Hitoshi Kagaya

【目的】前舌保持嚥下法(THS)が嚥下時の咽頭腔に与える影響について,320列面検出器型CT(CT)を用いて3次元的に運動学的解析を行った.THSでは咽頭腔体積が唾液嚥下(SS)に比べ減少する,つまり咽頭がより縮小すると仮説を立てた.【方法】言語聴覚士6名(22-29歳)を対象とした.SSとTHSをCTにて撮影し,咽頭腔体積,舌骨喉頭の運動距離,食道入口部(UES)の開大面積を計測し,SSとTHSで比較した.【結果】嚥下中の咽頭腔体積はSSに比しTHSで縮小する例だけでなく,拡大する例も認めた.嚥下開始時の舌骨,および最大上方位の舌骨喉頭はTHSで有意に高かった.UES面積はTHSで有意に大きかった.【考察】THSによる咽頭腔体積への影響は一定の傾向を認めなかった.今後,挺舌長などTHSの方法論について検討する必要が示唆された.また舌骨喉頭挙上およびUES開大にも寄与する可能性が示された.(著者抄録)

【目的】前舌保持嚥下法(THS)が嚥下時の咽頭腔に与える影響について,320列面検出器型CT(CT)を用いて3次元的に運動学的解析を行った.THSでは咽頭腔体積が唾液嚥下(SS)に比べ減少する,つまり咽頭がより縮小すると仮説を立てた.【方法】言語聴覚士6名(22-29歳)を対象とした.SSとTHSをCTにて撮影し,咽頭腔体積,舌骨喉頭の運動距離,食道入口部(UES)の開大面積を計測し,SSとTHSで比較した.【結果】嚥下中の咽頭腔体積はSSに比しTHSで縮小する例だけでなく,拡大する例も認めた.嚥下開始時の舌骨,および最大上方位の舌骨喉頭はTHSで有意に高かった.UES面積はTHSで有意に大きかった.【考察】THSによる咽頭腔体積への影響は一定の傾向を認めなかった.今後,挺舌長などTHSの方法論について検討する必要が示唆された.また舌骨喉頭挙上およびUES開大にも寄与する可能性が示された.(著者抄録)

Introduction: The safety and tolerability of incobotulinumtoxinA 400 U for upper- and lower-limb post-stroke spasticity was assessed in a small cohort of Japanese patients during the open-label lead-in tolerability periods (LITP) of two phase 3 studies (CTI-153029 and CTI-153030; Japan Pharmaceutical Information Centre).Methods: Adult patients received a single incobotulinumtoxinA injection session (total dose of 400 U) in the upper (J-PURE) or lower limb (J-PLUS). Adverse events (AEs) were assessed at 1, 4, 8 and 12 weeks post-injection during the 12 week follow-up.Results: The LITP of J-PURE and J-PLUS included 11 patients each. Mild/moderate AEs were reported by 5/11 (45.5%) and 8/11 (72.7%) patients in J-PURE and J-PLUS, respectively. No serious AEs were reported. Non-serious, transient AEs of special interest reported by two patients in J-PURE comprised muscular weakness and eyelid ptosis. No patient discontinued due to AEs.Conclusion: Preliminary results in this small population suggest that incobotulinumtoxinA 400 U is well tolerated for treating upper- or lower-limb post-stroke spasticity in Japanese patients.

【目的】摂食嚥下リハビリテーションに関する臨床および研究は、依然として未知の事柄が多く、根拠が確立されていない知見も多い。今後さらに摂食嚥下リハビリテーションの分野が発展していくためには、正しい手順を踏んだ研究が行われ、それから得られた知見を公開していく必要がある。本稿の目的は臨床家が正しい知見を導くために、研究報告に関するガイドラインを紹介し、論文作成とそれに必要な情報を収集するための資料を提供することとした。【方法】日本摂食嚥下リハビリテーション学会誌に投稿される論文は症例報告、ケースコントロール研究、コホート研究、横断研究が多いことから、本稿では症例報告に関するCase report(CARE)ガイドラインと、The Strengthening the Reporting of Observational Studies in Epidemiology Statement(STROBE声明)において作成された。観察研究の報告において記載すべき項目のチェックリストについて紹介した。【結果】CAREガイドラインについては、症例報告の正確性、透明性、および有用性を高めるために作成された13項目のチェックリストを説明した。STROBE声明については研究報告の質向上のために作成された。観察研究の報告において記載すべき22項目のチェックリストを解説した。【結論】紹介した2つのガイドラインで推奨されている項目をすべて記載することは理想であるが、すべてを網羅することは困難である。しかしながら、これらのガイドラインに示された項目を念頭に日々の臨床に臨むことで、診療録が充実しガイドラインに沿った学会発表や論文発表を行うことに繋がり、個々の臨床家の資質が向上するだけでなく、摂食嚥下リハビリテーションに関する研究、臨床のさらなる発展に繋がっていくと思われる。本稿によって、より質の高い論文が数多く本誌に投稿され、摂食嚥下リハビリテーションに関する臨床と研究が発展する一助となることに期待する。(著者抄録)

