Volume 27, No.1, June, 2004

Title: Physiotherapy for two hemiplegic patients with cerebro-vascular disorders during the spastic period - Focusing on lower limb functions -

Organization: Department of rehabilitation, Rokujizo general hospital
Author: Hirofumi Watanabe, RPT
Organization: Research center of neurological diseases, Kansai College of Oriental Medicine
Author: Toshiaki Suzuki, RPT
Key Words: hemiplegic patients with cerebro-vascular disorders, spastic period, lower limb functions

In this article, two case reports of hemiplegic patients with cerebro-vascular disorders who had received physiotherapy in the acute stage at the different hospital, than the author's hospital will be presented. In both cases, patients were wearing ankle-foot orthoses immediately following the onset and have received walking exercises, using parallel bars or a four-pointed cane. Possibly caused by those exercises, the patients exhibited abnormal muscle tone around the ankle on the paralyzed leg and their sensory disorders were exaggerated. The sole part of the foot of patient 1 did not make sufficient contact with the ground without his ankle-foot orthosis. In the patient 2, the sole part of the foot failed to function as a base of support due to sensory disorders. Those conditions in which their soles have lost the function as a base of support has interfered with activities of their trunks which are the central parts of the body, and brought about instability in postures, while standing up, standing still, and walking.
For these two patients, the initial objective of physiotherapy (PT) was to make their soles function as a base of support. During physiotherapy sessions, activities of their trunks, which are the central parts of the body, were facilitated by the means of movements such as standing up, standing still, and walking.
In case 1, the state of out-of-alignment in the leg due to the abnormal muscle tone in the area of the ankle joint was greatly affecting his control of posture. The abnormal relationships between the extremities and the central trunk, and that in paralyzed and non-paralyzed sides in the trunk are presenting the serious problem. In case 2, disorder in weight perception was causing abnormal support activities in the paralyzed lower extremity. In addition, case 2 was excessively using his non-paralyzed upper limb to compensate for their reduced capacity to support their body parts by their paralyzed lower limb, especially while walking. These 2 cases have provided confirmation of the importance of lower limb functions, especially those of the foot as a base of support, for movements such as standing up, standing still, and walking.

Title:An approach based on the analysis of postural control strategies

Organization: Hiroshima College of Rehabilitation
Author: Atsushi Yamakawa, OTR
Key Words: home-based rehabilitation, postural control strategies, walking

In this paper, a home-based rehabilitation program for a patient with hypotonia at the central part of the body as a result of left hemiplegia following the hemorrhage of the right thalamus, which was provided by the Japanese Long Term Care Insurance, is reported.
This case fell into a vicious circle due to associated reactions caused by following three factors;
1) Hypotonia both in his lower trunk and around his hip joint of his paralyzed side.
2) Abnormal linkage between his upper trunk and the pelvis of his paralyzed side, as well as the loss of ability to perform pelvic anti-gravitational extensive movements.
3) His postural control strategies made for compensating these above-mentioned factors.
In order to deal with these three factors, the therapy was focused on the following two points;
1) Adjustments of hypotonia in his paralyzed hip joint, through the manual handling of a therapist, accompanied by enhancement of sensory stimulation which provided information about his base of support, by using a chair.
2) The placing of his paralyzed lower limb while bending his knee to increase linkage between the upper trunk and the pelvic band during the swing phase of the paralyzed lower limb.
As a result of the therapy, his total extension pattern of the lower limb in his paralyzed side, being the patent's compensatory postural control strategy, decreased and the patient could more easily stand up, stand still, and swing out his paralyzed lower limb while walking. At the same time, however, in@turn due to the reduction of his total extensive pattern of his paralyzed lower limb, which was his postural control strategy, the instability at his paralyzed knee area during the stance phase increased, which resulted in the deterioration of his daily walking capability.
The experience of the therapy for this patient has revealed that identifying useful strategies and detrimental strategies through analysis of the patient's postural control strategies within his/her daily life is very important.

