REHABILITATION INSTITUTIONAL BASED REHABILITATION COMMUNITY BASED REHABILITATION

1. P a g e | 1 Dr. Nithin Ravindran Nair (PT)
REHABILITATION + INSTITUTIONAL BASED REHAB. + COMMUNITY BASED REHAB.
Definition: Rehabilitation is defined as the coordinated use medical, social,
educational and vocational measures for training and retraining the individuals to the
highest possible level of functional ability.
Delivery of Rehabilitation Care: The Team
• Patient with disability
• Family members of PWD
• Community members
TEAM MEMBERS
Medical • Physiatrist
• Surgeon – Orthopedic, Neuro,
Cardiac, Plastic, General
• Neurologist
• Psychiatrist
• Pediatrician
• Obstetrician
• Geneticist
• Neonatologist
• Rheumatologist
• Cardiologist
• Oncologist
• Urologist
• Ophthalmologist
• Otorhinolarngologist
• Physician – General, Family
Paramedical • Physiotherapist
• Occupational Therapist
• Prosthetist – Orthotist
• Rehabilitation Nurse
• Speech Therapist
• Psychologist
• Biomedical Engineer

2. P a g e | 2 Dr. Nithin Ravindran Nair (PT)
Socio-vocational • Social Worker
• Vocational – counselor, evaluator
• Skilled Instructors
• Placement officers
• Child development specialist
• Special educator
• Employment agencies
• Industries
• Banks and Funding Agencies
• NGO
Types of Rehabilitation:
Medical Rehabilitation: restoration of function.
Vocational Rehabilitation: restoration of the capacity to earn a livelihood.
Social Rehabilitation: restoration of family and social relationship.
Psychological Rehabilitation: restoration of personal dignity and confidence.
Models of Rehabilitation: (Ref: Alhadi Jahan et. al, 2017)
Six conceptual rehabilitation related model were identified. The components on
which the models are built were linked to the domains of the International
Classification of Functioning, Disability and Health (ICF) Model.
TYPES
MEDICAL VOCATIONAL SOCIAL PSYCHOLOGICAL

3. P a g e | 3 Dr. Nithin Ravindran Nair (PT)
Biomedical:
o It focuses just on medical therapeutics.
o There is complete ignorance to the psychological, social and environmental
factors.
o It limits the selection of the outcome measures and tools especially - chronic
disease management (external factors significantly important in treatment
development and planning)
Social:
o It presents disability as a result of a socially created problem, not the medical
factors.
o It proposes that systemic barriers, negative attitudes and exclusion from the
society are ultimate factors.
o It suggests that all people are equal in terms of functional ability and
participation, and everyone can participate successfully in life if environment is
appropriate.
o Great focus on environment (society) but ignores the characteristic of the
individual that might participate in the disability process.
MODELS
BIOMEDICAL SOCIAL BIOPSYCHOSOCIAL ICIDH CBR
HEALTH RELATED
QOL
NORMAL
STATE
DISABLED
STATE
DISEASE, TRAUMA OR
HEALTH CONDITION
NORMAL
STATE
MEDICAL
INTERVENTION

4. P a g e | 4 Dr. Nithin Ravindran Nair (PT)
Biopsychosocial:
o Combination of 3 dimensions – Biomedical + Psychological + Social.
o Biomedical – Biological component (medical), Psychological – cognition,
emotions, attitudes etc., Social – economic, environmental, and cultural.
o Currently practiced model.
ICIDH:
o In this model 3 main concepts were recognized – Impairment, Disability and
Handicap
o Unidirectional (Linear model)
o Focused on disease and related conditions and ignored the effect of individual
and the environment in disability.
o Same limitations like biomedical model.
CBR:
o CBR is a strategy within the community development for the rehabilitation,
equalization of opportunities and social integration of all the people with
disabilities.
BIOMEDICAL
HEALTH
SOCIAL
PSYCHOLOGICAL
DISEASE OR
DISORDER
IMPAIRMENTS DISABILITIES HANDICAP

5. P a g e | 5 Dr. Nithin Ravindran Nair (PT)
o Principles of CBR revolves around these 5 ideas – Equality, Social Justice,
Solidarity, Integration and Dignity.
o Models of CBR:
✓ WHO model: Uses trainers, booklets on health-conditions.
✓ Neighborhood model: A resource center in the community adopts
another center, trains personnel and in due course this becomes another
resource center.
✓ DRC model: Launched by Government of India in January 1985. It surveys
disabled population and works on all aspects of their rehabilitation –
prevention, early detection, medical intervention etc.
HRQOL:
The Ferrans and colleagues revised version of Wilson and Cleary model
Symptom
status
Physiological
variables
CHARACTERISTICS
OF INDIVIDUAL
General health
perception
Overall QOLFunctional
health
CHARACTERISTICS
OF ENVIRONMENT

