Written by Brandon Johnson, Class of 2023
This past summer I had the invaluable opportunity to complete my second clinical experience in an international format in Italy! Istituto Prosperius Fiesole is a private rehabilitation facility currently offering primarily outpatient and some inpatient rehabilitation to neurological, orthopedic, and sports injury patients. It is located in Florence, Tuscany, in the northern central region of Italy. The facility in Fiesole houses two operating rooms and an inpatient unit with a current capacity of 90 beds. The Istituto provides rehabilitation services for orthopedic patients with total joint replacement and those who have had traumatic injuries due to accidents and sports. Admitting patients immediately post-surgery, the orthopedic and sports rehabilitation services treat patients to return to the highest level of function. Neurological patients admitted to the Istituto include those with spinal cord injury, stroke, multiple sclerosis, Parkinson’s Disease, head trauma, and neurodegenerative diseases. A team model of care is employed and include physicians (physiatry, neurology, and internal medicine), physical therapists, occupational therapists, speech/language pathologists, art therapists, psychologists, and social workers.
The most relevant and meaningful physical (PT) skills I learned were manual skills. With most of my patient population being orthopedic, a vast majority of them were joint replacements. The most common diagnosis I was treated were hip, knee, and shoulder replacements. I learned new techniques related to limb handling when conducting range of motion. Similarly, I learned a myriad of manual stretching techniques for the lower and upper extremities. Additionally, the clinic I was placed at had no high-low plinths; thus, I had to learn positions that were biomechanically efficient for me to conduct treatment. An interesting manual skill I was mentored on was myofascial manipulation. This is a manual therapy technique that was coined in Italy and involves the dysfunctions and adhesions that originate within the fascial network. Dysfunctional fascia can be reshaped by applying a mechanical force to increase tissue temperature and stimulate the body’s natural inflammatory response. My Clinical Instructor (CI) was a specialist in the area and I was able to learn a great deal about the assessment, application of the technique, and functional outcomes. This was one of the best aspects of the experience – learning different techniques that aren’t common practice in America.
Italian PT is very different from what we study and practice here in the States. The foundational concepts are the same, however, the scope of practice is starkly different. Physiotherapists do not possess the level of autonomous practice as we do in the US. For example, to progress a patient you need approval from the physician. Moreover, you are limited in the modalities and interventions you can employ. For example, vestibular testing, manipulations, and modalities such as dry needling and Graston techniques are prohibited. I treated a patient who was being seen for a hip replacement, but also presented with positional vertigo. After presenting the evidence to my CI on interventions, he allowed me to apply some of the techniques we learned at Regis to the patient which cured her vertigo. Under normal circumstances, this would not be allowed and the patient would have had to be referred to a vestibular specialist to address her impairments. The educational process is different as well – physiotherapists in Italy attend school for three years and their education is paid for. Additionally, their compensation is not nearly to the caliber of ours here in the States. Therapists in Italy make an average of $13,500 per year as opposed to the $91,000 per year average we make.
As a new Italian speaker, the language barrier was present but not insurmountable. I worked alongside Italian therapists and directly with the patients. I performed evaluations, treatments, and all the regular aspects of therapy to aid in the rehabilitation process of the geriatric residents; however, providing care in a foreign language was my biggest challenge. Coming in with very surface-level Italian, communication with patients proved difficult. All of the patients spoke Italian and little to no English. To address this, I had to use multiple non-verbal methods of communication. Frequently I would demonstrate the action, movement, or task I wanted the patient to do when I couldn’t verbalize it. I also learned to be more in tune with my patients’ fascial expressions, pain response, and using my hands as an extension of my eyes to assess soft tissue. I took advantage of technology in numerous ways, using translators, videos with Italian subtitles, and images to convey my messages when working with patients. The patients were so open and willing to allow me to work with them although I did not know the culture or the language and I sincerely appreciated that.
One of the most apparent virtues that were nurtured over my clinical experience was my deeply entrenched value for providing holistic care – cura personalis. In the hospital there were circumstances where patients presented with multiple impairments impacting their functionality, however, treatment of these additional impairments was either not approved by the physician or within the scope of practice of an Italian physiotherapist, therefor it was not our responsibility to address it. I did not resonate with this style of compartmentalized treatment because I’ve incorporated into my resolve as a practitioner that when developing a plan of care for a patient, it to collaborate and communicate with the multidisciplinary health care professionals to ensure the care being provided is holistic in nature. I believe that in physical therapy, patients are seeking experts who are willing and able to help them overcome challenging circumstances and guide them on a path to a higher quality of life. If we refrain from providing holistic healthcare by simply treating the main impairment, then we are failing to provide services that have the potential to permeate the multifaceted aspects of patient wellness. In essence, it is paramount that we advocate for our patients because they are in need our help and we are well-equipped with the tools to make a significant impact on their quality of life.
Aside from the patient interaction, the food, the culture, and traveling with the other American students was a sublime experience! My lodging was on a wine vineyard with a family owned Italian restaurant on the property. Here I tried probably every type of Italian dish and they were all delectable. During my time in Italy, I walked the Colosseum of Rome, visited the Duomo’s of Florence, took ferry rides to the five villages of Cinque Terre, ate my way through the Amalfi Coast, indulged in wine and music at wine festivals in Tuscany, walked on the campus of the oldest university in the world that resides in Bologna, and took part in historical Italian festivals. The culture is nothing less than enchanting. It is steeped in a rich and robust heritage of art, history, religion, cuisine, architecture, and fashion. The Italians value family and spending time with them, religion and maintaining Catholic traditions, and the pleasure of eating good meals prepared with love and dedication. It truly is a beautiful, expressive, and inclusive culture. This is the most beautiful country I have ever been to and I would unquestionably do this experience again given the opportunity.
My advice to others completing an international clinical experience would be to cast aside your current worldview and come into this experience with no expectations and a completely open mind. A challenge for the professional Doctorate of Physical Therapy curriculum is to prepare its graduates for practice in a rapidly changing society in a condensing world. Providing an international clinical experience opportunity allows students to delve into the various facets of international collaboration and education. This is a prime opportunity to exchange and share knowledge. Some of the potential benefits of engagement in an international clinical experience include a wider breadth of PT practice, an expanded worldview, and changes within oneself in the role as a PT student and practitioner. The capacity of PTs to practice within the confines of other countries reinforces the demand to prepare professional students for clinical practice broadly and globally, and this is an experience that does precisely that. Additionally, I would recommend equipping yourself with simple and common clinical terms and phrases. Knowing how to communicate with a patient to determine if they are experiencing pain or are fatigued, and simple commands (i.e. up/down, left/right, in/out) will make your experience that much more meaningful.