Volume 31, No.1, June, 2008

Title: Assisting development of nonverbal communication for a child with severe cerebral palsy
-Discussion of the postural movement patterns and development of visual perception and interpersonal relationships-

Organization: Shimada Rehabilitation Center for Children with Disabilities
Author: Yoko Ikeue,ST
key word: Nonverbal communication, joint attention, and relationship between three items

Children with cerebral palsy who have a sensori-motor disorder experience difficulty in nonverbal communication (for example, eye contact, gazing, or the visual comparison of objects) and are barely able to acquire joint attention. The author treated a six-year-old child with cerebral palsy (dystonic athetoid typejso that he would be able to obtain joint attention.
The patient had a fundamentally low postural tone, though became hypertonic while moving. His trunk was unstable and he could hardly control his head. Consequently, for his visual function, he could "compare two things at the same focal length"ione stage of visual development, mentioned by R. P. Erhardt in "Developmental Visual Dysfunction"j though was unable to "compare two targets at different focal points" (another stage of visual development). Therefore, his communication ability was at the level of a "child-object" and "child-human" two-item relationship based on "gazing." He did not, however, have the "ability to make visual comparisons" necessary for "joint attention".
The attending therapist stabilized his trunk in a sitting position and encouraged him to control his head so that he could compare two objects. Once this was achieved, the therapist increased the difficulty of the task, that is, the comparison between an object and a human. Additionally, the therapist helped the patient to experience a sense of shared fun with other children while playing with toys.
The number of times in which the patient alternately looked from a switch to a toy increased. At times, the patient gazed at the switch when the therapist looked at the switch. It was confirmed that the patient was gaining the ability of "joint attention."
For children with cerebral palsy, obtaining both visual and visual comparison functions contribute to the experience of joint attention. This case showed that improved posture and motor abilities of children with cerebral palsy advance the visual function which contributes to the development of communication. It was suggested that posture, motor ability, visual function and the ability to build interpersonal relationships supported the total development of children.
yGlossaryzJoint attention: An ability to adjust behavior to pay attention to objects or topics in order to share interest with others.

Title: Occupational therapy for a child with asymmetry spastic diplegia

Organization: Hokkaido Medical Center For Child Health and Rehabilitation
Author: Yuko Ohshita,OTR
key word: Diplegia, body perception, and activity

The various sensory experiences of children with cerebral palsy are limited due to inappropriate postural control and movement patterns. Their spontaneous exploratory activities of external environments are limited since their lack of sensory experience affects their cognitive development regarding their body. As a result, their experience of failures accumulates and they have difficulties in performing age-appropriate activities and social activities which facilitate their growth.
This paper describes an occupational therapy approach for a pre-school, five-year-old male with spastic diplegia who had refused to both use his left upper limb and perform visuo- perceptual tasks.
The patient was able to walk independently, though exhibited a significantly asymmetric posture with right side dominance, and presented with esotropia (left>right) and poor eye movement. During therapeutic play, he tended to use the right upper limb only and was unable to handle tools effectively changing toys one after another. Significant assistance was required for his ADL with the exception of meals. He said that he did not want to perform visuo-perceptual or cognitive tasks and refused to do such activities.
The author concluded that the most serious problem in this case was the patient's asymmetrical body perception, which inhibited the development of skilled movements and concentration resulting in the patient's rejection of age-appropriate activities and difficulties in performing ADL.
During the occupational therapy session, the author helped the patient to increase the space where he performed activities in sitting and standing positions as well as while walking. Throughout the therapy, the author selected activities so the patient would integrate visual information, somato-sensory information and physical activities and easily understand the sequence and result of play. After a three-month approach, his weakness in visuo-perceptual tasks and his ability to change clothes were improved. Additionally, increased concentration was observed during play.
During the occupational therapy for this case, the approach used encouraged the integration between bilateral physical activities and visuo-perceptual information, as well as the awareness of external spaces around the body. The author believes these approaches have improved the readiness for learning and the ADL of the patient..

