EPIDEMIOLOGY OF DISABILITY
Disability indicators, being an important medical and social criterion of public health, characterize the level of socio-economic development of society, the ecological state of the territory, and the quality of preventive measures.
The word "invalid" comes from the Latin invalidus - weak, infirm. Handicapped it is considered a person who has a health disorder with a persistent disorder of the body's functions, caused by diseases, the consequences of trauma or defects, leading to a limitation of life and necessitating his social protection.
Under disability understand social insufficiency due to health disorders from the stand by a disorder of the body's functions, leading to limitation of life and causing the need for its social protection.
Thus, disability is a social failure. What is social failure? Social inadequacy – these are the social consequences of health disorders leading to limitation of life activity, impossibility (in whole or in part) to fulfill the usual role for a person in social life and necessitating social protection.
The cause of disability is a health disorder with a persistent disorder of the body's functions, i.e. violation of physical, mental and social well-being due to loss, disorder, abnormality of the physical, mental or anatomical structure or function of the human body.
3.1. The main causes of disability :
1. Disability due to general illness is the most common cause of disability, with the exception of cases directly related to occupational diseases, work injury, military injury, etc.
2. Disability due to work injury is established for citizens whose disability has occurred as a result of damage to health associated with an accident at work.
3. Disability due to occupational disease is established for citizens whose disability has occurred as a result of acute and chronic occupational diseases.
4. Disability since childhood: a person under the age of 18 who is recognized as a disabled person is assigned the status of a “disabled child”; upon reaching the age of 18 years and older, these persons are determined to be "disabled from childhood".
5. Disability among former military personnel established in case of diseases and injuries associated with the performance of military duties.
6. Disability due to radiation accidents is established for citizens whose disability has occurred as a result of the elimination of accidents at the Chernobyl nuclear power plant, PA "Mayak", etc.
The degree of impairment of body functions is characterized by various indicators and depends on the type of functional impairment, methods of their determination, the ability to measure and evaluate the results. The following disorders of body functions are distinguished:
· Violations of higher mental functions (mental disorders, other psychological disorders, speech, language disorders);
• violation of the sense organs (visual disturbances, auditory and vestibular disturbances, disorders of smell, touch);
· Movement disorders;
• visceral and metabolic disorders, eating disorders;
· Disfiguring violations;
· Violations associated with reasons of a general nature.
Based on a comprehensive assessment of various parameters, taking into account their qualitative and quantitative values, three degrees of impairment of body functions are distinguished:
1st degree - slightly pronounced dysfunctions;
2nd degree - moderately severe dysfunctions;
Grade 3 - pronounced and significantly pronounced dysfunctions.
As follows from the definition, disability leads to limitation of life, i.e. to a complete or partial loss of a person's ability or ability to carry out self-service, independently move, navigate, communicate, control their behavior, learn and engage in work. Thus, the main criteria for life activity that are limited by disability are:
· The ability to self-service, i.e. the ability to cope with basic physiological needs, to use common household items;
· Ability to move, i.e. the ability to walk, run, move, overcome obstacles, control body position;
· Ability to learn, i.e. the ability to perceive knowledge (general education, professional, etc.), mastering skills (social, cultural and everyday);
· The ability to orientate, i.e. the ability to independently navigate in the environment through sight, hearing, smell, touch, thinking and adequately assess the situation with the help of intellect;
· Ability to communicate, i.e. the ability to establish and develop contacts between people thanks to the perception, understanding of another person, the ability to exchange information;
· The ability to control one's own behavior, i.e. the ability to feel and behave correctly in everyday life.
Depending on the degree of deviation from the norm of human activity due to health disorders, the degree of limitation of life activity is determined. In turn, depending on the degree of limitation of life and the degree of impairment of body functions to a person recognized as a disabled person, the degree of disability is established.
Rehabilitation aids, such as support and tactile canes, crutches, supports, handrails, contribute to the performance of various statodynamic functions of a person: maintaining a person's vertical posture, improving stability and mobility by increasing the additional support area, unloading a diseased organ, joint or limb, normalizing weight loads, facilitating movement, maintaining a comfortable position.
