Today we had a wheelchair distribution day. This was a day where people in PG and the surrounding villages in the Toledo district were able to come out and get a free wheelchair. We had previously measured them all for their chairs and we were going to customize each chair for their specific needs when they got there. This was very exciting since a lot of these people have not been able to have any mobility for their entire life. As expected, the schedule that was made for people to come was not followed. No one was able to come to the location to pick up their chair because they had no way of getting there. To fix this we decided to go pick people up and bring them to the site. There was a church group there from Texas who were helping distribute the chairs so me and the rehab tech Amira went in their car to go get patients while Jonas (my CI) and Joe went in another car. This became a very eventful day. I was educating all the people from Texas about the different ways to transfer people into and out of cars. This was not an easy task since a lot of the patients can’t walk and the van we were using was very high up. I had to explain to the different helpers exactly what to do for each step of the way. This was more difficult than expected because I had to break it down into very basic steps since they had not background in transfers. We ended up picking up 8 people in our van. This allowed me to really nail down my car transfer skills since I transferred them into the car to get to the center, out of the car at the center, into the car to go home, and again at their home. This was about 24 car transfers that I did that day.
Not only was my day filled with car transfers but I also was able to work on sizing wheelchairs for people and adjusting them as needed. We even had to put the wheelchairs together. This is not an easy task at all. I was much happier doing the transfers but that’s just me loving to interact with people rather than reading instructions. At the end of the day we ended up working a much longer day than planned but I was happy to do it. I was learning so much about car transfers and wheelchairs and I was able to see the faces of people who were receiving wheelchairs who have never had a wheelchair or have just been using on that doesn’t actually fit them by any means. This was an awesome event to be a part of.
Just building a wheelchair
Walking my favorite patient to her new wheelchair
Today I went to visit a home health patient. She was a 26 year old female with cerebral palsy. This patient had a lot of spasticity on her right side, especially with elbow extension, knee flexion, ankle plantarflexion, and toe flexion. I started the treatment working on coordination of movements which were very similar to the other patients who have had cerebral palsy that I have previously mentioned. This involved functional tasks such as putting her hair up, bringing her hands to her mouth, and putting the cap back on a pen. Once we were done working on coordination of movements I wanted to work on the spasticity. I decided to start with passive range of motion but then quickly changed my mind and decided to work with pressure support. I started my pressing through her leg onto the ground. Since I had another therapist nearby I decided to try to stand with her. We ended up standing her for 3 minutes with max assist times 2. She was mainly putting her weight on her left foot but this was still a lot more progress than before and it was really helping break up some of the spasticity. We sat her down and stood her again for another 3 minutes. She appeared to love in. As my plan of care I suggested we look into getting her a standing frame. As I have mentioned before these are not easy devices to come by but I feel it will be very beneficial for her to have. I think she would make great progress with this. Hopefully someone crafty enough will be able to make her something suitable for standing!
Today I treated a woman I have talked about before. The woman who I have to refer back for kidney issues came back to the clinic. It was amazing to see how much her spirit had changed. She ended up having kidney stones and an enlarged kidney. Once the medics gave her some medicine to help with her pain and improve her kidney function, her pain FINALLY decreased. She has come into our clinic two times and both times her pain was way too high to actual identify where it was stemming from other than the potential problem with her kidney. I was aware that it was either low back or SI joint but that is not very helpful when treating. This time she came back in and I was actually able to identify the specific lumbar vertebrae that the pain was occurring at. I was also able to find exercises that made her pain decrease even more. I ended up sending her home with prone press ups and bird dogs to work on core stabilization. This patient was awesome to experience because you could really see how pain can change the way a person presents. The first time she came in I was very frustrated because every motion I did she was in pain and she was very apathetic during the entire session. This time she was smiling and laughing and very excited to be treated. She was eager to get better and was asking questions about her body. This was great to see because often the patients here don’t ask questions about their pain or diagnosis. She wanted me to explain to her why the pain was happening and what she could do to make it stop. I am excited to see her again to see how much more she has progressed and what else I can do for her.
