A patient with left hemiplegia after right thalamic hemorrhage had a tendency to fall backwards while in a standing posture for toilet activities, and he was referred to us for physical therapy. In the standing posture, load bearing by the lower limb was difficult because of the following problems: left-side rotation and posterior displacement of the pelvis caused by flexion, adduction, and internal rotation of the left hip joint; backward tilt of the lower leg; plantar flexion of the left ankle; flexion, left paralyzed side flexion, and non-paralyzed side rotation of the trunk. The patient was asked to stand and hold the railing with the right non-paralyzed hand. Hypotonia was found in the longissimus, internal oblique, and external oblique muscles of both sides. Also, the tone of left-side muscles was lower than that of the corresponding right-side muscles. In addition, we found: hypotonia in the lower gluteus maximus fibers, gluteus medius, and iliac muscle of the left side; hypertonia in the rectus abdominis muscle of both sides; and range of motion restriction during trunk extension. Therefore, physical therapy was directed primarily at these impairments. After physical therapy, immediately after the patient stood, improvement was observed in rotation of the left pelvis due to improvements in flexion, adduction, and internal rotation of the left hip joint; however, a few seconds later, the tendency to fall backwards reappeared, as before the initiation of physical therapy. Therefore, a thorough re-evaluation was performed which found that improvement of hypertonia in the left adductor longus muscle was insufficient. Accordingly, a stand-up exercise was added to improve the hypotonia of the lower gluteus maximus fibers and gluteus medius, keeping in mind the hypertonia of the adductor longus. Eventually, the stability of the standing posture improved, leading to improvements in toilet activities. The present case demonstrates that during physical therapy, when attempting to improve the hypotonia of muscles with primary problems, it is also necessary to consider problems in antagonistic muscles.
