園田 茂

【目的】リハビリテーション(リハ)目的で入院した右被殻出血患者を対象に、半側空間無視の有無やその検出法に関与する要因について検討した。【対象と方法】対象は回復期リハ病棟に入院した右被殻出血103名で、発症から評価までの期間は40.5±27.4日。発症時のCTより血腫型を評価し、血腫量を算出して、半側空間無視がみられたかどうかや、その検出法を診療録より後方視的に調査した。【結果】半側空間無視は103名中58名(56.1%)でみられた。血腫量が多く、血腫が内包前後脚または視床に及ぶ広範な場合に半側空間無視は高率にみられた。半側空間無視の検出率は消去現象と注意で最も高く、次いで模写試験、視空間認知の順であった。【結論】回復期リハの時期でも被殻出血の半数以上に半側空間無視を認め、その発現には血腫量や血腫型が関与した。半側空間無視の検出に複数の課題を用いることで、見落としを大きく減らすことができた。(著者抄録)

It has been suggested that serotonin (5-HT) may be implicated in functional recovery after stroke; however, the underlying molecular mechanisms remain unknown. Here, the role of 5-HT was verified using ritanserin, a potent 5-HT2A receptor antagonist, and protein expression and modification were analyzed to further understand the association between paralysis recovery and molecular mechanisms in the brain. Experimental cerebral cortex infarctions were induced by photothrombosis in rats. Voluntary exercise was initiated 2 days after surgery. Motor performance was then measured using the rotarod test. Differences in protein expression and phosphorylation in the perilesional cortex were analyzed using western blot. In behavioral evaluations, performance in the rotarod test was significantly increased by exercise. However, there was a significantly lower value in time until falling after combined exercise and ritanserin administration compared with that of exercise alone. Protein expression analysis revealed that phosphorylation of protein kinase C (PKC) , PKC epsilon, and growth-associated protein 43 (GAP43) was significantly upregulated by exercise. These effects were attenuated by ritanserin administration. These data suggest that 5-HT may be related to the underlying mechanisms of exercise-dependent paralysis recovery, that is, exercise-dependent plasticity through the phosphorylation of PKC and GAP43.

Introduction/Background: For stroke patients with hemiplegia, walking exercise are conventionally practiced using orthoses. For severe hemiplegic patients, knee-ankle-foot orthoses (KAFO) are frequently used to prevent giving way in the stance phase. However, it is very difficult to swing paralytic leg with KAFO. As a result, walking exercise with KAFO requires a high level of assistance and raise low exercise intensity. To solve these problems, we developed Welwalk, which has a motor on the knee joint with KAFO-like framework. Welwalk can extend and flex the knee in appropriate timing. This time, we examined whether subacute stroke patients with hemiplegia using Welwalk show early improvement in walking independence compared to patients using KAFO. Material and method: Fourteen patients who satisfied the following criteria were included: patients with hemiplegia caused by primary supratentorial intracerebral hemorrhage or cerebral infarction, within 60 days after onset, aged 20 to 75 years, Functional Independence Measure (FIM) walking score ≤ 3, Stroke Impairment Assessment Set (SIAS) lower extremity total score ≤ 6, and use of KAFO. Rehabilitation was conducted for a maximum of 3 hours a day, including 40 minutes of walking exercise using Welwalk. A historical control group was selected from among patients admitted to the ward for intensive inpatient rehabilitation at Nanakuri Memorial Hospital. One control patient matching the criteria of each subject was selected, with a total of fourteen in the control group. The primary outcome measure was the improvement in efficiency of FIM-walk, defined as the gain in FIM walking score from the baseline to supervised walking divided by the number of weeks required. Results: The mean improvement in efficiency of FIM- walk was 0.9 in the Welwalk group and 0.5 in the control group, and was significantly higher in the GEAR group (P &lt 0.01). Conclusion: Walking exercise using Welwalk may facilitate early improvement in walking independence.

Background: Thalamic hemorrhages cause motor paralysis, sensory impairment, and cognitive dysfunctions, all of which may significantly affect walking independence. We examined the factors related to independent walking in patients with thalamic hemorrhage who were admitted to a rehabilitation hospital. Methods: We evaluated 128 patients with thalamic hemorrhage (75 men and 53 women; age range, 40-93 years) who were admitted to our rehabilitation hospital. The mean duration from symptom onset to rehabilitation hospital admission was 27.2 +/- 10.3 days, and the mean rehabilitation hospital stay was 71.0 +/- 31.4 days. Patients' neurological and cognitive functions were examined with the National Institutes of Health Stroke Scale (NIHSS) and Mini-Mental State Examination (MMSE), respectively. The relationship between patients' scores on these scales and their walking ability at discharge from the rehabilitation hospital was analyzed. Additionally, a decision-tree analysis was used to create a model for predicting independent walking upon referral to the rehabilitation hospital. Results: Among the patients, 65 could walk independently and 63 could not. The two patient groups were significantly different in terms of age, duration from symptom onset to rehabilitation hospital admission, hematoma type, hematoma volume, neurological symptoms, and cognitive function. The decision-tree analysis revealed that the patient's age, NIHSS score, MMSE score, hematoma volume, and presence of ventricular bleeding were factors that could predict independent walking. Conclusions: In patients with thalamic hemorrhage, the neurological symptoms, cognitive function, and neuroimaging factors at onset are useful for predicting independent walking.

Background: Multiple linear regression analysis is often used to predict the outcome of stroke rehabilitation. However, the predictive accuracy may not be satisfactory. The objective of this study was to elucidate the predictive accuracy of a method of calculating motor Functional Independence Measure (mFIM) at discharge from mFIM effectiveness predicted by multiple regression analysis. Methods: The subjects were 505 patients with stroke who were hospitalized in a convalescent rehabilitation hospital. The formula "mFIM at discharge = mFIM effectiveness x (91 points - mFIM at admission) + mFIM at admission" was used. By including the predicted mFIM effectiveness obtained through multiple regression analysis in this formula, we obtained the predicted mFIM at discharge (A). We also used multiple regression analysis to directly predict mFIM at discharge (B). The correlation between the predicted and the measured values of mFIM at discharge was compared between A and B. Result: The correlation coefficients were.916 for A and.878 for B. Conclusion: Calculating mFIM at discharge from mFIM effectiveness predicted by multiple regression analysis had a higher degree of predictive accuracy of mFIM at discharge than that directly predicted.

<p>日常会話で明らかな問題を示さない軽度の失語症を見過ごさないために他の神経心理学検査を用いた代わりの方法について検討した．対象は標準失語症検査（Standard Language Test of Aphasia: SLTA）総合評価尺度が10 点であった脳卒中患者33 名で，失語症に特徴的な症状の有無から失語群と非失語群に分け，種々の神経心理学検査の得点を比較検討した．その結果，失語群は非失語群に比べ，Frontal Assessment Battery とWord Fluency Test で低値を示した．決定木分析を実施したところ，Word Fluency Test の結果により失語症の有無を判別できる可能性が示唆された．</p>

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 (similar to 6 degrees/s) and moderate (similar to 120 degrees/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 degrees/s constantly in a range of motion between -60 and 60 degrees 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. (C) 2017 The Authors. Published by Elsevier B.V. on behalf of Nalecz Institute of Biocybemetics and Biomedical Engineering of the Polish Academy of Sciences. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

[Purpose] Accurate measurement of unaffected lower extremity muscle strength on the unaffected side is useful in patients with hemiparetic stroke however, muscle strength measurement results in patients with hemiparetic stroke vary greatly compared with those in healthy individuals. The objective of the present study was to determine the characteristics of patients with hemiparetic stroke who yield highly reliable muscle strength measurements. [Subjects and Methods] The subjects were 55 incipient patients with hemiparetic stroke. Muscle strength was measured twice. Based on the measured changes and on error ranges in repeated measurements in previous studies, the subjects were divided into two groups: subjects whose measurement results were within the acceptable range, and those whose measurement results were not within the acceptable range. Logistic regression analysis was performed with this separation of groups as the dependent variable, and demographic data, physical functioning, and functional independence measure (FIM) as independent variables. [Results] From the analysis results, the FIM cognitive subscore was selected as a criterion for patient selection the cutoff score was 19. [Conclusion] The results of the present study indicated that muscle strength measurements were highly reliable in patients with hemiparetic stroke with an FIM cognitive subscore of ≥19.

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 degrees DF (T10 degrees-slow and T10 degrees-fast) extracted as defining parameters for stiffness and muscle tone, respectively. Results: Correlations between both T10 degrees-slow and T10 degrees-fast variables with minimum PF torque were fair among ankle DF MMT 0-3 groups (r = 0.71 -0.74, p &lt; 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.

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.

