Several forms of different medical treatment, such as exercise therapy in physical medicine, occupational therapy in rehabilitation medicine, applied training therapy in sports medicine and behavior therapy in clinical psychology can be classified in to a single therapeutic category which fundamentally depends upon the therapeutic potential of the functional movement or exercise of the body.
Although they developed for different purposes and methodology, they have similar problems in evaluating their subjects and the effectiveness of the individual approaches.
Four problems were presented, analysed and discussed.
Several recent reports were introduced and criticized, which mainly dealt with physical findings obtained by exercise therapy, with respect to the importance of psychological intervention.
A future outlook of the exercise therapy was given as a personal view, and it was pointed out that the present therapeutic category should get closer each other and col-laborate in order to establish a wider concept of exercise therapy in the future.

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Three-hundred and eight patients with chronic physical problems have been treated with the psychiatric psychosomatic approaches at the Murayama Byoin National Sanatorium durin gthe years from 1976 to 1982.
The psychiatric psychosomatic problems of these patients have been summarized as follows: 1) severe and long-lasting pain, sensory abnormalities, epilepsy, and writer's cramp caused by the physical disorders, 2) anxiety, insomnia, depression, and disturbance of consciousness caused by the psychiatric disorders, 3) lack of motivation, aggression, and frequent recurrence of the diseases caused by disorders of the personal activity.
Of 308 patients treated with the psychiatric psychosomatic approaches, 196 (63.6%) were suffered from the degenerative diseases of the spine or joint; 20 (6.4%) were spinal cord injury; 20 (6.4%) were collagen diseases; 19 (6.2%) were organic diseases of the brain; and so on.
The diagnostic analysis from these approaches to 308 patients was revealed as follows: psychosomatic diseases in 81 patients; neurosis in 51; organic diseases of the brain in 34; schizophrenia in 27; and depression in 26.
The results of these approaches to the patients with various problems were satisfac-tory. The favorable result was obtained in 70% of the patients with pain problems from the degenerative diseases, and ranged from 60% to 40% in the patients with spinal cord injury and organic diseases of the brain. Low back pain was 74.6% and shoulder-neck pain was 62.2% with the favorable result.

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Normal pressure hydrocephalus (NPH) initially described by Adams et al. (1965) represents clinically bizarre gait disturbance, progressive dementia and urinary inconti-nentia. This syndrome develops following cerebrovascular diseases (CVD) such as suba-rachnoidal hemorrhage. In the practice of rehabilitation program for the patients with chronic or subchronic stage of CVD, NPH may be one of the most annoying “negative factor”. The purpose of this report is to analyze and clarify the characteristic pathophys-iology of this gait disturbance. We examined motor function of the lower extremities in 43 patients with CVD presenting NPH syndrome (Group with NPH), utilizing the ADL scoring, gross power grading by Ueda and assessment of the ventricular system on CT scan films. These were compared to the results in patients with CVD without showing NPH (Group without NPH).
(1) Motor function of the lower extremities such as gait was more severely involved in Group with NPH when compared to Group without NPH. There was no significant difference in motor function of the upper extremities between these two groups.
(2) Effect of rehabilitation for motor function was less in the group showing high grade ventricular dilatation on CT scan than group with mild hydrocephalus. Effectiveness may be closely related to coexisting “dementia” in the group with high grade hydrocephalus. The patients with dementia showing below 10 points on Hasegawa-shiki dementia scoring will not be able to carry out effective rehabilitation program, at this moment.
(3) The presence of periventricular lucency (PVL) on CT scan was another deeply involved “negative factor” for rehabilitation.
(4) Gait disturbance closely related to the severity of ventricular dilatation and PVL may lead us the assumption, as Fisher (1982) described, that motor function in gait could be due to subcortical involvement rather than due to cortical damage in nature. Further analysis of the mechanism of this gait disturbance will be discussed in the following reports utilizing Cybex II and “POLGON” gait analyzer.

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We analyzed the course of motor disability in patients with Duchenne type muscular dystrophy (DMD) with respect to the duration of disability by means of motor age evalu-ating method.
Motor age was divided into nine parts from lower motor age to higher motor age. The performance rate was calculated from the performed motor tasks in each part and the course of motor disability in patients with DMD was studied with respect to the duration of disability.
The following results were obtained.
1) The performance rate which belonged to the motor tasks within lower motor age decreased gradually but the performance rate which belonged to the motor tasks within higher motor age decreased acutely or subacutely in accordance with the duration of disability.
2) The performance rate which belonged to the motor tasks within lower motor age ranged between 20% and 30% even if the duration was over 15 years.

