武田 和也

BACKGROUND: The COVID-19 pandemic has affected physical and occupational therapist education in various ways. OBJECTIVE: This study investigated whether the pandemic changed clinical placement, thus influencing the clinical competence of physical and occupational therapists at a hospital in Japan. METHODS: Eleven therapists (seven physical and four occupational) participated in this study in April 2021. Clinical placement teaching methods were surveyed using an online questionnaire. The Objective Structured Clinical Examination (OSCE), comprising attitudinal and technical items, was used to examine clinical competence. The results were calculated as the sum of the attitudinal and technical scores, and the ratios of these scores to the full score were compared using a paired-sample Wilcoxon signed-rank test. RESULTS: During the pandemic, some schools implemented shortened practical clinical placements. The substituted classes included online-only classes and combined online and face-to-face classes. Regarding clinical competence, scores on the OSCE were mostly high. The median proportion of the total attitudinal score to the perfect score was 100% for all three items (range-of-motion test, muscle strength test, Stroke Impairment Assessment Set). The median proportion of the total technical score to the perfect score ranged from 56.7% to 76.7% for the three items. The ratio of the total attitudinal score to the full score was significantly higher than that of the total technical score to the full score (p = 0.001). CONCLUSIONS: Most clinical placements were canceled or partially administered through online learning during the pandemic. This decrease in clinical placements did not affect newly recruited physical and occupational therapists’ clinical competence.

Introduction Qualitative information in the form of written reflection reports is vital for evaluating students’ progress in education. As a pilot study, we used text mining, which analyzes qualitative information with quantitative features, to investigate how rehabilitation students’ goals change during their first year at university. Methods We recruited 109 first-year students (66 physical therapy and 43 occupational therapy students) enrolled in a university rehabilitation course. These students completed an open-ended questionnaire about their learning goals at the time of admission and at 6 and 12 months after admission to the university. Text mining was used to objectively interpret the descriptive text data from all three-time points to extract frequently occurring nouns at once. Then, hierarchical cluster analysis was performed to generate clusters. The number of students who mentioned at least one noun in each cluster was counted and the percentages of students in each cluster were compared for the three periods using Cochran’s Q test. Results The 31 nouns that appeared 10 or more times in the 427 sentences were classified into three clusters: “Socializing,” “Practical Training,” and “Classroom Learning.” The percentage of students in all three clusters showed significant differences across the time periods (p < 0.001 for “Socializing”; p < 0.01 for “Practical Training” and “Classroom Learning”). Conclusion These findings suggest that the students’ learning goals changed during their first year of education. This objective analytical method will enable researchers to examine transitional trends in students’ reflections and capture their psychological changes, making it a useful tool in educational research.

The number of post-graduate rehabilitation therapists (novice therapists) is increasing due to the growing demand for rehabilitation services in Japan. This study investigated the acquisition status of Japanese novice therapists’ basic clinical skills to clarify their quality and characteristics. Eleven participants’ basic clinical skills (eight physical and three occupational therapists) were assessed using an Objective Structured Clinical Examination. Tasks included exercises of joint range of motion, muscle strengthening, getting up, standing up and sitting down, and transferring between wheelchair and bed. Assessment items were subdivided into categories: attitude, preparation, intervention, safety management, and feedback. One-way ANOVA and Friedman test were used for statistical analysis to compare the data between tasks and categories. The scores for each task’s achievement rate were not statistically significant. However, the achievement rate of each category including tasks was 92.6% (SD 4.0%) for attitude, 81.4% (SD 11.1%) for preparation, 77.9% (SD 14.7%) for intervention, 87.6% (SD 17.3%) for safety management, and 64.0% (SD 14.2%) for feedback. There were significant differences between attitude and feedback (p < 0.001), and between safety management and feedback (p = 0.012). Post-graduate training programs should focus on improving the quality of clinical skills, especially in skills related to feedback.

