“The problem is not how to wipe

out the differences but how to

unite with the differences intact”.
– Rabindranath Tagore
PHYSICAL MEDICINE AND REHABILITATION (PMR)
HEALTH
WHO’s definition:
Physical, psychological and socially
complete well-being.
IMPAIRMENT
Definition: Any loss or abnormality of
psychological, physiological, or
anatomical structure or function.
 IMPAIRMENT
Impairment includes clinical features or
manifestations of the disease or
condition. Examples: weakness,
limited ROM, confusion etc.
In this definition function is the function
of a body part, not the whole-person
function.
DISABILITY
Any restriction or lack
resulting from
impairment of ability to
perform an activity in the
manner or within the
range considered
normal for a human
being.
What is Disability?
 Disability results from an interaction between a
non-inclusive society and individuals:
Person using a wheelchair might have difficulties
gaining employment not because of the
wheelchair, but because there are environmental
barriers such as inaccessible buses or staircases
which impede access
Person with extreme near-sightedness who does
not have access to corrective lenses may not be
able to perform daily tasks. This same person
with prescription eyeglasses would be able to
perform all tasks without problems.

Convention on the Rights of Persons with

Disabilities
HANDICAP
A disadvantage for a
given individual
resulting from an
impairment or a
disability that limits or
prevents the
fulfillment of a role
that is normal
(depending on the
age, gender, social
and cultural factors)
for that individual.
WHO DEFINITIONS

Impairment↔ Organ or Tissue

Disability ↔ Whole Person

Handicap ↔ Society
Quick Clarification
 Impairment
anatomical or physiological dysfunction
 Disability
unable to perform a human activity
 Handicap
unable to meet a societal role
International Classification
 ICIDH 1980
 ICIDH-2 ICF
 ICF – International Classification of
Functioning, Disability and Health
 Models of disability
 Medical
 Social
 Business – Administrative
Disability Status
Disability Status: (Global Position)
1. USA 20%
2. Japan 5%
3. Australia 15%
4. Sri Lanka 5%
5. B’desh 10%
6. Nepal 5%
7. India 2.13%

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Disability Status
 According to the Census 2001: 2.19 crore
people with disabilities in India ( 2.13 per cent)
 This includes persons with visual, hearing,
speech, locomotor and mental disabilities.
 75% of persons with disabilities live in rural
areas,
 49 per cent are literate.
 Only 34 per cent are employed.
 The earlier emphasis on medical rehabilitation has
now been replaced by an emphasis on social
rehabilitation.

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Disability Status
Disability data as per Census India 2001
1. Movement 28%
2. Seeing      49%
3. Hearing           6%
4. Speech            7%
5. Mental          10%

Disability data as per National Sample Survey Organisation

(NSSO) 2002
6. Movement 51%
7. Seeing           14%
8. Hearing          15%
9. Speech          10%
10. Mental           10%

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Sources of Data
 Population Census,2001
 Disability Survey
of National
Sample
Survey,2002
Number of disabled persons : 21.9 million

Estimated number
of disabled
persons :18.5
Note: The number of disabled persons is about 2 % of the total
millionof the country.
population
Aims
 to provide a scientific basis for consequences of health
conditions
 to establish a common language to improve communications
 to permit comparison of data across:
 countries
 health care disciplines
 services
 time

 to provide a systematic coding scheme for health

information systems
Foundations of ICF
Human Functioning - not merely disability
Universal Model - not a minority model
Integrative Model - not merely medical or social
Interactive Model - not linear progressive
Parity - not etiological causality
Context - inclusive - not person alone
Cultural applicability - not western concepts
Operational - not theory driven alone
Life span coverage - not adult driven
 Human Functioning not disability alone
 Body functions vs impairments
 Body Structures

 Activities vs activity limitation

1980 disability

 Participation vs handicap
Models of disability (if you must)
Individual or
Medical Model
 Focus is on the clinical
diagnosis
 Focus is on what someone
can’t do
 Sees the person as the
problem that needs to be
fixed or cured
 Medical, psychological,
rehabilitation as answer
Structural or
Social Model
 Focus is on the context
 People are disabled by
society, not by their
bodies
 Discrimination, prejudice
as the problem
 Barrier removal as the
way forward
Medical versus Social Model
 PERSONAL problem vs SOCIAL problem
 medical care vs social integration
 individual treatment vs social action
 professional help vs individual & collective responsibility
 personal vs environmental adjustment manipulation
 behaviour vs attitude
 care vs human rights
 health care policy vs politics
 individual adaptation vs social change
Sequence of Concepts
ICIDH 1980

