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Report

Therapeutic Exercise for Children with Spastic Spinal Paraplegia"

Masamichi FURUSAWA'", Nobuhiro HIURA, Masahiro TAKESHITA,

Yuki NOMOTO, and Kanako IZUMI

Abstract '

The purpose of this research is to ascertain the characteristics that differentiate

spastic spinal paraplegia (SSP) from spastic diplegia of cerebral palsy (CP ･ SD), an.dthe points that should be taken into consideration in the treatment of SSP by physi-

cal therapists, We report on ways of physical therapists can 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 in comparison with CP (SD) children who had had lumbago and foot pain,

No child with SSP was born at a birth weight of less than 2,500 g, unlike the typical

scenario for CP (SD) children (p<O,Ol), All children acquired the ability to walk 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 patterns of the lower extremities and selective movements

of individual joints. Lumbago was present in 5 (45.4%) at 7.8± 1.3 years and foot

pain was present in 4 (36.3%) at 8.5± 2.6 years of our 11 cases. Postural tone of the

lower trunk tended to be low in SSP. In order to obtain walking and prevent lum-

bago, physical therapists should make efforts to promote sustained coactivation of

the lower trunk musculature early in the course of treatment,

Key words Children with spastic spinal paraplegia, Spastic diplegia, Therapeutic

exerclse

Introduction

Spastic spinal paraplegia (SSP) is paralysisdue to degeneration in the spinal cord mainly

'

,JivaffM,trpm,msWzzfiAdiffbltwix'S

Bebath Memorial HospiLal (1-6-5 Higashinakahama, Joto-ku, Osaka 536, Japan) (Received June 21, 19941Accepted August 31, 1996}

with bilateral involvement to the cor-

ticospinal tractsi). It has recently been

reported that spastic spinal paraplegia in pe-

diatric patients is not necessarily limited to

the spinal cord but possibly includes

degenerative changes in higher centers of the

brain2-5). Differential diagnosis from other

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498 wa7diza\

diseases is important because of the different

clinical picture that ultimately emerges.

Most children with SSP who received thera-

peutic exercise at eur hospital were original-

ly diagnosed 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 in SSP. In this study, we ascertain the

characteristics that differentiate SSP from CP

(SD), and the points that should 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). Prior to 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 the condition had been evaluated as

unknown in two (18.2%). Thus, the rnajority

of these children had been treated by physi-

cal therapists under the diagnosis 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 in any of these ehildren. The mean

age at initial examination was 6.8± 2.3 years

(ranging 'from

2 to 13 years). Five children

were treatcd on beth an inpatient and an out-

patient basis, and 6 werc treated by thera-

peutic exercise only on an outpaticnt basis.

Diagnosis prior to treatment at our hospi-

ee 23 igag 8 e

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.

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 in order to find

out abnormal patterns caused by spasticity

in legs and compensatory movements espe-

cially in trunks, Postural tone 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

differentiation of both groups in the birth

weights and the gestational ages. 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 disturbance or not,

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Therapeutic Exercise for Children with Spastic Spinal 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 hospital under the diagnosis

of CP (SD) and one remained undiagnosed.

Cephalic presentation was common to the

birth of all the children, The values of jaun-dice were 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 birth weight. 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 three children with asphyxia had

been born at gestations of 39 weeks and 40

weeks. Three children had speech disturb-

ance. A pair of 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" :--oH --o 1H ,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 to walk 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 in five children, and the surface of

adductor longus was released bilaterally to

alleviate flexion and 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 bilaterally in one child for treatment

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 6 years to

10 years), and four (36.3%) had foot pain at

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500

Table

ve\wtzaeig ee23igees･g-

l Comparison of birth weight between SSP and CP {SD)

Birth weight (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±

5,6 years (ranging from 5 years 2 months to

22 years), and five diplegic children 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 the therapisVs handling, chil-

dren with SSP were better able than children

with CP (SD) to maintain the lower ex-

tremities extended 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 in movement 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 in children with SSP

is lower than that in children with CP (SD),and that SSP is associated 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 is not necessarily limit-

ed to the spinal cord but can also include the

brain2-5). Two brothers, 10 and 8 years old,

did indeed exhibit slight intellectual handi-

caps. However, they were independent in ac-

tivities of daily living and they could socially

interact with other persons.