This study used 320-row area detector computed tomography (320-ADCT) to determine whether kinematic swallowing events and bolus movement through the oropharynx are affected by bolus consistency and angle of recline. Fourteen healthy adults (4 men, 10 women; age, 22-90 years) underwent 320-ADCT assessment during three 10-mL barium swallow tests, with honey-thick liquid at 60° recline (60°thick), thin liquid at 60° recline (60°thin), and thin liquid at 45° recline (45°thin). The times of swallowing events were measured and compared among the different tests. Bolus propulsion, onset time of true vocal cord (TVC) closure, and upper esophageal sphincter opening were significantly earlier for 60°thin than for 60°thick. Onset time did not significantly differ between 60°thin and 45°thin; however, greater variability was noted for onset of TVC closure with 45°thin, as the TVC started to close before onset of swallowing in 30% of participants. Modulation of TVC closure depends on bolus transport in different reclining positions. The 45° reclining position elicited pre-swallow TVC closure in some participants, which suggests that excessive recline can increase perceived risk of airway invasion during swallowing.

OBJECTIVES: Shoulder subluxation is a common problem after stroke. It causes shoulder pain that affects activities of daily living. This study aimed to investigate the effect of repetitive peripheral magnetic stimulation on shoulder subluxation after stroke. METHODS: We enrolled 12 consecutive patients who, as a result of stroke, suffered shoulder subluxations, measuring at half of a fingerbreadth or more. All subjects underwent conventional rehabilitation, as well as repetitive peripheral magnetic stimulation of their supraspinatus, posterior deltoid, and infraspinatus muscles. We assessed the following parameters: shoulder subluxation, evaluated as the acromio-humeral interval using measurements taken from X-rays; shoulder pain, evaluated using the Numerical Rating Scale; the active range of motion of shoulder abduction; and the motor impairment of the upper extremities, evaluated using the upper extremity of the Fugl-Meyer Assessment scale. RESULTS: The acromio-humeral interval before treatment was 22.8 ± 5.7 mm (mean ± SD). It significantly decreased to 19.6 ± 7.0 mm (p = 0.004) after treatment. Shoulder pain (p = 0.039), active range of motion of shoulder abduction (p = 0.016), and total (p = 0.005), subscale A (p = 0.005), and subscale C (p = 0.008) Fugl-Meyer Assessment scores also improved significantly after treatment. CONCLUSIONS: Repetitive peripheral magnetic stimulation effectively reduced shoulder subluxations and shoulder pain caused by stroke and improved voluntary upper-limb movements in stroke patients.

【目的】舌骨挙上障害を持つ摂食嚥下障害に対する末梢磁気刺激治療の実現可能性を検討した。【方法】2秒間の磁気刺激を30回で1セットとして1日に2〜3セット、1週間に5日以上の反復末梢磁気刺激治療(repetitive peripheral magnetic stimulation:rPMS)を6週間、舌骨挙上障害を持つ摂食嚥下障害患者2例に対して施行した。【結果】2例ともに、6週間のrPMSを問題なく施行可能であった。82歳の誤嚥性肺炎後の廃用症候群患者ではrPMS後に筋力および舌骨挙上距離の改善を認めた。47歳の皮膚筋炎患者ではrPMS介入後に筋力および筋疲労の改善を認めた。磁気刺激後には頸部のこわばりが軽減し食事中の疲労感が軽減した。【結論】舌骨挙上障害に対するrPMSは新しい治療法となりうる可能性がある。(著者抄録)

