Assessments

So many interesting things happened this week that I feel like I could write forever! But I will try to keep it short and will talk about the most exciting thing for me: the assessments. In my opinion the re-evaluations are the best part of the job as you get to see all the hard work paying off. This week we did many assessments on new children as well as re-evaluated several people and modified their treatment plans. The assessment tool used here at Toñito for many of the children is the Milani-Comparetti tool developed in 1967. What I like about the assessment is that it is simple to administer, quick, objective, and the results are clearly mapped out on a chart where progress can be clearly identified.

If a child cannot lift its head then all the exercises in the treatment plan focus on this goal. If they cannot sit or stand independently, then all exercises focus on developing these skills. It makes prescribing a treatment plan simple when using this method. I am dying to know if the Milani-Comparetti Assessment is used in Canada. It is very old, however many theories used today are based on research from long ago.

One girl we assessed had progressed significantly since her last test and I have noticed significant changes in my short time here. She could not walk independently when I arrived and had severe “atetosis” (uncontrolled movements), but now she can walk independently, count out loud, and her atetosis have diminished by a lot making it easier for her to develop more precise and planned movements. Not all the cases we evaluated were as progressed as this, but it definitely makes for a great reward!

Language Barrier

This week I got to talking with my husband about the fact that, for the most part, Peruvians don’t tend to question authority such as the word of doctors, therpists, or other authority figures. I see this presented in therapy at Toñito where the parents and caregivers seem to take the therapists word for gospel. No one ever questions the exercises. At times when kids are screaming and crying uncontrollably, no one ever seems to question why and what is worse, in my opinion, is that no one ever bothers to ask if another treatment should be sought out. After 7 years of University I have been trained to ask questions and think critically so it is difficult to accept this way of thinking. This is something that is uncommon in Canada where parents often question exercises and challenge those who care for their children to the point that it is almost excessive and counterproductive to therapy for the children. I suppose that as with most things, the grass is always greener on the other side of the fence.

My lack of Spanish has left me frustrated this week more so than usual as I wish to have answers and explanations about many things. For example the therapist was explaining that every child at Toñito has to do arrastre, an exercise where the client drags themselves on the ground with their elbows (it looks like a soldier or warrior in battle). I asked the therapist why each kids does the same exercise if every child is different and has different needs. He said that every child needs to be stimulated by feeling the ground or carpet as it rubs against their body. I confirmed by saying (with doubt) “but do ALL children needs this stimulation?” and he said yes. This is when I wish I had the words to say that there are possibly other ways to achieve each patient’s goals (not that they have actual goals) or improve each patient’s physical ability and that this one exercise might not fit each person’s needs. I don’t want to express my thoughts unless they are clear and they don’t come off as condescending or rude, and I just don’t have the vocabulary yet to do so. There is also a girl that works with a couple of the children who gets a kick out of purposely saying something extremely quickly to me and then laughing about it after because I don’t understand her, which adds to my frustration.

On another note, my favorite little girl is now able to crawl on her own!!

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Dia de Fatima

When I first began my internship, I thought Toñito was absolute madness, but then I became used to it and adapted to the organized chaos. However, this week, we had so many new kids, it made my first week seem like a cake walk. I am literally run off my feet. I find it interesting the way the children are assessed and by how physio and other therapies are planned. For example, a new girl was admitted today who is autistic, however has no physical deficits whatsoever. Despite this, she was still put on a physical therapy regime (almost identical to most of the other patients) in order to maintain her current function. My training and experience would suggest that during rehabilitation of any kind, one would focus on what are the most important goals and leave tasks that the patient has mastered. However, this is just another example of the differences in cultures and methods of physiotherapy between Canada and Peru and I am forced to accept and adapt.

