We describe the following 3 important points in muscle tone evaluation. (1) It is important to examine the tension of the skin and other soft tissues as well. (2) The results of research into the rectus abdominis indicate that muscle tone in the central belly may not reflect the overall tone of that muscle. (3) Detailed evaluation of the function of all abdominal and back muscles should be performed.
The range of motion test (ROM-T) and the manual muscle test (MMT) are basic tests used to evaluate muscle dysfunction. However, it is difficult to accurately diagnose a clinical condition only by quantitative evaluation, which measures a range of motion and muscle power. To determine the clinical condition of a patient with shoulder disorder, it is necessary to perform ROM-T and MMT on the glenohumeral joint and the scapular girdle as well as evaluate movement of the scapula girdle (qualitative evaluation), which has varying mobility and individual muscle strengths. Therefore, informing patients of this evaluation along with educating them on the techniques for performing ROM-T and MMT is important to gain clinical experience.
In clinical practice, sensory tests are performed for patients with a disorder to establish a diagnosis or verify a hypothesis concerning sensory impairment. The hypothesis is set up by the therapist through observational assessment and a graphic display of movements based on a top-down approach. This paper discusses sensory testing based on a top-down approach by presenting effective clinical methods to identify sensory impairments.
We utilize the deep tendon reflex test for the evaluation of central nervous system disease as part of physical therapy. Deep tendon reflexes are affected by the Ia fibers of the same as well as other muscles, Renshaw cells, and the upper central nervous system. In this paper, we confirm the neurophysiological significance of the deep tendon reflex and describe devices for performing the reflex test.
The aim of this study was to clarify the function of the abdominal muscles in stabilizing the trunk during shoulder flexion. We used surface electromyographic (EMG) data from the rectus abdominis (RA) and external oblique abdominis (EO) muscles of 7 healthy male subjects (age 29.4 ± 4.7 years). Muscle activities of the right anterior deltoid, serratus anterior (SA), RA, and EO muscles were recorded while maintaining right shoulder flexion. The subjects held a plumb-bob of 5% of body weight. The angles of shoulder flexion were 30°, 60°, 90°, and 120°, and they were maintained for a full 5 s in each position. EMG activities of EO during shoulder flexion of 120° and 90° were significantly greater than that during shoulder flexion of 30° (p<0.05). EMG activity of SA during shoulder flexion of 120° was significantly greater than that during shoulder flexion of 30° (p<0.05). EMG activity of RA during shoulder flexion of 120° was significantly higher than those during shoulder flexion of 30° and 60° (p<0.05). The abdominal muscles are necessary to stabilize rotation of the trunk when the scapula is moved and rotated upward by concentric contraction of SA. Therefore, EO on the side of movement plays a major role in controlling trunk rotation toward the contralateral side. Although the activity level of RA was low, we consider that the finding that this muscle showed significantly greater EMG activity was due to its activity in efficiently fixing the rectus sheath while acting in concert with EO. In physical therapy evaluating motor function of the upper extremities, it is important to evaluate the abdominal muscles as well.
Quadriceps setting is widely used as a muscle strengthening exercise for the quadriceps femoris muscle. It is frequently employed from the early post-operative stage for patients receiving knee joint replacement surgery, such as total knee arthroplasty, at our hospital. Quadriceps setting is frequently performed with ankle joint dorsiflexion in the supine position. Patients performing quadriceps setting often say “I can’t understand where to flex the muscle in the leg.” Therefore, we analyzed this exercise in patients receiving knee joint treatments such as total knee replacement surgery. The patients were explained in a simple and easy-to-understand manner the correct way of performing quadriceps setting for efficient restoration of the quadriceps femoris muscle activity. In addition, we devised a quadriceps setting exercise involving knee extension and ankle dorsiflexion with the heel pressed down, encouraging simultaneous contraction of the quadriceps and gluteus maximus muscles, and analyzed the effectiveness of this exercise on quadriceps femoris muscle activity.
Limited range of motion in the knee joint is often observed in patients after total knee arthroplasty. Decreased extensibility of the skin is one of the factors limiting motion. The purpose of this study was to examine the extensibility of the skin over the knee during knee flexionat at angles of 0°, 30°, 60°, 90°, 120°, 150°, and maximal flexion as performed by 30 healthy subjects (15 males, 15 females). The skin covering the anterior area of the knee was divided into 4 sections: skin over the femur, the suprapatellar bursa, the patella, and the patellar ligament. The dimensions of each section at each flexion position were measured. The results indicate that the extensibility of the skin over the suprapatellar bursa and the patella in positions from 0° to 30° was significantly greater than that covering the femur and the patellar ligament (p<0.05). In addition, as the degree of knee flexion increased, the extensibility of the skin over the suprapatellar bursa and the patellar ligament was greater than that over the other areas. The results of this study indicate that evaluation of skin extensibility during physical therapy for patients with limited range of motion in the knee must include not only the area that shows limited motion but also the surrounding areas.
