A day out for casting of splints

On Tuesday 24th August we bundled up into the van and took Chan Chea, along with her mother and cousin, to 'Cambodia Trust', in Phnom Penh, for casting of ankle foot orthoses (AFOs), spending the entire day there! Step by step in Cambodia :)

Below you can see Chan Chea's feet when serial casts were removed.

We are able to correct her foot into a better position in sitting, with her knees bent, than we are when her knees are straight. This shows there is tightness and contracture in the muscles that cross her knee as well as her foot. By casting her into as best position as possible when sitting, and then practicing standing and having her legs out straight, we hope this will continue to stretch the muscles and tissues, but it is still highly likely surgery will be required to obtain a more functional position. By making splints for Chan Chea, she will be in a much more comfortable, will be able to remove the splints for washing, and they are much lighter. They will hold her foot in the best position we could get with casting, but will not progress the stretch, as we did with serial casting. Wearing the splints will enable her to continue to work on strength and balance, and then we can come back to further correcting her foot position.
These pictures show the process of casting for the AFOs with the PO (prosthetist/orthotist).

You can see the corrected position of the foot - you can see that the heel still turns inwards a bit.

This is the best angle that was able to be achieved - this will mean that the heel of the splint will need to be built up, so as to provide a 90 degree angle to the ground so that Chan Chea can practice standing and walking.

The right foot is a bit harder to correct than the left.

We will return to Cambodia Trust (CT) next week for fitting of the AFOs. In the meantime, Chan Chea's feet have been placed in casts once again until splints are available.

Chan Chea - stronger and stronger!

Thursday 19th August saw us head out to Chan Chea's village once again, this time arriving to masses of rice drying out all over the village. As we arrived, Chan Chea greeted us happily, with a big smile, and swiftly sat herself up on the edge of the bench. Her independence in movement transitions about the bed have improved so much, and she really has much less reliance upon her mother already. We can notice a difference in her personality, she exudes much more confidence as she tries every move on her own first, before getting help. She's smiley, and she trusts the small team of physios working with her. Chan Chea is now able to shift herself along the edge of the bed without any assistance from anyone else, only the rail, semi-standing briefly and shuffling herself along.

Chan Chea's mother also greets us warmly as we arrive, offering us delicious 'num t'nout', small rice cakes with palm sugar and coconut, wrapped in banana leaf. Such an amazingly generous family, so happy to give when they are a family with not much. It's the Khmer way, to share. Hardworking Mum then heads out to turn the rice out the front of the house.

So after our social catch up and snack, it's time to work. Sokny and Hoe run through leg strengthening exercises with Chan Chea, and prepare her legs and muscles for standing. She is able to stand up with light assistance, using her own muscles to get into the upright position. Once standing, she requires significant support to maintain her balance. Having not stood for 4 years, her balance and is not good and her awareness of centre of gravity not there. While her leg and trunk strength are improving, her ability to transfer weight and maintain an upright position needs a lot of work. Only once this improves will she be able to progress to taking steps. At the moment, with significant support, she can move her legs in a stepping motion in standing, but is unable to maintain her centre of gravity or control shifting her weight to walk. But this will come!!

Giving standing a go - lots of practice to stand tall, chin up, hips in the middle.

This is practicing reaching and weight shift in the sitting position. You'll see that Chan Chea's hips stay flat in the chair. What will be aimed for will be controlled raising of the opposite side of her pelvis when reaching out, transferring her weight and being able to reach further. Sokny and Hoe will come up with ideas for treatment sessions to help this skill develop, and then carry it over into learning to walk.

Thirsty work!!!

The plan from now with Chan Chea is to progress her function skills and improve her strength. Chan Chea had a slight set back a couple of weeks ago with experiencing pain in her left foot. We arranged to have an X-ray taken, and it has revealed Chan Chea has very poor bone density. This could be for a variety of reasons, including: she has not been weight-bearing for 4 years, lack of nutrition, and the possibility that she was given steriod medication for a long period of time (a LOT of medicines are prescribed here in Cambodia, and they are not always necessary).

So we eased off a little with the casting stretch, and cast her into correct positions, but not pushing too hard. Her pain has significantly decreased, which is great. Rather than do surgery now, the decision has been made to refer to Cambodia Trust to have ankle foot orthoses (AFOs) made, which are splints for her feet. These will need to be modified, with a heel build-up to enable a 90 degree angle with the floor so she can practice standing and walking. Building up her strength, working on her balance and progressing her function skills seems a good option at the moment, and give her a break from the casts. Then surgery can be looked at in a few months time, once she is stronger.

First planning visit to Health Centre, and Construction so far

On Friday 6th August, we headed out to Svay Ro Lum, a Health Centre about 7km from Chey Chumneas Hospital. Sokny, physiotherapist, lead a meeting with Mr Lonh Komsath, Manager of the Health Centre. Plans were discussed for educational training and awareness sessions for local health centre staff about how physiotherapy can help people with disabilities. Mr Komsath reported he has not seen physiotherapists at the Health Centre before, and is very interested in staff learning more about physiotherapy, and what can be done to help improve the lives of those with disabilities.

Meanwhile, while we are busy out in the community and seeing outpatients in the office, construction on the therapy areas continues.

Below you will see the progressions.

Roof is on, concreting done

The original window of the room to become a small therapy room is turned into a doorway

And space for windows is knocked out