New Delhi, the 1st June, 2001 Subject :—Guidelines for evaluation of various disabilities and procedure for certification, No, 16-48/87-NI. I.—in order to review the guidelings for evaluation of verious * Gisabilties and procedure for certification as given in the Ministry of Welfare's OM, No..4-2/83-HW.-Il, dated the 6th August, 1986 and fo recommend ‘appropriate modifications/aiterations keeping in view the Persons with Disabilties (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995, Govemment Of India in Mintstry of Social Justice and Empowerment, vide Ordor No. 16-1 a/87- NI. |, dated 28-8.1998, set up four committees under the Chairmanships of Director General of Health Services—one each inthe area of mental rstardation, Locomotor) Onhopasdic disabllity::Visual-disability and-Speech"& Hearing disability: Subsequently, ancthier Committee was also constituted on 23-7-1989 for evaluation, easesement of multiple disablities and categorization and extent of disability and procedures for cettification 2. After having considered the reports of these committees the undersigned is directed to convey the approval of the President ts Notify the guidelines tor, evaluation of following disabilities end procedure’ tor certificatior Visual impairment ite Locomotor / Orthopaedic disability Speech & hearing disability Mental retardation Muttiple Disabilities. 009.01 the Report is enciosed herewith as Annexure: peeonn 3. The minimum degree of disability should be 40% in order to be Gligible for any concessions/benefitsMe se ‘THE GAZETTE OF INDIA ; EXTRAORDINARY (ParI—se. t] 4 According to the Persons with Disabilities (Equal Opportunities, ‘anc Full Participation): Rules, 1808 notifedsans c ‘ intral Government in exercise of thé powers conf a és by sub-section (1) and (2), of 73 of thé Persons with Disabilities 3 s (Equal Opportunities, Protection’ of Righ's and Full Paricipation) Act. 1695 (lof 1996), authorities to give disebilty Certiicate will be a Medical Board Guly constituted by the Central. end the State Government - The State govemment may cénstitute'a Medical Béard ‘consisting of at least three - members out of which at least one shall bea special particular field cluding low -visionMhearing and speech < leprosy, cured, as fhe case may be. disabilit aorary. the validity can be shown as ‘Permanent. 4 The States Govemments/UT “Adm | medical boards indicated in para 4 above int trations _may.-constitute the imediately, if not done’so fer. 8. Family Welfare will be: the final controversy/doubt regarding the. ic definitions/clessifications/evaluations tests etc. a GAURI CHATTER, Jt-Secy.Bs orts of the Comrtities set up to review uidelines for evaluation of yarlous_disabilties_and procedure for_certification and_to recommend ai jiaie_modi erations ina _in_view the is with . In order to review the definitions of various types of disability, the Quidelines for evaluation of various disabilities and procedure for certification 2s Siven in the Ministry of Welfere's O.M.No.4-2/82-HWiIl, dated the 6 August, 1886 and to recommend appropriate edtestenel ons keeping in. view Persons with Disabiités (Equal Opportunt fection of Rights end Full Participation) Act, 1995, ve Sub-Committees were constituted in the areas of Mental Retardation, OrthopeciciL ocomotor Disabilty, Visual Disabilty, Speech & Hearing and Multiple Disabilities, under the Chairmanship of Dr SP Agarwal, Director General of Health Services, vide the Ministy >f Social Justice & Empowerment’s Order No16-18/97-NIl, dated 268.1998 and 21.7.1999. A copy each of the Order is at Appendix... 2, ‘These Sub-Committees, after detailed deliberations, have submitted their reports. List of participants of the meetings taken by the Committee is at Appendix. The reports of the Committees set up to review the guidelines for svaluation of various disabilities end procedure for certification on each of the . area of the-disabilties are given'n Appendixa 16-] 8/ENIS jovemment oftndia Ministry fecal Justice & Empowerment New Delhi, Dated 28% August, 1998. ORDER z _ In order to review the definitions of various pes of disability, the guidelines for evaluation of various sb ni paoeeatee for Saraaon 3s tf Heth, snd Furl Wetec, ‘Nirman Bhawan” New Delhi-l1 2. DeRSrinivastava Murthy, Meinberfort easy 4 Th mL Dr. BK Menon Director National inst. fot Meftall: Handicapped Sectinderdbid Sub-Corttaltee on Locombior / Orthopaedic Disability: Dr.$ P Aggarwal DGHS. Minisuy of Health Nittiah BRavan New Delhi-1) Dr. Balu Sankaran EX-DGHS & FX-Chairinan ALIMCO. New Delhi Dr. Suranjan Bhattachagi HOD: Depn. of PMR CMC Hospital . Vellore De. RK Srivastava Medical Superintendent. Safdarjung Hospital New Delhi Dr. BP Yaday Ex-Chairman Rehab Cenvieil at tidia New Delhi, Dr. BR Avadhani Director [PH New Delhi Subs Commitee on visual Disability Dr. $ P Apganval D.GHS. Ministr: of Health New Dethi Co-Chairperson Chairperson Member Member Member Member Member -Secretary Chairpersoneieseat “THE GAZETTE OF INDIA EXTRAORDINARY Dr-V.K.Dada, _ Head. Dr RP.Cenire. ANMS, New Delhi. 