This Thursday was “Dia de Fatima”**(See explanation below) which meant that therapies ended early in order to gather together in prayer. Everyone came together in the courtyard and dutifully recited prayers in unison. It was just assumed that everyone attending the center is catholic and that the prayers would take precedence over the therapies. The culture and customs here are so strong and seem to take priority over all else. In Vancouver where all cultures reside and all religions and beliefs are present, an act such as praising god during a therapy session is far from the norm and could potentially be considered strange. For me, this dedication, unity and connectedness to religion, family and culture fosters an environment of togetherness and is ultimately therapeutic in its own way. Although the “meta” or therapy plans for each child stray from what we might recommend as North Americans, it is still therapeutic but in a different sense.

On the other end of the spectrum, when a child hates therapy and screams either in pain, discomfort or just for the sake of screaming, they are scolded (not comforted), called lazy (instead of encouraged) and sometimes restrained or forcefully coaxed into completing an activity. This is something that constantly bothers me and goes against my instincts; however I think it’s safe to say that children in North America are often coddled. I am in a constant internal battle within myself wondering which is right. Is this abusive or an extreme form of tough love?

The culture, customs and ways of Peruvians constantly keep me intrigued by highlighting the differences to what I have been brought up by in my own culture. Never a dull moment!

**As I am not Catholic myself, I had to look up what today was all about. Fatima is another word for the Virgen Mary and it is said that she had 3 secrets which were revealed to her in the form of visions that she described to one sole witness, Lucia who committed the revelation to paper and gave it to the pope. The first two secrets were related to hell and how to save souls from hell. I am confused about the third secret and if it was ever revealed, but for more info go to wikepedia.

Amazonas

This weekend I went to search for books about rehabilitation to use as a reference and to help me learn the Spanish vocabulary for rehabilitation. I couldn’t find anything in the stores near my house so I asked a few people I work with where to go. They all said the same thing: “Amazonas”, which is a market in the center of the city. This is where university students can purchase their textbooks and where medical references can be found. When we arrived, we were greeted by stacks and stacks of thousands of books that seemed totally disorganized in various venders’ stalls. We must have asked 20 different people if they had any books about physiotherapy and rehabilitation but all they had were EXTREMELY old (by old I mean publishing date, they were actually brand new books) and outdated books with ancient pictures and diagrams. Unfortunately, I didn't find what I was looking for.

Some of the highlights from this week were:

· “Classes with Professor Carlos (one class about the Spanish words for the cranial nerves and one about ‘Williams’ exercises)
· Working with an 11 month old baby who cannot control his head (he was strangled by the mother’s umbilical cord and has brain damage as a result)
· Learning Spanish vocabulary
· An ‘Actuacion’ (a play put on by all of the children for Mother’s Day)
· Reviewing with the professor the reflexes throughout development
· Soap in the bathroom! (I guess everyone else was as excited as I was, so we are now back to having no soap because it was quickly used up)

Something I find interesting is that many of the assistants as well as the therapists have side businesses to supplement their income. For example, a group of women sell food each day at lunch and another lady sells jewelry and bath products. I don’t know the exact pay for the therapists, but it ranges from s./800 to s./1500 which is approximately $275-500 per month. Although the cost of living here is less than in Canada, this wage is insufficient and it would be almost impossible to provide adequate housing and food for a family. This aspect of life here and what people do to survive sheds some light on how lucky we are in Canada. As Canadians, we complain a lot about health care coverage, the system as well as wages for health care workers, but in comparison to most people in Lima (and other places in the world), we are extremely lucky! !

Here are some shots from the performance the kids did for Mother's Day.

There were 6 different groups who put on a skit or sang a song. Every child was included in this. It was a fantastic day!

Adapting

I have started to adapt which is a little frightening considering what a shock some of the treatments were when I initially arrived. The mothers of the children as well as the other assistants are much more receptive to my presence and as a result I feel more comfortable in asking questions and (attempting to) speak Spanish.

This week has been fantastic because one of the therapists (who is called Professor Carlos) has decided to teach me everything he knows. For this reason, I have seen a wide variety of patients and have been working collaboratively with Professor Carlos to carry out treatments.

