Report Lira Final

Even prior to being a qualified physiotherapist I have always wanted to travel to less economically developed countries to assist however I could, but an opportunity never arose. I then qualified as a physiotherapist, completed my rotations in Poole Hospital and have specialised in paediatric physiotherapy for the last 3 years. I had heard of a couple of other physiotherapists that had volunteered for Poole Africa Link, however I wanted to be confident I could contribute with my knowledge and skills before volunteering myself. After nearly 6 years I decided I was ready to give it a go, but an ongoing worry of mine was whether I was skilled enough, and if someone else would be more useful than me.

I have never been on a long haul flight before, the furthest I had been was Morocco, which was very touristy. Coming to Uganda was a huge culture shock. The 6 hour drive to Lira from Entebbe was eye opening, the roads being very bumpy (due to large pot holes), women walking with large containers and platters balanced on their heads, and little communities living in huts. I have always been a meat eater, however spending 2 weeks in Uganda has made me seriously consider becoming vegetarian, at the very least reducing my meat intake. A common sight was chicken with their feet tied together, still alive, hanging from boda boda handle bars, alongside pigs with their mouths and trotters tied together squealing and cows with their tails and heads drawn up on large trucks. The first night was a whirlwind of emotions, feeling overwhelmed and just trying to process what I had seen, the number of mosquitos and also what might happen over the coming two weeks.

The next day I was introduced to the referral hospital and the university, as it was a bank holiday it wasn’t as busy as usual. Again, I started to really understand the lack of resources, and cleanliness in Uganda. The university had a good skills lab with lots of equipment we could use for teaching. However, the referral hospital was full with patients, with the outside areas by the wards crammed with family members. I found it especially difficult when members of the family would come and ask for help, which we were unable to provide for individual cases, as the focus of the trip was teaching. It was very apparent of the poverty in Uganda, and made me very grateful for the healthcare systems we have in the UK.

Dr Judy Mella who has been to Uganda on multiple trips had made me aware of a charity rehab centre on the outside of Lira, called the Adina Foundation. I went on Tuesday and was introduced to the team which included two physiotherapists, a nurse, a teacher, a social worker, finance managers among other team members. They work with both inpatient and outpatient children. For the inpatients they fund surgeries and then provide daily rehabilitation. The outpatients tend to come on a Tuesday morning, where the children tended to have more long term conditions such as cerebral palsy, muscular dystrophy and global developmental delay . The common conditions seen in the inpatients were osteomyelitis and genu valgum surgery (knock knees), but also included children with CTEV and amputees. I joined sessions during my time in Adina with these children, teaching the staff around strengthening as there was a high focus on stretching. I found the amputee patient a good challenge, as typically the Ugandan children did all the exercises without questioning, however he was trickier to motivate to do the exercises he found difficult, often cheating. I went through the importance of increased weight bearing and gluteal muscle strengthening in order to improve his gait pattern. Luckily, they had lots of equipment in their gym, likely due to sponsors, including two treadmills, cross trainers, some upper body chest weight machines, wall rails, mats, trampoline and some hand weights. Interestingly, they didn’t have many toys to use to help encourage therapy through play, the majority of children would just do formal exercises set by the physiotherapists. What was lovely to see was how happy the children were there, and Adina took a real holistic approach to their recovery. Including psychological support and counselling, on what to expect post operation and also start to improve their self-esteem as a lot of children will have been made fun of, and accused of witchcraft as to an explanation of their injuries/conditions. Once rehabilitation is complete, they then reintegrate in the community, after educating the parents on the ongoing post-op care. They provide two goats in order to encourage the child to remain active, and give a purpose to continue their rehabilitation and also generate income overtime. (Interestingly, they report the reason they choose goats is that they are really easy to care for and reproduce quickly, therefore able to sell some after a couple of years). All the food for the children was cooked on site and they tried to cook a healthy diet, using things they have grown themselves which was a range of fruit and vegetables. The whole area was powered on solar panels only.

I then spent some time teaching the students at the university, including assisting with the newborn resuscitation (I must admit, I learnt a lot about this during the trip), also explaining key components of child development and what conditions could be causing a developmental delay. I was very shocked to find that none of the students were aware of cerebral palsy or muscular dystrophy but some knew about down syndrome. Therefore, the session was focussed on the causes of these conditions as there is a large stigma around this in Uganda. The professionals at Adina had informed me that parents with conditions such as cerebral palsy often had high incidences of domestic abuse and divorce as each parent would blame the other for them being the responsible one.

On another university day the team completed a safer surgery course, although this was not my area of expertise, I learnt a lot from the other professionals in the team whilst also contributing talking about consent, teamwork and paediatric pain. At the end of the day the team was on a huge high, after the students seemed to really enjoy and take a lot from the day, all of them very excited about getting their certificates and we were all going on safari the following day! I guess we felt we had earned the break.

