Sensory-Motor Associations in the Treatment of Stroke Patients By L t . - C o l . J . K . M c C O N N E L L , d .s .o ., m . b .e ., m .c . M e m b e r o f t h e C h a r t e r e d S o c ie ty o f P h y s io th e r a p y June, 1968 P H Y S I O T H E R A P Y Page 5 F o r m a n y y e a r s t o c o m e th e r e w ill d o u b t l e s s c o n t i n u e to b e n u m e r o u s p a t i e n t s s u ffe rin g s t r o k e s a n d r e q u ir in g r e h a b ilita tio n . T h e fo llo w in g id e a s a n d a c t i o n s e n a b le t h e p a tie n t t o h e lp h im s e lf d u r i n g r e h a b i l i ta t io n , a n d t o m a k e th e b e s t o f w h a t r e m a in s t o h im . C o n s e q u e n tly , th e y a r e o f g e n e ra l i n t e r e s t ; th e y a r e e a sily a p p lie d b y t h e p a t i e n t , a n d a ffo rd e c o n o m ie s o v e r a ll, b e in g b a s e d o n c o n s id e r a b le e x p e rie n c e b o th g e n e ra l a n d p e r s o n a l. I N N A T E S E N S O R Y - M O T O R C O N T R O L T h e b a s ic id e a u n d e r ly in g t h i s a r tic le is t h a t w h e n th e p a tie n t’s m e n ta l a b ility is a t its lo w e s t e b b , it is p re fe ra b le , w h e n e v e r p o s s ib le , t o b r in g o u t h is la te n t reflex p e d i- m a n u a l a b ilitie s, r a t h e r t h a n e i t h e r t o te a c h h im fre s h a c tiv itie s o r ev e n m e re ly t o a p p ly p a s siv e m o v e m e n ts . T h is p r o c e d u r e a im s a t c h e c k in g h is f e a r o f f a llin g a n d e n c o u r a g in g h is m e n ta l a b ilitie s . T h e w a y in w h ic h t h i s is d o n e w a s b r o u g h t t o m y m in d b y t h e fo llo w in g e x a m p le o f s e n s o r y - m o t o r c o n t r o l , n o w in n a te in m a n a n d r e a d y >o b e b r o u g h t in t o u s e a s r e q u ir e d . It se e m s t h a t t h i s ty p e o f s e n s o r y - m o t o r c o n t r o l — in w h ic h ta c tile s e n s a tio n s a r is in g in t h e h a n d s a n d f e e t a r e u tiliz e d — ev o lv e d a s fo llo w s : In The A n tecedents o f M a n , S ir W illia m L e G r o s C la r k d e s c rib e s h o w o u r r e m o te a n c e s t o r s lo s t t h e i r c la w s in e x c h a n g e f o r f in g e r- n a ils a n d f in g e r- p a d s . B e in g r ic h ly s u p p lie d b y s e n s o r y n e r v e s th e y f o r m e d t a c t i l e o r g a n s w ith a fa n ta s tic a lly h ig h d e g re e o f s e n s itiv ity . T h u s , t h e i r l o c o ­ m o tio n t h r o u g h t h e f o re s t a n d t h e b a la n c e o f t h e i r b o d ie s w ere g o v e r n e d t o a la r g e e x te n t b y t a c tile im p u ls e s f ro m th e ir h a n d s . T h is m a d e th e ir a r b o r e a l a c r o b a t i c s p o s s ib le . D u r i n g s u b s e q u e n t e v o l u t i o n o f p r i m a te t o m a n th is ty p e o f s e n s o r y - m o t o r m a n u a l c o n t r o l w a s r e ta in e d , a l t h o u g h it w a s o f c o u r s e n o lo n g e r u s e d in a n a r b o r e a l e n v ir o n m e n t. W h a t m a n h a d t o d o w a s t o le a r n refle x ly h o w t o c o m b in e th e a c tiv itie s o f h is h a n d s w ith th o s e o f h is fe e t. T h e a b o v e s u g g e s ts t o a n y th o u g h t f u l p h y s io th e r a p is t th a t w e h a v e in h e r ite d f r o m o u r r e m o te a n c e s t o r s s e n s o r y - m o t o r a s s o c ia tio n s b y w h ic h t a c tile im p u ls e s f r o m t h e f in g e r ­ tip s c a n h e lp t o r e g u la te t h e b a la n c in g o f t h e b o d y o n t h e feet. It is e a s y a ls o t o d e m o n s tr a t e t h a t th is is s o : if o n e s ta n d s o n a n u n s ta b le s u r f a c e o r is s t a n d in g o n o n e leg w ith o n e ’s e y e s s h u t , b a la n c e is f o r th w ith im p ro v e d a u to m a tic a lly , th e i n s ta n t o n e la y s a f