Practical Positioning for People with Disabilities: An Educational Service Project in Guatemala

Practical Positioning for People with Disabilities

Olivia DeSena Fleming, SPT

Background

Each year, UNC’s physical therapy department has the opportunity to send third-year physical therapy students, faculty, and clinicians to Guatemala for an international service-learning trip. During the week of service, the group provides physical therapy services alongside Guatemalan therapists, disseminates information and supplies at community health fairs, and provides professional education to local clinicians. This trip has been on my radar since the beginning of physical therapy school because it perfectly blends many of my personal and professional interests, including the Spanish language, working in underserved communities, and working with children with disabilities.

I am excited to provide professional education on positioning to clinicians at Las Obras Sociales del Santo Hermano Pedro (Las Obras) during this year’s trip. Las Obras is a private non-profit hospital and long-term care facility in Antigua, Guatemala.^1,2 Its impact is far-reaching: in 2018, the organization provided care to over 395,000 patients and performed nearly 6,000 surgeries.¹ The organization employs about 300 paid workers and is supported largely by donations and volunteer services.² I will present to physical therapists and nurses at Las Obras’ long-term care facility, who provide care to 248 patients with disabilities, most commonly cerebral palsy.^1,2

Statement of Need / Purpose

The professional education component of this service-learning trip aims to create lasting impact from our short week of service in Guatemala. Dr. Lisa Johnston reached out to gauge my interest in providing professional education in Guatemala due to my interest in working with Spanish-speaking patients, and I agreed that this would be a great fit for my capstone project. Instead of solely providing temporary support to Guatemalan clinicians and communities, the purpose of my capstone presentation is to encourage sustainable improvements in patient positioning at Las Obras.

I ensured that my capstone topic fulfills a need by reaching out to Jessica Anleu, a physical therapist and coordinator at Las Obras, and through discussion with UNC faculty who regularly attend the Guatemala service-learning trip. Each of these stakeholders agreed that patient positioning is an area of need at Las Obras due to the severity of physical disability of many of the long-term care residents.

Project Overview

Positioning is a relevant topic for children and adults with physical disabilities who spend the majority of their waking hours in a wheelchair. While the overall quality of evidence to support any particular positioning program is low, incorporating a variety of good positions throughout a patient’s day may prevent or manage pressure wounds, contractures, scoliosis, hip dislocation, and aspiration.^3-7 My presentation provides practical recommendations for positioning during functional activities including during sleeping, feeding, and playing. The presentation also covers specifics about wheelchair pressure relief and how to create standing programs for non-ambulatory individuals. In recognition that the clinicians at Las Obras have limited personnel and resources, I will offer ways to incorporate positioning into daily activities using materials that are already available at Las Obras.

I recognize how important it is to approach this professional education opportunity with humility, as I will be presenting to experienced clinicians in a clinic and culture that is not my own. During the presentation, I will approach local clinicians as partners in learning, and will allow opportunity for discussion and collaboration throughout.

Products

I created this PowerPoint (English / Spanish) with accompanying script and integrated lab activities to present in Spanish to Guatemalan clinicians. I used presentation guidelines to develop an engaging presentation, including by minimizing number of slides, using hands-on practice as an active learning strategy, and using content boosters such as handouts, visual aids, and demonstrations.⁸ I also created a summary handout (English / Spanish) for clinicians to use a quick reference and to educate local volunteers. I translated all materials myself initially, then sent them to fluent Spanish speaker and UNC DPT alumna Sarah van der Horst for edits.

Evaluation

My capstone advisor, committee members, and the physical therapy coordinator at Las Obras provided me with feedback throughout the development of my capstone project. This feedback was extremely valuable in helping me create a clinically relevant, engaging, and evidence-based presentation. I created an evaluation form (English / Spanish) that will allow Guatemalan clinicians to provide feedback about effectiveness of the presentation and how they will incorporate information learned into clinical practice. I also welcome viewers of this site to provide feedback on my capstone through the comments function.

