大高 洋平

BACKGROUND: Gait-a frequently performed activity of daily living-is thought to reflect multiple dimensions of an individual's physical and cognitive status. Individuals with frailty or mild cognitive impairment (MCI) show decreased gait speed. However, previous studies have not simultaneously considered both statuses, although they frequently co-occur and may act as confounders. The direct association between frailty and gait is well-understood. In contrast, the association between cognitive decline-independent of physical function-and decreased gait speed, as well as the relationship among these three factors (frailty, cognitive decline, and gait speed), is not fully understood. METHODS: This study examined the effect of MCI on gait speed after accounting for frailty. Older individuals were categorized as (1) frailty with MCI, (2) frailty without MCI, (3) pre-frailty with MCI, (4) pre-frailty without MCI, (5) non-frailty with MCI, and (6) non-frailty without MCI. Frailty was assessed using the Kihon checklist and MCI using the Montreal Cognitive Assessment. Participants completed a 10-m walk test under two conditions: comfortable walking and fast walking. Two types of analyses were conducted: mediation analysis and two-way analysis of covariance (ANCOVA). RESULTS: Mediation analysis supported independent relationships between frailty and MCI status and gait speed, suggesting a direct association between MCI and gait speed, even when accounting for frailty. In addition, two-way analysis of covariance indicated significant main effects of both frailty and MCI on gait speed, with no significant interaction between them under the two walking conditions. CONCLUSIONS: These findings suggest that the observed association between MCI and gait speed is largely independent from frailty status, providing additional evidence supporting the association between cognitive function and gait performance.

Abstract Background Patients with hip fractures are at high risk of falling. In hospitals, identifying high-risk patients based on their capabilities and implementing targeted prevention strategies is essential. Because fall risk changes with functional recovery, it should be assessed longitudinally rather than at a single time point. This study aimed to determine whether the risk of falls (falls per 1,000 person-days) was stratified by motor and cognitive functional status and to examine the relationship between fall incidence rates and the actual number of falls in each functional status. Methods This retrospective observational study included 824 consecutive patients with hip fractures admitted to a rehabilitation hospital. Data on falls during hospitalization and Functional Independence Measure (FIM) scores were retrieved from medical records. Average FIM scores for the motor and cognitive items were obtained and categorized into complete dependence, modified dependence, and independence. Fall rates and number of observed falls in each combined condition were investigated. Results The highest fall rate was observed when patients were in states of modified motor dependence and complete cognitive dependence (11.4 falls/1,000 person-days; 17 falls; 9.3% of all falls). In contrast, patients in independent motor and cognitive states had a lower fall rate (2.0 falls/1,000 person-days) but accounted for a larger proportion of total falls (32 falls; 17.6% of all falls), representing 1.9 times the total number of falls observed in the highest fall-rate group. Conclusion This study successfully demonstrated that fall risk in patients with hip fractures varies according to functional status, peaking during phases of modified motor dependence and complete cognitive dependence. However, owing to longer observation periods, a greater number of falls occurred among those in low-risk states than among those in high-risk states, demonstrating the “prevention paradox.” Effective management requires a dual strategy: intensive interventions targeting high-risk phases and standardized preventive measures for all patients to address cumulative risk during the recovery process.

OBJECTIVES: To investigate the feasibility of robot-assisted hand movement training using a novel end-effector robot in individuals after stroke. METHODS: Eleven individuals with subacute stroke with hand motor impairment underwent robot-assisted repetitive finger flexion/extension for 20 min daily and repeated this training on 7 non-consecutive days. The robot was designed to allow the flexion and extension of the metacarpophalangeal and proximal interphalangeal joints of the index to the little fingers, and to provide assistive torque if the movement did not reach the target angle within a limited time. We assessed the co-contraction index (CCI) of the flexor digitorum superficialis and extensor digitorum muscles and assessed the active range of motion (AROM) of the index finger before and after training each day (intra-day effect). We performed clinical assessments of motor function and spasticity and evaluated the CCI and AROM before and immediately after the 7-day training (inter-day effect). RESULTS: Ten participants completed the 7-day training. For the intra-day effect, the CCI was significantly decreased immediately after training, particularly during active finger flexion, and the AROM tended to improve from the middle of the training days. For the inter-day effect, there were no significant changes in the Stroke Impairment Assessment Set for Finger Function, modified Ashworth scale, CCI, or AROM after the 7-day training. CONCLUSIONS: Repetitive finger movement training with the assistance of the novel robot improves muscle activation patterns, reducing co-activation between the agonist and antagonist muscles immediately after training.

Mobile phones are increasingly being proposed as tools to support daily life among older adults with cognitive impairment; however, empirical data on their actual ownership and use in clinical settings remain limited. This study aimed to clarify mobile phone ownership and usage patterns among older adults with cognitive impairment attending memory clinics. Eighty-two older adults with cognitive impairment (mean age: 80.4 y; mean Mini-Mental State Examination score: 18.1 points) were included. Data were collected using caregiver-administered questionnaires and analyzed descriptively. Among the participants, 65 (79.3%) owned a mobile phone, with an almost equal distribution of smartphones (n=33) and featured phones (n=32). Fifteen phone owners did not use their devices. Reported use was largely limited to basic communication functions. These findings indicate limited mobile phone ownership and functional use among older adults with cognitive impairment and underscore the need to consider cognitive limitations when implementing mobile technologies.

