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IJOT : Vol. XXXV : No. 1 April - July 2003

Satish Mishra,

Mobility India, Bangalore

OCCUPATIONAL THERAPY IN COMMUNITY BASED REHABILITATION

HARD FACTS

* 1 Billon population distributed over 27 States & 7 UnionTerritoties that are further divided into 557 administrative units

called districts.

* About 5% persons with disabilities.

* 78% population lives in rural areas.

* 15% people who live in urban areas have access to some kind

of rehabilitation service whereas in rural areas it is only 1%.

* On average 5-10% person with disabilities has access to basic

rehabilitation services.

* India has more disabled people than the total population of

UK, Canada or Australia.

* India: Disabled population is about 6 crores.* UK: Total population is 5.9 crores.

* Canada: Total population is 3 crores.

* Australia: Total population is 1.9 crores.

India: disabled population 6 crores-these are conservative

estimates. Some sources estimated 10-11% of the total population

with disabilities, implying 10-11 crores.

Earlier understanding was Impairment leads to Disability but the

most significant aspect of the change in present days, is the

recognition, that role of people with disabilities can be limited intheir participation in family, community and societal roles not merely

because of physical or mental impairments, but because of societal

attitudes and environmental barriers.

POVERTY & DISABILITY

Majority of the disabled people are in the rural areas. Lack of

access to basic health care and other services, lack of work and

economic security, unsafe living conditions, lack of access to safe

drinking water, lack of access to education and information, unsafe

roads and transport systems, unsafe working conditions, natural

disasters like floods and draughts, violence and conflicts all are

causes of disability. All these factors are directly linked withpoverty.

The Indian Journal of Occupational Therapy : Vol. XXXV: No. 1

Correspondence :Dr. Satish Mishra

Occupational Therapist,

Mobility India,1st & 1st A Cross, 2nd Phase, J.P. Nagar,

Bangalore - 560078. (Tel.: 6492222, 6494444)

E-Mail - [email protected]

The paper was presented with Youth Talent Award for the best

paper on C.B.R., during XXXXthNational Conference of AIOTA

in Feb.2003 at Bangalore

The links between poverty, illiteracy, poor health and disability

are well recognised - ALL Related to EACH OTHER.

Our images about disability/ disabled people are generally

NEGATIVE. We were not born with the images. We have developed

ideas about disabled people by hearing and seeing. We have very

rarely seen disabled people in everyday roles like others. A major

consequence of disability is social isolation: disabled people are

not part of general life and often face rejection from society. Often

it is a social stigma to have a disablity or a disabled person in the

family.

If we want to bring about a change in the attitudes and ideas of the

general people (and disabled people) there is a need for them to see

disabled people in everyday life like anybody else in the family,school, workplace, social and political life. There is a need for all

to see disabled people in different roles (parent, earning member,

student in the local school, decision maker, player etc.) both at the

level of the family and the community at large.

NEEDS - Statistics shows that

* 10 million people require some kind of therapy

* 10 million people need some kind of orhtoses or prosthesis

* Beside medical professionals, ratio of personnel needed to

rehabilitate 20 million population is 1:1000

* 10000 Orthtist/Prosthetist

* 10000 therapists

* 40000 CBR workers (1:500)

* 2000 CBR managers (1:10,000)

Seeing the above statistics, where is the human resource and how

to meet to need????

To reach the Mass: to ensure rehabilitation facilities for the ma-

jority we also need to understand our health structure and then

explore the possibilities to integrate rehabilitation facilities in the

existing health care delivery system.

* Primary Health Centres & Sub-Centres

* Community Health Centres

* District Hospital/Health Centre

* Specialist Hospitals

* Teaching Hospitals

* Camps

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DIFFERENT APPROACHES IN

REHABILITATION

INSTITUTE BASED REHABILITATION (IBR)

Medical Model:

Usually followed by Institutes whereas service providers only

concentrate on medical problems-look at the eyes, hands or legs,

prescribe, occasional ly in tervenes and consider medicalrehabilitation is the only answer-RELATIONSHIP OFTEN GIVER

& TAKER

Uaually from Centre/ Outreach/ Mobile/Camp

COMMUNITY BASED REHABILITATION (CBR)-

Medical + Social Model :

In this model the community and persons with disabilities are major

resource. It is more democratic in nature where people with

disabilities play an important role in decision making. It reflects

rights perspective rather than typical charity. Most of the

Rehabilitation Intervention takes place at the doorstep of people

with disabilities. Social inclusion is more important than medical

rehabilitation

Early Intervention-Regular Follow Up-Total Rehabilitation are the

main highlights

CBR-DEFINITION BY UN:

CBR is a STRATEGY within general community development for

rehabilitation, equalization of opportunities and social inclusion of

all people with disabilities.

