関節リウマチの新しい治療体系におけるリハビリテーションの意義…村澤　　章，中園　　清，石川　　肇，大谷　　博，青木　可奈　271

膝関節に対する運動療法・筋力トレーニングのup to date—血流制限下筋力訓練を中心に—…桜庭　景植　276

慢性腰痛のリハビリテーション…松平　　浩　282

大腿骨近位部骨折のリハビリテーション…田中　一成，佐浦　隆一　290

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摂食・嚥下機能の評価方法として，嚥下造影検査(VF)が広く用いられている．しかし発熱や肺炎等，VF後の呼吸器合併症について検討された報告は少ない．そこで今回，VF後に施行した胸部X線像上のバリウム残留位置の分布，および呼吸器合併症発症例の検討を行った．対象はVFおよび胸部X線撮影を行った198 例である．誤嚥のない86 例ではX線像上の残留を認めず，誤嚥のある112 例中，40 例でX線像上の残留を認めた．移乗能力および認知機能と，誤嚥の有無の間には有意な関係を認めなかった．発熱を認めた10 例と，誤嚥の有無および残留の有無の間に有意な関連を認めなかった．1 例が肺炎の診断基準を満たしたが，胃瘻からの経管内容の逆流が疑われた症例だった．以上よりVF後の早期呼吸器合併症は重篤なものは少なく，また呼吸器合併症評価のための胸部X線撮影の有用性は明らかでなかった．

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The following report illustrates a rare case of dysphagia caused by secondary adrenal insufficiency in a patient with isolated ACTH deficiency. A 76-year-old man with progressive appetite loss, weight loss and general fatigue was hospitalized due to dehydration, aspiration pneumonia and hypoglycemia. He was unable to stand and walk by himself. His serum cortisol and ACTH levels were both low. An endocrinological examination resulted in a diagnosis of isolated ACTH deficiency. Following the administration of 15mg of glucocorticoids daily, his symptoms diminished without dysphagia. Furthermore, we investigated his swallowing function using a videofluoroscopic examination of swallowing (VF). The VF showed an impaired laryngeal movement as well as an upper esophageal opening and severe aspiration without a delay in his swallowing reflex. Oral intake was judged to be impossible, but his swallowing function gradually improved and he was able to resume eating all of his meals 2 months after treatment. Dysphagia is not a common symptom in ACTH deficient patients but a few similar cases have been reported. The swallowing function of the patients in these cases was not evaluated in detail, so we evaluated this case according to the results of the VF and the patient's process of recovery. Careful monitoring of swallowing function and appropriate treatment for both dysphagia and adrenocortical failure are required for the recovery of such patients. In conclusion, practitioners should be wary of isolated ACTH deficiency in elderly patients with progressive weight loss and dysphagia.

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