We have participated in the Model Project to Support People with Higher Brain Dysfunctions, which started in 2001, as the representative of Okayama Prefecture from the beginning. Even now, active involvement is being carried out as the prefecture-based Support and Dissemination Project. Although higher brain dysfunctions such as memory dysfunction, executive dysfunction, attention dysfunction, and social behavior dysfunction have been discussed as cortical localization theory or dynamic localization theory, existence of functional brain networks and their plasticity cannot be ignored when considering pathophysiology of diffuse axonal injury and functional improvement by treatment. Networks related to frontal lobe function include the superior longitudinal fasciculus II (caudal part of the inferior parietal lobe - DLPFC) , the superior longitudinal fasciculus III (supramarginal gyrus - VLPC) , the inferior fronto-occipital fasciculus (occipital pole - frontal pole) , the uncinate fasciculus (OFC - temporal pole) , and the cingulum bundle (cingulate gyrus - parahippocampal gyrus) . Regarding improvement of higher brain dysfunction, not only learning as functional training but also environmental stimulation and guidance by treatment staff are considered to have many effects. It seems to be important to carry out the Support and Dissemination Project to promote reinstatement and continuous employment support, in order to improve higher brain dysfunction.

  The rehabilitation field has a long history, and deals with a variety of diseases and disorders. Clinical rehabilitation offers healthcare professionals a wealth of opportunities to examine and treat patients with higher brain dysfunction. To avoid overlooking or discounting such dysfunction, providers must thoroughly evaluate patients and regularly re-assess their illness and pathology to identify issues of concern. Likewise, it is crucial to envision a patientʼs lifestyle when designing and implementing their rehabilitation program, as most people affected by higher brain dysfunction also have various problems in everyday life and social activities. Rebuilding lives and lifestyles is the essence of rehabilitation, making it imperative that family members living with and caring for a patient clearly understand his/her functioning and capabilities, and select and adjust activities accordingly.

  The acquisition of compensatory strategies, such as drawing and gestures, can help people with aphasia when it is difficult to reach a practical level of language function improvement with single strategies alone. However, few reports on compensatory strategies specify detailed information on the evaluation criteria for each expression or examine how specific strategies affect daily communication. In this study, we set criteria for the instruction and evaluation of seven people with chronic aphasia, provided staged drawing and gesture training, and examined changes in the outcomes of each strategy and changes in participant motivation and ability to communicate in daily life. The results revealed an immediate improvement in drawing performance compared to that of gestures at the end of the training, and the improved drawing performance was maintained for three months after the training ended. In terms of changes in participant motivation and ability to communicate, there was improved performance of tasks based on daily life situations, and there were many opportunities for the participants to use compensatory strategies in conversation after training. These results suggest that proactive introduction of compensatory strategies improves the motivation and ability of people with aphasia to communicate in daily life.

  Our case presented with cerebral infarction with global aphasia. At the beginning of the onset, the patient was mute, but a few days later showed real word recurrent utterance (RWRU) of the word “mild”. About 10 days after onset, her RU changed to RWRU with function words. About 8 months after onset, significant improvements were detected in the comprehension, repetition, reading aloud, and reading compre-hension subtests of the Standard Language Test of Aphasia. However, at the same time, a new RWRU called “Yakult” (name of a beverage product) was also mixed in her speech, and the appearances of RWRUs were limited to the content word parts. Based on “good maintenance of comprehension and repetition” and “the fact that her RUs were RWRUs”, we considered that the failure of the word-finding process in the phono-logical output lexicon could have caused the output of her RUs. In addition, the strong stereotypy of RU indicated that the promotion or suppression of the intended / un-intended vocabulary was difficult to control. We considered the possibility that damage to the basal ganglia, common in RU cases, had an effect on the imbalance of neural circuit activity (hyperdirect pathway, direct pathway, an indirect pathway) of the basal ganglia.

  We report here an interesting case, who demonstrated phonemic paraphasia and disability of repetition postoperatively after a lesionectomy in the left opercular part of the frontal lobe, that is, main part of classical Brocaʼs area. She was in her 30s with uncontrolled epilepsy. Surgery was performed for control of epilepsy, under awaken condition with monitoring for language function. Intraoperatively, when the cortex was gently removed by piecemeal fashion in the left opercular part and subcortical fibers was explored, she presented phonemic paraphasia. Postoperatively, she demonstrated many phonemic and paraphasic errors despite of well-preserved auditory and visual comprehension, similar to conduction aphasia. This case showed important findings for the neural basis of language. A damage in subcortical fibers running beneath the cortex of the opercular part can cause phonemic paraphasia and disability of repetition. Those fibers were considered a part of the SLF (superior longitudinal fasciculus) III, and/or arcuate fasciculus. To comprehend the relationship between the anatomy and symptoms, hodological approach considering brain networks is necessary.

