加賀谷 斉

A number of tests for evaluating dysphagia without using videofluoroscopic examination of swallowing (VF) or videoendoscopic evaluation of swallowing (VE) have been developed. The simple swallowing provocation test (SSPT) is unique because it is performed while in a supine position and does not require the patient's cooperation. However, whether the SSPT detects aspiration or penetration correctly is unclear because its validity determined by VF or VE has not been evaluated. Therefore, we determined the sensitivity, specificity, and predictive accuracy of SSPT followed by VF in 45 patients. The sensitivities of the first-step and the second-step SSPT for the detection of aspiration, silent aspiration, or penetration were 72-75% and 13-17%, respectively; the specificities of the first-step and the second-step SSPT were 38-44% and 80-89%, respectively; and the predictive accuracies of the first-step and the second-step SSPT were 58-67% and 31-49%, respectively. These data suggest that SSPT has limited applicability as a screening tool for aspiration, silent aspiration, or penetration because of its low sensitivity. This test may be useful for patients who cannot undergo other tests due to cognitive and/or linguistic dysfunction.

Videofluoroscopic examination of swallowing (VF) is the gold standard in diagnosis and management of dysphagia. During VF, the patient ingests radiopaque foods and liquids, and oral, pharyngeal, and esophageal stages of swallowing physiology are observed and evaluated. Aspiration is defined as passage of materials through the vocal folds, and laryngeal penetration is defined as passage of materials into the larynx, but not through the vocal folds. In this study, we compared the risk of laryngeal penetration or aspiration during VF using various liquid volumes and food consistencies. Between January 2006 and September 2008, 229 patients with suspected dysphagia each were fed at least 2 out of 6 types of liquids or foods during VF in an upright posture without compensatory maneuvers. The 6 types were pudding-thick barium of 4 ml (PD), thin liquid barium of 4 ml (LQ4) and 10 ml (LQ10), one swallow of thin liquid barium from a cup (CUP), corned beef hash (8 g) with barium (CB), and a two-phase mixture of corned beef hash (4 g) with barium and thin liquid barium of 5 ml (MX). The paired comparisons revealed that laryngeal penetration risk increased in the following order: PD, CB, LQ4, LQ10, MX and CUP, while aspiration risk after PD increased in the following order: CB, LQ4, LQ10, CUP and MX. Thus, risk of laryngeal penetration or aspiration varies, depending on food types. In conclusion, risk of aspiration is highest with the two-phase food, and multi-textured foods should be used with caution in individuals with dysphagia.

Teranishi T, Kondo I, Sonoda S, Kagaya H, Wada Y, Miyasaka H, Tanino G, Narita W, Sakurai H, Okada M, Saitoh E. A discriminative measure for static postural control ability to prevent in-hospital falls: Reliability and validity of the Standing Test for Imbalance and Disequilibrium (SIDE). Jpn J Compr Rehabil Sci 2010; 1: 11-16<br>Purposes: To determine the reliability, validity, and clinical significance of the Standing Test for Imbalance and Disequilibrium (SIDE), a discriminative measure of standing balance, before using it to prevent falls in clinical settings.<br>Methods: In all, 30 patients (18 men and 12 women) with a mean (standard deviation) age of 57.4 (16.97) years (range, 25-85 years) who were admitted to the &ldquo;Kaifukuki&rdquo; rehabilitation ward voluntarily participated in this study. In the reliability study, 2 physiotherapists independently classified the level of static postural control ability by using SIDE. Functional balance control ability was simultaneously evaluated using the Berg Balance Scale (BBS). Cohen's &kappa; statistic was used to determine the inter-rater reliability, and the Spearman rank-correlation coefficient between the BBS score and SIDE level was used to determine the criterion-related validity.<br> Results: Inter-rater reliability of SIDE showed excellent reproducibility (Cohen's &kappa; statistic = 0.76). Criterion-related validity was very high between SIDE levels and BBS scores (Spearman rank-correlation coefficient = 0.93; p < 0.01).<br>Conclusion: SIDE can be used to efficiently and accurately classify balance control ability across individuals and has remarkable concurrent validity in balance evaluation compared to BBS.

