INTRODUCTION
Locomotor Disability means restriction in the movement of the limbs. Strictly speaking Locomotor Disability means problem in moving from one place to another — i.e. disability in legs. But, in general, it is taken as a disability related with bones, joints and muscles. It causes problems in person’s movements (like walking, picking or holding things in hand etc.)
The term Locomotor is derived from the Latin words loco – “from a place” and motivus – “causing motion”. So locomotion means movement from one place to another. And thus locomotor disability hampers movement from one place to another.
Locomotor disability is also known as mobility disability. Disability of the bones, joint or muscles leading to substantial restriction of the movement of the limbs or a usual form of cerebral palsy. Some common conditions giving raise to locomotor disability could be poliomyelitis, cerebral palsy, amputation, injuries of spine, head, soft tissues, fractures, muscular dystrophies etc.
CHILDHOOD SYMPTOMS OF
LOCOMOTOR DISABILITY
1. The child is not able to raise both the arms fully without any difficulties.
2. The child is not able to grasp objects without any difficulty.
3. The child has absence of any part of the limb.
4. The child has a difficulty in walking.
CATEGORIES OF LOCOMOTOR
DISABILITIES
· Permanent Physical impairment of Upper Limb
· Permanent Physical impairment of Lower Limb
· Permanent Physical impairment of Trunk (Spine)
· Permanent Physical impairment in case Short Stature/ Dwarfism
· Permanent Physical impairment in Amputees
· Longitudinal deficiencies
· Permanent Physical impairment in Neurological conditions
· Permanent Physical impairment due to cardiopulmonary Diseases
CAUSES
A person's inability to execute distinctive activities associated with moving, both personally and objects, from place to place, and such inability resulting from afflictions of musculo-skelatol and, or nervous system, has been defined as the Locomotor Disability Locomotor disability can be classified as: congenital and acquired. The common causes of these two forms of affliction can be classified as: congenital and developmental. Common examples being : cerebral palsy, CTEV, meningocele, meningo myelocele, phocomelias, congenital dislocation of hip. Causes of the acquired disability can be put within the following jackets : Infective and Traumatic. The infective ones are: tuberculosis of spine or other joints, chronic osteomyelitis, septic arthritis, acute poliomyelitis, G.B. syndrome, leprosy, encephalitis, AIDS etc. Traumatic ones are: traffic accidents (air, water, road), domestic accidents, industrial accidents, agricultural accidents, fall from height, bullet injuries, explosions, violence, sports injuries, natural catastrophies like earthquakes, floods etc. Then there can be other causes as well, such as vascular. Common examples are: cerebro vascular disease, peripheral vascular disease, perthe's disease. Neoplastic conditions are yet another cause of locomotor disability. For example, brain tumors like astrocytoma, meningioma, spinal tumors like meningioma, astrocytoma, and osteo sarcoma etc.
Metabolism, as has been said earlier, too can be the villain. Common examples are: rickets, diabetes mellitus, gout etc. There can be degenerative causes too. Examples are: motor neuron disease, parkinson's disease, multiple sclerosis, osteo arthritis, spondylosis etc. Among the miscellaneous causes can be musculas dystrophies, rheumatoid arthritis, systemic lupus erythematoses, lathyrism, ankylosing spondylitis, iatrogenic, and so on .
A brief numeration of common conditions causing Locomotor disability is given below:
Poliomyelitis
The number of polio disabled people in India is quite colossal. A 1994 World Health Organization (WHO) report on global situation on polio estimated that of the 10 million people affected with polio, approximately 60% live in India alone. The recent reports on India have, however, shown a decline in the number of cases, which is encouraging. Whereas over 20,000 cases of poliomyelitis were reported in 1986, the number came down to 3400 odd cases in 1995. The decline may be attributed to the National Immunisation Programme, and the recent introduction of Pulse Polio Programme, aimed at eradication of poliomyelitis. Poliomyelitis is an acute infective disease caused by the Poliovirus. There are three distinct serotypes of the virus, viz., 1, 2 and 3. Humans are the sole natural reservoir for poliovirus. Infection is transmitted by the oropharyngeal faecal circuit. Poliovims enters the human body through the mouth and alimentary tract. The virus multiplies in the intestines. It then travels to the regional lymph nodes and reticulo endothelial structures.