in g e r o n a n y firm , s t a t i o n a r y o b je c t. (c o ntinued fr o m p a g e 4.) S U M M A R Y A N D C O N C L U S I O N T h e k e y s t o t h e p r e v e n tio n o f t h e la te , c r i p p lin g e ffe c ts o f r h e u m a to id a r t h r i t i s a r e e a r ly d ia g n o s is a n d e ffe c tiv e tr e a t m e n t b e f o r e jo i n t d e s t r u c t i o n a n d c a p s u l a r d e g e n e r a tio n o c c u r. T h e a p p l i c a t i o n o f th e s e p r in c ip le s t o t h e r h e u m a t o i d h a n d a n d w ris t is d e s c rib e d a n d t h e v a lu e o f e a r ly s p lin ta g e a n d s y n o v e c to m y a r e e m p h a s is e d . A C K N O W L E D G E M E N T B e ta m e th a s o n e a c e t a t e a n d b e t a m e t h a s o n e d is o d iu m p h o s p h a te ( C e le s to n e S o lu s p a n ) f o r u s e in th e s e p a tie n ts w a s s u p p lie d b y S c h e r a g ( P ty .) L td ., J o h a n n e s b u r g . R E F E R E N C E S P u lk k i, T . (1 9 6 1 ): R h e u m a to i d D e f o r m itie s o f t h e H a n d , A cta R h eu m . Scand., 7 , 85. S h o rt, C . L ., B a u e r, E . a n d R e y n o ld s , W .E . (1 9 5 7 ): R h e u m a ­ to id A r th r i t i s . C a m b r id g e , H a r v a r d U n iv e r s ity P re ss . T a c tile im p u ls e s f r o m t h e fin g e rs c o - o r d i n a t e m u s c u la r a c tiv ity t h r o u g h o u t t h e b o d y t o s t a n d o n t h e fe e t. It w ill b e s h o w n t h a t t h i s i n b o r n s e n s o r y - m o t o r a s s o c ia tio n a p p lie s e v e n t o t h e s t r o k e p a t i e n t . H e m e re ly r e q u ir e s t o b e i n s t r u c t e d h o w t o u tiliz e th e s e a s s o c i a t i o n s u n d e r th e v a r i o u s c ir c u m s ta n c e s r e n d e r e d n o v e l b y h is s tr o k e . H e d o e s n o t n e e d t o le a r n t h e b a s ic a s s o c i a t i o n s a f r e s h ; b u t h e m a y h a v e t o le a r n h is p o o r u s e o f th e m in h is p a s t life. I n m a n , t h e b a la n c in g e le m e n t in th is a r m / f o o t b a la n c e a s s o c i a t i o n a lte r s in a c c o r d a n c e w ith t h e v a r y in g p r o p r i o ­ c e p tiv e im p u ls e s c o m in g i n t o t h e c e n t r a l n e r v o u s sy s te m fr o m t h e h a n d a n d a r m a n d t h r o u g h m u s c le s d o w n t o h is fe e t. I f t h e h a n d - g r a s p r o u n d a b a r , o r t h e h a n d p re s s u re a g a in s t a f la t s u r f a c e , u tiliz e s t h e in tr in s ic m u s c le s o f t h e t h u m b a n d h a n d , t h e b a la n c e o f t h e b o d y is f a r b e tte r t h a n w h e n th e fin g e rs a r e m e r e ly u se d a s a h o o k (lik e th o s e o f t h e th u m b le s s W e s t A f r ic a n C o l o b u s m o n k e y s ). T h is c o n t r i b u ti o n t o b a la n c e b y im p u ls e s f r o m t h e in trin s ic m u s c le s o f t h e h a n d o c c u r s n o t o n ly in t h e n o r m a l h u m a n b e in g b u t a ls o in t h e s t r o k e p a t i e n t . T h e s e in flu e n c e s d u e t o c o m b in e d ta c tile a n d p r o p r i o c e p t i v e im p u ls e s t a k e e ffe c t a u t o m a t i c a l l y a n d s h o u l d b e fu lly e x p lo ite d d u r i n g r e h a b i l i ta t io n . A D J U S T I N G T H E S E N S O R Y F I E L D A t t h e ris k o f o v e r -s im p lif ic a tio n , o n e c a n s a y : (a) T h e a v e r a g e p a t i e n t ’s s e n s o r y field is p r o b a b l y re s tr ic te d a n d / o r e v e n d is t o r t e d . (b) W h e n h e fe e ls t h a t h e is u p r i g h t, h is b o d y is p r o b a b ly s lo p in g a n d v ic e v e r s a ; h e n c e t h e p a t i e n t ’s sid e w a y s s lu m p w h e n s ittin g o r re c lin in g . T h is d i s t o r t i o n o f h is s e n s o r y field is lin k e d w ith h is f e a r o f fa llin g . (c) I f h e i n t r o d u c e s i