松浦 大輔

The efficacy of cognitive stimulation therapy (CST) in patients with vascular cognitive impairment has not been explored, and no studies investigating CST in the convalescent rehabilitation phase have been reported. This study examined the effect of CST on the cognitive function of patients with vascular cognitive impairment. A randomized controlled, assessor-blinded, single-centered trial with two parallel groups was conducted in a convalescent rehabilitation hospital. Twenty participants were randomly allocated to CST (n=10) and control (n=10) groups. Participants in the CST group underwent two CST sessions a day, five times a week for 8 weeks, in addition to conventional rehabilitation. Participants in the control group underwent conventional rehabilitation only. The primary outcome was the Mini-Mental State Examination (MMSE) score, and the outcome between the groups was compared using a generalized linear mixed model (GLMM). The mean (standard deviation) scores of MMSE increased by 3.50 (3.08) points and 4.50 (1.61) points from baseline to the end of the study (week 8) in the CST and control groups, respectively. The GLMM showed a significant effect of TIME on MMSE (F=21.121, P<0.001), whereas no significant effect on MMSE was observed for GROUP (intervention vs. control, P=0.817) or the interaction term (TIME×GROUP, P=0.649). Although a significant improvement in cognitive function was observed in each group, no significant effect of CST was evident. This result indicates that the effect may have been masked by improvements caused by natural history or rehabilitation. Future studies with a sufficient sample size are required to confirm the findings.

Dysphagia is one of the most common symptoms of stroke and can lead to other complications such as pneumonia, dehydration, and malnutrition. This retrospective cohort study evaluated the predictive value of a comprehensive swallowing assessment tool, the Mann Assessment of Swallowing Ability (MASA), in the acute phase of stroke for oral intake status at discharge. Among 1,133 consecutive patients with acute stroke, 512 patients whose swallowing function was assessed using the MASA within 24 h of admission were included. Data including demographic information, stroke severity, MASA, Oral Health Assessment Tool, body mass index, and serum albumin level were collected. Predictive factors for oral intake were analyzed using a multiple logistic regression model, and the receiver operating characteristic (ROC) curve analysis was used to determine the cutoff values of the MASA score for determining oral intake at discharge. Oral intake at discharge was established in 69.1% of the cohort (354/512). The multiple logistic regression analysis identified a higher MASA score, younger age, and higher serum albumin level as significant predictors of oral intake at discharge. The cutoff value of the MASA score for oral intake was 136.5 points, with an area under the ROC curve of 0.87. These findings suggest that the MASA is a valid tool for predicting oral intake in patients with dysphagia during the acute phase of stroke.

OBJECTIVES: Although the standard falls prevention strategy is to identify and respond to patients with high-risk conditions, it remains unclear whether falls in patients with high fall risk account for most observed falls. In this study, fall risk and number of falls were calculated based on patients' motor and cognitive abilities, and the relationship between the two was examined. DESIGN: We conducted a retrospective cohort study. SETTING AND PARTICIPANTS: We included 2518 consecutive patients with stroke who were admitted to a rehabilitation hospital. METHODS: Data on falls during hospitalization and biweekly assessed Functional Independence Measure scores were retrieved from the medical records. The average Functional Independence Measure scores for the motor and cognitive items were obtained and categorized as complete dependence, modified dependence, and independence. The fall rate (falls/1000 person-days) and number of observed falls in each combined condition were investigated. RESULTS: Modified dependence on motor ability and complete dependence on cognitive ability had the highest risk of falls, with a fall rate of 10.8/1000 person-days and 51 fall observations, which accounted for 4.3% of all falls. Independent motor and cognitive ability had the lowest risk of falls, a fall rate of 2.6/1000 person-days and 146 observed falls, accounting for 12.4% of all falls, which was 2.8 times higher than the number of falls observed in the highest risk of falls condition. CONCLUSIONS AND IMPLICATIONS: The combined motor-cognitive ability with the highest risk of falls in stroke inpatients did not have the highest number of observed falls. Rather, the combined motor-cognitive ability with the lowest risk of falls tended to have a high number of observed falls. A different strategy is needed to reduce the total number of falls.