Approximately two decades have passed since the concept of

community based rehabilitation (CBR) was presented as a strategy

for improving the lives of people with disabilities. BUT, despitethe progress made in the past two decades, there are still MILLIONS

of people with disabilities do not receive basic rehabilitation

services and are not participating equally in school, work, or social

activities. CBR promotes Human Rights

DIFFERENCE BETWEEN IBR AND CBR

IBR

* Mostly in cities

* Service providers are decision makers - one way traffic

* Decision is taken considering ideal condition* Usually Responsive

* Late Identification

* Late Intervention

* Follow up??

* Most of the work carried by Professionals

* Person with Disability often has to travel long distance

sacrificing their daily wage

* Easy to tackle complicated problems

* Expensive

* Medical

CBR

* Can be anywhere

* PWD/family play an important role in decision making

* Environment is equally considered

* Usually Proactive

* Early Identification

* Early Intervention

* Guaranteed Follow Up

* Most of the work carr ied by CBR Workers or Semi

Professionals

* Nearer often within reach

* Difficult to tackle complicated problems

* Economic

* Holistic

CBR & IBR BOTH NEEDED BUT WITH A

BALANCE. ALL IBR SHOULD HAVE A NUMBER

OF CBR PROGRAMS. SUCCESS OF CBR ALSO

DEPENDS ON GOOD IBR BACK UP/REFFERAL

SYSTEM.

Link between CBR & Occupational Therapy Service

* Occupational Therapy Service becomes more effective with

the existence of CBR structure

* Give priority to the early detection of disabilities

* Consider the socio-economic situation and needs of persons

with disabilities

* Guide persons with disabilities towards sources of funding for

treatment

* Act as link between the person with disability, and the

occupational therapy services

* Explain the treatment programme to the person with disabilityand the family

* Refer persons with disabilities to the appropriate support or

service level together with information about the needs and

expectations of the person

* Assist persons with disabilities in preparations for the fitting

and use of prosthetic and orthotic devices

* Encourage the person with disability to carry out needed

therapeutic activities and exercises

* Assist with follow-up of the person with disability with regard

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to therapy, the use of Orthosis and Prosthesis

* Assist in complete rehabilitation of the person with disability

* Assist with adaptation of the environment and take measures

to facilitate accessibility, good hygiene and activities of daily

living

* Help to prevent causes of disabilty, e.g. through good hygiene,

wound treatment, and prevention of secondary deformities such

as contractures and bed-sores

* Arrange for maintenance and repairs to prosthetic and orthotic

devices

* Help in the provision of simple mobility and rehabilitation

devices

* Help persons with disabilities to be integrated into society,

e.g. through education and work opportunities

* Promote awareness of the benefits of Therapy and using

prosthetics and orthotics devices

* Provide information to the appropriate support level with regard

to follow-up and the acceptance and use of devices

What is Rehabilitation - to compensate individual's impairments/

disability?

To restore individual's full capacity, that is not only correcting a

deformity or providing an Orthosis/Prosthesis - rehabilitation goes

much beyond....

"TOTAL REHABILITATION" - a child has to go to school or

adult have to go for skill training or income generation activities

after surgical/rehabilitation intervention

To ensure that all related professional work as TEAM

NEED OF REHABILITATION SERVICE

Only 15% people living in urban areas and 3% people living in

rural areas can avail rehabilitation service - in India, total coverage

according Ministry of Social Justice & Empowerement is only

5.7%.

We all need to work together to address the need as a "TEAM".

As part of our Mobility India team approach in Community Based

Rehabilitation, the efforts are made to provide the neccessary

Rehabilitation Services in the 15 urban slum of Banglore, reachingout to more than 500 PWDs through a networking of more than 20

staffs and 10 volunteers.

The task is huge, resources are less but we need to work on. Any

element of team missing will affect the whole program drastically?

To certify my presentation I have few case studies

* Irfana is a 13 year-old girl of bilateral PPRP. She lives in

Ilyas Nagar a slum in Banglore where CBR program is run.

Her father is a driver. They have 3 female children and she is

the second daughter. When CBR workers went to their house

they told that no one is disabled in their house. Then CBR

workers slowly started to communicate with the family and

built rapport with them. Occupational Therapist visited their

house for assessment and found that she was using Metal

KAFO(Rt) but not regularly due to heaviness. She was not

going out of the house. She stopped her schooling up to 5th

standard because she was not able to walk. After getting

the history, therapist explained clearly about the condition and

the importance of plastic KAFO. They also discussed with the

family regarding her studies. At last they accepted to use

Orthosis and send her to school. Orthotic & Prosthetic took

measurement for her and she was given Rt. KAFO with elbow

crutches. She was given gait training and now she is able to

walk independently. She has joined the school again. Now she

came out from the corner of house to the outside world and

started to enjoy the life.

