International Support Group for Chartered Physiotherapists
N E W S L E T T E R October 2005
No. 9
Contents
Page Item
1 / Editorial3 / CBR in Northern Ghana and Southern Burkina Faso
by Marjolein Baltussen
8 / Integrating physiotherapy into community based rehabilitation programmes in Jordan
by Mahmoud Salem and Josi Pickartz
12 /
ISG4CP Study Day 12th August 2005
by Jannine Ebenso
13 / Therapists let loose on the world! Account of CourseCerebral Palsy in Under Resourced Areas – the Bobath Perspective
By Joy Campbell and Valerie Gawn
14 / Ad for APT Courses
Editorial
In this issue of our International Support Group Newsletter we have two articles from people with first hand experience of working in community based rehabilitation (CBR) programmes. The first is from Marjolein Baltussen, a Dutch physio who has been working for several years for Christoffel Blinden in programmes in rural areas of Ghana, Burkino Faso and Togo. She will inspire you with her enthusiasm and the enjoyment she finds in her work but she will also describe the difficulties of providing sustainability in these kinds of programmes. The second article is jointly written by a husband and wife team in Jordan. Mahmoud Salem is a Jordanian special needs teacher with a passion for ensuring that the best sustainable services reach the children with disabilities and their families in his country. His wife Dr. Josi Pickatrz, a clinical psychologist, has supported this work and many other projects in Jordan that empower and support vulnerable groups.
The other two articles in this newsletter describe the ISG study day which was held in the CSP on 12th August and the Bobath course on Working with Children with CP in Under Resourced Areas – the Bobath Perspective.
In all of these articles it is clear that our main role in working in under resourced areas of the world is to pass on knowledge and skills to local people that will enable them to provide good expertise in much needed programmes. We are doing our best to prepare members of our group to do this, but it is hard not to feel that what we are able to provide is a drop in the ocean of what is really needed. How wonderful it would be to set up a whole training service whereby therapists who want to work abroad could choose from a range of courses that would prepare them best to do this; where younger, or less experienced therapists could shadow experienced therapists on assignments and where a panel of clinical experts could advise and monitor therapists at all stages. I believe that this kind of service would allow the dissemination of expertise in the best possible developmental way.
I had hoped that the programme I worked out with BESO would go some way towards establishing a well structured training programme of this kind for therapists and others in developing countries working with children with CP. The BESO programme officer who worked with me on this was enthusiastic and committed to the idea but then came the merger with VSO and now it seems the programme will not be continued. This is because VSO only works in a limited number of countries and in those countries, if the local VSO office has not identified people with disabilities as a client group, then there is no possibility of either short or long term rehabilitation experts being assigned there.
I can see that the reason for this is to give local people a choice in what help they need and also because it is necessary for VSO to narrow down its focus in order to be effective but I also know that rehabilitation, even for young children, is just not flavour of the month with most aid agencies at the moment. I don’t know why this should be but my guess is that with the development of CBR, aid agencies decided it was more politically correct to support inclusive education and income generation for disabled adults than rehabilitation in any shape of form. But my question is how are parents of disabled children in developing countries to know that therapy exists and could be available for their children? And since they don’t even know that it exists how can they ask for it? The same is probably true for people with recent disabling injuries.
Can we, as therapists, do something about this without being accused of wanting to impose western ideas on the developing world? I would so like to know what you, our members, think about this. Please do email me on
Archie Hinchcliffe
PR Officer and Newsletter Editor
Editor’s Stop Press Note
We now have 5 people ready to volunteer to be moderators when we set up our ISG4CP website. We need just one more. Might you be the one??
Community Based Rehabilitation (CBR)
in Northern Ghana and Southern Burkina Faso.
I would like to share with you my experiences as a physiotherapist, working in Ghana with several CBR programmes in the region.
Our Physiotherapy Unit is situated in Bawku in the North of Ghana, just near the border of Burkina Faso. Our Physiotherapy project was established in 2003. We are linked to Bawku Presbyterian Hospital and provide services for the physically disabled population of northern Ghana, southern Burkina and northern Togo, focusing on children and young adults. Our Unit contains a theatre, an orthopaedic ward, a physio-gym, a hostel for 20 children for post-operative care and rehabilitation and an orthopaedic workshop. The project is supported by Christoffel Blinden Mission (CBM). I work in close contact with the orthopeadic surgeon attached to our project.
The Importance of CBR-programmes as key to success;
The unit works in close contact with the CBR programmes in the region. Through these programmes we can reach and follow up children with disabilities. This is crucial for obtaining good results in our work.
We work together with 2 CBR programmes in Ghana, 4 in Burkina Faso and 1 programme in Togo. I am in contact with the physio-assistants and fieldworkers of these programmes which operate in the remote rural areas where there is no access to health services. Almost every CBR-programme has a physiotherapy assistant and around 12 fieldworkers. The fieldworkers come from local communities and their role is to stimulate the involvement of their own village and facilitate communication, as so many different languages are spoken in these areas.
My work & training in the field;
Twice a year, I go with the orthopaedic surgeon on a 2 weeks outreach to the several CBR – stations. The physio-assistant will already have selected children for us to see with the help of the fieldworkers.
We screen the children for possible surgery or physiotherapy. Sometimes children need to come for a 3 month stay in our units for physiotherapy but most of the time I give advice to the physio-assistant and the fieldworker on treatment and possible assistive devices for individual children.
