Adjusting Therapeutic Care Cautiously and Respectfully

It can be a difficult situation to insert yourself into a place that isn’t your stomping grounds and try to impart change. There are many variables to take into account, especially in a different country, such as cultural differences, local resources, language barriers, etc. Building trust and mutual respect is the first step.

I want to share an example of this from my most recent trip to our Kenya site, Compassionate Hands for the Disabled Foundation (CHDF). Part of this will be hard to see, but I’m sharing this because it is reality and it’s extremely important. This story also encompasses the whole point of what we will be doing as an organization.

Meet my friend. For the purposes of this post, let’s call him Ben. Here is a typical, happy Ben.

Ben is one of the kids at CHDF. CHDF employs a local physiotherapist who provides therapy 6 days a week. Here is a photo of Ben (and you may recognize my other, typically happy friend as well) in therapy.

You can tell from the photo that they are clearly upset. As a therapist, you may also be able to recognize how poor their alignment is and how inappropriately constrained they are. I can tell you from being there that they are crying and in pain. Ben would specifically point to his right knee. He kept looking me in the eye and begging, “please.”

As hard as this is to see, proceed with caution. Jumping in immediately to try and “fix” things is not going to work. First and foremost, don’t judge. Don’t make assumptions. Instead, start a calm dialogue with the physiotherapist and ask questions. Figure out what he is hoping to achieve with this method. Most importantly, continue to demonstrate respect and recognize that this is not being done out of malice. This is being done with the child’s interest in mind and in hopes of helping them to improve, because that is what he has been taught. Levels of education vary dramatically in other countries, and this may be the only way that this physiotherapist knows to achieve his goal.

He has them in this position to work on weight bearing and upright trunk positioning, but not realizing that weight bearing in inappropriate alignment is actually detrimental and that the child is not active in this process, therefore limiting progress. His goal of the children standing is well-intended, but there are more effective ways to work on these components that would be more appropriate for their level of functioning.

As is necessary, I have formed a relationship with this physiotherapist and we have a mutual respect for each other. He understands my equally good intentions, he knows that I am there to help, and most importantly, he has demonstrated that he is receptive to this. I have been able to successfully navigate the delicate process involved in training without offending, and while taking into account cultural differences and desires of both the therapist and child. Having the management of CHDF involved in this process is also extremely helpful. Everybody understands that we are working together for the best benefit of the child. Because they trust me, I have then been able to begin bringing in other therapists to help as well. Enter Liz!

After discussing Ben’s abilities and limitations with the local physio, and what the phsyio is hoping for, Liz and I then spent several hours demonstrating ways that he can work on this same goal, but broken down into appropriate and active techniques, such as trunk extension activities where the child is active in the process. We demonstrated prone extension activities, which work on the trunk strengthening he is looking for, as well as glute strengthening, which is also important for a goal of standing.

We offered an alternative of working on trunk extension strengthening in kneeling, which again is still working on core and glutes, as well as achieving some of the weight bearing he was hoping for. And look at that smile in this video when he actively achieves upright posture himself!

Kneeling may provide a bigger base of support and a lower center of gravity, which might be what Ben needs right now in order to work on his trunk while having more stability. Here, he is active in maintaining the upright positioning, as opposed to being strapped in the stander.

Since the local physio still wanted to be working on weight bearing through the feet, we offered different activities in which this could be achieved, such as pushing with legs against a therapy ball. Note: I am writing this as an occupational therapist, not a physical therapist. But I am NDT certified (best decision I’ve made), and I learned a lot about incorporating techniques related to other disciplines and working with the body as a whole. I love the leg pushing activity, because aside from leg strengthening and weight bearing through the feet which relates to his PT goal, it also relates to our mutually agreed upon OT goal for Ben, which is for him to don his pants independently. This is what his house mother had suggested for his OT goal. Interdisciplinary care: check!

The best part about all of this? Ben’s motivation and active participation. He listened intently and did everything we asked of him for hours. He trusted us, and we made it very clear that we want him to be working, but to not be in pain. He smiled throughout. When we were finally finishing because it was well past lunchtime, unprompted, he said, “thank you”. I can’t remember the last time a patient of mine thanked me at the end of a session.

This local physio is the only therapist there for 94 children. It’s no wonder that it’s easier for him to put multiple kids in standers at one time, as opposed to individualized sessions with each of them. Enter Therapists Without Borders! We are excited to start sending volunteer therapists and to train other local Kenyan therapists or those interested in becoming therapists, and they are equally as excited to receive us, learn from us, and grow with us.

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Comment on "Adjusting Therapeutic Care Cautiously and Respectfully"

  1. jackie stanley

    Well written with knowledge, sensitivity, and compassion, Lauren! So proud of your efforts and perseverance!

  2. Edna G

    Love your post!

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