What is Disability?

ACCORDING TO PERSON WITH DISABILITIES (EQUAL OPPORTUNITIES, PROTECTION OF RIGHTS AND

FULL PARTICIPATION) ACT, 1995.

"Disability" means-

1. Blindness;
2. Low vision;
3. Leprosy-cured;
4. Hearing impairment;
5. Loco motor disability;
6. Mental retardation;
7. Mental illness;

“Blindness" refers to a condition where a person suffers from any of the following conditions, namely:-

1. Total absence of sight. or

2. Visual acuity not exceeding 6160 or 201200 (snellen) in the better eye with correcting lenses; or
3. Limitation of the field of vision subtending an angle of 20 degree or worse.

"Leprosy cured person" means any person who has been cured of leprosy but is suffering from-

1. Loss of sensation in hands or feet as well as loss of sensation and paresis in the eye and eye-lid but with no manifest
deformity;
2.  Manifest deformity and paresis; but having sufficient mobility in their hands and feet to enable them to engage in
normal economic activity;
3. Extreme physical deformity as well as advanced age which prevent him from undertaking any gainful occupation,
and the expression "leprosy cured" shall be construed accordingly.

"Hearing impairment" means loss of sixty decibels or more in the better year in the conversational range of' frequencies.

"Loco motor disability" means disability of the bones, joints muscles leading to substantial restriction of the movement of the
limbs or any form of cerebral palsy.

"Cerebral palsy" means a group of non-progressive conditions of a person characterized by abnormal motor control posture
resulting from brain insult or injuries occurring in the pre-natal, peri-natal or infant period of development.

"Mental retardation" means a condition of arrested or incomplete development of mind of a person which is specially
characterized by sub normality of intelligence.

"Mental illness" means any mental disorder other than mental retardation.

ACCORDING TO NATIONAL TRUST FOR THE WELFARE OF PERSONS WITH AUTISM, CEREBRAL PALSY,
MENTAL RETARDATION AND MULTIPLE DISABILITIES ACT, 1999

"Autism” means a condition of uneven skill development primarily affecting the communication and social abilities of a
person, marked by repetitive and ritualistic behaviour.

"Cerebral Palsy" means a group of non-progressive conditions of a person characterized by abnormal motor control posture
resulting from brain insult or injuries occurring in the pre-natal, perinatal or infant period of development.

"Mental Retardation" means a condition of arrested or incomplete development of mind of person which is specially
characterised by sub-normality of intelligence.

“Multiple Disabilities" means a combination of two or more disabilities as defined in clause (i) of section 2 of the Person with
Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995.

ACCORDING TO WHO:
"disability is an umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a
problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or
action; while a participation restriction is a problem experienced by an individual in involvement in life situations. Thus
disability is a complex phenomenon, reflecting an interaction between features of a person’s body and features of the society in
which he or she lives."

Source: http://www.who.int/topics/disabilities/en/ 

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH (ICF)

ICF belongs to the “family” of international classifications developed by the World Health Organization (WHO) for application
to various aspects of health. The WHO family of international classifications provides a framework to code a wide range of
information about health (e.g. diagnosis, functioning and disability, reasons for contact with health services) and uses a
standardized common language permitting communication about health and health care across the world in various disciplines
and sciences. In WHO’s international classifications, health conditions (diseases, disorders, injuries, etc.) are classified
primarily in ICD-10 (shorthand for the International Classification of Diseases, Tenth Revision), which provides an etiological
framework. Functioning and disability associated with health conditions are classified in ICF. ICD-10 and ICF are therefore
complementary, and users are encouraged to utilize these two members of the WHO family of international classifications
together.

The overall aim of the ICF classification is to provide a unified and standard language and framework for the description of
health and health-related states. It defines components of health and some health-related components of well-being (such as
education and labour). The domains contained in ICF can, therefore, be seen as health domains and health-related domains.
These domains are described from the perspective of the body, the individual and society in two basic lists: (1) Body Functions
and Structures; and (2) Activities and Participation. As a classification, ICF systematically groups different domains for a
person in a given health condition (e.g. what a person with a disease or disorder does do or can do).  Functioning is an umbrella
term encompassing all body functions, activities and participation; similarly, disability serves as an umbrella term for
impairments, activity limitations or participation restrictions. ICF also lists environmental factors that interact with all these
constructs. In this way, it enables the user to record useful profiles of individuals’ functioning, disability and health in various
domains.

