DISABILITY EVALUATION

RADHIKA CHINTAMANI
 CONTENTS

Definition
Introduction
Principles of disability assessment
Guidelines for evaluation
Components
 Definition

 Impairment: An impairment is a
permanent or transitory
psychological, or anatomical loss
and /or abnormality. For example a
missing or defective part, tissue organ,
or “mechanism” of the body, such as
an amputated limb, paralysis after
polio, myocardial infarction,
cerebrovascular thrombosis, restricted
pulmonary capacity, diabetes, myopia,
disfigurement, mental retardation
 Functional limitation: Impairment may cause functional
limitations which are the partial or total inability to
perform those activities necessary for motor, sensory, or
mental functions within the range and manner of which a
human being is normally capable such as walking, lifting
loads, seeing, speaking
The universal guidelines for the assessment and
certification of the following disabilities were
finalised by a group experts and were notified by
Ministry of Social Justice and Empowerment.
1. Visual impairment
2. Locomotor disability
3. Speech and hearing
4. Mental retardation
5. Multiple disabilities
 Disability: Disability in which functional limitation and or
impairment is a causative factor, is defined as an existing difficulty
in performing one or more activities which, in accordance with the
subject’s age, sex and normative social role, are generally accepted
as essential, basic components of daily living
 According to PWD Act (persons with disability) the empowered
persons to give disability certificate will be a Medical Board
consisting of at least 3 members out of which atleast 1 shall be a
specialist in a particular field for assessing
locomotor/visual/hearing and speech, MR , duly constituted by
central and state government.
The minimum degree of disability should be 40% in
order to be eligible.
`disability` means-
1. Blindness
2. Leprosy cured
3. Hearing impairment
4. Locomotor disability
5. Mental retardation
•“Expert Group Meeting on Disability Evaluation” was
held in September, 1981 in New Delhi with the
objective to develop simple norms for evaluation of
permanent physical impairment in Indian patients.

• Guidelines developed at the meeting were given due

trial at various centres in the country.

•It was then followed by “National Seminar on

Disability Evaluation & Dissemination” held in
December, 1981.
 Evaluation of permanent physical impairment of

(i) Upper limbs

(ii) Lower limbs
(iii) Trunk (spine)
(iv) Amputations
(v) Neurological conditions
(vi) Facial injuries, burns of head, neck, trunk &
genitalia
(vii) Cardio-pulmonary diseases
BROAD PRINCIPLES OF DISABILITY ASSESSMENT

Functional loss : it is the assessment of functional

loss on some uniform test resulting from permanent
physical impairment caused due to congenital or
acquired conditions

Individual function requirement :functions are

assessed in relation to standard desired functions of
anatomical part.
Where to decide percentage on extent of function/activity-

1. No loss – activity can be performed normally

without assistance
2. Partial loss – activity can be performed partly or
with assistance
3. Total loss – activity cannot be performed even with
assistance.
 Guidelines for evaluation

In order to arrive at the total % of multiple disability,

the combining formula is:
a + b (90 – a)
90
where “a” will be the higher score
“b” will be the lower score
This formula is used to evaluate permanent physical
impairment.
 Variables in assessing locomotor disability

The following variables need to be taken into

consideration while assessing disability:
1. Strength of muscle
2. Range of motion of joint
3. Coordination
4. Stability
5. Limb length discrepancy
6. Hand function ( prehension, sensation and
strength
7. Sensation
8. Deformity
9. Complications like pain, infection
10. Extremity dominant or non dominant.
GUIDELINES FOR EVALUATION OF PERMANENT PHYSICAL
IMPAIREMENT

UPPER LIMB

ARM HAND
 ARM COMPONENT

Total value of arm component is 90%

It consists of measuring:
1. Loss of movement
2. Muscle strength
3. Coordination activities
 Range of motion assessment

The value of maximum ROM in the arm component

is 90%
Each of the three joints of arm is weighted equally
(30%) each

Example: the intra articular fractures of bones of

right shoulder may affect ROM after healing. The
loss of ROM can be calculated as
Arc of ROM Normal value Active ROM Loss of ROM

Shoulder flexion 0-180 90 50%

Rotation 0-180 90 50%

Abduction- 0-180 90 50%

Adduction

• Hence the mean loss of ROM of shoulder will be

50+50+50 = 50 %
3
• Shoulder movements constitute 30% of motion
of the arm component, so the loss of motion of
arm will be 50*0.30= 15%.
 Principles of evaluation of Strength of muscles
Manual muscle strength grading Loss of strength in percentage
0 100%
1 80%
2 60%
3 40%
4 20%
5 0

• MRC grading is done and tested for strength

from 0-5. Loss of muscle power can be given
percentages.
• The mean % of loss of muscle strength is
multiplied by 0.30
 Principles of evaluation of coordinated activities