Patients with chronic obstructive pulmonary disease (COPD) are commonly referred for pulmonary rehabilitation (PR), but the use of PR is not common for patients with restrictive lung disease, neuromuscular diseases, and those who have sustained a severe respiratory illness or undergone thoracic surgery. We investigated the effects of PR in patients with restrictive lung diseases in comparison with COPD patients using a home-based setting. Twenty-six restrictive lung diseases patients and 40 COPD patients who had a Medical Research Council (MRC) dyspnea score &gt;= 2, a clinically stable condition, and who had completed a 6-month PR program, were enrolled in the present study. The definition of restrictive lung disease was a forced vital capacity (FVC) of &lt;= 80% of the predicted value with a forced effort volume in one second/FVC of &gt; 70%. Our PR consisted of breathing retraining, exercise training, respiratory muscle stretching calisthenics, level walking, inspiratory and expiratory muscle exercises, and a monthly education program. Patients were strongly instructed to practice this program daily at home, and were supervised by a respiratory therapist every 2 weeks in our hospital. Patients with restrictive lung diseases showed the significant increases in inspiratory and expiratory muscle forces, the 6-minute walking distance, the Chronic Respiratory Disease Questionnaire and the Short-Form 36, and decreased MRC scores after 6 months. In conclusion, our home-based PR improves respiratory muscle forces, exercise tolerance, health-related quality of life, and the perception of dyspnea in patients with restrictive lung disease to the same extent as in COPD patients.

Hip fracture is common in the elderly, and its incidence is predicted to increase in many countries. This article focuses on femoral neck and intertrochanteric fractures in the elderly, specifically discussing their classification, conservative and operative treatment, rehabilitation protocol, period of functional recovery, activities of daily living (ADL), instrumental activities of daily living (IADL), predictors for outcome, and health-related quality of life (HRQOL). The information was obtained from a Medline search of articles published in the English language literature. Femoral neck fractures should be classified into undisplaced and displaced fractures, and intertrochanteric fractures should be divided into stable and unstable fractures. Conservative treatment may be considered for undisplaced femoral neck and intertrochanteric fractures, but most of these fractures have been operated on. Immediate unrestricted weight bearing after surgery does not seem to increase the failure of any types of hip fracture. The appropriate intensity for rehabilitation is still controversial. Home-based rehabilitation with early discharge may be an alternative. Motor ADL, IADL, and HRQOL increase following hip fracture, but the majority of patients do not regain their prefracture levels. Statistical models with predictive accuracy from an independent sample are useful to predict functional outcome. © 2007 by Begell House, Inc.

Background Although operative treatment for lumbar disc herniation is a commonly performed neurosurgical procedure, no reports have described whether health-related quality of life before surgery affects the operative treatment outcome. This prospective study assessed health-related quality of life before and after surgery and evaluated the predictor variables affecting outcomes. Methods. Subjects were 45 consecutive candidates for lumbar disc herniation surgery who gave informed consent. The Medical Outcomes Study Short Form 36 (SF-36) and 15-point Japanese Orthopaedic Association (JOA) score were evaluated before and after surgery, and the magnitude of the effect was calculated. The possible predictor variables for outcomes were physical functioning, role physical, bodily pain, general health, vitality, social functioning; role emotional and mental health from the SF-36 subscales; subjective symptoms and clinical signs from the JOA scores; and the patient's age, sex, pain. occupation, and history of low back pain and/or leg pain Results. Four patients were excluded from the analyses because they were lost to follow-up within 1 year after operation. All subscales of the SF-36 and JOA scores increased significantly at 6 months and 1 year of follow-up with a maximum effect size in bodily pain and a minimal in general health. Operation results were 29 good, 11 fair, and 1 poor. The selected predictor variables affecting the outcomes were patient age and social functioning on SF-36. Conclusions. Surgery for lumbar disc herniation improved health-related quality of life. Patients &lt; 50 years old with a &lt; 60 score in social functioning on SF-36 were considered good candidates.

