歩行リハビリテーションと老人

(1)

Japanese Physical Therapy Association

NII-Electronic Library Service

JapanesePhysicalTherapy Association

-Ytwza"

ce

20 tsee

7 e

430 -

432 H

(1993

ff)

NSUmsE]

Walking

Rehabilitationand

Elderly

Persons"

DoreenBauer"

Introduction

T.he health care systems of many

developed

na-tions

are under close scrutiny to-day

because

fund-ing

_Podies,

both _government and insurance, are

concerned about rapidly increasing costs. Some of

thiscost increase is,of course, due tothe growing

demand

for

services, especial}y accruing from a

rapid escalation

in

the numbers of elderly persons

who tend tobe heavy users of

health

care $ervices.

A large measure of the cost

increase,

however,

is

due

to the _{professionalisation} of the health care

workers who

demand

and receive _professional

sal-aries or

fees

for

the work they

do,

For

example, a

decade ago an

Australian

physiotherapist

com-mellced work at a salary equivalent to

\1,440,OOO

to-day, a new _graduate begins at

\2,400,OOO

an

in-crease of 67% intenyears.

Unfortunately,

there isvery littleevidence

avaia-able at the _present time to demonstrate the value,

or cost effectiveness, of

these

health care

profes-sionals.

We

all

believe

that'we are essential

but

it

is

difficult

to prove

it.

Health

economists

in

Aus-tra}ia,

and in many other countries, are closely ex-amining orgqnisational budgets and many are

using very large shears to _prune all unessential

costs. Physical therapy is,sadly, one of many

disei-plineswhich islikelyto have budgets reduced

be-cau'se ithas been very slow to develop objective

data basesand toinstjtuteobjective evaluation

pro-grams to show _precisely what

physical

therapists

±

_tsfi

_i)_.x_lf_iJ_f- _ti

! YtZYk th" _WCPT _{Reprcscntative}

of

Asia-Western

Pacific

(trpage?veszameca7

g7

･

)kgzgeftx)

have contributed tothecare of clients, toshow

pre-cisely what the effects of that contribution

have

been,especially ineconomic terms.

As

a manager, a major _part of my

job

is

ensuring

that the services _provided

by

my staff are _guided

by

strategtc plans which conform te the objectives of the

hospital,

have

clear goals, targets and

per-formance measures, and are demonstrably effective

and efficient. Thus, we work

diligently

and

con-stantly at evaluation, especially examining

pro-cesses and procedures to eliminate any activity

which

does

not contribute toa planned outcome.

About 70% of the clients in our rehabilitation

programs: inpatient,outpatient and domiciliary,are aged 65+. We need toremind ourselves constantly

that the lifeexpectancy of an elderly _person after a major episode such as a stroke or amputation isnot

great,

80%

living less than 5 _years. Thu$, old

people

do

not

have

time to waste

in

_prolonged

rehabilitation _programs, they want to achieve a particular

functional

level

which will allow them to

go

home.as

quickly

'as

possible,

Walking

Rdhabilitation

The majority of clients attending our

rehablita-tion program$

have

problems

[elated

to mobility.

On

admission many can not walk because of

strokes, fractures or amputations. Many others

findwalking diMcult because of arthritis or

neuro-logicaldisorders. These clients come to us forhelp

tobecome safe and effective walkers again. Gener-ally, _physical thetiapistsundertake an assessment

and develop a listof _goals:toreduce _pain,improve

range of motion, increase strength, improve

co-tt

(2)

Wa

ordination and endurance,

develop

balance and,

finally,

reeducate walking.

Most

clients, though,,

are not

interestecl

in all those intermediate goals,

they

just

want to

be

able towalk.

Now,

the

international

physical therapy

literature

contains thousands of references to

"walking

re-education". Physical therapistshave tended touse "part-learning"

or "sequential-learning"

concepts as

the

basis

or re-learning motor skillssuch as

walk-ing.

Task

analysis

has

been

applied

to

walking, the

whole task

broken

down

into

many elements.

The

physical therapistthen works with the client,

mo-bilisingthis

_joint,

strengthening that muscle,

devel-oping balance

in

sitting, practising standing up and

sitting

down,

learning toweight-shift while

stand-ing in _parallelbars, _practising heel-strike,knee

bends

and weightshifts and so on and on.

Some

physical therapists

insist

thatclients learntocrawl

again while others

keep

clients

in

wheelchairs until

they have mastered all the individualelements of

the walking _process, Weeks, _perhaps even months, may

be

consumed in this elaborate ritual called "walking

rehabilitation" but,eventually, the client

is allowed to _put all the elements together and actual, real walking begins. The education, though,

continues, the client learning to walk in _parallel

bars,

gradually decreasing reliance on the bars

untiKhey can _proceed without

hoiding.

Endurance

on

level

surfaces then

becomes

theobjective,

gradu-ally steps, stairs, rough

_ground

and so on are added

until the _physicaltherapistissatisfied thatthe

best

standard of walking has been achieved and the

client isdischarged.

The

client's rehabilitation

'has

taken

many weeks,

inAustralia at _present itwill have cost an average

of

\24,OOO

per

day.

Don't ask what the long-term value of _the rehabilitation will bebecause we

prob-ably will not know, the _physical therapistis too

busy with the next client tofollow-up.

The

Queen

Elizabeth

Center

'

In 1985 we decided that this _traditional_physical

therapy approach to walking rehabilitation needed

lking

Rehabilitation

and

Elderly

Persons

431

rnajor changes and we

began

work on a

long-term

project.A number of staff began toexplore the

lit-erature, especially the

broad

science of motor

learn-ing.

