Volume 28, No.1,June,2005

Title:Approach to intraoral intake -Discussion concerning gastrostomy-

Organization: Isawa Spa Hospital
Author:Mayumi Hirota, OTR
Key words: starting from rehabilitation principles, gastric fistula, and meal


In this report, the intraoral intake of patients with gastric fistula is discussed and one patient's course of treatment is taken as an example. The patient underwent a gastrostomy 7 months after a brain contusion. He got around in a wheelchair and his activities of daily living (ADL) were fully assisted. When he ate rice gruel processed in blender and performed a reaching movement toward his mouth, which required high tone in the head and neck area and down into the trunk, this posterior retraction of the parts around the mouth cavity, such as his mandible, tongue and bucca were enhanced. Also, raising the tongue and soft palate made closing the oral and nasal cavities difficult. As a result, aspiration occurred as a result of delayed swallowing. Consequently, the author tried the four following approaches:
@Realignment of the region around shoulders, improvement of mobility of the upper extremities, trunk, head and neck, and inducement of coordinated body actions
AEnhancement of the mobility of the tongue and bucca by providing contact inside of the oral cavity (i.e., by sucking a lollypop) to encourage use of the oral cavity as a perception-based exploratory organ
BActivation of cooperative reactions between the upper extremities, head and neck area and the oral cavity in order to normalize the serial stages of the swallowing function
CProvision of treatments for the patient, so that he could take semisolid meals on a daily basis
As a result, he was able to eat yogurt without aspiration even though his swallowing was liable to be delayed. He was able to enjoy eating with ease, although he received his nutrition mainly from the gastric fistula.
The gastric fistula makes it easier to start training for eating and swallowing than to start training with a nasogastric tube. However, we therapists should keep in mind that most patients with a gastric fistula also have dysfunctions due to long-term use of nasogastric tubes.

Title: A report on a support program for a patient to return home from the convalescence rehabilitation ward

Organization: Kitamurayama Kouritsu Hospital
Author:Osamu Suzuki, RPT
Key words:home visit, convalescence rehabilitation ward, and team approach

Abstract: The patient suffered a stroke in the left corona radiate on October 3 in 2004, and started rehabilitation on October 4.
Then, she was transferred to the convalescent rehabilitation ward on October 28.
The patient had severe palsy in the upper and lower extremities and fingers of her right side.
The patient required assistance with daily living activities other than for meals and grooming.
Family members worried about the patient being released from the hospital to return home, because there were many steps to go up and down in the house;
The attending physical therapist (PT) visited the home on December 19th, before the date of discharge was fixed.
The PT provided the family members and care manager with information about her actual movement abilities and goals, and provided guidance about how to assist the patient.
It became apparent that the patient could hardly cross the threshold or go up and down stairs, so, the PT added these activities to the patient's program.
In the training for the stairs, the patient went up and down them facing the wall (i.e., crawl-fashion).
The PT guided the lower limbs while providing stimuli in order that the medial part of the ankle joints brushed against the edge of the steps.
As a result, the associated reactions of the upper and lower extremities of the patient were reduced in fundamental movements.
So, the patient fell less. Additionally, the patient was able to walk around indoors assisted by family members.
The attending PT reduced the anxieties of the patient and her family members by structuring daily life activities in a practical manner.
Generally, repeated practices were required for recovery of functions in patients with central neurological diseases.
With this patent, it also became clear that therapists should understand patients' life circumstances in order to make thoserepeated practices meaningful and high-quality.
Also evident was the importance of providing information to regional and local staff who takes care of patients after they are discharged from hospitals.

Title:Occupational therapy in a medical ward

Organization: Juntendo University Juntendo Tokyo Koto Geriatric Medical Center
Author: Akira Nagasawa, OTR
Key words: emotion, life in a medical ward, and cooperation with nurses