In my first journal I said that there are few assessments done on patients. However, I was wrong about that because I saw 3 patients get assessed this week! It seems they are assessed upon arrival at the clinic using the “Millany” assessment which determines the child’s neurological age as well as the course of treatment. In my first week, there were no new patients, therefore I did not see anyone get assessed. He explained the assessment and tested me to make sure I understood, which was great. Something of interest to me, is that you might imagine that there would be a filing system for all of these assessments. ..well there is. They are shoved in no particular oder in a folder inside the therapists personal locker. I really like organization, so for me, this was a shock, but it seems to work for them.

One concern I have is that patient confidentiality at Toñito is virtually nonexistent. Everyone knows everything about everyone else and patients are spoken about loudly in hallways, stairways and in rooms with open doors. I think this is an example of a cultural difference between Canada and Peru that I am learning to become accustomed to. It seems as though in Latin America, the family unit and their involvement in eachother's lives, is given higher importance than protecting privacy and independence. Tonito has a family feel which I like and it seems like no one is trying to keep any information from anyone else.

Some of the interesting things I saw and have done this week are: Traction, ROM on a quadriplegic (scary because their methods of ROM are different than what we have learned as they do it very quickly and force the limbs and as well as extremely quickly as if it’s a race), “Recreation Therapy” (we played outside all morning, there was 1 client and 3 adults…I think it was more for the therapist!), Percussions on a quadriplegic (I only observed this)
I now have a patient of my own (picture on the left) under the therapist's direction. She is a very very cute little girl who is 18 months old, but is only just learning to crawl. We work on core strength, functional tasks like rolling over, sitting up, balance and crawling. I absolutely love working with her and she loves therapy and giggles the whole time.



One major issue that I have is that not all of the children like therapy and some of them are put through these awful, rough therapy sessions and scream the whole time in pain. They will likely never walk, never talk and never be able to feed themselves so why are we trying to rehabilitate them to do so? What are their goals? It seems to me like torture to no benefit to the client and their quality of life is ultimately compromised.

Peru is so different from Canada and it is sometimes difficult to accept new ways of thinking or different ideas about medical treatments or therapies. For example, Professor Carlos and one of the other assistants tried to tell me today that it is very common for a stroke to occur when it’s cold out and this is very often the cause of CVA. I argued, but to no avail. Another example is that transfers are conducted completely contrary to how we were taught in Canada. Therapists at Tonito often drag or carry the kids from point A to point B even if the child could potentially transfer independently or with assistance.

It has also become very clear that the equipment available at Tonito is not up to the standards of a Canadian hospital or rehabilitation facility. Today I was advised to make sure I have the wheelchair brakes on before I move a client. However, as you may have noticed if you watched the video, the wheelchairs are a little worse for wear and the brakes are so rusted and broken that they are totally useless.

One other thing I have observed that is frustrating for me is that patients are also told to crawl and drag themselves along the ground as a form of therapy even though they can walk. I asked why they are practicing to crawl when they can walk and the response was that they practice because they don’t walk properly and also to increase strength. From my training and experience, there are other ways to achieve the goal of increasing strength and correcting gait. However, that is just how things are done here and this gringo is not going to be changing anyone’s mind!

Even though it can be crazy in this place and I don’t necessarily agree with many of the things that go on, I am enjoying it the experience and I find it fascinating. I think the therapist I have been working with does know a lot of useful and interesting information and he loves to teach me, so I am thankful for that.

Below is a picture of a typical wheelchair. Definately a little worse for wear!

Overview of Placement

Interesting week to say the least. I'm still trying to get over the fact that there are no toilet seats, toilet paper or soap in the clinic. I guess I expected a little more in a clinic in a nice part of town where parents have to pay for the service, but I guess resources are still limited.

The clinic I will be an intern at is called ‘Toñito’ and was founded by a man named Dr. Silva. He had a child with developmental delay and decided to start this clinic for other children with brain disorders or injuries. The clinic is large and has one small room for Occupational Therapy, one small room for SLP, a classroom, a therapy pool (which is unfortunately freezing cold), several rooms for sensory stimulation, and 3 very large open area gym areas where I will be mostly working. This clinic is in a nice area of Lima and parents have to pay for the services. Having said that, much of the equipment seems primitive and the setting is not totally professional by our standards.