Viremia may occur for a short period. As a result of this, type specific antibodies are produced in the blood and gut. If the immune response is adequate and fast, the virus is neutralized and illness does not occur. If conditions for spread of the virus are present, the virus involves the nervous system. Poliovirus selectively damages some special areas in the nervous system, the most commonly affected area being the anterior horn of the spinal cord. There is no sensory involvement. Poliomyelitis occurs mostly in, young children. It is uncommon in adolescents and adults. The clinical picture ranges fiom inapparent illness to extensive paralysis of the muscles, respiratory failure and even death. Either of the following manifestations may present :
Asymptomatic Infection
· Abortive poliomyelitis: Illness lasts for 1-4 days. Symptoms are fever, headache, sore-throat, nausea, vomiting, loss of appetite, vague abdominal pain. Neurological manifestation are absent.
· Aseptic meningitis like syndrome without paralysis: The symptoms are like those of abortive type. In addition, there is pain and stiffness of the back and legs. Neck rigidity is usually present and is necessary for diagnosis.
· Paralytic poliomyelitis: It is the least common of all. The manifestations are similar to non-paralytic type. In addition, there is weakness of one or more muscle groups. Distribution of paralysis is characteristically patchy. Depending on the site of involvement, it may be classified as follows :
· Spinal: There is weakness of muscles of the neck, abdomen, trunk diaphragm, thorax or extremities.
· Bulbar: There is weakness in the motor, distribution of one or more cranial nerves and may affect voice, breathing and swallowing.
· Bulbospinal: is combination of bulbar and spinal forms.
· Encephalitic: the child is irritable and may become disoriented and drowsy, tremors and convulsions may occur.
There are three stages of paralytic poliomyelitis-acute, convalescent and residual. Recovery may occur noticeably in the first six months of the illness, but after a period of two years, the paralysis does not show further recovery.
Post polio syndrome: Decades after recovering much of their muscle strength, survivors of paralytic polio experience unexpected fatigue, pain and weakness. The cause appear to be degeneration of motor neurons.
Cerebral Palsy
Incidence of cerebral palsy is quite alarming in India with various reports having indicated that 1.5 to 3.5 per thousand of all live births may be followed by the child developing cerebral palsy. Cerebral palsy is a "persistent disorder of movement and posture appearing early in life and due to a developmental non-progressive disorder of the brain." Cerebral palsy is not a disease, nor is it hereditary. Although the abnormality of movement and posture cannot be completely corrected, they may improve as the child's nervous system grows and matures. There are different types of cerebral palsy. Spastic type is most common and comprises 70% of all patients. Dyskinetic type is present in 10% of all patients, while mixed type (a combination of spastic and dyskinetic types) is present in 20% of all patients. Based on the topographic distribution of neuromotor involvement, classification is also made as (a) quadriplegia (b) diplegia (c) paraplegia (d) hemiplegia (e) triplegia and (f) monoplegia.
Various problems frequently co-exist in cerebral palsy. Seizures occur in about half the children, more often in those with spastic hemiparesis or quadriparesis and rarely in those with pure dyskinetic form. Mental retardation is more common in children with microcephaly, seizures and spastic quadriparesis. It is rare in dyskinetic type. Mental retardation is mild in one-third of all children with cerebral palsy. Visual problems occur in about half the children with cerebral palsy. Most common problem is strabismus. Hearing problem occurs in 12% cases. Speech impairment is frequently associated with drooling and feeding problem. They are most commonly seen in children with spastic dyskinetic or dyskinetic cerebral palsy. Attention deficits, easy distractiability, learning disabilities, emotional lability and behaviour problems are common in children with cerebral palsy. Other medical problems include failure to thrive, constipation, frequent colds, ear infection, wheezing etc. Common orthopaedic problems include joint contractures, hip dislocation and scoliosis.