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The study was under taken in order to analyze the disability stage of gait independence (stage I, II, III, IV) in Duchenne muscular dystrophy and to decide the subtype of the stage of gait independence. With respect to the motor age evaluating method, normal children develop the motor function completely within 72 months after birth. Motor age evaluating chart consisted of 63 motor tasks.
The index for subdivision of the stage of gait independence was designed as follows. The performance rate of each motor task was calculated within the same stage group and the items of 50±20 (30-70) % in performance rate of each motor task were picked up to discover the significant difference in motor function. This items were regarded as the fundamental indicator for the subdivision of the stage of gait independence. The fol-lowing results were obtained.
1) The possibility of the subdivision in each stage was suggested.
2) In stage I, the following motor tasks were important for subdivision; running, jumping, jumping away and walking up and down the staircase with legs alternatively.
In stage II, the following motor tasks were the important tasks for subdivision; head elevation with supine position, crawling in all limbs, walking up and down the staircase without support and one foot standing with eyes closed.
In stage III, the following motor tasks were important for subdivision; body support in all limbs, crawling up the staircase, standing with support and striding over.
In stage IV, the following motor tasks were important for subdivision; head elevation in prone position, turning over and crawling movement.
Further investigations are required to clarify the subdivision of the disability stage of gait independence.

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The intertrochanteric fractures of the femur, most of which are seen in the elderly people, are frequently complicated by other lesions at the time of injury. Therefore, surgical treatment is undertaken for the purpose of the early return to the ambulatory status. Since 1973, we have performed Richards compression screw method which can fix the fragments so firmly that the patients can walk bearing their weight in the early phase of the therapy, and this report describes the overall results including complications, failures, and the type of technical errors encountered with this procedures.
Eighty-two patients (84 hips) were operated including 2 cases of bilateral fractures. The patients' age ranged from 16 to 94 years (average, 73.8). Forty-one fractures were stable (48.8%) and 43 fractures were unstable (51.2%). The average delay from admission to surgery was ranged from 0 to 23 days (average, 4.8). The operative time ranged from 41 minutes to 3 hours and 50 minutes (average 1 hour and 44 minutes). The estimated intra-operative blood loss was 30 to 1100 milliliters (average 345.8), and intra-operative transfusion volume was 0 to 1000 milliliters (average, 411.5). In the patients who could walk after surgery, they could walk 2 to 41 days postoperatively (average, 10.1). In this series the patients who could walk or return to the preoperative daily activity after surgery were considered “good” and the other patients who could not walk or the fixation was lost by virtue of the technical problem were considered “poor”. “Good” results were obtained in the 70 hips (83.3%), and “poor” results in the 14 hips (16.7%). In these “poor” cases, 4 cases had technical failures, and the other 10 patients could not walk because of their age or complications.
Four technical failures were cutting-out of the lag screw, nonunion, marked varus de-formity of the femoral head after plate bending, and refracture after nail removal respec-tively.
We think Richards compression hip screw system is the one of the best method treating the patients suffering from the intertrochanteric fracture of the femur at the present time. This system can fix the fragments firmly and correspond to the bone resorption at the fracture surface without loss of stability. But, in this fracture, whatever sufficient fixa-tion can be obtained immediately after injury, some of the patients cannot walk because of their age or complication, especially cases suffering from senile dementia, severe car-diopulmonary diseases or losing desire to walk because of severe debility. There remained a difficulty.