Self-Assessment and Reflection

Looking back, I am pleased with the work that I dedicated to my capstone project. Previous Spanish classes and volunteer work with Spanish-speaking communities set me up with a foundation to be able to deliver this presentation in Spanish. To further prepare for the Spanish language component, I took the Advanced Spanish for Health Professions elective during the fall semester. To improve my practical skills with positioning and working with pediatric patients, I completed an independent study that included 52 clinical hours with pediatric physical therapists.

During the capstone development process, I followed my advisor’s suggestions to research information about the Guatemalan health care system, nursing and physical therapist education in Guatemala, and evidence-based positioning recommendations. I was disappointed in the general scarcity of high-quality evidence to support positioning recommendations, but I incorporated evidence and practical information to the best of my ability. I completed draft presentation materials in English by midterm, which allowed ample time for revisions and integration of feedback from committee members. Revisions included eliminating a section on positioning to prevent torticollis due to lack of clinical need, incorporating suggestions to make the presentation interactive, and enhancing visual content.

In the near future, my capstone project will culminate with a presentation to nurses and physical therapists at Las Obras. I plan for the clinician handout and collaborative positioning checklist to provide Guatemalan clinicians with tools to advance clinical practice beyond the time I serve in Guatemala. Personally, I believe that this project will help me develop better cultural understanding, improve my ability to work with patients with disabilities, and further my Spanish language skills for future use with patients.

Acknowledgements

I would like to thank my capstone advisor and Guatemala service trip coordinator, Dr. Lisa Johnston for encouraging me to pursue this capstone idea. You have been selfless with your time, and I appreciate the guidance you provided during our multiple meetings. Your passion for this service-learning trip is evident and contagious. To my committee member and academic advisor Dr. Laurie Ray, you have spoiled me with advice and good conversation over these past three years. Thank you for providing great ideas for making the presentation engaging and relevant, your technology tips, and for helping me to never underestimate the power of cultural humility. To my committee member Dr. Cathy Howes, thank you for allowing me to learn from your expertise during clinic hours and for the helpful suggestions you provided for my presentation materials. Licenciada Jessica Anleu, I appreciate your communication and willingness to invite nursing to my presentation – I look forward to meeting you at Las Obras! Dr. Sarah van der Horst, thank you for making corrections to my Spanish materials and for allowing me to learn from the local Latina community through Amigas en Salud. Finally, I would like to thank occupational therapist Lurinda Prinsloo of Cerebral Palsy Eastern Cape for granting me permission to use photos from the Hambisela project in my presentation.

*To follow our upcoming service-learning trip in Guatemala, I invite you to visit the UNC PT Outreach blog!

References

1. Asociación Obras Sociales del Santo Hermano Pedro. Available at: https://obrashermanopedro.org/. Accessed April 16, 2019.
2. Edwards N. Introduction to Health and Disability in Guatemala. 2010.
3. Cerebral Palsy Association Eastern Cape. Getting to Know Cerebral Palsy: Positioning Your Child. 2008. Available at: https://www.physio-pedia.com/images/7/79/Hambisela_Module_3.pdf. Accessed February 19, 2019.
4. Alghadir AH, Zafar H, Al-Eisa ES, Iqbal ZA. Effect of posture on swallowing. Health Sci. 2017;17(1):133-137. doi:10.4314/ahs.v17i1.17.
5. Gmelig Meyling C, Ketelaar M, Kuijper M-A, Voorman J, Buizer AI. Effects of postural management on hip migration in children with cerebral palsy: A systematic review. Phys. Ther. 2018;30(2):82-91. doi:10.1097/PEP.0000000000000488.
6. Smithard DG. Dysphagia management and stroke units. Phys. Med. Rehabil. Rep. 2016;4(4):287-294. doi:10.1007/s40141-016-0137-2.
7. Dicianno BE, Morgan A, Lieberman J, Rosen L. Rehabilitation Engineering & Assistive Technology Society (RESNA) position on the application of wheelchair standing devices: 2013 current state of the literature. Technol. 2016;28(1):57-62. doi:10.1080/10400435.2015.1113837.
8. Plack M, Driscoll M. Systematic Effective Instruction: Keys to Designing Effective Presentations. In: Teaching and Learning in Physical Therapy: From Classroom to Clinic.; 2011.