水野 志保

OBJECTIVE: To examine the effect of onset to admission interval (OAI) and stroke type on activities of daily living (ADL) outcome. MATERIALS AND METHODS: Stroke patients (n=3112) admitted to and discharged from comprehensive inpatient rehabilitation wards at Nanakuri Memorial Hospital were classified into 8 OAI segments and by stroke type [intracerebral hemorrhage (ICH) and cerebral infarction (CI)]. Motor subscore of the Functional Independence Measure (FIM-M) on admission, FIM-M at discharge, FIM-M gain, length of stay (LOS), and FIM-M efficiency in the ICH and CI group matched by OAI segment were compared using the Wilcoxon test. Multiple comparisons using the Steel-Dwass test of FIM-M on admission, FIM-M at discharge, FIM-M gain, LOS, and FIM-M efficiency by OAI segments were performed. RESULTS: FIM-M on admission was lower in the ICH group than the CI group in matched OAI segments. However, FIM-M improvement was greater in the ICH group than the CI group, resulting in no difference in FIM-M between groups at discharge. In both groups, the longer the OAI, the lower the FIM-M on admission and at discharge. The distribution pattern of significant differences among OAI segments differed between the groups. LOS tended to be longer and FIM-M efficiency tended to be higher in the ICH group than in the CI group. CONCLUSIONS: The brain mass effect at the time of admission was larger and took longer to decrease in the ICH group than in the CI group. These results may improve prediction of outcomes in comprehensive inpatient rehabilitation wards.

Objective To assess quantitatively the efficacy of oral baclofen for spasticity poststroke. Methods The participants were 29 persons poststroke with increased resistance to passive ankle dorsiflexion and ankle clonus on clinical assessment. Baclofen was administered at 20 mg/day for 1 week. The ankle joint was passively dorsiflexed at either 5°/s (slow stretch) or 90°/s (fast stretch) by a custom-built device. The ankle joint angle and resistive torque were measured during the ramp-and-hold stretch, with gastrocnemius electromyogram. The main outcome measures were the numbers of ankle clonus during hold, and the torques at 10° of ankle dorsiflexion in slow stretch (T-slow) and fast stretch (T-fast). Moreover, the velocity-dependent torque (ΔT = T-fast - T-slow) was compared between before and after oral baclofen. Results The numbers of ankle clonus, T-slow, T-fast, and ΔT for all participants did not exhibit significant differences between before and after baclofen administration. However, reduction in the number of ankle clonus of five or more was accompanied with a reduction in ΔT (4.0 ± 1.8 Nm) in three participants (the responders). Conclusion Although the responder rate was low, some participants responded to oral baclofen. Thus, a short-term trial of oral baclofen, and quantitative and electrophysiological assessments of muscle tone and ankle clonus are recommended.

Background Individuals exhibiting hemiplegia and increased ankle plantar flexors muscle tone following stroke are frequently prescribed an ankle-foot orthosis (AFO) to regain functional ambulation. The effect of muscle tone on ankle kinetics when walking with an AFO remains unknown. Objectives To investigate the effect of plantar flexion (PF) muscle tone on ankle plantar flexion torque during walking with an ankle-foot orthosis Methods The study included 80 participants with first-ever stroke whose manual muscle testing (MMT) of ankle DF 0-4, and 10 healthy subjects. Participants were instructed to walk on a treadmill, at a comfortable speed, wearing an instrumented AFO. Minimum PF torque during the last half of swing was extracted as an outcome measure. Resistive PF torques during passive slow and fast stretches were measured with a custom-built device, with torques at 10° DF (T10°-slow and T10°-fast) extracted as defining parameters for stiffness and muscle tone, respectively. Results Correlations between both T10°-slow and T10°-fast variables with minimum PF torque were fair among ankle DF MMT 0-3 groups (r = 0.71 -0.74, p < 0.01), with no correlation observed among the MMT 4 group and healthy subjects. Conclusions Effects of muscle tone on ankle kinetics during swing phase, with an AFO, were observed in persons with severe ankle DF paresis. Quantitative evaluation of ankle kinetics during gait with an AFO in addition to evaluation of muscle tone at rest is contributory to objective assessment of a muscle tone, not subjective rating scale at rest, or visual inspection of walking.

