谷川 広樹

Background: The toe clearance of a paretic limb in the swing phase of gait is related to tripping, which is considered a major cause of falls. The biomechanical factors for obtaining toe clearance are more complicated in hemiparetic gait than that in normal gait because of the compensatory movements during swing phase. Understanding the biomechanical factors should help in targeting the point for rehabilitative interventions. Objective: To clarify the biomechanical factors behind toe clearance during swing phase in hemiparetic gait. Methods: Fifty patients with hemiparesis after a stroke participated in this study. Three-dimensional motion analysis was used for the kinematic analysis of the hemiparetic gait. The correlation coefficients between limb shortening and angle changes and between limb shortening and hip elevation and foot lateral shift were calculated. Limb shortening was defined as the shortening of the hip-toe distance. The significant factors that determine toe clearance were examined by multiple regression analysis. Independent variables were limb shortening, hip elevation, and foot lateral shift. Results: Limb shortening was negatively correlated with hip elevation (r = -0.75) and foot lateral shift (r = -0.41). Multiple regression analysis showed a significant contribution of limb shortening and hip elevation to toe clearance. The coefficient of determination was 0.95. Conclusions: Toe clearance was mainly determined by limb shortening and hip elevation, which were found to be in a trade-off relationship. These results warrant further investigation into the use of three-dimensional motion analysis in the rehabilitation clinic to facilitate targeted rehabilitative training to restore gait ability.

BACKGROUND: In a patient with severe hemiplegia, the risk of the knee giving way is high during the early stage of gait exercise with an ankle-foot orthosis. However, use of a knee-ankle-foot orthosis has many problems such as large amount of assistance and compensatory motions. To resolve these problems, we have engaged in the development of the Gait Exercise Assist Robot (GEAR). OBJECTIVE: To evaluate the improvement efficiency of walk with GEAR in a stroke patient. METHODS: The subject was a 70-year-old man presented with left thalamus hemorrhage and right hemiplegia. The patient underwent exercise with the GEAR 5 days a week, for 40 minutes per day. We evaluated the Functional Independence Measure score for walk (FIM-walk score) every week. The control group consisted of 15 patients aged 20-75 years with hemiplegia after primary stroke, who had equivalent walking ability with the subject at start. As the primary outcome, we defined improvement efficiency of FIM-walk, which was gain of FIM-walk divided the number of required weeks. RESULTS: Improvement efficiency of FIM-walk of the subject was 1.5, while that of control group was 0.48 +/- 3.2 (mean +/- SD). CONCLUSIONS: GEAR is potentially useful for gait exercise in hemiplegic patients.

【目的】Hand-held dynamometerによる股関節外転筋力測定において,非測定下肢機能が測定値に与える影響を明らかにすること.【方法】健常者30名と片麻痺患者59名を対象とし,背臥位で両側股関節外転筋力を,非測定下肢を固定する方法(固定法)としない方法(非固定法)で測定した.同一法における左右および麻痺側・非麻痺側,固定法と非固定法での測定値を比較し,片麻痺患者では麻痺側筋力を従属変数,非麻痺側筋力と麻痺の程度を独立変数として重回帰分析を行った.【結果】非固定法の計測値が固定法よりも有意に小さかった.健常者では非測定下肢の固定によらず左右の相関が高かったが,片麻痺患者では非固定法において相関が低かった.重回帰分析の結果,固定法における麻痺側筋力は非麻痺側下肢機能の影響を強く受けていた.【考察】固定法では非測定下肢機能の影響を受け,測定下肢の筋力を正確に反映していないと考えられた.(著者抄録)

<p>Pongpipatpaiboon K, Mukaino M, Tsuchiyama K, Ohtsuka K, Matsuda F, Tanikawa H, Yamada J, Saitoh E. The use of a holistic figure in gait analysis: a preliminary study on the effect of ankle-foot orthosis. Jpn J Compr Rehabil Sci 2016; 7: 80-86.</p><p>Objective: To examine the practical usefulness of a simplified three-dimensional treadmill gait analysis with a Lissajous overview picture (LOP), a holistic figure of marker trajectories, to present the effect of ankle-foot orthoses (AFO) on hemiparetic gait.</p><p>Methods: Seven patients with hemiparesis who were able to walk without an orthosis or gait assistive device were included in this study. Patients were measured with a simplified three-dimensional treadmill gait analysis system as they walked with and without an orthosis in a rehabilitation center of a university medical center. Gait was analyzed using the LOP, and quantitative comparisons were made to evaluate the changes in joint angles and joint position displacements during the swing phase.</p><p>Results: Using the orthosis decreased ankle plantar flexion during the swing phase (p = 0.028) and significantly reduced compensatory patterns, including hip elevation, knee elevation, and circumduction (p = 0.028, 0.018, and 0.028, respectively).</p><p>Conclusions: The quantitative assessment by a simplified gait analysis system clarified the effect of AFO on reducing the compensatory movement in a hemiparetic gait. The use of LOP helps to understand the holistic effect of AFO and to analyze the individual patterns of gait disturbance.</p>