n t o h is s e n s o r y field s u p p le m e n ta r y s e n s a tio n s , e .g . ta c tile a n d p r o p r i o c e p t i v e s e n s a tio n s f r o m h is s o u n d h a n d s t r e tc h e d o u t o n t h e h o r iz o n ta l s u r f a c e o f a b e d s id e ta b le , o r a g a i n s t a c o n v e n ie n t v e r tic a l s u r f a c e , t h e s e n s o r y - m o t o r a s s o c ia tio n w h ic h r ig h ts h is b o d y b a la n c e m a y w ell o v e r -r id e t h e a s s o c ia tio n w h ic h c a u s e d h is s lu m p s id e w a y s a n d h is f e a r o f fa llin g . (d ) H e is a d j u s ti n g h is b o d y in r e l a t i o n t o t h e h o r iz o n ta l o r v e r tic a l p o s itio n o f h is s o u n d h a n d . P r o p r io c e p tiv e im p u ls e s g iv e i n f o r m a t i o n c o n c e r n in g t h e p o s itio n o f t h e h a n d in r e la tio n t o t h e b o d y ; a n d a ls o o f t h e b o d y a n d fe e t in r e la tio n t o t h e h a n d . I n a c t u a l p r a c tic e , t h e r e s u lts o f e v o k in g th e s e a s s o c ia tio n s a r e b o u n d t o b e s o m e w h a t p a tc h y . I t c o u ld n o t b e o th e r w is e , t a k i n g i n t o a c c o u n t t h e w id e v a r ie ty o f c o n d i t i o n s a n d b r a in d a m a g e c o v e r e d b y t h e te r m “ s t r o k e ” . T w o b a s ic f a c t o r s m a y in te r fe r e . F ir s tly , t h e p a t i e n t m a y b e u n a b le t o c o - o p e r a t e o r e v e n t o g r a s p t h e s e in t e r - l i m b r e la tio n s h ip s . S e c o n d ly , c o n f u s in g in flu e n c e s m a y e m e r g e f ro m h is ey es. I t a lw a y s h e lp s t h e p h y s i o t h e r a p i s t t o h a v e t h e d o c t o r ’s o p i n i o n . T h e p a t i e n t m a y h a v e d o u b l e v is io n o r a s e rio u s c o n flic t b e tw e e n h is v isu a l a n d v e s t ib u l a r o r p e r ip h e r a l s e n s o r y b a l a n c e m e c h a n is m s . I f th e s e a r e t r o u b le s o m e , t h e p a t i e n t m a y r e s p o n d f a v o u r a b ly b y h a v in g o n e o r o t h e r ey e c o v e r e d w ith a s h ie ld o r a b a n d a g e , a n d t h u s is o la tin g o c u la r in te r f e r e n c e w ith t h e o t h e r r ig h tin g re fle x e s o f h is b o d y . T h e p a t i e n t ’s i n n a t e t e n d e n c y t o s i f t / s o r t a n d i n t e g r a te t h e v a r i o u s s e n s o r y - m o t o r a s s o c ia tio n s , a n d t o o v e r c o m e h is f e a r o f fa llin g w h ils t e lim in a tin g p a s t f a u lty a s s o c ia tio n s o r le a r n in g o ld reflex e s a n e w , is h a r d t o e x p la in . I f t h e p a t i e n t c a n a c h ie v e c o n t r o l o f h is s lu m p , b y th is s im p le u s e o f h is h a n d in b e d , it g iv e s h im c o n f id e n c e f ro m 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 6 P H Y S I O T H E R A P Y June, 1968 t h e o u ts e t, a n d h e is se t fa ir f o r im p ro v e m e n t in b a la n c e a n d a c t i o n , w h ilst w a lk in g a f te r w a r d s . V I S U A L I N F L U E N C E S D u r i n g e v o lu tio n , m a n h a s l e a r n t t o re ly la rg e ly o n h is e y e s f o r b a la n c e . T h e a s s o c ia tio n o f h is v isu a l in flu e n c e s w ith im p u ls e s f ro m h is ta c tile p a d s o f h ig h s e n s itiv ity is o f g r e a t im p o r t a n c e a s r e g a r d s s i f t i n g /s o r tin g a n d in te g r a tin g s e n s o r y d a t a . L e t u s ta k e f o u r e x a m p le s o f a c ts t h a t a r e sp e c ia lly re le v a n t t o t h e s t r o k e p a t i e n t : (a ) I f t h e p a t i e n t ’s t e n d e n c y t o s lu m p s id e w a y s w h ilst s ittin g h a s n o t b e e n im p r o v e d b y u tiliz in g m e s sa g e s f ro m h is s o u n d h a n d , th e a s s o c ia tio n o f th e s e w ith v isu a l in flu e n c e m a