ICF identifies different components of functioning, disability and health. These components are followings:

Body functions are the physiological functions of body systems (including psychological functions).
Body structures are anatomical parts of the body such as organs, limbs and their components.
Impairments are problems in body function or structure such as a significant deviation or loss.
Activity is the execution of a task or action by an individual.
Participation is involvement in a life situation.
Activity limitations are difficulties an individual may have in executing activities.
Participation restrictions are problems an individual may experience in involvement in life situations.
Environmental factors make up the physical, social and attitudinal environment in which people live and conduct their lives.

Source: http://www.who.int/classifications/icf/site/intros/ICF-Eng-Intro.pdf  

Guidelines for evaluation of various disabilities and

procedure for certification
Page 1 of 15

1.In order to review the guidelines for evaluation of various disabilities and procedure for certification as given in the Ministry
of Welfare's O.M. No. 4-2/83-HW.-III, dated the 6th August, 1986 and to recommend appropriate modifications/alterations
keeping in view the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995,
Government of India in Ministry of Social Justice and Empowerment, vide Order No. 16-18/97-NI. I, dated 28-8-1998, set up
four committees under the Chairmanships of Director General of Health Services-one each in the area of mental retardation,
Locomotor/ Orthopaedic disability, Visual disability and Speech & Hearing disability. Subsequently, another Committee was
also constituted on 21-7-1999 for evaluation, assessment of multiple disabilities and categorization and extent of disability and
procedures for certification.

2. After having considered the reports of these committees the undersigned is directed to convey the approval of the President to
notify the guidelines for evaluation of following disabilities and procedure for certification:-

Visual impairment
Locomotor / Orthopaedic disability
Speech & hearing disability
Mental retardation
 Multiple Disabilities.

3. The minimum degree of disability should be 40% in order to be eligible for any concessions/benefits.

4. According to the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Rules, 1996
notified on 31.12.1996 by the Central Government in exercise of the powers conferred by sub-section (1) and (2) of section 73
of the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 (1of 1996),
authorities to give disability Certificate will be a Medical Board duly constituted by the Central and the State Government. The
State government may constitute a Medical Board consisting of at least three members out of which at least one shall be a
specialist in the particular field for assessing locomotor/Visual including low vision/hearing and speech disability, mental
retardation and leprosy cured, as the case may be.

5. Specified test as indicated in Annexure should be conducted by the medical board and recorded before a certificate is given.

6. The certificate would be valid for a period of five years for those whose disability is temporary. For those who acquire
permanent disability, the validity can be shown as 'Permanent'.

7. The State Governments/UT Administrations may constitute the medical boards indicated in para 4 above immediately, if not
done so far.

8. The Director General of Health Services Ministry of Health and Family Welfare will be the final authority, should there arise
any Controversy/doubt regarding the interpretation of the definitions/classifications/evaluations tests etc. 

A. MENTAL RETARDATION

1. Definition:- Mental retardation is a condition of arrested or incomplete development of the mind, which is
especially characterised by impairment of skills manifested during the development period which contribute to the over
all level of intelligence, i.e., cognitive, language, motor and social abilities.
2. Categories of Mental Retardation:-
1. Mild Mental Retardation:- 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
interfere with the development of independence may persist into adult life.
2. Moderate Mental Retardation: - The IQ is in the range of 35 to 49. Discrepant profiles of abilities are
common in this group with some individuals achieving higher levels in visuo-spatial skills than in tasks
dependent on language while 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.
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 motor impairment or other associated deficits indicating the presence of
clinically significant damage to or mal-development of the central nervous system.
4. Profound Mental Retardation: - The IQ 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 restricted in mobility, incontinent and capable at most of only very rudimentary forms of non-
verbal communication. They posses little or no ability to care for their own basic needs and require constant
help and supervision,
3. Process of Certifications:-
1. A disability certificate shall be issued by a Medical Board consisting of three members duly constituted
by the Central/State Government. At least, one shall be a Specialist in the area of mental retardation, namely.
Psychiatrist, Paediatrician and clinical Psychologist.
2. The examination process will consist of three components, namely, clinical assessment, assessment, of
adaptive behaviour and intellectual functioning.

