Volume 29, No.2, Dec, 2006

Title: An approach for a cerebral-palsied child with difficulties in control of arousal status and emotion - Through his changes in eating activity -

Key words: periventricular leukomalacia (PVL), arousal status, and emotional control.

Among children we commonly attend to, we, as therapists, often encounter the issue that the rhythm of waking and sleeping significantly affects their daily life. Their arousal status not only affects their range of activities but also significantly affects their emotions. I am reporting on a treatment of a preschooler with cerebral palsy (Periventricular leukomalacia) whose arousal status during the daytime was low and didn't have an adequate rhythm of waking and sleeping. I treated this child for twenty six weeks as an inpatient and twelve times on a weekly basis as an outpatient. His emotional control was immature, for example, crying continuously when disturbed during his favorite activity. I treated him through activities connected to daily life. Throughout the whole term of occupational therapy, I helped him keep his posture stable in a midline position. Additionally, I led him to maintain visual attention to activities while helping him to receive continuous somatosensory information from his base of support using auditory attention as a cue. When in this state it was difficult for him to stop any activity he had been doing before meal time and to concentrate on eating. In addition, he refused to maintain using a spoon. I recognized the importance of a meal setting in his treatment. I set four goals for his treatment. (1) For the child to be able to feel somatosensory information continuously through his hands holding a spoon while having a meal. (2) For the child to be able to understand the direction and distance between food and a spoon. (3) For the child to be able to maintain visual attention continuously. (4) For the child to be able to explore food continuously. While having a meal is an activity which main purpose is to explore taste, it is also a continuous activity of exploring an environment through visual and somatosensory information. As a result of occupational therapy provided mainly during meal time, the child's ability to eat and his ability to control his arousal status and emotional status were improved.

Title:What is the Body Connection? - Through a Treatment of a Patient with Right Hemiplegia-

Organization: Suwa Red Cross Hospital
Author: Junko Arai, RPT
Key words: trunk activity, function, and connection

I attended an advanced course for the treatment of adults with hemiplegia in November 2005. The lecturer was Ms. Christel Auer and the title was "Upper Extremities and Trunk activity". Based on my experience from this course, I assessed and treated a patient who had right hemiplegia for a year. I thought about "The body connection"deeply trough her treatment. The course raised three main points: (1) Function is a complex purposeful process of activities.It is made up of the three subsystems , activity, sequence of movements and components of movement. (2) The three main points for assessing the trunk are as follows; @the alignments of Central Key Point (CKP) and Proximal Key Points (PKP); A starting movements from CKP; and B movements from CKP induce movements in PKP and the distance from CKP to PKP changes as a result in a synchronized way. (3) "Connection" is explained as the combination of trunk and scapula movements by muscle activities. The patient was walking cautiously with a four-legged crutch and a short leg brace (SLB). Her trunk was in a flexed position and has no movement. She could move her affected upper limb to some extent but was not using it for her daily life activities. I facilitated her trunk activities by assisting the movements of her body from CKP through an on-hands treatment. I then trained her to stand up and remain in the standing position in order to facilitate the stability of her trunk and the mobility in her limbs. When she acquired selective movements of her trunk, I felt her movements distend from CKP to other parts of her body. As a result it became easier for me to move her limbs. From this experience, I strongly recognized that the term" connection" expresses not only the relationship of confined body parts, but also the relationship between all parts of the body based on movements. Therefore it creates selective movements.

Title: Treatment for severely nonfunctional hands

Organization: Yuuyuu Health village Hospital
Author: Katsunori Ibayashi ,OTR
Key words:hypotonia, bilateral hands' movements, and skill

Purpose This paper reports on a treatment for the paralyzed upper limb of a 68-year-old male three weeks after the onset of severe hypotonia and sensory disturbance. He has no voluntary movement in his upper limb. Therapy My treatment of his upper limb not only reduced hypertonia of the antagonists that were causing reciprocal inhibition, but also built up postural tone and responsiveness of the hypotonic muscle by stretching and correcting the alignment of those muscles with his skin and subcutaneous tissues. I helped him do an activity by moving both of his hands in sitting and standing positions. In the advanced phase of the therapy, he was given a treatment requiring dexterity such as typing on a computer keyboard. Result The patient was able to adjust his posture in various positions and became independent in his daily life. By absorbing proprioceptive sensations produced from muscle stretching, voluntary movement of his upper limb emerged. His sensory disturbance was improved. With the help of the OT for activities using both hands, his postural tone modurated around the shoulder girdle. He became able to reach his mouse and the other limb with the affected upper limb. He was also able to hold objects with both hands. Discussion Dr. Kapandji says the movement and position of the bilateral shoulder girdles are closely connected to the movements of the spine and trunk. Also, Mr. Kashiwagi says the bilateral shoulder girdles and upper limbs play a role in controlling balance activities, which is an important source of proprioceptive information. Excessive activity of the non-affected side inhibits sensory input to the affected side by" the Gating Mechanism". Activities with both hands reduce excessive activity of the non-affected side and facilitate sensory input in the affected side. Furthermore, by intercerebral bilateral integration, not only sensory information from the affected upper limb but also appropriate them from non-affected upper limb facilitates selective movements of the affected upper limb. Studies using functional MRI etc. have revealed that the brain can be more easily activated by movements requiring skillful muscle control such as manipulating an object with dexterity rather than by movements of the upper limbs requiring maximum muscle contraction. Conclusion In treating patients with hemiplegia, doing activities with both hands, especially those requiring dexterity, are effective.

