PRINCIPLES IN

THREE R E H A B I L I T A T I O N

with the
tools they need to
disabled people on.
selt-determination

INTRODUCTION TO REIABILITATION and

independence
attain
of psychological
abnormality
Definition "Any loss or
anatomical
structure or
or
physiological,
The derelopment of a person fo the fullest function".
phusiological, social, ocational, avocational and
cducational potential consistent with his or her
Examples
physiological or anatomic impairment and
Amputation
C17rO11n1ental limitations".
Fractured femur
or
Low back pain
The process of restoration of skills by a person
who has had an illness or injury so as to regain Confusion
maximum self-sufficiency and function in a
limitation) (Flow chart
normal or as nearnormal manner as possible Disability (Activity
or the maintenance and restoration of physical 3.1)
and psychological health necessary for resulting from an
"Any restriction or lack, to
independent living and functional impairment of ability perform an
independence. Thus the restoration of within the range
activity in the m a n n e r or
someone to a useful place in society, considered normal for a human being"
transforming them from disabled to
differently abled. Examples:
Person with paraplegia is unable to
Rehabilitation of people with disabilities isa walk
enabling them to reach and
process aimed at Pro-quarterback with broker finger
maintain their optimal physical, sensory,
dominant hand
intellectual, psychological and social
functional levels. Rehabilitation provides
Impairment (Flowchart 3.1)

Flowchart 3.1

Organ level Person level Societal level

Conditions:

Pathology Behavioral Role assignment

Anatomical, Performence Environmental

physiological, deficits within and societal
mental and the physical deficits infulenced
psycological and social by social norms
deficits environments and social policy

determine contribute to create

Key terms:

Impairement Disability HandicapP

(organic dysfunction) (difficulty with tasks) (social disadvantage)

Limitations in using skils, performing activities, and fulfilling social roles

Analysis:
Selected diagnostic Selected performance Selected role
descriptors (behavioral) descriptors descriptos
Functional assessment of abilitilies and activities

Interventions:
Medical and Adaptive equipment and Supportive services
restorative therapy reduction of physical and and social policy
attitudinal barriers changes
All needing long-range coordination to improve and maintain functioning

Physiotherapy in Community Health and Rehabilitation

 (eg. simplicity of language) r
Models of disability coveraye (eg, ezplaining iSuEs oAher
definition
indud
The simplest, and maybe the initial, may take for granted)
insura
to be the
of a disabled person appears Physical structures, for e/ample
in his/her society is The r
following: "a person who buildings with sloped acces and
as disabled, because
of a difference to
regarded elevators
in appearance and/or behaviour". People
in
funct
"know" who is "disabled", and there
are
Handicap (Participation restriction) placed
all societies one or several terms to indicate whic
tradition of what is
(Flowchart 3.1) 15 not
this. There seems to be a

and what is not "different". "A disad vantage for a

given individual evel
resulting from an impairment or of the
Medical model of disability - The medical
model of disability is a model by which
disability that limits or prevents the able
illness or disability is the result of a physical
fulfillment of a role that 1s norma appr
(depending on age, sex, social and cultural to
condition, is intrinsic to the individual (it is
part of that individual's own body), may factors) for that individual".
reduce the individual's quality of life, and
Examples:
causes clear disadvantages to the individual.
Work environment not wheelchair
Social Model of Disability The social accessible tor person with
model of disability proposes that
paraplegja
systemic barriers, negative attitudes and
a.
Impairment Organ
-

or tissue
leve
b. Disability Whole person (functiomal
-

exclusion by society (purposely or

level
inadvertently) are the ultimate factors
defining who is disabled and who is not C. Handicap - Society level

in particular society. It recognizes that

a The
while some people have Goals of rehabilitation program into
physical, sensory, a

intellectual, or psychological variations,

which may sometimes
Reduction of disability
cause individual
functional limitation or Prevention of complications e.g.
do not have to lead to
impairments, these Sores
pressur
disability, unless
society fails to take account of and include Restoration of neuromuscular function
people regardless of their individual strength, ROM exercises, etc.
differences. The social model of
often focuses on disability
changes required in The rehabilitation team
society. These might be in terms of: The
A rehabilitation program is med
Attitudes, for example a more specificall
attitude towards certain mental positive designed for each individual depending
traits the o
or
behaviors, not injury, disorder, or illness.
the
potential
or

quality
underestimating
of life of those multidisciplinary team approach for care anc
with potential impairments service is the basis of
rehabilitation treatment
Social support, for example helps Multidisciplinary
different
refers to the fact that ma
dealing with the above disciplines work together towards
resources, aids or barriers,
common goal.