Today in clinic I had a very interesting patient referred down to me. He was an 81 year old man coming in with left knee pain. When he came down I quickly discovered why he was having this pain. 40 years ago he had a below the knee amputation because of a snake bite. He has been walking around on his left knee with crutches for 40 years. You can imagine the damage and degeneration that has occurred in his left knee. Right before he came down to the PT gym he was provided with a wheelchair so a lot of our session consisted of wheelchair training for both his family and himself. The son was very involved which was great. I was showing him how to transfer into and out of the chair, how to go up and down a curb, and how to propel the chair in general. I also provided the patient some exercises that he could do for himself from the chair. These were mainly hip strengthening activities since his knee was too painful to move. My goal was to decrease some of the pain and inflammation of the knee now that he is in a wheelchair and then we can gradually work on the knee again. I just found this patient so interesting because I wasn’t expecting a patient to come into an outpatient clinic and have to be taught wheelchair management. I also was not expecting a referral for knee pain to be a man with an amputation due to a snake bite. It was definitely an interesting case to have.
Today I went on another mobile clinic. To start the morning off I went to a home health visit to treat a little girl with cerebral palsy. Compared to other individuals in Belize who I have been treating with CP, this patient was very functional. When we arrived she was sitting in her hammock doing her hair. She had athetoid CP which made controlling her arms and legs very difficult. She also was lucky enough to have a standing frame which she was instructed to use daily. This was not the case however. The mother reported that they stood in the frame “sometimes”. In this setting equipment like that is hard to come by and should be used as much as possible if someone is lucky enough to have one. To start the session I transferred her over to the standing frame and she stood for 10 minutes. While she was standing I wanted to distract her while simultaneously working on coordinating her movements. To do this I brought bubbles and a ball to play with. I started by blowing bubbles and making her pop them as she stood. Then we switched it and she was blowing the bubbles while I popped them. Once she was tired of the bubbles we switched over and played catch. After 10 minutes of standing she became tired and wanted to get out of the standing frame. I transferred her back over to a chair and we working on kicking a ball to coordinate the movements of her legs. Her right leg was much more controlled than the left but still needed some work. This case in particular frustrated me a little because in the states a patient with CP and this level of function would be receiving much more care and would potentially be enrolled in a program at school to keep her engaged in the community. Here in Belize she is unable to leave her home and is not getting any form of an education or any social interaction with other peers her age. This combined with the mothers lack of implementing the home exercise program is limiting a lot of the potential I think this young woman has.
Before coming back to the clinic site to continue treating I decided to explore a little bit around the village. I quickly found a river and a cool bridge that crossed over it. I also found a group of woman doing their washing in the river.
Working very hard as you can tell
The woman washing in the river
Back at the clinic site I co-treated a patient with another PA student again. In her chart her age was written as 90s? because the woman was completely unaware of how old she was but suspected that she was in her 90s. This woman had pain EVERYWHERE. Low back, upper back, headaches, abdominal, bilateral knees, and hips. Initial hearing this I assumed she had a large amount of osteoarthritis which is common with age but that was not the case. Since there was abdominal pain, the PA student started her screen first. She quickly found two large masses in her stomach. The supervising doctor stepped in to examine the patient’s stomach and we quickly recognized that she had two large tumors in her stomach. This was very upsetting because at her age and her village location, there is little treatment that can be done for her suspected cancer. Obviously this finding prevented me from continuing my evaluation since cancer is a clear contraindication for a lot of physical therapy activities. Instead I discusses with my supervising therapist the options of providing her activities to do that would both keep her from regressing more as well as keep her spirits high. She was crying during the entire session and appeared to be unable to make smile. At one point she told me (through translation since she spoke kekchi) that she wished should would just die. Being the person that I am I decided this was not how the treatment session was going to go. Instead I decided to find a way to lift her spirits. I was providing her exercises and was attempting to speak the little kekchi that I know. We were doing the basic task of extending her knee and lifting her leg and putting it back down (LAQs combined with a seated march). In this setting the patients understand the task by saying “taxi” which means lift and “coopsi” which means down. I started to slowly pick up the pace that I was saying these two words making her kick her leg up and down at a very fast pace and before I knew it she was laughing out loud and smiling. As you can imagine it is hard to make someone laugh after they just received the news that they have cancer and there is not treatment to help them at this point. It was great to be able to find a way to keep her spirits up and keep her laughing.
Today at clinic I was on another mobile clinic. To start this was a very far away clinic and you spend 2 hours on a bumpy road that can’t be good for anyone’s spine. But not exactly the point.
Patiently waiting for my patients to arrive in my private treatment room
The Physician Assistant treatment area–not working with much here as you can see
The first patient I tried to see was a female who had cervical neck pain and headaches. I tried to do my interview with the patient and she appeared very hesitant. Once I asked her to start actually moving she denied me completely. I tried my hardest to convince her that there was so much I could do to help her with her pain and that she could be in control of some of her aches but she refused. All she wanted was some ibuprofen for the pain. This was extremely frustrating as you can imagine. I couldn’t force her to let me evaluate her so all I could do was walk away. This was not fun.
