A RETROSPECTIVE ANALYSIS OF DISABILITY EVALUATION FINDINGS IN PERSONS WITH PHYSICAL DISABILITIES: EXPERIENCE OF OCCUPATIONAL THERAPISTS FROM AN INDIAN PERSPECTIVE
Punita Vasant Solanki*, Stephen Brian Austin Sams**, Indira Ramesh Kenkre**, Sapna Gulabrao Wankar**
ABSTRACT
This study aimed to analyse the disability evaluation findings in persons with physical disabilities and to highlight the importance of the occupational therapist's role from an Indian perspective. One hundred and thirteen persons (100 men, 13 women, mean age 46 years) whose records were analysed in this study were referred to the occupational therapy out-patient department for disability evaluation for various reasons. A thorough medical and occupational history, therapeutic activity performance, tabletop tasks and an interview with care givers were also part of the assessment. Of the 113, 107 were referred from neurology, 3 from orthopedics and 3 from general surgery. A strong association (r = -0.81, p<0.0001) was found between Activities of Daily Living (ADL) status and the disability score. There was also a strong agreement between reasons for evaluation and suggestions made by the therapists (Kappa = 0.902, p<0.0001). All people fit for duty or light duty had a lower disability score and higher ADL status and vice versa. It was observed in certain cases that some standardised tests like LOTCA when included, helped the therapists in deciding on their comments/suggestions. The authors conclude that an occupational therapist plays an important role as one of the team members for disability evaluation.
INTRODUCTION
Occupational therapy services include evaluation and treatment of persons with physical and psychological disabilities. Evaluation is the first step towards the therapeutic treatment plan, and is the process of determining how a client's physical and/or psychological problems are interfering with his/her competence in occupational performance areas.
In the Indian context, a person with disability is a person with not less than 40% of any disability as certified by a medical authority (1). Disability evaluations are done for various reasons including primary, secondary and tertiary prevention of impairments. Disability evaluation gives an occupational therapist an opportunity to interact with persons with disability, understand their perspectives and develop a treatment plan that is meaningful, can ease their discomfort, calm and assist in reintegration into their community.
METHOD
All persons with disabilities (N = 113) whose records were analysed in this study were referred to the occupational therapy out-patient department for disability evaluation for various reasons from General Medicine, Neurology, Neurosurgery, Orthopedics and General Surgery units of our Hospital. All clients were managed for their illness in our hospital or other government Hospitals. Of 113 persons with disabilities referred from June 2005 to October 2007, 100 were males and 13 were females between the ages of 5 to 80 years with mean age of 46 years. Every person with a disability underwent disability evaluation based on "Guidelines for evaluation of various disabilities and procedure for certification by Ministry of Social Justice & Empowerment Notification, June 2001" (2), and Activities of Daily Living (ADL) scoring using Gosumec Functional Independence Measure Profile. In some clients certain standardised tests were included such as LOTCA (Loewenstein Occupational Therapy Cognitive Assessment) (3). A thorough medical and occupational history, therapeutic activity performance, tabletop tasks and an interview with the client's care givers were also the part of our assessment. Persons with intellectual disabilities were referred to a clinical psychologist for assessment. In some clients clinical cardiopulmonary evaluations were done. One occupational therapy staff, a postgraduate student and an intern were involved in each client evaluation. On completion of assessment, all clients were given the findings along with appropriate suggestions and sent back to the referring physician/surgeon of our hospital for the disability certificate.
RESULTS AND DISCUSSION
Of all persons with disabilities (N=113) evaluated for disability score, 94.69% (N=107) were referred from neurology (95 men and 12 women), 2.65% (N=3) were from orthopedics (2 men and 1 woman), and 2.65% (N=3) were from general surgery (all men). Of the 107 from neurology, 29.9% (N=32) were affected on the left side, 45.8% (N=49) on the right side, and 24.3% (N=26) had bilateral difficulties. Table 1 shows the diagnosis of the clients.
