Guest blog by RMUoHP faculty Dr. Tamara Gravano.
I had never practiced physical therapy (PT) overseas. I had admired many of my colleagues who performed this kind of service, but I had not yet pursued it. So I didn’t hesitate when Dr. Richard Jackson of the Jackson Clinics, based in Virginia, contacted me in December to teach geriatric physical therapy for two weeks to physiotherapists in Nairobi, Kenya this spring. The opportunity to perform international service had all but fallen in my lap.
The Jackson Clinics Foundation (JCF) has been sending US-trained PTs to provide continuing education to the physiotherapists who enroll in their Higher Diploma program since 2012. Until now, they had only sent orthopedic PT specialists, and they wanted to broaden their curriculum to mirror the education received in other more developed countries. I represented the first PT sent to teach a geriatric course and to establish the course content for the program moving forward.
As a physical therapy faculty member, I had to cover my classes and receive the permission of the chair of my department. After that was taken care of, I began to make plans to fly out in February.
Preparation
The education system in Kenya is vastly different in terms of PT preparation. In the US our entry-level degree is a Doctor of Physical Therapy and a passing score on the National Physical Therapy Examination. In Kenya, students take up to three years of courses in physiotherapy directly after high school, leaving very little room for exploration of specialty areas. Continuing education becomes a much valued experience and an asset for any physiotherapist who chooses to pursue it.
Teaching my Geriatric Physical Therapy course was not just a manner replicating my existing course, but I had to completely rethink it in terms of prerequisite preparation. Reviewing relevant anatomy, neuroanatomy, physiology, and other topics that US students have learned prior to stepping foot in a DPT program had to all be included as I introduced each system. My 80 content hours filled up quickly.
During this time, I had to get a visa in order to teach in Kenya. This was a simple, online process, which cost approximately $130, and required a letter of invitation from my host, the JCF. There may have been less expensive options, but this one was convenient enough for me.
The next part of preparation was the series of vaccinations—Yellow fever, Hepatitis A and B, Typhoid Fever, and Tetanus. I elected to get them all done the same day at the health clinic in Provo. Other than two days of feeling run-down, there were no problems with side effects. In addition, I got a prescription for antibiotics, just in case, and some antimalarial medications to take over the course of two-weeks.
Having never been to Kenya, I spoke to other US instructors that the JCF had sent over to get their perspective on the experience. I learned more about the cultural expectations, hotel logistics, and food, which put my mind at ease. The DPT department had a pile of extra RMUoHP DPT T-shirts that I packed as gifts for my 15 students and three hosts.
Arrival
It was a long flight from Salt Lake City, Utah, to Nairobi, Kenya. In fact, the first leg took nine hours from Salt Lake City to Amsterdam, and then seven and a half hours from Amsterdam to Nairobi.
Once I arrived I found my driver who took me to my hotel. My first experience riding in a car in Kenya was quite unnerving because they drive on the right side of the car and on the left side of the road. However, I quickly adapted.
The hotel was accommodating and used to hosting the PT faculty instructors. The next day one of the teaching assistants met me for a brief review of the expectations and a tour of the school. There is extensive security everywhere, “as a precaution,” the teaching assistant added. Every building, including the hotel, had a guard or two to search your bag and inside your car or trunk. I never felt unsafe knowing there were guards everywhere. The classroom was a fairly large gymnasium with wooden floors and treadmills and other machines lining the room. The projector screen was the standup tripod type. The desks were treatment plinths lined in four rows to accommodate six students across. Class started at 8am Monday morning.
Week 1
At 8:20am, there were seven students in the room, but I was expecting 15. I decided to start slowly by introducing myself and asking them to tell me about themselves. Over time, students trickled in and one by one and introduced themselves. Two of them had traveled eight hours overnight from Mombasa to attend the course, while others were local.
The experience of the students ranged from 6-30 years, and everyone was interested in furthering their education to provide better care for their patients. I enjoyed getting to know each student and their experience as a physiotherapist. Everyone spoke English, although not everyone was from the same tribe. There are 42 tribes in Kenya and I heard several different English accents in the room.
I explained to them that we would be learning from each other, that way I could determine what information would be most valuable to them. Throughout the course, we discussed the cultural differences in aging between Kenyan and US culture. For example, there is much more emphasis on intergenerational living and there are no nursing homes. I was pleased to learn that aging adults hold a significantly higher status in Kenya than in the US, where youth is valued over age.
Week 2
After the first week, we had covered a lot of ground. The students had done well on two quizzes and a lab skill check off, and they had several more quizzes and a final exam left to take. They confided in me that they had not known what to expect, but not this level of work. But they admitted they appreciated that I had high expectations. Apparently, other teachers had “gone easy” on them.
