February 9, 2010 by afp


I would venture to say many of us have issues with spasticity or tone. What is this, what does it mean, and what is the difference? My, oh, my, I was confused when they would mention these two different terms, and then I decided to dig. I found out it was more confusing trying to express the meanings.

I did find out that spasticity seems to react differently for each of us. Spasticity and tone affects us with weird mannerisms. Some do well on medications, some do not. Some have pain associated with this, where some do not. Some are assisted by physical therapy, whereupon reading further, it shall be detailed.

　

Overview of spasticity

The most common causes of spasticity are lack of oxygen to the brain before, during, or after birth (cerebral palsy); physical trauma (brain or spinal cord injury); blockage of or bleeding from a blood vessel in the brain (stroke); multiple sclerosis (MS); or infection of the brain (encephalitis) or the covering of the brain and spinal cord (meningitis).

When damage that causes the eventual spasticity first occurs, the muscles are usually flaccid before they become spastic. Spasticity may not be present all the time—it may be related to a trigger, or stimulus, such as pain, pressure sores, a urinary tract infection, ingrown toenails, tight clothing, or constipation.

Spasticity may be painful, especially if it pulls joints into abnormal positions and or prevents a normal movement of the joints. Spasticity may range from slight muscle stiffness to permanent shortening of the muscle. When the muscle is permanently shortened, the joint becomes misshapen. This is called a contracture and is one of the most significant consequences of spasticity. Another closely related problem with muscles in many people who have spasticity is clonus, or rapid repeated muscle spasms.

While spasticity may affect any muscle group, there are some common patterns. When spasticity affects one or both arms, flexed (bent) elbow, flexed wrist, and clenched fist may result. These can all affect the person’s ability to dress, eat, or write or may interfere with balance, thereby causing difficulties with walking. Spasticity of the legs can cause flexed hip, adducted (or scissoring) thigh, stiff knee, flexed knee, equinovarus foot, and hyperextended great toe (which is also called the hitchhiker’s toe). Spasticity of one or both legs may interfere with the ability to walk, position in bed, sit, transfer, or stand.

　

Epidemiology

Overall, spasticity affects about 500,000 people in the United States, and more than 12 million people throughout the world. The number of people affected depends upon the cause of the spasticity. In the United Kingdom, approximately 100,000 people have a first-time stroke every year, and an additional 30,000 have a repeated stroke. Stroke afflicts almost 2,000 out of every 1 million people per year worldwide. Almost 40 percent of people who have a stroke continue to have spasticity one year later.

One year later? Ha! I bet, besides myself, many still have it years later.

　

Clinical examination

A standard evaluation of the nervous system forms the basis of the clinical examination in spasticity. Strength and reflexes are both assessed in this examination. The clinician asks the patient to relax and then moves the joints through their full range of motion at various speeds. Spastic muscles may have a “spastic catch,” exhibit the “clasped knife” phenomenon, or both. Observing the person with spasticity perform activities such as walking, drinking from an open cup, and moving from one position to another often yields valuable information.

The clinical examination also includes an evaluation of deep tendon reflexes. The most commonly used method of testing these reflexes is the tapping technique. With the patient sitting on the examination table and his or her legs hanging freely, the examiner gently but firmly taps below the knee (testing the patellar reflex), first on one leg and then the other.

The responses should be the same in the two legs. Similar techniques may be used to test reflexes in the Achilles tendon (behind the ankle), and reflexes may also be checked in the biceps, triceps, and brachioradialis muscles of the arms.

　

The Spasticity Management Team

The best treatment of spasticity usually includes an active patient or advocate and caregivers working with several health-care professionals from various medical backgrounds. Members of this team may include one or more of the following people.

Neurologist
A neurologist is a medical doctor trained in disorders of the nervous system. The neurologist may diagnose the neurologic problem; prescribe treatments, including medications and physical and occupational therapy; and refer the patient for surgical evaluation if necessary. The neurologist may also inject the chemodenervation treatments (see the section on treatment that follows).

Physiatrist
A physiatrist is a medical doctor who specializes in physical medicine and rehabilitation. The physiatrist may design the rehabilitation program, working with other team members to maximize the patient’s function and minimize the disabling aspects of the neurologic injury. The physiatrist may also prescribe medications and administer chemodenervation treatments.

Physical Therapist
A physical therapist is a healthcare professional who is responsible for the physical aspects of treatment. The physical therapist may perform or direct another person to perform the exercises that are necessary to assist in maintaining the range of motion of limbs affected by spasticity. The physical therapist may also apply and fit braces, splints, or casts that may be prescribed by the physiatrist or other treating physician.

In addition, the physical therapist may direct training to improve the patient’s ability to walk or move and may instruct patients and caregivers on how to position affected arms and legs to help reduce spasticity. A physical therapist often works closely with an occupational therapist to design changes in the home and equipment that might be necessary to accommodate the patient’s needs.

Occupational therapist
An occupational therapist is a healthcare professional who specializes in adaptation of the physical environment to meet the patient’s needs. The occupational therapist may teach modifications for dressing, feeding, and grooming to the patient and caregiver. This therapist may also offer expertise on adaptive devices such as wheelchairs and bath equipment and may advise on home and workplace modifications to increase accessibility and ease of use. The occupational therapist is usually the medical professional who advises the school on issues such as seating, writing, and use of facilities.

Neurosurgeon
A neurosurgeon is a medical doctor who is specially trained to perform surgical procedures related to the nervous system. For example, when a patient with severe spasticity has a positive response to a screening test (intrathecal baclofen bolus) and is then recommended to receive continuous intrathecal baclofen (ITBTM Therapy), the neurosurgeon may implant the baclofen delivery pump.

Neurosurgeons may also perform an operation to destroy selected sensory nerves at their entry point into the spinal cord (selective dorsal rhizotomy) when other treatments cannot offer adequate spasticity relief. When a patient requires exposure of a target nerve for chemodenervation, the neurosurgeon is usually the physician who performs that operation; a neurologist or physiatrist then usually performs the chemodenervation.

Orthopedic surgeon
An orthopedic surgeon is a medical doctor who is specially trained to perform operations related to bones, joints, muscles, and surrounding connective tissue. These types of procedures may help to reduce or correct contractures that lead to abnormal positioning of joints. Orthopedic operations often involve reconstruction or revision of tendons and bones. The orthopedic surgeon may also assist with the fitting of braces and assessing growth and development.

Spasticity treatment
In some patients with mild spasticity, the best treatment may be no treatment, with a watch-and-wait strategy. Typically, treatment is reserved for spasticity that causes pain, interferes with activities of daily living or sleep, or leads to increasing levels of functional disability.

Some key questions that should be answered before beginning any treatment for spasticity include:
1. Is treatment necessary?
2. Do the patient and caregiver have the time and resources necessary to put the treatment into action?
3. Will the treatment improve the patient’s or the caregiver’s quality of life?

　

Treatment goals

Patient and family expectations regarding the possibilities of treatments and outcomes may be realistic or unrealistic. Inappropriate expectations about the effectiveness of treatment may lead to disappointment regarding relief of symptoms and pain. Therefore, ongoing communication and agreement by the patient, caregivers, and healthcare professionals regarding the goals of treatment are extremely important. The following list includes goals that are commonly developed in the treatment of spasticity.
· Relieve the signs and symptoms of spasticity
· Reduce pain, frequency of spasms, or irritating stimuli
· Improve gait, hygiene, activities of daily living, or ease of care
· Reduce problems with passive function, that is, the functions provided by the caregiver, such as dressing, feeding, transfer, and bathing
· Improve voluntary active motor function, that is, the behaviors and functions that are under the patient’s control, such as reaching for, grasping, moving, and releasing an object

　

Types of treatment

A combination of various types of treatment is usually required to attain the specific goals of treatment for a particular patient. Most people with spasticity require physical and occupational therapy to improve or maintain the range of motion in their spastic limbs.

Description of types of therapies: You can follow this at the following web link: www.wemove.org/spa/spa_pot.html.

　

Physical and occupational therapy

Although physical therapy is a mainstay of treatment for spasticity, there has been surprisingly little research conducted to support the use of these techniques. Physical therapy for spasticity refers to a range of physical (as opposed to drug or surgical) treatments. These treatments of spastic muscles are designed to reduce muscle tone, maintain or improve range of motion and mobility, increase strength and coordination, and improve care and comfort.

The choice of treatments is individualized to meet the needs of the person with spasticity. Physical therapy is the most common form of treatment for spasticity in children. The success of the therapy is often based upon the motivation of the person with spasticity and the caregiver, as well as the physical therapist’s skills.

Please note the last paragraph. Team effort is a must. The success of therapy is often based upon motivation of the person and the caregiver. If you are alone, the team may be you and the therapist. It will not work unless you have motivation. I refer it as “attitude.” I have written about “attitude” in previous articles. Get one !!! Never give up, I improve everyday despite two brainstem strokes.

