北村 新

Objective: To clarify the time-course of longitudinal changes in the independence level of subtasks composing bed–wheelchair transfer among patients with stroke.Design: Single-institution prospective cohort study.Patients: A total of 137 consecutive post-stroke patients using wheelchair on admission to the subacute rehabilitation wards.Methods: The independence degree in each of the 25 transfer-related subtasks was assessed using the Bed–Wheelchair Transfer Tasks Assessment Form on a three-level scale every two weeks, from admission to the endpoint (either discharge or when achieving independent transfer). Patients were classified based on admission and endpoint assessment form scores using two-step cluster analysis.Results: Patients were classified into three clusters. The first cluster included 50 patients who exhibited a greater independence level in all subtasks on admission (52.0–100% of patients performed each subtask independently) and at the endpoint (64.0–100%). The second included 30 patients who showed less independence on admission (0–27.8%) but achieved greater independence levels at the endpoint (44.4–97.2%). The third included 51 patients whose independence level remained low in many subtasks from admission (0–5.8%) until the endpoint (0–29.4%).Conclusion: The independence level and its changing process during transfer were categorized into three time-courses, each requiring different intervention strategies.

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

OBJECTIVE: To evaluate the effectiveness of a dyadic outpatient rehabilitation program focused on improving the real-life daily activities of patients with mild cognitive impairments or dementia and their caregivers. DESIGN: Retrospective study. SUBJECTS: Eight patients with mild cognitive impairments or dementia and their caregivers. METHODS: The rehabilitation program comprised eight 1-hour sessions by occupational therapists with patients and his/her caregivers. Patients were assessed for motor function, cognitive function, and quality of life, and their caregivers were assessed for depression and caregiver burden. Participants were assessed at pre-program and post-program, and 3-month follow-up. RESULTS: The scores of caregiver-assessed Quality of life in Alzheimer's disease scale in patients significantly improved at post-program (median [interquartile range], 30.0 [7.0]) compared with pre-program (27.0 [2.8], effect size = 0.77, p = 0.029). In caregivers, the Zarit Caregiver Burden Interview scores decreased significantly at post-program (16.5 [13.0]) compared with pre-program (22.0 [17.5], effect size = 0.72, p = 0.042). There were no significant differences in other assessments. CONCLUSIONS: The rehabilitation program focused on real daily activities and demonstrated to improve patients' quality of life and caregivers' depression and caring burden through patient-caregiver interaction. Future enhanced follow-up systems are warranted.

Arm reaching is often impaired in individuals with stroke. Nonetheless, how aiming directions influence reaching performance and how such differences change with motor recovery over time remain unclear. Here, we elucidated kinematic parameters of reaching toward various directions in people with post-stroke hemiparesis in the sub-acute phase. A total of 13 and 15 participants with mild and moderate-to-severe hemiparesis, respectively, performed horizontal reaching in eight directions with their affected and unaffected sides using an exoskeleton robotic device at admission and discharge. The movement time, path length, and number of velocity peaks were computed for the mild group (participants able to reach toward all eight directions). Additionally, the total amount of displacement (i.e., movement quantity) toward two simplified directions (mediolateral or anteroposterior) was evaluated for the moderate-to-severe group (participants who showed difficulty in completing the reaching task). Motor recovery was evaluated using the Fugl-Meyer Assessment.The mild group exhibited decreases in movement parameters when reaching in the anteroposterior direction, irrespective of the side of the arm or motor recovery achieved. The moderate-to-severe group exhibited less movement toward the anteroposterior direction than toward the mediolateral direction at admission; however, this direction-dependent bias in movement quantity decreased, with the movement expanding toward the anteroposterior direction with motor recovery at discharge. These results suggest that direction-dependent differences in the quality and quantity of reaching performance exist in people after stroke, regardless of the presence or severity of hemiparesis. This highlights the need to consider the task work area when designing rehabilitative training.