discrimination to positive The team is

overcome them
with other
usually directed by a physiat
Information, for specialists playing
suitable formats (e.g.example using in the
treatment and educationimportant ro
braille) or levels members involved process. l1Ea
10 depend on many ra Phys
Principles in Rehabilitahor
 including patient need, facility resources, and The para-medical team compromised of
insurance coverage for services.
Physiotherapist
The major concern of the rehabilitation field
is to improve the ability of the person to
Occupational therapist
Orthotist and prosthetist
function optimally within the limitations
placed upon them by a disease process for Speech-language pathologist/Speech
which there is no known cure. The emphasis therapist
is not on the full restoration to the premorbid Rehabilitation nurse
level of function, but rather the optimization
of the quality of life for those who may not be
Clinical psychologist
Rehabilitation engineer
able to achieve full restoration. A team
approach to chronic conditions is emphasized Horticulture therapist
to coordinate care of the patients. Music therapist
Patient and family: The socio-vocational team compromised of
The patient and fanmily are considered
the most important members of the Social worker
rehabilitation team. Health educator
The multidisciplinary rehabilitation Mental health educator
team may include, but is not limited Rehabilitation counselor
to, the following team members are Vocational counselor
included:
NGOs
The rehabilitation team can be categorized Bank
into Special schools

Medical Special education teacher

(Role to limit Disability) Community

Paramedical or Allied Health
Professionals ROLES OF INDIVIDUAL
(Role - to reduce Handicap)

Sociovocational
Physiatrist: Physical medicine and
rehabilitation (PM & R) or Physiatry is a
branch of medicine which aims to enhance and
The medical team compromised of all
restore functional ability and quality of life to
medical specialties such as
those with physical impairments or
Physiatrist -

Team Leader disabilities. A physician who has completed

Orthopedic surgeon training in this field is referred to as a
General surgeon physiatrist.
Physician Physiatrists are physicians who specialize in
Pediatrician diagnosing problems in the musculoskeletal
system and applying non-surgical solutions.
Ophthalmologist The physiatrist manages, directs, and
Obstetrician and gynecologist supervises a patient's rehabilitation program,
Psychiatrist assuring that the care, a patient receives is
Consistent with his or her diagnosis, functional

Physiotherapy in Community Health and Rehabilitation 11

 Education of the individe his/her anil
also
The physiatrist members or caregivers as to heir disabilu
and prognosis. towards
limitations, team
interdisciplinary Recommendatios for h o e and/or w l
directs the
facilitating treatment goals. modifications i.e. ergonmics
Physiotherapist: Physiotherapists evaluate
Physiotherapy support for palionts wl
to mobility,
problems relating long term and progressiVe conditions
and treat endurance.
and They
coordination,
strength, level of Referral
to gain
the highest
independence within the
help patients
functional
conditions. A Occupational therapist: Occupaliq.
of their
limitations therapists evaluate and treal physi.al .
instruct the patient
will also functional ability in daily ativities. 1 O
physiotherapist and exercises
her family in activities occupational therapist can help improve
and his or
decrease
The
pain.
and
to enhance
recovery
is to improve quality ability to perform everyday tasks, sueh,
role of physiotherapist
Members of the dressing, eating, personal hygiene, me
of life of the
person. preparation, housekeeping, and communi
rehabilitation
physiotherapy staff
including
all focus on the and prevocational skills. Members of t
and technicians,
assistants occupational therapy staff includine
individual reaching their potential. rehabilitation assistants and technician, all
have been identified, a focus on the individual reaching theu
Once problem areas
treatment
will be
program potential. The evaluation assesses t
customized
individual. The treatment
developed for that term goals
individual's ability to complete everyd
plan will include short and long functional activities called activities of dail
of the following
designed to improve any living ADLs consist of bathing, dressing,
of the medical
dependent upon the severity grooming, self-feeding, toileting, and
condition: homemaking skills. In addition to assessing

Assessment of the patient's condition and these skills, occupational therapists al

