宮坂 裕之

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.

Sensory disorder is a factor preventing recovery from motor paralysis after stroke. Although several robot-assisted exercises for the hemiplegic upper limb of stroke patients have been proposed, few studies have examined improvement in function in stroke patients with sensory disorder using robot-assisted training. In this study, the efficacies of robot training for the hemiplegic upper limb of three stroke patients with complete sensory loss were compared with those of 19 patients without complete sensory loss. Robot training to assist reach motion was performed in 10 sessions over a 2-week period for 5 days per week at 1 h per day. Before and after the training, the total Fugl-Meyer Assessment score excluding coordination and tendon reflex (FMA-total) and the FMA shoulder and elbow score excluding tendon reflex (FMA-S/E) were evaluated. Reach and path errors (RE and PE) during the reach motion were also evaluated by the arm-training robot. In most cases, both the FMA-total and the FMA-S/E scores improved. Cases with complete sensory loss showed worse RE and PE scores. Our results suggest that motor paralysis is improved by robot training. However, improvement may be varied according to the presence or absence of somatic sensory feedback.

Rehabilitation and mobility training of post-stroke patients is crucial for their functional recovery. While traditional methods can still help patients, new rehabilitation and mobility training methods are necessary to facilitate better recovery at lower costs. In this work, our objective was to design and develop a rehabilitation training system targeting the functional recovery of post-stroke users with high efficiency. To accomplish this goal, we applied a bilateral training method, which proved to be effective in enhancing motor recovery using tactile feedback for the training. One participant with hemiparesis underwent six weeks of training. Two protocols, “contralateral arm matching” and “both arms moving together”, were carried out by the participant. Each of the protocols consisted of “shoulder abduction” and “shoulder flexion” at angles close to 30 and 60 degrees. The participant carried out 15 repetitions at each angle for each task. For example, in the “contralateral arm matching” protocol, the unaffected arm of the participant was set to an angle close to 30 degrees. He was then requested to keep the unaffected arm at the specified angle while trying to match the position with the affected arm. Whenever the two arms matched, a vibration was given on both brachialis muscles. For the “both arms moving together” protocol, the two arms were first set approximately to an angle of either 30 or 60 degrees. The participant was asked to return both arms to a relaxed position before moving both arms back to the remembered specified angle. The arm that was slower in moving to the specified angle received a vibration. We performed clinical assessments before, midway through, and after the training period using a Fugl-Meyer assessment (FMA), aWolf motor function test (WMFT), and a proprioceptive assessment. For the assessments, two ipsilateral and contralateral arm matching tasks, each consisting of three movements (shoulder abduction, shoulder flexion, and elbow flexion), were used. Movements were performed at two angles, 30 and 60 degrees. For both tasks, the same procedure was used. For example, in the case of the ipsilateral arm matching task, an experimenter positioned the a_ected arm of the participant at 30 degrees of shoulder abduction. The participant was requested to keep the arm in that position for ~5 s before returning to a relaxed initial position. Then, after another ~5-s delay, the participant moved the affected arm back to the remembered position. An experimenter measured this shoulder abduction angle manually using a goniometer. The same procedure was repeated for the 60 degree angle and for the other two movements. We applied a low-cost Kinect to extract the participant’s body joint position data. Tactile feedback was given based on the arm position detected by the Kinect sensor. By using a Kinect sensor, we demonstrated the feasibility of the system for the training of a post-stroke user. The proposed system can further be employed for self-training of patients at home. The results of the FMA, WMFT, and goniometer angle measurements showed improvements in several tasks, suggesting a positive e_ect of the training system and its feasibility for further application for stroke survivors’ rehabilitation.

【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)

Neuromuscular electrical stimulation (NMES), specifically functional electrical stimulation (FES) that compensates for voluntary motion, and therapeutic electrical stimulation (TES) aimed at muscle strengthening and recovery from paralysis are widely used in stroke rehabilitation. The electrical stimulation of muscle contraction should be synchronized with intended motion to restore paralysis. Therefore, NMES devices, which monitor electromyogram (EMG) or electroencephalogram (EEG) changes with motor intention and use them as a trigger, have been developed. Devices that modify the current intensity of NMES, based on EMG or EEG, have also been proposed. Given the diversity in devices and stimulation methods of NMES, the aim of the current review was to introduce some commercial FES and TES devices and application methods, which depend on the condition of the patient with stroke, including the degree of paralysis.

