Volume 25, No., June 2002

Title: Application of Bobath concept in early therapy for cerebrovascular disease

Institution:National Osaka Hospital
Author:Kiyonori Manabe, RPT
Key words:cerebrovascular disease, therapy in the acute stage, Bobath concept

It is said that the function of patients with cerebrovascular disease depends on the therapy given within 3-6 hours of onset. Therapists start their therapy early after the onset with due attention to risks.
In acute stage, it is very important for therapists to give patients good positioning. The purposes of positioning are to produce and maintain a good alignment of the head, scapular, and pelvis, and to improve the blood circulation in the extremities. They also give them afferent massage to improve their peripheral blood circulation. It is also important to give skin care simultaneously. It is useful not only for cleaning skin but also for preventing the sensory disturbance the shortening of skin and the depressin of muscle elasticity. These treatments are given by nurses and families as well as therapists do in cooperation with each other.
In acute stage, therapists should not instruct them to move their extremities on the affected side with voluntary effort. They should help them restore sensation that is essential for their normal life in the future. Although muscles are hypotonic in this stage, their shortening has already begun. Therapists should prevent muscle shortening by mobilization so that patients can maintain mobility that is essential for selective movement. They should pay attention to risks when they change the posture of patients into antigravity one. In the sitting position, therapists assist them to adapt their base of support and to keep good alignment in other to sit symmetrically. They assist them support on the hand without weight- bearing to prevent subluxation of the shoulder. In the standing position, they instruct patients to stand on one leg and to learn the timing and sense of another leg leaving from the floor. Therapists facilitate their balance in step-position. Expecting the restoration of gait in the future, therapists make preparations for the patterns of coordinated movement, postural tone, and automatic reactions of patients. Although patients have poor spontaneous movements of the upper extremity, therapists give them massage, mobilization, and instructions so that they can learn the sense of movement of the upper extremity and use them functionally in the future. Appropriate therapy to patients with acute cerebrovascular disease is considered absolutely necessary to induce as much cerebral plasticity as possible.

Title: Early intervention in rehabilitation for stroke patients based on the point of view of occupational therapy

Institution:Kameda Sogo Hospital Rehabilitation Center
Author:Yusuke Sasaki (OTR), Masaki Sawagata (OTR), and Naomi Matsuda (OTR)
Key words:early rehabilitation, client-oriented, and continuous

After the revision of treatment fee in April in 2000, a rehabilitation center was created for patients in the recovery period. Since then, we have had three rehabilitation centers for the acute, recovery and maintenance periods, but the role of occupational therapy in the treatment of patients with acute disease has not been clarified yet. Therefore, we have tried to clarify what occupational therapy should be given to such patients.
Before giving occupational therapy to patients early after the onset of disease, occupational therapists (hereinafter referred to as OT) ask the attending physicians about their symptoms, changes in the symptoms, and the course of treatment to acquire an accurate understanding of the condition of disease. It is important for OT to exchange information on the disturbance of consciousness and risk management with the physicians and nurses. It is also important for OT to evaluate the physical function and disability of patients in detail and to assess their requests and problems with reference to their social factors, life up to that time, and cultural background.
There are two important points in early occupational therapy. One of them is to give occupational therapy in the ward as the place of daily life. Adjusting the environment and attaching importance to the rhythm of patients' daily life, OT should give occupational therapy for improving ADL. After evaluation and treatment, they should cooperate with nurses so that patients' requests can be most appropriately reflected in their daily life. Another important point is that patients have a strong desire for adaptation. This is important, because its importance continues even after they leave the hospital.
Actual examples at Kameda Sogo Hospital are reported here. Our hospital is a major general hospital for tertiary life-saving emergency medical care. It is in a town with a population of 130,000, which is located at Minami-Boso in Chiba Prefecture. It has 30 departments and 784 beds. The average duration of hospital admission is 19 days in the hospital as a whole, while it is 51.7 days in cerebrovascular disease patients admitted to Rehabilitation Center. It has 6 OT in the ward for inpatients and 2 OT in the Department of Internal Medicine (Neurological Disease). They give occupational therapy in the ward so that patients can acquire ADL in the place of daily life. To facilitate their transfer to continuous care, we try to determine the prognosis of patients early and find appropriate institutions for them, for example, living in our own institution followed by return to home. Before and after discharge, guidance about home care is given at home. Briefly, advice about environmental adjustment, guidance for the confirmation of behavior required for patients living at home, guidance to families, etc. are given before discharge, while guidance about verification of preparations before discharge, guidance for smooth transfer to living at home, advice about additional repair of houses, etc. are provided after discharge. The guidance and advice mentioned above are given to compensate for the short duration of hospital admission.

