平野 哲

Background: The efficacy of botulinum toxin A (BoNTA) injection on spasticity is usually measured using Modified Ashworth Scale (MAS), but this only evaluates muscle tone at rest and has poor reliability. There are no reports that quantitatively evaluate pes varus during walking after botulinum treatment. The purpose of this study was to evaluate the efficacy of BoNTA injection on pes varus during gait using 3-dimensional motion analysis. Methods: Twenty-four hemiplegic patients with spastic pes varus deformity during gait received BoNTA injection into lower limb muscles. MAS score, comfortable overground gait velocity, and pes varus angle during treadmill walking were evaluated before, 2, 6, and 12 weeks after the injection. Five healthy subjects were also recruited to develop the pes varus/valgus angle as a normal reference. Results: The median MAS scores were significantly lower at 2 and 6 weeks after the injection. The maximum pes varus angle during the swing phase was significantly lower at 2, 6, and 12 weeks after the injection. It was significantly lower at 6 weeks after the injection during stance phase. The comfortable overground gait velocity was also improved after the injection. However, 2 patients experienced pain during gait and their pes varus angle increased during the follow-up period. Conclusions: BoNTA injection improved pes varus angle during gait. Evaluating motion in addition to spasticity at rest is recommended because improvements in limb function do not always parallel improvements in spasticity at rest.

Purpose: To develop and clinically evaluate a novel assistive walking system, the Wearable Power-Assist Locomotor (WPAL). Methods: To evaluate the performance of WPAL, a clinical trial is conducted with four paraplegic patients. After fitting the WPAL, patients learned to use the WPAL. The length and duration of independent walking was measured and compared to conventional orthosis (Primewalk). Results: After training, all patients were able to stand, sit, and walk independently with the WPAL. Compared to a conventional orthosis (Primewalk), the duration and distance of independent ambulation increased. The physiological cost index (PCI), perceived exertion and EMG of upper extremities decreased. Conclusions: WPAL might greatly enhance the possibility of restoration gait to paraplegic patients. Implications for Rehabilitation WPAL is developed to provide independent and comfortable walking for spinal cord injury patients. WPAL is less demanding physically than conventional orthosis (Primewalk). Even patients who cannot walk independently with conventional orthosis might be able to do so with WPAL. © 2013 Informa UK, Ltd.

Objective: To examine the efficacy of postural strategy training using a personal transport assistance robot (PTAR) for patients with central nervous system disorders. Design: Single-group intervention trial. Setting: Rehabilitation center at a university hospital. Participants: Outpatients (N=8; 5 men, 3 women; mean age, 50 +/- 13y) with a gait disturbance (mean time after onset, 34 +/- 29mo) as a result of central nervous system disorders were selected from a volunteer sample. Interventions: Two methods of balance exercise using a PTAR were devised: exercise against perturbation and exercise moving the center of gravity. The exercises were performed twice a week for 4 weeks. Main Outcome Measures: Preferred and tandem gait speeds, Functional Reach Test, functional base of support, center of pressure (COP), muscle strength of lower extremities, and grip strength were assessed before and after the completion of the exercise program. After the exercise program, enjoyment of exercise was investigated via a visual analog scale questionnaire. Results: After the program, statistically significant improvements were noted for tandem gait speeds (P=.009), Functional Reach Test (P=.003), functional base of support (P=.014), and lower extremity muscle strength (P<.001-.042). On the other hand, preferred gait speeds (P=.151), COP (P=.446-.714), and grip power (P=.584) did not change. Finally, subjects rated that this exercise was more enjoyable than traditional balance exercises. Conclusions: Dynamic balance and lower extremity muscle strength were significantly improved in response to postural strategy training with the PTAR. These results suggest that postural strategy training with the PTAR may contribute to fall prevention of patients with a balance disorder. Archives of Physical Medicine and Rehabilitation 2013;94:59-66 (C) 2013 by the American Congress of Rehabilitation Medicine

BACKGROUND: Due to physical and psychosocial issues associated with long-term sitting in a wheelchair, devising new ways to facilitate upright mobility is a key issue in rehabilitation medicine. Wearable Power-Assist Locomotor (WPAL) is a motorized orthosis and is developed for providing independent and comfortable walking for paraplegic patients. METHODS: The WPAL consists of a wearable robotic orthosis and custom walker. To facilitate alternate usage with a wheelchair, the wearable robotic orthosis is based on a medial system with motors located at the bilateral hip, knee and ankle joints to reduce the increase in heart rate during gait. The gait parameters include stride length, toe clearance height, swing time, double support time, etc. (gait speed: up to 1.3 km/h). Independent gait with the walker can be learned through a five-stage gait exercise sequence. The first two stages are stepping and gait exercises with parallel bars. The third stage is gait exercise on treadmill. The subsequent two stages are gait exercise with walker. RESULTS: Seven motor-complete paraplegic patients (spinal cord functional levels: T6-T12) participated. Through a series of exercises, all users achieved independent gait on a level floor (Functional Ambulation Categories: 4). The mean duration and distance of consecutively walking were 14.1 +/- 11.4minutes and 165.6 +/- 202.6 m, respectively. The most competent user was able to walk continuously for as long as 40 minutes and 640 m whereas only for 6 minutes and 107 m with a conventional orthosis. CONCLUSIONS: These results suggest that WPAL might be useful device for supporting upright walking in persons with paraplegia.

Pancreatoduodenectomy has been described as a possible treatment for gallbladder cancer that presents with evidence of direct invasion to the pancreas and/or the duodenum. This procedure does, however, carry a significantly higher morbidity and mortality if performed with a hepatectomy. An alternative procedure, therefore, of wedge resection of the invaded organ(s) was investigated in this study. On recognition of infiltration of the tumor into the pancreas and/or the duodenum, an en-bloc wedge resection of the organ(s) combined with the original tumor was the intended procedure. However, a pancreatoduodenectomy was performed if the tumor was not resectable by an attempted wedge resection. Operative and long-term outcomes were compared between patients who underwent wedge resection (n = 9) and pancreatoduodenectomy (n = 8). One patient in each group was incorrectly diagnosed preoperatively as having cancer invasion, as opposed to inflammatory changes, as recognized by subsequent histology. All tumors were excised with tumor-free pancreatic and duodenal margins. Postoperative complications occurred in one patient with wedge resection and four with pancreatoduodenectomy. One in-hospital death occurred in each group; one patient died with wedge resection of sepsis and one patient with pancreatoduodenectomy died of a pancreatic leak. No local recurrence occurred in either group. There was no difference in cumulative survival rates between the groups. Wedge resection was considered to be a feasible surgical procedure, in terms of morbidity, respectability, and long-term outcome.