Title: Therapy for Walking and Self-Organization

Organization:Nanasawa Rehabilitation Hospital Comprehensive Stroke Center
Author: Takayuki Fujii, RPT
Key words:self-organization, instability, and walking

Introduction Patients in the chronic phase of hemiplegia tend to move using a stereotyped strategy, so they have a lot of problems to adapt an appropriate method according to the changes of the environment. In order to facilitate flexibility and adaptability to the environment of the patient, it is important to have several strategies about their posture and movements. This paper reports on a therapy which used instability of the system of posture, movements and cognition to build a variation in strategies through the self-organization. Case A 61-year-old male patient. Hemorrhagic infarction (right hippocampus region and right middle cerebral artery region) and multiple cerebellar infarctions were observed in MRI findings. It had been eight months since the onset when therapy was started. The patient was expending too much effort in the both phases of swing and stance in his walking and he fixated his posture through walking. He did not have various coping strategies and was experiencing difficulty walking even with a slight change in environment. Therapy My aim was for the patient to gain flexible control of his posture and improvements in the stability and efficiency of his walk. Furthermore, I tried to change his method of walking as follows: (1)I got it difficult for him to use his current method of his postural control and movements and facilitated to change his method. The meaning behind this therapy was to use underlying instabilities in the patient's self-organizing system .(2) I assisted him in the changes of his senses so that he could move easier. Result The patient's problem of expending too much effort when walking was reduced. Additionally, speed, stability, endurance, symmetry of posture, and the movement pattern of his walking were improved. The patient became able to visually explore and displayed a relaxed expression when walking. The hypertonia in his upper extremity in a standing and walking was reduced. Discussion I consider the self-organization system is made from either the organization or the disorganization of the strategies of the patient's adaptation to the environment. We call it " Edge of chaos". It is important to select tasks which the patients can execute them not too difficult but not too easy. I think the patient made new strategies instinctively through his self-organizing system by disturbing his current posture, movements and cognition.

Title:A study of feeding positions for children with severe disabilities:about cases to whom the generally-recommended positions cannot be applied

Key words: children with severe disabilities, eating-swallowing functions, and feeding positions

Subject As to oral feeding positions for children with disabilities, the following three points have been generally recommended; 1) An upright or slightly-reclined sitting position. 2) A position with a flexed neck or a tucked chin. 3) A symmetrical position with the head in midline. However, I have often experienced cases to which these recommendations can not be applied. This study investigated more appropriate feeding positions for three of these cases. Method In each case, (A) a generally-recommended position was compared with(B) one regarded as clinically more appropriate through videofluoroscopy and clinical observation. Each position was compared as follows: Case 1; a sitting position (A) versus a side lying position (B). Case 2; a slightly-backward-tilted sitting position (A) versus a slightly- forward-tilted sitting position (B). Case 3; A position with the head in midline (A) versus a position with the turned head (B). Results and discussion In each case, the B position was superior to the A position,because of no aspiration and less residue in his/her pharynx as well as better-coordinated tongue movements. In addition, in each case, the slightly-protracted-chin position was superior to the tucked-chin position, because of smoother bolus transition. Spinal deformities were common in these three cases. The inappropriate alignments of their head and trunk due to their spinal deformities seem to have resulted in their narrowed pharyngeal space. Each position that was regarded as clinically more appropriate did provide patients with wider pharyngeal space for safe and efficient swallowing, which resulted in the promotion of better oral movements. On the other hand, each generally-recommended position was not effective in enlarging the narrowed pharyngeal space. It was suggested that we should find an appropriate feeding position for each child with severe disabilities, without necessarily following general recommendations.

Title: Single Case Study as a Foundation for Evidence-Based Medicine

Organization:Suwa Red Cross Hospital
Author: Shinichi Funami, RPT
Key words:Evidence-based Medicine, Timed Up and Go test, and Core-stability

This study aims to consider a single case study based on the Bobath concept. It has been proved that a well-designed single case study can be a foundation of evidence-based medicine (EBM). The case in this paper involves a 79-year-old male patient with right hemiplegia due to cerebral infarction. I evaluated his gait function using the "Timed Up and Go" (TUG) test which was used as a standard evaluation index. The TUG was evaluated before and after each treatment sessions. The duration of the test was four weeks. Efficacy of the treatment based on the Bobath concept was analyzed by the change in the results of the TUG test. The result of the TUG testing showed significant decrease in post-treatment value compared with pre-treatment value of each test. It also revealed that the TUG value increased after a two-day withdrawal of the therapy. Therefore due to the results of TUG test during intervention and comparing to the break, we can show that the therapy was effective. Furthermore, there was a significant decrease in the TUG value throughout the four weeks of the therapy, indicating a carry-over of the therapeutic effect. The therapy started with the adjusting of muscle alignment of the trunk and lower limbs. Then Core-stability was facilitated by handling. I thought that the pontine-reticulospinal system was activated, which in turn stimulated the graviceptor in visceral organs, which also increased the loading on the calcaneus during the stance phase of the affected side and excited the vestibular system. When a patient is able to walk, the TUG is the simplest test to evaluate the balance of the patient in daily life activity. I think that the foundation of EBM can be established by accumulating objective data similar to this study from many Bobath therapists.