. Deptt. of Psychiatry, NIMHANS. Bangalore-22.
- Dr. G G.Prabhu, Member Workchil Court Mysore.
- Dr. (Mrs.)NeenaVohra, Member Consultant & HOD, Psychiatry, Dr.R.M.L.Hospital, New Delhi.
- Dr Anand Pandit, Member Hony. Prof & Director KEM Hospital Pune-11.
- Dr. D.K Menon, Member-Secretary Director National Instt. for Mentally Handicapped Secunderabad
II. Sub-Committee on Locomotor / Orthopaedic Disability:
- Dr. S P Aggarwal, Chairperson DGHS. Ministry of Health Nirman Bhavan New Delhi-11
- Dr. K.K. Singh. Co-Chairperson Prof. & Head. AHMS. New Delhi.
- Dr. Balu Sankaran, Member FX-DOHS FX-Chairman AL1MCO. New Delhi
- Dr. Suranjan Bhattacharji, Member HOD. Deptt. of PMR CMC Hospital. Vellore.
- Dr. R K Srivastava Member Medical Superintendent. Safdarjung Hospital New Delhi.
- Dr. B P Yadav Member Ex-Chairman Rehab Council of India New Delhi
- Dr. B R Avadhani Member - Secretary Director IPH New Delhi
III. Sub - Committee on visual Disability.
- Dr. S P Aggarwal Chairperson D.G.H.S. Ministry of Health New Delhi
- Dr.V.K.Dada. Co-Chairperson Head. Dr R.P.Centre. AIIMS. New Delhi.
- Dr.Hari Mohan. Member Director. Mohan Eve Institute. Rajender Nagar. New Delhi
- Shri Lal Advani Member Consultant Saket. New Delhi
- Dr. Bhushabn Punani Member Blind Men's Association Ahmedabad
- Shri S A Datrange Member National Association for the Blind Mumbai.
- Dr. S R Shukla Member-Secretary Director NIVH. Dehradun.
IV. Sub- Committee on Speech & Hearing Disability:
- Dr. S P Aggarwal Chairperson D.GH.S. Ministry of Health. New Delhi
- Dr.S.K.Kacker. Co-Chairperson Ex-Director. AIIMS. New Delhi.
- Dr S Nikam Member Director AllMS, Mysore.
- Dr. J.M.Hans. Member Sr.ENT Surgeon. Dr. RML Hospital. New Delhi
- Dr. M Raghunath Member Professor in Audiology PGIMER. Chandigarh
- Dr. (MRS) RekhaRoy Member-Secretary Director AYJNIHH Mumbai-400050.
1 The terms of reference for the Committees are as follows:
- Providing uniform definitions and categorisation of degree and extent of the disability.
- Recommending authorities competent to give certification.
- The Committees will submit their report in two months.
TA/DA to the members of the Committee will be borne by the concerned
Institute whose Director is included as Member-Secretary of the Sub- Committee.
(Gauri Chatterjee) Joint Secretary to Govt. of India
Tele No. 3381641
All Members of the Committees.
Copy for information to :
PSs to Secretary (SJ&E)/AS(SJ&E),JS(DD)
ShastriBhavan, New Delhi. Dated 21st July1999
It has been decided to constitute a Sub-Committee in the sector of Multiple Disability, in order to have standard definitions and guidelines for evaluation and procedure for certification, arid to make appropriate recommendations. keeping in view the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995. Accordingly, a Sub-Committee is hereby constituted in the sector of multiple disability, with the following Members:
- Dr. SP Aggarwal, Chairman Director General of Health Services Ministry of Health & Family Welfare Nirman Bhavan, New Delhi.
- Smt. Aloka Guha. Member Director, Spastics Society of Tamil Nadu, Opp.TTTI, Taramani Road, Ohennai-13
- Dr. H.C. Goyal, Member Consultant, Rehabilitation Department Safdarjung Hospital, New Delhi.
- Dr. Uma Tuli, Member General Secretary Amar Jyoti Charitable Trust, N-192,Greater Kailash -1 New Delhi - 110048.
- Dr DK. Menon, Member- Secretary Director, National Institute for the Mentally Handicapped, Manovikasnagar, Secunderabad-500 009,
3. The terms of reference for the Committee are as follows:-
- Providing uniform definitions and categorisation of degree and extent of the disabilities.
- Recommending authorities competent to give certification.
- The Committee will submit its report in two months.
4. TA/DA to the members of the Committee will be borne by the National Institute for the Mentlally Handicapped, Secunderabad.
Joint Secretary to the Government of India.
Tele No.338 1641
All Members of the Committees
Copy for information to-:
PSs to Secretary (SJ&E)/ AS (SJ&E)/ JS(DD).
List of participants of the meeting held on 29.2.2000 under the Chairmanship of Dr. S.P.Agarwal. Director General of Health Services with the Members of Subcommittee constituted vide Order No.16-18/96-NI.I (PWD). dated 28.8.1998 of Ministry of Social Justice & Empowerment
- Dr. R.K. Srivastava. Addl.Director General of Health Services.
