Volume 24, No.1, May, 2001

Title: A report of physical therapy for a child with cerebral palsy who has a difficulty of adaptation to environment.

Organization & Author: Wakabaen (Day-care center and clinic for disabled children)
Toshihito Babasaki, RPT
Address: 2-28, Tutogawa-cho, Nishinomiya-shi, Hyogo-ken, 663-8233, Japan

Page number: 3 - 8
Key words: severely underweight child, mal-adaptation to environment, physical therapy

Abstract: It has been recently quite often seen that severely underweight children with cerebral palsy are ill humored, often crying, being unable to adapt to the environment of the childcare facilities during their visit. There are many cases of failure in which the children's mothers, being at a loss in dealing with such problems, tried to please them, but in vain. In this paper, the author reports one clinical case, in which the child recovered from displeasure, owing to the PT treatment and guidance to the mother. As a result, the mother could deal with her child without anxiety. The case was an underweight child with cerebral palsy, having the body weight of 732 kg at birth and born 24 weeks and 6 days after conception. The mass of white matter around the lateral ventricles was small, the ventricular walls were uneven, and the corpus callosum was thin. The symptoms led to a diagnosis of periventricular leucomalacia. The child had received PT treatment and care once a week since the age of one. Out-and in-patient treatments were given to the child between the ages of one year and three months, and one year and nine months. The clinical picture showed hypotonicity in the central trunk, and stability in the central part and the midline was unobtainable. Anti-gravitational extension movement was not adequate, and head control was also poor. Due to poor maintenance of the midline posture, it was difficult for the child to keep a stable position. The child had only peripheral vision perception and visual tracking was difficult. Auditory and tactile perception was hypersensitive. The child was unstable even in a supine position and bending backward with abduction of upper and lower limbs was frequent. In the end result, the physical therapist could enhance postural tone in the central part of the body, stabilize the trunk, and facilitate more postural control in a prone or sitting position. The mother became gradually more skillful in dealing with her child, enabling her to bring about a more stable emotional condition. The PT developed a therapy by providing a base of support utilizing a pillow and a cushion, which relieved the child from fear. On a step-by-step basis, the mother was instructed on handling the base of support as well as how to hold the child in her arms, and eventually the child became more emotionally stable.

Title: Approach for cerebral palsied children with perceptual problems: what influence do the tactile problems exert on praxis?

Organizations & Authors: College of Medical Technology Kyoto University
Toshihiro Kato, OTR
Rakusei Aiikuenn
Junko Miyashita, OTR
Tamaki Yamanishi, OTR Address: 53, Kawahara-cho, Shogoin, Sakyou-ku, Kyoto-shi, 606-8507, Japan

Page number: 9 - 12
Key words: tactile problems, conduct disorder, environmental adaptation

Abstract: There are increasing opportunities to encounter cerebral palsied children with differences between motor ability and conduct ability to perform behavior that has objectives. The authors analyzed the praxises of such children based on the three conduct courses of ideation, sequencing and execution, as Ecker described. Hereunder is made a report on the result of one clinical case, in which the tactile problems exerted on praxis and in which treatment was given from May 2000 to January 2001. The case was a four-year-old cerebral palsied child, visiting by himself to the facilities, and suffering from callosal defect, hydrocephalus, mental, developmental retardation and epilepsy. The clinical symptoms showed overall hypotonicity, but maintaining a sitting position on a bed with both hands supporting, and crawling were possible. If the posture was controlled, standing by grasping was possible, but supine or prone position made him cry from fear. Objective based play was impossible, and strong resistance was expressed toward manipulative motion on a table and dynamic play. Furthermore, an extreme resistance was shown toward new and different play. Hypersensitive tendency was indicated for various tactile stimulations. For this child, taking into consideration the way of giving tactile-sensory information, the authors helped him to experience the nursery program, and stabilized the sitting position in a chair by wrapping up part of buttocks with a blanket. Thus, he reached a period when resistance toward activities was reduced, and then advanced to a point whereby the contour of his physique became clear to him by wrapping his whole body in a blanket or cloth. The child became adapted to more dynamic exercise accompanied by changes in posture, and further progressed to a period when his direction of movement and the transfer of his center of gravity and base of support could be recognized with helping hands provided. Through such changes in care, the child reached a point in daily life when he could change his posture by himself, thus improving postural stability and enabling himself to participate positively in a play.

