ISPO An Asian Prosthetics and Orthotics Workshop '98 in Japan Final Report

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RELATIONSHIP BETWEEN PROSTHETICS AND ORTHOTICS SERVICES AND COMMUNITY-BASED REHABILITATION

Norman A Jacobs

Introduction

In the 1970s the World Health Organisation (WHO) introduced a new approach to disability prevention and rehabilitation known as Community-Based Rehabilitation. Its aim was to provide rehabilitation services to all people with disabilities whether they are rich or poor or whether they live in a city or in the countryside.

This approach involves measures taken at community level to use and to build upon the resources of the community as well as making use of the services offered at district and central institutions. Thus, through community-based rehabilitation, the provision of rehabilitation services is based on a three-tiered referral system consisting of a basic home and community level; an intermediate support level (provided by the district); and a specialised service level offered centrally.

The supporting personnel of the specialised service level at the central institution and the intermediate support level at the district institution are the professionals which one would expect to be working in the rehabilitation services. The supporting personnel at the community level, however, are a new type of professional. They are likely to be local persons with minimal conventional or specialised education. They are usually referred to as community rehabilitation workers.

The success of such a referral system will be centred on the development of an integrated and co-ordinated programme with the activities at each level being clearly defined. It will also rest with the development of an educated and trained workforce with the role of the different types of personnel being well defined.

It has been suggested by WHO that about 70 % of all rehabilitation can be carried out in the disabled person's own community. However, about 30% of disabled persons have to be referred to other rehabilitation services outside their own community. Amongst this group are found those people requiring prostheses and orthoses. This is due to the fact that it is not realistic to believe that prosthetic and orthotic devices of an acceptable quality can be made in every single community within a country. This means that for the successful, widespread provision of prosthetics and orthotics services there should be a strong relationship between these services and community-based rehabilitation programmes.

With regard to the provision of prosthetics and orthotics services, ISPO has gone some way in defining the job descriptions and educational requirements for the different categories of professionals directly involved in this field, that is, prosthetists/orthotists (Category I), orthopaedic technologists (Category II) and prosthetics/orthotics technicians (Category III). Some consideration needs to be given with respect to the use of these categories of professionals in WHO's three-tier referral system and, in particular, to the role and training of the community rehabilitation worker in prosthetics and orthotics.

The following statements summarise some early thoughts on how community-based rehabilitation and the three-tiered referral system may be used to help promote and improve prosthetics and orthotics services in developing countries.

Specialised service level

The specialised service level will be situated in a central or national institution and will be staffed by all categories of prosthetics and orthotics professionals up to and including Category I if possible.

The specialised service level will:

provide specialised prosthetics and orthotics services, i.e. it is expected to provide the full range of prosthetics and orthotics devices and services;
develop and co-ordinate a national policy with regard to prosthetics and orthotics services and referral. The specialised service level is expected to provide help and advice to government in helping to develop its policy with regard to the planning, organisation and administration of the prosthetics and orthotics services. This is of great importance if the concept of community-based rehabilitation in prosthetics and orthotics is to be adopted by a country. There is no model that can be copied. Each country would have to develop a system suitable to its particular needs and resources;
develop a central policy for disability prevention in the field of prosthetics and orthotics. The specialised service level would work with the government in helping to prepare its policy for disability prevention in the field of prosthetics and orthotics. This may include such items as vaccination programmes, workplace safety programmes, wound hygiene, etc.;
develop programmes of education and training for all personnel involved in the provision of prosthetics and orthotics services, including community rehabilitation workers. The role of the community rehabilitation worker and his/her education and training will be discussed later;
oversee the professional development of all personnel involved in the provision of prosthetics and orthotics services. In every country there is a need for professional development of personnel if one wishes the prosthetics and orthotics services to improve and flourish;
monitor and evaluate prosthetics and orthotics services and programmes of disability prevention from a national viewpoint. It is important that all services and programmes are evaluated in order to see whether they meet the needs of the country and to determine ways in which the may be improved.
assist with the rehabilitation of the disabled person and adaptation to the environment, e.g. use of the device at home, use of the device in work, instructions in the care of the device, hygiene with regard to use of the device, etc.;
provide or arrange for simple maintenance and repairs to prosthetic and orthotic devices, e.g. changing the prosthetic foot, replacing a screw or rivet, replace a broken strap, etc. It is important for the community rehabilitation worker to recognise what repairs can be done locally and what repairs should be referred to the intermediate support level,
provide information to intermediate support level with regard to the acceptance and use of devices ;
provide information to intermediate support level with regard to numbers of people with disabilities and the types of disabilities found;
help to prevent disease, e.g. through hygiene, wound treatment, vaccination programmes, etc.;
help persons with disabilities reintegrate into society, e.g. through education, work possibilities, etc.

