A Critical Pathway for Regional Stroke Care Networks in Kanagawa Prefecture <Original>…Toshinori YAMASHITA, Koji YORIZUMI, Hidemasa TOMITA, Yoshikazu UCHIYAMA 409

A Clinical Pathway for the Stroke Network in Megapolis Tokyo…Chikafusa KADOWAKI 415

Sapporo’s Clinical Pathway for a Stroke Care Local Network…Shigeki HASHIMOTO 425

A Clinical Pathway for the Local Stroke Network in the Kitakyushu Medical Care Zone <Original>…Taiji ODA, Masanori TAKAHASHI, Yasuyuki MATSUSHIMA, Satoru SAEKI, Kenji HACHISUKA 432

A Liaison Critical Pathway : A Look at the Western District of Saitama <Original>…Shinichiro MAESHIMA, Aiko OSAWA, Norio TANAHASHI 441

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Limb lymphedema is a serious complication following surgery or radiation therapy for malignant soft tissue tumors. We have recently experienced two cases where we provided symptomatic relief for lymphedema as part of palliative care for patients with sarcoma in the advanced stage. For the treatment of lymphedema, complex physical therapy (manual lymphatic drainage, compression, and exercise therapy), elevation of the affected limb, and skin care were carried out after ruling out the presence of deep venous thrombosis. Inelastic bandaging provides containment and effectively arrests the progression of swelling that stretches the skin. Since obstructive masses interrupt the entire lymphatic quadrants, lymphatic drainage is focused on creating a collateral flow in the truncal territories and in the limb. No complications associated with treatment were observed. In spite of refractory edema due to disease progression in both cases, the swelling of the affected limb or patients' subjective symptoms were temporarily improved by the treatment. While aiming to reduce swelling, the provision of comfort, relief from pain or other swelling-related symptoms, and maintenance or restoration of function are desirable and beneficial outcomes. Palliative therapy for lymphedema may lead to an improvement of the quality of life (QOL) of patients with sarcoma in the advanced stage.

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Injury of the anterior cruciate ligament, which works for anterior restraint, is especially important among the knee joint ligaments because it can result in the knee to giving way and requires surgical reconstruction before the patient can return to sports activities. On the other hand, injury of the posterior cruciate ligament, which works for posterior restraint, rarely results in the knee joint giving way and so the patient's comeback to sports is easier. Our motion analysis of the muscular skeletal model indicated that general motions mainly need posterior restraint and hardly require anterior restraint at all. Anatomy also shows that the anterior knee does not have a muscular tissue which works for restraint while the posterior knee has the stout gastrocnemius, which takes charge of posterior restraint. From the above facts, the assumption is that properly balanced motions of the knee joint only need posterior restraint with the posterior cruciate ligament and the gastrocnemius while an unexpectedly ill-balanced motion in the middle of sports activity can cause an anterior restraint which results in the knee joint giving way if the anterior cruciate ligament is insufficient. Accordingly, it is suggested that rehabilitation after anterior cruciate ligament reconstruction can be safely performed if only losing balance in an unnatural motion is avoided. In addition, newly developed methods are hoped to serve as powerful additions with benefits such as an increase in muscle size and strength by rehabilitation with vascular occlusion and neuro-function improvement by applying whole body vibration. Lastly, an issue of equal importance remains, which is to develop a method of preventing anterior cruciate ligament injuries.

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