Page 2 P H Y S I O T H E R A P Y March, 1967 PHYSIOTHERAPY TREATMENT for a PATIENT with a HEAD INJURY By N . L E N N A R D , B.Sc. P h y s. R a n d T h e W orld C o n fe d e ra tio n for P hysical T h e ra p y in 1963, follow ing th e f o u r th congress, p u b lish ed a series o f articles o n traffic ac cid e n ts. T h e statistic s fro m th e W orld H e a lth O rg a n isa tio n , w h ich a re q u o te d in th ese articles, in d ic ate th a t 1 0 0 , 0 0 0 p e o p le in th e w hole w orld a re killed ea ch year by traffic ac cid e n ts. F o r every d e a th 30 to 40 p eo p le are in ju re d a n d o n e -th ird o f th ese a re severely in ju red . T h e artic le o n C r a n io C e re b ra l injuries, by K . V aernet, senior su rge o n o f th e N eu ro -S u rg ica l D e p a r tm e n t, R ig sh o sp ital, C o p e n h a g e n , sta te s th a t th e n u m b e r o f p eople w ith head injuries a d m itte d to th e N eu ro -S u rg ica l d e p a rtm e n ts o f th e C o p e n h a g e n a r e a is now n early th re e tim es as large as it was 15 years ag o . T o th o se o f us w ho trav el to w ork ea ch day by m o to r ca r, it is a p p a re n t th a t m o to r traffic is increasing in S o u th A frica ju s t as it is in creasin g all o v e r th e w orld an d th e ac cid e n t r a te is increasing in S o u th A fric a ju s t as it is elsew here. N ew legislation in th e U n ite d S tates re g ard in g safety m ea su re s to be in c o rp o ra te d in to th e design o f m o to r ca rs is th e la te st resu lt o f m u c h resea rc h . H ow ever a t th e p re se n t tim e th e incidence o f head in ju ries c o n tin u e s to rise a n d it is c lear th a t p h y sio th e ra p ists will be called u p o n m o re a n d m o re freq u e n tly to tr e a t such cases. T re a tm e n t o f a p a tie n t w ith a head in ju ry is in a n y case co m plicated a n d challenging. I n a d d itio n , how ever, n o tw o h e a d injuries sh o w ex actly th e sam e sy m p to m s because th e sy m p to m s will v a ry ac co rd in g to th e p o sitio n a n d th e degree o f th e d am a g e su sta in e d . P a tie n ts w ith b ra in stem dam a g e w hich involves th e R e tic u la r System o r th e C e rebellu m to a gre ate r o r lesser e x te n t, show a very d ifferent d is trib u tio n o f hy p er o r h y p o to n ia a n d for th is re a so n it is im possible to w rite a g en e ra l d e sc rip tio n o f th e tre a tm e n t o f head injuries. I am th e re fo re going to d esc rib e a p a rtic u la r case w hose p ro g ress I follow ed for 18 m o n th s fro m th e tim e he recovered consciousness sufficiently to hav e th e tra c h e o sto m y tu b e rem oved a n d beg an to hav e d aily tre a tm e n t in th e p h y sio ­ th e ra p y d e p a rtm e n t o f a g eneral h o sp ita l. I will d esc rib e th e p h y sio th e ra p y a p p ro a c h a n d som e o f the te ch n iq u es w hich w ere used a n d will try to give a critical assessm ent o f th is p a tie n t’s resp o n se to d ifferent m o d alities a n d te ch n iq u es. A lth o u g h th e te ch n iq u es desc rib e d h ere have been a d a p te d to th e n eeds o f o n e p a rtic u la r p a tie n t, th e y have nevertheless p o in ts o f general ap p licatio n . T h is a rtic le is essentially a d e sc rip tio n o f tre a tm e n t by m ea n s o f a sen so ry m o to r a p p ro a c h w hich co m b in e s several te ch n iq u es. T h e B o b a th a p p ro a c h w as used as well as P ro p rioc ep tiv e . N e u ro m u sc u la r F a c ilita tio n . Ice p ac k s w ere used in a n a tte m p t to red u ce spasm a n d R o o d ty p e sensory stim u la tio n o f c e rta in in h ib ite d m uscle g ro u p s w as also u sed . T h e tr e a tm e n t w as carried o u t in close c o -o p eratio n w ith a n O cc u p a tio n a l T h e ra p y D e p a r tm e n t a n d th e O c c u p a ­ tio n a l T h e ra p ists c o n c e n tra te d m ainly o n th e space p e rc e p ­ tio n p ro b le m s, o n m em ory tra in in g a n d o n re -e d u c a tio n o f w riting a n d fine finger m o v em en ts. L a te r th e p a tie n t w as sen t fo r w o o d w o rk tra in in g . T h e p a tie n t w as also assessed by a P sychologist w h o re n d e re d v alu a b le assistan c e to th e P h y sio th e ra p y D e p a r tm e n t reg ard in g th e h a n d lin g o f the p a tie n t. M E D IC A L H IS T O R Y T h e p a tie n t w as a 17-year old b o y w h o w as a d m itte d to h o sp ita l o n 9 th M ay , 1965, deeply u n co n sc io u s, follow ing a n ac cid e n t in w hich his m oped w as stru c k by a ca r. T h e final diag n o sis w as hea d in ju ry w ith e x te rn a l hy d ro -ce ph a lu s in th e rig h t T e m p o ra l region. O n ad m issio n th e p a tie n t w as deeply c o m a to se a n d re sp o n d e d little to p a in fu l stim uli. B lo o d P ressu re w as 140/90 a n d th e p u lse r a te 112. T h e rig h t p u p il w as la rg er th a n th e left b u t reac ted to light. T h e re was a m ild b i-lateral p a p illo d e m a w hich pro d u ced b lu rrin g o f th e m edical m a rg in s o f th e discs a n d filling o f th e o p tic cups. A left facial paresis w as n o ted . A ll lim bs w ere m a rk e d ly sp astic b u t som e m ovem ent co u ld be o b ta in e d fro m th e rig h t a rm on p a in fu l stim uli. T h e reflexes w ere brisk b u t e q u a l o n b o th sides. T h e ab d o m in a l resp o n ses w ere a b se n t a n d b o th p la n ta r resp o n ses w ere ex te n so r. T h e p a tie n t h ad bi-late ra l pes caves w ith h a m m e r toes an d s h o rt T e n d o A chilles, w hich w ere ob v io u sly o f long sta n din g. A b d o m e n , C h e st a n d C a rd io -V a sc u la r system were clinically n o rm a l. T h e re was a fra c tu re o f th e left clavicle w ith considerable o v erlap . T h is fra c tu re w as n o t red u ce d because o f the severity o f th e p a tie n t’s co n d itio n . O n a d m issio n a su b -d u ra l h a e m a to m a w as d iag n o se d and b u rr holes w ere p e rfo rm e d , o n e ab o v e th e left e a r a t the level o f th e Sylvan F issu re a n d o n e a few cen tim etres off th e m id-line im m ediately in f ro n t o f th e rig h t m o to r cortex. O n 25 th M ay , tw o weeks a fte r th e ac cid e n t, a n o th e r burr ho le w as pro v id e d in th e