Here are some additional sites for more info:
- www.webmd.com/pain-management/pain-management-spasticity
- www.geocities.com/aneecp/terms.htm
- www.ninds.nih.gov/disorders/spasticity/spasticity.htm

By Beth Johnson
Radiation treatments for bone cancer at the age of 11 precipitated a condition that resulted in the amputation of Kevin Clancy’s right leg at age 48. Clancy remembers waking up on November 16, 2008 and noticing that his right foot was unusually cold. “Some of the toes had turned blue,” he recalls. “Ever since I had cancer, I’ve had poor circulation in that leg, but nothing like this.”
He was taken to an acute-care hospital the same day, where doctors discovered that only one artery was working. The decision was quickly made to remove the leg above the knee. The surgery was done November 23, and within 10 days, Clancy was transferred to Providence Hospital’s Amputee Rehabilitation program to begin rehab. Providence Hospital is one of the three integrated care divisions within Providence Healthcare in Toronto’s east end that also offers long-term care and community outreach services.

During his two months at Providence, Clancy was fitted with a prosthetic leg, and made a couple of trips home to determine what changes would need to be made to ensure a smooth transition home. Another step taken to ensure a smooth transition home was introducing Clancy to Providence’s newest service, the Mobility Clinic, where he met with his new physical and occupational therapists.

The new Mobility Clinic is designed for outpatients of Providence Hospital with muscular-skeletal impairments. It ‘fills the gap’ that opens once a patient returns home by continuing to support their therapy needs within a safe, professional, and compassionate environment.

There are two ultimate goals for the Clinic. The first is to provide individualized health-care services to improve functional abilities and promote independence. The second, more important goal, is re-integrating clients into their community and giving clients back their confidence and freedom to take charge and manage their own health care and new lifestyles.

“Kevin was confident while at Providence or at home, but there was a lot of fear each time he faced a new, public environment,” explains Clancy’s wife Christie. “For example, we had to go shopping for a light bulb, but Kevin was hesitant. He knew they were stocked at the back of the hardware store. But he did it – he summoned the confidence he needed to walk to the back of the store, find what he was looking for, get back to the car and return home.” A weekend trip to the hardware store is something we take for granted, but a milestone for someone learning to walk again after the sudden loss of a leg.

The Clinic helps people overcome fears by instilling a sense of independence through using innovative rehabilitation equipment and best practices. Physiotherapist Dellene Sakaguchi says, “Strengthening exercises help patients learn how to trust their balance again. We use tools such as a ‘core pole’ for total body conditioning.” The Clinics’s state-of-the-art gymnasium includes a variety of rehabilitation equipment, a mock kitchen and laundry room for training purposes, and a Sony Wii game system to strengthen muscles and enhance dynamic balance skills in a fun way.

“We take the time to learn about what each person’s day-to-day life involves then reintroduce them to these activities, and adapt them however necessary,” explains occupational therapist Lynne Mycyk. Staff introduced and adapted exercises and activities that would help Clancy get back to the things he loves doing, such as golfing, cooking and participating in the drum corps.

Staff members also help clients understand their injuries, their rehabilitation goals, and their achievements. Education fosters understanding; when clients see the ‘big picture’, they develop a belief in what they are doing, thereby increasing their chance of success. Beyond the physical rehabilitation provided, a sense of camaraderie and hope permeates the clinic. Clients of the service encourage each other’s progress and celebrate achievements.

With 347 beds, Providence Hospital is one of the largest rehabilitation hospitals in Ontario, and the Amputee Rehabilitation unit alone discharges up to 80 patients annually. The new Mobility Clinic is Providence’s solution to ensuring a smooth continuum of care on the patient’s journey to recovery.

Beth Johnson is the Director of Communications at Providence Healthcare.

by Holly McCarthy on May 14, 2009
This is a guest post on the EasyStand Blog, contributed by Holly McCarthy, who writes on the subject of the sports management degree programs at an accredited university. She invites your feedback at hollymccarthy12 at gmail dot com.

Kids and Adults with disabilities can benefit from recieve rehabilitative benefits from playing Wii, besides having fun!

The Nintendo Wii has been one of the most popular game systems this decade and has even been used in rehabilitative applications for people coping with a variety of ailments. A little over a year ago doctors in Canada thought of using the system, which had been used as entertainment for young spinal cord injury recovering patients, and as therapy for patients after strokes.
What they began to realize is that this system, the Nintendo Wii, could be just what is needed to help with rehabilitation because of its ease of use and friendly interface. There are several benefits of using the Wii in rehabilitative treatments (commonly termed at Wii-hab), a few of which will be explored below.
Balance - Whether the patient is standing or sitting in a wheelchair, the controllers used to play the Wii console require balance and proper form for the best results. Using a standing frame while playing Wii can promote movement while standing, which research has shown to improve bone mineral density and strengthening.
Hand-Eye Coordination - Over time, hand-eye coordination improves through the use of video games. This is especially true of the Wii since the players’ movements are mimicked on the screen.
Entertainment - Therapy becomes more enjoyable when put in the context of a game. People who use a standing frame for Physical or Occupational Therapy can prolong their standing time by “multi-tasking” by playing Wii.
Competitive Spirit - The competitive spirit in patients who may not otherwise be able to compete is awakened. This can be great for increasing social skills as well as self-esteem.
Extension of Therapy to Home ­- While many things that are found in a therapists office are far too cost-prohibitive to be kept at home, the Wii is an affordable method of treatment that can be taken beyond the office and into the home for around $250. Additionally, friends and family can play along and join in the fun.
Helps With Memory, Problem Solving, and Decision Making Skills - All of these skills are honed through the use of video games according to studies, which may or may not be good news for parents. Playing sophisticated games helps with short-term, long-term, and muscle memory. Strategic games require problem solving and decision making skills, all of which help to enhance the experience.
The Nintendo Wii is finding enthusiasts of many abilities these days. Games and hardware have made participating in many activities from the comfort of your own home possible with a small price tag that can bring benefits to those in and out of rehabilitation care.
Have you used the Nintendo Wii for rehab or fun? What games have you enjoyed the most?

Publish Date: Sunday,26 April, 2009, at 12:27 PM Doha Time

Dr Shaarani: ‘Two to three years of age is the time to show an affected child to a surgeon

By Bonnie JamesSurgical interventions improve the quality of life of children with cerebral palsy, Hamad Medical Corporation’s consultant orthopaedic surgeon Dr Mohamed Shaarani said yesterday.“Surgery enables many wheelchair-bound children to be transferred to walkers and those who are crippled to get on to wheelchairs,” he explained to Gulf Times on the sidelines of the first cerebral palsy symposium in Qatar.

Children with cerebral palsy have spasticity (stiff or rigid muscles with exaggerated, deep tendon reflexes, for example, a knee-jerk reflex), which can interfere with walking, movement, or speech.“We elongate some muscles and cut some others to make them loose and allow movement and flexibility,” pointed out Dr Shaarani, also a consultant paediatric orthopaedic.

Between two to three years of age is the ideal time to show an affected child for the first time to a surgeon, he added.In a presentation about dental problems in cerebral palsy, Primary Healthcare Department’s senior consultant Dr Mutaz Ahmed observed that incidence of dental decay is higher in this group, mainly due to poor oral hygiene.“Dental caries, gum disease, malocclusion, enamel defects, increased incidence of dental trauma, drooling, and grinding of teeth are among the main problems,” he explained.The incidence of gum disease is three times more among those with cerebral palsy than in the general population. The affected group also have a higher rate of dental enamel defects.“The increased risk for dental trauma can be attributed to problems with balance and muscle weakness in legs,” Dr Ahmed pointed out.Giving sedation, including general anaesthesia, is a very important option when doing dental procedures on an individual with cerebral palsy, as it may otherwise be difficult to control the patient.Highlighting the significance of maintaining proper dental hygiene in those with cerebral palsy the senior consultant suggested that parents should be instructed by dentists in this regard.“Cerebral palsy patients should be seen by a dentist every six months,” Dr Ahmed recommended while observing that electric toothbrush can be very useful for them.

Radiology, seizure disorders, growth and nutrition, medical management of spasticity, roles of physiotherapy, occupational therapy, orthotic, speech therapy and dietician, and education were the other topics of presentations at the symposium.

During my recent holiday from work, Mum and I visited the Stockton Independent Living Centre with our Occupational Therapist, to have a look at there adapted kitchen and see what could be done to help us.

I have to say that Mum and I was impressed with the demonstration kitchen there. The room had 2 kitchens setup, one being a height adjustable one, and the other being a conventional height. When I looked I was supprised at the height difference, although it didn't make it look out of place. Mind you when we came home and just looked at our kitchen as it is it felt a bit over powering and felt as if it was coming in at you.

I cant wait for it to get started because it is going to make such a difference too us, we just have to wait on the Council now to process all of the forms and our application for a grant. Once this has been sorted out the work can start.

By showing how yoga can help disabled students, one enthusiastic teacher has made the discipline standard practice. > By John H. Tucker

Inside the gymnasium of P.S.811x, in the East Morrisania section of the Bronx, Martha Gold weaved her way around 50 yoga mats, adjusting the poses of her students. "Hug your knee, give it a big kiss, and say 'I'm perfect just the way I am,'" she chirped, eliciting a chorus of giggles.

For most New Yorkers, yoga, with its deep stretches and wicked bends, can be difficult. But at P.S.811x, which enrolls children with cerebral palsy and other disabilities, it's uniquely challenging. With limited range of motion, many of the students here can't eat or dress on their own. Several are confined to wheelchairs.

On this day, however, the room was astir with moving limbs as the students took to their mats. After a decade or two of working its way into New York's mainstream, yoga is now flowing into the city's District 75, an umbrella classification for the classes and schools that serves students with brain damage, autism and other developmental, behavioral or psychological disabilities. Physical therapists at these schools are beginning to discover the benefits of the practice, and some estimate that nearly half the schools offer a yoga class. Not long ago, that percentage was close to zero.

