Volume 27, No.2, Dic, 2004

Title: Approaches to cognitive dysfunction based on the Bobath concept

Organization: Tokorozawa rehabilitation Hospital
Author: Aya Sugiyama ,ST
Key words: Cognitive dysfunction, Aphasia, perception

In this article, the speech therapy sessions for two patients with impaired communication abilities (an aphasic patient and a patient with right hemisphere symptoms) will be discussed based on the Bobath concept.
The author considered that the two patients were having problems with adapting to their environment due to central neurological disorders. The author gradually induced clear and meaningful sensory information with postural stability.

Case 1
The patient showed severe right hemisphere symptoms. He had cognitive dysfunctions (attention, orientation, multifaceted and systematic thinking, emotion, behavior, lack of insight into disease and memory) and unilateral spatial neglect. These factors caused his communication disorder.

E Therapist stabilized his posture. Additionally, therapists helped
him to achieve automatic movement.
E Therapist helped the patient actively perceive an object through
visual and somatic sensation and to explore it.
E Therapist performed therapy in order to improve the patient's memory while stabilizing his posture.

The physical and cognitive functions of the patient were improved. His unilateral spatial neglect was also alleviated. He learned to maintain his attention to the activities of his daily life. Additionally, his emotional was balanced. He did the frequency of appropriate behaviors in circumstances and contexts.

Case 2
@ The patient had right hemiplegia and severe aphasia with apraxia of speech and oral facial apraxia. His auditory-based perception was impaired. His answers to yes-no questions were ambiguous. He had no speech. However, he had no orofacial paralysis.

E Therapist encouraged him to recognize visual, auditory and kinesthetic sensations as well as his movement. Therapist then set a treatment goal for the patient to master communication ability.
E Therapist prepared his movement to be able to express words easily. Therapist reduced the muscle tone of the patient's whole body. Additionally, therapist reduced both the excessive extension of the neck and the flexed fixation of the patient's trunk.
E The therapist selected brush calligraphy and water-color painting as expression-based therapeutic activities. Through these activities, therapist helped the patient to receive sensory information from the unaffected arm more easily.
E The therapy helped the patient perceive his own articulatory movements.
E Therapist had the patient utter the "P"sound - an easy sound for him - accompanied with his movement using articulatory motion.

The patient was better able to utilize his body functions. The patient's facial expressions increased and he learned to express Yes and No clearly. The amount of communication using gestures was increased. Additionally, the patient learned to pass on some meaningful information by writing characters and drawing pictures.

Title: Occupational therapy approach for a patient with left hemiplegia who can't wear a sleeve through the affected upper limb

Organization: Bobath Memorial Hospital
Author: Takeshi Shirayama, OTR
Key words: left hemiplegia, dressing, exploration

This paper reports on therapy for a left-side hemiplegic patient with impaired voluntary movement who cannot put the affected arm through a sleeve.
The patient knew how to dress herself. However, she was only able to place the clothing against the affected hand without being able to get it through the sleeve. Additionally, she could not recognize that her posture in the wheel chair came out of alignment.

The OT proposed the following three reasons for her not being able to put the affected hand through the sleeve.
@ She had difficulty in receiving somatic sensory information from the affected arm due to the excessively fixed posture and motor patterns of the unaffected side.
A The patient had poor awareness of the affected side, in particular poor visual orientation, due to the mild unilateral spatial neglect. So she could not find her affected hand.
B It was difficult for her to feel the affected hand because of the instability in the affected lower trunk and around the shoulder girdle, based on unilateral spatial neglect and disturbance of sensation.

The OT gave her the visual and somatic sensation and encouraged her to explore her environment by using the affected arm and hand. The OT anticipated the following three improvements by using the patient's exploratory activity:
@ The patient being able to feel the changes of her base of support and move her trunk and affected arm forward.
A The patient being able to appropriately move the whole body based on the tactile motor sensation of the dorsal surface of the affected hand.
B The patient being able to perceive her affected arm and make appropriate movements to manipulate her clothing.

