Title: Approaches to the lower limb functioning of patients with sensory disturbance

Organization: Tokyo metropolitan Koto geriatric medical center
Author: Miwako Shimoraku, RPT
Key words: walking, standing balance, and sensory disturbance

In this report, the lower limb function in ADL(activities of daily living)is discussed from the viewpoint of the acts of walking and standing.
Walking requires movements with a stable symmetrically postured upper body and an asymmetri-cally postured lower body. The act of standing requires that the lower body should maintain appro-priate symmetry to keep balance when the upper body assumes various postures.
The lower limb function is analyzed in the acts of walking and standing through an analysis of normal movement and through therapy sessions with a hemiplegia patient with severe sensory disturbance and balance problems. At first, the acts of normal standing and walking were ana-lyzed. Then the difference in reactions with and without handling in parallel and step positions was analyzed. These analyses showed that treatment in the parallel position facilitates the mobility of the trunk, pelvic girdle muscles and lower limbs so that the upper limbs can be used in various spaces (left, right, up and down). It was thought that treatment in the step position could improve walking and movements in a standing position through the facilitation of upper body stability and the control of lower limbs in the stance terminal phase and heel contact phase. In addition, during the therapy sessions it was important to consider the relationship between postural control to fundamental motion and proprioceptive sensibility input.
In therapy sessions for this case, in the parallel position a therapist stabilized the patient in the midline axis by using handling techniques from the CKP(central key point), and helped the patient control the flexion, extension, and rotation of the trunk and lower limbs, gradually making tasks more difficult for the patient. In the step position the muscle activity responsible for moving between the stance and swing phases was encouraged, while proprioceptive sensory input was improved through stretch stimulation of the muscle spindle and the Golgi tendon organ in the antigravity muscles of the crus and thigh. The author believes that because the above-mentioned practices have alleviated sensory disturbance in the lower limbs and accelerated motor learning, they are therefore effective in improving everyday mobility and standing ability.

Title: An Approach to the lower extremities and trunk based on the postural control mechanism

Organization: Hoshigaoka Kouseinenkin Hospital
Author: Ryuji Hori, RPT
Key words: postural control mechanism, body schema, and thalamus

An approach to the postural control mechanism was applied to a case of left hemiplegia after a thalamic hemorrhage. During the approach, the relationship between postural control and body schema, the importance of alignment between the lower limb, pelvis and dorsal column, and the interaction between postural control and motor control were considered.
The treatment goal for this case was set to be effective standing posture. In other words, it was the release of static degree of freedom and adaptable walking to various conditions. Adaptable walking to various conditions is produced by the activation of the rhythm generation system accompanying the released static degree of freedom. During therapy sessions, the following issues were considered;
1) Protective immobilization of the less affected side's lower limb and dorsolumbar part, caused by the low back pain from which the case had been suffering before the onset of the thalamic hemorrhage. Additionally, reduced mobility in the direction of the less affected side caused by excessive fixation of the less affected side's dorsolumbar part (this is caused by the patient's excessive effort to adapt to the environment). Also, reduced stability caused by hypotone in the abdomen and the upper and lower limbs.
2) Coordination disorder between visual and vestibular sensation, caused by the superficial sensory disturbance, deep-seated sensory disturbance and the collapse of the head alignment in the affected side as well as the dysgnosia of the body schema caused by the lack of synchronicity be-tween visual and motor awareness.
3) The stereotyped gait caused by both the freeze of static degree of freedom and the accompanying inactivation of the rhythm generation system, which is an inefficient postural control caused by 1) and 2).
Approaches to the lower extremities and trunk were implemented, taking into consideration the postural control mechanism. As a result, his gait had changed and his balance while standing and walking had improved, although no significant improvement of motor and sensory functions had been observed after five weeks from the onset of the thalamic hemorrhage.
In this case, the superficial sensory disturbance, deep-seated sensory disturbance, and the lack of synchronicity between visual and motor awareness were caused by the thalamic disorder. As a result, in this case it was supposed that the recognition of the body schema was affected and the static degree of freedom was frozen in order to adapt to the environment.
Through the therapy sessions, the patient's plantar sensation as well as his visual and vestibular sensation were remedied and his postural control was improved. This may have been due to the correction of his body alignment between the trunk and lower extremities which, in turn, counteracted the compensatory immobilization in his trunk. The release of the static degree of freedom allowed the original static fluctuations to take place and activated the rhythm generation system. The rotation in his trunk and lower extremities caused by the rhythm generation system resulted in the improvement of his gait. Additionally, during the therapy sessions, his ability to recognize the body schema had improved. It is supposed that this improvement was facilitated by the therapist who helped to integrate visual and motor awareness in an interactive and dynamic manner, using a cycle of the exploratory recognitions and actions, especially in the visual environment.

