Various motor centers reaching the spinal cord from the cerebrum are involved in smooth movement. We do not have smooth movement even if impaired wherever of this course. The cerebellum takes various parts and communication in the central nerve thickly, and the cerebellum function is important at all in conducting smooth movement. First we describe the classification of ataxia. Then, we describe rehabilitation for ataxia from the viewpoint of cerebellum function.

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It is essential for physical therapists, whose main role is to help people to improve their activities of daily living, to have an ability to solve muscle weakness and muscle tonus abnormality. This article describes the mechanisms of muscle power increase from the perspective of absolute muscle power and cross-sectional area of a muscle. In addition, two examples of the most commonly used exercises in clinical practice are used to show how the authors developed a way to enhance the activities of weak muscles by showing EMG wave patterns. We hope this article will help physical therapists to review their basic knowledge of muscle strengthening exercises.

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In physical therapy for contracture of the shoulder (or frozen shoulder), it is important to make an effort to understand the condition as well as to communicate closely with orthopedists. Inflammation around the shoulder limits shoulder movement through pain and contracture of the shoulder joint, and it is classified as the freezing stage, the frozen stage, and the thawing stage, each of which needs an appropriate choice of therapy. In the freezing stage, pain relief and maintaining range of motion are important. It is necessary to pay attention to the loading and positional relationship of the humerus and scapula, while avoiding pressure and tension, which can cause pain, on the rotator cuff, subacromial bursa, and coracoacromial ligament. The objective of therapy in the frozen stage is the improvement of range of motion, and rotator cuff and shoulder girdle functions. It is important to perform range of motion training with an anatomical understanding of the features of the rotator cuff interval region, which is the focal point of shoulder contracture. In particular, it is necessary to look out for the shoulder shrug phenomenon when performing arm elevation, because of its detrimental effect on the function of the supraspinatus muscle. With this in mind, the authors propose a shoulder exercise method in the side-lying position, which suppresses the shoulder shrug phenomenon, while improving the function of the rotator cuff and shoulder girdle muscles.

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For the adequate management of abnormal muscle tonus, it is important to first determine the underlying etiologies. These include primary causes such as spasticity, rigidity, and flaccidity, and secondary causes such as muscle and skin shortening. This study discusses whether abnormal muscle tonus is directly caused by primary etiologies or by a combination of primary and secondary etiologies, and describes treatment strategies for both types. Specific approaches for the management of abnormal muscle tonus are as follows. For secondary impairments such as skin and muscle shortening, measures to directly stretch the muscles and skin are considered effective. For primary impairments, prolonged stretching, motor imagery, and measures to enhance voluntary movements are important approaches. Patients can be self-trained in these approaches, which can improve the muscle tonus by altering brain and muscle function.

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Somatic sensation has an important role in the control of movement. The information from a receptor produces perception in the cerebral cortex. Movement is adjusted using this sensory information. In addition, movement is sometimes adjusted by reflex through the spinal cord or brain stem, and it is not perceived. In order to perform a suitable sensory stimulus, physiological consideration of the observed phenomenon is required. In this paper, a previous study of sensory motor function is reviewed, and physiotherapy is discussed.

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This study examined the influence of knee flexion in a standing position on the patellar rotation angle in the frontal plane using radiographs. The study included 20 limbs of 10 healthy adults (mean age: 26.5 ± 3.2 years). The participants were instructed to randomly change the flexion angles of both knees in a standing position from 0° to 60° at intervals of 10° and frontal images were captured. The inward and outward movements of the lower part of the patella were regarded as external and internal rotations, respectively, and the patellar rotation angle in the frontal plane was calculated with a view to clarifying the influence of changes in knee flexion angle on the patellar rotation angle in the frontal plane, as well as the level of change in the patellar rotation angle with changes in knee flexion angle of 10°. The patellar rotation angle in the frontal plane showed a tendency to externally rotate with increase in the knee flexion angle. The increase in the patellar rotation angle was more marked at knee flexion angles of 40°, 50°, and 60° than at 0° (p<0.05). Furthermore, the external patellar rotation angle increased more markedly at knee flexion angles of 0° and 10° than at the other angles (p<0.05). These results may be explained by the lower extremity rotating internally during knee flexion, with regard to the position of the femur, consequently pulling the lower part of the patella inward through the patellar ligament. Contraction of the vastus medialis may also have acted to externally rotate the patella. Considering that the contact area between the patella and intercondylar notch of the femur is small at a knee flexion angle of 0°, the change in the external patellar rotation angle is likely to peak in the early stage of knee flexion.

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The purpose of this study was to investigate the electromyographic (EMG) activities of the multifidus, longissimus, and iliocostal muscles in the standing and forefoot standing positions in order to understand the relationship between each muscle activity and thoracolumbar extension in the forefoot standing position. This study recruited 10 healthy male volunteers (mean age: 28.4 ± 6.1 years). The EMG activities of the multifidus, longissimus, and iliocostal muscles were measured in the standing and forefoot standing positions. The values of the integrated EMG activities of each task were compared. Each muscle showed a significant increase in the value of the integrated EMG activities in the forefoot standing position (p<0.01). The activities of the iliocostal muscles were separated into two types: Group A, in which the EMG activities did not increase much, and Group B, in which the EMG activities clearly increased. In group A, the forefoot standing position involved extension of the hip joint, and lumbar alignment was almost identical to that in the standing position. In group B, lumbar lordosis and anteversion of the pelvis were significantly greater in the forefoot standing position than in the standing position.

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This study investigated the influence of inter-onset interval (IOI) shift from 1 to 20% of 1,500 ms on the control of reactive movements. Ten healthy individuals (8 males, 2 females; mean age, 25.5 ± 3.7 years) participated in this study. All subjects performed reaction time tasks, raising their right ankles in response to an auditory stimulus. There were 21 test conditions: periodic auditory stimuli at an IOI of 1,500 ms, and shifts in the IOI from 1 to 20% of 1,500 ms, in successive stimuli at an IOI of 1,500 ms. The electromyographic reaction times (EMG-RTs) were compared among EMG-RT responses to stimuli 6 to 10, EMG-RT responses to stimuli which shortened IOI, and EMG-RT responses to stimuli 1 to 5 which shortened IOI. EMG-RT responses to stimuli which shortened IOI were compared among the 21 conditions. Under each condition, the EMG-RT responses to stimulus 2 were significantly shortened compared to the response to stimulus 1 (p<0.01). Under conditions of periodic auditory stimuli at an IOI of 1,500 ms and a shift in the IOI from 1 to 7% of 1,500 ms, the EMG-RT responses after stimulus 3 were significantly shortened compared with stimulus 2 (p<0.01). Under conditions of shift in the IOI from 8 to 20% of 1,500 ms, the EMG-RT responses to stimuli which shortened IOI were significantly delayed compared with stimuli 3 to 5 (p<0.01). The EMG-RT responses after stimuli 1 to 5, which shortened IOI, were significantly shortened compared with stimuli which shortened IOI (p<0.01). For shifts in the IOI from 12 to 20% of 1,500 ms, EMG-RT responses to stimuli which shortened IOI and after stimuli 1 to 5, which shortened IOI, were significantly delayed compared with stimuli 3 to 5 (p<0.01). In the comparison of the 21 conditions, the EMG-RTs of shifts in IOI from 8 to 20% of 1,500 ms were significantly delayed compared with periodic auditory stimuli with an IOI of 1,500 ms, and shifts in IOI from 1 to 7% of 1,500 ms (p<0.01). Periodic rhythmic stimulation of 1,500 ms interval is predicted to comprise about 100 ms width, and reactive movements can be performed without delay under conditions with an IOI shift 7% of 1,500 ms.

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We performed physical therapy for a patient with post-cerebellar stroke who tended to fall to the right during the mid to late stance phases of gait. The thoracolumbar region and bilateral hip and knee joints remained flexed during walking. Right hip joint flexion and adduction were noted in the mid to late stance phases, with excessive movement of the pelvis to the right and back, rapid inward grounding of the sole of the lifted left foot, and narrowing of the step width and length. As a result, the stability of gait was reduced. Because the thoracolumbar region and bilateral hip and knee joints remained flexed, the right hip joint extension-induced forward shift of the pelvis over the right femur in the mid to late stance phases was reduced. Accordingly, there was no right gluteus maximus muscle activity, and right hip joint extension was limited. Moreover, flexion of the right hip joint in the mid to late stance phases led to difficulty in generating gluteus medius muscle activity to stop adduction in the neutral position. Because right hip joint flexion and adduction occurred in the mid to late stance phases of gait, we considered that physical therapy to treat the main cause of this condition, hypotonia of the gluteus maximus and medius muscles, was necessary. However, unless flexion of the thoracolumbar region could also be reduced, anterior deviation of the head over the base of the support would persist, even if hypotonia were improved and extension of the right hip and knee joints in the mid to late stance phases became possible. Therefore, therapy first targeted flexion of the thoracolumbar region and then treated the main cause of unstable gait, hypotonia of the gluteus maximus and medius muscles. Practicing right forward shift of body weight in the standing position and step motion with support for the right leg reduced the tendency to fall in the mid to late stance phases and increased the stability of gait. This case highlights the importance of designing physical therapy programs considering the order of dysfunction and their sequential execution.