Abstract: It is important for rehabilitation staffs to cooperate with ward nurses, because rehabilitation staffs often get involved in the lives of patients in a medical ward.
Nurses often seek advice from rehabilitation staffs about fundamental movements such as rolling over, positioning and transferring. So, cooperation among rehabilitation staffs and nurses is important for the functional recovery of patients.
The author attended a patient who had developed severe right hemiplegia and right unilateral spatial neglect a month ago.
The patient strongly resisted any assistance or alterations to his environment, therefore, he had been bedridden for a long period of time.
Out of the possible activities in the life of the patient in a medical ward, the author and nurses chose a specific activity to be improved on, in order to reduce the assistance load.
It was thought that the patient resisted assistance with activities not only because of decreased his systemic mobility but also out of displeasure.
We decided to improve bathing activities in consideration of these three following points:
1: It was an activity performed outside the private room (in order to get the patient out of bed)
2: It was a clearly defined activity (a habitual activity)
3: It was a source of pleasurable stimulation
The author explained to the nurse how elasticity of the skin and soft tissue, enhanced by washing patient's body in the bathroom, would improve balance responses such as the segmental movement of his trunk and the stability of sitting, and then showed the nurse specific methods.
As a result, his ability during bathing activities was functionally improved.
When the patient demonstrated functional improvement, the author realized again the importance of unified goals for each patient and effective implementation of specific care methods for each patient in collaboration with nurses.

Title:Life support after discharge through outpatient occupational therapy for patients suffering sequela from a stroke -Relationship between treatments for upper extremities and hands and life support-

Organization: Seiai Rehabilitation Hospital
Author: Kazumi Kondou, OTR
Key words: stroke, outpatient occupational therapy, and upper extremity-hand

Objective: In this report, the relationship between supporting a patient's life at home and outpatient occupational therapy is discussed concerning a patient with right hemiplegia.
Case: The patient developed right hemiplegia on January 25 in 2003. Outpatient rehabilitation started at our hospital one year and five months later.
The patient could walk by herself and go about her daily life without assistance, except for bathing.
Her upper extremities and fingers showed voluntary movements. However, the range of movement was limited and selective movement was lacking.
Both superficial and deep sensations were normal. Her problems were that the soft tissue of the hand on the paralyzed side lacked elasticity, and when cutting food products with a knife, motor sensations could hardly be processed based on the resistance of materials to be cut.
Additionally, pain occurred in the forearm when continuously using the hand on the paralyzed side. So, it was virtually impossible to use the hand on the paralyzed side.
The author treated her so that she could functionally use the hand on the paralyzed side as a functional hand.
Result: Mobility of the paralyzed hand and softness of her skin were improved as the muscle tension of the lower trunk was adjusted.
As a result, she could move her fingers actively and obtain the necessary perceptual information. She became able to use plastic wrap and a knife during cooking.
Discussion: The author adjusted her base of support and postural tone.
The author made the hand on the paralyzed side readily receive perceptual information; then carried out functional training of grasping things, from easy to difficult.
The author believes that through this series of therapies she was able to efficiently position her hands relative to objects, explore objects through tactual sensation, and handle them as well as relearn how to use her perceptions.
Struggling with specific problems identified through understanding the family situation and home environment contributes to supporting her life at home.

Title: Home life support by sharing the concept and method of a therapy among family members and therapists

Organization:(1)QOLER Rehabilitation Hospital, (2) Kibi International University
Author: Nobuhiro Suzuhigashi1), RPT and Keiko Suzuhigashi1), RPT, and Mitunori Yumioka2), RPT
Key words: home life support, instruction to family members, and continuance of therapy

Objective: This paper discusses a method for helping home-care patients through approaches implemented at a hospital.
Patient: Female, 16 years old, after effects of the cerebral infraction, disturbance of consciousness (+), paralysis of four limbs (+)
Method: @A therapist explained the analysis of the patient's treatment to family members concerning the base of support and postural alignment of the patient.
AThe therapist provided the treatment along with the family members and then shared the techniques.
BThe family members video taped the hospital treatment in order to improve the home treatment.
Result: The patient required a lot of assistance when starting the treatment.
However, the patient's balance improved and, less assistance was required when the author was preparing this report.
Discussion: Family members can be therapists by sharing the concept and method of treatment with an attending therapist, which results in a better synergetic effect.
For carry-over of the therapeutic effect, Furusawa mentioned that clinical challenges included identifying methods to maintain and improve the facilitatory effect of the function in which therapists were involved, and methods for generalizing the effect in daily life.
The Bobath approach essentially includes the medical team, patients, and family members. They find learning opportunities for everything in life with this approach.
The treatment for this case was a good opportunity for the author to experience and confirm that the treatment should be performed by a therapist first and then relayed to family members and people around the patient.