During the therapy sessions, the OT first stabilized her posture, prepared shoulder girdle muscle activation and facilitated upper limb selective movement against the trunk when handling objects on a desk. Then, in order to facilitate postural responses based on visual sensation and tactile motion sensation, the patient practiced putting her arm through a sleeve by simulating the motion over the affected arm using a towel. After the patient learned to move the affected arm smoothly, she practiced with both hands on a balloon to learn coordinated movement of the affected and unaffected arms. As a result of the above OT sessions, the patient learned to put the affected arm through the sleeve and put on and take off one-piece clothing by herself.
The OT concluded that the correlation between the patient and the environment in order to obtain the ability to get the affected arm through a sleeve was important.

Title: Treatment experience for the patient with recurrences of cerebral infarction

Organization: Nanshou Hospital
Author: Masanori Onodera, RPT
Key words: recurrence of cerebral infarction, reference point, activity

This paper reports on the therapy of a case where functionality was impaired due to repeated cerebral infarctions occurring at four different times. The neck and trunk were flexed and tilted forward and could not maintain their extended position. The patient had an unstable sitting posture and required moderate or extensive assistance to perform the activities of daily living. The patient's activity level was extremely low. The patient was almost always in bed. The patient had problems with the volition and recognition of movement and acted without thinking. This resulted in his falling down repeatly.

PT provided treatment for the case shown below:
@ The mobility of the patient's left lower limb was improved so that he could register sensory information from his feet.
A Segmental extension of the spine and forward tilting of the pelvis when standing up were facilitated.
B The segmental movement of the trunk of the patient was facilitated while he was encouraged to actively transfer his center of gravity.
C Antigravity extension movements were activated by practicing standing on one foot or going up stairs.
D PT helped the patient to maintain the extension movement from the central key point so that the patient could attain a certain level of rhythmic walking speed.

Additionally, PT instructed the patient's partner about methods of assistance. With such instruction, his partner could understand the scope of his ability and provide more effective assistance in daily activities. As a result, the amount of assistance the patient needed decreased.
It was important for the therapist to analyze patient's@ complicated problems and active and dynamic therapy was effective. Additionally, it was reaffirmed that providing help was important not only for the patient but also for the assistants.

Title:@Influence by standing on walking

Organization: Yamanashi Red Cross Hospital
Author: Masahiko Miyashita, RPT
Key words: Walking, Japanese life style,

The patient was hemiplegic with problems moving in Japanese-style rooms. The patient could independently walk outdoors, but had to live life in chairs in Japanese-style rooms. At home, he showed exaggerated motion and excessively elevated muscle tones when standing up from the floor with the hands on the low table, taking one step to turn around in an upright position, walking to the corner of the small table with an electric heater underneath and covered by a quilt. Additionally, she was likely to lose her balance if she walked on a cushion and was at risk of falling. It was supposed that she had difficulty in moving in a Japanese-style room because it was difficult for her to stand up from the floor or to sit on the floor. A squatting action was one of the basic action necessary for these functions.

Purpose of treatment
Improvement of trunk flexion and rotation towards the direction of gravity

Therapeutic program
1jThe therapist had the patient look at the sides of a large box that was put on the floor in both a sitting posture and an upright position.
2jThe therapist prescribed her the task of her head reaching the large box placed in front of her.
3jThe therapist set another task of walking on a soft mat in order to enhance trunk stability.

Two months later at the re-evaluation, the patient's movement had improved. Additionally, she could move easily in Japanese-style rooms.

Walking should be seen as one in a series of means used to perform a certain task.
As a Japanese-style table is lower than a standard western-style dining table.The distance between the head of a patient in a standing posture and the Japanese-style table is greater when compared to western-style tables. Therefore, a patient rarely utilizes visual information when walking alongside a Japanese-style table.
As a result, the body of a patient is likely to react excessively to compensate for the lack of visual information.

The important things for a patient to move effectively in a Japanese-style room are as follows;
@ Operation of the upper limbs so that the patient can obtain the perceptual information corresponding to the task.
A Actions of a patient that enable the patient to continue to explore of the patient's center of gravity.
B Sequence of movement from feet to neck

In this case, it was important that the patient could squat to obtain these three things.