y h e lp . H e c a n g la n c e w ith his s o u n d ey e a t a h o r i z o n t a l lin e . I f t h e lin e a p p e a r s to b e r u n n in g u p h ill ( c o m p a r e d w ith t h e d a t a fro m h is h a n d ) , th is is a s ig n a l t h a t h is sid e w a y s s lu m p re q u ire s a d j u s tm e n t . T h is s e n s o r y - m o to r a s s o c ia tio n b e c o m e s a u t o m a t i c . (ft) I f h e s t a n d s a n d lo o k s a t o n e o r b o th e y e s in a m i r r o r o r s t a n d s a n d lo o k s a l o n g a b r o a d w h ite lin e, his b a la n c e is p r o b a b l y im p ro v e d f o r t h w i t h , w h ilst w a lk in g . (c) T h e s a m e o c c u r s , w h e n h e g a z e s a t a s m a ll, e a s ily re c o g n iz a b le o b je c t a p p r o x i m a t e l y in lin e w ith his ey es. (d ) O n t h e c o n t r a r y , w h e n h e is t u r n in g a n d t h u s sw in g in g his lin e o f s ig h t fro m o n e o b je c t t o a n o t h e r , h is b a la n c e te n d s t o b e d is t u r b e d . A c c o r d in g ly , it is w ise f o r him t o s a fe g u a rd h im s e lf a g a in s t th is d i s t u r b a n c e o f v isu a l in flu e n c e b y b r in g in g in to p la y m e s sa g e s fro m his s o u n d h a n d in c o n t a c t w ith a n a p p r o p r i a t e o b je c t. I f h e h a s m a d e h im s e lf h a n d y w ith h is s tic k in his s o u n d h a n d , t h e m e s sa g e s fro m t h e e n d o f a f irm ly p la c e d s tic k w ill re a c h h is b r a i n v ia his fin g e r w h ic h p o in ts d o w n t h e s h a f t o f t h e s tic k a n d w ill h e lp t o p re s e rv e h is b a la n c e . T h e a b o v e a c t i o n s a r e o f v a lu e d u r i n g r e h a b ilita tio n , b e c a u s e th e y c a n b e u tiliz e d w ith t h e m in im u m o f in s tr u c tio n . T h e s e v is u a l in flu e n c e s a r e b a s e d o n a n c e s tr a l b e h a v io u r . T h is a r tic le d o e s n o t a t t e m p t t o c o v e r t h e w h o le o f t h i s s u b je c t, b u t th e r e a r e a few f u r t h e r v isu a l m a t t e r s t h a t s h o u ld b e m e n tio n e d . F o r in s ta n c e , t h e s e n s o r y in p u t d u e t o s id e t o s id e m o t i o n o f t h e h e a d is a d is tu r b in g f a c to r f o r m a n y s t r o k e p a tie n ts . T h e s i f t i n g /s o r tin g m e c h a n is m s o f n o r m a l p e r s o n s d e a ls w ith th is so e ffe c tiv e ly t h a t o n e is u s u a lly u n a w a r e o f th is s id e w a y s m o tio n , w h e n w a lk in g . T h a t it e x is ts c a n b e d e m o n s tr a t e d if o n e h a n g s a c o rd d o w n in f r o n t o f a lo n g m i r r o r , t h e n s t a n d s w ith t h e im a g e s o f o n e ’s e y e s o n e i t h e r s id e o f t h e c o r d , a n d w a lk s to w a r d s t h e m i r r o r . T h e im a g e s o f o n e ’s e y e s d a r t fro m s id e t o sid e a c r o s s t h e c o r d . I n f a c t, th e s u r p r is e c a u s e d b y th is m a y c a u s e s o m e a p p a r e n t l y n o r m a l p e r s o n s t o e x p e r ie n c e m o m e n ­ t a r y c o n flic t, d u e to u n c o - o r d i n a t e d v isu a l a n d la b y r in th in e in flu e n c e s, c o m p a r a b l e t o t h a t su ffe re d b y t h e s t r o k e p a tie n t. B la c k in g o u t t h e v is u a l in flu e n c e s o f p a t i e n t s w h o su ffe r f ro m a b n o r m a l h e a d p o s t u r e s h a s a lr e a d y b e e n m e n tio n e d . T r a n s i e n t r e lie f f ro m t h e p a t i e n t ’s d is tr e s s w h ic h re s u lts f ro m th e a b n o r m a l s e n s o r y - m o t o r a s s o c ia tio n s m a y b e g iv e n b y u s in g a n e y e - s h a d e o n o n e e y e o r t h e o t h e r , o r b y b lin d -f o ld in g h im , o r b y a d v is in g h im t o sit m o s tly w ith his ey e s c lo s e d ; b u t t h e r e q u ir e m e n ts o f in