rig h t te m p o ra l reg io n . T h e d u ra w as o pened to reveal a d iste n d e d su b -a ra c h n o id space. Inc isio n o f th e A ra c h n o id led to co p io u s disc ha rg e o f C e re b ro sp in al fluid. H ow e ve r, th e u n d erly in g b ra in was slack a n d p u lsated n o rm a lly . A b ra in c a n n u la w as passed in to th e T e m p o ra l lo b e b u t n o h a e m a to m a en c o u ntered . T h e C erebro -spin al-flu id p re ssu re w as fou n d to be 90. F o llo w in g th e in se rtio n o f a ca n n u la a ir encep h alo g rap h y p ro d u c e d good v en tricu lar filling w ith very slight displace­ m e n t o f th e ventricles to th e left, m u ch less th a n previously in d ic ated by an g io g rap h y a n d th is confirm ed th e im pression th a t th e sh ift w as d u e to e x te rn a l h y d ro c ep h alu s. O n 7 th Ju n e, 1965 fo u r weeks a fte r th e ac cid e n t, th e state o f consciousness seem ed to hav e im p ro v ed slightly. T here w as go o d m o v em e n t o f th e rig h t a rm b u t th e p a tie n t still show ed a m ark ed d ec ereb ra te rigidity. O n 19th Ju n e, 1965 six weeks a fte r th e ac cid e n t, th e re was n o real change in th e p a tie n t’s c o n d itio n . H e w as still un co n sc io u s. O n 21st Ju ly , 1965, te n weeks a fte r th e a c cid e n t, the p a tie n t h ad im proved sufficiently to rem o v e th e trach e o sto m y tu b e . H e ta lk e d in a w hisper b u t ra tio n a lly a n d appeared well o rie n ta te d . T h ere w as goo d v o lu n ta ry m o v em e n t of th e r ig h t a rm a n d a lth o u g h th e r ig h t leg w as rigidly extended so m e v o lu n ta ry m o v em e n t w as p re sen t. T h e re w as some slight m o v em e n t o f th e left side o f th e bod y . T h e left up p er lim b a n d b o th lo w er lim bs still m an ifested m ark ed h yper­ to n ia . T h e n e u ro su rg e o n reco m m e n d ed d aily p h y sio th erap y tre a tm e n t a n d th e p a tie n t w as tra n sfe rre d to a general h o sp ita l a n d a t th is stage I did a n assessm ent o f th e p atien t to d ete rm in e fu tu re p h y sio th e ra p y tre a tm e n t. PH Y S IO T H E R A P Y A S S E S S M E N T General Appearance: T h e p a tie n t h ad a facial p aresis o f th e left side. H e showed a n in te rm itte n t div erg en t sq u in t. (It w as la te r ascertained th a t th is s q u in t caused h im d o u b le vision a n d th is p roblem received successful surgical a tte n tio n 18 m o n th s later.) 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. ) March, 1967 P H Y S I O T H E R A P Y Page 3 T he p a tie n t’s speech w as h o a rse a n d difficult a lth o u g h his b re ath in g w as satisfa cto ry a n d his chest clear. (T he h o a rse ­ ness o f his speech w as la te r fou n d to be caused by p ap illo m a o f th e la rynx w hich h a d been tre a te d fo r m a n y years p re ­ viously.) H ead C on tro l: I t w as n o ted th a t th e p a tie n t’s h ead w as c o n sta n tly flexed o n to his chest a n d ro ta te d c o n sta n tly to th e left, b u t th a t th e p o sition o f th e h ead did n o t seem to affect th e m uscle to n e to a n y g re at e x te n t. H ow ever, h ead c o n tro l was very p o o r. T he p a tie n t co u ld really on ly lift his head up m o m en tarily . The la ck o f h ead c o n tro l affected his ab ility to balance. M uscle T one: O n testing, th e rig h t a rm a n d leg show ed a n increase o f ex te n so r to n e a n d th e left a rm a n d leg show ed a m arked increase o f flexor to n e . In su p in e p o sitio n s th e tr u n k m u scu ­ la tu re show ed a n increase o f ex te n so r to n e a n d in p ro n e p o sitio n s th e flexor m uscles w ere h y p e rto n ic . I f placed in a w heel-chair th e p a tie n t slid fo rw a rd s o u t o f th e c h a ir because the stre tc h o n his h a m strin g m uscles in th is p o sitio n caused a reflex m ass c o n tra c tio n o f his ex te n so r m uscles. The A rm s: T h e left sh o u ld e r w as very p a in fu l w h en elevated ab o v e 90 degrees. T h is w as th o u g h t to be d u e to spasm o f th e sternal fibres o f th e P e cto ralis M a jo r a n d o f th e Biceps muscles, b o th o f w hich resisted th e m o v em e n t o f elevation. T he sh o u ld e r jo in t w as also stiff d u e to th e lim ita tio n o f full ran g e m o v em e n t. T h e left elbow could n o t be extended passively o r actively d u e to spasm o f th e B iceps m uscle a n d to th e p a tie n t’s co m p le te inab ility to in itia te c o n tra c tio n o f the T riceps m uscle. T h e fingers o f th e left h a n d w ere tightly closed, th e w rist slightly flexed a n d U ln a dev ia ted a n d the th u m b a d d u c te d . T h e re w as little o r n o v o lu n ta ry m ovem ent o f th e left a rm b u t th e rig h t a rm could be m oved v o lu n tarily th ro u g h a full ran g e o f m o v em e n t a t ea ch jo in t. The L eg s: T h e left h ip a n d knee show ed a loss o f ex te n so r m ovem ent which varied in d ifferent te stin g p o sitio n s, b u t th e knee could n o t be fully exte n d ed in an y p o sitio n d u e to th e spasm o f th e h ip flexors a n d H a m strin g m uscle g ro u p . T h e re was little o r n o v o lu n ta ry ex te n so r m o v em e n t o f th e left low er lim b. M o v em e n t o f th e rig h t low er lim b w as b etter, as m ass p a tte rn flexion a n d ex te n sio n w as p re sen t. H o w ever th e limb w as m a rk e d ly in c o -o rd in a te a n d th e re w as a severe tre m o r o n effort. The T ru n k : T h e h y p e rto n ia o f th e tr u n k caused a lim ita tio n o f m ovem ent o f th e spine. R eflexes: T h e flexor w ith d ra w a l reflex w as exaggerated bilaterally but m o re so o n th e left th a n th e rig h t. T h e Q u ad ricep s a n d the G astro c n e m iu s a n d Soleus m uscles show ed h y p e rto n ia o n te stin g a n d w h en th e p a tie n t w as p laced in a sta n d in g p o sitio n th e sp asm increased. O n c o n ta c t w ith th e floor th e rig h t a n k le show ed e q u in o -v ares. O n c o n ta c t w ith th e floor th e left leg w ith d rew in to m ass flexion. T re m o r: T h e p a tie n t show ed a tre m o r o n effort w hich w as w orse on th e rig h t side th a n th e left. T h e tre m o r increased m a rk