In connection with new and, one might say, unexpected amendments to the Schedule of Diseases, our specialists are receiving many questions. Of course, because scoliosis of the 2nd degree with an arc of up to 17 degrees has now become quite a challenging disease. We must immediately make a reservation, there is one “but”: they can still be drafted into the army with such a diagnosis only if there are no spinal dysfunctions. Let's try to figure out what this function includes and how to determine the degree of violation.
As you know, the spine performs protective, static and motor functions in human life. Fitness category “B” will be assigned to a citizen suffering from the disease “scoliosis” if there is at least a slight impairment of this function. Examination of citizens subject to conscription this disease, is regulated by Article 66 of the Schedule of Diseases, the explanations to which indicate that dysfunctions are assessed in aggregate: protective, static and motor functions are taken into account. In other words, the assessment occurs comprehensively.
According to medical experts, a comprehensive assessment of spinal function should be based on interpretation protective function, then on the results of a study of static function, and, last of all, on the limitation of active movements in the spine (motor function). Please note: the static function characterizes a person’s ability to maintain a certain position of the body for a long time, and a violation of the protective function is characterized by neurological disorders. About the presence of a violation motor activity may indicate limitations in movement and associated pain.
So, what is the manifestation of a slight dysfunction of the spine in the disease “scoliosis”? Minor spinal dysfunction is characterized by:
Clinical manifestations in the form of incomplete loss of sensitivity in the area of one neuromere, loss or decrease in the tendon reflex, decrease in muscle strength of individual muscles of the limb with general compensation of their functions;
Inability of the spine to bear a vertical load in the form of severe pain after 5-6 hours of being in an upright position;
Limiting the range of motion in the corresponding parts of the spine to 20%.
How is dysfunction assessed and what research methods are used? Static function is examined by performing myotonometry, electromyography and remote thermography of the back muscles. Neurological disorders are determined by magnetic resonance imaging or computed tomography, and the neurological status is assessed by a neurologist.
Let us note once again that only the totality of the above manifestations of the disease gives grounds to determine the degree of dysfunction as insignificant.
If you have any questions medical specialist, engaged by our lawyers, will give you the necessary explanations and recommend necessary types research:
Violation of the static-dynamic function of the hip joint
1. Mild violation characterized by a slight limitation of mobility in the joint, a slight (2-3 cm) relative shortening of one of the limbs if the patient has a residual subluxation or dislocation. X-rays may show signs of precoxarthrosis, stage 1 and 2 coxarthrosis.
A) In the stage of pain compensation. Lameness is practically absent, can be detected mild symptom Trendelburg, a slight decrease (up to 4 points) in muscle strength. If shortening is noted, it is fully compensated by pelvic distortion. The support loads on both limbs are equal or there is a slight decrease (up to 45%) in the support on the affected leg. The rhythmicity coefficient is 1.0.
B) In the subcompensation stage, there is pain during physical activity, a decrease in support on the affected limb by up to 40%, usually accompanied by a decrease in the rhythmicity coefficient to 0.89-0.8 and slight lameness of the patient during long walking, which decreases after rest and taking painkillers. Trendelburg's symptom is mild to moderate, that is, the main compensatory mechanisms are aimed at unloading the affected limb.
C) There is no stage of decompensation.
2. Moderate impairment of static-dynamic function is characterized by a limitation of the range of motion in the hip joint in the sagittal plane to degrees or a limitation of extension to 155 degrees, a limitation of abduction and rotational movements; moderate shortening of at least one of the limbs, radiological instability of the hip joint and (or) radiological signs of stage 1-3 coxarthrosis.
A) The compensation stage is characterized by the same signs as with a slight violation of the static-dynamic function.
B) In the subcompensation stage, in addition to the above changes, there is moderate (2-3 cm) wasting of the thigh and lower leg muscles, a decrease in muscle strength up to 3 points. The skew and tilt of the pelvis compensates for the shortening of the limb by 2-3 cm. Patients are forced to use additional means of support (cane). Compensatory increased lumbar lordosis spine. Possible development of compensatory scoliosis, initial stages secondary osteochondrosis and arthrosis in the adjacent joint.
C) In the stage of decompensation, the supporting ability of the affected limb sharply decreases with a decrease in the supporting load of less than 40%, which is associated with incomplete compensation of shortening, skew and tilt of the pelvis. Lameness, as a rule, is pronounced, combined with a unilateral lesion with a decrease in the rhythmicity coefficient to 0.8 or less. Patients can use support aids when standing and walking. It is possible to develop secondary osteochondrosis with radicular and pain syndrome, axis changes lower limbs(more often hallux valgus deformity knee joints). The strength of the thigh muscles decreases to 2-3 points, and there is pronounced wasting of the thigh and lower leg muscles (more than 3 cm).