Purpose: To increase the clinical competence of novice physical and occupational therapists, an accurate assessment of their clinical competence is necessary. However, no previous study has objectively analyzed the changes in novice therapists’ clinical competence in Japan. Hence, this study investigated and evaluated the changes in the clinical competence of such therapists using an objective analysis. Method: The study included 34 novice therapists with 1–3 years of experience in clinical practice. Participants were divided into groups according to their years of experience. The clinical competence of the novice therapists was evaluated twice using a clinical competency evaluation scale. For comparison among the 3 groups, the scores of the first evaluation were used. For comparison within each experience-year, the scores from both evaluations were used. Results: A comparison of the 3 groups showed that therapists with 3 years of clinical experience had significantly higher clinical competence than therapists with 1 year of clinical experience. Between the first and second evaluations, all therapists with 1 year of clinical experience demonstrated increased scores, whereas scores decreased by approximately 50% for therapists with 2–3 years of clinical experience. Conclusion: These findings suggest that it is necessary to increase educational opportunities for therapists with 2−3 years of clinical experience and re-examine the content of their education and training.

Background and Purpose: There are no reports regarding the effect of Lee Silverman Voice Treatment® BIG (LSVT® BIG) on standing balance ability evaluated using quantitative assessment. This case report aimed to describe and evaluate the influence of LSVT® BIG on the center of pressure (COP) trajectory in a patient with Parkinson's disease (PD). Methods: Although this paper focused on one case, quantitative assessment on the effect of LSVT® BIG on standing balance ability was performed. A 67-year-old woman patient diagnosed with PD at age 59, with a Hoehn and Yahr stage 3 disability severity, underwent a 4-weeks supervised LSVT® BIG program. The total distances of the COP trajectory (two-dimensional [2D] horizontal plane, anterior-posterior [AP] direction, and medial-lateral [ML] direction), and the mean COP velocity for each direction, postural stability, and posture subsections of the Unified Parkinson's Disease Rating Scale (UPDRS) Part 3 were assessed at pre- and post-intervention. Results: The total distances of the COP trajectory, mean COP velocities, and scores of postural stability and posture subsections of the UPDRS Part 3 improved after intervention (from 124.6 to 76.6 cm [2D], 89.4 to 57.7 cm [AP], 77.4 to 38.5 cm [ML]; 4.0 to 2.6 cm/s [2D], 3.0 to 1.9 cm/s [AP], 2.6 to 1.3 cm/s [ML]; and 3 to 0, and 3 to 2, respectively). Discussion: LSVT® BIG may be effective in improving the total distance of the COP trajectory, mean COP velocity, and both postural stability and posture subsections of the UPDRS Part 3 in the presented PD case.

Introduction: Upper limb motor function and activities of daily living (ADL) are related in chronic stroke patients. This study investigated this relationship after removal of the influence of motor function of the affected lower limb, which until now has remained unclear. Methods: This retrospective cross-sectional study included 53 patients with chronic stroke. Upper and lower limb motor function and ADL were assessed using the Fugl-Meyer assessment of the upper (FMA-UL) and lower limbs (FMA-LL) and functional independence measure motor score (FIM-M). To clarify the relationship between FMA-UL and total FIM-M before and after removal of the influence of FMA-LL, Spearman’s rank correlation coefficient and partial correlation analysis were used. The relationship between FMA-UL and each item of FIM-M after removal of the influence of FMA-LL was assessed using partial correlation analysis. Results: Before the influence of FMA-LL was removed, FMA-UL was moderately to well correlated with total FIM-M. This became weak after the influence was removed. Regarding each item of FIM-M, FMA-UL was correlated with dressing (upper body), toileting, and walking or wheelchair after removal of the influence. Conclusion: The relationship between upper limb motor function and ADL is strongly influenced by lower limb motor function.