BACKGROUND: Electrical stimulation is shown to be effective for the amelioration of paralysis. The stimulation pattern can have a direct relation to injected charge in the stimulated area resulting in a wider area stimulation and consequently better recovery. OBJECTIVE: In this study, we investigated the effect of two electrical stimulation waveforms, rectangular and exponentially climbing. Three parameters of current, voltage, and knee extension torque of the 2 waveforms were recorded and used for the comparison of the two waveforms. METHODS: Fifteen male and 15 female able-bodied subjects (age: 25.0 ± 3.2) were recruited. Electrical stimulation was applied to right quadriceps muscles. At the maximum tolerable intensity, the 3 parameters were recorded for each of the 2 waveforms. Using the recorded knee extension torques, the adjusted maximum electrically induced contraction to voluntary torques in percent (%MEIC) of the two waveforms were calculated. Together with the other two parameters, current and voltage, the 2 waveforms were compared. RESULTS: The %MEIC and maximum voltage were significantly higher with the exponentially climbing waveform than with the rectangular waveform (%MEIC:p &lt 0.05, max voltage:p &lt 0.01). The maximum current did not differ significantly between conditions. CONCLUSION: These results indicate that an exponentially climbing waveform may induce stronger torque than a rectangular waveform and might thus be useful when applying NMES in clinical situations.

The consistency of torque measurements during repetitive moving arm movements and also during passive wrist movements at two angular velocities of slow (∼6°/s) and moderate (∼120°/s) was investigated. The designed and developed device was applied to 3 cases, to a spring, to 8 able-bodied subjects and to 2 hemiplegic patients. While the mean of the intra-class correlation coefficient of subjects were 0.65 and 0.75 for slow and moderate angular velocities, those of the hemiplegic patients and the spring respectively ranged between excellent values of 0.93–1 and 0.91–1. The Pearson's product-moment correlation coefficients of the 3 cases for the 2 slow and moderate angular velocities ranged between 0.80 and 1. We could verify that the device can be used in our future researches and it can (1) reliably rotate a moving arm horizontally with angular velocities between 3 and 350°/s constantly in a range of motion between −60 and 60° and (2) simultaneously capture the data of angular displacement, torque, and two electromyogram activities. For the standardization of our future studies with the device, we could verify the stability of the last two repeated passive wrist movements in case of patients. The results of the study with the able-bodied subjects are also important as a reference for our studies with the hemiplegic.

We investigated whether untriggered neuromuscular electrical stimulation (NMES) can increase the effectiveness of shoulder and elbow robotic training in patients with hemiparesis. Thirty subacute stroke patients were randomly equally allocated to robot only (RO) and robot and electrical stimulation (RE) groups. During training, shoulder and elbow movements were trained by operating the robotic arm with the paretic arm, and the robotic device helped to move the arm. In the RE group, the anterior deltoid and triceps brachii muscles were electrically stimulated at sub-motor threshold intensity. Training was performed (approximately 1 h/day, 5 days/week for 2 weeks) in addition to regular rehabilitation. Active range of motion (ROM) values of shoulder flexion and abduction, and Fugl-Meyer assessment (FMA) scores were measured before and after training. Active shoulder ROM was significantly better after than before training in the RE group; however, no such improvement was noted in the RO group. FMA scores were significantly better in both groups, and there was no significant difference between the groups. Untriggered NMES might increase the effectiveness of shoulder and elbow robotic training in patients with hemiparesis. Additionally, NMES at a sub-motor threshold during robotic training might facilitate activation of paretic muscles, resulting in paralysis improvement. (C) 2016 The Author(s). Published by Elsevier Ltd on behalf of IPEM. This is an open access article under the CC BY-NC-ND license.

In this paper, a programmable, multi-pattern, wide frequency and duty cycle range electrical stimulator is presented. Using a programmable micro-controller, two waves of carrier and modulating sources are produced. By modulating the two sources, 3 bi-phasic charge-balanced rectangular, triangular and sinusoidal stimulating patterns are produced. The frequency range of the carrier is fixed at 2.5 kHz and the carrier source frequency can be adjusted between 1 and 500 Hz. The duty cycle of both sources can be adjusted between 10% and 90%.