3. Dr-Hari Mohan’ Direcior. Mohan Eye Institute. Rajender Nagar. ‘New Delhi.” 4. Shri Lal Advani Consultant Saket, New Defhi 5. Dr, Bhushabn Punani ‘Blind Men's Association ‘Abmedabad eewsree- 6 Shri A Datrange Co-Chaimerson Member Member National Association forthe Blind Mumbai 7 Dr.S Shukla Director NIVH. Dehradun. ‘Member-Secretarv tv, Sub-Committee on Speech & Hearing Disability: 1 Dr SP Aggarwal D.G.HS.. Minisry of Health, New Delhi AIIMS. New Delhi. 3. Dr. SNikam Director AIMS. ‘Mysore. 4. Dr .M.Hans. ‘STENT Surgeon. Dr.RML Hospital. New Delhi Chairperson Co-Chairperson Member Member piensa es: ‘ Professor in Audiology - PGIMER. Chandigarh 6. Dr. (MRS.) Rekha Roy Member-Secretan’ Director AYJNIHH ? Mumbai- 400050, 2,” The terms of reference for the Committees are as follows : ns and cateyorisation of deuree and extent of 2) Providing uniform definiti the disability b) Recommending authorities competent to git e certification. *) The Committees..will_ submit their report in yo months, Tacs saree “ ‘ 3. TA/DA to the members of the Committee wil! be bome by the concemed Institute whose Direcior is included as Member-Secretary ofthe Sub- Commitice (Gauri Chatterjee) Joint Secretary to Govt. of India Tela No 338 16-41 To. All Members of the Committees. Copv for information to PSs to Secretary (SJ&EVAS(SJKEV/IS(DD) ‘818 Gi72001—12OF Mt ity evaluation and. pro recommend Oo RE Government of India Ministry of Social Justice & Empowerment thes been decided to: ns. ke multiple disability, with the following Members: fe 2 4 Dr. S.P. Aggarwal, Director General of Health Services Ministry of Health & Family Welfare Nirman Bhavan, New Dein. Smt. Aloka Guha. Director, - Spastics Society of Tamil Nadu, Opp.TTTI. Taramani Road, Chennai-13 Dr. H.C..Goyal... ‘Gonauiane Rehabilitation Department ‘Safdarjung Hospital, New Delhi. Dr. Uma Tull, General Secretary Amar Jyoti Charitabie Trust, N-192,Greater Kailash —1 New Delhi - 110048. Shastri Bhavan, New Delhi. Dated 21* July, 1989. eeping in ersOns: isabilities pperturnities, Protection of Rights and Full Participation) Act, ‘Accordingly, @ Sub-Committee is hereby constituted In the sector of Chairman Member Member 1995. hav(arises 1) STON: rT Soar DieDIK-Menamis.2: eee Member. Secretary Director, National Institute for the Mentally Handicapped, Manovikasnagar, Secunderabad-500 099. 3. The terms of reference for the Committee are as follows:~ 2) Providing ‘uniform definitions and categorisation of degree and extent of the disabilities. (®) _ Recommencing authorities competent to give certifcation, (©) » The Committee vill submit ts report in two montis: ‘2 ADAsto the members of the Commitee. willbe: bome: by- the” “National institute for tie Mentally Handicapped, Secundereted (Gauri Chatter) doint Secretary to the Goverment of indie Tele No.338 1641 To: 4ll Members of the Committees Copy for information to: PSs to Secretary (SJ&EV/ AS (SJ&EW JS(DD).2 ‘THE GAZETTE OF INDIA : EXTRAORDINARY. is i 2 Id on 29.2 2000 uni # Chairman: yr. $.P. Aga ior General of i bers of Sub- Committes Se vide Or ark Ie 1Seea (PWD), dated 288.1998 of Ministry of Social Justice & Empowerment, 4. DrRK Srivastava, Addl. Director General of Health Services. ‘ = 2 Dr.V.K. Dada, Head, RP. Centre, AIMS, New Delhi ; 3. _-Dr. R-Srinivasa Murthy, Prot. & HOD, Deptt. bf Psychiatry, _ NIMHANS, Bangalore. % Dr. D.K. Menon, Director, NIMH, Hyderabad?” Dr. Rekha Roy, Director, NIHH, Mumbai Dr. S.R. Shutla, Director, NIV, Dehradun" Dr. Dharmendra Kumar, Officiating Director, NIRTAR, Cuttack. Dr. AS. Bais, Deputy Director General (Medical). ‘Medioal-Boatd,*Dr. 10. Or. L.S. Chauhan, ‘ADG (H, 11. Dr. AN. Sinha, CMO (HA). * List of partici it 78.2000 \airmanshi Or. S.PAgar irector Heath vi : ‘ommittee constituted vide No,16-18/96-N1.! 4,7.1989. Ministry of Sociat Justice iy Dr. RK Srivastava, Addl, Director General of Health Services 2. Dr. HC. Goyal, Consultant & HOD, Rehabilitation, S.J. Héspital, New Delhi. 4 3. Dr.D.K. Menon, Director, National Institute for the Mentally sg: Handicapped, Secunderabad. 4, Smt Aloka Guna, Director, Spastic Society of Tamil Net, Opp. TTT, Taramani Road, Chennai-13. : : 5. Dr. AN. Sinha, CMO (HA).. (aminwer ty ST TE: STeTT 2 A. MENTAL RETARDATION 1, Definition: Mental retardation ‘is @ condition of arrested or incomplete development of the mind, which is especially charactericed by impairment of ‘i skills manifested during the development period which contribute to the ovrealll level of intelligence, i.e., cognitve, language, motor and social - abilities. 