Volume 24, No.2, December 2001

Title: Support for social participation of adult patients with cerebral palsy: Role of therapist in the work center

Author Terushige Kuniyasu, RPT
Organization Toyonaka Municipal Welfare Center "Himawari"
Address 1-1-20, Inatsu-cho, Toyohashi-shi, Osaka-fu, 561-0854, Japan

Translator Tomoko Hirai, RPT
Organization Minami-Osaka Children's Hospital
Address 5-11-21, Yamasaka, Higashi-sumiyoshi-ku, Osaka-shi, 546-0035, Japan

Page number 131-134
Key words revolution of care system, social participation, and visiting rehabilitation

ABSTRACT: A new version of the International Classification of Impairment, disability, and handicap was introduced at the General Meeting of the World Health Organization in the spring of 2001. Among the newly revised classification, those related to therapists are 1) participation in society by persons with disabilities was emphasized, and 2) handicapped factors were divided into environmental factors and individual factors. In the new classification, it is thought that the social handicap does not directly connect to functional disability but it might be varied with individual activities and social participation. This idea seems similar to the concept including "individualized intervention" and "improvement of the social environment" which are emphasized by the Bobath concept. In Japan, various reform plans for the medical system including the nursing care insurance system are now scheduled. The conventional medical services for rehabilitation will be considerably modified in the near future. On the other hand, there is another nursing system that allows for home nursing. This had not been covered by the conventional medical services in facilities and hospitals. Now, we will discuss the problem on the limits of the ordinary nursing approach in facilities and hospitals. Which facilities are best suited to for young cerebral palsy patients scheduled to graduate from high school, vocational aid centers, work centers, or day-care facilities? What kind of advice can a therapist provide to such patients? A therapist has some information about the patient's physical conditions but little information about the status of facilities' activities and practical nursing care. Often because of a lack of knowledge, the choice of facilities for such patients is left mainly in the hands of the mother. In addition, it is likely that a patient is often given professional, but impractical advice, such as "you shouldn't work more than once a week because the activities in the work center may affect your physical condition." For care management techniques for persons with disabilities, these conditions under the old medical model system have been regarded as abusive. Therapists should tackle such important problems as social participation of persons with disabilities through highly realizable means with respect for the will of the person concerned. So, the care management procedure for persons with disabilities is very important and critical for that purpose. To realize the methodology, various systems like local support systems for children and adults with disabilities would be useful. The practice of providing therapy as a physical therapist and also as a Bobath therapist combined with the knowledge, techniques, and evaluation are indispensable in providing good care management to persons with disabilities. We therapists, would support social participation of adult patients with cerebral palsy through visiting them in work centers and interviewing them, concurrently accumulating various experience in hospitals and facilities.

Title: A therapeutic approach to patients with cerebral palsy in adolescence: Listening to the voice of the patient

Author Junichi Takashio, RPT
Organization Biwako Gakuen Hospital

Address 8-3-113, Kasayama, Kusatsu-shi, Shiga-ken, 525-0072, Japan

Author (life history) Atsuko Fukusaka
Organization Work Center "Nikkori"

Translator Kumiko Kosuge, ST
Organization Fuji Onsen Hospital
Address 1177, Komatsu-shimogawara, kasugai-cho, Higashi-yamanashi, Yamanashi-ken, 406-0004, Japan

Page number 135-139
Key words patient with cerebral palsy, adolescence, and life history

ABSTRACT: In Japan, about 30 years have passed since early intervention was introduced for infants with disabilities. The infants who received early intervention at that time have now reached adult status. Although medical staff has largely acknowledged the super-early intervention combined with the marked progress of perinatal medicine, the number of medical facilities that are involved in the care of adult patients with cerebral palsy has not been increasing in line with the growing number of adult patients with cerebral palsy who want to receive treatment. To provide appropriate treatment for these adult patients, a physical therapist must not only focus on the impairment, but also focus on symptoms of age-associated change, environmental equipment such as care support devices and engineering techniques, and various services provided by health management teams and medical facilities. To support adult patients with cerebral palsy, it is important for a physical therapist to understand the differences between the close and open systems proposed by Gray Kielhofner et al. The close system is characterized by: 1) all phenomena are regarded as mechanical events, 2) all phenomena are reduced to their most fundamental elements for analysis, 3) over simplification, and 4) human specific characteristics such as recognition, decision making, and self consciousness are disregarded. Whereas the open system is characterized by: 1) all phenomena are analyzed as Gestalt-qualitat total, 2) complexity is recognized, 3) much attention is paid to human specific behavior to pursue spontaneous activities and stimuli, 4) creative and productive behaviors are thought to be admirable, 5) human-specific behaviors such as individual will and decision making are explained by emphasizing the process of consciousness like purposefulness and targeting. It is indispensable for therapists to change their opinion based on the close system to that based on the open system. In this article, the author described a case report on the basis of one life history that was written by an adult patient with cerebral palsy suffering from secondary impairments. In the case report, the author proposed an evaluation and support program based on the view of the open system.

