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Multifaceted Analysis of Factors affecting Home Discharge of Patients with Cervical Spinal Cord Injury

Kazue TSURUMI ; Takashi ISAJI ; Koichi OHNAKA

The Japanese Journal of Rehabilitation Medicine.2012;49(10):726-733. doi:10.2490/jjrmc.49.726

Objective : To examine the characteristics of rehabilitation in patients with cervical spinal cord injury, we statistically analyzed the factors that affected their home discharge. Methods : We examined 122 inpatients diagnosed with cervical spinal cord injury in our hospital from January 2001 to December 2010. We categorized the patients into a home discharge group and a non-home discharge group, and ruled out inpatients that underwent rehabilitation at other hospitals after discharge. We analyzed the following factors with regard to their influence on home discharge : sex, age, length of stay, surgery after injury, cervical vertebral fracture at injury, the grade on the Frankel grading system, Functional Independence Measure (FIM) scores, movement ability, pain severity, the number of comorbidities, complications, and the number of caregivers. Results : The factors that favored home discharge included : improvement of paralysis, improvement of FIM scores, high-FIM scores at both admission and discharge, and high potential for movement at discharge. The factors that hindered home discharge included : advanced patient age, long length of stay, pain severity, and urinary infection. Multivariate analyses showed that age, pain severity, and movement ability were the most relevant factors that influenced home discharge. Conclusion : Pain control as well as improvement of movement ability are important factors affecting home discharge in rehabilitation units.

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A Case of Myotonic Dystrophy misdiagnosed as Higher Brain Dysfunction after Acute Epidural Hematoma

Atsuko SHO ; Shin TAKANO

The Japanese Journal of Rehabilitation Medicine.2012;49(10):734-737. doi:10.2490/jjrmc.49.734

A 43-year-old man was admitted to our hospital for rehabilitation of higher brain dysfunction caused by traumatic brain injury. He had undergone an emergency operation for acute epidural hematoma after a fall. He had impaired cognitive function with regard to memory, attention, and executive function. However, he also exhibited facial features such as frontal baldness and hatched face. Neurological examination showed mild distal muscle weakness in the extremities, gait disturbance, and grip and percussion myotonia. Needle electromyography showed myotonic discharges. Brain magnetic resonance imaging did not show any intra-axial abnormalities. Myotonic dystrophy (DM) was therefore diagnosed. Rehabilitation resulted in improved gait stability, but the patient's cognitive function did not improve. Severity of illness in DM patients varies from a floppy infant to a lack of awareness of the disease throughout one's lifetime. Therefore, DM patients might not be properly diagnosed because of the mildness of their clinical symptoms. It is important for non-neurologists to be aware of the possible occurrence of this disease.

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Rehabilitation for Parkinson Disease

Kinya HISANAGA ; Nobuo TAKAHASHI

The Japanese Journal of Rehabilitation Medicine.2012;49(10):738-745. doi:10.2490/jjrmc.49.738

Patients with Parkinson disease present with a variety of symptoms as well as the so-called 4 classic symptoms : tremor, muscle rigidity, akinesia, and postural instability. To treat this disease, the best combination of various antiparkinsonism drugs, deep brain stimulation, and rehabilitation should be determined and administered. Muscular training in rehabilitation for patients should place great importance on some especially vulnerable muscles including the truncal muscles, extensor muscles for hip and knee joints, and dorsiflexor muscles for ankle joints. Shifting the center of gravity and using rhythmic movements are important factors in getting the patient standing and walking. Training using visual and auditory cues and music is effective in Parkinson disease. Speech therapy using weighted noise is also available. In rehabilitation we have to pay attention to cognitive function and psychiatric symptoms in patients including depression, anhedonia, hallucination, delusion, dopamine dysregulation syndrome, and impulse control disorder. What priority should be set for rehabilitation differs according to the stages of disease. Utmost efforts must be made for patients in the advanced stage of Parkinson disease to prevent them from being bedridden, tube-fed, and demented. Medical staff must be creative in coming up with new ideas to assist such patients in sitting comfortably on chairs for long periods and in eating by mouth safely.

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Food and Liquid Swallowing Difficulty in Stroke Patients : A Study based on the Findings of Food Tests, a Modified Water Swallowing Test and Videofluoroscopic Examination of Swallowing

Aiko OSAWA ; Shinichiro MAESHIMA ; Norio TANAHASHI

The Japanese Journal of Rehabilitation Medicine.2012;49(11):838-845. doi:10.2490/jjrmc.49.838

We compared food and water swallowing tests to investigate the reliability of the tests to exclude aspiration following acute stroke. Subjects were 155 patients with cerebral strokes aged between 20.98 years (66.6±12.9 years) and for whom videofluoroscopic examination of swallowing (VF) was performed for swallowing difficulty or suspected swallowing difficulty. Food tests (FTs) using jelly and rice porridge, and a modified water swallowing test (MWST) were evaluated during VF. The results showed fewer occurrences of choking, cough, wet voice and aspiration during the FTs than in the MWST. The sensitivity and specificity of the FTs for aspiration ranged from 80.0% to 83.3% and 25.5% to 41.3%, respectively. The MWST gave a sensitivity of 58.0% and a specificity of 72.4% for aspiration. There were more incidences of silent aspiration in the MWST than in the FTs. However, the validity of the FTs and their positive predictive value were lower than for the MWST. Choking and cough had a significant relation to aspiration in both tests. We recommend that we need to use each of these tests with an understanding of their characteristics and limitations in order to obtain correct findings in stroke patient swallowing assessments.