The next few patients were way different though. I had one woman who had cervical pain because she was carrying heavy objects on her head for hours at a time. Imagine carrying a bucket of water on your head. Obviously the neck pain was going to happen. As I evaluated her she was very interested in my treatment. This is rare especially in the villages. The villages usually have people who only speak Kekchi and they are usually unwilling to listen to my suggestions and help. This was exciting though because she allowed me to show her different activities and seemed very excited to follow her home exercise program. Every time I bring out a cohune nut (a nut from the trees here that is hard) and give it to a patient as a personal massage tool to get knots out of their back and to break up some tissue, they all just laugh at me. It works so well and they enjoy it but they all laugh at how I am making them rub a piece of a tree all over their muscles. I also tried to use some of the Kekchi lingo that I have picked up from listening to my translators. This is something that everyone laughs at. I clearly am not saying anything correctly but hey whatever I am trying. That should count for something!
I finished the day off with a patient similar to the one I started with. He had low back pain and was eager to get some medicine. When I examined him I quickly learned that he lifted heavy objects in the fields all day long and he was constantly bending at his back rather than his knees. This can cause so much pain and damage to someone if they do it constantly. When I tried to demonstrate to him how to properly lift up heavy objects he blatantly told me that he has been doing it his was his entire life and he doesn’t plan on changing that. Once again I tried my best to explain how it was bad for his back and that he was causing his own pain but he refused to listen. In the end I basically asked him to try to lift the proper way for one week and if he can do that than he might start to feel some improvements. I am not sure if he will listen but it was the best I could do for a non-adherent patient.
Today I went on another mobile clinic to a village where it is very common to carry buckets of water on the woman’s head. As you might have guessed, I had multiple patients coming in with headaches and neck pain. This mobile went very well because the new PA students pulled in the PT students right when they read the file that said anything with pain. This allowed for us to participate in the interview and decide whether or not we felt the patient was suitable for PT. This also helped us avoid asking the patients the same questions 5 different times. A lot of my patients were similar at this mobile. The one patient I had came in with neck pain. I evaluated her and determined that she had a hypomobility in her cervical spine. For this type of setting it is difficult to suggest mobilizations for hypomobilities because we are only visiting the villages once every 3 months. Instead I decided to focus my treatment on correcting her posture and educating her on why her pain was occurring. We started off with chin tuck exercises which are surprisingly very difficult to describe to a patient. Then we worked on scapular retractions to pull the shoulder blades back and realign the patients posture. The patient also had very tight upper traps and trigger points were palpable throughout the supraspinatus and rhomboids. To help with this I provided the patient the cohune nut massage that I have mentioned before. This way she could do the exercises on her own and didn’t require someone else to help massage out the muscles. Patient education is huge in this setting. I explained how after carrying buckets of water on her head she needs to perform active range of motion in all directions for the cervical region to decrease some stiffness. It is frustrating that in this culture it is so common for people to carry things on their head and we can’t tell them to stop. Instead we just have to give them other options to decrease their pain.
This is the building we did our mobile in today
This is one of the rooms I was doing my co-treatments in with the PA students
I also went on a home visit in this village. This patient was a 90 year old woman who was living alone in a small house. She had general weakness of her lower extremities and was unable to perform very many functional tasks independently. When I visited her she was laying in her hammock. I started the session with basic motions while sitting in the hammock. In the beginning of this rotation I would always laugh when I was working with patients in their hammock but now I enjoy it because it adds an additional balance challenge to my patient while they perform their exercises. Once we warmed up we went for a walk. Once standing I quickly realized that she has not walked outside of her house for a few days because she was afraid to fall. This gave me even more incentive to walk her outside. Although we only made it a few feet outside her home due to the heat once outside, it was exciting to see her up and moving. This was a case that was sad to see because it was clear that she was slowly regressing and there was not much that one session every 3 months would be doing to help her.