Background The motivation for rehabilitation is important in encouraging stroke patients to participate in rehabilitation; however, its relationship with outcomes is not well known. In addition, changes in patient motivation during hospitalization have not been examined. Aim To examine the relationship between motivation and rehabilitation outcomes for subacute stroke patients and to investigate the changes in motivation. Design Prospective cohort study. Setting Subacute rehabilitation hospital. Population The study enrolled a consecutive sample of patients (n = 201) with stroke admitted to a subacute rehabilitation ward from October 2017 to March 2019. Methods The functional independence measure and motivation in stroke patients for rehabilitation scale was evaluated at admission; at one, two, and three months after admission; and at discharge. The effectiveness and efficiency of the functional independence measure were calculated as rehabilitation outcomes. The effect of motivation on outcomes and the change in motivation in stroke patients for rehabilitation scale scores over time were analyzed using a linear mixed model. Results The median (interquartile range) converted motivation in stroke patients for rehabilitation scale scores (converted to a range of 0–100) at admission; one, two, and three months after admission; and discharge was 86 (76–95), 83 (77–94), 81 (74–95), 81 (71–93), and 84 (75–95), respectively. The median (interquartile range) of effectiveness and efficiency of the functional independence measure from admission to discharge was 0.82 (0.68–0.91) and 0.41 (0.30–0.59), respectively. Motivation in stroke patients for rehabilitation scale scores were not significantly associated with the effectiveness and efficiency of the functional independence measure (p > 0.05). Motivation in stroke patients for rehabilitation scale scores were significantly lower at two (β = −3.1, 95% confidence interval [−5.3, −0.9], p = 0.005) and three (β = −4.4, 95% confidence interval [−7.3, −1.6], p = 0.002) months after admission than at admission. Conclusion Motivation might not directly affect rehabilitation outcomes assessed by the functional independence measure. Furthermore, many participants remained highly motivated, although their motivation decreased at one or three months after admission. Clinical rehabilitation impact Assumptions that rehabilitation is ineffective because of low motivation may not be correct. To examine the influence on outcomes, both motivation and daily activities should be considered.

重度左片麻痺と高次脳機能障害を呈した脳卒中患者に対して,トイレ移乗動作の介入を反復して実施するも自立度の改善を認めなかったため,介入方法を見直すためにToileting Tasks Assessment Form(以下,TTAF)を用いたトイレ動作の詳細な工程分析を行った.得られた結果をもとに,段階的な難易度調整を施したトイレ移乗動作の練習を行った結果,一部の工程において自立して動作が可能となり,その他の工程の自立度も向上した.TTAFは,トイレ動作の詳細な評価に基づいた介入の立案とその効果判定を可能とし,症例の自立度の改善に貢献した可能性がある.(著者抄録)

Objective: To examine whether alternating training with both the non-paretic and paretic sides (alternating bilateral training), expecting trial-to-trial inter-limb transfer of training effects from the nonparetic to the paretic side, improves upper-limb motor performance in post-stroke patients, compared with unilateral training involving only the paretic side.Design: An assessor-blinded pilot randomized controlled trial.Subjects: Twenty-four right-handed post-stroke patients with hemiparesis.Methods: Participants were randomly allocated to either an alternating bilateral training group or a unilateral training group (n = 12/group). Participants underwent dexterity training of the paretic arm using the Nine-Hole Peg Test, completing 10 trials/day for 7 consecutive days. The alternating bilateral training group additionally performed alternating trials with the non-paretic limb. Performance change, assessed 1 day and 1 week after the 7-day training period, was compared between groups.Results: Although the improvement was comparable in both groups at both post-training time-points, a sub-analysis in which those with left hemiparesis and those with right hemiparesis were analysed separately revealed potential benefits of the alternating bilateral training, specifically for those with left hemiparesis.Conclusion: Alternating bilateral training may augment training effects and improve upper-limb motor function in patients with left hemiparesis.