Objective: To compare the activities of daily living before and after hip fracture and construct a statistical model for discharge destination and independent walking. The classification accuracy of the model was determined from an independent sample. Design: Prospective study: FIM(TM) prefracture, at discharge, and at 6-mo follow-up were obtained from 63 patients who underwent operations for acute hip fractures. A statistical model for discharge destination and independent walking was made and classification accuracy was checked using 78 independent samples. Results: The motor FIM scores at prefracture decreased significantly at discharge (P &lt; 0.0001) and at 6-mo follow-up (P &lt; 0.0001), but at 6-mo follow-up, they had increased significantly compared with those at discharge (P = 0.0103). A mobility subscale was used to predict discharge destination, and mobility and social cognition subscales were related to independent walking. The predictive accuracy was 87%. Conclusions: Motor FIM scores increase for at least 6 mos after hip fracture, and discharge destination and independent walking were highly predictable from FIM mobility and social cognition subscales.

Joint contractures decrease the patient's ability to walk, but usually other parts of the body compensate the affected joint contractures. When we restore the gait performance in paraplegic patients by means of functional electrical stimulation, however, we cannot expect complications of compensation. A computer simulation was done to clarify how the contractures affect the gait pattern when no complications of compensation were expected. A seven-segment link mechanical model was used for simulation of human walking in the sagittal plane. In turn, using a personal computer stance and swing-leg joint contractures of the ankle, knee, and/or hip were simulated. When stance-leg contracture was simulated, step length became short with increasing hip flexion contracture. The trunk was tilted backward during knee flexion or ankle plantarflexion contracture simulation. When the swing-leg contracture was simulated, step length became short with increasing knee flexion contracture. We found that hip or knee flexion contracture of less than or equal to15degrees, or ankle plantarflexion contracture of &lt;0degrees was required to maintain positive step length and forward movement of the center of gravity. These findings suggest that 15degrees of hip and knee flexion contracture, and 0degrees of ankle plantarflexion contracture are critical when gait restoration is performed by functional electrical stimulation.

COPD患者に外来呼吸リハビリテーションを施行しその長期効果を検討した．呼吸筋ストレッチ，呼吸筋訓練，上下肢の筋力訓練などを外来で指導し自宅で継続させ，2週間ごとに外来で経過観察と指導を行い，12ヵ月後まで経時的に呼吸機能，運動耐容能，健康関連QOLの評価を行った．その結果，COPD患者ではVC, RV, PImax, PEmax, 6MD, CRQが12ヵ月後までに有意に改善した．以上の成績からCOPDにおける外来呼吸リハビリテーションは呼吸機能，運動耐容能および健康関連QOLを長期に改善させる可能性が示唆された．

Study Design. Case Report. Objectives. To present a rare case of a giant schwannoma of the cauda equina. Summary of Background Data. Giant spinal schwannoma of the cauda equina, which involves many nerve roots, is rare and there is usually no ossification in the schwannoma. It is unknown whether or not complete excision is preferable if the tumour is located in the lumbar lesion. Methods. A 57-year-old woman had a 10-year history of low back pain. Scalloping of the posterior surface of the vertebral bodies from L3 to the sacrum was found. Magnetic resonance imaging disclosed a giant cauda equina tumor with multiple cysts. Central ossification revealed by computed tomography and an unusual myelogram made the preoperative diagnosis difficult. Results. The patient underwent incomplete removal of the tumor, decompression of cysts, and spinal reconstruction. The tumor was proved to be a schwannoma. The postoperative course was uneventful and she has been almost free from low back pain for 3 years and 4 months. Conclusions. Giant schwannoma in the lumbar spine region is usually excised incompletely, because complete removal had the risk of sacrificing many nerve roots. In spite of the incomplete removal of the tumor, the risk of recurrence is low.