Title: Problems of locomotion in patients with hemiplegia

Organization: Haku-juku
Author: Kashiwagi Masayoshi, OTR
Key words: locomotion, visual information, and postural control mechanism

    In the area of human locomotion and postural control, visual information plays an extremely im-portant role. However, patients with hemiplegia are not able to receive and/or use their visual information appropriately. When they try to go through narrow or congested spaces, or ever wide spaces, their body muscles become hypertonic and they have difficulty in moving smoothly because of their abnormal movement control.
After hypothesizing about and subsequently investigating the relationship between visual information, postural tone, and motor control, I was able to confirm that visual information perceived in and around the visual field influences postural tone and motor control smoother.
During therapy sessions, it was my intention to have the patients experience a sensation similar to that which a small child would experience when he/she takes their first tentative steps. In such a situation, as is so in the case of a small child taking their first tentative steps, it is necessary for the patient to view objects such as furniture in close proximity in order to effectively negotiate congested spaces.
As a result of the therapy, the patients with hemiplegia, who could walk independently but clumsily in crowded surroundings, were able to move more smoothly in such surroundings.
So, as discussed, treating the visual problem, using congested spaces, has shown a marked im-provement in the patient's locomotion.

Title: ADL and lower limb function: the mutual interaction among the task, the environment and the individual

Organization: Yanagawa Rehabilitation Hospital
Author: Seiichi Nagata, OTR and Noriko Endo, OTR
Key words: lower extremity function, associated reaction, and emotional system

In the process of discussing the mutual interaction among the task, the environment and the individual, therapists should consider the effects of internal information, including the affective system, as well as various sensory systems and motor systems. Adaptations to environments in the ADL lead to changes in the internal environments of individuals. The roles of the lower limb function in the ADL are divided into the following three aspects:
1) Locomotion and transfer
2) An aspect where lower limbs play a predominant role such as taking off or putting on shoes  and getting into a bathtub, etc
3) An aspect where lower limbs become support bases
Most ADL include any one of the above-mentioned aspects, and what follows is a report based on these aspects. A male patient (age 54) with left hemiplegia after an intracerebral hemorrhage could walk indoors using a T-cane and AFO. His Functional Independence Measure(FIM)score was 119. Therefore, his degree of autonomy was relatively high. However, the score of items related to the upper limbs in the Fugl-Meyer Test was 48/126 because his sensory functions, perceptual functions and upper limb functions were affected by the associated reaction of the affected upper limb and by the amount of exertion required on the less affected side. In the following part of this report, the contents and progress of the therapy sessions for this patient are explained mainly on the basis of two therapy situations. One therapy situation was aimed at reducing the associated reaction and increasing the use of the affected upper limb. The other was targeted at adapting to the environment while taking a bath. Through the former therapy situation, the associated reaction was reduced, the frequency of use of the less affected side's upper limb was increased, and affected upper limb function was improved.
Additionally, the Fugl-Meyer Test score for the upper limb was increased to 70/126. Then, in the latter therapy situation, the relationship between physical exertion and the affective system in the adaptation to the environment (while taking a bath) was taken into account. According to the au-thor's opinion, the therapy sessions focused on the relationship between sensation and movement promoted a pleasurable emotional reaction inherent in the act of bathing, which in turn positively influenced the patient's physical movements.

Title: Lower limb function and ADL: Indispensable popliteal angle and reaction time of body righting reaction acting on the body for lower limb function and ADL

Organization: Institute of Health Sciences, School of Medicine, Hiroshima University
Author: Mitsutoshi Kawamura, RPT, MS
Key words: popliteal angle, placing reaction, and tilt angle of standing table