BACKGROUND: There are no reports regarding the long-term retention of effects of Lee Silverman Voice Treatment® BIG (LSVT® BIG) on improvements in quality of life (QOL) among patients with Parkinson's disease (PD). OBJECTIVE: This study aimed to evaluate the short-term effect of LSVT® BIG on QOL improvement and its retention in a patient with PD. Motor symptoms, walking ability, and walking speed were evaluated as factors associated with QOL. METHODS: A 63-year-old woman who was diagnosed with PD received a 4-week LSVT® BIG program under the supervision of certified LSVT® BIG physical therapists. The participant's disease severity was classified as Hoehn and Yahr stage 2. The Parkinson's Disease Questionnaire-39 (PDQ-39), Movement Disorder Society-sponsored Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part 3, timed up-and-go test (TUG), and 10 m walk test (10 MWT) were evaluated before, after, and 1-year after the intervention. RESULTS: The results indicated short-term improvements in the PDQ-39, MDS-UPDRS part 3, TUG, and 10 MWT which were retained for up to 1 year. CONCLUSIONS: This case report suggests the possibility of 1-year retention of improvements in QOL, motor symptoms, walking ability, and walking speed resulting from LSVT® BIG intervention in a patient with mild PD.

Introduction: Lee Silverman Voice Treatment® BIG (LSVT® BIG) is widely used to improve motor symptoms in patients with mild-to-moderate Parkinson's disease (PD).Objective: To describe the effect of LSVT® BIG on the motor symptoms of a patient with severe PD.Case Description: A 77-year-old woman who was diagnosed with PD received a 4-week LSVT® BIG program under the supervision of certified LSVT® BIG physical therapists. Her disease severity was classified as Hoehn and Yahr stage 4. The unified Parkinson's disease rating scale (UPDRS) part 3, 10-m walk test (10MWT), timed up-and-go test (TUG), Berg balance scale (BBS), and 30-s chair stand test (30-s CST) were used for assessment before and after intervention.Outcomes: The UPDRS part 3, 10MWT, TUG, BBS, and 30-s CST improved after intervention (33 to 26, 0.51 to 0.69 m/s, 38.1 to 23.2 seconds, 11 to 34, and 3 to 9 times, respectively). All improvements exceeded the Minimal Clinically Important Difference or Minimal Detectable Change values (2.5, 0.16 m/s, 3.5 seconds, 5, and 3 times, respectively).Conclusions: These results indicated that LSVT® BIG appears to have improved motor symptoms in a patient with severe PD. Further studies, ideally randomized controlled trials, are needed to confirm these findings.

Background: The rate of force development (RFD) is an indicator of muscle strength. A previous study reported that the RFD of hip abductor muscles was increased by neuromuscular electrical stimulation (NMES) to gluteus medius (GM) during gait in healthy adults. However, the effects for patients following femoral head replacement for hip fracture are unclear.Purpose: The aim of this case report was to investigate the effects of gait training with sub-motor threshold NMES on RFD of hip abductor muscles in two patients following femoral head replacement for hip fracture compared to gait training without NMES.Case description: Two elderly patients following femoral head replacement for hip fracture received both interventions of gait training with sub-motor threshold NMES to GM and without NMES. Intervention phases involved 14 sessions each, for 28 sessions total.Outcomes: The RFD of hip abductor muscles, maximum walking speed, six-minute walk distance (6MWD), Berg Balance Scale, one-leg standing time (OLST), functional independence measure, and Numeric Pain Rating Scale (NPRS) were used as outcome measures. In both patients, RFD, 6MWD, OLST, and NPRS were improved by gait training with NMES compared to without NMES.Conclusion: Our results suggest the potential of NMES as a treatment methodology for these two patients undergoing femoral head replacement for hip fracture.