The present study investigated whether forward movement of the front extremity over the center of mass during foot touchdown contact, or backward movement of the rear extremity during foot release, affects step length elongation. Step length can be subdivided into touchdown distance (TD) and release distance (RD). The subjects were 6 healthy men. Their target walking speeds, recorded using three high speed cameras, were 1.3 m/s, 1.9 m/s, and 2.5 m/s. Step length showed a significant linear increase with increase in walking speed (r=0.74, p<0.001). TD increased as the walking speed increased from 1.3 m/s to 1.9 m/s, with a subsequent decrease after 1.9 m/s. No significant correlations were observed between step length and TD. RD demonstrated a significant positive correlation with step length (r=0.50, p<0.05) and the angles of external pelvic rotation (r=0.56, p<0.05), hip extension (r=0.61, p<0.05), and ankle plantar flexion (r=0.50, p<0.05) during foot release. These results show that backward movement of the rear extremity during foot release can cause step length elongation.
In this study, we conducted physical therapy sessions for a patient with right hemiparesis following cerebral infarction, who had difficulty washing the left arm with the right hand due to impaired flexion movement of the right elbow. During the treatment sessions, we attempted to correct the subject’s sitting posture and provided body-washing activity training to promote effective right elbow flexion. We observed that the subject had difficulty in reaching the left arm with the right hand, and no improvement was observed in the body-washing activity. We evaluated the tone of the biceps muscle (the primary elbow flexor) on the right side using a muscle tonus test. The proximal biceps was shortened and hypertonic, the muscle belly was hypotonic, and the distal biceps was normotonic. We hypothesized that the hypertonia and shortening of the proximal biceps on the right side modified the afferent activities of the hypotonic muscle belly by extending it during attempted elbow flexion. Passive stretching was performed to decrease the hypertonia and lengthen the proximal biceps on the right side. This resulted in restoration of the tone of the muscle belly and improvement in right elbow flexion. In addition, electromyography demonstrated improvement of muscular activities in the muscle belly of the right biceps. Thus, an improvement was noted in the elbow flexion range on the affected side and the patient was able to wash the left arm with the right hand. The present case suggests the necessity of evaluating the muscle tone of different parts of a single muscle when evaluating abnormal muscle movements.
We performed physical therapy for a patient with osteoarthritis of the right knee accompanied by decreased support of the right lower limb while walking down stairs. The patient experienced increased rotation of the right crus with rapid right knee joint flexion in the right stance phase while walking down stairs. This was accompanied by pain in the lateral side of the right patellofemoral joint and the medial side of the right knee joint. In healthy subjects, electromyography detects muscle activity in the right medial hamstrings and vastus; however, the same was not detected in this patient. Physical therapy evaluation suggested the presence of anteromedial rotatory instability of the right knee. In addition, shortening of the right lateral hamstrings and weakness in the right medial hamstrings were observed, suggesting excessive external rotation of the crus, which decreased the strength of the right medial vastus and subsequently caused rapid flexion of the right knee joint. We assumed that these events caused lateral deviation of the right patella. Moreover, compression of the lateral side of the patellofemoral joint and extension of the medial side of the right knee caused pain. The patient’s physical therapy regimen included stretching of the lateral hamstrings, which increased the range of motion during extension of the right knee joint. Muscle strengthening exercises were performed for the right medial hamstrings and medial vastus. After 2 months of treatment, the strength of the medial hamstrings and vastus increased while shortening of the lateral hamstrings decreased. Electromyography revealed muscle activity in the medial hamstrings and vastus, similar to that observed in healthy subjects. Excessive external rotation of the crus improved, and slow flexion of the knee joint was achieved without pain while walking down stairs. These findings suggest that the medial hamstrings are involved in the control of excessive lateral rotation of the crus accompanied by anteromedial rotatory instability of the knee. To control abnormal knee joint movement accompanied by excessive rotation of the crus, it is useful to concentrate on rotatory instability of the crus and improve corresponding muscle activity.