Background and objective: Malocclusion induced by raising the bite causes chronic stress. Chronic stress leads to increased plasma corticosterone levels and impaired hippocampal function due to impaired neurogenesis or increased apoptosis in the hippocampus. The present study aimed to clarify the mechanisms underlying the impaired hippocampal function induced by the bite-raised condition in aged senescence-accelerated mouse prone 8 (SAMP8). Design: Nine-month-old aged SAMP8 mice were randomly divided into control and bite-raised groups. The vertical dimension of the bite was raised by applying resin to the molars. We evaluated newborn cell proliferation, survival, differentiation, and apoptosis in the hippocampal dentate gyrus (DG). Hippocampal brain-derived neurotrophic factor (BDNF) levels were also measured. Results: The bite-raised mice exhibited a significant decrease in proliferation, survival, and differentiation of newborn cells into neurons in the hippocampal DG compared with controls. The number of apoptotic cells in the hippocampal DG was increased at 7 and 14 days after the bite-raising procedure. Expression of BDNF protein and mRNA in the hippocampus was also decreased in the bite-raised mice. Conclusion: Bite-raised aged SAMP8 mice exhibited decreased neurogenesis, increased apoptosis in the hippocampal DG, and decreased hippocampal BDNF expression, in association with hippocampus-dependent learning and memory deficits. (C) 2016 Elsevier Ltd. All rights reserved.

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 degrees of PF to more than 10 degrees of DF at 5 degrees/second (slow stretch) or 90 degrees/second (fast stretch). Angle and torque were measured twice during the stretches. The intraclass correlation coefficients (ICCs) of torque at 10 degrees 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.

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.

[Purpose] This study aimed to determine the effects of increased amount of physical therapy exercise on improvements in the walking ability of patients with stroke. [Subjects and Methods] The subjects were selected from patients with stroke who were hospitalized in the convalescent rehabilitation ward, and included 91 patients who received physical therapy for 2.5-3 exercise sessions per day during 2005-2006 (PT3unit group), and 86 patients who received physical therapy for 4.5-6 exercise sessions per day during 2010-2015 (PT6unit group). The functional independence measure (FIM) score evaluates the walking ability of patients during hospital admission, 2 and 4 weeks after admission, and at discharge. The FIM score was stratified according to the degree of lower limb motor paralysis and subsequently compared between groups. [Results] Among the patients with complete paralysis and severe paralysis, the FIM-Walking scores at 4 weeks after admission and at discharge were significantly higher in the PT6unit group than in the PT3unit group. No significant differences were found between the PT6unit and PT3unit groups for patients with mild and moderate paralysis. [Conclusion] Higher amounts of physical therapy exercise contributed to improvements in the walking ability of patients with complete and severe lower limb paralysis.

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 &gt;= 70 at the time of discharge for motor items and &gt;= 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.

<p>視床病変では，運動障害や感覚障害などの神経症状だけでなく，失語症や半側空間無視，記憶障害など多彩な神経心理学的症状をしばしば伴う．一方，失語症を伴わない読み書きの障害が単独でみられることは少ない．読み書きの障害を生じる視床の局在病変として明らかにされているのは，背内側核（DM核）と外側腹側核（VL核），後外側腹側核（VPL核）であり，それぞれ大脳皮質の前頭葉，運動関連領野，感覚野へ投射する．既報告例の多くで，SPECT検査が実施され，同側の頭頂葉や前頭葉，側頭葉の皮質・皮質下に局所脳血流の低下による機能的病変が示されている．</p>

歩行再建では社会生活を見据えつつ，歩行の基盤となる機能レベルの底上げを図り，障害の残存を考慮して装具などを用いた新たな動作を学習することになる．その実践には運動学習の理論に基づいた高強度・高密度でのリハビリテーションが不可欠である．われわれが開発したFIT programには365日の訓練を可能とする仕組み，リハビリテーションの質を担保するためのコミュニケーションなどが内包されている．<br> 訓練量の増加は片麻痺の改善，歩行能力の改善をもたらす．装具を用いた訓練難易度の最適化は大切である．さらに効率を高めるためにロボットやトレッドミル，安全懸架などの手段を用いたり，病棟での訓練を調整することも重要となる．

A 62-year-old right-handed man was diagnosed with a cerebral infarction in the ventromedial region of the left lower pons. He showed left abducens nerve palsy, left-sided supranuclear palsy of the lower part of the face and right hemiparesis. We hypothesized that the mechanism underlying the patient's ipsilateral supranuclear facial palsy involved the corticofacial fibers after they crossed the midline.

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%.