its impact on everyday activities within evaluate vision, balance, coordination,
the home and local community perceptual skills, and cognition.
Assessment, treatment and ongoing
For injured workers, occupational therapist
management of specific musculoskeletal can develop ergonomic assessments, assist in
(muscle and bone), respiratory (breathing) pre-employment screening, and crealion of
and neurological (brain and nerve)
modified return to work jobs, Wor
conditions
Uditioning and transitioning program
Recommerndation and, wherever possible, Once problem areas have been identified, thr
provision of appropriate orthotics
therapist will help the individual developth
(surgical appliances-devices used to treat abilities by focusing on a treatment plar
or
support different parts of the body, e.g. designed to:
collars, leg braces, shoe insoles),
aids and minor
walking
equipment Achieve maximum degree
Provision of individualized exercise independence in bathing, dressi
programmes which patients can follow to feeding and grooming
improve their mobility, agility and
Exercises to strengthen upper arms, Na
strength in order to maintain independent and body positioning
living Determining the need for adaptive devi
Teaching family members and caregivers such as hand Sp
on how to assist the individual
other self
splints, use of grooming th
care aids
12 Ph
Tinciples in Rehabilital
 Homemaking skills based on individual's
needs
Money management based on individual's
needs
Cognitive skills and prevocational skills
Driver training potential as indicated
Job modifications
Orthotists and prosthetists
The prosthetist is the professional who designs
and fabricates prostheses for individuals with
partial or total absence of a limb. The orthotist
provides care to individuals with disabling
conditions of their limbs or spine by
ommending, fitting, fabricating and
maintaining orthopaedic braces that support
or limit the movement of weakened joints or
limbs
The orthotist - prosthetist is a member of the
rehabilitation team and enables people
suffering from disabilities to live as normally
as possible.
Interpreting the surgeon's prescription by
taking precise measurement, making
traces from the patient's body and making
plaster casts
Creating orthosis/prostheses that are both
well-fitting and functional by examining
the disability and modifying positive
plaster forms which will serve as models
until both the patient and the orthotist-
prosthetist are fully satisfied with the
results
Welding, working with a variety of steels
and undertaking minor fitting and
turning, spray-painting, panel-beating
and woodwork
Providing rehabilitative (prosthesis)and
curative (orthotics) services to the public
Manufacturing surgical footwear for
patients with deformities, such as club-feet
Speech-language pathologist/Speech
therapist: A speech-language pathologist
Physiotherapy in Community Health and Rehabilitation
(specch therapist) cvaluates and treats
cognitive, communicative, and swallowing
deficits that may interfere with the ability to
speak, understand, read, write, focus,
remember, or solve problems. Individual and
group treatments will help to provide
techniques to compensate for difficulties in
these areas.
Rehabilitation nurse: Nurses are an integral
part of the entire rehabilitation team. A nurse
who specializes in rehabilitative care and
assists the patient in achieving maximum
independence, especially in regards to medical
care, prevention of complications, and patient
and family education. They often help to
facilitate the carry over of the rehabilitation
program throughout the hospital stay. In
addition to daily bedside care, rehabilitation
nurses work on ensuring bowel and bladder
continence, maintaining good skin care,
ensuring healthy, nutritional intake,
medication management and reinforcing
carryover of learned skills. Education of the
individual and family are vital to achievinga
successful return back home.
Psychiatrist, psychologist, or
neuropsychologist: A physician or counselor
who conducts cognitive (thinking and
learning) assessments of the patient and helps
the patient and family adjust to the disability.
Their role is to work with the individual,
family and entire rehabilitation team to assist
with adjustment difficulties and other
psychological issues that can develop during
the rehabilitation process. Counseling and
support are essential for the individual and
family during this time.
Rehabilitation engineering is the systematic
application of engineering sciences to design,
develop, adapt, test, evaluate, apply, and
distribute technological solutions to problems
confronted by individuals with disabilities.
Functional areas addressed through
rehabilitation engineering may incluae
13
 and rehabilitati.
therapy
activity. Music find to a common nich
vISiOn, are starting
hearing, medicine who hat.
with clients
communications,
with together ave
mobility,
and
activities
education,
associated
in working
neurological,
orthopaedic, an
and cognition, various
independent living, Iherapeutic applicatio
employment,
community. paediatricconditions.
and integration
into the
with music in
rehabilitation
contributes to
the
of i n d i v i d u a l s with disabilis
rehabilitation
process
for people
assistive quality of
life of lities
improvina
The
entails the design of to Combined goals
could include
ing
often
disabilities

such as walking
aids
intended

into the strength, range

ot motion,
balance
devices
their users communication, and cognition. Continttoed
i n c l u s i o n of and
promote commerce,

clinical practice
wit
and research
of society, efforts in
information already available to
mainstream

recreation. build on the

of
further detine
possible applications ic
included the following and its outcome
therapy rehabilitation, and
Horticulture
viewing
nature, therapy in
nature,
forms; imagining and, most benefits.
a hospital
healing garden also reterred to as
visiting It w a s expected Recreational therapists
actual gardening. increase
important, recreation specialists; provide
alleviate stress,
influence healing, therapeutic
to in social and recreation activities for
participation treatment services
well-being and promote for people
with disabilities or illnesses. U'sine
re-employment individuals with
life and
illness. The
Horticultural
including arts and
mental or physical a variety of techniques,
regarding the games, dance and
crafts, animals, sports,
described
was
therapy garden
outdoor
environment,
music, and communi
movement, drama,
design of the tools, cultivation
adaptations of garden improve and maintain the
material. This therapy
outings, therapists
methods and plant mental, andemotional wellbeing
mental healing, physical, individuals to
programme
for mediating their clients. Therapists help
interaction, sensory and anxiety; recover
recreation, social reduce depression, stress,
and
stimulation, cognitive re-organization basic motor functionin8
and reasonin:
outlined
motor function is and socializ
training of sensory abilities; build contidence;
and the teaching of
and pre-vocational skills that they can enjoy greater
are assessed. effectively so

ergonomical body positions independence and reduce or eliminate th

effects of disability. In additior

effects of their illness or
Music therapist: therapeutic
The
with disabilitie
music are being recognized increasingly
in the therapists help people
teachin:
field of rehabilitation medicine. More music integrate into the community by
them how to use community resources an
therapists are being employed in physical
recreational activities. Recreational therapis*
medicine and rehabilitation centers, with the Wh
different from recreation workers,
goal of using music therapy services to assist are

in the physical recovery and health organize recreational activities primarily t

maintenance of clients. Inspite of the benefits enjoyment.
of physical rehabilitation programs, client
Community based recreational therapistsen
participation to their full potential is often not Work in park and recreation departme
observed. Music encourages participation in special education programs for SC
exercises and activities. Music can ease the
districts, or assisted living, adult day care
discomfort and difficulty associated with Substance abuse rehabilitation centers. In t
exercise and therapy activities, and ensure
consistent participation. One of the goals of programs, therapists use interventi0 idin