BACKGROUND: Quantification of increased muscle tone for patients with spasticity has been performed to date using various devices to replace the manual scales, such as the modified Ashworth scale or the Tardieu scale. We developed a device that could measure resistive plantar flexion (PF) torque of the ankle during passive dorsiflexion (DF) as an indicator of muscle tone of ankle plantar flexors. METHODS: The primary objective was to explore the test-retest intrarater reliability of a custom-built device. Participants were 11 healthy subjects (7 men, 4 women; mean age 47.0 years) and 22 patients with poststroke hemiplegia (11 hemorrhagic, 11 ischemic; 14 men, 8 women; mean age 57.2 years). The device was affixed to the ankle. Subjects were seated with knees either flexed or extended. The ankle was passively dorsiflexed from 20° of PF to more than 10° of DF at 5°/second (slow stretch) or 90°/second (fast stretch). Angle and torque were measured twice during the stretches. The intraclass correlation coefficients (ICCs) of torque at 10° of DF (T10) in the 4 conditions-slow and fast stretches with knee flexed or extended-were calculated. RESULTS: The T10 ICCs of the 4 conditions were .95-.99 in both groups. The healthy subjects showed significantly higher T10 of knee extension than of knee flexion during slow and fast stretches. The patients showed increased velocity-dependent torque during fast stretches. CONCLUSIONS: Excellent reliability was observed. The device is suitable for measuring resistive PF torque during passive stretch in a flexed knee condition.

PURPOSE: The aim of our study was to investigate the presenting conditions of patients with hemorrhagic transformation (HT), the frequency of HT and its treatments at a rehabilitation hospital. SUBJECTS AND METHODS: 165 patients with cerebral infarctions transferred to our rehabilitation hospital during the study period were enrolled. HT was diagnosed by two stroke specialists using computed tomography (CT) at the time of transfer to our rehabilitation hospital and other imaging data from previous consultations. Neurological status, activities of daily living, administered agents, patient age, duration from stroke onset to transfer and length of hospital stay were examined. RESULTS: 30 of the 165 patients (18.2%) were diagnosed with HT. Decreased activities of daily living at admission and discharge as well as longer hospitalization stays were more prevalent in HT patients than in those without HT. We did not change antiplatelet or anticoagulant agents, but continued rehabilitation over a defined period while monitoring blood pressure; we confirmed with CT that the patients' physical conditions did not deteriorate. CONCLUSION: With careful symptom and CT monitoring over a defined period, rehabilitation can be continued in patients who develop HT at the time of transfer to a rehabilitation hospital in the acute phase of cerebral infarction.

BACKGROUND: Convalescent rehabilitation wards assist stroke patients in acquiring skills for activities of daily living to increase the likelihood of home discharge. However, an improvement in activities of daily living does not necessarily imply that patients are discharged home. We investigated the characteristics of patients with putaminal haemorrhage who are discharged home following convalescence in rehabilitation wards. METHODS: The sample comprised 89 patients (58 men and 31 women) with putaminal haemorrhage hospitalised in the convalescent rehabilitation ward of our hospital between August 2012 and July 2013. Their age ranged from 29 to 88 years (61.9 ± 11.9 years). The lesion occurred on the right side in 48 and on the left in 41 patients. The mean period from onset to hospitalisation in the convalescent rehabilitation ward was 30.8 ± 17.2 days, and the mean hospitalisation period was 70.7 ± 31.8 days. We examined age, sex, haematoma volume, duration from onset to hospitalisation, neurological symptoms, cognitive function, functional independence measure, number of cohabitating family members and whether the patient lived alone before stroke, and the relationship among these factors and discharge destination (home or facility/hospital) was assessed. RESULTS: The discharge destination was home for 71 and a facility or hospital for 18 patients. Differences were observed in age, haematoma volume, neurological symptoms, cognitive function, functional independence measure score on admission and discharge, number of cohabitating family members and whether the patient lived alone before stroke for patients discharged home. Patients who required long-term care and were discharged home were more likely to be living with family members who were present during daytime. Home discharge was possible if functional independence measure score was ≥70 at the time of discharge for motor items and ≥24 for cognitive items, even if a patient lived alone before stroke. CONCLUSIONS: Although the presence of cohabitating family members was important, the factor most strongly influencing home discharge was the patient's activities of daily living status at the time of discharge. For patients who lived alone before stroke, physical and cognitive functions must be maintained for them to be discharged home after rehabilitation.