BACKGROUND: Treatment with Botulinum toxin A (BoNT-A) is effective in decreasing upper limb spasticity. OBJECTIVE: This study aimed to determine the differences in the outcome based on the upper limb motor function before BoNT-A treatment. METHODS: The subjects were 61 patients who underwent BoNT-A treatment for upper limb spasticity. Limb function was evaluated using the Fugl-Meyer Assessment upper extremity (FMA-UE), modified Ashworth scale, passive range of motion and disability assessment scale before treatment as well as 2, 6, and 12 weeks after treatment. We divided the total and each subscale of FMA-UE before BoNT-A administration into beyond-the-mean-score group (higher score group) and below-the-mean-score group (lower score group). RESULTS: In both the higher and lower score groups of the FMA-UE total and modified Ashworth scale scores improved significantly after treatment. In FMA-UE, the higher score group of subscale A improved significantly, but subscale C decreased significantly at 2 and 6 weeks after the administration. The lower score group of total, subscale A, and B improved significantly. In the disability assessment scale, the self-dressing capability at 6 weeks and limb position at 2, 6 and 12 weeks after the administration improved significantly in the higher score group. In the lower score group, the hygiene capability at 2 weeks as well as the dressing capability and limb position improved significantly at 2, 6 and 12 weeks after administration. CONCLUSIONS: The time course after administration of BoNT-A differed based on upper limb motor function before injection. When administering BoNT-A into the finger flexor muscles of a patient, we should carefully judge the indications for administration.

【目的】一口嚥下,連続嚥下,咀嚼嚥下の喉頭侵入,誤嚥のリスクを比較すること.【方法】2011年1月から2016年5月に嚥下造影検査において液体10mLの一口嚥下(LQ10),液体コップ30gの連続嚥下(CUP30),液体5mLとコンビーフ4gの混合物の咀嚼嚥下(MX)の3試行を座位かつ代償手技なしに行った136例の喉頭侵入,誤嚥の有無を評価した.それぞれの難易度はMcNemar検定で,Penetration-Aspiration Scale(P-A Scale)はSpearmanの順位相関係数を用いて検討した.【結果】喉頭侵入はLQ10で73例,MXで62例,CUP30で97例認め,CUP30ではLQ10よりも(p<0.001),またMXよりも(p<0.001)有意に多く認めた.誤嚥はLQ10で8例,MXで14例,CUP30で20例認め,CUP30ではLQ10よりも有意に多く認めた(p=0.009).P-A Scaleの相関係数はLQ10とCUP30ではρ=0.370(p<0.001)と有意であったがMXとCUP30はρ=0.100(p=0.312),LQ10とMXではρ=-0.202(p=0.055)と有意ではなかった.【結論】喉頭侵入の頻度はCUP30,LQ10,MXの順に高く,誤嚥の頻度はCUP30,MX,LQ10の順に高かった.MXのP-A ScaleはLQ,CUP30のそれとは有意な相関がみられなかった.(著者抄録)

Background: The recent development of wearable devices has enabled easy and continuous measurement of heart rate (HR). Exercise intensity can be calculated from HR with indices such as percent HR reserve (%HRR); however, this requires an accurate measurement of resting HR, which can be time-consuming. The use of HR during sleep may be a substitute that considers the calibration-less measurement of %HRR. This study examined the validity of %HRR on resting HR during sleep in comparison to percent oxygen consumption reserve (%VO2R) as a gold standard. Additionally, a 24/7%HRR measurement using this method is demonstrated. Methods: Twelve healthy adults aged 29 ± 5 years underwent treadmill testing using the Bruce protocol and a 6-min walk test (6MWT). The %VO2R during each test was calculated according to a standard protocol. The %HRR during each exercise test was calculated either from resting HR in a sitting position (%HRRsitting), when lying awake (%HRRlying), or during sleep (%HRRsleeping). Differences between %VO2R and %HRR values were examined using Bland-Altman plots. A 180-day, 24/7%HRR measurement with three healthy adults was also conducted. The %HRR values during working days and holidays were compared. Results: In the treadmill testing, the mean difference between %VO2R and %HRRsleeping was 1.7% (95% confidence interval [CI], - 0.2 to 3.6%). The %HRRsitting and %HRRlying values were 10.8% (95% CI, 8.8 to 12.7%) and 7.7% (95% CI, 5.4 to 9.9%), respectively. In the 6MWT, mean differences between %VO2R and %HRRsitting, %HRRlying and %HRRsleeping were 12.7% (95% CI, 10.0 to 15.5%), 7.0% (95% CI, 4.0 to 10.0%) and - 2.9% (95% CI, - 5.0% to - 0.7%), respectively. The 180-day, 24/7%HRR measurement presented significant differences in %HRR patterns between working days and holidays in all three participants. Conclusions: The results suggest %HRRsleeping is valid in comparison to %VO2R. The results may encourage a calibration-less, 24/7 measurement model of exercise intensity using wearable devices. Trial registration: UMIN000034967.Registered 21 November 2018 (retrospectively registered).