2. Categories of Mental Retardation: ‘ 2.1 Mild Mental Reterdation:- 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 5 interfere with the development of independence may persist into adult Ife -7/2-2, Moderate Mental. Retardation :- The .J@ is in tha fenge -of-35--te, 497 Oscrepant profiles of abilities are common’ in’ this group wit) some individuals achieving higher levels in visuo-spatial skills than in tesks dependent on language wnile 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 moter 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 limited. Most-of such individuals are immobile or severally Festicted in mobility, incontifent and capable at most of oniy very rudimentary forms of non-verbal communication. They posses ttle or no abllity to, care for their own basic heeds and require constant help and ie supervision” * 3. Process of Certifications 3.1 disability certificate shail be issued by a Medical Beard consisting of three members duly constituted by the Central/State Govemment. At least one shall be a Specialist in the area. of mental retardation, namely, Psychiatrist, Pediatrician and cinical Psychologist. 2 The examination process will consistof three components, namely , clinical assessment, assessment, of adaptive behaviour and intellectual functioning,94 ‘THE GAZETTE OF INDIA : EXTRAORDINARY. B VISUAL DISABILITY 1. Definition:- Blindness raters toa condition where a persons suffers from any of the condition, namely, i) _ total absence of sight; or |i) visual acuity not exceeding 6160 or 20/200(snellen) in the better eye with best correcting lenses; or lit) limitation of field of vision subtending an angle of 20 degree or worse; 3 2, Law Vision :- Barsons 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 + aos of fd in ry one of te folaving categnres:~ Worseeye._. | % age impairment : [eaten a Bi24to 6/38. | 20% == (Category! (e-636____._ | 6/60 to Nik 40%: Category TI ‘G/40-4/60. or. field | 3/60 to Ni 75% = Gi.yision 10°-20° ed x Category i 360 fo 160c0r|F.C.at tft to Nil | 100% field of vision {0° wets | ae Category Vv F.C.at 1. ft. 0 Nil or field of vision 40%. One eyed persons | 6S . ‘ | J = Note: F.C. means Finger, Count 4, Process of Certification A disability certficate shall be issued by 2 Medical Board duly constituted by : the CentralStats Goyémment having, at least three members. Out of which, at least one member shall = a Specialistin ophamainstogy. B. SPEECH & HEARING DISABILITY |. Definition of Hearing :- A persons with hearing impairment having tty of various degrees in hearing sounds is an impaired person.) Seed SRI: TTT Ba: 2. Categories of Hearing Impaiment’ Caiegory | Type of | DB Level ‘Speech % age of Impairment discrimingtion_| Impairment I Mild “ hearing |DB 26 to 40 80 to 100% in|Less - than impairment dB in better - better ear 40% Slgber tenet ear Ta) Moderate | 41 0 60 dBin 50 to G0% in] 40% to 50% heering __|betterear __better ear | Te) Severe 61 to 70 dB 40 to 50% in| S1%t0 10% heering hearing better ear Impairment impairment in better ear Ti ]2) Profoun [71 to90d8 Less than| 71910 100% 4 40% in better hearing { frcaestnora sunelwe = INDIE, age ent ©) _Tolal/91_ cB and: Very. poor| 100% deaness | above/in discrimination better ear/to hearing : j Pure tone average of leaming in 500, and 2000 HZ, 4000 HZ ty Conduction (AC and BO ). should be taken as basis for consideration as per the test recommendations. 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. §l)_ Wherever there is no response (NR) at any of the 4 frequencies (600, 3 # ne 1000,2000 and 4000 HZ), it should be considered as equivalent to 100 GB loss for the purpose of classification of disability and in arriving at the average Process of Certification disability certificate shall be issued by’ a Medical Board duly constituted by 'e Central and the State Government. Out of which, at least, one member shall be a specialist in the field of ENT. €. LOCOMOTOR DISABILITY 1 i) ii) Definition ~ Impairment: An impairment in any loss or abnormality of psychological, physiological or anatomical structure or function in a human being, Functional Limitations: Impairment may cause functional {imitations which are partial or total inability to perform those activities, necessary for motor, sensory or mental function within the range or manner of which @ human being is normally capable.‘THE GAZETTE OF INDIA : EXTRAORDINARY. pasts yh r iit) Disability:-A disability is any restriction or lack ( resulting from an impairment ) of ability to perform en activity in ‘the manner or within the range considered normal fora human being. _° : ‘W) Locomotor Disability: Locomotor disability. is defined as @ persons inability to execute “distinctive activities associated with moving both himself and objects, from place to place and such inability resulting from - affiction of musculoskeletal and/or nervous system. 