和田 義敬

Background: The importance of being physically active and avoiding staying in bed has been recognized in stroke rehabilitation. However, studies have pointed out that stroke patients admitted to rehabilitation units often spend most of their day immobile and inactive, with limited opportunities for activity outside their bedrooms. To address this issue, it is necessary to record the duration of stroke patients staying in their bedrooms, but it is impractical for medical providers to do this manually during their daily work of providing care. Although an automated approach using wearable devices and access points is more practical, implementing these access points into medical facilities is costly. However, when combined with machine learning, predicting the duration of stroke patients staying in their bedrooms is possible with reduced cost. We assessed using machine learning to estimate bedroom-stay duration using activity data recorded with wearable devices. Method: We recruited 99 stroke hemiparesis inpatients and conducted 343 measurements. Data on electrocardiograms and chest acceleration were measured using a wearable device, and the location name of the access point that detected the signal of the device was recorded. We first investigated the correlation between bedroom-stay duration measured from the access point as the objective variable and activity data measured with a wearable device and demographic information as explanatory variables. To evaluate the duration predictability, we then compared machine-learning models commonly used in medical studies. Results: We conducted 228 measurements that surpassed a 90% data-acquisition rate using Bluetooth Low Energy. Among the explanatory variables, the period spent reclining and sitting/standing were correlated with bedroom-stay duration (Spearman’s rank correlation coefficient (R) of 0.56 and −0.52, p < 0.001). Interestingly, the sum of the motor and cognitive categories of the functional independence measure, clinical indicators of the abilities of stroke patients, lacked correlation. The correlation between the actual bedroom-stay duration and predicted one using machine-learning models resulted in an R of 0.72 and p < 0.001, suggesting the possibility of predicting bedroom-stay duration from activity data and demographics. Conclusion: Wearable devices, coupled with machine learning, can predict the duration of patients staying in their bedrooms. Once trained, the machine-learning model can predict without continuously tracking the actual location, enabling more cost-effective and privacy-centric future measurements.

There are currently no abstract classifiers, which can be used for new diagnostic test accuracy (DTA) systematic reviews to select primary DTA study abstracts from database searches. Our goal was to develop machine-learning-based abstract classifiers for new DTA systematic reviews through an open competition. We prepared a dataset of abstracts obtained through database searches from 11 reviews in different clinical areas. As the reference standard, we used the abstract lists that required manual full-text review. We randomly splitted the datasets into a train set, a public test set, and a private test set. Competition participants used the training set to develop classifiers and validated their classifiers using the public test set. The classifiers were refined based on the performance of the public test set. They could submit as many times as they wanted during the competition. Finally, we used the private test set to rank the submitted classifiers. To reduce false exclusions, we used the Fbeta measure with a beta set to seven for evaluating classifiers. After the competition, we conducted the external validation using a dataset from a cardiology DTA review. We received 13,774 submissions from 1429 teams or persons over 4 months. The top-honored classifier achieved a Fbeta score of 0.4036 and a recall of 0.2352 in the external validation. In conclusion, we were unable to develop an abstract classifier with sufficient recall for immediate application to new DTA systematic reviews. Further studies are needed to update and validate classifiers with datasets from other clinical areas.

Objective: To compare the functional outcomes of patients with lower limb amputations receiving haemodialysis and those not receiving haemodialysis.Design: A retrospective cohort study. Patients: Patients with lower limb amputation who were admitted to a convalescent rehabilitation ward between January 2018 and December 2021.Methods: The primary outcome was the effectiveness of the Functional Independence Measure (FIM) during hospitalisation in the ward. Secondary outcomes included the total and subtotal (motor/cognitive) FIM scores at discharge, gain in the total and subtotal (motor/cognitive) FIM scores, K-level at discharge, length of hospital stay in the ward, rehabilitation time, and discharge destination. Outcomes were compared between the non-haemodialysis and haemodialysis groups.Results: A total of 28 patients (mean [standard deviation] age, 67.0 [11.9] years; men, 20) were enrolled in this study. Among them, 11 patients underwent haemodialysis. The FIM effectiveness was significantly higher in the non-haemodialysis group than in the haemodialysis group (median [interquartile range], 0.78 [0.72 – 0.81] vs 0.65 [0.28 – 0.75], p = 0.038). The amount of rehabilitation and all secondary outcomes were not significantly different between the groups (p > 0.05).Conclusion: Patients with lower limb amputation who were receiving haemodialysis had poorer FIM effectiveness than those not receiving haemodialysis.LAY ABSTRACTChronic kidney disease is a risk factor for foot ulcers and lower limb amputation. Thus, patients with lower limb amputation often require maintenance dialysis. However, there is a lack of knowledge on whether patients with lower limb amputation receiving haemodialysis can achieve functional outcomes comparable to those not receiving haemodialysis. This study aimed to compare functional outcomes between patients with lower limb amputations receiving haemodialysis and those not receiving haemodialysis. This retrospective cohort study enrolled 28 patients who underwent amputation surgery and were admitted to a rehabilitation ward, including 11 patients undergoing haemodialysis (8 with diabetic nephropathy, 1 with chronic glomerulonephritis, 1 with rapidly progressive glomerulonephritis, and 1 with acute kidney injury). Although the amount of rehabilitation did not differ between groups, the improvement in the activities of daily living was significantly better in the non-haemodialysis group than in the haemodialysis group. Thus, even the same amount of rehabilitation for patients with lower limb amputations receiving haemodialysis may not lead to functional outcomes comparable to those without haemodialysis.

