SEMINAR ON

CONCEPTS AND FOUNDATIONS OF REHABILITATION

By: SANTHOSH A. KURIAN Moderator: Mr. AMITESH NARAYAN Date: 10/11/2004

CONTENTS
INTRODUCTION DEFINITION GOALS OF REHABILITATION CONCEPTS 1. Principles & priorities in rehabilitation 2. Components of Rehabilitation 3. Strategies in Rehabilitation 4. General knowledge and skills in medical rehabilitation 5. Models in rehabilitation 6. Professional competencies for Rehabilitation 7. Related care Facilities in Rehabilitation REFERENCES

Introduction To rehabilitate (Latin) means, to restore. Rehabilitation of people with disabilities in developing countries was always a matter of great concern. Today approximately 250 million populations are disabled in these countries with moderate to severe degrees. In this group per year 10 million populations are added. Most of them are poor, dependent, abused, neglected, excluded from education, training and jobs; they die early and have no power while alive. Presently 15- 20% of all people (living below the poverty level) has disability. [WHO-1994] Therefore necessary measures are required to improve the quality life of persons with disabilities. Since all people have the right to good health; so countries working for disabled people are motivated by belief in equality and desire to limit the severity of disability and the hardship it imposes on individuals and families. These measures help to minimize the loss, which occurs, when a section of the population is economically unproductive. At International conference on Primary Health Care-1978, held at Alma-Ata, decisions were made that primary health care will be used to address the health problems in the community to promote Health for All by 2000 through the provision of promotive, preventive, curative, and rehabilitative services. These declarations lead WHO to promote community-based rehabilitation (CBR) as a means of integrating rehabilitation with health and developmental activities at the community level. Medical and legal literature refers rehabilitation as a process of restoring to a former capacity by focusing on residual and recoverable functions and capacities. Health and social care professionals meet individuals requiring rehabilitative strategies to assist them in gaining their optimal physical, psychological and social functioning. So the word REHABILITATION has come to the fore in recent years.

Definitions a. Rehabilitation 1. Rehabilitation is the process of adapting a person back into the workforce and into his/her personal life style following injury or illness. 2. Rehabilitation is a progressive, dynamic goal-oriented and often time-limited process, which enables an individual with impairment to identify, and reach his or her optimal mental, physical cognitive, and/or social functional level. Rehabilitation provides opportunities for the individual, the family and the community to accommodate a limitation or loss of function and aims to facilitate social integration and independence. [Ontario Ministry of Health [OMH] 1995. b. Concepts- An abstract idea [oxford dictionary] c. Foundations- An underlying basis for something [oxford dictionary] Goal of Rehabilitation: To maximize the function or abilities of an individual, in spite of existing or developing impairments in the least intrusive way (in a way that is most enjoyable, with least cost, time and effort expended, and least burden to the person and family). It assist individuals in their efforts to achieve the highest possible levels of emotional, social, vocational, cognitive and physical functioning

Concept of rehabilitation It lays stress on: a. Functional training of disabled individual; b. Interventions in changing or adapting the environment; c. Equalization of opportunities of disabled persons in the society; and d. Protection of human right of disabled people. Principles and Priorities of the Rehabilitation Services The Rehabilitation Services is committed to providing individuals with disabilities; with the assistance and opportunities they need to achieve high-quality employment and independence in their communities. Principles of Rehabilitation: 1. Individuals with disabilities are capable of achieving competitive, high-quality employment in integrated settings and living full and productive lives in their communities. 2. Major barriers to the employment and independence of individuals with disabilities are the low expectations and misunderstanding society (Grantee agencies, service providers, or consumers themselves) have about their abilities, capacities, commitment, creativity, interests, and ingenuity. 3. Individuals with disabilities are able to make informed choices about their own lives- includes their employment options, types of services they need, the selection of service providers and are able to assume responsibility for their decisions. 4. The primary role of Vocational Rehabilitation agencies and other Rehabilitation services is to empower individuals with disabilities by providing the information, skills training, education, confidence, and support services individuals need to make informed choices about their professional and personal lives. 5. Rehabilitation services are best delivered within a framework of accountability, efficiency, and least administrative burden.