6. P a g e | 6 Dr. Nithin Ravindran Nair (PT)
ICF MODEL
CONTEXTUAL FACTORS
Approaches of Rehabilitation:
The delivery of rehabilitation care is done through the following approaches:
✓ Institution Based Rehabilitation (IBR)
✓ Community Based Rehabilitation (CBR)
✓ Homes
✓ Day Care Centers
✓ Out Patient Clinic
✓ Camp Approach
Institution Based Rehabilitation
Characteristics Advantages Disadvantages
• Urban Based
• Large number of rehab
personnel available
• Excellent infrastructure
• Referral center for all
diseases and
conditions
• Research Programs
• Statistics Generated
• Rigorous Program
• Rare conditions can be
treated
• Costly
• Patients admitted –
cut off from society
• No follow-up
• Late identification,
intervention
HEALTH
CONDITION
BODY STRUCTURES
AND FUNCTIONS
ACTIVITY
ENVIRONMENTAL
FACTORS
PERSONAL
FACTORS
PARTICIPATION

7. P a g e | 7 Dr. Nithin Ravindran Nair (PT)
Community Based Rehabilitation
Characteristics Advantages Disadvantages
• Community Based
• PWD and their family
members are decision
maker
• CBR workers or semi-
professionals are
service providers
• Economical
• Guaranteed Follow -up
• Early identification,
intervention
• Difficulty to tackle
complicated problems
• Skilled personal care
not given
Homes
Characteristics Advantages Disadvantages
• Cater to patients of a
homogenous group
• Patients stays in
campus
• Limited – rehab
professionals
• Empathetic approach
• Low cost nursing care
• Patients admitted –
cut off from society
• Very little medical
care
• Family responsibility –
limited to monetary
Day Care Centers
Characteristics Advantages Disadvantages
• Patients of a
homogenous group
brought daily to center
• Some medical rehab
work is undertaken
• Integrated with special
schools
• Holistic approach
• Family members get to
interact – rest of the
day
• Difficult task to get
the patient to the
center
• All rehab team
members not present
Outpatient Clinic
Characteristics Advantages Disadvantages
• Caters to a large group
• Medical / Therapy
advice – case to case
basis
• All rehab team
members present
• Useful in developing
countries
• All services provided at
a cheaper cost
• Can’t cater to
moderately to severe
disabled
• Hardly any follow up
of patients

8. P a g e | 8 Dr. Nithin Ravindran Nair (PT)
Camp Approach
Characteristics Advantages Disadvantages
• Single contact with
large numbers of rehab
professionals at the
same time
• Many people can be
evaluated on the spot
• Organized by local
organization for people
from lower strata of
society
• Statistics can be
obtained – incidence
and prevalence
• Community awareness
• Some management
can be given free of
cost.
• Depends entirely on
sponsors
• No follow up of
patients
Rehabilitation Strategies (Ref: WHO Guidelines)
✓ Identify needs and priorities
✓ Facilitate referral and provide follow-up
✓ Facilitate rehabilitation activities: Provide early intervention activities for child
development, encourage functional independence, facilitate environmental
modifications, link to self-help groups
✓ Develop and distribute resource materials
✓ Provide training
Present Rehabilitation Services in India
1) District Rehabilitation Center (DRC) Project started in 1985
2) Four Regional Rehabilitation Training Centers (RRTC) have been functioning
under the District Rehabilitation Center (DRC) scheme at Mumbai, Cuttack,
Chennai and Lucknow.
3) National Information Center on Disability and Rehabilitation
4) National Council for Handicapped Welfare
5) National Level Institutes –
o National Institute for Mentally Handicap (NIMH) -Secunderabad
o National Institutes for Hearing Handicap (NIHH) - Mumbai
o National Institute for the Visually Handicap (NIVH) – Dehradun
o National Institute for Orthopedically Handicap (NIOH) – Kolkata
o Institute for the Physically Handicap (IPH) – Delhi
o National Institute of Rehabilitation Training and Research (NIRTAR) -
Cuttack, Odhisha.