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The anesthetic management of patients undergoing surgery of lower extremity is fre-quently done under hyperbaric spinal anesthesia with dibucaine, and general anesthesia is used for operations of longer duration, such as total hip replacement. In hospitals with a rather small staff in the department of orthopedic surgery and no anesthesiologists avail-able like ours, the anesthetic management has to be done by the doctors of other depart-ments or anesthesiologists of other hospitals. So we took advantages of hypobaric spinal anesthesia with tetracaine. The advantages of this technic are: 1) Good analgesia and muscle relaxation can be achieved without respiratory or myocardial depression. 2) It is easy to place patients unaffected side up during the spinal puncture. 3) Relatively longer duration of anesthesia can be obtained.
The solution used for hypobaric spinal anesthesia is 20 mg tetracaine diluted in 37°C distilled water 10 ml with 0.1% epinephrine 0.1 ml. For premeditation scopolamine 0.5 mg and Atarax P^(R) 25 mg are administered. The position for lumbar puncture is lateral decu-bitus position with unaffected side up and with slight head down. We compared the blood loss and operative duration of total hip replacement under general and hypobaric spinal anesthesia. Total hip replacements were performed twenty seven times in 28 patients from 1976 to 1983. The number of operations under general anesthesia were 15 in 14 patients; hypobaric spinal anesthesia; 12 in 10 patients. Average blood loss was 1172±498 g for general anesthesia and 547±182 g for spinal anesthesia. Average time of operation was 154±25 min. for general and 120+34 min. for spinal anes-thesia. Average blood loss per hour was 496±233 g for general and 251±80 g for spinal anesthesia. Blood loss was less and duration of operations was statistically shorter under spinal anesthesia compared with general anesthesia.
The disadvantages of this technic incude hypotension which is controlled by fluid infu-sion or intravenous injection of Carnaculin^(R), consciousness during the operation, the possible complication of spinal anesthesia itself and discomfort produced by prolonged immobility. But they can be minimized by careful management. Thus we recommend usefulness of this technic which can be performed safely and steadily.

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The causes and results of non-union were investigated in 41 patients (43 non-unions) who were treated at Misasa-Onsen National Hospital during the period of 1976 to 1983.
Twenty femurs, nine tibiae and/or fibulae, eight humeri and six other bones had non-unions.
As to the causes of non-unions, the errors of indication of the management, and in the cases of open reductions, incomplete reductions, insufficiency of the internal fixations and infections were considerable in primary treatment of the fractures.
For the surgical treatment of the non-unions, hemiarthroplasty using prosthesis was performed in two cases of transcervical non-unions of the femoral neck. In the majority of other non-unions, dual plating or intramedullary nailing was tried for internal fixation after refreshing the surfaces of non-unions and bone grafting. But the transverse fixation between the distal fragment and the intramedullary nail by a screw was done in several cases that intramedullary nailing had been applied to non-unions of the shafts of the femurs by closed method. Zuggurtung method was combined with intramedullary nailing in the non-unions of the surgical neck of the humerus and the malleolus.
Hemiarthroplasty yielded acceptable results in two non-unions.
Successful union occurred in all of other 41 cases but one, which was the patient of rheumatoid arthritis with the trochanteric fracture of the femur with affected hip and osteoporosis.

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Tibial diaphyseal fracture with infected non-union were treated by posterior bone grafting during fifteen years (from October 1969 to September 1982)
These included 7 cases, of which 5 cases were open fracture associated with severe damage of the soft tissue and 2 cases were open reduction of closed fracture.
Multiple operative attempts had been made to obtain union previously.
Drainage from the anterior surface of the leg was present in 5 cases at the time of or prior to the grafting, but not in 2 cases.
In all cases, cancellous bone chips and cortical cancellous bone were grafted posterolat-eraly to the site of non-union to obtain tibio-fibular synostosis and union was obtained in all cases.
The drainage was terminated and the infection did not recur in all but two cases; one continued over nine months and the other stopped ten months after grafting but recurred with ref racture and continued for nine months.
Overall results were rated excellent in four cases and satisfactory in three cases.
We believe that the posterior bone grafting method for the treatment of the infected non-union of tibial diaphyseal fractures was useful and reliable.

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The use of bone plate for osteosynthesis is indicated to the limited cases. Various kinds of trouble have been reported, with the use of Kuentscher's nail or long bone plate for the fracture of middle or lower part of the femur. The reason for this is the fact that the fractured femur with physiological lordosis has been fixed internally with straight material. Most bone plates on market at present are of straight type.
The present report describes the experience of our newly developed type of bone plate for the re-operated cases of non-union and delayed union of the shaft fracture of the femur. This bone plate is 20 cm in length, 1.6 mm in width and 4 mm in thickness. It has been well matched to the lateral part of the fractured femur with strong fixation.

