Happy Anniversary Advance Studies Physical Therapy Students!

Richard and Anna Jackson of The Jackson Clinics, LLC – Physical Therapy, recently visited their Ethiopian advance studies program administrators and physical therapy students at Black Lion Hospital, Addis Ababa, to celebrate the two year program anniversary. Each student was presented with their own personalized physical therapy tool kit. The bags were donated by TJC and Scott Moffett of Dominion Medical Equipment, Chantilly, VA, and included new goniometers, inclinometers, reflex hammers, stethoscopes, and other essential tools needed. A great dual gift!

“Students & volunteers have worked hard and we are proud of each and every one of them. A big thanks to all who have helped make our first 2 years a success!” Anna Jackson

See more photos and read about our latest Program launch in Kenya.

Higher Diploma in Orthopaedic Physical Therapy. Pictured is the first class with teachers Ben Keeton, PT, DPT, OCS & Joe Godges, PT, DPT, OCS.

The Jackson Clinics, LLC - Physical Therapy in Northern VA, launches Advanced Studies Orthopaetics in Nairobi, Kenya!

The Jackson Clinics, LLC (TJC) is working with Kenya Medical Training College (KMTC) to train 16 Kenyan physical therapists in advanced orthopaedics over the next 18 months. The program kicked off in September with Joe Godges, PT, DPT, OCS and Ben Keeton, PT, DTP, OCS teaching the first semester – “Clinical Reasoning in Orthopaedic Physical Therapy”.

The Clinical Practice Guidelines from the Orthopaedic Section of the American Physical Therapy Association (APTA) and International Classification of Functioning (ICF) language will be used as the cornerstones of the evidence-based approach to this education. Five more quarters are already scheduled over the next 15 months. Volunteers from TJC and faculty from Doctor of Physical Therapy programs throughout the US will be delivering this education.

“We are genuinely excited by the enthusiasm of the new students and pleased to facilitate the advancement of orthopaedic clinical standards in Kenya.” Richard Jackson, PT, OCS

 Ethiopia Students Celebrate Two Year Anniversary | ETHIOPIA PROJECT

I arrived home at 8:53am on Saturday morning. My boyfriend picked me up from the airport and it was so good to see him. As soon as I stepped foot in my house, I ran to take a much needed shower. It was AMAZING to feel the hot water and to use fresh soap. I emptied my luggage into the washing machine and started to feel cleaner by the minute.

As I look back at the last two weeks, it is amazing to see the difference that I made in the residents’ knowledge and care for patients. It was also amazing to see how my perspective has changed too. I greatly value the cleanliness of our health system, the advantages that we have as physical therapists with the knowledge that we have, and the opportunities that we have with today’s technology.

When I laid down to rest last night, I immediately felt like something was wrong. Unfortunately, I was right and I was up all night long, the sickest I have ever felt. I had no energy or desire to move in the morning and I sent Lili to teach without me. I couldn’t keep anything down, not even water, so I spent the morning either in my bed or the bathroom. By noon, I had run out of water and none of it had stayed down. I really thought I might die if I tried to stay all afternoon in that apartment by myself, without water. I found strength somewhere and managed to dress myself and get out the front door. The driver took me to the hospital where I almost crawled into the department. Tigist found me within minutes and was very kind to run out and purchase a bottle of water for me.

I spent the rest of the afternoon in the classroom participating in the presentations. I was very proud of the residents because they were clearly getting it at this point. They could correctly identify the impairments in the correct order of priority, and most of their colleagues were thinking critically with them to resolve challenges. However, it is still very apparent to me that they lack knowledge and understanding of proper stretching, the difference between strengthening and stretching, and proper exercise progression.

After class, Michel and Lili went to the pharmacy for me and bought an electrolyte substance and little shots of liquid glucose that I was to drink every 6 hours. We drove home after class and I slept the rest of the afternoon and night. I took the glucose, which was obviously very sweet and I felt more energy almost immediately. The electrolyte substance was gross, but I needed it.

On Friday, I woke with a little more energy and was determined to make it to class. Lili and I carefully planned three sets of exercise progressions for scapular stability, rotator cuff strengthening and a glute strengthening progression. As we took the residents through each exercise, they seemed to really enjoy the exercises, but also got very fatigued. It was interesting to observe the residents attempts because many of them lacked the strength to perform the moderate to challenging exercises.

