Top-down assessment is an important evaluation process in physical therapy. It is essential to correctly understand top-down assessment, conduct appropriate movement analysis, and implement appropriate physical therapy based on the issues identified through the assessment.

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Movement in patients with lower limb musculoskeletal disorders is often influenced by factors such as joint and tissue condition, surgical history, and intra– or extra–articular inflammation. In clinical settings, pain is frequently the primary complaint, which limits the opportunity for repeated movement observations. Therefore, collecting adequate pre–assessment information to understand the overall clinical picture and determine the key movements to observe becomes crucial. In sports injuries, fundamental actions such as running and jumping are typically combined in complex ways and performed at high speed, making movement analysis particularly difficult. To address this issue, we introduced the “F Task” in Kansai Physical Therapy Journal, Volume 24, as a novel method for movement assessment. This task is designed to account for the injury mechanism and disorder onset, allowing clinicians to evaluate movement characteristics even within confined clinical environments. By using a top–down assessment framework within the“F Task”, functional impairments can be systematically identified, potentially aiding physical therapists who may be less experienced in analyzing dynamic sports movements. This paper reports the practical application of top–down evaluation for lower limb musculoskeletal disorders, presenting one postoperative hip surgery case with difficulty in abduction and three sports injury cases successfully managed with the “F–task ” Therapeutic strategies are also outlined.

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One of the advantages of the top–down approach is that it allows for a focused approach to problems in a short period of time. In order to maximize this advantage, each process must be carried out with a high degree of precision. The accuracy of the approach will be improved if we can grasp what we need to be aware of in each process in the sequence of interviewing the patient, beginning with movement observation, building a hypothesis of the problem, evaluation, treatment, and reevaluation. The first half of this paper will explain the points to be aware of in each process, and the second half will explain the top–down approach by providing actual cases while understanding the normal behavior of hand–behind–back movements.

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Patients with trunk locomotor disease often fail to hold the trunk upright when gait, and trunk movements is vary from side to side. The main problems in such cases include restricting range of motion in the thoracolumbar region and weakness in the trunk muscles. However, due to functional impairment of lower limbs, a similar phenomenon can be observed in the trunk when gait. This paper presents two cases that trunk muscle dysfunction was a main problem in the decreased practicality of gait. We hypothesized functional impairment by top–down assessment in each cases, taking into account the relationship between the trunk and lower limbs, and we explained to details of the assessment and approach.

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Central nervous system diseases are diseases that occur when some lesion occurs in the central nervous system, such as the brain or spinal cord, and there is a wide variety of medical conditions. In this lecture, we will discuss the assessment and approach to getting up and standing up in the context of cerebrovascular disease and spinocerebellar degeneration. In the first case, the interpretation and approach to getting up in cerebrovascular disease will be described. In the normal movement of getting up, the thorax is rotated to the same side by flexing the shoulder girdle on the getting up side. However, in the case of the patient with left hemiplegia due to cerebrovascular disease, the flexion of the right shoulder girdle causes insufficient right rotation of the rib cage when the patient rises to the nonparalyzed side. Through this case study, we will explain in what cases the flexion of the shoulder girdle on the rising side becomes inadequate. The approach to be taken in such cases will also be discussed. In the second case, we will discuss the interpretation and approach to standing up movements in spinocerebellar degeneration. In the flexion phase of standing up, the movement begins with trunk flexion, followed by hip flexion. In the extension phase, the trunk, hip, knee, and ankle joints move in tandem. In spinocerebellar degeneration, movements are sometimes interpreted in such a way that “the patient is unable to link movements due to cerebellar ataxia”. However, it is important to analyze movement from a kinematic perspective to clarify and approach the functional impairment. In this lecture, after clarifying the functional disability based on the interpretation of movement, we will explain how to devise an approach based on the characteristics of the case.