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We performed physical therapy for a patient with left hemiplegia after right putaminal hemorrhage who had a tendency to fall backwards toward the paralyzed left side while standing up. In the standing-up motion of this patient, hip joint flexion on the paralyzed left side was poor in the flexion phase, and flexion, abduction, and internal rotation of the hip joint on the non-paralyzed right side caused slight pelvic anteversion from retroversion, and pelvic depression and forward inclination of the trunk on the right side. In addition, the hip joint on the paralyzed side was externally rotated, and the ankle joint was in the plantar flexion position and lifted the medial sole from the floor, increasing weight-bearing on the lower limb on the non-paralyzed side when the gluteal region was lifted from the seat. Consequently, weight-bearing on the paralyzed left side was insufficient, and the gluteal region was lifted from the seat by extension of the hip and knee joints on the non-paralyzed right side. This movement of the right lower limb induced hip joint flexion and adduction, knee joint extension, ankle joint plantar flexion, and an associated contralateral reaction: inversion of the left foot, which lifted the sole on the paralyzed side, leading to a tendency to fall backwards toward this side with hip joint extension and adduction, knee joint extension, and ankle joint plantar flexion on the right side in the subsequent extension phase. Thus, physical therapy was performed to improve the problem with the standing-up motion after the gluteal region had been lifted from the seat, focusing on a symmetric seated posture, symmetric movement in the flexion phase of standing up, and the application of tactile and pressure sensations to the sole on the paralyzed left side. In addition, the patient was instructed to load weight carefully on the lower limb on the paralyzed side while visually confirming sufficient contact of the sole on that side with the floor by half standing, followed by slowly increasing the seat height and weight-bearing on the left lower limb. Through this procedure, the patient became aware of weight-bearing on the paralyzed side and was able to support lifting of the gluteal region and the extension phase of the standing-up motion with both lower limbs, thereby achieving a standing position. Through this case, we confirmed the necessity of considering the environment and limb positions in physical therapy, and the awareness of weight-bearing on the paralyzed lower limb by patients with severe tactile disorder of the sole and difficulty in weight-bearing on the paralyzed side. In addition, we learned that support by the paralyzed lower limb can be acquired and an abnormal pattern of standing-up movement can be improved by repeated practice of the normal motion, with emphasis on the application of tactile and pressure sensations to the sole on the paralyzed side.

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At our institution, patients are provided with physical programs such as device-assisted muscle-strengthening, aerobic exercise, and sling exercise, with the aim of maintaining and increasing physical fitness. We also design personalized programs for independent training utilizing a stabilometer (Digital Mirror, Panasonic). In the present study, we performed physiotherapy assessments using action observation and stabilometry for a patient with thoracic ossification of the ligamentum flavum who presented difficulty in rotating the body to the right while standing. The patient’s right body rotation was characterized by flexion of the right hip joint at the end of the motion, accompanied by forward inclination of the trunk and increased adduction of the right hip joint, with lifting of the right foot medial arch and calcaneus, inducing talar joint supination and plantarflexion of the ankle joint. In this motion, the center of pressure (COP) of the right foot shifted forward and oscillated, which was likely to make right body rotation difficult. Therefore, we provided the patient with one exercise session focusing on muscle tension around the right hip joint; however, this did not affect the COP or body movements. Following this, we focused on disturbance of deep sensibility in the right ankle joint and prescribed exercise treatment. This effectively altered the COP position and body movements at the end of right body rotation, allowing the patient to complete the motion. Here we report our observations and discuss the case in detail. The patient was informed of the publication of this article and appropriate patient consent was obtained.

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We report the physical therapy conducted for a quadriplegic patient after incomplete sixth cervical spinal cord injury. The patient had difficulties in transfer movements with a tendency to fall backwards to the right during standing up movements. We therefore analyzed the patient’s standing up movement. First, we improved the abnormal muscle tone. Then we applied sensory stimulation to the right foot sole. Subsequently, the movement of standing up was practiced, focusing on awareness of the load on the right lower extremity (physical therapy A). We observed an improvement in the flexion phase of the standing up movement and also in the sitting posture. However, joint dorsiflexion and inversion of the right ankle occurred in the phase during which the patient’s hip was lifted. Moreover, the anteromedial part of the right foot sole moved away from the floor. Anterior tilting of the lower leg with dorsiflexion of the right ankle joint was not observed. Hence, we considered that the patient needed to keep the anteromedial part of the right foot sole in contact with the floor surface by ankle joint eversion movement using the action of the right peroneus longus. Furthermore, in addition to physical therapy A, we treated the patient for hypotonia of the right peroneus longus (physical therapy B). Subsequently, the patient regained the ability to perform anterior tilting of the lower leg with the anteromedial portion of the right foot sole grounded on the floor during the standing up movement.