Background: Dysphagia occurs frequently during the acute phase of cerebral hemorrhage; however, there are few reports of dysphagia associated with cerebral hemorrhage in the subacute and chronic phase. We focused on putaminal hemorrhage at a rehabilitation hospital and evaluated the relationships between the frequencies of dysphagia, focus, and hematoma volume and type. Methods: A hundred patients with putaminal hemorrhage referred to our rehabilitation hospital were evaluated. Bedside swallowing assessments (BSAs) were conducted and results were evaluated relative to the information obtained on computed tomography imaging, including hematoma type and volume, and oral intake at the time of admission/discharge from the hospital. Results: A regular diet was provided to 48 patients, dysphagia diet to 44 patients, and enteral feeding to 8 patients. There were significant feeding group differences in age, hematoma volume and type, existence of ventricle rupture, neurological manifestation, cognitive function, existence of unilateral neglect and aphasia, initial BSA, activities of daily living (ADL) score using the Functional Independence Measure at the time of admission/discharge from the hospital, and length of stay. At discharge, we provided a regular diet to 81 patients and dysphagia diet to 19 patients. Age and ADL score had the greatest influence on oral intake at the time of discharge from the hospital. Conclusion: The prognosis of dysphagia caused by putaminal hemorrhage is good, with no patient requiring enteral feeding, although putaminal hemorrhage often causes dysphagia. Patient age and ADL score on admission are used to predict the residual factors of dysphagia.

Objective: The therapeutic effectiveness of phenol motor point block in patients with spasticity of the lower extremity was assessed by measuring ankle plantar flexion torque. Patient factors influencing therapeutic effectiveness were evaluated. Methods: Twelve patients with spasticity of the lower extremity after cerebrovascular disorders were enrolled in this study. Plantar flexion torques at 5°/s or 90°/s under passive ankle dorsiflexion were measured before and after treatment with phenol motor block in flexor muscles of the lower leg. Patient factors influencing therapeutic effectiveness were evaluated before and after treatment using torque changes as an indicator of therapeutic effectiveness. Results: Therapeutic effectiveness showed a significantly negative correlation with plantar flexion torques at 5°/s before treatment (ρ= -0.741, p = 0.006) and with the time from onset (ρ= -0.680, p = 0.015). A significantly positive correlation between therapeutic effectiveness and presence of self-exercise (ρ= 0.661, p = 0.019) was observed. Conclusion: Patients who were less affected by immobilization including those with small plantar flexion torque at 5°/s or those who engaged in self-exercise are expected to achieve large therapeutic effects with regard to phenol motor point block against spasticity of the lower extremity.