The assessment of the ability to maintain an upright posture is carried out with the help of special devices and certain parameters characterizing the process of standing, analysis of their changes under external and internal influences on a person. This approach underlies the techniques of stabilography, cephalography, etc.
The stabilography technique consists in registering and analyzing the parameters characterizing the movement of the horizontal projection of the common center of mass (GCM) of a standing person.
The body of a standing person continuously oscillates. Body movements while maintaining an upright posture reflect various muscle control responses. The main parameter by which the regulation of muscle activity takes place is the movement of a person's GCM.
The stabilization of the position of the GCM is carried out due to the stabilization of the body, which in turn is provided on the basis of processing information about the position and its movement in space due to the receipt of information by the visual, vestibular, proprioceptive apparatus.
Another technique, cephalography, is a recording and analysis of head movements while standing. This technique is widely used in clinical practice.
Changes in the vestibular apparatus significantly disrupt the provision of a vertical posture and are manifested in a change in the nature of the cephalogram, stabilogram and body movements aimed at maintaining a vertical posture.
In such a state of a person, an increase in the additional support area is required due to the auxiliary means of rehabilitation.
In addition to violations of statistical functions, there are violations of the function of walking in a person with damage to the ODA.
Clinical indicators of such violations of the ODA are:
- shortening of the limbs;
- limitation of joint mobility, severity and type of contracture;
- hypotrophy of the muscles of the lower extremities.
The presence of a shortening of the lower limb (LK) significantly affects the structure of walking and stability when standing.
The stability of standing is characterized by the amplitude of the oscillation of the general center of mass (GCM) and is slightly disturbed with slight and moderate shortening of the NC. Even with a pronounced shortening of the NC, there is a slight and moderate violation of stability. At the same time, no pronounced disturbance of the GCM oscillations is observed, which indicates the effectiveness of compensation mechanisms aimed at maintaining stability. The result of the shortening of the lower limb is the skew of the pelvis. Shortening more than 7 cm leads to significant changes in the static-dynamic functions. The study of such violations is carried out using a special stand with a predominant distribution of the weight load on a healthy NK (more than 60% of body weight) using a shortened NK as an additional support with a pronounced metatarsal-toe position.
Restriction in joint mobility is expressed primarily in dysfunctions in the hip, knee, ankle joints, foot, and a moderate and severe degree of dysfunction can be determined.
Hip joint (HJ)
- decrease in the range of motion to 60º;
- extension - not less than 160º;
- decrease in muscle strength;
- shortening of the lower limb - 7-9 cm;
- locomotion speed - 3.0-1.98 km / h;
- limitation of mobility in the form of a decrease in the amplitude of movement in the sagittal plane - not less than 55º;
- when unbending - not less than 160º;
- pronounced flexion contracture - extension less than 150º;
- decrease in the strength of the gluteal muscles and thigh muscles by 40% or more;
- locomotion speed - 1.8-1.3 km / h.
Knee joint (KJ)
1. Moderate degree of dysfunction:
- flexion to an angle of 110º;
- extension up to 145º;
- decompensated form of joint instability, characterized by frequent pathological mobility with minor loads;
- locomotion speed - up to 2.0 km / h with severe lameness.
2. Pronounced degree of dysfunction:
- flexion up to an angle of 150º;
- extension - less than 140º;
- locomotion speed up to 1.5-1.3 km / h, severe lameness;
- shortening of the step to 0.15 m with a pronounced asymmetry of lengths;
- rhythm coefficient - up to 0.7.
Ankle joint (AJ)
1. Moderate degree of dysfunction:
- limitation of mobility (flexion up to 120-134º, extension up to 95º);
- locomotion speed up to 3.5 km / h.
3. Pronounced degree of dysfunction:
- limitation of mobility (flexion less than 120º, extension up to 95º);
- locomotion speed up to 2.8 km / h.
Vicious position of the foot.
1. heel foot - the angle between the axis of the leg and the axis of the calcaneus is less than 90º;
2. Equino-varus or equinus foot - the foot is fixed at an angle of more than 125º or more;
3. valgus foot - the angle between the support area and the transverse axis is more than 30º, open inward.
4. valgus foot - the angle between the support area and the transverse axis is more than 30º, open outward.
