Volume 28, No.2,December, 2005

Title: An Introduction of the Bobath Approach and a History of its Development at Minami-Osaka Ryouikuen.

Organization: Minami-Osaka Ryouikuen
Author: Ichiro Kajiura, MD

Abstract: "Ryoiku" (a system in which medical treatment and education are provided at the same time) for cerebral palsy (CP) started in Japan when Professor Noritsugu Takagi of Tokyo University appealed for the necessity of a "dream care canter (an institute in which medical treatment, education and vocational education are provided)".
The first Seishi-Ryougoen, (an institute for children with mainly physical disabilities), was established in Tokyo in 1946 and since then, similar institutes have been set up one after another all over Japan.
In the beginning, most of the inpatients of the institutes for children with mainly physical disabilities were affected by polio, congenital hip dislocation and bone-joint tuberculosis.
However, from 1966, these diseases had almost disappeared and most pediatric inpatients began to be affected by CP instead.
The level of medical rehabilitation technology and brain science at that time was insufficient to treat CP, which is a brain disorder, and as a result, little focus was given to the treatment of CP, with the long-term institutionalization of pediatric patients becoming the major treatment method, in the name of welfare.
It was against this setting that, in 1964, Dr. Kajiura and Dr. Inoue, of Osaka University's Orthopedic Department in the Faculty of Medicine, in cooperation with Dr. Ebe of the Public Health Department, played a central role in establishing a CP research group at Osaka University.
The CP study group began researching the possibility of the early detection and treatment of CP.
Until that time, care for pediatric patients began with their institutionalization at the age of approximately six, though the CP study group aimed to start home treatment for babies from the age of zero.
The CP study group prepared Japan's first questionnaire concerning the motor development of babies, and built techniques for detecting and diagnosing CP from six months old. In 1970, Mr. Kii RPT (Registered Physical Therapist) attended a twelve-week Bobath Method course in London and in the same year the early treatment of CP, using the Bobath Approach, began for the first time in Japan, at Seibo-Ryoikuen.
In 1982, Bobath Memorial Hospital was opened and full-scale rehabilitation for strokes began, using this approach.

Title: Visiting Rehabilitation in Osaka

Organization: Bobath Memorial Hospital
Author: Masamichi Furusawa, PhD, RPT Kenji Kise, OTR
Key words: visiting rehabilitation, stroke, home care

We have been carrying out visiting rehabilitation service since 1990 in Joto district, Higashinari district and Chuo district in Osaka. We visited totally two hundred and thirty six patients for two years and one month from July 2002 to July 2004.
The frequency of visiting rehabilitation was once a week and one course consisted of fifteen visits. Seventy-eight percent of patients suffered strokes, and more than half of all patients were seventy-five years, or older.
An almost equal number of patients from all levels of care insurance system requested visiting rehabilitation service.
The author considers there are six important points for performing rehabilitation at their homes, based on clinical experiences.
1. Therapists should clearly understand the guidelines concerning therapy and ADL (Activities of Daily Livings), for patients with central neurological diseases, including mainly patients suffering from strokes.
2. Therapists should possess expertise in eating disorders and dysphagia.
3. Therapists should possess a detailed knowledge of chest physiotherapy, since the patients are often affected with pneumonia.
4. Therapists should understand the techniques of physical therapy to alleviate neck, shoulder, back and knee pain, and refer patients to physicians when patients complain of thalamic pains.
5. Therapists should be skilled in maintaining and improving the endurance of patients.
6. Therapists should possess the ability to modify a patient's house, depending on his/her type and level of disorder (i.e., environmental modification).
Promoting the participation of speech therapists is required for improving the quality of visiting rehabilitation. In addition, the government is required to intervene in regional medical systems so that therapists become engaged in visiting rehabilitation in regions where none are being carried out.

Title: Spatial Environment and Postural Control Mechanisms

Organization: Yamanashi Spa Hospital
Author: Hiroko Takamura, RPT
Key words: spatial environment, postural control mechanisms, peripheral visual field

It is believed that an internal world corresponding to a three-dimensional visual space needs to be constructed in the brain based on the gravitational, anterior-posterior (front-behind) and lateral (left-right) coordinates so that spatial perception and motor behavior cooperate in an appropriate manner.
Sensory information from the outside world such as optical sensation, auditory and vestibular information (i.e., quantity of self motion perceived by the patient) and relevant memory information are also involved in this process.
In order to move effectively in the environment, patients' interactions with their own motions, objects and environmental conditions appear to play an important role.
This report sheds a light on how visuo-perceptual information synchronized with postural control mechanisms could be utilized by reporting the clinical case below.
The case presented here showed widespread infarction from the brain stem to the right occipital lobe. The female patient initially appeared passive towards everything and showed few signs of activity.
Her eyeballs constantly deviated to the right side, the head and neck were also turned to her right side and she was unable to stay in a midline position voluntarily.
In addition, she was unable to voluntarily move the paralyzed side of her body and required substantial assistance with all bed and transfer activities.
In terms of postural muscle tone, significant hypotonicity in the trunk and hypertonicity in the right posterior cervical region and regions around the shoulder girdle were observed.
Her trunk was bent to the right side.
The patient remained in a lying position while preparations for the treatment were being made.
Then, the therapist selected a scene designed to provide an understanding of the relationship between tasks and a sense of accomplishment to enhance the hand eye coordination.
During the therapy, while the therapist encouraged the appropriate postural control including the standing posture against the base of support, the patient was made aware of the visual changes of objects and scenery around her caused by her active movements.
As a result of the treatment, the amount of assistance required for her activities was reduced and she was able to accomplish her toilet activity with assistance from a family member. Moreover, she learned to verbally communicate with others and modify her gaze to the midline position.
The author suggests that when treating patients with central nervous system disorders, given the unstable postures and motions, considerable amount of attention should be given to spatial environments where one moves around in order to prevent maladaptation in the visual as well as emotional systems.

Title:Roles for Therapists in Spatial Movement: A Case Focusing on Walking in Spaces for Living

Organization:Kofu Jonan Hospital
Author:Tomoo Saitou, RPT
Key words: space, vision, and locomotion

The gap between therapy rooms and spaces for living often becomes an issue in the spatial movement of hemiplegic patients.
Therefore, therapeutic ideas are required for patients to utilize abilities, obtained from basic therapeutic exercises, in spaces for living.
The author thought that perceiving changes in information, obtained from the visual sensation, allowed patients to create postural sets in accordance with spatial movements.
A female at the age of sixty-six developed left thalamic infarction on August 25th, 2004.
The MRI images of the patient showed multiple low density areas restricted to the left thalamus and basal ganglia region.
The author thought that the patient's major problem was the inability of selective mobility of her trunk, as a result of compensatory fixation from the head and neck areas to the trunk and the accompanying hypotonicity around the right hip joint.
She barely recognized visual changes in the space where she moved and also hardly created postural sets according to the changes in the walls (vertical structures).
As a result, the enhanced asymmetrical posture made it difficult for her to perform peripheral movements.
The three objectives of the therapy included:
1. Selective mobility of the trunk in a midline position.
2. Modification of alignment of muscles surrounding both the hip joints and the feet, as well as improvement of the antigravity extensions of the lower trunk, pelvic girdle and lower extremities.
3. Understanding changes in vertical structures (e.g., walls) and horizontal structures (e.g., floors) by the visuo-perceptual function as well as improvement of body responses while walking along corridors and turning corners.
As a result of the therapy, the patient was able to easily modify the asymmetry of the trunk and perform antigravity extension activities.
In addition, the patient was also able to move corresponding to the vertical structures, perceiving the scenery as it continuously changed.
At the same time, the patient became able to raise and extend the upper extremities, because the instability of the proximal part of the paralyzed side was reduced.
Walking is a purposeful means of moving within environments and the cyclic relationship between environment, perception and motion, is important for human beings to walk well. Walking allows human beings to obtain ever-changing perceptual information from the environment.
It was the belief of the author that the changes in perceptual information brought about postural reactions. Based on that concept, the author treated the patient in such a way that she could adapt to changes of the horizontal and vertical structures, while considering perceptual changes.
As a result of the treatment, her postural reactions in the spaces where she moved as well as walking movements were improved.

Title: Roles for Speech Therapists in Assisting Food Intake

Organization: Rehabilitation Amakusa Hospital
Author: Yukiko Ogawa, RST
Key words: life in a ward and meals

In assisting with food intake, speech therapists (ST) are required not only to be experts in the treatment of eating disorders and dysphagia, but also to act as expert advisers and coordinators within multi-disciplinary teams.
STs must perform multiple therapeutic interventions at mealtimes, including postures during meals and the utilization of sensory information.
This paper, in particular, reports on treatments for chewing and swallowing functions, and explains specific treatment programs, while assuming stereotyped motor patterns of hemiplegic patients, including trunk flexion, head extension, lower-jaw protraction, the low tone of chewing muscles and the typical high tone of intrinsic and extrinsic muscles of the tongue.
First, while treating the chewing function, STs should mobilize the skin of the scalp to prepare for the muscular activities of the head and neck area and stabilize the lower jaw with both hands, while providing the base of support (BOS) to the head and neck area, so that the masseter muscle is able to move easily.
Next, STs should pull the lower jaw, according to the extension of the head of the patient and then flex the head. These activities should be repeated.
Further, STs should adjust the alignment of the jaws, to promote chewing.
While treating the swallowing function, STs should adjust the tone of the suprahyoid muscles and extrinsic muscle of the tongue in order to raise mobility of the suprahyoid and hyoglossus muscles.
Next, STs should apply BOS to the tongue in order to enhance the stability which in turn will induce the mobility of the tongue muscle.
Further, STs should assist with swallowing activities by promoting the contact between the tongue and upper jaw; this induces coordinated motions among the tongue, lips and jaws.
This report introduces specific treatment techniques, devised by the author, so that patients would more readily be able to feel their own muscular movements when the above-mentioned treatments are offered.

Title: Role of Occupational Therapists in Supporting a Patient's Life during the Recovery Stage

Organization: A civic Toyonaka Hospital
Author: Kinuyo Takemura, OTR
Key words: a recovery stage, life support, and ICF

The International Classification of Functioning, Disability and Health (ICF) was adopted by WHO in June, 2001.
ICF discusses the importance of departure from "theory of reduction to the base" in rehabilitation medicine.
This report introduces a treatment process based on the task-oriented approach of the Bobath Method, to support the patients' actual lives.
The use of chopsticks was selected as a task for the treatment, as requested by a patient, who persisted in attempting to improve her dysfunctions but could not establish goals at home after discharge from hospital.
The patient was analyzed and treated. The OT in charge considered that the patient hardly used the chopsticks, due to increased dystonia, because the patient could not continuously perceive information from the peripheral parts of her body, as a result of the hypertension caused by excessive efforts.
The OT modified her static postural control by making her obtain perceptual information from peripheral parts of her body in an appropriate manner.
The OT helped her experience the changes in sensory information from rice bowls, chopsticks and food, through the actual use of chopsticks, in order to improve her ability to use them.
As a result, with each treatment, the patient recognized the difficulty in using chopsticks with her affected hand and agreed to change her dominant hand from her affected hand to her less affected hand.
The treatments reduced the effects of her static postural control and she was able to perform ADL almost by herself and set a feasible goal of taking on the role of housewife, discussing a specific training program with the OT to perform activities required in domestic affairs.
In an approach ranging from the acute to recovery stage, it is essential not only to improve patients' dysfunctions, but also to verify working hypotheses in detail, through treatments concerning the relationship between tasks tackled by patients and their dysfunctions.
Patients and therapists, together, should verify these hypotheses so that patients are able to recognize their dysfunctions and gain a more realistic perspective on their lives.

Title: Life Support for Outpatients with Aftereffects from a Stroke

Organization: Fujioka Municipal Hospital outpatient center
Author:Keisuke sekine, OTR
Key words: outpatient rehabilitation, perceptual experiences of movements, and manipulation of chopsticks

For outpatient rehabilitation, personalized treatments which correspond to the lifestyles of each patient are necessary.
This report introduces a treatment for a right-hemiplegic patient to gain the ability to manipulate chopsticks.
The patient could walk without assistance, though he was unable to use the right hand effectively when manipulating chopsticks and writing characters.
He had two problems: first, he manipulated chopsticks with excessive effort when eating meals with the right hand, which resulted in poor manipulation of them.
Second, due to stereotyped motor patterns, he could not obtain sensory information from food and the tips of the chopsticks, which is necessary for manipulating them.
The following therapy situation was provided so that he would manipulate chopsticks to obtain sensory information from food and promote postural reactions which accompanied the manipulation.
In his daily life, the patient lapsed into a static posture in order to compensate for the instability of his lower trunk.
Through analysis, the OT in charge considered that the static posture spread up to the scapulas and upper extremities, disrupting the alignment of the hand which manipulates the chopsticks.
In general, when a human being is without dysfunction, his/her body moves towards the object before starting an action. At the beginning of his treatment, the OT manually improved the motions of the static body parts which prevented the patient's body from moving towards the object.
Then, the OT prepared him to manipulate tools by inputting sensory stimuli into his hands and fingertips, while he manipulated the theraplast (plastic clay) and washed his hands.
During the treatment of this patient, the important issue was not the learning of the motions, but the reactions based on sensory information from the objects.

Title: Rehabilitation in the Day Care Center

Organization: Assistjapan Dayservice Center 1
Author: Ichiro Masuda, OTR
Key words: day care center, support at home, and multi-disciplinary collaboration

Objective: Currently, we, as occupational therapists, are involved in three fields consisting of the acute, the recovery and the maintenance stage fields.
Various professionals are involved in the maintenance stage field. We provide our own original rehabilitation services at the day care center where only health care services have been provided so far.
This report will introduce our original services for the patients in the maintenance stage.
Activities: The center in which the author works provides a day care service covered by the national nursing-care insurance and the care cost support system. 70% of the patients suffered from the aftereffects of a stroke.
Current status: This center is characterized by the fact that the number of patients, who are discharged several days early from recovery-stage medical institutions, as well as those who request specific individualized rehabilitation programs rather than conventional services which mainly consist of recreation, is increasing.
Method: Activities at the center will be illustrated by the progress of a hemiplegic patient, in this thirties who lives alone.
Result: Because of an intervention by occupational therapists and other specialists, the patient's ADL and the range of his social activities have changed.
Discussion: Within the public insurance system, it is important to continuously provide a certain level of high-quality services, with simple straight-forward procedures.
The usefulness of an individualized rehabilitation service at a day care center supported by the public insurance system has been confirmed by this case study. In the future, interdisciplinary network-building will be an important challenge.

Title: Roles of Therapists for Patients at Home: Communication with the Family for Six Months

Organization: Sato Hospital
Author: Susumu Fujiyoshi, OTR
Key words: cerebral hemorrhage, total assistance, and mimicry

Abstract: Objective: Many families that use home-visits for rehabilitation have trouble caring for patients every day.
In particular, family members feel anxious about the long-term care for their family member who develops a disease in middle or advanced age, because of the difficulties in curing the disease.
This report discusses the relationship between the Bobath Approach, functional recovery and the bond of family in home-visits for rehabilitation, through a case in which the patient developed cerebral hemorrhage during middle-age, and was unable to verbally communicate with family members.
Method: One of the treatment objectives was for caretakers to realize physical changes in the patient. The specific challenge for the patient was to maintain the seated posture.
As a first step, the OT in charge provided a treatment so that the patient would maintain a symmetrical seated posture.
The OT gradually facilitated the appropriate connection among his pelvis, trunk and shoulder girdle so that he would use the upper extremities on his less affected side for manipulation, rather than support.
Result: As the patient became able to sit with more stability, the ability to manipulate his less affected upper extremities increased, and he began to imitate the gestures of the caretakers.
As his facial expressions became richer, the caretaker became involved, increasingly, in activities other than ADL with the patient, and his family members were able to increasingly enjoy this involvement.
Discussion: It is generally said that in home-visits for rehabilitation patients rarely recover their functions. However, there are many reports that using the Bobath Approach improves the functions of patients, even in cases in the chronic phase.
In this study, the author experienced the dramatically changing attitudes of family members as the patient recovered an increasing number of functions during the chronic phase.
The author will continue to support patients in home-visits for rehabilitation, based on the Bobath Approach in the future.

Title: Visual attention for children with cerebral palsy.; A challenge to improve visual perception in children with PVL

Organization1 Omichikai Medical corporation Bobath memorial hospital
2 Minami Osaka Ryouikuen Hospital for Children
Author: Mitsuo Suzuki OTR.PhD. 1. Akane Matsumoto OTR.2 :Yukari Tanaka OTR.1@Taki Hamamoto OTR1
Key words: vision, perceptional dysfunction, and cerebral palsy

In recent years the number of babies born premature or with low birth weights has increased due to the development of the perinatal medicine.
They sometimes show not only primitive postures and movements but also hyper-responsiveness to visual and somatosensory stimulations from their environment.
At the same time, the clinical picture of cerebral palsy has changed.
Children with periventricular leukomalacia (PVL) tend to suffer from impaired visual perception, because optic radiations projected to occipital areas are located near the posterior horn of the lateral ventricle.
They sometimes show difficulties not only in locomotion, postural changes, and hand skills but also in visual functions such as difficulties in sustention of attention, ocular pursuit, and gaze shift.
Consequently they often have difficulty in developing their visual perception, especially spatial perception, and forming perceptions necessary to perform activities of daily living such as play and attending classes.
It is a challenging task for therapists to organize and create a learning environment suitable for children with PVL, and it is an important strategy to facilitate sensory-motor experiences and to combine postural control with visual and somatosensory information.
In this paper, we show examples of neuro-developmental treatments to improve the postural control and movements for three preschool children (4-5 years old) with PVL.
While we assist their visual perception during play, we try to improve functional skills such as dressing and eating with a spoon.
The purpose of this study is to describe the characteristic problems of visual perception in children with PVL and to discuss how to assist them in improving their visual perceptional dysfunction by means of using play