Eight (72.5%) of the 11 children with SSP

had been treated by therapeutic exercise

under the diagnosis of CP (SD) prior to beingbrought to our hospital, in day-care centers

for disabled preschool children. Birth weight

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

finally diagnosed 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. AII of the children

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

at birth, so none werc low birth weight in-

fants. This difference in distribution be-

tween the CP (SD) and SSP children was sig-

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Table 2 Comparisen of gestational ages between SSP and CP CSD)

501

Gestational age (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 gestational ages 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 full term,

From the viewpoint of motor development,

rolling over and sitting were achieved very

late only 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 in some children.

In Japan, differentiating SSP from CP (SD)is difiicult because 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 therapists to

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-

tremities than typically found 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 to rule out CP (SD}. Besides the differentiation of SSP from CP

(SD), it is also 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 therapist suspects

that the condition of a child may not be cere-

bral palsy with spastic diplegia, the therapist

should clearly describe the various responses

obtained through therapeutic exercise and

speculate Qn the reasons for those responses.

2. Essential points on therapeutic exercise

The distribution of spasticity in the lower

extremities of children with SSP and their

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abnormal walking patterns resembled the ab-

normal developmenti7) in CP (SD). Eight of

the 11 SSP children had been treated by

therapeutic exercise under a diagnosis of CP

<SD) before being brought to our 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 the ability

to walk in children 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-

tremities of all SSP children. According to

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

with CP require iliopsoas release because the

muscle is shortened due to severe spasticity.

None of the present children 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

therapists in our group. Physical therapists

should promote continuous contraction of

the child's lower trunk, particularly the ab-

dominal muscles, when attempting to elicit

antigravitational extension of the trunk

ee 23 gee 8 e

during the walking portion of treatment.

The appearance of lumbar and foot pain in

seven (63.6%) of the SSP children, ranging in

age from five years 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 diplegic children (p<O,05), but foot

pain showed no such significant difference

between the two groups. The results of the

analysis suggest that pain, especially lumba-

go, tends to appear in pediatric patients with

SSP earlier than in those with CP (SD),

Lumbar lordosis was particularly remarka-

ble in nine clients (Fig. 1). Postural tone test-

ing revealed slight to moderate spasticity in

flexors and 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 posterior tilt

of the pclvis and extension of the lower ex-

tremities. Since righting activities from the

pelvis and lower trunk appear late as 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 lateral flexion of the

lumbar spine by excessively using the back

muscles, All five patients who complained of

lumbago showed lumbar lordosis in standing

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 therapeutic exercise. Contraction

of the abdominal muscles is sustained during

extension of the trunk and lumbar lordosis is

thereby reduced (Fig. 3). In this process, mo-

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Therapeutic Exercise for Children with Spastic Spinal Paraplegia

Fig.3. Promotion of sustained coactivation in trunk musculatures.

bility improves in painful lumbar extensors.

Whcn occasien demands, soft tissue mobiliza-

tion is transiently performcd in the lurnbar

region2i) to reduce pain prior to continuing

therapeutic exercise. As a result, lumbago

may disappear after this approach. To im-

prove gait and prevent lumbago in SSP,

physical therapists should reduce the

spasticity of flexors and 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 to foot pain, evaluation of pos-

tural tone revealed spasticity with a slight to

moderate degree of resistance9) in the tibialis

anterior, the tibialis posterior and

gastrocnemius muscles, Postural tone testing

revealed moderate spasticity in the

plantarflexors. Intrinsic musclcs of the foot,

however, exhibited low tone. The arrange-

ment of the longitudinal arch of the foot was

disrupted and pes pianovalgas was observed.

503

These findings were considered to be respon-

sible for pain 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 the difference in distribution

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

left parts of Fig. 4)22}. Loading in the stand-

ing position was then gradually increased

(right and left parts of Fig. 5), The foot pain

disappeared with stepwise progression of this

Fig. 4.Desensitization of hypersensitivity in solesand triceps suraes to weight on hee]s.