[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] To develop a device for measuring the torque of an ankle joint during walking in order to quantify the characteristics of spasticity of the ankle and to verify the functionality of the device by testing it on the gait of an able-bodied individual and an equinovarus patient. [Subjects and Methods] An adjustable posterior strut (APS) ankle-foot orthosis (AFO) was used in which two torque sensors were mounted on the aluminum strut for measuring the anterior-posterior (AP) and medial-lateral (ML) directions. Two switches were also mounted at the heel and toe in order to detect the gait phase. An able-bodied individual and a left hemiplegic patient with equinovarus participated. They wore the device and walked on a treadmill to investigate the device's functionality. [Results] Linear relationships between the torques and the corresponding output of the torque sensors were observed. Upon the analyses of gait of an able-body subject and a hemiplegic patient, we observed toque matrices in both AP and ML directions during the gait of the both subjects. [Conclusion] We developed a device capable of measuring the torque in the AP and ML directions of ankle joints during gait.

[Purpose] To develop a device for measuring the torque of an ankle joint during walking in order to quantify the characteristics of spasticity of the ankle and to verify the functionality of the device by testing it on the gait of an able-bodied individual and an equinovarus patient. [Subjects and Methods] An adjustable posterior strut (APS) ankle-foot orthosis (AFO) was used in which two torque sensors were mounted on the aluminum strut for measuring the anterior-posterior (AP) and medial-lateral (ML) directions. Two switches were also mounted at the heel and toe in order to detect the gait phase. An able-bodied individual and a left hemiplegic patient with equinovarus participated. They wore the device and walked on a treadmill to investigate the device's functionality. [Results] Linear relationships between the torques and the corresponding output of the torque sensors were observed. Upon the analyses of gait of an able-body subject and a hemiplegic patient, we observed toque matrices in both AP and ML directions during the gait of the both subjects. [Conclusion] We developed a device capable of measuring the torque in the AP and ML directions of ankle joints during gait.

Wavelet transform energy analyses of the mean and standard error of the electromyogram (EMG) and electroencephalogram (EEG) of eight subjects were investigated in passive movement mirror therapies with no delay (in-phase) and with delay (out-of-phase) situations in two frequency bands of 7.81-15.62 and 15.62-31.25 Hz. It was found that the energy levels of EEG at electrode C4 in the in-phase situation were lower than those in out-of-phase situations, while the energy levels of flexor and extensor forearm muscle groups were larger. With two exceptions, this pattern could be seen in all other subjects. The difference between the in-phase (D0) and out-of-phase situations (D025 and D05) for the frequency range of 15.62-31.25 Hz was found to be significant at a significance level of 0.05 (paired t-test analysis). The respective elevation and decline of EEG and EGM with regard to the increase of the delay may indicate the necessity for synchronization of passive movement and mirror therapy.

Background: To apply advanced methods of communication, sensing, and instrumentation technologies to make a system that can help patients suffering from hemispatial neglect caused by higher cortical function disorder. Method: By using several sensors and actuators, the objective was to construct a tailor-made system for each patient. The input part of the system consists of sensors, an interface and transmitters. The output part consists of a receiver, logical arithmetic, an output interface and actuators. The information from the input part is sent to the output part in a wireless manner allowing the mobility of the input and output parts. Results: The system and its functionality were realized. Voice alarming and neck muscle stimuli were applied to two patients. We could verify the applicability of the system to remind the patients to put on their wheelchair's brake and raise its footrest before attempting to stand for transferring to their beds. Conclusion: The designed and constructed multi-input/output system can be used effectively to alarm the patients.

要旨：脳卒中患者の麻痺側上肢訓練の一つとして電気刺激療法があり，運動麻痺改善や痙縮抑制効果などが報告されている．われわれは電気刺激療法の一種である随意運動介助型電気刺激(IVES)を回復期脳卒中患者の麻痺側上肢に行い，治療同日の持続効果について検討した．IVESによる訓練は1週間継続し，開始時と1週間後の治療前，治療直後，治療後から30分毎に120分後までの手関節背屈自動運動角度の経時変化を評価した．手関節背屈自動運動角度は，開始時に比べ，有意な改善がみられた．SIAS，MASは開始時と比べ，改善を認めたが有意差はみられなかった．また，治療直後の角度が有意に低下するのが開始時は治療後60分，1週間後は治療後90分であり，継続した使用により効果が持続されやすいと考えられた．