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We used physical therapy to treat a patient experiencing difficulty in elevating the upper body from a supine position after a compression fracture of the second lumbar vertebra and resolution of an intestinal obstruction. Although the patient was able to walk independently using a walking aid, she had difficulty in elevating the upper body from a supine position to sit on the edge of a bed. Therefore, improving her ability to execute these movements was considered necessary, with a view to extending her range of activities in the ward. Because bone healing after the compression fracture was insufficient, the patient used a lumbosacral orthosis to prevent trunk flexion/rotation from increasing compressive/rotative stresses on the affected vertebra. On assessing the patient’s ability to elevate the upper body after turning right (according to the arrangement of the patient’s bedroom at home), we found that she could not fully assume the right recumbent position because of insufficient horizontal adduction of the right shoulder and adduction/internal rotation of the right hip. Because of the limited range of these movements, range of motion (ROM) exercises for the right shoulder and hip were initiated. After the exercises, the patient regained the ability to turn right to assume the lateral recumbent position; however, it was still difficult for her to support her upper body using her right elbow in this position. There have been no reports regarding the execution of these movements, i.e., from adopting a right recumbent position using the right elbow to support of the upper body with a lumbosacral orthosis attached. Accordingly, we examined these movements in healthy individuals to determine the relevant regions, and the patient underwent examination and measurement again. The results revealed weakness in the right latissimus dorsi (a muscle important for right shoulder extension), scapular depression/adduction, and trunk flexion to the right. Therefore, the patient was prescribed exercise to strengthen the right latissimus dorsi, and subsequently practiced supporting the upper body with the right elbow in the lateral recumbent position. These approaches improved her ability to elevate the upper body in bed as well as the strength of the right latissimus dorsi.

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We conduct physical therapy for patients with brain stem infarction who complain that “the movements of hip flexion and raising the hand are poorly coordinated, particularly on the affected side; so it is difficult to reach an object above shoulders.” In the process of reaching for an object with both hands, subjects remain in a flexed position and the trunk tilts forward and bends at both hips. The trunk continues to stretch. Then, both hands need to be lifted; however, patients are unable to reach things on the affected side and grab the thigh immediately. In addition, before and after the aberrant bending extension of the lower thoracolumbar region of the body, the patient is asked to test the movement of raising the hand via bending both shoulder joints, but execution of this movement is difficult. We consider that the aberrant movement of the lower thoracolumbar region influences the entire movement (reaching and taking). Accordingly, this process was subjected to evaluation and treatment. We observed that there was a reduction in the anteroposterior sway because of bending extension in the thoracic spine (bottom and lumbar). Thus, practical improvement in the movement to reach and pick up an object from above shoulders was achieved for both hands.

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A patient with a distal fracture of the right tibia and fibula and burst fracture of the third lumbar vertebra with a tendency to fall backward during the right stance phase of gait was examined. At the initial assessment, the wearing of a hard corset and half weight bearing on the right leg were instructed by the orthopedist. Thus, half-weight-bearing walking was observed and evaluation and treatment were performed, indicating that the problems arose after permission to progress to full weight bearing. In partial-weight-bearing walking, the trunk was bent, the pelvis was inclined backward, and the right hip joint was extended during the early to middle stance phase of the right leg. At that time, reduced stability on the posterior side due to increased bending of the right knee joint was noted. Reduced right knee extensor strength and reduced right hip extensor strength were found in muscle strength tests. Therefore, we considered that in addition to increase in the right knee flexion, due to reduced right knee extensor strength, the patient’s ability to maintain the right hip joint in the neutral position between flexion and extension was decreased due to reduced right hip extensor strength, exacerbating the right knee flexion, reducing stability on the posterior side. We concluded that the problems observed in partial-weight-bearing walking would be more prominent in full-weight-bearing walking. Therefore, muscle strength training and weight-bearing and walking exercises were prescribed to improve the right knee extensor strength and right hip extensor strength. After the training, the patient could maintain the right hip joint in the neutral position between flexion and extension during the early to middle stance phases of the right leg in full-weight-bearing walking. Also, the patient’s right knee flexion was reduced, which improved stability on the posterior side.

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We report the case of a patient who had a spinal cord tumor removed, resulting in unstable gait. The unstable motion occurred during the right swing phase of walking, and started from the right mid-stance phase. Input from deep sensory receptors was impaired because of the intramedullary tumor of the thoracic spinal cord (Th10). We considered that the cause of the unstable gait was enlargement of the joint position sense of the right leg. In order to improve the patient’s unstable gait, we performed physical therapy focusing on the muscle spindles of the right lower limb. Through physical therapy, the patient’s unstable gait became more stable, and the sensory disorder of the right lower limb improved despite a general assessment of no change in sensory ability. In this case, focusing on high muscle spindle activity may have led to a good result. We believe that motion training is effective as it uses the conserved deep sensory mechanisms. Physical therapy for sensory impairment should be considered depending on the characteristics of sensory receptors.

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