Never Give up Aphasia Rehabilitation, Mister Nagashima!
Limitation of Functional Environment, Insurance Problems, or Personal Factors? Tweet

July 22, 2009

Dear Mr. Shigeo Namashima,

On March 5, 2004, you were hospitalized for a suspected stroke, which later proved to be an embolism on the left hemisphere of your brain and accompanying right hemiplegia and aphasia, or speech disturbance. Once blood stopped flowing, nerve cells in the area died, which showed low density (black) areas in the tomography of your CT or MRI image. As a result, you experienced paralysis on the opposite side of your body and accompanying psychological problems. Now that you are able to walk again, and are still training hard to improve further, you may be unsatisfied with the speech disturbances still evident during your slow recovery. Whatever hurdles you face, may Mister Giant never give up aphasia rehabilitation! As a physical therapist with 28 years of experience and case manager certified in Japan, I am writing mainly to give my advice and encouragement.

To review, you may need too, I summarize stroke from Stedman's Medical Dictionary (Piper T. et al. 2006).

* stroke = cerebral vascular accident (CVA)
   cerebral hemorrhage = bleeding inside brain
   cerebral infarction = blood clotting inside brain
       cerebral thrombosis = clotting forms inside brain
       cerebral embolism = clotting comes from other organ
* stroke of left hemisphere of brain
   right hemiplegia (hemi-paralysis)
       aphasia, one of neuro-psychological problems, sometimes occurs
* … of right hemisphere
   left hemiplegia
       right hemisphere syndrome, a variety of neuro-psychological problems, occur

The main nerve routes named Pyramidal Tracts originate from either side and cross at the brainstem, so a left hemisphere stroke causes right hemiplegia (hemi-paralysis), and sometimes aphasia. Aphasia is a quite complicated speech disorder, not a motor problem of articulation or dementia but one of neuro-psychological problems of higher brain functions. Injuries of the left hemisphere that affect correlative language systems such as Broca’s or Wernicke’s Areas can cause speech disorders. Patients with the major Broca type, called motor aphasia, can understand what they hear but have difficulty changing their thought into words.

From past to present, you have been called Mr. Giant, Tokyo-based pro baseball team player and director, or just Mister because of your popularity among Japanese citizens. With your sportsmanship, personality, and humor, your existence has been a hope of Japan, especially of baseball players who have followed you, like Boston Red Sox pitcher Dice-K Matsuzaka, slugger Hideki Matsui, average hitter Ichiro Suzuki, or Olympic Team Japan. Born in Chiba in 1936, since your debut as a slugger in the Rikkyo University baseball team, your hard training in both defense and offense has been known to us later generations. “Picking up balls with my glove and throw one after another ... til almost invisible after dark,” you later confessed. In 1958, you joined the Yomiuri Giants, where you had become 3rd fielder and 4th batter, a hero of whole Japanese citizens for us TV generations impressed not only by your play, but by your warm and humorous conversation from the black and white to color display, to the Internet era.

An easily-excitable person, Mister hit a home-run at last on the occasion when the late Emperor visited Korakuen Stadium to watch the game. On humiliated situations at a pitcher letting a home-run 3rd batter, Oh, walk in 4 balls, and challenged you instead, you were excited and often made a long hit or home-run in revenge. When you had to give up directing the team of Athens Olympic right after stroke in the summer of 2004, you sent a message of your privileged uniform number “3” on the Flag of Japan written even by your paralyzed right hand on the game occasion after a hard rehabilitation, which, a shaken letter, encouraged very much whole team members, Japanese people, and children. Nice guy Nagashima never give up!

Problem 1: speech disturbance and functional environment hindering recovery. During your rehabilitation in a Tokyo hospital, your messages were presented typed to us general public. After you quickly recovered to walk again, you did not appear on TV, so in experts' guesses it was clear that speech has been your first priority and you may have suffered from the big gap from your previous fluency. It was after your long absence in February 2008 when Nihon Hoso Kyokai (NHK) Educational broadcast “tatakau (fighting) rehab” showing a brief interview with you and your gait exercise machine as an example (NHK on air February 2008).

However, how pitiful, you must have been humiliated playing back the program that the interviewer anticipated your story and did NOT allow your spontaneous conversation as is often happen in nonprofessionals surrounding people with aphasia. Further, she expected your “Yes” answer and said, “You were disappointed, weren't you?” Then, you replied mechanically like a parrot as often happened, “Yes, I was disappointed,” with subtitle of all the conversation! Was a pro broadcaster good in enhancing conversation? Aphasia is a difficult problem that needs time, committed personal devourer, and more importantly, functional environment, a new expression I created. Speech therapists learn well and facilitate the recovery of patients' active involvement in communication waiting patiently for their generally slow response. Plus, an expert on the team takes care NOT to anticipate but wait a patient's word in hinting only the beginning tone of the word. Yes, in a long process of recovery in speech compared with physical functions, what I call functional environment in daily life may be one of the key points and family members should understand their role and should NOT underestimate your capacity or potentiality.

Evidence 1: History of neuro-rehab may encourage you because of newly established, especially after Wars, self-re-education based in-valuable effectiveness (NERVE), which is my terminology, too. Instead of the mainly Orthopedic based rehab before WW II for such as amputee, fracture, or polio myelitis, pioneer therapists developed after WW II new methods comprehensively named neuro-physiological approaches for such as stroke, cerebral palsy, learning disability, and other neurological problems:

* Bobath B., physiotherapist and Bobath K., psychiatrist and neuro-physiologist (Br.)

They ran away from Nazi and began practicing in London in 1943 for neurological problems for the first time based solely on neurology. Mentoring and having courses for cerebral palsy, stroke, or neurological disorders, they trained physical therapists, occupational therapists, speech therapists, nurses or physicians worldwide based on a new methodology. I am a member of Japan Bobath Association whose center located at Osaka.

* Voss D. et al. (U.S.)

A system they call proprioceptive neuro-muscular facilitation (PNF) is unique and strengthen neuro-muscular circuit stimulating proprioception, or body and movement perception located at whole muscles or joints.

* Ares, A., occupational therapist (U.S.)

Her in-depth idea of sensory integration for the treatment of learning disability (LD) children has been influential to other methodologists.

* Carr, J. and Shepherd, R. (Australia)

They are one of the authentic contemporaries of us in terms of followers of above in neurological and pediatric re/habilitation both in practice, teaching, and authoring. In case of a child, it is called habilitation. Re/habilitation derives from habilis in Latin, suitable, and means make suitable (again). As the word is used the rehabilitation of Jean of Ark, and the recovery of human rights and physical medicine has been bound, philosophy and technology are often on discussion.

Neurological Rehabilitation (1998) by Carr and Shepherd or Physiotherapy in Pediatrics (1995) by Shepherd have now become classics, and have encouraging contents both for patients and experts (Carr, J and Shepherd R. 1998, Shepherd R. 1995). For example, the former starts writing on the brain’s plasticity and recovery following disease, which had been proved by many years of practitioners' efforts in the new fields after World War II, with fully documented proof of experiments and clinical practices, and I believe you would admire, even at a glance, the list of references in the first chapter (pp. 3 - 22). In a monkey experiment, it was proved that forced use of the affected arm could enhance the skilled functional recovery. Further, more interestingly, authors assert to arrange challenging environment so that patients can get optimizing motor performance, and stories should not limit to movement recovery. Their advice of arranging challenging environment corresponds to my terminology of functional environment, you may agree with. Individual's motive is important, of course, but an overprotective as well as annoying environment could be harmful for your aphasia rehabilitation.

Problem 2: personal factors concerning depression. To be honest, let me refer to your situation of depression as a personal factor; excuse me, for it is important. Although you were motivated enough, the NHK announcer may have forced you to answer, “Yes, I was depressed.” In your functional environment, anything may happen or your family may underestimate your recovery or speech. Therefore, my recommended reading for you as an evidence 2 and precedent is:

Yamada, K. (1978) Shitugo-sho no Uta (Song of Aphasia) paperback ed.

He had cerebral hemorrhage and surgery to get rid of the hematoma, so must have been functionally limited more than you. After committed endeavor for years, Yamada succeeded in getting his speech and human rights again, and published his experience, which has become one of classics of this kind in Japan. How encouraging for people with disabilities not only aphasia!

Problem 3: insurance and systems. Health insurance is a problem, too, although the Japanese, west Europeans, or Nordics are more advantageous for it is national. American president Barack Obama and his administration are making a hard effort to get rid of barriers to make insurance system cover EVERY citizen and resident, but a capitalist country's way may be a third party between insurers, service providers, and consumers. However, in this economic crisis, unless it can cover every resident the gap between the sick and the health, the poor and the rich will increase eventually. In contrast, in addition to national health insurance, Japanese governments supplemented nursing care insurance in 2000 at a high speed of aging society and longevity with disabilities. Yet you may face difficulty in keeping a long term speech therapy even it’s necessary for aphasia. In a prescription based rehab system therapists have to work with doctors, and center controlling bureaucrats are just like nonprofessional bank managers guided by old type, authoritative doctors, in Japan behind the standard. Stroke rehabilitation in hospitals is mechanically cut under 180 days and you may be impossible to find a skilled nursing home that serves speech therapy on nursing care insurance. You have to consult a good case manager, and a speech therapist.

The World Health Organization (WHO) adopted the International Classification of Impairment, Disability, and Handicap (ICIDH) as a common language in 1980. To avoid negative connotation of these terms experts participated in a revising process in accordance with the Internet around 1997. The“IMPORTANT”document was first shown among the beta-1 draft but which no longer appears, so I reproduced asking the WHO's permission (1997. <http://www.ergod.org/essay/important.html> attached document 1).

Through beta-2 revision, the International Classification of Functioning, Disability, and Health (ICF) was finally published after years of revision by WHO in 2001. Anyway, classification of "Functioning," according to my understanding, is what hard efforts including prognosis or capacity looking for brighter aspects in people who have to live with difficulties seem to have resulted in terminology change. It needs to create, not the learning of disability, but the learning of functioning as a prerequisite (Hosoe T. 2009. <From Learning of Disability into * functionics >) Here, my term functionics means establishing a new learning based on ICF, an individual therapist can't afford to systematize though. Medieval physician Galen called the true successor of Hippocrates has his famous work titled “On the Natural Faculties,” which corresponds to the ICF and my interpretation significantly rather than ICD, the classification of disease (Galen, 1916)

Table 1. An Overview of ICF (pp. 11, 2001) I quoted and also made a bilingual web page so that Japanese people easily understand and compare with English. As I color red, every factors should be understood surrounding positive aspect, not negative such as classification in 1980 that may mislead to depressive or underestimate prognosis and results. Instead, capacity or potentiality of functioning must be reinforced, so active participation is another key word, you should understand. As I pointed out before, if functional environment hinders recovery, motivated and committed effort could pave your way forward like pioneer forerunners.

Discussion: A physical therapist is responsible for physical rehabilitation, but never mentions motor rehab. Why? Speech is your main problem, obviously.

1. Compared with people with left hemiplegia, you may be fortunate because their neuro-psychological problems are far difficult and even called right hemisphere syndrome, combination of symptoms.

2. A long term speech therapy and your language training with “active participation” works such as Yamada K.

3. Functional environment, I mean mainly family conversation, is a key. Your son seems to have underestimated your ability and surprised at your song and appeal in Yujiro Ishihara's memorial party. (Mainichi.jp. [7/18/2009] Mr. Shigeo Nagashima: Enthsiastic singing dedicated for late Ishihara.

4. Health insurance reform in the U.S. is and has become one of the economic key issue. Even living in ancien regime you can make use of both health and nursing care insurance, which is your advantage.

5. One thing I care is that you may be still hardworking for gait and physical exercise as a sportsman, but which seems unfortunately, by a fair minded person, almost the stage of plateau after 5 years.

6. Aphasia often accompanies depression, since both patients and families are worried, not knowing how to deal with an unusual condition. You have to handle and educate surrounding people to improve yourself. Yes, You Can!

Good news came while I'm writing to you that you took part in Ishihara Y's memorial party together with celebrities, sang a song and finally shouted in memory of him, “Arigato (thank you)!,” in front of many audiences. I confirm a hope for you at this news, and now urge you to get your speech recover until you publish your experience not of your physical training but your effort of speech for the sake of similar sick persons. Everyday routine seems to be ball and catch of conversations with no change, but in which, Yamada, K. is sure, you will become an encouraging author of “aphasia experience.” Never give up, Mister!


References:

Ayres, A. J. (2005).Sensory Integration and the Child: 25th Anniversary Edition. Los Angeles: Western Psychological Services

Bobath, B. and Bobath, K. (1975). Moter Development in the Different Types of Cerebral Palsy. London: The Whitefriars Press.

Bobath, B. (1990). Adult Hemiplegia: Evaluation and Treatment. 3rd Ed. Oxford: Butterwoth-Heinemann.

Bobath, K. (1980). A Neurophysiological Basis for the Treatment of Cerebral Palsy. 2nd Ed. Suffolk: Lavenham Press.

Carr, J. and Shepherd, R. (2011). Neurological Rehabilitation Optimizing Motor Performance. 2nd ed. Churchill Livingstone.

C arr, J. and Shepherd, R. (2002). Stroke Rehabilitation. Oxford: Butterwoth-Heinemann.

Galen. (1916). On the Natural Faculties. Edinburg: St Edmundsburg Press.

Mainichi.jp. (7/18/2009). Mr. Shigeo Nagashima: Enthsiastic singing dedicated for late Ishihara, Y.
<http://mainichi.jp/enta/geinou/news/20090718spn00m200009000c.html>

Hosoe, T. (2009). From Learning of Disability into * Functionics. <http://www.ergod.org/essay/holistic-en.html#principles>

NHK Educational TV (on air 2/10/2008) Tatakau (fighting) Rehab <http://www.nhk.or.jp/special/onair/080210.html>

Piper T. et al. (2006) Stedman's Medical Dictionary 28th ed, Baltimore: Lippincott Wiliams & Wilkins.

Shepherd R. B. (1995). Physiotherapy in Pediatrics. 3rd Ed, Oxford: Butterwoth-Heinemann.

Shogakish Fukushi Kenkyu-kai. (2002) Kokusai Seikaktsu Kino Bunrui (Jap. Ed. of ICF) Tokyo: Chuo-hoki
<http://www.amazon.co.jp/ICF-%E5%9B%BD%E9%9A%9B%E7%94%9F%E6%B4%BB%E6%A9%9F%E8%83%BD%E5%88%86%E9%A1%9E%E2%80%95%E5%9B%BD%E9%9A%9B%E9%9A%9C%E5%AE%B3%E5%88%86%E9%A1%9E%E6%94%B9%E5%AE%9A%E7%89%88-%E9%9A%9C%E5%AE%B3%E8%80%85%E7%A6%8F%E7%A5%89%E7%A0%94%E7%A9%B6%E4%BC%9A/dp/4805844175>

Voss D. et al. (1986). Proprioceptive Neuromuscular Facilitation: Patterns and Techniques 3rd Ed. Baltimore: Lippincott Williams & Wilkins.

WHO. (1997). IMPORTANT. one of beta-1 draft ICIDH-2 International Classification of Impairments, Activities, and Participation.Geneva: WHO <http://www.ergod.org/essay/important.html> Hosoe T's reproduction

WHO. (2001). International Classification of Functioning, Disability, and Health (ICF). Geneva: WHO
<http://www.who.int/entity/classifications/icf/en/>

WHO. (2001). Table 1. An overview of ICF. International Classification of Functioning, Disability, and Health (ICF). Geneva: WHO (pp. 11)
<http://www.ergod.org/essay/table.html> Hosoe T's bilingual reproduction with Jap. Ed.

Yamada, K. (1978). Shitugo-sho no Uta (Song of Aphasia) paperback ed.
<http://www.amazon.co.jp/gp/offer-listing/B000J8MH04/>


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