川上 健司

BACKGROUND: The impact of different stroke types on specific activities of daily living (ADL) is unclear. OBJECTIVE: To investigate how differences between intracerebral hemorrhage (ICH) and cerebral infarction (CI) affect improvement of ADL in patients with stroke within a hospital by focusing on the sub-items of the Functional Independence Measure (FIM). METHODS: Patients with first-stroke hemiplegia (n = 212) were divided into two groups: ICH (86 patients) and CI (126 patients). Primary assessments included 13 motor and 5 cognitive sub-items of the FIM assessed at admission and discharge. Between-group comparisons and multiple regression analyses were performed. RESULTS: Upon admission, the ICH group exhibited significantly lower FIM scores than those of the CI group across various activities, including grooming, dressing (upper body and lower body), toileting, bed/chair transfer, toilet transfer, walking/wheelchair, and stairs. Age and FIM motor scores at admission influenced both groups' total FIM motor scores at discharge, whereas the duration from onset affected only the CI group. CONCLUSION: Several individual FIM motor items were more adversely affected by ICH than by CI. Factors related to ADL at discharge may differ depending on stroke type. Recognizing these differences is vital for efficient rehabilitation practices and outcome prediction.

Practicing walking in a safety suspension device allows patients to move freely and without excessive reliance on a therapist, which requires correcting errors and may facilitate motor learning. This opens the possibility that patients with subacute stroke may improve their walking ability more rapidly. Therefore, we tested the hypothesis that overground gait training in a safety suspension device will result in achieving faster supervision-level walking than gait training without the suspension device. Twenty-seven patients with stroke admitted to the rehabilitation ward with functional ambulation categories (FAC) score of 2 at admission were randomly allocated to safety suspension-device group (SS group) or conventional assisted-gait training group (control group). In addition to regular physical therapy, each group underwent additional gait training for 60 min a day, 5 days a week for 4 weeks. We counted the days until reaching a FAC score of 3 and assessed the probability using Cox regression models. The median days required to reach a FAC score of 3 were 7 days for the SS group and 17.5 days for the control group, which was significantly different between the groups (P < 0.05). The SS group had a higher probability of reaching a FAC score of 3 after adjusting for age and admission motor impairment (hazard ratio = 3.61, 95% confidence interval = 1.40-9.33, P < 0.01). The gait training with a safety suspension device accelerates reaching the supervision-level walking during inpatient rehabilitation. We speculate that a safety suspension device facilitated learning by allowing errors to be experienced and correct in a safe environment.

OBJECTIVES: In stroke patients, the assessment of gait ability over time is important. For quantitative gait assessment using measuring devices, the walking speed condition for measurement is generally based on the patient's preferred walking speed or the maximum walking speed at the time of measurement. However, because walking speed often increases during the convalescent stage, understanding the effects of change in walking speed on gait when comparing the course of recovery is necessary. Although several previous studies have reported the effects of change in walking speed on gait in stroke patients, the time-distance parameters described in these reports may not be generalizable because of the small case numbers. Therefore, we measured treadmill gait at the preferred walking speed (PWS) and 1.3 times the PWS (130% PWS) in 43 post-stroke hemiplegic patients and analyzed the effects of change in walking speed on time-distance parameters. METHODS: Forty-three patients with hemiplegia after a first stroke, who were able to walk on a treadmill under supervision, were recruited as subjects. Using a three-dimensional motion analysis system, treadmill gait was assessed under two conditions: PWS and 130% PWS. The primary outcome measures were the time-distance parameters, which were compared between the PWS and 130% PWS conditions. RESULTS: Cadence, stride length, and step length of the affected and unaffected lower limbs increased significantly at 130% PWS compared with at PWS. In terms of actual time, single stance time and initial and terminal double stance time in both affected and unaffected limbs decreased significantly at 130% PWS. In terms of relative time (% of the gait cycle), compared with PWS, relative single stance time increased significantly, whereas relative initial and terminal double stance times decreased significantly at 130% PWS in both the affected and unaffected limbs. CONCLUSIONS: This study on treadmill gait in patients with hemiplegia after a first stroke confirmed the effects of change in walking speed on time-distance parameters. Our results will help in the interpretation of time-distance parameters measured under different walking speed conditions.