- Dr. V.K. Dada, Head, R.P. Centre, AIIMS, New Delhi.
- Dr. R.Srinivasa Murthy, Prof. & HOD, Deptt. of Psychiatry, NIMHANS, Bangalore.
- Dr. O.K. Menon, Director, NIMH, Hyderabad.
- Dr. Rekha Roy, Director, NIHH, Mumbai.
- Dr. S.R. Shukla, Director, NIVH, Dehradun.
- Dr. Dharmendra Kumar, Officiating Director, NIRTAR, Cuttack.
- Dr. A.S. Bais, Deputy Director General (Medical).
- Dr. S.Chug, Consultant in Medicine & Chairman, Medical Board, Dr.RML Hospital.
- Dr. LS. Chauhan, ADG (IH),
- Dr. A.N. Sinha, CMO (HA).
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.
- Dr. R.K. Srivastava, Addl. Director General of Health Services
- Dr. H.C. Goyal, Consultant & HOD, Rehabilitation, S.J.Hospital. New Delhi.
- Dr. O.K. Menon, Director, National Institute for the MentallyHandicapped, Secunderabad.
- Smt. Aloka Guha, Director, Spastic Society of Tamil Nadu, Opp. TTTI,Taramani Road, Chennai-13.
- Dr. A.N. Sinha, CMO (HA).
A. MENTAL RETARDATION
- Definition:- Mental retardation is a condition of arrested or incomplete development of the mind, which is especially characterised by impairment of skills manifested during the development period which contribute to the over all level of intelligence, i.e., cognitive, language, motor and social abilities.
- Categories of Mental Retardation:- 2.1 Mild Mental Retardation:- The range of 50 to 69 (standardised IQ 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 in the range of 35 to 49. Discrepant profiles of abilities are common in this group with some individuals achieving higher levels in visuo-spatial skills 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 while others have only enough language to communicate their basic needs. 2.3 Severe Mental Retardation:- The IQ is usually in the range of 20 to 34. In this category, most 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 IQ in this category estimated to be under 20. The ability to understand or comply with requests or instructions are severally limited. 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 little or no ability to care for their own basic needs and require constant help and supervision,
- Process of Certifications:- 3.1 A disability certificate shall be issued by a Medical Board consisting of three members duly constituted by the Central/State Government. At least, one shall be a Specialist in the area of mental retardation, namely. Psychiatrist, Paediatrician and clinical Psychologist. 3.2 The examination process will consist of three components, namely, clinical assessment, assessment, of adaptive behaviour and intellectual functioning.
B. VISUAL DISABILITY
- Definition: - Blindness refers to a condition where a persons suffers from any of the condition, namely, i) total absence of sight; or ii) visual acuity not exceeding 6/60 or 20/200(snellen) in the better eye with best correcting lenses; or iii) limitation of field of vision subtending an angle of 20 degree or worse;
- 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 in the better eye or impairment of field in any one of the following categories:- a) reduction of fields less than 50 degrees b) Heminaopia with macular involvement c) Altitudinal defect involving lower fields.
- Categories of Visual DisabilityAll with correction
CategoryBetter eyeWorse eye% age impairment
Category 06/9-6/186/24 to 6/3620%
Category I6/18-6/366/60 to Nil40%
Category II6/40-4/60 or field of vision 10o -20o3/60 to Nil /td>75%
Category III3/60 to 1/60 or field of vision 10oF.C. at 1 ft. to Nil100%
Category IVF. C. at 1 ft. to Nil or field of vision 10oF.C. at 1 ft. to Nil100%
One eyed persons6/6F. C. at 1 ft. to Nil or field of vision 10o30%
C. SPEECH & HEARING DISABILITY
- Definition of Hearing: - A persons with hearing impairment having difficulty of various degrees in hearing sounds is an impaired person.
- Categories of Hearing Impairment.
CategoryType of ImpairmentD B LeveSpeech discrimination% age of impairment
IMild hearing ImpairmentDB 26 to 40 dB in better ear80 to 100% in better earLess than 40% to 50%
II (a)Moderatehearing 41 to 60 dB in better ear50 to 80% in better earbetter ear 40% to 50%
II (b)Serve hearingImpairment 61 to 70 dB hearing Impairment in better ear40 to 50% in better ear51% to 70%III a) a) Profound hearing Impairment b) Total deafness 71 to 90 dB 91 dB and above/inbetter ear/to hearing Less than 40% in better ear Very Poor discrimination 71% to 100% i) Pure tone average of learning in 500, and 2000 HZ, 4000 HZ by conduction (AC and BC ) should be taken as basis for consideration as per the test recommendations. ii) When there is only as island of hearing present in one or two frequencies in better ear, it should be considered as total loss of hearing. iii) Wherever there is no response (NR) at any of the 4 frequencies (500, 1000,2000 and 4000 HZ), it should be considered as equivalent to 100 dB loss for the purpose of classification of disability and in arriving at the average.
