/ 12 February 2020

Long walk to recovery: This rural hospital revolutionised rehab

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Cape Town's Madwaleni Hospital. (Dylan Bush/Bhekisisa)

It’s a summer’s night in the Mother City and Khayalethu Shukuma is celebrating. It’s payday. And it’s December. 

A relatively recent arrival to Cape Town from the Eastern Cape, Shukuma had spent the past year at his new job as a construction worker. 

But tonight, the music is blaring and Shukuma has had just enough beer to make the city lights go fuzzy. 

It’s a perfect atmosphere. 

Then a man walks by. 

That guy, Shukuma thinks to himself, has been looking for trouble the whole night. The two had already had a run-in. 

Suddenly, the man turns to face Shukuma, looking him right in the eye. That’s when he says it: “Kwedini.”

The word, an isiXhosa term reserved for boys who have not yet attended initiation school, implies Shukuma isn’t a real man.

Shukuma sees red, figuratively. Then, a glint of silver.

And then, he sees nothing at all. 

The next day, Shukuma woke up in Cape Town’s Groote Schuur Hospital. The man who had insulted him had also brought an axe down onto his skull.  

That was a year ago. 

“This whole side was dead,” he says, gesturing to the left half of his body. Gone too was his ability to speak after the attack, at least temporarily.

Today, Shukuma is sitting on a bed 1 200km away from Cape Town at Madwaleni Hospital, about two hours’ drive from Mthatha. From the hospital window, he can see the green hills spilling out beyond its frame.

He’s at the rural hospital’s rehabilitation ward, called Siyaphila, or “we are well”. Shukuma is one of eight patients who have just finished a week of intensive physical rehabilitation — what the hospital calls “block therapy”. 

For some patients, like Shukuma, this means working with healthcare workers such as occupational, physio, and perhaps even speech therapists to regain abilities they might have lost after an accident or a stabbing. For others, such as children with disabilities wheeled in on special prams, professionals will help them with posture and stretching to prevent them from developing, for instance, permanent hunches. 

Typically, a team of therapists

will meet with patients on the first day to brainstorm the week’s goals, says occupational therapist Erica Bourn.

Some patients might want to improve the way they walk. Others may want to strengthen their limbs. 

Shukuma’s aim was to be able to walk faster, and to stay balanced while doing so. 

Bourn says: “Sometimes, people need skills as simple as learning to wash themselves again, to use the toilet or to feed themselves.” 

Once the game plan is set, the work begins. 

A patch of lawn separates Madwaleni Hospital’s general ward and Siyaphila. The rehab centre’s name is spelled out in a mosaic of shiny, multicoloured tiles and mirrors. A friendly dog lazes at the entrance, next to a wheelchair. 

Inside the ward, surrounded by the powder-blue walls of the men’s section, Shukuma’s features soften as he slowly gets onto all fours on the narrow hospital bed. He places one arm at a time underneath the opposite shoulder, and shifts his weight from one side to the other, leaning deeply into the stretch each time. 

This is one of the many exercises that the therapy team taught Shukuma to help rebuild his strength after the axe attack. 

He thinks back to when he started at Siyaphila, still using a wheelchair. 

“They gave me exercises, medication and training,” he says. “Training, training, training.”

It took six months of gruelling one-week-long therapy sessions like this one before he could slowly walk again. 

Today, his gait betrays only a slight limp. 

More than two-million South Africans are living with disabilities, according to 2011 data from Statistics South Africa. There is no recent information about how many adults like Shukuma need rehabilitation services but a 2006 study of children in Orange Farm — a township outside Johannesburg — found that only about a quarter of children who could benefit from rehab services received them. 

The findings, write authors in the journal Child: Care, Health and Development, probably reflect the situation in most other disadvantaged areas of the country. 

And as of 2015, there was also no data on how many healthcare workers in the public sector were equipped to provide this kind of help, said occupational therapist Kate Sherry in that year’s edition of the South African Health Review by the Health Systems Trust. 

At Madwaleni Hospital, services were available but even then, in the past, many patients only managed a visit to Siyaphila for hour-long rehab sessions once a month at best. 

“Patients have to travel really far to get to the hospital,” says Bourn. “It’s expensive.”   

And people often battled to find money for transport — whether in the form of a neighbour’s car or minibus taxis that can charge riders an extra fare to accommodate wheelchairs. 

These costs can put strain on the families looking after patients like Shukuma. 

For the year since he was attacked with an axe, Shukuma has been unable to work, and has been dependent on his father and aunt to provide for him.

He says: “I lost my livelihood.”

Healthcare workers soon realised that patients who attended rehab for only one hour a month weren’t able to repeat the exercises at home.

Speech therapist Sarah Wilkins heads up Siyaphila. There’s only so much information you can absorb in an hour each month, she says.

So the team came up with a plan: Ask patients to come to the hospital less frequently but for longer periods of time. 

