For each intervention target, appropriate interventions were assigned to one or more of Simon’s healthcare team members (see Table 3 below). Simon’s independence had increased to such a degree that nursing assistance was largely unnecessary except for managing medications and some instruction when needed. Given the goal-focus on locomotion and object handling, the majority of the interventions in this Rehab Cycle were divided between the physical, sports and occupational therapists, with many overlapping responsibilities.
Systematic reviews of randomized trials on types of locomotor training and pharmacological interventions for spasticity have led to inconclusive results.
Interventions selected to best achieve a walking recovery range from the pharmacological to the physical. As mentioned earlier, there is often insufficient evidence for making an absolute determination about an intervention and its desired results. Systematic reviews of randomized trials on types of locomotor training32 and pharmacological interventions for spasticity33 have led to inconclusive results. Notably, one review emphasizes that a mix of physiotherapeutic interventions has been shown to have better functional outcomes than rehabilitation plans focusing on one type of intervention.34
Clinical decisions on the best course of action must also take into account a patient’s own needs, limitations, recovery progress and context. In Simon’s case, interventions were determined based on available evidence along with his health professionals’ informed opinions.
In terms of a walking recovery and given Simon’s previous progress, a number of interventions were considered promising by the healthcare team. A number of drugs were chosen that could potentially help control spasticity and consequently promote locomotion.35 A variety of physical trainings were undertaken by different healthcare team members. Interventions included a combination of approaches to cover the many aspects necessary for walking.
- To improve respiratory functions as well as the control of voluntary movements in the trunk and limbs, Vojta therapy was applied to Simon (see Box 4). While conclusive evidence for the effectiveness of Vojta therapy is lacking, it is believed that the intervention may offer some success for a number of neuromuscular and skeletal disorders. 36 37 38 39 40
- To improve exercise tolerance, arm ergometer training was implemented. Studies, though not conclusive, have shown that overall training can increase aerobic capacity 41 42
- To improve mobility in the shoulder joint passive and active shoulder exercises, based on manual therapy were chosen. 43 44
- To improve standing and reaction functions, body balance training and table tennis were implemented
- To improve bending and shifting Simon’s center of gravity, repetitive training in these activities was applied 45 46
- To improve capacity in gait pattern functions, short- and long-distance walking and walking on different terrains and around obstacles, walking and outdoors training was exercised 47 To improve the performance in these activities, a city training exercised Simon’s ability to move about in outdoor and indoor environments other than home and the rehabilitation center 48
Box 4: Vojta Method Therapy
The Vojta Method is another name for what is also referred to as reflex-locomotion, a therapeutic method of treating physical and neurological disorders. Developed by a Czechoslovakian neurologist, Dr. Vaclav Vojta, who was studying motor rehabilitation, reflex-locomotion focuses on the following therapeutic goals:
- To facilitate the automatic regulation or control of the body’s position;
- To facilitate the active maintenance of the support functions of the extremities;
- To stimulate coordinated muscle activities;
- To increase control of breathing to improve vital capacity;
- To control neuro-vegetative reactions and promote balanced growth of the anatomical locomotor system
- To prevent orthopedic degradation.
Vojta therapy was originally applied to children with cerebral palsy and later extended to adolescents and adults as a rehabilitative intervention.
The therapy begins with a three-staged clinical evaluation that includes a study of automatic postural reactivity, kinesiological analysis of spontaneous motor function and reflexology. This evaluation helps identify the initial degree of a patient’s development, clearly define the optimal development of postures and movements and, lastly, make a prognosis. Once an evaluation is complete, therapy continues utilizing movements that stimulate muscle activity that do not consciously take place in a patient. The intended result is an “increased economy of movement” leading to an overall improved quality of life.
Interventions included a combination of approaches to cover the many aspects necessary for walking.
Simon’s sports therapist supplemented and assisted with a number of interventions, including strength and endurance training in the gym. In addition, he helped Simon to experience other sports activities to emphasize sports and leisure.
The occupational therapist focused on the “handling” interventions of CG2. These included:
- Specific touch stimulations utilizing different materials to improve touch functions
- Repetitive training to improve the control of voluntary movements and joint mobility in the upper extremity. Therapeutic games that centered on improving fine hand functions, lifting and carrying objects contributed to the improvement of these activities
- Assistance and instruction in activities of daily living, such as preparing meals and dressing himself, to improve performance in the hand and arm functions
In addition to physical interventions, the occupational therapist assisted with planning for future employment by working with Simon’s former employer. Other important activities included in the Rehab Cycle were driving lessons and weekend stays at home. Both would lead to improvements that would help Simon achieve his two cycle goals.
Figure 3: ICF Intervention Table PT: Physiotherapist, OT: Occupational therapist, Spo: Sport therapist, SW: Social worker