Abstract Background Pill‐swallowing difficulty is common yet under‐recognised, and patients rarely seek or receive support from healthcare professionals. Lubricating jelly pastes are widely available in Japan, yet evidence for their effectiveness in pill administration remains limited. The PILL‐5 enables validated, self‐reported screening of clinically relevant pill‐swallowing difficulty. Aim This study aimed to explore whether a lubricating jelly paste reduced self‐reported pill‐swallowing difficulties using the Japanese version of the PILL‐5 questionnaire. Method In a pilot randomised, parallel‐group trial, 24 participants with PILL‐5 scores ≥2 were stratified and randomised 1:1 to one‐week pill intake using a lubricating jelly paste (IDDSI Level 4) (intervention group) or pill intake as usual (control group). The PILL‐5 was administered at baseline, Day 1, and Day 7. The primary outcome was change in total PILL‐5; between‐group differences were tested with the exact Mann–Whitney U test. Ethical approval was granted by the Ethics Review Committee of Fujita Health University (Reference no: HM20‐076; HM20‐619) and the study conforms with the Declaration of Helsinki. Informed consent was obtained from all participants via the distribution of project information and completion of written consent forms. The study was registered in the UMIN Clinical Trials Registry (UMIN‐CTR) (Registration ID: UMIN000057324). Results The median PILL‐5 scores at baseline were 4.5 and 5.5 for the intervention and control groups, respectively (p = 0.525). At Day 1, median scores were 3.0 and 4.5 in the intervention group and control group, respectively and on Day 7, median scores were 3.0 and 4.0 in the intervention and control groups, respectively. From baseline to Day 1, the between‐group median difference in change (intervention minus control) was 2 (95% confidence interval [CI] 0–2, p = 0.037), indicating a greater reduction in the intervention group. On Day 7, the between‐group difference was 1 (95% CI 0–2, p = 0.119) and not significant. Conclusion Lubricating jelly paste use was associated with an early, self‐reported reduction in PILL‐5 scores at Day 1, with a significant between‐group difference. By Day 7, the between‐group difference was not significant, likely due to floor effects from low baseline severity. Future studies with stricter inclusion criteria and larger sample sizes are warranted to further clarify the potential benefits.

ABSTRACT To evaluate dysphagia, pharyngeal high‐resolution impedance manometry (P‐HRM‐I) is used in conjunction with videofluoroscopic examination of swallowing (VF) or videoendoscopic evaluation of swallowing to obtain additional objective data that cannot be captured by conventional assessment methods. Based on the Leuven Consensus of the International Pharyngeal Manometry Working Group for diagnosing pharyngeal and upper esophageal sphincter (UES) motility disorders, we present a case series of two patients illustrating the recovery process of dysphagia following lateral medullary syndrome. Two patients with severe dysphagia due to lateral medullary infarction caused by vertebral artery dissection were evaluated. In both patients, the initial P‐HRM‐I showed profound impairment of the UES opening and bolus passage, preventing oral intake. Balloon dilation of the UES, laryngeal elevation exercises, tongue strengthening exercises, and direct swallowing training were performed, and the functions of the pharynx and UES were regularly evaluated using VF and P‐HRM‐I. Following UES dilation, PHRM‐I revealed improved UES opening, enhanced pharyngeal contraction, and restoration of pharyngeal peristalsis. Both patients regained sufficient swallowing function to resume a regular diet. P‐HRM‐I may be a useful tool for quantitatively assessing UES function and bolus propulsion, identifying the pathophysiological components of dysphagia, guiding individualized treatment, and monitoring post‐intervention recovery.

BACKGROUND: The use of diapers among older adults is increasing in aging societies. However, the optimal method of wearing them remains unknown. We aimed to explore procedural variations in leg-through motion during diaper wearing in older adults. METHODS: A multicenter cross-sectional study was conducted in 19 facilities in Japan. Individuals aged 65-99 years in nursing homes/adult daycare facilities and able to maintain a sitting posture in a chair were recruited via convenience sampling between March 2024 and January 2025. Leg-through motion during diaper wearing was recorded with the participants seated in a chair. The motion patterns were visually classified according to predetermined criteria. The classification of the observed motion patterns was subjected to a simple descriptive analysis. The inter-rater agreement of the classifications between the two assessors was determined using Cohen's kappa coefficient. RESULTS: Among 149 older adults (mean [standard deviation] age: 87.0 [7.2] years), the motions "keep the foot off the floor and use both hands" and "keep feet on the floor and use both hands" collectively accounted for 65.7% of the initial leg motions. For the subsequent leg, three motions-"keep the foot off the floor and use contralateral hand," "keep the foot off the floor and use ipsilateral hand," and "keep the foot off the floor and use both hands"-accounted for a total of 59.1%. Furthermore, the leg-through motion patterns varied according to the participants' usual means of mobility. The inter-rater agreement was good for the initial leg (kappa = 0.72) and subsequent leg (0.80). CONCLUSIONS: We classified the motion patterns of older adults during diaper wearing. Our results provide fundamental insights into appropriate care and rehabilitation interventions. Furthermore, these findings inform further hypothesis-driven research on diaper-wearing kinematics and support the development of effective strategies to enhance independence diaper use in older adults.

OBJECTIVES: We aimed to develop and validate a model to predict gait independence at discharge from inpatient rehabilitation in individuals with subacute hemiparetic stroke who have very severe gait disorder. METHODS: Overall, 298 individuals with subacute hemiparetic stroke and completely dependent gait were selected in one hospital as the training cohort. Seventy-seven individuals were selected in another hospital as the validation cohort. The prediction model was developed using multivariable logistic regression analysis, with individual characteristics selected based on a p-value threshold (<0.10) in the training cohort. Sensitivity, specificity, and area under the curve of the receiver operating characteristic curve were calculated in the training cohort, and external validation was conducted using the validation cohort. RESULTS: In total, 102 (34.2%) and 40 (52.0%) individuals in the training and validation cohorts achieved independent gait while hospitalized, respectively. The prediction model factors were age, days from onset to admission, stroke type, affected side, severity of paresis, unaffected side function, and cognitive function. The sensitivity, specificity, and area under the curve in the training cohort were 0.81, 0.80, and 0.88, respectively. Corresponding values in the validation cohort were 0.82, 0.70, and 0.83, respectively. CONCLUSIONS: A model combining age, days from onset to admission, stroke type, affected side, severity of paresis, unaffected side muscle strength, and cognitive function effectively predicted gait independence at discharge in individuals with very severe gait disorder due to subacute hemiparetic stroke.