With the pathology of the hip joint, the muscles of the thigh and gluteal muscles suffer, with the pathology of the knee joint (KJ) - the muscles of the thigh and lower leg, with the pathology of the ankle joint (AJ), hypotrophy of the muscles of the lower leg is noted.
The hypotrophy of the muscles of the lower extremities, reflecting the state of the muscular system, has a certain effect on the structure of a person's walking, in particular on the duration of the phases of support and transfer of the limbs, and in moderate and severe hypotrophy, a pronounced violation of temporal parameters is observed.
Muscle hypotrophy up to 5% is attributed to mild, by 5-9% - to moderate, by 10% - to a pronounced degree of decrease in muscle strength.
A decrease in the strength of the flexor and extensor muscles of the thigh, lower leg or foot of the affected limb by 40% in relation to the healthy limb is regarded as light; 70% as moderate, more than 700% as pronounced.
Decreased muscle strength on electromyographic (EMG)
studies, is characterized by a decrease in the amplitude of bioelectrical activity (ABA) by 50-60% of the maximum with moderate dysfunction.
With a pronounced dysfunction, ABA decreases significantly in the muscles of the distal extremities to 100 μV.
The choice of rehabilitation aids should be carried out individually for each patient, with the help of which he can achieve relative independence (improved mobility in the apartment and on the street, self-service, participation in the production process, etc.).
| Article timetables diseases |
Name of diseases, degree of dysfunction |
Category suitability for military service |
| Article 43. | Hypertonic disease: | |
| a) with significant impairment of the function of "target organs" | "D" | |
| b) moderate dysfunction of "target organs" | "V" | |
| c) with minor impairment and without impairment of the function of "target organs" | "V" |
For the purpose of military medical expertise, a classification of the degrees of arterial hypertension (VNOK, 2010) and a three-stage classification of hypertension (WHO, 1996, VNOK, 2010) are used, depending on the degree of dysfunction of the "target organs".
Item "a" refers to stage III hypertension, which is characterized by high blood pressure (at rest - systolic pressure is 180 mm Hg and above, diastolic - 110 mm Hg and above), including confirmed results daily monitoring of blood pressure. Blood pressure readings can be lowered in people who have had myocardial infarction or stroke. The clinical picture is dominated by severe vascular disorders, which are closely and directly related to the syndrome of arterial hypertension (large-focal myocardial infarction, dissecting aortic aneurysm, hemorrhagic, ischemic strokes, generalized narrowing of the retinal arteries with hemorrhages or exudates and papillary edema with impaired optic nerve function serum creatinine level more than 133 μmol / l and (or) creatinine clearance less than 60 ml / min (Cockcroft-Gault formula), proteinuria more than 300 mg / day.
If the diagnosis of stage III of hypertension is established only in connection with a minor stroke and (or) small-focal myocardial infarction, military personnel undergoing military service under a contract are examined under item "b".
Item "b" refers to stage II hypertension with II degree arterial hypertension (at rest - systolic pressure is 160 mm Hg and higher, diastolic pressure is 100 mm Hg and higher), which does not reach optimal parameters without constant drug therapy, confirmed, among other things, by the results of repeated daily monitoring of blood pressure and moderate dysfunction of "target organs".
In the clinical picture of the II stage of hypertension with moderate dysfunction of "target organs", vascular disorders prevail, which are not always closely and directly related to hypertensive syndrome (myocardial infarction, persistent heart rhythm and (or) conduction disturbances, the presence of atherosclerotic changes in the main arteries with moderate dysfunction, etc.). In addition, cerebral disorders are possible - hypertensive cerebral crises, transient ischemic attacks or stage II discirculatory encephalopathy with motor, sensory, speech, cerebellar, vestibular and other disorders, as well as FC II exertional angina and (or) FC II chronic heart failure.
Item "c" refers to stage II hypertension with arterial hypertension of I - II degrees (at rest - systolic pressure is from 140 to 179 mm Hg, diastolic - from 90 to 109 mm Hg) with a slight dysfunction "target organs" (chronic heart failure I FC, transient disturbances of the heart rhythm and (or) conduction, discirculatory encephalopathy stage I) or without dysfunction of the "target organs", as well as stage I with increased blood pressure (at rest systolic pressure is from 140 to 159 mm Hg, diastolic - from 90 to 99 mm Hg). At stage I of hypertension, a short-term increase in blood pressure to higher numbers is possible. There are no signs of target organ damage.