PURPOSE This systematic review aimed to investigate the efficacy of telemedicine (TM) using videoconferencing systems in outpatient care for patients with cancer. METHODS We searched six electronic databases (CENTRAL, MEDLINE, EMBASE, CINAHL, ICTRP, and ClinicalTrials.gov) through June 2021 to identify randomized controlled trials that evaluated the use of TM using videoconferencing systems compared with usual face-to-face care in outpatient care for patients with cancer. We assessed the certainty of evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation. RESULTS From the 2,400 articles screened, six randomized controlled trials were eligible for this study. Two studies evaluated the use of TM in cancer follow-up and four investigated psychotherapy for cancer. TM using videoconferencing systems may result in no differences in primary outcomes such as patient satisfaction (standardized mean difference, 0.11; 95% CI, –0.18 to 0.40) and outpatient attendance complete proportion (risk difference, 0.02%; 95% CI, –0.04 to 0.09), and secondary outcomes such as medical professional satisfaction, time devoted to outpatient care, and depression score. The certainty of evidence for these outcomes was low. Although the average money spent on outpatient visit was a primary outcome, the level of evidence was uncertain. CONCLUSION Our results suggest that TM using videoconferencing systems in outpatient care for patients with cancer may be as effective as usual face-to-face care. Use of TM more frequently may be considered for patients with cancer who are expected to obtain benefit from TM using videoconference systems.

BACKGROUND: Repetitive peripheral magnetic stimulation (rPMS) is a non-invasive treatment method that can penetrate to deeper structures with painless stimulation to improve motor function in people with physical impairment due to brain or nerve disorders. rPMS for people after stroke has proved to be a feasible approach to improving activities of daily living and functional ability. However, the effectiveness and safety of this intervention for people after stroke remain uncertain. This is an update of the review published in 2019. OBJECTIVES: To assess the effects of rPMS for improving activities of daily living and functional ability in people after stroke. SEARCH METHODS: We searched the Cochrane Stroke Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; MEDLINE; Embase; the Cumulative Index to Nursing and Allied Health Literature (CINAHL); PsycINFO; the Allied and Complementary Medicine Database (AMED); OTseeker: Occupational Therapy Systematic Evaluation of Evidence; the Physiotherapy Evidence Database (PEDro); Ichushi-Web; and six ongoing trial registries on 5 October 2021. We screened reference lists and contacted experts in the field. We placed no restrictions on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: We included randomised controlled trials (RCTs) conducted to assess the therapeutic effect of rPMS for people after stroke. The following comparisons were eligible for inclusion: 1) active rPMS only compared with 'sham' rPMS (a very weak form of stimulation or a sound only); 2) active rPMS only compared with no intervention; 3) active rPMS plus rehabilitation compared with sham rPMS plus rehabilitation; and 4) active rPMS plus rehabilitation compared with rehabilitation only. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion in the review. The same review authors assessed methods and risk of bias, undertook data extraction, and evaluated the certainty of the evidence using the GRADE approach. We contacted trial authors to request unpublished information if necessary. Any disagreements were resolved through discussion. MAIN RESULTS: We included four trials (three parallel-group RCTs and one cross-over trial) involving a total of 139 participants. This result was unchanged from the review published in 2019. Blinding of participants and physicians was well reported in three trials, with no information on whether personnel were blinded in one trial. We judged the overall risk of bias across trials as low. Only two trials (with 63 and 18 participants, respectively) provided sufficient information to be included in the meta-analysis. We found no clear effect of rPMS on activities of daily living at the end of treatment (mean difference (MD) -3.00, 95% confidence interval (CI) -16.35 to 10.35; P = 0.66; 1 trial; 63 participants; low-certainty evidence) and at the end of follow-up (MD -2.00, 95% CI -14.86 to 10.86; P = 0.76; 1 trial; 63 participants; low-certainty evidence) when comparing rPMS plus rehabilitation versus sham rPMS plus rehabilitation. We found no statistical difference in improvement of upper limb function at the end of treatment (MD 2.00, 95% CI -4.91 to 8.91; P = 0.57; 1 trial; 63 participants; low-certainty evidence) and at the end of follow-up (MD 4.00, 95% CI -2.92 to 10.92; P = 0.26; 1 trial; 63 participants; low-certainty evidence) when comparing rPMS plus rehabilitation versus sham rPMS plus rehabilitation. We observed a decrease in spasticity of the elbow at the end of follow-up (MD -0.41, 95% CI -0.89 to 0.07; 1 trial; 63 participants; low-certainty evidence) when comparing rPMS plus rehabilitation versus sham rPMS plus rehabilitation. In terms of muscle strength, rPMS treatment was not associated with improved muscle strength of the ankle dorsiflexors at the end of treatment (MD 3.00, 95% CI -2.44 to 8.44; P = 0.28; 1 trial; 18 participants; low-certainty evidence) when compared with sham rPMS. No studies provided information on lower limb function or adverse events, including death. Based on the GRADE approach, we judged the certainty of evidence related to the primary outcome as low, owing to the small sample size of the studies. AUTHORS' CONCLUSIONS: There is insufficient evidence to permit the drawing of any conclusions about routine use of rPMS for people after stroke. Additional trials with large sample sizes are needed to provide robust evidence for rPMS after stroke.

