Multidisciplinary approach in management of disability

Bhaskar Borgohain
MS , DNB, Fellow (Arthroplasty)

Asst Professor, Orthopaedics & Trauma N.E.I.G.R.I.H.M.S., Shillong

THE PAST

THE BAD NEWS FROM THE PAST:

Nihilistic ideas from the beginning to the end Defeatist’s attitude.

THE FIRST BARRIER
Negative attitude towards disabled is the first barrier in rehabilitation

The paradox

Disability is a worldwide phenomenon. But positive steps to prevent and manage disability are painfully not so universal despite the fact that we all belong to 21st century.

THE PRESENT LOOKS GOOD

It’s all about attitude

Fortunately, attitude is changing slowly but surely. We are now beginning to understand them better Disabled are often "differently able” in another direction.

VIBGYORTM : 7 Rays of hope
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D- Don't Underestimate I - Innocent S- Sensitive A- Able To Do Many Other Things B- Basic Needs Must Be Fulfilled L- Learning Will Give Them Hope And Employment E- Economic Support

Definition of Disability: W. H.O.
Any restriction or lack resulting from an impairment of ability to perform an activity in the manner or within the range considered normal for a human being.  This impairment may be temporary or permanent

Rehabilitation: Definition
“Ultimate restoration of disabled persons to his maximum capacity: physical, emotional and vocational” Make him as independent as possible in the shortest possible time.

Disabled: improve ability

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Medical support: Adaptive adjustments & retraining to gain maximum potential to improve his quality of life. Emotional support from Family & Society Vocational support from Government Technological support: information learning & research

The “M” factors
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Money Manpower Motivation Medical service facility Monitoring progress of rehabilitation Medical research

Why Multimodality Approach?

Multiple problems at the same time: Disabled person suffers due to his multidimensional limitations. Deal with all needs: The most successful role model addresses physical, emotional and vocational needs based on team approach Adopt Various positive steps at the same time to Minimize all potential complications One expert alone is not enough.

What is a ‘TEAM’
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A team is nothing but a combination of motivated people who share a common goal. The shared goal: To reduce or prevent barrier to successful rehabilitation Every team member play their own unique role besides coordinating with each other with positive & negative feedbacks to other members to achieve this shared goal.

ROLE OF THE DISABILITY (Medical) MANAGEMENT TEAM
THE GOAL: “To reduce or prevent barrier to successful rehabilitation.”  Provide Physical & emotional rehabilitation  To prevent or treat potential complications

The medical team: Essential members

Physician from various medicalsurgical specialties Nurses from various medical- surgical specialties Physical therapist & Occupational therapist, Orthotic /Prosthetic expert

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Psychologist/ Psychiatrist Speech therapist, Medical social worker as well as the patient and his family members. New team member may be added from time to time if need arises.

INDIVIDUAL ROLES OF TEAM MEMBERS

Role of nursing staff: To take care of the bodily needs of the disabled Nursing: Nutrition, hygiene, handling of secretions and psychological support. Physical therapist: maximizes motor function and maintain musculoskeletal & cardiovascular physiology by various physical means.

INDIVIDUAL ROLES OF TEAM MEMBERS

Speech therapist: Develop effective communication skills to children born with MR. Psychiatrist/ Psychologist: Emotional rehabilitation through motivation & development of positive attitude towards the disability Orthotist (Brace-maker): Custom-made splints suitable for musculoskeletal disabilities like polio to improve motor function & prevent deformities from developing.

Common goal: Important Objectives

Accurately diagnosing all current existing problems Adequately treating these problems Establishing adequate nutrition Monitoring for any complication that may impede progress in recovery

Mobilizing the patient as early as possible Restoration of function including training for readjustment to altered life style Social & psychological rehabilitation Vocational rehabilitation

Role of Government: Emotional/Vocational
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Legislations Disable friendly Employment & Reservation Information & Communication

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‘Health for all’ Education Proactive & not reactive Prevention

Role of NGO’s
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Information & communication Emotional & vocational rehab. Pressure group & support group Agent of change-Attitude Prevention

Prevention is better than cure

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Holistic management of a disable person is a huge task and it is easier said than done. So, Prevent disability from occurring. Only Prevention can ultimately contain the epidemic of disability. Prevention is the only cure of any disability

Types of prevention

Primordial prevention: Nip it in the bud. e.g. fortification of foods by government to prevent Vitamin A deficiency blindness. Primary prevention: Protecting the potential high risk groups. Example, vaccination against polio. Secondary prevention: It means early diagnosis and treatment. MTP (medical termination of pregnancy) may be an example to reduce Down’s Syndrome

Tertiary prevention is called ‘Management’

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Prevention of complications of manifested symptoms of the disease Treatment of manifested symptoms of that disease through rehabilitation. Management of disability Example: Early mobility to a spinal injury paraplegic patient to prevent bed sores, deep vein thrombosis and fatal pulmonary embolism.