The experience has been very hands-on and the people are very welcoming and seem happy to have another set of hands. There is one doctor, 3 physiotherapists, one speech language pathologist, one occupational therapist and a teacher. I will be working alongside the physiotherapists to carry out therapy programs for various clients who are approximately 1 year to 18 years old.














The main gym where I will be spending most of my time will have up to 8 or 9 different clients working on various things. There are many assistants, volunteers, parents and nannies who also help with the therapy. One client can take up to 5 people to assist in an exercise. There is little in the way of charts, goals or paperwork of any kind for the clients. In that regard it is different than Canada.















My major challenge has been my struggle with the language. People speak very quickly, so I am constantly having to ask them to repeat things or slow down. However I have been able to communicate by acting and copying. The language will come in time, and I am able to learn the different exercises without too much trouble. The exercises are quite repetitive for each client, so once I have them all down, I will feel more confident.

Because of the language barrier, I am unable to get all the information I would like to about the specific reason behind each exercise. I want to ask why we are doing what we are doing (sometimes it is very clear, but often it is not).
Another difference from what I am used to is that the therapist does not meet for one child at a time for 20-30 minutes. They seem to haphazardly jump from one client to the next, then back again in what seems like no particular order. However, one thing that I have learned about Peru is that although things may seem highly disorganized and random, there is almost always a complex and intricate system that takes time to work out. I suspect that is what is going on at this clinic. There is a method to the madness, I just haven’t discovered it yet.

Some other issues that I struggle with are that most of the children hate the exercises and are literally forced to do them and they scream the entire time. It seems like often they are screaming for a reason and could possibly be in pain as some of the activities can be a bit rough (in my opinion). However, I have not worked in a therapeutic setting with children prior to this, so I cannot say if that is normal or not, but to me, it does not seem therapeutic or client centered. I question some of the methods used as they seem a bit archaic and contradict some things we have learned in school. For example, maintaining good posture and alignment while sitting with equal weight bearing on both sides was something that we learned to focus on and there were several occasions where this theory did not seem to apply while kids flop around on a ball while sitting in terrible alignment. But again, I am not an expert and I do not always know what the client is working towards so I am trying to leave my judgments at the door in order to adapt and learn.

One final issue that concerns me is the cleanliness. Assistants, volunteers and therapists go from one client to the next without washing their hands EVER. There is not even soap in the bathroom, let alone caviwipes or any sort of disinfectant to use to wash the equipment after it is used. Sometimes it feels like we overdo it in Canada, but this is definitely not okay!

After discussing all of the problems, I should also mention the interesting and exciting things I have seen. We work a lot on teaching children to crawl by first manually practicing hand over foot and hand, then teaching the child to go on all fours etc. This is very similar to what we learned in class, so it has been fantastic to make some connections from what I learned in school to what we are doing here in the clinic. We also work with clients on a ladder (which I apprehensive about) to climb up and down the ladder and swing (as if they are monkey bars) to practice grip strength, grasp and release as well as reaching. The part of this activity that I question is the way in which the child is held. Sometimes I think the arms are going to come loose from the sockets due to the lack of support of the body, especially children with low tone whose joints seem quite lax.

Also, there is an exercise on the ladder where the ladder is adjusted to mimic a seesaw. The child will climb up halfway, then the ladder will tip in the opposite direction and crash to the ground and will now be angled downwards so the child will crawl down.

We also work on equilibrium training, working on reflexes, core stability, getting up, and rolling over.

What I like about this placement is that it will be a unique challenge to learn the language and adapt to the methods used here.

Introduction

I have decided to start a blog to share my experience working in Lima, Peru in a rehabilitation center for children with neurological disorders. The reason I wanted to share this experience is because of the different approach to therapy compared to what we might see in Canada. Please feel free to respond with comments and thoughts as I am interested to know what other's may take from this.

I hope you enjoy reading!