Diffuse axonal injury (DAI) is identified as one of the most important causes of cognitive disorders in patients with traumatic brain injury. Radiologic recognition of DAI can help in understanding the clinical syndrome and in making treatment decisions. However, CT and conventional MRI are often normal or demonstrate lesions that are poorly related to the cognitive disorders present. Recently, diffusion tensor imaging (DTI) and fiber tractography (FT) have been shown to be useful in detecting various types of white matter damage. The aim of this study was to evaluate the feasibility of using DTI and FT to detect lesions in DAI patients, and to correlate these DAI lesions with the patients' cognitive disorders. We investigated 9 normal volunteers and 9 patients with DAI. The DAI patients had impaired intelligence, as well as attention, memory and executive function disorders that restricted their activities of daily living. In the DAI patients, DTI showed abnormal brain areas in the corpus callosum, fornix, frontal and parietal lobe white matter, and FT revealed interruptions of the white matter fibers in the corpus callosum and the fornix when compared with the normal volunteers, while no lesions were found on conventional MRI. DTI and FT can directly visualize DAI lesions, which cannot be reliably detected by conventional methods. Accordingly, both DTI and FT may be useful techniques for the evaluation of DAI, and may have the potential to be applied to planning rehabilitation therapy, and predicting the neurologic prognosis in DAI patients with cognitive disorders.

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Objective : To describe the effect of low-frequency (1 Hz) repetitive transcranial magnetic stimulation (rTMS) on unilateral spatial neglect (USN) in 22 right-handed stroke patients with right hemispheric damage and the corresponding change of regional cerebral blood flow (rCBF) before and after rTMS, speculating on the neural basis for recovery from USN. Methods : The time of onset to the initiation of rTMS was 70 to 220 days (mean : 128.3 days), on chronic stage in all patients. The therapeutic schedule consisted of 7 sessions of 1 Hz-rTMS delivered every other day for two weeks, with 14 sessions in two patients. Each session consisted of one train of 500 pulses applied over P5 (10/20 EEG system) at 90% motor threshold using a figure-eight-shaped coil. Assessment was made using the Japanese edition of the Behavioural Inattention Test (BIT) and a computed visual search task at four times as well as a cold-xenon CT (Xe-CT) at two times. Results : rTMS induced a significant improvement of USN patient performance in cancellation tasks and the BIT figure copy task as well as in visual search reaction time, an improvement which lasted 2 weeks after rTMS. Xe-CT showed a significant increase in rCBF in the right cerebellum after rTMS. Conclusions : It is conceivable that low-frequency rTMS may be useful for improving USN and it is a promising therapeutic tool. Also, the cerebellum, by forming a neural network with the parietal and frontal lobe, may play an important role in patient recovery from spatial neglect.

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Requisites for Physiatrists Responsible for Education of the Residents : What are required of us by the Japanese Board of Medical Specialties ?…Yasutomo OKAJIMA 491

The Postgraduate Clinical Training Curriculum for Rehabilitation Specialists in Japan —Its Status Quo and View—…Jun YAMAGUCHI 495

Continuing Medical Education System for Physiatrists in Japanese Association of Rehabilitation Medicine…Satoru SAEKI 500

Current Status and View of Practice Training for Physiatrists…Junko FUJITANI 504

Research-oriented Educational Program for the Physiatrist…Tetsuya TSUJI 507

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