Title:Effectiveness on Bobath approach for adults with post-stroke hemiplegia

Organization: Bobath Memorial Hospital
Author: Masamichi Furusawa, RPT
Key Words: post-stroke hemiplegia, Bobath approach, effectiveness

The purpose of this article is to discuss how we might build evidence concerning effectiveness on Bobath approach for treatment of adults with post-stroke hemiplegia through review of literature available throughout the world.
The basic principles of Bobath approach, which are hypothesis testing and improvement of therapists' handling skills through case studies, will never change. Limited budgeting within the field of medicine due to the current economical situation in Japan, however, has resulted in remuneration tending to favor treatments which has been established based on medical evidences. Thus, unless we demonstrate medical evidences for the effectiveness of treatments, fees for treatments in the medical insurance, even in the long term care insurance later on, might be faced with downward revision. In Bobath approach which has been developing mainly through hypothesis testing in case studies, medical evidences should be established. Scientific criticism and discussion will certainly improve the quality of the contents of Bobath approach. Thus, to establish evidences in the effectiveness of Bobath approach for adults with post-stroke hemiplegia, randomized controlled trials (RCT) are required. We must keep in mind that, as evident in foreign reports, RCT are conducted in the US and Europe where the awareness of the notion of human rights is more acute as compared with that in@Japan. Toward promoting RTC studies, we must strive to establish closer therapist-physician relationship.

Title:"Access to Success" treatment program in school-settings for a child with spastic diplegia: collaboration of physical therapists at a hospital-school and ones at a day care center for children

Organization: Minami Osaka Children's Hospital
Author: Misako Nishiwaki, RPT
Organization: Inagawa Ryoikuen (Kishiwada municipal day care center for children with disabilities)
Author: Chidori Ohashi, RPT
Key Words: spastic diplegia, support for primary school enrollment, patient-family-centered treatment rearing, collaboration between institutional and regional services

Ms. Nishiwaki, as a physical therapist in an institution for children with physical disabilities, and Ms. Ohashi, as a physical therapist in a regional day care center for children with physical disabilities, have had an opportunity to treat a girl with spastic diplegia. Ms. Nishiwaki and Ms. Ohashi, by means of their collaboration through full use of each service's advantages, attempted to provide practical assistance to the girl for school enrollment. The objective of the treatment was that the girl could effectively acquire functions and make use of these functions at her school. In this article, primarily from a viewpoint of motor learning, physiotherapy treatment process to the girl is reported.
As the girl's equinus pattern had increased while walking, she was hospitalized for 6 months from the age of 6 years and 3 months in Minami-Osaka Children's Hospital for remedial surgery and intensive treatment. In providing physiotherapy treatments in the institution, the following four points were considered:
1) Ms. Nishiwaki set up the treatment objectives in cooperation with the girl and her family (family-centered treatment rearing).
2) Ms. Nishiwaki promoted the girl's motor learning by means of recognition of tasks, oral directives, demonstration, manual guidance, feedbacks, and environmental adjustments.
3) Ms. Nishiwaki tried to provide task-oriented exercises that would be required at the girl's daily school life.
4) Ms. Nishiwaki arranged the exercise program in order to motivate the girl to improve her functions as an active learner.
As a result, at the time of discharge from the institution, the girl was able to walk again through recovery of her heel contact ability. In comparison with the beginning of her hospitalization, the girl was also able to stand in a more stable manner and capable of walking longer distances without falling by the time of discharge. After discharge, the girl enrolled in a local primary school.
After discharge from the institution, Ms. Ohashi, the regional physical therapist, took over the care of the girl. Ms. Ohashi concentrated in applying the girl's newly acquired capabilities in her daily life, through arrangement of her physical living environment as well as people who were around her, such as other family members and teachers.
She is now in the second grade of the local primary school and is happily attending the school.

Title: Motor learning in a sixth-grader with athetosis
-Toward occupational therapy programs which support children's lives for life-

Organization: Minami Osaka Children's Hospital
Author: Naoko Mohara, OTR
Key Words: Motor learning, athetosis, sixth-grader, life skills

Objective: This paper reports a process of occupational therapy which focused on improving the patient's standing capability and upper limb functions as well as psychosocial skills (life skills) for a girl with athetosis who stopped going to school.
Method: While the girl was institutionalized for 5 months starting from December 1st , 2002, occupational therapy for her had been provided. The occupational therapist evaluated and treated her in the areas of "building of self-respect", "decision-making", "confidently being able to express herself", "setting personal goals" and "stress management". The therapeutic objectives were decided mainly based on the patient and her mother's requests. A comprehensive rehabilitation plan for her was made and implemented by a team comprised of therapists and ward staff. With respect to the occupational therapy, a graded set of exercise plans of increasing difficulty were applied in order to enable the patient to learn new skills in practical situations.
Results: The girl's upper limb functions improved as her ability to stand became increasingly stabilized. In order for the girl to be able to make use of her new-learned skills in everyday life, however, she needed to learn how to ask her attendants for what she needed in specific terms.
Conclusions: Each child with disabilities during the primary school period must have motor learning programs appropriate for his/her level of cognitive abilities. From the standpoint of their age and motor learning level, environmental adjustments and continuing efforts in repetitive learning to facilitate habit formation in acquiring their life skills are required.
Discussion: In order for children with disabilities to be able to freely express themselves, their learning environment must continually and holistically be re-adjusted. In order for children with disabilities to use movements as a technique to actively live their own lives, specialists are required to carry the role through which adjustments of social environment for children with disabilities can be achieved.

