A National Award Winning Article

‘Saudi Arabia Journal of Disability & Rehabilitation’ January – March 2000 issue

THE DEVELOPMENT OF PHYSICAL MEDICINE AND REHABILITATION  IN INDIA

                                                                                                                 Kurian Zachariah

This article traces the development of Physical Medicine and Rehabilitation in India, which is a new field of medical practice in the country. The author discusses the different models of medical practice that are prevalent for the care of disabled individuals and their lacunae, and makes some suggestions for the growth of Physical Medicine and Rehabilitation in India, with special emphasis on  a holistic approach which is comprehensive, cohesive and cost-effective.

Key words: Physical medicine, Rehabilitation, India

Running title: Physical medicine and rehabilitation in India

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Introduction

The population of India is estimated to cross one billion in  2000. Though there are no absolute figures, a rough estimate is that 1% of any population ‘needs’ rehabilitation. In India therefore there are probably 10 million people who are dependent in varying degrees on their caregivers. This in turn adversely affects the productivity of the caregivers, and further handicaps them. The reduced productivity of disabled people and their disadvantaged caregivers results in an enormous drain on the country’s resources, which it can ill-afford. Hence it   is of paramount importance to rehabilitate disabled people by all means, for their own betterment and for the economic health of the country. Rehabilitation will augment the economic health of the community in two ways. More directly, by realising the potential of the disabled person, and indirectly, by reducing the burden on the caregivers who were previously either unemployed or under-employed.

Rehabilitation goes beyond restoring people with disability to normalcy to the extent possible. It is a philosophy for transforming the lives of disabled people into personal triumphs of incredible dimensions. Rehabilitation is also not about accepting and coping, but about enabling people to use the full potential that they have. Rehabilitation is a science which concerns itself with functional ability. During the rehabilitation process, all possible resources and all possible methods, both within and without, are utilised to enhance an individual’s function. Thus, functional recovery is achieved even if anatomical and physiological recovery is impossible.

Rehabilitation principles can be applied in any situation for the benefit of any person who is willing to apply these principles in his or her life. The aim of rehabilitation is to enable a person to do the best that he or she is capable of doing. Enhanced function of the individual translates to enhanced performance, independence, increased productivity and integration into society. The various components of rehabilitation include treating the complications that the disabled person may have,  teaching the person and the caregivers how to avoid complications in the future, training the person to become as functionally independent as possible, and finally, improving the confidence of the person to be able to overcome the challenges of the road-ahead.

Models of rehabilitation in medical practice

There are two basic models in medical practice, namely, the traditional medical model and the rehabilitation model. The traditional medical model - which includes all medical and surgical disciplines - focuses its interventions on the etiology of the disease process. This approach has had only limited success because the etiology in many disease processes is still unknown, as in the example of essential hypertension. Sometimes even where the etiology is known, as for example, in traumatic and congenital cases, the disease process may not be amenable to an etiology-based intervention. Thus, while a better understanding of the etiological process may help in primary prevention for future generations, the traditional etiology-oriented medical model is of only limited benefit to many affected individuals.

When doctors trained in this etiology-focused medical model of patient management are unable to successfully intervene to alleviate the problem, they often communicate a feeling of hopelessness and helplessness to the disabled person and the relatives. An example is when the doctor tells the relative of a patient that no further recovery is possible. What is almost never understood is that it is only neurological recovery that is hampered by the presence of an unknown etiology. On the other hand, functional recovery, the purpose of rehabilitation, is independent of both the etiology and the neurological recovery.

Thus the medical model, which is structured for the pursuit of the etiology of the disease process, often finds itself helpless in addressing the patient’s functional needs.  However, there are large numbers of paramedical rehabilitation workers who are trained under a different model, where the core issue of management is developing functional ability. In India, there are about 150 physiotherapy colleges, and the majority of the paramedical rehabilitation workers are physiotherapists.