INTRODUCTION: Toileting comprises multiple subtasks, and the difficulty of each is critical to determining the target and priority of intervention. The study aimed to examine the difficulty of subtasks that comprise toileting upon admission and the reacquisition of skills of subtasks during hospitalization. MATERIALS AND METHODS: This was a single-center prospective cohort study. We enrolled 101 consecutive stroke patients (mean age: 69.3 years) admitted to subacute rehabilitation wards. The independence in each of the 24 toileting subtasks was assessed using the Toileting Tasks Assessment Form (TTAF) every two or four weeks. The number of patients who were independent upon admission, as well as those who were not independent upon admission but became independent during hospitalization, was examined in each subtask. RESULTS: The most difficult subtask upon admission was "Lock the wheelchair brakes" (16.8% of patients were independent), followed by "Turn while standing (before urination/defecation)" (17.8%), "Pull the lower garments down" (18.0%), "Turn while standing (after urination/defecation)" (18.8%), "Pull the lower garments up and adjust them" (18.8%), and "Maintain a standing position (before urination/defecation)" (18.8%). The most difficult subtask for those who were not independent but became independent was "Dispose of incontinence pad/sanitary items" (19.3%), followed by "Press the nurse call button (after urination/defecation)" (28.3%), "Take the foot off the footrest and place it on the ground" (28.6%), and "Clean up after urination/defecation" (29.0%). CONCLUSIONS: The difficult subtasks upon admission and those for reacquired skills were different. The most difficult subtasks upon admission were main tasks, and the difficult subtasks in reacquiring skills were preparatory tasks.

OBJECTIVE: Bed-wheelchair transfer comprises multiple subtasks; hence, it is important to know the difficulty of each subtask to identify and prioritize subtasks that must be practiced. This study aimed to investigate the difficulty of the subtasks that comprise bed-wheelchair transfer upon admission and reacquiring subtask skills during hospitalization. MATERIALS AND METHODS: This was a single-center prospective cohort study. We enrolled 137 consecutive stroke patients (mean age: 69.8 years) admitted to subacute rehabilitation wards who used wheelchairs upon admission. The degree of independence in each of the 25 subtasks that comprised transferring was assessed using the Bed-wheelchair transfer Tasks Assessment Form every 2 weeks. The number of patients who were independent in the subtasks upon admission and those who were not but became independent during hospitalization were examined. RESULTS: The most difficult subtask for independent patients upon admission was "Manipulate the handrail for the bed" (18.3%), followed by "Ready the wheelchair for transfer" (19.3%), "Maneuver the wheelchair toward the appropriate place for transfer to the bed" (20.6%), "Wear shoes/brace" (24.8%), and "Turn while standing" (25.5%). The most difficult subtask for those who were not independent but became independent was "Ready the wheelchair for transfer" (32.1%), followed by "Manipulate the handrail for the bed" (32.9%), "Press the nurse call button" (36.4%), "Press the nurse call button (wheelchair-to-bed)" (36.7%), and "Lock the wheelchair brakes" (37.3%). CONCLUSIONS: Subtasks related to preparation for transfer were difficult upon admission, and this tendency became more pronounced during the skill acquisition process.

OBJECTIVE: To investigate the long-term cumulative risk and factors associated with fall-related fractures in stroke survivors discharged from convalescent rehabilitation wards. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 786 stroke survivors discharged from a rehabilitation hospital. METHODS: Data regarding fall-related fractures posthospital discharge were collected using self-reported questionnaires. The Kaplan-Meier method was used to calculate the cumulative incidence of fall-related fractures, and risk factors were analysed using Cox proportional hazard regression analysis. RESULTS: Of 1,861 consecutive stroke survivors who had been discharged from hospital, 786 (42.2%) provided information concerning fall-related fractures. Duration from time of discharge to time of collection of questionnaires ranged from 1 to 6 years (mean 38.0 months). The cumulative incidence of fall-related fractures at 1-, 2-, 3-, 4-, and 5-years post-discharge was 4.2%, 7.9%, 10.8%, 12.5% and 13.7%, respectively. Cox proportional hazard regression analysis indicated that female sex (hazard ratio (HR) 1.69) and moderate lower limb paresis (HR 3.08) were significant risk factors. CONCLUSION: The cumulative risk of fall-related fractures in stroke survivors post-discharge from a rehabilitation hospital was notably high. Intensive preventive intervention should be considered for female stroke survivors with moderate lower limb paresis.