At the end of the day, we said our goodbyes and took final pictures. The residents were so kind and purchased Lili and I each a scarf to remember them by. Mine was of course, pink =)

Ted picked me up from the hospital and we went back to the apartment to collect my things. We spent the rest of the afternoon at a coffee place where I ate one more croissant as we talked and watched the sun go down.

He dropped me off at the airport and I almost immediately started to feel more sick as I entered the first security gate. I stood in the ticket counter line and really thought I was going to pass out from dehydration. Somehow I made it through and then had to go stand in another line for customs. When I finally got through, I went up the escalator where I thought I would be able to find a seat and just relax before my flight in two hours. To my surprise, there were very few seats and it reeked of Ethiopian spices, EVERYWHERE. This smell made me feel so ill that I almost started panicking, as I couldn’t find a place to sit. I finally settled in the far corner on the floor where I stayed until the benches opened up in front of me. I was relieved when they called my flight to go through the final security screen about 45 minutes later because I knew I was finally on my way home.

Another rainy afternoon in Addis Ababa. This morning and early afternoon were actually quite nice, sunny and warm. But the clouds rolled in around 2:30 and it’s going to be wet the rest of the evening. Thank goodness for my rainboots!

I had the most amazing chocolate frosted donut for breakfast this morning at the hospital cafeteria. It was D-licious!

My first group brought in a woman who had fractured her tibial plateau during a car accident 2 months ago. For the last 8 weeks, she has been in a long leg cast, atrophying and stiffening away. She came to us with wooden axillary crutches that were way too tall and non weight bearing through the leg. As we examined her, she was very hesitant and anxious anything to do with her knee. I honestly believe that if I had not been there, she probably would have been placed on a modality and sent on her way to return for the next visit. However, after we thoroughly evaluated her, I started working on some gentle and then more aggressive joint mobilizations, followed by instruction with tactile cueing for quad sets, and 30 minutes later, we had increased her knee extension by 5 degrees. I thought this was very exciting, but our patient suddenly became visibly upset. After some chattering back and forth between the residents and the patient, I was informed that she thought her knee was never going to recover and that today’s treatment did not go very well because she had so much difficulty with the quad activation. This was a really good teaching moment for me because I was able to assist the residents in educating her that she actually performed quite well today. I also encouraged them to keep a very positive attitude with her and to encourage her along the way. We agreed to have her return tomorrow before the grand rounds presentation so that the entire class could learn from this case. Before I let her go, I insisted that the residents take a look at her axillary crutches and readjust them as they could for better ambulation.

The second group brought a patient who had sustained a surgical neck fracture of his humerus, as well as an undocumented clavicle fracture, 12 weeks ago during another car accident. As we looked through the chart, we are starting see good carryover of the prioritization of impairments and treatment techniques. We also observed documentation of previous treatments, although the details are still lacking. During the mentoring session, I was pleased to observe the residents applying the new assessments and treatment techniques to this patient. At the end of the treatment, we had gained 55 degrees of passive range of motion. Wintana told me, “55 degrees is a lot for me! I’m good with it!” There was some debate regarding what home exercises would be most appropriate, but what I am really pleased with is that they are considering the home exercise program for every patient.

Our group did a follow up treatment on the proximal humerus fracture that we have been treating over the last week. She continues to make steady progress, but what I am finding to be frustrating is the lack of enthusiasm and lack of initiative demonstrated by this final group, especially with the patient in front of them. It was a good opportunity to educate the residents on proper frequency of physiotherapy, as this patient is still healing at the fracture site and would benefit from reduced frequency until the fracture has been cleared with appropriate healing documented.

Our driver took us to ALERT hospital again today so Lili and I could go to the handmade gift shop on the campus. All of the items in this shop were handmade by the patients being treated at the hospital. We thought this was a really good opportunity to support such a good cause, so we each bought an item that were actually very nice and good quality. On our way out, we observed a man with no fingers weaving a mat using a loom. It was pretty amazing.

This evening we went to Top View Restaurant which has an amazing view of the city and had a very relaxing and delicious dinner. I had the lasagna and ice cream for dessert. It was a bit out of the way, but well worth the drive. Our cab driver, Ermias, is always good for interesting conversation and knowledge about the city.