Objective: To find the most energy-efficient standing-up motion for quadriceps and to restore that motion in a person with complete paraplegia by using hybrid functional electrical stimulation. Design: Nonrandomized control trial. Setting: A referral center and institutional practice providing outpatient care. Participants: Twenty-nine volunteer samples were used to collect normal data. One patient with complete paraplegia received treatment for the restoration of standing-up motion. Main Outcome Measurements: Joint angles and ground reaction forces were investigated during the standing-up motion with arms crossed in front of the chest with an ankle-foot orthosis set at various angles. The electromyogram (EMG) was performed during the standing-up motion with and without the orthosis. The energy costs of quadriceps during the standing-up motion were calculated using a mathematical model. Standing-up motion in a person with complete paraplegia was restored and then analyzed by measuring the vertical ground reaction force and the hip and knee angles. Results: Quadriceps energy cost was lowest (p &lt; .05) in subjects wearing the ankle-foot orthosis set at neutral with a flat sole line. In the integrated EMG the peak value of rectus femoris contraction was larger with the orthosis than without it (p &lt; .05). A patient with complete paraplegia was able to stand up smoothly from a wheelchair based on stimulation patterns obtained from healthy subjects. Conclusions: Energy-efficient standing-up motion ina patient with complete paraplegia was restored when the patient used an ankle-foot orthosis set at neutral with a flat sole Line. (C) 1999 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.

The purpose of this study was to evaluate differences in the, gait patterns of healthy and osteoarthritic hips, and changes in these patterns after intertrochanteric varus osteotomy of the femur, in relation to the strength of the muscles around the hip joint. We measured the strength ratio of hip abductor muscles, temporal and distance factors, and pelvic movement, and carried out dynamic electromyography (EMG) in 24 women who underwent unilateral varus osteotomy of the femur for hip osteoarthritis (OA), 30 non- surgically-treated women with hip OA, and 54 healthy women. The stance phase time was shorter and the strength ratio of hip abductor muscles was lower in the operated patients than these values in the other two groups, changes in pelvic obliquity and tilt were smaller, and changes in the percent maximum voluntary contraction of the gluteus medius and tensor fascia latae muscles were greater than these values in the healthy subjects. This study showed the postoperative reappearance of the simulated conditions in the hip before varus osteotomy of the femur, providing evidence that the pelvis was horizontally maintained during walking due to the decreased stance phase time and increased performance of the hip abductor muscles achieved after this procedure.

Objective: To evaluate denervated muscles in persons with incomplete paraplegia due to thoracolumbar spinal injury (TLSI) using macro electromyography in determining indications for functional electrical stimulation (FES). Design: A randomized clinical trial and a criterion standard. Setting: A department of orthopedic surgery in a university hospital. Patients and Other Participants: Eighteen patients with incomplete paraplegia, including 11 with TSLI, and 50 healthy adults. Intervention: Area and amplitude of macro motor unit potential (macro MUP) were measured at the tibialis anterior, the vastus lateralis, and the vastus medialis. The normal limits of macro MUP parameters were defined based on values from healthy subjects. Abnormal denervated muscles were detected by macro EMG and conventional EMG in paralytic patients. The correlation between macro MUP parameter values and muscle forces of the tibialis anterior and quadriceps femoris induced by electrical stimulation was analyzed. Main Outcome Measures: The number of abnormal muscles, parameter values, and muscle force induced by electrical stimulation. Results: Abnormal muscles were found only in the TLSI patients and 13 abnormal muscles were detected by macro EMG only. The abnormal muscles defined by macro EMG showed insufficient contraction induced by electrical stimulation. The increase of parameter value negatively correlated with the muscle force (tibialis anterior area r = -.797, amplitude r = -.866; quadriceps area r = -.866, amplitude r = -.893; p &lt; .001). Conclusions: These results suggest that macro EMG is useful in detecting denervated muscles, in determining indications for FES, and in predicting FES effects before implantation of electrodes. (C) 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.