A fetus in the womb experiences various motions under lower gravity conditions. However, a neo-natal infant first experiences motion under stronger gravity. The fixation of joints, which allows human beings to support a part of their weight, becomes possible only after obtaining the mobility allowed by the degrees of freedom of their joints. The fixation and mobility of joints develops in tandem, leading to increasing mobility.
In recent years, physical therapies have started being provided for spastic diplegia and quadriplegia due to periventricular leukomalacia (PVL)from the period of the NICU. Positive inducement of the spontaneous movements in the lower limbs of these infants is necessary to avert otherwise un-avoidable problems of lower limb functionality. It is thought that the most effective way of bringing about an increase in the spontaneous movements of lower limbs of infants is by stimulating the proprioceptive placing reactions of the lower limbs in early infancy not only anteriorly but also later-ally. Spasticity plays a part in suppressing the mobility of the lower limbs. Comprehension of the degree of the spasticity is possible by evaluating the popliteal angle. Therapists should take care that the popliteal angle does not drop below 120°.
It goes without saying that the muscle force of lower limbs is necessary to support body weight while maintaining the upright position. Trunk stability is also indispensable. An anti-gravity posture is possible only through the maturing of the body righting reaction acting on the body, which con-tributes to the stability of the trunk. A stable upright position can not be obtained unless the amount of time required for accomplishing the body righting reaction acting on the body, which accompa-nies the rotation of the trunk in order to sit up is shortened to approximately three seconds.

Title: Analysis of walking and mobility: An application of fetal midline stability

Organization: Bobath Memorial Hospital
Author: Yoshinori Yamanaka, RPT
Key words: midline stability, posture of fetus, walking, and balance reaction

When considering the relationship between the ADL and the lower limb function, midline stability is considered to be the most important factor. All ADLs are based on the unconscious balance and righting reactions. The basis of the balance and righting reactions is the midline stability. Effective balance reactions and righting reactions are not achieved without the midline stability. A fetus learns the basis of the midline stability unconsciously in the mother's womb during its forty weeks of development. A fetus in the womb is constantly subject to the pressure of the amniotic fluid , which means that the entirety of the fetus' skin becomes its supporting surface. The fetus is therefore in the state of one-sixth gravity due to the buoyancy of the amniotic fluid.
The brain of a patient with orthopedic diseases in a part of the body gives an order to compensate for those diseases by using the entire body, and the patient's midline stability is lost. As a result, the balance reactions that should be performed unconsciously are disturbed. In this report, the midline stability was applied to treatments for a child with cerebral palsy and a stroke patient. The treatment outcomes were evaluated by the degree of improvement of the sitting balance reactions and standing balance reactions that form the bases of walking.

Title: Role of the lower limbs in the upper limb activities of children with spastic diplegia

Organization: Hokkaido Prefectural Rehabilitation center for Handicapped Children, Sapporo Unit
Author: Koji Osawa, OTR
Key words: child with spastic diplegia, base of support (BOS), and lower limbs

In order to handle toys with the upper limbs and play in a creative manner, it is required that the trunk and lower limbs of children with spastic diplegia should move autonomously to provide stabil-ity of posture. In this case, a child had been treated for four months. The child had a gestational age of 34 weeks, a birth weight of 1720g and was diagnosed with periventricular leukomalacia. The child had good overall body mobility in spite of an imbalance involving low tone in the trunk and hypertonia in the lower limbs.
The main problems were as follows:
1. Postural tone imbalance
2. Poor abdominal muscle activity
3. Hypertonia in his lower limbs with predominant extension on motion
4. Asymmetry when using the upper limbs
5. Weak sensory perception in feet
6. Immaturity of lower limb body image
In addressing these issues, the following two therapeutic goals were established:
1. Increased use of two-handed activities by stabilizing the platform sitting position
2. Improvement of his lower limb body image by means of sensory stimuli to the feet
The three following approaches were taken:
@ The therapist applied inhibitory mobilization to the feet so that the feet of the patient could perceive sensory inputs from the floor more easily and regain balance in a more adaptive manner based on those inputs.
A The therapist supported the trunk of the patient in the platform sitting position, set the alignment of his head and trunk, and encouraged him to perform the two-handed activities.
B The therapist encouraged the patient to put on and take off shoes and socks on the floor or in the platform sitting position.
As a result, the trunk and lower limbs of the patient were stabilized in the platform sitting position. He came to be able to use his upper limbs in space. Additionally, his body image of his lower limbs and feet was improved and he came to express more interest in putting on and taking off shoes and socks.
It was likely that the patient experienced stability in the proximal part of his body through fetal movements. Owing to that experience, in spite of low muscle tone in his trunk, he had the potential capacity to readily increase it by adjusting both the alignment and muscle tone in the proximal part of his body. It is supposed that as a result of this potential capability, he was able to learn selective movements in his limbs. Additionally, taking this approach towards the feet enhanced peripheral nervous system responses which in turn helped the feet adapt to the floor thanks to the sensory feedback from his soles contacting the floor. As a result, the patient seemed to be able to better construct his body image through the somatosensation.