Background: Coronavirus disease 2019 (COVID-19) is associated with an increased risk of thrombotic complications. Nonetheless, there is a paucity of clinical knowledge regarding rehabilitation of patients with COVID-19 after lower-limb amputation. Case: A 74-year-old woman with COVID-19 was admitted to a university hospital. During hospitalization, she underwent right transfemoral amputation due to acute limb ischemia. Three months after admission, the patient was transferred to a convalescent rehabilitation ward in the same hospital. A femoral prosthesis was prescribed 2 weeks after her transfer to the rehabilitation ward. It featured ischial-ramal containment with a soft liner and belt suspension, 668-g multiple linkage-type safety knee joint (Imasen Engineering; M0781 SwanS), and a solid-ankle cushioned-heel foot. The total rehabilitation time during the patient's stay in the acute-care and rehabilitation wards was 65.5 h (0.99 h/day, 66 days) and 275.0 h (3.02 h/day, 91 days), respectively. In the rehabilitation ward, the patient underwent 54.4 h (19.8%) of muscle strength training, 48.1 h (17.5%) of comprehensive assessments, and 47.1 h (17.1%) of gait training. The patient was discharged home 6 months after admission, with a total Functional Independence Measure score of 120. The patient could walk slowly [44.2 s (0.23 m/s) in the 10 m-walk test] with a femoral prosthesis and a quad cane but exhibited limited endurance (75.0 m in the 6-min walk test). Discussion: Following appropriate rehabilitation, a patient was able to walk independently after lower-limb amputation despite the complication of COVID-19, although her walking ability was limited.

【はじめに】Coronavirus disease 2019(COVID-19)に対するリハビリテーションの報告はあるが,重症例の回復期リハビリテーションやVV-ECMO後の大腿神経麻痺の併発の報告はほとんどない.【症例】50代男性.COVID-19に対する治療過程でVV-ECMO管理が行われ,腸腰筋血腫による大腿神経麻痺を併発した.第120病日よりADL改善・運動耐容能改善を目的とした運動療法,ADL訓練,呼吸リハビリテーションを中心とした回復期リハビリテーションを行い,呼吸機能,FIM,6分間歩行テストが改善した.第196病日に自宅退院した.以降も,増悪なく経過している.【考察】重症COVID-19のADL・運動耐容能低下に対して,呼吸リハビリテーションを中心とした回復期リハビリテーションは改善に寄与した.また,VVECMO後の大腿神経麻痺には注意が必要である.(著者抄録)