Title: Early treatment for stroke patients based on the point of view of physical therapy

Institution:Nakamura Memorial Hospital
Author:Tomoko Izumi (RPT) and Takao Nomiya (RPT)
Key words:early rehabilitation, disturbance of consciousness, and adaptation to environments

Patients receiving treatment based on the Bobath concept from the early stage after the onset of disease are reported here.
(Case 1) A 56-year-old male was diagnosed as having cerebral hemorrhage of the left putamen. Onset was on September 11, 2001 and he was treated by conservative medical care. On September 13, PT was started. The level of consciousness was JCS (Japan Coma Scale) 3-10, and yawn was sometimes observed. Concomitant strabismus of the left eyeball was noted. He was often supine in the left part of his bed with his extremities on the unaffected side on the bed frames and could not sit up. Moderate low tone and severe hypesthesia were noted from the cervical region to the extremities through the trunk on the affected side. On September 26, the level of consciousness improved to JCS 2. Although talkativeness was observed, yawn and concomitant strabismus of the left eyeball tended to disappear. He could turn over and then sat in the bed by gripping the frames. However, he should be helped to transfer from the bed to the wheelchair and could not walk.
(Problems and goals) The patient had the problems: disturbance of consciousness, decreased attentiveness, concomitant strabismus of the left eyeball, sensory disturbance on the affected side, and low tone from the upper and lower extremities to the pelvis through the cervical region and trunk on the affected side. These problems induced hyper activities of the unaffected side and inhibited bilateral integration. Therapy was given to prevent the organization of his abnormal patterns, to improve his potential ability, and to enable walking. He was required to be aware of the midline by handling with the key-point of control. As a result, his hyper activities on the unaffected side reduced and integration of both sides and connection of the upper and lower parts of the trunk became possible. On October 16, he had clear consciousness and could walk.
(Case 2) A 48-year-old woman had cerebellar hemorrhage on August 8, 2000 and underwent surgical resection of hematoma. On August 15, PT was started. The level of consciousness was JSC 10, and slight somnolence was noted. Severe vertigo was noted, which got worse when she turned over or sat. She had decreased attentiveness and impaired concentration and tended to reject instructions from the therapist. She could perform turning over accompanied with slight rotation of the trunk by gripping the bed frames. She could sit up only with assistance.
(Problems and goals) Her problems were coordination disturbance mainly in the left extremities, decreased ability of keeping posture against gravity, aggravation of vertigo and vomiting on exposure to gravitational stimulation, and adaptation disorder to gravity. During therapy, the therapist adjusted the tone of the trunk and promoted her adaptation to gravitational environments, attaching importance to relearning of posture-keeping ability and fundamental activities. To resolve somnolence, speech and tactile stimulation was input actively from the early stage after the start of treatment to improve her wakefulness. In Case 2, the therapist advanced a hypothesis that her symptom was "disturbed adaptation to gravity environments" and tried to verify it during treatment with controlled amounts of gravity stimulation. As a result, vertigo and vomiting decreased and she could turn over without assistance and gained assist gate with a quad cane. Early leaving sickbed is usually included in the goals of early rehabilitation. However, it is considered dangerous that therapists mechanically give "therapy, such as early rising up and sitting," to patients with problems. On the other hand, it is extremely effective if therapists have an accurate understanding of the condition of patients, clarify the relationship between clinical symptoms, predict potential disturbances, and then give such treatments while trying to verify hypotheses.

Title: Occupational therapy approach for a patient with left hemiplegia in the recovering stage

Author:Tetsuhiko Hyodo (OTR),
Institution:Kokuritsu Ryoyosho Hukuoka Higahshi Hospital
Address:1-1-1, Chidori, Koga, Fukuoka, 811-3195, Japan
Key words:cerebrovascular accident, recovering stage, and selective movement

