Volume 31, No.2, December, 2008

Title: Assessment and treatment for walking practically in a patient with right hemiplegia in the chronic phase after an intracerebral hemorrhage

Organization: Rokujizo General Hospital
Author: Hirofumi Watanabe, RPT
key word: walking practically, trunk of the less-affected side, and foot of the affected side

This report discusses a case regarding a patient after the recovery phase with right hemiplegia caused by an intracerebral hemorrhage. The patient began rehabilitation exercises centered on walking using braces at the early stage just after the onset of the intracerebral hemorrhage. The patient had difficulty walking even using braces due to a severe sensory disorder on the foot of his affected side, the remarkable inversion of the foot during movement (particularly during walking) and also due to instability of the trunk. The aim of the physical therapy treatment for the patient was to achieve indoor walking without braces. A therapist in charge provided the patient with treatment referring to what the therapist learned at the advanced training course by Ms. Mary Lynch (a senior instructor) taken in April 2007.
During barefoot walking, in the early swing phase of the affected side, there was remarkable inversion of the affected-side foot, flexion of toes, and an associated reaction of the flexion in the upper extremity of the affected side. In the early stance phase of the affected side, the patient contacted the ground only with the lateral part of the sole in a state of foot inversion, and had difficulty supporting his own weight from the mid stance phase to the late stance phase. The therapist believed that the main problem for the patient was the decreased potential of the affected-side sole as a base of support due to severe sensory disorder and limited range of motion around foot joints of the affected-side and the presence of postural tone abnormality.
During the treatment sessions, in view of the limited range of motion and the sensory disorder in the affected-side foot, the therapist helped the patient to notice the affected-side foot and use its sole as a base of support. As a result of these sessions, the inversion of the foot was reduced during the swing phase of the affected side. In addition, the patient has become able to contact the floor with his entire sole in the early stance phase of the affected side and required movement has been improved from the mid stance phase to the late stance phase. However, there continued to appear abnormal patterns in the early swing phase of the lower extremity of the affected side, such as compensatory movement which became a cause of side flexion of the less-affected-side trunk when the affected lower extremity was moved. In order to improve this problem, the therapist helped the patient move his weight to the less-affected side and to elongate the less-affected-side trunk. As a result, the abnormal patterns in the early swing phase of the affected side were reduced and the patient has been able to walk with bare feet with only remote supervision in the rehabilitation room.

Title: Physical therapy approach for an infant with hemiplegia: interrelationship between perception and movement

Organization: Funabashifutawa Hospital
Author: Masaaki Muraki, RPT
key word: perception, movement, and hemiplegia

This report discusses a boy with right hemiplegia due to left cerebral artery infarction. He has received physical therapy treatment since the age of 11 months.
The boy predominantly used his less-affected side of body and showed a specific asymmetric posture. The asymmetry of his posture made it difficult for him to change
his posture and caused deformation in sensory inputs of visual, proprioceptive and somatic sensation. During the treatment, a therapist in charge helped the boy experience symmetric postures such as a tailor's sitting position and an all four position. This treatment allowed the boy to gain repeated experience in movement under conditions with little deformation of sensory input. The therapist also employed a treatment program for movements following gravity (e.g. moving from a standing position to a sitting position), as well as for movements against gravity (e.g. from a lying position to sitting and standing positions).
As a result, the boy has become able to routinely move with symmetric postures such as a prone position and an all four position, and his asymmetric posture has been improved. Moreover, in addition to becoming able to walk alone, he can also change his posture in response to environments, such as playing with a jungle gym.
Through the treatment for the boy, the therapist understood that the following points were important when treating infants who have difficulties in perceptual-motor experience.
1. To employ treatment programs for symmetric postures from a very early stage of life.
2. To help infants correct discoordinated sensory inputs derived from multiple sensory modalities.
3. To help infants repeat better sensori-motor experiences.

