Apply for the Vargas Award

Armenia is a very small mountainous country of approximately 3 million people, nestled between Turkey, Iran, Azerbaijan, and Georgia. Armenia, with a culture enriched by many legends and folklore, is one of the world’s oldest civilizations. It was the first country in the world to officially embrace Christianity as its religion (c. 300 A.D.)

The territory of Armenia has changed often during its difficult history, as the Armenians have suffered through invasions by many different empires, and most recently was part of the Soviet Union. With the dissolution of the Soviet Union, the Armenian economy deteriorated, as the Soviet factories closed, and utilities were only minimally functional. Although their economy has made some improvements in recent years, Armenia still relies heavily on foreign aid, and direct support provided from Armenians living in other parts of the world.

Health care in Armenia is slowly changing from its Soviet influences, which from a therapy standpoint, mainly involved massage and mobilization as the primary treatment methods. Following a massive earthquake in 1988, The Red Cross established Armenia’s first post-traumatic rehabilitation center, with trained Occupational and Physical Therapists. Gradually formal educational programs for Kinesio-Therapists and Occupational Therapists were developed, with the main areas of practice being pediatric rehabilitation, and rehabilitation following CVA’s and spinal cord injuries for adults. There currently are no formal therapist training programs which are specific to upper extremity pathologies or splinting.

My affiliation with Armenia began several years ago, when I was contacted through the IFSHT (International Federation of Societies for Hand Therapy) web site by an Armenian therapist named, Hovik Piranyan. Initially we made plans for Hovik to come to our clinic for a hand therapy educational experience. When Hovik was not able to obtain a United States visitor’s visa, I had the idea to submit Yerevan Armenia as a possible location for a Vargas Mission. The preparation for this mission spanned over two years as we secured Armenian physician support, and obtained invitations from several facilities in Armenia. I received the award from the American Association for Hand surgery in 2010, however was not able to complete the mission that year, due to various scheduling delays.

Davit Abrahamyan, MD, Paula Galaviz MS, OTR, CHT,
and Robert Schenck, MD.

Meanwhile, in Chicago, Dr. Robert Schenck was being encouraged by an Armenian friend, to conduct a medical mission to Armenia. Through the magic of Google, Dr. Schenck discovered that I would be going to Armenia as a Vargas Award recipient. Even more incredible was the fact that I used to work for Dr. Schenck about 20 years ago. We arranged to complete the mission together, spanning from May 2nd through May 12th, 2011. Unfortunately, Hovik who has been in France for the past few years completing therapy training was not available during our mission. Our host for the mission was Dr. Davit Abrahamyan, a plastic surgeon.

My initial three days were spent providing therapy consultations during Dr. Abrahamyan’s physician clinics. Although therapists were present during many of these appointments, there was little time available for hand therapy training. I learned that Dr. Abrahamyan, very skillfully has been fabricating his own splints for patients when needed, and essentially did not refer patients to the therapists. He also was hoping that I would teach his new employee, with no medical background, the essentials of splinting.

It was following much pressure from me and Dr. Schenck together that I was finally allowed to spend more time working directly with the therapists. I found that as the days passed, more therapists and students were eagerly showing up at clinics where I was at, with some coming all the way from the country of Georgia. I utilized every opportunity to provide splinting demonstrations, education regarding diagnoses, discussions on hand therapy treatment techniques, and to provide educational presentations from my laptop. Language was a barrier as many of the therapists did not speak English, necessitating additional time for interpretation. I was very impressed with the knowledge of the therapists for basic therapy techniques, and for their eagerness to learn more.

The majority of the patients seen were children, and quite a few of them had birth-related brachial plexus palsy. There were some adult patients with various forearm or digit lacerations, now presenting with contractures for splinting. My most interesting case involved spotting a factitious disorder in a 15 year old boy. In the evenings of our final three days, Dr. Schenck and I presented a seminar to over 100 physicians and therapists. Our topics included tendon repair and rehabilitation, compression disorders, brachial plexus palsy, and a presentation about hand therapy in the USA. Throughout these presentations, the skills, knowledge and important contributions of hand therapists were highlighted, especially stressing the therapist/physician team approach.

Armenia’s Health Care Ministry provides free services for children, handicapped individuals, and veterans. Hospital’s will complete required surgeries in an emergency for adult trauma patients, but follow-up care, elective surgery, diagnostic tests, and therapy must be paid for out of pocket. Insurance is available for adults, at a cost, which most cannot afford. As a result, medical services are unattainable for the majority of Armenians. The concept of a multidisciplinary team caring for patients is for the most part, absent. Most physicians manage cases independently of rehabilitation, and do not yet seem to recognize its importance.

I think there are many obstacles to overcome for a first hand therapy clinic to be established, including the following:

1. Improved physician recognition of the importance of therapy, improved physician communication with therapists, and improved physician utilization of therapy.
2. Improved therapy education and skill development in the schools, and through professional development methods (courses, written materials).
3. Establish an affordable method of payment for adult therapy services, so that provision of therapy can be a viable service.
4. Obtaining equipment and supplies (i.e. goniometers, splinting materials, modalities, etc.) – which currently are practically non-existent.

I think additional exposure to the successful models of hand surgery and therapy in the U.S. and perhaps other European countries is needed to romote the continued growth of therapy in Armenia. This could happen through future mission trips by U.S. therapist/ physician teams to Armenia, or through Armenian physician/ therapist visits to the U.S.

Armenians seem to be of the mindset that they can only accomplish things through foreign monetary investments. I believe that they could work through many of their procedural difficulties using the resources that they have, perhaps with some outside guidance. Consulting with professionals in organizations such as AAHS who have faced similar issues in other countries, could be very beneficial.

I have been working on a few issues since my return home. I have asked Scott Kozin, M.D. from Shriner’s Hospital in Philadelphia, if he would be willing to host a visit from Dr. Abrahamyan, and provide training in surgeries for irthrelated brachial plexus palsy. He graciously accepted, and Dr. Abrahamyan was very excited when he learned of this opportunity. I have been communicating with a large service organization for people with developmental disabilities, regarding their potential interest in arranging a service project in Armenia to educate care providers about program services for people with developmental disabilities. I spent a portion of a day touring an Armenian residential institution, and feel that enhanced programming could improve the residents’ quality of life. I have also provided treatment advice via the internet to Dr. Abrahamyan while encouraging him to refer the patient for therapy.

I am very thankful to AAHS for this fantastic opportunity. I hope my visit results in some positive opportunities for growth for therapists, physicians and residential care programming services.