Background: We investigated differences in factors affecting judgments regarding the creation of new adjustable posterior strut knee-ankle-foot orthoses (APS-KAFO) and knee-ankle-foot orthoses with metal struts (traditional KAFO) for hemiplegic stroke patients for whom KAFO were created in rehabilitation wards. Methods: Subjects were 50 patients with hemiplegia due to new-onset stroke (cerebral infarction: n = 25, cerebral hemorrhage: n = 25) who were prescribed KAFO. Patient ages ranged from 36 to 90 years, and the mean duration from stroke onset to hospitalization was 28.8 +/- 13.8 days. Neurologic symptoms, cognitive function, activities of daily living, duration from hospitalization to orthosis creation, hospitalization duration, walking ability at discharge, outcome after discharge, and so forth were compared. Results: Fourteen patients were prescribed APS-KAFO, and 36 were prescribed traditional KAFO. Those prescribed APS-KAFO had somewhat milder neurologic symptoms and cognitive dysfunction and a shorter hospitalization duration than those prescribed traditional KAFO. Patients prescribed APS-KAFO also had a higher score and efficiency on functional independence measure at admission and discharge. Walking independence at discharge was seen in 8 of the 14 patients for whom APS-KAFO were created and 8 of the 36 patients for whom traditional KAFO were created. Conclusions: APS-KAFO was chosen for patients with a high level of activity in the ward and with a higher likelihood of acquiring walking ability using APS-AFO at discharge, whereas traditional KAFO tended to be chosen for patients with relatively severe symptoms who were not expected to acquire practical walking ability.

[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.

Patients with pontine hemorrhage usually experience severe disturbances of consciousness, pupillary abnormalities, quadriparesis, and respiratory failure. However, little is known regarding cognitive dysfunction in patients with pontine hemorrhage. We report the case of a rehabilitation patient presenting with hemiplegia, ataxia, and cognitive dysfunction caused by a pontine hemorrhage. A 55-year-old, right-handed male suffered sudden onset of vertigo, dysarthria, and hemiplegia on the right side. He was diagnosed with brain stem hemorrhage, and conservative treatment was administered. The vertigo improved, but dysarthria, ataxia, hemiplegia, and gait disorder persisted. He was disoriented with respect to time and place and showed a poor attention span, impaired executive function, and reduced volition. A computed tomography revealed hematomas across the pons on both sides, but no lesions were obvious in the cerebellum and cerebrum. Single-photon emission tomography showed decreased perfusion in the brain stem, bilateral basal ganglia, and frontal and parietal lobes in the left hemisphere. The patient received exercise therapy and cognitive rehabilitation, and home modifications were performed to allow him to continue living at home under the supervision of his family. His symptoms improved, along with enhanced regional cerebral blood flow to the frontal and temporal lobes. These findings suggest that the pontine hemorrhage caused diaschisis resulting in secondary reduction of activity in the cerebral hemisphere and the occurrence of cortical symptoms. Therefore, rehabilitation is necessary, along with active instructions for the family members of patients with severe neurological deficits. This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC). Usage and distribution for commercial purposes requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Objective: This research aimed to develop a system to measure the stiffness of the ankle joint for evaluating spasticity or contracture, and for quantifying the characteristics of spasticity. Functionality of the system was verified by testing it on an able-bodied individual and a hemiplegic patient. Additionally, a biomechanical model was developed to estimate the plantar flexion torque caused by viscoelasticity and muscle contraction. Methods: An electromotor, rack and pinion, potentiometer, and torque sensor were installed on a double Klenzak ankle-foot orthosis (AFO). By rotating the electromotor, the ankle joint of the AFO moves dorsally at a fixed speed. The angle and torque of dorsiflexion were measured simultaneously. The subjects sat either in a chair or a wheelchair and wore the abovementioned AFO in the knee-extension and knee-flexion positions, while the AFO moved dorsally. Electromyograms of the tibialis anterior and gastrocnemius muscles were recorded concurrently. The contributions of elastic, viscous, and muscle-contraction components to the plantar flexion torque were calculated using the system identification approach. Results: The system’s ability to measure dynamic characteristics, and also its accuracy, were confirmed. The plantar flexion torque was found to be larger in the knee-extension position than in the knee-flexion position in both the able-bodied person and the patient. Moreover, the patient showed larger plantar flexion torque than the able-bodied subject. Conclusions: A system that measures ankle-joint stiffness for evaluating spasticity was developed, and sufficient functionality was verified by applying it to both an able-bodied individual and a hemiplegic patient. In addition, plantar flexion torque caused by viscoelasticity and muscle contraction was estimated.