Critical in all types of prevention.

Information, Education & Communication with common people by the Government, Healthcare providing machinery & NGOs NGO can play a major pathbreaking role, esp. in primordial and primary prevention of disability

Diagnosis is Easy, but Management is Not

A good clinical history taken by an experienced doctor from the parents or family regarding the progression and chronology of events of the disease from the onset often clinches the exact diagnosis. Additional laboratory tests and radiological investigations may be needed sometime to conclude a diagnosis. But identifying the real cause of disability may be difficult in some cases particularly when the disability is occurring in a small growing child who cannot communicate with others.

The Challenges.
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Exact assessment of severity of disability, ultimate prognosis & outlook of the disabled. The damage to the brain for example may significantly alter a person’s ability to understand & respond to commands creating tremendous obstacles in retraining & rehabilitation Huge long term social and financial burden along with continuous need to keeping up the moral of the patient and the family are real challenges.

Multimodality approach:

Treat the cause whenever treatable to minimize more disability from occurring Treat all current problems simultaneously with multimodality approach Prevent all potential/anticipated problems Interdisciplinary coordination

Maintain adequate nutritional needs and hygiene Make them as independent as possible Target short-term goals first to increase motivation Aim for long-term goal through coordinated plan by discussion amongst all members of the team.

Prognostic Factors

Root cause of the disability (Treatable Vs Untreatable) Extent and severity of the disability Cognitive abilities: Speech, learning & intelligence for effective communication with care-givers

Neuromuscular status & Mobility Emotion & Motivation (Optimism Vs Denial) Attitude & Approach to the problems (Positive Vs Negative)

Other Prognostic factors

Family support (financial and psychological) Nutritional status at onset of disability Associated present problems (comorbid conditions)

Modifiable Vs Un-modifiable factors
Modifiable factors: Should be targeted to improve outcome of rehabilitation. Improving cognitive functions of speech and learning can help a mentally retarded cerebral palsy child to get a vocational training and a job. Un-modifiable factors: Realistic goal during management.

Common medical problems in rehabilitation

Inadequate nutrition Emotional lability Cognitive impairmentsSpeech and learning disability Auditory & Visual disability limiting traditional learning Urinary tract infection

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Spasticity or abnormal gait Sensory impairment leading to pressure-sores Secondary acquired musculoskeletal deformities like contractures Secondary acquired musculoskeletal disuse atrophy Osteoporosis with risk of easy fractures, muscle wasting and deconditioning, pressure paralysis of nerve.

Common non-medical problems
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Poor access to health: neglect Financial limitations: undertreatment Emotional deprivation & isolation Vocational deprivation Unemployment: feeling of burden Nutritional deprivation Attitude of neglect

The Indian scenario
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Limited information, financial crisis and limited access to health-care facilities In small towns or rural areas remains important burning problems encountered by disabled families in India. Special school and disable-friendly school and disable-friendly recreation facilities are often unheard of in rural India.

India: the future

India: Developing country with high population & Can’t support a holistic healthcare facility to all Prevention: More important than providing limited rehabilitation facilities to a handful of disabled of urban India

Science & disability: the present & the future
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PREVENTION: At all levels RESEARCH: better understanding COMPUTER & IT: user-friendly SATTELITE:GPS during driving GENE THERAPY: contain or cure BIOTECHNOLOGY & BIOENGINEERING NANOTECHNOLOGY: Gene therapy

EPILOGUE: THINK POSITIVE.

Disability doesn’t mean hopelessness and inaction. Rehabilitation is all about hope and action. Any disabled must have access to proper Nutrition, Hygiene, Psychological support, Vocational training and Social support and Social justice.

Attitude: Half a glass of water?

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Look for their abilities (both existing and potential) rather than disability. They are disable but not unable. Help them to make the most effective use of their residual function. Call them ‘These able people’ rather than ‘DIS-able people’.

NOTHING SUCCEDS LIKE SUCCESS

Former US President Roosevelt: Fought two great wars in life and won both… his polio affected legs and the World War II. So, my dear friends believe in the words of Helen Keller “look to the sunshine and you will never see shadow”!

THANK YOU

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