Background: Previous studies have reported a relationship between upper limb motor function and activities of daily living. However, their relationship after removing the influence of lower limb motor function has not been clarified. Objective: This study aimed to investigate the relationship between Fugl-Meyer assessment upper limb and total Functional Independence Measure motor score and between Fugl-Meyer assessment upper limb and each item contained in Functional Independence Measure motor score after eliminating the influence of the motor function of the affected lower limb. Methods: This retrospective cross-sectional study included 58 subacute stroke patients. To investigate the relationship between the Fugl-Meyer assessment upper limb and total Functional Independence Measure motor score before and after removing the influence of Fugl-Meyer assessment lower limb, Spearman's rank correlation coefficient and partial correlation analysis were used. Additionally, the relationship between Fugl-Meyer assessment upper limb and each item of Functional Independence Measure motor score after removing the influence was assessed. Results: Before removing the influence of Fugl-Meyer assessment lower limb, Fugl-Meyer assessment upper limb was strongly correlated with total Functional Independence Measure motor score (r = 0.74, p < 0.001). However, it became weak after removing the influence (r = 0.27, p = 0.04). Regarding each item of Functional Independence Measure motor score, Fugl-Meyer assessment upper limb was correlated with grooming (r = 0.27, p = 0.04), bathing (r = 0.28, p = 0.03), dressing upper body (r = 0.33, p = 0.01), dressing lower body (r = 0.31, p = 0.02), and stair-climbing (r = 0.31, p = 0.02) after removing the influence. Conclusion: These findings suggest that the relationship between the upper limb motor function and activities of daily living is strongly influenced by lower limb motor function.

Purpose/aim of the study: An increase of hip abductor muscle strength contributes to the increase in gait speed. It is known that the rate of force development (RFD), an indicator of muscle strength, is increased by the combined use of low-intensity neuromuscular electrical stimulation (NMES) to the glutaeus medius (GM) and low-load resistance training (RT). However, it is unclear whether low-intensity neuromuscular electrical stimulation of the glutaeus medius during walking also increases the rate of force development. The aim of this study was to clarify whether NMES to the GM during gait modulates the RFD of the hip abductor muscles in healthy adults.Materials and methods: Twenty-two healthy adults randomly received both gait with sub-motor threshold NMES and gait with sham NMES conditions. The RFD was assessed at pre- and post-intervention. A two-way repeated measures analysis of variance was used to analyse the effects of time and intervention.Results: Gait with sub-motor threshold NMES condition significantly increased the RFD in shorter time interval (0-50 and 0-100 ms) compared to gait with sham NMES condition.Conclusions: These findings suggest that the adding low-intensity NMES of the GM to gait is effective in increasing the RFD of the hip abductor muscles.

INTRODUCTION: The rate of force development (RFD) is increased by high-load isometric resistance training (RT), whereas not by low-load isometric RT. However, it is unknown whether low-load isometric RT with neuromuscular electrical stimulation (NMES) can increase the RFD. PURPOSE: The aim of this study was to clarify the short-term effects of low-load isometric RT with NMES on the RFD. METHOD: Twenty-four healthy subjects randomly received both low-load RT of the hip abductor muscles with NMES and sham NMES condition. The RFD of the homonymous muscles was assessed at pre-and post-intervention. Time intervals of the RFD were set to 0-50ms (50RFD), 0-100ms (100RFD), 0-200ms (200RFD), and 0-300ms (300RFD). Two-way repeated measures analysis of variance was used to analyze the effects of time and intervention. RESULT: Low-load RT with NMES significantly increased 50 and 100RFD compared to sham NMES condition. On the other hand, 200 and 300RFD were not changed by either condition. CONCLUSIONS: The significantly increased RFD might be related to the factors affecting each RFD interval. This finding might have an important clinical implication for developing a mechanism-based effective training.

INTRODUCTION: Falling is a leading cause of injury-related death. Previous studies reported that an impairment of standing balance is one of the causative factors associated with falling. The combined use of static and dynamic stretching has been reported as a treatment method for improving standing balance. As one of the combined methods, stretching based on Mézières' concept, which has an efficacy on the improvement of body flexibility, has been used. However, it is not fully clear whether stretching based on Mézières' concept can improve standing balance. This study aimed to examine the effects of combined method of static and dynamic stretching of anti-gravitational muscles based on Mézières' concept on body flexibility and standing balance. METHODS: This study employed a quasi-randomized controlled trial design. Thirteen subjects were assigned randomly to one of two groups: stretching or control. A sit and reach test (SRT), functional reach test (FRT), and total trajectory length of center of pressure (COP) during static standing were assessed at pre- and post-intervention. An independent t-test was used to compare the rate of improvement between both groups at each assessment. RESULTS: The stretching group demonstrated a significantly larger rate of improvement in the total trajectory length of COP compared to the control group. In the SRT and FRT, the stretching group showed a trend toward improvement compared to the control group, but did not achieve statistical significance. CONCLUSIONS: The combined use of static and dynamic stretching of anti-gravitational muscles might have the potential to improve the standing balance.

