Volume 32, No.1, June, 2009

Title: An approach for increasing the locomotion of a teenager with cerebral palsy

Organization: Nakagawanosato Ryouiku Center
Author, Tomoko Ando, RPT
Key words: teenager, cerebral palsy, and locomotion

This report is discussed a physical therapy treatment for a high-school student with cerebral palsy. The therapist in charge has treated him to achieve walking using crutches for a year. As a result he is able to walk using crutches. Moreover, he has acquired various posture and motor patterns. When considering the increased sense of achievement and self-confidence that he has gained from the expansion of his locomotion range, this treatment has proven its significance.
He was born prematurely at the gestational age of 34 weeks with the birth weight of 2,280g. He was a 14-year-old boy at the start of the treatment and diagnosed with spastic quadriplegia. He used a wheelchair for daily life and had no experience walking. He had moderate flexion contracture on his hip/knee joints due to spending a long time in a sitting position. It was assumed that his body schema was undeveloped due to lack of experience with standing and walking.
Treatment programs
The therapist in charge helped him obtain appropriate body schema in his lower extremities in order to stabilize his lower trunk and his hip joints. Additionally the therapist facilitated his motor planning and programming. Therefore his fixed posture and motor patterns changed variety. Considering that he was a high school student, the therapist instructed him in home programs to enable him to control his body at his home and school.
While walking with crutches, he changed his motor patterns from static to varied. He increased stability in his lower trunk and his hip joints as well as improved the ability to support his weight on his lower extremities. By using home programs for self-management, his chronic low back pain was eased.
In this case, the achievement of walking by himself brought improvement to his Quality of Life (QOL) and was of great significance. Regardless of a patient's age at the time the treatment started, therapists should accurately evaluate a teenager's potential and should develop his/her ability to the maximum level through positive intervention.

Title: A case report of a girl who acquired the ability to walk at 9 years old

Organization: Tokyo Pediatric Nursery Hospital
Author, Masami Kodama, RPT
Key words: growth in a special environment, base of support, and body schema.

A physical therapy treatment approach for a 9 year-old girl with arthrogryposis multiplex is discussed in this report. She suffered from chronic respiratory failure and her breathing was regulated by means of a ventilator installed after a tracheotomy. She had spent her life only in a Growing Care Unit (GCU) until she was transferred to our clinic. She spent her life in a prone position all day long due to severe skeletal deformation. She had never experienced self-locomotion. In regards to this girl who had grown in such a special environment, the therapist in charge provided physical therapy treatment with the goal of achieving practical locomotion over a period of several years.
Treatment programs
The therapist adjusted her postural muscle tone and bone alignment, encouraged her active movement, and helped her to recognize her base of support (BOS). Moreover, the therapist encouraged her to change her posture in accordance with recognition of the BOS. The therapist advanced the program in stages with the ultimate goal of enabling the girl to achieve antigravity posture/movement.
The girl is able to recognize her BOS, feel her body schema, and keep sitting/standing postures. In addition, she is able to walk by herself using a postural control walker (PCW) and move by a powered wheelchair.
The girl could not recognize her BOS due to her growth in a special environment and her severe skeletal deformation. This prevented her from obtaining a means of locomotion. This treatment has changed her body schema and thereby developed her potential. She has acquired practical locomotion methods and has become able to successfully perform more activities in her daily life.

Title: Potential of treatment for emotional incontinence in a patient with cerebrovascular disorder

Organization: Hokuto Hospital
Author, Toshikazu Horiuchi, RPT
Key words: emotional incontinence, postural control, and respiration

For patients with cerebrovascular disorders, occurrences of emotional incontinence may result in a difficulty in communication and a disadvantage in social life. This report discusses a case in which a patient with cerebrovascular disorders had emotional incontinence during daily conversation. The therapist in charge provided treatment to her under the assumption that emotional incontinence is related to breathing. As a result of the therapy, her emotional incontinence was improved. This report uses this case to create a discussion about the treatment prospects for emotional incontinence.
The patient was a 70-year-old female with a right putaminal hemorrhage. Although she was able to communicate, she often experienced emotional incontinence during daily conversation. She often showed symptoms of emotional incontinence during an expiratory phase of breathing in conversation. During the treatment, the therapist improved the elasticity of her trunk and improved her core-stability in accordance with breathing. As a result, the symptoms of her emotional incontinence were improved. A magnet encephalograph (MEG) was employed to prove the effectiveness of the treatment. During verification, a spontaneous magnetic field was used for the photographing method in a supine position. Brain activities "during rest", "during the occurrence of emotional incontinence induced by auditory stimuli", and "during hands-on treatment sessions (facilitated extension of her trunk in order to aid breathing) by the therapist" were photographed and analyzed. When comparing these three conditions, the difference in the right-and-left brain activities at rest was further expanded during the occurrence of emotional incontinence. Also, brain activity in both the damaged side and the non-damaged side of her brain changed after handling by the therapist. In view of these findings, the therapist reasons that the elimination of emotional incontinence was achieved through the improved activity in both sides of the brain.

Title: Postural control in an infant with cerebral palsy accompanied by cerebellar hypoplasia after a surgical operation for realigning hip joints

Organization: Morinomiya Hospital
Author, Yuko Yamamoto, RPT
Key words: body schema, postural control, and body orientation

This report discusses a physical therapy treatment approach for an infant with cerebral palsy accompanied by cerebellar hypoplasia after a surgical operation for realigning hip joints. He was born at the gestational age of 24 weeks. Cerebellar hypoplasia, porencephaly after bleeding around ventricles, and an ischemia lesion on the posterior limb of the left internal capsule were found on his brain images. Based on these lesions, the therapist in charge predicted that he would show cerebellar mental retardation and not be able to keep his postural balance.
He experienced great fear immediately following the removal of the cast and refused the treatment. He did not have the experience of maintaining a sitting/standing posture or of standing-up in a state in which his soles were in contact with the floor. In addition, his soles were hyper-sensitive. Due to these two factors, he was unable to refrain from lifting up both of his lower extremities when practicing an exercise to support weight on his lower extremities, and he had great difficulty in keeping his soles on the floor. Therefore, instead of stretching his lower extremities to have his soles contact the floor, the therapist encouraged him to gradually stretch the lower extremities using their own weight. This method allowed him to feel the floor with his own toes before allowing his soles to contact the floor, as well as enabling him to recognize the proprioceptive feelings that arise by stretching the muscles.
The author believes that he was able to recognize his feet as a part of his body schema and use the lower extremities by going through these processes. In addition, as a result of his understanding the orientation of body segments related to gravity, the author assumes that he could contact his soles on the floor using the weight of his lower extremities. The author believes that this change in his behavior could be explained based on the concept of orientation shown in Neuronal Network Action & Biomechanical Control (Massion J (1994)). In this case, the author assumes that his abilities to support his weight on his lower extremities against gravity as well as to adjust his posture while moving have just begun to develop.