Title: Discussion regarding the support of body functions at transitional facilities -From dependency on a therapist to self-management-

Organization:Kagawa prefectural rehabilitation center for the physically handicapped. Rehabilitation facilities for a physically handicapped.-Sun hope-
Author: Hideki Sogawa, RPT
Key Words: support for body functions, dependency on a therapist, and self-management

At the facility where the author works, attending staffs provide support for general lives of the patients and conduct training for them.
In addition to occupational activities and group activities, medical staffs perform therapies and offer advice on health care.
This report discusses how physical therapists should provide support for chronic patients who have been in the transitional facilities for a long period. (i.e., 18 months or more)
Insufficient training for self-management may increase the tendency towards "dependency on a therapist".
Therapists and patients should share a common awareness and patients should be progressing towards self-management.
If problems occur, physical therapists and patients should devise concrete ideas for dealing with problems in their daily life.
The flow of support is as follows:
@ Elucidation of the individual's problems
A Addressing an individually tailored exercise plan
B Execution of plans and appropriate guidance for patients and support staff (including family members)
C Re-confirmation
The following two items are important for executing individual exercise plans:
@ Incorporate the time for individual exercise program in daily life
A Building a coalition with support staff
The author believes that the therapist should provide suitable guidance to patients, in order to make them realize that they can improve and maintain their functions.

Title: Life support based on the Bobath concept: from the therapeutic intervention to the environmental improvement

Organization:Osaka Developmental Rehabilitation Center
Author: Kaoru Tsuji, OTR
Key Words: Bobath concept, life support, and occupational therapy

The goal of therapy based on the Bobath concept is to improve the function of the child's participation in activities and to help him/her in the accomplishment of tasks.
To maintain function and participation in activities, environmental considerations are taken into account without requiring an excessive effort and work load from him/her.
Moreover, the importance of supporting parents and providing a team approach is advocated for promoting the child's development and managing his/her secondary problems.
Such an idea is consistent with "the learning theory of movements" mentioned by Schmidt.
In this report, an example of the occupational therapy intervention for an infant with PVL was presented.
Through this example of an intervention, the practice of the Bobath concept is explained.
The infant showed an unstable arousal state and problems with sensory modulation and adaptation to the environment as well as difficulties in eating.
Sensory motor preparations of her hand functions were implemented by handling her in order to improve her eating ability.
An occupational therapist introduced play activities involving some visual components and hand movements to her mother.
Her mother learned the how to handling during treatment sessions. Her father and brother cooperated with her mother and enjoyed communication with her through eye contact and physical play at home.
In the day@care nursery, a seating system which supported her postural and movement control was made for her.
Moreover, the occupational therapist frequently consulted with the nursery teachers about play activities and her developmental tasks.
As a result, the infant was able to eat, using a special spoon with her mother's assistance.
The assessment and treatment of the infant's sensory motor function by the occupational therapist in order to plan specific play and activities for the infant were very important.
Additionally, repetitive practice of suitable play and activities for her in the context of a team approach was a good strategy for getting better outcomes.

Title:Supporting the daily living of children with severe disabilities -Relating to positioning, breathing function and eating function-

Organization: Kanagawa Children's Medical Center
Author: Takaaki Hirai, RPT, Tomoko Hirota, RPT and Miwa Motoyoshi, RPT
Key Words: children with severe disabilities, general health status, and daily living support

Introduction: It is important to monitor changes in postural tone, respiratory status and swallowing function caused by change in posture, when we therapists support the daily living of children with severe disabilities.
Based on those changes, we should choose a posture which allows the best general health status and the highest activity level in daily life.
Method: Contrast imaging for swallowing, ventilatory volume, postural tone and activity level in various postures were evaluated in four cases.
Additionally, special chairs suitable for each patient were prepared to investigate the effect on their daily life.
Results: The prone position showed the best score for swallowing, ventilator volume and postural tone.
In the contrast imaging, swallowing movement was performed the most effectively in a prone position with the least aspiration and inflow.
The special chairs prepared stabilized the posture and respiratory condition of the cases studied, increased the amount of ventilation, alleviated vomiting, and significantly reduced the annual average number of respiratory tract infections of the patients.
As their health improved, the four patients became more active and developed socializing skills.
Intraoral intake function was maintained and the patients became to use upper extremities frequently.
Discussion: The vicious cycle of breathing disorders, eating disorders and muscle stress due to abnormal postural tone must be addressed at the same time as daily living support is to be given to children with severe disabilities who suffer from life-threatening
problems. The vicious cycle can be terminated easily through positioning based on a prone position.

Title: Daily life support for school-age children with severe cerebral palsy

Organization: (1)Akita Prefectural Rehabilitation and Nursery Center for Children with Disabilities, (2) Nakadori Rehabilitation Hospital, (3) Yuri Union General Hospital
Author: Makoto Watanabe1), OTR, Takeo Hiraide2), RPT, and Sachiko Mura3), OTR
Key Words: children with severe disabilities, daily life support, and school- age child.