3. Pronounced violation static-dynamic function is characterized by limited mobility (less than 30 degrees) in the sagittal plane in the hip joint or placement of the limb in a flexion position at an angle of less than 155 degrees, which leads to the appearance of pronounced functional shortening (more than 6 cm), which is not fully compensated by the skewing and tilt of the pelvis. The development of adductor contractures with the installation of the limb at an angle of less than 90 degrees and the absence of rotational movements in the hip joint are also characteristic. A pronounced violation of static-dynamic function should also include a combination of clinical and radiological instability in one of the hip joints.
A) The compensation stage practically does not occur.
B) The stage of subcompensation is characterized by the same changes as with moderate violation static-dynamic function.
C) The stage of decompensation, in addition to changes similar to that of the same type, with a moderate violation of the static-dynamic function is characterized pronounced symptom Trendelburg, decrease in muscle strength to 1-2 points, persistent pain syndrome.
1. Nature of violations of statodynamic functions
Auxiliary means of rehabilitation, such as support and tactile canes, crutches, supports, handrails contribute to the performance of various statodynamic functions of a person: maintaining a vertical posture of a person, improving stability and mobility by increasing additional area support, unloading a diseased organ, joint or limb, normalizing weight loads, facilitating movement, maintaining a comfortable position.
The ability to maintain a vertical posture is assessed using special devices and certain parameters that characterize the process of standing, and analysis of their changes under external and internal influences on a person. This approach underlies the methods of stabilography, cephalography, etc.
The stabilography technique consists of recording and analyzing parameters characterizing the movement of the horizontal projection general center mass (MCM) standing man.
The body of a standing person continuously makes oscillatory movements. Body movements while maintaining an upright posture reflect various reactions control of muscle activity. The main parameter by which muscle activity is regulated is the movement of the human central mass.
Stabilization of the position of the GCM is carried out due to stabilization of the body, which in turn is ensured on the basis of processing information about the position and its movement in space due to the receipt of information by the visual, vestibular, and proprioceptive apparatus.
Another technique, cephalography, is the recording and analysis of head movements while standing. This technique is quite widely used in clinical practice.
Changes in the vestibular apparatus significantly disrupt the provision of a vertical posture and are manifested in changes in the nature of the cephalogram, stabilogram and body movements aimed at maintaining a vertical posture.
In this condition of a person, an increase in additional support area is required due to aids rehabilitation.
In addition to disturbances in statistical functions, disturbances in the human walking function occur when the musculoskeletal system is damaged.
Clinical indicators of such musculoskeletal disorders are:
Limitation of joint mobility, severity and type of contracture;
Hypotrophy of the muscles of the lower extremities.
The presence of lower limb shortening (LLT) significantly affects gait structure and standing stability.
Stability of standing is characterized by the amplitude of oscillation of the general center of mass (GCM) and with slight and moderate shortening of the NC it is slightly disturbed. Even with pronounced shortening of the NC, a slight and moderate violation of stability is observed. In this case, no pronounced disturbance of GCM oscillations is observed, which indicates the effectiveness of compensation mechanisms aimed at maintaining stability. The consequence of shortening the lower limb is pelvic distortion. Shortening of more than 7 cm leads to significant changes in statodynamic functions. The study of such disorders 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 dysfunction in the hip, knee, ankle joints, and foot, and moderate and severe degrees of dysfunction can be determined.
Hip joint(TBS)
Reduced range of motion to 60º;
Extension – at least 160º;
Decreased 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 - at least 55º;
During extension – at least 160º;
Severe flexion contracture - extension less than 150º;
Reduced strength of the gluteal and thigh muscles by 40% or more;
Locomotion speed is 1.8-1.3 km/h.
Knee joint (KJ)
1. Moderate degree dysfunctions:
Bending to an angle of 110º;
Extension up to 145º;
Decompensated form of joint instability, characterized by frequently occurring pathological mobility under light loads;
Locomotion speed is up to 2.0 km/h with pronounced lameness.
2. Severe degree of dysfunction:
Bending to an angle of 150º;
Extension – less than 140º;
Locomotion speed up to 1.5-1.3 km/h, severe lameness;
Shortening the step to 0.15 m with pronounced asymmetry of lengths;
Rhythmicity coefficient – up to 0.7.
Ankle joint (AJ)
1. Moderate degree of dysfunction:
Limitation of mobility (flexion up to º, extension up to 95º);
Locomotion speed up to 3.5 km/h.
3. Severe degree of dysfunction:
Limited mobility (flexion less than 120º, extension up to 95º);
Locomotion speed up to 2.8 km/h.
Vicious position of the foot.
1. calcaneal foot – the angle between the axis of the tibia and the axis of the calcaneus is less than 90º;
2. equinovarus 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 hip joint pathology, the thigh muscles and gluteal muscles, with pathology knee joint(KS) – muscles of the thigh and lower leg, with pathology ankle joint(GSS) there is hypotrophy of the lower leg muscles.