9. P a g e | 9 Dr. Nithin Ravindran Nair (PT)
o National Institute for Empowerment of Persons with Multiple Disabilities
(NIEPMD) - Chennai
o Indian Sign Language Research and Training Center (ISLRTC) - Delhi
6) Ministry of Social Justice and Empowerment has set up Composite Regional
Centers for Skill Development, Rehabilitation and Employment of Persons
with disabilities in various states to provide preventive and promotional
aspects of rehabilitation.
7) The Government of India formulated National Policy for person with
Disabilities, 2006 which deals with physical, educational and economical
aspects of rehabilitation.
Recent Advances:
Rehabilitation in health systems: Guide for Action / Rehabilitation 2030
o It is initiated by WHO which helps governments to strengthen their health
systems.
o 4 phase process and 12 steps
PHASES STEPS
1) STARS – Systematic Assessment
of Rehabilitation Situation
1) Prepare for situation assessment
2) Collect data and information
3) Conduct assessment in the country
4) Write, revise, finalize report and
communicate findings.
2) GRASP – Guidance for
Rehabilitation Strategic Planning
5) Prepare for strategic planning
6) Identify priorities and produce first
draft of plan
7) Consult, revise, finalize and
complete costing of plan
8) Endorse and disseminate strategic
plan
3) FRAME – Framework for
Rehabilitation Monitoring and
Evaluation
9) Develop monitoring framework
with indicators, baselines and targets
10) Establish evaluation and review
processes
4) ACTOR – Action on Rehabilitation 11) Establish a recurring
implementation cycle
12) Increase capacity of rehabilitation
leadership and governance.

10. P a g e | 10 Dr. Nithin Ravindran Nair (PT)
DIFFERENCE BETWEEN CBR AND IBR
HEADINGS CBR IBR
Definition
CBR is a strategy within
the community
development for the
rehabilitation, equalization
of opportunities and social
integration of all the
people with disabilities.
IBR is the rehabilitation of
PWD at or through
institutions often away
from their home.
Location
Anywhere and community
based
Urban and institution
based
Decision maker PWD and their family Service providers
Service providers
CBR workers and semi
professionals
Mainly professionals
Services At door step (Holistic) Far (Medical)
Accessibility of services Accessible to all
Only few institutions are
accessible
Extension of services Can be done Not possible
Quality of service Not good Good
Social rehab Possible Not possible
Psychological rehab Possible Not Possible
Skilled personal Care Not given Given
Socioeconomic status Considered Not considered
Action Proactive Responsive
Active participation Possible Not possible
Awareness / Promotion Yes Not

11. P a g e | 11 Dr. Nithin Ravindran Nair (PT)
Identification Early Delayed
Intervention Early Delayed
Follow up Guaranteed Not Guaranteed
Complicated problems Difficult to tackle Easy to tackle
Cost of treatment Economical Costly
Physiotherapy
o Indirect service
provision to client
o 1 therapist to a given
population
o Service receiver
addressed as client
o Often works in group
o Therapy time allocated
as per population need
o Direct service provision
to client
o 1: 1 - therapist to
patient ratio
o Service receiver
addressed as patient
o Rarely works in group
o Therapy time allocated
as per individual need
CBR and IBR should be viewed as dynamic continuum (the two can operate
interdependently
THE CONTINUUM
Acute care
and
specialist
facility
Outreach
services
Home care
programme
Social
services
Community
workers
Volunteers Family /
Caregiver
PWD
IBR CBR

12. P a g e | 12 Dr. Nithin Ravindran Nair (PT)
COMMUNITY BASED REHABILITATION
Definition: CBR is a strategy within the community development for the
rehabilitation, equalization of opportunities and social integration of all the people
with disabilities.
CBR MATRIX
AIMS OF CBR:
✓ Prevention of disabilities
✓ Identification of high-risk infants and mothers
✓ Early detection of disability and its management
CBR MATRIX
HEALTH
PROMOTION
PREVENTION
MEDICAL CARE
REHABILITATION
ASSISTIVE DEVICE
EDUCATION
EARLY CHILDHOOD
PRIMARY
SECONDARY &
HIGHER
NON - FORMAL
LIFELONG
LEARNING
LIVELIHOOD
SKILLS
DEVELOPMENT
SELF
EMPLOYMENT
WAGE
EMPLOYMENT
FINANCIAL
SERVICES
SOCIAL
PROTECTION
SOCIAL
PERSONAL
ASSISTANCE
RELATIONSHIPS,
MARRIAGE &
FAMILY
CULTURE & ARTS
RECREATION,
LEISURE & SPORTS
JUSTICE
EMPOWERMENT
ADVOCACY &
COMMUNICATION
COMMUNITY
MOBILIZATION
POLITICAL
PARTICIPATION
SELF - HELP
GROUPS
DISABLED
PEOPLE'S
ORGANIZATION

13. P a g e | 13 Dr. Nithin Ravindran Nair (PT)
✓ Assessment of the needs of the PWD and their family
✓ Homebased or Neighbourhood based programs
✓ Parental involvements
✓ Playgroups and integrated schooling for children
✓ Organization for and by the PWD
OBJECTIVES OF CBR:
✓ Provide all rehabilitation services needed
✓ Reducing or eliminating environmental barriers
✓ Promoting social integration and self-actualization
✓ Protective and ensuring security of disabled
✓ Empower disabled people
✓ To raise awareness in the community (sensitization and education)
BASIC PRINCIPLES OF CBR:
✓ Shifting services from institutions to homes of the disabled people
CBR
PRINCIPLE
SOCIAL
JUSTICE
SOLIDARITY
INTEGRATIONDIGNITY
EQUALITY