Title: An occupational therapy approach for apraxia based on clinical features: Postural reaction and task accomplishment with a patient with severe aphasia

Organization: Fuji-onsen Hospital
Author: Minoru Yamada ,Occupational therapist
Key words: postural reaction, postural set, feedback

In this paper, an experience of occupational therapy with a patient@with severe aphasia having apraxia symptoms is going to be reported. During the occupational therapy sessions, an occupational therapist focused on helping the patient correct his unsuccessful actions. At the end of these sessions, the occupational therapist confirmed that the patient's ability to prepare his postural set was indispensable to successfully accomplish tasks.

A patient had been suffering from right hemiplegia and severe aphasia due to a post subarachnoid hemorrhage. According to his CT imaging, the patient had low density areas in his left frontal lobe, temporal lobes, parietal lobe and occipital lobe.

The patient couldn't control his posture while moving because he couldn't change high tone in his upper trunk and right shoulder girdle according to his movements. He couldn't successfully accomplish tasks such as serving tea. The therapist noticed that the patient had difficulty in organizing several actions to accomplish specific tasks. He couldn't connect one action with a subsequent action. Therefore he couldn't continue his actions.

The therapist set up 2 activities: cutting pieces of paper with scissors; singing songs and moving body in accordance with the songs. The therapist expected an improvement of the patient's postural control through adequate peripheral sensory inputs as well as visual and auditory inputs. The therapist helped the patient to be interested in the activities.

The patient's high tone was reduced, and his posture control was improved. The clinical features of the patient were changed. Eventually the patient could correct his inadequate actions by himself while serving tea.

Patients with aphasia often have difficulty in accomplishing tasks. Although people without aphasia can also make careless mistakes while trying to accomplish tasks, they can usually correct their mistakes when doing them carefully. In contrast, patients with aphasia could be confused when they fail to accomplish tasks once.

It seems that the patient with aphasia having apraxia symptoms couldn't correct his inadequate behaviors because of his poor anticipatory postural reactions which were not able to get feed back from preceding actions. The patient needed to perceive changes in sensory information based on automatic postural control in order to accomplish tasks. The postural control is successfully performed based on not only proprioceptive sensation but also specific sensations such as visual and auditory sensations. Correcting inadequate actions while trying to accomplish tasks also requires feedback from sensory systems. Improvement of the patient's postural control is indispensable to improving his apraxia.

TitleF Organization of sensory information and postural control in a child with cerebral palsy caused by PVL without sitting function

OrganizationF Tokyo Children's Rehabilitation Hospital
AuthorF Mutsumi Marumori, RPT
Key WordsF PVL, The organization of sensory information, Postural control

This paper reports that the PT helped the child with cerebral palsy caused by PVL to organize visual sensation, somatic and vestibular sensation, and eventually improved his postural control. After treatment, he could sit alone with the support of the his upper extremities, focus his eyes upon objects when using his upper extremities, stand up and sit down by using a table in front of him, and alternately swing lower extremities when he walked with an SRC walker. Before the treatment, he focused blankly around him. However, after the treatment, his visual perception was improved and he could enjoy playing with toys.

PT identified the child with five problems as follows:
@ Hypotonic lower trunk and hypertonic pelvis and lower extremities
A Insufficient establishment of body schema of his lower trunk and lower extremities
B Difficulty in perceiving visual information effectively
C Difficulty in perceiving the supporting surface by using proprioceptive information
D Hyperextension of his body, caused by the reactions of the vestibular system due to unstable movements of his head

PT performed the following treatments for him.
@ PT helped him to make a good alignment of his body and to mobilized his skin and muscles, so that he could take in the information from his hands, palms, bottom and soles easily.
A PT helped him to maintain a sitting posture with his arm support. Additionally, PT encouraged him to regain his balance in the sitting posture by feeling changes in visual information, somatic sensation, and vestibular information. Through such therapy, his balance was improved.
B PT encouraged him to perform upper limb manipulation tasks that enhance visual response and sitting balance.

PT planned a gradual improvement program by devising tasks to improve his upper limb ability and visuoperceptual function. It was important that he should move actively during therapy sessions. PT assumed that people make use of many perception systems to perceive the position of their body in space, so perceptual systems effect each other and induce functionally.