ed ly and becam e g eneral if th e p a tie n t w as u n d e r duress. C o-ordination: T h e p a tie n t’s ab ility to m ak e p u rp o siv e v o lu n ta ry m o v e­ m ents w as v irtu ally nil. H e could n o t m ove in to a w eight su p p o rtin g p o sitio n o n his elbow s a n d he could n o t sit up o r roll over. H ow e ve r, he could c a rry o u t sim ple m ass p a tte r n m ovem ents w ith his rig h t arm . Balance and E quilibrium : N o balance o r eq u ilib riu m re a c tio n s w ere p re se n t b u t th e p a tie n t feared loss o f b alance a n d felt insecure all th e tim e. F e a r o f loss o f b alance increased th e spasticity. C onsciousness: T h e re w ere b rie f o ccasio n al lapses o f consciousness w hich caused th e p a tie n t to slum p in his c h a ir m o m en tarily . G en eral Im pression: T h e p a tie n t tire d easily physically a n d m e n ta lly an d fo u n d c o n c e n tra tio n very difficult. P e rse v eratio n o f ideas was m a rk e d a n d th e p a tie n t also a p p e a re d to h a v e p erce p tu al difficulties. I t w as n o ted th a t h e h a d been le ft-h a n d e d p rio r to th e ac cid e n t a n d w ould have a p ro b le m o f la te ra lity d u e to th e fact th a t th e injuries h ad affected th e left side o f th e bod y m o re severely. H ow e ve r, d e sp ite all th ese difficulties he a p p e a re d faily well o rie n ta te d o n a v erb al scale a n d this w as la te r confirm ed by th e P syc h o lo g ist’s re p o rt. T h e follow ing p la n o f tr e a tm e n t w as developed. T R E A T M E N T The C h est: P rio r to th e rem oval o f th e tra c h e o sto m y tu b e a n d before th e ab o v e p h y sio th e ra p y assessm ent w as d o n e , th e p a tie n t w as given tre a tm e n t w ith a view to k eeping th e chest clear o f a n ac c u m u lta io n o f sec re tio n s, i.e. as d ry as possible. T h e tre a tm e n t w as d o n e d aily in co n ju n c tio n w ith th e n u rsin g staff, ju s t befo re th e r o u tin e tw o -h o u rly ch a n g e o f p o sitio n to p re v en t bed-sores. T h e p a tie n t w as tre a te d first in side lying o n o n e side, th e n in su p in e lying a n d th e n side lying o n th e o th e r side. I n side lying th e p a tie n t w as p e r ­ cussed well o v er th e la te ra l co stal a n d p o s te rio r basal a rea s. T h e re a fte r th e chest w all w as firm ly v ib rated a s th e p a tie n t b re a th e d o u t a n d th e ch est w as su ctio n ed d u rin g th e p erio d o f e x p ira tio n , th r o u g h th e tra c h e o sto m y tu b e . P assive m o v em e n ts o f th e a rm a n d leg w ere carried o u t as fully as p ossib le , b u t g re at difficulty w as experienced d u e to th e spasm . T h e passive m o v em e n ts o f th e a rm w ere d o n e to m a in ta in th e m o b ility o f th e chest w all as w ell as th e m ob ility o f th e lim b itself. In su p in e lying th e p a tie n t w as v ib rated first in th e low er c o stal a n d th e n in th e apical reg io n , su ctio n - ing in betw een a s well as a t th e e n d . W h en th e p a tie n t was tu rn e d o n to th e o th e r side, p ercu ssio n , v ib ra tio n a n d su ctio n - ing w ere re p e a te d , as well as passive m o v em en ts o f th e a rm a n d leg. A s s o o n as th e p a tie n t reco v e red co nsciousness he w as ta u g h t to cough. W h e n th e ab o v e p h y sio th e ra p y assessm ent w as d o n e by th e w rite r, th e chest w as clear a n d th e b re a th in g goo d . H o w e ve r, th e passive m o v em en ts o f th e a rm a n d leg h ad n o t b een en tire ly successful d u e to th e difficulties caused by th e h y p e rto n ia a n d p o te n tia l flexor c o n tra c tu re s w ere d ev e loping in th e left elbo w , sh o u ld e r a n d knee. T h e m o bility o f th e spine w as very p o o r. G eneral T re atm e n t W h e n consciousness re tu rn e d a n d a fte r th e p h y sio th e ra p y assessm ent w as d o n e, it w as decided th a t th e im m ediate essentials o f tr e a tm e n t w ere: (a) H ead c o n tro l. (b) P o sitio n in g o f th e lim bs a n d sp in e to gain m obility. T h e c o -o p e ra tio n o f th e b o y ’s M o th e r w as so u g h t, a n d he w as re g u larly p o sitio n e d th ro u g h o u t th e d ay . H e w as placed in p ro n e lying, as in Fig. 1 w ith his w eight s u p p o rte d o n his elbow s, his chest su p p o rte d o n a p illow a n d his feet dorsi-flexed o v er th e end o f th e b ed . H e w as en c o u ra g e d to lift his h ead a n d lo o k a t v a rio u s c e n tra lly p laced o bjects. T h is p o sitio n fav o u rs ex te n sio n o f b o th h ip s a n d knees an d sp in e b u t en c o u rag e s dorsi-flexion o f th e ankles. In th is p o sitio n th e a c tio n o f g ravity a n d th e w eight o f th e p a tie n t fav o u rs a le ng the n in g r e a c tio n in th e a p p ro p ria te flexor m uscles. H e w as en c o u ra g e d to ch a n g e his w eight fro m o n e elbow to a n o th e r as h e lo o k ed ro u n d th e w a rd , in o rd e r to facilitate w eig h t-b earin g o n th e a rm s w ith sh o u ld ers sta b le. A t th is tim e th e p a tie n t w as also en c o u rag e d to lie p ro n e w ith his a rm s extended fo rw ard s, a s in Fig. 2. I n th is p o sitio n th e sp asm o f th e P e cto ralis M a jo r a n d o f th e B iceps m uscle o f th e left a rm g ra d u a lly d ec re ased d u e to th e te n sio n in th e m uscle causing a leng then in g re a c tio n . T h u s th e sp asm w as 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 4 P H Y S I O T H E R A P Y March, 1967 Fig. 1. Prone lying elbow support position. Chest is supported by a pillow. Feet hang down over the edge o f the bed. o So Fig. 2. Prone lying, arms extended forwards. Chest is supported by a pillow. Feet over the bed edge. Fig. 3. Side lying on alternate sides. Arm elevated forwards 90 degrees, supported on a cushion. Roll o f bandage in the hand. One leg flexed and one extended. 