Myanmar has a population of 51 million with Mandalay accommodates around 1.2 million inhabitants. An estimated 200 physiotherapists are working in Myanmar and no Occupational Therapists.

Dr Wim Theuvenet, from the HAB team, who is a specialist in plastic, reconstructive and hand surgery has been visiting Myanmar on a regular basis to teach and train doctors and staff in reconstructive surgery at Mawlamyine Christian Leprosy Hospital (MCLH).

In 2016 a Hands Across Borders (HAB) project was conducted and then it was concluded that future visits would be valuable and were considered. This Hand Therapy Workshop 2017 at Mandalay Orthopaedic Hospital (MOH) was planned after the 2016 invitation by Prof Win Ko of the MOH. Dr Zaw Moe Aung, country Director of The Leprosy Mission Myanmar has been involved in coordinating both the 2016 and 2017 visit and was supported by Mr Jan Robijn from the Netherlands Leprosy Relief (NLR) association who supported both projects. Through email and Skype commutations between Mr Robijn, Dr Zaw and Dr Wim Theuvenet and Ton Schreuders a program was constructed on two sites at the same time: a 6 day surgical camp at the MCLH and a 5 day workshop at Mandalay and a joined workshop at the Yangon Orthopaedic Hospital.

Members of the Myanmar Project 2017:

• Dr Wim Theuvenet (M.D., Ph.D) Plastic surgeon
• Ms Aly Boven OT Nurse
• Dr Ton A.R. Schreuders (PT, PhD) Hand therapist
• Mrs Hanneke Zoutendijk – van Beelen (PT) Hand therapist
• Dr Zaw Moe Aung Director The Leprosy Mission Myanmar
• Dr Myat Thida Field Operations Manager TLM Myanmar

The members were divided into two teams: Mawlamyine Team and Mandalay Team and travelled independently. On Sunday 22nd January 2017 a short meeting at breakfast in 7 Mile Hotel Yangon took place with the four members and Dr Myat Thida, Field Operations Manager of The Leprosy Mission in Myanmar. Dr Wim Theuvenet, Ms Aly Vrijhof and Dr Myat Thida travelled to Mawlamyine for a week of seeing patients and doing surgery with the team of the Yenanthar Leprosy Hospital that had come for training to Mawlamyine Hospital. Hanneke and Ton were joined by Dr Zaw Moe Aung, director The Leprosy Mission Myanmar in travelling to Mandalay.

Monday 23rd January

This was the first day of this workshop, which was attended by a large group of about 60 persons consisting of surgeons, therapists and physiatrists (rehabilitation doctors) from the main Hospitals in Mandalay.

The topics for this first day were anatomy of the hand and examination of the hand with patients demonstrations. Several patients with severe injuries to their upper extremity were presented by MOH staff and discussions about therapy done surgery was done. Patients with crush (machinery), knife injuries, but also a large number of young male patient with brachial plexus injuries after motorcycle accidents.

MOH serves the whole north of Myanmar with 500 beds and a special unit for hand surgery with three hand surgeons and 11 Physiotherapists.

Tuesday 24th Jan:

Presentations were given on flexor, extensor tendon injuries and tendon transfers. In the afternoon several patients were seen who had undergone this surgery. It was common practice to start therapy 2 weeks after surgery, resulting in most patients having stiff hands. Those with 4 strand repair were not given a splint and some probably had ruptures. It was concluded that their was a genuine need for a Mandalay Flexor Tendon Protocol.

Tuesday night a group of medical staff was participating at a dinner with discussions about training and organization of care for these patients.

Wednesday 25th Jan:

The plan was to start with a presentations about International Classification of Function (ICF) model* by one of the physiatrists but due to some misunderstanding of one participant who was asked to prepare a presentation on the ICF model was kindly taken over by Dr Zaw Moe Aung, director The Leprosy Mission Myanmar. Discussion about the ICF function/structure – activities – participation followed and important measurement instruments in the different domains were discussed and presented.

A lack of measurements instruments for activities was apparent and suggestions were made to translate the DASH questionnaire in Myanmar language. In the afternoon many patient were seen with focus on their activities and disabilities.

* http://www.who.int/classifications/icf/en/

Thursday 26th January:

Presentations were given on splinting and the management of stiff joints, followed by demonstration of splinting. The thermoplastic material send by Yangon manufacturer was unfortunately of a kind which need a high temperature and a long time before it is useable. The same material was used in Yangon and did not seem to have this problem.

The rest of the afternoon was spend on splinting; e.g. making Kleinert splints for the surgeons and intrinsic plus splints for the therapists. For some patients splints were made.

Plans were discussed to construct a flexor tendon protocol, with the therapists, physiatrists and Prof Dr Htin Aung Lin (hand surgeon).

In the evening a dinner was arranged where two visiting surgeons also joined in, one from France (Toulouse) and another from Spain (Alicante) who regularly visited Mandalay, invited by a Children Action organization and were specialist in paediatric surgery (brachial plexus) and spine surgery. They also spoke about the need for brachial plexus therapy and surgery.

Friday morning 27th Jan:

The Flexor Tendon Injury Protocol /All Zones 2017 was presented again and critical points discussed. The desire was expressed to evaluate the protocol within the year. Outcome measure were discussed and determined. Dr May Hmin (physiatrist) volunteered to supervise the project, make a register and a form and collect the data for evaluation.

