Steps to Follow: The Comprehensive Treatment of Patients with Hemiplegia

543 Pages·2000·19.95 MB·English

by  Patricia M. Davies MCSP

Patricia M. Davies, Steps to Follow, 2. Edition
Springer-Verlag Berlin Heidelberg GmbH
Free to choose where, when and with whom
he would like to be, or even to be on his own
(Chapter 10)
Patricia M. Davies
Steps to Follow
The Comprehensive Treatment
of Patients with Hemiplegia
Second, Completely Revised Edition
With a Foreword by Prof. Jiirg Kesselring, M. D.
With 401 Figures in 740 Separate Illustrations
Springer
Patricia M. Davies, MCSP, Dip. Phys. Ed.
Switzerland
Photographs:
David J. Briihwiller Foto Fetzer, CH -7310 Bad Ragaz
Rainer Gierig, D-82362 Weilheim, Germany
ISBN 978-3-540-60720-5
Library of Congress Cataloging-in-Publication Data
Davies, Patricia M.: Steps to follow : the comprehensive treatment of patients with
hemiplegia / Patricia M. Davies. - p. ; cm. - Rev. ed. of: Steps to follow / Patricia M.
Davies. 1985. - Includes bibliographical references and index.
ISBN 978-3-540-60720-5 ISBN 978-3-642-57022-3 (eBook)
DOI 10.1007/978-3-642-57022-3
- 1. Hemiplegics-Rehabilitation. 1. Title: Steps to follow. II. Davies, Patri-
cia M. Steps to follow. III. Title. - [DNLM: l. Hemiplegia-rehabilitation. 2. Rehabilita
tion-methods. WL 346 D257s 2000) RC406.H45 D38 2000 - 616.8'42-dc21
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Foreword
A true paradigm shift is taking place in the field of neurology. Earlier it
was regarded as the science of exact diagnosis of incurable illnesses, re
signed to the dogma that damage to the central nervous system could
not be repaired: "Once development is complete, the sources of growth
and regeneration ofaxons and dendrites are irretrievably lost. In the
adult brain the nerve paths are fixed and immutable - everything can
die, but nothing can be regenerated" (Cajal1928). Even then this could
have been countered with what holds today: rehabilitation does not
take place in the test tube, being supported only a short time later by
an authoritative source, the professor of neurology and neurosurgery
in Breslau, Otfried Foerster. He wrote a 100-page article about thera
peutic exercises which appeared in the Handbuch der Neurologie (also
published by Springer-Verlag). The following sentences from his intro
duction illustrate his opinion of the importance of therapeutic exercises
and are close to our views today (Foerster 1936):
"There is no doubt that most motor disturbances caused by lesions of
the nervous system are more or less completely compensated as a re
sult of a tendency inherent to the organism to carry out as expedient
ly as possible the tasks of which it is capable under normal circum
stances, using all the forces still available to it with the remaining un
damaged parts of the nervous system, even following injury to its sub
stance. This happens spontaneously, when neither a reversal of the da
mage nor a regeneration of the destroyed tissue is possible, simply by
means of a reorganisation of the remaining parts of the nervous sys
tem, which is not a machine composed of individual parts that stands
still when one part fails; rather, it possesses an admirable plasticity
and exhibits an astonishingly extensive adaptability, not only to
changed external conditions but also to disruptions of its own sub
stance. Therapeutic exercises influence the course of spontaneous re
storation; they support it, strengthen it. Not infrequently, in fact,
they actually set it in motion when the forces essential to restoration
lie fallow and are not deployed by the organism ...."
Due to new findings about the above-mentioned plasticity of the ner
vous system (Stein et al. 2000), and thanks to new pharmacological pos
sibilities, but above all through the systematic application of neurore
habilitation, neurology has in fact become a therapy-driven speciality
VI Foreword
(Kesselring 1997). Research into cells and their connections as well as
into neurotransmitter systems, the description of functional changes
by means of imaging procedures (Frackowiak et a1. 1997), and the (al
beit difficult) measurement of the effects of rehabilitation show that
the central nervous system of the adult has an astounding potential for
regeneration and adaptability, which can be specifically enhanced.