d iv id u a l p a tie n ts m a y v a r y f ro m d a y t o d a y o r e v e n d u r i n g t h e s p a n o f e a c h d a y in th is re s p e c t. A s e c tio n o n “ O p t o k i n e t i c P o s t u r a l R e a c t i o n s ” (T h e C e re b r a l C o n tr o l o f M o v e m e n t— T h e S h e r r in g to n L e c tu re s V I I I , 1966, D e r e k D e n n y - B r o w n ) d is c u s s e s e x p e r im e n ta l d a m a g e t o t h e m i d - b r a i n o f a m o n k e y a n d s h o w s tw o p h o t o g r a p h s o f t h e m o n k e y s ittin g w ith h is h e a d w ell o n o n e s id e a n d s i ttin g b lin d fo ld e d w ith h is h e a d s tr a ig h t. “ I m m e d ia te ly h e w a s b lin d fo ld e d t h e h e a d b e c a m e s tr a ig h t, o n ly t o d e v ia te im m e d ia te ly t h e e y e s w e re u n c o v e r e d ” . T h e r e is n o r e c o r d o f t h e r e s u lt o f c o v e r in g a sin g le e y e . A d ju s tm e n t o f th e p a t i e n t ’s s e n s o r y field , i.e. r e d u c in g th e v isu a l in flu e n c e a n d in c r e a s in g t h e ta c tile in p u t, a s e x p la in e d e a r lie r, a p p e a r s to n e e d f u r t h e r in v e s tig a tio n fo r t h e t r e a t ­ m e n t o f s t r o k e p a tie n ts . A C T I O N A N D B A L A N C E W H E N E R E C T A n u m b e r o f p o in ts a r is e in th is c o n n e c tio n , b u t t a k i n g i n t o a c c o u n t w h a t h a s b e e n d is c u s s e d , th e y c a n b e d e a lt w ith b riefly . S e lf -H e lp a n d F e a r o f F a llin g . D u r i n g r e h a b i l i ta t io n a f te r a s t r o k e m o s t p a tie n ts s u ffe r fro m a n e x a g g e ra te d f e a r o f fa llin g . I n o r d e r to e n c o u r a g e th e p a t i e n t to h e lp h im s e lf, h e s h o u ld b e s h o w n sa fe w o r k in g u n d e r c o n d i t i o n s w h ic h h e c a n i m p ro v e b y e x p e r im e n t. C le a rly , w h a t h e is a llo w e d t o d o m u s t d e p e n d o n h is m e d ic a l s t a te ; b u t th e e m p h a s is s h o u ld b e o n se lf-h e lp . H e s h o u ld re -le a rn to s ta n d w ith m o s t o f h is w e ig h t o v e r h is s o u n d f o o t, t a k in g p a r t o f h is w e ig h t, a n d b a la n c in g h im se lf, b y a firm h a n d g r i p o n a h o r iz o n ta l b a r w ith h is s o u n d h a n d a b o v e o r a t s h o u l d e r level. In th is p o s itio n h e c a n sa fe ly a c c u s to m h im s e lf t o a n y c o n f u s i o n o r g id d in e s s d u e t o sw in g s o f h is lin e o f s ig h t f ro m o n e o b je c t to a n o t h e r , o r t o tu r n in g h is h e a d a n d b o d y . H e c a n a ls o b a la n c e o n h is s o u n d f o o t, w h ilst h e m o v e s h is s o u n d h a n d , th e r e b y c h e c k in g t h e r e la tio n s h ip s b e tw e e n b a la n c in g a n d t h e v a r i a t i o n s in p o s itio n s o f h is b o d y ’s s u p p o r t s . A g a in , h e c a n d is c o v e r h o w m u c h w e ig h t h is s o u n d h a n d m u s t ta k e , w h e n h is w e a k leg b e g in s t o b e a r w e ig h t o r h e b e g in s t o m o v e it. W ith h is p e lv is a n d t r u n k firm ly h e ld b y t h e m u s c u la tu r e o f h is s o u n d s id e a n d w ith t h e f o r e p a r t o f h is w e a k f o o t in c o n t a c t w ith t h e g r o u n d , h e h a s su p p lie d h im s e lf w ith t h e s e n s o r y e le m e n t o f t h e s e n s o r y - m o t o r a s s o c ia tio n w h ic h e n c o u r a g e s h is w e a k leg t o b e g in t o b e a r w e ig h t. P ro v id e d t h a t t h e p a t i e n t is c a p a b l e o f g r a s p in g t h e r e la tio n s h ip s b e tw e e n s e n s a tio n s a n d a c tio n s , th e s e p r e ­ lim in a r y e x p e rie n c e s in th is sa fe p o s itio n in t r o d u c e h im to tw o f u r t h e r f u n d a m e n ta l se lf-h e lp a c t i v i t i e s : firs