Diagnosis (N =113) | Number | Percentage |
---|---|---|
Cerebro vascular accidents | 85 | 75.22% |
Guillian Barre Syndrome | 02 | 1.76% |
Infective conditions (Cerebral malaria, encephalitis), Space occupying lesions | 03 | 2.65% |
Primary muscular disorders | 03 | 2.65% |
Epilepsy with or without mental retardation | 03 | 2.65% |
Wilson's disease | 01 | 0.88% |
Amputation | 03 | 2.65% |
Parkinson's disease | 02 | 1.76% |
Rheumatoid arthritis | 01 | 0.88% |
Post -polio residual paralysis | 01 | 0.88% |
Fracture with Brachial Plexus Palsy | 01 | 0.88% |
Systemic lupus erythematosis and deep vein thrombosis | 01 | 0.88% |
Myasthenia Gravis | 01 | 0.88% |
Spinal misorders (Myelopathy, myelomeningocoele) | 03 | 2.65% |
Cerebellar disorders | 03 | 2.65% |
Duration of onset of illness varied from 1 month to 30 years, prior to their referral to our department. Twenty five persons with disabilities were referred within 6 months of illness of which 21 (84.00%) were fit for duty or light duty. Of the remaining, 2 were unfit, 1 was assessed for extra time for examination and 1 for concession. The rest (88 persons with disabilities) were referred 6 months after onset of illness for evaluation.
Table 2 shows the degree of disability in the referred clients and the reasons for referral for evaluation.
No. of clients | Reasons for Evaluation | ||||||
---|---|---|---|---|---|---|---|
Degree of Disability & Disability Score |
Applying for job in quota | Concessions /benefits |
Extra time for exam paper | For fitness for Job | For lack of fitness for job | Total | |
1. | Nil (0%) | 0 | 0 | 0 | 11 | 0 | 11 |
2. | Mild (<40%) | 0 | 5 | 1 | 23 | 1 | 30 |
3. | Moderate (> 40% & < 75%) | 1 | 4 | 2 | 4 | 0 | 11 |
4. | Severe (75% & above ) | 0 | 14 | 0 | 25 | 18 | 57 |
5. | Profound (100%) | 0 | 3 | 0 | 0 | 1 | 4 |
Total | 1 | 26 | 3 | 63 | 20 | 113 |
Correlation of Disability Scores and Activities of Daily Living (ADL) status was carried out using Spearman's Correlation as seen in Table 3 and 4.
N | Min. | Max. | Mean | S.D. | |
---|---|---|---|---|---|
Disability Score | 113 | 0.00 | 100.00 | 50.70 | 26.65 |
ADL Status | 113 | 1.00 | 6.00 | 4.63 | 1.49 |
Correlation of Disability Score & ADL Status | 'r' | 'p' |
---|---|---|
Spearman's Correlation ( N=113) | -0.810 | <0.0001* |
* Correlation is significant at the 0.01 level (2-tailed).
We found a strong association (r = -0.81, p<0.0001) between ADL status and Disability Score. All persons with disabilities fit for duty or light duty had a lower disability score and higher ADL status and vice versa. ADL status scoring uses a more functional approach towards evaluation and helps the therapists in decision making for appropriate suggestions and comments.
A test of agreement i.e. Cohen's Kappa's Reliability Test was used for assessing the agreement between the reasons for evaluation and the suggestions made by the therapists, the result of which is presented in Tables 5 and 6.