The advantages of yoga for healthy people are well-documented: increased strength, flexibility and relaxation. But for the child with developmental disabilities, the benefits are perhaps greater. Heightened sensory awareness, vocalization skills and breathing capacity are just a few.

"A lot of these children have a reduced respiratory system,” said Joe Cattelona, a physical therapist at P.S.138m, a District 75 program in East Harlem. “Yoga gives them better oxygenation to the blood, which circulates to their brain and allows them to breathe in ways they don't normally do."
By prompting the brain to release serotonin and dopamine, yoga also helps lower the heightened anxiety that's characteristic of children with cerebral palsy, said Susan Flynn, an occupational therapist at P.S.10x in the Bronx.

Last month, Mayor Bloomberg frightened education advocates by announcing that budget cuts could lead to the elimination of 14,000 education jobs. Some feared that the city’s physical education programs — which include District 75 yoga classes — might also be impacted. But because of the newly approved stimulus package, which is expected to endow the city with more than $1 billion for education — including a large portion for special-needs education — many of those fears have been put to rest.

Even if education cuts were made, yoga programs and other physical education classes wouldn’t have taken much of a hit, said Director of Fitness and Health Education Lori Rose Benson. A reason for this, she said, is that her office is largely funded by the city’s Department of Health and Mental Hygiene, in a collaborative effort to fight childhood obesity.

Under the seven-year chancellorship of Joel Klein, “a significant” amount of money has been injected into the department’s physical education budget for the first time in decades, said Benson. The money has gone toward equipment, training programs and — in the case of District 75 — a newly appointed physical education director and new outreach efforts with Special Olympics officials.
~
The surge of yoga within District 75 — which comprises 56 schools — is primarily thanks to Gold, a physical therapist who arrived at P.S.811x, also known as the Academy for Career and Living Skills, several years ago. One day she introduced a number of poses to four able-bodied students in class. A few weeks later, six others joined. Eventually, the sessions outgrew the classroom.

In 2004, Gold and three colleagues began offering weekly workshops for other special-education professionals in the city. The workshops eventually reached 200 therapists and teachers, many of whom immediately began implementing programs with their own students.

"After that, it spread like wildfire," recalled Katherine Deats, who co-taught that workshop and is now a yoga instructor for two District 75 schools in Manhattan. "These kids have such a hard time succeeding in anything," Deats said. "But they can go to yoga and succeed. If you can breathe and chant, you succeed."

Gold, a Queens native in her later 30s, is a slight woman, shy, with jet-black hair, siren-red lipstick and a penchant for bright velvet jumpsuits. Popular among fellow teachers, she's known for the enormous audio speaker she rolls to and from yoga class each day like a worn-out suitcase. She greets colleagues in the hallway by clasping her hands in prayer, bowing down and politely saying "Namaste," a Sanskrit greeting of deep respect. The teachers return the gesture.

Luis Quintana, the school’s assistant principal, said he’s grateful for Gold's vision. "I see a decrease in aggressive-violent behaviors among the children immediately after her class," Quintana said.

"Martha is one hard-working woman who puts her heart and soul into helping children," said Debra Krasinski, a Columbia University professor and physical therapist, who each year invites Gold to give a yoga workshop to her doctoral students.

Gold also runs her workshops for other physical and occupational therapists, special education teachers and nurses across the city. She offers training sessions to members of the District 75 PTA, as well as educating skeptics who worry yoga is too religious for their children. "It's not religious, it's spiritual," says Gold, who one day wants to open a studio where able-bodied and disabled children can come together to practice yoga in order to learn the value of acceptance.

"If you take the physical body and all of its limitations out of the equation and get down to the level of the soul, we are all equal and ideal," she said.

Speech-language pathology is the study of disorders that affect a person’s speech, language, cognition, voice, swallowing (dysphagia) and the rehabilitative or corrective treatment of physical and/or cognitive deficits/disorders resulting in difficulty with communication and/or swallowing. Speech-language pathologists (SLPs) or Speech and Language Therapists (SLTs) address people’s speech production, vocal production, swallowing difficulties and language needs through speech therapy in a variety of different contexts including schools, hospitals, and through private practice.

Communication includes speech (articulation, intonation, rate, intensity), language (phonology, morphology, syntax, semantics, pragmatics), both receptive and expressive language (including reading and writing), and non-verbal communication such as facial expression and gesture. Swallowing problems managed under speech therapy are problems in the oral, laryngeal, and/or pharyngeal stages of swallowing (not oesophageal).

Depending on the nature and severity of the disorder, common treatments may range from physical strengthening exercises, instructive or repetitive practice and drilling, to the use of audio-visual aids and introduction of strategies to facilitate functional communication. Speech therapy may also include sign language and the use of picture symbols (Diehl 2003).

The practice is called:

Speech-language pathology (SLP) in the United States and Canada
Speech and language therapy (SLT) in the United Kingdom, Ireland and South Africa
Speech pathology in Australia
Speech-language therapy in New Zealand
Other terms in use include speech therapy, logopaedics and phoniatrics.

Contents
1 Scope of practice
2 Professional roles
3 Education
4 Methods of assessment
5 Patients/clients
6 Place of work
7 Colleagues
8 See also
9 External links




Scope of practice
The practice of speech-language pathology involves:

Providing prevention, screening, consultation, assessment and diagnosis, treatment, intervention, management, counseling, and follow-up services for disorders of:
speech (i.e., phonation, articulation, fluency, resonance, and voice including aeromechanical components of respiration);
language (i.e., phonology, morphology, syntax, semantics, and pragmatic/social aspects of communication) including comprehension and expression in oral, written, graphic, and manual modalities; language processing; preliteracy and language-based literacy skills, including phonological awareness;
swallowing or other upper aerodigestive functions such as infant feeding and aeromechanical events (evaluation of esophageal function is for the purpose of referral to medical professionals);
cognitive aspects of communication (e.g., attention, memory, problem solving, executive functions).
sensory awareness related to communication, swallowing, or other upper aerodigestive functions.
Establishing augmentative and alternative communication (AAC) techniques and strategies including developing, selecting, and prescribing of such systems and devices (e.g., speech generating devices.)
Providing services to individuals with hearing loss and their families/caregivers (e.g.,auditory training; speechreading; speech and language intervention secondary to hearing loss; visual inspection and listening checks of amplification devices for the purpose of troubleshooting, including verification of appropriate battery voltage).
Screening hearing of individuals who can participate in conventional pure-tone air conduction methods, as well as screening for middle ear pathology through screening tympanometry for the purpose of referral of individuals for further evaluation and management.
Using instrumentation (e.g., videofluoroscopy, EMG, nasendoscopy, stroboscopy, computer technology) to observe, collect data, and measure parameters of communication and swallowing, or other upper aerodigestive functions in accordance with the principles of evidence-based practice.
Selecting, fitting, and establishing effective use of prosthetic/adaptive devices for communication, swallowing, or other upper aerodigestive functions (e.g., tracheoesophageal prostheses, speaking valves, electrolarynges). This does not include sensory devices used by individuals with hearing loss or other auditory perceptual deficits.
Collaborating in the assessment of central auditory processing disorders and providing intervention where there is evidence of speech, language, and/or other cognitivecommunication disorders.
Educating and counseling individuals, families, co-workers, educators, and other persons in the community regarding acceptance, adaptation, and decision makes about communication, swallowing, or other upper aerodigestive concerns.
Advocating for individuals through community awareness, education, and training programs to promote and facilitate access to full participation in communication, including the elimination of societal barriers.
Collaborating with and providing referrals and information to audiologists, educators, and health professionals as individual needs dictate.
Addressing behaviors (e.g., perseverative or disruptive actions) and environments (e.g., seating, positioning for swallowing safety or attention, communication opportunities) that affect communication, swallowing, or other upper aerodigestive functions.
Providing services to modify or enhance communication performance (e.g., accent modification, transgendered voice, care and improvement of the professional voice, personal/ professional communication effectiveness).
Recognizing the need to provide and appropriately accommodate diagnostic and treatment services to individuals from diverse cultural backgrounds and adjust treatment and assessment services according.

Professional roles
Speech-language pathologists serve individuals, families, groups, and the general public through a broad range of professional activities. They:

Identify, define, and diagnose disorders of human communication and swallowing and assist in localization and diagnosis of diseases and conditions.
Provide direct services using a variety of service delivery models to treat and/or address communication, swallowing, or other upper aerodigestive concerns.
Conduct research related to communication sciences and disorders, swallowing, or other upper aerodigestive functions.
Educate, supervise, and mentor future speech-language pathologists.
Serve as case managers and service delivery coordinators.
Administer and manage clinical and academic programs.
Educate and provide in-service training to families, caregivers, and other professionals.
Participate in outcomes measurement activities and use data to guide clinical decision making and determine the effectiveness of services provided in accordance with the principles of evidence-based practice.
Train, supervise, and manage speech-language pathology assistants and other support personnel.
Promote healthy lifestyle practices for the prevention of communication, hearing, swallowing, or other upper aerodigestive disorders.