On Tuesday of the second week, we had a visit from a patient currently undergoing care in the hospital across the street. She was an aging woman with a low back pain a history of osteoporosis, who had hurt her back bending over in the tub to bathe. She used a walker and was progressively getting slower.
The students translated for me as I performed the exam and provided her therapist and family with a treatment plan. We spent an hour with her and the students each took turns answering my questions, asking more questions, and participating in the treatment. It was the highlight of my trip to engage the students in a real encounter with a patient. I asked her PT to keep me informed on her progress, and requested five more patients on Thursday so that the whole class could get involved.
On Thursday, my expectations were exceeded. Six patients and the lead PT arrived in the morning. We split the class into groups of three to perform a comprehensive exam and treatment of each patient, which included patient education and a home exercise program. I was so proud of the students’ ability to ask a thorough history, perform a full battery of tests, set specific goals, and educate each patient about their condition(s).
I was so proud of the student’s ability to ask a thorough history, perform a full battery of tests, set specific treatment goals, and educate the patient about their condition(s). Each patient received a home exercise program, and their plan of care was provided to the Kenyatta hospital so the regular PTs could continue the plan. Some of them were in my class, so I knew it would carry over. My heart was full of pride to see the students apply all the new information that they had learned in the last 12 days.
The Patients
I was equally impressed with the independence of the patients. When asked to perform flexibility measures, one women in her mid-80’s did a standing hip flexor stretch many middle age adults would envy. One aging gentleman was at the top of all of his age group norms for aerobic capacity, flexibility, and only needed work on higher level balance and upper body strength.
Another woman had a 10-year history of lymphedema in her arm since her mastectomy, but has not been able to fit into a standard lymphatic compression sleeve. The hospitals had delays in getting materials. We performed some lymphatic drainage massage and were able to help her with her range of motion in the meantime. She also needed improvement in aerobic capacity so a walking program with a specific target heart rate was calculated for her.
There was a gentleman with a six-month-old total knee replacement who wanted to walk without his cane. He scored well for gait speed and distance measures, but the key key issue seemed to be proprioception (sense of self-movement and body position). A high-level balance program was prescribed and combined with flexibility, strength, and continued walking. He was all smiles after we got him working up a sweat.
One of the other women had developed back issues after years of picking tea leaves on her land. She had to move to Nairobi with her daughter temporarily to seek PT care. She wanted to, and likely will, return to picking tea in a few weeks. To look at this woman through an American lens, I never would have expected her to score so high on her tests. She was fiercely independent and could reach well past her toes, but faced balance issues.
Another aging woman with back pain arrived wearing a low-back corset around her breasts, she had pulled it up so high to be comfortable on the bumpy bus ride into town that it no longer supported her back. She had poor vision and fell frequently. She also had some memory problems beginning to surface. However, her bed mobility was excellent, and she was able to position herself prone for exercise surprisingly well. Her husband accompanied her and he was so happy for us to provide an explanation about his wife’s health. After testing, we gave her a home program for balance, environment modifications, and strengthening.
When we had finished treating all of the patients, the students presented their cases to the class for discussion. The students continued to impress me with their clinical decision-making skills for their choice of examination measures and determination of necessary treatments.
Embracing Opportunity
On the last day of class my students took a written exam. When the exam was completed, the class gave me gifts and stood up individually to thank me for the education, and for spending time with them away from my family. Their kindness and gratitude touched me. Afterwards, one of my PT students from the hospital across the street, took me to see the hospital.
The building was massive and there were people everywhere. It was built in 1901, served thousands of people from Kenya and surrounding countries. Many patient rooms were wards, with eight to ten twin beds in an open space. When family would visit it quickly became crowded.
The PT department was extremely busy with many therapists treating patients across the lifespan, with nearly every conceivable condition, and serviced both inpatients and outpatients. I was saddened at the lack of resources, but also impressed with the dedicated group of physiotherapists who had a drive to continue to learn and provide the highest level of care they could.
After seeing the hospital, I knew my decision to include examination and treatment methods that required little, if any, equipment was the right approach. Any therapist can do a lot with painters’ tape, stopwatches, TheraBands, hand weights, and a set of stairs. Ultimately, the right attitude makes all the difference. The physical therapists at Kenyatta National Hospital taught me that creativity is one of the most important tools in a therapist’s toolbox. I can easily rely on the modern and expensive equipment we have in the US, but that is not what really matters. Identifying a patients needs is universal and the therapists at KNH have shown me that the heart and the hands are the most valuable tools.