- Process of Certification A disability certificate shall be issued by a Medical Board duly constituted by the Central and the State Government. Out of which, at least, one member shall be a specialist in the field of ENT.
D. LOCOMOTOR DISABILITY
- Definition :- i) Impairment: An impairment in any loss or abnormality of psychological, physiological or anatomical structure or function in a human being. ii) Functional Limitations: Impairment may cause functional limitations which are partial or total inability to perform those activities, necessary for motor, sensory or mental function within the range or manner of which a human being is normally capable. iii) Disability: A disability, is any restriction or lack. ( resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. iv) Locomotor Disability: Locomotor disability is defined as a persons inability to execute distinctive activities associated with moving both himself and objects, from place to place and such inability resulting from affliction of musculoskeletal and/or nervous system.
- Categories of Locomotor Disability The categories of locomotor disabilities are enclosed at Annexure-A.
- Process of Certification A disability certificate shall be issued by a Medical Board of three members duly constituted by the Central and the State Government, out of which, at least, one member shall be a specialist from either the field of Physical Medicine and Rehabilitation or Orthopaedics. Two specimen copies of the disability certificate for mental retardation and others (visual disability, speech and hearing disability and locomotor disability) are enclosed at Annexure-B. It was also decided that whenever required the Chairman of the Board may co-opt other experts including that of the members constituted for the purpose by the Central and the State Government. On representation by the applicant, the Medical Board may review its decision having regard to all the facts and circumstances of the case and pass such order in the matter as it thinks fit.
ANNEXURE-A LOCOMOTOR DISABILITY
REVISED GUIDELINES FOR EVALUATION OF THE PERMANENT PHYSICAL IMPAIRMENT
1.1 Guidelines for Evaluation of Permanent Physical Impairment of Upper Limb
- The estimation of permanent impairment depends upon the measurement of functional impairment and is not expression of a personal opinion.
- The estimation and measurement should be made when the clinical 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.
- The upper limb is divided into two component parts; the arm component and the hand component.
- Measurement of the loss of function of arm component consists of measuring the loss of motion, muscle strength and co-ordinated activities
- Measurement of loss of function of hand component consists of determining the prehension, sensation and strength. For estimation of prehension opposition, lateral pinch cylindrical grasp, spherical grasp and hook grasp have to be assessed as shown in Hand Component of Form A Assessment Proforma for upper extremity.
- The impairment of the entire extremity depends on the combination of the functional impairments of both components
Total value of arm component is 90%
1.2.1 Principles of evaluation of range of motion (ROM) of joints
- The value of maximum ROM in the arm component is 90%
- Each of the three joints of the arm is weighed equally (30%;
The intra articular fractures of the 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 ROMNormal valueActive ROMLoss of ROM
Hence the mean loss of ROM of shoulder will be 50+50+50/3 =150/3 = 50%
Shoulder movements constitute 30% of the motion of the arm component, therefore the loss of motion for arm component will be 50 X 0.3d = 15% If more than one joint of the arm is involved the loss of percentage in each joint is calculated separately as above and then added together.
1.2.2. Principles of evaluation of strength of muscles:
- Strength of muscles 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.
- Loss of muscle power can be given percentages as follows:
- The mean percentage of loss of muscle strength around a joint is multiplied by 0.30.
- If loss 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 motion.
- 1.2.3 Principles of evaluation of coordinated activities:
- 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)
- Each activity has a value of 9%
- Total value of sensation in hand is 30%
- It should be assessed according to the distribution given below: i)Complete loss of sensation Thumb ray 9% Index finger 6% Middle finger 5% Ring finger 5% Little finger 5% ii) Partial loss of sensation: Assessment should be made according to percentage of loss of sensation in thumb/finger(s)
- Total value of strength is 30%
- It includes: i) Grip strength 20% ii) Pinch strength 10%
- Strength of hand should be tested with hand dynamo-meter or by clinical 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 2. Infection 3. Deformity 4. Mat-alignment 5. Contractures 6. Cosmetic disfiguration 7. Dominant extremity-4% 8. Shortening of upper limb First 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.
- Total value of mobility component is 90%
- It includes range of movement (ROM) and muscle strength
- The value of maximum range of movement in mobility component is 90%
- Each of three joints i.e. hip, 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 in different are should be assessed as given in Form B (Assessment Proforma for lower extremity). (Appendix.I of Annexure.A) Affected Joint - Rt. Hip:
Manual muscle Strength gradingLoss of Strength in percentage
Arc of MovementNormal ROMActive ROMLoss in percentage
Rotations0-903066%Mean loss of ROM of Rt Hip = (50+33+66)/3 = 50% Since the hip constitute 30% of the total mobility component of the lower limb the loss of motion in relation to the lower limb will be 50 x 0.30=15% If more than one joint of the limb is involved the mean loss of ROM in percentage should be calculated in relation to individual joint separately and then added together as follows to calculate the loss of mobility component in relation to that particular limb. For example. Mean loss of ROM of Rt. Hip: 50% Mean loss of ROM Rt. Knee: 40% Loss of mobility component of Rt. Lower Limb will be: (50 x 0.30)+(40 x 0.30) = 27% 2.1.2. Principle of Evaluation of Muscle Strength:
- The value for maximum muscle strength in the limb is 90%
- 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.