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. ) March, 1967 P H Y S I O T H E R A P Y Page 5 Fig. 5. Prone lying elbow support position. Patient’s knee is flexed in various positions and he is asked to hold the position. He is assisted to hold the position by means o f sensory stimulation. Fig. 6. Facilitation o f head control in crook lying position. Patient’s shoulder girdle and trunk are flexed, side flexed and rotated. / Figs. 6 and 7. Prone lying position. The shoulders are lifted and the trunk is side flexed and rotated for facilitation o f head control. The arms may be grasped in order to facilitate head control. Fig. 8. Patient sits on a stool. Operator grasps the shoulder points and flexes, side flexes and rotates the spine in order to facili­ tate head control. Gentle shaking movements o f the trunk are used to facilitate stabilisation o f the head. 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 March, 1967 relieved an d as th e p a tie n t’s to le ra n c e o f th e stre tc h o n stiff jo in ts in creased , full ra n g e sh o u ld e r a n d k n e e m ovem ents becam e possible. H ow ever, full ran g e m o v em en t o f th e elbow was n o t successfully achieved by p o sitio n in g a n d this received f u rth e r a tte n tio n , as described later. A t th is stage th e p a tie n t w as still being tu rn e d tw o -h o u rly to h a lf side lying o n a lte rn a te sides. A lte rn a te legs w ere flexed o r e x te n d ed a n d th e u p p e r a rm was elevated fo rw ards 90 degrees a n d su p p o rte d o n a cu sh io n . In th is p o sitio n th e left h a n d w as o p en e d as m u ch as possible by m eans o f a ro ll o f b a n d a g e (see F ig . 3). I n th e side lying p o sitio n th e sh o u ld e r w as m obilised in th e w ay described by B o b a th , i.e. by g ra sp in g th e S c ap u la r a n d m oving it forw ard an d back in a s big a ra n g e as possible. I t w as also m oved slow ly passively o n th e P .N .F . d iag o n als. T h is w as d o n e in o rd e r to n o rm a lise th e m uscle to n e before co m m encing w ide a rm m o v em en ts a t th e sh o u ld e r jo in t. T a p p in g a n d s tro k in g o f th e in h ib ite d m uscle g ro u p s was also used to n o rm a lise th e m uscle to n e b e fo re a n d so m e­ tim es d u rin g m o v em e n t o f th e sh o u ld e r a n d elbow o f th e left arm . T h e p a tie n t w as assisted to r e a c h o u t a n d to u c h c e rta in objects w hich w ere placed in different p o sitio n s each d ay . A t first h e w as assisted by th e o p e r a to r so th a t he received th e c o r re c t sen so ry im p ressio n o f th e m o v em en t, b u t as he p ro g resse d , less assistan c e w as given a n d m o re was ask ed o f th e p a tie n t. T h e em p h a sis w as o n n orm al m o v em e n t w ith n o rm a l tim in g. T h is was successful as regards th e rig h t a rm b u t th e spasm a n d c o n tra c tu re o f th e left arm m ad e m o v em en t difficult. M o b ilisa tio n o f th e sp in e was c a rried o u t d aily in p ro n e lying w ith th e a rm s elevated forw ards. W ith th e o p e ra to r’s a rm u n d e r th e p a tie n t’s sh o u ld e rs th e sp in e w as very slow ly first side flexed a n d th e n ro ta te d to o n e side a n d th e n to th e o th e r. T h is was rep ea ted fro m th e lu m b a r e n d by ho ld in g th e p a tie n t u n d e r th e legs ju s t ab o v e th e knees, first side flexing th e p a tie n t a n d th en ro ta tin g th e hips v ery slow ly to a lte rn a te sides (see F ig . 4). T h e m o b ility o f th e sp in e a n d sh o u ld e r im p ro v ed a gre at deal in a m o n th . In th e p ro n e lying elbow s u p p o rt p o s itio n th e p a tie n t’s knees w ere flexed in to v ario u s p o sitio n s a n d th e p a tie n t w as asked to ho ld th e p o sitio n . T a p p in g th e lim b in all d irectio n s a n d p ro p rio c e p tiv e stim u la tio n w as used to assist th e p a tie n t to hold in v a rio u s p o sitio n s (see F ig . 5). I n su p in e c r o o k lying, h ead c o n tr o l w as fa cilitated , as d escribed by th e B o b a th s (see F ig . 6 ). T h a t is, th e p a tie n t was g rasped by th e sh o u ld e rs o r th e elbow s a n d m oved in a circ u la r d ire c tio n co m b in in g side flexion a n d r o ta tio n o f th e tr u n k as well as flexion o f th e tr u n k . W h en th is is d o n e to th e n o rm a l p a tie n t th e head au to m a tic a lly a tte m p ts to re m a in in th e v ertic al p la n e d u e to th e rig h tin g reac tio n s. O u r p a tie n t’s h ead c o n tro l im p ro v ed q u ick ly w ith daily p ractice. I n p ro n e lying th e sh o u ld ers w ere lifted a n d th e tr u n k side flexed a n d th e n ro ta te d to facilitate h ead co n tro l (see Fig . 7). A t th is stag e head c o n tro l began to im p ro v e a n d new exercises w ere a d d e d a n d th e exercise p ro g ra m m e began to be varied daily, a s it w as th r o u g h o u t th e p erio d o f tr e a t­ m en t. H e a d c o n tro l w as facilitated w ith th e p a tie n t in a sittin g p o sitio n w ith his legs o v er th e ed g e o f th e bed. H e w as g rasped by th e sh o u ld e r p o in ts a n d gentle sh ak in g m o v em en ts o f th e tr u n k w ere used to fa c ilita te th e p a tie n t to stabilise th e h e a d . C ircling m o v em en ts o f th e tr u n k in c o rp o ra tin g side flexion a n d r o ta tio n w ere also used (see F ig . 8 ). H e a d c o n tro l was pro g ressed in th is w ay th ro u g h th e stages o f d ev e lo p m en t, i.e. u p to th e sta n d in g p o sitio n , as described by th e B o b a th s. A ll th e fac ilita tio n o f elbow s u p p o rtin g p o sitio n s w hich a re described by th e B o b a th s w ere u sed , e.g. S u p in e lying u p to side lying elbo w s u p p o rt. V ario u s sittin g p o sitio n s using elbow s u p p o rt p o sitio n s w ere u s e d . T h e a b ility to s u p p o rt w eight w ith a sta b le sh o u ld e r im p ro v ed . H o w ever th e p ro g ressio n to w eight su p p o rtin g p o sitio n s w ith a n e x te n d ed elbow p re sen te d a p ro b le m because o f th e p a tie n t’s co m p le te in ab ility to in h ib it th e a c tio n o f th e B iceps m uscle o f th e left arm . T h e p a tie n t still co u ld n o t in itia te a c o n tr a c tio n o f th e T ric ep s o f th e left a rm a n d th e elbow still co u ld n o t be exte n d ed passively because o f th e spasm . E lev a tio n o f th e le ft a rm w as still lim ited. T h e c o -o rd in a tio n o f th e rig h t a rm was m u c h im proved. T h e p a tie n t co u ld w eight s u p p o rt o n