Objective: To investigate the long-term cumulative risk and factors associated with fall-related fractures in stroke survivors discharged from convalescent rehabilitation wards.Design: Retrospective cohort study.Participants: A total of 786 stroke survivors discharged from a rehabilitation hospital.Methods: Data regarding fall-related fractures posthospital discharge were collected using self-reported questionnaires. The Kaplan–Meier method was used to calculate the cumulative incidence of fall-related fractures, and risk factors were analysed using Cox proportional hazard regression analysis.Results: Of 1,861 consecutive stroke survivors who had been discharged from hospital, 786 (42.2%) provided information concerning fall-related fractures. Duration from time of discharge to time of collection of questionnaires ranged from 1 to 6 years (mean 38.0 months). The cumulative incidence of fall-related fractures at 1-, 2-, 3-, 4-, and 5-years post-discharge was 4.2%, 7.9%, 10.8%, 12.5% and 13.7%, respectively. Cox proportional hazard regression analysis indicated that female sex (hazard ratio (HR) 1.69) and moderate lower limb paresis (HR 3.08) were significant risk factors.Conclusion: The cumulative risk of fall-related fractures in stroke survivors post-discharge from a rehabilitation hospital was notably high. Intensive preventive intervention should be considered for female stroke survivors with moderate lower limb paresis.LAY ABSTRACTThis study aimed to investigate the risk of fall-related fractures and associated factors in stroke survivors who had been discharged from rehabilitation wards. A questionnaire was sent by post to 1,861 post-discharge stroke survivors to investigate their experiences of fall-related fractures, to which 786 stroke survivors responded. The incidence of fall-related fractures at 1, 2, 3, 4, and 5 years post-discharge was 4.2%, 7.9%, 10.8%, 12.5% and 13.7%, respectively. The presence of moderate lower limb paresis and female sex were associated with 3.08- and 1.69-times higher risk of developing a fall-related fracture, respectively. Intensive preventive intervention should be considered for female stroke survivors with moderate lower limb paresis following discharge from rehabilitation wards.

OBJECTIVE: To elucidate the performance of a shock-absorbing floor material with a mechanical metamaterial (MM-flooring) structure and its effect on the gait and balance of older adults. METHODS: The drop-weight impact was applied to evaluate the shock-absorbing performance. The falling weight was adjusted equivalent to the energy exerted on the femur of an older woman when she falls, which was evaluated on the MM-flooring and six other flooring materials.Nineteen healthy people over the age of 65 years participated in the gait and balance evaluations. The timed up and go and two-step tests were adopted as gait performance tests, and the sway-during-quiet-balance test with force plates and the functional reach test (FRT) were adopted as balance tests. All the participants underwent these tests on the MM-flooring, shock-absorbing mat and rigid flooring. RESULTS: The shock-absorbing performance test revealed that MM-flooring has sufficient shock-absorbing performance, and suggesting that it may reduce the probability of fractures in the older people when they fall. The results of the gait performance test showed that the participants demonstrated the same gait performance on the MM-flooring and the rigid floor. In the quiet standing test, MM-flooring did not affect the balance function of the participants to the same extent as the rigid floor, compared with the shock-absorbing mat. In the FRT, no significant differences were found for any of the flooring conditions. CONCLUSIONS: MM-flooring has the potential to prevent fractures attributed to falls and does not affect the gait or balance of older adults.

Objective This study aimed to develop the Motivation in stroke patients for rehabilitation scale (MORE scale), following the Consensus-based standards for the selection of health measurement instruments (COSMIN). Method Study participants included rehabilitation professionals working at the convalescent rehabilitation hospital and stroke patients admitted to the hospital. The original MORE scale was developed from an item pool, which was created through discussions of nine rehabilitation professionals. After the content validity of the scale was verified using the Delphi method with 61 rehabilitation professionals and 22 stroke patients, the scale’s validity and reliability were examined for 201 stroke patients. The construct validity of the scale was investigated using exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and item response theory analysis. Cronbach’s alpha confirmed its internal consistency. Regarding convergent, discriminant, and criterion validity, Spearman’s rho was calculated between the MORE scale and the Apathy Scale (AS), Self-rating Depression Scale (SDS), and Visual Analogue Scale (VAS), which rates the subjective feelings of motivation. Results Using the Delphi method, 17 items were incorporated into the MORE scale. According to EFA and CFA, a one-factor model was suggested. All MORE scale items demonstrated satisfactory item response, with item slopes ranging from 0.811 to 2.142, and item difficulty parameters ranging from -3.203 to 0.522. Cronbach’s alpha was 0.948. Regarding test-retest reliability, a moderate correlation was found between scores at the beginning and one month after hospitalization (rho = 0.612. p < 0.001). The MORE scale showed significant correlation with AS (rho = -0.536, p < 0.001), SDS (rho = -0.347, p < 0.001), and VAS (rho = 0.536, p < 0.001), confirming the convergent, discriminant, and criterion validity, respectively. Conclusions The MORE scale was verified as a valid and reliable scale for evaluating stroke patients’ motivation for rehabilitation.