Title: The approach to perceptual disabilities for a child with severe cerebral palsy.

Organization & Author: The Social Welfare Bureau for Handicapped Children in Hyogo Prefecture Therapy Center.
Misako Sekiguchi, ST
Address: Kobe-Yamate-Hanshin-Building, 5-1-1, Nakayamatedori, Chuo-ku,
Kobe, 650-0004, Japan

Page number: 13 - 16
Key words: severe cerebral palsy, perceptual disabilities, subjective activities

Abstract: The author reports on the approach for a 3-year-6-month-old girl who was diagnosed as suffering from intracranial hemorrhage, nutation epilepsy, atrial septal defect and cerebral palsy. Clinical Picture: According to the Onjo's Simplified Infants Developmental Test, the patient was recognized as having a two-month level of gross motor ability, a one-month level of upper limb movement, a three-month level of daily life ability, a three-month level of personal interactions, a four-month level of speech expression, and a six-month level of language understanding. Pleasure and displeasure of the patient were recognized through facial expressions, crying, and speaking. Active movement was found only during postural change from a supine position to a prone position, while other active movements did not take place. The basic muscle tone in the central part of the body was low, and the left side of the trunk was shortened, while the upper trunk and peri-shoulder girdle were in high tone, and head control was poor. In a supine position, the four limbs were in a Kangaroo-like position. Side bending was often seen at the head and neck, and the patient was able to turn her head only to the right. Maintenance of a sitting position was impossible. During adaptation to the environment in a sitting position supported by a sitting maintenance device, her head and neck as well as upper trunk collapsed in a forward direction. But the collapse was easily counteracted by the uncontrollable reflex of the whole body's flexion or extension pattern caused by a sound stimulation or postural changes that were beyond the allowable range of the child. Problems: Due to the above-described postural pattern, (1) basic ability for visual search, fixation and tracking of objects and for seeking, catching and grasping is lacking during visuo-motor development. (2) For this child, a startled reaction to an unexpected auditory stimulation may lead to the whole body's extension pattern, making it difficult to understand the content of the information provided by the sound source, and inhibit development of auditory reception / speech ability. (3) Dis-coordination of the thoracico-abdominal region, irregular respiratory function, and a lack of initial oral sensory-motor experience such as teething, etc, further worsen retardation in speech development. Treatment: Control of postural tone of the whole body in a supine and sitting position, or in leaning forward in a standing position with the use of a balloon facilitated vocalization and led to the patient's ability to sit in a symmetrical position. Then the treatment was advanced to the oral and peri-oral regions. Results: It was observed that, in a supine position, the child was able to bring her left hand to her mouth, and she ceased to dislike a sitting position in a chair, with the head-up motor ability to look around spontaneously. Phonation also increased with an enjoyment of the vibratory stimulation of her lip or incisive tooth.

Title: A study of community physiotherapy in England

Organization & Author: Aomori University of Health & Welfare
Hideo Ito, RPT
Address: Mase 58-1, Hamadate, Aomori, 030-8505, Japan

Page number: 17 - 21
Key words: England, community physiotherapy, health and welfare system

Abstract: The author studied the community physiotherapy for five weeks in England. The objective was to learn about the system of care management for disabled persons at home and the role of the physiotherapist in the system, and furthermore to gather educational and research literature through the opportunity to experience the on-site work place of a visiting physiotherapist.
For study the author participated in various meetings, visited facilities for outpatient physiotherapy and facilities for physically challenged persons, observed home therapy and guidance and service networks for regional health and welfare, etc., so that the author could grasp the outline of health and welfare policy in England to maintain the health and life of regional inhabitants.
A hospital at home (HAH) is designed to provide at home treatment for adults at an acute stage such as that usually given at hospitals. Treatment of one to twenty eight days is provided by a specialist team in home care, in cooperation with general practitioners (GP), so as to assist the patients and health caretakers in preparation for an early return to home. Disabled Adult Resource Team (DART) is a home care team for disabled adults at a chronic stage, providing visiting services for a longer term than that of HAH. A senior physiotherapist working in DART described during his interview that "the concept of Bobath is based on providing treatment not only for hemiplegia, but also for all kinds of patients."
Specific results obtained in this study were (1) having an opportunity to observe a challenging spirit for drawing out the latent ability of a disabled person and to understand the underlying idea of normalization, (2) having again recognized a professional consciousness to prevent disablement and unnecessary hospital admission, an excellent therapeutical technique by highly experienced physiotherapists, and especially the concept of Bobath for cerebral palsied or stroke patients. Furthermore, the author learned many things about the effect of lung physiotherapy at home for chronic respiratory patients and about the activities of the physiotherapist, and about the techniques as well as the viewpoint of occupational therapists in addressing guidance for, and consultation with home patients and health caretakers.