OBJECTIVES: Falls can occur daily in stroke patients and appropriate independence assessments for fall prevention are required. Although previous studies evaluated the short physical performance battery (SPPB) in stroke patients, the relationship between SPPB and fall prediction and walking independence remains unclear. Therefore, we aimed to verify whether SPPB is a predictor of walking independence. MATERIALS AND METHODS: The present study included 105 hemiplegic stroke patients who were admitted to the rehabilitation ward and gave consent to participate. Cross-sectional physical function and functional independence measure cognitive (FIM-C) evaluation were conducted in hemiplegic stroke patients. Logistic regression analysis using the increasing variable method (likelihood ratio) was performed to extract factors for walking independence. Cutoff values were calculated for the extracted items using the receiver operating-characteristic (ROC) curve. RESULTS: Among 86 participants included in the final analysis, 36 were independent walkers and 50 were dependent walkers. In the logistic regression analysis, SPPB and FIM-C were extracted as factors for walking independence. The cutoff value was 7 [area under the curve (AUC), 0.94; sensitivity, 0.83; specificity, 0.73)] for SPPB and 32 (AUC, 0.83; sensitivity, 0.69; specificity, 0.57) for FIM-C in ROC analysis CONCLUSIONS: SPPB and FIM-C were extracted as factors for walking independence. Although SPPB alone cannot determine independent walking, combined assessment of SPPB with cognitive function may enable more accurate determination of walking independence.

【目的】歩行能力評価法Gait Ability Assessment for hemiplegics(GAA)の作成と妥当性,検者間信頼性を検証すること.【方法】新たな歩行能力評価であるGAAを考案した.次に,脳卒中患者を対象とし,2名の理学療法士によるGAAの検者間信頼を検討した.次に,既存の評価法であるFunctional Ambulation Categories(FAC),Functional Independence Measure(FIM)歩行,最大歩行速度,FIM運動項目合計点,Stroke Impairment Assessment Set(SIAS)の麻痺側運動機能の合計点(以下,SIAS-L/E),とGAAとの妥当性を検証した.【結果】GAAの検者間信頼性は,κ係数が0.76,weighted κ係数は0.96であった.GAAとの相関係数は,FACが0.95,FIM歩行が0.95,最大歩行速度が0.82,FIM運動項目合計点が0.89,SIAS-L/Eが0.61であり,いずれも有意な相関を認めた(p<0.01).【結論】GAAは高い検者間信頼性と歩行能力評価法としての妥当性を有しており,研究や臨床で応用できることが示唆された.(著者抄録)

PURPOSE: This trial aimed to validate the effectiveness of using the Gait Exercise Assist Robot (GEAR) in patients with hemiplegia after primary stroke. METHODS: The study design was open-label randomized controlled trial. Twenty-six patients with hemiplegia after primary stroke admitted to the comprehensive inpatient rehabilitation wards were enrolled and randomized to a group using GEAR in gait training and a control group. The intervention period was 4 weeks. Evaluations were conducted at admission, during intervention period, 8 weeks from start of intervention, and at discharge. Primary outcome measure was improvement efficiency of Functional Independence Measure (FIM)-walk score (FIM-walk improvement efficiency) that was calculated at the time of achieving FIM-walk score 5 (supervision level) during the intervention period or as weekly gain in FIM-walk score during 4 weeks for those who did not achieve score 5. RESULTS: FIM-walk improvement efficiency was .7 ± .4 in GEAR group and .4 ± .3 in control group, and was significantly higher in GEAR group (P = .01). The FIM-walk score gain after 4 weeks was significantly higher in the GEAR group (P = .01), but there were no significant differences between 2 groups after 8 weeks and at discharge. CONCLUSIONS: Gait training using GEAR for 4 weeks improved walking ability of subacute stroke patients. GEAR contributes to early improvement of walking ability probably by the knee flexion assist during swing phase on the paralyzed side thereby increasing the volume of training, and by the finely adjustable stance/swing assist mechanism for the paralyzed limb which optimizes the training difficulty level.

【目的】本研究では,下肢練習用アートデバイスを用い,有効性を検討した.【方法】本研究はランダム化比較試験として,回復期リハビリテーション病棟に入院した患者をArt Device群(AD群)11名と対照群(CT群)17名に分けた.AD群はHead Mounted Display(HMD)を装着し,対照群はHMDなしで起立着座動作を行った.訓練期間は10分/日,5日/週,2週間とし,起立着座回数とデバイスに対するアンケート(楽しみ感,満足感を7段階で評価)を評価した.【結果】AD群は開始時と比較し2週後の起立着座回数が有意に改善した(p<0.05).しかし,両群間の起立着座回数の利得に有意差はなかった.楽しみ感のアンケートは,AD群の初日の開始前と終了後に有意に改善したが,練習最終日まで維持できなかった(p<0.05).【結論】リハビリテーションにアートデバイスを併用することは練習初回の能動性を向上し,運動回数増加につながる可能性が考えられる.(著者抄録)