ABSTRACT Radial extracorporeal shock wave therapy showed immediate spasticity reduction and sustained range of motion improvement in a patient with subacute stroke. However, twice‐weekly sessions were insufficient for lasting spasticity control, suggesting that more frequent treatments may be required. Further research is needed to optimize treatment protocols.

PURPOSE: To evaluate factors influencing the range of motion (ROM) in shoulder flexion and abduction, which are often compromised by postoperative conditions, including pain, soft tissue damage, and muscle weakness, 1 month after breast cancer surgery in patients undergoing inpatient rehabilitation. METHODS: In this retrospective study, the electronic medical database of a university hospital was searched for patients who underwent inpatient rehabilitation following breast cancer surgery between May 2014 and April 2020. The extracted data included age, sex, affected side, body mass index, number of nodes removed, levels of axillary lymph nodes, type of mastectomy, chemotherapy, radiation therapy, duration of postoperative drain placement, and length of hospital stay after the surgery. Passive shoulder joint ROM was examined before and 1 month after surgery. Multivariable logistic regression was performed to explore the prevalence of and factors associated with the presence of shoulder joint ROM limitations 1 month after surgery. RESULTS: This study enrolled 258 patients. A total of 210 participants (81.4%) had shoulder ROM limitation after the surgery. Shoulder flexion and abduction ROM decreased after surgery by an average of 31.3° and 35.9°, respectively. Age, number of nodes removed, and total mastectomy were significantly associated with shoulder joint ROM limitation after surgery. CONCLUSION: Over 80% of participants had reduced shoulder ROM 1 month after surgery, even after inpatient rehabilitation. We identified age, number of nodes removed, and total mastectomy as risk factors for reduced shoulder ROM, providing useful prognostic information regarding the restriction of passive shoulder ROM after breast cancer surgery.

We aimed to evaluate the applicability of a newly developed joint angle measurement system comprising six-axis inertial measurement unit sensors and tablet-based application for estimating joint angles from angular velocity and acceleration data. The application calculated orientation angles from single sensor data, with relative angles calculated using multiple sensors. In experiment 1, validity and reliability were examined using a test device. In experiment 2, static angles of five joints were calculated in four healthy participants using attached sensors and compared with universal goniometer values. In experiment 3, usability and satisfaction were evaluated using the System Usability Scale (SUS) and Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST)-like scale. In experiment 1, mean difference and root mean squared error (RMSE) between the developed system and test device were < 0.2° and < 1.0°, respectively, across all axes. In experiment 2, when data from all joints were pooled, mean difference and RMSE were 0.2° and 3.8°, respectively. Mean difference and RMSE across each joint were < 5°, indicating the system is comparable to universal goniometer. In experiment 3, median SUS and QUEST-like scores were 73.8 and 4.0, respectively, indicating good usability and satisfaction. The developed system has high accuracy and sufficient validity for human joint angles, with good usability and satisfaction.

OBJECTIVES: A new classification of heart failure based on the effects of medication has recently come into use. According to this classification, heart failure is divided into heart failure with normal ejection fraction (HFnEF; defined as an EF ≥55% for men and ≥60% for women) and non-HFnEF. However, the characteristics of patients with HFnEF are still unclear. Accordingly, in this study, we sought to identify the background characteristics, including non-cardiac factors, of patients with HFnEF. METHODS: We retrospectively divided 304 eligible patients who were hospitalized for worsening heart failure at our institution between December 2020 and December 2022 into an HFnEF group (n=37) and a non-HFnEF group (n=267) and compared their demographic and clinical characteristics. RESULTS: There were more elderly patients in the non-HFnEF group, along with fewer patients with coronary artery disease and low serum hemoglobin and NT-proBNP levels and a higher proportion of patients with a low skeletal muscle index (<7.0 kg/m2 for men and <5.7 kg/m2 for women). Multivariate analysis with addition of patient sex identified a low skeletal muscle index (odds ratio 2.96, p<0.01) to be an independent determinant of HFnEF along with older age and low NT-proBNP. CONCLUSIONS: A low skeletal muscle index was significantly more common in patients with HFnEF than in those with non-HFnEF. Intensive nutrition and exercise therapy to increase skeletal muscle mass may improve the prognosis in patients with HFnEF who respond poorly to standard pharmacological treatment.