  Readability refers to how easy texts are to read, and studies have been conducted on the readability scoring formula. However, readability for aphasic patients has not been studied in Japan. Our study aimed to investigate whether common texts are readable by aphasic patients, and if not, to determine the types of texts that are readable by aphasic patients. First, we calculated the readability scores of texts often encountered in daily life, such as local community newsletters, nationwide newspapers, and weekly magazines. Second, we created original reading tests for each readability level, which we tested on a group of 10 people with mild and chronic aphasia and 15 age- and sex-matched non-stroke controls. The severity of aphasia was determined based on the aphasia 10-stage rating scale of the standard language test of aphasia. The results showed that local community newsletters, nationwide newspapers, and weekly magazines scored within the difficult range of readability levels. In the reading tests, many aphasic patients scored at an intermediate level, which controls passed. We found a statistically significant difference in the reading tests scores between the aphasia groups and controls. Our results suggested that patients with mild aphasia had difficulty reading texts often encountered in daily life. In addition, our findings may be applied in the selection texts with a suitable readability level for reading therapy for aphasic patients.

  Patients with memory disturbance after hemorrhage of the caudate nucleus are known to have good prognosis ; however, we experienced a case in which memory disturbance was prolonged after hemorrhage of the right caudate nucleus. A 46-year-old male came to our hospital 10 months after onset of symptoms because he had difficulties in performing activities of daily living (ADL) and work. His intellectual ability, frontal lobe function, and motivation were preserved, and projection from the caudate nuclei to the frontal lobe was preserved. His short-term memory was severely disturbed, however, so that he was unable to adapt to spaced retrieval training. During rehabilitation, he underwent perspective memory training, and a compensation method was introduced using an external aid with errorless learning. Post-training, the patientʼs existence recall improved, although content recall and short-term memory were still disturbed, and he could not obtain intentional recall. His recovery process was similar to that of temporal lobe amnesia. Disturbance in the process of memory consolidation caused by damage to the projection from the caudate nucleus to the medial temporal lobe may be the reason why memory disturbance was prolonged.

  The aim of this study was to consider what types of pre-on-road driving assessment would be clinically useful to administer for evaluating the fitness-to-drive of stroke patients without severe deficits.
  The study was conducted on 144 stroke patients whose fitness-to-drive had been evaluated by on-road driving assessment. The method used was, based on the on-road assessment results, to assign the subjects into two groups: fit-to-drive and unfit-to-drive ; then, using patient attributes and neuropsychological tests for univariate analysis, the fitness-to-drive of the two groups was compared using a driving simulator and J-SDSA. Next, decision tree analysis (CART) was performed using items for which significant differences existed between the groups as independent variables and the results of the pre-on-road driving assessment as dependent variables. The result showed that, as a pre-on-road driving assessment related to fitness-to-drive, road signs of J-SDSA were selected first ; second, in the Trail Making Test Part A, a compass was selected for the fit-to-drive group, Ray-Osterrieth Complex Figure Reproduction was selected. The model had a correct classification rate of 83.3% and correctly predicted 94.6% of the fit-to-drive group and 63.5% of the unfit-to-drive group. For pre-on-road driving assessment, we concluded that it would be clinically useful to combine these tests hierarchically.

  “Variability of speech errors” has been accepted as a distinguishing feature of apraxia of speech（AOS）, but in recent years this concept has been challenged. We examined whether variability of speech errors is useful to distinguish AOS from conduction aphasia or ataxic dysarthria. This study was conducted in three groups: (1) AOS group (with mild aphasia) , (2) conduction aphasia group (CA group) , and (3) ataxic dysarthria group (AD group) . The study consisted of a task of repeating each word three times, and four measures of variability (variability of error type, variability of error location, error rate, correction rate) were calculated based on Scholl et al. (2018) . The results showed a significant difference between the AOS group and the CA group on the two scales of “variability of error location” and “correction rate,” and both scales showed a significant difference between the CA group and the AD group. The AOS group and the AD group showed no difference on all four scales. These results were mostly consistent with the results of McNeil et al. (1995) . We concluded that variability of speech errors is not a feature exclusive to AOS, but that it may be of limited use as a feature that distinguishes AOS from CA.

  We investigated activities of daily living and social life among aphasics without physical disabilities. We examined the support items which were required, and the associations between their severity level of language function and their difficulties in daily living and social life. The subjects were 38 chronic aphasic persons without hemiplegia. We surveyed support needs and severity of language function. Pass rates of language tests among persons with aphasia was 100% in auditory comprehension of words or sentences, and 34% in speech production of words or sentences. Aphasic persons without physical disabilities showed good recovery on auditory comprehension, but speech production disorders continued to exist, and they needed assistance on communication-related activities. Different social support was needed according to the severity of aphasia. Even mild aphasic persons needed assistance on social activities that required communication. And persons with severe aphasia who have disability of speech production needed assistance for a wide range of social activities.