Physical Disabilities Rehabilitation in Africa

Original Editor - Anarème Kpandressi  as part of the WCPT Network for Amputee Rehabilitation Project

Top Contributors - Sheik Abdul Khadir and Amrita Patro  

Introduction

Africa.png
Africa [1] is the world's second-largest and second-most-populous continent. With 1.1 billion people as of 2013, it accounts for about 15% of the world's human population. The continent is surrounded by the Mediterranean Sea to the north, both the Suez Canal and the Red Sea along the Sinai Peninsula to the northeast, the Indian Ocean to the southeast, and the Atlantic Ocean to the west. The continent includes Madagascar and various archipelagos. It has 54 fully recognized sovereign states ("countries"), nine territories and two de facto independent states with limited or no recognition.

According to UN statistics, there are currently over 600 million persons [2] with disabilities throughout the world of whom 400 million live in developing countries and 80 million in Africa. Most common disabilities in Africa are: physical, sensory (blindness) and mental disabilities. Our main focus in this paper will be on physical disability.

The main interventions being implemented regarding physical disability are:

  • Community based rehabilitation, CBR,
  • Provision of orthopedic devices and mobility aids
  • Training and capacity development of rehabilitation personnel and orthopedic technicians, physiotherapists, etc.
  • Policy development on disability and action plan on behalf of persons with disabilities, PwDs.

Community Based Rehabilitation

Community based rehabilitation (CBR) is a strategy within community development for the rehabilitation, equalization of opportunities, poverty reduction and social integration of people with disabilities. CBR is implemented through the combined efforts of disabled people themselves, their families and communities and the appropriate health, education vocational and social services.

Provision of orthopedic devices and mobility aids

Many programmes, centres, initiatives whether nationally, regionally or internationally recognized are set up to help people with physical disability to get an orthopaedic device that will help them get back up on their “feet”. These orthopaedic devices range from ankle foot orthoses, knee orthoses, knee ankle foot orthoses, hip knee ankle foot orthoses, trunk braces, foot prostheses, tibial prostheses, femoral prostheses, hip disarticulation prostheses to crutches, canes and wheelchairs. The technologies of Orthoses and Prostheses vary from country to country. In some countries, local solutions are being implemented whereas in others (more developped), new technologies are used. International/Regional organizations such as Handicap International, SFD/ICRC and OADCPH [3] play an important role in the provision of orthopaedic devices and components on the continent.

Training and capacity development of rehabilitation personnel and orthopedic technicians, physiotherapists

Many formal schools and training institutes exist and different types of training are offered to different kinds of people in order to ensure quality rehabilitation services to patients.

Prosthetics and Orthotics training and capacity development

The existing schools, which are well distributed on the continent geographically as well as linguistically are in Tanzania, Togo, Sudan, Ethiopia, South Africa, Nigeria, Ghana, Rwanda, etc. Some of them are internationally recognized and thus train students from different countries whereas others are nationally recognized.

The training efforts in Africa are not just limited to those formal training institutions and schools alone but are also supported by some NGOs and Regional/International Organizations especially by providing a continuing education and modular trainings, such as SFD-ICRC, Human Study, etc.  Innovative methods such as e-learning are also implemented.

The different types of offered trainings are :

  • P&O Cat.1 (Bachelor of Sciences): TATCOT-Tanzania ; HUMAN STUDY-Germany (e-learning) ; TUT-South Africa
  • P&O Cat.2 : ENAM-Togo; Ethiopia, Rwanda
  • Wheelchairs : TATCOT-Tanzania (Basic & Intermediate levels) ; FATO-WHO ;
  • Spinal Orthotics : TATCOT-Tanzania (e-learning)
  • Lower Limb Prostheses and Orthoses (one-month training) : SFD-ICRC (Togo and Tanzania)
  • Upper limb prostheses (one-month training) : SFD-ICRC (Togo and Tanzania)

Physiotherapist training and capacity development

Physiotherapy is much more represented and recognized on the continent. For instance, in Burkina, the government doesn’t have Orthopaedic Technologists (OT) in their Official document nor in the list of Healthcare professions and OT are officially  "Physiotherapist ". Many schools and training institutions exist on the continent. Countries in Africa who train Physiotherapists[4] include Zambia, Zimbabwe, Kenya, Tanzania, Uganda, South Africa (up to PhD), Nigeria, Ethiopia, Rwanda, Egypt, Togo, Benin, Côte d’ivoire, etc. Physiotherapists training, initially leading to Diploma, has changed and moved towards Degree Programmes (B.Sc, M.Sc, PhD). Countries who don’t have training institutions are dependant on others who have it in order to have their own Physiotherapists.
NGOs are also involved in developping Physiotherapy in Africa by providing short/modular courses (SFD/ICRC), scholarships for formal training.

All these schools and training institutes exist but the needs in number of professionals, in continuing education, in training offers are far from being covered. Much more efforts must be done, new schools and training institutions must be created, other types of trainings must be added and new strategies need to be implemented in order to establish a strong, effective and sustaining education mechanism in rehabilitation in Africa.

Policy development on disability and action plan on behalf of persons with disabilities

A series of surveys conducted by FATO [5] revealed that there remains a lot to be done regarding policy development on disability. The surveys involved 29 african countries and revealed the informations contained in the following table:

              

National development plans and Policies on Disability in Africa
Strategy on poverty reduction UN Convention on the Rights of People with Disabilities Strategy on disability Strategy or plan on physiotherapy and prosthetics & orthotics

YES
Existence Budgeted Signed Ratified Existence Budgeted Existence Budgeted
27 countries 20 countries 26 countries 19 countries 18 countries 12 countries 14 countries 11 countries
NO 2 countries

5 countries

3 countries 10 countries 10 countries 7 countries 14 countries 17 countries

Amputee rehabilitation in Africa

Generally speaking, amputee rehabilitation on the continent is performed on a multidisciplinary basis involving the surgeon, the nurse, the psychologist, the physiotherapist, the orthopaedic technologist, the social worker, etc. However, local or remote settings do not always involve all those actors. Sometimes the management stops at the amputation without any referral to a rehabilitation centre. At other times, it involves only the surgeon and the Orthopaedic technologist, and all these at the disadvantage of the amputee. National examples canstopsnational examples are worthy to be taken into account.