t, a d ju s tin g h is a c t i o n s a n d b a la n c e w h ilst risin g w ith a s s is ta n c e f r o m a c h a i r ; a n d s e c o n d , s t r e n g th e n in g h is w e a k leg b y th e f re ­ q u e n t u se o f a n “ a r tific ia l f lo o r ” in b e d . R is in g fro m a C h a ir . T h e p a tie n t s its d o w n o n a c h a ir in f r o n t o f t h e h o r iz o n ta l b a r w h ic h h e h a s b e e n g r a s p in g ; t h e h ig h e r t h e c h a ir , t h e e a s ie r it w ill b e fo r h im t o g e t u p a g a in . A t firs t, w h e n p r a c tis in g g e ttin g u p , t h e p a t i e n t s h o u ld a d o p t w h a t m u s t h a v e b e e n t h e a n c e s tr a l m e t h o d : lo o k in g u p , r e a c h in g u p a n d risin g . T h is is a s e n s o r y - m o t o r a s s o c ia tio n in ita te d b y v isu a l im p u lse s a n d r e g u la te d b y th e ir a s s o c ia tio n w ith t a c tile a n d p r o p r io c e p tiv e im p u lse s f ro m t h e h a n d a n d a r m . T o e n c o u r a g e th is , a w a lk in g stic k is h u n g o n th e h o r iz o n ta l b a r . T h e s o u n d f o o t is p la c e d slig h tly o n t h e m e d ia l s id e o f t h e s t i c k ; t h e p a tie n t lo o k s a t t h e c r o o k o f t h e s tic k , a n d , a s h e rise s , r e a c h e s u p a n d g r a s p s th e b a r j u s t la te r a l t o t h e c r o o k o f t h e stic k . T h e v e rtic a l s h a f t o f th e s tic k s e rv e s t o p o s itio n h is h a n d in r e la tio n t o h is s o u n d f o o t. H e is a lr e a d y a c c u s to m e d b y b a la n c e sa fe ly in t h e u p r i g h t p o s itio n w ith his s o u n d h a n d g r a s p in g t h e b a r , s o t h a t t h e f e a r o f fa llin g d o e s n o t in h ib it h is e ffo rt, a n d h e g a in s in c re a s e d c o n ­ fid e n c e . T H E “ A R T I F I C I A L F L O O R ” I N B E D T h e m a in t a s k f o r t h e p a t i e n t is t o r e -c o n n e c t h a n d s a n d fe e t. H e m u s t first s tr e n g th e n th e a c t i o n o f w e a k b u t t o c k a n d q u a d r ic e p s m u sc le s f o r t h e a c t o f w e ig h t- b e a r in g b y b e g in n in g a t t h e e a r lie s t p o s s ib le s ta g e t o m a k e s o m e u se o f tlie m “ little a n d o f t e n ” . H is s e n s o r y e x p e r ie n c e s d u r in g h is a t t e m p t s a t s t r a ig h te n in g t h e w e a k leg in t h e sa fe e r e c t p o s itio n , a s a lr e a d y d e s c rib e d , w ill e n a b le h im t o re -e n a c t a n d t h u s s tr e n g th e n th is a c t i o n in b e d , s t a r t i n g w ith t h e f o r e p a r t o f h is w e a k f o o t a g a in s t t h e v e rtic a l b o a r d . H e c a n a d ju s t t h e p o s itio n o f t h e b o a r d b y m e a n s o f h is s o u n d h a n d 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. ) June, 1968 P H Y S I O T H E R A P Y Page 7 w h ile h o ld in g a lo o p o f c o r d a t t a c h e d t o e ith e r e n d o f th e b o a r d , a n d b y h is s o u n d f o o t ’s p o s itio n in g th e b o a r d . I n th is w a y h e le a r n s a n d a c q u ir e s t h e s e n s o r y a s p e c t o f a n d e le m e n t jn t h e s e n s o r y - m o t o r a s s o c ia tio n o f t h r u s t i n g t h e h e e l o f t h e w e a k leg t o w a r d s t h e v e r tic a l b o a r d . T h is b o a r d is v a lu a b le : it h o ld s t h e b e d - c lo th e s o f f h is fe e t, w h ile it is h eld d o w n b y t h e w e ig h t o f th e c lo th e s . A h o r iz o n ta l m e m b e r a t e ith e r e n d o f t h e b o a r d h e lp s t o h o ld t h e b o a r d u p r ig h t. T h e s tr e n g th o f t h e p a t i e n t ’s f o o t a c t i o n s n e e d o n ly b e sm a ll. C o - o r d i n a t io n a n d t h e s e n s o r y - m o t o r a s s o c ia tio n a r e t h e a im s : th e s e a r e e n c o u r a g e d , if th e in d