Saturday. Day and night: bus to Yangon.

Sunday: Meeting with Mawlamyine group.

Tuesday 24 January:

Operation program. The OT department has one larger and one smaller OT, the latter for minor procedures. At the end of the morning the Mawlamyine team operated in the small OT a boy of 13 with contractures at the ankles and knees. At the end of the operation there suddenly was a cardiac problem with a sinus tachycardia and in spite of several attempts to correct this, it resulted in cardiac failure upon which the boy passed away. Needless to say that this tragedy had great impact on the whole team and the family. It appeared from further discussions by the medical team with the family, that the boy was known with a muscle problem and that perhaps this condition was responsible for the cardiac failure. Dr Myat Thida played a significant role in discussing all aspects with the bereaved family , who were content with all explanations at the end.

General anaesthesia other than with ketamine was not available at Mawlamyine Leprosy Hospital thus far and with great effort of the leprosy Mission Netherlands (“Leprazending”) an apparatus suitable for SevoFlurane GA was obtained from Medic and sent to Mawlamyine to be used for this course and hereafter. Unfortunately, the young anaesthesiologist contracted for her assistance during this course was incapable to use this type of GA apparatus which blocked us from operating on 2 patients with severe burn contractures.

Wednesday to Friday 25 – 27 January:

Dr Sithu Won assisted or was the first surgeon in a great number of procedures. Most of these were tendon transfers (e.g. for triple nerve palsy, claw hand, foot drop, lagopthalmus and other indications)

Saturday 28 January:

“Great ward round” for the final check of the 30 operated patients and the post-op arrangements. Evaluation: It was concluded that the level of expertise of Dr Sithu Won was greatly enhanced. Possibilities of a strengthening cooperation between Mawlamyine and Yenanther Hospital were formulated.

After Lunch Dr Sar, Aly Boven and Wim Theuvenet took one of the small boats to visit the island in front of Mawlamyine and on the back of 3 scooters the Island was toured. With the evening bus Aly and Wim returned to Yangon where they arrived in the early morning, to be joined by Ton and Hanneke later the same morning.

Monday 30th Jan Hand Therapy Workshop at the Department of Physical and Rehabilitation Medicine of Yangon General Hospital (YGH).

All four members participated in the one day work shop at the Yangon Orthopaedic Hospital. A group of over 70 persons attended the workshop; therapists, surgeons, physiatrists.

Two presentations were given by local staff; one on hand injuries in Yangon and one on hand surgery. An impressive number of 45 toe- to hand transfers were performed in the past and replantation of upper and lower arm were performed. Micro surgery was done by the orthopaedic surgeons.

Ms Thet Zar Chi is a PT trained in hand therapy and presented several cases with tendon injuries, fractures and brachial plexus lesions.

A Thai company kindly provided thermoplastic splinting material and demonstrated the use of this.

1. The timing was right, surgeons are eager and planning to expand there hand surgery services and expressed the need for better trained therapists

2. Leprosy has been talked about in several circumstances as patients needing care of therapists and surgeons and a patient was brought into the workshop in MOH

3. English for some of the therapists is still a problem, translation should be provided. Resource persons Dr Zaw, Dr Myat Thida and Mrs Mayflower were crucial in helping out in translate and explanation.

4. Thermoplastic material Myanmar is still something that needs discussion about price, durability and its usage in hot climate

5. Need for measuring instruments like goniometer and dynamometers and can possibly considered by NGOs to be sponsored. The DASH can be translated into Burmese language.

6. Still many surgical issues in MOH like usage of k-wire pinning, tendon grafting (FDS for FDP), treatment post-op.

7. Expressed need by medical staff for knowledge and input on CP treatment, stroke and brachial plexus

8. Cooperation with other groups like Australian group is preferable.

TLM

• Dr Zaw Moe Aung Director The Leprosy Mission Myanmar

• Dr Myat Thida Field Operations Manager The Leprosy Mission Myanmar

MOH

• Prof Win Ko orthopaedic hand surgeon

• Prof Dr Htin Aung Lin orthopaedic hand surgeon

dr.mhhk10@gmail.com

• Dr Phyo Kywe ortop surg trainee phyokywe99@gmail.com

• Dr May Hmin physiatrist trainee

• Dr Hay Mar Myint physiatrist trainee dr.haymarmyint@gmail.com

• Ms Daw Lwin Lwin Win Chairperson Dep. physiotherapy MOH

• Ms May Yamone Phoo PT helped in flexor tendon protocol

mayyamonephoophysiotherapist@gmail.com

• Ms Khaing Zin Thein PT, khaingzinthein.pt@gmail.com

YOH

• Prof Dr Khin Myo Hla head of PM&R Department Yangon

• Dr Kyaw Zaya ass prof Hand Unit Yangon Orthopaedic Hospital

• Ms Thet Zar Chi PT, most experienced hand therapist

RoyalOasisClinic@gmail.com

• Ms Thi Thi San Director MediGuard (providing splinting material)

Anita@mmnshipping.com

We sincerely thank Mr Jan Robijn of the NLR, and Dr Zaw Moe Aung and Dr Myat Thida of TLMM for facilitating and sponsoring the local costs of this visit.

We thank Dr Tin Shwe of American Leprosy Mission in facilitating temporary medical registration for Dr Wim Theuvenet to be able to undertake surgical procedures at MCLH.