Stage II hypertension is also characterized by left ventricular hypertrophy (detected by X-ray examination (cardiothoracic index> 50 percent), electrocardiography (Sokolov-Lyon sign> 38 mm, Cornell product> 2440 mm x ms), echocardiography (left ventricular myocardial mass index> 125 g / m2 for men and> 110 g / m2 for women) and 1 - 2 additional changes in other "target organs" - fundus vessels (generalized or local vasoconstriction of the retina), kidneys (microalbuminuria 30 - 300 mg / day ., proteinuria and (or) creatinine level 115 - 133 μmol / L for men and 107 - 124 μmol / L for women; creatinine clearance 60 - 89 ml / min (Cockcroft-Gault formula) and great arteries (signs of thickening of the artery wall ( thickness of the "intima-media" complex) with ultrasound examination is more than 0.9 mm) and (or) atherosclerotic plaques in them).
In the presence of a syndrome of high blood pressure, closely associated with the presence of autonomic disorders (hyperhidrosis of the hands, "red" persistent dermographism, lability of the pulse and blood pressure with a change in body position, etc.), the examination is carried out on the basis of article 47 of the schedule of diseases.
The presence of hypertension in persons examined according to columns I, II of the disease schedule must be confirmed by an examination in stationary conditions and the results of a documented previous dispensary observation for at least 6 months with the obligatory repeated daily monitoring of blood pressure.
In each case of hypertension, differential diagnosis with symptomatic hypertension is performed. Examination of persons with symptomatic arterial hypertension is carried out according to the underlying disease.
When identifying diseases associated with essential hypertension, medical examination is also carried out on the basis of the relevant articles of the schedule of diseases.
1. Violation of psychological functions: perception, attention, thinking,
speech, emotions, will;
2. Violation of sensory functions: vision, hearing, smell, touch;
3. Violation of statodynamic functions: motor functions of the head, trunk, limbs, statics, coordination of movements;
4. Violation of the function of blood circulation, respiration, digestion, excretion,
metabolism and energy, internal secretion;
5. Violations of language and speech functions: violations of oral speech (rhinolalia, dysarthria, stuttering, alalia, aphasia), written speech (dysgraphia, dyslexia), verbal and non-verbal speech, impaired voice formation.
6. Disorders caused by physical deformities: external deformity (deformities of the face, head, trunk, extremities), abnormal openings of the excretory tracts (digestive, urinary, respiratory), abnormal body size.
7.2. Classification of the main categories of vital activity
1. Ability to self-service - the ability to independently satisfy basic physiological needs, to carry out daily household activities, to carry out personal hygiene;
The ability to move independently - the ability to move in space, overcome an obstacle, maintain body balance;
Learning ability - the ability to perceive and reproduce knowledge (general education, professional, etc.), mastering skills and abilities (social, cultural and everyday).
4. Ability to work - the ability to carry out activities in accordance with the requirements for the content, volume and conditions of work.
5. Ability for orientation - the ability to be defined in time and space.
6. Ability to communicate - the ability to establish contacts between people through the perception, processing and transmission of information
The ability to control one's behavior is the ability to self-awareness and adequate behavior, taking into account social and legal norms.
7.3. Classification of bodily dysfunctions by severity
1 degree - minor or moderate dysfunctions;
2 degree - severe dysfunctions;
Grade 3 - significantly pronounced dysfunctions.
7.4. Criteria for establishing the degree of restriction of the ability to work
The ability to work includes:
A person's ability to reproduce special professional knowledge, skills and abilities in the form of productive and effective work;
The ability of a person to carry out labor activities in a workplace that does not require changes in sanitary and hygienic working conditions, additional measures for the organization of labor, special equipment and equipment, shift, pace, volume and severity of work;
A person's ability to interact with other people in social and labor relations;
Ability to motivate work;
Ability to follow a work schedule;
The ability to organize the working day (organization of the work process in a time sequence).