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The evaluation and approach to standing and walking of hemiplegic patients with cerebrovascular disease will be presented. In patients with hemiplegia due to cerebrovascular disease, there are many possible functional impairments in the upper and lower extremities of the paralyzed side. Based on the idea of top-down evaluation, the process of narrowing down the top functional impairment and approaching them is explained.

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We believe that physical therapy assessment of cerebral palsy and other paediatric conditions is better suited to top-down assessment. The reason is that it is difficult to understand verbal or non-verbal instructions to guide the desired movement or action, making active and purposeful movement or action difficult. In addition, there are no standardised and quantitatively defined developmentally appropriate joint range of motion measurements or muscle strength assessments, making it difficult to proceed objectively. Therefore, a top-down assessment of the child's expressed movement and behaviour is important. On the other hand, unlike adult diseases, developmental history needs to be considered in the top-down assessment. In paediatric diseases, deformities in the trunk can result in scoliosis, which can have serious life-sustaining consequences, such as the risk of aspiration and problems with breathing. In this report, the assessment and approach to a girl in her early teens diagnosed with mitochondrial encephalopathy will be described in detail.

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Physical therapists are motion experts who aim to improve the basic movements of daily life, such as turning over, getting up, standing up, and walking. In this paper, we will first introduce the key points we make when teaching students and newcomers about the practicality of movement and its relation to joint movement and life, the story of movement and hypotheses about problems, and innovations in teaching movement analysis through case studies. These topics are important for learning about posture and movement analysis. Next, regarding gradual post-graduate education from student teaching to new and mid-career physical therapists, effective teaching methods and development of clinical skills, importance of on-the-job training and in-hospital training leading to continuous learning, importance of improving clinical reasoning skills through the use of video materials and movement analysis, establishment of team conferences and research groups and relationship between education and skill development will be explained.

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This study investigated the effects of inhibitory techniques in acupoint stimulation physical therapy (ASPT) based on individual differences in the excitability of the spinal motor neuron function at rest. ASPT inhibition techniques were applied to 19 healthy participants during a 25% MVC pinch movement, and the excitability spinal motor neuron function was evaluated using F waves. Individual differences in ASPT inhibition effects were examined by analyzing the correlation between resting F/M amplitude ratios and the reduction in F/M amplitude ratios after the pinch movement. The higher the amplitude of the resting F/M ratio, the greater the reduction in the F/M ratio immediately after ASPT (rs=0.75, p < 0.01). It has been reported that there are individual differences in the excitability of motor neuron function, and it has been shown that individuals with high resting excitability are sensitive to inhibitory effects. Therefore, in this study, the results showed that the higher the resting excitability of spinal motor neurons function, the greater the inhibitory effect of ASPT.

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Acupoint Stimulation Physical Therapy (ASPT) is a therapeutic technique that adjusts muscle tone through pressure stimulation of acupoints. This study compared the effects of ASPT suppression techniques on excitability changes in spinal motor neuron function in healthy participants, using pressure stimulation intensity at LU5 set at 30% and 100% of the pain threshold. The objective of this study was to examine differences in spinal motor neuron excitability between ASPT suppression techniques applied at 30% intensity relative to pain threshold and those applied at 100% intensity relative to pain threshold. Results showed that at 100% of the pain threshold intensity, the relative amplitude F/M ratio decreased significantly at 10 and 15 minutes compared to during the pressure stimulation, but no difference was observed at 30% of the pain threshold intensity. These results suggest that at 30% of the pain threshold intensity, the inhibitory effect following pressure stimulation cannot be expected. Therefore, when performing ASPT suppression techniques clinically, it is necessary to perform them at 100% of the pain threshold intensity.