No. of clients | Reasons for Evaluation | |||||
---|---|---|---|---|---|---|
Reasons for Evaluation | Concession | Fit for duty | Extra Time forexam | Light duty | Unfit | Total |
Concession/benefits | 22 | 0 | 0 | 0 | 5 | 27 |
Extra time for exam | 0 | 0 | 3 | 0 | 0 | 3 |
Fitness for job | 0 | 20 | 0 | 41 | 2 | 63 |
Unfit for job | 0 | 1 | 0 | 0 | 19 | 20 |
Total | 22 | 21 | 3 | 41 | 26 | 113 |
Evaluation Done For | Fit for duty / light duty | Unfit | Total |
---|---|---|---|
Fitness for job | 61 | 2 | 63 |
96.8% | 3.2% | 100.0% | |
Unfit for job | 1 | 19 | 20 |
5.0% | 95.0% | 100.0% | |
Cohen's Kappa = 0.902 (i.e. perfect agreement between evaluation done & suggestion by therapist) |
We found a strong agreement between reasons for evaluation and suggestions made by the therapists (Kappa = 0.902, p<0.0001). However, keen clinical observation suggested ruling out those who malinger for undue benefits. As seen in Table 5, there was one person who had come to be certified as unfit for job, inspite of being fit for duty. This may be due to factors such as low motivation, low self esteem or attempt to get the benefits available for persons with disabilities. On the other hand there were 2 persons with disability who came to be certified as unfit for job, but wanted to resume work, which shows good motivation and willingness to work.
Mann Whitney "U" Test was performed for comparing the LOTCA score with the Disability Score. But the test could not be applied as the data available was only of 7 persons. However, the descriptive (mean and S.D.) values for the degree of disability are given in Table 7.
Number of Clients | LOTCA Score | ||
---|---|---|---|
Degree of Disability | N | Mean | SD |
Mild (< 40%) | 3 | 65.33 | 6.51 |
Moderate (> 40% & < 75%) | 4 | 52.75 | 15.19 |
Total | 7 | 58.14 | 13.22 |
A larger sample is required for conclusions about statistically significant importance of LOTCA scoring in addition to disability evaluation as per the guidelines of Government of India, in areas of cognition and perception. Our clinical observation suggested that standardised tests such as this should be included for appropriate suggestions and comments or there should be some percentage allocated for cognitive - perceptual deficits in the disability evaluation guidelines.
CONCLUSION
From our analysis we found a strong association between ADL status and disability score. We also found a strong agreement between the reasons for evaluation and suggestions made by therapists.
An occupational therapist thus plays an important role as one of the team member for disability evaluation and for rehabilitation. It is mandatory on the part of the therapist to have expertise and skills in clinical evaluation, along with knowledge of rules and regulations for persons with disability in India. Occupational therapists can play a role in the preparation of the disability evaluation guidelines, as we use a holistic approach towards persons with disabilities.
*Address for correspondence
C/48, 3rd Floor, Bhanu Jyoti C.H.S Ltd
Nivetia Road, Malad East,
Mumbai- 400097, Maharashtra. India
Email: punitasolanki@kem.edu therapistindia@gmail.com
**Occupational Therapy Training School & Centre
Seth G.S. Medical College & K.E.M Hospital
Dhurmal Bajaj Orthopedic Centre, 1st Floor
E Borges Marg, Parel, Mumbai: 400012, Maharashtra, India.
ACKNOWLEDGEMENT
The authors would like to thank Dr. M. E. Yeolekar, The Director (M.E & H) of Seth G. S. Medical College & K.E.M Hospital, Mumbai for allowing us to conduct the study and for permission to publish this paper; our thanks to all the Unit Heads of General Medicine, Neurology, Neurosurgery, General Surgery and Orthopedics for referring their clients for disability evaluation; to our Post Graduate students and interns for being part of our team; to Dr Deepak G. Langade, Lecturer (Pharmacology) Sir J. J. Group of Hospitals, for his help in statistical analysis and processing the data; and to all our clients and their care givers for their cooperation during the disability evaluation process.
REFERENCES
- The Gazette of India, Extraordinary Part Ⅱ, Section Ⅰ. The Persons with Disabilities Act. Ministry of Law, Justice & Company Affairs (Legislative Department), 1995.
- Government of India. Guidelines for Evaluation of Various Disabilities and Procedure for Certification. Ministry of Social Justice & Empowerment Notification, New Delhi, 1st June 2001. Website: http://socialjustice.nic.in.
- Katz N et al. Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) Battery for Brain Injured Patients: Reliability & Validity. Am J Occup Ther. 1989; 43(3):184-192.