Two weeks in Toamasina

I have just finished my time in Toamasina, or Tamatave, a City on the East coast of Madagascar. I decided to travel to Toamasina to gather more information from a wide variety of areas which I will collect in the report I am writing about Physiotherapy in Madagascar. The two weeks were jam packed and helped further develop my understanding of Physiotherapy in Madagascar and how it differs depending on where you are and which centre you are working in within the country.

Service D’Appareillage et De Reeducation (SAR)
The hospital I was working in in Toamasina is called Hopital Be, with the rehab department called Service D’Appareillage et De Reeducation (SAR).  There are six physiotherapists based at SAR who all made me feel very welcome! I did not have a translator with me in Toamasina, so one of the physiotherapists who spoke basic English helped with this. This also gave me a chance to work on my very basic French!

SAR is a specialist centre for club foot, and the physiotherapists are trained in the Ponsetti method, a manipulative technique using plaster cast that corrects congenital club foot without the need for invasive surgery. The physiotherapy skills I observed in SAR for the correction of club foot were excellent. The physiotherapists made use of Goniometers, recorded their findings in objective charts, and even uploaded their notes to an online system using their phones, something which is still being developed in the NHS! The training for club foot was provided by Mercy Ships, a Charity who spent 10 months based in Toamasina training the physiotherapists on the Ponsetti method.

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Although the physiotherapists at SAR were specialised in treating club foot, they would also treat patients with a wide range of different conditions. The gym in the rehab department would usually be completely full of patients who all tend to arrive at once as treatment is based on a ‘first come first serve’ approach. This can be difficult for families who live miles away, like one family who had to travel two hours each way for the weekly physiotherapy session for their child with cerebral palsy. Due to the high volume of patients and limited number of physiotherapists, the physio would often end up treating two or three patients at once, setting up one patient with a certain exercise and then moving on to the next patient. When I asked why they don’t give each patient a set appointment time, they explained that travel is difficult and patients would often miss their appointment due to the traffic.

One particular patient that struck a chord with me was a lady who had had a stroke. She was carried into the rehab room by her husband and son and laid flat on a plinth. I began to wonder what support she had at home. In the UK, stroke rehab units exist in most hospitals which aim to rehab patients back to a functional level. On discharge from hospital in the UK, the patient will often have support from carers who can help with getting the patient out of bed, washing, dressing, or meal preparation as required. I wondered what help this patient had? How much in her life has changed since her stroke? What family support or network does she have? As I sat watching the physiotherapist complete exercises with the patient I began to understand that although the impact of a stroke can be devastating on a patient’s life, where you live or where you are from can also determine how much of a recovery you can make. Once again it made me very grateful for the NHS!

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Delivering a training session
On another occasion I was observing a new patient assessment of a patient who described how two years ago they began to suffer from urinary retention for a period of 3 months. The patient then developed symptoms of saddle anaesthesia (numbness between the legs and in the groin), and blood in their urine. They were admitted to hospital for a period of 6 months and were then referred to physio for management of their ongoing symptoms of urinary incontinence.

I was completely horrified by this story! Cauda equina syndrome is something we are taught about from pretty much day one at University and the Red flag symptoms or warning signs to look out for with this syndrome. The physiotherapists had never treated a patient with these symptoms before and asked me to deliver a training session on the treatment of urinary incontinence.

My training session focused on Cauda Equina syndrome, Red Flags, and the management and treatment of incontinence. I explained to the therapists that it is possible that this patient will not make a full recovery due to the duration and type of their symptoms, however there are a range of coping methods which can help manage their symptoms. I then discussed the anatomy of the pelvic floor muscles, and physiotherapy treatment and management of weak pelvic floor muscles. The physiotherapists explained that as the centre is a specialist centre for club foot, the only training they receive is based on this, however they still receive a variety of patient conditions despite lack of training in these areas.

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Rheumatology conference
My time in Toamasina also coincided with a Doctor from Newcastle called Clive Kelly. Clive is a Consultant in Rheumatology and was delivering a training session to the Malagasy doctors on the symptoms and treatment of Rheumatic diseases. Clive was also giving a talk on Physiotherapy management of Rheumatological conditions, and asked me to help with this. We focused on the management of 3 main conditions: Rheumatoid Arthritis, Ankylosing Spondylitis, and Osteoporosis.

I really enjoyed the conference and made sure it included a practical element to demonstrate how basic exercises can really benefit patients with rheumatic diseases. This seemed to go down really well!

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The coming weeks
I really enjoyed my time in Toamasina and feel that it has given me a much greater understanding of Physiotherapy in Madagascar. In the next week, I will travel to Mahajanga in the North West of Madagascar to join a team from Leeds who are delivering a training session on Amputee Rehab. I am looking forward to this new challenge and continuing to further develop my knowledge and understanding of Physiotherapy in Madagascar!

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