Prosthetic Rehabilitation Training and a very important workshop in the Gambia

Emily HancockGambia

Legs4Africa, for the most part, is a charity of logistics, developing links, monitoring stocks of prosthetic legs and meeting the material needs of our partner clinics. Emily Hancock’s role is far more personal. An amputee physiotherapist, Emily joined the Legs4Africa team last year as a technical consultant. She advises on amputee rehabilitation and the clinical aspects of providing a prosthesis. We are very excited to have her on board and look forward to the improvements in our service that her expertise will bring.

I was excited about returning to The Gambia. I had a brief introduction to the smallest country in mainland Africa in December 2016, when I joined the Legs4Africa team on an evaluation visit to their partner prosthetic centre in Banjul. The initial visit to the Edward Francis Small Teaching Hospital was to assess what follow up and rehabilitation the amputees were receiving after having a prosthesis. It was also to determine whether the team there may need any further support. The main thing that struck me about The Gambia was how hospitable, warm and friendly the people were. We were greeted with smiles throughout our trip and the amputees we met were dignified, resilient and resourceful.

According to the World Health Organisation (2017)1 Rehabilitation is instrumental in enabling people with disabilities whose functions are limited, to remain in or return to their home or community, live independently, and participate in education, the labour market and civic life’. Rehabilitation after amputation is very important, both before and after receiving a prosthesis. In order to get the most out of a new leg, an amputee needs good strength and movement of the remaining limbs. Advice and exercises are important as soon as possible after surgery, to avoid complications, which can make walking with a prosthesis difficult.

During our visit, it was clear that many amputees had not been referred to physiotherapy from hospital and did not receive the essential advice that was needed. One young man I met developed tightness in his hip, which meant that walking with a prosthesis was extremely difficult and uncomfortable. I taught him some stretches, which he was keen to learn – he seemed motivated and interested and told me that no one had told him this information before. He appeared frustrated – if he had this advice months previously, he may have found prosthetic use much easier.

I have worked in the NHS for many years and have often found the large amounts of paperwork, policies and procedures challenging. Here I was, on a humid Sunday evening, on the sandy floor of Muhammed’s house, realising how important these were.

The Gambia has 4 qualified physiotherapists, – for a population of 2 million people. To put this into perspective the UK has 52,915 physiotherapists2. As you can imagine, these 4 clinicians are high in demand and very busy! The Gambian physiotherapists were knowledgeable, highly skilled and worked hard to try and ensure that amputees were referred to physiotherapy prior to having a prosthesis.

Awareness of the importance of physiotherapy and rehabilitation in The Gambia has been increasing in recent years, however many of the surgeons were not aware of the importance of their role following amputation and many amputees were being discharged home without referral. We also found that many amputees were not told about the prosthetic service on the ward and did not know that having an artificial leg was possible. In the UK, we could take for granted that we will be referred to the appropriate professional, depending on our needs. Muhammed’s situation was the result of him not being referred to physiotherapy due to a lack of awareness of the profession and no formal pathway in the hospital. I decided there and then that I wanted to try and change this situation. This called for team work.

I returned to The Gambia in March 2017 and worked in collaboration with physiotherapists Penda Sidibeh, Samba Bah, Alfredo Barosso, prosthetist Gabriel Jarju and Legs4Africa Amputee Community Support Worker Bubacarr Jabbie, to organise the workshop ‘An Overview of Rehabilitation following Amputation’. The aims were to improve team working and to explain the prosthetic service. It was also to highlight the importance of physiotherapy before and after having a prosthesis, to surgeons and physiotherapy students.

As per the pathway in the hospital, if able, some amputees attended gait training with Gabu, but did not routinely receive physiotherapy after receiving a prosthesis. This is important – to teach amputees exercises that can improve their walking pattern with the new leg and activities such as going up and down stairs and getting on and off the floor. It was hoped that the workshop would help to improve the awareness of this role amongst the staff and participants.

The workshop was a huge success – physiotherapy staff and students, along with surgeons and members of the Gambia Amputee Association attended. Participants learnt about the role of physiotherapy before and after receiving a prosthesis and surgeon Dr Muhammed A.Kah, did an excellent presentation on the surgical aspects of amputation. Gabu did a brilliant talk on the prosthetic service, which improved the participants awareness of this. There was also a small group activity and a discussion following a demonstration of various walking patterns in the amputee participants.

After the workshop, Penda, Samba, Gabu and myself did a summary of the talk at the weekly Surgical Team Meeting – this was to further increase awareness of physiotherapy and prosthetics to the whole surgical team, so that patients were referred after surgery.

Penda Sidibeh, Principal Physiotherapist and one of the key speakers in the workshop says:

The aim of the workshop was to inform the participants especially the doctors about how soon physiotherapy is involved in amputees, because patients are not referred in a timely manner and most are not referred at all.

The workshop was timely considering the increase in the number of amputations in the hospital – about 5 every month. The most common amputation is below knee and most of these are due to diabetic foot.

One of the most important outcomes of the workshop was a proposal to establish an amputee clinic team in the hospital consisting of physiotherapist, prosthetist and a surgeon and we are hopeful that it will happen soon’. Gabu Jarju, also a key speaker, tells us:

The training was a good and a better working relationship has been started. The physiotherapy students became more aware of their role in the rehabilitation (per-prosthesis) and stump care. It was an eye opener for junior doctors and better understanding of the subject by these young surgeons was achieved. We solicit this kind of training be organised every six months or yearly and to done in two or more days’.

During my visit, I did some training sessions with Penda on prosthetic gait training. Another important outcome from the trip was that Penda is now going to see amputees after receiving a prosthesis. This will greatly improve the support that amputees receive following a new prosthesis – advice and gait training can help to reduce complications and help amputees learn the skills to use their prosthesis for what is important to them.

Most importantly the workshop was a chance for the team to work and learn together. The various professionals shared their expertise and also learnt a great deal from the members of the Gambian Amputee Association, who told their stories about having an active and fulfilling life after amputation.

Thank you to everyone who made the day such a huge success!