Today was a really long day. I got up and went running again around the neighborhood, but the elevation is a killer! We had our routine breakfast at the cafeteria in the hospital. They have the most amazing croissants! I am going to miss them.

The first group brought in a new patient today, presenting with shoulder pain and weakness. The resident had already filled out the mentoring form that we initiated last week, so we had a good head start on learning about this patient. However, it became apparent rather quickly that there were gaping holes in the history and understanding of this patient’s needs. We soon discovered that this patient had actually dislocated his shoulder 9 months previous and he was also complaining of tingling in the hand. Only some of the neurological screen had been performed and we were missing a lot of range of motion and strength data. I put the residents to work and within twenty minutes, we had our information. With my guidance, we improved his cervical range of motion and shoulder elevation before leaving the clinic today. We also structured the rest of his plan of care to emphasize range of motion and strength, rather than primary focus on pain management. The biggest problem that I saw with this case was that the resident had not considered the effect of this dysfunction on his life. As we gathered more of our data, we learned that he had not been working for the last 9 months because he could not function as a mechanic without the strength in the shoulder. I hope I was successful in driving this point home, that identifying his functional limitations helps to guide treatment, establish goals, and ultimately, get the patient better.

Unfortunately, the second and third groups did not have patients for the clinic today. So instead, we reviewed cases that residents were seeing and learned several manual techniques to address thoracic and capsular dysfunction. I’ve noticed that the residents are good at learning new skills, but they don’t always know the appropriate times to use them. On the other hand, we discussed desensitization for hypersensitivity during our second group today and Lili reported that she saw some really good techniques for desensitization while shadowing on the pediatric floor this afternoon. This was exciting to hear, that the topics of discussion are applicable and they are being used in the clinics.

After class today, we had to wait quite a long time for our driver to pick us up. It was a good opportunity to enjoy the nice weather outside, although cooler today than usual, and watch the most interesting individuals as they walked to and from the rehabilitation building. I have seen the most interesting and creative assistive devices during my time here, but I am also becoming numb to it as well. It is quite common to see people using sticks in a rowing like fashion to ambulate with only one lower extremity down the street. I have also noted that the hospital has done a really nice job of creating job opportunities within the hospital for people with physical disabilities.

We were dropped off at the Hilton this afternoon so we could get some emails out. When we finished, we sat for a few minutes in the bar and enjoyed nice cold tonic water. We noted that this wasn’t much different than sitting in any hotel in the U.S., which was nice for a change. We asked the front desk about restaurant recommendations and we were pointed in a direction to try a new restaurant. However, when we had gone past the 100m that was indicated, we decided to turn back to look elsewhere. A very nice Ethiopian man stopped us and wanted to direct us to the restaurant. After following him through a poorer section of the block, I started to become very anxious about where he was taking us. I suggested to Lili that we just try somewhere else tonight, especially since we seemed to be drifting far from the hotel and any signs of safety. She agreed despite the man’s insisting that we were safe and the restaurant was just up the road. As we turned back, my heart stopped racing and I felt much more at ease with our situation. We caught a cab and headed back for the Canadian embassy.

We decided to try Loti’s, a French restaurant, for dinner tonight. This was a very cute restaurant set back in the middle of all of the large mansions. We were the only ones in the restaurant from 6:30-8pm, but it was delicious! I had stuffed ravioli with spinach and cheese with vanilla ice cream for dessert. Lili had very delicious tilapia and caramel brulee. We both left very satisfied and ready to go to bed tonight.

We are planning to take a trip back to Alert Hospital tomorrow to do some shopping from the local patients who apparently make homemade crafts. I’m hoping for another great day… only 3 more to go!

We had our three shoulder patients return today for follow-up treatments. I can see that the residents are getting it now. They can verbalize the primary and secondary impairments, and, they are thinking outside the box and limiting themselves to a single joint. With our clavicle fracture patient, we were able to work on joint mobilizations to increase her motion by about 5 degrees, but we significantly reduced the pain in the back of the shoulder that she initially reported.