Shes only cringing because of the sun I promise she wasn’t in that much pain I am not that mean of a therapist 😀
Today I worked in the OPC in the morning again. The first patient I had was a little boy who fractured his tibia. He started off the session very shy as most kids do but gradually he became more comfortable with me as his therapist. We started off the session with him showing me all the exercises he is supposed to be doing at home. These included: side planks, side lying hip abduction, calf raises, and supine bridges. We then moved on to incorporate new activities in the session. Working with kids can be either really difficult to keep them engaged or really easy. This boy in particular was very easy. Since his ankle and lower extremity in general was unstable, I decided to work on some activities that would work on balance and stability. The first activity we did was passing a soccer ball (football as they call it here in Belize) back and forth. I made sure that he was stopping the ball with one foot and passing it back with the other. This required him to perform single leg stance dynamically with both legs which worked on stability. Once he became tired of this we switched over and decided to play catch. To incorporate balance I had the patient stand on a dynadisc and balance while throwing the ball to him. This task appeared to be difficult for him as he kept falling off the disc. It is very exciting to see a patient happy to be involved in therapy, especially in Belize. This boy was excited to play with these activities and his father was watching the entire time and could see his progress. After the session I was talking to the father and he appeared very happy with the progress his son was showing and he made it clear that he makes sure his son does his exercises at home. No matter what country you are in it is often hard to get people to do their exercises at home on their own. This is a very important aspect of therapy here in Belize since we only see these patients every 2 weeks. If they don’t perform their exercises daily there can be limited progress overall.
Today we went out to a school to do a disability awareness program again. This school was special though. It was on a beach called Punta Negra. We had to take a boat out there in order to teach our lesson. I was perfectly happy with this work day. We went down to the dock early and got picked up by a Belize man named Asha. He is the cook at an amazing restaurant in town and he is so friendly. He took us out to the island on his boat. He volunteered to do it because this was the island he grew up on and we were going to the school that he once attended. The boat ride out was beautiful. We “think” we saw a manatee but to be honest I have no idea what I was looking at I just pretended to have seen it. When we got to the land I was amazed. It was beautiful! I can’t even imagine living on a place like this. We went into the school and they had put together a little performance for us. I don’t think they get many visitors so they were extremely excited! After the performance we gave our presentation. When we were done we went outside and played with the kids for a little while. We played catch with one hand as if they had a broken arm. Then we played football (soccer) with one foot as if they had a broken foot. After we played for about an hour we said goodbye and wandered over to Asha’s aunt restaurant for lunch. She made us an amazing meal. I got to spend some time talking to Asha about his life in Belize and I was in hysterics. He is a hilarious man and so much fun to talk to. He was cracking so many jokes. Then he walked over and cut me down a coconut so I could try the coconut water. It was delicious. Never had a coconut before but there is way too much liquid in those things for one person to drink in one sitting. When we were done in Punta Negra, we got back on the boat and went around the ocean some more. Asha took us down a part of the ocean sort of like a river that was supposed to have a bunch of alligators but we didn’t end up seeing any. This was probably the best “work day” I have had in forever.
The boat ride to Punta Negra
The view from where we ate lunch
The PT crew and the children from the school
Me and my new best friend Asha
Today I went on another mobile clinic. One patient I had today was experiencing back pain in her thoracic region. As I did my evaluation I discovered she was very hypomobile in her thoracic spine. In any other setting I would be seeing this patient 2-3 times per week. This would allow for me to do some mobilizations to her thoracic spine to help improve her range of motion. In Belize that is not the case; especially on mobiles. We only see these patients once every 2-3 months. This makes treating someone like this patient difficult because ideally I want to help her improve her range. Instead I have to provide her with some self-mobilization techniques that she would have to do on her own. The issue with her spine was she had decreased thoracic extension all throughout her thoracic region. I had her sit in a chair and do self-mobs over the back of the chair. She was advised to line up the level of the spine that she had pain with the chair and do the mobilization there. This is hard enough to explain to someone in the United States, let alone a woman who doesn’t speak English and lives in a village where they don’t have any idea what physical therapy does. Finally she began to understand what I was trying to have her do. Hopefully she continues to do this on her own to help decrease her pain and improve her range.
Once I was done treating this patient the med team came up to treat her with a pelvic floor exam. She had with her a 2 month old baby and a 2 year old baby. As the med team arrived she quickly handed me the baby and left me in a room with her two children. I looked at this in two ways: 1. She trusted me enough after our examination to watch her kids during her exam, and 2. She was happy to get them off her hands because the 2 year old would NOT stop crying. I had the 2 month old in my arms sleeping as I am trying to entertain this 2 year old boy who was just not having it. Finally someone else came up and helped calm the 2 year old while I hung out with the 2 month old for about a half hour. My preceptor kept laughing at me because whenever he came upstairs I was still playing with the baby rather than actually working on my own patients. Whoops. But he was so darn cute I wanted to steal him away. Not the 2 year old though. He was not so cute but more on the evil side.
My PT table and station set up and ready to go
All of the pharmacy meds we bring to the villages