BACKGROUND: Various digital biomarkers have been explored to detect cognitive impairment in community-dwelling older individuals, among which electricity consumption (EC) data obtained from smart meters are novel and promising because they pose no burden to the individuals. OBJECTIVE: The study aimed to explore the potential of EC as a digital biomarker to screen older individuals with cognitive impairment living alone. METHODS: We recruited 40 older individuals living alone and recorded their 1-year daily household EC data. We used the Japanese version of the Montreal Cognitive Assessment to categorize participants into 2 groups: those with and without cognitive impairment. As the pattern of daily household EC is different between lower and higher temperature ranges because of the use of heating and cooling equipment, we divided the daily household EC into 3 temperature ranges. Using a linear mixed model, we evaluated the association between daily household EC, daily outside temperature, and the groups. RESULTS: After excluding 12 participants, they were categorized into 2 groups: those with (10/28, 36%) and without cognitive impairment (18/28, 64%). The daily household EC data consisting of 9391 points showed two characteristics: (1) daily household EC was significantly lower in the group with cognitive impairment than in the group without cognitive impairment in the high temperature range (2.158 kWh at 25 °C, P=.02; 3.712 kWh at 30 °C, P<.001). The increase in EC with rising temperature from 25 °C to 30 °C was less in the group with cognitive impairment (2.387 kWh, P<.001) than in the group without cognitive impairment (3.940 kWh, P<.001); and (2) a tendency for lower daily household EC in the group with cognitive impairment was observed in the moderate temperature range (1.795 kWh at 15 °C, P=.06; 1.582 kWh at 20 °C, P=.08). CONCLUSIONS: The group with cognitive impairment may use less cooling equipment in the high temperature range and fewer home appliances in the moderate temperature range. Daily household EC might be useful in screening cognitive impairment in older individuals living alone.

OBJECTIVES: To investigate the prevalence of aspiration and its association with GI involvement and clinical features in systemic sclerosis (SSc). METHODS: Fifty patients with SSc who underwent the videofluoroscopic (VF) swallowing study were included. Aspiration was identified by the presence of aspiration and/or penetration defined by the Penetration-Aspiration Scale. The radiological findings including the residue in the oral cavity, pharynx and esophagus, which reflect oral, pharyngeal, and esophageal involvement, were also evaluated. RESULTS: Twenty-three patients (46%) had aspiration and/or penetration. Patients with aspiration and/or laryngeal penetration had more pharyngeal vallecular residue (None 22%, Trace 44%, Mild 56%; p = 0.072) and esophageal residue (None 0%, Mild 20%, Moderate 40%, Severe 61%; p = 0.010). Esophageal, pharyngeal, and lower GI involvement were found in 98%, 83%, and 54%, respectively. Notably, the group with esophageal and pharyngeal plus lower GI involvement had a higher frequency of aspiration and/or penetration (79% vs 28%; p = 0.003), higher FSSG scores (18.4 ± 11.8 vs 5.4 ± 5.7; p = 0.002), and higher UCLA GIT-2.0 total scores (None-to-Mild 47% vs 100%, Moderate 42% vs 0%, Severe-to-Very severe 11% vs 0%; p = 0.001) compared to those limited esophageal and pharyngeal involvement. By multivariate analysis, aspiration and/or penetration was associated with pharyngeal vallecular residue (Odds ratio (OR) 3.71; p = 0.012) and esophageal residue (OR 2.92; p = 0.011), and higher UCLA GIT-2.0 scores for diarrhea (OR 3.68; p = 0.028) and the total score (OR 4.21; p = 0.046). CONCLUSION: In our study, about half of the patients had aspiration and/or penetration in SSc. Aspiration was associated with the extent of radiographic abnormalities of pharyngeal and esophageal involvement on the VF swallowing study. Patients with lower GI have aspiration and high UCLA GIT-2.0 scores suggesting that these patients had more severe GI manifestation.

BACKGROUND: In Japan, a growing number of older adults with heart failure (HF) are experiencing physical frailty. Healthcare providers recommend multicomponent exercise program for frail patients; however, their effectiveness in older Japanese adults with HF, who differ physiologically from their Western counterparts, remains unclear. In this study, we will compare the feasibility and efficacy of a multicomponent exercise program with those of conventional exercise therapy as pilot study of the randomized controlled trial, Japanese REHAB-HF (J REHAB-HF) trial. METHODS: In this multicenter study, frail older adults hospitalized with worsening HF will be randomly assigned to participate in a program of either multicomponent or conventional exercise therapy. We developed a multicomponent exercise program to target characteristics of physical frailty: poor gait performance, balance ability, muscle strength, and exercise tolerance. The primary outcome is the total score on the Short Physical Performance Battery; additional outcome measures include feasibility and safety of the programs. CONCLUSION: The pilot study of the J REHAB-HF trial is an evaluation of whether a multicomponent exercise program enhances physical function more effectively than does conventional exercise therapy in frail older adults with HF. The findings will guide the design of the main J REHAB-HF trial and improve care for these individuals.

BACKGROUND: Robot-assisted gait training (RAGT) has proven effective in addressing gait disorders in patients with stroke. However, its efficacy in patients with acute stroke has not yet been demonstrated. This pilot study is designed to evaluate the following: (1) feasibility of conducting a randomized controlled trial on RAGT for enhancing gait postacute stroke and (2) to obtain preliminary estimates regarding the potential efficacy of RAGT for achieving gait independence during the acute phase. METHODS: We will conduct an assessor-blinded, single-center, randomized controlled pilot trial involving 32 patients with acute stroke who are unable to walk. Participants will be randomly assigned to either the RAGT or the conventional gait training (CGT) groups. Each participant will receive 180 min of daily rehabilitation, including 60 min dedicated to gait training. The RAGT group will receive 40 min of RAGT and 20 min of CGT, while the CGT group will engage in 60 min of CGT. Interventions will continue for up to 8 weeks, or until participants achieve gait independence, as indicated by a Functional Ambulation Category score of ≥ 3. Feasibility outcomes will include recruitment, enrollment, protocol adherence, and retention rates. The primary clinical outcome will be the incidence of achieving gait independence during the intervention period. Secondary clinical outcomes will include gait performance measures, assessments of physical function and activity, and intervention dose. Adverse events associated with RAGT and CGT will also be documented to evaluate the safety of both interventions. DISCUSSION: Implementing RAGT during the acute phase of stroke may facilitate earlier attainment of gait independence compared to CGT. We aim to provide valuable insights into the feasibility of the proposed study design and generate preliminary data on the potential effects of RAGT on gait independence in the acute phase of stroke, providing a framework for future larger-scale trials. TRIAL REGISTRATION: This clinical trial was registered with the Japan Clinical Trials Registry (jRCT) on 19 June 2023 (registration number: jRCTs042230040). The study protocol was initially registered as version 1.0 and has since undergone minor amendments-currently on version 4.0. This protocol was written based on the latest version (ver. 4.0) registered with jRCT.

This study aimed to determine the impact of bolus volume on UES opening. Twenty-two healthy subjects (10 males and 12 females, 23-45 years) underwent a CT scan while swallowing 3-, 10-, and 20 ml of thin liquid. Upper esophageal sphincter (UES) cross-sectional area and hyoid and laryngeal displacement were measured at every frame across three conditions. The timing of UES opening onset, UES maximum opening, and duration of UES opening were also measured. With increasing bolus volume, the UES maximum opening area increased, at the UES opening onset, at the UES maximum opening was earlier, and the duration of the UES opening prolonged. The maximum displacement of the hyoid and larynx was significantly more anteriorly and higher with a large bolus volume. However, the hyoid displacement at the timing of UES maximum opening did not change across three bolus volumes. This result suggests that the increase in the UES maximum opening area with increasing bolus volume was modulated by the bolus itself rather than by the hyoid movement.

BACKGROUND: Visuospatial function is a core domain of functional cognition in stroke. Post-stroke cognitive impairment disrupts rehabilitation practice, highlighting the importance of characterizing patients with higher-order visuospatial dysfunction to inform personalized rehabilitation strategies. Although neuroimaging offers insights into disease-related mechanisms, its clinical application remains limited. AIM: The aim of this paper was to investigate whether the residual resting-state functional connectivity supports higher-order visuospatial function after stroke and whether changes in connectivity can characterize patients with visuospatial dysfunction. DESIGN: Observational study. SETTING: Inpatient rehabilitation ward at Fujita Health University Hospital in Japan. POPULATION: Fifty-eight patients with stroke. METHODS: Visuospatial analogical reasoning was assessed using Raven's Colored Progressive Matrices (RCPM). Resting-state functional connectivity was evaluated using functional magnetic resonance imaging (fMRI). Empirical covariance matrices and group-sparse inverse covariance (GSIC) matrices were computed from the fMRI data, with the latter negated to estimate partial correlations representing direct connectivity. Correlations between connectivity measures and RCPM scores were analyzed, alongside data-driven clustering to stratify patients. RESULTS: No significant correlation was found between empirical covariance connectivity and RCPM scores. However, GSIC-based analysis revealed a significant inverse correlation between connectivity of the posteromedial and the left inferior parietal cortex and RCPM scores. Higher parietal connectivity was associated with lower RCPM performance. Patients in the highest connectivity cluster exhibited severe impairments in visuospatial analogical reasoning, particularly in tasks requiring the integration of discrete figures into spatially related wholes. The lesions in these patients were predominantly localized in the left subcortex. CONCLUSIONS: Medio-lateral parietal connectivity may underlie visuospatial analogical reasoning after stroke. CLINICAL REHABILITATION IMPACT: Clustering analysis highlighted a distinct pattern of low scores in patients with increased parietal connectivity, suggesting that parietal connectivity changes have the potential for characterizing patients with severe dysfunction.

OBJECTIVE: To determine the time course of longitudinal changes in the independence level of toileting-related subtasks in post-stroke patients. DESIGN: Single-institution, prospective cohort study. SUBJECTS/PATIENTS: A total of 101 consecutive patients with stroke admitted to subacute rehabilitation wards who urinated/defecated in bathrooms using wheelchairs upon admission. METHODS: Occupational therapists assessed the independence level of patients in each of the 24 toileting subtasks on a 3-level rating scale using the Toileting Tasks Assessment Form every 2-4 weeks from admission to the endpoint (achieving independent toileting or discharge). Patients were classified based on admission and endpoint assessment form scores using a two-step cluster analysis. RESULTS: Patients were classified into Cluster 1 (30 patients who exhibited a greater independence level in all subtasks upon admission [46.7-100% of patients performed each subtask independently] to the endpoint [73.3-100%]), Cluster 2 (41 patients who showed less independence upon admission [0-26.8%] but gained greater independence at the endpoint [34.1-73.2%]), and Cluster 3 (30 patients whose independence levels remained low in many subtasks from admission [0-26.7%] to the endpoint [3.3-26.7%]). CONCLUSION: Changes in toileting independence levels could be classified into 3 time courses. Effective intervention strategies may differ between each group.

OBJECTIVE: To define long-term changes in subjective symptoms among polio survivors in Japan. DESIGN: Prospective cohort study. PATIENTS: Sixty-five polio survivors. METHODS: Surveys were conducted on subjective symptoms including muscle weakness and limb atrophy during 2007 and 2021. The results of manual muscle tests of the upper and lower limbs on both sides during 2007 were summed and scored, and the side with lower scores was defined as the poor side. The participants were classified as younger or older groups based on the median age at the first survey (i.e., 58 years old) and the subjective symptoms were compared between the two groups. RESULTS: As a whole, muscle atrophy and weakness progressed in the lower and upper limbs while fatigue was reduced. Muscle weakness progressed especially in the lower limbs on the poor side in the younger group, and in the older group it progressed in the lower limbs on the good side and the upper limbs on the poor side. CONCLUSION: The timing of progressive muscle weakness differed between the upper and lower limbs of younger and older polio survivors.