Disease
or Impairments Disabilities Handicaps
disorder
 Interaction of Concepts
ICF 2001
Health Condition
(disorder/disease)

Body function&structure Activities Participation

(Impairment) (Limitation) (Restriction)

Environmental Personal
Factors Factors
 Components of ICF
Health condition
(disorder or disease)

Body Functions Activity Participation

and Structures (activity limitation) (participation
(impairment) restriction)

Environmental Personal
Factors Factors
Structure ICF Classification

Part 1: Part 2:
Functioning and Contextual
Disability Factors
Parts

Body
Functions Activities and Environmental Personal Components
and Structures Participation Factors Factors

Change in Change in Constructs/

Body Body Capacity Performance Facilitator/
Functions Structures Barrier
qualifiers

Item Item Item Item Item Domains and

levels: levels: levels: levels: levels:
1st 1st 1st 1st 1st categories
2nd 2nd 2nd 2nd 2nd at different levels
3rd 3rd 3rd 3rd 3rd
4th 4th 4th 4th 4th
ICF Components
Body Functions Activities Environmental
& & Factors
Structures Participation

Functions Capacity Barriers

Structures Performance Facilitators

Body Functions and Structures
Mental functions
Sensory functions and pain
Voice and speech functions
Functions of the cardiovascular,
haematological, immunological and
respiratory systems
Functions of the digestive, metabolic
and endocrine systems
Genitourinary and reproductive
functions
Neuromusculoskeletal and
movement-related functions
Functions of the skin and related
structures
Structures of the nervous system
The eye, ear and related structures
Structures involved in voice and
speech
Structures of the cardiovascular,
immunological and respiratory
systems
Structures related to the digestive,
metabolic and endocrine systems
Structures related to the genitourinary
and reproductive systems
Structures related to movement
Skin and related structures
Activities and Participation

1 Learning &Applying Knowledge

2 General Tasks and Demands
3 Communication
4 Movement
5 Self Care
6 Domestic Life Areas
7 Interpersonal Interactions
8 Major Life Areas
9 Community, Social & Civic Life
Environmental Factors

1. Products and technology

2. Natural environment and human-
made changes to the environment
3. Support and relationships
4. Attitudes
5. Services, systems and policies
Examples of disabilities that may be associated with the three levels of functioning linked to a
health condition.

HEALTH IMPAIRMENT ACTIVITY PARTICIPATION

CONDITION   LIMITATION RESTRICTION
     

Leprosy Loss of sensation Difficulties in Stigma of leprosy

  of grasping objects leads to
  extremities   unemployment
 
Panic Disorder Anxiety Not capable of going People's reactions
    out alone leads to no social
      relationships

Spinal Injury Paralysis Incapable of using Lack of

    public transportation accommodations in
      public transportation
      leads to low
participation
Juvenile diabetes Pancreatic None (impairment Does not go to school
  dysfunction controlled by because of stereotypes
    medication) about disease

Vitiligo Facial None participation in social

  disfigurement   relations owing to fears
      of contagion
 
Person who formally None None Denied employment
had a mental health   because of
problem and was   employer's prejudice
   
treated for a  
psychotic disorder  
   
Inclusive Education is a
process of increasing the
participation of all students in
school, including those with
disabilities
 Legislativ The Constitution
e (Eighty-sixth Amendment)
Act 2002
Framewo
rks 1999
National Trust for the Welfare
of Persons with Autism,
Cerebral Palsy, Mental Retardation
and Multiple Disabilities

1995
The Persons with Disabilities
(Equal Opportunities,
Protection of Rights
and Full Participation ) Act

1992
Rehabilitation Council
Of
India Act
India has one of the more progressive disability
policy frameworks in the developing world
 PWD Act, 1995

 National Policy on Persons with Disabilities, 2005

 Ratification of UN Convention on Rights of Persons with

Disabilities (Oct. 2007)

 State Policies starting (e.g. Chhattisgarh)

 Sector-specific policies emerging – e.g. National Action Plan

for Inclusion in Education of Children and Youth with
Disabilities – 2005/06
Present Scenario
Changing Scenario

Inclusive
Education

Integrated
Education

Special
Education
INTERNATIONAL INITIATIVES
•Second Wave of Reform
beginning in 1970s – The
Community Living
Movement.
Vision: People with
disabilities integrated into
communities.
•Third Wave of Reform
beginning in 1990s – The
Self-Determination
Movement
Vision: People with
disabilities as valued,
contributing citizens of
their communities
 The UN Declaration on the Rights of Disabled
Persons(1975)- deficiency-integration in normal life
 World Programme of Action(1982)- Whenever possible
education should take place in an ordinary school
system
 Convention on the Rights of the Child (1989-90)
Disabled children have a right to access and
integration subject to available resources &
appropriate to the child’s condition
 Jometien World Declaration of Education for All
(1990)
 UN Standard Rules on the Equalization of
Opportunities for Persons with Disabilities(1993)
Moved forward towards a social model in Rule 6 on
education but emphasis on access and equality & not
quality
 The Salamanca Statement and Framework for Action
on Special Needs Education (1994)- inclusive
education as athe means by which education for all
may be achieved
 Daker World Education Forum (2000) & Daker
Framework of Action
 Millennium Declaration (2000)-
Goal 2: Achieve universal primary education: by 2015
 International Classification of Functioning and Disability
(WHO,2001)-TWO DIMENSIONS- functioning and
disability (body functions/structures, activities
/participation) & contextual factors (Envt., personal)
 The Biwako Millenium Framework for Action (2002)-
inclusive, barrier-free and rights-based society for
persons with disabilities
 The Convention on the Rights of Persons with
Disabilities (2006)- equal access to primary and
secondary education
Law Relating to Disability
International Conventions
1. Convention on the Rights of Persons with Disabilities
( 50 Articles)

2. Optional Protocol to the Convention on the Rights of

Persons with Disabilities (18 Articles)
Disability Legislation in India
1. The Persons with Disabilities (Equal Opportunities,
Protection of Right and full Participation) Act 1995
2. National Trust Act 1999
3. Mental Health Act 1987
4. Rehabilitation Council of India Act 1986

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 It is estimated that around 5 crore persons in India suffer from some
disability or the other. India has made considerable progress in all the
categories of action for persons with disabilities & there has been a
shift in emphasis in policies towards disabled persons, from a welfare&
charity approach to that of equalization of rights & opportunities.

The Persons with Disabilities (Equal Opportunities, Protection of Rights

& Full Participation ) Act, 1995, identifies the following seven
categories of disability which will now be used in India :

 Blindness
 Low vision
 Locomotor disability
 Leprosy cured
 Hearing impairment
 Mental retardation
 Mental illness
Each type of disabled are further divided into four categories :-

1.Mild [below 40%]

2.Moderate [above 40% but less than 75%]
3.Severe [75%]
4.Profound [100%]

 To meet the basic needs of the disabled some measures have

been taken by Govt.

 Disabled with 40% disability & above are eligible to avail

facilities
& benefits of grant, scholarship etc.

 Disability Certificate are issued from District hospital / Sub

division hospital.
What is CBR?
CBR extends the biomedical model of disability
to incorporate social concerns, such as the
exclusion of persons with disabilities from
mainstream education and discrimination in
health services. Its development has been
driven by participation from stakeholders in
disability activism and persons with
disabilities (Hartley, Finkenflügel, Kuipers, &
Thomas, 2009).

Presented by cbrbasics.weebly.com
What is CBR?

The new understanding of CBR can be represented by the

CBR matrix which includes 5 major dimensions of
rehabilitation: health, education, livelihood, social, and
empowerment (ILO, UNESCO & WHO, 2010).
 What is CBR?

CBR emphasizes the use of

mainstream, existing resources, such
as health facilities, educational
institutions, community services, and
non-governmental organizations
(ILO, UNESCO & WHO, 2010).