The Puzzle of Pediatric Physiotherapy

(Originally published on OrthoCanada’s blog, July 29, 2014 – here)

Physiotherapy is a never-ending puzzle. That’s the challenge of this profession – we are constantly being driven to expand our anatomical and functional knowledge, amp up our kinaesthetic abilities for assessment and treatment techniques, and cultivate our movement creativity.

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In 2011, I completed the Master of Physical Therapy program at the University of British Columbia, and graduated with similar knowledge and experience to the other 66 students in my class. I was given the opportunity to work at Kids Physio Group, the first private paediatric clinic created to serve the greater Vancouver area. Entering the world of pediatrics right after graduation was daunting, as I was concerned that I didn’t possess enough pieces of the puzzle to enter this realm. I felt I hadn’t learned sufficient anatomical or functional knowledge regarding a kiddo’s growing body, nor was I prepared with any specialized treatment techniques for the plethora of pathologies that might present in the pediatric world. I also didn’t think I was very creative (as I believed I was always more “left-brained” and factual). Needless to say, I was hesitant to start a career in such a specialized field. Now, after three years of working at this unique facility, I realize that the physiotherapy aspect of this job is only a small piece of what makes paediatric physiotherapy such a puzzle.

The complexity of cases in paediatrics never ceases to amaze me. This past spring, I met an amazing 4-year-old girl who was born to a substance-abusing mother. She and her twin sister were adopted into a phenomenal and passionate family who goes to great lengths to give them all they need and more. This young girl was diagnosed with diplegic cerebral palsy, has an array of serious gastric issues and associated surgeries, and is completely hearing impaired (which has led me to late-night googling of physio- and play-related sign language and using my NetFlix account to access “Signing Time”). I’ve learned to quickly set up a puzzle, stabilize this squirmy child’s pelvis to help her step up onto a box, and simultaneously sign “Great job! Again!” ten times in a row while wiping my glistening brow in between reps. And despite all of the challenges she faces on a daily basis, this girl is a determined and strong-willed child whose cheerfulness is infectious, and I look forward to problem-solving all aspects of her treatment and learning from her every week.

It’s slowly becoming clear to me that family structures and social dynamics are complex and can strongly contribute to a child’s success in a rehabilitation setting. As a late-twenties young professional who has very few friends with children, I had to dig deep into the memory bank to empathize how it might feel to be in highschool at 15-years-old, living under my parents roof, and worrying that if I might not be a part of the popular crowd if I didn’t make the cut for the volleyball team because my physio told me to rest my knee. I’m understanding that kids are pressured from all directions – school, peers, sports, and home – and these puzzle pieces need to be taken into account as I create my overall treatment plan.

Many therapists may agree that perhaps the largest puzzle piece in paediatrics is solidifying a child’s buy-in and compliance to complete an activity that causes discomfort in the form of pain or difficulty. We see many children and youth of all ages that require a regular stretching program, but as many of us know, stretching is uncomfortable and boring. Similarly, some children present with lower muscular tone than average which limits them from participating to the same level as their peers. A regular strengthening program is the typical course of action however the trick is to devise a series of games or activities that encourage the child to complete the recommended sets and reps despite ‘feeling the burn’.

Additionally, I’ve learned that it’s crucial to establish authority within the first few sessions to maximize the therapeutic relationship between myself and the child. Building a solid sense of trust through exciting games, meaningful conversation, and fulfilled promises for rewards and end-of-session “Thomas The Train” stickers leads the child to happily participate throughout the intense 45-minute treatment session.

Pathologies and conditions certainly differ between the adult and child populations, but paediatric physiotherapy is so much more than the anatomical and physiological side. It is an art that combines mastering behavioural strategies, possessing continual ingenuity for games and obstacle courses, and having an ability to relate to any child regardless of their age, cognitive ability, or physical state. Nothing in school could have prepared me for this extensive puzzle, as I’ve found that much of this can only be learned through on-the-job successes and even greater failures. I still get a bit nervous when a new assessment walks through the door, but get excited as I start to unfold various pieces of that puzzle. After all, it is fascinating to witness the progress that evolves when those puzzle pieces come together and overall picture of a child becomes apparent.

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Chipmunks, Bunnies, and Pollywogs… Oh My!

Chipmunks and bunnies are two of my favourite… shoe inserts! Cascade Dafo in Washington is one of Kids Physio’s trusty suppliers for shoe inserts. They carry multiple creatively-named models that are appropriate for different children depending on the shape of their foot and how much support they require. Their soft materials and detailed design make them comfortable for most children, and they certainly help improve the alignment of the whole body when fitted correctly.

When I was organizing this trip, I reached out to Cascade and asked if they might be willing to donate a few of their products for us to bring and use with children at Samuha. I was surprised with their enthusiastic response, saying that they would love to support our efforts. When we asked Kylie in the Business Development department to send us a quick pic of what they had gathered so far (as we wanted to post about their generosity on social media), they sent us this pic… whoa:donations

In mid-December, it was like an early Christmas when we received this massive box of shoe inserts! We were so excited and thought about how many of the children we could help with these.photo 2 photo 3

We opened our luggage and out tumbled over 50 pairs of inserts – the orthotist Muttana was overwhelmed with gratitude and expressed how impressed he was by the high quality light-weight materials that the Dafos were made of:

L to R: Andrea, Muttana, volunteer Liander, office manager Prakarippa, orthotist apprentice Mantesh

L to R: Andrea, Muttana, volunteer Liander, office manager Prakarippa, orthotist apprentice Mantesh

Yesterday we saw a child named Gousidappa, who has an undiagnosed disorder but presented with high tone in his limbs and low tone in his trunk. He also had moderate to severe pronation of his feet as he was apparently 14 years old (there’s no way, he must have been 8 or 9 max) and wasn’t walking independently so his foot muscles were very underdeveloped. We tried several options but finally found that the Chipmunk, a submalleolar model, provided what he needed to practice standing and stepping in a proper alignment.

