DISABILITY (Dr. Anil Kumar Gupta) MD (PMR), DNB (PMR), CEPC Assistant professor, Department of Physical Medicine & Rehabilitation, KING GEORGE’S MEDICAL UNIVERSITY, LUCKNOW, INDIA

Disability “ Functional loss due to permanent physical impairment resulting from congenital condition, disease or trauma*.” It excluded illness/injury of recent origin (morbidity) resulting into temporary loss of ability to see, hear, speak or move.

World Health Organization’s(WHO) International Classification of Functioning, Disability and Health (ICF), uses ‘disability’ as an umbrella term for any or all of the following components: impairments—problems in body function or structure activity limitations—difficulties in executing activities participation restrictions—problems an individual may experience in involvement in life situations.

THREE CONFUSING TERMS : WHO definitions DISABILITY HANDICAP IMPAIRMENT IMPAIRMENT- It is any loss or abnormality of psychological, physiological or anatomical structure or function.

DISABILITY It is 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.

HANDICAP It is 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 age, sex, and social and cultural factors) for that individual.

Difference between Impairment , Disability and Handicap Society Whole person Organ or tissue

TWO TYPES OF BASIC DISABILITIES Primary Disability Secondary Disability

PRIMARY DISABILITY Disabilities that are direct consequences of a disease or condition are called primary disability . Paraplegia following spinal cord injury, Inability to walk after fracture .

SECONDARY DISABILITY Disabilities that did not exist at the onset of primary disability but develop subsequently are called secondary disability . eg. Joint contractures in poliomyelitis .

Epidemiology National Sample Survey Organisation (NSSO) has conducted thrice the survey of PWD (People With Disabilities) in 1981, 1991, and 2002. In July-Dec 2002 survey for the first time information on mentally disabled was also included. 1755 PWD every 1 lac person identified who were either physically or mentally disabled i.e. 1.8% of total population. Prevalence among rural and urban residents 1.85% and 1.50% respectively. .

Prevalence in male > female ( 2. 12% rural & 1. 67% urban : 1 Prevalence in male > female ( 2.12% rural & 1.67% urban : 1.5% rural & 1.31% urban) except in blindness where female exceed male Prevalence of locomotor disability is highest f/b hearing and visual disability. More than one type of disability was present in 10.63% PWD. Prevalence highest in Orissa f/b Kerala and Punjab. Lowest rate seen in Assam, Jharkhand and Rajasthan.

CLASSIFICATION NSSO (2002) categorized disability into various groups Mentally disabled – mental retardation(MR), mental illness(MI). Visually disabled – blindness and low vision. Hearing diasbility. Speech disability. Locomotor disability.

Percentage distribution of disabled persons by types of disability (NSSO-2002)

Mental Disability Persons who had difficulty in understanding routine instructions, who could not carry out their activities like others of similar age or exhibited behaviours like talking to self, laughing/ crying, staring, violence, fear and suspicion without reason were considered as mentally disabled for the purpose.

The “activities like others of similar age” included activities of communication (speech), self-care (cleaning of teeth, wearing clothes, taking bath, taking food, personal hygiene, etc.), home living (doing some household chores) and social skills.

Two types- Mental retardation (MR) Mental illness(MI).

CAUSES OF MR- Illness during childhood 42% Head trauma in childhood 10%. Pregnancy and birth related problems 3%. Hereditary 2%. Unknown cause 23%.

CAUSES OF MI Pregnancy and birth related problems 46% Unknown cause 36%. Illness during childhood 9%.

Age at onset- Since birth in 87% 0-4 years in 8%. Manifestation of MR is completed within teenage. Problem of MI is more of old age.

VISUAL DISABILITY (VD) Loss or lack of ability to execute tasks requiring adequate visual acuity.

Visually disabled includes, (a) those who did not have any light perception - both eyes taken together (b) those who had light perception but could not correctly count fingers of hand (with spectacles/ contact lenses if he/ she used spectacles/ contact lenses) from a distance of 3 metres (or 10 feet) in good day light with both eyes open. .

3rd highest of all disabilities. Night blindness was not considered as visual disability. 3rd highest of all disabilities. Age of onset- 68-72% acquire VD at age of 60 years and above. 1-2% are VD by birth. Two types- Blindness Low vision.

CAUSES OF BLINDNESS- Old age 24%. Cataract 21%. Other eye diseases 17%. CAUSES OF LOW VISION- Oldage or cataract 57%. Other eye diseases 12%. Unknown cause 10%.

Hearing disability(HD) This referred to persons’ inability to hear properly. Hearing disability is judged taking into consideration the disability of the better ear. In other words, if one ear of a person is normal and the other ear has total hearing loss, then the person was judged as normal in hearing for the purpose of the survey. Hearing disability was judged without taking into consideration the use of hearing aids (i.e., the position for the person when hearing aid was not used).