【はじめに】回復期リハビリテーション病棟入院時に歩行全介助であったが,歩行能力を再獲得した重症ギラン・バレー症候群(GBS)例を経験した.特に,下肢筋力向上に合わせて長下肢装具・短下肢装具を調整した歩行訓練が歩行能力改善に寄与したと示唆されたため報告する.【症例】20代女性.前医でGBSと診断され,第57病日に当院回復期リハビリテーション病棟に転院した.当院入院時下肢筋力MMT1,FIM運動項目合計(mFIM)13点であった.Tilt tableと長下肢装具を用いた立位訓練から開始した.入院9週目より調整機能付き後方平板支柱型短下肢装具で歩行訓練を行い,筋力の回復に合わせ足関節を固定・制動・制限・遊動と調整した.退院時は,補助具・装具無しで歩行自立,mFIM91点と改善した.退院2ヵ月後に仕事に復帰した.【考察】回復期リハビリテーションで重症GBS患者に下肢装具療法を用いた立位・歩行訓練は,歩行能力の改善に寄与したと示唆された.重症GBS患者に対して医学的管理と高強度のリハビリテーションによる回復期リハビリテーションは重要である.(著者抄録)

OBJECTIVE: To evaluate whether ankle-foot orthosis (AFO) has a beneficial effect on dorsiflexion angle increase during the swing phase among individuals with stroke and patient-important outcomes in individuals with stroke. LITERATURE SURVEY: Randomized controlled trials (RCTs), randomized crossover trials, and cluster RCTs until May 2020 were researched through CENTRAL, MEDLINE, EMBASE, PEDro, CINAHL, and REHABDATA databases. Studies reporting on AFO use to improve walking, functional mobility, quality of life, and activity limitations and reports of adverse events in individuals with stroke were included. METHODOLOGY: Two independent reviewers extracted the data and assessed the risk of bias. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. SYNTHESIS: Fourteen trials that enrolled 282 individuals with stroke and compared AFO with no AFO were included. Compared with no AFO, AFO could increase the dorsiflexion angle of ankle joints during walking (mean difference [MD, 3.7°]; 95% confidence interval [CI], 2.0-5.3; low certainty of evidence). Furthermore, AFO could improve walking ability (walking speed) (MD, 0.09 [m/s]; 95% CI, 0.06-0.12; low certainty of evidence). No study had reported the effects of AFO on quality of life, adverse events, fall frequency, and activities of daily life. CONCLUSIONS: Our findings suggest that AFO improved ankle kinematics and walking ability in the short term; nonetheless, the evidence was characterized by a low degree of certainty.

OBJECTIVES: We aimed to evaluate the characteristics, quality, and related factors of the Japanese Clinical Practice Guidelines (CPGs) published in recent years. STUDY DESIGN AND SETTING: In this cross-sectional, meta-epidemiological study, we conducted a Google search for CPGs published by 30 Japanese medical societies that are the basis for training specialties between 2018 and 2019. We used the Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool and the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement to evaluate the quality. RESULTS: We included 53 systematic review-based CPGs. The median score was 0.54 (IQR, 0.38-0.62) for Stakeholder involvement, 0.57 (IQR, 0.51-0.66) in Rigor of development, 0.33 (IQR 0.21-0.46) in Applicability, and 0.63 (IQR 0.46-0.73) in Editorial independence. The number of guideline developers/clinical question ratio (odds ratio [OR]: 4.14, 95% confidence interval [CI]: 1.97, 8.70) and the adopted guideline development methods (OR: 3.69, 95% CI: 1.14, 12.0) were significantly related to the Rigor of development. CONCLUSION: The quality of Japanese CPGs published in recent years remains low. Our study suggests that increasing contributors and adopting the latest guideline development methods at the beginning of the project may improve the quality of the Japanese CPGs.

Objectives: The aim of this study was to examine, using PubMed, the number of articles in the field of physical medicine and rehabilitation medicine originating in Japan, especially those containing high-quality scientific evidence (randomized controlled trials [RCTs], systematic reviews, meta-analyses) and those published in high impact factor journals. Methods: We searched the PubMed database to identify articles, RCTs, systematic reviews, and meta-analyses from Japan covering physical medicine and rehabilitation published between 2001 and 2019; we then calculated the proportion of articles from Japan. Additionally, using Journal Citation Reports, we selected the top ten highest impact factor journals on "Rehabilitation" each year between 2001 and 2019. For each year, we searched PubMed for the total number of articles in these top ten journals and for articles originating in Japan. The Cochran-Armitage test was used to evaluate the change in the proportion of publications from Japan over time. Results: The proportion of articles on physical medicine and rehabilitation originating in Japan increased from 2001 to 2019 (P<0.0001). An increase in the percentages of systematic reviews (P=0.046) and meta-analyses (P=0.0013) originating in Japan and a decrease in the percentage of original articles published in the top ten highest impact factor journals were demonstrated (P=0.002). However, there was no change in the percentage of RCTs from Japan over time (P=0.055). Conclusions: Our findings suggest that the proportion of articles from Japan containing high-quality scientific evidence is increasing. However, there is a need to expand the support system for research while considering the quality of research.