Before:

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After trying a pair of chipmunks and asking the parents to buy shoes, he had a great improvement in his alignment! IMG_5416

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Gousidappa pictured here with Physio student Danielle Boyd

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So happy to be able to donate this pair of orthoses to this family!! Thanks so much Cascade! Check out http://www.dafo.com for more info on these awesome products!

Same Same, But Oh-So Different

Being open-minded has been crucial to maximizing our experience here at Samuha in rural South India. We’re so used to living and working in the Western World that we sometimes forget  how vastly different therapeutic environments can be around the world, and the challenges that come with practicing outside of our familiar workplaces. Through our observations, we have compiled a table to compare and contrast the therapy practices, culture, and environment between Canada (specifically an urban centre like Vancouver) and India.

Canada India
Full confidentiality for client information, private treatment rooms, high value for patient dignity (full effort to drape exposed body parts, use curtains to separate patients etc) Maximum capacity in treatment room, all families and patients watch and listen to the others’ sessions. All treatments happen in the same room in front of everyone, there aren’t any curtains, children are changed freely
Strong emphasis on therapist body mechanics,  safety, and health; lots of equipment available to facilitate therapist comfort (ex. high-low beds, sitting stools, no-lift policies which require ceiling lifts) Therapy on floor, therapist body mechanics are not a priority. Mechanical lifts are rare
There is a piece of equipment or a gadget for everything (ankle-foot maximizer, K-Tape, theraband, grip strengthener, toe separators, off-the-shelf orthotics, multiple measurement tools such as goniometers, blood pressure cuffs, disposable gloves) Minimal equipment, rare disposable supplies like tape or gloves. This is improving slowly but often the equipment isn’t available in rural centres and if it is, the organizations don’t have the financial means to purchase these items
High level of general health knowledge, often taught from very young age. Media frequently has articles regarding positive exercise, diet, and lifestyle habits Much of the health knowledge is based on old wives tales; but slowly increasing health education in schools
Although many smaller workplaces foster workplace friendships, some therapists compartmentalize work and personal lives. Many therapists change jobs multiple times throughout their career High focus on inter-work friendships, the staff here stay in one workplace for many years, they are like a family (go to community events together, celebrate birthdays, etc)
High value on objective outcome measures and  evidence-based practice Infrequent use of outcome measures. Not common to initiate further research for difficult cases or  unknown topics
High focus on client-centred care. Decisions for a patient are often made as a group (patient, family, physician, allied health). Multiple treatment options are explained to patient to allow him/her to make an informed decision about his/her care Goals and treatment plans are often determined by health care professionals (paternalistic management). We have seen patients coming from other health care professionals with strict recommendations without detailed explanations or other options (ex. a physiotherapist in a nearby town told a family that their child MUST get a back brace and cannot come back for treatment without one. We assessed the child and found that he didn’t need one and that regular exercise would be a much better option)
Ready access to diagnosing processes (MRIs, blood work, and particularly genetic testing) Blanket diagnoses of either ‘developmental delay’ or ‘cerebral palsy’
Easy and high access to high quality health care professionals and multiple others for second opinions etc High quality surgeons and doctors are rare in rural areas. Families have to travel far to seek care
It is inappropriate to eat during a treatment session and in front of the client Chai and tea biscuits are almost always served during sessions
When something breaks we often replace or if we want a new piece of equipment we order/buy it. Workers are very resourceful and creative, are able to build, modify, fix and design equipment. Nothing goes to waste
Usually fixed/limited treatment sessions (ex. 30 minutes). Therapists often wish we had more time to complete a thorough assessment/treatment  Unlimited time with each client, can do as much treatment as necessary; no set appointment times. Families are more than happy to wait all day to be seen
But it’s important to note that therapists in Canada and India certainly have one major thing in common: We are all passionate about caring for our patients and doing whatever we can to improve the quality of life for each and every patient we interact with. 
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Using the Peanut Ball in Canada and India

Introducing… Maegan Mak!

I’m thrilled that I get to travel to India and work at Samuha with my dear friend, Maegan! Read on to learn a bit about her background, as well as her thoughts on our upcoming adventure…

“I am SUPER excited to be going to Koppal, India with Andrea. Currently, I’m a second year physical therapy student at UBC and will be graduating in November 2014. I have an extremely diverse background: I first obtained my Bachelor of Science at the University of Calgary, then went on to get my Bachelor of Kinesiology at UBC.

I began working at Kids Physio Group in May of 2011 and have been intrigued with pediatric physiotherapy ever since! I first met Andrea in the summer of 2011 when she began volunteering with Kids Physio. We quickly became friends and as soon as she told me about her placement at SAMUHA I knew I wanted to have a chance at the same opportunity.

I love working with children and am excited to finally have a pediatric placement with Andrea. I am looking forward to challenging my practical skills by working in an environment with different resource availability, limited English and with therapists who have different backgrounds and experience. I am eager to share my positivity, enthusiasm and fun-filled physio games with the children!”

– Maegan Mak

Maegan