- Manual muscle grading can be given percentage like below:
Power Grade of MsLoss of strength in percentage
- Mean percentage of muscle strength loss around a joint is multiplied by 0.30 to calculate loss in relation to limb
- 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
- Total value of the stability component is 90%
- It should be tested by clinical method as given in From B (Assessment Proforma for lower extremity). There are nine activities, which need to be tested, and each activity has a value of ten per cent (10%). The percentage valued in relation to each activity depends upon the percentage of loss stability in relation to each activity.
3.1.1 Cervical spine injuriesPercentage of PPI in relation to Spine
i) 25% or more compression of one or two adjacent vertebral bodies with No involvement of posterior elements, No nerve root involvement, moderate Neck rigidity and persistent Soreness.20%ii) Posterior element damage with radiological Evidence of moderate parties dislocation/subluxation including whiplash injury. A) With fusion healed, No permanent motor or sensory changes B)Persistent pain with radiologically demonstrable instability. 10% 25% iii) Severe Dislocation: a) Fair to good reduction with or without fusion with no residual motor or sensory involvement; b) Inadequate reduction with fusion and persistent radicular pain 10% 15%
3.1.2. Cervical Intervertebral Disc LesionsPercentage of PPI In relation to Spine
i) Treated case of disc lesion with persistent pain and no neurological deficit10%
ii) Treated case with pain and instability15%3.1.3. Thoracic and Thoracolumbar Spine Injuries:
i) Compression of less than 50% involving one vertebral body with no neurological manifestation10%
ii) Compression of more than 50% involving single vertebra or more with involvement of posterior elements,healed, no neurological manifestations persistent pain, fusion indicated20%
iii) Same as (b) with fusion, pain only on heavy use of back15%
iv) Radiologically demonstrable instability with fracture or fracture dislocation with persistent pain.30%3.1.3. Thoracic and Thoracolumbar Spine Injuries:
i) Compression of less than 50% involving one vertebral body with no neurological manifestation10%
ii) Compression of more than 50% involving singlevertebra or more with involvement of posterior elements, healed, no neurological manifestations persistent pain, fusion indicated20%
iii) Same as (b) with fusion, pain only on heavy use of back15%
iv) Radiologically demonstrable instability with fracture or fracture dislocation with persistent pain.30%3.1.4 Lumbar and Lumbosacral Spine: Fracture
a)Compression of 25% or less of one or two adjacent Vertebral bodies, No definite pattern or neurological Deficit>15%
b)Compression of more than 25% with disruption of Posterior elements, persistent pain and stiffness, healed With or without fusion, inability to lift more than 10 kgs.30%
c)Radiologically demonstrable instability in low lumbar or Lumbosacral spine with pain35%3.1 5 Disc lesion:
a)Treated case with persistent pain15%
b)Treated case with pain and instability20%
c)Treated case of disc disease with pain activities of lifting moderately modified25%
d)Treated case of disc disease with persistent pain and stiffness, aggravated by heavy lifting necessitating modification of all activities requiring heavy weight lifting30%3.2 NON TRAUMATIC LESIONS: 3.2.1 Scoliosis: Basic guidelines - following modification is suggested:- The largest structural curve should be accounted for while calculating the PPI 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 position should be used. The curves have been divided into following groups depending upon the angle of major structural scoliotic deformity.
GroupCobb's AnglePPI in relation to Spine
IV101 & above30%3.2.3 Torso Imbalance: In addition to the above PPI should also be evaluated in relation the torso imbalance. The torso imbalance should be measured by dropping a plumb line from C7 spine and measuring the distance of plumb line from gluteal crease.
Deviation of Plumb linePPI
Upto 1.5 Cm4%
1.6 - 30 Cm8%
3.1 - 50 Cm16%
5.1 and above32%3.2.4 Head Tilt over C7 spine PPI
More than 1510%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 following method whichever seems more reliable clinically at the time of assessment. The value thus obtained may be added by combining formula.
a. Chest ExpansionPPI
4 - 5 Cm.Normal
Less than 4 cm reduction in Chest expansion5% for each cm
No expansion25%b counting in one breathe:
More than 40Normal
Less than 525%3.2.6 Associated Problems: To be added directly but the total value of PPI in relation to spine should not exceed 100%. a) Pain
-mildly interfering with ADL4%
-moderately restricting ADL6%
-severely restricting ADL10%b) Cosmetic Appearance:
-No obvious disfiguration with clothes onNil
-severe disfigurement4%c) Leg Length Discrepancy.