OBJECTIVE: To determine whether poststroke fatigue at admission is associated with the degree of independence in activities of daily living in patients with stroke at discharge from subacute rehabilitation wards. DESIGN: Retrospective cohort study. SETTING: Subacute rehabilitation hospital. PARTICIPANTS: A consecutive sample of patients (N=156) with stroke who were admitted to a subacute rehabilitation ward between December 2012 and November 2013 were enrolled in the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Poststroke fatigue was assessed using the Fatigue Severity Scale within 2 weeks of admission. Poststroke fatigue was defined as the mean score of 4 points or more from among 9 items in the Fatigue Severity Scale. Functional outcome was assessed by using FIM motor items. RESULTS: Fifty-six (35.9%) of the 156 participants had poststroke fatigue at admission. The scores of the FIM motor items at admission and discharge were significantly lower in the fatigue group than in the nonfatigue group (P<.05). Multiple regression analysis with potentially confounding variables revealed that poststroke fatigue was a significant independent factor for discharge FIM motor items score (P<.05). CONCLUSION: Poststroke fatigue at admission was significantly associated with functional outcome at discharge from subacute rehabilitation wards. Our findings emphasize that rehabilitation professionals need to manage poststroke fatigue in addition to providing the interventions to improve daily activities in patients with subacute stroke.

OBJECTIVE: To elucidate the characteristics of subacute stroke survivors with post-stroke cognitive impairment, and examine the factors associated with cognitive recovery. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 218 consecutive stroke survivors, who were admitted to a rehabilitation hospital between April 2014 and March 2015, were included. METHODS: The prevalence of post-stroke cognitive impairment, defined as having a Mini-Mental State Examination (MMSE) score < 24 was investigated. Among those with post-stroke cognitive impairment, the characteristics of patients with clinically significant improvement in MMSE scores (change ≥ 4) were explored. Univariable and multivariable regression analyses were performed to examine the relationship between Functional Independence Measure (FIM) items and improvement in post-stroke cognitive impairment. RESULTS: Post-stroke cognitive impairment occurred in 47.7% of participants. The mean improvement in their MMSE scores was 3.43. Participants who showed improvement had significantly higher FIM scores at discharge than those who did not show improvement. Regarding FIM items, eating (odds ratio 1.3; 95% confidence interval 1.0-1.7; p = 0.041) and social interaction (odds ratio 1.5, 95% CI 1.1-2.1, p = 0.010) were associated with cognitive improvement. CONCLUSION: Approximately half of subacute stroke survivors have post-stroke cognitive impairment. Eating and social interaction are significantly associated with cognitive improvement.

STUDY OBJECTIVES: We aimed to elucidate the prevalence of sleep-disordered breathing (SDB), effect of SDB severity on the functional outcome, and feasibility of continuous positive airway pressure (CPAP) therapy in patients with subacute stroke. METHODS: We recruited 433 consecutive patients (mean age: 66.5 years, 271 men) admitted to our rehabilitation wards for subacute stroke (8 to 90 days after onset) from August 2011-November 2013, who had undergone at least one successful sleep study within 4 weeks after admission to the wards. We investigated the prevalence of SDB, defined as a respiratory event index (REI) ≥ 5 events/h; the relationship between SDB severity and the functional outcome at discharge; and the number of patients receiving and adhering to CPAP therapy. RESULTS: REIs ≥ 5 and ≥ 15 events/h were observed for 87.3% (n = 378) and 46.4% (n = 201) of patients, respectively. The Functional Independence Measure score at discharge was significantly lower for patients with REI ≥ 15 events/h than for those with REI < 15 events/h. However, REI was not an independent factor for functional outcome after adjustment for potential confounders, irrespective of stroke types. CPAP therapy was administered to 41 patients (9.5%). During the mean follow-up period of 21.6 months, 20 patients (48.8%) dropped out from the CPAP therapy. Among the 23 patients who continued CPAP therapy until discharge, 17 (74%) continued its use throughout the follow-up period or discontinued therapy because of improvement. CONCLUSIONS: SDB prevalence was high in patients with subacute stroke at admission. However, SDB severity was not significantly related to functional outcome at discharge. Although the overall adherence was not good, relatively good adherence to CPAP therapy after discharge was observed when CPAP was successfully introduced during hospitalization.

