脳梗塞後慢性期左片麻痺患者の麻痺側上肢に対する筋電誘発型電気刺激を用いた理学療法

―麻痺側手指の開排能力の向上を目的としたアプローチ―

抄録

A patient had chronic left hemiplegia following a cerebral infarction and difficulty in the abduction of fingers on the paralyzed side due to hypertonia of the upper limb flexors that was associated with myodystonia of the trunk. He was treated with physical therapy. In order to meet the patientÅfs need, expressed as "I want to stably hold my grandchild with my left hand (the upper limb on the paralyzed side)," we employed an approach aimed at acquiring a baby-holding motion by assisting the upper limb on the paralyzed side. During the evaluation, a volleyball was used as a substitute for a baby, and a task simulating the holding of a baby was observed. The patient was seated; he placed the paralyzed hand with the dorsal side down on the thigh on the paralyzed side, held the ball in the palm, and supported the lateral side of the ball with the nonparalyzed upper limb. This task resulted in lateral bending in a rotatory position toward the paralyzed side of the trunk, and stabilizing the ball on the palm was difficult because of flexion of the shoulder girdle, internal rotation of the shoulder joint, flexion of the elbow joint, pronation of the forearm, palm flexion, ulnar deviation of the wrist joint, adduction of the thumb, and flexion of the 2nd-5th fingers on the paralyzed side. Problematic muscle tonus during this motion included hypotonia of the abdominal muscles, hypertonia of the dorsolumbar muscles and upper limb flexors, and hypotonia of the dorsal flexors of the wrist joint, radial flexors, and abductors of the thumb on the paralyzed side. In order to overcome these problems, the patient practiced body weight transfer from the paralyzed to the nonparalyzed side while in a seated position in order to activate the abdominal muscles and reduce the tonus of the dorsolumbar muscles on the paralyzed side. Abduction of the paralyzed hand was then promoted after extension of the paralyzed upper limb flexors. Myodystonia of the trunk and the accompanying hypertonia of the upper limb flexors on the paralyzed side were reduced, and extension of the 2nd-5th fingers became possible, but dorsal and radial flexion of the wrist joint and radial abduction of the thumb were difficult. In order to improve these, muscle action potential-inducing electric stimulation was added to the dorsal and radial flexors of the wrist joint and abductors of the thumb on the paralyzed side. The abduction capacity of the paralyzed hand increased and enabled adjustment of the palm in order to hold the ball, thus meeting the patientÅfs need. For this patient, control of trunk posture and reduction of the muscle tonus of the upper limb flexors on the paralyzed side were necessary, after which an approach employing muscle action potential-inducing electric stimulation of the dorsal and radial flexors of the wrist joint and abductors of the thumb was effective.