The assessment of indicators of the ability to work is carried out taking into account the existing professional knowledge, skills and abilities.
The criterion for establishing the 1st degree of restriction of the ability to work is a health disorder with a persistent moderately severe disorder of the body's functions, caused by diseases, the consequences of injuries or defects, leading to a decrease in the qualifications, volume, severity and intensity of the work performed.
With the I degree of restriction of the ability to work, a citizen cannot continue to work in his main profession, but can perform other types of work of lower qualifications in normal working conditions:
When performing work in normal working conditions in the main profession with a decrease in the volume of production activity by at least 2 times, a decrease in the severity of labor by at least two classes;
When transferring to another job of lower qualifications in normal working conditions due to the inability to continue working in the main profession.
The criterion for establishing the 2nd degree of restriction of the ability to work is a health disorder with a persistent pronounced disorder of the body's functions caused by diseases, the consequences of injuries or defects, in which it is possible to carry out labor activities in specially created working conditions, using auxiliary technical means and (or) with the help of other persons.
The criterion for establishing the 3rd degree of restriction of the ability to work is a health disorder with a persistent, significantly pronounced disorder of body functions caused by diseases, the consequences of injuries or defects, leading to a complete inability to work, including in specially created conditions, or contraindications to work.
· Minor violations:
1.reduction of muscle strength to 4 points with a full range of active movements;
2. shortening of the limb by 2-4 cm;
3. muscle wasting up to 5% of the due;
4. a slight increase in tone (with cerebral palsy) of the spastic type, discoordination of movements in the hyperkinetic form, which does not significantly affect the walking pattern;
5. Electromyographically decrease in the integrated (total) activity during walking by 10-25%.
· Moderate violations:
Difficulties in independent movement are revealed, the duration of walking without fatigue is limited, the time spent on walking increases, which is due to
1. moderate (up to 3 points) decrease in muscle strength (for gluteal and gastrocnemius up to 3 points);
2. muscle wasting by 5-9% of the due;
3. limitation of the amplitude of active movements in the hip, knee and ankle joints (15-20 °);
4.Moderate increase in muscle tone by spastic type or muscle hypotension with pathological (flexion, extension, adduction) installations in the joints during verticalization and walking, discoordination of movements in hyperkinetic form, but with the ability to support the limb without auxiliary devices;
5. decrease (redistribution) of the bioelectrical activity of muscles during walking by 25-50%;
6. moderate (by 30-40%) decrease in stride length, pace of walking and rhythm coefficient;
7. the presence of a limb shortening from 4 to 6 cm, failure of the osteoarticular system, necessitating the use of special orthopedic devices that improve the stato-dynamic abilities of the affected limb.
With moderate functional impairments, additional support on the cane is possible.
· Expressed violations.
With pronounced functional disorders of walking, as a rule, it is possible either with outside help or with the use of special orthopedic devices, which is due to:
· Shortening of the limb by 7-9 cm;
· Restriction of active movements in the hip (7-10%), knee (8-12%), ankle (6-8%) joints with a pronounced decrease in muscle strength up to 2 points;
A pronounced increase (or decrease with flaccid paresis) tone, leading to pathological settings and deformations (flexion, flexion-abduction or adduction contracture of the hip joint over (15-20 °), extensor at an angle over 160 °, flexion-extensor contracture of the knee joint more than 30 °, ankylosis of the knee joint in the vicious position of varus, valgus over 20-25 °, equinus deformity of the foot at an angle over 120 °, calcaneal deformity of the foot at an angle of less than 85 °), pronounced discoordination in hyperkinesis. The ability to walk with the use of complex orthopedic devices and additional support on crutches, "walkers" or with assistance.
· Decrease in bioelectric activity when walking by more than 55-75%, decrease in stride length by more than 50-60%, pace of walking more than 70%, rhythm coefficient over 40-50%.
· Significant violations.
With significantly pronounced dysfunctions caused by flaccid or spastic paralysis, significant (over 50-60 °) contractures of the joints, their ankylosis in vicious positions, verticalization of the patient and independent walking with outside help and the use of modern means of prosthetics is impossible. Electromyographic and biomechanical studies are impractical.
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