2nd highest among all. Causes- old age 25% & 30% for rural & urban respectively. other illnessess. ear discharge. Age of onset- 60 years & above in 56%(rural) & 62%(urban) Since birth in 7%.

SPEECH DISABILITY (SD) This referred to persons’ inability to speak properly. Speech of a person is judged to be disordered if the person's speech was not understood by the listener. Persons with speech disability includes those who could not speak, spoke only with limited words or those with loss of voice.

It also included those whose speech is not understood due to defects in speech, such as stammering, nasal voice, hoarse voice and discordant voice and articulation defects, etc.

Causes- Paralysis & other illness 46%(rural) & 49%(urban). MR/MI 9%. Voice disorders 8%. Old age 1%. Age at onset – 60 years & above in 35%(rural) & 43%(urban) congenital speech defect in 38 %(rural) & 31%(urban).

LOCOMOTOR DISABILITY (LD) A person with, (a) loss or lack of normal ability to execute distinctive activities associated with the movement of self and objects from place to place and (b) physical deformities, other than those involving the hand or leg both, regardless of whether the same caused loss or lack of normal movement of body – was considered as disabled with loco-motor disability.

LOCOMOTOR DISABILITY (LD) Highest among all disabilities Includes- Paralysis of limb or body Deformity of limb- maximum Loss of limb e.G. Amputation Dysfunction of limb Deformity of joints of limbs Deformity of the body other than in limbs eg. Hunch back, deformed spine etc.

Causes- Polio 30%(rural) & 27%(urban) injury other than burns 26%(rural) & 27%(urban) old age 3-4% leprosy 3% Age at onset- 60 years and above 49%(rural) & 57%(urban). 45-49 years 27%-29%.

AREAS OF SUFFERING OF DISABLED PERSON SOCIAL ECONOMICAL PSYCHOLOGICAL EMOTIONAL

Social Status Literacy – defined as ability to read & write a simple message with understanding. 55% of PWD are illiterate. 9% complete higher secondary education. literacy highest among MR 87%. f/b visually disabled 74%-77%.

Marital status - 47% PWD never married. 31% females were widowed, divorced or separated. 5% living with their spouse. majority of MR persons were unmarried. situation is better for people with hearing disability.

Employment status – among all 37% PWD employed. Only 15-35 out of 1000 PWD were able to complete some vocational course. Employment lowest among MR 6%.

DISABLITY PREVENTION Disability prevention relates to all preventive measures aimed at Reducing the occurance of impairments (first level prevention) Limiting or reversing disability caused by impairment(second level prevention) Preventing the transition of disability into handicap(third level prevention)

FIRST LEVEL PREVENTION- MOST EFFECTIVE Eradicating malnutrition- increasing food production & proper distribution. Disabling communicable diseases eg eradication of small pox. Immunization against communicable diseases like polio,tuberculosis,measles, whooping cough, diphtheria. Providing extensive coverage of perinatal care to children thro’ primary health care.

Providing safe water and sanitation facilities. Attempts to reduce accident rates. Promote socioeconomic development of individuals and country as a whole. Health education. Limiting use of alcohol,psychotropic drugs and tobacco. Preventing child neglect and abuse.

2nd level prevention Provision of adequate drugs (e.g. for leprosy, tuberculosis, earinfections, hypertension, diabetes, trachoma) Provision of essential surgery (e.g. in the treatment of wounds, fractures, limb injuries, and cataract)

Provision of rehabilitation as soon as possible during the span of disability. Effective system of referral to health centres at the district or regional level. Vocational and educatioal counselling. Can reduce the incidence & severity of disability by 10%-20%.

3RD LEVEL PREVENTION Includes rehabilitation. Orthopedic orthoses and prosthesis. Glasses for VD & low vision. Hearing aid for HD. Vocational schools and training for the disabled. Education and upliftment of the economic status of disabled. Speech therapy, vocational training. Provision of jobs for the disabled.

1.Latest classification used for describing functioning and disability. International Classification of Functioning, Disability and Health,(ICF). International Classification of Impairments, Disabilities, and Handicaps,  (ICIDH). ICD (International classification of disease) Diagnostic and Statistical Manual of Mental Disorders (DSM)

2. Which of the following is the 2nd level of prevention regarding disability prevention. Giving orthopaedic orthosis to a patient of Polio. Immunization with OPV. Cataract surgery. Hearing aid for HD

3. 2nd most common type of Disability is, Blindness. Hearing disability. Locomotor. Mental Retardation.

4. The correct sequence of events leading to disability and handicap, Disease- disability- Handicap- Impairment. Disease- disability- - Impairment- Handicap Disease - Impairment- Disability- Handicap. Disability-Disease-Handicap-Impairment.

5.Which of the following is a correct match, Accident- Disability Loss of foot- Handicap Unemployed- Impairment Can not walk- Disability

Ans 1(a) 2(b) 3(b) 4(c) 5(d)

Thank you