Today, this approach hasn’t only saved patients money but there’s also strong evidence to suggest that longer, more intensive therapy is linked to faster recoveries for people who have severe brain injuries, like Shukuma. 

Patients who undergo this kind of therapy also need shorter hospital stays. This is according to a systematic review of evidence conducted by the Cochrane Center in 2015. The organisation’s hallmark reviews evaluate existing research on a topic to summarise the evidence for different types of medical treatments.

Cochrane researchers also found that brain-injury patients fare particularly well in team programmes like the one at Siyaphila, especially alongside other people battling the same types of problems.

And block therapy gave Madwaleni Hospital therapists more time with patients to ensure they understood how to do their rehabilitation exercises — and do them well. 

“If you want patients to do their exercises at home, they have to know why they’re doing it,” Bourne says. 

This is especially true when it comes to the rehab centre’s stroke and head trauma patients like Shukuma, since simply popping a pill won’t improve their muscle function. Instead, they have to relearn actions that once seemed like second nature. 

The team can also help patients to predict which obstacles at home might prevent them from keeping up with the daily exercises they need to do to get better — and how to solve them. For example, it helps to know whether people like Shukuma have someone around to help them to get to the bathroom.

This kind of planning has been linked to improving how well people stick to their exercise schedules once they go home, according to a 2016 paper published in the journal Musculoskeletal Care

At the end of the week, when Shukuma and the seven other patients leave, a new bunch will take their place. 

“One week will be all the children with cerebral palsy,” says Wilkins, “the next it could be all the kids with learning disabilities.”  

But switching patients from monthly sessions to a weeklong stay at the hospital does come at a price, says the facility’s acting clinical manager, Andrew Miller. 

Keeping patients for longer pushes up laundry, food and cleaning costs slightly. But since the building that is now being used for block therapy used to be one of the hospital’s tuberculosis (TB) wards anyway, the increase didn’t break the bank. 

One important change, Miller says, was to make sure there were nurses available to take care of patients while they’re there. Luckily, patients being booked in for therapy aren’t critically ill, so only one nurse is necessary. 

In addition, Siyaphila allows patients to bring a caregiver with them to block therapy, so they aren’t ever completely alone. Moms heading to Siyaphila for block therapy are also encouraged to bring their babies along, which solves the problem of finding somebody to care for them while they’re away. 

Miller says the hospital is hoping to set up a shuttle service for patients in the future, but for now transport costs still fall on patients and their families.

Bourn sits in Siyaphila’s storeroom. A long line of wooden cubby holes sits against one wall, brimming with board games, children’s books and the odd building block. The legs of well-loved stuffed teddy bears piled on top dangle over the edge. Tucked away to one side is a jumble of seemingly random household items. 

Like most hospitals in South Africa, according to the health department’s most recent rehabilitation action plan, Madwaleni’s therapists don’t have the luxury of fancy therapy equipment. 

Instead, simple toys and household items are the tools of their trade. 

Back in the men’s ward, Bhojana Mathunywa is sitting on his hospital bed. In his lap lies a small cardboard box. Seven washing pegs sit perched on its edge. Mathunywa is slowly, patiently moving the clothes pins around the lip of the box, one at a time. The action of pinching and releasing each pin is helping Mathunywa to regain his fine motor skills after a group of men attacked him. 

Not only are these kinds of tools cheap to source and to replace, Bourn says, they’re also designed to mimic the activities of ordinary life, like hanging up the laundry. 

Or, perhaps, making bread for the family. Every so often, Bourn says, the rehab team will set up a baking station for their female stroke and head-injury patients to improve how easily they can move their upper limbs. 

“The process of kneading helps wake up the muscles again and to retrain them,” she says. 

But this wasn’t an activity Bourn learned as part of her training. 

“At university, you are taught how to deal with sports injuries from running or cycling,” says physiotherapist Adri Burger. “But not how to rehabilitate muscles you use for rubbing cow dung into the floor of your hut.”

If curriculums could use a change to better serve rural South Africans, so too perhaps could the make-up of the rehabilitation professionals they train.

A survey of 150 speech and language therapists, for instance, found that nearly 100% spoke and understood only English or Afrikaans, according to research published in the South African Journal of Communication Disorders in 2016. There is no recent, publicly available data on how many occupational and physiotherapists who come from rural areas are trained each year. 

At Siyaphila, the rehabilitation team depends heavily on specially trained rehab assistants to gauge how they should tailor their treatments for the rural, Xhosa population they serve. These assistants are also skilled in how to translate important medical advice about their injuries to patients, and help explain why it’s important that they do their exercises correctly. 

Back in the men’s ward, Shukuma is gathering his possessions. It’s been a long week of gruelling therapy, but if it means he could start work again soon, he’s happy to do it. 

Shukuma throws a suave leather jacket over his red T-shirt and struts confidently across the grounds to begin the long trek home. 

He says: “I didn’t think I would ever walk again.”

This story was produced by the Bhekisisa Centre for Health Journalism, http://bhekisisa.org.

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