Guidelines for Evaluation of Permanent Physical Impairment of Upper Limb

Guidelines for various disabilities and procedure for certification:

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

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

ARM COMPONENT

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%;

Example:

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).

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:
  

  Manual muscle Strength grading	Loss of Strength in percentage
  0	100%
  1	80%
  2	60%
  3	40%
  4	20%
  5	0%

• 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%

1.2.4 Combining values for the Arm Component:

The total value of loss of function of arm component is obtained by combining the value of loss of ROM, muscle strength and coordinated activities, using the combing formula.

a + (b(90-a)/90)

where a = higher value and b = lower value

Example

Let us assume that an individual with an intra articular fracture of bones of shoulder joint in addition to 16.5% loss of motion in arm has 8.3% loss of strength of muscles and 5% loss of coordination. These values should be combined as follows:

Loss of ROM – 16.5% 16.5+8.3(90-16.5)

Loss of strength of muscles – 8.3% To add = 23.33%

Loss of coordination – 5% 23.3+5(90-23.3)/90=27.0%

So the total value of loss of function in Arm component will be 27.0%

1.3 HAND COMPONENT:

1 Total value of hand component is 90%

2 The functional impairment of hand is expressed as loss of prehension, loss of sensation and loss of strength

1.3.1 Principles of evaluation of prehension:

1 Total value of prehension is 30%

it includes

a)Opposition – 8%

Tested against – Index finger – 2%

– Middle finger – 2%

– Ring – 2%

– Little finger – 2%

b)Lateral pinch -5% – Tested by asking the patient to hold a key between the thumb and lateral side of index finger.

c)Cylindrical grasp – 6% Tested for

i) Large object of 4 inches size – 3%

ii) Small object of 1 inch size – 3%

d) Spherical grasp -6% Tested for

i) Large object of 4 inches size – 3%

ii) Small object of 1 inch size – 3%

e) Hook grasp – 5% -Tested by asking the patient to lift a bag

1.3.2. Principles of Evaluation of sensation:

• 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)

1 33. Principles of Evaluation of strength

• 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.

1.3.4. Combining values of hand component:

The final value of loss of function of hand component is obtained by summing up values of loss of prehension, sensation and strength.

1.3.5. Combining values for the Extremity:

Values of impairment of arm component and impairment of hand component should be added by using combining formula:

a + (b(90-a)/90)

where a = higher value and b = lower value

Example:

Impairment of Arm – 27% 64+27(90-64)/90

Impairment of hand – 64% =71.8%

The total value can also be obtained by using the Ready Recknoer table for combining formula given at

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