BACKGROUND: Step count is used to quantify activity in individuals using accelerometers. However, challenges such as difficulty in detecting steps during slow or irregular gait patterns and the inability to apply this method to wheelchair (WC) users limit the broader utility of accelerometers. Alternative device-specific measures of physical activity exist, but their specificity limits cross-applicability between different device sensors. Moving standard deviation of acceleration (MSDA), obtained from truncal acceleration measurements, is proposed as another alternative variable to quantify physical activity in patients. OBJECTIVE: This study aimed to evaluate the validity and feasibility of MSDA for quantifying physical activity in patients with stroke-induced hemiparesis by comparing it with the traditional step count. METHODS: We enrolled 197 consecutive patients with stroke hemiparesis admitted to a convalescent rehabilitation ward. Using the hitoe system, a smart clothing-based physical activity measurement system, we measured the MSDA of trunk movement and step count. The correlation between MSDA and step count was examined in all participants. Based on their daily living mobility levels, measured using the Functional Independence Measure (FIM), participants were categorized into 6 subgroups: FIM1-4, FIM5 (WC), FIM5 (walking), FIM6 (WC), FIM6 (walking), and FIM7 (walking). Intersubgroup differences in MSDA were analyzed. RESULTS: A strong correlation was observed between MSDA and step count (r=0.78; P<.001), with a stronger correlation in the walking group (r=0.79; P<.001) compared with the WC group (r=0.55; P<.001). The Shapiro-Wilk test indicated no significant results for MSDA across all subgroups, supporting a normal distribution within these groups. In contrast, the step count data for the WC subgroups showed significant results, indicating a deviation from a normal distribution. Additionally, 10.2% (20/197) of participants recorded zero steps, demonstrating a floor effect in the step count data. The median MSDA values for the 6 subgroups (FIM1-4, FIM5 WC, FIM5 walking, FIM6 WC, FIM6 walking, and FIM7) were 0.006, 0.007, 0.010, 0.011, 0.011, and 0.014, respectively, reflecting their levels of independence based on the FIM mobility scores. The median step counts for these subgroups were 68, 233, 1386, 367, 2835, and 4462, respectively. FIM5 participants who walked had higher step counts than FIM6 participants using WCs, though the difference was marginally but not statistically significant (P=.07), highlighting the impact of mobility type (walking vs WC). CONCLUSIONS: The results suggest the validity of MSDA as a variable for physical activity in patients with stroke, applicable to patients with stroke irrespective of their mobility measures. This finding highlights the potential of MSDA for use in individuals with motor impairments, including WC users, underscoring its broad utility in rehabilitation clinical practice.

BACKGROUND: Dysphagia significantly impacts prognosis in individuals with multiple system atrophy (MSA). While video-based assessments are practical, their limited availability highlights the need for a simple tool such as the Dysphagia Severity Scale (DSS) in clinical practice. OBJECTIVES: To evaluate the utility of the DSS in assessing dysphagia in MSA patients and its correlations with clinical indices. METHODS: We examined 43 MSA patients using the DSS and other clinical measures, including the Unified MSA Rating Scale (UMSARS) and cerebrospinal fluid 5-hydroxyindoleacetic acid levels. As a follow-up, 11 of 43 patients underwent a secondary DSS evaluation. Spearman's correlation and linear mixed models were used to analyze cross-sectional and longitudinal relationships. RESULTS: DSS scores were significantly correlated with UMSARS Parts 1, 2, and 4, as well as disease duration and blood pressure changes. This indicates that the DSS is sensitive to MSA-related motor and autonomic dysfunctions, and that the DSS could provide a more detailed assessment of swallowing function compared with the UMSARS Part 1 swallowing subscore. Additionally, DSS score was correlated with cerebrospinal fluid 5-hydroxyindoleacetic acid levels. Our longitudinal analysis further supported the role of DSS score as a reliable marker of dysphagia progression over time. CONCLUSIONS: The DSS is a sensitive and practical tool for evaluating dysphagia. Thus, combining the DSS and UMSARS could improve dysphagia monitoring in individuals with MSA. Our data support the use of the DSS as a valuable clinical and research tool in MSA management.

Objective: To clarify the percentage of stroke patients who are independent in performing tasks involved in public transportation use and problems faced while doing so.Design: Single-institution retrospective study.Patients: A total of 237 post-stroke patients utilized public transportation during their hospitalization in subacute rehabilitation wards.Methods: Participants’ actual performance in 14 tasks involving public transportation use was assessed using the Public Transportation Use Assessment Form. For each task, the percentage of participants who could perform the task independently was calculated and identified performance problems were categorized.Results: The task with the lowest percentage of independent participants was “Walking in crowds”, with 146 of 236 (61.9%) participants performing this independently, followed by “Selecting departure time and platform” (149 of 229, 65.1%), and “Getting on and off trains” (162 of 230, 70.4%). Problems faced when “Walking in crowds” included the “Risk of colliding with others” (n = 34), “Stopping abruptly” (n = 16), “Lack of attention to surroundings” (n = 14), and “Unable to walk with the flow of people” (n = 11).Conclusion: A significant number of patients could not perform tasks independently and faced various performance problems. These issues should be addressed during rehabilitation to enable patients to use public transportation.

