Disability evaluation

Assistant Professor at Krishna Institute of Medical Sciences
Mar. 26, 2020

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Disability evaluation

  2. CONTENTS Definition Introduction Principles of disability assessment Guidelines for evaluation Components
  3. 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
  4.  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
  5. 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
  6.  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
  7. 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.
  8. 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
  9. •“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.
  10. 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
  11. 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.
  12. 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.
  13. 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.
  14. 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
  15. 7. Sensation 8. Deformity 9. Complications like pain, infection 10. Extremity dominant or non dominant.
  17. ARM COMPONENT Total value of arm component is 90% It consists of measuring: 1. Loss of movement 2. Muscle strength 3. Coordination activities
  18. 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
  19. Arc of ROM Normal value Active ROM Loss of ROM Shoulder flexion 0-180 90 50% Rotation 0-180 90 50% Abduction- Adduction 0-180 90 50% • 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%.
  20. 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
  21. 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.
  22. 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
  23. 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
  24. 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%
  25. 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
  26. 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
  27. 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
  28. 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.
  29. 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
  30. 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%
  31. 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
  32. 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
  33. 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
  34. 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
  35. 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 ANGLE PPI in relation to the spine 1 0-20 Nil 2 21-50 10 3 51-100 20 4 101 and more 30
  36. 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%
  37. 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
  38. 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%
  39. 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. Guidelines for Evaluation of Permanent Physical Impairment in Amputees
  40. 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%
  41. Index finger Middle Finger Ring Finger Little Finger 13. Amputation through proximal phalanx or disarticulation through MP joint 15% 5% 3% 2% 14.Amputation through middle Phalanx or disarticulation Through PIP joint 10% 4% 2% 1% 15.Amputation through distal Phalanx or disarticulation Through DIP joint 5% 2% 1% 1%
  42. 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%
  43. 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%.
  44. 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.
  45. Neurological Status: Physical Impairment Altered sensorium 100% Intellectual Impairment (to be assessed by psychiatrist/clinical psychologist) Degree of mental retardation IQ Range Intellectual Impairment Border line 70-79 25% Mild 50-69 59% Moderate 35-49 75% Severe 20-34 90% Profound Less than 20% 100%
  46. 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
  47. 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
  48. 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%
  49. 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%.
  50. Ataxia (Sensory or Cerebellar) Severity of Ataxia Physical Impairment Mild (detected on examination) 25% Moderate 50% Severe 75% Very severe 100%
  51. 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
  52. 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. Upper 6 Lower 4 Lower 4 20 4. Pinna Right Left 10 10 5. Nose 10 6. Lips Upper 5 Lower 5 10 7. Cheek & Lateral Area of Face Right 5 Left 5 10 8. Neck 10
  53. Trunk and Genitalia Total Points 100 SR. NO REGION MALE FEMALE 1 Front of the trunk & abdomen excluding breasts 5 10 2 Breast 10 40 3 Total Back 10 5 4 Groins 10 10 5 Buttock 5 5 6 Genitalia 60 30
  54. (B) FACIAL INJURIES Head and Neck as a Unit 100 points SR. NO COMPONENT POINTS 1 Scalp and Vault including forehead 10 2 Eye Brows Rt. & Lt. (5 +5) 10 3 Eye Lids –Rt. Upper 6 Lower 4 Lt. Upper 6 Lower 4 20 4 Pinna Right 10 Left 10 20 5 Nose 10 6 Middle and lower third of face (excluding nose & pinna) 30
  55. 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.
  56. 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.
  57. 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.).
  58. 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.