Fig. 5.Treatrnent in walking. In order to de-crease lordosis and to prevent compensato-

ry sidefiexion of his trunk, contraction of

abdominal muscles is sustained jn stand-ing and walking.

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program.

A pair of 8 year-old twin boys and one 6.5

year-old girl underwent speech therapy be-

cause all three had dithculty with speech due

to dysarthria, They were suggested

supraspinal involvement, but their intellectu-

al abilities were normal. Takahashi et at.3>5)

reported autosomal recessively inherited SSP

with dysarthria. Physical therapists should

help the SSP child to sustain a syrnmetrical

neutral position of the head and neck during

walking, in conjunction 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

flexion of 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 therapists carry out treat-

ment by reducing the spasticity of the hip

flexors and adductors and eliciting sustained

coactlvation of the abdominal muscles and

gluteal muscles with the aim of helping the

child rnaintain the head and neck in neutral

position without compensatory movements

during walking. With these ways physical

therapists must 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 ad-

ministering therapeutic exercise for acquisi-

eg 23 tseg 8 -ij

tion of the ability to walk were also

described. Physical therapists 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 372-

375 {In Japanese>. 2) Mukai E, et al.: Clinical stuciy of familial spas-

tic paraplegia. Rinsho Shinkeigaku (Clinical Neurology) 27 (1}: 1399-14･09, 1987 (In Japa- nese).

3) Takahashi A, Mukai E: Familial spastic para- plegia. Shinkei Kenkyu no Shinpo (Advances in Neurologicai Sciences) 31 {6}: 954-956, 1987

(In Japanese). 4) Joshita Y: Familial spastic paraplegia: Report

of fourteen cases and comparison with cases in

the Iiterature. Shinkei Naika (Neurological Medicine) 28 (2): 190-197, 1988 (In Japanese). 5) Takahashi A, Mukai E: Familial spastic para-

plegia. Spine and Spinal Paraplegia 2 C2): 127-

134, 1989 (In Japanese). 6) Segawa M: HerediLary progressive dystonia

with marked diurnal fluctuation. Shinkei

Kenkyu no Shinpo (Advances in Neurological Sciences) 25 "): 73･-81, 1981 (In Japanese) 7) Yokochi M: Clinical characteristics of juvenile Parkinsonism and possible participation of

hypothalamic mechanism to Parkinsonism.

Shinkei Kenkyu no Shinpo (Advances in Neu- rological Sciences) 25 {D: 82-94, 1981 (In Japa- nese),

8> Yamashita H, Kurnasawa Ji Neurogenic blad-

der due to HAM. Journal of the Japan Medical Society of Paraplegia 3 {1}: 124-125. 1990 (In Japanese).

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9) Suzuki T: Diagnosis on Motor Development:

Bobath Approach. Ini Suzuki K, Akiyama T

(eds) Noseimahi Kenkyu <Research of Cerebral

Palsy). Vol. ll, Kyodo I$ho Shuppansha,

Tokyo, 1979, pp 147-158 (In Japanese).10) Bobath K: A Neurophysioiogical Basis for the

Treatment of Cerebral Palsy. Clinics in

Developmental Medicine, No. 75, WMiam

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Heinernann Medical Books Ltd. London, 1980,

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11) Suzuki T: Treatment for Cerebral Palsied In-

fants at NICU. In: Tezuka K (ed) Noseimahi

(Cerebral Palsy). No. 10, Kyodo Isho

Shuppansha, Tokyo, 1990, pp 1-21 (In Japa- nese),

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cal Therapy) 23 {7): 471-476, 1989 (In Japa- nese}.

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for Children with Spastic Spinal Paraplegia 505

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Kenkyu (Research of Cerebral Palsy), Vol, I,

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150 {In Japanese).20) Kii K: Bobath Approach. In: Hosoda K,

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Japanese 　Physloal 　Therapy 　Assoolatlon

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 脊髄性痙性対麻痺 （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 とで ある。

対象は 11名の SSP で， 方法は ビ デ オ と写真に よ る歩行パ タ

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名，不明 2名で 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歳 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 は 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 踵 に体重 を荷重す る こ とで 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