Title: Assistance for eating in a child with severe cerebral palsy: Based on advice done at an advanced training course

Organization : Aitoku Medical and Welfare Center
Author : Takeo Sugitani, OTR
Key words : perception, environment, and management

This report discusses the assistance for eating of a 7 year-old boy with cerebral palsy, who lives in an institution. The assistance was provided, referring to advice received at the advanced training course held by Ms. Heather Holgate in 2007.
Needs from his family were that, "We would like to raise him if we felt confident to feed him."
This boy showed asymmetric and systemic extension patterns during eating and swallowing. Such patterns included pushing his head back and to the right, thrusting his tongue, and retracting his shoulder girdles. The therapist in charge reasoned that he may have central visual disorders since he appeared afraid of his spoon approaching closer to him. It was difficult for staff in the hospital ward to feed him.
One approach used by the therapist was to make a chair with an appropriate seating system to be used at meals. In order to stably support his head, the head rest was made to provide wide support from his posterior cervical region to lower jaw bilaterally. In order to control the extension patterns and stably support his upper extremities on the table, a cushion was made to support his bilateral shoulder girdles from the sides so that he could protract his shoulders. During meals, his chair was placed in a position where the spoon is lit up and easily visible.
For the next step, staff shared information of the boy's reactions during the meals and held discussions to find better assistance methods. On the other hand, the therapist in charge gave treatment sessions during mealtime. One treatment session lasted for 20 minutes. In addition, the therapist instructed his mother, who sometimes visits the institution, on how to assist with his eating.
As a result of the treatment, this boy has become able to eat and swallow, holding his head in midline. The therapist received the following compliments.
1. "It is easier for us to feed him." from staff.
2. "We can now feed him more easily. As a result, we enjoy mealtime with all of the family." from his family.
Through the treatment for this boy, the therapist understood the following two points.
1. In order for children to maximally exercise their potential in perceptual processing and sensori-motor abilities found during treatment, it is important to control physical environments in daily life.
2. It is important that therapists assist a child's family and caregivers in gaining an increased understanding of the child's potential as well as independently arranging ways to assist the child.

Title: Occupational therapy approach for a child with spastic diplegia having a visual perceptual disorder

Organization : Morinomiya Hospital
Author : Emi Yamanaka, OTR
Key words: visual perceptual function, upper extremities' functions, and activities of daily living (ADL)

This report discusses an occupational therapy approach which focuses on the visual perceptual functions of a five year-old child with spastic diplegia and which targets improvement in coordination between eyes and hands, as well as improvement in the child's ADL.
He was often sitting in a W-sitting position. He could not use his soles of a foot to keep balance while sitting in a chair. He needed his upper extremities to keep his sitting position while bending his lower trunk to one side. In addition, he had a squint which caused the lateral flexion of his head when looking at objects. He handled objects within reach of his dominant hand, only using the dominant hand. He could handle objects only in a limited space. He needed to be assisted in activities of daily living (ADL) except for eating. He could not play in a constructive way.
During the occupational therapy sessions, the therapist in charge assisted him in using his lower extremities to support his body and keep balance by actively moving his lower extremities while stabilizing the midline of his body. In addition, the therapist assisted him in controlling the direction in which he moves objects, considering the positional relationship between objects as well as using both of his hands at the same time. The therapist also assisted him in paying attention to the positional relationship of four directions (right, left, up, and down) at the same time. Meanwhile, in order to facilitate the development of his visuo- perceptual functions, the therapist assisted him in controlling the direction in which he moves objects while integrating somatic sensory information and visual information. Moreover, the therapist modified environments for the ADL so that he could perform his ADLs as independently as possible.
As a result of the occupational therapy approach at the hospital for seven months, he has become able to do the following items:
1. He has become able to eat with less spilling, dropping, etc.@
2. He has become able to balance by the foot and stand with a handrail.
3. He has increased the extent of his cooperation when changing clothes.
4. He has been able to perform constructive plays which necessitate movements including four directions (right, left, up, and down) by himself.

Title: Occupational therapy process until a child with autistic spectrum disorder and mental retardation is able to understand pointing functions: Application of key points of control for helping a child perform occupational activities

Organization : Heisei Rehabilitation College
Author : Yoshiharu Hara,OTR
Key words : autistic spectrum, occupational activities, and key points of control

This report discusses an occupational therapy approach for a child with autistic spectrum disorder and mental retardation. The child showed low postural tone and aspired for information such as somatic sense, vestibular sense, and sense of smell. During occupational therapy sessions, the therapist in charge used a method of guiding the child from behind based on the proprioceptive control method. Using this method allowed the therapist to assist the child in cooperating with a person positioned in front of him in order to perform occupational activities through mutual negotiation. The therapist initially guided his hands. Then, in order to gradually increase his autonomy, the therapist guided him from the central part of his body. As a result of this treatment, the child has become able to understand the meaning of the pointing functions and has also become able to perform easy constitutive assignments and is able to trace writing.