<p>Objective: Although previous studies have evidenced the value ofthree-dimensional gait analysis (3DGA) for evaluating gait disorder, the time-consumingmeasurement process and space requirement has hampered its use in the clinical setting.The aim of this study was to examine the feasibility of a simplified 3DGA system forstroke patients. Methods: Thirteen pairs of stroke patients and age- (± 1year), gender-, and gait speed- (± 0.5 m/s) matched controls were drawn from the FujitaHealth University gait analysis database. 3DGA was performed using theKinemaTracer^® treadmill gait analysis system. Comparisons of thespatiotemporal and kinematic parameters were performed between stroke patients and matchedcontrols. The correlations between items from the Wisconsin Gait Scale (WGS) and 3DGA datain stroke patients were also investigated. Results: 3DGA measurements clearlyshowed reduced toe clearance, hip flexion, and knee flexion in stroke patients comparedwith the matched controls. In contrast, significant increases were observed in hipelevation, shoulder elevation, shoulder lateral shift, and step width in stroke patients.For the four items drawn from the WGS, a significant correlation with three 3DGAparameters was observed: stance time on the impaired side, stance width, and knee flexionfrom toe off to midswing. Conclusions: In this study, significant differencesin gait parameters of stroke patients and age-, gender-, and speed-matched controls werefound using a simplified 3DGA system. A significant correlation with WGS was alsoobserved. These results support the validity of the clinical measurement of gaitparameters using a simplified 3DGA system.</p>

Background: Gait assessment is important to determine the most effective strategy to regain gait function during stroke rehabilitation. To understand the mechanisms that cause abnormal gait patterns, it is useful to objectively identify and quantify the abnormal gait patterns. Objective assessment also helps evaluate the efficacy of treatments and can be used to provide suggestions for treatment. Objective: To evaluate the validity of quantitative indices for retropulsion of the hip, excessive hip external rotation, and excessive lateral shift of the trunk over the unaffected side in hemiplegic patients. Methods: Forty-six healthy control subjects and 112 hemiplegic patients participated. From the 112 patients, 50 patients were selected into each abnormal gait pattern 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 three abnormal gait patterns was calculated from the three-dimensional coordinate data. The index values of patients were compared with those of healthy subjects and 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 three abnormal gait patterns (-0.56 to -0.74). Most of the patients with an abnormal gait pattern had a higher index value than the healthy subjects. Conclusions: The proposed indices are useful for clinical gait analysis. Our results encourage a more detailed analysis of hemiplegic gait using a motion analysis system.

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.

Itoh N, Kagaya H, Saitoh E, Ohtsuka K, Yamada J, Tanikawa H, Tanabe S, Itoh N, Aoki T, Kanada Y. Quantitative assessment of circumduction, hip hiking, and forefoot contact gait using Lissajous figures. Jpn J Compr Rehabil Sci 2012; 3: 78-84.<BR>Objective: To quantitatively assess gait abnormalities using Lissajous figures obtained from three-dimensional motion analysis of treadmill gait, with the goal of applying the findings to the treatment of gait disorders.<BR>Methods: Thirty-nine healthy subjects and 30 hemiplegic patients were studied. Treadmill gait analysis was conducted using a three-dimensional motion analysis system. Using the Lissajous figures obtained from the gait analysis, quantitative indexes were developed for three gait abnormalities: circumduction, hip hiking, and forefoot contact. The indexes were validated through comparison with observational assessment by physiotherapists with expertise in gait analysis. <BR>Results: The values obtained for all the indexes were significantly higher in hemiplegic patients compared to healthy subjects (p < 0.001). Correlation analysis was conducted between the index values and observational scores for each gait abnormality, yielding Spearman's rank correlation coefficients of -0.82 for circumduction, -0.64 for hip hiking, and -0.84 for forefoot contact (p < 0.001).<BR>Conclusion: We successfully developed objective quantitative indexes for gait abnormalities, which were not influenced by rater bias.

[目的]視診による異常歩行重症度スコアリングの評価者間信頼性を検討した.[方法]臨床経験6年以上の理学療法士10名を評価者とし,片麻痺患者13名のトレッドミル歩行ビデオ画像を観察させ,分回し歩行とトゥクリアランス低下の重症度を5段階評価させた結果の評価者間信頼性をCohenのκ係数を用いて検討した.また,評価者を経験年数と観察した部位・相で分け,κ係数を求めた.[結果]評価結果のκ係数は0.09〜0.58であり,経験年数にかかわらず低かった.観察部位・相を揃えた群のκ係数も0.03〜0.32と低かった.[考察]一致率の程度はslight〜moderateにとどまり,評価者間信頼性は低かった.観察部位・相を揃えても信頼性は向上せず,評価者の主観的尺度と評価基準の相違が主な原因と思われた.視診による歩行分析の信頼性を高めるには,異常歩行を定義したうえで,明確な重症度基準を定める必要があると考えられた.(著者抄録)