Title: A clinical approach to motor skill learning in a child with sequela of cerebral basal ganglia hemorrhagic infarction

Organization: Department of rehabilitation, Juntendo university hospital
Author: Eriko Kitahara, RPT
Key Words: cerebral basal ganglia, procedural learning, motor skill

In this paper, we will discuss the treatment experience for a ten-year old boy who has difficulties in mastering "physical skills" such as playing catch and jumping rope. When he was three-years old, he experienced an episode of hemorrhagic infarction in the basal ganglia of the cerebrum. MRI analysis revealed an area of abnormal signs in the frontal area of the putamen. He demonstrated fluctuating muscle tone in his right lower limb and hypertonus at the terminal ranges in external rotation of the shoulder joint, extension of the elbow joint, spination of the forearm, and dorsiflexion of the wrist on his right side of body. His throwing action was awkward and experienced difficulty in throwing a ball at a target. He was unable to control his knee joint in a step-wise fashion. The physical therapist assessed the boy's motor learning process through the button-pushing exercise (Hikosaka, 1995). After repetition of the tasks, the time for task performance didn't become shorter in visual-directed tasks, but became shorter in procedural memory tasks. The PT hypothesized that procedures to follow for performing movement tasks might help the boy accomplish movement tasks automatically. The PT proceeded to make adjustments of muscle tonus of his right upper and lower limbs. The PT, then, clearly stated the steps to follow while standing up and ball-throwing to the patient and assisted the patient to repeatedly perform required movements, taking the prescribed steps into account. In 9 months of continual treatments, the boy learned to bend his right knee in harmony with the flexion-rotation movement of trunk during the ball-throwing movements, and he was able to aim the ball at a target. The PT assumed that the frontal lobe brain activities that take notice of the steps of movements would have helped the activities of the basal ganglia to transfer from the anterior part to the posterior part. Such transference is thought to make movements automatic.

Title:An occupational therapy approach for a child with spastic diplegia

Organization: Bobath Memorial Hospital
Author: Kenji Kise, OTR
Key Words: visual perception capability, posture, ocular movement

Due to technological advancement in medicine during the perinatal period, the etiological causes of cerebral palsy have begun to change. Many of the current causes are actually periventricular leukomalacia (PVL). A major symptom of PVL is spastic diplegia. The characteristics of the symptom in the diplegia caused by PVL differ from those of the diplegia caused by the perinatal asphyxia.
Most children with diplegia at the Bobath Memorial Hospital are brought on by the PVL. At the Bobath Memorial Hospital, occupational therapists are engaged in a program of visual perception problems for children with diplegia.
In this paper, a 6-month occupational therapy program for a child with diplegia who was four years and six months old is chronologically described with an emphasis on the issues of visual perception.
In the present case, habituation of her way of looking at objects asymmetrically, where her right eye was predominant, was causing asymmetric visual perception with her neck laterally flexing to the left. The asymmetric visual perception resulted in increasing retraction at her left upper limb and lateral flexion to the left at her neck. The alignment of her neck was fixed without self-realignment in lateral flexion to the left during the movements of the upper limbs. The problems were the fixation of her neck alignment. The occupational therapist (OT) has concluded that her ability to visually perceive both a space which is located in her left side and the depth in space, which provides the basis for perceiving vertical alignments of objects, could remain immature.
Thus, the OT analyzed the relationship between her posture and visual perception or her posture and proprioception, and built the treatment schedule, which had several steps according to the patient's recovery. And the OT continuingly treated the patient after surgery. As a result of the therapeutic process, the simultaneous use of two hands became easier to the patient and facilitated the perception of her midline. Her ability to use her upper limbs, as well as her postural control had made improvements.
These improvements not only gave her improved movements, but also gave her a sense of ease for her overall activities. In addition, they also made her move on the basis of prediction and gave her the opportunity to actively cope with external environment on her own without any help from the adults.
It is important in treating children with diplegia to focus on the relationship between proprioception and visual perception and repeatedly test hypothesis during the treatment.