e x fin g e r o f t h e s o u n d h a n d feels t h e p r o x im a l b o r d e r o f t h e p a te lla e , as th e y b e g in t o m o v e . C O N C L U S I O N T h e e s s e n tia l f e a t u r e o f th is n e u r o lo g ic a l a p p r o a c h to r e h a b ilita tio n o f t h e s t r o k e p a t i e n t is its i m p a c t o n r e h a b ili­ t a t i o n o f h is m e n ta l a b ilitie s . T h e l a t t e r is e n c o u r a g e d b y th e lin k in g u p u n d e r f a v o u r a b le w o r k in g c o n d i t i o n s o f n u m e r o u s s e n s o r y - m o to r a s s o c ia tio n s . T h is m e n ta l r e h a b i l i ta t io n a p p r o a c h a p p lie s a ls o to o t h e r g e r ia tric c a se s. I t is n o t j u s t a flash in t h e p a n . I t w a s e x p la in e d in m y b o o k o n The A d ju stm en t o f M uscular H a bits (1933) a n d S ir W ilf re d L e G r o s C la r k p o in te d o u t in h is F o r e w o r d t h e r e t o t h e im p o r ta n c e o f th e p sy c h o lo g ic a l e le ­ m e n ts in th is ty p e o f s e lf-h e lp b y w h ic h t h e p a tie n t e n c o u r a g e s h im s e lf t o c o n t i n u e h is p ro g re s s . T h is a r tic le h a s d is c u s s e d s o m e p r a c tic a l m e th o d s b y w h ic h t h e p a t i e n t c a n b e t a u g h t t o g a in c o n t r o l o f s e n s o ry - m o t o r a s s o c ia tio n s d e s p ite th e u n f a v o u r a b le ite m s in his s e n s o ry field . T h e y c a n d o u b tle s s b e e x te n d e d a n d im p ro v e d b y o t h e r s . T h e e s s e n tia l f e a tu r e o f th is n e u r o lo g ic a l a p p r o a c h to r e h a b i l i ta t io n o f t h e s t r o k e p a t i e n t is its im p a c t o n r e h a b ilita tio n o f h is m e n ta l a b ilitie s . A s t h e g e n e ra l p r in c ip le s u n d e r ly in g t h e f o re g o in g r e m a rk s a n d r e c o m m e n d a t i o n s w e re d isc u sse d a t le n g th in m y la st little b o o k N a tu ra l M o v em e n t (1 9 6 2 , L ew is L o n d . 103 p p .) a n d w e re f o u n d in t h e w o r k s o f t h e n u m e r o u s w e ll-k n o w n a u th o r i ti e s q u o t e d th e r e in it is u n n e c e s s a ry f o r m e t o re p e a t th e m h e re . Giving those Fibrocytics the Bird (and other Treatments) A . B U R R , m .c .s .p ., S e n io r P h y s io th e r a p is t, T r a n s v a a l M e m o r ia l H o s p ita l f o r C h ild r e n , J o h a n n e s b u r g M a n y a r e t h e v ic iss itu d e s in g iv in g c h ild r e n w ith f ib r o ­ c y s tic d ise a se t r e a t m e n t w ith t h e B ird r e s p i r a t o r , a n d its a f t e r m a t h o f “ c o u g h in g a n d s p ittin g ” . I h a v e b e e n o n th is j o b f o r o v e r a y e a r n o w , a n d h a v e le a rn e d m a n y p r e c io u s p o in ts in th is tim e . T h e o b je c t o f th is a r tic le is n o t f o r t h e b e n e fit o f th o s e w ish in g t o k n o w t h e w h y s a n d w h e r e f o re s o f c o p in g w ith t h e a c t u a l d o w n t o e a r t h h a n d lin g o f t h e B ir d r e s p i r a t o r itse lf, o r a n y o t h e r ty p e o f t r e a t m e n t . O n t h e c o n t r a r y , m y w h o le id e a is t o p r e s e n t t h e p s y c h o lo g y in c o p in g w ith e a c h sp e c ific c a s e u n d e r t r e a t m e n t . I h a v e f o u n d th e s e c h ild r e n o n t h e w h o le p lu c k y , in te lli­ g e n t, c u r i o u s a n d la s t b u t b y n o m e a n s le a st, o b s t i n a t e t o t h e la s t f r u s t r a t i n g d e g re e . O f c o u r s e t h e r e a r e e x c e p tio n s t o e v e ry r u le , b u t I m y se lf, in th e 14 y e a r s I h a v e w o r k e d a t t h e C h ild r e n ’s H o s p it a l h a v e m e t o n ly tw o e x c e p tio n s t o th is o v e r a ll d e s c rip tio n . L e t m e e x p la in h e re t h a t , a l t h o u g h 1 