Translated to the level of the physiology of the organism as a whole,
and of psychology, this can be understood as the basis of learning.
Whereas a previous main objective of neurology was to describe the
deficits and their pathogenesis as precisely as possible according to
the lesions, interest today has shifted more to identifying the potential
still available and promoting it through a learning process.
When this pioneering work by Pat Davies, which was to become one
of Springer-Verlag's most successful titles, first appeared in 1985, the
field of neurorehabilitation was regarded as a marginal discipline. Neu
rologists who wished to follow her methods, were disregarded by their
academic colleagues with a contemptuous smile, or at most were
thought to be moving in a direction which could only lead to a dead
end. With very few exceptions, rehabilitation at that time was not a sub
ject for the university; it was neither taught nor studied there. However,
under the self-confident direction of just such practised and didactical
ly experienced therapists as Pat Davies it has become possible to study
particular aspects of behaviour following disturbances of brain func
tion, allowing a broader understanding of the field of clinical neurology.
This therapeutic approach promotes more extensive training to im
prove function, with more comprehensive guidance and care of patients
with chronic sequelae of diseases and injuries of the nervous system,
thus enabling them to cope with the problems of everyday life. This is
what is truly relevant.
Neurorehabilitation can become an outstanding example of the ur
gently needed attempt to unite under one roof the two cultures within
which medicine is developing. The one is the scientific side and the
other the practical, or what has on occasion been called the "humanis
tic aspect" (Wulff 1999). The famous English haematologist Sir David
Weatherall used the dilemma as the title of his book, which is well
worth reading: Science and the Quiet Art. Medical Research and Patient
Care (Weatherall 1997). He searches for the complement to his own oc
cupation as a scientist, which he experiences as being one-sided despite
his success. He finds it in a quotation from Virgil's Aeneid, which
speaks of the "quiet art" which should be practised "regardless of
fame". It is the esteem and the respect, however, shown by such a fa
mous scientist and director of an institute of molecular medicine to
those who practise the quiet art in their daily work, which lend a special
significance to this book and its basic approach.
Man's basic intellectual interests point in two main directions. On
the one hand are the technical interests, which have developed into
modern scientific medicine, and with which objective facts are collec
ted, described and tested. These can be likened to the way in which
Foreword VII
man earlier had to learn to hunt, gather edible food and distinguish it
from that which was poisonous, seek shelter, and warm himself. On
the other hand, we are also social beings and in order to survive we
must be capable of communicating with one another which is the inter
pretative or hermeneutic interest. It has a horizontal orientation, in that
we must understand and interpret what others say here and now and
how they behave in relation to the current situation, as well as a vertical
orientation learned from earlier experiences and from those of previous
generations.
Karl Popper (Popper and Eccles 1982) takes a more radical view, re
ferring to two different worlds in which we move and to which he as
signs numbers. "World I" is the objective world, the playing field of
the natural sciences and all too often the only area of interest to one-si
ded physicians. "World 2" is the subjective world of our feelings, mem
ories and thoughts. Each one of us is part of "world I" but there is al
ways a small, subjective "world 2" within each of us, to which no one
else has direct access. In this world our moods, our state of health, suf
fering and sickness, and fears of the future interplay - they with us and
we with them. Medical science belongs to "world I", but the aim of ev
ery medical and therapeutic effort lies in "world 2". In her book, Pat
Davies concerns herself with this aspect.
Popper distinguishes still another world - "world 3": the cultural
achievements of many generations. Examples are languages, works of
art, scientific theories, Zeitgeist (the feeling of that generation) and, of
particular significance in this connection, ethical values, norms and
rules of behaviour.
Clinical considerations usually begin in "world 1" if we work from
theoretical knowledge and regard the patient firstly as a biological or
ganism, a natural phenomenon with its healthy or restricted functions.
In every case considerations from "world 3" playa role here as well,
from the cultural context in which these aspects of medicine are learned
and practised. In particular, we must learn to take also the "world-2"
aspects of an illness into consideration - the way in which the patient
experiences and interprets his illness or disability within the framework
of his life experience, and how he himself contributes to changing the
situation.