2. Categories of Locomotor Disability - ‘The categories of locomotor disabilities are enciosed at Annexure-A. 3. Process of Certification ‘A disability’ cetificaie shall be issued by e Medical Board of three members duly constituted by the: Central 1@ State'Government, out of which, at cialist sical Two specimen: copies’ of the disabilty certificate for mental retardation anc others (visual disability, speech and hearing disability and locomotor disability) . are enclosed et, 2 it was also decided that whenever required the Chairman of the Board may co- opt other experts including thet of the members constlluted for the purpose by the Central and the State Government... - On representation by the applicant, the Medical Boerd 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 eros1-1 Guidelines for Evaluation of Permanent Physical Impairment of Upper Limb 1. @fhe estimation of permanent impairment depends upon the ‘Measurement of functional impairment and is not expression of a personal opinion. 2, The estimation and measurement should bs made when the clinical condition has reached the stage: of ‘maximum improvement fom tne Medical weatment. | Normally the time Rerjod is to, be. decided by the me ‘ie case for issuing the PPI Certificat the certificate. 3. . The upper limb is divided into two component parts: the am ‘component and the hand component 8 per Stardard format of ‘ 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 Grasp, 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 of the entire extremity depends on the ‘combination of the functional 42 ARM COMPONENT: Total value of arm component is 90% 12.4 Principles of evaluation of range of motion (ROM) of joints 1. The value of maximum ROM in the erm components 90% 2. Eech of the three joints of the arm is weighed equally (20%) 19 GIAODI— 15 Goctor Who.is evaluatingo8 ‘THE GAZETTE OF INDIA : EXTRAORDINARY, [Paes Bec: SSR Example: The intra articular fracture jones of right’shoulder joint may affect range of Sabor exo ener peal ng: Fhe OM should be calculated in - gach arc of motion” igaged in tho Assessment Form A (Assesment Proforma for Upper Extremity). ArcofROM ©“ Nofmalvaiué Active ROM Loss of ROM Shoulder Flexton-.. 0-220, Rotation’ ‘Abducton-Adduction ~ 0” 1.2.2, Printiples 61 ue ‘5 1. Strength of muscles. fone Bs Britain Rooenting Upon the: athod and graded een of Great 2. Lossof: osen=d Jos 3. The meen percentage of loss of muscle strength. around a jointis muttiplied by 0.30. 4. Plo88\6t mastie stergth tavewvés' more than on joint the mean joss of percentage in each joints calculated separately and then: added together as has b mn described forloss of motion. 1.23 Principles of evaluation ercsonenaied activities: 1, The total value for coordinated activities is. 90%Cree 1) SET TNS = TATE 99 2... Ten dfferent coordinated ectvities should be tested! as qué it Form A, (Appendix.! of Annexure-A) + 3. Bach activity has a value of 9% 1.2.4 Combining values for the Arm Component: The total value of loss of function of arm compenet is obtained by combining the value of loss of ROM, muscle strength and coordinated activities, using the combing formula a#b(90-a) 90 where igher value lower value “6 Cet bs’assuime that an incividual with an intra fracture of bones of shoulder joint in addition to 16.5% loss Of motion 1A 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% 16.5+8.3/90-16.5) 4 9c : Loss of strength of muscles — 8.3% =23.33% To add Loss of coordination— 5% 23.345(90-23 3)=27 0% = 36 So the total value of loss of function in Arm component wili be 27.0% 1.3 HAND COMPONENT: 1 Total value ofhand component is 90% 2. The functional impairment of hand is expressed as loss of Prehension. loss of sénsation arid logs of strength 1.3.1. Principles of evaluation of prehension: 1, Total value of prehension is 30% itinciuses, 3) apposition - E% ‘Tested against ~ index finger - 2% ~Middie finger —2 % -Ring © -2% Little finger - 2%100 ‘THE GAZETTE OF INDIA : EXTRAORDINARY, [Part—see.1) | seneeiey vb) eordateral pinch, 5% - Tested by asking -the patient to-.0.-) ‘key between the thumb and lateral. side of ind c) Sauer = 6% Ts i Tested for, Large object of 4 Secs see 3% i). Small objectof finch size 3¥ % Tested for - sa . i) Large object of inches size - 3% fe ) | Small object of 1 inch size. -3% : “d) Spherical grasp + e) Hook grasp - 5% -Tested by asking the patient to : EZ lifta bag + . Midde finger 5% : fumes Gs sinh seeyoe inger 5% ji) “Partial loss of sensation: Assessment should be made according to percentage. of. loss. of sensation in thumbifinger(s) Juation of strength * Total 2 ttincudes: é : . D] : j Strength of hand should be tested with hand dyname-meter or by clinical method (grip method). s SEE ‘Additional weightage — A total of 10% additional weightage can be given to following accompanying factors if they are continuous and persistent despite treatment. . Pain ; Infection Deformity Naalignment Contractures Cosmetic disfiguration OaREN>E (ym ers) 101 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 PP! should net exceed 100% in any case. 1.3.4. Combining values of hand component: -The final value of loss of function ct 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 compenent and impairment of hand component should be added by using combining formula: (90-2) == e= higher value Ae ath ——— b= lower value 90 * Example; » Impairment of Arm - 27% 64+27(60-64) 80 Impairment of hand -64% 511.8% The total value can also be obtained by using the Ready Recknoer table for combining formula given at Appendia.ll of Annexure.A. 2, Guidelines for Evaluation of permanent physical Impzirment in Lower Limb . The measurement-of-loss of function in lower extremity is divided into: ‘two comporients: Mobility and standing components. 