-First1/2 " shorteningNil
-Every1/2" beyond first1/2"4%d) 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 with the following modifications:
3.3.1 Spinal DeformityPPI
Less than 20Nil
Above 6030%3.3.2 Torso Imbalance - Plumb line dropped from external ear normally falls at ankle level. The deviation from normal should be measured from ankle anterior joint line to the plumb line.
Less than 5 cm in front of ankle4%
5 to 10 cm in front of ankle8%
10 to 15 cm in front of ankle16%
More than 15 cm in front of ankle32%(Add directly) Miscellaneous conditions: Those conditions of the spine which cause stiffness and pain etc. are rated as follows.
ASubjective symptoms of pain, no involuntary muscle spasm,, not substantiated by demonstrable structural pathology-0%
BPain, persistent muscles spasm and stiffness of spine, substantiated by mild radiological change.-20%
CSame as B with moderate radiological changes-25%
DSame as B with severe radiological changes involving any one of the regions of spine-30%
ESame as D involving whole spine-40%4. Guidelines for Evaluation of PPI in cases of Short Stature/Dwarftsm:
- Recumbent length or longitudinal height below 3rd percentile or less than 2 Standard Deviation from the mean is considered to have short stature.
- The evaluation of a Short Statured person should be considered only when it is of disproportionate variety and is accompanied by an underlying pathological conditions, e.g., Achondroplasia,Chandrodysplasia Punctata, spondyloepiphysical dysplasia,mucopoly and acchrydosis, etc.
- The ICMR norms as enclosed at Appendix III of Annexure. A should be used as a guideline for the height.
- Every 1" vertical height reduction should be valued as 4% permanent physical impairment.
- Associated skeletal deformities should be evaluated, separately and total percentage of both should be added by combining formula.
- In cases of multiple amputees if the total sum of permanent physical
- impairment is above 100%, it should be taken as 100% only.
- If the stump is unfit for fitting the prosthesis additional weightage of 5%
- should be added to the value.
- In case of amputation in more than one limb percentage of each limb is added by combining formula and another 10% will be added but when only toes or fingers are involved only 5% will be added
- Any complication in form of stiffness of proximal joint, neuroma infection, etc., should be given upto a total of 10% additional weightage.
- Dominant upper extremity should be given 4% additional weightage.
Upper Limb AmputationsPPI & loss of physical function of each limb
3.Above Elbow upto upper 1/3 of arm85%
4.Above Elbow upto lower 1/3 of forearm80%
6.Below Elbow upto upper 1/3 of forearm70%
7.Below Elbow upto lower 1/3 of forearm65%
9.Hand through carpal bones55%
10.Thumb through C.M. or though 1st MC joint30%
11.Thumb disarticulation through metacarpophalangeal Joint or through proximal phalanx.25%
12.Thumb disarticulation through inter phalangeal joint or Through distal phalanx.15%
Index Finger(15%)Middle Finger(5%)Ring Finger(3%)Little Finger(2%)
13.Amputation through Proximal phalanx or Disarticulation through M.P. Joint15%5%3%2%
14.Amputation through Middle phalanx or Disarticulation through PP joint.10%4%2%1%
15.Amputation through Distal phalanx or disarticulation through DIP joint.5%2%1%1%1.3 Lower Limb Amputations:
3.Above knee upto upper 1/3 of thigh85%
4.Above knee upto lower 1/3 of thigh80%
6.B.K. upto 8 cm70%
7.B.K. upto lower 1/3 of leg60%
13.Loss of first toe10%
14.Loss of second toe5%
15.Loss of third toe4%
16.Loss of fourth toe3%
17.Loss of fifth toe2%6. Guidelines for Evaluation of Permanent Physical Impairment of Congenital deficiencies of the limbs. 6.1 Transverse Deficiencies-
- Functionally congenital transverse limb deficiencies are comparable to acquired amputations and can be called synonymously as congenital amputation, however, in some cases revision of amputation is required to fit in a prosthesis.
- The transverse limb deficiencies therefore should be assessed on basis of the guidelines applicable to the evaluation of PPI in cases of amputees as given in the preceding chapter.
For example:PPITransverse deficiency Rt. Arm complete (shoulder disarticulation)90%Transverse deficiency at thigh complete (hip disarticulation)90%Transverse deficiency Proximal Upper arm (Above elbow Amp.)85%Transverse deficiency at lower thigh (Above knee Amp. Lower 1/3)80%Transverse deficiency forearm complete (elbow disarticulation)75%Transverse deficiency lower forearm (Below Elbow Amp.)65%Transverse deficiency carpal complete (wrist disarticulation)60%Transverse deficiency Metacarpal complete (Disarticulation through carpal bones)55% 6.2 Longitudinal Deficiencies: 6.2.1 Basic Guidelines
- In cases of longitudinal deficiencies of limbs due consideration should be given to functional impairment
- In upper limb, loss of ROM loss muscular strength and hand functions like prehension, etc should be tested while assessing the case for PPI
- In lower limb clinical method of stability component and shortening of lower limb should be given due weightage.