Study Design: Single case report. Introduction: A previous study clarified that spasticity and motor function were improved by combined treatment with botulinum toxin type A (BTX) injection and 1-Hz repetitive transcranial magnetic stimulation (rTMS) with intensive motor training at 4 weeks after injection. However, it is not clear whether 1-Hz rTMS with intensive motor training immediately after BTX injection also improves spasticity and motor function in stroke patients. Purpose of the Case Report: The purpose of this case report is to test the short- and long-term effects of BTX injection and rTMS with intensive motor training on the spasticity, motor function, and usefulness of the paretic hand in a stroke patient. Methods: A 64-year-old male, who suffered from a right cerebral hemorrhage 53 months previously, participated in the present study. BTX was injected into the spastic muscles of the affected upper limb. He then received the new protocol for a total of 24 sessions. The Modified Ashworth Scale (MAS), Fugl-Meyer Assessment (FMA), and Motor Activity Log, consisting of the amount of use and quality of movement scales, were assessed before and immediately after BTX injection, at discharge, and monthly for up to 5 months after discharge. Results: For the short-term effects of the therapy, the MAS scores of the elbow and wrist, FMA score, and quality of movement score improved. For the long-term effects of the therapy, the MAS score of the fingers, FMA score, and amount of use score improved for up to 5 months after discharge. Conclusions: The present case report showed the improvement of all assessments performed in the short and/or long term and suggest the possibility of shortening the intervention period of combined therapy of BTX and rTMS with intensive motor training.

Background: The spatiotemporal parameters were used for sophisticated gait analysis in widespread clinical use. Recently, a laser range sensor has been proposed as a new device for the spatiotemporal gait measurement. However, measurement using a single laser range sensor can only be used for short-range gait measurements because the device irradiates participants with lasers in a radial manner. For long-range gait measurement, the present study uses a modified method using dual laser range sensors installed at opposite ends of the walking path. The aim of present study was to investigate the concurrent validity of the proposed method for spatiotemporal gait measurement by comparison to a computer-based instrumented walkway system. Methods: Ten healthy participants were enrolled in this study. Ten-meter walking tests at 100, 75, and 50% of the comfortable speed were conducted to determine the concurrent validity of the proposed method compared to instrumented walkway measurements. Frequency distributions of errors for foot-contact (FC) and foot-off (FO) estimated times between the two systems were also calculated to determine the adequacy of estimation of FC and FO from three perspectives: accuracy (smallness of mean error), precision (smallness of variability), and unambiguity (monomodality of histogram). Intra-class correlation coefficient (2,1) was used to determine the concurrent validity of spatiotemporal parameters between the two systems. Result: The results indicate that the detection times for FC and FO estimated by the proposed method did not differ from those measured by the instrumented walkway reference system. In addition, histogram for FC and FO showed monomodality. Intra-class correlation coefficients of the spatiotemporal parameters (stance time: 0.74; double support time: 0.56; stride time: 0.89; stride length: 0.83; step length: 0.71; swing time: 0.23) were not high enough. The mean errors of all spatiotemporal parameters were small. Conclusions: These results suggest that the proposed lacks sufficient concurrent validity for spatiotemporal gait measurement. Further improvement of this proposed system seems necessary. Trial registration: UMIN000032710. Registered 24 May 2018. Retrospectively registered.