In most cases the only link that the traditional medical model has with the rehabilitation model is through these allied paramedical rehabilitation workers and the usual, and sometimes the only, mode of communication is the therapy requisition slip. Transfers from one milieu to the other occur at least once during the course of the disabled person’s admission. Each time this happens, the progress of the person falters to some extent. Disabled persons are usually transferred from the medical setting to the rehabilitation setting for further rehabilitation, after the acute stage is over. Transfers from the rehabilitation setting to the medical setting occur usually for surgical interventions. Problems often occur in both these cases due to the inherent differences that exist between the two models.

There are only a handful of physiatrists (doctors practising rehabilitation)  currently available in India, when compared to doctors in the traditional medical and surgical specialities. The Medical Council of India noted that out of 140 medical colleges in the country in 1999, only 14 had departments of Physical Medicine and Rehabilitation (1). Young doctors rarely opt for Physical Medicine and Rehabilitation (PMR) as a career option, because the rehabilitation model is unable to attract doctors in search of a challenging and well respected career. More than 30 years after the first PMR department in the country came into existence, many medical interns today are still unaware of the existence of specialisation in this field.

The rehabilitation model in developed countries is commonly a super-specialisation of medicine. In the United Kingdom, rehabilitation follows a multi-disciplinary approach, where specialists of various allied medical and surgical sub-specialities together run regional centres. In India, however, rehabilitation follows a surgical model that also includes medical interventions, the best example of which is the “spinal injury rehabilitation model”.

The Spinal Injury Rehabilitation Model

There are two types of surgically biased rehabilitation models practised in several centres in India. In the more common “orthopaedic model” only orthopaedic surgeries are performed. A more recent model is the “spinal injury rehabilitation model” in which all common surgical and medical interventions required for spinal injuries are undertaken by the same team.

Two Indians are jointly responsible the creation of this model. Dr. Mary Verghese, head of one of the first Physical Medicine & Rehabilitation Department in India, was the beacon of hope for many spinal cord injured patients, because she herself was a spinal cord injured patient. The rehabilitation model she used was the now common orthopaedic model with its multi-disciplinary approach.

Following her demise, Dr. Suranjan Bhattacharji continued her work. He had observed that a multiple speciality approach for such patients only fragmented the care, frustrated the doctors, quadrupled the costs, and confused the patients. It became obvious to him that when confronted with the multiple problems of the spinal cord injured patients, the existing models were inadequate because the problems spanned across the traditional sub-divisions of surgery and medicine.

Dr. Suranjan trained himself in the three relevant surgical disciplines of orthopaedics, plastic surgery and urology. He then incorporated the relevant parts of the 3 specialities into Physical Medicine and Rehabilitation as it is being practised at the Christian Medical College (CMC), Vellore for the past 15 years. A post-graduate course that imparts the holistic surgical and medical rehabilitation model is now available at CMC Vellore. Though the spinal injury rehabilitation model was created for the holistic rehabilitation of spinal cord injured patients, it can also be used to comprehensively manage any group of patients.

Some suggestions to improve the existing rehabilitation models

There are many inherent problems to be dealt with in the existing rehabilitation models. For rehabilitation to become meaningful it is imperative that the various categories of rehabilitation personnel come together with a deeper appreciation of each other’s worth and of their role in the team. A holistic approach, as in the spinal injury model of rehabilitation, which is comprehensive, cohesive and cost-effective, seems by far to be the best means of rehabilitation.

There is another resource that can be harnessed in any rehabilitation model, namely, the family. The family may be less important in the Western countries, but is still a pillar of Indian society. The family does not fit so well into the traditional medical model. If one goes to any medical ward, one sees the family being asked to leave when the doctors arrive. This approach is logical in a medical model as long as cure is achieved in the hospital. In the rehabilitation model, where a lifetime of care is needed, the family involvement and appreciation of the disease processes can spell the difference between success and failure. Support from family members can also substantially help to reduce running costs in a rehabilitation centre. It is equally important to recognise and cater to the psychological needs of the family members if continuing support is to be secured.   