We initiated the Robotic Smart Home (RSH) project to develop a comfortable, safe home environment for all people, including the elderly and individuals with disabilities. An important consideration when introducing robots into a home environment is the confined living space, the so-called space problem. The RSH project plans to simultaneously develop robots and an architectural design for living spaces to create an optimal home environment that will help elderly people live independently at home for longer periods. The RSH accommodates the following three robotics and assistive systems: mobility and transfer assist system, operational assist system, and information assist system. The mobility and transfer assist system includes three types of devices (lifting type, lateral-transfer type, and suspension type), which can be available to users as appropriate according to the severity of their disability. The operational assist system combines a hand robot with an environmental control system for the convenience of users. An information assist system connects the RSH with remote locations for communication. Inside the RSH, a home automation and monitoring system connected to the Internet of Things provides residents with comfort and security. As part of this project, two RSH centers have been established for effective facility adoption.

OBJECTIVES:: The aim of this study was to determine the shape and area of the pharyngoesophageal segment (PES) during swallowing using 320-row area detector computed tomography, which can acquire a volume data set covering a 16-cm area in a single rotation. METHODS:: Twenty healthy subjects were scanned during swallowing 3, 10, and 20 mL of honey-thick barium (5% w/v). PES was identified using cross-sectional images of 0.5-mm slice thickness, and the area in each section was measured. RESULTS:: The PES opening area and the anteroposterior and lateral diameters of the PES were volume dependent. However, there was no statistical difference in anteroposterior and lateral diameters between 3- and 10-mL bolus swallowing. CONCLUSIONS:: Three hundred twenty-row area detector computed tomography provided new information about PES. This technique will facilitate further understanding of the mechanisms of PES opening and swallowing physiology.

BACKGROUND: Most people with hemiplegia experience gait changes after a stroke. Abnormal gait patterns in stroke patients vary across subjects and this make it difficult to assess the cause of gait abnormalities. Therefore, it is necessary to quantitatively evaluate abnormal gait patterns through gait analysis for stroke patients. OBJECTIVE: To develop and evaluate the validity of quantitative assessments of the degree of knee extensor thrust, flexed-knee gait, insufficient knee flexion during the swing phase, and medial whip. METHODS: Forty-six healthy control subjects and 112 people with hemiplegia participated. From the 112 patients, 50 patients were selected into each abnormal gait pattern (knee extensor thrust, flexed-knee gait, insufficient knee flexion during the swing phase, and medial whip) with some overlap. Participants were instructed to walk on a treadmill and were recorded using a three-dimensional motion analysis system. An index to quantify each of the four abnormal gait patterns exhibited by the patients was calculated from the three-dimensional coordinate data. The indices were developed based on the definition of the abnormal gait patterns. The index values for the patients were compared with those of healthy subjects as well as with the results of observational gait assessment by three physical therapists with expertise in gait analysis. RESULTS: Strong correlation was observed between the index value and the median observational rating for all four abnormal gait patterns (-0.64 to -0.86). Most of the patients with an abnormal gait pattern had a higher index value than the healthy subjects. CONCLUSIONS: The use of these indices in gait analysis of people with hemiplegia can help to diagnose severity of gait disorder, determine the appropriate treatment, and evaluate the effectiveness of the treatment.

The physiological mechanisms underlying Stage II transport (STII), during which comminuted solid food is transported from the oral cavity into the meso-pharynx for aggregation into a pre-swallow bolus, have yet to be clarified. The purpose of the present study was to investigate relationships between tongue-palate contact during mastication and incidence of STII by synchronised analysis of tongue pressure production on a hard palate and video-endoscopic (VE) images during mastication. Tongue pressure at 5 measuring points with an ultra-thin sensor sheet attached to the hard palate and trans-nasal VE images while masticating corned beef was recorded for 12 healthy subjects. All recordings were divided into 2 groups: mastication with STII and without STII. Tongue pressure duration was longer at the anterior-median part in the group with STII than in the group without STII. Integrated values of tongue pressure were greater at the anterior-median parts and posterior circumferential part in the group with STII. Integrated values of tongue pressure per second were greater in late-stage mastication than in early-stage mastication in the group with STII. These results suggest that the tongue-palate contacting at the anterior-median and post-circumferential parts of the hard palate is related with the incidence of STII.