Improvement of ADL is the first goal of rehabilitation in the recovering stage of cerebrovascular accident. This case report describes the efficacy of occupational therapy in the recovering stage from the standpoint of ADL in 1 patient. The patient was a 64-year-old woman who had left hemiplegia due to subarachnoid hemorrhage. She used a wheelchair and needed assistance for self-care. She had the following problems on the affected side: decreased mobility from the cervical to the scapular region on the affected side, pain in the upper extremity on the affected side, hypersensitivity of the palm on the affected side, decreased stability of the trunk, visual-spatial perception on the affected side, decreased body awareness on the affected side, and emotional problems.
The occupational therapist (OT) tried to improve patient's stability of the trunk, body awareness, and attention by promoting the selective movement of the trunk. He also tried to improve the awareness of relationship between the external environment and her physical movement by promoting environment-adapted body movement while instructing her to visually recognize environmental changes. As a result of these treatments, pain in the upper extremity and hypersensitivity of the palm reduced on the affected side, and visual-spatial perception improved. Furthermore, emotional problems, such as decreased relations with others, also improved. She could walk under close watching, and her self-care generally improved. The Barthel index improved from 41 to 75.
These results indicate that environment-adapted movement is made possible by promoting selective body movement and improving visual awareness of environmental changes. Further, the improvement of environment-adapted movement means a new understanding of "oneself". Briefly, they begin to explore the environment and try to increase their relations with others, showing emotional changes.

Title: developmental support for very low birth weight infants: role of NICU

Institution:Kanagawa Children's Medical Center
Author:Kumi Kishimoto (RPT), Tomoka Matunami (RPT), and Yasuko Tanaka, (OTR)
Key words:very low birth weight infant, developmental support, and family support

Although perinatal medical care has progressed, problems about the development of very low birth weight infants (VLBW) have not been solved yet. These problems are subtle neurobehavioral abnormalities related to motor function, behavior, learning, etc.
This report describes the overall situation of developmental support to VLBW at our center.
For inpatients, physical therapists (PT) are engaged in environmental adjustment, such as adjustment of light, sound, and position, respiratory physical therapy, neurological evaluation and treatment, sucking training, and support to parents and families.
As follow-up activities for patients after discharge, our hospital performs medical examination by physicians specialized in rehabilitation, PT therapy (where necessary), overall conference on continuous medical care, management of associations for infants aged 1-2 years or children before entering school and their parents, and follow-up survey and evaluation by tests, including JMAP (Japanese Version of Miller Assessment for Preschoolers) and SRAT (Schooling Readiness Assessment Test). In the evaluation of schooling readiness by the SRAT, the score was 33% in the group receiving no environmental adjustment during hospital admission, while it was 59% in the group receiving it.
To cooperate with local communities, we ask local home nurses and hygienists to come to our hospital before discharge to give them information about the patients to be discharged. We also hold lecture meetings for hygienists and give advice to them at group guidance meetings sponsored by health centers.
Through these activities, we do not intend to emphasize the importance of special support to parents of very low birth weight infants, but we want to help them understand ordinary child-raising and take some effective measures for their infants. It is important for us to support the parents so that they can have confidence and affection which are essential for child-raising.

Title: Early checkup and early therapeutic education in NICU by using Brazelton's neonatal behavioral assessment scale

Author:Maki Fujioka (RPT), Yoshihiro Kawarai (RPT), Makiko Ichiguchi (RPT), and Yuri Inagaki (OTR)
Institute:Osaka Boshi Sogo Hoken Iryo Center
Address:840, Murodo-cho, Izumi, Osaka 594-1101, Japan
Author:Toru Shibata (M.D.)
Institute:Bobath Memorial Hospital
Address:1-6-5, Higashi Nakahama, Joto-ku, Osaka 536-0023, Japan
Key words:high-risk infant, Brazelton's neonatal behavioral assessment scale, and early therapeutic education

The NICU of our center evaluates high-risk infants using Brazelton's neonatal behavioral assessment scale. Among the high-risk infants evaluated by this method, 29 infants who were also followed up to check development after discharge were classified as the normal development, developmental disorder, and cerebral palsy groups and compared with respect to the results of evaluation.
The score for induction reaction (neurological test for abnormal reflex) was higher, but the score for stress reaction to noxious stimulation was lower in the high-risk infants of the normal development group than in the term infants. The score for induction reaction was higher, but the score for stress reaction was lower in the cerebral palsy group than in the normal development group. It was difficult to measure their direction-related reaction (reaction of paying attention to visual or acoustic stimulation), because the consciousness of infants did not continue or because stress reaction occurred. The score for induction reaction was higher in the developmental disorder group than in the normal development group.
These results suggest that the behavioral evaluation of high-risk infants detects the characteristics of the cerebral palsy group in the neonatal period and is useful as the index of early diagnosis of developmental disorder/early therapeutic education. We will continue behavioral evaluation in a larger number of high-risk infants and follow up them for development in studies on the significance of early therapeutic education.