Hypotrophy of the muscles of the lower extremities, reflecting the condition muscular system, has a certain influence on the structure of a person’s walking, in particular on the duration of the phases of support and transfer of the limbs, and with moderate and severe malnutrition, a pronounced violation of time parameters is observed.
Muscle wasting up to 5% is classified as mild, 5-9% as moderate, and 10% as a pronounced decrease in muscle strength.
A decrease in the strength of the flexor and extensor muscles of the hip, leg or foot of the affected limb by 40% in relation to the healthy limb is regarded as mild; 70% as moderate, more than 700% as pronounced.
Decreased muscle strength with electromyography (EMG)
studies, is characterized by a decrease in amplitude bioelectrical activity(AAA) by 50-60% of the maximum with moderate dysfunction.
With severe dysfunction, AAA decreases significantly in the muscles of the distal limbs to 100 µV.
The choice of auxiliary means of rehabilitation should be carried out individually for each patient, with the help of which he can achieve relative independence (improving mobility in the apartment and on the street, independent self-care, participation in the production process, etc.).
Classification of the main types of dysfunction of the body when establishing disability
The main types of dysfunction of the human body, which are determined by medical and social examination, include:
Violations of mental functions (perception, attention, memory, thinking, speech, emotions, will);
Violations sensory functions(vision, hearing, smell, touch, pain, temperature and other types of sensitivity);
Violation of static-dynamic functions (head, torso, limbs, mobile functions, statics, coordination of movements);
Disorders of circulatory, respiratory, digestive, excretory, metabolic and energy functions, internal secretion, immunity, etc.;
Speech disorders (not caused by mental disorders), violation of voice formation, language form - violation of oral (rhinolalia, dysarthria, stuttering, alalia, aphasia) and written (dysgraphia, dyslexia), verbal and non-verbal speech;
Disorders that cause distortion (deformation of the face, head, torso, limbs leading to external distortion, abnormal defects of the digestive, urinary, respiratory tracts, violation of the size of the torso).
The criteria for human life include the ability for self-care, movement, orientation, control of one’s behavior, communication, learning, performance labor activity.
The ability to move is the ability to move effectively in one’s environment (walking, running, overcoming obstacles, using personal and public transport).
Evaluation options: nature of walking, pace of movement, distance covered by the patient, ability to independently use transport, need for help from others when moving.
The ability to self-service is the ability to effectively perform social and everyday functions and satisfy needs without the help of others.
Evaluation options: the time interval through which the need for help arises: episodic help (less than once a month), regular (several times a month), constant help (several times a week - regulated or several times a day - unregulated help).
The ability to orientate is the ability to independently navigate in space and time, to have an idea of the surrounding objects. The main orientation systems are vision and hearing (provided normal condition mental activity and speech).
Evaluation options: the ability to distinguish visual images of people and objects at a distance and in different conditions(presence or absence of obstacles, familiarity with the environment), the ability to distinguish sounds and oral speech (auditory orientation) in the absence or presence of obstacles and the degree of compensation for the impairment auditory perception oral speech in other ways (writing, non-verbal forms); the need to use technical means for orientation and assistance of other persons in various types of daily activities (at home, study, at work).
The ability to communicate (communicative ability) is the ability to establish contacts with other people and maintain social relationships (communication disorders associated with mental disorders are not considered here).
The main means of communication is oral speech, auxiliary - reading, writing, non-verbal speech (gesture, sign).
Evaluation options: characteristics of the circle of people with whom it is possible to maintain contacts, as well as the need for help from other people in the process of learning and work.
The ability to control one's behavior - the ability to lead in accordance with moral, ethical and legal norms public environment.
Evaluation options: the ability to be self-aware and adhere to established social norms, identify people and objects and understand the relationships between them, correctly perceive, interpret and adequately respond to traditional and unusual situations, maintain personal safety and personal hygiene.
Learning ability is the ability to perceive, assimilate and accumulate knowledge, to develop skills and abilities (everyday, cultural, professional and others) in a targeted learning process. Opportunity vocational training- the ability to master theoretical knowledge and practical skills and abilities of a specific profession.
Evaluation options: the opportunity to study in regular or specially created conditions (special educational institution or group, home training, etc.); volume of the program, terms and mode of training; opportunity to master various professions qualification level or only certain types of work; need to use special means with the assistance of other persons (except the teacher).
The ability to work is the totality of a person’s physical and spiritual capabilities, which is determined by the state of health, which allows him to engage in various types labor activity.
Professional ability to work is a person’s ability to perform high-quality work required by a specific profession, which allows employment in a certain area of production in accordance with the requirements of the content and volume of the production load, established mode work and working environment conditions.
Impaired professional ability to work is the most common cause of social disability, which can occur primarily when other categories of life activity are not impaired, or secondarily due to limitations in life activity. The ability to work in a specific profession for disabled people with limitations in other life activity criteria can be preserved in whole or in part or restored by means vocational rehabilitation, after which disabled people can work in regular or specially created conditions with full or part-time working hours.