[Purpose] This study aimed to determine the effects of increased amount of physical therapy exercise on improvements in the walking ability of patients with stroke. [Subjects and Methods] The subjects were selected from patients with stroke who were hospitalized in the convalescent rehabilitation ward, and included 91 patients who received physical therapy for 2.5-3 exercise sessions per day during 2005-2006 (PT3unit group), and 86 patients who received physical therapy for 4.5-6 exercise sessions per day during 2010-2015 (PT6unit group). The functional independence measure (FIM) score evaluates the walking ability of patients during hospital admission, 2 and 4 weeks after admission, and at discharge. The FIM score was stratified according to the degree of lower limb motor paralysis and subsequently compared between groups. [Results] Among the patients with complete paralysis and severe paralysis, the FIM-Walking scores at 4 weeks after admission and at discharge were significantly higher in the PT6unit group than in the PT3unit group. No significant differences were found between the PT6unit and PT3unit groups for patients with mild and moderate paralysis. [Conclusion] Higher amounts of physical therapy exercise contributed to improvements in the walking ability of patients with complete and severe lower limb paralysis.

[Purpose] The motor paralysis-improving effect on the hemiplegic lower limb was compared among mirror therapy, integrated volitional-control electrical stimulation, therapeutic electrical stimulation, repetitive facilitative exercises, and the standard training method in post-stroke hemiplegia patients. [Subjects and Methods] Eighty one stroke patients admitted to a convalescent rehabilitation ward were randomly allocated to the above 5 treatment groups. Each patient performed functional training of the paralytic lower limb for 20 minutes a day for 4 weeks, and changes in the lower limb function were investigated using the Stroke Impairment Assessment Set. [Results] The hip and knee joint functions did not significantly improve in the standard training control group, but significant improvements were observed after 4 weeks in the other intervention groups. Significant improvement was noted in the ankle joint function in all groups. [Conclusion] Although the results were influenced by spontaneous recovery and the standard training in the control group, the hip and knee joints were more markedly improved by the interventions in the other 4 groups of patients with moderate paralysis, compared to the control group.

[Purpose] The purpose of this study was to find whether a fast treadmill gait training speed is effective for the gait training of stroke patients in the early rehabilitation stage. [Subjects and Methods] Thirty-nine stroke patients were the subjects of our investigation. They walked on a treadmill with handrail supports at a fast speed (130% of their comfortable gait speed in the 2nd week). The treadmill gaits of the patients were recorded using a 3-dimensional analysis system at two and six weeks after their admissions. Intraclass Correlation Coefficients (ICC) of the temporal and spatial parameters of the two periods were statistically analyzed. [Results] For all of the patients, the ICCs of the measured parameters were greater than 0.58. In the case of patients whose gait speeds of the two periods were close, the ICC units were greater than 0.7. [Conclusion] The fast gait speed training allowed us to expose the patients to a gait speed that they were expected to acquire at a later stage of their rehabilitation. This training method was found to be beneficial for the mildly paralyzed patients.

【目的】回復期脳卒中患者の歩行能力の経過を歩行能力および下肢運動麻痺の重症度別に明らかにすること.【方法】脳卒中片麻痺患者1,698例を対象とした.入院時のFunctional Independence Measureの歩行(FIM歩行)により1〜7点,入院時のStroke Impairment Assessment Setの麻痺側運動機能項目から下肢3項目の合計点により,完全麻痺群,重度麻痺群,中等度麻痺群,軽度麻痺群の4群に分類して合計28区分へ層別化したのち,FIM歩行の経過を検討した.【結果】入院時FIM歩行が1点や2点の完全麻痺群は退院時のFIM歩行が他の麻痺群に比べ有意に低く,入院時FIM歩行が3点や4点では麻痺の違いによる退院時のFIM歩行への影響は比較的小さくなる傾向にあった.【結論】入院時の歩行能力や運動麻痺の違いにより,脳卒中患者の歩行能力の経過が一様ではないことが明らかとなった.(著者抄録)