Muscular Dystrophies
The muscular dystrophies are a heterogeneous group of inherited disorders with gradual degeneration of the muscle fibres. There are three main types of muscular dystrophies. These are : pseudohypertrophic or duchenne type, fascio scapulo humeral type and limb girdle type. The most common type is Duchenne muscular dystrophy. It occurs only in male children. Early development of the child is normal or slightly delayed. It starts with difficulty in walking, running and climbing stairs when the child is around 2 or 3 years of age. The child has difficulty in standing up from the recumbent position, and, classical "Gowers sign" may be present in moderately severe disease. Waddling gait is present. There is hypertrophy of calf muscles. Weakness of shoulder girdle muscles occur subsequently. Eventually all the muscles atrophy and the child becomes severely incapacitated and bed-ridden. Arnbulation usually ceases by 12 to 14 years of age, and death occurs prior to age 20 years in 75% of cases due to intercurrent infection or associated cardiomyopathy. Intelligence is usually in the subnormal range. Fascio scapulohumeral type affects both sexes. Age of onset is around puberty. There is weakness of facial and shoulder girdle muscles. Forceful eye closure and whistling are not possible. Progress of weakness is slow and is compatible with a normal life span.
Limb-girdle muscular dystrophy may start to appear during childhood, adolescence or adulthood. Pelvic girdle muscles are most commonly affected. Course of illness is slower and moderately progressive.
Arthritis
The word 'arthritis' literally means joint inflammation. It is characterized by pain, swelling and limitation of joint movement. There are many types of arthritis, such as: Osteo arthritis (OA): This is the most common type of arthritis. Osteo-arthritis is a degenerative joint disease. It is characterized by loss of joint cartilage and the formation of bony out growths at the edges of the affected joints. Usually one or two of the larger joints are affected. The joints most frequently involved are those of spine, hips and knees. The exact mechanism for loss of cartilage is not known but obesity and stress to the joint contributes to the damage. The likelihood of OA increases with advancing age. It is estimated that nearly 75% of people over 60 years of age will experience symptoms of OA. Young people can also get osteoarthritis when the joint has been damaged by disease or injury or congenital deformity. OA may manifest as pain, stiffness, limited range of motion and swelling of the joint. Osteophyte or bone spur is the single most common feature of OA. Muscular wasting is always present to a greater or lesser extent. quality of life is affected by OA by limiting mobility and functioning. Rheumatoid Arthritis (RA): It is far less common than osteo arthritis but potentially more serious. Rheumatoid Arthritis is a systemic disease. The common symptoms are joint pain, stiffness, fatigue, anorexia, weight loss and fever. Small joints in the hands and feet, wrists, ankles and knees are commonly affected, usually in a fairly symmetric pattern. Subcutaneous nodules may appear over pressure joints (for example, just distal to the elbow). Range of motion of joint is restricted and correctable in early cases. In later stages of the disease, severe restriction with contractures and fixed deformities occur. The disease may occur at all ages, but the usual onset is in the fourth decade. It affects women 3 times more than men. The exact cause is unknown, but it is thought to be the result of several factors, some of which may be genetically determined, while others may be of environmental origin that triggers an abnormal immune response. The disease may be self limiting or run a prolonged course; there are times when the disease is "quiet" and times when it flares up. During the "quiet" periods of remission, the symptoms of the disease disappear. The severity of RA varies widely, from minor pain and inflammation in the joints to life-threatening complications involving the internal organs.
Stroke
Stroke is characterized by sudden loss of motor control usually hemiplegia i.e. involvement of face, arm and leg of one side. It may be accompanied by unconsciousness, speech disturbance, visual and hearing loss, numbness, burning pain, sensory deficit and psychiatric disturbances. In mild cases of stroke, the manifestation is trivial and does not interfere with the activities of daily living. Stroke is the most common cause of severe disability in the aging population, only 28% of strokes occur in persons younger than 65 years of age. Incidence of stroke is higher among men than women. Several risk factors have been identified. They include hypertension, diabetes mellitus, heart disease, smoking, excessive alcohol use, and sickle cell disease. The risk factors are found to be higher in some races (Blacks, Japanese). The causes of stroke can be grossly classified as ischemia (deficiency of blood) or haemorrhage (due to rupture of blood vessel). Ischemic brain injury is the cause of stroke in 85% of cases and occurs due to occlusion of blood vessel from thrombosis or emboli. Thrombosis occurs most commonly in the presence of atherosclerotic cerebrovascular disease while cerebral emboli are usually of cardiac origin. All body functions are represented in the brain, some in the left and some in the right hemisphere. Right sided functions like motor, sensory or visual fields have representation in the left hemisphere and left sided functions are represented in the right hemisphere. The nerve fibres, both motor and sensory, cross at different levels in the nervous system. The knowledge of the site where the fibres cross is important in localisation of the damaged area. The neurological deficit in stroke reaches its maximum within seconds, minutes, hours or a few days, depending on the nature of the lesion. Later in the course of the illness, if the attack is not fatal, stabilization occurs and is followed by improvement in varying degrees. This improvement gradually takes place over weeks or months.