One of the most remarkable occurrences of today is the way in
which earlier trust in progress is turning into a fear of progress. Grate
ful appreciation of medical success is being replaced by a suspicious
and radical criticism of medicine. The dramatic growth of our ability
to conquer diseases is condemned as increasing dehumanisation of
medicine and as exploitation of the patients. What was once welcomed
and celebrated as a chance for healing is now looked upon as an instru
ment of inhumanity. This grave re-evaluation of progress as an agent of
destruction is sustained by the tendency to forget. It is easy to forget
man's earlier captivity in disease, pain and suffering, which have been
relieved and reduced through medical progress. Progress has led to ad
vantages in life, the absence of which would not only be unpleasant but
VIII Foreword
even inhumane. Why is it that the more successes medicine achieves,
the more criticism it attracts? Progress is often said to be Janus-faced,
because it not only eliminates evil, but also engenders it. Why is it
that we are interested only in the latter of the two faces? The increasing
rational control of our environment, our reality, necessitates a greater
division of labor and, in turn, a greater need for mutual trust. But it is
exactly this aspect which is questioned today and changed into mis
trust. Where progress really succeeds and does eliminate evil, the newly
attained state of affairs is quickly taken for granted but the negative as
pects which remain become increasingly exaggerated. Just as goods
which are scarce become more and more expensive, so the vestiges of
evil become ever more tormenting and finally unbearable, to the point
where people suffer from precisely that which spares them from the
other kinds of suffering. The current criticism of medicine speaks not
for its failure but rather for its success, even if there is, unquestionably,
still much room for improvement in order to allow further progress.
Medicine's inadequacy can just as well be explained by excessive expec
tations and demands as by any lack of accomplishment. Because abso
lute demands are always disappointed, we should learn to dispense
with them.
Perhaps the claim that medicine is a science is unrealistic to begin
with. Even today it can fulfil only some of the criteria which define a
mature scientific discipline such as mathematics or biology (Kuhn
1965). Medicine is still partly at the stage of lists of descriptions, partly
at that of competing theories; little of daily practice is indeed evidence
based. One reason for the crisis in which modern Western medicine
finds itself may be that the various paradigms on which it was founded,
and which were held to be unshakable, have begun to falter simulta
neously and are drifting apart, without any force in sight which might
hold them together. One of these paradigms is the reductionist path of
molecular medicine and genetics. Undeniably great results have been
obtained along this road, particularly in the field of clarifying disease
mechanisms and their pathogenesis, and more are being achieved at
breakneck speed. Many valuable qualities pertinent to the practice of
medicine are lost, however, in the attempt to understand the mechan
isms of diseases instead of the troubles and needs of sick people. One
problem with reducing medicine to a molecular level lies in the fact
that personality, experienced by us directly as "I" and "you", disap
pears or goes astray. As in the study of space, we have no organ which
allows perceptions in the molecular field without instruments. Specta
cles, a cane or even a wheelchair are accepted immediately as personal
aids because they are of obvious advantage. The extension of basic
technology to the astronomical dimensions of space and time is even
more easily tolerated because these are domains far beyond our own
temporal and spatial horizons. The aids which permit indirect percep
tion at the molecular level, however, are complicated and rather diffi
cult to visualise, so that they are mastered by only a few expensively
trained specialists. Nevertheless, in the field of medicine, there is the
Foreword IX
feeling and the assumption that the object of investigation is ourself or
someone close to us. Lack of knowledge of the area of perception al
ways causes anxiety, which is probably one reason why many people
are sceptical about scientific knowledge gained from areas which are
not accessible via direct experience and straightforward examination.
In philosophy, and thus in the minds of those affected, reducing inter
pretation to the molecular and genetic level leads, despite the use of
the most modern technology, to a return to the days when anxiety
ruled because all life was interpreted as being predestined - at that
time by either fate or God.
A second paradigm shift in medicine is manifested by the impetus of
so-called alternative medicine, which profits precisely from its stand
point opposing scientific medicine. A "holistic" view of the human
being is advocated here, the factual basis of which is often accessible
only to the initiated. This type of medicine is no longer content with
trusting in the ability of the body to heal itself and in recommending
a healthy way of life and physical exercise; rather, it has now caught up
with classical medicine with regard to costs. An essential contrast to
scientific medicine lies in the fact that, in the alternative scene, an im
provement in the subjective assessment of a given case is judged to be
proof of the success of the therapy. Scientific medicine, although con
cerning itself, as a safeguard, with elements from "world 3", requires
statistical support based upon parameters of measurement which have
been established with sufficiently large numbers of patients examined
over an adequate period of time, before a treatment may be considered
useful. In the area of "hands-on" therapy which is of the greatest impor
tance in neurorehabilitation, other criteria for judging effectiveness
than those used in scientific studies of the efficacy of medication have
to be applied. If these therapies are to induce a learning effect, they
must be compared with pedagogic or training effects. It would not oc
cur to anyone to test the efficacy of education or of a sports training
camp in a double-blind study. Of course, prejudices, a lack of readiness
for change, and authoritarianism have delayed progress in every age.
Medicine is still an art, but one which has become more difficult to
practise because the knowledge of our ignorance and our unawareness
is increasing.
A further paradigm change in our society is having an effect on
medicine as well. Suddenly, the till which for so long had been able to
finance all desires for development and reform is empty, but the de
mands that everything which can be done must be done have not
ceased and these demands have not become quieter or more modest.
From this point of view, neurorehabilitation should be compared less
with other therapeutic methods in medicine and more with other cul
tural services and educational functions, and financed accordingly. A
fourth problem of modern medicine, one which is only very reluctantly
addressed, lies in the realisation that work to preserve and prolong life,
which is beneficial per se in the individual case, has catastrophic conse
quences in the overriding, more general and politically relevant aspect
x
Foreword
of demographic evolution. Neurorehabilitation, however, is concerned
not with prolonging life, but rather with improving the quality of life,
and this is justified from all points of view.
Pat Davies' fundamental clinical (practical-humanistic) approach, so
comprehensively reflected in this book, is a fitting example of how the
"uneasiness with modern medicine" (Kesselring 1998) can be coun
tered. In addition to her original, practice-relevant views on the phy
siology of the nervous system as it manifests itself in behavior patterns
seen daily in clinical practice, her instructions for direct, practical
treatment of patients preclude the danger of concentrating only on dis
eases in the abstract instead of on the people who suffer from them.
There is no fundamental contradiction between a scientific under
standing of disease mechanisms and their influence, on one hand, and
providing good care and attention to sick or disabled persons on the
other. Certainly, the prerequisites for clinical work and research are
not identical; they are, in part, even opposite. Clinicians should radiate
self-confidence and assurance, should convey trust and hope - quali
ties which enhance the healing process and make it easier to deal
with sickness and disability. They will do some things without being
aware of any exact scientific basis for them; they often have to assess
and treat on a basis of limited information, and this skill tends to be
called intuition. Discussions related to the extent of our ignorance and
unawareness cannot be carried out at the bedside. To endure the uncer
tainty and insecurity and nevertheless convey assuredness and take ac
tion is one of the clinician's most difficult tasks, one which can never
be completely resolved. Characteristic of the researcher, on the other
hand, is a fundamental skepticism which involves repeated questioning
and answer-seeking, because only such an approach can give rise to
further studies and to a critical appraisal of the results. Of course,
much in science serves more the self-glorification of the researcher
than a practicable path or aim.
Pat Davies is one of the very few persons who win wide recognition
through their clinical work, who come up again and again with creative
possibilities for solving problems relevant to daily life, and who are
also, at the same time, didactically skilled and charismatic teachers.
Clinical researchers and academic teachers need to be able to enter
into communication and be able to understand problems and suggested
solutions, even when these are proposed by persons who do not come
directly from their field of work. Only then can they integrate theoreti
cal findings into daily practice. Leadership of a team in which people
from various fields of training work together, indispensable for the
complex task of neurorehabilitation, can only succeed if proof can be
presented of successful work in both scientific medicine and clinical
practice, and especially of a willingness to cooperate. In contrast to the
days of George Bernard Shaw, the "Doctor's Dilemma" today consists
of resolving the contradiction between scientific medicine and clinical
practice and in forming a synthesis of the two. This requires new edu
cational curricula and the practical instruction which stem from criti-