Guidelines for Evaluation of Physical Impairments in Neurological conditions

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Guidelines for various disabilities and procedure for certification:The measurement of loss of function in lower extremity is divided into two components: Mobility and standing components.A fracture of right hip joint bones may affect range of motion of the hip joint.

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

1. Guidelines for Evaluation of Permanent Physical Impairment of Upper Limb

2.Guidelines for Evaluation of permanent physical Impairment in Lower Limb

3. Guidelines for Evaluation of Permanent Physical Impairment of Trunk (Spine)

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.

5. Guidelines for Evaluation of Permanent Physical Impairment in Amputees:

Basic Guidelines:

  • 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 Amputations PPI & loss of physical function of each limb
1. Fore-quarter amputations 100%
2. Shoulder Disarticulation 90%
3. Above Elbow upto upper 1/3 of arm 85%
4. Above Elbow upto lower 1/3 of forearm 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 though 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 Finger(15%) Middle Finger(5%) Ring Finger(3%) Little Finger(2%)
13. Amputation through Proximal phalanx or Disarticulation through M.P. Joint 15% 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:

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 keen 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%

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: PPI
Transverse 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%.

7.2 Table – I

Neurological Status Physical Impairment
Altered sensorium 100%

7.3 Table – II

Intellectual Impairment (to be assessed by Clinical Psychologist)

Degree of Mental Retardation IQ Range Intellectual Impairment
Border line 70-79 25%
Mild 50-69 50%
Moderate 35-49 75%
Serve 20-34 90%
Profound Less than 20 100%

7.4 Table – III

Speech defect Physical Impairment
Mild dysarthria Nil
Moderate dysarthria 25%
Servere dysarthria 50%

7.5 Table – IV

Type of Cranial Nerve Involvement Physical Impairment
Motor cranial nerve 20% for each nerve
Sensory cranial nerve 10% for each nerve
Sensory cranial nerve 10% for each nerve

7.6 Table-V

Motor system Disability

Neurological Involvement Physical Impairment
Hemiparesis:-
- Mild 25%
- Moderate . 50%
- Severe 75%

7.7 Table-VI

Sensory System Disability

Extent of Sensory Deficit Physical Impairment
Anaesthesia Upto 10% for each limb
Hypoaesthesia Depending upon % of
Paraestheis Loss of sensation up to 30% depending
Hands/feet sensory loss Upon % of loss sensation

7.8 Table – VIII

ladder 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%

7.9 Table – VIII

Post Head Injury Fits and Epileptic 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 10 fits/months On adequate – Medication 75%

7.10 Table – IX

Ataxia (Sensory or Cerebellar)

Severity of Ataxia Physical Impairment
Mild (Detected on examination) 25%
Moderate 50%
Severe 75%
Very Severe 100%

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8.Guidelines for Evaluation of Physical Impairment due to Cardiopulmonary

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