6. The most effective Vocational Rehabilitation, Independent Living, Training and other programs result from a strong alliance between individuals with disabilities, grantee agencies, service providers, and organizations representing each. These alliances encourage accountability through systematic and ongoing assessments of a grantees policies, programs and practices. The above principles help to establish rehabilitation priorities, reflecting commitment for improving the lives of individuals with disabilities. Rehabilitation Priorities: Improve self-determination, empowerment, choice, and participation of individuals at both the individual and systemic levels. Enhance the timely and effective delivery of services. Ensure accountability for measurable results and foster improved performance by Rehabilitation services providers. Promote education, including post-secondary education, and other strategies that enable persons with disabilities to obtain high-quality employment, advance in their careers, and lead independent lives. Develop effective strategies for transitioning individuals with disabilities from school to employment and independence. Improve the training of disability professionals through course curriculllum. Reduce administrative burden on, and preserve flexibility of grantees. Rehabilitation Professionals: Various categories of disabilities are been cared by rehabilitation services; so, multiple professional fields are needed for the rehabilitation consumers. Eg: people with physical disabilities need orthopedic/neurological clinician, Physiotherapists, Occupational therapists, vocational training, barrier-free facilities, assistive equipment or aids; people with mental retardation need

early identification, psychological consultant, special education, vocational training, etc. Health professionals, teachers, family members and disabled people work together as a team. It helps to enhance more positive attitudes towards disability, while promoting the concept of independent living and full participation. Thus, professionals working in the field of rehabilitation need to add new skills to their traditional knowledge and values so that professional behavior becomes more oriented towards counseling and collaboration with families and communities. Rehabilitation: Need of Professional competencies 1. Understanding of expressed wishes and needs of disabled people both generally and as individuals 2. Wide knowledge of disabling disorders, including their etiology, treatment and prognosis 3. Ability to diagnose and manage disabling symptoms where the underlying pathology is refractory to medical or surgical treatment 4. Ability to evaluate disabled person's rehabilitation potential, taking account of their medical, personal and environmental circumstances 5. Ability to define and negotiate a rehabilitation plan with the disabled person, informal care givers, professional staff and others who may contribute to the implementation of the plan 6. Ability to revise and monitor the outcome of a rehabilitation plan in the light of changes in the level of disability, or changes in the disabled person's wishes and circumstances 7. Knowledge of up-to-date advances in all aspects of rehabilitation medicine 8. Implementation of clinical audit

Components of Rehabilitation 1. Medical rehabilitation: It includes screening and diagnosing disabilities, functional assessment, identifying rehabilitation needs of disabled, making rehabilitation plan for disabled individual, functional training of disabled and disability prevention. 2. Educational rehabilitation: It includes regular and special education, vocational and technical training for disabled people. It helps to strengthen physical and psychological compensation and assist in creating access to independent living for disabled. 3. Vocational rehabilitation: "Getting work" is the basic human rights. Vocational rehabilitation is an important task in the overall rehabilitation process as well as a measure for independent living of disabled persons. 4. Social rehabilitation: Social rehabilitation means the measures through which disabled persons can take an active role in society and live a independent life with full participation in family life and social activities. It enables disabled people to realize self-esteem and selfactualization.