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The patient was a male in his 80s diagnosed with cervical spondylotic myelopathy. He was unable to lower his pants to the middle of his femur in the standing position and also had decreased safety backward during the movement. He also had left upper limb dysfunction due to his medical history and needed to lower his pants primarily with his right upper limb. When we examined the motion of lowering his trousers, we found that it was important to perform the motion while creating appropriate “tension” in the waist elastic due to an anterior pelvic tilt. The patient had a posterior pelvic tilt due to flexion of the thoracolumbar vertebral transition area from the beginning of the movement caused by increased muscle tone in the upper fibers of the rectus abdominis muscle. In addition, hypertonia of the left latissimus dorsi muscle resulted in insufficient right lateral flexion of the trunk, making it difficult for the patient to lower his pants over the bulge of the hallux valgus. Physical therapy on the upper fibers of the rectus abdominis muscle and the left latissimus dorsi muscle increased anterior pelvic tilt and right lateral trunk flexion. As a result, the patient was able to lower his trousers to the middle of his thighs from a standing position, which improved his backward safety during movement.

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A case was managed in which a patient underwent right total hip arthroplasty. The primary complaint of this case was the desire to cut the toenails, necessitating the acquisition of a nail-cutting motion that avoided the dislocated limb position. In a seated position, the patient exhibited right lateral flexion and extension at the thoracolumbar transition, along with an elevated right pelvis in space. In the hip abduction in flexion motion, there was limited right hip abduction and external rotation, and the thoracolumbar transition exhibited poor flexion, making it difficult to position the right foot on the left knee. Consequently, the patient was unable to reach the toes located in front, complicating the acquisition of the desired motion. Assessment and measurement revealed increased muscle tone in the bilateral iliocostalis muscles at the right L2 level, as well as decreased skin elasticity. Treatment was administered targeting the right iliocostalis muscle and skin tension. As a result there was improvement in the right lateral flexion at the thoracolumbar transition, and the elevated right pelvis position in space. Additionally, flexion at the thoracolumbar transition improved, allowing the patient to make contact with the toes, ultimately leading to the successful acquisition of the toenail-cutting motion.

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We experienced a case in which a patient with a dislocated fracture of the left shoulder joint, who had undergone hematologic treatment, had difficulty in performing the food service operation that was necessary for returning to work as a boarder. The patient was able to lift a plate to the height of the counter, but was unable to deliver the dish to the target position on the counter due to insufficient left shoulder joint abduction, excessive left shoulder blade elevation, upward rotation, thoracolumbar transitional extension, and right lateral flexion. Therefore, we analyzed the components necessary for the left forward reaching motion when serving food with the left upper limb, and focused on the left and related thoracolumbar transition and left scapula movements that occur with the left shoulder joint abductor muscles for evaluation and treatment. As a result of physical therapy, the left shoulder joint abductor muscle strength improved, and the patient was able to perform a food preparation movement with the left upper extremity.

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While transporting a pitcher with both hands and making a 180° turn to the left, we experienced a patient with left hemiplegia, who showed instability in the left posterior direction and a decrease in safety stability. During the directional change while transporting the pitcher, there was a lack of left pelvic rotation accompanied by left hip internal rotation, leading to excessive lateral tilting of the lower leg due to the entire left foot spatially externally rotating while resting on the little toe side with left hip adduction and left foot eversion, causing the pelvis to displace toward the left posterior direction, resulting in left posterior instability. Physical therapy was conducted for the muscle, which acts as an abductor and internal rotator, resulting in improvement of posterior instability and acquisition of the turning motion while transporting the pitcher.

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Physical therapy was performed on a patient with post-interstitial pneumonia disuse syndrome who had difficulty with getting up and moving. In the supine position, the patient had right scapula abduction and downward rotation. In the getting up movement, the patient had poor right rotation of the trunk due to flexion of the right shoulder girdle with abduction of the right scapula, and was unable to assume the right elbow support position. Physical therapy was performed to address the weakness of the right scapular abduction and upward rotation muscles and the hypertonia of the right rhomboid major muscle, which resulted in a reduction in right scapular abduction and downward rotation in the supine position. In addition, we report that right rotation of the trunk increased due to flexion of the right shoulder girdle associated with right scapular abduction, and that the patient was able to assume a right elbow support position.

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