a n ex te n d ed rig h t arm . Assessment o f the Problem o f the P atien t’s Left Arm T h e left a rm was re-assessed b ecause th e p ro g ress w as n o t entire ly sa tisfa c to ry a n d th e follow ing p o in ts w ere n o t e d : (i) Sensory loss. (ii) C o n tr a c tu re o f th e Biceps. (iii) L im ita tio n o f m ovem ent o f th e elbow jo in t. (iv) W eakness o f th e e x te n so rs o f th e elbo w , w rist and fingers. (v) D ifficulty elev ating th e a rm ab o v e 90 degrees.. T w o to th re e weeks a fte r th e p a tie n t co m m enced tr e a t­ m e n t he co u ld c o n c e n tra te sufficiently well fo r a sensory te st to be d o n e o n th e left a rm a n d h a n d . T actile d isc rim ina­ tio n an d steriognoses w ere fou n d to be defective. H ow ever, th e n e u ro lo g ist w ho tested th e p a tie n t felt th a t sen satio n w ould im p ro v e as th e oed e m a o f th e b ra in su b sid ed a n d th a t fu r th e r te sts sh o u ld be c a rried o u t in th e fu tu re . Sensory te sts w ere d o n e a t re g u la r in te rv als a n d it is in te re stin g to n o te t h a t th ere has been ste ad y im p ro v em en t in th e results o f th ese tests u p to th e p re sen t tim e. T h e general a p p e a ra n c e o f th e a rm w as n o te d . T h e re was co n sid e ra b le w asting o f th e m u sc u la tu re o f th e left up p er lim b. I n sittin g p o sitio n s th e re stin g p o sitio n o f th e arm was o fte n flexed, a d d u c te d a n d m ed ially r o ta te d . T h e elbow was flexed a n d slightly su p in a te d . T h e w rist was flexed and U ln a dev ia ted a n d th e fingers w ere tig h tly flexed. T his p o sitio n becam e ex ag g erated if th e p a tie n t m ad e a n effort o f a n y kin d . T h e follow ing p ro g ress was n o te d . T h e m o b ility and sta b ility o f th e sh o u ld e r h a d im p ro v ed d u e to p o sitio n in g an d w eig h t-b earin g exercises a n d th e elbow co u ld flex and ex te n d a few degrees v o lu n ta rily . T h e p a tie n t co u ld sim u l­ ta n e o u sly flex his w rist a n d e x te n d his fingers a n d v o lu n ­ ta rily ex te n d his w rist w ith sim u lta n e o u s flexion o f the fingers. I t w as felt t h a t th e ex a g g era ted reflex a n d excessive fa c ilita tio n o f th e Biceps a n d P e cto ralis m uscles co n stitu ted a serio u s p ro b le m a n d it w as dec id ed th a t Ice-P a ck s m ight in h ib it th e d ischarge o f th e spindles o f these m uscles thereby allo w in g easier fa c ilita tio n o f th e ex te n so rs. T h e Ice-Packs w ere follow ed by P ro p rio c ep tiv e N e u ro m u sc u la r F a cilitatio n p a tte rn s th a t w ould facilitate th e a c tio n o f th e T riceps and th e elev ato rs o f th e s h o u ld e r girdle. Ice-Packs I t was observed th a t o n so m e d ay s th e ap p lic a tio n o f Ice-p ac ks seem ed m o re effective th a n o n o th e r days. I f the p a tie n t’s g eneral te m p e ra tu re d ro p p e d a n d he began to sh iv er, th e sp asm w as if a n y th in g in creased . I t w as found th a t th e resu lts w ere b e tte r if th e p a tie n t w as k e p t w arm in a b la n k e t o r even w arm ed by th e use o f h o tw a te r-b o ttle s on cold days, w hile th e ice-packs w ere ap p lied , i.e. a n a tte m p t was m a d e to m a in ta in th e p a tie n t’s g eneral te m p e ra tu re a t a n o rm a l level. T h is o b se rv a tio n is c o rro b o r a te d by re su lts o f e x p e rim e n ts p u b lish ed in a n a rtic le en title d “ M uscle Spindle R e sp o n s e to B o d y H e a tin g a n d L ocalised M uscle C o o lin g ” — w hich w as p u b lish ed in th e A m erican P hysical Therapy Journal. T h e Ice-p ac ks w ere follow ed by sen so ry stim u la tio n in the fo rm o f q u ick stro k in g , p o u n d in g a n d ta p p in g o v er th e T ric ep s a re a a n d its te n d in o u s in se rtio n . Proprioceptive Neuromuscular Facilitation (P .N .F .) S ensory stim u la tio n w as follow ed by th e P .N .F . p a tte rn o f ex te n sio n , a b d u c tio n a n d m edial r o ta tio n , a s fo r ex te n ­ sio n o f th e elbow . A s alw ays th e r o t a to r c o m p o n e n t was stro n g ly stresse d , to g e th e r w ith s tro n g a p p ro x im a tio n o f th e sh o u ld e r, elbow a n d w rist jo in ts. O n com m e n ce m en t o f th is tr e a tm e n t th e re w as a daily im p ro v e m e n t in th e p a tie n t’s a b ility to in itia te a c o n tra c tio n o f th e T ric ep s m uscle o f th e le ft a rm a n d a rm balance re a c tio n s began to a p p e a r o n th e left side as o n th e rig h t side w hen fa cilitated . A t th e e n d o f th e m o n th th e p a tie n t could 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. ) nd his elbo w well a g a in st resistan ce. T h e Ice-p ac ks w ere H 'c o n tin u e d a s so o n a s th e p a tie n t co u ld e x te n d his elbow f ' mv vo lu n tarily a n d co u ld easily be facilitated in to a w eight iinoorting p o sitio n o n a n ex te n d ed elbow . D u rin g th is p e rio d th e p a tie n t w as p lac ed in a side lying tit io n o n th e r ig h t side, th e left elbow a n d w rist w ere tended as m u c h as p ossible a n d th e o p e r a to r placed ressure o n th e e n d o f th e R a d iu s a n d U ln a w hile su p p o rtin g fhe back o f th e elbow jo in t. S tro n g a p p ro x im a tio n was nnlied th ro u g h th e sh o u ld e r a n d elbow jo in ts a n d th e natient was asked to p ra ctise th r u s t m o v em e n ts w ith th e rm a t varying degrees o f elev ation . Slight resista n ce o f th e fhrust p a tte r n facilitated th e e x te n sio n o f th e elbow . T he P .N .F . p a tte rn s fo r elev ation o f th e S c ap u la r w ere f o u n d to be p a rtic u la rly effective fo r stre n g th e n in g th e w eak m usculature o f th e left sc a p u la r. T h e p a tie n t b egan to be able to elevate his a rm a n d g ain e d ste ad ily in stre n g th and Because o f th e orig in al assessm ent o f m uscle to n e , P .N .F . extensor p a tte rn s w ere facilitated first in th e left u p p e r lim b and flexor p a tte r n s in th e rig h t u p p e r lim b . A s th e a rm im proved all th e P .N .F . p a tte r n s f o r th e a rm w ere tried . Reversals o f p a tte r n a n d bi-late ra l a rm p a tte rn s w