OBJECTIVES: To examine the relationship between patients' transfer ability and fall risk in stroke patients during hospitalization. MATERIALS AND METHODS: We retrospectively enrolled 237 stroke patients who were transferred to a convalescent rehabilitation ward from acute wards in the same hospital. Using incident reports, we investigated their fall rates and activity status at the falls according to their transfer abilities, which were assessed with Functional Independence Measure (FIM) transfer scores. The bi-weekly time trend of fall rates in all patients and in three subgroups based on FIM transfer scores of 1-3, 4-5, and 6-7, and activity status at the falls, were investigated. In addition, changes of patients' transfer ability on admission, at the first fall, and at discharge were investigated among falling patients. RESULTS: The fall rate was the greatest in patients with a FIM transfer score of 4 (14.3 times/1000 person-days). The majority of falls for patients with a FIM transfer score of 1 occurred at the activity status of "on the bed" and "sitting", while three quarters of patients with a FIM score of 7 had falls during "standing" and "walking". No longitudinal trend in fall rates was found overall; however, the fall rate trends differed depending on the FIM transfer score. The majority of the patients who fell required full assistance for transfers upon admission but required no assistance at discharge. CONCLUSIONS: Fall risk differed among patients with various transfer abilities; the greatest risk was in those who needed minimal assistance for transfers.

<title>Abstract</title><sec> <title>Background</title> Patients with stroke in rehabilitation wards are at an increased risk of falling. Although patients’ participation in establishing medical safety is considered crucial, there is limited evidence on their perspectives of falls. This study aims to comprehensively elucidate the subjective falling experience of patients with stroke who have been admitted to rehabilitation wards. </sec><sec> <title>Methods</title> Twenty-three consecutive patients with stroke (44 to 90 years) who experienced a fall during hospitalisation were interviewed within 1 week after the fall, and thematic analysis was used to analyse the data. </sec><sec> <title>Results</title> Five themes surrounding fall events were extracted from the narratives: ‘Psychological background before the action’, ‘Support for the action’, ‘Direct causes of the fall’, ‘Patients’ awareness after the fall’, and ‘Changes in attitudes and behaviours after the fall’. ‘Psychological background before the action’ comprised hastiness or hesitation to call for help. Participants often took an action based on ‘Support for the action’ derived from their past experiences of moving safely, their confidence, and/or motivation to challenge themselves to move. ‘Direct causes of the fall’ consisted of unfamiliar actions, training fatigue, the surrounding environment, reduced physical function due to paralysis, lack of attention, overconfidence in their ability, and insufficient prediction of falls. ‘Patients’ awareness after the fall’ consisted of re-affirming difficult movements, the need for rehabilitation, a reduced ability to move, an increased risk of falling, the need for attention while moving, a fear of falling, and a lack of lessons learned from falling. Finally, patients demonstrated ‘Changes in attitudes and behaviours after the fall’ such as embodying a positive attitude to cope with the risk of falling or behavioural changes to reduce the risk of falling. </sec><sec> <title>Conclusions</title> Comprehensive information on patients’ perspectives before and after the fall was elucidated, uncovering many aspects including the psychological background for why patients engaged in risky behaviours resulting in falls, presence of positive thinking, and behaviour after the fall. By incorporating the patients’ views on fall incidences and their assessment, we can develop appropriate prevention strategies against falls. </sec>

<bold>Background:</bold> Motivation is essential for patients with subacute stroke undergoing intensive rehabilitation. Although it is known that motivation induces behavioral changes toward rehabilitation, detailed description has been lacking. Motivation can be intrinsic or extrinsic; however, it is unclear which type of factors mainly motivates patients' daily rehabilitation. <bold>Purpose:</bold> This study aimed to examine the factors influencing patients' motivation and to explore the behavioral changes induced by motivation, especially age-related differences. <bold>Method:</bold> Twenty participants (mean age 65.8 years [standard deviation 13.7]) who had a subacute stroke and underwent rehabilitation at a convalescent hospital were recruited using convenience sampling. Semi-structured interviews were conducted by an occupational therapist with an interview topic guide regarding factors influencing motivation and how it affects behavioral change. Interviews were recorded, transcribed to text, and analyzed by three occupational therapists using thematic analysis. The participants were divided into two groups: aged patients (aged ≥ 65 years) and middle-aged patients (aged &amp;lt; 65 years), and data were analyzed according to the groups. This study was conducted according to the consolidated criteria for reporting qualitative research. <bold>Results:</bold> Seven core categories were identified as factors influencing patients' motivation: patients' goals, experiences of success and failure, physical condition and cognitive function, resilience, influence of rehabilitation professionals, relationships between patients, and patients' supporters. The first four and last three core categories were further classified as personal and social-relationship factors, respectively. The categories related to intrinsic motivation such as enjoyment of rehabilitation itself were not derived. In both age-groups, motivation affected the frequency of self-training and activity in daily lives. In some aged patients, however, high motivation restrained their self-training to conserve their physical strength for rehabilitation by professionals. Some aged patients do not express their high motivation through their facial expressions and conversations compared to middle-aged patients; therefore, motivation is not always observable in aged patients. <bold>Conclusions:</bold> Interventions tailored to extrinsic factors are important for maintaining patients' motivation. Observational evaluation may lead to mislabeling of their motivation, especially for aged patients. Rehabilitation professionals should use validated evaluation scales or patients' narratives to assess patients' motivation.