C. LOCOMOTOR DISABILITY

1. Definition .-
 i. Impairment: An impairment in any loss or abnormality of psychological, physiological or anatomical structure or
function in a human being.
ii. Functional Limitations: Impairment may cause functional limitations which are partial or total inability to perform those
activities, necessary for motor, sensory or mental function within the range or manner of which a human being is normally
capable.
iii. Disability: A disability, is any restriction or lack. ( resulting from an impairment) of ability to perform an activity in the
manner or within the range considered normal for a human being.
iv. Locomotor Disability: 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.
2. Categories of Locomotor Disability
The categories of locomotor disabilities are enclosed at Annexure-A.

3. Process of Certification
A disability certificate shall be issued by a Medical Board of three members duly constituted by the Central and the State Government,
out of which, at least, one member shall be a specialist from either the field of Physical Medicine and Rehabilitation or Orthopaedics.

Two specimen copies of the disability certificate for mental retardation and others (visual disability, speech and hearing disability and
locomotor disability) are enclosed at Annexure-B.

It was also decided that whenever required the Chairman of the Board may co-opt other experts including that of the members
constituted for the purpose by the Central and the State Government.

On representation by the applicant, the Medical Board 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.

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

1. The 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 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.
3. The upper limb is divided into two component parts; the arm component and the hand component.
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 impairments of both components

2 ARM COMPONENT
Total value of arm component is 90% 

1.2.1 Principles of evaluation of range of motion (ROM) of joints

1. The value of maximum ROM in the arm component is 90%

2. 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).

Arc of ROM Normal value Active ROM Loss of ROM

Shoulder Flexion- 0-220 110 50%

Rotation 0-180 90 50%

Abduction-Adduction 0-180 90 50%

Hence the mean loss of ROM of shoulder will be 50+50+50/3 =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:

1. 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.
2. 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%

3. The mean percentage of loss of muscle strength around a joint is multiplied by 0.30.
4. 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:

1 The total value for coordinated activities is 90% Ten different coordinated activities should be tested as given inForm A. (Appendix.I of
Annexure-A)

2. 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 

          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)

                                                                                      90
Loss of strength of muscles - 8.3%                         =23.33%
To add
Loss of coordination - 5%                             23.3+5(90-23.3)=27 0%
                                                                             90 

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

Guidelines for evaluation of various disabilities and

procedure for certification
Page 4 of 15

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:

1. Total value of sensation in hand is 30%

2. It should be assessed according to the distribution given below:
i. Complete loss of sensation
1. 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

1. Total value of strength is 30%

2. 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)  a= higher value

                    90      b= lower 

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

Appendix.ll of Annexure.A.

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

The measurement of loss of function in lower extremity is divided into two components: Mobility and standing components

2.1 Mobility Component:-

1. Total value of mobility component is 90%

2. It includes range of movement (ROM) and muscle strength

2.1.1. Principles of Evaluation of Range of Movement:

1. The value of maximum range of movement in mobility component is 90%

2. Each of three joints i.e. hip, knee and foot-ankle component is weighed equally - 30%.
Example:
A fracture of right hip joint bones may affect range of motion of the hip joint. Loss of ROM of the affected hip in different are
should be assessed as given in Form B (Assessment Proforma for lower extremity). (Appendix.I of Annexure.A)

Affected Joint - Rt. Hip:

Arc of Movement Normal ROM Active ROM Loss in percentage
Flexion-Extension 0-140 70 50%
Abduction-Adduction 0-90 60 33%
Rotations 0-90 30 66%

Mean loss of ROM of Rt Hip =50+33+66= 50%

                                          3

Since the hip constitute 30% of the total mobility component of the lower limb the loss of motion in relation to the lower limb will
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 calculated in relation to individual
joint separately and then added together as follows to calculate the loss of mobility component in relation to that particular limb.

For example.

Mean loss of ROM of Rt. Hip     50%

Mean loss of ROM Rt. Knee      40%
Loss of mobility component of Rt. Lower Limb will be
                     (50 x 0.30)+(40 x 0.30) = 27%

2.1.2. Principle of Evaluation of Muscle Strength:

1. The value for maximum muscle strength in the limb is 90%.

2. Strength of muscles can be tested by Manual Method and graded 0-5 as advocated by MRC of Great Britain depending
upon the residual strength in the muscle group.
3. Manual muscle grading can be given percentage like below:

Power Grade of Ms Loss of strength in percentage

0 100%
1 80%
2 60%
3 40%
4 20%
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 a loss muscle strength involving more than one joint the values are added as has been described 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-a)
                                        90
(a = higher value, b = lower value)

Example: Let us assume that the individual with a fracture of right hip bones has in addition to 16% loss of motion, 8% loss of muscle
strength also.      

Combined values

Motion-16%                               16+8(90-16)
                                                         90
Page 6 of 15

3.1.3. Thoracic and Thoracolumbar Spine Injuries:

i) Compression of less than 50% involving one vertebral body with no neurological manifestation 20%
ii) Compression of more than 50% involving singlevertebra or more with involvement of posterior elements, healed, no 20%
 neurological manifestations persistent pain, fusion indicated
iii) Same as (b) with fusion, pain only on heavy use of back 15%
iv) Radiologically demonstrable instability with fracture or fracture dislocation with persistent pain. 30%

3.1.4 Lumbar and Lumbosacral Spine: Fracture

a) Compression of 25% or less of one or two adjacent  Vertebral bodies, No definite pattern or neurological Deficit 15%

b Compression of more than 25% with disruption of  Posterior elements, persistent pain and stiffness, healed With or without 30%
) fusion, inability to lift more than 10 kgs.

c) Radiologically demonstrable instability in low lumbar or   Lumbosacral spine with pain 35%

3.1 5 Disc lesion:

a) Treated case with persistent pain 15%

b Treated case with pain and instability 20%

)

c) Treated case of disc disease with pain activities of lifting moderately modified 25%

d Treated case of disc disease with persistent pain and stiffness, aggravated by heavy lifting necessitating modification of all 30%
) activities requiring heavy weight lifting

3.2 NON TRAUMATIC LESIONS:

3.2.1 Scoliosis:

Basic guidelines - following modification is suggested.

  - The largest structural curve should be accounted for while calculating the PPI and not the compensatory curve
or both structural curves.

3.2.2 Measurement of Spine Deformity:

Cobb's method for measurement, of angle of curve in the radiograph taken in standing position should be used. The curves have been
divided into following groups depending upon the angle of major structural scoliotic deformity.

Group Cobb’s Angle PPI in relation to Spine

I 0-20 NIL

II 21-50 10%

III 51-100 20%

IV 101 & above 30%

Strength-8%                               =22.6%

2.2 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 nine activities, which
need to be tested, and each activity has a value of ten per cent (10%). The percentage valued in relation to each activity depends upon the
percentage of loss stability in relation to
each activity.

2.3 Extra points:

Extra points have been given for pain, deformities, contractures, loss of sensations and shortening Maximum points to be added are 10%
(excluding shortening). Details are as following.
i) Deformity In functional position 3%
In non-functional position 6%
ii) Pain Sever (grossly interfering with function) 9%
Moderate (moderately inter-fering with function) 6%
Mild (mildly interfering with function)
3%
iii) Loss of sensation Complete Loss Partial Loss 9%
iv) Shortening First 1/2" Nil
Every 1/2" beyond first 1/2" 4%
v) Complications Superficial complications 3%
Deep complications

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

Basic guidelines:

1. As permenanent physical impairment caused by spinal deformity tends to change over the years, the certificate issued in relation
to spine should be reviewed as per the standard format of the
certificate given at Annexure -B of Appendix.III.
2. Permanent physical impairment should be awarded in relation to spine and not in relation to whole body.
3. Permanent physical impairment due to neurological deficit in addition to spinal impairment should be added by combining
formula. The local effects of the lesions of the spine can be conventionally divided into traumatic and non-traumatic. The percentage
of PPI in relation to each situation should be valued as follows:

3.1 TRAUMATIC LESIONS:

3.1.1 Cervical spine injuries Percentage of PPI

 in relation to Spine
i) 25% or more compression of one or two adjacent vertebral bodies with No involvement of posterior 20%
elements, No nerve root involvement, moderate Neck rigidity and persistent
Soreness.
ii) Posterior element damage with radiological Evidence of moderate parties dislocation/subluxation  
including whiplash injury.
  a) With fusion healed, No permanent motor or sensory changes. 10%
  b) Persistent pain with radiologically demonstrable instability. 25%
iii) Severe Dislocation:  
  a) Fair to good reduction with or without fusion with no residual motor or sensory involvement; 10%
  b) Inadequate reduction with fusion and persistent radicular pain 15%
       
3.1.2. Cervical Intervertebral Disc Lesions Percentage of PPI In
relation to Spine
i) Treated case of disc lesion with persistent pain and no neurological deficit 10%
ii) Treated case with pain and instability 15%
       
3.1.3. Thoracic and Thoracolumbar Spine Injuries:
i) Compression of less than 50% involving one vertebral body with no neurological manifestation 10%
ii) Compression of more than 50% involving single vertebra or more with involvement of posterior 20%
elements,healed, no neurological manifestations persistent pain, fusion indicated
iii) Same as (b) with fusion, pain only on heavy use of back 15%
iv) Radiologically demonstrable instability with fracture or fracture dislocation with persistent pain. 30%
3.2.3 Torso Imbalance:

In addition to the above PPI should also be evaluated in relation the torso imbalance. The torso imbalance should be measured by dropping
a plumb line from C7 spine and measuring the distance of plumb line from gluteal crease.

Deviation of Plumb line PPI

Upto 1.5 Cm 4%
1.6 - 30 Cm 8%
3.1 - 50 Cm 16%
5.1 and above 32%

3.2.4 Head Tilt over C7 spine PPI

Upto  15 4%
More than 15 10%

3.2.5 Cardiopulmonary Test

In cases with scoliosis of severe type cardiopulmonary function tests and percentage deviation from normal should be assessed by one of
the following method whichever seems more reliable clinically at the time of assessment. The value thus obtained may be added by
combining formula.

a. Chest Expansion   PPI

4 - 5 Cm.   Normal
Less than 4 cm reduction in Chest expansion   5% for each cm
No expansion   25%
     
b counting in one breathe:    
Breathe Count   PPI
More than 40   Normal
0-40   5%
0-30   10%
0-20   15%
0-10   20%

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%
-moderately restricting ADL 6%
-severely restricting ADL 10%
b) Cosmetic Appearance:  
-No obvious disfiguration with clothes on Nil
-mild disfigurement 2%
-severe disfigurement 4%
c) Leg Length Discrepancy.  
-First½ " shortening Nil
-Every½" beyond first½" 4%
d) Neurological deficit - Neurological deficit should 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 on the similar guidelines as use for scoliosis with the following modifications:
       
3.3.1 Spinal Deformity   PPI
Less than 20   Nil
21-40   10%
41-60   20%
Above 60   30%
       
332 Torso Imbalance - Plumb line dropped from external ear normally falls at ankle level. The deviation from normal should be measured
from ankle anterior joint line to the plumb line.
       
Less than 5 cm in front of ankle   4%
5 to 10 cm in front of ankle   8%
10 to 15 cm in front of ankle   16%
More than 15 cm in front of ankle   32%
(Add directly)    

Miscellaneous conditions:
Those conditions of the spine which cause stiffness and pain etc. are rated as follows. 