ere fou n d to be p a rtic u la rly effective fo r tr a in in g c o -o rd in a tio n . M any o f th e tr u n k p a tte r n s w ere successfully trie d , e.g. th e p atterns fo r Q u a d ra tu s L u m b o ru m , b u t resista n ce o f th e patterns o f th e d ev elo p m en tal sequences w ere n o t used, because by th is tim e th e p a tie n t co u ld easily be facilitated by the B o b a th m e th o d a n d resista n ce o f th ese p a tte r n s did not seem justifie d as resista n ce p ro d u c e d a g re at increase o f associated m ovem ents. D etrim en ta l A sso cia ted m o v em e n ts w ere p a rtic u la rly noticeable w ith P .N .F . p a tte rn s involving th e e n tire b o d y in effort.As a general ru le P .N .F . p a tte r n s w ere s ta rte d first o n th e proxim al jo in t o f th e lim b a n d if th e p a tie n t w as in diffi­ culties w ith th e c o -o rd in a tio n th e p a tte r n s w ere b ro k e n do w n into co m p o n e n t p a rts befo re try in g th e e n tire p a tte r n . T his often m ad e it ea sier fo r th e p a tie n t b ecause his c o n c e n tra ­ tion was n o t so severely taxed. A ssociated M ovem ents P .N .F . p a tte rn s w ere alw ays c a rrie d o u t w ith th e p a tie n t in a Reflex In h ib itin g P o sitio n , as desc rib e d by th e B o b ath s. D u ring th e tim e t h a t th e p a tie n t w as ex p eriencing difficulty with th e P .N .F . p a tte rn s , because o f th e w eakness an d in co -o rd in atio n , assoc iated m o v em e n ts w ere a w orrying problem . H o w ever a s th e p a tie n t g ain e d stre n g th a n d c o ­ o rdination a n d c a rrie d o u t th e p a tte r n s m o re easily, th e A ssociated m o v em e n ts decreased. H ow e ve r, associated spasm w as alw ays n o te d a n d c o u n te ra c te d as f a r as possible by po sitio n in g , a n d som etim es it w as necessary fo r a n assis­ ta n t to ho ld th e lim b in a Reflex In h ib itin g P o sitio n to control a n A sso cia ted m o v em e n t. A s th e p a tie n t gained muscle c o n tro l he w as asked to c a rry o u t a m o v em en t opposite in p a tte r n to th e d e trim e n ta l A sso cia ted m o v em en t. Usually th e A sso cia ted m o v em en ts w ere m o st tro u b le so m e when th e rig h t side w as being exercised b ecause th e y te nd e d to reinforce th e flexion alrea d y existing o n th e left side. Sim ultaneous E xtension o f the W ris t an d Fingers In su p in e c ro o k lying th e p a tie n t’s a rm w as elevated 180 degress, tu rn e d in to full la te ra l r o ta tio n a n d h e w as ask e d to stabilise it in th is p o sitio n w ith th e elbow , w rist a n d fingers extended as m u c h as possible. T h e o p e r a to r ap p lie d stro n g a p p ro x im a tio n th r o u g h th e w rist, elbow a n d sh o u ld e r gripping a s fo r th e flexion, a b d u c tio n a n d la te ra l ro ta tio n P .N .F . a rm p a tte r n a n d resiste d th e p a tie n t’s a tte m p t to stabilise by p u sh in g th e a rm d o w n as fo r th e P .N .F . p a tte r n o f ex ten sio n , a b d u c tio n a n d m edical r o t a tio n . T h o u g h th e patient co u ld n o t a t first o p e n his w rist a n d fingers sim u l­ taneously, he ev e n tu ally le arn e d to d o th is by m ea n s o f th e technique d e sc rib e d above. T he P ro b lem o f H y perex ten sio n o f the P a tie n t’s K nee in W eight-bearing P ositions A s a p r e p a ra tio n fo r w alking th e p a tie n t’s b a la n c e a n d March, 1967 Page 7 e q u ilib riu m re a c tio n s h a d been facilitated in all o f th e p a tte rn s o f th e d ev elo p m en tal sequences, p a rtic u la rly u p ­ rig h t kneeling, b u t as so o n as he sto o d u p o r a tte m p te d to w alk th e rig h t knee h y p erex tend ed a n d th e p a tie n t co u ld n o t achieve a heel to e gait b ecause o f th e back kn ee in g a n d th e p e rsiste n t e q u in o v ares a t th e a n k le . T h is o cc u rred d esp ite th e B o b a th sensory m o to r tra in in g o f th e p a tte r n s o f w alk in g , a n d th e a p p lic a tio n o f Ice-packs o n th e Q u ad ricep s m uscle g ro u p a n d G a stro c n e u m o u s a n d Soleus g ro u p . T h e sp asm c aused co n sid e ra b le u n stea d in ess o f th e p a tie n t’s sta n ce a n d g ait. H e was placed sittin g w ith his legs over th e edge o f th e bed w ith th e o p e ra to r sittin g in f r o n t a n d ask e d to c a rry o u t th e P .N .F . p a tte rn o f F lex io n , A b d u c tio n a n d M ed ia l R o ta tio n as for th e knee a n d F lex io n , A d d u c tio n a n d L a te ra l R o ta tio n as fo r th e k n ee, a n d w ith b e tte r a b ility to in h ib it o n e m uscle g ro u p fo r a n o th e r th e back k n ee in g w as c o n ­ tro lle d a n d did n o t w o rry th e p a tie n t so m u c h . H is bala n ce im p ro v e d as a d irect co n sequence o f b etter m u sc u la r c o n tro l bu t it is still n o t n o rm a l. The P roblem o f Equino V ares o f the P a tie n t’s R ig h t A nkle T h e p a tie n t could c a rry o u t all th e P .N .F . a n k le p a tte rn s very w ell b u t as s o o n a s s u m m a tio n o f stim u li o c c u rre d in w eig h t-b earin g p o sitio n s fro m th e p o sitive s u p p o rtin g reflex, th e crossed e x te n so r reflex a n d fro m a p p ro x im a tio n o f the jo in t surfaces, th e e x te n so r m uscles w ere facilitated a n d th e a n k le assum ed th e p o s itio n o f e q u in o vares. T h e p a tie n t was p lac ed in a la rg e v a rie ty o f w eig h t­ b e a rin g p o sitio n s a n d th e to es w ere tic k led in o rd e r to fa c ilita te dorsi-flexion o f th e to es a n d a n k le co m b in e d w ith ev e rsio n o f th e an k le . H e w as asked to sta m p o n th e m ed ial side o f th e heal an d to dorsi-flex a n d ev e rt th e a n k le . A n a tte m p t w as m ad e to stre n g th e n th e a b d u c to r m uscle g ro u p o f th e hip b ecause th e y belong to th e sam e P .N :F . synergy as th e e v e rto rs a n d dorsi-flexors o f th e a nkle. M a n y p o sitio n s w ere trie d th a t involve a m ix tu re o f synergies w ith th e fo o t in a w eight-bearing p o sitio n . F a c ilita tio n o f leg bala n ce re a c tio n s a n d eq u ilib riu m re a c tio n s in w eight-bearing p o sitio n s w as freq u e n tly re p e