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mp7eszaee

eg

23

Uas

8il 497--506

R'

(1996

F)

Report

Therapeutic

Exercise

for

Children

with

Spastic

Spinal

Paraplegia"

Masamichi

FURUSAWA'",

Nobuhiro

HIURA,

Masahiro

TAKESHITA,

Yuki

NOMOTO,

and

Kanako

IZUMI

Abstract

'

The purpose of thisresearch

is

toascertain the characteristics that

differentiate

spastic spinal paraplegia

(SSP)

from

spastic

diplegia

of cerebral palsy

(CP

SD),

an.d

the pointsthatshould be taken

into

consideration

in

the treatment of SSP by

physi-cal therapists, We report on ways of physicaltherapistscan prevent,by therapeutic

exercise, abnormal development of SSP children. Eleven SSP children are analyzed

through clinical charts, and with video-films, photographs, and Bobath's postural

tone

test

incomparison with CP

(SD)

children who had had lumbago and footpain,

No

child with

SSP

was

born

at a

birth

weight of

less

than 2,500g,unlike the typical

scenario

for

CP

(SD)

children

(p<O,Ol),

Allchildren acquired the ability towalk at

2.6±

1.4

years on average

(ranging

from

1

year to

5

years

1

month).

Eight

achieved

independent without

braces,

one with short

leg

braces,

two with Lofstrand crut6heS

and short leg

braces.

SSP children were clearly superior to

diplegic

children in

terms

of normal extensor patternsof thelower extremities and selective movements

of individual

joints.

Lumbago was present

in

5

(45.4%)

at 7.8±1.3years and foot

pain was presentin4

(36.3%)

at 8.5±2.6years of our 11 cases. Posturaltone of the

lower trunk tended to be low inSSP. Inorder to obtain walking and prevent

lum-bago,

physical

therapists

should make efforts

to

promote sustained coactivation of

the

lower

trunk musculature early inthecourse of treatment,

Key

words

Children

with spastic spinal paraplegia,

Spastic

diplegia,

Therapeutic

exerclse

Introduction

Spastic

spinal paraplegia

(SSP)

is

paralysis

due todegenerationinthe spinal cord mainly

'

,JivaffM,trpm,msWzzfiAdiffbltwix 'S Bebath Memorial HospiLal

(1-6-5Higashinakahama,

Joto-ku,Osaka536, Japan)

(ReceivedJune21,19941AcceptedAugust31, 1996}

with

bilateral

involvement

to the

cor-ticospinal tractsi).

It

has

recently

been

reported thatspastic spinal paraplegia

in

pe-diatric

patients

is

not necessarily

limited

to the spinal cord but possibly includes

degenerativechanges inhigher centers of the

(2)

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498

wa7diza\

diseasesisimportant

because

of the

different

clinical picture that ultimately emerges.

Most children with SSP who received

thera-peuticexercise at eur

hospital

were

original-lydiagnosed elsewhere as having spastic

di-plegia of cerebral palsy

(CP・SD).

Physical

therapists should

differentiate

SSP

from

other conditions and proceed with treatment after having obtained a 'thorough knowledge of thc characteristics of abnormal

develop-ment inSSP. Inthisstudy, we ascertain the characteristics that

differentiate

SSP

from

CP

(SD),

and the pointsthatshould be taken

into

consideration in the treatment of SSP by physical therapists,

Subjects

and

Methods

The

subjects were eleven children with

SSP,

who received therapeutic exercise at

Bobath Mernorial Hospital between August

1982

and

July

1993

(Fig.

1). Priorto

receiv-ing treatment at our hospital,cight children

(72,7%)

had originally been diagnosed as

having

had

CP

(SD>,

one

(9.0%)

as having

SSP, and thecondition

had

been

evaluated as unknown

in

two

(18.2%).

Thus, the rnajority

of these children

had

been

treated

by

physi-cal therapistsunder thediagnosis of CP

(SD),

They were seven boys and four girls.None

had

Segawa

disease

(hereditary

progressive

dystonia)6}or

juvenile

Parkinsonism7),

both

of

which can produce symptorns similar to

those of

SSP.

Neurogenic

bladder8)

was not

observed inany of these ehildren. The mean age at

initial

examination was 6.8±2.3years

(ranging

'from 2 to

13

years).