Abstract. [Purpose] The purpose of this study was to examine the locus of the center of pressure (COP) of standing postures with different feet positions. [Subjects] Sixty healthy young adults participated in the experiments as subjects. [Methods] The COP was measured using a force plate. Subjects stabilized themselves on the force plate, and the change of the COP trajectory was measured for 30 s. The COP was measured in three standing postures: wide-base, tandem, and one-foot standing. The relative center of anterior-posterior sway was examined as a proportion of the base of support length. [Results] Using one foot length, l, measured from the heel to the toe of the foot as a standard, the mean of the center of anterior-posterior sway was 44.5 ± 5.5% of l in the wide-base stance, 50.2 ± 4.4% of l in the one-foot dominant stance, and 50.4 ± 4.3% of l in the one-foot non-dominant stance. Since the length of the feet is 2l in the tandem posture, the mean of the center of anterior-posterior sway was 41.0 ± 7.0% of 2l with the dominant foot in front and 41.5 ± 6.0% of 2l with the non-dominant foot in front. [Conclusion] The mean of the center of anterior-posterior sway was inclined toward the anterior position in single leg standing compared to the wide base standing. In tandem standing, the COP was located on the rear foot. The results of this study might be useful in considering the mechanism of postural control of patients with hemiplegia.

The standing test for imbalance and disequilibrium (SIDE) is a discriminative measure developed for the purpose of identifying balance deficits that may cause falls. The purpose of the present study was to determine the validity of the sequence of postures used in SIDE. Subjects comprised 30 men with a mean (+/- standard deviation) age of 21.9 +/- 3.11 years (range 19-32 years) and 30 women with a mean age of 20.7 +/- 1.24 years (range 19-23 years). Center of pressure (COP) was measured using a stabilometer recording for 30 s with a 20-Hz sampling frequency. The measurement postures that were similar to postures adopted in the SIDE were: standing with feet 20 cm apart: standing with legs close and the insides of both feet touching; two tandem standing positions (with the dominant foot forward and with the non-dominant foot forward); and two single-leg standing positions (on the dominant foot and on the non-dominant foot). We calculated total path length and envelopment area of sway from the COP data. Statistical differences in means were determined using the Tukey-Kramer multiple comparison test. Results indicate that the orders of total path length and envelopment areas of sway in each posture were consistent with the item order of SIDE. Significant differences existed between the means of total path length and envelopment areas of sway in each posture (p &lt;0.05), with the exception of both tandem standing positions and both one-leg standing positions. The item order of SIDE appears to show concurrent validity in terms of the amount of body sway in the adopted postures. (C) 2011 Elsevier B.V. All rights reserved.

The purpose of this study was to determine whether high-speed treadmill training improved the gait velocity of patients whose maximum walking speed was assumed to have reached a plateau level. The subjects included seven patients with hemiplegia after stroke. The high-speed treadmill training was performed as the maximum gait velocity of each patient was presumed to have reached a plateau level. The patients walked 20% faster than their maximum gait velocity of the day for 5 days (phase I). Then they walked 20% slower than maximum gait velocity of the day for 5 days, and they repeated the fast treadmill walking for further 5 days (phase II). Before phase I, mean maximum gait velocity of the day was 0.84 m/sec before phase I, 1.08 m/sec after phase I, and 1.24 m/sec after phase II. These results demonstrated that training at a speed 20% faster than the maximum gait velocity of the day on the treadmill for 5 days could further increase a patient&apos;s gait velocity.

省スペースの定常環境下にて多数歩採取が容易となるトレッドミルを用いて三次元動作解析を行い,歩行中の足部内外反運動の計測を試み,その計測方法と分析結果について検討した.整形および中枢疾患の既往歴のない健常成人男性5例を対象とした.平均歩数は,12.2歩であった.歩行周期の内外反運動は,踵接地では内反位を呈し,立脚中期に正中および軽度外反位,立脚中期から遊脚期にかけて内反になる運動パターンの傾向を示し,5例ともほぼ同じ傾向であった.トレッドミル歩行分析では,多数歩にて正規化後加算平均処理が容易となるため,歩行周期の足部内外反運動を明確に示すことが可能になった.また,標準偏差,変動係数といった統計学的検討も可能となるため,臨床の歩行分析において非常に有用な指標になると思われた