a te d w ith o u t achieving sa tis­ fa c to ry im p ro v em en t a n d finally in d esp e ra tio n a F o re st T o w n ty p e sp lin t w as m ad e o u t o f p la s te r o f P a ris. T h e sp lin t p o sitio n e d th e to e s in m ax im al dorsiflexion w ith th e a n k le in m axim al dorsi-flexion a n d eversion. I t w as w o rn d u rin g re s t p erio d s. T h e aim w as to p lace th e o v er stim u la te d m uscle g ro u p o n m axim al te n s io n in a n a tte m p t to p ro d u c e a u to g e n o u s in h ib itio n o f th e stre tc h e d m uscles. Im m ed ia tely a fte r restin g he was ask e d to w alk in as g o o d a p a tte r n as possible. H is g a it a n d his bala n ce slow ly im p ro v ed b u t it w as difficult to decide w hich te c h n iq u e h a d h elp e d th e p a tie n t m o st. P R O G R E S S F iv e m o n th s a fte r th e a c cid e n t th e p a tie n t co u ld c a rry o u t m o st o f th e P .N .F . p a tte r n s very well in deed b u t h e still h a d a slight w eakness a n d inab ility to facilitate th e m u sc u la ­ tu r e o f th e left side. B a lan ce a n d eq u ilib riu m h a d received m u c h a tte n tio n b u t it w as still o n e o f th e g re ate st difficulties. T h e p a tie n t h ad le a rn t to w alk orig in ally w ith tw o q u a d rip o d sticks a n d h a d pro g ressed to w alk in g w ith tw o o rd in a ry sticks b u t he could n o t w alk u n s u p p o rte d by sticks. F iv e m o n th s a fte r th e ac cid e n t th e N e u ro -su rg e o n w ro te th is r e p o r t : “ T h e p a tie n t has d o n e very w ell. H e is ab le to w alk w ith sticks. H e does n o t c o m p la in o f h ea d ach e s. D o e s get b rief lapses o f consciousness a n d falls occasionally, C ran ia l n erves a re in ta c t a lth o u g h th e p a tie n t is tro u b le d w ith D ip lo p ia . L im b s: T h e re is so m e h y p e rto n ia in th e left u p p e r lim b. T h e re is so m e w eakness a n d a te n d e n c y fo r th e lim b to fall aw ay. T h e reflexes a re exag g era ted . C o -o rd in a ­ tio n is p o o r. T actile lo ca lisa tio n a n d d isc rim in a tio n a n d ste rio g n o ses a re n o t as g o o d o n th e left as o n th e rig h t. H o w e ve r, th e recovery th u s fa r h a s been re m a rk a b le .” T h e p a tie n t w as advised a t th is stage to ta k e E p in e u to n a n d L u m in a l to c o n tro l th e p e tit m a l a tta c k s w hich p re c ip i­ ta te d so m e o f th e falls. P H Y S I O T H E R A P Y 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. ) P a ge 8 P H Y S I O T H E R A P H Y March, 1967 E ig h tee n m o n th s a fte r th e a c cid e n t th e r e p o rt s ta te d : “ T h e p a tie n t’s g a it is still u n ste a d y b u t he w alks w ith o u t sticks. H e c a n ju m p w ith b o th feet to g e th e r a n d c a n go up a n d d o w n steps w ith o u t s u p p o rt. H ow e ve r, h e c a n n o t ju m p fro m o n e leg to th e o th e r, o r h o p , o n th e le ft leg o r r u n . H e w rites well b u t r a th e r slow ly w ith th e le ft h a n d . H e still has a loss o f som e fine selective m o v em en ts o n th e left side a n d h e is still tro u b le d by th e tre m o r o n th e rig h t side w hen u n d e r d u re ss.” T h e m ain p ro b le m a t th e tim e o f w ritin g is th e p a tie n t’s difficulty in ac ce p tin g th e lim ita tio n s o f a p o o r m em ory , v isual p erce p tio n p ro b le m s a n d a loss o f a b s tra c t reaso n in g , all o f w hich m ak e it im p o ssib le fo r h im to ta k e his m atric . E m o tio n a l a c ce p tan ce is p a rtic u la rly difficult fo r this p a tie n t because o n a v e rb a l scale his intelligence is on ly very slightly below th e average. T H E P R IN C I P L E S O F T R E A T M E N T T h e d e v e lo p m en ta l m o v em e n ts p re p a re th e h u m a n in fa n t fo r erec t lo c o m o tio n . I n th e sam e w ay th is p a tie n t was re -e d u c a te d ste p by ste p to w a rd s assum in g th e ere c t p o stu re . H e w as p re p a re d b y w eight b ea rin g o n th e a rm s a n d by sensory tr a in in g o f w ide a rm p a tte r n s a n d b y th e d ev e lo p ­ m e n t o f sufficient ex te n sio n in th e lim b to achieve gra sp a n d release, fo r th e fine c o -o rd in a tio n th a t is necessary f o r w riting a n d o th e r in tric a te m o v em en ts w hich a re d e m a n d e d o f the h u m a n h a n d . R e p e titio n o f n o rm a l living p a tte rn s a n d n o rm a l tim in g o f m o v em en ts w ere stressed in o rd e r to im p ro v e th e p a tie n t’s c o -o rd in a tio n . H e w as p ra ise d on ly w hen he p e rfo rm e d well, so t h a t he g ained a c o rre c t sensory im p ressio n o f m o v em en t. B o b a th fa c ilitatio n s o f th e p a tte r n s o f d aily living w ere included daily. N o t all th e tr e a tm e n t th a t was given to th e p a tie n t has been desc rib e d in d e ta il, b u t th e salient p o in ts re g a rd in g pro b le m s a n d difficulties hav e b een m ad e. In a n a tte m p t to n o rm a lise m uscle to n e a n d allow free m o v em e n t th e p a tie n t w as facilitated first to in h ib it o n e m uscle synergy fo r a n o th e r by m ea n s o f R o o d ty p e sensory s tim u la tio n a n d P .N .F . a n d th e n h e w as en c o u ra g e d to p e rfo rm iso la ted selective m ovem ents. S u m m a tio n o f sensory stim uli a n d th e use o f Reflex In h ib itin g P o sitio n s w ere em p loy ed in o rd e r to suppress p rim itiv e sp in al reflexes a n d th e m o re com plex p a tte rn s o f R ig h tin g re a c tio n s a n d B a lan ce a n d E q u ilib riu m re a c tio n s w ere also e n c o u ra g e d , in o rd e r to su p p re ss th e p rim itive reflexes. A n a tte m p t w as m a d e to estab lish c o n tr o l o f pro x im al jo in ts first, b ec au se th e p o sitio n o f th e p ro x im al jo in t influences th e p o s itio n o f th e d ista l jo in ts. E V A L U A T IO N O F T E C H N IQ U E S A n a tte m p t will be m a d e to assess th e valu e o f c e rta in te ch n iq u es o r m o d a litie s as reg ard s th is p a r tic u la r p a tie n t, as it m a y be o f v alu e to o th e r p h y sio th e ra p ists w ho w ish to tr y using som e o f th e sensory m o to r te c h n iq u e s described a bove. E valuation o