A conclusion on inability to work is prepared only if the disabled person agrees (except for cases where the disabled person is declared incompetent).
Evaluation options: preservation or loss of professional suitability, the possibility of working in another profession, which is equal in qualifications to the previous one, assessment of the permissible amount of work in one’s profession and position, the possibility of employment in ordinary or specially created conditions.
The degree of disability is the magnitude of deviation from the norm of human activity. The degree of disability is characterized by one or a combination of several of its most important criteria.
There are three degrees of disability:
Moderately expressed Limitation of life activity is caused by dysfunction of organs and systems of the body, leading to moderate limitation of the ability to learn, communicate, orientate, control one’s behavior, move, self-care, and participate in work activities.
Expressed Limitation of life activity is caused by a violation of the functions of organs and systems of the body and consists of a pronounced impairment of the ability to learn, communicate, orientate, control one’s behavior, move, self-care, and participate in work activities.
Significant limitation of life activity occurs as a result of significant impairment of the functions of organs or systems of the body, which leads to the impossibility or significant impairment of the ability or possibility of learning, communication, orientation, control of one’s behavior, movement, self-care, participation in work activities, and is accompanied by the need for outside care ( outside help).
A person who is recognized as disabled, depending on the degree of dysfunction of the organs and systems of the body and the limitation of her life activity, is assigned disability group I, II or III.
Group I disability is divided into subgroups A and B depending on the degree of loss of health of the disabled person and the amount of need for constant outside care, assistance or care.
The criteria for establishing disability are determined by paragraph 27 of the Regulations on the procedure, conditions and criteria for establishing disability, approved by Resolution of the Cabinet of Ministers of Ukraine dated December 3, 2009 N 1317.
The causes of disability are established in accordance with paragraph 26 of the Regulations on the procedure, conditions and criteria for establishing disability, approved by Resolution of the Cabinet of Ministers of Ukraine dated December 3, 2009 N 1317.
When disability groups increase due to general illness, industrial accident, occupational disease, wounds, contusions, mutilations and other diseases, in the event of a severe general illness, the cause of disability is determined at the patient’s choice.
If one of the causes of disability is disability since childhood, MSEC in the conclusion on the examination of the disabled person indicates two causes of disability.
Re-commission of disabled people is carried out in accordance with paragraph 22 of the Regulations on the procedure, conditions and criteria for establishing disability, approved by Resolution of the Cabinet of Ministers of Ukraine dated December 3, 2009 N 1317.
Medical and social examination
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DEGREES OF VIOLATION OF STATODYNAMIC FUNCTIONS OF THE HUMAN BODY IN PARESIS AND PLEGIA OF THE LIMB
Federal State Institution "Main Bureau of Medical and Social Expertise in the Samara Region", Samara, 2011
Generalized experience presented neurological practice on the development of standards for compliance with the degree of impairment of limb functions in paresis and plegia and the degree of impairment of statodynamic functions, which can be used in the practical activities of neurologists both in the medical and social examination service and in medical and preventive institutions.
Key words: paresis of the limbs, plegia of the limbs, severity of disorders
In practice, every doctor-specialist in medical and social examination, including a neurologist, is guided by the classifications and criteria used in the implementation of medical and social examination of citizens by federal government agencies medical and social examination approved by order of the Ministry of Health and social development Russian Federation dated December 23, 2009 No. 1013n, which distinguish 4 degrees of severity of the main types of dysfunctions of the body:
I degree - minor violations;
II degree - moderate violations;
III degree - pronounced violations;
IV degree - significantly pronounced violations.
Based on more than 20 years of neurological experience in medical and social examination institutions, the authors propose for a unified assessment of the correspondence between the severity of paresis and plegia of the limbs and the degree of disturbance of static-dynamic functions that the lesions lead to nervous system with focal organic symptoms, use the following in the practice of medical and social examination approximate standards, presented in the form of tables (Tables 1-5).
Disturbances of statodynamic functions in upper mono- and paraparesis
The severity of disturbances in static-dynamic functions
Classification of the main types of dysfunctions of the body and the degree of their severity
The degree of impairment of body functions is characterized by various indicators and depends on the type of functional impairment, methods for their determination, the ability to measure and evaluate the results.
The following disorders of body functions are distinguished:
- disturbances of mental functions (perception, attention, memory, thinking, intelligence, emotions, will, consciousness, behavior, psychomotor functions)
- violations of language and speech functions (violations of oral (rhinolalia, dysarthria, stuttering, apalia, aphasia) and written (dysgraphia, dyslexia), verbal and non-verbal speech, voice formation disorders, etc.)