症例は52歳男性で、右ワレンベルグ症候群と診断され、発症2週間後に誤嚥性肺炎を併発した。人工呼吸管理の後、気管切開を施行されたが、経口摂取が困難なため、発症5ヵ月後に胃瘻造設された。その後、本人が経口摂取を強く希望し、発症1年2ヵ月後に当科紹介となった。本症例の摂食嚥下障害は、咽頭への食塊送り込み不良、舌骨挙上不良、食道入口部通過不良が原因と考えられ、さらに高解像度マノメトリーと筋電図検査から食道入口部通過不良は咽頭圧低下と食道入口部の弛緩不全に起因すると推測した。保存加療では経口摂取の実現は困難と判断し、手術療法について検討した。入院71日目に喉頭挙上術(甲状軟骨舌骨下顎骨固定術)および両側輪状咽頭筋切断術を行った。術後1ヵ月で摂食嚥下障害臨床的重症度分類は4(機会誤嚥)となり自宅退院し、常食とnectar thickの経口摂取を継続した。

Background: The effect of botulinum toxin A (BoNTA) injection on flexed-elbow deformity is usually evaluated using the Modified Ashworth Scale (MAS), but only with the muscle tone at rest. Some patients show the flexed-elbow deformity during gait despite low muscle tone at rest. Objective: This study aimed to evaluate the effect of BoNTA injection on flexed-elbow deformity during gait using a three-dimensional motion analysis system. Methods: Twenty stroke patients with spastic flexed-elbow deformity during gait received BoNTA injections into the upper limb muscles. The MAS score of the elbow flexors, passive elbow range of motion, comfortable overground gait velocity, and elbow flexion angle during treadmill gait were evaluated just before and 2, 6, and 12 weeks after the injection. Twenty-five healthy subjects were also recruited to provide a normal reference of the elbow flexion angle. Results: The MAS scores at 2, 6 and 12 weeks after the injection were significantly lower than that before the injection. Some patients showed no spasticity at rest but an obviously flexed elbow during gait. The elbow flexion angles during gait at 2 and 6 weeks after the injection were significantly lower than that before the injection. Conclusions: BoNTA injections to the upper limb muscles reduced muscle tone at rest and flexed-elbow deformity during gait. However, the elbow flexion angle during gait returned to its pre-injection level sooner than the muscle tone at rest. We strongly recommend evaluating muscle tone during motion and at rest, preferably using three-dimensional motion analysis since it can objectively detect small changes.

OBJECTIVES: Neuromuscular electrical stimulation has been widely used in patients with dysphagia. However, obtaining sufficient hyoid bone movement through surface electrodes seems difficult. The aim of this study was to evaluate hyoid bone movement at rest through peripheral magnetic stimulation of the suprahyoid muscles in normal individuals. METHODS: Healthy adult men were recruited. A specially designed coil was connected to the peripheral magnetic stimulator. The coil was placed on the submental area of the subjects. Magnetic stimulation was performed at 30 Hz for 2 sec. The intensity level selected induces hyoid bone movement without causing intolerable pain to the subjects. The hyoid bone at rest between on- and off-magnetic stimulations of the suprahyoid muscles were identified using fluoroscopy at 30 frames/sec in lateral projection. Pain during peripheral magnetic stimulation was evaluated using the numerical rating scale (NRS). RESULTS: Eleven subjects aged 32 ± 9 years participated in this study. Magnetic stimulation resulted in 10.9 ± 2.8 mm forward displacement and 8.3 ± 4.1 mm (mean ± SD) upward displacement of the hyoid bone. The median NRS score during magnetic stimulation was 1. CONCLUSIONS: Peripheral magnetic stimulation is noninvasive and easy to perform. It does not require skin preparation, facilitates sufficient hyoid bone movement, and causes minimum level of pain.

Objective: To compare the energy efficiency of Wearable Power-Assist Locomotor (WPAL) with conventional knee-ankle-foot orthoses (MSH-KAFO) such as Hip and Ankle Linked Orthosis (HALO) or Primewalk. Study design: Cross over case-series. Setting: Chubu Rosai Hospital, Aichi, Japan, which is affiliated with the Japan Organization of Occupational Health and Safety. Methods: Six patients were trained with MSH-KAFO (either HALO or Primewalk) and WPAL. They underwent 6-minute walk tests with each orthosis. Energy efficiency was estimated using physiological cost index (PCI) as well as heart rate (HR) and modified Borg score. Trial energy efficiency with MSH-KAFO was compared with WPAL to assess if differences in PCI became greater between MSH-KAFO and WPAL as time goes on during the 6-minute walk. Spearman correlation coefficient of time (range: 0.5–6.0 minutes) with the difference was calculated. The same statistical procedures were repeated for HR and modified Borg score. Results: Greater energy efficiency, representing a lower gait demand, was observed in trials with WPAL compared with MSH-KAFO (Spearman correlation coefficients for PCI, HR and modified Borg were 0.93, 0.90 and 0.97, respectively, all P &lt 0.0001). Conclusions: WPAL is a practical and energy efficient type of robotics that may be used by patients with paraplegia.