BACKGROUND: Robot-assisted gait training (RAGT) is an effective method for treating gait disorders in individuals with stroke. However, no previous studies have demonstrated the effectiveness of RAGT in individuals with acute stroke. This study aimed to investigate the effects of RAGT initiation within 1 week after onset on degree of gait independence in individuals with hemiparetic stroke. METHODS: This retrospective cohort study used propensity-score matching. Individuals admitted to Fujita Health University Hospital after stroke onset and underwent RAGT between March 2017 and June 2023 were enrolled. Ninety-two individuals were eligible and grouped into the acute (≤ 7 days after the onset) and subacute groups (8-90 days after onset). RAGT was conducted using Welwalk, primarily comprising a knee-ankle-foot orthosis type robot worn on one paralyzed lower extremity, with training sessions lasting approximately 40 min/day, occurring 3-7 days/week. The primary outcome was the gait under supervision within 90 days of onset, which was compared between groups using the log-rank test. RESULTS: After propensity-score matching, 36 individuals were included in the analysis, including 18 each in the acute and subacute groups; the participant demographics were not significantly different between the groups. RAGT was initiated at a median of 6 and 25 days after onset in the acute and subacute groups, respectively. The Kaplan-Meier curves after the log-rank test showed a significantly higher percentage and shorter median days to achieve gait under supervision in the acute group than in the subacute group. The cumulative incidence of gait under supervision events at 90 days after onset was 82.2% and 55.6% in the acute and the subacute groups, respectively. Half of the individuals achieved gait under supervision within 49 days and 75 days in the acute and subacute groups, respectively (p = 0.038). No significant differences were observed in the dose of rehabilitation program and gait training per day from onset to achieving gait under supervision. CONCLUSION: Initiation of RAGT within 1 week after stroke onset in individuals with hemiparesis may reduce the number of days required to achieve gait under supervision and increase the percentage of gait under supervision.

OBJECTIVES: We aimed to design and implement a community-based rehabilitation (CBR) curriculum to promote community engagement by multidisciplinary teams. METHODS: Participants in this prospective interventional study at a rehabilitation institution for people aging with disabilities included learners, the chief executive officer of the institution, program auditors, and community members. A customized CBR curriculum was developed using systems thinking design. Thirty-five learners were trained through 36 instructional contact hours and 60 hours of guided self-directed learning. Learners completed pre-training self-reported questionnaires regarding knowledge and experience of CBR. During training, learners were evaluated continuously through observation, assignments, self-reported feedback questionnaires, and CBR projects. The chief executive officer was interviewed during the study. The program auditors were interviewed and wrote reports on the curriculum and observations regarding the CBR projects. Learners reported on community participation in these projects. RESULTS: Thirty-three of 35 learners completed the program, 31 (94%) of whom had no prior knowledge of CBR. Learners implemented nine community engagement CBR projects, in which 1,293 community members participated. The auditors commended the curriculum content and its positive impact on learners and the community. The chief executive officer implemented inclusive community engagement at work. A CBR curriculum was dynamically developed for multidisciplinary rehabilitation team training to promote community engagement. CONCLUSIONS: The custom-designed CBR curriculum enabled multidisciplinary teams to practice community engagement at work. Equipped with CBR knowledge and skills, teams engaged with multiple sectors of the community to enhance patients' rehabilitation potential and increase public awareness through the implemented projects.

OBJECTIVE: To determine the impact of mobilization training time during the first postoperative week on the length of hospital stay for postoperative patients admitted to an intensive care unit. DESIGN: A retrospective cohort study. PATIENTS: Consecutive patients who underwent elective surgery and stayed in the intensive care unit of a university hospital for more than 48 h between July 2017 and August 2020 were enrolled. METHODS: The total duration of mobilization training during the first postoperative week and clinical variables, including demographic information, were collected from medical records. Multivariable regression analysis was used to investigate the impact of mobilization training time on the length of hospital stay, adjusting for potentially confounding variables. RESULTS: In total, 773 patients (504 males; median age, 70 years) were enrolled. Multivariable regression analysis showed that an increase in mobilization training time during the first postoperative week was associated with a shorter length of hospital stay (β = -0.067, 95% confidence interval: -0.120, -0.017, p = 0.010), with each 1-h increase in training time associated with a 4.02-day reduction in the length of hospital stay. CONCLUSION: Increased mobilization training during the first postoperative week significantly reduced the length of hospital stay in postoperative patients.

BACKGROUND: The economic burden on individuals with stroke is a major concern, and measures to mitigate the negative effects of stroke on labor productivity are imperative. However, few studies have explored the return to work (RTW) of individuals with stroke after their discharge from rehabilitation wards. We therefore aimed to explore the proportion of patients with stroke who returned to work after discharge from a convalescent rehabilitation ward and to explore the characteristics of patients with stroke who achieve RTW compared to those who do not. METHODS: This descriptive study was conducted in a convalescent rehabilitation ward at a university hospital in Japan. It included patients with stroke in the working-age population (15-64 years) who worked before the onset and were discharged from the rehabilitation ward to their homes between January 2018 and April 2022. The participants were required to respond to a questionnaire, which was sent by mail, and the RTW status at 6 months after discharge from the rehabilitation ward was investigated. They were classified into RTW and non-RTW groups, and their characteristics were compared between the groups. RESULTS: Fifty-nine patients [mean (SD) age 53.0 (9.0) years; 42 men] among 125 who met the criteria returned the questionnaire, and their data were included in the analysis. Thirty-nine individuals [66.1%; mean (SD) age 53.0 (8.2) years; 31 men] achieved RTW. Compared to the non-RTW group, the RTW group had significantly higher total functional independence measure (FIM) scores at admission (p = 0.046) and discharge (p < 0.001), a significantly shorter duration of ward stay during hospitalization (p = 0.002), and a significantly smaller proportion of patients with aphasia (p = 0.019). CONCLUSION: Two-thirds of the patients in this study population had achieved RTW at 6 months after discharge from the convalescent rehabilitation ward. Patients who achieved RTW had better motor function and FIM scores at discharge than those who did not.