- disorders of sensory functions (vision, hearing, smell, touch, tactile, pain, temperature and other types of sensitivity);
- violations of static-dynamic functions ( motor functions head, torso, limbs, statics, coordination of movements)
- visceral and metabolic disorders(functions of blood circulation, respiration, digestion, excretion, hematopoiesis, metabolism and energy, internal secretion, immunity)
- disorders caused by physical deformity (deformations of the face, head, torso, limbs, leading to external deformity, abnormal openings of the digestive, urinary, respiratory tracts, disturbance of body size)
Based on a comprehensive assessment of various parameters characterizing persistent dysfunctions of the human body, taking into account their qualitative and quantitative values, FOUR degrees of their severity are distinguished:
1st degree - minor violations
2nd degree - moderate violations
3rd degree - severe disturbances
4th degree - significantly pronounced violations.
Disability leads to limitation of life activity, i.e. to a complete or partial loss of the ability or ability to carry out self-care, move independently, navigate, communicate, control one’s behavior, learn and engage in work.
In a comprehensive assessment of various indicators characterizing the limitations of the main categories of human life, 3 degrees of their severity are distinguished:
Self-care ability - a person’s ability to independently carry out basic physiological needs, perform daily household activities, including personal hygiene skills:
1st degree - the ability for self-service with a longer investment of time, fragmentation of its implementation, reduction in volume, using, if necessary, auxiliary technical means
2nd degree - ability for self-care with regular partial assistance from other persons, using auxiliary technical means if necessary
3rd degree - inability to self-care, need for constant assistance and complete dependence on other persons
Ability for independent movement - the ability to independently move in space, maintain body balance when moving, at rest and changing body position, to use public transport:
1st degree - the ability to move independently with a longer investment of time, fragmentation of execution and reduction of distance using, if necessary, auxiliary technical means
2nd degree - ability to move independently with regular partial assistance of other persons using assistive technical means if necessary
3rd degree - inability to move independently and need constant assistance from others
Orientation ability - the ability to adequately perceive the environment, assess the situation, the ability to determine the time and location:
1st degree - the ability to navigate only in a familiar situation independently and (or) with the help of auxiliary technical means
2nd degree - ability to orient with regular partial assistance from other persons, using auxiliary technical means if necessary
3rd degree - inability to orientate (disorientation) and need for constant assistance and (or) supervision of other persons
The ability to communicate is the ability to establish contacts between people by perceiving, processing and transmitting information:
1st degree - ability to communicate with a decrease in the pace and volume of receiving and transmitting information; use, if necessary, assistive technical aids
2nd degree - ability to communicate with regular partial assistance from other persons, using auxiliary technical means if necessary
3rd degree - inability to communicate and need for constant help from others
The ability to control one’s behavior is the inability to self-awareness and adequate behavior taking into account social, legal, moral and ethical standards:
1st degree - periodically occurring limitation of the ability to control one’s behavior in difficult situations life situations and (or) constant difficulty in performing role functions affecting certain areas of life, with the possibility of partial self-correction;
2nd degree - a constant decrease in criticism of one’s behavior and environment with the possibility of partial correction only with the regular help of other people;
3rd degree - inability to control one’s behavior, inability to correct it, need for constant help (supervision) from other persons;
Ability to learn - the ability to perceive, remember, assimilate and reproduce knowledge (general education, professional, etc.), mastery of skills and abilities (professional, social, cultural, everyday):
1st degree - ability to learn, as well as to receive education at a certain level within the framework of government educational standards V educational institutions general purpose using special teaching methods, special regime training, using, if necessary, auxiliary technical means and technologies;
2nd degree - ability to learn only in special (correctional) educational institutions for students, pupils with developmental disabilities or at home special programs using, if necessary, auxiliary technical means and technologies;
3rd degree - learning disability
The most important thing in medical and social examination is the examination of a person’s ability to work, which determines:
- human ability to reproduce special professional knowledge, skills and abilities in the form of productive and efficient work;
- a person’s ability to carry out labor activities in a workplace that does not require changes in sanitary and hygienic working conditions, additional measures on the organization of work, special equipment and equipment, shifts, 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 adhere to work schedule;
- ability to organize the working day (organization labor process in time sequence).
Assessment of indicators of ability to work is carried out taking into account existing professional knowledge, skills and abilities.
The criterion for establishing the 1st degree of limitation of the ability to work is a health disorder with a persistent moderate disorder of body functions, caused by diseases, consequences of injuries or defects, leading to a decrease in qualifications, volume, severity and intensity of the work performed, the inability to continue working in the main profession if it is possible to perform other types of lower-skilled work under normal working conditions in the following cases:
- when performing work under 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 work by at least two classes;
- when transferred to another job of lower qualifications under normal working conditions due to the inability to continue working in the main profession.
The criterion for establishing the 2nd degree of limitation of the ability to work is a health disorder with a persistent pronounced disorder of body functions caused by diseases, consequences of injuries or defects in which it is possible to carry out work in specially created working conditions, with the use of auxiliary technical means and (or) with the help of others.
The criterion for establishing the 3rd degree of limitation of the ability to work is a health disorder with a persistent, significantly expressed disorder of body functions, caused by diseases, consequences of injuries or defects, leading to complete inability to work, including in specially created conditions, or work activity that is contraindicated .