Background: Pirogoff amputation is a calcaneal amputation invented by Nicolás Pirogoff that involves partial preservation of the calcaneus. Case: A 59-year-old woman was diagnosed with left Lisfranc and Chopart joint fracture-dislocation 9 months after a fall. The patient underwent debridement together with Pirogoff amputation and surgery to place an Ilizarov external fixator. Five months later, the patient was transferred to a rehabilitation hospital. Because of inadequate bone fusion, for 3 months after the amputation the patient underwent gait training with a patellar tendon weight-bearing orthosis to avoid loading the amputated side. After fusion of the bone, the patient was able to walk using a Syme prosthesis and a cane. Three months after discharge from the rehabilitation hospital, the patient was diagnosed with hallux osteomyelitis of the other foot that was associated with the exacerbation of hallux valgus. The patient underwent hallux correction surgery. Three and a half months after the second hospital admission, the patient was again admitted to the rehabilitation hospital. At the end of the rehabilitation program, the patient was able to walk using a cane and a prosthesis. Discussion: Appropriate orthotic treatment and care of the non-amputated limb are of great importance in patients who have undergone a partial foot amputation.

【目的】脳卒中片麻痺患者の内反尖足に対する2回のA型ボツリヌス毒素製剤(BoNT-A)投与の定量的な治療効果を明らかにする.【方法】2011年4月から2013年3月に当院リハビリテーション科外来で2回のBoNT-A投与(投与間隔:平均136.0(10.5)日)を行い,各投与前後にシート式下肢加重検査を行った慢性期脳卒中患者(くも膜下出血・再発例を除いた)8名を対象に診療録を後方視的に観察した.投与前,初回投与4週後,2回目投与4週後に麻痺側最大足底接地面積・麻痺側/非麻痺側最大足底接地面積比・Modified Ashworth Scale(MAS)を測定した.【結果】麻痺側最大足底接地面積は初回投与後と2回目投与後間で有意に増加した.麻痺側/非麻痺側最大足底接地面積比は初回投与前と初回投与後間,初回投与前と2回目投与後間で有意に増加した.MASは初回投与前と初回投与後間,初回投与前と2回目投与後間で有意に軽減した.【結論】内反尖足に対するBoNT-Aの治療効果判定に足底接地面積を用いるのは有用性が高いと示唆された.(著者抄録)

【目的】回復期リハビリテーション病棟入院脳卒中患者の重回帰分析によるADL帰結予測重回帰式の精度を比較した.【方法】当院回復期リハビリテーション病棟を入退院した脳卒中患者1,502例を予測式を作成する作成群と予測精度を確認する検証群の2群に分けた.作成群で退院時mFIMが従属変数の重回帰分析の予測式(S予測式),Reciprocal重回帰分析の予測式(R予測式),mFIM effectivenessが従属変数の重回帰分析から退院時mFIMを求める式(E予測式)を作成した.検証群で退院時mFIMの予測値を算出し,実測値と予測値の級内相関係数・実測値から予測値を引いた残差の絶対値を比較した.【結果】級内相関係数はS予測式0.86,R予測式0.90,E予測式0.89であった.残差の絶対値はS予測式9.38±6.62,R予測式7.30±6.56,E予測式7.56±6.45であった.Steel-Dwass検定でS予測式とR予測式,S予測式とE予測式間で有意差(p<0.05)を認めた.【結論】重回帰分析によるADL帰結予測式ではモデルを線形に近づける変換を加えることで予測精度を高められた.(著者抄録)

症例は26歳女性で、痙攣発作があり、レベチラセタムを静脈内投与され経過観察となった。その後、自宅で再度痙攣発作があり、自己免疫性脳炎として治療を開始された。全身精査時に右卵巣奇形腫が疑われた。卵巣奇形腫の診断には至らなかったが、抗NMDA受容体脳炎と診断され、ステロイドパルス療法、血漿交換を施行された。発症54日目に当院回復期リハ病棟に転院した。訓練は入院当日より理学療法・作業療法・言語聴覚療法を開始した。特に記憶障害、注意障害に対して、直接刺激法で反復課題を用いて本人が苦手と感じる語想起や聴覚的注意力への訓練を中心に行った。105日目の退院後、復職への準備として模擬出勤等の仕事復帰を前提とした外出を計画して行った。その結果、発症156日目に元の職場・部署にて同じ仕事内容で週5日での仕事復帰を果たした。