24 Mobility Component: a Total value of mobility component is 90% 2 It includes range of movement (ROM) and muscle strength 21.1. Principles of Evaluation of Range of Movement: 1. The value. of maximum range of movement in mobility component is 90%102 “THE GAZETTE OF INDIA : EXTRAORDINARY [Parr}-feo. 1) Example. {A fracture of right hip jeint bones may affect range of motion of the hip Joint. Loss of ROM of the affected hip in different are should be assessed es given’ in Form B (Assessment Proforme for lower extremity). (Appendix of Annexure.A) siete. ka VIO ay aeeRenBr? Affected Joint — Rt. Hi Since the hip constitute 30% ‘ofthe total mobiliy component of the lower limb, the Jo8s of motion in relation to the lower limb wit 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:calculeted in relatioin to. individual joint separately and then added together as follows to calculale the loss of mobility component in relation to that particular lim. For example: on cae staan ch AGM a HB 2 ov : te ie crn ale Rt Lower Linbwilbe 1: 2. Strength of mustles can be = ey a and graded 05 as advocated by MRC in depending upon the rer (mee inthe muscle group, 3. Grading can be given percentage ike below. | Power Grade ofMs | Loss of strenath in percentage 0 100%... 1 i 80% 2 60% 3 40% 4 20%_, GS ee UT TT 9 ys ce a ae 5 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 aloss muscle strength involving more than one Joint the values are added as has been describad for loss of ROM - 2.1.3. Combining values for mobility component: + 1. The values of loss of ROM and loss of muscle Strength should be combined with the help of combining formula: a+b(90-2) 90 (@=higher value, b = lower value) ‘so Fxample: Let us assume thet the’ incividual with a tachi® of ght hones” has in addition to 16% loss of motion, 8% loss. of muscle strength also. Combined values Motion ~ 16%. 16+6(90-16) 90 Strength 8% = 22.6% 22 Stability component: 1. Total value of the stability component is 90% 2." It should be tested by clinical method as given in From B (Assessment Proforma for lower extremity). There are rine activities which need to be tested and each activity has a value ot fen per cent (10%). The percentage valued in‘relation to each : activity depends upon the percentage of loss stability in relation ta each activity. 2.3 Extra points: > Extra points have been given for pain, deformities, contractures, loss of shortens one Shortening Maximum points to be added are 10% (excluding shortening). Details are as following: 1) Deformity: In functionel position 3% In non-functional position 6% ii) Pain Sever (grossly interiering 9% with function) Moderate (moderately inter 695 fering with function) Mild (mildly interfering with 3% function)ee Who _ THE GAZETTE OF INDIA : EXTRAORDINARY. ii) ~ Loss of sensation Complete Loss 9% Partial Loss 8% iv) Shortening First 2° - Nil Every % beyond first ° 4% vy) Complications Superficial. complications: 3% Deep complications sui diane aan tien 88 Lear UGE 3. Guldelines for Evaluation of Permanent Physical Impairment of Trunk (Spine) nt ake : Basic guidelines: As permenanent physical impairment caused by spinal deforrity tends to chang i over the years, the certificate issued jn relation 10 cert Appeni 2. Permanent physical impairment should be awarded in relation to spine and notin relation to whole bécy.: : 3. Permanent physical impairment ‘due to neurological deficit in 3 addition 0 spinal impairment should ‘be added by combining formula. The iocal effects of the lesions of the spine can be conventionally divided into traumatic and-non-traumatic. The percentage of PFI in relation to each situation should be valued as follows: oath < i) > 25% or more compression of one or two adjat ‘vertebral bodies with No involvement of posterior elements, No nerve foot involvement, moderate Neck rigidity and per Soreness: F EBLE Va i) Posterior element damage with radiological Evidence of maderate parla! dslocation/subluxation including whiplash injury 2) With fusion healed, No permanent motor or 10% ‘sensory changes. b) Persistent pain with radiologically demonstrable 25% instability.= 408 a) —_ Feirto good reduction with or without fusion with 10% No residual motor or sensory involvement: b) _ Inadequate reduction with fusion and persistent15% radicular pain 2.1.2. Cervical Intervertebral Disc Lesions Percentage of PPI ie : In relation to spine 1) Treated case of disc lesion with persistent p2in10% ‘and no neurological deficit tt) Treated case with pain and instability 15% ee. > Thoracic and Thoracolumbar Spine Injuries: <<" D.