- Apart from functional assessment the lost joint/part of body should also be valued as per distribution Given in chapter Guidelines for Evaluation of PPI in upper extremity and lower extremity The values so obtained should be added with the help of combing formula Example: Congenital Absence of humorous where forearm bones directly articulate with scapula. There will be miled reduction in ROM and strength of muscles in the existing joints apart from loss of body part. Loss of shoulder joint can be given - 30% Loss of ROM of Elbow/Shoulder & Wrist All the components should be added together by the combining formula of a + b (90-a)/ 90 6.2.2 In cases of loss of single bone in forearm the evaluation should be based on the principles of evaluation of Arm component which include Evaluation of ROM, Muscle strength-and coordinated activities. The values so obtained should be added together with the help of combining formula. 6.2.3 In cases of loss of single bone in leg the evaluation should be based on the principles of evaluation of mobility component and stability components of the lower extremity. The values obtained should be added together with the help of combining formula. 7.Guidelines for Evaluation of Physical Impairments in Neurological conditions. 1.1 Basic Guidelines:
- Assessment in neurological conditions is not the assessment of disease but the assessment of its effects, i.e. clinical manifestations.
- These guidelines should only be used for central and upper motor neurone lesions.
- Proformas (form A & B) will be utilized for assessment of lower motor neurone lesions, muscular disorders and other locomotor conditions.
- Normally any neurological assessment for the purpose of certification has to be done six months after the onset of disease however exact time period is to be decided by the Medical Doctor who is evaluating the case and has to recommend the review of certificate as given in the standard format of certificate.
- Total percentage of physical impairment in any neurological condition should not exceed 100%
- In mixed cases the highest score will be taken into consideration. The lower score will be added telescopically to it by the help of combining formula a+b(90-a)/90
- Additional rating of 4% will be given for dominant upper extremity.
- Additional weightage up to 10% can be given for loss of sensation in each extremity but the total physical impairment should not exceed 100%.
Neurological StatusPhysical Impairment
Altered sensorium100%7.3 Table - II Intellectual Impairment (to be assessed by Clinical Psychologist)
Degree of Mental RetardationIQ RangeIntellectual Impairment
ProfoundLess than 20100%7.4 Table - III
Speech defectPhysical Impairment
Servere dysarthria50%7.5 Table - IV
Type of Cranial Nerve InvolvementPhysical Impairment
Motor cranial nerve20% for each nerve
Sensory cranial nerve10% for each nerve
Sensory cranial nerve10% for each nerve7.6 Table-V
Motor system Disability
Neurological InvolvementPhysical Impairment
- Moderate .50%
- Severe75%7.7 Table-VI
Sensory System Disability
Extent of Sensory DeficitPhysical Impairment
AnaesthesiaUpto 10% for each limb
HypoaesthesiaDepending upon % of
ParaestheisLoss of sensation up to 30% depending
Hands/feet sensory lossUpon % of loss sensation7.8 Table - VIII ladder disability due to neurogenic Involvement
Bladder InvolvementPhysical Impairment
Severe(occasional but recurrent Incontinence)75%
Very Severe (Retention/Total Incontinence)100%7.9 Table - VIII Post Head Injury Fits and Epileptic Convulsions
Frequency/Severity of ConvulsionsPhysical Impairment
Mild - occurrence of one convulsion OnlyNil
Moderate 1-5 Convulsions/month on Adequate - Medication25%
Severe 6-10 Convulsions/month on Adequate medication50%
Very Severe more than 10 fits/months On adequate - Medication75%7.10 Table - IX Ataxia (Sensory or Cerebellar)
Severity of AtaxiaPhysical Impairment
Mild (Detected on examination)25%
Very Severe100%8 Guidelines for Evaluation of Physical Impairment due to Cardiopulmonary Diseases. 8.1 Basic Guidelines:-
- Modified New York Heart Association subjective classification should be utilised to assess the functional disability.
- The assessing physician should be alert to the fact that patients who come for disability claims are likely to exaggerate their symptoms. In case of any doubt patients should be referred for detailed physiological evaluation.
- Disability evaluation of cardiopulmonary patients should be done after full medical, surgical and rehabilitative treatment available, because most of these diseases are potentially treatable.
- Assessment of cardiopulmonary impairment should also be done in diseases which might have associated cardiopulmonary problems, e.g.,amputees, myopathies, etc.
- For respiratory assessment, routine respiratory functions test should be done, however, in cases of interstitial lung diseases, diffusion studies may be done.
- In cases of Angina pectoris (chest pain) base line studies in resting ECG should be done. When there is persistence of symptoms, exercise or stress test should be done.