Total value is 90%

10 different activities are tested
Value of each activity is 9%

Total value for the arm component is obtained by

combining value of loss of ROM, muscle strength and
coordinated activities.
 Principles of evaluation of Prehension
Total value is 30%
1. Opposition 8%
Index finger 2%
middle finger 2%
ring finger 2%
little finger 2%
2. Lateral pinch 5%
tested by asking patient to hold a key between
thumb and lateral side of index finger
3. Cylindrical grasp: 6%
Large objects 4” diameter
Small object 1” diameter

4. Spherical grasp: 6%
Large objects 4” diameter
Small object 1” diameter

5. Hook grasp: 5%
Tested by asking patient to lift
a bag
 Principles of evaluation of sensation

Total value of sensation is 30%

Complete loss of sensation-
1. Thumb 9%
2. Middle finger 5%
3. Index finger 6%
4. Ring finger 5%
5. Little finger 5%
 Principles of evaluation of strength

Total value of strength is 30%

grip strength 20% pinch strength 10%

Strength can be assessed using hand dynamometer.

Additional weight age can be given to the following

accompanying factors if they are continuous:
1. Pain
2. Infection
3. Deformity
4. Mal alignment
5. Contractures
6. Cosmetic disfiguration
7. Dominant extremity- 4%
8. Shortening of extremity- first 1” no weight age for each
1” beyond 1st is 2% disability

Combining values for the extremity:

( a + b ) 90 – a
90
Guidelines for evaluation of disability in
lower limb
The measurement of loss of function in lower
extremity is divided into

mobility stability

Mobility component : total value is 90%

ROM Muscle strength

 Evaluation of ROM

The value of maximum range of motion is 90%

Each of the three joints hip, knee and ankle are
measured equally at 30%.
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 to calculate the loss of mobility.
 Evaluation of Strength of muscles

Maximum value is 90%

Can be tested using MRC
Mean % of strength loss is around a joint is
multiplied by 0.30

Combining values for the extremity:

( a + b ) 90 – a
90
 Extra points
Deformity :
1. in functional position 3%
2. In non functional position 6%
 Pain :
1. Severe 9%
2. Moderate 6%
3. Mild 3%
 Loss of sensation:
1. Complete loss 9%
2. Partial loss 6%
 Guidelines for evaluation of Permanent
Physical Impairment of Spine
PPI caused by the spine tends to change over years.
PPI should be awarded in relation to spine and not in
relation to the whole body.
PPI due to neurological deficit in addition to spinal
impairment should be added by combining formula.
traumatic
PPI of spine
non traumatic
 Traumatic lesions

25% or more compression of one or two adjacent vertebral

bodies with no involvement of posterior elements and no
nerve root involvement, moderate neck rigidity and
persistent soreness – 20
Posterior element damage with radiological evidence of
moderate/ partial dislocation including whiplash injury:
1. With fusion healed, no permanent changes- 10
2. Persistent pain with radiological evidence – 25
 Severe dislocation
1. Fair to good reduction with or without fusion- 10
2. Inadequate reduction - 15
Cervical and intervertebral disc lesions:
1. Treated case of disc lesions with persistent pain and no
neurological deficit: 10
2. Treated case with pain and instability: 15

Thoracic and thoraco-lumbar spine injuries:

3. Compression <50% with 1 vertebral body + no
neurological manifestation: 10
4. Compression >50% with 1 or more posterior element,
healed, no neurological manifestation, pain, fusion- 20
5. Same as 2 but pain only on heavy use- 15
6. Fracture + dislocation/ instability with persistant pain -
30
Lumbar and lumbo-sacral spine:
Compression of 25% or less of 1 or 2 adjacent vertebral
bodies , no neurological deficit-15
Compression of >25% + disruption of posterior elements+
persistent pain+healed with or no fusion+ inability to lift
>10kg- 30
Radiologically demonstrable instability + pain- 35
Disc lesion:
1. Treated case + pain: 15
2. Treated case + pain + instability: 20
3. Treated case of disc disease + pain + lifting affected- 25
4. Treated case of disc disease + pain + lifting affected +
modification of all activities required- 30
 Non traumatic lesions

Scoliosis:
Cobb`s method for measurement of angle of curve in the
radiograph taken in standing position should be used.