Education
In the UK( United Kingdom) , SLTs undertake a three to four year degree course devoted entirely to the study of clinical language sciences and communicative disorders. This qualifies them to work in any of the three main clinical areas. The course, which varies according to university, includes intensive study of core theoretical components underpinning competence to practice , Linguistics, Psychology and Medical science, in addition to the study of a range of communicative disorders in children and adults. Students are also expected to become familiar with a range of policies, processes and procedures relevant to working in different contexts, including health and education. The course is very demanding, and is assessed via coursework, exams and clinical placement. Some universities require students to assess and diagnose an ‘unseen client’ prior to completing their degree course; all require the completion of a pilot study related to the field of Speech and Language Therapy. Throughout the course, students undertake a variety of clinical placements in which their ability to practise is continually assessed. All courses require students to complete a certain amount of hours of clinical placement, although the structure of placement differs from course to course.

Upon qualifying SLT’s enter the profession as a newly-qualified practitioner. The recommended career course is that they then achieve a number of competencies, which qualify them to work autonomously. The Royal College of Speech and Language Therapists, the professional body representing Speech and Language Therapists in the UK, provides a framework of competencies which therapists are expected to achieve within 12–18 months of beginning clinical practice. Access to supervision during this period varies from trust to trust, and each individual therapist is expected to provide documentary evidence of competencies achieved to a senior colleague (usually a manager) who determines whether a therapist meets the required criteria for admission to the ‘full register’.

Speech and Language Therapists in the UK are required by law to register with the Health Professions Council, a regulatory body governing a range of health professions. The Health Professions Council has the power to discipline members who do not meet the rigorous standards for effective and safe clinical practice, and may ’strike off’ or deregister members who fail to maintain these standards.

In the United States, Speech Language Pathology practice is regulated by the laws of the individual states. However, by 2006, the minimal requirements to be a certified SLP member of the American Speech-Language Hearing Association were: a graduate degree in Speech-Language Pathology, which typically entails 2 years of post graduate work; a completed clinical fellowship year, which is generally employment for a year while supervised by a practicing SLP who is also ASHA certified; and passing the Praxis Series examination. The graduate degree work to acquire a Master’s in Speech-Language Pathology is rigorous and demanding, requiring many hours of supervised clinical practica, and intensive didactic coursework in medical sciences, phonetics, linguistics, phonology, scientific methodology, and other subjects.

Certification by ASHA is noted as carrying one’s “C”s. (Certificate of Clinical Competence) It is noted after an SLP’s name as: CCC-SLP.

In Australia, Speech Pathologists either undertake a four year undergraduate degree, or a two year Masters degree to qualify. These dual pathways are considered by Speech Pathology Australia to produce equally prepared graduates. To be eligible for optional membership of Speech Pathology Australia, students must study in one of the accredited courses outlined on their website. Speech Pathology degrees in Australia vary in curriculum, but always include streams teaching anatomy and physiology, professional practice, communication and swallowing disorders, and often some elementary psychology and audiology. Most include no or minimal elective subjects. All degrees include a heavy clinical component, and many also include a research component in final year. Once graduated, students become fully qualified Speech Pathologists and are eligible for any Level 1 position, without the need for an internship or general examination. Registration is only required in the state of Queensland, and membership of the professional organization is optional, although it is encouraged.


Methods of assessment
There are separate standardized assessment tools administered for infants, school-aged children, adolescents and adults. Assessments primarily examine the form, content, understanding and use of language, as well as articulation, and phonology. Oral motor and swallowing assessments often require specialized training which includes the use of bedside examination tools and endoscopic/modified barium radiology procedures.

Individuals may be referred to an SLP for the following: Traumatic brain injury; Stroke; Alzheimer’s disease and dementia; Cranial nerve damage; Progressive neurological conditions (Parkinson, ALS, etc); Developmental delay; Learning disability (speaking and listening); Autism Spectrum Disorders (including Asperger Syndrome); Genetic disorders that adversely affect speech, language and/or cognitive development; Injuries due to complications at birth; Feeding and swallowing concerns; Craniofacial anamolies that adversely affect speech, language and/or cognitive development; and Augmentative Alternative Communication needs.

There are myriad Speech-Language Assessment tools used for chidren and adults, depending on the area of need.


Patients/clients
Speech and language therapists work with:

Babies with feeding and swallowing difficulties
Children with mild, moderate or severe:
learning difficulties
physical disabilities, language delay
specific language impairment
specific difficulties in producing sounds (including vocalic r and lisps)
hearing impairment
cleft palate
stammering
autism/social interaction difficulties
dyslexia
voice disorders
Adults with eating and swallowing and/or communication problems following
stroke
head injury (Traumatic brain injury)
Parkinson’s disease
motor neuron disease
multiple sclerosis
Huntington’s disease
dementia
cancer of the head, neck and throat (including laryngectomy)
voice problems
mental health issues
learning difficulties, physical disabilities
stammering (dysfluency)
hearing impairment
transsexual women seeking voice therapy
In the United States, the cost of speech therapy for a child younger than three years old is likely covered by the state early intervention (zero to three) program.

In Britain, the majority of Speech and Language therapy is funded by the National Health Service (and increasingly, by partners in Education) meaning that initial assessment is available cost-free to all clients at the point of service, regardless of age or presenting problem. The large numbers of referrals contribute to high caseloads and long waiting lists, although this differs from area to area. To meet the needs of many of these clients, it has become necessary for many services to focus heavily on training and consultative models of service provision. The number of hours of direct therapy available to clients varies widely from trust to trust and most areas operate strict guidelines for prioritisation to meet the high clinical demand.


Place of work
Speech and language therapists work in community health centres, hospital wards and outpatient departments, mainstream and special schools, further education colleges, day centers and in their clients’ homes. Some now work in courtrooms, prisons and young offenders’ institutions.

Some speech and language therapists who work independently will see children and adults in their own homes, and may offer appointments on a Saturday.


Colleagues
SLTs/SLPs work closely with others involved with the client, for example difficulties with eating and drinking may also involve an occupational therapist. Speech and language therapists also work closely with parents and caregivers and other professionals, such as audiologists, teachers, nurses, dietitians, physiotherapists, and doctors.

Well we are nicely into the new year and rising to the new challenges that face us. It has been a busy time for me since Christmas so much so that it feels that Christmas didn't happen, it went that quick. Things have been going ok for me and for Mum, Mum is progressing nicely with her physio and has tried elbow crutches very briefly not too keen !!!. I am still suffering with pain in my hips and back and I am hoping to see my spine consultant soon, I haven't seen him for 6 years, so in so respects although I am going with a new problem, it will be nice to see him and let him see how my back is doing. I am hoping the pain will settle soon as its pulling me down a little I have to say as I don't feel as mobile as I have been and feeling a little frustrated.

I have some high points to report on so its not all doom and gloom, during my time off at Christmas it sort of came to a head really how difficult it was becoming for Mum and me in the kitchen with us both using wheelchairs in there, I need to bee in my powerchair to help to carry things and help prepare things. So I decided that enough was enough something had to be done, I contacted my occupational therapist to arrange an assessment for Mum and to see if we could convert our existing kitchen into a height adjustable one so that it is a bit easier for us both. Anyway my OT came out and carried out the initial assessment and is very hopeful that we can have the kitchen adapted Way to go!!!!!, we are just waiting for the architect to come out from the Council and the kitchen designer to have a look at the existing space and what can be done.

While we are waiting for them my OT is arranging for Mum and I to go to our Independent Living Centre where they have a fully adapted kitchen installed, we cant wait to go and have a look and to test the gadgets.

MANSFIELD -- He's 67 and recovering from a stroke, but Joe Lakes bowls, boxes and plays golf.


Since the Nintendo Wii was introduced into the occupational therapy program at MedCentral/ Mansfield Hospital, manager Trey Counts said patients have benefited in a variety of ways while enjoying familiar sports all year long.

"The Wii is being used more and more in the rehab setting," Counts said. "We have a lot of patients who have a history of playing sports and being active, so it's nice to be able to offer this to them," Nintendo says on its Website.

The Wii is an interactive videogame system.

"A distinguishing feature of the console is its wireless controller, the Wii Remote, which can be used as a handheld pointing device and detect movement in three dimensions."

Medical News Today reported Wii is being used for rehabilitation in hospitals around the country.

"You have to do the majority of the movements involved in the real-life activity," Counts said. "There are buttons involved, so it's not exactly the same as in real life, but it can become very engaging."

The occupational therapy department, which treats those with head injuries, multiple sclerosis, Parkinson's, amputations, etc., currently offers 10 different games. Counts said they plan to offer the Wii Fit as soon as one becomes available for purchase.

"Everyone seems to be sold out of them," he said. "These games help the patients work on endurance, balance and range of motion. Some games involved cognitive skills, like sequencing, memory and keeping score."

Lakes said he had a stoke on Nov. 1, which impaired the left side of his body.

"I'm just starting to get feeling back in there, but I had to learn how to balance myself all over again," the Mansfield man said. "The Wii has been great for that. I've tried the bowling and the boxing. With bowling, if you lunge forward too much that can throw off your balance."

Lakes said using the Wii was not difficult.

"Plus, it adds a little bit of fun," he said.

Counts said he believes those as young as 3 and as old as 90 would easily be able to pick up the skills.

"We use these in the rehab stage and have gotten a lot of positive feedback," he said. "We can choose the games based on their goals, but also to get them back into their old habits. If they like to play golf, we can have them play the Wii golf game to get some of those skills back. It's fun, and they don't even realize they're working on balance and endurance. I mean they'll really get fatigued playing some of these."