INTRODUCTION: Gait robots have the potential to analyze gait characteristics during gait training using mounted sensors in addition to robotic assistance of the individual's movements. However, no systems have been proposed to analyze gait performance during robot-assisted gait training. Our newly developed gait robot," Welwalk WW-2000 (WW-2000)" is equipped with a gait analysis system to analyze abnormal gait patterns during robot-assisted gait training. We previously investigated the validity of the index values for the nine abnormal gait patterns. Here, we proposed new index values for four abnormal gait patterns, which are anterior trunk tilt, excessive trunk shifts over the affected side, excessive knee joint flexion, and swing difficulty; we investigated the criterion validity of the WW-2000 gait analysis system in healthy adults for these new index values. METHODS: Twelve healthy participants simulated four abnormal gait patterns manifested in individuals with hemiparetic stroke while wearing the robot. Each participant was instructed to perform 16 gait trials, with four grades of severity for each of the four abnormal gait patterns. Twenty strides were recorded for each gait trial using a gait analysis system in the WW-2000 and video cameras. Abnormal gait patterns were assessed using the two parameters: the index values calculated for each stride from the WW-2000 gait analysis system, and assessor's severity scores for each stride. The correlation of the index values between the two methods was evaluated using the Spearman rank correlation coefficient for each gait pattern in each participant. RESULTS: The median (minimum to maximum) values of Spearman rank correlation coefficient among the 12 participants between the index value calculated using the WW-2000 gait analysis system and the assessor's severity scores for anterior trunk tilt, excessive trunk shifts over the affected side, excessive knee joint flexion, and swing difficulty were 0.892 (0.749-0.969), 0.859 (0.439-0.923), 0.920 (0.738-0.969), and 0.681 (0.391-0.889), respectively. DISCUSSION: The WW-2000 gait analysis system captured four new abnormal gait patterns observed in individuals with hemiparetic stroke with high validity, in addition to nine previously validated abnormal gait patterns. Assessing abnormal gait patterns is important as improving them contributes to stroke rehabilitation. CLINICAL TRIAL REGISTRATION: https://jrct.niph.go.jp, identifier jRCT 042190109.

OBJECTIVES: This study aimed to establish standardized categories of rehabilitation approaches in long-term care and evaluate their appropriateness through a Delphi survey with an expert panel. METHODS: We adopted the Delphi method using the RAND/UCLA Appropriateness Method. A panel of 15 multidisciplinary rehabilitation experts comprising physicians, physical therapists, occupational therapists, and speech-language-hearing therapists was established. We developed a questionnaire comprising 10 main categories and 58 subcategories based on the glossary review and cross-sectional survey. Panelists rated the categories on a Likert scale from 1 (extremely inappropriate) to 9 (extremely appropriate). The survey was repeated until all categories reached a consensus on "appropriate" and "agreement." RESULTS: All 15 panelists participated in three rounds of the Delphi survey. In the first round, although all categories were deemed "appropriate," one main category and six subcategories did not achieve "agreement." In the second round, all categories reached the status of "appropriate" and "agreement." However, some of the comments needed further consideration. After making minor revisions, all items ultimately reached the status of "appropriate" and "agreement." CONCLUSIONS: This study achieved consensus on the terminology for standardized categories of rehabilitation approaches in long-term care. Future research should assess their reliability and validity using real-world clinical data.

INTRODUCTION: Dose (number of repetitions) has been suggested as a key element in the effectiveness of rehabilitation exercises to promote motor recovery of the hemiparetic upper limb. However, rehabilitation exercises tend to be monotonous and require significant motivation to continue, making it difficult to increase the exercise dose. To address this issue, gamification technology has been implemented in exercises to promote self-engagement for people with hemiparesis in continuing monotonous repetitive movements. This study aimed to investigate how subjective perspectives, specifically enjoyability, motivation to continue, and expectancy of effectiveness, change through continuous daily exercise using a developed gamified exercise system. MATERIALS AND METHOD: Ten people with stroke suffering upper limb dysfunction underwent daily gamified exercise for seven days. The gamified exercise consisted of an electromyography (EMG)-controlled operating system that enabled users to play virtual games using repetitive finger movements. The participants performed conventional self-exercise on the same day as the control exercise, and rated their subjective perspectives on both exercises on a numerical rating scale on each exercise day. RESULTS: Ratings for enjoyability and motivation to continue consistently showed significantly higher scores for the gamified exercise than for conventional self-exercise on all exercise days. A similar trend was observed in the ratings for the expectancy of effectiveness. No changes over time were found in any of the ratings throughout the exercise period. CONCLUSIONS: Exercise using the developed EMG-controlled gamified system may have the potential to maintain motivation and enjoyment in people with stroke to continue monotonous repetitive finger movements.

This study investigated the effects of ankle dorsiflexion angle adjustments in ankle-foot orthoses (AFOs) on the gait of healthy individuals. Fifteen healthy participants engaged in treadmill walking tasks while wearing AFOs with dorsiflexion angles set at 0°, 5°, 10°, and 15°. Three-dimensional treadmill gait analysis was used to collect data during treadmill walking. The analysis focused on toe clearance and the contribution of the vertical component of limb shortening (LS), and compared them across different dorsiflexion angles. The results indicated a significant increase in toe clearance at 10° (median [interquartile change]: 5.03 [0.90] vs. 5.98 [1.18], p < 0.01) and 15° (5.03 [0.90] vs. 5.82 [1.11], p < 0.01) dorsiflexion angle conditions compared to the 0° condition. Similarly, LS demonstrated significant increases at 10° (4.89 [1.97] vs. 5.87 [1.31], p < 0.01) and 15° (4.89 [1.97] vs. 5.61 [1.65], p < 0.01) conditions when compared with the 0° condition. These findings support the notion that higher dorsiflexion angles in AFOs lead to increased toe clearance and LS, suggesting the effectiveness of dorsiflexion angle adjustments as a strategy to address reduced toe clearance.