GROUP COBB`S PPI in

ANGLE relation to
the spine
1 0-20 Nil
2 21-50 10
3 51-100 20
4 101 and 30
more
 Torso Imbalance

Measured by dropping a plumb line from C7 spine

and measuring the distance of plumb line from
gluteal crease.
Deviation of plumb line PPI
Up to 1.5 cms 4%
1.5- 3 cms 8%
3.1-6.0 cms 16%
6.1 cms and more 32%
Head tilt over C7 spine PPI
Upto 15 4%
More than 15 10%
Cardiopulmonary test
Chest expansion PPI
4-5cm normal
less than 4 cms 5% for each cm
No expansion 25%

Associated problems
1. Pain
2. Cosmetic appearance
3. Leg length discrepancy
4. Neurological deficit
 Kyphosis

Evaluation should be done on the similar

guidelines as used for scoliosis with the following
modifications.

Spinal deformity PPI

less than 20 Nil
21-40 10%
41-60 20%
Above 60 30%
 Guidelines for Evaluation of Permanent
Physical Impairment in Amputees
1. In case of multiple amputees, if the total sum of percentage
permanent physical impairment is above 100%, it should be
taken as 100%.
2. Amputation at any level with uncorrectable inability to wear
and use prosthesis, should be given 100% permanent physical
impairment.
3. In case of amputation in more than one limb percentage of
each limb is counted and another 10% will be added, but when
only toes or fingers are involved only another 5% will be added.
4. Any complication in form of stiffness, neuroma, infection
etc. has to be given a total of 10% additional weightage.
5. Dominant upper limb has been given 4% extra percentage.
Upper Limb Amputation Percent PPI and loss of physical function of each
limb
1. Fore-quarter amputation 100%
2. Shoulder Disarticulation 90%
3. Above Elbow upto upper 1/3 of arm 85%
4. Above Elbow upto lower 1/3 of arm 80%
5. Elbow disarticulation 75%
6. Below Elbow upto upper 1/3 of forearm 70%
7. Below Elbow upto lower 1/3 of forearm 65%
8. Wrist disarticulation 60%
9. Hand through carpal bones 55%
10.Thumb through C.M. or through 1st MC Joint 30%
11. Thumb disarticulation through metacarpophalangeal joint or through proximal
phalanx 25%
12.Thumb disarticulation through inter phalangeal joint or through distal phalanx
15%
 Index Middle Ring Little
finger Finger Finger Finger

13. Amputation 15% 5% 3% 2%

through proximal
phalanx or
disarticulation
through MP joint
14.Amputation 10% 4% 2% 1%
through middle
Phalanx or
disarticulation
Through PIP joint
15.Amputation 5% 2% 1% 1%
through distal
Phalanx or
disarticulation
Through DIP joint
Lower Limb Amputations
1. Hind quarter = 100%
2. Hip disarticulation= 90%
3. Above knee upto upper 1/3 of thigh=
85%
4. Above knee upto lower 1/3 of thigh =
80%
5. Through knee = 75%
6. B.K. upto 8 cm=70%
7. B.K. upto lower 1/3 of leg = 60%
8. Through Ankle= 55%
9. Syme’s= 50%
10. Upto mid-foot=40%
11. Upto fore-foot =30%
12. All toes=20%
13. Loss of first toe =10%
14. Loss of second toe= 5%
15. Loss of third toe= 4%
16. Loss of fourth toe=3%
17. Loss of fifth toe=2%
 Miscellaneous conditions

Those conditions of the spine which cause stiffness and

pain etc and rates as follows.
Conditions Percentage PPI
a) Subjective symptoms of pain, no involuntary muscle spasm, not
substantiated by mild radiology change: 20%
b) Same as A with moderate radiological changes : -25%.
c) Same as B with moderate radiological changes involving Anyone
of the regions of spine : -30%.
d) Same as C involving whole spine :-40%.
Guidelines for evaluation of disability(PPI) in
Neurological conditions may/may not be
associated with Spine.
Basic Conditions:
1) Assessment of neurological conditions is not the
assessment of disease but the assessment of its
effects. i.e clinical manifestation.
2) These guidelines should only be used for central
and upper motor neuron(UMN) lesions.
3) Performa (form A & B) will be utilized for
assessment of lower motor neuron lesions,
muscular disorders and other loco motor
conditions.
Neurological Status: Physical Impairment
Altered sensorium 100%

Intellectual Impairment (to be assessed by

psychiatrist/clinical psychologist)
Degree of mental IQ Range Intellectual
retardation Impairment

Border line 70-79 25%

Mild 50-69 59%
Moderate 35-49 75%
Severe 20-34 90%
Profound Less than 20% 100%
Speech defect PPI
Mild dysarthria Nil
Moderate dysarthria 25%
Severe dysarthria 50%

Cranial nerve disability

Type of Cranial nerve Physical Impairment
Involvement
Motor cranial nerve 20% of each nerve
Sensory Cranial nerve 10% of each nerve
 Motor system Disability – Hemi paresis