62歳男。受診前日にふらつきと歩きにくさを自覚し、受診当日、左半身の力の入りにくさも出現したため来院した。頭部CTで脳出血を認め、入院となった。トイレ動作や食事などの基本的動作に問題はなかったが、着衣障害を認めた。着衣障害に関する先行研究で山本らは、同障害の出現形式から「視覚認知エラー」「操作エラー」「手順エラー」の3つに誤反応を分類しており、本例はこれらのうち「視覚認知エラー」と「操作エラー」を合併していると考えられた。保存的治療により約1ヵ月で退院となり、若干の視覚性運動失調が残存したものの、着衣障害は改善した。その理由として、血腫の進展が運動野や意識に関係している脳幹や視床まで及ばなかったことや、右半球損傷であったため言語の理解や表出に大きな障害がなかったことなどが考えられた。着衣障害を生じた機序については、右の上頭頂葉出血により背背側経路が損傷されたことで、行為の無意識的制御が破綻した可能性が考えられた。

OBJECTIVE: To identify the predictors for the resumption of oral feeding at discharge among tube feeding-dependent stroke patients admitted to rehabilitation wards. MATERIALS AND METHODS: This study was a retrospective analysis of 107 stroke patients (mean age, 72.1 years) dependent on tube feeds at admission to a rehabilitation ward. Data analyzed included demographic information, severity of impairments, functional independence, body mass index, nutritional and inflammatory laboratory markers at admission, and videofluoroscopic examination findings, if conducted. The variables were compared between the groups with and without resumption of oral intake. The predictive factors for resumption of oral intake were analyzed by using a stepwise multiple logistic regression model. RESULTS: At discharge, 69.2% (74 of 107) of the patients resumed oral intake. There were significant differences in age, the Functional Independence Measure, body mass index, serum albumin, C-reactive protein, white blood cell count, and duration of stroke onset at admission between the 2 groups. Multiple logistic regression analysis identified age (odds ratio [OR] .55; 95% confidence interval [CI] .31-.95), body mass index (OR 1.34; 95% CI 1.12-1.60), and white blood cell count (OR .76; 95% CI .60-.97) as significant predictors for the resumption of oral intake in these patients. CONCLUSION: Older age, lower body mass index, and higher white blood cell count were significant independent negative predictors for the resumption of oral feeding among stroke patients dependent on tube feeding at admission to rehabilitation wards.

症例は70歳代男性で、数年前から歩行障害を認めていたが、急激に歩行障害が悪化した。他院で実施した画像診断でC1-C7の後縦靱帯骨化症とTh10/11、Th11/12の黄色靱帯骨化症を認め、脊柱管拡大術と椎弓切除術が施行された。術後2日目より離床を開始し、リハビリテーション目的で当院に紹介となった。歩行は、両側T字杖使用下では失調様歩行であり、歩幅にばらつきを認めたため、日常の移動には歩行器を使用した。深部感覚の低下によるバランス障害(脊髄性の運動失調)がみられ、これは主に黄色靱帯骨化症により慢性的に脊髄の圧迫をきたし、後索障害が現れた結果と考えた。そのため、視覚および前庭機能による代償を最大にすること、失調を補う能力、特に筋力増強などを目的に運動療法を展開した。24日間の介入により、機能的自立度評価表は入院時109点(運動項目合計74点)から退院時116点(運動項目合計81点)と改善を認めた。歩行は屋内歩行器使用からフリーハンドで可能となり、屋外は片側杖を使用することで外出可能なレベルまで回復した。歩行速度、下肢筋力は継時的に改善を示し、歩行のばらつき具合を示す周期変動係数も改善した。さらに、6分間歩行距離、Physiological Cost Index、バランス能力、重心動揺についても改善した。退院後の経過は良好であり、術後5ヵ月まで新たな疼痛や転倒などは生じていない。