【目的】本研究では,訓練方法による麻痺改善効果の違いを検討することを目的とした.【方法】当院回復期リハビリ病棟に入院した初発脳卒中患者131名を対象とし,麻痺側上肢に,ミラーセラピー(MT),随意運動介助型電気刺激(IVES),治療的電気刺激(TES),促通反復療法,通常訓練の五つの異なる訓練方法をランダムに割り付け,1日20分,4週間の介入を行った.患者に合った訓練方法を検討するために,4週後のFMA上肢運動項目合計点を目的変数とし,年齢,発症後期間,訓練方法,入院時の上肢機能評価項目を説明変数とし決定木分析を行った.【結果】FMA手指<3点で,かつFMA肩・肘<3点では,MT,TES,促通反復療法が選択された.また,FMA手指≧8点で,かつFMA手関節<8点では,通常訓練以外の訓練方法が選択された.【結論】回復期段階の脳卒中患者のリハビリ方法決定の一助として今回の決定木の論理を利用しうると考えられる.(著者抄録)

Purpose: The purpose of this study was to identify major risk factors of the falls of the patients with stroke whom live at home by analyzing patients' information and functional evaluation tools data such as FIM (Functional Independence Measure) instrument and SIAS (Stroke Impairment Assessment Set). Methods: Sixty-four stroke outpatients who had earlier discharged from Fujita Health University Nanakuri Sanatorium were participated in our study. We evaluated the following baseline characteristics for all patients: age, sex, stroke type, affected side of the body, number of stroke suffered, maximum walking speed, use of ankle foot orthosis, use of cane, use of medicine that may increase the risk of falling, and frequency of the falls of the patient during their rehabilitation period in the hospital, FIM, SIAS, and Mini-Mental State Examination scoring were also done before their discharge from the hospital. We first carried out bivariate analysis to determine which variables differed significantly between the non-fallers and fallers. Those variables of significant statistical values were then included in a multivariate logistic regression analysis. The model was simplified in a Forward Selection Method (Likelihood Ratio) by removing variables. Results: Those patients with a falling experience comprised 25 patients out of the total 64 patients (39.1% ). The logistic model was refined until it excluded all the predictors except two. These two predictors were maximum walking speed, and use of ankle foot orthosis. Conclusions: Those patients with a slow speed of walking and/or the patients who required the use of ankle foot orthosis were at a higher risk of falling.

【目的】脳卒中患者の退院直前の各種医療情報を多変量解析することで転倒予測に関わる要因を検討することを目的とした。【方法】対象は、当院を退院した脳卒中患者64名である。退院時の年齢、性別などのプロフィールの他、Functional Independence Measure、Stroke Impairment Assessment Set、最大歩行速度、下肢装具、杖、転倒に関わる薬剤の使用、Mini-Mental State Examination、入院中の転倒などを測定・調査し、変数増加法(尤度比)ロジスティック回帰分析から転倒予測要因を抽出した。【結果】退院6ヵ月後の転倒率は39.1%であった。転倒が予測されたのは最大歩行速度が時速2.5km以下の患者と、下肢装具を使用している患者であった。【結論】脳卒中患者の歩行速度には運動麻痺が大きく影響し、下肢装具は運動機能の補助として使用されることを考慮すると、下肢運動麻痺と深く関連する因子が転倒予測因子として抽出されたと考えられた。(著者抄録)

Wada Y, Kondo I, Sonoda S, Yamada K, Narukawa A, Kawakami K, Nonoyama S, Miyasaka H, Teranishi T, Nagai S, Takeshima N: Mirror therapy for severely affected ankle joints of stroke patients. Jpn J Compr Rehabil Sci 2011; 2: 71-76.<br>Objective: This study investigated the improvement in dorsiflexion of severely affected ankle joints of first-stroke patients after mirror therapy.<br>Methods: Nine first-stroke patients participated in this study. A mirror was placed to reflect the non-paralyzed lower limb. A set of 50 dorsiflexion movements of the ankle joint was performed 4 times a day for 7 days. Foot functions of the Stroke Impairment Assessment Set (SIAS-F) and the foot-floor angle at active dorsiflexion were measured every 7 days starting from 14 days before initiation of the mirror therapy training to 7 days after, for a total of 5 times.<br>Results: SIAS-F did not differ among the cases before mirror therapy training. After the mirror therapy training, 5 of the 9 patients showed SIAS-F improvement. Significant differences were found between the scores at the beginning and at the end of the mirror therapy training, and between the scores at the beginning and 7 days after training. The mean foot-floor angle changed from 0 degrees at the beginning of training to 3.0 degrees at the end of training and 1.2 degrees 7 days after the training; however, these values did not differ significantly.<br>Conclusion: Significant improvement in dorsiflexion of the ankle joint, as measured by SIAS-F, was achieved with mirror therapy.