The second patient was our cervical radiculopathy patient who had reported that he was feeling much better with only 1/10 pain over the weekend. However, after watching a lot of TV last night, he woke this morning with 4/10 pain in the left shoulder. After addressing his cervical spine, thoracic spine, and neural tension, we were able to move into the posture and strengthening phase of his rehabilitation, which is the more interesting and fun part of our job. I tried to challenge the residents by giving them a piece of equipment and having them create exercises that would target both posture and upper back strengthening. It was interesting to observe them interact with their patient and to see the poor quality of exercise that their patient got away with. However, when this patient left today, he had no pain in the left shoulder and was educated thoroughly on proper sitting posture.

We enjoyed lunch today with Tes again in Ambassador Park where we sat outside. I enjoyed my tuna sandwich and 7up while we talked about our families, PT in the USA, and life in Addis. It was interesting to learn how much inflation has occurred in this country in the last few years. He told us that 5 years ago the price of a coke was 1.25 birr. Now, the price is more in the 5-6 birr range.

Our final patient was the proximal humerus fracture. During our treatment today, I was able to help the residents think outside the shoulder, and we addressed cervical, thoracic, elbow and scapular mobility in all different positions. When we had finished, her cervical range of motion increased 6x the initial measurement into extension and her lateral flexion doubled. This was so important for the residents to see because we accomplished all of this without the use of modalities. They have been stuck in their pattern of modality usage and modality usage, that they have not seen the potential of their manual skills. Both the residents and the patient left very happy.

This afternoon is a rainy one. It POURED as we waited for our driver to come pick us up today. On the way home, we saw yet another accident, this time involving a dump truck and a small car. Right in front of the accident was a very large stream going across the road in which a taxi was stuck. To avoid possible difficulties with cars in the water, we decided to alter our initial evening plans of going out to explore to instead, walking over the Korean restaurant. This restaurant was a little more pricey (my entire meal was $5), but very very good!

I’m excited to come home in 4 more days. I am really looking forward to seeing my boyfriend, my family, my dog and taking a very long, hot shower with soap. I’m excited to do laundry with a machine, drive my car in a city with traffic lights, and see patients that have “normal” pathologies. While I have enjoyed my time here and I want to return again, I am ready to return to my convenient lifestyle and simple luxuries.

What an exciting day! We started off at the cafeteria and I was able to try one of their croissants, which was delicious! We headed up to the classroom where I was surprised to find that my presentation did not make it onto my thumb drive, so I would have to do the lesson from memory… yikes! It turned out just fine and we discussed frozen shoulder quickly and thoroughly. Then we started our special test lab, where I had them practice and quizzed on all of the special tests for instability, rotator cuff tears, biceps pathology and impingement. I was quite surprised at how fast they were learning, but by the time lunch came around, I could tell both the residents and I were getting fatigued as we completed our 20th special test and quiz.

During lunch, Lili and I were taken to the Club Foot Clinic were I was able to cast two legs for an 5 week old infant! I definitely won’t be doing that in the U.S. any time soon! The residents were happy to report that they typically have very good outcomes with their serial casting. They typically have infants younger than 3 months return weekly, and those older than this returning bimonthly.

We had a quick lunch at the cafeteria where I had the most interesting juice mix consisting of strawberry, mango, and avocado. I have a strong feeling that I am going to get sick from this in the next day or so, but I’m crossing my fingers.

After lunch, we went back to the building and realized Ted’s computer was about the blow up from possible water damage. After finding the source of this horrific smell, we were able to unplug the culprit and we probably prevented to huge fire. PHEW!

For the second half of the day, I started the class with a quick quiz to get feedback about their level of understanding from the week’s material. As I read the answers, it was apparent that only 25% of the class is really understanding the difference between tactics and treatment. They enjoyed the Snickers rewards, however. We ended the day with a thorough review of proper goniometric measurements of the shoulder and some treatment for glenohumeral gliding and scapular distractions. The residents seemed to really enjoy this part of the day and gave me a standing ovation as we ended class.

After class we headed to the Mercato with Wintana. However, along the way there, our driver got into a minor fender bender with one of the scary blue vans. After about ten minutes of arguing with two policeman there to mediate, it was determined that the other car was at fault and he had to pay our driver for a touch up paint job. I was a bit terrified as I sat there and observed this interaction because the attraction perked a lot of attention and before we knew it, a lot of beggars and creepy people were surrounding our car and peeking in at us. I was relieved that we at least had two policeman right there.