Title: Approach to a stroke patient with hemiplegia in geriatric health services facilities.

Organization and Author: Geriatric Health Services Facilities
"Crdne" Emi Odaka, OTR
Address: 1078, Ishikawa, Ichihara-shi, Chiba-ken, 290-0551, Japan

Page number: 22 - 26
Key words: adult hemiplegia, construction of abnormal, postural movement patterns, follow-up treatment.

Abstract: With the introduction of the geriatric health services insurance system, the length of hospital stay has shown a tendency of reduction. Under such a situation, the inpatients of sub-acute, adult hemiplegia and the outpatients of chronic hemiplegia in the facilities are increasing in number. In this paper, the author discussed the present situation of rehabilitation and its importance in the geriatric health services facilities through a case study of one in-house patient and one outpatient.
The admission system of geriatric health services facilities is expected to play an important role as a system that provides the services where exercises of functional recovery can be given, to some intensive degree, for subacute adult hemiplegia after hospital discharge. However, due to lack of rehabilitation staff, adequate treatment in the facilities cannot be actually provided.
There is a drawback in the outpatient system of geriatric health services facilities necessitating provision of rehabilitation treatment under a tight schedule. On the other hand, the system has such advantages as (1) reducing the patients' staying-at-home time by going out, (2) helping to increase the time out of bed by spending a long time at the facilities, (3) heightening a desire to live and giving a diversion of mind through doing a work or recreation, (4) enabling an easier approach to ADL and (5) making it possible to provide a continued treatment for a long period of time.
In this paper, it has been found that geriatric health services facilities are able to play an important role in providing a continued rehabilitation treatment for adult patients with hemiplegia.

Title: Application of Bobath Approach in the geriatric health services facilities

Organization & Author: "Green Life"
Takeshi Yamada, OTR
Address: 9-3-9, Higashi-Nakahama, Joto-ku, Osaka-shi, 536-0023, Japan

Page number: 27 - 30
Key words: geriatric health services, outpatient rehabilitation, advanced age

Abstract: The "Green Life" geriatric health services facilities were established in 1998. Current staff consists of two occupational therapists and one physical therapist, providing in-house and outpatient rehabilitation services. For in-house services, a therapist in charge provides individual, group, and hot-bath therapies. For outpatient services, a group therapy is performed. In-house clinical report: The case was a patient with left hemiplegia caused by a cerebral hemorrhage, and 6 months had passed since the onset of the event. At the onset of therapy, the patient was independent in life with the use of a wheel chair with help. At our facilities, he was able to walk with a cane, but the trunk was bent sideways, raising the pelvis to thrust out the lower limbs. Voluntary movement of the upper and lower limbs was possible. As he had been previously directed to "straighten the body by extending the trunk upward from the waist", he stopped in the movement of each step forward to extend the trunk outward, intensifying excessive tension on the palsied side and lumbo-dorsal region. The problem was that his conscious effort to assume a good posture intensified excessive tension, hindering a smooth walk. Therapy was designed to bring about movement of the pelvis and hip joints during exercise. And at the same time, the author paid attention in such a way that the patient did not make an excessive effort in daily life. As a result, it became possible for the patient to independently walk with a cane indoors. It is thought that the patient should be expected to understand that the contents of the exercises in accordance with the stage of recovery and that voluntary training or different activities in daily life would lead to functional improvement. Outpatient Clinical Case Report: The case was a patient with right hemiplegia cause by a cerebral infarction. A long time had passed since the onset of the event. The patient had come regularly to our facilities since its establishment. He was independent in life with the use of a wheel chair. Walking with a quadricane under supervision was possible, but from a strong fear of falling, he refused to walk alone. The problems were a reduced endurance in walking and a fear caused by lack of walking experience. The treatment was designed to increase the opportunities for walking within the group and to enhance endurance in a standing position. After about two years, walking indoors with the use of a quadricane became possible. The effect of a long-term approach could be observed.
The author wishes to provide an effective rehabilitation under efficient exchange of information among the different facilities.