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A Survey of Patients with Muscle Disease Who Continue Driving Automobiles

Haruhi INOKUCHI ; Toshiyuki YAMAMOTO ; Yoko KOBAYASHI ; Toshiko SAKURAI ; Yasushi OYA ; Nobuhiko HAGA

The Japanese Journal of Rehabilitation Medicine.2012;49(12):909-915. doi:10.2490/jjrmc.49.909

Objective : The purpose of this clinical research was to create an assessment for patients with muscle disease who wish to continue driving by investigating their motor function and driving experience. Methods : Twenty-four patients with muscle disease who visited our hospital from December 2009 to April 2010 were enrolled in our research. For patients who were still driving, physiatrists evaluated their motor functions, examined simulated driving motions and recorded their driving capabilities and techniques, their ability to get into and out of the vehicle and their ability to store and remove their wheelchairs. Patients no longer driving were asked why they had given up driving. Results : Fifteen patients who continued driving had enough upper limb strength and could simulate driving motions, though the location and degree of their muscle weakness were variable. Five of fifteen drove with the aid of a hand-operated brake and accelerator. Seven needed personal assistance: three to get into and out of the vehicles, six to store and remove wheelchairs. The nine patients who had stopped driving reported that the primary reason for discontinuing driving was that they recognized their muscles were insufficient to control the vehicle. Conclusions : We propose to evaluate muscle strength and to test simulated driving motions when assessing patients with muscle disease. A hand-operated brake and accelerator is efficient for patients with lower limb muscle weakness. However, since no efficient automobile modifications are available for those patients who cannot get into and get out of their vehicles or store and remove their wheelchairs by themselves, we suggest arranging personal assistance for such patients.

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Rehabilitation for Upper Limb Hemiparesis after Stroke:

Masahiro ABO ; Nobuyuki SASAKI ; Toru TAKEKAWA ; Wataru KAKUDA

The Japanese Journal of Rehabilitation Medicine.2012;49(12):916-920. doi:10.2490/jjrmc.49.916

A multi-institutional study using our protocol of low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) showed significant improvement of motor function of the affected upper limb in poststroke patients. The response to the treatment was not influenced by age or time after stroke onset. Our protocol is a safe, feasible, and potentially useful neurorehabilitative intervention for upper limb hemiparesis after stroke. The extent of the improvement seems to be influenced by the baseline severity of upper limb hemiparesis. The results suggest that patients with Brunnstrom stage 4 or 5 upper limb hemiparesis are best suited for this protocol. Botulinum toxin type A (BoNT-A) has been reported to be an effective treatment for limb spasticity after stroke. However, the spasticity reduction after BoNT-A injection alone does not ensure an improvement in the active motor function of the affected limb. Our proposed protocol of a BoNT-A injection, followed by home-based functional training seems to have the potential to improve the active motor function of the affected upper limb after stroke.

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Report from a Kaifukuki (Convalescent) Rehabilitation Ward in the Disaster-Affected Region : What to do in a Kaifukuki Rehabilitation Ward during an Earthquake

Takeshi SATO

The Japanese Journal of Rehabilitation Medicine.2012;49(5):224-231. doi:10.2490/jjrmc.49.224

Our hospital is located in the prefectural capitol of Fukushima, where tremors just below magnitude six were recorded during the Great East Japan Earthquake of March 11, 2011. The building was spared major damage, but for safety, patients hospitalized at the Kaifukuki rehabilitation ward were evacuated within the hospital to rehabilitation rooms in the new annex, where they spent two nights. The day after the earthquake, a group rehabilitation session was conducted, but because patients showed signs of exhaustion from lack of sleep and anxiety, it was switched to individual rehabilitation. On a questionnaire, many patients noted that conversations with the staff helped ease their anxiety. This suggests that, although group rehabilitation can be efficient and effective in providing psychological support to patients, individual rehabilitation tends to be more favorable in disaster situations where patients suffer from exhaustion and psychological stress. Accordingly, disaster rehabilitation should be conducted on a patient-by-patient basis. In comparison with patients from the same time the previous year, the number of rehabilitation intervention units per day was one less, but the period of hospitalization was longer. A similar improvement in FIM was also achieved. At the time of an earthquake, although it is important for hospitals that escape structural damage to accept new patients, it is also important to continue treating the patients who were already there. Furthermore, hospitals should always have stockpiles of meals on hand and form cooperative relationships with the community to ensure that they can continue to provide service after an earthquake.