The reliability of a closed double helix electrode in the lower limbs was studied, This electrode is an implanted intramuscular electrode and is used for a totally implantable functional electrical stimulation system, Eighty electrodes were evaluated retrospectively with a mean period of 15 months, The total implant time was 1222 electrode months, The cumulative proportion surviving was 0.934 at 6 months, 0.855 at 1 year, 0.765 at 2 years, and 0.730 after 30 months, Fifteen of 80 electrodes failed, seven showed increasing electrode impedance, and eight had undesirable changes in recruitment, Of the failed electrodes, 2/3 failed during the first 10 months, The reliability was 0.91 at 6 months and 0.80 at 1 year after implantation in all muscle groups, The closed double helix electrode displayed an increased reliability when compared with the open double helix electrode at 6 months, and an equivalent reliability as compared with the electrodes developed by Handa and colleagues at 6 months and 1 year, using the chi squared test for independence, This study suggests that the closed double helix electrode has an acceptable reliability and can be used as a part of a totally implantable functional electrical stimulation system.

Joint contractures have been one of the contraindications for use of functional electrical stimulation for standing in paraplegic patients. A simulation study using a three-segment link mechanical model of the human body was performed to calculate the muscle moments at the ankles, knees, and hips during standing with and without having joint contractures. The knee and hip angles were varied in 5 degrees increments, whereas the ankle angles were varied in 1 degrees increments. It was assumed that energy efficient posture was obtained with the least sum of the squared moments of the ankles, knees, and hips joints by the muscles. Ankles at 5 degrees of dorsiflexion, knees at 0 degrees, and hips at 15 degrees of extension resulted in the most energy efficient posture without joint contractures. The muscle moments increased with the increase in angle of contractures. The joint contractures at ankle angles greater than or equal to 6 degrees of plantar flexion, knee angles greater than or equal to 20 degrees of flexion, and/or hip angles greater than or equal to 20 degrees of flexion produce a potentially unstable posture. These findings suggest that some degree of joint contractures can be tolerated in paraplegic patients using functional electrical stimulation for standing.

Objective: To evaluate the clinical use of the percutaneous intramuscular elec Design: Randomized and controlled study. Setting: A referral center and institutional practice providing outpatient care. Patients: Seventeen patients (12 men, 5 women) who had implanted percutaneous intramuscular electrodes for more than 1 year were examined. The average follow-up time after implantation of electrodes was 2.2 years (range, 1yr to 4yr 10mo). Overall, there were 327 electrodes (83 upper extremities and 234 lower extremities). Intervention: The indwelling electrode was composed of helically coiled Teflon-coated rope stranded from 19 hard drawn wires of SUS 316L stainless steel (SES 114). Main Outcome Measures: The rates of breakage, movement, and infection. and the number of electrodes that needed reimplantation were evaluated. Results: Only one electrode broke (0.3%) in the iliopsoas muscle at 12 weeks after implantation. Eight electrodes (2.4%) were removed because of loss of sufficient contraction force caused by movement of the electrodes. Movements occurred at 9 weeks in 6 electrodes and at 5 months in two. The failure rate of electrodes in the lower extremities was 3.7%. No failures occurred in the upper extremities, Ten electrodes (3.1%) required reimplantation. Although ten superficial infections (3.1%) were seen around the site of electrode insertion, no removals of electrode were needed. All electrodes in one patient were removed, however, because of generalized methicillin-resistant Staphylococcus aurcus infection complicated with renal disease. Electrodes were reimplanted after improvement of the infectio. Conclusions: The ultrafine percutaneous intramuscular electrode was considered practical for long-term FES use. (C) 1996 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Percutaneous intramuscular electrodes and a portable multichannel system were used to restore the function of the paralyzed lower extremities in six patients with complete paraplegia. The total number of inserted electrodes was 168. All of the patients could stand, two could walk in parallel bars, and two could walk with a walker. The rate of breakage of electrodes was only 0.6% in our series. There were 10 (6.0%) superficial infections, and 10 (6.0%) movement of electrodes which required reimplantation. The results suggest that the ultrafine intramuscular electrode is practical for long term use with paraplegic patients. Although the system can be used for paraplegic patients during the activities of daily living, it will be necessary to develop a closed-loop controller to reduce the amount of stimulation to the extensor muscles and extend the endurance of upright activity to reduce fatigue.