The spinal injury model is ideally suited, both for rehabilitating patients who have a wide spectrum of problems, and for attracting young doctors to the speciality. The uni-disciplinary approach of the spinal injury model allows the same treating team to manage all facets of the patient’s disease. This model fills a real niche and is capable of producing excellent results simply because it is comprehensive, cohesive and cost-effective. It is attractive to both the surgically and medically minded doctors. The good results and the large volume of patients desiring rehabilitation assure good career prospects for those who are genuinely interested. With only 14 out of the 140 medical colleges having a PMR department, there thus exist 125 vacant heads of department posts in India today.

However, the very survival of PMR depends on the building of closer and stronger links between the medical and rehabilitation models. This can be achieved by improving the prescription writing of the medical model students and doctors, and ensuring better recording and reporting back by the paramedical rehabilitation professionals. Such an approach will ultimately create increasing appreciation of rehabilitation, and help to attract more young doctors to the speciality.

The aim of rehabilitation has to change from ‘getting as many people into PMR as possible’ to ‘getting PMR into as many people as possible’. In order to do this successfully, one has to review the various models of rehabilitation available today to assess which model is most suited for India. The postgraduate curriculum in Physical Medicine and Rehabilitation should then be made uniform, and awareness should be promoted amongst professionals about the potential of rehabilitation. Awareness should also spread beyond the postgraduate curriculum to undergraduate medical students, who should be taught to write a therapy prescription in the correct manner.  Finally, physiotherapists and occupational therapists should attend the weekly ward rounds together with the medical staff.  The aim is to bring about a change in the attitudes of these two sets of professionals over a period of time through interaction.
 

While everyone perceives the need for rehabilitation, it must be appreciated that the process of rehabilitation is costly and slow in achieving results. These are the two common reasons for patients dropping out from the programme before achieving the rehabilitation goals that were set jointly at the beginning. Incomplete interventions usually result in the patient reverting to the pre-rehabilitation state, with the family more financially and emotionally exhausted. The long duration and high cost of rehabilitation is often due to the complications that the patients have prior to their entry into the rehabilitation programme. 

These complications usually occur as a result of inadequate holistic care and education of the patient and his family about his condition. Successful rehabilitation  depends less on how much the treating professionals know about the patient’s condition, and more on how much the patient and his family know  about it at the time of discharge. The rehabilitation paramedical professionals should also educate the patient and facilitate the active participation of the patient and the family. For too long rehabilitation has been seen as a service which the patient gets, instead of something that he participates in.

Dr. Mary Verghese had her dreams of specialising in obstetrics and gynaecology shattered when an accident during her internship made her a paraplegic. Her attempts to put the broken pieces of her life together is epitomised in her biography “Take My Hands” (2). This willing acceptance, and readiness to utilise the stumbling block of spinal cord injury in her life, were the stepping stones through which India entered in the world of PMR. The continuing development of PMR in India may depend upon how we react to some of the fundamental issues that have been raised, but will ultimately be a test of endurance and faith.

CONCLUSION:

The development of PMR in India – as anywhere else - is important for two reasons. Firstly, the huge numbers of handicapped people in the country adversely affects the national economy. The early rehabilitation of these people would result in enhanced performance and increased productivity. Secondly, the rehabilitation model, with its focus on function, is ideal in restoring these people to a more independent state and integrating them to society. This is possible even when traditional medical approaches are unable to alleviate the person’s situation.

Though there are various models of rehabilitation that are available in India, a holistic approach which combines surgical and medical treatment modalities is most beneficial to the patient. Such a uni-disciplinary approach by one treating team is comprehensive, cohesive and cost-effective. The ultimate success of rehabilitation will depend on the knowledge that is imparted to the patients by the treating team, and the mental strength of the patient. Accordingly, rehabilitation must strive to achieve these two goals in all patients.

There is an urgent need to get young doctors to take up this speciality, because the development of PMR will ultimately depend on them. This would require a dedicated and systematic approach, and it will take many years before PMR becomes a well established speciality. The development of PMR till this happens, and thereafter, must focus on building of stronger and closer links with the more ubiquitous medical model, with special emphasis on educating the medical students.

References:

• Resolution of the 5th Conference of the Central Council of Health and Family Welfare, 8th-10th January, 1997
• Take My Hands by Dorothy Clarke Wilson