Abstract: Introduction: In this report, daily care by family members and teachers in the case of a school-age child with severe cerebral palsy is presented in connection with a therapy intervention. The case: 12-year-old female. Diagnosis: Congenital brain malformation (hypoplastic callosum and cerebellum). Her systemic postural tone is basically low. She is often in the supine position. Her hip joint is dislocated and decreased systemic mobility. The author provides an occupational therapy (OT) session approximately every other month. Additionally, she receives a physical therapy (PT) session once a week at a local hospital and an OT session once a fortnight at a rehabilitation hospital. Intervention plan: Intervention includes the three following factors: @improvement of the asymmetrical pelvis and vertebral column, and of the deformation and contracture of the four limbs, A prevention of pulmonary problems, B improvement of somatic sensation, of vision and of the complementary relationship between sensorimotor function and perceived motion. Intervention: Family members (her mother and grandmother), a teacher, local PT, OT from the rehabilitation hospital and the author assigned care and treatment responsibilities to each member in accordance with the treatment plan. Discussion: Most approaches at home and school were combinations of simple activities. For example, family members and teachers extended parts of her body if bent, padded her because she fell, and showed her red things because she saw red things more frequently. Those approaches were performed under ordinary daily care conditions at home and at school in a routine, natural, easy and pleasant manner without taking up much time. Family members independently devised and developed in accordance with the child-rearing methods at home with reference to the intervention methods of therapy. The role of therapists is to help family members raise children with severe cerebral palsy in an independent, natural and enjoyable manner.

Title:Actual condition of community support by pediatric physical therapists

Organization:Developmental Medical Center
Author: Mayumi Fujii, RPT and Masaki Takeda, RPT
Key Words: child with physical disabilities, physical therapy, and support in several settings

The local care support program services for children and adults with disabilities include outpatient care, home-visit nursing care and support facilities.
This paper reports on the actual condition of support facilities, using different cases.
Support facilities were offered in the form of day-care facilities, schools for children with disabilities, and local schools.
@ Day-care facilities: The objective in the first year was to make staff understand the characteristics, the natural developmental course and the prognosis of disorders and dysfunctions of the children with disabilities.
In the second year or later, home room teachers at the school for children with disabilities participated in meetings where changes, objectives and challenges for each child were discussed.
A School for children with disabilities: At first, the author advised teachers by responding to their questions.
From the second time, the author confirmed whether or not the objectives from the previous consultation had been accomplished.
The author realized that teachers needed advice regarding basic care methods such things as how to carry a child.
B Local schools: Meetings were held by parents, school personnel and physical therapists concerning support before entering elementary school.
At first, the author helped school staff to understand the disabilities of the children, evaluated
environmental factors at the elementary school, and assessed the safety and usefulness of each child's behaviors.
Additionally, the author extracted points for particular notice and consideration.
Three points to be considered for support facilities are as follows:
@ Pay attention to facility support projects and recognize their efficacy
A Start facility support when patients receive surgery, or are discharged from hospitals or are starting to positively participate in society
B Clarify the problems and advise about solutions in a specific and feasible manner

Title: Rehabilitation in support of children's living activities \Activities at non-medical local care facilities\

Organization:Suginami City Center for Mental and Physical Development of Children
Author:Yasuhiro Suzuki, RPT
Key Words:local caring, life support, and local governments

There are many "care facilities" all over Japan. However, they vary in scale and mode of operation.
Most care facilities established by prefectural governments have medical functions.
They undertake local care while receiving medical and technical service payments.
However, at the care facilities established by most cities and wards, physicians work part-time and no medical treatment is performed.
Therapists at care facilities with no medical care function should obtain medical information about children from medical institutions and report the current situation of the children to the medical institutions in order to come up with scientifically based therapies for children.
Therapists cannot by themselves resolve the problems of children during their development ameliorate the living difficulties caused by those problems and advise parents and support personnel around children concerning child care and education.
They need to take a high quality team approach in cooperation with people in various roles inside and outside care facilities.
A high quality team approach can help transfer positive therapy results into the daily life for individual children.
Likewise, the multi-institutional and multi-disciplinary team approach can enhance and improve the care for individual cases but also can strengthen and help mature the local care system.
Therapists working for care institutions should perform therapies for individual children from a long-term viewpoint in consideration of the characteristics of the region and the organization of the community-based care system.
In this way they will be able to perform rehabilitation that provides living support to children.