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Interview with Dr. Tracy Spitznagle

January 28, 2016

Board Member and Rehabilitation Advisory Council (RAC) Director

Theresa Monaco Spitznagle PT, DPT, MHS, WCS

Q. You recently visited Danja Fistula Center to observe and advise the Physical Therapy (PT) program through the RAC. What can you tell me about your experience?

A. During my visit, I observed that the women needed physical activity throughout their day, especially while waiting for surgery. PT increases their lower extremity strength and endurance.

Before a fistula, a woman would walk miles every day to collect firewood or bring back water for cooking and cleaning. With fistula, however, many women are isolated or abandoned. They reduce their activity level, with the hope of healing the fistula, and they hide away to avoid drawing attention to their incontinence.

Once at the Danja Fistula Center (DFC), PT empowers these women. They feel safe and able to get stronger so they can return to their prior lifestyle. DFC is a heaven to these girls and women. When you walk through the village, you can feel the comradery and confidence. They engage in the community and it is a thrill to see them  braiding each other’s hair, chatting amongst themselves and giggling!

Q. What is the physical toll fistula takes on a woman or girl?

A. Fistula physically alters a woman’s entire lower extremities. The prolonged compression, from the baby’s head, occurs in the organs, muscles, nerves and blood supply to the pelvis. This compression affects all the muscles in the hips, thighs and feet, leading to long-term difficulty carrying heavy loads, walking long distances and getting out of squatting positions. Squatting is a large part of Nigerien Hausa culture, incorporated in to social interaction, daily chores, as well as voiding.

Q. Why is PT such an important part of recovery?

A. After a successful fistula repair surgery, PT helps correct the changes that occur in all women after pregnancy. The most common issues are abdominal and pelvic floor muscle weakness, as well as loss of control of abdominal pressure which can cause stress urinary incontinence. 20% of all patients who undergo fistula repair surgery are not dry. This can be quite devastating, but PT can help if the reason they are wet is stress urinary incontinence.

Hausa women participate in heavy lifting, carrying and walking great distances. Losing control of their pelvic floor and constantly leaking urine or feces makes daily activities difficult, if not impossible. In the presence of pelvic muscle weakness, PT is the key to getting these women back to these activities.

Q. What are the biggest challenges you face when working with fistula survivors?

A. The greatest challenge comes from the desire of the patient herself to get better. Unfortunately, some women believe if they remain inactive they will self-heal. However, the  lack of movement can lead to more muscle weakness and worsening endurance.

One method we started on my recent visit was a team approach. I believe it is critical for all members of the DFC team to participate at the same level of commitment. When the patient hears the same message from nursing, PT, and the MD, I am optimistic that this will foster better recovery.

Q. Are there women who do not completely recover?

A. There is a percentage of women whose fistula cannot be repaired. They must learn compensative techniques to control their urine loss. One type of treatment is a urethral plug: a soft device inserted into the urethra that can be opened and emptied throughout the day. In the U.S., nurses take on this role of teaching and implementing, however, at DFC, it is commonly the job of the PTs.

Q. What do you find most rewarding about your work at DFC?

A. The most rewarding aspect has been facilitating communication across all of the DFC teams in order to maximize the PT program. The team approach of keeping the patient the focus is invaluable. It was very rewarding to end the week with a planning meeting that included the entire DFC team to develop a plan for ongoing communication and PT services.

Another immense reward is that PT returns confidence to women who are dry from surgery, or become dry through PT. The coordination and strength they gain through PT is the final element to healing their pelvic floor. PT not only provides these women with physical confidence but also emotional confidence.

Q. As Director of the RAC, how do you think it has improved the DFC program?

A. The RAC has provided great insight in to how the PT program is doing and any needs or issues it has. The focus of WFF’s RAC is to lay the ground work and provide support to facilitate Africans taking care of Africans. I am proud to say our DFC staff is dedicated to our mission and willing to help build the quality of our program.

Q. What goals do you have for the PT program?

A. My goal at DFC is to encourage interdisciplinary care so that  nursing, MD and PT teams can work together for best recoveries. I am optimistic that better communication between each team member  will help these women exceed their recovery potential.

I am also excited that we have two PTs visiting DFC this April to start putting our PT plan in to action. My hope is that members of the RAC will visit DFC four times a year to maintain best practices.