園田 茂

The Medical Outcome Study 36-Item Short Form Health Survey (SF-36) is a widely used method to evaluate health-related quality of life and has been applied for patients with stroke. However, because it is a self-assessment tool, there is a risk in using results of the survey because of lack of information on patients who cannot answer the questionnaire. For this report, 38 patients with stroke hospitalized in the rehabilitation department filled out the SF-36 and motor items of the Functional Independence Measure (FIM) and the Stroke Impairment Assessment Set. We then examined characteristics of patients who could not be evaluated by the SF-36. Of the 38 patients, 19 patients could and 19 patients could not be evaluated by the SF-36. There was no remarkable relationship among capacity or incapacity for evaluation by the SF-36, motor subscores on the FIM, and motor items on the Stroke Impairment Assessment Set. All 10 patients having a communication subscore on the FIM of 10 points or less and/or a social cognition subscore on the FIM of 13 points or less could not be evaluated by the SF-36. The remaining unevaluable patients were not cooperative. Studies in which the entry criteria include the ability to answer the SF-36 questionnaire neglect patients with poor cognition. Therefore, when administering the SF-36 for patients with stroke, we recommend using an interview setting. © 2008 National Stroke Association.

回復期リハビリテーション病棟での栄養サポートチーム(NST)介入効果をFIMを用いて後方視的に検討した.脳卒中患者304名を対象にNST介入対象者を栄養強化群と減量群に分類し,各々をNST介入非対象者(非NST群)と比較した.FIM利得は栄養強化群17.3±15.9,非NST群16.7±12.5と両群に有意差はなかったが,FIM効率は栄養強化群0.20±0.19,非NST群0.27±0.19と有意差を認めた.入院時FIM得点が54点以下の患者ではFIM利得,FIM効率ともに両群に有意差を認めなかった.入退院時BMI変化とFIM変化の間で一定の傾向を認めなかった.栄養介入を要した栄養強化群は一般的には予後不良の群と判断されるにもかかわらず,非NST群と差がなかった今回の結果は,NSTという栄養介入が有用であった可能性を示唆している.

近年、脳卒中患者に対してトレッドミル歩行訓練が積極的に行われるようになってきたが、個々の歩行能力や回復過程を考慮にいれた訓練介入方法は確立されていないのが現状である。今回、個々に応じた介入方法立案の手がかりとすべく、脳卒中片麻痺患者19名にトレッドミル歩行を行ってもらい、歩行周期に占める両側の単脚支持時間と両脚支持時間の割合を算出し、歩行速度、歩行自立度、歩行形態との関連について検討した。結果、手すりを用いた監視下トレッドミル歩行の適応となるのは歩行自立度(歩行FIM)4点以上の症例であり、歩行周期パターンからみた適応のポイントは「回復初期(入院後2週程度)」で平地快適歩行速度が「1.0km/h以下」かつ歩行形態が「3動作歩行」の患者であると考えられた。

外傷性脳損傷による高次脳機能障害患者109名の帰結と入院中の評価との関係を検討した.評価は,入退院時FIM,FAM障害適応項目を用いた.帰結は5段階に分類し,5:就労・就学5名,4:在宅自立29名,3:施設訓練21名,2:在宅で要介護15名,1:転院39名であった.FIM運動合計は入院時52点から退院時63点へ,FIM認知合計は19点から22点へ,FAM障害適応は2.1から3.3へと改善した.重回帰分析による帰結予測は,入院時FIM運動項目の寄与率が42.1%と高かった.CARTによる帰結のパーティションの結果と実際の帰結との一致率は,退院時データを用いた予測で55.0%で,FIM運動合計73点以上かつFAM障害適応4点以上であれば就労または在宅自立となる可能性が高かった.帰結には,FIM運動項目が大きく関わるとともに,FIM認知項目,FAM障害適応(メタ認知)の関与が明らかとなった.