Depending on the degree of deviation from the norm of human activity due to health impairment, the degree of limitation of life activity is determined. In turn, depending on the degree of disability and the degree of impairment of body functions, a disability group is established. Criteria for establishing disability groups
The criterion for determining the FIRST GROUP OF DISABILITY is a person’s health impairment with a persistent, significantly pronounced disorder of body functions, caused by diseases, consequences of injuries or defects, leading to limitation of one of the following categories of life activity or a combination of them and necessitating his social protection:
- self-service abilities of the third degree;
- ability to move third degree;
- orientation abilities of the third degree;
- communication abilities of the third degree;
- ability to control one's behavior to the third degree.
The criterion for establishing the SECOND GROUP OF DISABILITY is a person’s health impairment with a persistent severe disorder of body functions, caused by diseases, consequences of injuries or defects, leading to limitation of one of the following categories of life activity or a combination of them and necessitating his social protection:
- self-service abilities of the second degree;
- mobility ability of the second degree;
- orientation abilities of the second degree;
- communication abilities of the second degree;
- ability to control one's behavior to the second degree;
- learning abilities of the third, second degrees;
- ability for work activity of the third, second degrees.
The criterion for determining the THIRD GROUP OF DISABILITY is a person’s health impairment with a persistent moderately severe disorder of body functions, caused by diseases, consequences of injuries or defects, leading to limitation of the ability to work 1st degree or limitation of the following categories of life activity in their various combinations and causing the need for his social protection:
- self-care abilities of the first degree;
- first degree mobility ability;
- orientation abilities of the first degree;
- communication skills of the first degree;
- ability to control one's behavior first degree;
- first degree learning abilities.
The examination of childhood disability is based on modern concept WHO, which believes that the reason for assigning disability is not the disease or injury itself, but the severity of their consequences, which manifest themselves in the form of violations of a particular psychological, physiological or anatomical structure or function, leading to limitation of life activity and social failure.
Indications for establishing disability in children are pathological conditions that arise from congenital, hereditary, acquired diseases or after injuries.
In accordance with the adapted version of the “International Nomenclature of Impairments, Disabilities and Social Disabilities”, the category of disabled children includes children under 16 years of age who have significant disabilities leading to social maladaptation due to impaired development and growth of the child, loss of control over their behavior, ability to to self-care, movement, orientation, training, communication, and work in the future.
Medical indications for determining disability in children include three sections:
Section 1 - a list of pathological conditions leading to temporary limitation of life activity and social maladaptation of a child in the event of severe but reversible disorders of the functions of organs and systems and giving the right to be declared disabled for a period of 6 months to 2 years;
Section 2 - pathological conditions leading to partial limitation of life activity and social maladaptation of the child with the predicted possibility of full or partial restoration of the impaired functions of organs and systems. There are two groups of pathological conditions: 2A - with the right to establish disability for a period of 2 to 5 years, i.e. re-examination is carried out every 2-5 years; 2B - with the right to establish disability for a period of up to 5 years or more, i.e. re-examination is carried out no more often than after 5 years;
Section 3 - pathological conditions leading to significant limitation of life activity and social maladjustment of the child with pronounced irreversible dysfunction of organs and systems. Medical report for pathological conditions regulated by section 3, it is issued once before the age of 16.
The category “disabled child” is determined in the presence of disabilities of any category and any of three degrees of severity (which are assessed in accordance with age norm), necessitating social protection.
Based on expert ITU decisions a conclusion is drawn up in the form of an “ITU Certificate”, which is issued to the disabled person. The certificate indicates the group and cause of disability, work recommendations, and the deadline for the next re-examination. In addition to the certificates, ITU sends a notice of the decision to the institution within three days.
In cases where the examinee does not agree with the decision made, he can submit a written statement to the chairman of the ITU or the head of the district social protection department within a month.
The degree of limitation of the main categories of human life activity is determined based on an assessment of their deviation from the norm corresponding to a certain period (age) of human biological development.
The disability group is established for citizens over 16 years of age. The examination of childhood disability does not provide for differentiation by group. When identifying a disability under the age of 16, the concept of “disabled child” is used.
· Minor violations:
1. reduction in 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 normal;
4. a slight increase in tone (with cerebral palsy) of the spastic type, incoordination of movements in the hyperkinetic form, which does not significantly affect the walking pattern;
5. electromyographic decrease in integrated (total) activity when walking by 10-25%.
· Moderate violations:
Difficulties in independent movement are identified, 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 the gluteal and calf muscles up to 3 points);
2. muscle wasting by 5-9% of normal;
3. limitation of the amplitude of active movements in the hip, knee and ankle joints (15-20°);
4. moderate increase in muscle tone of the spastic type or muscle hypotonia with pathological (flexion, extension, adduction) settings in the joints during verticalization and walking, incoordination of movements in the hyperkinetic form, but with the ability to rely on a limb without auxiliary devices;
5. reduction (redistribution) of bioelectrical activity of muscles when walking by 25-50%;
6. moderate (30-40%) decrease in step length, walking tempo and rhythmicity coefficient;
7. the presence of shortening of the limb from 4 to 6 cm, failure of the osteoarticular system, necessitating the use of special orthopedic devices that improve the static-dynamic abilities of the affected limb.