The week after I returned to Adina as the physiotherapists were keen for me to help with their outpatient clinic. On talking to the physiotherapists, they were quite open that muscular dystrophy is not a condition they know much about, and by chance a 15 year old boy turned up to the clinic. Unfortunately, due to the number of patients that had turned up, I was unable to work with the physiotherapists when seeing the patients, and instead a translator came with me. On speaking to the grandad, he reports he is the caregiver and has noticed he is getting worse, 2 years ago he could walk and had now lost this skill. On questioning I then uncovered they weren’t aware that this was a progressive condition. I found it extremely challenging to tackle this, however explained to grandad that we would not expect his function to improve but we can work toward maintaining what he has for as long as possible and reducing pain, albeit through a translator which was not an ideal situation. There were huge contractures in his ankles as Uganda doesn’t have access to splints, and the manual handling and movement of the child was extremely poor, grandad reporting he gets back pain and there was no access to hoists or other similar equipment. I spoke through with the physiotherapists after the morning, discussing the importance of stretching, maintaining functional strength, positioning and the importance of teaching the caregivers good manual handling (as previously they didn’t think there was anything they could do). I did complete a presentation which I was supposed to give to the physiotherapists on this last day, but unfortunately due to illness I was unable to complete this, so sent the presentation instead.

I also saw children with delay at the outpatient clinic. On assessment it seemed very obvious this child had cerebral palsy after a very traumatic birth, with increased tone in all 4 limbs. It was nice to see these parents had been before and were doing appropriate exercises including side sitting and knees to arm work. I was able to show them some progressions of these exercises including 4 point kneel, forward lean sitting encouraging pushing up, and bucket sit to stand. The mum was very grateful for this but this then led to questions as the cause of her delay. I answered them as best as I could, again unsure on how the translator interpreted this. Explaining I would expect her to continue to gain more skills as she gets older, however the initial injury at birth is a permanent injury. Trying to also ensure she understood this is nothing of her doing. At the end of the morning to say I felt emotionally drained was an understatement, in my current job I never have to break this news as this would be done by a paediatrician, and explaining through a translator made this even more tricky. In discussion with the physiotherapists, she reports she will sometimes give the diagnosis as they tend not to be diagnosed till much later. If I was to go back to Adina, I feel some toys/games and some theraband to aid strengthening through range would be useful to take out. I would also arrange some formal physiotherapy teaching on CP, useful positions for development (although they did seem to know some of these), alongside the importance of strengthening. They did try and cast to lengthen hamstrings by casting, which she reported didn’t work, I then explained why this was the case, but this would be good to cover CP muscle fibres and the importance of strengthening in more detail.

On visits to the referral hospital, I spent a lot of time in the therapeutic feeding centre, as there were a lot of malnourished children that as a consequence also had developmental delay. I assisted Laura the dietician in teaching the medical students, and worked alongside a paediatrician during a ward round for a child with hypertonia. After we had seen the patient I had an opportunity to ask around the diagnosis of CP. She informed me they would only do this after the age of 2, and prior to this the diagnosis is developmental delay. I challenged her on this as the baby had a significant hypertonia in all 4 limbs, which would not be due to delay. I was very saddened to hear another reason for the delay in diagnosis is due to a large proportion of child abandonment if the diagnosis is given too early. This is something that I found really challenging as early intervention in CP can be really beneficial however, the ethical dilemma of increasing the child’s risk of abandonment is not something they can ignore. We spoke with the nutritionist, who creates the feeding plans for the children in the centre. She reported that the children that request breast milk formula were unable to feed in periods of rain, or at night time. This was because the mums would have to go and chop firewood to boil the water to heat the feed. Both myself, Laura and Jane were horrified by this and went to find a shop to buy a kettle to give to them the day after!

On my last day in the referral hospital I learned there was a physiotherapy department, although I was really pleased this existed, as up until then I didn’t think there were physiotherapists in the hospital. However, I was also very frustrated that I hadn’t found this sooner! It is located behind the feeding centre and the domiciliary block, and you can’t see it from any of the paths through the hospital. I spoke to the physiotherapist there who explained that there is a team of 5 staff (3 physio’s and 2 OT’s) that treat all adult and child conditions. He currently had an ataxic CP child using the parallel bars, and he also reported they tend to get a lot of back pains in adults. Interestingly, the Ugandan population tend to have a large lordosis and when bending down, don’t use their knees – this was based on observation of people working in the fields when driving through different communities. I would have loved to shadow him working that day, but unfortunately, he already had one student with him, and no other colleagues were available. I will definitely be returning there on my next visit! It was explained to me that there were very few physiotherapists in the country, as they have a training course for 3 years for a diploma in a university in Kampala (only one course in the whole country!), which takes approximately 20 students a year.

Overall, I had a fantastic time in Lira! There were some days where I found it extremely emotionally challenging but I had to remind myself I was here for a reason, and what I have done to educate and help (although little, I do hope it makes a difference). We had a great team that all supported one another to spend time in the areas they were passionate about, alongside being happy to chat through the difficult days, and celebrate the good ones! It took me some time to find what I could contribute and where I am best placed, but now that I am leaving I feel I have a good grip on what I can offer as a physiotherapist and what topics I would like to teach in the future. I am looking forward to having the opportunity to come back in order to fulfil this!