develop specific skills, while prov

the music therapist is to provide a means for ulatie
in a musical OPportunities for exercise, mentalstimu
the client to express him/herself
Principles in Rehabilht
14
creativity, and fun. Those few who work in
schools help counselors, teadhers, and parents
address the special needs of students,
including easing disabled student's transition
into adult life.
Social worker assist people by helping them
cope with and solve issues in their everyday
lives, such as family and personal problems
and dealing with relationships. Some social
workers help clients who face a disability, life-
threatening disease, social problem, such as
inadequate housing, unemployment, or
substance abuse. Social workers also assist
families that have serious domestic conflicts,
metimes involving child or spousal abuse.
Additionally, they may conduct research,
advocate for improved services, or become
involved in planning or policy development.
Many social workers specialize in serving a
particular population or working in a specific
setting.
The medical social worker is a liaison between
the healthcare staff, the patient and family.
Social worker record the patient's general
background or psychosocial history, including
information about the patient's pre-injury
personality and lifestyle, emotional and
financial resources, educational history, work
and leisure interests, special relationships, and
previous problems. The family can turn to
social workers for advice, support, and
counseling regarding treatment options and
the various issues involved in the recovery
process.
Health educators work to encourage healthyy
lifestyles and wellness through educating
individuals and communities about behaviors
that can prevent diseases, injuries, and other
health problems.
Health educators attempt to prevent illnesses
by informing and educating individuals and
communities about health-related topics, such
as proper nutrition, the
importance of exercise,
how to avoid sexually transmitted
diseases,
Physiotherapy in Community Health and Rehabilitation
and the habits and behaviors necessary to
avoid illness. They begin by assessing the
needs of their audience, which includes
determining the appropriate topics to cover.
For example, they may hold programs on self-
examination for breast cancer to women or
may teach classes on the effects of being
drinking to college students. Health educators
must take the cultural norms of their audience
into account. For example, programs targeted
at the elderly need should be different from
those aimed at a college-aged population.
Within medical care facilities, health educators
tend to work one-on-one with patients and
their families. In this setting, a health
educator's goal is to educate individual
patients on their diagnosis and how that may
change or affect their lifestyle. To this end, they
may explain the necessary procedures or
surgeries as well as how patients will need to
alter their litestyles to manage their illnessor
return to full health. They may also direct
patients to outside resources, such as support
social
groups, home health agencies, or
services. Often, health educators work closely
with physicians, nurses, and other staff to
create educational programs or materials, such
as brochures, Websites, and classes. In some
cases, health educators train hospital staff
about how to better interact with patients.
Mental health counselors work with individuals,
families, and groups to address and treat
mental and emotional disorders and to
promote mental health. They are trained in a
variety of therapeutic techniques used to
address issues such as depression, anxiety,
addiction and substance abuse, suicidal
impulses, stress, trauma, low self-esteem, and
grief. They also help with job and career
Concerns, educational decisions, mental and
emotional health issues, and relationship
problems. In addition, they may be involved
in community outreach, advocacy, and
mediation activities. Some specialize in
the
delivering mental health services torwork
otten
elderly. Mental health counselors
15
 losely with other mental health education
curriculum to meetth
such as specialists, general
needs and providin
psychiatrists,
sOcial workers, psychologists, clinical child's individual
required remedial instruction. NG
psychiatric nurses, and school NC
counselors. teachers use variou
Special education g0
learning. Depending on
techniques to promote methods can lev
Rehabilitation counselors help people deal with the student, teaching
includ rol
the personal, social, and vocational effects of instruction, problem
intensive individualized bo-
and small-group work
disabilities. They counsel people with both solving assignments,
When students need special accommadations
physical and emotional disabilities resulting
from birth defects, illness or disease, accidents, curriculum or to take
to learn the general a