f Proprioceptive N eurom uscular F a cilita tio n for this P a tie n t P .N .F . p a tte rn s w ere th o u g h t by th e w rite r to be a n effective m eans o f : (a) F a cilita tin g th is p a tie n t’s in h ib ite d m uscle g ro u p s, i.e. w h ere sp asm p re v en te d a n o p p o sin g m uscle g ro u p fro m c o n tra c tin g v o lu n tarily . (b) Im p ro v in g c o n tro l a n d stren g th o f w eak m uscle g ro u p s. (c) G a in in g jo in t ra n g e d u e to im p ro v e d c o n tro l a n d stre n g th o f w eak m uscle g roups. (d ) P re p a rin g f o r th e d e v e lo p m en t o f iso la te d selective m o v em e n t, b ecause c o n tro l a n d stre n g th m u st be p re sen t b e fo re selective m o v em en ts ca n occu r. (e) Im p ro v in g th is p a tie n t’s m o ra le , bec au se h e so m u ch en jo y e d w o rk in g a g a in st resistan ce. H o w e ve r, w h en he co u ld p e rfo rm all th e P .N .F . p a tte rn s a g a in st re sista n c e h e still co u ld n o t c a rry o u t m an y o f th e p a tte r n s o f d aily living w ith o u t stre tc h resista n ce facilitatio n a n d he re q u ire d fu r th e r sensory m o to r tr a in in g w ith o u t resista n ce. E valuation o f the B obath T re a tm e n t for this P a tie n t I n th e o p in io n o f th e w rite r th e B o b a th a p p ro a c h w as a p a rtic u la rly effective m ea n s o f : (a) Im p ro v in g th e p a tie n t’s eq u ilib riu m re a c tio n s. lb) Im p ro v in g th e p a tie n t’s b a la n c e re a c tio n s o f th e u p p e r a n d low er lim b. (c) G a in in g th e a b ility to c a rry o u t m a n y o f th e dev e lo p ­ m e n ta l p a tte r n s th a t are d e p e n d e n t o rig in ally o n th e R ig h tin g rea c tio n s, e.g. ro llin g , g ettin g fro m lying to sittin g . (d ) G a in in g selective m o v em en ts w hich w ere often effec­ tively facilitated by th e sen so ry m o to r a p p ro a c h . (e) P e rfo rm a n c e o f th e p a tte rn s o f d aily living w ith o u t th e fa c ilita tio n o f resista n ce a n d stre tc h k e p t th e stro n g A sso cia ted m o v em e n ts m in im a l. H o w e ve r, th e p a tie n t’s p e rfo rm a n c e o f th e p a tte rn s o f d aily living w as, in th e o p in io n o f th e w rite r, freq u e n tly im p ro v ed by h av in g gained stren g th a n d c o n tro l by th e use o f P .N .F . Ice-packs and Sensory S tim ulation T h e re su lts o f ice-packs used o n th is p a tie n t w ere n o t co n sis te n t en o u g h to gauge th e success o r fa ilu re ac cu rate ly . H o w ever o n occasions th e p a tie n t show ed a p a rtic u la rly goo d re sp o n se to Ice-p acks. I t is th e o p in io n o f th e w rite r th a t sen so ry s tim u la tio n is a very im p o r ta n t line o f th o u g h t a n d yields im p o rta n t benefits fo r p a tie n ts. Successful facilitatio n is s u m m a tio n o f sensory stim uli. C O N C L U S I O N A s alw ays w hen co n sid erin g a p a rtic u la r p a tie n t it is difficult to decide ho w m u ch s p o n ta n e o u s reco v e ry w ould hav e o cc u rred a n d how fast th is reco v e ry w ould have o c c u rre d as th e oed e m a o f th e b ra in su b sid ed a n d th e c irc u la tio n re-e stab lish ed itself. H o w e ve r, it is th e o p in io n o f th e qualified p h y sio th e ra p ists a n d stu d e n ts w h o saw th is p a tie n t t h a t he m a d e a definite d aily re sp o n se to tr e a tm e n t. H e d id n o t seem to p ro g ress a t all i f fo r a n y re a so n he did did n o t receive tre a tm e n t fo r a p erio d in th e la tte r stages, a n d it is th e w rite r’s o p in io n th a t c o m b in in g several sensory m o to r te ch n iq u es in itia te d a b e tte r re sp o n se th a n a n y o n e te c h n iq u e a lo n e achieved fo r th is p a tie n t. I t is th e w rite r’s o p in io n th a t n o t en o u g h a tte n tio n was p a id to th e p re v e n tio n o f c o n tra c tu re s by s ta tic p o sitio n in g in th e e a rly stages o f tre a tm e n t a n d t h a t n o t e n o u g h a tte n tio n w as p a id to m o b ilisatio n o f th e spine by th e m eth o d d esc rib e d by th e B o b a th s in th e e a rly weeks o f tre a tm e n t. T h e w rite r accepts th e o p in io n th a t th e use o f resistance te c h n iq u e s increases th e d a n g e r o f A sso ciated m o v em en ts w hich m a y re in force b ad p a tte rn s . H ow e ve r, as th is p a tie n t im p ro v e d he re q u ire d less effort to p e rfo rm m o v em e n ts a n d in co n se q u en ce th e im pulse re sp o n sib le fo r A ssociated m o v em e n ts d id n o t reac h th re sh o ld stre n g th . P ossibly, th e re fo re , o n e sh o u ld weigh th e risk s a n d if o n e is g aining g ro u n d d aily w ith a resista n ce te c h n iq u e a n d th e re is every h o p e o f success, o n e sh o u ld ta k e p re c a u tio n s ag a in st A sso ­ ciated m o v em en ts such as th o se m e n tio n e d in th is a rtic le a n d c o n tin u e to use th e te c h n iq u e as w as d o n e f o r this p a tie n t. T h e w rite r is o f th e o p in io n t h a t P .N .F . c a n n o t be ap p lied in d isc rim in ately fo r th e tre a tm e n t o f u p p e r m o to r n e u ro n lesions a n d feels th a t it is im p o r ta n t th a t th e m uscle to n e sh o u ld initially be c o rre ctly assessed. A t first P .N .F . p a tte rn s sh o u ld on ly be used fo r th o se m uscle g ro u p s w hich a re in h ib ite d by th e spasm . L a te r w hen th e p a tie n t h as im p ro v ed a n d th e m uscle to n e is m o re n o rm a l he c a n be ta u g h t to sta b ilise a lim b a n d ch a n g e fro m o n e synergy to a n o th e r. I f th e p a tie n t is ca p a b le th e aim sh o u ld ultim ately be iso ­ la te d selected m ovem ents w hich c a n n o t be achieved by P .N .F . a lo n e a n d th e re fo re th e sen so ry m o to r tr a in in g o f th e p a tte r n s o f daily living w ith o u t resista n ce fa c ilita tio n a re o f g re at valu e in m y o p in io n . F in ally , o n e sh o u ld c o n sid e r th e p a tie n t’s physical a n d m en tal p ro b le m s as a n in te g rated w hole in o rd e r to achieve th e b est re su lts f ro m tre a tm e n t involving th e use o f c o m b in e d te ch n iq u es. 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. )