Poliomyelitis (polio) is a highly infectious disease caused by a virus. It invades the nervous system, and can lead to paralysis of both upper and lower limbs in a matter of hours. It can strike at any age, but affects mainly children under five years (more than half of all cases). In the rural areas of India, polio is yet to be eradicated and those who are exposed to the disease are threatened by a life of physical disability and social exclusion. To help the lives of these sufferers, an organisation called Mobility India has been developing and disseminating improved, appropriate limb-supporting technology. They accompany this technology with patient therapy and training courses for potential health professionals.
Polio in India
Polio (infantile paralysis) is a communicable disease, which is categorised as a disease of civilisation. A communicable disease is one that is caused by a biological agent (e.g. virus, bacterium, or parasite), as opposed to physical (e.g. burns) or chemical (e.g. intoxication) causes. Polio spreads through human-to-human contact, usually entering the body through the mouth via water or food that is contaminated with faeces. The poliovirus is a small RNA (ribonucleic acid) virus that has three different strains and is extremely infectious. The virus invades the nervous system, and the onset of paralysis can occur in a matter of hours. While polio can strike a person at any age, over 50 per cent of cases occur in children between the ages of three and five. The incubation (the time before being exposed to infection and showing first symptoms) period of polio ranges from three to thirty-five days.
Polio can spread widely before physicians detect the first signs of an outbreak. Surprisingly, most people infected with the poliovirus have no symptoms or outward signs of the illness and so are never aware they have been infected. After the person is exposed to the poliovirus, the virus is expelled through faeces for several weeks and it is during this time that a polio outbreak can occur in a community. The three strains of poliovirus result in paralytic polio, non-paralytic polio, and bulbar polio. In all forms of polio, the early symptoms of infection are fatigue, fever, vomiting, headache and pain in the neck and extremities.
Spinal paralytic polio
This strain of the poliovirus attacks the spinal column, where it destroys the anterior horn cells, which control movement of the trunk and muscle limbs. Although this strain of the poliovirus can lead to permanent paralysis, fewer than one in 200 cases with symptoms will result in paralysis. The most common paralysis will affect the legs. Once the poliovirus invades the intestines, it is absorbed by the capillaries in the walls of the intestine and is then carried by the bloodstream throughout the body. The poliovirus attacks the spinal column and the motor neurons, which originate in the spinal column and control physical movement. It is during this period of infection that flu-like symptoms occur. However, for people who have no immunity, the virus usually goes on to infect the entire spinal column and the brain stem (the route of communication between the forebrain and spinal cord). This infection affects the central nervous system (CNS), spreading along nerve fibres. As the virus continues to multiply in the CNS, the virus destroys motor neurons. Motor neurons do not regenerate and any affected muscles will no longer respond to CNS commands. The most common paralysis occurs to the muscles of the legs. The result is that the limb becomes floppy and lifeless, a condition known as acute flaccid paralysis (AFP). An extreme infection of the CNS can cause extensive paralysis of the trunk and muscles of the thorax and abdomen (known as quadriplegia).
Bulbar polio is thought to be the result of a person having no natural resistance to the poliovirus, allowing the brain stem to be attacked. The brain stem contains the motor neurons that control:
- Cranial nerves, which signal the various muscles that control eyeball movements;
- The trigeminal nerve and facial nerve, which supply nerves to cheeks, tears, gums, and muscles of the face, etc;
- The auditory nerve which provides hearing;
- The glossopharyngeal nerve, which in part controls swallowing and functions in the throat, tongue movement and taste;
- The nerve that sends signals to the heart, intestines, respiratory (lungs) and the accessory nerve that controls upper neck movement.
Thus bulbar polio could affect any or all of these functions.
Without respiratory support, bulbar polio usually results in death. To this day there are still polio survivors who must spend their entire day or most of their day in an iron lung or attached to a respiratory machine to stay alive. An iron lung is a large machine that enables a person to breathe when normal muscle control has been lost or the work of breathing exceeds the person’s ability. Accurately, it is called a negative pressure ventilator.
Of those who become infected, 5 to 10 per cent will die when their breathing muscles become immobilised. Death usually occurs after damage to the cranial nerve responsible for sending the signal to breathe to the lungs. Bulbar victims may also die from damage to the swallowing function; a victim can drown in their own secretions unless adequately suctioned, or given a tracheotomy to suction secretions before the liquid enters the lungs. The mortality rate of bulbar polio ranges from 25 to 75 per cent, with the variable being the age of the person.