Title: Management of ADL at the nursing home for aged persons

Organization & Authors: Bobath Memorial Hospital
Kenji Kise, OTR
Misao Nishimura, RPT
Address: 1-6-5, Higashi-Nakahama, Joto-ku, Osaka-shi, 536-0023, Japan

Page number: 31 - 33
Key words: nursing home for aged persons, ADL management, FIM

Abstract: At the "Sunrose Osaka" Nursing home for the aged persons, each one of the registered occupational therapists and the registered physical therapists provides once a week exercises for improving the daily life activities of home inhabitants and also teach care management to the home health caretakers, thus engaging themselves in assisting self support of the home inhabitants. The authors followed the way of life in the home and the changes in FIM for 8 months, and discussed the contents and method of guidance and approach.
The subjects were 24 inhabitants of the home, with the mean age of 78.7}8.79 years, whose mean period of stay was 32.88}10.89 months. They were specifically classified into such physical conditions as (1) persons with a severe degree of deformation and contracture who require constant cautions in postural maintenance in a wheel chair and bed-positioning, (2) persons who need a great deal of assistance in postural changes, bath-taking and toilette behavior, (3) persons clearly showing the gradual reduction of activity and decreased ambulatory capability, (4) persons requiring exercise therapy after a bone fracture and (5) persons who feel pain during exercise.
By reviewing the details of guidance and method of approach according to the degree of care, a certain tendency has been found such that proposal of direction in ADL management to staff may be recognized as a relatively common problem. Thus, if ADL management could be performed in the environment of daily life of the home inhabitants, it would be easy for the therapists to set up specific goals, and to make it possible to provide care and to manipulate the patients' bodies on the spot together with the main staff members who are regularly involved. In such a way, the authors thought that more efficient exchange of information was necessary for common possession of expert knowledge, being conducive to enhancement of the daily life of all the home inhabitants.

Title: Visiting rehabilitation to a person with cerebellar infarction.

Organization & Author: Nomura Hospital
Takamasa Sainou, RPT
Address: 8-3-6, Shimorenjo, Mitaka-shi, Tokyo, 181-8503, Japan

Page number: 34 - 42
Key words: cerebellar infarction, visiting rehabilitation, care

Abstract: Based on six years of experience, the author considered how visiting rehabilitation should be carried out and that there were many problems to be solved. Presenting the case of a 65-year-old woman with cerebellar infarction, for whom the author was involved in visiting rehabilitation for two years, he discusses hereunder the approach to visiting rehabilitation from seven points of view. (1) The treatment situation was set up so that her latent capacities could be drawn out. When she felt ease of movement after the treatment, it was thought that such movement would potentially lead to an independent life. (2) Her tremor due to ataxic movement of her trunk was compensated for by hypertonus of her back muscles. Conversely, she could not make delicate positioning changes in the trunk of her body. In treatment, mobility of the lower leg and foot, pelvis, peri-thoracic, shoulder girdle and cervix was promoted, and muscular coordination of the abdomen, buttocks and hip joints was also promoted. As a result, postural reaction easily developed in the trunk and cervix, enhancing stability in a sitting position. (3) As she had long been bed-ridden, having no experience in active positional transfer, walking experience prompted her to recall her past, her living space and her desire in life, and it drew out a sense of self-fullness and gave her a self-confidence in continuation of life at her own home. (4) Timing was important for her family to participate in the treatment. Guidance for the family was suggested according to the level of understanding by family members, their skillfulness and their affection to the patient. (5) A visiting therapist is required to have a flexible attitude that can be accepted by sensitive patients and family members. Only in the case whereby a visiting therapist accepts with affection the patients' and family members' sense of life, will he or she be accepted by the patient and family members without anxiety. (6) From a long-term viewpoint, it is necessary to consider the procedural measures of visiting rehabilitation in view of the generational characteristics of the subject. (7) During visiting rehabilitation, a therapist may encounter the death of his or her patient. Therefore, a therapist should endeavor in his or her efforts to be of assistance to and to meet the expectations of the patient.