For example, a 2 year old floppy child with severe Cerebral Palsy caused by cerebral malaria needs posture training and a special chair to be able to sit. We go through the exercises during a session with the physio-assistant, the fieldworker and the child and her caretaker. Involvement of caretaker and fieldworker are essential, as they will carry out the daily treatment. The physio-assistant will keep the measurements for a CP-chair, which will be made by a local carpenter.
In these areas we see many children with disabilities that are linked to poverty, malnutrition, neglect, consanguineous relationships and lack of medical care during deliveries and childhood. Pathologies like Cerebral Palsy, severe bowed legs (Genu Valgum) and knocked knees (Genu Varum) due to rickets, osteomylitis, congenital deformities and polio are common.
Twice a year, I, together with my Ghanaian colleague, give physiotherapy training for fieldworkers and physio-assistants. We teach the field workers some basic skills so they will be able to provide simple exercises and post-operative care that suit the needs of the children in their own environment. This is the important part of my work because the quality of CBR workers still needs improvement. During training sessions we make use of role-play and we see children selected by the CBR workers themselves.
My personal experiences working with the CBR programmes are very positive. It is rewarding and motivating to see the difference we can make for children with disabilities in rural areas. It gives me the opportunity to experience daily life deep down in African societies. I am much more aware of the problems people are facing when, with the fieldworker, I visit local compounds (mud-huts build in a circle) in small villages. In the dry season, once a week my colleague or I visit some of these areas. On one occasion, after a ride on the motorbike through the bush we arrived at the hut where a child with severe cerebral palsy lives. Everybody was busy farming and the child was left behind lying on a mud floor with no access to food or sanitation. The fieldworker went to look for the mother and the elder sister and together we saw how we could improve the quality of life for that child. During such a fieldtrip you see clearly that it is important to look for an intervention that doesn’t cost much extra time for the rest of the family as they are already very busy with daily activities necessary for survival. This child for instance was able to sit in a corner, with a big bowl between her straight legs to prevent contractures and to be able to help her family in the household. In another compound I reviewed a child of 4 years I saw three months earlier. At that time he wasn’t walking; but now, with the help of the fieldworker and the commitment of the mother, the child can walk with the support of a locally made walker.
As thanks, you often get a chicken, a watermelon or mangos, depending on the season you visit.
Working with the CBR-programmes I have had the experience that this is a good way to deliver physio services to people in our region.
The advantages of CBR are many;
· These remote areas are very difficult to reach by health workers as there are no roads or very bad roads. The only way is by bike or motorbike, used by the CBR –fieldworkers and me. It is often the only way for children to have physio services because health centres are too far away and too expensive. It may also not be possible to send the mother to a physio-unit with one child as there are too many other mouths to feed and too much work to be done on the land.
· The CBR workers are able to inform people in their own community better than any outsiders because, in Africa, each tribe has its own culture and fears which they will never tell a foreigner or somebody from another tribe. (Beliefs that disabilities are caused by witchcraft or a curse, involvement of local bonesetters and witch-doctors, stigma etc.etc.) Counselling, explanation of disability or treatment are one of the main issues to create awareness that people can be helped. It is very important that a CBR-worker takes time to interview the family so we fully understand their main problem. This will enable us to set up functional treatment goals together with the family. The CBR worker can also better explain the purpose of the exercise to encourage commitment of the family. I found out that this is the only way that the advice I give (how to dress, carry, feed the child etc.) is really followed up.
· CBR can provide early detection and intervention. It can also prevent severe contractures and the need for expensive long treatments or surgery. (mainly children with cerebral palsy, polio, clubfoot or osteomyelitis). If a child with severe spasticity is detected early we can prevent flexion contractures and give the child an increased possibility of being able to walk. Babies with clubfoot can start the ponsetti POP-casting treatment, which, together with the use of a Dennis brown splint will fully correct their feet. Older children with severe neglected clubfoot, walking on the dorsal part of their feet, will need complex surgery.
· A CBR programme provides support for the rest of the family, teaching them how to cope with the extra pressure of having a disabled child and showing them how to help their child harness his or her potential. As soon as a family sees improvement in their child, they know the potential that is there and they are encouraged to keep providing the attention and stimulation their child needs to develop. The harmful stigma will then cease.
Working with physically disabled people in CBR, I also got more aware of the problems fieldworkers and families are facing:
· Lack of finance for treatments.
· Lack of good explanation to family members by CBR workers about the reasons for therapy. We are trying to work on this, within our tight time-schedules.
· Lack of time for family members to follow up advice and exercises. Therefore together with the CBR worker and family, we look for postures and exercise which are part of the activities in their daily life.
· Influence of local beliefs such as witchcraft which undermines efforts to change the situation.
· The need for improvement in the quality of training for the fieldworkers The CBR-fieldworkers have a heavy workload as they also have to look after visual, hearing and mentally impaired persons. Therefore they don’t always have time to supervise exercise programmes and regularly do follow up.
· Lack of CBR programmes in the region; there is a great need to establish comprehensive CBR projects all over rural Ghana. This would allow the early identification of children with physical disabilities and their referral to the physiotherapy centre for treatment, thus avoiding/preventing surgery. Unfortunately this link is missing in many rural areas.