We carried out three experimental trials to determine antidiabetic effects of Aloe arborescens Miller components. Firstly, ICR mice which received frequent injections of streptozotocin (Sz) in small doses (low-dose Sz-induced diabetes mice) were fed ad libitum with basal diets supplemented with components of Aloe arborescens Miller var. natalensis Berger (Kidachi aloe) and Aloe vera Linne from 31 days before to 73 days after the Sz injections. Variation in blood glucose levels, incidence rates of insulitis and blood insulin levels were examined during the trial. As a result, groups receiving diets supplemented at the rate of 2% with whole leaf of Kidachi aloe and 10 KDa fraction powder (a fraction with less than 10 KDa molecular weight derived from Kidachi aloe leaf skin juice by ultra filtration) significantly suppressed the elevation of blood sugar as compared to a control group receiving basal diet. In contrast, there was no significant effect with Aloe vera leaf pulp powder. Insulitis emerged at the rate of 87% in the basal diet group. On the contrary, the whole aloe leaf and 10 KDa fraction groups significantly decreased the incidence of insulitis and incidence rates of whole aloe leaf and 10 KDa fraction powder were 51 and 38%, respectively. While insulin levels in the basal diet group averaged at 0.05 ng, more than four times the insulin level was observed in the 10 KDa group relative to the basal diet group. Secondary, the inhibitory effects of test materials on intestinal glucose absorption were observed using the jejunum of rats. A strong inhibitory action on intestinal glucose absorption was observed in the 10 KDa fraction powder group. Thirdly, phenol compounds derived from aloe in the blood serum and organs were quantitatively measured by a HPLC following forced administration of aloe components to rats to determine absorption kinetics of aloe components inside the body. The primary component of aloe phenol compounds is the same component of the 10 KDa fraction powder and it was found in the pancreas and liver in addition to in the blood serum. The above results indicate that fore and aft when Sz injections could cause selective toxicity to B cells of islets, the dietary administration of 10 KDa fraction powder to mice would lead to the persistence of aloe phenol compound having an antioxidant activity in the pancreas and blood, which could protect islets of Langerhans from the destruction caused by methyl radical derived from Sz. The results also suggested the possibility of the 10 KDa fraction powder to alleviate the burden of insulin secretion as it has an inhibitory action on glucose absorption in the jejunum of rats. © 2005 Elsevier Ireland Ltd. All rights reserved.

We examined the modifying effect of freeze-dried whole-leaf Aloe arborescens Miller var. natalensis Berger (Kidachi aloe in Japan designated as 'ALOE') on azoxymethane (AOM)-induced intestinal carcinogenesis in rats. Male F344 rats (4 weeks old) were fed basal diet or experimental diet containing 0.2% or 1% ALOE for 28 weeks. Starting two weeks later, the animals received subcutaneous injections of AOM once weekly for 10 weeks. The incidence of colorectal adenocarcinomas in the 0.2% (but not 1%) ALOE group showed a strong tendency for decrease (p = 0.056) from the control group. Further, the adenocarcinoma incidence in the entire intestine (small and large intestines) in the 0.2% ALOE group was significantly (p = 0.024) decreased compared to the control value. However, there were no significant differences in tumor multiplicities of colorectal or entire intestines among the 3 groups. In addition, we also studied the safety of long-term ingestion of ALOE as a health food or natural thickening stabilizer. Rats were fed the basal diet or 1% ALOE diet for 35 weeks without AOM treatment. Feeding with 1% ALOE did not affect most hematological and serum biochemical parameters in the rats. These results indicate that a low level of ALOE ingestion might have a mild suppressive effect on intestinal tumor growth without harmful side effects.

OBJECTIVE: To investigate the relationship between the bisection test and the severity of behavioral hemineglect and to verify if this test can predict the behavioral hemineglect. METHODS: Thirty stroke patients with left hemiparesis were divided into 4 groups according to the Catherine Bergego Scale, which assessed the behavioral hemineglect: severe unilateral neglect (UN), moderate UN, mild UN, and lack of UN. Eleven healthy subjects served as age-matched control subjects. In the bisection test, 18 lines were presented on the left, middle, and right of an A4 paper, respectively. The subjects were asked to place a short cross mark in the exact middle point of each line on the paper using their right hand. The middle 6 lines in the above bisection test were extracted on another sheet of A4 paper for the rebisection test. The subjects were asked to divide a line into 4 segments by successive bisections. The proportion of the right part to the length of line for bisecting was calculated. RESULTS: In the bisection test, the main effect of space was significant in every group except the mild neglect group. The crossover effect of space location was found in the severe UN group, the group without UN, and the controls. In the severe UN group, the patients bisected the left and middle lines with rightward bias (<50%) but bisected the right lines with leftward bias (>50%). In the group without UN and the controls, the subjects bisected the left lines with leftward bias (>50%) but bisected the middle and right lines with rightward bias (<50%). Almost the same results were seen in the rebisection test. CONCLUSIONS: This study showed that if the spatial crossover effect occurred in the right space condition, it was strongly supported that this patient had moderate to severe behavioral hemineglect. The crossover effect of the space location was explained by a new model.

【目的】当院で実践しているFull-time Integrated Treatment （以下，FIT ）programは，空間と情報の共有・統合により，多量（毎日）で高密度（全日）のリハビリテーション（以下，リハ）を可能とする回復期リハのシステムである．このFIT programが，従来のリハに比べより短い在院日数で，より大きなADL改善をもたらすことを我々は報告してきた．また，FIT programによる治療効果の優位性が退院後に維持されている結果も得られている．今回は，FIT programによる治療効果の退院後の優位性をより長期的に調査したので報告する．<BR>【対象・方法】対象は2000年12月以降にFIT programによる治療を受け，退院後6か月および18か月の計2回の時点でFunctional Independence Measure（以下，FIM）運動項目を追跡調査できた，テント上に一側性の病変を有する初発の脳卒中片麻痺患者77名とした．入院中，訓練に支障を及ぼすような重篤な併存症を有していた症例，今回の発症以前に明らかなADL障害を有していた症例，また退院後に脳卒中を再発した症例は予め除外した．ADL調査は，退院後6か月と18か月の時点でFIM質問紙を郵送して行った．このFIM質問紙は，当院にて新たに作成されたフローチャート式の質問紙であり，その信頼性は確認済みである．返信後不備のあった場合には，電話での補足確認を加えた．経過の検討として入・退院時，退院後6か月と18か月の4期においてFIM運動項目合計（以下，FIMM）の平均点を比較，検討した．また，退院後6か月と18か月のFIM各項目の平均点変化を比較した．<BR>【結果および考察】FIMM平均点推移では，退院時と比較すると，退院後6か月と18か月では有意に低下していた．しかし，6か月後のFIMMが18か月後にさらに低下する傾向はなく，維持されていることが確認された．FIM各項目別の平均点でみても，退院後6か月と18か月を比較すると特定の項目が低下する傾向は認められず，全項目において維持されていた．<BR>これまでの先行研究ではリハビリ施行後，達成されたADLレベルを維持することは困難な場合が多いと報告されている．とりわけ，従来よりも短い在院日数で大きなADL改善の効果が得られるFIT programでは，退院後の低下が懸念されていた．今回の結果より，退院後6か月の時点でADL能力は低下するものの，退院後18か月の時点では更に低下することなく維持されていることから，ADL能力低下の要因として経時的低下ではなく，病院環境と住宅環境の差異による低下と考えられる．また，FIMM項目別の比較の結果では，特定の項目の低下を認めないことから，入院中のADLに密着した訓練により，どの項目においても十分に訓練・指導が行えていたことが示唆された．今後の課題としては，退院直後のADL能力低下を軽減するために，入院時により高いADL能力獲得を目指し，退院時のADLレベルを上げるだけではなく，在宅生活のシミュレーション訓練の強化，外泊などによる在宅生活のリハーサルの機会を増やすことが重要であると考えられる．

Objective: To validate the effectiveness of the Full-time Integrated Treatment (FIT) program that is characterized by rehabilitation 7 days/wk, encouragement of daytime activity, and enhanced communication between staff in stroke rehabilitation. Design: Since our facility changed from the conventional rehabilitation system of 5 days of treatment to the FIT program in December 2000, we compared the conventional rehabilitation program with the FIT program at our hospital. The conventional treatment group and the FIT group consisted of 48 and 58 first-stroke hemiplegics, respectively. Results: The motor subscore of the FIM(TM) instrument at admission and at discharge was 64.3 and 77.0 in the conventional group and 60.6 and 80.9 in the FIT group, respectively. The length of stay and efficiency of the FIM instrument were 80.0 days and 0.16 in the conventional group and 69.8 days and 0.30 in the FIT group, respectively. These differences between groups were statistically significant, with the exception of admission FIM data. Conclusions: Because the FIT program attained a higher discharge FIM level with a shorter length of stay, the FIT program was concluded to be an efficient and effective method of stroke rehabilitation.

目的 慢性期脳血管障害者における種々の障害の長期間にわたる変化の実態を明らかにする目的で，心身の評価を入院から発病 5 年までの定期的追跡調査として実施した。調査は継続中であり，今回，慢性脳血管障害者における入院時（発病後平均2.5か月目）および退院時（発病後平均 6 か月目）の心身の障害特性について述べる。<br/>対象および方法 対象は，リハビリテーション専門病院である茨城県立医療大学附属病院に，平成11年 9 月から平成12年11月までに初発の脳血管障害で入院した障害が比較的軽度な87人である。その内訳は，男64人，女性23人であり，年齢は42歳から79歳，平均59歳であった。方法は，入院時を起点とした，退院時，発病 1 年時，2 年時，3 年時，4 年時，5 年時の発病 5 年間の前向きコホート調査である。<br/>結果 入院から退院にかけて運動麻痺機能，一般的知能，痴呆が有意に改善した。また，ADL（日常生活活動）と作業遂行度・作業満足度が有意に改善した。一方，明らかな変化を認めなかったのは，うつ状態であり入退院時とも40%と高かった。また，麻痺手の障害受容度も変化がなく，QOL は低いままであった。逆に，対象者を精神的に支える情緒的支援ネットワークが有意に低下していた。<br/>考察 発病後平均 6 か月目である退院時における慢性脳血管障害者の特徴として，機能障害，能力低下の改善が認められたものの，うつ状態，QOL は変化がみられず推移し，また，情緒的支援ネットワークは低下したことが挙げられる。したがって，退院後に閉じこもりにつながる可能性が高く，閉じこもりに対する入院中の予防的対策の重要性が示唆された。

第1腰髄レベルの不全対麻痺者に対して内側股継手付長下肢装具 (Primewalk) を用いて歩行訓練を行った. 歩行レベルに合わせて装具を変更し, 歩行能力のスムーズな改善を得た. まず, 左長下肢装具の外側支柱を外し, 内側支柱の膝部をオフセットジョイントとした. さらに歩行能力が増した時点で, 股継手を外して右長下肢装具, 左短下肢装具とした. 歩行時の酸素消費量には股継手の有無で有意差を認めなかった. 股継手を外すことには, 歩幅の制限が解消されるために歩行速度が向上するという利点と, 上肢への過負荷をもたらすため結果的に連続歩行距離が短くなるという欠点が併存していた.

Objective-The ability of 46 patients with supratentorial stroke and 15 healthy subjects to localise sounds was tested using an apparatus with headphone and sound space processor. Methods-With a binaural sound space processor, sounds were randomly presented from seven directions in the 180 degree frontal area of the subject at intervals of 30 degrees. The subject was asked to imagine a clock face through the horizontal plane passing through the subject's ears with 12 o'clock denoting a sound from directly in front of the subject. After each sound, the subject indicated the direction from which he or she thought the sound came by mentioning the corresponding hour hand on the clock face; therefore, the answer directions were also separated by 30 degrees. A total of 21 sounds with three sounds from each direction, were presented in random order. The error between the presented direction and the answered direction of each sound was calculated. Results-The mean absolute error which does not distinguish whether an error was in the counterclockwise or clockwise direction, was larger in the patients with stroke than in the healthy subjects. Overall, the patients with stroke who had right brain damage (n=29) had a larger mean absolute error than those who had left brain damage (n=17). The patients with right brain damage did not show any systematic deviation such as a rightward error or leftward error. Conclusion-A right brain lesion or left brain lesion can cause a patient to have error in sound localisation, and patients with right brain damage generally have a larger mean absolute error of sound localisation. The difference in the mean absolute error of sound localisation between patients with stroke with right brain damage and those with stroke with left brain damage may be explained by the inattention theory of hemispatial neglect.

Purpose: This paper describes a motor-driven orthosis for paraplegics which has been developed. This orthosis is composed of a medially-mounted motor-driven hip joint and bilateral knee-ankle-foot orthosis. With the gear mechanism, the virtual axis of the hip joint of this orthosis is almost as high as the anatomical hip joint. Method: A paraplegic patient with an injury level of T10/11 walked using bilateral lofstrand crutches and this new orthosis with or without the motor system. The motor is initiated by pushing a button attached at the edge of the grab of the crutches. Result: Faster cadence and speed and smaller rotation angle of the trunk was obtained in motor walking compared with nonmotor walking. The patient did not feel fearful of falling. Conclusion: The benefit of motor orthosis is that it can be used even in patients with Lower motor lesions and that it provides stable regulation of hip flexion movement in spastic patients. In conclusion. this motor orthosis will enhance paraplegic walking.

This study was designed to examine the scale quality of our newly developed short behavior scale and to identify its role in predicting the functional outcome of stroke patients. The short behavior scale consists of six items that assess cognitive function related to the daily behavioral status of a patient in activities of daily living and exercise. It can be scored quickly through observation of a patient's behavior. We assessed 190 stroke inpatients, who had a mean age of 61 years. The mean days and length of stay from onset were 47.3 and 138.2, respectively. We examined internal consistency with the Cronbach's alpha coefficient. Interrater reliability was tested by having two examiners evaluate 30 patients independently. We studied how the short behavior scale correlated with the admission Functional Independence Measure, Mini-Mental State Examination scores, and speech and visuospatial functions. We also studied how the short behavior scale contributed to the prediction of discharge Functional Independence Measure raw scores with stepwise multiple regression analysis. In another group of 116 patients, we cross-validated our predictive equation. The Cronbach's alpha coefficient was 0.88. The intraclass correlation coefficient was 0.84 for total score. The short behavior scale correlated significantly with cognitive Functional Independence Measure scores and Mini-Mental State Examination scores. We could explain 70.8% of the variance of discharge Functional Independence Measure scores from the Short Behavior Scale, days from onset to admission, age, speech scores, and admission Functional Independence Measure scores. Stability of the predictive equation was shown in cross-validation to a second sample of 116 patients. In conclusion, our newly developed short behavior scale proved reasonable and would be useful to enhance the precision of outcome prediction in stroke rehabilitation.