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Cancer Rehabilitation in the Regional Hospital for Cancer Treatment

Akiko SAGARA ; Juichi KAWAKAMI ; Takayo CHUMA ; Shuichi SHINZATO ; Kazuhisa DOMEN

The Japanese Journal of Rehabilitation Medicine.2012;49(6):313-320. doi:10.2490/jjrmc.49.313

Background & Purpose : For cancer patients and survivors, some rehabilitation seems to be required in order for them to function properly and to maintain their ADL and QOL. To improve outcomes, the subject of cancer rehabilitation in our hospital, one of Japan's regional centers for cancer treatment, was examined. Methods:Our section met 246 patients who were admitted to our hospital for cancer treatment from April, 2008 to March, 2010. We assessed their age, cancer origin, disability, the term between admission, operation and consultation, the period of hospitalization and rehabilitation, and the outcome. Results:Most patients had some deficits due to their cancer, which included neurological defects, bone and joint troubles, especially bone metastasis, or dysphasia. “Disuse syndrome” was found in 101 patients who had been lying in bed without these deficits. Owing to their treatment, 139 patients were discharged home with some functional inconvenience. Their length of stay in our hospital was suggested to be shortened by early consultation with our section (R=0.84). Despite their efforts, 90 patients died. They enrolled in some program for an average of 56.4±6.3 days, and continued their rehabilitation for 7.6±1.2 days on average before their deaths. Conclusion:Patients who are suffering from cancer need rehabilitation in all stages of their disease, which are preventive, restorative, supportive and palliative. Both in a hospital setting and in community-based medicine, a better rehabilitation system is required for most cancer patients, not only the survivors, especially those falling into “disuse syndrome” unnecessarily, but also terminally ill patients.

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Medical View of Developmental Disorders

Hironobu Ichikawa

The Japanese Journal of Rehabilitation Medicine.2012;49(7):421-427. doi:10.2490/jjrmc.49.421

Developmental disorders are defined in the Japanese Support Act for Developmental Disorders by ICD-10 (WHO). Representative disorders are Pervasive Developmental Disorders, Attention Deficit/ Hyperactivity Disorder and Learning Disorders. The incidence of these disorders has increased from 30% (1993) to 55% (2009) in child & adolescent psychiatric hospitals. These disorders are estimated to originate in brain dysfunction but details are as yet obscure. We attempt to identify these disorders as early as possible, but many parents are reluctant for their children to be diagnosed during their early childhood years. So we must take care to inform parents about these disorders. Developmental disorders are much more popular than other disorders, such as visual disorders, auditory disorders and physical disorders. These disorders are borderless, indistinguishable, and changeable and they are regulated by hereditary background. They also concern many social problems, such as school refusal, social withdraw, bullying and child abuse. Developmental disorders are also correlative to public health, education, welfare, working and crime. About 60 Support Centers for Developmental Disorders have been founded. Special education support is also provided for children with developmental disorders. In employment bureaus, special working courses are set up for them. Regarding the justice system, legal staff must take considerations to ensure fair trials for individuals with developmental disorders. Finally, medical staff must cooperate with other occupational members and endeavor to provide even greater support for these individuals.

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Efficacy of Pharmacological Classification of Complex Regional Pain Syndrome caused by Brachial Plexus Injury : A Case Report

Akiko HACHISUKA ; Yasuyuki MATSUSHIMA ; Kenji HACHISUKA

The Japanese Journal of Rehabilitation Medicine.2012;49(8):512-517. doi:10.2490/jjrmc.49.512

Pharmacological classification, based on a so-called drug challenge test (DCT), is one method to evaluate intractable pain following experimental administration of medicines. In this scenario, the appropriate medicine is prescribed for a patient with intractable pain based on the result of the DCT. A 61-year-old man was healthy until 2003, when he sustained a brachial plexus injury caused by a gas explosion. He had experienced fulgurant pain in his left upper limb since 2006, and had undergone stellate ganglion blocks, and treatment with amitriptyline. He was admitted for further treatment in 2010 because these treatments did not alleviate his fulgurant pain. He could not move his shoulder, elbow, wrist and fingers because of severe paralysis and arthrodesis of his left shoulder joint, and complained of fulgurant pain and persistent dullness in his left upper limb. He was diagnosed to have complex regional pain syndrome (CRPS) due to the brachial plexus injury, and electromyographic examinations showed evidence of a partial regrowth after sural nerve transplantation. Gabapentin was prescribed for the patient's CRPS based on the remarkable effect of thiamilal on this fulgurant pain. The frequency of the fulgurant pain decreased following the initiation of gabapentin therapy, and the persistent dullness disappeared. DCT is recommended for patients with intractable pain such as CRPS, in addition to neurological and electromyographic examinations, in order to elucidate the details of the pain and select the appropriate medication.

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