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Certification Procedure for Locomotive Impairment (Includes Cerebral Palsy)

Locomotor Disability

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 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.

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.

Locomotor Disability

Locomotor disability is defined as a person's 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 for evaluation

  • Guidelines for Evaluation of Permanent Physical Impairment of Upper Limb
  • Guidelines for Evaluation of permanent physical Impairment in Lower Limb
  • Guidelines for Evaluation of Permanent Physical Impairment of Trunk (Spine)
  • Guidelines for Evaluation of PPI in cases of Short Stature/Dwarfism
  • Guidelines for Evaluation of Permanent Physical Impairment in Amputees
  • Guidelines for Evaluation of Permanent Physical Impairment of Congenital deficiencies of the limbs

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.

1.2 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%)
Assesment Performa for Upper Extermity

Hand Component( Total Value 90%)
30% prehension
1. Hand Component 		Movement Normal Value

A. Opposition
B. Lateral Pinch (5%)
C. Cylindrical grasp 		1. Index
2. Middle
3. Ring
4. Little Key holding
a. large object (4)
b. Small object (1)
a. Large object (4)
b. Small object (1)Lifting bag 		2
2 } 8%
225%
3}3}
6%
3}3}
6%
5%

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 Performa 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 0.30 = 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.

Arm Component (Total Value 90%)

Summary value for upper extremity is calculated from component and hand component values

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:
Loss of Muscle Power
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

  1. The total value for coordinated activities is 90%
  2. Ten different coordinated activities should be tested as given in the ASSESSMENT PFROFORMA FOR UPPER EXTERMITY
  3. 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 componet 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%

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


Total value of prehension is 30%. It includes;
  1. Opposition - 8%
    Tested against
    • Index finger - 2%
    • Middle finger -2 %
    • Ring- 2 %
    • Little finger- 2%
  2. Lateral pinch -5% - Tested by asking the patient to hold key between the thumb and lateral side of index finger.
  3. Cylindrical grasp - 6% Tested for
    1. Large object of 4 inches size -3%
    2. Small object of 1 inch size - 3%
  4. Spherical grasp -6% Tested for
    1. Large object of 4 inches size - 3%
    2. Small object of 1 inch size - 3%
  5. 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:
Complete loss of sensation
  • Thumb ray-9%
  • Index finger-6%
  • Middle finger-5%
  • Ring finger-5%
  • Little finger-5%
Partial loss of sensation: Assessment should be made according to percentage of loss of sensation in thumb/finger(s)

1.3.3. Principles of Evaluation of strength

  1. Total value of strength is 30%
  2. It includes:
    1. Grip strength-20%
    2. 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. Pain
  2. Infection
  3. Deformity
  4. Mal-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 the combining formula

[A+B(90-A)/90]

A= higher value
B= lower value

Example

Impairment of Arm - 27%

therefore, [64+27(90-64)/90] = 71.8%

Impairment of hand - 64%

The total value can also be obtained by using the table below:
Ready Reckoner Table for

[A+B(90-A)/90]

Source : http://www.disabilityindia.org/locomotor.cfm