Neurological Involvement Mild Impairment

 Mild 25%
 Moderate 50%
 Severe 75%
Sensory System Disability
 Anesthesia Hypoaesthetia : Up to 10% for each limb depending
upon % of loss of sensation
 Paraesthetia: Loss of sensation upto 30% depending
 Hands/feet sensory loss : upon % loss sensation
Bladder disability due to neurogenic
involvement

Bladder involvement Physical

impairment
Mild (Hesitancy/Frequency) 25%
Moderate(precipitancy) 50%
Severe (occasional but recurrent incontinence)
75%
Very Severe(Retention/total incontinence) 100%
 Post head injury Fits & Convulsions

Frequency/severity of convulsions Physical

impairment

Mild-occurrence of one convulsion only Nil

Moderate 1-5 convulsions/month on adequate medication.
25%
Severe 6-10 convulsions/month on adequate medication
50%.
Very severe more than 10fits/mth on adequate medication
75%.
 Ataxia (Sensory or Cerebellar)

Severity of Ataxia Physical Impairment

Mild (detected on examination) 25%
Moderate 50%
Severe 75%
Very severe 100%
Guidelines for Evaluation of Physical Impairment in
(A) Burns of Head and Neck, Trunk and Genitalia (B)
Facial Injuries
(A)TEN-POINT FORMULA FOR EVALUATING POST-
BURN DISFIGUREMENTS AND DEFORMITIES OF HEAD
AND NECK
Head & Neck As a Unit 100 Points Distribution amongst
Equatable Components
SR. NO COMPONENT POINTS
1. Scalp & Vault Including Fore head 10
2. Eye Brows Rt. & Lt. (5 + 5) 10
3. Eye Lids – Rt. Upper 6 Lf. 20
Upper 6
Lower 4 Lower
4
4. Pinna Right 10
Left 10
5. Nose 10
6. Lips Upper 5 10
Lower 5
7. Cheek & Lateral Area of Face Right 5 10
Left 5
8. Neck 10
 Trunk and Genitalia Total
Points 100
SR. NO REGION MALE FEMALE
1 Front of the trunk 5 10
& abdomen
excluding breasts
2 Breast 10 40
3 Total Back 10 5
4 Groins 10 10
5 Buttock 5 5
6 Genitalia 60 30
 (B) FACIAL INJURIES
Head and Neck as a Unit 100 points
SR. NO COMPONENT POINTS
1 Scalp and Vault including 10
forehead
2 Eye Brows Rt. & Lt. (5 +5) 10
3 Eye Lids –Rt. Upper 6 20
Lower 4
Lt. Upper 6 Lower
4
4 Pinna Right 10 20
Left 10
5 Nose 10
6 Middle and lower third of 30
face
(excluding nose & pinna)
Guidelines for Evaluation of Physical Impairment due
to Cardio Pulmonary Diseases
• Modified New York Heart Association subjective
classification should be utilized to assess the functional
disability.
•The physician should be alert to the fact that patients who
come for disability claims are likely to exaggerate their
symptom. In case of any doubt patients should be referred
for detail 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
treat able.
•Assessment of cardiopulmonary impairment should also be
done in diseases which might have associated
cardiopulmonary problems, e.g. amputees, myopathies etc.
Group 0 : A patient with cardiopulmonary disease who is
asymptomatic (i.e. has no symptoms of breath-lessness,
palpitation, fatigue or chest pain).
Group 1 : A patient with cardio-pulmonary disease who
becomes symptomatic during his ordinary physical activity
but has mild restriction (25%) of his ordinary physical
activities.
Group 2 : A patient with cardiopulmonary disease who
becomes symptomatic during his ordinary physical activity
and has 25-50% restriction of his ordinary physical
activity.
Group 3 : A patient with cardiopulmonary disease who
becomes symptomatic during less than ordinary physical
activity so that his ordinary physical activities are 50-75%
restricted.
Group 4 : A patient with cardiopulmonary disease who is
symptomatic even at rest or on mildest exertion so that his
ordinary physical activities are severely or completely
restricted (75-100%).

Group 5 : A patient with cardiopulmonary disease who gets

intermittent symptoms at rest (i.e. patients with bronchial
asthma, paroxysmal nocturnal dyspnoea etc.).
 References
 Kumar R. Assessment and Certification. Guidelines and
Gazette Notification. National Institute for the
Orthopedically Handicapped.
 Manual for Doctors to Evaluate Permanent Physical
Impairment. National Seminar on disability Evaluation and
Dissemination. A.I.I.M.S. New Delhi 1991.
 The ACC User Handbook to the AMA “ Guides to the
Evaluation of Permanent Impairment”. 4th edition. 2010
 Guidelines for Other Disabilities. Ministry of Social Justice
and Empowerment. New Delhi, 1st June 2001.
 WHO Global Disability Action Plan. 2014-2021. Better
Health for All People With Disability.