* Aysha is case of C.P. spastic diplegia of 4 years old. Mother

is a housewife and father works in a shop and they live in theirbrother's house. Aysha's elder brother Nausad is also a C.P.

Father has to look after the family but he doesn't have specific

job, just working in a petty shop and getting less wages that

can only fulfill their daily needs. In this condition, she was

identified by CBR workers. Occupastional therapist did

assessment for her in her house. It was found that she has

difficulty in standing and walking and has tightness in hip,

knee and ankle (bilateral). Their residence is in Wilson Garden

but mother with her two children came to her sister-in-law's

house in Ilyas Nagar for regular therapy, for two days in a

week. The regular therapy could release her tightness of hip,

knee and ankle. Now she is able to walk with support. She is

going to school and independent in her ADL activities.

* Jane Saldhna is a Bilateral PPRP of 20 years old. When she

was one year old, her father left her in their relative's house.

Her father used to visit when he had time. At 3 years old, she

got fever and her both legs became weak. When she was 10

years old, she developed contractures in her lower limbs due

to disuse of limbs. Her sisters took her to hospital and doctor

suggested for surgery. She underwent surgery at the right

lower limb. At 14 years, surgery was done at left lower limb

also and she was given Bilateral Metal HKAFO but she didn'tuse because of pain. Jane's life began to bloom when CBR

worker met her in a wheel chair and gave her the confidence

that she can also prove herself. Occupational therapist did

assessment and prescribed Bil. KAFO with axillary crutch.

She joined Mobility India in December - 2001 in P & O workshop

for training. Regular therapy was given for her tightness in

knee and T.A. in both legs. She started to use Plastic KAFO

and gait training was given to her. Slowly she started to walk

by herself. With her confidence and therapy support, now she

finds that her life has some meaning in it.

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* Subramani is 8 years old and was born with cerebral palsy

(Spastic Quadriplegia). He and his family live in Bansankari

area, Banglore. When CBR workers and occupational therapist

visited the family at the first time, Subramani's mother

described his life. 'At the age of 6 months he got severe fever

and admitted in Sanjay Gandhi Hospital, Banglore for the

treatment and he also got an epileptic attack after the fever.

Subramani was not able to move his hands, legs and body veryeasily. He was suggested some therapy at the hospital, but as

they were poor they had difficulty to raise money for their

daily food and clothes, so after some time they stopped trying

treatment for him thinking that it was their fate.'

We motivated the family members that it is imporatant for

them to help Subramani because he is growing up and you

cannot always do every work for him at least we should make

the person independent as much as possible in his daily work.

Through the regular exercise his body tightness started reducing

and initiated to do many voluntary movements.

After regular therapy he was able to sit without support and hewas trying to use the hands. With the regular stretching we

planned to involve some activity for his both hands to make

some voluntary movements, which will help in participation

of his ADL. We provided lapboard with some pegs so that the

child should sit with minimum support and make use of hands

to play with the pegs. We also aimed that with this activity the

child may also improve his sitting balance. Through ADL

training, child is now able to do independent feeding, and

upper body dressing. We have also planned to send child to

special school, which might help him to attend the schooling

in future.

Similar efforts are an ongoing part with the rural based organisations

that are19 in numbers, rendering services in most of the southern

states of India.

Another Example

SAMUHA is an integrated rural development organisation, in

Jlahali village, 75 km. north west of Raichur, Karnataka. In late

90s they started CBR programme, which aimed at working PWDs

within the community. It involved mobility, education, health and

income generation.

Till now they have been successful in Rehabilitation of more than600 person with disabilities. Medical rehabilitation is important,

but it is seldom realised that it is a goal oriented and time limited

process. Putting the level of 'rehabilitation' on all actions concerning

disabled persons, can obstruct fulfilment of their potential for self-

determination and participation.

The purpose of this presentation is to continue to promote and

support CBR and its objectives as part of the ongoing efforts that

are needed to achieve equalization of opportunities for people with

disabilities. So, policy-makers and program managers has to have

a clear understanding about implementing/promoting CBR, to

promote increased participation of Disabled People's Organizations

in CBR programs, and to encourage increased collaboration and

co-operation among all governmental and non-governmental

services and groups that can contribute to the success of CBR.

*

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