Page Fourteen P H Y S I O T H E R A P Y July, 1954, THE PLACE OF O C C U P A T IO N A L TH ERAPY IN REHABILITATION B y S. C Y N R IN , D ip. O.T. (Rand.) and J. H A R R ISB E R G , D ip. O.T. (Rand.). T 9 EH A B I L IT A TIO N has been defined as “ the rest or- -®-*-ation o f the handicapped to the fullest physical, mental, social, vocational and economic usefulness o f which they are capable.” . O ccupational T herapy plays an im portant p art in the physical an d m ental aspects o f rehabilitation, an d is also able to assist in pre-vocational guidance and preparation o f the patient for contact w ith the outside world. - As all these aspects o f O ccupational T herapy cannot be dealt with in one article, it is proposed to discuss only the “ physical” rehabilitation o f the patient. However, although the term “ physical” is used, it m ust be stressed th a t th e essence o f O ccupational T herapy is to combine actual physical movem ent w ith treatm ent o f the psycho­ logical factors associated w ith every case o f disability. Indications for Occupational Therapy. 1. Nervous System—disease and injury. (a) Upper M otor Neurone Lesions—particularly Residual Hemiplegia, C erebral -Palsy, Paraplegia; (b) Lower M otor Neurone Lesions—with particular ' reference to A nterior Poliomyelitis, Peripheral N euritis and Peripheral Nerve Injuries; ^ (c) Conditions involving Loss o f Co-ordination—as in Athetosis, C horea, post-operative cerebellar tum ours. 2. Bones, and Joints— disease, injury and surgical repair e.g. R heum atoid A rthritis and O steo-arthritis, Con- ~ genital deformities, Fractures, H ip A rthroplasty. 3. Muscles and Tendons—disease and injury an d surgical repair e.g. M uscular D ystrophy, T endon Sutures and Transplants. 4. Circulatory and R espiratory Systems—e.g. Congestiye. C ardiac Failure, A sthm a, etc. * 5. Plastic Surgery and Burns. M ention m ust also be m ade o f th e rehabilitation o f Amputees, a som ewhat specialised field, where particularly in th e U.S.A-, the function o f the O ccupational Therapist is prim arily to train patients in the perform ance o f every­ day skills by means' o f their prostheses. Aims of Occupational Therapy. (a) The basic aim is to provide a means o f assisting in the restoration o f function through the m edium o f crafts o r other m otivated activity, thus distracting attention from the disability. T he patient whose m ind is occupied with an interesting activity is m ore receptive to tre a t­ m ent, for, being m ore relaxed, fear o f pain on m ove­ m ent is minimised. (b) Specific Aim s are governed by the sym ptom atology o f th e cases to be treated—examples are tabulated below : A nterior Poliomyelitis Paraplegia Burns Cerebral Palsy (Athetoid) 1. R e-education o f muscle function—graded from assistance—resistance. 2. To establish new asso­ ciation pathways. 3. T o . m a i n t a i n b lo o d supply to muscles. 4. To encourage concen­ tration and general co­ ordination o f move­ ment. 5. To prevent depression • and m orbid introspec­ tion. A. Where complete section o f cord. 1. Strengthening vof torso and upper extremities for crutch walking. 2. Training, when neces­ sary, for a sedentary o c c u p a tio n w h e re b y patient can earn a live­ lihood. B. Where recovery of lower limbs is likely 1. R e-education and re­ laxation of spastic m us­ cles o f lower limbs. 1. To prevent contrac­ tures. 2. To increase range of active movem ent and improve circulation. 3. W here the area o f the .chest is involved—chest expansion and preven­ tio n o f deformities. 1. T rain new brain p ath ­ ways to take over the fu n c tio n o f th e d a m ­ aged areas. 2. Afford the child op p o r­ tunities for norm al de­ velopment. 3. Relaxation. 4. Im prove grasp and co­ ordination. 5. T rain perform ance of every day skills, e.g. dressing. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) July, 1954, P H Y S I O T H E R A P Y Page Fifteen CASE H IST O R Y I. Medical Prescription: Miss X. Age: 26. D ate: 16/1/53. Diagnosis: A N T E R IO R PO LIO M Y E LITIS. ' H istory: Poliomyelitis is o f approxim ately 6 weeks’ duration. Both legs affected—left leg very weak a t hip and knee, and there is only a flicker in pesonei at ankle. Right leg improving rapidly. Slight weakness spinal muscles, right side. Movements Required: O f left leg mainly. Patient must be treated in lying position due to weak spinal muscles. " Psychological Aspect o f Case: Patient is an intelligent young woman, very depressed at the mom ent. Treatment and Progress : ^ 1711 153. M ovem ents left leg tested: . K N E E : Quadriceps— very weak (vastus medialis absent). H am strings—flicker. H IP : Flexors—weak. G lutei— very weak. Tibialis anterior—absent. Psychological aspect: Patient weeps easily—feels she ivill never walk again. I t was decided to concentrate on quadriceps only at first, as all muscle o f leg were to o weak to w ork actively in com bination. Craft Analysis: W EA V IN G was chosen as being most suitable for leg movem ent, especially while patient was in bed. A small, simply-operated loom was clam ped o n ­ to a bed table across the patient, so she was able to see her work while lying flat in bed. A lead was taken from the loom through a pulley to a sling around th e knee in such a way th at p a rt o f the weaving process was carried out by quadriceps contraction. The rest o f the weaving process was completed by hand and arm movement. A foot-board a t the end o f the bed prevented “foot- drop” and acted as a lever for th e leg. Work Period: Patient w orked for 5 minutes, then complained o f fatigue. 25/1/53. Patient w orked fo r 30 minutes. .M uch more cheerful. H as confessed th a t she thought in the beginning th a t O ccupational T herapyvhad been prescribed because she was “m ental.” ■ 7 /2/53. Im provem ent in psychological outlook has helped patient’s concentration and hence re-education o f neuromuscular function. N ow able to produce tw o move­ ments while weaving— extension and flexion o f knee. Quadriceps still weak, vastus medialis—flicker apparent, i 17/3/53. Patient perm itted to be treated sitting up in |department. On exam ination left leg : Quadriceps— weak.- Hamstrings Glutei—very weak. Tibialis A nterior—query flicker. Weaving again chosen, this time on large foot-pow er loom with special adaptation for flexion and extension o f both knees, the right leg thus assisting the weaker left leg. In the Physiotherapy D epartm ent th e patient is learn­ ing to walk with tw o sticks, and a caliper w ith a pelvic band. 2/4/53. Flexion and extension hip and knee im­ proved. Left leg now w orking independently o f right. 11/4/53. R esistance: 3-lbs. to quadriceps—added to loom. 3-lbs. to ham strings „ „ „ In addition to weaving, patient now works on a bicycle fret saw for strengthening and co-ordination o f all hip and knee movements. 13/5/53. Patient w orked o n treadle sewing machine tor assisted movement o f left tibialis anterior, and con- n n Hc bicycIe saw ar,d 5-lbs. resistance to quadriceps 5-lbs. to hamstrings, while weaving. Patient now has full daily program m e as follows: 8.30 9.30 a.m .: Physiotherapy—general exercises. 9.30— 10.30 a.m . : O ccupational T herapy—quadriceps and hamstrings exercise through weaving. 10.30-—11.30 a.m .: .G am es Therapy— Physiotherapist and O ccupational Therapist working in conjunction. Games are played w ith a group of patients, all A nterior Polio­ myelitis o r P araplegia-cases. A mong o ther games, darts are used fo r balance and co-ordination, carpet bowls fo r knee an d hip movement. ’ " 12 noon— 1.30 p .m .: Lunch and rest period. 1.30 p.m .—2.30 p .m .: Physiotherapy— re-education of walking. 2.30 p.m .— 4 p .m .: O ccupational Therapy— bicycle saw and treadle machine. 3 /8 /5 3 . C ontinued improvement. Q uadriceps an d G lutei m uch stronger. Resistance on loom increased to- Quadriceps—7-lbs. H am strings—7-lbs. 1 /3/54. Patient has gone on leave for personal reasons and because it is felt she is becoming overhospitalized N ow w alking with only one stick an d spring support for weak tibialis anterior. Will return in 3 m onths’ time. C ASE H IST O R Y H . JO H A N N E S, P. A ge: 24 years. A dm itted to hospital 2 5 /1 /5 4 at 7.45 a.m . Was stabbed in the back 2 4 /1 /5 4 a t 6 p.m. C .O.E. (1) Stab a t level T6, ju st left o f mid-line. (2) Anaesthesia below T10. (3) Flaccid paralysis o f both legs. (4) H as passed no urine since stabbed. By 29/1 /54 spasticity had developed in the legs. Ab- - dom inal reflexes absent. Bladder training commenced. 