A young man was admitted in the morning hours and appears calm and even-tempered. In the afternoon, upon being awakened from a nap the man becomes agitated and angry. The man is found on the floor and the nurses cannot calm him enough to return him to bed. The nurses discover that the man views his leg as being that of someone else and in an attempt to throw the foreign leg out of his bed the man throws himself upon the floor. The nurses point out to the man that the leg is his own leg. The patient has complete loss of awareness of his hemiplegic limb but interestingly enough he is unable to tell whether his own leg on that side was in bed with him because he is so caught up with the unpleasant foreign leg that was there.
Cognitive therapy is reported to be based on the theory that holds that much of how the individual feels is determined by what the individual thinks. Cognitive therapy involves the therapist working with the individual and challenging errors in their thinking through leading them to alternative views about a life situation. (Herkov, 2012, p.1) Hemiplegic limbs often occur in individuals who have strokes or in younger individuals with cerebral palsy. This study investigates the use of cognitive psychotherapy for the young man in this scenario and intends to demonstrate how cognitive psychotherapy can enable the individual in a functional and effective manner in such as the case at hand.
I. Cognition and Intervention
The mind's power over the body and its functions, health, and physically fit status is well acknowledged in contemporary science. One method has linked together physical movement combined with the individual's 'thinking' processes aligned to physical movement in a cognitive physical therapy that results in a part of the brain learning how to process certain information and send the correct information to the individual's limbs to perform specific actions related to physical movement and function.
This method is known as the KAWAHIRA Method, which involves activation of neurons, by a "stretch reflex" which is a timed to "discharge when neuronal excitation of the patient's intention comes from the prefrontal cortex." (Kawahira, 2006) Involved in this therapy is a repetitive movement exercise therapy for recovery of motor function of hemilplegia. (Kawahira, 2006) In fact, there are various therapies when combined with cognitive psychotherapy that will assist individuals such as the young man in this scenario in regaining use of hemiplegic limbs. It is reported that part of assessing patients with hemiplegia requires assessing "mental functions, speech, motor system, sensory system, cranial nerves, pain, cardio-respiratory system, balance, ADL, and gait." (Kawahira, 2006)
II. Treatment Principles
Treatment principles for successful rehabilitation includes " a problem-solving approach" requiring that the therapist conducted assessment of the patient and identify the disorder to the movement and choose strategies for treatment that are appropriate. Motor relearning is described as "an active process…" and the patient must have the capacity for active participation in activities and exercise in what is a treatment focused on functional improvements since the best facilitation is that of muscle groups rather than isolated exercise of muscles. Practice is critical and the therapy required is focused on repetitive movement in a skill acquisition process. While this may sound simple enough in reality, it is the ongoing repetition, repeating difficulties that the individual must overcome in their way of thinking before they will have the commitment that is needed to face yet another exercise session in a long line of many that regaining use of the hemiplegic limb requires. Stages of recovery include the "early recovery stage (acute or shock stage) involving variation in the flaccidity stage between patients ranging 2 to 6-week. Rehabilitation can begin immediately upon the medical stabilization of the patient and generally between 24 to 36 hours. (Sullivan and Schmitz, 2006) Involved in this phase of the therapy are the beginning activities of learning to cope with the hemiplegic limb. General goals include minimizing the "effects of tone abnormalities among other tasks including that of the individual initiating "self-care activities." (Sullivan and Schmitz, 2006) Included in the early tasks are such as positioning of the patient, ROM exercises, neuromuscular electrical stimulation, and motor skill relearning. (Sullivan and Schmitz, 2006) Also included is addressing oromotor activities or to "normalize respiratory, facial and swallowing functions. This can be achieved through manual contact on the chest wall, assuming different positions, respiratory exercises, and postural drainage. Assuming an upright sitting posture with slightly flexed head reduces possibilities of aspiration and promotes normal swallowing." (Sullivan and Schmitz, 2006) The middle recovery stage referred to as the spastic stage involves a continuation of earlier recovery stage activities and the patient sets goals and begins activities and therapies. Motor control training is a problem-solving initiative as well involving training that has its focus on the improvement of motor control through "stressing selective movement patterns." (Sullivan and Schmitz, 2006) Also included is balance and ambulation training described as follows:
"Balance could be achieved by progressing the patient through a series of upright postures. Supported standing in between parallel bars should be begun in this stage. Full weight bearing on the affected side should precede unweight-bearing and stepping. Orthoses are required when persistent problems prevent safe ambulation e.g. FA splints. "(Sullivan and Schmitz, 2006)
The late recovery stage involves obtaining normal timing and coordination of movement patterns, regaining normal gait and normal manipulation and dexterity as well as promotion of cardiorespiratory endurance." (Sullivan and Schmitz, 2006)
Rehabilitation is defined as "the (re) learning of motor control." (Sullivan and Schmitz, 2006) It is reported that the work of Fitts and Posner proposed a "theory of motor learning that has been widely accepted…" and which proposes "three phases of motor learning; the cognitive, associative, and automatic phase." (Sullivan and Schmitz, 2006) Reported as centric of this theory is that "….improvements in a motor skill run parallel with a decrease in cognitive or attentional resources needed to perform the task (Fig. 1a). In the third and ?nal phase, the motor skill requires only a minimal amount of attention and the skill is said to be automated." (Sullivan and Schmitz, 2006) It is additionally reported that the "close relationship between cognitive processes and motor-skill learning has important implications for functional recovery. Stonnington (2006) in the work entitled "Altered Awareness Syndromes" writes that the "unawareness of impairment" is a cognitive/behavioral phenomenon, with a variety of syndromes related to damage of various neteromodel brain areas…" (p.1)
Five factors noted to influence "an outcome of functional autonomy" are those of:
(3) motor upper extremity;
(4) motor balance; and (5) significant other factors. (Stonnington, 2006, p.1)
Complete Anosognosia in a patient with hemiplegia (particularly left hemiplegia, but can occur in right hemiplegia): Denies that hemiplegic side belongs to him/her…" (Stonnington, 2006, p.1) Levels of awareness may involve:
(1) complete anogsognosia,
(2) intellectual awareness or understanding the difficulty experienced in a specific activity;
(3) emergent awareness or understanding having difficulty in many circumstances; and (4) anticipatory awareness or understanding the implication of deficit." (Stonnington, 2006, p.1)
It is noted that there is a "positive association between accurate self-awareness and favorable employment outcome." (Stonnington, 2006, p.1) Delisa and Walsh (2006) report an extended study, which indicated that "the functional recovery after a formal behavioral approach" including cognitive therapy is equal to "a match program of Bobath-based PT. Both were more clinically and significantly effective. (Stonnington, 2006, paraphrased)
Summary and Conclusion
This study has related that cognitive therapy is such that has as its bases the belief that how the individuals feels is greatly determined by what the individual believes. Cognitive therapy is such that serves to challenges the individual and specifically related…