Strategies for Rehabilitation: a. Institution-based rehabilitation Provided in a residential setting or in a hospital where disabled people receive special treatment or short-term intensive therapy. The institution-based approach focuses on the persons disability and gives little attention to the persons family and community, or to other relevant social factors. The major shortcomings of institution-based care are its high cost and its location, usually in urban centers, making it inaccessible to those living in outlying areas. Competent institution-based care, however, is an important part of the rehabilitation referral system for special assessments, surgical interventions, other skilled treatment, and specialized equipment. Its features are: Designed and controlled by professional groups Delivered by professionals Centralized Referral based Specialized Resources and technology intensive

b. Out-reach rehabilitation Provided by health care personnel based in institutions. In this rehabilitation personnel visit the homes of people with disabilities. It focuses on the disabled person, and perhaps the persons family. Education and vocational training are generally not included. Community involvement in these services is usually limited, with the result that they evoke little social change. The cost per person treated is high. Outreach services can be a valid part of the referral system, however, when used in special situations, such as the delivery of services to extremely remote areas. c. Community-based rehabilitation (CBR) CBR is characterized by the active role of people with disabilities, their families, and the community in the rehabilitation

process. Here knowledge and skills for the basic training of disabled people are transferred to disabled adults themselves, to their families, and to community members. A community committee promotes the removal of physical and attitudinal barriers and ensures opportunities for people with disabilities to participate in school, work, leisure, social, and political activities within the community. A person is available in the community to work with disabled people and their families in rehabilitation activities. Community members are encouraged to provide local job training for disabled members. Community groups assist the families of disabled people by providing care for their disabled children or adults, transportation, or loans to initiate income-generating activities. Community resources are supported by referral services within the health, education, labor and social service system. Personnel skilled in rehabilitation technology train and support community workers, and provide skilled intervention, as necessary. Its key features are: Community and client centered Focused on prevention and early intervention Collaborates with institutional facilities Consistent and flexible Coordinated by a referral system Inter-disciplinary, multi-sectoral Focused on information sharing Selects appropriate technology to fit community need

Models of Rehabilitation Most rehabilitation care models attempt to address the unique needs of the persons they were designed to serve; the heterogeneity of the client population can make this a difficult process. The various models in rehabilitation are: a. Client centered models Also known as consumer driven, because they emphasize the needs, the thoughts, feelings and expectations of the client. Its characteristics are: Respect for clients values, preferences and expressed needs Coordination and integration of care Information communication and education Physical comfort Emotional support, alleviation of fear and anxiety Involvement of family and friends Transition and continuity b. Provider centered model The number and type of health care providers is integrally linked to the model of rehabilitation. Reimbursement systems and third party payers also shape the provider types and thus the model of rehabilitation. c. Collaborative Practice Model This includes a team of rehabilitation workers (physical, and occupational therapists, nurse, medical practitioner, recreational and speech therapist, social worker, dietitian, and orthotist etc). Here Importance is been given for the interaction among the team members and management, which follows the positive inputs by the members for the successful outcome. Its major strengths are: It is well established Promotes good communication and collaboration among disciplines Address comprehensive aspects of care

 Energizes staff Views the client holistically Its weakness are: Cost Inefficiency Reduction in time for direct client care Psychological strain on staff Problems related to role diffusion, Ambiguity Status concerns Interpersonal conflicts Lack of commitment of some team members Concerns regarding competency Rehabilitation: Related care Facilities Extended care facility: Like skilled or Intermediate care facility for patients who do not need more than nursing care Halfway Houses: Rehabilitation center providing help to hospitalized patients to re-enter society Home care service: Includes Nursing, Physiotherapy, Occupational Therapy, Psychiatric Nursing & social work services Hospices: It uses clinicians, nurses, social workers & volunteers to provide in- & out-patient supportive care to terminally ill patients (expected to live <6months). Its primary features are grief counseling, group support & administration of Pain medication. Rehabilitation: Future challenges Although the comprehensive rehabilitation team has been viewed as the foundation of rehabilitation ; there are questions raised whether the team approach will erode in the face of economic constraints and health care reform.

Accounts of third party payers opting for a limited number of specific services, rather than paying for comprehensive care, are becoming more common. References Physical medicine and rehabilitation by Braddom Rehabilitation nursing, process and applications, by Shirley p. Hoeman Neurological rehabilitation by Darcey Umphred WHO publications 1994-1998. Community based rehabilitation by Malcom Peat www.who.org