The Mercato was an experience. I have to agree with Ben’s experience of feeling like he went back several hundred years in time. I saw men carrying ten mattresses on their heads, 8 large barrels on one man’s back, men and donkeys carrying very heavy bags on their backs, small piles of potatoes and other produce on mats on the ground, lots of dirt, and thousands of small shops with each owner calling you towards them. I was overwhelmed at first, and quite honestly, terrified. Lili went to shopping right away and purchased some really fun things. After a few aisles, I felt a little more comfortable and started to purchase small gifts for my family and friends.

We risked our lives in a blue minivan when we left. There were ten passengers, a driver and his money collector/caller, all in the size of my family’s old Volkswagen van. There definitely was not room for personal space in this vehicle. We got out at Mexican square where we walked with Wintana to a nice pizza place where we had dinner.

By the time we got home, Lili and I were both tired and ready for bed. Tomorrow we leave bright and early at 5am for the airport for our trip to Lalibella!

Today I woke up to another beautiful morning with clear skies. It is consistently about 70-80 degrees and nice in the morning with afternoon torrential downpours, and then nice again in the evening. I can handle this!

Today was the first grand rounds presentation and the students were visibly nervous and shy to present to their peers. I had each group sit in front to present their case while I made notes on the board. As we went through the case, it was clear that the students were starting to catch on to the vocabulary that Ben had introduced and I have been reinforcing. However, we came to a screeching halt when we got to the Non Patient Identified Problem and they continued to demonstrate difficulty with prioritizing and identifying the important factors. This challenge continued while establishing the list of tactics for each impairment. To better gauge their understanding, as well as their interest, I had each of them come to the board with the marker and outline treatments techniques to address each tactic. It was interesting to see how easy this was for some residents, and yet so difficult for others. My favorite tactic today was modalities for pain management because the list continued to grow and grow, and before I knew it, they were listing off items that I had never even heard of! We talked for a few minutes about discharge criteria before ending with a very good discussion and practice for establishing goals. By the end of the first case, three residents were able to verbalize a goal that was measurable, attainable, time sensitive, patient specific, and addressed level of assistance.

The second and third groups went smoother and a little faster as well, but they continued to struggle through the NPIP, tactics, treatment techniques, and discharge criteria. However, they were beginning to show improvement with their ability to establish functional goals and required only minimal cueing from me. I think I may have intimidated them a little bit today by having them come to the board individually, but I was really proud of each one of them, as they were able to come up with at least one treatment approach without giving up.

For the final few minutes before lunch, I had one of the residents present a case on a patient with a stiff knee so they could practice and apply the development of the treatment plan of a different body part. This was an eye opening experience as Lili and I realized that they had no concept of exercise progression…. Period. We discussed swelling management (which they did a fantastic job of listing of the ARICE protocol), ROM for the knee including joint mobilizations above and below the knee, strengthening, gait training and balance/proprioception. As we talked about the progression of a quad set, they were able to list SAQ and LAQ as the next logical progression, but had never heard of a quad set with a SLR or terminal knee extensions. They were awed by my demonstration of quad set, to quad set with SLR, standing TKE, standing TKE with resistance, step up with TKE and finally step up with TKE against resistance… they were scribbling notes as fast as they could. I continue to be amazed at their desire to learn and to mature as doctors of the profession…. It truly is something else. One interesting twist that we discussed today was the comorbidity of this final patient who happened to be HIV+. This is certainly not a typical comorbidity for me and I was humbled to know how to respond. Through discussion with the residents, Lili and I both learned that swelling in the joints is a typical symptom and that it is typically contraindicated to perform joint mobilizations on them. So, I obviously have some homework for the weekend.

After lunch with Mahider and Abinet where I enjoyed delicious pieces of white bread, we returned to the lecture portion of the day where I instructed them on special tests and pathologies of the shoulder. The challenge for me was that they are not seeing these types of injuries or surgical procedures, yet. However, with the growth that is occurring in this town and likely in other parts of the country, I wouldn’t be surprised if they started to see more advanced procedures in the near future. Because of this, I felt that it is my responsibility to at least expose them to the pathologies and surgical procedures to prepare them for that day. We had a good discussion on special tests to end the day.