With moderate functional disorders additional support on a cane is possible.
· Expressed disorders.
With severe functional impairments, walking is usually 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;
· limitation 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 in flaccid paresis) of tone, leading to pathological settings and deformations (flexion, flexion-abduction or adduction contracture of the hip joint over (15-20°), extension at an angle over 160°, flexion - extension contracture CL more than 30°, ankylosis of the CL in the vicious position of varus, valgus over 20-25°, equinus deformity of the foot at an angle of over 120°, calcaneal deformity of the foot at an angle of less than 85°), pronounced incoordination with hyperkinesis. Ability to walk using complex orthopedic devices and additional support on crutches, walkers, or with assistance.
· A decrease in bioelectric activity when walking by more than 55-75%, a decrease in step length by more than 50-60%, a decrease in walking tempo by more than 70%, and a decrease in rhythm coefficient by more than 40-50%.
· Significantly expressed disorders.
In case of 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 assistance and use modern means prosthetics is impossible. Electromyographic and biomechanical studies are not advisable.
What is the insignificance of the perfect? administrative offense?
If the administrative offense committed is of minor significance, the judge, body, or official authorized to resolve the case of an administrative offense may release the person who committed the administrative offense from administrative liability and limit himself to an oral remark (Article 2.9 of the Code of Administrative Offenses of the Russian Federation).
A minor administrative offense is an action or inaction, although formally containing the elements of an administrative offense, but taking into account the nature of the offense committed and the role of the offender, the amount of harm and the severity of the consequences, which does not represent a significant violation of protected public legal relations.
A minor offense occurs in the absence of a significant threat to protected social relations. Circumstances such as, for example, the identity and property status of the person held accountable, voluntary elimination of the consequences of the offense, compensation for the damage caused, are not circumstances indicating the insignificance of the offense. These circumstances, by virtue of Parts 2 and 3 of Art. 4.1 of the Code of Administrative Offenses of the Russian Federation are taken into account when imposing an administrative penalty.
It must be borne in mind that, taking into account the signs of the objective side of some administrative offenses, under no circumstances can they be considered insignificant, since they significantly violate the protected public relations. These, in particular, include administrative offenses provided for:
a) Art. 12.8 of the Code of Administrative Offenses of the Russian Federation on driving a vehicle by a driver who is in a state of intoxication, transferring control of a vehicle to a person who is in a state of intoxication;
b) art. 12.26 of the Code of Administrative Offenses of the Russian Federation on failure by the driver of a vehicle to comply with the requirement to pass medical examination for a state of intoxication.
The insignificance of an administrative offense may be established by the court, in particular, when:
a) consideration of a case on bringing to administrative liability;
b) consideration of a case challenging a decision administrative body on bringing to administrative responsibility.
Having established the insignificance of the offense when considering a case on bringing to administrative liability, the reasoning part of the court decision must contain the following conclusions:
a) refusal to satisfy the demands of the administrative body;
b) on exemption from administrative liability due to the insignificance of the offense;
c) on the application of a measure in the form of an oral remark.
In this case, legal expenses incurred by a person released from administrative liability due to a minor offense are not subject to compensation to this person.
If the insignificance of the offense is established during the consideration of the case challenging the decision of the administrative body to bring to administrative responsibility, the court, guided by Part 2 of Art. 211 of the Arbitration Procedure Code of the Russian Federation and Art. 2.9 of the Code of Administrative Offenses of the Russian Federation, makes a decision to declare this resolution illegal and to cancel it.
When qualifying an administrative offense as minor, courts must take into account that Art. 2.9 of the Code of Administrative Offenses of the Russian Federation does not contain any reservations about its non-application to any offenses provided for by the Code of Administrative Offenses of the Russian Federation.
The possibility or impossibility of qualifying an act as minor cannot be established in the abstract, based on the structure of the administrative offense formulated in the Code of Administrative Offenses of the Russian Federation, for which liability is established. Thus, the qualification of an administrative offense as minor cannot be refused only on the grounds that in the relevant article of the Special Part of the Code of Administrative Offenses of the Russian Federation, liability is defined for failure to fulfill any obligation and is not made dependent on the occurrence of any consequences.
The classification of an offense as minor can only occur in exceptional cases and is made taking into account the above provisions in relation to the circumstances of the specific act committed by the person. At the same time, the court’s application of the provisions on insignificance must be motivated (clause 18 of the Resolution of the Plenum of the Supreme Arbitration Court of the Russian Federation dated June 2, 2004 N 10 “On some issues that arose in judicial practice when considering cases of administrative offenses").