~ Gompression of less than 50% involving one 10% vertebral body with no neurological manifestation I) Compression of more than 50% involving single 20% vertebra or more with involvement of posterior elements, healed, no neurological manifestations persistent pain, fusion indicated ii) Same as (b) with fusion, paln only on heavy use of 15% back : - WV) Radiologi¢ally demonstrable instability wth 30% fracture or fracture cislocation with persistent pain. 3.14 Lumbar and Lumbosacral Spine: Fracture a) Compression of 25% or less of one or two adjacent 15% | vertebral bodies, No definite pattem or neurological i deficit u 5) Compression of more than 25% with disruption of 30% | posterior elements, persistent pain and stittness, healed \with or without fusion, inability to lif more than 10 kgs. ° Radiologically demonstrable inetabiity in low lumbar or 35% lumbosacral spine with pain. Aes 1819 Giec01—14106 a) Treated. case with persistent pain. 15% >) “Treated case with pain and instability 20% ty Treated case of disc diséase with pain actiVities of 2% pee to} Treated case of disc disease with persistent pan and| 30% __THE GAZETTE OF INDIA “EXTRAORDINARY (Pax fs! i ee eT a “345 Disc lesion iting moderately modified = | stifmess, aggravated by heavy lifting, necessitating : modifications of ail activities requiring heavy Weight Lining: “ s Zork Seti 32 3.2.1 Scoliosis: Basic guidelines — follow cutye should be accounted for while \Otthe compensatory curve or both CEES In addition to the above PP should clsolbe evaluated in relation the torso imbalance. The torso imbalance ‘should be measured by dropping @ plumb Ine fiom C7-s e and meastiring the ‘distance of plumb line from gluteal crease % ane Deviation of Plumb line 2S PPE Upic 15. Cm 4% 8% 16% 32%tartare 1) S2.4-Hoag THe ; Upto 15, 4% P More than 15 10% | 107 4,2.8 Cardiopulmonary Test e In cases with scoliosis of severe type cardiopulmonary function tests end , percentage deviation from normal should be assessed by one of the follwing methgc whichever seems more reliable clinicaly al the time of assessment. The value thus obtained may be added by combining ‘ formula, 2. Chest Expansion PPI 4-5Cm. Normal Less than 4m 5% for each om No expansion b.counting in one breathe: Breathe Count PR More than 40 Normal 0-40 5% 0-30 10% 9-20 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%. a) Pain . - mildly interfering with ADL 4% a - moderately restricting ADL. alee 6% - severely restricting ADL. 10% b) Cosmetic Appearance: - No obvious disfiguration with clothes on Nit ~ mild disfigurement 2% - severe disfigurement AM c) Leg Lenoth Discrepancy * - First 4" shortening Ni - Every %' beyond first 42 aios ‘THE GAZETTE OF INDIA : EXTRAORDINARY [Paxri—Sec. 1] d)-~" Neurological deficit - Neurological deficit shauld: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 én the similar quidelines as use for scoliosis with the following modifications: x Sa lye? Setasceiesrd 3.3.4 Spinal Deformity “35.2 Torso Imbalance - Plumb’ line dropped from extemal ear normally falls at ankle level: The.devi of tae should be . meastired from ankle anterior j e to the, nt Less than 5 em in front of ankle a% Sto 10 cmin front of ankle SBME 10 to 18 min front of ankle 16% Morathan 15 cmintrontofenke 32% < (Add directly) 3.4.1. Miscellanéous condition: z # nt Bie 5 * whicaa) Rasiey or Those conditions of the spine which calise stifmess and pain etc. are rated as follows: : 2 “| Conditions Percentage PPI | B Subjective symptoms of pain, no involuntary muscle O% | ‘i t spasm,, not substantiated by demonstrable structural i | [pathology #4 5' ‘gob thet iB Pain, persistent muscles spasm. ai 2% | | sping, substantiated by mild radiologicakehange. | it Same as 8 with moderate radiological changes: 2% i. Same as 8 with severe radiological . changes. 30% | : involving any one of the regions of spine” Le Same as D involving whcle spine“ * 40%(orp 1) TTS: STITT a 109 4. Guidelines for Evaluation of PPI in cases of Short Stature/Dwarftsm: ? 4, Recuribent lenath or fongitucinai height below 3% percentile or a 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 disproportionate variety and is accompanied by . an underlying pathological’ conditions, e.g, Achondroplasia, ee Chandrodysplasia Punctata, spondyloepiphysical dysplasia, ucopaly end acchrydosis, etc. , 3 The ICMR norms 2s enciosed at Appendix tl! of Annexure. A should be used as a guidelines for the height. - 4. Every 1° vertical height reduction should be valued as 4% permanent physical impairment. Aoeivirt ‘san = + Bp. Associated skeletal.deformities, should be evaluated, senarctely and total percentage of both should be added by combining formula. §, Guidelines for Evaluation of Permanent Physical Impairment in Ampuigesi Baste Guidelines: 4. In cases of multiole amputees if the total sum of permanent physical impairmentis above 100%, it should be taken as 100% only. 2. Ifthe stump is unfit for fiting the prosthesis additional weightage of 5% should be added 10 the valug, 3. _In-case of