Five

children

were treatcdon beth an inpatientand an

out-patient basis,and 6 werc treated by

thera-peuticexercise only on an outpaticnt basis.

Diagnosis

prior to treatment at our

hospi-ee

23

igag

8

e

Fig.1. Pattern of walking inchildren with spastic

spinaE paraplegia. Lordosisisremarkable

and compensatory sideflexion of trunk is observed when he shifts hisweight toone

leg.

tal,

birth

history,family history,locomotor

development, presence or absence and the

oc-casion of

lumbago

and foot pain, and any

previous surgical opcrations were ascertaincd

from

medical charts.

Standing

posture and walking patterns were assessed from

video-films

(VTR)

and photographs inorder to find

out abnormal patterns caused by spasticity

in

legsand compensatory movements espe-cially in trunks, Posturaltone was assessed

with the postural tone test advocated

by

Bobath9). Points that should be taken into

consideration

in

treating

pediatric patients

with SSP by our approachiO} were in-vestigated by comparing our data on SSP children with the report of CP

(SD}

children

by

Suzukiii),

many clinical

features

of which resemble those of

SSP.

We checked on the

differentiationof both groups in the birth

weights and the gestationalages. Lumbago and foot pain of SSP were compared with

those of

CP

<SD)

in scanning the clinical

records. They were also tested to have speech disturbanceor not,

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TherapeuticExerciseforChildrenwith SpasticSpinal Paraplegia 499

Results

Eight children had blood relatives who

either had

definitive

SSP

or were suspegted

of having

SSP.

SSP

was a known entity in

two pairs of twins

(four

children), two

fathers,a mother, and an eider sister.

One

uncle was suspected of

having

SSP.

Among

the eight children who had

blood

relatives with

SSP,

six

had

been

diagno$ed

as

having

CP

(SD)

and one as having

SSP,

and the

con-dition had been evaluated as unknown in

one.

Of

the three children who

had

no

known

blood

relatives with

SSP,

two were referred to our hospitalunder the diagnosis of

CP

(SD)

and one remained undiagnosed.

Cephalic presentation was common to the

birthof all the children, The values of

jaun-dicewere within normal range. Four of the

childrcn weighed 2,500-3,OOOg at birth,and

the other seven 3,OOO-3,500g, so none of

them had abnormally low birthweight.

As-phyxia was present

in

3

children

(27.2%),

who were maintained in incubators fer less

than 7 days after birth,and their subsequent conditions was favorable.

Gestation

had

been

36

weeks

for

two children, 38 weeks for one, 39 weeks

for

four,and 40 weeks for

four.

The threechildren with asphyxia

had

been

born

at gestations of 39 weeks and 40 weeks. Three children had speech disturb-ance. A pairof 8 year old twin boys and a

6,5

year old girl had

dysarthria.

Locomotor

development

is

shown

in

Fig,

2,

The

chil-dren could roll over at 7,l±2.4 months on

the average

(ranging

from 4 to 12 months).

Sitting was achieved at 7.7±2.6 months

(ranging

from 5 to 13 months), although the

age was uncertain in one child.

Crawling

was achieved at

11.8

±

4.8

months

(ranging

WALKINGWITHOUTBRACES

WALKING WITH SHORT L.EG BRACES WALKINGWITHLOFSTRAND CRUTCHESANDSHORTLEa BRACESWALKINGWITHWALKER CRUTSINGLOCOMOTIONASSESSMENT F --o " :--o H --o 1 H , M , '111'''/11''1T''b' IN:TtAL ASSESSMENTF]NALASSESSMENT

Fig.2. Change of locomotion.

from 6 to 16 months), but with the ages un-certain

in

two children.

The

children could cruise along the furniture at

18.8

±

11.1

month

(ranging

from

9

months to

2.6

years),

All

children acquired the ability to walk,

As

shown in Flg. 2, nine ambulated

inde-pendently, but two needed Lofstrand

crutches. They

became

able towalk at 2,6±

1.4

years

(ranging

from

1 year to 5 years 1

month).

Six

of the children underwent surgical

proceduresi2)i3). The Baker operation to

lengthen the gastrocnemius was performed

bilaterally

infivechildren, and the surface of adductor

longus

was released bilaterallyto

alleviate flexionand adduction contracture of

the hip

joints

in one child.

Medial

ham-strings were clongated

bilaterally

in

one

child to increase the ability to extend the

knees. The flexor hallucis longus was

released bilaterallyinone child fortreatment

of hammer toes.