症例は63歳男性である。47歳時に関節炎と皮膚潰瘍を発症し、血管炎をともなう慢性関節リウマチ(悪性関節リウマチ)と診断され、プレドニゾロンとシクロスポリンAの内服治療を受けていた。今回、頭痛、痙攣を主訴に来院し、リンパ球優位の髄液細胞数増多、頭部MRIで左大脳半球の脳表に限局した病変をみとめた。病変部位はFLAIR画像にて高信号を呈し、病変の一部は拡散強調画像でも高信号を呈した。ステロイドパルス療法をおこない、症候、検査所見とも改善した。リウマチ性髄膜炎はまれな疾患であるが、一側テント上に限局する軟膜病変を呈しやすく、本例ではFLAIR画像と拡散強調画像の併用が病変の経時的な評価に有用であった。(著者抄録)

1999年7月～2004年6月に開頭外減圧術を行った急性期脳梗塞患者にアンケート調査を行った.急性期脳梗塞2905例のうち,開頭外減圧術を行った15例(0.5%)を対象とした.手術生存率は93%(14例)であった.調査時のADLが部分介助であった予後良好群は8例(53%)で,発症から手術までに73.4±56.7時間を要し(予後不良群:38.4±28.7時間),術前Japan Coma Scaleは5例(62.5%)が2桁(10～30)であった.又,左半球症例4例全例が含まれていた.アンケートは14例(93.3%)から回答を得た.予後良好群の7例(87.5%),予後不良群の71.4%(5例)が手術を受けてよかったと答えた.開頭外減圧術の適応を病側,年齢,手術時期,術式について考察し,術後のQOLを踏まえた前向きな検討が手術施行には必要だと思われた

37歳男.ソフトボールが顎に当たり,4日後に右後頸部痛,左半身のしびれ感・脱力,回転性めまい,構音障害が出現した.頸部血管エコーで右椎骨動脈は第4～6頸椎レベルに限局した狭窄を認め,頭部MRIでは右小脳半球上内側部から虫部にかけて新しい梗塞巣を認めた.脳血管造影では第4～6頸椎レベルの右椎骨動脈の壁不整と,右上小脳動脈閉塞を認めた.頭蓋外右椎骨動脈解離による動脈原性脳塞栓症と診断し,ヘパリン,エダラボン,グリセロールの投与で左片麻痺,めまい,感覚障害は第6病日までに消失した.しかし,第7病日に一過性の左同名半盲が出現し,頸部血管エコーおよび脳血管造影で解離部の狭窄進行を認めた.その後も一過性脳虚血発作を繰り返し,薬物療法の限界と考え,血管内治療を施行した.Guglielmi detachable coilを解離部に挿入し,右椎骨動脈近位からの順行性血流を完全に遮断した.その結果,新たな症状の出現はなく,発症6ヵ月までには症候は消失し,日常生活の支障はない

68歳女.自宅前で倒れているのを発見された.右共同偏倚と中枢性の左顔面麻痺,左上下肢の麻痺を認め,頭部MRIで右放線冠と右島皮質に拡散強調画像で淡い高信号を,頭部MRAで右中大脳動脈M1の閉塞と両側内頸動脈の壁不整を認めた.アテローム血栓性脳梗塞と考え,アルガトロバン,低分子デキストラン,エダラボンで治療を開始した.第9病日に経食道心エコーを行い,右左シャントと卵円孔開存を認め,大動脈弓部に潰瘍形成を伴うプラークを認めた.下肢静脈エコーを施行したところ,左下肢に後脛骨静脈末梢部から浅大腿静脈にかけて連続する血栓を認めた.血栓の先端は浅大腿静脈と大伏在静脈の合流部にあり,可動性を有していた.また,肺血流シンチでは右中肺野,左上肺野に血流欠損を認めた.脳梗塞および肺塞栓症再発のリスクが高いと考え,下大静脈フィルターを下大静脈と奇静脈の腎静脈下に挿入し,ワルファリンカルシウムの投与を開始した.第17病日に血栓の可動性消失を確認し,リハビリテーション目的で転院した