Occupational therapist Charles Prinz said the Wii doesn't take away from other activities.

"This is just an addition here," he said. "It just makes things a little easier on us. A bowling simulation makes it easier because in the gym, we'd have to have one of our staff members there to set back up the pins and retrieve the ball. Now this frees up someone to do something else."

Prinz added the Wii is not forced on anyone.

"If someone doesn't like sports, then we wouldn't offer this to them," he said. "They'll spend anywhere from 15 minutes to an hour on here. Everyone really seems to enjoy it."

Senior citizens’ therapy utilizes game system

Willietta Jackson, right, an occupational therapist assistant, helps Golden Living Center resident Claudia Demarnville use the Wii controller during a game of bowling.

Many years ago it was bowling alleys, heavy balls, and goofy shoes. These days, all she needs is a small controller, her Nintendo game system and a television.

“I always liked bowling,” said the rehabilitation patient at the Golden Living Center in Edwardsville about the Nintendo Wii bowling game. “I’d never heard of it before coming here. I enjoy it more. It’s good for my arm.”

Neff is just one of several Golden Living residents taking advantage of a new rehabilitation activity the center now offers. In July, the center’s therapists began using the Nintendo Wii, which is a video game system that has players physically move a hand-held controller to control the game’s action, as part of their physical therapy sessions.

“It can get boring at times,” said Armi Pecana, rehabilitation program coordinator for the center. “We try to change exercises, but it’s still exercise. (The Wii) is just a fun thing to do for everyone.”

Pecana said that the motions the patients make with the Wii controller help with problems such as balance, coordination and range of motion. The repetitive movement of rolling a bowling ball or casting a fishing line, Pecana said, are similar to other, traditional exercises, but with a more interesting twist.

The most popular games among the center’s residents are bowling, fishing, hunting and pool. Pecana said even the patients who don’t always participate in the games enjoy watching others play, and act as a cheering section for the competitors. In addition to therapy sessions the game system is used in recreation and social activities.

“They feel a sense of self-satisfaction,” said Patti Young, facility director, as she watches one patient throw her hands in the air in celebration of a strike. “They smile more than with traditional therapy.”

Friday morning therapy has become something to look forward to, Young said in a T-shirt that shows the iconic Rosie the Riveter holding a Wii controller with the slogan, “Wii can do it.” Between the snacks of popcorn and fruit to the cheering and game-playing, Young said the center is full of energy when the Wii is turned on.

The idea for using the Wii, Young said, came from the director of operations for the entire Golden Living community after reading about other places across the country that had already started the program. In addition to the Edwardsville location, the Golden Living Center in Lansing has also started its own Wii program.

Young said the installation of the Wii program is relevant as a younger generation enters the work force. She said technology is becoming more important and the center wants to move forward and take advantage of that whenever possible.

Because of the success of the Wii program, Young said she’s got big plans for the future. She would like to purchase a music game so the center could form a community band and members could play different instruments. She also thinks that a dance game might be appropriate for some patients.

“I think it’s very progressive step, utilizing technology with our senior population,” Young said. “As our population changes and we see more baby boomers with their cell phones and wireless Internet, we need to adapt.”

Video games keep patients engaged

While nobody is recommending joint replacement as an enjoyable option for your next vacation, the often-arduous rehabilitation process just got a lot more fun.
Patients at the Westland House in Monterey are improving their strength, balance, dexterity, coordination and flexibility by playing games on Wii, Nintendo's virtual-reality video experience that allows players to simulate the physical actions of activities like tennis, boxing, golf, baseball, soccer, bowling and a multitude of others.

The physical motions necessary to play those games on the Wii system are proving to be effective treatment for a wide range of rehabilitation clients, including those recovering from strokes, joint surgery and brain-injuries, as well as people who suffer from acute and chronic pain.

"This doesn't replace any of the rehabilitation techniques we've been using, but it's a valuable adjunct to what we're doing here," said physical therapist Sherry Brient, rehabilitation supervisor at Westland House. "These are being used nowadays at schools, convalescent homes, senior centers. More recently, the rehab community has discovered Wii as a good tool to enhance the rehab process. We initially had a loaner here, but we liked it so much that we bought our own system."

A hand-held control interacts with a receiver. A television screen shows an opponent — a tennis player, a boxer, a baseball pitcher. Or a golf course. Or a realistic bowling lane with pins waiting at the opposite


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"I actually worked with a man who had been a boxer when he was younger, so we tried him out with the boxing game," said Tony Fusco, an occupational therapist at Westland House. "He was dealing with some brain issues, and it was the first time I ever got a smile, or any kind of real reaction out of him."


Unathletic can benefit


The enjoyment factor is a major part of the reason rehabilitation specialists are sold on the Wii as a therapy tool. Routine exercises — weight training, aerobics, etc. — that are designed to help a patient regain strength, balance, endurance, flexibility, dexterity and coordination often can become tedious. The patient can lose interest.

"It keeps the person entertained, more involved in their care," said Shilpa Oza, an occupational therapist. "They're having fun while they're exercising, so they tend to be much more engaged in what they're doing."

People with no athletic history, and little ability, can benefit from Wii and enjoy the games, because many of the game programs are designed to accommodate various ability levels. Ex-athletes and weekend warriors are naturally enamored.

"It works really well because a lot of our patients have a history with some of the sports that are available on Wii," Fusco said. "They like to play, they have some skills, and it's realistic for them. I've worked with a lot of tennis players, a lot of golfers, a lot of bowlers."

Kate Staples, a Seaside resident who suffered a stroke about a month ago, carried a 160 average as a young bowler and was excited to add Wii's bowling game to her rehabilitation.

"It was a lot of fun. I enjoyed it a lot more, both mentally and physically, than the regular exercises," she said. "I wasn't very good at it because it's a little bit different than real bowling, but it gave me confidence because it helped me regain some of my balance."


Programs measure balance


Pacific Grove resident Daphne Winters, another stroke victim, hasn't bowled since she was "in my 20s," she said, but fell in love with Wii during her physical therapy sessions.

"I did a lot of other kinds of exercises, like walking on a treadmill with my legs tied together with elastic, but the bowling was great. I got three strikes in a row," she said with a laugh. "I had to work at it a little bit, though, before I could figure out how to get the curve back in my ball."

Specific programs are designed to measure a person's balance. In one game, the player walks on a virtual balance beam, watching his cartoon counterpart move across the video screen. Too much weight on one foot will cause the cartoon character to lean to one side, waving his arms frantically, as if to regain balance. Over-adjust, and the character wobbles the opposite way.

Another balance-oriented program shows the cartoon character standing on a round disc. The player attempts to maneuver a ball into a hole in the disc by adjusting his balance to tilt the platform. If balance is poor, the ball will roll off.

"We can learn things about the patient by watching them as they play," Fusco said. "We can see whether they have issues with hand-eye coordination, or cognition. We can see how they process some of the instructions. A lot of games are too difficult for certain patients, but we can modify the games to accommodate those people."

One of the most-attractive aspects of using the Wii as an enhancement to normal physical-therapy methods is that the games can be played at home, after treatment at the Westland House has ended. Some patients purchase a unit for home use and use it as a viable and fun way to exercise.

"We've had a lot of patients who, when they're done here, say 'I'd love to get one of these,'" Brient said.

"The original purpose was for an activity to give (residents) something to do and then once we had it, we realized the potential to use it for therapy as part of the rehabilitation program here," said Korey Flick, activities director.

Nintendo Wii is an interactive video game system, allowing players to "experience" golf, tennis and bowling, among other games.

"It was a good way for the staff to interact with the residents in a social and nonmedical way, which was good for everyone," Flick said. "We've tried golf and we've tried tennis. Bowling's the one that everyone's the most successful with. Generally on a Thursday we set it up for the day and the residents and the staff rotate."

Local nursing homes and health facilities throughout Schuylkill County are jumping on board the technology trend that they say helps residents with cognitive abilities and motor skills.

Nintendo Wii systems were also donated by Family Home Medical Support System of Mount Carmel, 121 E. Fifth St., to the Shamokin-Coal Township, Mount Carmel and Kulpmont senior action centers.

The Schuylkill Regional Resource Center, 138 W. Centre Street, Mahanoy City, hosts a "Wii Wednesday!" each week from 1 to 3 p.m.

Physical therapists at Genesis HealthCare Orwigsburg Center and Schuylkill Center, long- and short-term skilled nursing centers and rehabilitation facilities in Orwigsburg and Pottsville, are using Nintendo's Wii video game technology to help patients after an illness or injury.

"It's good cognitive activity to keep the mind active," said Amanda Schwalm, a speech language pathologist at Tremont Health and Rehabilitation Center "In that respect, it's working on your deductive reasoning skills, and that's a big part of what I do for short term to home (care.)"

When the Tremont Health and Rehabilitation Center -- a 180-bed skilled nursing facility for short-term and long-term care -- first got the system in August, the staff and residents split into teams, challenging each other and bringing a social layer to the work environment.

Kristy Deeter, an occupational therapist, said all residents have access to the system, adding that bowling is the game of choice for many.

"What it helps for people in therapy is, number one, they're getting some arm movements -- full range of motion," she said. "That movement's a natural movement for the arm, so I think that's why we've been more successful with that one."

"It builds up the muscles and it makes the brain think," resident Dave Wolfe said. "It's a lot cheaper than going to a bowling alley."

Wolfe shows up to the activities room each week to play. Facility administrator Dan Daub counts Wolfe among the "rowdy bunch," of cheering and excitable players.

"I used to do regular bowling, but this is a lot different," Wolfe said Tuesday, gearing up for his turn against resident Nancy Gibble. "Today I can't get a strike to save my soul."

But Wolfe spoke too soon, tossing a strike in his next shot.

Gibble bowled 130, saying she doesn't really care who wins, she just tries to do the best she can.

Is competition a factor in the virtual sport?

"There is to an extent, but it's mostly all in fun and trying to beat your score from the week before," Gibble said.

"It's kind of a growing trend and a unique way to get therapy done, so we're glad we could latch on to that," Daub said.

By Erik Nieuwenhuis
October is National Physical Therapy Month, and this year’s theme is “It’s All About Movement!”Physical therapists are the movement experts. We help people move forward. e help people who have had a stroke or an amputation regain their independence. We help millions of Americans manage or eliminate their neck or back pain. We educate and lead workers and companies to work smart and improve the ergonomics in their workplace and homes. We help children with cerebral palsy improve their overall function and participation in life.Movement is essential to our everyday lives at work, home and play. Movement is an essential ingredient in your daily health and quality of life! Having the ability to move safely and effectively is crucial in our lives and the lives of the people physical therapists treat. The physical therapy profession empowers people to move forward and take control of the movement that is essential in everyone’s life.

What is a physical therapist?Physical therapists are good people to know. They’’re educated in understanding the interaction of all your body parts. Their hands-on approach begins with examination, diagnosis, and then treatment of the immediate problem. Then they teach you how to take care of yourself by showing you how to do exercises and how to use and move your body properly to gain strength and mobility while preventing injury and wear and tear to your body. You’ll find them advising on proper work smart posture and body mechanics in the workplace, treating injuries, consulting on fitness/wellness and self care of the working, aging body. You’ll also find them treating patients in the hospital, clinic or home settings. Today physical therapists provide help for every part of the body and to everyone from infants to the elderly, serving more than one million people each day.Where do physical therapists practice?- Outpatient clinics or private practice n 41.5 percent- Outpatient hospitals n14.5 percent- Acute hospitals n 13.1 percent- Patient’s home (home health) n 7.9 percent- Skilled nursing, extended care, or sub-acute facilities n 5.6 percent- Academic institutions n 4.8 percent- Schools (Pre-School, Primary and Secondary) n 4.1 percent- Inpatient rehab facilities n 3.5 percent- Hospices- Industrial, workplace or occupational environments- Fitness centers, health clubs, sports training facilities- ResearchAPTA website June 2007 http://www.apta.org/Educational requirementsCurrently, nearly 200 colleges and universities nationwide offer professional physical therapy education programs.Des Moines University, the University of Iowa, the University of Nebraska Medical Center and the University of South Dakota offer physical therapy programs close to the tri-state area. Western Iowa Tech Community College also offers a physical therapy assistant program. Most physical therapy programs require a student graduate from an accredited four year college and take prerequisite classes for the physical therapy school the student is applying to.Employment outlookThe demand for physical therapists is expected to grow much faster than the average for all occupations through 2014. The demand for physical therapists should continue to grow as the number of individuals with disabilities or limited function increases. Job opportunities are expected to be particularly good in acute hospital, rehabilitation, and orthopedic settings because the elderly receive the most treatment in these settings. Plus, widespread interest in health promotion should increase demand for physical therapy services at the worksite and health clubs. A growing number of employers are using physical therapy services to evaluate worksites, develop exercise programs and teach WorkSmart and safety habits to employees to reduce injuries, claims and costs.Daily job tasksWe treat patients to: improve mobility, relieve pain, increase strength and balance, improve coordination and prevent or limit permanent physical disabilities of patients suffering from injuries or disease.Physical therapists restore, maintain, and promote overall fitness and health.Our patients include accident victims from motor vehicle accidents and slip, trip and fall injuries, individuals with disabling conditions such as lower back pain, arthritis, heart disease and stroke, diabetes or those with amputations, fractures or total knee and hip replacements among others.Physical therapists determine the patient’s ability to be independent and reintegrate into the community or workplace after an injury or illness with the goal of improving how an individual functions at work, play and home.Therapists also teach patients how to use assistive and adaptive devices to improve their safety and independence.Sources:1. American Physical Therapy Association Website at http://www.apta.org/2. US News and World Report 20063. Erik Nieuwenhuis MS, PT My Life and Career as a Physical TherapistContact Erik Nieuwenhuis at St Luke’s IMPACC WorkSmart and WELLness Services at 712-279-1842 or Nieuween@stlukes.org

15 October 2008, 05:31:21 | adiemusfree



As the proud possessor of a brand new Wii and WiiFit, I’m a convert to the addictive powers of the Wii. I’m not the only, and certainly not the first person to think of the rehabilitative potential of the Wii - in fact it’s been one of the most successful ‘cross-over’ toys that the computer geeks have come up with.

I am planning to use the Wii and WiiFit to study whether it can help develop balance, activity tolerance and especially increase proprioceptive awareness in people experiencing persistent pain and complex regional pain syndrome. There are clinical guidelines I’ve just discovered here at RehabCare who have produced a podcast covering clinical practice guidelines for using the Nintendo Wii. And I’ve just found an occupational therapist’s site called WiiHab!


I’ve had mine for two days now, I don’t want to admit to the number of hours I’ve spent on it (sad but true!), and there are a few quibbles about it for my purposes: the main problem with the WiiFit component is that it’s not modifiable so as a therapist I can’t select the exercises I want to prescribe for the people I work with; and I haven’t yet worked out how to transfer the cumulative graphical information into another format. But I do like the English (UK) instructors accent, and that it’s possible to view how to do the exercises from front or back. I also love the portability of it, and the relative lack of bits and pieces apart from the controller and WiiFit platform.

With a bit of tweaking from some geeky types, I’m sure it will be possible to modify the bits I’m less than happy with, or perhaps Nintendo will work out that this is a feature that it could provide in a ‘therapy-specific’ version of the programme. From the search I completed on Google just using the term ‘Wiihabilitation’ which came up with 9,920 hits, it seems clear that there is a demand for it within health and rehabilitation settings.

For pain management? Well apart from my specific study, I think the Wii has further application as an alternative to the many gym-based exercise programmes that are funded by major rehabilitation funders such as ACC or WorkCover.

To date there is no conclusive evidence that any specific fitness programme is superior to any other for the management of chronic pain (particularly low back pain), so it seems reasonable to think that any activity that is engaging, motivating and appeals to families might be able to be purchased or loaned as part of a pain management programme. Under the supervision of a therapist (occupational therapist or physiotherapist) a person with chronic pain can be guided through the process of gradually regulating their engagement in activity while at the same time learning how to integrate pain management skills.

It would be even more appropriate if the therapist can select and grade the level and type of activities the person uses. Hey, adding in a couple of biofeedback elements (like a heart rate monitor or skin conductance monitor) would make it even more useful!

The main concern I have with any exercise-focused pain management is that in the enthusiasm to engage in ‘fitness’ it becomes the goal rather than a means to develop activity tolerance, reduce avoidance, and a method for developing appropriately paced activity.

I think a time-limited loan or rental of something like the WiiFit could be a great way for someone to develop the skills until they move into the next phase of learning to live with chronic pain - returning to ‘normal’ activities. And if fitness or exercise becomes part of the person’s general pain management regime, and a Wii is something they use, it might be helpful. Of course, if they prefer to salsa dance, go rock climbing, trot around the shopping mall at full tilt, or perhaps go to a local tai chi class - then that might be a better option!

The main thing is that here is a gadget that is fun, well-accepted, and emininently modifiable. Oh, and it makes for team-building as well as family fun while the therapist/s are learning to use it!!

Laura Schlobohm of Emporia enjoyed a game of bowling recently, cheering on her spares and attempting to coax the ball to hit the pins. Only Schlobohm wasn’t at a bowling alley. She was participating in Wii-habilitation and was one day from returning home from Newman Regional Health’s inpatient rehabilitation unit. The amazing thing: She had broken her hip just over two weeks earlier.

Part of Schlobohm’s rehabilitation exercises was to use the Nintendo Wii system, which is being used around the country not only for entertainment purposes but now for rehabilitation programs. The program is called Wii Fit and Wii Sport. The results are proven to speed up the rehabilitation process in patients who have had injuries or strokes, said Kim Bales, program director of Newman’s inpatient rehabilitation unit.

Bales said the whole purpose of inpatient rehabilitation is to get patients home and have them be as safe as possible when going home. The Wii system is another tool to work toward that goal. It’s now being used in several different wards for strengthening and balance.

Bales added that patients from 39 to 89 years old have enjoyed using the system. “Our average age is 79 that comes in (inpatient rehab) and they all love it (Wii).”

Dale Barb, a physical therapist at Newman, said there are many ways the Wii game system can be used in rehabilitation. Barb said the system helps patients practice tasks they will have to perform when they go home from the unit, including standing, balance and coordination.

The game helps patients stand longer and distracts them from the task at hand and gives them something fun to focus on, Barb explained as Schlobohm cheered in the background with her registered occupational therapist, Julia Gotchall.

“It’s fun,” Schlobohm said after she was done with her session. “I think it’s wonderful. It’s terrific exercise. It’s a wonderful program and the whole thing up here is wonderful.”

“My friends ask me if I can walk,” she said. “I said, ‘Run, no; walk, yes.”‘

Deborah Thompson, a 62-year-old mother who thrives on heart-pounding challenges like mountain climbing and biking, can't stand video games.

"I hate them," she said. "My son plays them, but I think it's the worst waste of time."

But there she stood recently, cheering herself on and pumping her fist each time she scored a point against her computer opponent - the Wii.

Thompson is recovering from a nagging knee injury and is now taking part in the latest video game craze for her rehabilitation.

Under the supervision of physical therapist Wen-Chih Shih at Harvard Vanguard Medical Associates in Burlington, Thompson is one of about 40 patients who are boxing, bowling, playing tennis, golf, and baseball, all in the name of Wii-habilitation.

"It doesn't feel like work, and I guess that's the benefit," said Thompson of Lexington. "You can pretend you're Roger Federer."

Shih said she came up with the idea of using it for patients while playing her son's Nintendo Wii last winter. She did some research online and saw that she wasn't the only one who saw the game had potential to help her patients recover.

Across the nation, senior centers and rehabilitation centers are turning to the Wii to help the elderly improve balance and core muscle strength and patients heal from certain injuries. At the Littleton Senior Center, residents have even formed a weekly bowling league.

Though the Wii was developed for fun, Nintendo officials said they are thrilled the game is being used in other ways. They attribute the Wii's popularity to the fact that it's not intimidating to use and can be played with other people.

"We developed Wii to be a video game console that everyone could enjoy, regardless of their age, gender, or prior experience with video games," said Denise Kaigler, vice president of corporate affairs for Nintendo of America.

"We're glad that so many people are finding new ways to enjoy Wii and its games."

Shih said the interactive games force people to simulate the action they would make if they were playing the sport. Unlike traditional video games during which players sit in front of a screen, Wii players move around to swing the controller like a tennis racket, golf club, or bowling ball.

Shih said many of the games work on arm and shoulder movements, but other body parts can be worked as well. In tennis and bowling, for example, players must take steps similar to lunges, a traditional physical therapy exercise.

Now, when patients are far enough along in their rehabilitation to really work their bodies, Shih turns on the Wii for a tennis match instead of having them lunge back and forth across the room. She said it breaks up the monotony for both patients and therapists.

"If you swing, you automatically lunge," Shih said. "Instead of lunging five repetitions back and forth, they are actually doing something and getting feedback."

After a player completes a game or exercise, the Wii reports how he or she did and how to improve.

Shih said she thought the Wii would be a good motivating tool for teenagers, but it has worked well for all age groups - even those, like Thompson, who are adamantly opposed to video games.

"It's much more fun and you can keep challenging yourself," Thompson said. "To people who are used to exercising, it feels good."

Harvard Vanguard started the Wii-habilitation at its Burlington site, but Shih said she'd like to add it at other locations as space permits.

New England Rehabilitation Hospital at Billerica also started using the Wii during its physical therapy sessions about two months ago.

Joana Ingram, manager of the hospital's outpatient clinic, said about 50 patients have used the game and many have purchased one for their home.

The outpatient clinic, specializing in physical therapy, occupational therapy, and sports injuries, works primarily with the Wii Fit because it has a program that allows patients who have injured an ankle, for example, to work on regaining balance, Ingram said.

"It's been a wonderful thing for the patients," Ingram said. "It allows them to take their mind off their injury and be a kid by playing a game."

The Wii has also found its way into senior centers across the region, including Lexington, Littleton, Tewksbury, and, soon, Concord and North Andover.

Council on Aging officials said the Wii provides a way for seniors to get exercise and work on improving strength and balance, all in a fun, nonthreatening environment.

Donna Delaney, outreach coordinator for the senior center in North Andover, said seniors are looking forward to the new game.

She said the Wii will be available after the center completes its renovation project in the coming months.

"I understand there are a lot of good balance and coordination exercises for the seniors," Delaney said. "If they can improve their balance, they'll be more safe walking and have less falls and broken bones."

Concord also has a Wii that will be available for seniors later this month.

Lori Kalinoski, the program supervisor for the Concord Council on Aging, said many seniors are eager to try it because they've seen their children or grandchildren play video games.

Kalinoski said the center offers many exercise programs but the Wii will be another option for seniors who aren't interested in taking a high-impact class.

"It's a way of using new technology that's a nonthreatening way to have fun and get some exercise," she said. "It seems like it's a nice way to exercise."

The seniors in Littleton have been using the Wii since the spring after a high school student group did a project testing seniors' reflexes and reactions to different games. The seniors liked the games so much, the center bought its own.

Roberta Ware, 73, and three friends have formed an informal Wii bowling league.

"We're having a lot of fun with it, and it's great exercise," Ware said. "We play once a week here, and hopefully the group will grow."

by jmorona

Thomas Ondrey/The Plain DealerRecovering stroke patient Marilyn Smigelski gets into the rhythm of a Wii Fit hula game with the help of physical therapist Nancy Ditzel at LakeEast Hospital in Painesville. Fit is used in conjunction with other therapy modalities.

Physical therapy is best served with a little camaraderie and light conversation, but therapist Nancy Ditzel also dished out some fun to recovering stroke patient Marilyn Smigelski recently.

The LakeEast Hospital therapist put Smigelski to work on the latest Nintendo Wii video system game, called Fit. While the American Physical Therapy Association magazine recently reported widespread use among members of Wii games that simulate sports like tennis and bowling, the Lake hospital system is the first locally to use the Fit game in physical therapy.

The $90 Fit game -- a white plastic platform motion detector operated through a $250 Nintendo Wii console -- translates a person's real-time movements onto a screen and offers 40 activities in yoga, aerobics, strength training and balance, many appropriate for therapy, Ditzel said. And with so many possibilities, therapists can tailor patient sessions, monitoring carefully to avoid the overuse common with Wii's simulated sports.

Ditzel's hoping that even patients who cannot walk or stand will also get in on the fun by sitting on the platform, called a balance board. That application has yet to be tested, though patients in wheelchairs already can use some Wii sporting games.

The game is also useful in occupational therapy, which helps patients relearn daily living skills, like getting dressed.

In addition to weakness in her right side, Smigelski, a retired ICU nurse, is frustrated by double vision. But she persevered, using her balance to steer a bubble down a river without bumping into the river bank and, later, to head-butt virtual soccer balls while dodging shoes and helmets.

She was also challenged to keep a penguin from sliding off an ice floe while helping him catch fish jumping out of the water. The fish are assigned different values based on color, so a laughing Smigelski could see her improvement in successive games.

"There's a learning curve," said Ditzel, firmly clutching a safety belt encircling Smigelski's middle. "The average person isn't excellent right away."

The Hula-Hoop game was the most physically demanding, requiring Smigelski to swivel her hips like she was using one of the toys. Slowing down too much caused the hoop to fall, thus ending the game, while speeding up increased her score, as well as her heart rate. And when another hoop was virtually thrown her way, she had to lean to the left or the right to catch it with her whole body and then resume her swiveling.

"Get those hips going! Big circles! Big circles," Ditzel coached.

Dressed for action in khaki shorts and running shoes, Smigelski was panting after a few rounds and just a tad embarrassed that some patients and staff had clustered to watch her.

"In my 15 years as a therapist, it's the coolest thing to come along," Ditzel said. "It's an interactive fun adjunct to conventional therapy."

At Smigelski's urging, Ditzel took a turn at the Hula-Hoop game. When she finished a lively performance that drew cheers from spectators, she felt for her pulse in her neck and pronounced the activity "aerobic."

The games are most challenging to patients unfamiliar with video games and computers.

"They're timid and unsure of themselves," Ditzel said. But once patients are up and running, they're happy. "Time passes quickly, and it's not drudgery. If they're scared, they forget they're doing something fearful."

Lake physical therapist Chris Haladyna said the Fit has gotten good reviews from her patients, too. "It's work, but it's fun. One grandpa bought one for home after he was discharged."

The game is slowly making its way into physical therapy around the country, said Lisa Rubin Falkenberg, the hospital's system's director of rehabilitation. She ordered it on a hunch in March, a couple months before its release, and has been delighted with the outcome.

Thomas Ondrey/The Plain DealerMarilyn Smigelski gets into the rhythm of a Wii Fit exercise under the guidance of physical therapist Nancy Ditzel at LakeEast Hospital.
"It's a way to make rehab less tedious. You're not counting repetitions. You're playing a game," she said. "The patients love it. And the therapists are thrilled with it." She plans to purchase it for the hospital's other sites.
Because Wii Fit lets the patient see how they affect the game by changing their balance, a therapist can better explain center of gravity and help patients use that knowledge. Most people in rehab have balance problems, Rubin Falkenberg said.

"Stroke patients are afraid to shift their weight. They can have a weakness on one side of their body, so they lean toward their 'good side,' and therapists are always trying to straighten them up. It's easier when they have feedback like Wii."

If she hadn't pre-ordered the game, she probably still would be waiting to buy one. They've been in very short supply, said Tom Vitko, gaming supervisor at Best Buy, Brookpark Road, Cleveland.

In the first three weeks that they were available, only 100 were delivered to the store. "The same with the Wii consoles," he said. "They're not in our warehouse. They're always on order. We have people waiting when the store opens, looking for Wiis."

It doesn't help to be a Best Buy employee. You'd still have to wait in line, Vitko said, and be "off the clock."

By Lindsey Tanner,

CHICAGO (AP) -- Some call it "Wiihabilitation.''Nintendo's Wii video game system, whose popularity already extends beyond theteen gaming set, is fast becoming a craze in rehab therapy for patientsrecovering from strokes, broken bones, surgery and even combat injuries.

The usual stretching and lifting exercises that help thesick or injured regain strength can be painful, repetitive and downrightboring.

In fact, many patients say PT -- physical therapy'snickname -- really stands for "pain and torture,'' said James Osborn, whooversees rehabilitation services at Herrin Hospital in southern Illinois.

Using the game console's unique, motion-sensitivecontroller, Wii games require body movements similar to traditional therapyexercises. But patients become so engrossed mentally they're almost obliviousto the rigor, Osborn said.

"In the Wii system, because it's kind of a gameformat, it does create this kind of inner competitiveness. Even though you maybe boxing or playing tennis against some figure on the screen, it's amazing howmany of our patients want to beat their opponent,'' said Osborn of SouthernIllinois Healthcare, which includes the hospital in Herrin. The hospital, about100 miles southeast of St. Louis, bought a Wii system for rehab patients latelast year.

"When people can refocus their attention from thetediousness of the physical task, oftentimes they do much better,'' Osbornsaid.

Nintendo Co. doesn't market Wii's potential use inphysical therapy, but company representative Anka Dolecki said, "We are happyto see that people are finding added benefit in rehabilitation.''

The most popular Wii games in rehab involve sports --baseball, bowling, boxing, golf and tennis. Using the same arm swings requiredby those sports, players wave a wireless controller that directs the actions ofanimated athletes on the screen.

The Hines Veterans Affairs Hospital west of Chicagorecently bought a Wii system for its spinal cord injury unit.



Pfc. Matthew Turpen, 22, paralyzed from the chest down ina car accident last year while stationed in Germany, plays Wii golf and bowlingfrom his wheelchair at Hines. The Des Moines, Iowa, native says the games helpbeat the monotony of rehab and seem to be doing his body good, too.

"A lot of guys don't have full finger function so itdefinitely helps being able to work on using your fingers more and figuring outdifferent ways to use your hands'' and arms, Turpen said.

At Walter Reed Army Medical Center, the therapy iswell-suited to patients injured during combat in Iraq, who tend to be in the 19to 25 age range -- a group that's "very into'' playing video games, saidLt. Col. Stephanie Daugherty, Walter Reed's chief of occupational therapy.

"They think it's for entertainment, but we know it'sfor therapy,'' she said.

It's useful in occupational therapy, which helps patientsrelearn daily living skills including brushing teeth, combing hair andfastening clothes, Daugherty said.

WakeMed Health has been using Wii games at its Raleigh,N.C., hospital for patients as young as 9 "all the way up to people intheir 80s,'' said therapist Elizabeth Penny.

"They're getting improved endurance, strength,coordination. I think it's very entertaining for them,'' Penny said.

"It really helps the body to loosen up so it can dowhat it's supposed to do,'' said Billy Perry, 64, a retired Raleigh policeofficer. He received Wii therapy at WakeMed after suffering a stroke onChristmas Eve.

Perry said he'd seen his grandchildren play Wii games andwas excited when a hospital therapist suggested he try it.

He said Wii tennis and boxing helped him regain strengthand feeling in his left arm.

"It's enjoyable. I know I'm going to participatewith my grandkids more when I go visit them,'' Perry said.

While there's plenty of anecdotal evidence that Wii gameshelp in rehab, researcher Lars Oddsson wants to put the games to a real test.

Oddsson is director of the Sister Kenny Research Centerat Abbott Northwestern Hospital in Minneapolis. The center bought a Wii systemlast summer and is working with the University of Minnesota to design a studythat will measure patients' function "before and after this 'Wiihab,' assomeone called it,'' Oddsson said.

"You can certainly make a case that some form ofendurance related to strength and flexibility and balance and cardio would bechallenged when you play the Wii,'' but hard scientific proof is needed toprove it, Oddsson said.

Meantime, Dr. Julio Bonis of Madrid says he has proofthat playing Wii games can have physical effects of another kind.

Bonis calls it acute "Wiiitis'' -- a condition hesays he developed last year after spending several hours playing the Wii tennisgame.

Bonis described his ailment in a letter to the NewEngland Journal of Medicine -- intense pain in his right shoulder that acolleague diagnosed as acute tendonitis, a not uncommon affliction amongplayers of real-life tennis.

Bonis said he recovered after a week of ibuprofen and noWii, and urged doctors to be aware of Wii overuse.

Still, as a Wii fan, he said in an e-mail that he couldimagine more moderate use would be helpful in physical therapy "because ofthe motivation that the game can provide to the patient.''

Wii Therapy And Exercise

The Wii is all about innovation and opening up gaming to a whole new audience. With the console now being used for exercise and therapy, has it gone beyond Nintendo’s wildest expectations?

Simple answer to the question, yes. When Nintendo started bleating on about the Wii a couple of years ago they constantly talked about expanding the gaming horizon. They wanted to get new people playing videogames and to create a system with a hugely varied userbase. What they’ve got, is a cultural revolution. When something catches the imagination of the world like the Wii has it tends to get some fairly interesting press.

The other day a story popped up about how the Wii is being used by the US Army as a means of healing the wounded. Never in Nintendo’s wildest dreams could Nintendo have expected this. Over the last few months we’ve seen it being used in old folks homes, as part of exercise regimes and even as a method of shedding the pounds to get into shape. All of these cases have demonstrated one thing: the Wii can move beyond the videogames industry and into wider culture. Once there, the world of ‘self help’ is its oyster. Fitness and gadgetry are two of the biggest obsessions in Western culture, and the Wii is able to tap into both. The media has an obsession with telling us how we can get fit and healthy and there are always new and ‘exciting’ ways of doing so popping up. The Wii is perhaps the biggest new entry on the scene.

At the Sedgebrook retirement community in Lincolnshire (USA), where the average age is 77. A report in the Chicago Tribune details how the residents, most of whom have never picked up a video game controller in their life, are turning to the Wii for entertainment.

"I've never been into video games," said 72-year-old Flora Dierbach last week as her husband took a twirl with the Nintendo Wii's bowling game. "But this is addictive...They come in after dinner and play," she said. "Sometimes, on Saturday afternoons, their grandkids come play with them. A lot of grandparents are being taught by their grandkids. But, now, some grandparents are instead teaching their grandkids." Sunday afternoon at the home is now all about the Wii. This sort of thing is great publicity for the Wii.

Over the years the industry has gotten some very bad press, but feel good stories about the Wii bringing together kids and grandkids and helping keep the eldery healthy and entertained is a glowing endorsement of what Nintendo are doing. It would seem that in one swift move, all the negative stigmas about gaming in the mainstream press have somewhat been ebbed away.

In an article published on the online version of the US military newspaper Stars and Stripes, it has been revealed that in certain cases the Wii can prove to be a useful tool for healing the wounded. Army Spc. Shawn Roberts who is assigned to the 581st Signal Company in Kuwait, volunteered to use the game as part of his therapy routine. The Wii is being used to help him regain full movement after he broke his wrist and elbow and partially tore his rotator cuff when the vehicle he was in rolled over. He couldn’t move his wrist for more than a month because of the screws holding it together.

“I wasn’t expecting much out of it,” said Roberts after using the game. “You know, it’s a video game. How much could it really do? But you don’t notice it while you’re doing it because your mind’s on the game. But then when you’re done? I was sore....I do all the same exercises, but with the Wii, your mind’s off of it, and you do it a lot more. It’s more fast paced and that kind of thing.”

Staff Sgt. Bryan Vallerie, an occupational therapy technician, said the game wouldn’t replace anything in the department’s physical therapy repertoire but could enhance treatment for some patients. “It’s a healthy, fun alternative to doing these things,” he said. The department are going to analyse the results of using the Wii for therapy. The advantage of using the system, they claim, is that it gets rid of the monotonous tedium of physical therapy. With the Wii, you’re doing the exercise but at the same time you’re having fun.

The most detailed analysis of the Wii’s impact on personal health came thanks to one man’s idea to use the Wii to get into shape. Entitled the ‘Wii Sports Experiment’, it aimed to prove that playing Wii was a viable method of exercise. Mickey DeLorenzo, a 25-year-old living in Philadelphia, decided to meld exercise and gaming together and form a full report on what he found. The blog he kept attracted a huge amount of interest from publications such as the New York Times, CNN, the BBC, TIME, The LA Times, The Sydney Morning Herald and also on TV through FOX and NBC. The media circus that surrounded one mildly plump man playing Wii to get a bit more toned was somewhat ridiculous. But it worked. Mr. DeLorenzo got into shape, lost 9lbs, his body fat percentage went down from 19% to 17.2% and his body mass index (BMI) went from 25.2 to 24.0. The full results of the experiment can be read through here:

http://wiinintendo.net/2007/01/15/wi...iment-results/.

So what does all this tell us? Well, whilst industry analysts go on about how the Wii is making a huge difference to the demographic of the gaming market and Nintendo drone on about how many units they are selling, perhaps this is the real story of the Wii. It is a cultural phenomenon, albeit a somewhat brief one so far, and it is really making a difference. Little by little the Wii is changing the world...sort of.