Bulbar polio and spinal polio often coexist. They are both a subclass of paralytic polio. Paralytic polio is not necessarily permanent. Someone who has had paralytic polio can recover seemingly normal function.
In 2004, India reported the lowest number of cases on record, with transmission limited to key districts in Western Uttar Pradesh, Bihar and Mumbai. The greatest barrier to successful prevention of poliovirus transmission in India remains the difficulties in reaching the final 10 per cent of children in these key, high-risk districts. Another health risk connected with polio is the incorrect storage of the polio vaccine. These vaccinations are often administered as oral drops, but if they are not kept at a cool temperature (the ‘Cold Chain’ has to be maintained when transporting and storing vaccines in any kind of climate) then the child receiving the vaccine continues to be at risk whilst believing they are protected. Many have been infected after receiving vaccines because of the failure in the Cold Chain.
In response, India is engaging its entire civil administration in an attempt to reach every child with oral polio vaccine. District and sub-district plans were developed in 2004 to reach under-served communities in high-risk areas, and to vaccinate children moving through busy transit points such as bus or railway terminals. But for those who are not reached by national programmes to eliminate polio, their life can be a daily struggle against disability. It was for this reason that Mobility India was established.
Mobility India: Improving Prosthetic Limbs
Mobility India has a research and development unit for developing mobility aids and appliances that are appropriate and affordable. This work is vital because the majority of aids available are produced in urban workshops and are unaffordable and inaccessible to the majority of people who require them. They also use materials like mild steel, aluminium and leather, which are heavy, uncomfortable, and cosmetically unappealing. Going back to their villages, the people usually find the appliances to be a misfit, or inappropriate for use in their environment. Mobility India therefore designs low-cost artificial limbs (prostheses) , callipers or braces (orthoses ) and developmental aids appropriate for rural settings. These include developing lightweight plastic callipers, an adaptation to the Jaipur foot, and redesigning the orthotic knee joint. Mobility India also works with other institutes, such as the Indian Institute of Science, to develop a variety of assistive devices for the benefit of people with disabilities. Research and development has resulted in the following devices:
- Prefabricated Knee Ankle and Foot Orthosis (PFKAFO)
- Trans-Tibial Polypropylene Modular Components (TTPMC)
- Knee Joints
- Aluminium Uprights
- Plastic Ankle Joints
- Knee Aligner
- Lateral Bender
- Conical Drill Bit
Although Mobility India did not invent the Jaipur Foot, they have set up a Jaipur foot production unit to supply feet and have adapted a fitting to the Jaipur foot for it to be used with different types of limbs.
The PFKAFO technology is a new approach to production and delivery of plastic callipers. The technology, in a conventional sense, exists but PFKAFOs components are mass produced for off-the-shelf use. A PFKAFO kit as such does not work as people’s legs below knee and above knee (the thigh part) are of different sizes, so usually a combination of components are put together to make a calliper and not necessarily all from one kit.
Note: Orthosis for feet are designed to control foot functions by treating walking imbalances (bio-mechanical conditions). An ‘orthotic’ is a device designed to restore natural foot function. Foot orthotics re-align the foot and ankle bones to their neutral position, thereby restoring natural foot function.
Focus: Prefabricated Knee, Ankle and Foot Orthoses (PFKAFO) Project
The goal of the project has been to provide rehabilitation services to a greater proportion of the estimated 4 million people in India who are in need of an orthosis or brace, to prevent further disability, and to enhance individual mobility. To achieve this, the aim has been to create a system for the mass production of appropriate low-cost orthoses for wider distribution, rapid fitting and product testing.
- Dies developed and fabricated;
- Orthotic components mass-produced;
- Approximately 8000 people fitted;
- Product tested through training institutions;
- Product field-tested by rehabilitation NGOs;
- Approximately 15 trainers and 5 technicians trained in using this system;
- Orthoses production costs reduced;
- Reduction in complications due to lack of treatment;
- Awareness raised about the need and benefit of wearing orthoses.