Pain was noted

in

seven

(63.6%)

of the children with

SSP.

Five

(45.4%)

had

lumba-ge at 7.8±

1.3

years

(ranging

from 6years to

(4)

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500

Table

ve\wtzaeig

ee23igees・g-l Comparisonof birthweight betweenSSP and CP

{SD)

Birthweight

(g)

1,ooe-1,soe 1,500-2,OOO 2,OOON2,500 2,500--・3,OOO 3,OOO<

SSP

(N-11)

CP

(SD)

(N-9)'

o3 o2 o2 4o 72

'Suzuki 19goll).

8.5±2.6 years

(ranging

from

5 years to

12

years), In scanning our clinical records of

thirteen children with cerebral palsy, we

found

that eight

diplegic

children and one

diplegic

adult

had

suffered Iumbago at 12.9±

5,6years

(ranging

from 5 years 2 months to

22 years),and fivediplegicchildren had had

foot pain at 9.4±3,1 years

(ranging

from 5

years 9 rnonths to

l3

years).

All

of three children with CP

(SD)

could walk independ-ently without crutches,

When

spasticity of the

lower

extremities was reduced by thetherapisVshandling,

chil-dren with SSP were betterable than children

with

CP

(SD)

to maintain the lower

ex-tremitiesextended against gravity,which is

necessary for standing and walking. The chi!dren with

SSP

also

dernonstrated

greater

ability for selective movement at the hips,

knees,and ankles, especially inmovement

in-volving fiexion and extension of the knee and

dorsifiexion

of the ankle.

In

contrast, the children with

SSP

had

diMculty with coactivation in thc lower trunk, particularly

with sustaining contraction of the abdominal

muscles

during

extension of the trunk against gravity.

Our

clinical observations, gait analysis using VTR and photographs, and postural

tone testing have confirmed that postural

tone of the lower trunk inchildren with SSP

islower than that inchildren with CP

(SD),

and that SSP isassociated with a

tendency

(P<O.Ol)

for

marked

lumbar

lordosis.

Discussion

1.

Knowledge

of

SSP

in

terms of physical therapy

Some recent studies using

diagnostic

im-aging, such as computed tomography and magnetic resonance imaging, as well as

cere-brospinal

fluid

testing, have

Shown

that the

degeneration

Qf

SSP

isnot necessarily

limit-ed tothe spinal cord

but

can also includethe

brain2-5).

Two brothers,10 and 8 years old,

did indeed exhibit slight

intellectual

handi-caps. However, they were independent in

ac-tivitiesof dailylivingand theycould socially

interactwith other persons.

Eight

(72.5%)

of the

11

children with

SSP

had

been

treated by therapeutic exercise

under thediagnosisof CP

(SD)

priorto

being

brought to our hospital,in day-care centers

for

disabled

preschool children. Birthweight

was investigated

in

comparison with the

report by Suzukiii}

(Table

1). Arnong the nine children observed and fellowed

by

Suzuki

in

a neenatal

intensive

care unit and

finallydiagnosed as having CP

(SD),

seven

(77,7%)

were born at birth weights below

2,OOO

g, and the remaining two

(22,3%)

weighed 3,OOOg or more. AIIof the children

with SSP, howeyer, weighed 2,500g or more

at birth,so none werc low birth weight

in-fants. This differencein distribution

be-tween

the

CP

(SD)

and

SSP

children was

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TherapeuticExerciseforChildrenwith SpasticSpinalParaplegia

Table 2 Comparisen ofgestationalages betweenSSP and CP

CSD)

501

Gestationalage

(weeks)

2728293031323334353637383940

SSP

(N-

11)

CP

(SD)

(N

==9)*o1o1o1o1o1ooo1ooeo2ooo1o4!42

"Suzuki 19goil),

nificant

(p<O,Ol)

according to the

Mann-Whltney

U

test.

The

CP

CSD)

children and

SSP

children were compared according to gestational age

(Table

2). Nine

SSP

children

(8i.8%)

were

born

at gestationalages of

38

weeks or more,

According to the report by Suzuki,

however,

only three children

(33.3%)

with CP

(SD)

were

born

at

38

we6ks or rnore,

This

differ-ence

between

the

diagnostic

grouPs was sig-nificant

<p<O.05)

according to the U test.

Bobath

and

Blecki4)

have

also

described

many children with CP

(SD)

as having been

premature babies. Hagberg et al.i5) reported

that 88

(45.5%)

of 207 children with

CP

(SD)

were born at fullterm,

From

the viewpoint of motor

development,

rolling over and sitting were achieved very

lateonly in the twin boys with SSP, The

period of achievement of

these

behaviors

was

normal or only slightly

delayed

in

the other children. Six

(60%)

of the 10 children achieved cruising

by

one year of age, except

possibly

for

one child whose

data

were

un-known. The other four acquired cruising at

1

year

3

months to

3

years

2

months.

These

findings suggest the occult presentation of

SSP insome children.

In

Japan,

differentiatingSSP from CP

(SD)

isdifiicultbecause of the small number of

day-care centers for preschool handicapped

children that

have

full-time

specialist

doctors.

It

is

therefore

important,

in

differentiating

(p< O.05)

SSP

from

CP

(SD),

for

physical therapiststo

investigate gestational age at birth, birth

weight,

birth

history,

presence or absence qf

SSP

in

blood

relatives, course of motor

devel-opment, and presence or absence Qf

dysarthria.

Pediatric

patients' responses to stimulation

during

therapeutic exercise should also be observed carefully.・ SSP is characterized

by

deficiency

of sustained

con-traction of the abdominal muscles during

antigravitational extension of

the

trunk

and

by

more selective movement

in

the

lower

ex-tremitiesthan typicallyfound in spastic

di-plegia SSP should

be

suspected after a

com-prehensive assessment of all of the

informa-tion described above, and physicians should

be

requested to make a

differential

diagnosis,

attempting torule out

CP

(SD}.

Besides the differentiationof SSP from CP

(SD),

itisalso

important

in

planning

treat-ment to

differentiate

these disorders

from

human T-lymphotropic virus-type associated

myelopathy

(HAM),

as reported

by

Shimazaki

et al,i6)

When

a physical therapistsuspects

thatthe condition of a child may not

be

cere-bral

palsy with spastic

diplegia,

the therapist should clearly describethe various responses obtained through therapeutic exercise and speculate Qn the reasons forthose responses.

2. Essentialpoints on therapeuticexercise

The

distribution

of spasticity

in

the lower

extremities of children with SSP and

their

(6)

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so2 wreetw2kee

abnormal walking patternsresembled the

ab-normal developmenti7) inCP

(SD).

Eight of

the 11 SSP children had been treated by

therapeutic exercise under a diagnosis of CP

<SD)

before

being

brought

toour

hospital,

Bealsi8}reported that 52.6% of children

with

CP

(SD)

achieved independent

ambula-tion and 20.4%

became

able to walk with

crutches. Kajiurai9)similarly reported that

50% of children with CP

(SD)

became able to

walk

independently

while another 25%

became ambulatory with crutchcs. From

these reports, the rate of acquiring theability

to walk inchildren with CP

(SD)

can be

con-sidered

to

be

about 75%. In contrast, all of

the children with SSP acquired the ability to

walk, although 2

(18.1%)

were limited to crutch arnbulation. None of the patients

with

SSP

showed severe spasticity20), enough

to prevent movement, although moderate

spasticity was present

in

the

lower

ex-tremitiesof all

SSP

children.

According

to

Bealsi8)and Okawa et al.i3>, some children

with

CP

require iliopsoasrelease because the

muscle

is

shortened

due

to severe spasticity.

None of the presentchildren with SSP

under-went

this

operation.

It

is particularly

diMcult,

in

treating

SSP,

to obtain sustained

coactivation of

the

abdominal and gluteal

muscles, necessary for extending the pelvis and trunk against gravity during standing and walking. The diMculty in sustaining contraction of the abdominal muscles

in

an attempt to extend the trunk

in

therapeutic exercise was confirmed by comments of

therapistsin our group. Physical therapists

should promote continuous contraction of

the child's lower trunk, particularlythe

ab-dominal muscles, when attempting to elicit

antigravitational extension of the trunk

ee

23

gee

8

e

during the walking portionof treatment.

The appearance of lumbar and footpain in seven

(63.6%)

of the

SSP

children, ranging

in

age from fiveyears to twelve years of age, can

be

considered unusually frequent. These children could walk

fast

or even run,

Ac-cording to the Welch test,SSP children suffered lumbago significantly earlier than

the nine diplegicchildren

(p<O,05),

but foot

pain showed no such significant difference

between

the two groups.