1 2/2/54. An O ccupational T herapy c a rd 's e n t to the D epartm ent requested strengthening o f both upper limbs fo r crutch walking. T reatm ent to be comm enced in bed. C raft Analysis : Crafts giving bilateral movem ent an d to which resis­ tance can be added are m ost valuable in a treatm ent o f this nature e.g. weaving and cord-knotting. C raft chosen fo r Johannes—Cord-knotting, The emphasis here is an extension o f elbows and strengthening o f grip. The patient was treated in a lying position w ith one pillow for the head, the cord-knotting being attached to the overhead beam in such a m anner th a t the knotting could not, be done w ithout full extension o f th e elbows. By m eans o f a weight an d pulley circuit, with slings attached to the h a n d s , 2-lbs. resistance was given to elbow extension. The weight and tim e-factors were graded as follows : 3 m inutes work period—2 minutes rest period for 45 minutes. W ork period was gradually built up to- 6 minutes, then when weight was graded to 3-lbs. o n each triceps, th e work period was reduced to 3 minutes again, and progressed in same manner. 19/3/54. Patietit allowed to attend Occupational Therapy Dept. A special weaving loom has been adapted for all Paraplegia cases, to give the required muscle strengthening in the sitting position. Johannes attended every m orning fo r 30 minutes, this time being gradually increased to a maximum o f 1^ hours. Patient attended Physiotherapy' in the afternoon. F o r first week no resistance given, as the patient had to get accustomed to being up. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Sixteen- P H Y S I O T H E R A P Y July, 1954. 2 4 13 154. The following weights were applied to the loom to give the necessary resistance : (1) Triceps— 3-lbs. each. (2) Latissimus D orsi— 6-lbs. R hom boids „ Trapezius „■ Pectoralis , „ An overhead beater is also attached to the loom to give the necessary strengthening. 1 j4 /54. Weights graded to : (1) Triceps— 4-lbs. each. (2) Latissimus D orsi, etc.— 16-lbs. W hen the patient a tten d ed ,th e departm ent, Pre- Voca­ tional Training was also commenced. Johannes expressed an interest in cobbling and he started attending classes in the morning after his remedial treatm ent and a break for tea. 19/5/54. Patient started crutch-walking. R em edial Occu­ pational T h e ra p y . discontinued, and emphasis of treatm ent is now on re-vocational training. . CASE HISTORY HI. J.S.—N on-E uropean child aged 7, adm itted 2 1 /4 /5 4 with 2nd degree burns o f chest and axillae. Remedial O ccupational T herapy was requested 2 weeks- after adm ission when sufficient granulation tissue had formed to w arrant active movement. A t the same time Physiotherapy treatm ent was started. C.O.E. Right Shoulder ' L e ft Shoulder Flexion : 80° 100° Extension : 30° ‘’ 42° A bduction : 90° 90° These were the only movements th at could be measured because o f lim itation by heavy bandaging. Treatment' in Bed : 1. The first obstacle to be overcome a t this stage was fe a r o f pain. "It was found th at the child was-afraid to move, even within the limits o f pain. ■ A n attem pt was m ade to gain his confidence by giving him a brightly-coloured soft ball—and before long th e natural inclination to play ball overcame th e initial fear o f movement. In this way, play therapy was started, incorporating the requited range o f gentle active movem ent in a series o f different ball games. 2. D ue to pain, the child was developing a bad pos­ ture— Kyphosis and a m ild Scoliosis. To prevent this deform ity simple cord-knotting with brightly-coloured rug wool was chosen as a craft as this provided : (a) chest expansion; (b) bilateral active movem ent o f upper limbs. T R E A T M E N T IN D E P A R T M E N T commenced 5 /5 /5 4 . The child was brought down every afternoon, having attended Physiotherapy in the m orning, and having had a good rest period in the interval. . The following movements were concentrated on during treatm ent in the dept. 1. Abduction, Flexion and External Rotation o f Both Shoulder Joints. (a) Play therapy was continued, using a larger ball and concentrating mainly on overhead games against a wall using first both arm s together and then each arm individually. Careful supervision was necessary to^ ensure th at the correct movem ents were being obtained. (b) A t this stage the child was also able to play darts, using right and left arm s alternatively. T he dart- board was suspended above shoulder leVel in . order to ensure shoulder movements during the game. 2. Chest expansion. To mobilise the thoracic cavity and to encourage deep breathing, blowing games were'used e.g.' blow-football, bubble-blowing, and blowing paper windmills. These games were played with o ther children to foster the spirit o f com petition and to divert the atten tio n from , the true aims o f these games. 