Title: Therapeutic effect on walking due to increased adaption to side structures and discussion of this effect

Organization: Izumi Hospital
Author: Syuji Sato, OTR
Key words: Locomotion, visuo-spatial perception, and approach/contact

This paper describes approaches to improve the locomotive ability of a patient who developed intracerebral bleeding 20 years ago and recently developed left hemiplegia due to cerebral infarction.
The patient presented with left hemiplegia, ataxia and an emotional disorder as a result of the cerebral infarction. He could walk under supervision, though presented with fixed postural muscle tone because of a fear of falling. On the other hand, his flexed postural tone was also brought about in order to reduce the tremors caused by ataxia. He often lost balance in an upright position when moving along a side structure or avoiding obstacles. His head and neck were constantly fixed and bent to the right side, and his eye movement was also fixed. At times, he could not maintain a sitting position or an upright position because of the vertigo caused by the movement of his eyeballs, head and neck. The attending therapist reasoned that the fixed postural muscle tone of the patient was partly an intended fixation in order to avoid bumping against side structures, caused by the anticipation of the danger of such "bumping" based on visual information from side structures.
During therapy, the therapist helped the patient to adjust his body position according to side structures based on both the visual perception generated by his movement towards tables or walls and the tactile perception generated by contact with them. The therapist created changes in tactile pressure perception on the parts of the patient's body which were in contact with a wall and helped the patient to use that contact point as a reference point for his postural orientation. When the patient moved along the wall, the therapist taught the patient to look at the wall carefully. The therapist set up a therapeutic situation in which the patient could effectively use changes in visual information and optical flow generated by such movement for better locomotive ability. The therapist facilitated mobility of the patient's head, neck and eyeballs by using the visual information to prompt coordination among visual sensation, somatic sensation, and proprioceptive sensation systems.
As a result, the patient could walk around beds more easily and faster than prior to the therapy. As the patient adjusted himself to side structures, his fixed postural muscle tone improved. The author concluded that the patient's movement experience, which was based on the anticipated postural set for stable contacts and smooth optical flow which accompanied the patient's movements, improved the patient's symptoms. The author also concluded that the cooperative relationship among visual sensation, somatic sensation and proprioceptive sensation systems is important to his locomotive motor control.

Title: Body perception based on the relationship between objects in a patient with left hemiplegia

Organization: Kasugai Rehabilitation Hospital
Author: Koji Isono, OTR
Key words: Right hemisphere dysfunction, relationship among objects, and body perception

This paper describes a therapeutic process in which the domestic work was used to treat a restless patient with left hemiplegia who required constant monitoring by healthcare personnel.
The patient exhibited left unilateral neglect due to a right hemisphere dysfunction. It was difficult for the patient to control and maintain temporal and spatial attention and she also displayed hasty reactions towards proposed assignments, losing her balance and which consequently necessitated constant monitoring.
Her posture was characterized by her pushing movement towards her affected side of body and backward by the upper and lower limbs on the less-affected side as well as high muscle tone on the back muscles of her trunk. The author reasoned that her eye movement was fixed because it was difficult for her to orient the head and neck due to such postural characteristics. The author considered that the insufficient spatial information limited by the fixed eye movement, caused both the symptoms of the right hemisphere dysfunction to deteriorate and her restless and hasty behavior to be generated.
The author introduced sewing and cooking activities into the therapy sessions to improve the balance of the patient and provide continuous tactile movement sensation. When sewing, the resistance of the cloth persists while pushing the needle in and out, and the author considered that the sensory association from the resistance between the cloth and needle is maintained due to the thread, even when the needle is removed from the cloth. For the cooking task, the author attempted to gradually expand the activity space from which visual information was perceived and expected to provide an experience in which the patient would understand the relationship among objects and meanings of them. As a result of the therapy, the patient was able to calmly perform tasks and the time required to monitor the patient in daily life has decreased.
In these therapy sessions, the author helped the patient to understand the physical and sensory relationship between objects. As a result, the patient was able to understand more clearly the relationship between herself and the objects. The author believes that the patient's understanding of this relationship allowed her to regain the orientation of spatial information that she had lost and conduct herself in a more relaxed way.
Through this therapeutic experience, the author felt that it was clinically important and effective to analyze a patient's reactions and make good use of several therapeutic tasks' characteristics for the therapy of patients with a higher brain dysfunction who are exhibiting symptoms of a right hemisphere dysfunction.