Education of community rehabilitation worker

It is important to bear in mind that the community rehabilitation worker is neither a prosthetist/orthotist nor an orthopaedic technologist and will not be expected to fit prostheses or orthoses. He/she will have a wide training in many different aspects of rehabilitation of which prosthetics and orthotics is only one. The major purpose of any course undertaken in prosthetics and orthotics would be to prepare the community rehabilitation worker for the specific prosthetics and orthotics aspects of his/her job.

A syllabus to achieve this might include:

knowledge of the national prosthetics and orthotics services available and how to get access to them;
disabilities that can be helped by prostheses or orthoses;
the range of prosthetic and orthotic devices available from district and central institutions;
function of prosthetic and orthotic devices. This would be important in helping determine whether there was some problem with regard to fit and/or function of a prosthesis or orthosis.
training in the use of a prosthesis or orthosis. This is important in order that the community rehabilitation worker can help train the disabled person in the correct use of his/her device;
maintenance of prosthetic and orthotic devices. It is essential that the community rehabilitation worker has a proper knowledge of how prostheses and orthoses are properly maintained.
simple repairs to prostheses and orthoses. The community rehabilitation worker should know what repairs can be carried out by a local craftsman and what repairs need to be referred to the district workshop;
data collection. The community rehabilitation worker should be taught simple techniques to gather information about numbers of disabled, range of disabilities found, use of the prosthesis or orthosis, etc.

Clinic team

Throughout this talk I have only been talking about the personnel who are directly involved in the provision of prostheses and orthoses, that is, the Category I and Category II professionals and the community-based rehabilitation workers. In order for these professionals to work effectively they must all be part of a clinic team. Most people who require a prosthetic or orthotic device also require treatment from other medical and paramedical personnel such as surgeons, doctors, occupational and physical therapists, community health workers and social workers amongst others. The disabled person and his/her family are considered to be an important, if not the central part of the clinic team. In order for community-based rehabilitation to be effective in the provision of prostheses and orthoses there must be an integrated approach by all the members of the clinic team found at the community level, the intermediate support level and the specialised service level.

Discussion

There are a number of matters that need to be addressed before there are adequate prosthetics and orthotics services provided in developing countries. These are:

community, district and centralised services should all be part of the overall prosthetics and orthotics services. In order to provide an adequate prosthetics and orthotics delivery system there is a need to have all three services;
there is a lack of trained manpower in the prosthetics and orthotics services. There is still a great need to train Category I, Category II and Category III personnel as well as training community rehabilitation workers;
training of community. rehabilitation workers should not be seen as a replacement of training Category I or Category II personnel. They are a different type of professional with completely different skills and a different job to do;
there is a lack of financial resources. It is not possible to solve all the prosthetics and orthotics problems immediately. It is important to plan for the future and ensure that any developments are part of an overall plan to ensure that resources are well, used.
awareness of community-based rehabilitation and its role in prosthetics and orthotics. There is a need to make the public, the existing prosthetics and orthotics professionals and the government aware of community-based rehabilitation and how it can be used to improve the prosthetics and orthotics delivery system;
clinic team approach. Make proper use of all members of the clinic team when possible.

Conclusion

I have attempted to describe the relationship between prosthetics and orthotics services and community-based rehabilitation. I have attempted to show how the services offered by central, district and community institutions can work together in helping to provide a comprehensive prosthetics and orthotics service. There is no definitive model of community-based rehabilitation in prosthetics and orthotics available. Each country needs to develop its own system according to its needs and the resources available.

Commemorating the Mid-Point of Asia and Pacific Decade of Disabled Persons

ISPO An Asian Prosthetics and Orthotics Workshop '98 in Japan Final Report
- Papers : Relationship between Prosthetics and Orthotics Services and Community Based Rehabilitation -

Editors:
Eiji Tazawa
Brendan McHugh

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