3. Flexion, Extension o f Shoulders and Chest Expansion. Block printing was a craft chosen to give these p arti­ cular movements. (a) because the craft consisted o f using bright colours which most children enjoy; (b) because o f its adaptability by a horizontal bar 24-in. long, which is attached to the roller handle. B oth hands were used to hold the ends o f this handle when rolling the paint off th e glass and o n to the block, and in this way the required move­ ment of the shoulders were obtained. By varying the height o f th e chair on which the patient sat, the range o f m ovem ent was graded according to the 'requirem ents. ^ M easurem ents taken on 17/5/54 i.e. tw o weeks later > proved the following: Right Shoulder . L e ft Shoulder Flexion : 8 ° im provem ent 6 ° im provem ent Extension : 6 ° „ ' ■ 4 ° „ A bduction : ' Full ■ Full E xternal ro ta tio n : limited. very limited T hough a completely full range o f m ovem ent had not yet been obtained the patient was discharged from the W ard, due to the acute shortage o f beds in the H ospital. A ttending 3 times weekly as an out-patient for both Physio­ therapy and O ccupational Therapy treatm ent, the child has been making steady progress to date. CASE HISTORY IV. Name: P.O. Age: 6J years. Diagnosis: Tension athetoid w ith auditory perception difficulty. This patient was referred fo r treatm ent because of excessive abnorm al movements. ' Delivery at Birth: N orm al, no instrum ents, jaundice, annoxia o r convulsions. L abour 36 hours. . Parents both well. Birth weight: 9 j lbs. First child. ^ The mother noticed: 1. Baby very restless. 2. Difficulty in sucking. 3. U nable to sit at 9 m onths. 4. Crawled at 2 years. 5. Walked at 3 years. 6. Spoke sentences a t 4 years. C.O.E.: 1. Physical: G eneral health and posture good. C hild drools and has difficulty with breathing. H is gait is shuffling. H e is able to grasp large, sm all and m edium sized objects. His grasp is not developed and needs im prove­ ment. H e must learn to use his finger tips and not his palm! H is co-ordination is poor—he does n o t reach o r return directly. B oth hands are affected—the left to a lesser degree. H e is left-handed. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) July- 1954. P H Y S I O T H E R A P Y Page Seventeen 2. M ental: A t a clinic held in 1952 the child was assessed as being mentally retarded. Since treatm ent began in O ctober 1953 he has improved greatly in writing and general school work. H e has an excellent ability to concentrate and follow instructions, and despite adequate testing, on his school work it is felt his l.Q . is average. 3. Speech: M arked lim itation in basic functions. Articulatas are poorly utilized. Treatment : By constant repetition o f specific movements e.g. grasping, it is hoped to train new • brain pathways. Occu­ pational Therapy and th e general school program m e give the child everyday experiences and opportunities for norm al development. There are various methods o f achieving relaxation, a very satisfactory m ethod is one o f a calm, friendly relaxed approach on the p art o f the therapist, this is transferred to the patient. 1. Weaving: (a) on a fram e which involves grasp— [the shuttle is m ade a suitable size to involve use o f all the fingers in flexion. (b) co-ordination—the shuttle is darned in and out of the warp threads thus involving slow controlled movements. (c) elbow flexion and extension—as th e shuttle is drawn out o f the warp. • This teaches the same arm movement required in feeding. (d) abduction o f the 'fingers ,and extension o f the wrist in beating down the weft threads. This child has some tension and requires movem ent at the wrist joint. 