After

much study and

discussion

we decided

that walking rehabilitation

for

elderly _persons

should be based on two _principles. First,walking

isa skill which theclient has learned as a child and

practisedfordecades. Thus, the client know

how

towalk.

Secondly,

skillsare

best

developed

using `iwhole

learning"

process, "part-learning" onty

being

introduced

tocorrect specific aspects ef the

walk-ing

pattern,

if

and when required.

Ifwe were techange our approach thisway it soon

became

clear that we needed a measuring system which would _provide us with _precise,

accu-rate and objective data, Where were _the

best

placeswe could go

to

see such systems.

Facilities

in

the

USA,

Canada,

Britain,

Sweden

and,

I

am

'

happy

to

say, the

kanagawa

Rehabilitatiop

Centre,

ttt

here in

_Japan,

werg visited and an excellent

net-work of experts de'yeloped. Eventually, in 1989,

thanks tosome speeial requests, we _purchased

the

Swedish SelspotMovement Monitoring System at a

cost equivalent of

\24,OOO,QOO.

This system consists of 3 opto-electric cameras

and an AMTI force_ptatealllinked to a

dedicated

computer. The system isset up inthe middle of

the therapy area and alltherapists

have

learned

te

use

it,

assisted

by

our

data

_processing clerk.

The

system allows clinical therapiststo obtain

objective movement and _gaitanalysis data during

normal rehabilitation _programs and has encouraged

them to evaluate theirtreatment _procedures

accu-rately.

As a result we have developed a

different

ap-proach tothe walking rehabilitation of our elderly

clients. Remember, their _goal isto

_be

able to walk

effectively and safely as _quickly as _possibleso they

can _go home and _get on with livingthelast_year or two of theirlives.

We have based our ap'proach to walking

rehablli-tation on the concept of "whole _learning"

and we

(3)

432

ve\tsix\

as required, _promotes the achievement of

independ-ent walking more rapidly than the conventional

walking re-education regimens. Our clients begin

walking, _perhaps with _two _{persons-assisting,} as

soon as possibleand

they

walk with a purpose:

to

the toiletand to the

dining

room

being

the

first

goals.

The

physical therapistwill, of course,

prac-ticeeiements which are deficient,such as standing

balance or strengthening a muscle

but

frequent

ses-sions of walking will be undertaken, by the

physi-cal therapist,the occupational therapist, nursing staff, assistants or any other members of the

reha-bilitationteam who may be available, including

family

members,

Depending on the elienVs home situation: the

ayailability of family members willing and able to

help,the suitability of the home environment in

terms of steps and stairs, access totoiletand

bath-room and so on, and

distance

away from

Ballarat,

the client will

be

discharged home as soon as

possi-ble.

Old

people need to

be

re-integrated

in

their

home

quickly so the

family

does

not learn to

do

without them and so they do not

become

in-stitutionalised and

dependent

on the staff.

Ifnecessary, and ifthey desire tecontinue, cli-ents may return as out-patients torefine theirskills under the _guidance of the _physical therapistuntil

theirgoals are met.

We

have

found,

though, that

many continue to

improve

gradually as they move around theirusual environment,

Of

course, we

have

our

failures:

people who

do

net make functional _gains and remain dependent

on a wheelchair

for

mobility; _people who

do

not go

home

but

are

transferred

to

Iong-term

institutional

care; people

'who

die

beforethey can go home. We

have

found

that

itisvery diflicult

to

_predict who

will beinthe 75% who are successful so itis

worth-while giving everyone who wants

to

try

a chance.

ee

20

_ifca

7

_ag･

Conclusion

AsIsaid

at the

beginning,

health

care systems

in

Australia

are under close scrutiny.

Many

physical

therapy services are

being

threatened because they are unable todemonstrate cost-benefit effectiveness.

We

have,however, worked

hard

since

1985

to

eval-uate what we

do,

tointroduce new

ideas

and to

dis-card what we cannot

justify.

Our

rehabilitation service uses the

American

Functieinal

Independ-ence Measures

(FIM)

system to measure functional

improvement

and we partieipate in the Uniform

Data Service

(UDS)

which processes our client data and _provides regular reports comparing our results

with other services. This data _givesme conficlence

that we are _providing effective rehabilitation.

Japan

has a _growing market

for

_physical therapy

as services

for

a rapidly growing elderly _population

are developed. Your country, like mine,

though,

cannot afford a _physical therapy service which is

not constantly examining itsmethods, enhancing

those strategies which can be demonstrated

through objective measurement _to _give _positive

results and

discarding

all activity which cannot

be

justified

eventually

in

economic terms. Bibliography

CrattyBJ:Movement Behaviour and MotorLearning.I.ea

&

Febiger London, 1973.

Hubbard _W _A._Bauer _D:Programme evaLuation: what we

can learn frorntheUnited Statesexperience. The

traHan

Journa]

of Physiotherapy39

(1):

53-57,1993.

Hubbard WA: RehabiLitation outcomes for elderly lower Iimbamputees. The Australian

Journal

of apy 35

{4):

219-224, 1989.

Kelso JA: Human Motor Behaviour. Lawrence Erlbaum Ass,,Hilldale,New Jersey,1982.

SchmidtRA:MotorContreland Learning.2nd Ed.Human

KineticsPublishers,Illinois,1988.

Singer RW: Moter Learning and Human Performance.3rd

Ed,MacmMan New York,1980,