Title: Visiting rehabilitation for adult patients with cerebral palsy

Author Miyuki Sasaki, OTR
Organization Furano City Center for Disabled Children "Nakayoshi Kyoshitsu"
Address 24-15, Suehiro-cho, Furano-shi, 076-0011, Japan

Translator Hisashi Kuruma, OTR
Organization Asashio-en
Address 2-5-3, Yunagi, Minato-ku, Osaka-shi, 552-0004, Japan

Page number 140-142
Key words adult cerebral palsy patient, visiting rehabilitation, and social resources

ABSTRACT: Two cases of adult patients with cerebral palsy who received treatment by a visiting rehabilitation therapist were reported. The patient in Case 1 was a 33 year-old woman. Although this patient received help from her brother and sister who were living in the neighborhood, the physical burden placed on her parents gradually increased with their aging. So, we recommended her parents to receive care support of social resources and to utilize support devices like a bathing chair. But, it was difficult for the family to accept such a recommendation because their way of care had been fixed to a stereotype. The patient in Case 2 was a 21 year-old man. This patient was utilizing several social services aiming to obtain medical care and social communication, but the visiting rehabilitation given to this patient was not in cooperation with other facilities' services. So, we constructed a program for both this patient's functional improvement and stimulated information exchange among facilities to clarify the role of each facility. We felt that for the introduction of a new care instrument and/or a social service into a stereotyped daily life of a person with disabilities, it is indispensable to obtain enough understanding of their families through careful simulation. Even when several sorts of social services are utilized, those services are not necessarily so effective as to reduce the family's burden without clarifying the purposes and the efficacy of each service. Therefore, cooperation among facilities seemed very important for such cases. Visiting rehabilitation is effective for regular medical care of a patient who has difficulty going to hospital. In visiting rehabilitation, a practical approach to the patient is possible because the treatment is implemented in a place where the patient lives. Therefore, a visiting therapist should mediate information exchange among facilities as they know the patients' daily life well.

Title: A therapeutic approach for improvement of walking ability of a patient with right hemiplegia: a case report of a therapy focusing on CPGs and the related system

Author Nobuyuki Abe, RPT
Organization Public Okitama General Hospital
Address 2000, Oaza-nishi-otsuka, Kawanishi-cho, Higashi-okitama-gun, Yamagata-ken, 992-0601, Japan

Translator Hiromichi Harada, RPT
Organization Hamadera-chuo Hospital
Address 1-15, Hamadera-kouen-machi, Sakai-shi, 592-8346, Japan

Page number 143-147
Key words central Pattern generator (CPGs), dorsolateral system (corticolateral spinal tract and corticorubrospinal tract), and ventromedial system (corticoreticulospinal tract, corticotectospinal tract, vestibulospinal tract, and anterior corticospinal tract)

ABSTRACT: Purpose: When treatments are implemented for patients with cerebral vascular impairments, it is important to understand the nervous system and to apply knowledge about the nervous system to treatments. Here, we report a patient whose walking was improved by a treatment focusing on the relationship between CPGs, and the dorsal lateral and ventral medial nervous system. Case report: The patient of this case was a 51 year-old woman who developed right hemiplegia associated with a cerebral infarction on the 25th of March 1997. The patient received rehabilitation during hospitalization for 2 months after the onset of the infarction. She goes to hospital once or twice a week to participate in a rehabilitation program. Now, she is able to walk outdoors and take care of herself. Her walking is characterized by instability of the lower extremity of the affected side during stance phase. The affected leg was thrown forward after excessive rotation of the upper trunk and swing of both hands during swing phase. She always felt her affected leg was too heavy. Hypertonia is noted in the back lumbar region, and hypotonia is noted in the lower trunk and pelvic area. In the present treatment, the patient was urged to perceive the base of support (BOS) through balance training in a sitting position and a standing position, and to master the selective and segmental movement of the trunk, aiming for improvement of the stability of the lower leg on the affected side. For the purpose of mastering automatic walk during which the patient feels her affected leg to be lighter, an attempt was made to improve the functions of CPGs through controlling the relation between the dorsolateral and ventromedial nervous systems. Results: The stability of the lower trunk and pelvic area was increased. The feeling of heaviness in the lower leg on the affected side as well as the compensatory motion during swing phase was reduced. Conclusion: The importance of reasoning for applying knowledge about the nervous system including CPGs to clinical intervention was indicated through the present approach for improvement of walking.