I have seen some pretty amazing things the last few days. Today, we saw a man “ambulating” with both of his upper extremities using push up handles because his lower extremities were contracted into flexion contractures and atrophied, such that they didn’t touch the ground as he moved across the street. I wanted to take his picture, but didn’t want to be rude or inappropriate. First I was amazed by his upper body strength, but then I felt bad for this man because so much of the work in this country relies on the lower extremities and the ability to have some functional abilities. He stands barely 2 and a half feet tall.

We also ventured out by way of the blue taxis to the Hilton today to use the internet and to get money from the ATMs for our upcoming trip to Lalibella. On our way there and back, we were approached beggars carside while we waited at traffic lights. We found a really nice pizza place for dinner where I totally risked it to have two small slices of plain cheese pizza, thin crust. Our dinner, which consisted of the pizza, a bowl of soup, a sprite and a large bottle of water came out to $8 USD for two us. Our breakfast this morning, which consisted on a pastry, a bottle of water and a macchiato for Lili was under a dollar!! It makes me feel so privileged, so I try to leave a little extra tip everywhere I can.

Tomorrow, Lili and I will be setting up a stations for the students to further practice their ROM measurements and neurological screen with supervision. One of the students, Wintona, offered us her company as we venture into the Mercato tomorrow. It should make for a very exciting day!

I didn’t think I was going to make it out the door this morning, but somehow I found the strength and survived the whole day without food and still feeling pretty icky… and I am so glad that I did!

As we drove to the hospital this morning, we were in the middle of the world’s worst traffic jam as pedestrians EVERYWHERE made their way to the church for the morning service. It still amazes me that cars, cabs, mini vans and SUVs can all try to drive without lanes, honking their horns every ten seconds, and avoiding pedestrians and not get into any fights!We had three very good mentoring sessions today with the residents. The first group completed their evaluation of the patient with a clavicle fracture. With my guidance and supervision, they were able to improve her passive range of motion by about 30 degrees without pain, which they and the patient found to be very exciting. What touched me the most was how appreciative the patient was- as Lili and I walked into the building this morning, she immediately recognized and greeted me with a smile. I could detect when I was demonstrating techniques that she trusted me by the way she relaxed into my hands. When her treatment was over, she shook my hand with another big smile and agreed without hesitation to return on Monday.

The second group completed an evaluation of a patient presenting with cervical radiculopathy with pain in the shoulder. During this evaluation, I realized very quickly that the residents’ skills are still developing and that I need to help them with further development and refinement. However, through my guidance again, we were able to significantly change this man’s presentation and he left the clinic with improved thoracic mobility and a strong home exercise program to maintain these gains.

The third group treated their patient in the dark with the power having gone out around lunch. They brought in a patient who had sustained a proximal humerus fracture 3 weeks ago when involved in a motor vehicle accident. During this mentoring session, we were able to restructure the plan of care and establish a more appropriate treatment plan. When this patient left, she demonstrated a considerable increase in cervical range of motion and demonstrated good understanding of her home exercise program. She too was very appreciative of my presence and teaching and thanked me as she left.

Throughout the day, I observed so much potential in these residents. The vast majority of them are anxious to learn and have opened their minds to new concepts, techniques and treatments. We established a new standard of care today by following the HOAC model and prioritizing impairments. My hope is to open their eyes to the big picture of things so that they can plan accordingly and appropriately to treat every impairment on their list. For the most part, they can do this on paper and they know what their priorities are. However, as Lili and I have discovered, this does not translate to the clinic and these residents still rely heavily on modalities. The other area in which Lili and I have both recognized as being weak is general exercise progression. Lili described a case today where a man was asked to practice climbing stairs. As he struggled to perform this activity, she learned that he had yet to demonstrated a good quad set, glute activation or standing balance in order to perform this activity.

Having noted these things, I have decided to spend a good portion of my time these remaining days to educate the residents on prioritization of impairments, determining appropriate tactics and techniques, and proper exercise progression. And hopefully, after this week, there will be better understanding of proper exercise progression for the upper extremities that will translate to the lower half.

This evening, I am resting my stomach by snacking on saltines without salt and preparing for my presentation tomorrow… yum!