Case studies

Very little could be gathered on amputee rehabilitation in Africa in the literature; however national cases can be taken into account :

Case 1 : South Africa (example of the Western Cape)

J.P. Fredericks (2012) [6] reported that the Western Cape Department of health (WCDoH) published clinical guidelines on rehabilitation and prosthetic prescription for lower limb amputees in 2010. The purpose of the guidelines is to ensure that persons who underwent lower limb amputations in Western Cape Department of Health facilities are optimally rehabilitated and that appropriate candidates are referred for prosthetic rehabilitation. The objectives of the guidelines are to:

  1. “Provide clinical guidelines for the immediate post-operative management of amputees irrespective of their potential to receive a prosthesis" 
  2. “Provide guidelines for the appropriate referral to community and sub-acute resources in the Western Cape to ensure continuity of these early management plans.”
  3. “Provide general assessment guidelines as to the suitability of candidates for  prostheses”.

According to these guidelines amputation rehabilitation in the Western Cape should be initiated during acute care since comprehensive, early intervention leads to improved long term outcomes. Acute care intervention should be provided through a multi-disciplinary team. The team should ideally consist of doctors, nursing staff, occupational therapists, physiotherapists and social workers. In instances where members of a professional group are not available, other professionals should step in and ensure that the necessary interventions are performed. The focus of treatment during this phase should be on managing :

  •  co morbidities
  • wound care
  •  stump bandaging
  • prevention of contractures
  • independent self-care
  • bed mobility
  • crutch or frame walking
  • wheelchair mobility if appropriate
  • ordering appropriate assistive devices
  • home and work assessment
  • grief counselling
  • financial advice and
  • carer training.

Finally, this team should establish a rehabilitation and discharge plan for future holistic health and functional status management (WCDoH, 2010). Various rehabilitation and discharge management plans are presented in the guidelines. The most suitable one must be chosen for each client, “…depending on the patient’s needs for wound care, assistance with self-care, ability and potential to mobilise and availability of resources” (WCDoH, 2010). For client’s independent in self-care and with good mobility, referral for prosthetic rehabilitation should be considered. During the prosthetic rehabilitation phase different management strategies are again provided. In this instance they are based on the level of amputation since the kind of prosthesis which is provided and the potential to walk, differ according to the level of amputation (WCDoH, 2010).

Case 2 : Togo (Example of Lomé)

The national rehabilitation centre, CNAO, is the first and principal centre for amputee rehablitation. The approach is also multidisciplinar though the prosthetists (for instance) are not involved in the amputation decision (in the hospitals) in terms of level or technique of amputation. There are times some amputees rehabilitation and especially the prostheses would be less difficult if the prosthetist has given an opinion during the decision of amputation. CNAO is not inside a Hospital but stands elsewhere alone. This situation is also the source of challenges in the multidisciplinary approach. The amputation are made in Hospitals and clinics and the clients are sent to the rehabilitation centre. In many cases, there is nothing done to the stump before sending the client to the rehabilitation centre. In CNAO, Physiotherapists and Prosthetists work together in the management of amputees, supported by psychologist and social workers. The general steps established in the management of an amputee are as follows :

  • stump care
  • respiratory exercises
  • Active/Passive mobilization
  • Muscle strengthening
  •  Stump desensitization
  • Psychological counseling
  • Bed mobility
  • Transfers
  • Crutch/Frame walking
  • Use of wheelchair
  • Balance exercises
  • Manufacture of the prosthesis
  • Gait training
  • Follow up

SFD/ICRC has helped a lot the CNAO to implement a quality management of amputees.
Many other techniques exist in many other countries of Africa but this work is just about what is done in Western Cape (South Africa) and Lomé (Togo, West Africa).

Amputee management systems in these two countries are almost the same, though the two countries are not at the same economical, political levels. We can thus merge these two systems and establish the merged system as the one generally used regarding amputee rehabilitation in Africa.

Conclusion

There has been a real improvement on the continent regarding rehabilitation at large and amputee rehabilitation specifically. Some years back, the work was not multidisciplinary and the care was not comprehensive. The new approaches and prostheses techniques must be maintained and subject to constant improvement for the well being of amputees on the continent. Local initiatives are also encouraged, provided they follow the general rules that are set in the management of amputees. The overall result of all these will be higher quality, more effective amputee rehabilitation care which is of better value to society.

Reference

  1. Africa, http://en.wikipedia.org/wiki/Africa
  2. Disability in Africa, http://www.ascleiden.nl/content/webdossiers/disability-africa
  3. Organisation Africaine pour le Développement des Centres pour Personnes Handicapées, www.oadcph.org
  4. Jose Frantz, PhD, Challenges facing Physiotherapy Education in Africa. The Internet Journal of Allied Health Sciences and Practice. Oct 2007, volume 5 number 4, http://ijahsp.nova.edu
  5. Fédération Africaine des Techniciens Orthoprothésistes, www.fatoafrique.org
  6. Jerome Peter fredericks, 2012, Thesis, Description and evaluation of the rehabilitation programme for persons with lower limb amputations at Elangeni, paarl, South Africa,