The new and appropriate technology developed by the project is available for everybody and its acceptance is growing day by day. The new technology is removing the limitations of previous technology, which are cumbersome.. For most people who need orthoses, there is no longer a need to spend time and money visiting a workshop. Through the Mobility India project, 70 per cent of users can be fitted with the callipers on the same day. Results show that Mobility India can fit 60 per cent of clients with a complete pre-fabricated knee-ankle-foot orthosis (PFKAFO), while 20 per cent have to be measured for only the lower parts, and the remaining 20 per cent have to be measured/have a cast made for a custom-made knee-ankle-foot orthosis (KAFO) as their legs may have developed secondary deformities as a result of (not using orthosis) at an earlier stage.
User satisfaction with the PFKAFO is high, and the technology has already become popular in India. PFKAFO technology is also helping many disabled people who need other kind of orthoses, such as ankle-foot orthotics or night splints.
Changing Lives: Zabiullah
Zabiullah is 22 years old and lives in Yarab Nagar, which is in the Banashankari Slum area of Bangalore. He had polio when he was eight months old, which affected both his legs and he was unable to walk. At the age of one year, surgery was suggested, but his family rejected the option. As the days passed and he grew older he started to crawl.
When Zabi was 8 years old he started using metal callipers and a body brace. He also started going to school but after two months he stopped using the callipers because of discomfort. Then he started to crawl, but this restricted his mobility to his home, prompting him to try and use callipers again. However, most doctors that he consulted said that he would not be able to use callipers due to muscle weakness and severe scoliosis, and was advised to use wheelchair.
Zabi therefore approached Mobility India for a wheelchair. But when he was assessed, the therapist suggested that he use a calliper. Zabi felt this was impossible. The rehabilitation team, consisting of a therapist, prosthetist and orthotist, worked with Zabi to bring about a change in his mobility.
A regular therapy programme was planned and strengthening exercises for both upper limbs and back muscles were started initially. Zabi was also fitted with a modified bilateral KAFO. When he wore the callipers for the first time, it was a challenge for the team to make him stand upright. He gradually progressed to training inside parallel bars using bilateral callipers. After a month he was trained to walk outside the parallel bars using bilateral axillary (armpit) crutches. Later, he was trained to walk with bilateral elbow crutches and callipers. His confidence improved and he started walking on even surfaces, progressing to uneven surfaces and climbing up and down ramps. He was also trained to climb up and down stairs. The metamorphosis from crawling to walking with crutches and callipers took just six months.
Zabi has achieved something that he thought was impossible and he is now able to lead an independent life.
Reaching the Needy
Mobility is a birthright. But the majority of people with disabilities lead an isolated life due to lack of rehabilitation services, social prejudices and environmental barriers. Even today in India, the vast majority of people with disabilities cannot access even basic rehabilitation services despite the progress made since Independence. According to Government of India statistics, only 10 per cent of the population who need assistance have been reached so far. The majority of people that need these services are poor and cannot access rehabilitation services due to constricting socio-economic factors. To support the research into new and appropriate technologies, the Mobility India training programmes are establishing a cadre of helpers at the grass-roots level. In this way Mobility India is reaching remote areas of India and is having an impact on their lives.
Mobility India are also helping to spread new and appropriate technology to other developing countries. A programme to demonstrate PFKAFO technology to key people in the rehabilitation field in Ethiopia and the region has been initiated. A trial to show the effectiveness of PFKAFOs has been organised in which 100 children affected by polio will be fitted. Representatives of the World Health Organisation’s Disability and Rehabilitation Unit (DAR/WHO) and the International Society for Prosthetics and Orthotics (ISPO) will observe this work. The aim is to extend awareness of the technology across the region and elsewhere in Africa. ISPO has already carried out an evaluation of PFKAFOs in India and these findings and of the trial in Ethiopia will be shared with professionals at ISPO’s international consensus conference on lower limb orthoses to be held in Vietnam in April 2006.
Mobility India (2004). Prefabricated Knee Ankle Foot Orthosis (PFKAFO) Project Report.
World Health Organisation (2005). Weekly Epidemiological Record. 80 (17): 149-156.
Disability and Development Partners (DDP) ddpuk.org
Mobility India www.mobility-india.org
Donor and Supporting Organisations
Department for International Development (DFID) www.dfid.gov.uk
World Health Organisation (WHO) www.who.int/topics/poliomyelitis
International Society for Prosthetics and Orthotics (ISPO) www.ispo.ws
Global Polio Eradication Initiative www.polioeradication.org
ITDG Technical Briefs answers.practicalaction.org
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