INTRODUCTION: Transferring is a basic skill that is essential for mobility independence and indispensable for expanding activities of daily living of stroke patients using a wheelchair. Therefore, transfer independence is an important issue that greatly affects daily life in the hospital and at home. To offer an effective intervention to acquire a skill, developing an assessment for individual subtasks that comprise transferring would assist the identification of specific tasks that prevent independence in patients and facilitate interventions to improve transferring independence. OBJECTIVE: To examine the reliability and validity of a newly developed transfer assessment form, the Bed-wheelchair transfer Tasks Assessment Form (BTAF), for stroke patients to evaluate subtasks required for transferring. DESIGN: Validation and test-retest studies. SETTING: Subacute rehabilitation wards in Japan. PARTICIPANTS: A total of 82 therapists for verifying content validity; 30 patients for validation and test-retest study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The content validity was initially assessed based on a questionnaire. Subsequently, four occupational therapists used the form to evaluate the video-recorded transferring performances of stroke participants. Two assessors evaluated each performance once and then 2 weeks later. The inter-rater reliability, intra-rater reliability, internal consistency, and concurrent validity were examined. RESULTS: Fleiss's κ coefficient for inter-rater reliability for each item of the form was 0.66 or more. Cohen's κ coefficient for intra-rater reliability for each item was 0.73 or more. Cronbach's coefficient alpha ranged from 0.90 to 0.93. Spearman's rank correlation coefficients between the mean scores of our form and scores of the functional independence measure item "transfer to bed/chair/wheelchair" ranged from 0.53 to 0.78 (P < .01). CONCLUSIONS: The form demonstrated good reliability and validity. Its usefulness and efficacy should be further investigated in stroke patients to facilitate rehabilitation.

BACKGROUND: Acquiring toileting independence is an important target of stroke rehabilitation. In planning an intervention for acquiring toileting independence, developing an assessment for individual subtasks that comprise toileting would assist in identifying specific tasks that prevent independence in patients and would facilitate interventions to improve toileting independence. OBJECTIVE: To examine the reliability and validity of a newly developed toileting assessment form, the Toileting Tasks Assessment Form (TTAF), for assessing toileting subtasks in hemiparetic stroke. DESIGN: Validation and test-retest study. SETTING: Subacute rehabilitation wards in Japan. PARTICIPANTS: Eighty-two therapists verified the form's content validity; 30 stroke patients who were using a wheelchair participated in the validation and test-retest study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The content validity of the assessment form was initially assessed based on a questionnaire. Subsequently, four occupational therapists used the form to evaluate video-recorded toileting performances simulated by participants with hemiparetic stroke. Two assessors evaluated each video-recorded performance once and repeated the evaluation of the same performance at 2 weeks later. The interrater reliability, intrarater reliability, internal consistency, and concurrent validity of the form were examined. RESULTS: Fleiss' κ coefficient for interrater reliability for each form item was 0.61 or more. Cohen's κ coefficient for intrarater reliability for each item was 0.60 or more. Cronbach's coefficient alpha ranged from 0.94 to 0.95. Spearman's rank correlation coefficients for the mean score on the form and the Functional Independence Measure (FIM) score for "toileting" ranged from 0.88 to 0.93 (P < .001). Spearman's rank correlation coefficients for the mean score on the form and the FIM score for "toilet transfer" ranged from 0.91 to 0.93 (P < .001). CONCLUSIONS: The TTAF demonstrated good reliability and validity. Further multicenter studies involving patients at different stroke phases are required to verify the reliability and validity of TTAF and confirm the generalizability of these findings.