amputtation in more than one limb percentage of eact Imb is added py combining formula and another 10% wil be added but when only toas or fingers are involved only 5% will be added. y ‘complicaton in form ot stiffress of proximal joint! ‘reuroma 4 AR ; etc,, should be given upto a total of 10% additional weightage 4 5. Dominant upper extremity should be given 4% additional weigntage. [J Upper Limb Amputations | PPI & loss of | i physical Hunction of t Jeack timb I [100% TZ Snoulder Disarticutation 1 BO% 13 Above Elbow upto upper 1 of arm 185%110 THE GAZETTE OF INDIA : EXTRAORDINARY (BaarI—Sec. 1} ‘Above Elbow upto wwe? WS offorearm apace A Elbow disarticulaiion ~ 75% 1 ‘Below Elbow upto upper 1/3 of forearm: 70% Below Elbow upto lower 1/3 offorearm 85% ‘Wrist disarticulation = [0% Hand through carpal bones : [55% Tan BvolGh Gu oF GE TF MO jon 30% Thumb” disartictiation “through matacarpophala ingeal | 25% 2 eint or th imal : 72 _~ | Thumb cisarticulatior’ through Inter pRalangeal jaint or | 15% : through distal phalanx — pee | 1 i Lite | Fie lfm | i Ht “my 2%) | 3 ‘pion 5 12! imal phiala sane be 3 2 ticulation { through M.P.j apie Middle’ “phalanx”or Disarticulation | throu np it Hest i 7S PAmpurai [oe [2% i Distal phalanx or] | disarticuiation j | i ! through DIP joi pei 1.3 Lower Limb Amputations: ~ 1. Hind quarter 2. Hipdisarticulation —- 3. Above knee upto upper 1/3 of thigh 4. Abo lower 1/8 anion 3. : . 6 % 7. £8 Of leg. a, 36 . 3 3. 10. Upto mic-foot. 14. Upto forefoot 12 Alltoes: 13. Loss of first toe 14. Loss of second toe 18 Loss of third toe 168 Loss of fourth toe 17 Logs of fifth toe 6. Guidelines for Evaluation of Permanent Physical Impairment of Congenital deficiencies of the limbs:in Transverse Deficiencies 61 1. 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. 2, 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: < PPI - Transverse deficiency Rt. Arm complete 90% (shoulder disarticulation) - Transverse deficiency at thigh complete 90% 2 _ {hip disarticulation): ae 7 Transverse deficiency Proximal Gaol rm Bm " (Above elbow Amp.) - Transverse deficiency at lower thigh 80% (Above knee Amp: Lower 1/3) - Transverse deficiency forearm complete 75% (elbow disarticulation) - Transverse deficiency lower forearm 65% (Below Elbow Amp.) - » Transverse deficiency carpal complete 80% (wrist diserticulation) - Transverse deficiency Metacarpal complete 55% 62 624 (Disarticulation through carpal bones) = Longitudinal Deficiencies: 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 assessing the ‘stability component and shortening of lower limb should be given duo weiahtage Apert from functional assessment the lost joint/part of body stiould aiso be vaiued as per distribution given in chapter Guidelines for Evaluation of PP! in upper extremity ang lower extremity The values so obtained should be adged with the help of combining formule42 ‘THE GAZETTE OF INDIA: EXTRAORDINARY [Parse nt - 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 Dody part. Loss of shoulder joint can be given ~ 20% Loss of ROM of Elbow/Shoulder & Wrist All the components should be added together by the combining formule of a+b (00-2) a 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 ease) the help of combining - formula. 6.2.3 In cases of loss of single bone in tea the evaluation should be based on the principles of evaluation of mobility “component..and stability components of the lowerieytremity. The veluies obtained should be added together with the help of combining formula. 7.Guldelines for Evaluation of ‘Physical Impairments in Neurological “~" ” conditions. 14 Basic Guidelines: 4. Assessment in neurological conditions is not the assessment of disease but the assessment ofits effects, ¢, clinical manifestations 2. Tiiese guidelines should only be used for central and upper motor neurone lesions. 3. Proformas (form A & 8) will be utilized for assessment of lower motor neurone lesions, muscular disorders and other locomotor conditions, 4, Normally any neurological assessment for the purpose of certification has to be done six months after the pnset of disease however exact tipe period is to be decided by the Medical Doctor who is evaluating the case and has to recommend the review of certficate as given in the standard format of certficate. 5. Total percentage of physical impairment in any neurological condition should not exceed 100%Su ST TT : RTT 113 7 ieee) 8. 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 7, Adaitional rating of 4% will be given for dominant upper extremity. 8. Additional weightage up to 10% can be given for loss of sensation in ‘each extremity but the total physical impairment should not exceed 100%. 