The

results of the analysis suggest thatpain,especially

lumba-go, tends toappear inpediatric patientswith

SSP

earlier than inthose with

CP

(SD),

Lumbar lordosiswas particularly

remarka-bleinnine clients

(Fig.

1).Posturaltone

test-ing revealed slight to moderate spasticity in

flexorsand adductors of the hip

joints.

The

spasticity of these muscles was particularly marked in the outer range of hip

joints.

Spasticity

of

the

hip

flexors

and adductors

interferes

with antigravitational posteriortilt

of the pclvisand extension of the lower

ex-tremities. Since righting activities from the

pelvisand lower trunk appear lateas a

re-sponse,

however,

unilateral

loading

of body weight onto a lower extremity and

the

pro-pulsion necessary

for

walking are promoted

by hyperextension and lateralflexionof the

lumbar spine by excessively using the back

muscles, Allfivepatientswho complained of

lumbago showed lumbar lordosisinstanding

as well as

during

walking. The lumbago might have

developed

as a result of

repeti-tion of compensatory movements.

Treatment of lumbago

is

incorporated

into

systematic therapeuticexercise.

Contraction

of the abdominal muscles issustained during extension of the trunk and lumbar lordosisis

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Therapeutic Exercise forChildren with Spastic SpinalParaplegia

Fig.3. Promotion of sustained coactivation in

trunk musculatures.

bility

improves

in

painful lumbar extensors.

Whcn occasien demands, soft tissue

mobiliza-tion istransiently performcd in the lurnbar

region2i) to reduce pain prior to continuing

therapeutic exercise.

As

a result,

lumbago

may disappear after thisapproach. To

im-prove gait and prevent

lumbago

in

SSP,

physical therapists should reduce the spasticity of flexorsand adductors of the hip

joints,

promote sustained contraction of the

abdominal muscles

during

coactivation of the

lewer trunk, starting in infancy,particularly

during

extension of the trunk,and must con-sciously pursuc preventjon of lumbar

lordo-sis.

With regard tofootpain, evaluation of

pos-turaltone revealed spasticity with a slight to

moderate degree of resistance9) inthe tibialis

anterior, the tibialis posterior and

gastrocnemius muscles, Postural tone testing revealed moderate spasticity in the

plantarflexors.Intrinsicmusclcs of the foot,

however, exhibited low tone. The

arrange-ment of the longitudinalarch of the

foot

was

disrupted

and pes pianovalgas was observed.

503

These findingswere considered to be

respon-sible forpain resulting

from

loading

of

body

weight onto the

feet,

particularly the soles.

Before wcight loading onto the lower

ex-tremities,the

hypersensitivity

of

feet

was

desensitized

and thedifferenceindistribution

of postural tone of the lower cxtrernities and

feet

was cqualized while selective movements

of the lower extremities were performed in

supine or sitting during treatment

(right

and

leftparts of Fig.4)22}.Loading

in

the

stand-ing

position was then gradually increased

(right

and leftparts of Fig.

5),

The footpain

disappeared

with stepwise progression of this

Fig.4.Desensitization of hypersensitivity insoles and tricepssuraes toweight on hee]s.

Fig.5.Treatrnent in walking. In order to

de-crease lordosisand toprevent compensato-ry sidefiexion of his trunk, contraction of abdominal muscles issustained jn

stand-ing and walking.

(8)

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5o4

fft';'tasZkr'"

program.

A pair of

8

year-old twin boys and one 6.5

year-old girlunderwent speech therapy

be-cause all three had

dithculty

with speech

due

to

dysarthria,

They

were suggested supraspinal involvement, but their

intellectu-al abilitieswere normal. Takahashi et at.3>5) reported autosomal recessively inheritedSSP

with dysarthria. Physical therapistsshould

help

the

SSP

child

to

sustain a syrnmetrical neutral position of the

head

and neck

during

walking, inconjunction with speech therapy.

The

pelvis

in

such a child

is

insuMciently

mobile because of spasticity in the muscles surrounding the hip

joint.

During walking,

the center of gravity moves

in

a compensato-ry manner, with

lateral

fiexion

and anterior

flexionof the trunk,head and neck, and with

horizontal

instability

of the

jaw

(Fig.

1).