Physical therapy was administered to a patient with Parkinson's disease who had a tendency to fall toward the right rear side. The patient presented with a humpback posture, right lateroflexion, and left rotation in the sitting position. Spontaneous movement was deficient and a masked face was evident. When the patient shifted his weight to the right side, a sudden increase in right flexion of the trunk and forceful right upper limb movement were observed. Physical therapy included stretching the shortened muscles and shifting the body weight in the sitting position with the goal of improving the oblique abdominal muscle control. Although improvement was observed in the sitting position, no change was noted in the writing motion. Moreover, the patient became uncooperative during physical therapy, which resulted in intermittent treatment. Subsequently, ink brushing was employed as a treatment method for this subject for functional and emotional reasons. During treatment, positive reinforcement elicited a good response from the patient: changes in facial expressions were observed, the masked face diminished, and his ink brushing skills improved. Consequently, an improvement was observed in the oblique abdominal muscles. In addition, control of the upper right extremity and shoulder girdle was achieved. This improvement was observed in both the sitting position and during writing. In conclusion, ink brushing can be useful, both physically and emotionally, for patients with Parkinson’s disease.
We report our experience of performing physical therapy on a patient with altered practical gait due to neuropsychological deficit and left foot paralysis associated with left-sided hemiplegia caused by a stroke suffered two years ago. Neuropsychological deficits observed in this patient were left body agnosia, disturbance of attention, and memory disorder. In order to improve the gait, we initiated physical therapy for the paralyzed foot. However, the effects of physical therapy were only temporary. The patient’s practical gait was further altered with changes in the environment and base of support. Because of impaired recognition of the left side of the body, the patient routinely repeated the same movement and found it difficult to diverge from this fixed movement pattern. We then initiated a physical therapy regimen that emphasized relation of movement, perception, and cognitive function to identify new movement. Remarkably, the patient could adapt his gait according to changes in the environment, suggesting the effectiveness of this physical therapy approach.
We performed physical therapy for a patient who had great difficulty with walking due to pain-defense contraction of the right knee joint after total knee arthroplasty (TKA). This patient had much trouble restoring knee range of motion (ROM), even after TKA, because of a long period of suffering from pain in the right hip joint which limited the ROM. When walking, he could hardly move his knee joint and always showed knee flexion; his right hip joint was bent and his trunk leaned forward. He could not perform internal rotation of the right hip in the right stance phase. Instead, he elevated the left scapula and the left side hip joint and executed external rotation of the right side hip joint. We thought these problems resulted from limitation of ROM of the right knee joint, and we prescribed some exercises for ROM. Subsequently, ROM of the right knee joint and the joint position sense improved a little, but the patient still bent his right knee joint and showed no improvement of walking. After rethinking these problems, we concluded that we should provide therapy considering his habits before TKA. We set the bed in front of his trunk after he leaned against the bed because of relief of muscle hypertonia and position sense of knee joint. We asked the patient to lean against the bed to try and lengthen his hamstring. Subsequently, he showed less, compensatory motion of the trunk and pelvis, and internal rotation of the right hip joint gradually became possible, easing his walking difficulty. We have received the patient’s consent to publication of this report.
We administered physical therapy to a patient with hemiplegia caused by cerebrovascular disease. The patient presented to us with unstable gait due to the trailing of the right foot between the initial contact and midstance phases of the right lower limb. With physical therapy, the instability improved; however, abnormal muscle tone of the right hip extensors and adductors was noticed between the initial contact and midstance phases of the right lower limb. Improvement after physical therapy was monitored by electromyography, which focused on the right hip joint. The activity of muscles on the affected side improved along with the improvement in the muscle activation pattern of the right hip extensors and adductors between the initial contact and midstance phases of the right lower limb. We believe that the normalization of the muscle activation pattern was important for the improvement in the gait of this patient.
A patient with a trochanteric fracture of the left femur presented at our hospital. Initially, muscle strengthening of the left lower leg was attempted. This led to subsequent improvement in muscle weakness, and the patient could walk by herself with a cane. However, when she tried walking without a cane, the movement of her first step seemed unstable. We realized that the major impairment was instability at the first step of walking. To resolve this issue, we aimed at practical improvement of the instability. We focused on alignment of the pelvis and trunk, and on the center of pressure at the first step of walking. Efficient, smooth walking is possible due to a reverse reaction phenomenon derived from the standing position in a healthy person. However, in the present case, the movements of the center of pressure and the patient’s standing position at the first step were different from the general pattern. We concentrated on improving her posture and control in the standing upright position. Thereafter, the patient’s standing upright position and the center of pressure at the first step changed remarkably and she acquired smooth walking following the first step.