7.2Tabte- Neurological Status Physical Impairment Alfered sensorium 7 100% 7.3 Table = I Intellectual Impairment (to be assessed by Clinical Psychologist) Degree of Mental/1Q Range Intellectual Impairment * Retardation i = ere tie Oe bape cs. sn 258% Mid 50-69 50% = Moderate 35-40 75% ieee Severe 20-34 20% == Profound _ ____ bess than 20 ~ 100% - 7.4Table— Ill Speech defect Physical impairment - [Mild dysarthria SNE wane ch 25% Severe dysarthria J 50% cet 7.8TabledV Cranial Nerve Disability (Type of Cranial Nerve Involvement —_ Physical Impairment sei Motor cranial nerve 20% for each nerve Sensory cranial nerve 10% for each Nene 1819 Gi201—15M4 __THE GAZETTE OF INDIA “EXTRAORDINARY __- =a = 7.8Table-V = * Motor system Disabilhy Neurological Involvement Physical Impairment Hemiparesis:- 4 é - Mild 425% “3 - Moderate ‘ ‘ 50% = Severe 75% 7.7 TableVI as Sensory System Disability saiecusta 18 : [ Extent of Sensory Defeit _ iy -[Anaesthesia Paraesthesis Loss of sensation up to 30) Handsifeet sensory loss piri of es sensation : TS Table-Vis sire” » [Bladder involvement: Mild (Hesitanéy/Freaue | Moderate (preci = aie: [Severe (occasional but ecurient 75% incontinence} A Very Severe (Retention/Total 100% incontinence), “7.9 Table Vil . Post Head injury Fits and Epileptic Convulsions | adequate medication Beinn [Very Severe more than 10 fitsimonihs 75% on adequat(am inane 1) ies TAO Table= IK" Ataxla (Sensory or Cerebellar) Severity of Ataxia Physical Impairment Mild (Detected on examination) ee Moderate 5 50% Severe. 75% - Very 100% ® Guidelines for Evaluation of Physical impairment due to Cardiopulmonary Diseases. 8.1 Basic Guidelines:- Feit Modified New York Heart Association sibjedtive classification shold bs Ulised to assess the functional disability. 2, The assessing physician should be alert to the fact that patients who come for disability ciaims are likely to exaggerate their symptoms. In Case of any doubt patients should be referred for detailed iphysiological evaluation. foo 3, Disability evaluation of cardiopulmonary patients should be done after full medical, surgical and rehabilitative treatment available, because Most of these 'diseases are potentially treatable, 4. Assessment of cardiopulmonary impairment should also bé done in diseases which might have associated cardiopulmonary problems, e.g., amputees, myopathies, etc, 5. For respiratory assessment, routine respiratory functions test should be . Gone, however, in cases of interstitial lung diseases, diffusion studies May be done, 2esresnr- on fier agertishs 6 _ In cases of Angina pectoris (chest pain) base line studies in resting ECG should be done. When there is persistence of symotoms.-exercise or stress test should be done. 8.2The proposed classification with loss of function is as follovis:- Group 0: A patient with cardiopulmonary ‘disease who is asymptomatic (ie. ‘has no symptoms of breathlessness, palpitation, fatique or chest pain)né “THE GAZETTEOF INDIA EXTRAORDINARY. “"@rolip 1 A" patient with ear julmonaiy’ disease who. becomes ~~ symptomatic during his ordinary physical activity but has mild restriction (25%) of his physical activities. “Group symptomatic ae his ordinary physical restriction of his ordinary physical activities. etiviy: and -Apaient ith cardiepulmenary disease. who. becomes has er 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: are severely or completely Muttple disabilities. means 2 com ion of two or more di defined in clause. (i)* Opportunities, Protectic Full strata Ad. ‘1995. inorder to evaluate used as have been develo bby the imitiess: single disebility, viz. Mental retardation,” Pope disabilty, Visual disability, in Serene Sina Soe OS iv yn ed etsons with Disabilities (Equal ‘namely — and speech and hearing disability and recommended in the meetng held on 28.2.2000 under: the Chalemanship ef Dr 5. ‘Health Services, Government of India, with reference to Order N NII, dated 28" August, 1998 and communicated to Ministry of Social General cf 16-18/96- | Justice & Empowerment, Government of India, ‘vide letter eetoue adn dated 16" March, 2000.(Carmine 1) . SRA TT TIT However, in’ order to’arive at the total percentage of multi! ity, the combining formula 2 + b (80-a), as given in the “Manual for Doctors to Evaluate 90 Permanent Physical Impairment, Deyeloped by Expert Group meeting on Disability Evaluation’, shall be used, where “a” wil be the higher score and “b” will be the lower score. However, the maximum total percentage of multiple disabilites 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 ebove, the total Percentage of multiple disebiiy will be calculated as follows:- 30+ 0) 43% i. "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 292.2000. 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 cifferent disabilities using the combining formula, i.¢., a + b (90-a). In case, where two scores of disability are = 90 equal, the final certificate of multiple cisability will be issued by any one ofthem as decided by Local authority. 17[Pass Sec | a eee BHA 4] 095-0 |* 4 Due uonenepieur) —~ 408 i — epee Z| NIE ennDy) i ww] cue UoKey EWE qUOWsAoH 118 ‘ALIMQWLIX Badal UO VBI AL LNAWSSISSY Vv Wowl Yaancanny, 40 IXIGNadaY > -uoKay sto}. 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