Purpose: To establish the within-day and between-day intra-rater reliability, inter-rater reliability, validity and systematic errors of the tandem gait test (TGT). Materials and methods: Thirty participants performed the TGT and the timed up and go test (TUG) twice on the first day. Three independent raters measured these tests. After two weeks, the protocol was repeated by one tester to assess between-day reliability. The within-day and between-day intra-rater reliability was estimated by intraclass correlation coefficient (ICC) and Bland–Altman plots to assess systematic errors associated with the learning effect. Inter-rater reliability was estimated by ICC and minimum detectable change at 95% confidence. Concurrent validity was assessed by examination of the correlation between TGT and TUG using Pearson’s correlation coefficient. Results: Within-day and between-day intra-rater reliability were good (ICC > 0.9 and ICC > 0.7). The Bland–Altman plots showed systematic error in the between-day measurements. Inter-rater reliability was supported by strong values for ICC (ICC > 0.9). The Pearson’s correlation coefficient between the TGT and TUG showed a significant positive correlation (r > 0.67, p <.001). Conclusions: These results show that the learning effect of the TGT might be a considerable factor when interpreting follow-up measurements after a few days.

Background Intensive motor training with low-frequency repetitive transcranial magnetic stimulation (rTMS) has efficacy as a therapeutic method for motor dysfunction of the affected upper limb in patients with mild to moderate stroke. However, it is not clear whether this combination therapy has the same effect in chronic post-stroke patients with severe upper limb motor impairment. Objectives The aim of this study was to test the treatment effects of intensive motor training with low-frequency rTMS in chronic post-stroke patients with severe upper limb motor impairment. Methods A convenience sample of 26 chronic post-stroke patients with severe upper limb motor impairment participated in this study with the non-randomized, non-controlled clinical trial. All subjects were hospitalized to receive intensive motor training with low-frequency rTMS. During 2 weeks in which Sundays were excluded, a total of 24 sessions (2 sessions per day) of the intervention were conducted. The Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) were used to assess motor impairment and function of the affected upper limb, respectively, before and after intervention. Paired t-test was used to analyze the effects of the intervention. Results The FMA total score and WMFT log performance time significantly improved from before to after intervention (FMA: 12.6-18.0; WMFT: 3.6-3.3, p < 0.001). Conclusions The present results suggest that intensive motor training with low-frequency rTMS could improve motor impairment in chronic post-stroke patients with severe upper limb motor impairment and contribute to the expansion of the application range of this combination therapy.

The aim of this study was to clarify the intra- and inter-rater reliability of the rate of force development in hip abductor muscle force measurements using a hand-held dynamometer. Thirty healthy adults were separately assessed by two independent raters on two separate days. Rate of force development was calculated from the slope of the force-time curve that was divided into four time intervals (50, 100, 200, and 300 ms). The highest values of the three trials were used for statistical analysis. The intra-class correlation coefficient with a 95% confidence interval, standard error of measurement, and minimal detectable change at the 95% confidence level were calculated for each interval. For assessment of systematic error, Bland-Altman analysis was used. The results indicated that intra- and inter-rater reliability of the highest values at all intervals were sufficient (intra-class correlation coefficient >.7). The Bland-Altman analysis did not show systematic error in either reliability measure.

BACKGROUND: The relationship between peak torque of the knee extensor muscles and gait speed was previously investigated in patients with chronic stroke, but whether the rate of force development (RFD), another indicator of muscle strength, affected gait speed remained unknown. OBJECTIVE: To clarify the relationships between the RFD of the knee extensor muscles over multiple time intervals and gait speed in patients with chronic stroke. METHODS: Twenty chronic stroke patients participated in this study. The RFD of affected and unaffected knee extensor muscles was measured. Time intervals of the RFD were set to 0-50 ms, 0-100 ms (100RFD), 0-200 ms (200RFD), and 0-300 ms (300RFD). Gait speed was assessed at comfortable and maximum pace. Pearson correlation coefficient (r) was used to analyze the relationships between RFD and gait speeds. RESULTS: The RFD of affected knee extensor muscles over all intervals was moderately correlated with both comfortable and maximum gait speeds, whereas only limited combinations (100, 200 and 300RFD with maximum gait speed) were correlated on the unaffected side. CONCLUSIONS: The present results suggest that various factors related to the RFD of affected knee extensor muscles, such as neural drive and muscle size, affect gait speed.

