By Hovik Piranyan, PT, OTS, HT

History of General Therapy Practices in the Republic of Armenia

Origins of the Armenian Rehabilitation System
Armenia is one of the ex-Soviet countries. It is a small developing country with a low population density. Rehabilitation in Armenia was originally modeled according to the Soviet ideology. Initial therapists were masseurs who worked with all categories of pathologies and with all age groups. The treatment methods used were massage, mobilization and remediation of physical culture. These masseurs were educated in the Armenian State University of Physical Culture (ASUPCS), and the Sport Medicine Dept, where the programs of study were designed to prepare future trainers and sport instructors. Masseurs upgraded their skills through self study and by learning from other more experienced therapists.

It was not until after a terrible earthquake in 1988, that a new therapy profession began to evolve, when a number of foreign specialists began to practice in Armenia. In the International Post-Traumatic Rehabilitation Center (IPTRC) established by the Red Cross, the first Occupational Therapists and Physical Therapists helped injured patients. The first rehabilitation centers were established, and a new prosthetic and orthotics workshop was opened. The first splints in Armenia were fabricated.

In 1996, ASUPCS's Sport Medicine Department started a four-year educational program in Kinesiology. The program curriculum includes kinesio-therapy, anatomy, physiology, biomechanics, massage, kinesiology, pathology, neurology and essential skills in orthopedics. Ironically, the teachers of these subjects mainly were/are the same persons with the Soviet period education, and offered only general theoretical knowledge. After graduation, students still need to gain practice in hospitals where they want to work. Most of today's therapists have been trained in this program. Thanks to the joint efforts of ENTHE and Tempus, Occupational Therapy has become available as a profession since 2005, as a five-year education/bachelor degree.

The most developed areas of practice for kinesiotherapists and occupational therapists are pediatric rehabilitation (CP, Autism), rehabilitation after CVA's for adults, and vertebral problems. Most of the therapists practicing in Armenia today still lack critical theoretical knowledge of their profession, and are unable to objectively explain the mechanism of their treatments. One of the reasons for this deficient situation is the language barrier. Most therapy courses and most of the new literature and materials are in English, which prevents many Armenian therapists from participating. Compounding this deficiency is that many of the commonly used and most valid assessment tools have not been translated into the Armenian language. Despite these difficulties, we have physicians and therapists in Armenia with a good professional foundation, many of whom were trained abroad, or received training from visiting professionals.

Delivery of the Health Care Services in Armenia
The Health Care Ministry provides free services for the following individuals: children until they are seven years old, pregnant mothers, handicapped individuals, socially unsecured persons/families, veterans of the 2nd World War and veterans for the Arcax War (Armenia-Azerbaijan). For medical services like surgery or MRI's, the government's support for these individuals approximately covers only 20-40 percent of the whole expense. As a result, the medical services are often unattainable for a big part of our Society.

Armenia's more advanced medical institutions are located mainly in Yerevan, the capital of Armenia. Some larger cities have their own medical centers, and each region has local polyclinics, but in general, there are few medical services available in rural villages and small towns. Individuals utilizing the government's assistance usually apply to Yerevan's hospitals and centers. One of the gaps of the Armenian medical system is the lack or even absence of multidisciplinary team working. Usually cases are discussed among physicians only (surgeon, anesthesiologist, rehabilitologist, etc.). The majority of Armenian physicians do not realize the importance of rehabilitation.

Development of Hand Therapy
In Armenia, all kinesiotherapists and occupational therapists treat upper extremities, but there are no specialists in this field who are familiar with current treatment protocols for effective management of upper extremity pathologies. There are no special courses in hand therapy or splinting. Simple static splints (volar-based static night splints) are available in one of the pediatric rehabilitation centers for cerebral palsy at Yerevan. Customized splinting is not yet available.

The Hand Rehabilitation Project was started in November 2002 by Dr. Gevorg Yaghjyan of the Plastic Reconstructive Surgery & Microsurgery University Centre, and by Dr. Aram Gazarian of UMAF-Lyon. Since 2003 I have been collaborating with Dr. Yaghjyan and Dr Gazarian to establish a hand therapy service in ArBeS HCC. In 2005, I attended a short training program in Vienna, and in 2006 I attended a two-month fieldwork training in Lyon, Strasbourg and Grenoble in the field of splinting. Prior to this training, I relied on knowledge gained mainly from self-study.