Title: An approach for walking of a patient with hemi-spatial disorientation due to postapopletic sequela

Author Hidenori Togashi, RPT
Organization Clark Hospital
Address 8-20, 4-chome, 2-jo, Honmachi, Higashi-ku, Sapporo-shi, Hokkaido, 065-0042, Japan

Translator Toshiko Ishiyama, ST
Organization Nagao Hospital
Address 583-15, Kadota-cho, Hachioji-shi, Tokyo, 193-0941, Japan

Page number 148-151
Key words postapopletic sequela, walking, and hemispatial disorientation

ABSTRACT: We reported a case of Bobath Approach to a patient with cognitive failure who spent 5 months after the onset of cerebral infarction with stimulating neither physical nor environmental perception. During hospitalization, the patient hardly exhibited muscular contraction during placing as well as voluntary movement of extremities in the affected side responding to a command. Although he was able to roll over in bed and sit up, a great effort was required to do so on the affected side. There was also no attention to the affected side. His posture during walking was that the affected leg was dragged and that he walked obliquely to the non-affected side. When he started to move his lower leg, postural balance was lost and he needed support. When he paid attention to the lower extremities and/or the surrounding conditions, his autonomous movement was reduced and he fell into a dangerous state. The patient's problem was thought as follows: Fixation and movement on the affected side were attributed to the great effort in addition to poor cognition caused by a lowering of muscular and skin flexibility, leading to considerable strains of physical image and alignment. This would cause improper transmission of proprioceptive sensation to the central nervous system, resulting in perceptual dysfunction of the support system and spatial recognition. To improve such conditions, flexibility of soft tissue such as skin, muscles/tendons, and joints was improved and alignment was corrected so as to sufficiently improve the functions of sensory receptors in the peripheral system. Moreover, training for autonomous walking was repeated through a gait control system including the central pattern generator in unimpaired regions such as the spine and cerebellum. Also, training for perception of the spatial relationship between the patient and his surroundings was carried out through synchronization of movement, visual perception, and proprioceptive sensation. One month after training, his excessive effort during movement on the floor was reduced and the capability of movement for the trunk in a sitting position was increased. Three months after that, he became able to walk looking straight ahead and his excessive effort was significantly reduced, resulting in an improvement in his walking ability to a level of indoor walking with a cane under surveillance.

Title: Treatment of upper extremity and hand of a patient with postapopletic sequela

Author Seiichi Minami, OTR
Organization Bobath Memorial Hospital
Address 1-6-5, Higashi-nakahama, Joto-ku, Osaka-shi, 536-0023, Japan

Translator Takeshi Ono, OTR
Organization Bobath Memorial Hospital
Address 1-6-5, Higashi-nakahama, Joto-ku, Osaka-shi, 536-0023, Japan

Page number 152-157
Key words cerebral hemorrhage, upper extremity/hand, and putamen

ABSTRACT: The functions of cerebral basal ganglia have important roles in daily habitual activities. They are especially involved in complex and/or ordered movements of the hands/upper extremities responding to a situation. The hand thus becomes a functional organ that allows perceptual exploration of the environment and its manipulation. In order to organize perceptual information and movement information, information retrieval according to an active and reasonable exploration of the peripheral system is especially important. Here, we reported a clinical course of a patient with left hemiplegia due to bleeding from the putamen. Especially, the clinical changes for the hand and upper extremity in the affected side during the recovery period were presented. The most serious problem of this case was that postural muscle tone induced with excessive co-contraction occurred in various sorts of daily motions, leading to a restriction of the postural set. Thus, the patient's applicability for perception, movement, and exploration was poor in the upper extremity and the hand. During occupational therapy sessions, exploratory activities of the peripheral system including the hand and upper extremity were increased by repeating a wiping motion. In addition, postural responses such as exploration of proprioceptive sensation on the supporting surface and control of vestibular sensation were improved. As a result, the FIM, the SIAS, and the FUGL-MYER scores were raised and the activities of daily life (ADL) were improved. The present therapy was conducted aiming at stimulation of the anterior corticospinal tract, cortical reticulospinal tract, and lateral corticospinal tract in addition to proper response to perceptual information feedback from the respective peripheral regions. These results suggested that the treatments would stimulate the reorganization of the cooperative relationship between the peripheral and the central nervous system, which would then help the patient acquire various kinds of complex and/or ordered motions of the hands and extremities through the functions of basal ganglia.