This study investigated the influence of stimulus conditions of transcutaneous electrical nerve stimulation (TENS) on disynaptic reciprocal Ia inhibition (RI) and presynaptic inhibition (D1 inhibition) in healthy adults. Eight healthy participants received TENS (stimulus frequencies of 50, 100, and 200 Hz) over the deep peroneal nerve and tibialis anterior (TA) muscle in the resting condition for 30 min. At pre- and post-intervention, the RI from the TA to the soleus (SOL) and D1 inhibition of the SOL alpha motor neuron were assessed by evoked electromyography. The results showed that RI was not changed by TENS at any stimulus frequency condition. Conversely, D1 inhibition was significantly changed by TENS regardless of the stimulus frequency. The present results and previous studies pertaining to RI suggest that the resting condition might strongly influence the lack of pre- vs. post-intervention change in the RI. Regarding the D1 inhibition, the present results suggest that the effect of TENS might be caused by post-tetanic potentiation. The knowledge gained from the present study might contribute to a better understanding of fundamental studies of TENS in healthy adults and its clinical application for stroke survivors.

Neurophysiological studies in healthy subjects suggest that increased spinal inhibitory reflexes from the tibialis anterior (TA) muscle to the soleus (SOL) muscle might contribute to decreased spasticity. While 50 Hz is an effective frequency for transcutaneous electrical nerve stimulation (TENS) in healthy subjects, in stroke survivors, the effects of TENS on spinal reflex circuits and its appropriate frequency are not well known. We examined the effects of different frequencies of TENS on spinal inhibitory reflexes from the TA to SOL muscle in stroke survivors. Twenty chronic stroke survivors with ankle plantar flexor spasticity received 50-, 100-, or 200-Hz TENS over the deep peroneal nerve (DPN) of the affected lower limb for 30 min. Before and immediately after TENS, reciprocal Ia inhibition (RI) and presynaptic inhibition of the SOL alpha motor neuron (D1 inhibition) were assessed by adjusting the unconditioned H-reflex amplitude. Furthermore, during TENS, the time courses of spinal excitability and spinal inhibitory reflexes were assessed via the H-reflex, RI, and D1 inhibition. None of the TENS protocols affected mean RI, whereas D1 inhibition improved significantly following 200-Hz TENS. In a time-series comparison during TENS, repeated stimulation did not produce significant changes in the H-reflex, RI, or D1 inhibition regardless of frequency. These results suggest that the frequency-dependent effect of TENS on spinal reflexes only becomes apparent when RI and D1 inhibition are measured by adjusting the amplitude of the unconditioned H-reflex. However, 200-Hz TENS led to plasticity of synaptic transmission from the antagonist to spastic muscles in stroke survivors.

The case report describes the effects of 5 Hz repetitive transcranial magnetic stimulation (rTMS) combined with transcutaneous electrical stimulation (TES) in a patient with severe stroke. The patient was a 69-year-old male who was affected by a left middle cerebral artery infarction. The patient had no movement in his right hand. To assess the effects, cerebral blood flow and motor function were measured before and after treatment. This treatment delivered rTMS over the affected M1 with TES at the paretic wrist extensor muscles for 10 days. The regional cerebral blood flow (rCBF) in the entire brain was measured by positronemission tomography. To evaluate the motor function, the Fugl-Meyer assessment (FMA) was used. After treatment, the rCBF was increased (except for the stimulated region), and the FMA score was slightly improved. These results suggest the potential therapeutic use of rTMS combined with TES for recovery in severe stroke.