Spinal Cord Injury
It is a traumatic insult to the spinal cord that can result in alteration of normal motor, sensory or autonomic functions. It can result in paraplegia i.e. involvement of lower extremities, or quadriplegia i.e. involvement of all extremities. The involvement may be complete or incomplete. The injury is termed incomplete when there is sparing of some sensation, or motor function, or both, distal to the injury. Common causes of spinal injuries are fall from height (root, tree, stairs), motor vehicle accidents, gun shot injury, stab wounds, sports injuries and iatrogenic injuries of cord following surgical procedures. The incidence of spinal cord injury is 5-15 per million population. It is estimated that in our country there are 12000 fresh cases of paraplegia every year. In general, spinal cord injury should be suspected in patients where there is a history of trauma, who have head injury with loss of consciousness, and in those who have multiple injuries following a motor vehicle accident. A fall from a height associated with tenderness over the spinal column or paraesthesia in the lower limbs should arouse suspicion. A gap or angular deformity may be palpated on careful examination. Gross paralysis may be present. Spinal cord injury is a devastating injury. Except in cases where substantial or complete recovery occurs, the person is confined to bed or wheelchair existence for the rest of his life. In addition, he may have inadequate or loss of control over his bowel and bladder functions adding to his incapacitation. The spinal cord injury patient is prone to develop pressure sores and urinary tract infection. At the same time, mental and emotional functions are affected. In our country, large number of spinal cord injury patients succumb to complications for want of appropriate treatment.
Amputation
Amputation implies the absence of all or part of the limb. Amputations are musculo skeletal problems of a special nature because the disability results not from a pathologic condition, but from treatment that has eliminated the pathologic condition. It can also occur due to congenital skeletal deficiency and trauma. The causes of amputation may be broadly classified as congenital or acquired. Congenital skeletal deficiencies can be transverse or longitudinal. Transverse is defined as absence of all skeletal elements distal to the deficiency. It can further be described as total, upper one third, middle one third, distal one third. Longitudinal deficiency is an absence extending parallel to the long arm of the limb. The deficiency may be partial or total. Probable causes of congenital skeletal deficiencies are hereditary abnormalities, teratogenic agents, excessive radiation etc. The causes of acquired limb loss are : accidents, malignant tumors, death of tissue from peripheral vascular insufficiency of atherosclerosis and diabetes, death of tissue due to peripheral vasospastic diseases such as Buergers disease and Raynauds disease, thermal injuries both from heat and cold, long standing infections of bone and other tissues that leave no chance of restoration of function, uselessness of a deformed limb that is objectionable to the patient, neurogenic resorption.
Tuberculosis [TB] of Bones and Joints
Tuberculous infection of bone occlirs in vertebral bodies or in association with tuberculous infection of joints. It can also occur as an isolated lesion of a long bone or of a bone of the hand or foot. Tubercle bacilli reach the bone either through the blood strem or by direct extension from an adjacent focus in joint or soft tissue. The clinical picture depends on the site of the infection. There is usually evidence of constitutional ill health. Early symptoms include pain, spasm and limitation of movement. Tuberculosis of bones and joints usually results in locomotor disability because involvements of joints and causes loss of motion. In the spine, it may result in hunchback or paralysis of limbs, because of involvement of spinal cord.