or other causes. They evaluate the strengths
and limitations of individuals, provide
personal and vocational counseling, offer case
managenment support, and arrange for nedical
care, vocational training, and job placement.
Rehabilitation counselors interview both
individuals with disabilities and their families,
evaluate school and medical reports, and
confer with physicians, psychologists,
and physical, occupational,and
employers,
speech therapists to determine the capabilities
and skills of the individual. They develop
individual rehabilitation programs by
conferring with the client. These programs
often include training to help individuals
develop job skills, become employed, and
provide opportunities for community
integration. Rehabilitation counselors are
trained to recognize and to help lessen
environmental and attitudinal barriers. Such
help may include providing education, and
advocacy services to individuals to families,
employers, and others in the community.
Rehabilitation counselors work toward
increasing the person's capacity to live
independently by facilitating and
coordinating with other service providers.
Special education teachers work with children
and youths who have a
variety of disabilities.
A small number of special education
teachers
work with students with severe
cognitive,
emotional, or physical disabilities, primarily
teaching them life skills and basic literacy.
However, the majority of special education
teachers work with children with mild to
moderate disabilities, using or modifying the
16
education teachers ensure that TH
special
test,
appropriate
accommodations are provided ap
such as having material read orally or
m-
lengthening the time allowed to take the test
a.
Special education teachers help to develop anAn
Individualized Education Program (TEP) for
each student receiving special education
Special education teachers design and teach
appropriate curricula, assign work geared
toward each student's needs and abilities, and b
grade papers and homework assignments.
They are involved in the student's behavioral
social, and academic development, helping
them develop emotionally and interact
effectively in social situations. Preparing
special education students for daily life after
graduational also is an important aspect of the
job. Teachers provide students with career
counseling or help them learn life skills, such
as balancing a checkbook.
Technology is becoming increasingly
important in special education. Teachers use
specialized equipment such as computers with
synthesized speech, interactive educational
software programs, and audiotapes to assist
children.
Vocational counselor: The vocational
rehabilitation counselor evaluates our
vocational abilities and
employment history.
Vocational counselors can connect with career
training or
re-training and
services. They can recommend job placemen
and any adaptatior
equipment that may be
particular workplace, as well asnecessary n
related to you
transportation to/from the workplace.
Principles in Rehabilitation
 NGOs
NGOs supplement
the efforts made by
government. Local NGOs reach the grass-root
level and provide relief to the people. The brief
role of some NGOs is in 11th Chapter of the
book.
APPROACHES OF REHABILITATION
These programmes use several different
approaches, and should like to mention the
main ones:
Service
a. projects: personnel, equipment
etc. are sent to a developing country for a
limited time period. All services are
provided by expatriates, and they return
home without having trained the
nationals.
b. Development projects: these aim at the
transfer of knowledge and skills to a
developing country. Nationals are trained
by expatriates.
Development programmes may operate
several different levels. There are three main
types:
a. Institution-based: professional services
for people with disabilities are given in a
center (boarding or day-care). Such centers
are most often only set up to the capital or
big cities.
b. Outreach service programme: the
professional staff delivers services at home
to the extent possible.
C. Community-based programmes: build on
the idea of mobilizing community
resources. The person with a disability is
trained at home and in the community. A
family member acts as the trainer, and a
community worker as the local supervisor.
Community workers are trained in
rehabilitation tasks by an intermediate
level supervisor, who in most cases is a
professional. This programme needs the
support of referral services.
The institution-based and the outreach
service programmes require a lot of
personnel and are costly to operate. It is
unrealistic to assume that these
approaches will contribute much to the
reduction of the rehabilitation gap.
The community-based approach aims at a
massive transfer of knowledge and skills to
the person with disabilities, his or her family
and the community. Such a transfer of skills
and knowledge is a very clear characteristic
also of modern rehabilitation programmes in
the industrialized countries, where parents
on
and other relatives are trained to become active
partners in rehabilitation.
of
As we know there are various approaches
rehabilitation of persons with disabilities are
being advocated both in theory and in practice.
The two main approaches to rehabilitation are
Community Based Rehabilitation (CBR) and
Institutional Based Rehabilitation (IBR)
(Table 3.1).

Table 3.1: Difference between CBR and IBR

CBR IBR

Cost of treatment Cheaper Costly

institutions are
Accessibility of services Accessible to all Only few
accessible to all

Can be done without of much cost Not possible

Extension of services
Not possible as patient is away
Social relhabilitation Possible
from family

Much possible as they have Not much possible

Psychological rehabilitation
support of family
17
Physiotherapy in Community Health and Rehabilitation
 Given
Possible
Not given
Skilled personal care
Good
Not possible
adranced technique
Application of Not good Not possible
Quality of sercice N o t considered
Possible

Actire participation Considered Not

Socio-Economic status
Yes Not done
Promotion of auaremess

Done Possible
Community interaction
Difficult Interventions to discharge
the
Eraluation Interventions
to prepare patient from hospital
to his homne
Goal of training of client Cities arnd Institution based
re-entry based
and community
Anywhere Service providers (one way
Location PWD and their
family
Decision makers
traffic)
Professionals
professionals Many
or semi
CBR workers
Usually responsive
Serrice proriders
Proactive
Delayed
Action Early
ldentification Delayed
Early Not guaranteed
Interrention
Guaranteed
Far Medical
Follo-up
At door step Holistic
Services Easy to tackle
Difficult
Complicated problems

Many people need temporary b

assistance
CBR are that needs
The distinctive features of institution based
of persons with disabilities
are met within special services that are often
their own environment, involving family Among this group are people requiring
corrective surgery, physical and occupational
members and comnmunity:
1. It refers to measures taken at community
therapy, orthoses or prostheses. Therefore, for
successful implementation of rehabilitation
level to use and build on locally available between these
resources of the community. These
services, a close co-operation
resources include the disabled persons, specialized services and CBR programs shouli
be promoted.
their families and others in the community.
Government of India set up Rehabilitation
2 IBR on the other hand, is rehabilitation of
Council in 1986 as registered society. There
persons with disabilities at or through
institutions, often away from their homes. after this
was converted to a statutory bod
under the Rehabilitation council of India Ac
IBR generally leads to a transformation in
social behaviour of persons with w.e.f.31 July, 1993. This is under the
disabilities, making the process of their administrative control of Ministry of SOCl
social integration difficult. Justice and Empowerment. There are 31 PMK
(Physical and Medical Rehabilitatio
However, the quality of rehabilitation services
institutes, 9 of them are being upgraded.
provided through IBR tends to be better than
District Rehabilitation Centers are
through CBR, as services are provided by in 10
functionl
professionals and specialists, with the major states. Regional Rehabilitat
Centers (RRC) alsoThe
assistance of more sophisticated equipment functionin8
are
National Handicapped Finance an
and tools.
Development Corporation (NHFDC) has
18
Frinciples in Rehabilitat
incorporated by Ministry of Welfare, involving persons with disabilities. Locally
Government of India as a company not for available, low-cost, appropriate technology
profit. It extends loan to the persons with and other resources can be widely utilized. For
disability. training personnel in such units, an