- Definition of Multiple Disabilities: Multiple disabilities means a combination of two or more disabilities as defined in clause (i) of Section (2) of the Persons with Disabilities. (Equal Opportunities, Protection of Rights and Full Participation) Act, 1'995, namely - I. Locomotor disability including leprosy cured II. Blindness/low vision III. Speech and hearing impairment IV. Mental retardation V. Mental illness.
- Guidelines for Evaluation:- In order to evaluate the multiple disability, the same guidelines shall be used as have been developed by the respective sub-committees of various single disability, viz. Mental retardation, locomotor disability, visual disability, and speech and hearing disability and recommended in the meeting held on 29.2.2000 under the Chairmanship of Dr. S.P. Agarwal, Director General of Health Services, Government of India, with reference to Order No.16-18/96-Nl.l, dated 28th August, 1998 and communicated to Ministry of Social Justice & Empowerment, Government of India, vide letter No.S-13020/4/98-MH, dated 16th March, 2000. However, in order to arrive at the total percentage of multiple disability, the combining formula a + b (90-a)/90 as given in the Manual for Doctors to Evaluate
- Permanent Physical Impairment, Developed by Expert Group meeting on Disability Evaluation", shall be used, where "a" will be the higher score and "b" Will be the lower score. However, the maximum total percentage of multiple disabilities shall not exceed 100%. For example, if the percentage of hearing disability is 30% and visual disability is 20%, then by applying the combining formula given above, the total percentage of multiple disability will be calculated as follows:- 30 + 20(90-30) = 43% 90 3. Procedure for Certification of Multiple Disability:- The procedure will remain the same as has been developed by the respective sub-committees on various single disabilities and finalized in a meeting under the Chairpersonship of Dr. S.P. Agarwal held on 29.2.2000. The final disability certificate for multiple disability will be issued by Disability Board which has given higher score of disability by combining the score of different disabilities using the combining formula, i.e., a + b (90-a). In case, where two scores of disability are 90 equal, the final certificate of multiple disability will be issued by any one of them as decided by Local authority. APPENDIX.I OF ANNEXURE.A FROM A ASSESSMENT PERFORMA FOR UPPER EXTERMITY Name ___________..Age_______.Sex_____.Diagnosis______. Address____________O.P.D________.Deptt_________. ARM COMPONENT (Total Value 90%)
Arm ComponentComponentNormal Value (Degrees)Rt. SideLt. SideLoss of % Rt. SideLoss of % Lt. SideMean % Loss Rt. Lt.Sum of % Loss Rt. Lt.Combining Value Rt. Lt.% Summary Value for componentRange of Movement (Active) Value 90% Elbow1. Flexion-Extension Arc 2. Rotation Arc 3. Abduction - Adduction Arc0-220o 0-180o 0-180o Shoulder Range of Movement (Active) Value 90% Wrist 1. Flexion - Extension Arc 2. Radial - Ulnaardeviatior Arc 0-160o 0-55o Muscle Strength Value 90% Shoulder 1. Flexion 2. Extension 3. Rotation - Ext 4. Rotation - Int. 5. Abduction 6. Adduction Muscle Strength Value 90%1. Flexion 2. Extension 3. Pronation 4. Supination Muscle Strength Value 90% 1. Dors Flexion 2. Palmar Flexion 3. Radial Deviation 4. Ulnardeviatior Coordinated Activities Value 90%1. Lifting overhead objects remove and placing at the same place 9% 2. Touching nose with end of extremity 9% 3. Eating Indian Style 9% 4. Combing and Plaiting 9% 5. Putting on a shirt/kurta 9% 6. Ablution glass of water 9% 7. Drinking Glass of water 9% 8. Buttoning 9% 9 Tie Nara Dhoti 9% 10. Writing 9% HAND COMPONENT ( TOTAL VALUE 90%) 30% prehension 1. Hand Component A. Opposition(8%) B. Lateral Pinch (5%) C. Cylindrical Grasp D. Spherical Grasp E. Hook Grasp Movement 1. Index 2. Middle 3. Ring 4. Little Key Holding a. Large Object ( 4o) b. Small Object (1o) a. Large Object ( 4o) b. Small Object (1o) Lifting Bag Normal Value 2] 2] 8% 2] 2] 5% 3} 3} 6% 3} 3} 6% 5% 2. Sensation 30% 1. Radial Side } 2. Ulnar Side } Thumb 3. Radial } Fingers 4. Ulnar} 4:1 (4.8 : 1.2) 3.Strength 30% 1. Grip Strength 2. Pinch Strength 20% 10% Summary value for upper extremity is calculated from component and hand component values Add 4% for dominant extremity 10%. Additional weightage to be given to infection, deformity, malalignment, contracture, cosmetic appearance and abnormal mobility APPENDIX .I OF ANNEXURE . A FROM B ASSESSMENT PROFORMA FOR LOWER EXTERMITY Name________.Age________..Sex_______..Diagnosis__________.. Address______________..O.P.D. No_________..Deptt_______. Diagnosis______________________ MCBILITY COMPONENT (Total Value (90%)