14. P a g e | 14 Dr. Nithin Ravindran Nair (PT)
✓ Shifting the services from professional to trained community or family
members
✓ CBR should be flexible so that they can operate at local level, using locally
available resources
✓ Ensure that PWD is involved in planning and managing the program.
✓ CBR enables PWD to live independently through training in ADLs, education,
skills development, employment opportunity, accessibility and social
interaction.
✓ CBR should concentrate on changing people’s attitude to disability and
disabled people.
COMPONENTS OF CBR PROGRAM:
✓ Creating a positive attitude towards people with disability
✓ Provision of functional rehabilitation
✓ Provision of education and training opportunities
✓ Provision of care facilities
✓ Prevention of the causes of disabilities
✓ Creation of micro – and macro – income generation opportunities
✓ Management, monitoring and evaluation of CBR projects
APPROACH TO COMMUNITY / STRATEGIES TO INITIATE CBR ACTIVITIES:
Step 1: Understanding the community
✓ Knowing the community: Meet a group of disabled people to understand their
QOL, problems. Retrospective study – previous census book of revenue district
/ gazetteer of district / survey reports of PWD / records of AWW, NGO and
rehabilitation workers.
✓ Communication: Communicate with health worker, district disability officer,
social welfare officer, child development project office, directorate /
commissionerate of disability to know the available and utilized government
schemes.
✓ Visit: Visit a couple of village/ slums / tribes and meet formal and informal
leaders including women’s group and youth groups to understand the
prevailing situation of the disabled people.

15. P a g e | 15 Dr. Nithin Ravindran Nair (PT)
Step 2: Resource identification and mobilization
✓ Resource mapping: Find out following information
o No. of schools (Primary / Secondary)
o No. and type of vocational training schools in the proximity
o No. of special schools for children
o No. of PHC, subcenters, CHC, district and private hospitals
o Available nearest support – PT / OT
o Details of religious leaders, formal and informal leaders, AWW, health
workers, teachers etc.
o Details of officers – education officers, district disability officers, child
development project officer, district officer for employment and labor
etc.
o Details of occupations, sub-occupations, industrial training centers
o Details of community-based groups working for self-help, education,
health etc.
o Formal meetings with district / taluka / village level government and
functionaries
Step 3: Write a plan / proposal
✓ Background, rationale and situation analysis
o Why the effort is proposed?
o What is the present scene in the area?
o Who are the major players?
o What are the available resources?
o What is the magnitude of the problem?
o What is your vision, mission and goals?
✓ Approach and methodology
o How it is planned for implementation?
o How vocational needs are met?
o How parents / family members of PWD are approached counselled,
trained, organized?
o How aspects of Disability Act and available government resources
accessed?
✓ Organizational structure
o Risk factors anticipated

16. P a g e | 16 Dr. Nithin Ravindran Nair (PT)
o Expected outcomes/budget
o How monitoring / evaluation done?
o What and how records will be kept?
o Acknowledgement of people who helped in the development of
proposal.
Step 4: Start helping people simultaneously
o Holding awareness program
o Counselling
o Assessment camps
o Workshops on disabled people
o Helping with medical and surgical treatment
o Getting scholarships
o Providing bus pass
Step 5: Get support and mobilize resource
✓ One may like to broach the topic with –
o Panchayat members
o PHC staff
o Local community groups
o Management of your institutions
o Directorate of disabled welfare at state and center level
o National and international level organization
Step 6: Start systematic work once resource support is assured. Till then help
people ad hoc.
o Monitoring and recording systems
o Records for individuals with disabilities
o Records at village, group of villages, PHC area, field practice area
o Minutes of the meetings held
o Monthly / Quarterly reports
o Field visit reports
o Special camp reports

17. P a g e | 17 Dr. Nithin Ravindran Nair (PT)
REFERENCES:
❖ Community Based Rehabilitation – Malcolm Peat
❖ Community Based Rehabilitation of PWD – S Pruthvish
❖ Textbook of Rehabilitation – S Sunder (3rd
ed)
❖ Essentials of Community Based Rehabilitation – Satya Bhushan Nagar
❖ Physiotherapy in Community Health and Rehabilitation – Waqar Naqvi (1st
ed)
❖ WHO CBR Guidelines
❖ Textbook of Preventive Practice and Community Physiotherapy – Dr. Bharati
Vijay Bellare (1st
ed)