appropriately planned resource centre is also

In recent years, community based
needed.
rehabilitation has been advocated by various
organisations and professionals. Their
2. COMMUNITY BASED
arguments are based on the greater
REHABILI-TATION (CBR)
effectiveness and low cost of the CBR
approach. The CBR approach, according to CBR is a strategy within general community
them, enhances social integration of the development for the rehabilitation,
persons with disabilities more easily, and equalization of opportunities and social
inclusion of all people with disabilities.
keeps the social fibre largely undisturbed. The
cost of rehabilitation is also lower as a majority CBR was designed as a model by which cost
of the resources used are local. However,
effective community/home-based
despite the strong advocacy and emphatic rehabilitation could
be provided in
world opinion in favour of CBR, efforts in
India till now have been restricted to a few
developing countries. As defined it was not
seen to equate to all rehabilitation that takes
pockets, undertaken through a few NGOs,
National Institutes and District Rehabilitation place outside an institutional setting, CBR, as
internationally defined, is very much client-
Centres. Even the organisations that centric as opposed to profession centric.
implement the CBR approaches are doing it
in a limited way, often in a small rural pocket In trying to clarify what CBR is and to draw a
distinction with any care tlhat takes place in a
in a town.
community environment there are a few key
Although many definitions of CBR are given
points.
by different experts and people involved in
Various such programmes, however, in

general, community based rehabilitation

(CBR) and institution based rehabilitation
(IBR) are clearly distinct from each other. It is arn
also mentioned that through CBR, community
takes part in activities to help provide
rehabilitation services for the persons with
disabilities at home. While usually through
IBR, disabled people are abilitated at
institutions, in a new strange environment,
from
away from their homes and segregated
their communities. Thus CBR is considered a
better way to rehabilitate disabled people in
their own areas.

In some cultures, there can be such social

barriers where CBR as a specific model is not
allowed. Here, one of the solutions can be
establishment of small scale, day-care
rehabilitation units, supervised, run and Fig. 1: Community based rehabilitation
(Home made walker)
managed purely by the local community, also
Physiotherapy in Community Health and Rehabilitation 19
 development for
the rehabilitation
community
lowchart 3.2: CBR is a strategy within general with disabilities.

inclusion of all people

u a n z a t i o n of opportunities and social

Community Based
Rehabilitation
Inclusion Sustanibility Self advocacy
Principles: Participation

Livelihoods
Empowerment Social
Health Education

Early Skin Self-help Legal

Promotive childhood
development
groups protection
development
Disabled Culture
Income
people's and
Non-formal generatin8 organization religion
Preventive activities

Access to Social Sports and

Formal financial mobilisation leisure
Curative
school services

Open
Political Relationship
marriage and
Rehabilitative Higher employment empowerment
family
Economic Language Personal
Assistive devices Special contribution and and
assistance
transitaory social protection communication

Conversely CBR Involves Only outreach from a centre

Rehabilitation training in isolation
Partnerships with disabled people, adults
and children, their families and carers An approach which is determined by the
needs of an institution or groups ot
Capacity building of disabled people and
their families, in the context of their professionals
community and culture
Holistic approach encompassing physical, CBR has been described on the basis of component
social, employment, educational, features such as
economic and other needs Provision of functional rehabilitation
Promoting the social inclusion of disabled services
people in existing mainstream services Creating a positive attitude towards
A system based in the community, using people with disabilities
district and national level services for The creation of micro and
referral macro income
generation
CBR is not Vocational training
The prevention of the causes of
An approach that only focuses on the disabiln
It has
physical or medical needs of a person also been described on
s
the basis
o

About delivering care to disabled people philosophical

Helander (1999) has ideological
or thinkin
as passive recipients identified a numbe
Key principles are