Lathyrism
Lathyrism is a crippling disease caused by consumption of the pulse lathyrus laturis [Kesari dal] is large quantities. Kesari dal is a cheap product and is used to adulterate other dals. The disease is prevalent mostly in parts of Madhya Pradesh, Uttar Pradesh, Bihar and Orissa. Lathyrism, mainly affects adult males between 15 to 45 years of age. The disease is characterised by gradually developing spastic paralysis of the lower limbs. In the early stages of the disease, the patient walks with a slight limp, but as the disease progresses, there is bending of knees with crossing of legs and tendency to walk on toes, and he requires assistance of stick for walking. In advanced cases, the patient is unable to walk and is reduced to crawling. The scourge of lathyrism can be eliminated only if cultivation of Kesari Dal that causes it is banned.
Hansen's Disease
Every third leprosy patient of the world is an Indian. Prevalence rate of leprosy is about 6.7 per 10,000 population in India. Hansen's disease, which is commonly known as leprosy is a chronic infectious disorder caused by Myco-bacterium eprae. It primarily affects slun, peripheral nerves and other organs e.g. eyes. The cardinal features of Hansen's disease are insensitive skin and paralysis due to involvement of peripheral nerves such as median, ulnar or lateral popliteal nerve. The above defects usually result in unsightly deformities and ulcers in the affected extremities. The common deformities seen are wrist drop, foot drop, claw hand etc. depending on the peripheral nerve involved. The number of cases of Hansen's disease with deformities is quite large in India, although there is a considerable drop in the number of active cases of Hansen's with the advent of multidrug therapy [MDT] .
PREVENTION
Disability prevention includes all actions taken to reduce the occurrence of impairment (first level prevention) and its development into functional limitation (second level prevention), and to prevent the transition of functional limitation to disability (third level prevention).
First level
This includes all measures directed at reducing the occurrence of impairment i.e. action taken prior to the onset of disease. First level prevention of locomotor disability may be accomplished by measures designed to promote general health and well being and quality of life of the people, or by specific protective measures.
· Prevention of congenital diseases through prospective counselling (high risk cases) or retrospective counselling (by MTP, contraception etc.).
· Prevention of communicable diseases by immunisation, hygiene, health education
· Prevention of malnutrition and vitamin deficiency.
· Prevention of accidents by provision of safety measures at home and work place, and enforcement of legislation e.g. wearing of helmets to prevent head injury.
· Prevention of production, use and sale of anti-personnel landmines.
· Elimination of exposure to situations in which locomotor disabilities may occur, in particular, war and other forms of violence, and chemical and environmental pollution.
Reduction of incidence of locomotor disability at first level primarily calls for health education for the general public and also at the level of health personnel, especially attached to a PHC, village workers and anganwadis. Information, education and communication (IEC) actitvities are essential to accomplish proper health education to the masses.
Second level
When impairment occurs, it is necessary to try to prevent any long term functional limitation from occurring. To achieve it, measures are required specifically in the following three areas :
· Ability to identify the impairment that might lead to knctional limitation (i.e. development of diagnostic ability) e.g. to diagnose tuberculosis, Leprosy, Polio- myelitis, fractures etc.
· Proper and prompt care of impairment in the acute stage to avoid subsequent functional limitation i.e. care of acute cases e.g. administation of first aid measures, proper nursing care etc.
· Proper nursing care etc. e Proper care of impairment in the chronic stage to avoid functional limitation i.e. care of chronic cases. This includes provision of appropriate drugs for chronic diseases e.g. Tuberculosis, leprosy, hypertension, diabetes, mellitis etc. provision of theapeutic exercises and proper positioning to avoid deformities e.g. in polio myelitius, stroke etc.
In order to achieve it, proper diagnostic and treatment facilities should be uniformly available at all levels of health care. In the case of accidents, facilities for immediate evacuation and transfer to the proper place of treatment are essential. Adequate follow up and two way referral systems are also required to be developed in order to provide the patients continuous care and prevent complications, if any, at the earliest.
Third level
When long term functional limitation has developed, measures instituted should aim at prevention of disability. Such measures may be divided into medical, psycho-social, educational and vocational. Third Level Prevention of locomotor disability aims at enabling the individuals to perform the varying roles expected by the family, community and society at large to the extent possible and thereby restore the patient back to normal or near normal condition. The measures include training to increase independence in self care (ADL), educational and vocational measures aimed at achieving economic independence and psycho-social measures aimed at restoration of personal dignity and to ensure full integration and acceptance in the community.