As

a result, fine independent skillful movements

of the lower

jaw,

tongue, and lips,necessary

for

articulation,

do

not develop adequately,

exacerbating the

diMculty

with speech

devel-opment. Physical therapistscarry out

treat-ment

by

reducing the spasticity of the

hip

flexorsand adductors and eliciting sustained

coactlvation of the abdominal muscles and

glutealmuscles with the aim of helping the

child rnaintain the head and neck in neutral

position without compensatory movements

during

walking.

With

these ways physical

therapistsmust thus cooperate with speech

therapists in planning and administering

treatment.

Conclusion

Eleven pediatric patients with SSP were studied. The points to which physical

therapists should pay attention in

ministering therapeutic exercise for

acquisi-eg

23

tseg

8-ij

tion of the ability to walk were also

described. Physicaltherapists can contribute

to the preventien of abnormal

development,

Iumbago, and foot pain in SSP by applying

therapeutic exercise

based

on an adequate

knowledge of the characteristjcs and

differ-ences in the individual clinical features of

SSP and CP

(SD).

References

D Hirayama Ki Shinkeishokegaku

<Neurological

Semielogy). Bunkodo, Tokyo, 1984,pp

375

{In

Japanese>.

2)Mukai E,et al.: Clinicalstuciy of familial

tic paraplegia. Rinsho Shinkeigaku (Clinical

Neurology)27

(1}:

1399-14・09,1987

(In

nese).

3)Takahashi A, Mukai E: Familial spastic

plegia. ShinkeiKenkyu no Shinpo

(Advances

inNeurologicaiSciences)31

{6}:

954-956, 1987

(In

Japanese).

4)JoshitaY: Familial spastic paraplegia: Report

of fourteencases and comparison with cases in the Iiterature. Shinkei Naika

(Neurological

Medicine) 28

(2):

190-197, 1988

(In

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(10)

NII-Electronic Library Service 506 理学療法学  第 23巻第 8 号 〈要     旨〉 小 児 脊 髄 性 痙 性 対 麻 痺へ の運 動 療 法 古 澤 正 道,月浦 伸 祐,竹 下 正 弘,野 本 由 紀,泉 佳 奈 子 ボバ ース記 念病院  本研究の目的は小 児の 脊 髄 性 痙対 麻 痺

SSP

の特 徴を脳 性 麻 痺 痙 直型 両 麻 痺 (CP ・ SD) との対 比で明 確にすること と,  SSP の運 動 療 法 上の留 意 点 を 明らかにするこ である。 対象は 11 名の SSP で 方法はビデオ とに よる歩行パ ーン の分析  ボバ ース の姿勢 緊張テ ス ト, 診療録か らの 出産歴 ・腰痛 ・足部痛の 調 査で あ る。 来 院 前 診 断 名 は,CP (

SD

8

名, 

SSP

 l不 明

2

であっ た。 

SSP

には 2,500 g未 満の低 出生 体 重 児はいず, 在 胎 週で は 9名が満 期 産であっ た。 歩行はロ フ ス ト ラン ド杖を使用し た2 名を含め て, 2.

6

± 1.

4

歳 (

1

歳〜

5

1

カ月)で全員が獲 得 し た。 両 下 肢の正常な伸 展 運 動 と, 遊 脚 相で の 個々 の関 節の選 択 運 動 CP

SD

よ り高い能 力 を もっ ていた。 SSP の腰 痛は 5名 (45.4%, 7.8 ± 1.3 歳) 足部痛は4 名 (36.3%, 8.5± 2.6 歳)に生じ た。

CP

SD

)に比べ

SSP

の腰 痛は有意に早 く生じ た。 腰部の運動性を回復さ せ腰椎前弯の軽減を図る こと と, 足 部 内の 姿 勢 緊 張 を 整え た上で に体 重 を荷 重 するこ で疼痛は緩 解 した。安定し た歩行の 獲得と 腰 痛 防 止のために は,  早く か ら下部体幹の持続し た同時活動を促通し, 腰椎前弯を軽減す ること が重 要であ る。 N工 工一Eleotronlo  Llbrary  

Fig. 1. Pattern of walking in children with spastic             spinaE paraplegia. Lordosis is remarkable             and compensatory sideflexion of trunk is             observed when he shifts his weight to one             leg.
Fig. 4.Desensitization of hypersensitivity in soles and triceps suraes to weight on hee]s.

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