20
relating to CBR. They
Principles in Rehabilitat

qualit i a l justice solidarity integration
and dignitv These can be seen to relate to the
principles embedded in human rights
legislation.
2.1 Concept of CBR
CBR is a strategy within general community
development tor the rehabilitation
equalization of opportunities and social
inclusion of all people with disabilities.
CBR is implemented through the combined
efforts of people with disabilities themselves.
their families, organizations and communities
and the relevant governmental and non-
governmental health, education. vocational.
social and other services
them
2.2 Major objectives
To ensure that people with disabilities are
able to maximize their physical and mental
abilities, to access regular services and
opportunities, and to become active
contributors to the community and soaety
at large
To activate communities to promote and
protect the human rights people with
of
disabilities through changes within the
community, tor example, by removing
barriers to participation
2.3 Evolution of concepts in CBR
Althoughitsdetinition and major objectives
have not changed, there has been an evolution
of concepts within CBR and of stakeholder
involvement. This evolution is around the
concepts ot disability and rehabilitation the
emphasis placed on human rights and action
to address inequalities and alleviate poverty,
and on the expanding role of DPOs.
2.3.1 Disability and rehabilitation
Disability is no longer viewed as merely the
result of impairment. The social model of
disability has increased awareness that
Physiotherapy in Community Health and Rehabilitation
environmental barriers to participation are
major causes of disability. No nation has
eliminated all ot the environmental barmers
that contribute to disabilit.
Rehabilitation services should no longer be
imposed without the consent and
particapation ot people who are using the
services. Rehabilitation is now viewed as a
process in which people with disabilities or
their advocates make decisions about what
services thev need to enhance participation.
Professionals who provide rehabilitation
services have the responsibility to provide
relevant intormation to people with
disabilities so that they can make informed
decisions regarding what is appropriate tor
2.3.2 Human rights
CBR promotes the rights ot people with
disabilities to live as equal citizens within the
community, to enjoy health and well being, to
participate tully in educational, social,
cultural religious, economic and political
activities CBRemphasizes that girls and boys
with disabilities have equal rights to
schooling and that women and men have
equal rights to opportunities to participate in
work and social activities.
2.3.3 Poverty
There is a strong correlation between disability
and poverty. Poverty leads to increased
disability, and disability in turn leads to
increased poverty. Thus, a majority of people
with disabilities live in poverty. Studies show
that they have higher rates of unemployment
compared to non-disabled people even in
industrialized countries.
2.3.4 Inclusive communities
The term Inclusive' is now commonly used
with reference to educational provision that
welcomes all children, including those with
disabilities, to participate fully in regular
E r ~|Ë
the community, providingpromotive,
preventive, curative and rehabilitative governmental organizations (NGOs) and
groups that can contribute to a CBR
services. The health care system is
usually
responsible for providing medical care and programme. These may include relief and

rehabilitation services, including development organizations, faith-based

assistive organizations, and service clubs as well as
devices. Most basicrehabilitation activities can women's and youth groups. Some of these
be carried out in the disabled may
person's own provide services to people with disabilities,
community using local resources. while others can make special efforts to
include them in their activities.
5.3 Supports from the educational sector
Good co-operation between communities and 5.6 Supports from the media
the education sector is
of Education
imperative if the goals Newspapers, radio, television and the internet
for all are to be met. The can provide the public with intormation about
educational sector can make an
important disability issues, and also present a positive
contribution CBR by assisting
to
community image of individuals with disabilities at
schools within the regular school school, work or in social settings.
system to
become more inclusive. This involves, for
instance, adapting the content of the 5.7 Collaboration for support to the
curriculum and methods of teaching to meet
community
the needs of all children rather than
them to adapt to a
expecting CBR will not work if the sectors mentioned
rigid curriculum. Schools
above work in isolation. The following
may require assistance to change their
the types of collaboration
methods of teaching in order to provide example illustrates
that can work well.
quality education for all children. Within the
school system there are many people with ACBR worker contacts a social welfare officer
knowledge and skills that could be shared with information about an older child who has
with community schools. For example, there never been to school and who has
difficulty
are schools that teach only child with special with mobility and with learning. The officer
needs and the teachers from those schools can and the CBR worker collaborate to encourage
serve as resources to teachers in community the family to contact the health services and
schools. Schools that are already inclusive can the school. The health services assess the
help other schools learn how to respond to the situation to see if something can be done to
needs of all learners, treat all children with improve the child's mobility. The teachers at
respect, and be model schools. the school assess the child's learning needs. If
the child needs a wheelchair, for example, and
5.4 Supports from the employment and there are no resources to pay for one, the social
labour sector welfare officer requests assistance from other
Employment services organized by the sector sectors, including NGOs.
help job seekers with disabilities to find Role of physiotherapist in community based
employment opportunities in the open labour
market. In addition, the civil service can set a
rehabilitation
good example by employing workers with Physiotherapists undertake, or have the
disabilities. potential to undertake, a number of roles in
primary health care and CBR dependent on
5.5 Supports from NGOs local cultural and socioeconomic
circumstances. These have been identified as:
Most communities have a variety of non-

Physiotherapy in Community Health and Rehabilitation 23

 Health promotion and disease prevention
Preventing disability and deformity serissesu
rehabilitation
Curative and
Educating/training disabled people to
and managers
move around Team leaders

of direct care
Promoting self-care Troviders

Advocates for disabled people, local

Educating, training and transferring skills communities as well as the profession
to other staff
NGOs and l
Consultancy, advice, support and Advisers to governments,
communities
on
blishing CBR
supervision to other health care personnel
programmes

Physiotherapy in CBR

Physiotherapy in institutions
Mainly indirect
provision to the client
Direct service 1 therapist, to a given
population