  Conditions Percentage
PPI

A Subjective symptoms of pain, no involuntary muscle spasm,, not substantiated by demonstrable structural -0%
pathology

B Pain, persistent muscles spasm and stiffness of spine, substantiated by mild radiological change. -20%

C Same as B with moderate radiological changes -25%

D Same as B with severe radiological changes involving any one of the regions of spine -30%

E Same as D involving whole spine -40%

4. Guidelines for Evaluation of PPI in cases of Short Stature/Dwarftsm:

1. Recumbent length or longitudinal height below 3rd percentile or 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,Chandrodysplasia Punctata, spondyloepiphysical dysplasia,mucopoly and
acchrydosis, etc.
3. The ICMR norms as enclosed at Appendix III of Annexure. A should be used as a guideline for the height.
4. Every 1" vertical height reduction should be valued as 4% permanent physical impairment.
5. Associated skeletal deformities should be evaluated, separately and total percentage of both should be added by combining
formula.

Page 8 of 15

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

Basic Guidelines:

1. In cases of multiple amputees if the total sum of permanent physical impairment is above 100%, it should be taken as 100%
only.
2. If the stump is unfit for fitting the prosthesis additional weightage of 5% should be added to the value.
3. 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.
4. Any complication in form of stiffness of proximal joint, neuroma infection, etc., should be given upto a total of 10% additional
weightage.
5. Dominant upper extremity should be given 4% additional weightage.

  PPI & loss of physical function

Upper Limb Amputations 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 Middle Ring Finger Little Finger (2%)

(15%) Finger  (3%)
(5%)

13 Amputation through Proximal phalanx or 15% 5% 3% 2%

. Disarticulation through M.P. Joint

14 Amputation through Middle phalanx or 10% 4% 2% 1%

. Disarticulation through PP joint.

15 Amputation through Distal phalanx or disarticulation 5% 2% 1% 1%

. through DIP joint.

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-

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%

(hip disarticulation)

Transverse deficiency Proximal Upper arm 85%

(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 60%

(wrist disarticulation)

Transverse deficiency Metacarpal complete 55%

(Disarticulation through carpal bones)

6.2 Longitudinal Deficiencies:

6.2.1 Basic Guidelines

1. In cases of longitudinal deficiencies of limbs due consideration should be given to functional impairment.
2. In upper limb, loss of ROM loss muscular strength and hand functions like prehension, etc should be tested while assessing
the case for PPI.
3. In lower limb clinical method of stability component and shortening of lower limb should be given due weightage.
4. 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:

1. Assessment in neurological conditions is not the assessment of disease but the assessment of its effects, i.e. clinical
manifestations.
2. These guidelines should only be used for central and upper motor neurone lesions.
3. Proformas (form A & B) 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 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.
5. Total percentage of physical impairment in any neurological condition should not exceed 100%
6. 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. Additional 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%.

7.2 Table-l

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

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%

7.9 Table - VIII

Post Head Injury Fits and Epileptic Convulsions

Frequency/Severity of Convulsions Physical Impairment

Mild – occurrence of one convulsion Nil

Only

Moderate 1-5 Convulsions/month on 25%

Adequate – Medication

Severe 6-10 Convulsions/month on 50%

Adequate medication

Very Severe more than 10 fits/months  75%

On adequate – Medication
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%

8 Guidelines for Evaluation of Physical Impairment due to Cardiopulmonary Diseases.

8.1 Basic Guidelines:-

1. Modified New York Heart Association subjective classification should be utilised to assess the functional disability.
2. The assessing physician should be alert to the fact that patients who come for disability claims are likely to exaggerate their
symptoms. In case of any doubt patients should be referred for detailed physiological
evaluation.
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 be done in diseases which might have associated cardiopulmonary
problems, e.g.,amputees, myopathies, etc.
5. For respiratory assessment, routine respiratory functions test should be done, however, in cases of interstitial lung diseases,
diffusion studies may be done.
6. In cases of Angina pectoris (chest pain) base line studies in resting ECG should be done. When there is persistence of symptoms,
exercise or stress test should be done.

8.2 The proposed classification with loss of function is as follows:- 

Group 0: A patient with cardiopulmonary disease who is asymptomatic (i.e. has no symptoms of breathlessness, palpitation, fatigue or chest
pain).
Group 1: A patient with cardiopulmonary disease who becomes symptomatic during his ordinary physical activity but has mild restriction (25%)
of his 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 activities.
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.)