ArBes Health Care Center is a rehabilitation department of Arabkir Joint Medical Center (JMC). ArBes HCC is supporting our project by providing space for therapy and splinting, special furniture for hand therapy rooms, technical support and room for presentations and meetings. It will be good to have an upper extremity rehabilitation department at the institution where hand surgery is completed. I am able to observe surgeries 2X/month and collaborate with the orthopedic department and rehabilitologists, plastic surgeon and therapists (OT, PT, HT).

Each case is discussed before treatment, and 1X per week there are clinical visits organized to the Plastic Reconstructive and Microsurgery University Center. We receive referrals form three major departments and four individual specialists (orthopedic, micro and plastic surgeon, and neurologists). Each case is discussed before treatment, and each Monday there are clinical visits organized to the Plastic Reconstructive Surgery & Microsurgery University Centre.

Specific Problems and Goals
Despite the development of modern kinesiotherapeutic and ergotherapeutic (OT) services in a few clinics, the field of upper limb rehabilitation and hand therapy is underutilized, primarily due to:

1. Absence of skilled hand therapists.
2. Absence of upper limb rehabilitation and hand therapy special training courses for OT and PT practitioners.
3. Absence of clinical practice for OT and Kinesiology students.
4. Absence of qualified educational staff with hand therapy or upper limb rehabilitation knowledge at our universities.
5. Lack of educational resources such as professional literature (books and journals).
6. Lack of awareness among the medical staff of the benefits of therapy, or of a multi-disciplinary team approach.
7. Absence of adapted translations of commonly recognized and scientifically proven evaluation/assessment tools, intervention protocols and working frame of references and/or approaches.

Our group has established the following goals for the development of hand therapy:

• To prepare specialists who will be able to deliver advanced upper extremity rehabilitation in Armenia
• To inform medical staff of hospitals, medical and rehabilitation centers in Yerevan about the importance of hand therapy and available services
• To establish a workshop instructing how to properly equip a hand therapy and splinting room.

Equipment and Supply Needs

Splinting
In order to provide splinting, we need to have appropriate equipment, tools and materials. Unfortunately in Armenia we do not have all of the needed supplies and equipment. The government does not cover expenses for splinting and without government support, our hospitals will not be able to afford the expense of splints. The cost of thermoplastic and other splinting materials (padding, silicone, special items for dynamic splints, etc.) and shipping costs and taxes will cause splinting to be too costly for the majority of our clients to pay.

First and foremost, we are going to need to get official support from our government for splinting.
We have had similar previous experiences concerning to Orthotics and Braces. The government will want to see our results before any coverage will be approved.

Therapy Sessions
There is a serious need for apparatus like a myostimolators and TNS, cryotherapy, vacuum therapy, parafinotherapy, ultrasound and etc. We frequently see cases with severe contractures and atrophies of whole extremities. The application of mechanotherapy will tangibly help to cope with these problems.

I am providing a list of supplies and equipment that we need to deliver proper hand therapy in our country. I am hoping we could receive donations and/or assistance to attain these items.

• Materials for splinting
• Thermoplastics
• Padding
• Neoprene and Accessories
• Hook and Loop Straps
• Heating Pans
• Heat Guns
• Splinting tools and Accessories
• Splinting Supplies
• Supports and Slings
• Equipment for Edema Control and Taping
• Supplies for Lymph Edema management Scar and Wound Care
• Modalities
• Heat, Cold and Hydrotherapy
• Electrotherapy and Exercise Therapy
• Evaluation Tools

Next Steps
We are in the process of developing a fund for the development of Armenian hand therapy. All resources for this fund will be used for financing small projects and steps for enhancement and development of hand therapy, as follows:

• Organize clinical visits in regions and villages.
• Develop posters, leaflets and brochures for hand therapy enhancement.
• Prepare hand therapy short and long term courses for Armenian occupational and physical therapists.
• Create a Web page about hand therapy in Armenia and suggest links to this page from Armenian Medical Web pages.

For more information, or to arrange a donation, please contact:

Hovik Piranyan, PT, OTS, HT
ArBeS Health Care-Centre
32, Papazian str, 375012 Yerevan
Republic of Armenia
Tel: (++37410)261 142
Fax: (++37410)262 110
piranyanh@yahoo.fr