Auxiliary means of rehabilitation, such as support and tactile canes, crutches, supports, handrails contribute to the performance of various static-dynamic functions of a person: maintaining a vertical posture of a person, improving stability and mobility by increasing the additional area of support, unloading the diseased organ, joint or limb, normalizing weight loads, facilitating movement, maintaining a comfortable position.
The ability to maintain a vertical posture is assessed using special devices and certain parameters that characterize the process of standing, and analysis of their changes under external and internal influences on a person. This approach underlies the methods of stabilography, cephalography, etc.
The stabilography technique consists of recording and analyzing parameters characterizing the movement of the horizontal projection of the general center of mass (GCM) of a standing person.
The body of a standing person continuously makes oscillatory movements. Body movements while maintaining an upright posture reflect various reactions to control muscle activity. The main parameter by which muscle activity is regulated is the movement of the human central mass.
Stabilization of the position of the GCM is carried out due to stabilization of the body, which in turn is ensured on the basis of processing information about the position and its movement in space due to the receipt of information by the visual, vestibular, and proprioceptive apparatus.
Another technique, cephalography, is the recording and analysis of head movements while standing. This technique is quite widely used in clinical practice.
Changes in the vestibular apparatus significantly disrupt the provision of a vertical posture and are manifested in changes in the nature of the cephalogram, stabilogram and body movements aimed at maintaining a vertical posture.
With this condition of a person, an increase in additional support area is required due to auxiliary means of rehabilitation.
In addition to disturbances in statistical functions, disturbances in the human walking function occur when the musculoskeletal system is damaged.
Clinical indicators of such musculoskeletal disorders are:
- shortening of limbs;
- limitation of mobility in joints, severity and type of contracture;
- wasting of the muscles of the lower extremities.
The presence of lower limb shortening (LLT) significantly affects gait structure and standing stability.
Stability of standing is characterized by the amplitude of oscillation of the general center of mass (GCM) and with slight and moderate shortening of the NC it is slightly disturbed. Even with pronounced shortening of the NC, a slight and moderate violation of stability is observed. In this case, no pronounced disturbance of GCM oscillations is observed, which indicates the effectiveness of compensation mechanisms aimed at maintaining stability. The consequence of shortening the lower limb is pelvic distortion. Shortening of more than 7 cm leads to significant changes in statodynamic functions. The study of such disorders 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 dysfunction in the hip, knee, ankle joints, and foot, and moderate and severe degrees of dysfunction can be determined.
Hip joint (HJ)
- reduction in the amplitude of movement to 60º;
- extension – at least 160º;
- decreased 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 - at least 55º;
- during extension – at least 160º;
- severe flexion contracture - extension less than 150º;
- reduction in the strength of the gluteal and thigh muscles by 40% or more;
- locomotion speed – 1.8-1.3 km/h.
Knee joint (KJ)
1. Moderate degree of dysfunction:
- bending to an angle of 110º;
- extension up to 145º;
- decompensated form of joint instability, characterized by frequently occurring pathological mobility under minor loads;
- locomotion speed – up to 2.0 km/h with pronounced lameness.
2. Severe degree of dysfunction:
- bending to an angle of 150º;
- extension – less than 140º;
- locomotion speed up to 1.5-1.3 km/h, severe lameness;
- shortening the step to 0.15 m with pronounced asymmetry of lengths;
- rhythmicity 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. Severe degree of dysfunction:
- limited mobility (flexion less than 120º, extension up to 95º);
- locomotion speed up to 2.8 km/h.
Vicious position of the foot.
1. calcaneal foot – the angle between the axis of the tibia and the axis of the calcaneus is less than 90º;
2. equinovarus 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.
In case of hip joint pathology, the thigh and gluteal muscles suffer; in case of knee joint (KJ) pathology, the thigh and lower leg muscles suffer; in case of ankle joint pathology (AJ), hypotrophy of the lower leg muscles is noted.
Hypotrophy of the muscles of the lower extremities, reflecting the state of the muscular system, has a certain influence on the structure of a person’s walking, in particular on the duration of the support and transfer phases of the limbs, and with moderate and severe hypotrophy, a pronounced violation of temporal parameters is observed.
Muscle wasting up to 5% is classified as mild, 5-9% as moderate, and 10% as a pronounced decrease in muscle strength.
A decrease in the strength of the flexor and extensor muscles of the hip, leg or foot of the affected limb by 40% in relation to the healthy limb is regarded as mild; 70% as moderate, more than 700% as pronounced.
Decreased muscle strength with electromyography (EMG)
studies, is characterized by a decrease in the amplitude of bioelectrical activity (ABA) by 50-60% of the maximum with moderate dysfunction.
With severe dysfunction, AAA decreases significantly in the muscles of the distal limbs to 100 µV.
The choice of auxiliary means of rehabilitation should be carried out individually for each patient, with the help of which he can achieve relative independence (improving mobility in the apartment and on the street, independent self-care, participation in the production process, etc.).
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