【はじめに、目的】 近年，脳卒中患者様の運動麻痺に対する治療法に反復経頭蓋磁気刺激療法（Repetitive transcranial magnetic stimulation，以下rTMS）が用いられ始めている．過去の報告によると，軽度運動機能障害者の損傷脳への高頻度rTMSによって，上肢機能の改善が認められている．さらに現在，高頻度rTMSと治療的電気刺激（Therapeutic Electrical Stimulation，以下TES）の併用についての検討も始まっており，中等度運動機能障害者の上肢機能の改善が報告されている．しかしながら，現在までに行われているrTMSとTESの併用に関する研究は，電気刺激をトリガとして随意運動も行う練習法のみであるため，対象が随意運動可能な患者に限られている．そこで本研究では，随意運動の認められない重度運動機能障害者を対象に，rTMSと随意運動を行わないTESの併用を行い，その治療手法が運動機能と脳血流に及ぼす影響を検討した．【方法】 対象者は脳卒中右片麻痺患者（男性，70歳，発症後約 30か月）で，Stroke Impairment Assessment Set運動機能1-0-3-2-1，Brunnstrom Stage2-2-3，Modified Ashworth Scale3，Functional Independence Measure115点であり，感覚障害は軽度，骨関節疾患や代謝性疾患の併存は認められなかった．rTMSにはマグスティム社製Magstim Super Rapidを用い，健側の第一背側骨間筋の運動誘発電位が最小刺激強度で誘発可能な部位を，刺激周波数5Hzで8の字コイルを使用して刺激した．刺激強度は健側運動閾値の120％とした．TESには日本光電社製SEN-8203とSS-104Jを用い，周波数 40Hz，パルス幅 250us，刺激時間 500ms，刺激周期1Hzで手関節伸筋群を刺激した．刺激強度は手関節の伸展運動を誘発可能な強度とした．1セットはrTMS 8秒，TES 50秒，刺激前後1秒休息の計60秒とし，10セット10分間を１日2回，2週間施行した．運動機能の評価にはStroke Impairment Assessment Set運動機能，Brunnstrom Stage，Modified Ashworth Scaleを用い，治療前後で評価を行った．脳血流の評価にはPositron emission tomography （以下PET）を用いた．酸素15標識の二酸化炭素ガスを指標とし，steady-state法にて評価した．評価前の6時間は絶食，前日の運動を控えさせた．transmission scan後，酸素15標識の二酸化炭素ガス吸入後5分から10分までのデータを定量化した．画像データの統計学的画像解析には，中部療護センターのデータベースを使用したeasy Z-score Imaging Systemを用いた．【倫理的配慮、説明と同意】 本研究の実施手順および内容はヘルシンキ宣言に則り，当院倫理委員会の承諾を得た後に治療を開始した．また，治療は臨床神経生理学会のガイドライン2007を順守した．対象者には，医師により治療並びに評価の手順，意義，危険性，利益や不利益，プライバシー管理，研究目的，方法を説明の上，同意書にサインを頂いた．【結果】 治療前後でStroke Impairment Assessment Set運動機能，Brunnstrom Stageに変化は認められなかった．一方で，Modified Ashworth Scaleは3から2に改善を認めた．脳血流（mg/min/100ml）は治療前，脳梁辺縁14.60/8.92（それぞれ右/左），中心前15.76/11.34，中心15.09/1.02，頭頂13.15/4.84，角回16.36/12.60，側頭17.07/14.87，後大脳15.76/15.55，脳梁周囲15.84/11.41，レンズ核18.26/14.57，視床13.31/7.59であった．治療後，脳梁辺縁17.43/10.10，中心前19.32/13.43，中心18.00/0.99，頭頂14.98/4.57，角回20.05/13.83，側頭20.19/16.76，後大脳18.78/18.29，脳梁周囲18.58/12.88，レンズ核21.55/17.87，視床17.34/17.87であった．【考察】 脳卒中重度運動障害者に対する，rTMSと随意運動を行わないTESの併用効果について，運動機能と脳血流を用いて評価した．運動機能評価ではModified Ashworth Scaleでのみ改善が認められた．この結果は，本手法が筋緊張の軽減には有効であったものの，運動機能の改善までには至らない可能性を示唆している．また，損傷部位の周辺領域において脳血流の改善が認められた．過去の報告においては，運動機能改善と脳血流には関係があると報告されており，損傷部周辺領域の脳機能改善が脳血管障害者の運動機能改善に重要とされている．本研究で得られた周辺領域の脳血流改善は，筋緊張軽減の神経生理学的作用機序のひとつと考えらえる．【理学療法学研究としての意義】 本研究によって，随意運動が困難な重度運動麻痺患者に対してもrTMSとTESの併用が有効である可能性が示唆された．この結果は，rTMSとTESを併用する手法の適用範囲を拡大する上で大きな意義があると考える．