Volume30, No.1, Jun,2007

Title: Interventions into ADL and IADL based on the Bobath concept

Organization: Seiai Rehabilitation Concept
Author: Masako Fuchi OTR
Key words: the Bobath concept, activities of daily living (ADL), and instrumental ADL (IADL)..

The Bobath concept is the only approach to neurological rehabilitation which directs treatment towards improving postural control which is required for effective function.
It is also a problem-solving approach to the assessment and treatment of individuals with disturbances of functioning, movement and tone due to a lesion of the CNS.
It is believed that applying ICF to the Bobath concept allows for more effective analysis, planning and therapy.
Based on this concept, it is important for therapists to make therapeutic interventions in ADL and IADL for patients, based on the three points of view described below:
1. It is said that human behaviors are accomplished by voluntary movements of limbs, in coordination with non-voluntary movements which accompany them.
Therefore, therapists should set the necessary postural adjustments required for patients to perform specific ADL before starting the activities, and control the postures that accompany the constantly changing voluntary movements of patients, appropriately.
2. Therapists should recognize that individual ADL and IADL have common postural controls, and provide effective therapies.
3. Patients have performed ADL over the years and as such, their ADL have become automatic activities with own body schema and memorized movement patterns.
Consequently, it is necessary for therapists to modify the body schema and the acquired movement patterns of patients who are suffering from disabilities, and make them learn new ADL and IADL.
Based on the points shown above, therapists should improve the ability of patients to adjust their postures so that they are able to perform functional activities more effectively.
Therapists should treat patients, firstly, by making them perform functional activities through hands-on training and then by gradually shifting to hands-off training.

A discussion concerning approaches for improving the ability of a hemiplegic patient to walk on snow-covered roads

Organization: Fukui Red Cross Hospital
Author: Yasumi Toyoda , RPT
Key words: hemiplegia, snow-covered roads, and environmental adaptation.

Case: Male, 59 years old
Diagnosis: Left putamen hemorrhage
Onset: November, 2005
Current medical history: Craniotomy procedure to remove a hematoma three days after onset.
Walking on flat surfaces: Collapsed central trunk, poor anti-gravitational extension activities and hypertonicity on his less-affected side.
Objective: This paper reports on a rt. hemiplegic patient who was aiming to return to work, and the approaches taken to improve his ability to walk on snow-covered roads.
Methods: To begin with, the therapist improved the flexibility of the patient's lower limbs, and then adjusted the alignment of his shoulder girdles.
In addition, the therapist facilitated the stability of the lower limb on the affected side.
Further, because the treatment needed to correspond to the characteristics of uneven and slippery snow-covered roads, the therapist created an environment in which the patient could practice maintaining a standing position, based on visual information, on unstable supporting surfaces.
Meanwhile, the therapist facilitated the extension activities of the patient's trunk and lower limbs, using super balls and bed sheets.
The therapist led the patient through movements which required him to stabilize his body while shifting his weight from one side to the other as well as controlling his postures on all types of supporting surfaces.
Results: Sufficient muscle strength and postural control are required for humans to walk on snow-covered roads.
The patient's ability to walk on flat surfaces was improved as his alignment and postural tone were adjusted to the base of support in the sitting and standing position, though it didn't improve much on snow-covered roads.
The therapist, therefore, reviewed the factors required for walking on snow-covered roads and provided a therapy which focused on those factors.
During this therapy, the therapist assisted the patient in controlling his posture, while the patient explored the conditions of road surfaces using the soles of his feet.
As a result, the patient became able to control movements depending on his environments.
Discussion: Unlike flat surfaces, for snow-covered roads it is not only necessary for the patient to control his posture but also to simultaneously integrate sensory information from lower limbs with the proprioceptive information from the other various parts of the body along with the sensory information from the vestibular system caused by the change in his center of mass.
The author believes that this specialized therapy for walking on snow-covered roads accelerated the integration of these kinds of sensory information and improved the patient's ability to walk on such surfaces.
Conclusion: It is important to acquire the ability to walk appropriately according to given conditions and environments by controlling postures in various settings, in order to realize high-quality ADL and participate in a larger social context.

Title:Treatment of a patient with a stroke with severe sensory disorder of the left upper limb

Organization: Kobe Rehabilitation Hospital
Author: Hiroaki Mitsuhashi, RPT
Keywords: sensory disorder, body scheme, and active participation.

Introduction: The author treated a cerebral infarction patient with a severe sensory disorder of the left upper limb.
The author focused on the damaged body image of the patient and treated her so that she would be able to receive proprioceptive information and actively regulate herself.
This paper reports the effects of the treatment.
Case: The subject was a 58-year-old female with widespread cerebral infarction in the areas covered by the right middle cerebral artery.
She could walk by herself, though she had difficulty holding up her left upper limb in space.
She could flex her left fingers slightly, though she had difficulty extending them.
With regard to her postural tone, her left abdominal muscles, serratus anterior and triceps brachii muscles, etc. were flaccid.
Both the superficial and proprioceptive sensations of her left upper limb had severely diminished.
She rarely used the left upper limb in her daily life.
Therapy: The author activated her core-stability when she rolled over and provided her proprioceptive feedback through the weight bearing on her left upper limb.
He also helped her to put her left palm on a table and make her hand as a reference point while sit to stand.
After this treatment she could stay her hand on the table. He facilitate her to actively explore.
Results: Both the superficial and proprioceptive sensations of the patient were improved from severe to moderate level.
With regard to the functions of the upper limbs, the patient began to be able to reach the left hand to the head and right shoulder, and use the left hand to tuck a shirt-tail into trousers.
Improved functions of the left upper limbs carried over into her ADL, and thus the patient began to use her left hand more frequently during her daily life.
Discussion: The author considered that the main problem of this case was a disturbed body image generated by the dysfunction of the parietal lobe, because the thalamus was not directly damaged in this case.
Therefore, the author hypothesized that the approaches to activate her proprioceptive sensation and facilitate her active participation in the therapy would be effective.
In fact, these approaches eventually proved to be effective for improving the functions of the patient.
Conclusion: In order for patients to acquire skills and use them effectively, it is important that therapists not only improve the postural control mechanism of patients, but also provide them with therapeutic situations in which the patient can actively participate.

Title: How have behaviors of children with severe disabilities been understood?

Organization: Aitoku medical@welfare center
Author: Hideki Miyamoto
Key words: children with severe disabilities, intersubjective, and interaction.

Parents of children with severe disabilities often ask therapists what the child is feeling or how to make the child happy.
It is important to facilitate communication between children and their parents, and between children and the staff who care for children with severe disabilities.
The first step to treat children with severe disabilities is to guarantee physiological stability for them.
Therapists help children to maintain a pleasant state of awareness in which they readily take in information from the outside world.
Further, therapists should provide children with activities in which they have expressed an interest.
During therapy, therapists communicate with children mainly in a nonverbal way.
Therapists should predict children's intentions and reasons for their behaviors from the slightest changes in their gaze and physical movements.
In addition, therapists should estimate which environmental factors (for example, humans, objects, etc.) have caused these slight changes shown by children.
During therapy, it is important for therapists to provide an enjoyable time for children. If children feel happy with therapists, a reciprocal relationship is formed.
Furthermore, forming a reciprocal relationship between children and their parents will motivate the parents to raise the children at home.
In order to enhance a child's ability to interact with the people in their surroundings, it is important for therapists to improve their own intersubjective observation skills.
By using this skill, therapists should analyze the intentions of children and convey these to family members, in order to help mothers raise children with severe disabilities in a positive manner.
That assistance by therapists may encourage family members to continue raising their child with severe disabilities at home.

title:An approach to improve oral functions of a child with athetoid-type cerebral palsy- To eat with more skill

Organization: Osaka Developmental Rehabilitation Center
Author: Hiroko Hamada , RST
Key words: oral control, eating, and excessive mouth opening.

The author provided a series of speech and language therapy sessions (hereinafter "ST") for a 10-year-old female with athetoid-type cerebral palsy in order to improve her eating function.
Her major problem was spilling food from her mouth when she ate, which was caused by the excessive mouth opening and anterior projection of the tongue, as well as the excessive extension of the head and neck area, as a result of an unstable lower jaw.
The three objectives of the treatment included:
1. Suppression of the excessive movements of her lower jaw and anterior projection of her tongue
2. Taking in food with stable lips
3. Repetition of chewing movements without the excessive mouth opening
During the one year of hospitalization, ST was provided once or twice a week.
The author provided the oral control from her side, and stabilized her lower jaw while maintaining a good alignment of her head, neck area, and trunk.
The author helped her to eat some jelly by using her lips as well as chew solid foods continuously, while providing her with the oral control.
With cooperation from the hospital ward staff, we trained her to take in food by using the upper lip and to chew solid foods during mealtimes at the hospital ward.
Training for gargling was added during the ST.
The objectives mentioned above were accomplished by the aforementioned approaches at mealtimes both in the hospital ward and at home, and the amount of food dropping out of the patient's mouth was reduced.
The author would like to help her to maintain the functions that she has obtained, and in the future help her to obtain the ability to use straws and reduce drool.