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A case of progressive muscular dystrophy which began with congestive cardiac failure was reported by Norris et al, and had been classified as cardiopathic muscular dystrophy. We performed an autopsy on such a case. This case is considered to be quite rare in Japan. We report the clinical and pathologic findings of the heart.
The patient was a 29 year old male. At the first examination (August 1979), he noticed anasarca. There were no muscular weakness and atrophy, but serum CPK was as high as 361 mU/ml. This derived from the skeletal muscles because the MM com-ponent was 98 percent. A gastrocnemius biopsy was performed and the diagnosis of pro-gressive muscular dystrophy was confirmed. His mother demonstrated, a high CPK value of 308 mU/ml. althongh she had no skeletal muscle atrophy. She was considered to be a carrier.
His cardiac status was classified as grade III of the NYHA. The CTR was 60 percent. The liver edge was palpable 3 finger breadths below the right costal margin. The ECG showed low voltage in limb leads and an abnormal Q wave with a flattened T wave in lead V6. The echocardiograrn revealed dilatation of the left ventricule with hypokinesis. The ejection fraction was decreased to 0.38. A cardiac catheterization was performed. The mean MPA pressure reached the high value of 43 mmHg and the cardiac index was 1.62 1/min, /m².
It was noted that there was a great difference in the progress of this case from that of the usual case of progressive muscular dystrophy. Six months prior to his death, a manual test indicated that the muscle power of the extremities were preserved at fairly a good level. The cardiac failure was progressive. The CTR was 70 percent and he had been lying in bed all day. He died on February 1983, forty-two months after the first examination.
A postmortem examination was performed by the section only on the upper abdominal wall. His heart weighed 500 g and four chambers were dilated. Patchy fibrosis was observed mainly on the lateral and posterior epicardial portion of the left ventricle. How-ever, the valves and coronary arteries showed no particular changes.

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A fifty-five year old woman with rheumatoid arthritis developed ptosis, dysarthria, dys-phagia, and general weakness after taking D-penicillamine for seven months. Investi-gation rncluding edrophonium test, single-fiber EMG, and anti-acetylcholine receptor anti-body assay confirmed the diagnosis of myasthenia gravis. She was treated only with pyridostigmine for myasthenia. The myasthenic symptoms gradually subsided after D-penicillamine was discontinued. The anti-acetylcholine receptor antibody levels decreased to the normal range within six months.
We could find seven cases of D-penicillamine-induced myasthenia in the Japanese lit-eratures. Six patients out of eight including ours were female. Comparing with cases reported in other countries, Japanese cases were somewhat younger and developed myas-thenia with smaller dosages. Although it seemed difficult in some cases to determine whether D-penicillamine induced myasthenia or myasthenia occurred by chance, we noted that the clinical spectrum of D-penicillamine-induced myasthenia gravis may be wider than generally accepted.

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Total thymectomy for M. G. is a widely established surgical treatment since M. G. is not infrequently complicated with thymic disorders. We present a case of recurrent thy-moma where thymectomy didn't result in clinical improvement. This 35 years old female patient who at first complained of cervical asthenia, which subsequently progressed to bulbar symptoms was well responsive to anti-cholinergic agent. Thymectomy for compli-cated thymoma was then performed eight months later, Oct. 1978.
The operative finding revealed thymoma partially invaded into left side pleura which had been completely removed.
The postoperative course was not uneventful, i. e., dependance on anti-cholinergic agent and moderate general myasthenia which exacerbated during menstrual period were still on its way.
In December 1978, she developed several bouts of myasthenic crisis which required intensive care under mechanical ventilation.
The intensive treatment included the administration of high-dose corticosteroid, immu-nosuppressant and the use of plasmapheresis.
Although serum anti-acetylcholine receptor antibody titer showed significant decrease following immunosuppresion and plasmapheresis, she could not get weaned from mechanical ventilation for another four years.
Four years after first operative treatment, she underwent second surgical resection for the remnant of the invasive thymoma including adipose tissue at the anterior mediastinum which was diagnosed by chest computed tomography.
Three months following the second surgical procedure she could successfully get wean-ed from the ventilator for only four weeks in spite of the significant decrease of serum anti-acetyl choline antibody titer postoperatively.
She has been so far on ventilator up to present time,
This is a case report suggesting that M. G. is not necessarily a thymocentric disease.

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