JointComponentNormal ValueRt. SideLt. SideLoss of % Rt. SideLoss of % Lt. SideMean % Rt. Lt.Mean 0.30 Rt. Lt.Combing Value Rt. Lt.% Summary Value for mobility Component a+b (90+a)/90Range of Movement (Active) HIP1. Flexion-Extension arc 2. Abduction Adduction 3. Rotation arc 0-140° 0-90° 0-90° Range of Movement (Active) KNEE 1. Flexion Extension are 0-125°Range of Movement (Active) ANKLE & FOOT 1. Dors flexion Panterlexion are 2. Invesior - Extension are 0-70° 0-60° HH 1. Flexor Muscles 2. Extensor Muscles 3. Abductor Muscles 4. Adductor Muscles 5. Rotator Muscles (Ext. Int.) Muscles Strength KNEE 1. Flexor Muscles 2. Extensor Muscles Muscle Strength ANKLE & FOOT1. Panterliexor Muscles 2. Darsiflexor Muscles 3. Invertor Muscles 4. Exertor Muscles STABILITY COMPONENT (Total Value 90%) Based CLINICAL METHOD of Evaluation 1. Walking on plain surface 10 2. Walking on slope 10 3. Climbing Stairs 10 4. Standing on both legs 10 5. Standing on affected leg 10 6. Squatting on floor 10 7. Sitting Cross leg 10 8. Kneeling 10 9. Taking turns 10 Total 90 10% is given for complications like (I) Infection (ii) Deformity (iii) Loss of sensation. APPENDIX.II OF ANNEXURE .A Ready Reckon Table for A + B(90-A)/90
A(45)45.5046.0046.5047.0047.5048.0048.5049.0049.5050.0050.5051.0051.5052.0052.50READY RECKONER TABLE FOR A + B(90-A)/90
A(90)90.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.00READY RECKONER TABLE FOR A + B(90-A)/90
A(45)53.0053.5054.0054.5055.0055.5056.0056.5057.0057.5058.0058.5059.0059.5060.00READY RECKONER TABLE FOR A + B(90-A)/90
A(90)90.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.00READY RECKONER TABLE FOR A+ B(90-A)/90
A(45)60.5061.0061.5062.0062.5063.0063.5064.0064.5065.0065.5065.5065.5067.0067.50READY RECKONER TABLE FOR A + B(90-A)/90
A(90)90.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.00READY RECKONER TABLE FOR A + B(90-A)/90
A(45)68.0068.5069.0069.5070.0070.5071.0071.5072.0072.5073.0073.5074.0074.5075.00READY RECKONER TABLE FOR A + B(90-A)/90
A(90)90.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.00READY RECKONER TABLE FOR A+B (90-A)/90
A(45)83.0083.5084.0084.5085.0085.5086.0086.5087.0087.5088.0088.5089.0089.5090.00READY RECKONER TABLE FOR A+B (90-A) / 90
A(90)90.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.0090.00Appendix - III of Annexure. A STANDING HEIGHTS FOR INDIAN POPULATION (IN INCHES) MEAN AND STANDARD DEVIATIONS
21year+64.642.4059.8460.242.2455.76ANNEXURE - B CERTIFICATE OF MENTAL RETARDATION FOR GOVERNMENT BENEFITS This is to certify that Shri/Smt./Kum______________________________________________ Son/ Daughter of___________________________________________________ of Village/Town/City ___________________________________with particulars given below:- a) Age b) Sex c) Signature/Thumb impression CATEGORISATION OF MENTAL RETARDATION Mild/Moderate/Server/Profound Validity of the Certificate : Permanent Signature of the Government Doctor/Hospital with seal Chairperson Mental Retardation Certification Board Recent attested photograph showing the disability affixed here. Dated: Place: ANNEXURE - B STANDARD FORMAT OF THE CERTIFICATE Certificate No.____________ Date____________ CERTIFICATE FOR THE PERSONS WITH DISABILITIES This is to certify that Shri/Smt/Kum_____________________________________________________________ Son/wife/daughter of Shri____________________________________________________ Age_____________old male/female, Registration No.___________________ is a case of _______________________________________________________________ He/She is physically disabled/visual disabled/speech & hearing disabled and has______% (_______ per cent) permanent (physical impairment/visual impairment/speech & hearing impairment) in relation to his/her ______________________________________________________ Note:- 1. This condition is progressive/non-progressive/likely to impreove/not likely to improve.* 2. Re-assessment is not recommended/is recommended after a period of ______________________________months/years.* *Strike out which is not applicable. Sd/- Sd/- Sd/- (DOCTOR) (DOCTOR) (DOCTOR) Seal Seal Seal Signature/Thumb impression of the patient. Countersigned by the Medial Superintendent/CMO/Head of Hospital (with seal) Recent attested photograph showing the disability affixed here.