h a v e o n ly b e e n g iv in g th e s e c h ild r e n t r e a t m e n t w ith t h e B ird r e s p i r a t o r fo r j u s t o v e r a y e a r , I h a v e s w e a te d m y h e a r t o u t w ith o t h e r fo rm s o f t r e a t m e n t p r i o r t o t h e i n t r o d u c ti o n o f t h e B ird . W h a te v e r tr e a t m e n t I h a v e g iv e n , I h a v e f o u n d th e ir o b s t i n a t e t r a i t t h e g r e a te s t s t u m b lin g b lo c k a n d h a v e le a r n e d t o tr e a d v e ry g e n tly in th is re s p e c t. A t t h e tim e o f w ritin g , th e r e is n o k n o w n c u r e f o r t h is d e v a s ta tin g d ise a se , s o th e s e c h ild r e n h a v e t o lo o k i n t o a f u tu r e w h e re “ c o u g h in g a n d s p i t t i n g ” is a p e r p e tu a l a n d d a ily M U S T . I h a v e f o u n d t h a t t h e m o s t e ffe c tiv e a t t i t u d e t o a d o p t is a t a k i n g f o r g r a n te d t h a t t h e y c o u g h a n d s p it j u s t a s r o u tin e ly a s th e y c le a n th e ir te e th a n d d o th e ir h a ir. P la y in g g a m e s ta k e s u p tim e a n d b e c o m e s b o r in g — “ F a n c y c o m in g a ll th is w a y t o p la y w h e n I c a n p la y m u c h m o r e h a p p ily w ith E g b e rt n e x t d o o r ! ” T h u m p i n g a n d b a n g in g a n d p o s t u r a l d r a in a g e , e tc ., a r e a ll v e ry w ell a n d v e ry o r t h o d o x , b u t , a f t e r a ll, t h e m a in iss u e is t h e am ount o f s p u t u m ra is e d a n d t h i s th e y m u st d o t h e m ­ selves. B y t h e tim e o n e h a s t h u m p e d , b r e a th e d , p e rc u s s e d , e x e rc ise d , p la y e d g a m e s a n d g iv e n t h e B ird , y o u a r e n o t lik e ly t o ra is e t h e s a m e a m o u n t o f s p u t u m a n d t h e t r e a t m e n t w o u ld n o t b e m u c h s h o r t o f a life s tr e tc h . T h e B ir d in h a l a t i o n s m a k e c o u g h in g e a s ie r a n d q u ic k e r , s o I c o n c e n t r a t e o n th is . M o t h e r c a n , a f te r b e in g c o a c h e d , d o t h e p e r c u s s io n a n d p o s tu r a l d r a i n a g e a t h o m e . I f s h e is n o t c o - o p e r a tiv e a b o u t th is , y o u m ig h t a s w ell c u t y o u r lo ss e s fo r s h e p r o b a b l y w ill n o t b e r e g u la r in b r in g in g t h e c h ild e ith e r , a n d y o u r o c c a s io n a l o d d t r e a t m e n t s w o u ld b e lik e t a k i n g a th im b le fu ll o f w a te r o u t o f a fish p o n d . S o n o w , w ith a r e a lly c o - o p e r a tiv e m o t h e r d o in g h e r s tu f f a t h o m e , I m a k e m y p a r t o f it a r o u tin e . I sit t h e c h ild d o w n in f r o n t o f t h e B ird a n d , r e g a r d le s s o f s n o t a n d t r a n e le t th e m k n o w t h a t th e y h a v e t o b r e a t h e in t h e i r a i r b r o n in th e m o s t efficien t m a n n e r t o t h e la s t d r o p a n d t h e n c o u g h a n d s p it 2 0 , 2 5 , 30 tim e s , e tc . I g r a d u a l l y r a is e th e m t o a b o u t 50 “ s p i t s ” a tim e . T h is , w ith m o t h e r ’s h o m e w o r k , se e m s t o k e e p th e m fa irly c le a r. O f c o u r s e , th is is n o rig id r u l e a n d s o m e a r e d e fin ite ly d r y b e f o r e 50, a n d o t h e r s c a n d o m o re . H o w e v e r , w h a te v e r I feel e a c h c h ild is c a p a b l e o f , I s tic k t o t h r o u g h t h i c k a n d th in u n til th e y k n u c k le d o w n t o t h e f a c t t h a t t h e s o o n e r th e y g e t g o in g a n d fin ish , t h e s o o n e r th e y c a n g o h o m e . For quality printing consult J. G. INCE & SON (PTY.) LTD. • PRINTERS • STATIONERS • BOOKBINDERS • RULERS • LITHOGRAPHERS P r in t e r s of this J o u r n a l P.O. Box 200, BOOYSENS, Transvaal Telephone 8 3 4-420 1 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. )