2. Constructional toys such as “ Teachem” toys are given for co-ordination and grasp. 3. Skills: The patient is to button up and unbutton large buttons on a frame. 4. Feeding: The child practises feeding in front of a m irror. Being unable to supinate the child is taught to flex his elbow with the wrist in pronation, to bring the spoon to his m outh. The m irror assists him to reach his m outh directly. 5. Drooling is checked by constantly rem inding him - to keep his m outh closed. H e is given gum and sweets to check the flow o f saliva. This carried out in conjunction with the speech therapist. H e is a. co-operative and keen patient. -Unfortunately, due to lack o f time both on the part o f the therapist and th e child, who has a full program m e o f therapy and school, he is unable to participate in group activities, which would be particularly beneficial for— 1. A rt and finger painting—which gives opportunity for self-expression and finger dexterity. 2. Games—this prom otes a healthy spirit o f competi­ tion and an outlet for excess energy not forgetting the norm al desire o f children to play. , N o child is treated in isolation. Each therapist and teacher w ork as a closely knit team to equip these children to take their place in society, despite their handicap. Observation : As it can be seen from the treatm ent o f the aforesaid case histories it is impossible to draw a well defined barrier between th e function o f the various medical auxiliaries— for upon th e closer co-operation only, between the medical staff, physiotherapist, speech therapists, social w orker, teachers and the occupational therapist, depends th e success o f the R ehabilitation o f th e patient. Thanks: We w ould like to th an k the O ccupational Therapy D epartm ents a t the G eneral H ospital, Johannesburg, B aragw anath N on-E uropean H ospital, Edenvale H ospital and th e Forest Town School for C erebral Palsy Children fo r their co-operation in providing the case histories. THE HABILITATION OF THE CEREBRAL PALSIED CHILD B y F. M. TR A G O T T -V O R W E R G (Principal). SOPHIE LEVITT (Head Physiotherapist) Forest Town School for Cerebral Palsy. IT cannot be denied th at Cerebral Palsy and its treat­ment presents a growing problem all over the world today, not least in South Africa. F rom about the mid-nineteenth century, when D r. William Little gave some attention to “Spastics,” Cerebral Palsy cases were all labelled Little’s Disease, and those dealing with it, accepted an .associated m ental deficiency with a hopeless prognosis. Only in- recent years has it been realised th a t th e Cerebral Palsied had potentially greater abilities than hitherto suspected. Much o f the pioneering work in this field began in the U.S.A., under the direction o f such as C rothers, Phelps, Fay, Perlstein and others. _ I t was emphasized th a t a damaged brain did no t necessarily indicate m ental deficiency, and th at the condition is m anifest in several forms, of which Spasticity is only one. Definition. C erebral Palsy is comm only defined as a condition characterised by paralysis, weakness, inco-ordination, or any other aberrations o f m otor functions, due to -m a l­ function o f the m otor centres o f th e brain. . T he types o f Cerebral Palsy are described according to clinical findings rather than to aetiology, and the fol­ lowing classifications are generally accepted : Spasticity. The cases in this group may be quadriplegias, p ara­ plegias, hemiplegias and the rarer m onoplegias and tri- plegias. T he m ain features reveal postural deformities, e.g. internally rotated, abducted position o f the legs; increased tendon reflexes and the presence o f the hyperactive stretch reflex. Thus, when a muscle group contracts, the stretched antagonist contracts simultaneously instead o f relaxing to allow a sm ooth norm al movement, as referred to in Sherrington’s “ Law o f Reciprocal Innervation.” Athetosis. . These cases are comm only “ quadriplegias” and also hem iathetoids have been described. Athetoids exhibit in­ voluntary unpatterned movements, disturbances in balance, co-ordination and often tone. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )