"On what basis do you decide that a condition has successfully been treated?" The answer to this question is the point at which a patient can recover normality through rehabilitation. But the success of a treatment is influenced by the therapist's skill in delivering it. That is to say, a therapist needs to be able to perform a correct evaluation of patientsÅf needs, and be capable of developing a suitable treatment program and judging its results. Moreover, it is important to make self- training programs to maintain the therapeutic effect. I want all readers of this paper to aim at being "therapists who can perform successful treatment".

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In this paper, we introduce some approaches that have been used for hemiplegic patients with serious sensory disturbance in our hospital's convalescence rehabilitation ward. The highest function level in the present case was sitting in a leaning position, and this patient needed assistance in all the activities of daily living. Our treatment aimed to adjust the alignment of the trunk and the neck and improve the mobility of the non-paralyzed upper and lower limbs. Herein, we discuss our goal, potential outcome, and problems of impairment through the treatment and sitting posture in the wheelchair before and after treatment.

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We conducted evaluation and physical therapy for the affected arm function of a patient with cerebrovascular disease. In the evaluation of affected arm function, it is important to understand the relativity of the overall problem using observation not only of the movement of the affected arm but also of the whole body such as in walking. An effect of physical therapy on the problem of the affected arm may be found, but to maintain the effect of physical therapy we need an approach for the whole body together with the affected arm. ASPT (Acupoint Stimulated Physical Therapy) on Ba-geae was very effective for fine movement of the affected finger.

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In physical therapy, we often encounter situations in which sensory disorders impede normal movement. Sensory information always accompanies movement, and normal movement cannot be achieved without sensory information. In this report, we describe the changes in movement caused by proprioceptive input in healthy persons and a post-stroke patient.

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We report a case of baseball elbow that developed in a sidearm pitcher. The pitcher alternatively bowled over arm and sidearm in a practice session, which led to baseball elbow. He experienced pain at the inside of his right elbow and visited a hospital when the pain persisted. The pain was reproduced by the valgus test in the right elbow. Accordingly, motion analysis of his pitching form was performed to investigate the cause of the stress at the inside of the elbow. A lateral tilt towards the ball-throwing side of the torso was observed in the late cocking phase of pitching. This characteristic motion of the torso caused excessive abduction of the shoulder joint, because the right upper limb horizontally moved to the left while throwing a ball sidearm. Furthermore, on moving the left lower limb forward, the knee joint became positioned at an angle more acute than that of the ankle joint. Therefore, the axis of rotation of the torso shifted proximally and anteriorly. We considered that his pitching form employed centrifugal force, which would easily cause stress in the elbow joint. To improve his pitching form, rehabilitation programs, including facilitation of the righting reflex and range of motion (ROM) of lower limbs, were initiated. In addition, the pitcher studied the problems in his pitching form by comparing it with those of other professional players. His elbow pain disappeared in two weeks, and his pitching form improved. We believe that using professional pitching form as a reference helped our patient to understand the factors contributing to the appropriate form. This method can also be used for similar evaluation of other such patients in the future.

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The top-down evaluation that we recommend has the advantage of completing physical therapy in a short time, and it can clarify the relationship between disability and impairment. In order to perform a top-down evaluation, a basic knowledge and understanding of the relationship between motion and physical function is necessary. However, many relationships between the two are not fully understood, and we feel that this is a limitation of top-down evaluation. In such cases, we need to perform a case study to build a new theory. In this paper, we introduce the process of building a new theory in the analysis of a case of low back pain in which top-down evaluation was difficult.

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As the number of physical therapists is increasing, there is growing concern about the decrease in the quality of their work. Pioneer therapists with abundant experience have worked hard to establish the identity of physical therapists. On the other hand, mid-career therapists are impressed by their great predecessors and are now eagerly performing their duties to distinguish physical therapy from other therapies. In the current fluid society, we need to know how to guide goal-oriented students aspiring to become ideal physical therapists. A questionnaire was administered to the board of the Academy for Kansai Physical Therapy, which was established to develop skilled therapists. The results show that it is necessary to develop students' sensitivity and ability to perform, set goals and strive to achieve those goals.

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We examined the changes in electromyographic reaction time (EMG-RT) with increases in the number of auditory stimuli that were administered at regular intervals, and confirmed that the factor of forecast influenced EMG-RT when stimulation was carried out at regular intervals. In the present study, we examined whether the factor of forecast influences EMG-RT on the basis of the difference in interstimulus interval (ISI). Ten healthy subjects (eight males, two females; mean age 26.5 ± 5.6 years) participated in this study. The characteristics of the auditory stimulus study were a stimulus frequency of 900 Hz with 15 consecutive stimuli per trial. The subjects were requested to raise their right ankle in response to each auditory stimulus. A total of three different ISIs (900, 2,700, and 4,500 ms) were used in this study. The influence of the increase in the number of stimuli on EMG-RT was examined. At each ISI, EMG-RT showed a tendency to decrease at the 2^nd and 3^rd stimulus compared with 1^st and 2^nd stimulus. At an ISI of 900 ms (n=6), EMG-RT observed at the 8^th-15^th stimuli were significantly decreased compared with that observed at the 1^st stimulus, whereas EMG-RT observed at the 2^nd-7 ^th stimuli were not. At an ISI of 2,700 ms, EMG-RT observed at the 3^rd-15^th stimuli were significantly decreased compared with that at the 1^st stimulus. At an ISI of 4,500 ms, EMG-RT observed at the 3^rd-6^th and 8^th stimuli were significantly decreased compared with that at the 1^st stimulus, but EMG-RT at 7^th and 9^th, 15^th stimuli were not. Four subjects, whose muscle activities were recorded before the input of the auditory stimulus, were excluded from the analysis at 900-ms ISI. In the remaining six subjects, forecast was initiated following stimulus by recognition of ISI at the 3^rd stimulus and was adjusted to the frequency during the 3^rd-7^th stimuli. We consider that the results at the 8^th or subsequent stimuli may be affected by the factor or automation and the results at 2,700-ms ISI have been affected by continuation of attention to the stimulation as well as the forecast of the following stimulation. At the 4,500-ms ISI, the forecast of the following stimulation is difficult because recognition of periodic rhythm is difficult; therefore, attention should be paid to the ISI. We hypothesize that the attention continued up to the 8^th stimulus and attention at the 8^th or subsequent stimuli was diverted, which may have affected the results.

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We studied the relationship between the stand-up test using standing steps of different heights and isokinetic muscle strength of knee extension. In the stand-up test, whether or not a subject could stand-up on both legs or one leg from steps of different heights was assessed. As a result, the peak torque/body weight ratio was significantly greater in subjects who could stand on one leg than those who could not (p<0.05). In the subjects who could stand on one leg, the angle of peak torque (p<0.01) and total work (p<0.05) were significantly greater when using a step of lower height. It was revealed that while quantitative muscle strength (peak torque/body weight ratio) could be roughly evaluated by determining whether the subject could stand on one leg, the height of the step used in the stand-up test did not contribute to detailed evaluation of knee extensor muscle strength. However, using a step of lower height, it was found that the knee extensor muscle could function from the large flexion of the knee joint, thus making it possible to evaluate the qualitative muscle strength (angle of peak torque).

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The influence of lateral body weight shift during single-leg raising in a sitting position while stepping into a bathtub on integrated electromyograms of the external abdominal oblique muscle alone, overlapping abdominal oblique muscles, and internal abdominal oblique muscle alone on the weight-bearing and nonweight-bearing sides were investigated in 14 healthy subjects. Each subject was seated on 2 body weight scales arranged under the buttocks and asked to raise one leg and shift their body weight onto the contralateral gluteal region. Electromyography revealed a significant increase in the electromyograms of the external abdominal oblique muscle alone, the overlapping abdominal oblique muscles, and the internal abdominal oblique muscle alone on the ipsilateral side of the raised leg (p<0.05). The muscle activity the internal abdominal oblique muscle alone on the weight-bearing side increased as the weight load increased to 80%, and then decreased to the initial level as the weight load increased to 90%-95%. These findings suggest that, to practice lateral body weight shift during single-leg raising in a sitting position during the early motion of stepping over something from a sitting position, the external abdominal oblique muscle alone, the overlapping abdominal oblique muscles, and the internal abdominal oblique muscle alone on the weight-bearing and non-weight-bearing sides should be individually evaluated because the actions of each muscle region are different.

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This study examined how differences in the center of foot pressure in the sagittal plane affect the activity of muscles surrounding the hip joint in healthy young male subjects. With the subjects standing on one leg, integrated electromyography values of the muscles surrounding the hip joint, the point of center of pressure in the sagittal plane (Y-axis center displacement), and the trace length of the center of pressure in the frontal plane (X-axis trace length) were measured for three different loads with the center of foot pressure in the forefoot, midfoot and hindfoot regions. There was no significant difference in X-axis trace length between the three loading conditions. The activities of the rectus femoris, tensor fasciae latae and adductor magnus muscles were higher when the load was borne on the hindfoot than in the other two loading conditions. This indicates that these muscles have a flexor effect on the hip joint in the sagittal plane, and that they control the posterior movement of the center of gravity of the body. In addition, we consider these muscles control the center of gravity of the body in the coronal plane at the hip joint.

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Sometimes, when improving the range of motion or muscle strength of the shoulder joint, we fail to obtain sufficient therapeutic effects in subjects who have difficulty in raising their arms up along the spine from a position in which the arms are at the back (belt-tying movement). In many such cases, scapular motion is inadequate or different from the normal motion during belt-tying movement. On the other hand, we have experienced several cases in which the scapula moved more smoothly and belt-tying movement was improved by strengthening the scapular muscles using exercise therapy. This study aimed to elucidate the muscle activity pattern of scapular muscles during the belt-tying movement. We found that the upper trapezius muscle fibers elevate the scapula and middle trapezius muscle fibers maintain scapula adduction; and the lower trapezius muscle fibers and the serratus anterior muscle were considered to regulate anterior inclination of the scapula at T12 and lower vertebrae. Patients experiencing difficulty in belt-tying movement should receive a quantitative and qualitative assessment of the timing of movement of the trapezius muscle fibers and the serratus anterior muscle after gaining an understanding of the stage in which the patient starts to feel difficulty in movement.

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We investigated how proprioceptive input influences the hip joint in healthy subjects in a weight-bearing task. We found that weight bearing on the lower limbs increased while standing with the eyes closed, which show that the change in weight bearing was largely affected by sensory input associated with the movement of the hip joint.

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In the present study, we examined the effect of voluntary movement of one arm on the sensory system of the contralateral arm using somatosensory evoked potential (SEP). Eleven healthy right-handed subjects were enrolled in this study. The subjects were asked to perform tasks of confrontation movements with three fingers of the right hand whose complexity in movement is different at a movement frequency of 1 Hz. In task 1, the confrontation movement of the thumb and the 2^nd finger was continued. In task 2, the confrontation movement of the thumb and other fingers was continued (the 2^nd, 3^rd, 4^th, and 5^th fingers in that order). In task 3, the confrontation movement of the thumb and the other fingers was continued (2^nd, 4^th, 3^rd, and 5^th fingers in that order). No change was observed in any task at the N9 and N13 amplitudes compared with the baseline amplitude. Significant differences were observed in tasks 1 and 3 at the N20 amplitude compared with the baseline amplitude (p<0.01). These results indicate that the voluntary movement of one arm facilitates the primary somatosensory area of the contralateral arm, and that this facilitatory effect is affected by the complexity of the movement.

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We report the case of a patient with global rotator cuff tear who had difficulty in drinking soup using the left hand. Active flexion of her shoulder was more restricted than shoulder abduction. Excessive abduction was required to maintain the motion of keeping the cup at the height of the lips when the patient used her left hand. An electromyogram revealed excessive activities in the trapezius and deltoid muscles and low activity in the serratus anterior muscle. The function the patient's scapular girdle muscles was normal; however, upward rotation of the scapula was restricted. Physical therapy was administered mainly to improve the upward scapular rotation. Subsequently, active flexion improved. Stabilizing the scapular girdle and training the serratus anterior muscle resulted in an improvement in the motion of keeping the cup at the height of the patient's lips while drinking soup with her left hand flexed. The improvement in the scapular girdle function for flexion was useful for improving the shoulder function of our patient with global rotator cuff tear.

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Recently, we encountered a patient with osteoarthritis of the right knee who complained of right knee pain during walking. We administered physical therapy to this patient. Pain due to hallux valgus in the right foot was noted as an underlying condition. Right knee pain during walking was attributable to the gait pattern, which was aimed at avoiding the pain arising from hallux valgus. The gait pattern of this patient was characterized by toe overlap due to flexion of the toes during the middle to late stance phase, resulting in loading of the body weight primarily on the toes closest to the 5^th (little) toe. During the middle to late stance phase, pain in the medial side of the knee was due to supination of the subtalar joint, external rotation of the leg and genu varus. Based on these findings, knee pain of this patient was attributed to a disorder of the foot, and therapeutic intervention was carried out on the flexor hallucis longus muscle, flexor digitorum longus muscle and plantar aponeurosis. Two months after the intervention, pain in the right big toe and right knee during walking had disappeared. Improving the foot function was more important for the alleviation of knee pain in this case than improving the knee joint function.

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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.

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Recently, we encountered a case of open fracture of the right tibia with insufficient kick-off of the right lower extremity during the late stance phase. Physical therapy was administered for this case. In analysis of the gait pattern, this patient showed no anterior inclination of the right leg throughout the stance phase but exhibited hyperextension of the right knee joint. During the late stance phase, the right ankle joint remained in plantar flexion and kick-off was insufficient. To treat this condition, we initially provided range-of-motion (ROM) training to expand the range of dorsiflexion of the right ankle joint. This training alleviated the restricted ROM of the right ankle dorsiflexion; however, the right-knee hyperextension during the middle stance phase persisted and kick-off during the late stance phase did not improve. Electromyographic evaluation revealed insufficient activity of the triceps surae muscle of the right leg during the middle stance phase. We began muscular reinforcement training for the triceps surae muscle to improve the range of ankle joint dorsiflexion. Following the treatment, the electromyographic pattern became closer to the pattern observed in normal individuals. During the middle stance phase of the right lower limb, improvement was observed in the activity of the right triceps surae muscle in relation to the range of ankle joint dorsiflexion, enabling the patient to keep the leg inclined forward. As a result, right ankle dorsiflexion appeared during the middle stance phase, leading to the disappearance of knee-joint hyperextension. At the same time, the patient regained the capability of right ankle plantar flexion from the position of dorsiflexion and also showed improved kick-off during the late stance phase. Our experience with this case indicates the importance of considering the leg position in which muscular activity is poor.

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We administered exercise therapy to a patient with acute subdural hematoma and right hemiplegia with a risk of falling backward to the left during transfer to the non-paralyzed side. An assessment was performed categorizing the transfer movement into standing, left step forward, right step backward and sitting positions. In this case, trunk bending/bending to the right, anterior pelvic tilt/inclination to the right/rotation to the left, and bending of the right hip joint/abduction/extorsion during the left step forward movement resulted in the patient having difficulty in shifting weight to the right leg and the patient could not move the left leg forward. In addition, poor alignment of the trunk/pelvis observed during the left step forward movement was augmented in the following right step backward movement, resulting in bending of the left hip joint/adduction/intorsion. As a result, the patient was observed to have a risk of falling backward to the left. Hypotonia of the right-dominant bilateral abdominal oblique and bilateral gluteus muscles was considered to be the problem in these two movements. To address this problem, the patient was treated for 3 months. As a result, the patient was able to shift weight to the right leg, vertically suspend the trunk during the left step forward movement, and move the left leg forward. Furthermore, the patient was able to suspend the trunk vertically during the right step backward movement and rotate the body to the right. Thus, transfer movement was improved to the level of independence.

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We provided physical therapy for a patient with cerebrovascular disease presenting with left hemiparesis due to infarction of the right parietal, temporal and occipital lobes. The patient had difficulty standing up because of an abnormal muscle tone caused by deep sensory disturbance of the affected lower extremity. Physical therapy was provided to improve sensory function. After seven sessions of physical therapy in one week, deep sensation and abnormal muscle tone improved. Load-bearing ability of the affected extremity increased and the amount of support needed to stand up decreased because of the improved muscle tone. Sensation was also recognizable following this improvement. It was believed that the amount of support needed to stand up decreased, resulting in a change in the amount of exertion needed to adjust muscle tone. This indicates that physical therapy is necessary for considering the interaction between sensory disturbance and muscle tone in patients with hemiparesis caused by cerebrovascular accidents.

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We administered physical therapy to a patient with post-stroke right hemiplegia who had difficulty eating with the fingers of the affected hand. The functioning of the fingers was preserved, but their dexterity decreased because the affected upper limb could not maintain forward elevation. We believed that instability of the trunk and scapular region of the affected side influenced finger movements of that side. Therapeutic gain, after providing physical therapy to the trunk and affected shoulder region, was assessed using surface electromyography. Alignment of the trunk and affected shoulder region as well as feeding activity improved. Surface electromyography evaluation during forward elevation of the affected upper limb showed an improvement in the muscle activation pattern. Stability of the chest and scapula was necessary to attain finger dexterity in this patient.

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We report the case of a female patient with an incomplete tear of the supraspinatus muscle. The patient complained of difficulty while performing overhead work because of pain when raising her arms to perform such work. She also experienced this pain in shoulder flexion; however, there was no excessive elevation of the scapular girdle during flexion. The patient underwent physical evaluation, including various stress tests (an impingement test, a speed test, Yergason's test, etc.), electromyography, and simple radiographic assessments. On the basis of her test results, we concluded that her shoulder pain was caused by dysfunction of the infraspinatus muscle, which depresses the humeral head, and by excessive upward rotation of the scapula during the early phase of flexion. The patient was administered physical therapy targeted at improving the combined movements of the rotator cuff muscles and scapula, following which her pain decreased.

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