Predominantly 1:1 therapist: client ratio Person receiving

services addressed as client
addressed as
Person receiving services usually
patient Often works in groups
Rarely works in groups the needs of the
to individual
Allocates time based on
Allocates therapy time according population
needs Good basic care to all
Ideal to care for a few status
Perceived lower professional
status
Perceived higher professional Uses a strong social
model
model,
Can focus on a strong biomedical Teaches/trains local health workers arnd families
although attitudes and approaches are
to carry out day-to-day therapy acts as an expert

changing resource

individual. An understanding of the role ot

ROLE OF PHYSIOTHERAPY IN AIDS
The quality of life for people with human
immunodeficiency virus (HIV) and acquired
immune deficiency syndrome (AIDS) can be
and expanded
improved
physiotherapy intervention. With more than
13 million people throughout the world
infected with HIV, it is imperative that
rehabilitation professionals be prepared to
access and utilize all possible modes of
effective treatment
People with AIDS have needs that may involve
the services of virtually every member of the
rehabilitation team. The physiotherapist is an
important member of this multidisciplinary
team, whose services include those that
address the psychological, spiritual,
vocational, and physical health of the
24
physiotherapist can facilitate the rehabilitation
specialist's ability to make the best use ot these
professionals.
through While AIDS is still regarded as a termina
illness, survival rates have increased to the
point where rehabilitation is a predictablean
ot care
necessary part of the person's plan
Rehabilitation needs are usually the result e
disabilities caused as a primary or seconda
result of the HIV infection or disabilities o
injuries that result from etiologies unrelat
to HIV. In either case, physiothera
intervention may be divided into four ma
categories of goal-based activities.
These are:
Management of lain
Maintenance of Strength and Endural
Principles in Rehabilitat
 Independence in Self-Care have
Fducation negative consequences, including an
increased feeling of lack of control as well
a

Managenment of pain
as
general exhaustion. Based on the present
body of literature, exercises should be limited
Pain
experiCnced by people with AlDS may
to comfortable ranges that avoid fatigue
Come from any number of sources,
ranging (Spence, Galantino, Mossberg, and
from those seen across the Zmmerman, 1990)
general to those more population in
with the
specifically associated Self-care
sequelae of severe immune
deficiencies. The key factor in pain as it relates Self-care includes those activities relating to
to the role of the
on function. Pain
physiotherapist
is its effect
dressing, washing, feeding, taking
may be the primary cause of medications, wound dressing, and exercise
a reduction in function. This
can lead to a
loss of independence and increased reliance
rapid that are routinely employed by the client
(Galantino, 1992; Spence, Galantino,
on
caregivers. The physiotherapist may use a Mossberg, and Zimmerman, 1990; Levinson
combination of modalities and techniques for &O'Connell, 1991). Of particular importance
reducing pain. These include Ultrasound, to the physiotherapist is the individual's
Transcutaneous nerve stimulation (TENS), ability to apply any necessary splints, braces,
Laser, and counter-irritation. Manual therapy or other assistive devices necessary for
may be particularly successful in virus related maintaining function and independence.
myelitis. Reports of success in using Techniques of energy conservation are also
techniques called myofacial release and taught to enable the chronically ill person to
craniosacral therapy also have been published achieve the maximum amournt ofself-carewith
the least amount of unnecessary effort
Maintenance of strength and endurance
Education
Since one of the hallmarks of AlDs is that it is
a multisystem disease with a dharacteristically Fducation for the caregiver as well as the
uneven clinical course, the maintenance ot person with AlDS is of critical importance. In
strength and endurance is critically inmportant addition to developing, evaluating, and

In all cases, an individualized enercise moditying the plan of care for the patient, the
PrOgranm designed
is atter caretul and physiotherapist must be knowledgeable of
assessment. The
and able to teach infection control to the client.
thorough physiotherapy Both the client and the caregiver must be
the AlDS
intensity of exercises designed tor educated in methods to ensure that
client range trom light resistive exerciseS caretully
the activities of daily living are accomplished
similar to those used for chronically ill
and that quality of life is maximized.
persons-to assistive exercises, which are
to complete the caregivers will
ettective when strength As the disease progresses,
independent basis of the client's
appropriate motion on an become a more important part
is Whenever possible, the individual world. If they are to be effecti ve, caregivers
lacking. in bed to chair
should be encouraged t0 participate must be taught safe transfers from
level of tolerance. activities of daily
physical activities to his
Galantino and Pizzi (1991) report that they
as well as other important
the health and
living. Education to protect
data that support very is as important as that
have tound no
safety of the caregiver
In fact, exercises the individual with
aggressive exercise protocols. which pertains only to
ot tatigue may
that take the client to a point AIDS.

25
Health and Rehabilitation
hysiotherapy in Community
 In all cases,
AIDS education must activities. Education that addresses all aspects
include an
in-depth coverage of universal of the client's life serves as the framework
defined bv the Centers for precautions as
Disease Control. upon which safe, rational decisions can be
Although sexual abstinence is the
safe practice, those
who remain
only real made. AIDS is progressively becoming
should be educated in sexually active treatable. Effective and efficient treatment
the safest
In procedures. modalities can be selected only when the
summary, the
physiotherapist's role in the rehabilitation professional understands the
treatment of AlDS related
important one, and may include symptoms is an scope of possibilities. Including the
reduce pain, increase methods to physiotherapist in this process can greatly
and maintain strength and endurance, augment the
productivity and
independence through self-care for people with AIDS. quality of life

REFERENCES
1. Helander E