An electrical knee lock system that can be combined with functional electrical stimulation was designed for paraplegic patients. This knee system unlocks the knee electrically and allows knee flexion during the swing phase of the gait. When the knee is extended by electrical stimulation of the knee extensors, the knee is automatically locked by the weight of the locking bar, and the stimulation of the knee extensors is stopped. Since the knee extensors are stimulated for only a short period, muscle fatigue of the knee extensors seldom occurs. We applied this system to a T8 completely paraplegic patient. Standing-up, standing, walking, and sitting-down motions were all restored by our hybrid system. No electrical stimulation was necessary during standing, and the knee extensors were stimulated during only a small percentage of the 1-gait cycle. (C) 1996 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Sixteen patients (23 feet) who underwent split posterior tibial tendon transfers were evaluated, The patients were seen on a followup basis for a minimum of 1 year postoperatively, The causes were spastic cerebral palsy in 13 feet, spastic-athetoid cerebral palsy in 3 feet, hydrocephalus in 3 feet, and other diseases in 4 feet, The indication for surgery was varus deformity during the stance phase of gait and increased varus deformity during the swing phase of gait because of spasticity of the posterior tibial muscle, Heel cord lengthening was done on 17 feet, Preoperative and postoperative gaits were evaluated while the patients were walking, Axial radiographs of the calcaneus and the tibia were taken of all patients while they were weightbearing. There were 15 excellent, 6 good, and 2 poor results, The poor ratings were assigned to patients who had recurrence of varus deformity; there were no cases of overcorrection, Split posterior tibial tendon transfer was effective for treating spastic varus deformity of the hind part of the foot, This treatment also could be considered for a patient with spastic-athetoid cerebral palsy, if the deformity was determined to be caused by overactivity of the tibialis posterior muscle.

Changes in muscle force following therapeutic electrical stimulation (TES) in 5 patients with complete paraplegia were evaluated by computed tomography, Cybex II, a strain-gauge transducer, and manual muscle testing. The stimulation parameters included a frequency of 20 Hz, a pulse width of 0.2 ms, and an output voltage of -15 V. The cross-sectional areas of muscles, the muscle torques, and the muscle forces increased after TES, though the increased ratio differed in each muscle. The reasons why it differed are as follows: (1) The possibility of peripheral nerve injury; (2) The different patterns of nerve distribution in the muscles; (3) Implantation techniques; and (4) The possibility of breakage, movement, or changes in the impedance of electrodes. This study demonstrates that TES increases muscle force during electrical stimulation in paralyzed muscle, but that an initial TES-induced muscle force greater than a poor-minus level on manual muscle testing is necessary for practical use. TES treatment should be started as soon as possible after the onset of paralysis, in order to maintain muscle quality.

Objective: Restoration of stand-up motion in patients with complete paraplegia utilizing multichannel functional electrical stimulation, and analysis of the restored motion. Design: Nonrandomized control trial. Setting: General community, a referral center, institutional practice, and ambulatory care. Patients: Twelve volunteer samples were used for the collection of normal data. Two complete paraplegics received treatment for the restoration of stand-up motion. Main Outcome Measures: The electromyogram, joint angle, and poor reaction force were investigated during standing-up with arms crossed in front of the chest, and hands-assisted standing-up using parallel bars. The maximum knee joint torque during standing-up without hands-assists was calculated using a three-segment link model. Standing-up motion in complete paraplegics was restored, and then analyzed using the three-dimensional floor reaction force and the hip, knee, and ankle angles. Results: Main muscles used to stand up were the quadriceps, tibialis anterior, and paraspinal muscles. Hands-assists reduced the muscle activity and the vertical floor reaction force. Peak muscle activity was less during hands-assisted standing-up, except for the rectus femoris and the iliopsoas muscle, The maximum knee joint torque during standing-up was 1.6Nm/kg for both knees. Two complete paraplegics were able to stand up smoothly from a wheelchair based on stimulation data obtained from normal subjects. The characteristic pattern during standing-up was knee flexion preceding extension. Conclusion: Stand-up motion was restored utilizing electromyogram data and knee joint torque data from normal subjects. (C) 1995 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation