地域包括ケアシステムと地域リハビリテーションのあり方…浜村　明徳　171

医療リハビリテーションと地域連携…梅津　祐一　178

リハビリテーション科医の果たすべき役割…逢坂　悟郎　182

セラピストの果たすべき役割…中村　春基　187

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目的：炭酸ガス療法は炭酸ガスを経皮吸収させることで血流増加やボーア効果による組織酸素分圧を上昇させる作用によって生体に効果を及ぼすものと考えられている．本稿では，炭酸ガスの経皮吸収がラットの運動パフォーマンスへ及ぼす影響とそのメカニズムについて検討した．方法：ラット（Wistar系）を回転かごで1 週間の走行テスト後，炭酸ガスを経皮吸収させる群（炭酸ガス群，8 匹），運動のみを行う群（運動群，8 匹），運動も炭酸ガスも行わない群（コントロール群，8 匹）の3 群に分け，運動群と炭酸ガス群に毎日（5 日／週）30 分間の運動を4 週間実施した後で，すべての群の前脛骨筋を摘出し組織学的・生化学的に筋線維を解析した．結果：炭酸ガス群でコントロール群と比べて有意に運動パフォーマンスが向上した．また，筋線維の解析では炭酸ガス群でIIB線維からIID線維，IIA線維への移行やミトコンドリア数および血管密度の増加を認めた．結論：炭酸ガス経皮吸収はリハビリテーション後やスポーツ後の疲労回復効果などの臨床においても応用が期待される．

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Dysphagia is a syndrome associated with many diseases and is emerging as a big problem in the Japanese aged society. It is important to observe the symptoms and realize the causes of dysphagia. Swallowing disorders are often caused by organic etiology such as tumors and traumas, but many patients suffer from functional disorders after stroke and neuromuscular diseases. Nasogastric tube placement and medications can also iatrogenically cause swallowing problems. When making a diagnosis, it is important to understand the mechanisms and signs of pseudobulbar palsy and bulbar palsy. Whereas bulbar palsy occurs following a lesion in the brain stem swallowing center, pseudobulbar palsy relates to bilateral corticobulbar tract damage. Interestingly, some clinicians report that dysphagia can be caused by unilateral cortical lesions including lesions in the insular cortex. To detect dysphagia, questionnaires and screening tests are helpful, as are water swallow tests, RSST, cervical auscultation and so on, but clinical observation of the swallowing session is most valuable. Videofluoroscopic and videoendoscopic examinations are required for precise diagnosis and further management. To know the gap between the capability function and performance state of swallowing, it is good to establish treatment goals. It is also important to know if the disease is progressive or not. For patients with progressive disease such as ALS, compensatory management should be a priority. We use functional training including muscle strengthening and swallowing technique for non progressive disorders. Medical treatments using ACE inhibitors and so on are options which might be effective to prevent aspiration pneumonia, and also, surgical treatments such as cricopharyngeal myotomy and laryngeal suspension are indispensable in treating patients with severe dysphagia.

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Visceral impairment (VI), including cardiac, renal, pulmonary, hepatic, intestinal, urinary and rectal, AIDS is a worldwide public health problem. Recently, the number of patients with VI dramatically increased, reaching 30% of the total population of disabled patients in Japan in 2006, which corresponds to 60% of patients with limb impairment. Visceral rehabilitation (VR) is a coordinated, multifaceted intervention designed to optimize a patient’s physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the disease, thereby reducing morbidity and mortality. VR includes five major components : exercise training, diet & fluid management, medication & medical surveillance, education, psychological & vocational counseling. VR is a feasible, effective (Class I, evidence label A) and safe secondary prevention strategy following VI, and offers a promising model for a new field of rehabilitation. Medical science basically aims to “Adding Years to Life” by increasing life expectancy. Rehabilitation generally aims to “Adding Life to Years” by helping patients with impairment achieve, and use, their full physical, mental and social potential. However, recent growing evidence suggests that rehabilitation for patients with VI not only improves exercise performance and quality of life, but also increases survival. Therefore, modern comprehensive rehabilitation for patients with visceral impairment does not simply aim to “Adding Life to Years” but “Adding Life to Years and Years to Life”, which is a new rehabilitation concept. Urgent efforts should be made to increase the implementation rate of VR.

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