Frontline of Cardiovascular Rehabilitation…Nobuo MOROTOMI, Masazumi MIZUMA 16

Pulmonary Rehabilitation…Hiroko MIYAZAKI 21

Renal Rehabilitation…Masahiro KOHZUKI 28

Hepatic Rehabilitation…Osamu ITO 33

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Background : The aim of this study was to assess the effects of repeated injections of botulinum toxin type A (BoNT-A) combined with a rehabilitative program for treating spastic upper limb hemiparesis after stroke. Subjects and methods: Subjects were 112 poststroke hemiparetic patients with spastic upper limb (mean age : 55.5±11.6 years ±SD, mean period between onset and first injection : 5.1±3.5 years). For each patient, BoNT-A (maximum dose of each injection : 240 units) was injected in the spastic muscles of the affected upper limb twice with a minimum interval of 3 months. Following each injection, detailed one-to-one instructions for homebased functional training was provided. At the baseline (before injection) and at 1 and 3 month follow-ups after each injection, the patient's modified Ashworth scale (MAS), the range of motion (ROM) and Fugl-Meyer Assessment (FMA) were evaluated. Results : The total score for the upper limb and the scores of categories A and B of the FMA increased significantly not only after the first injection but after the second injection compared with the second baseline, while the FMA score for category D increased significantly only after the second injection. MAS also decreased significantly not only after the first injection but after the second injection compared to the second baseline. Conclusion : A more significant improvement was found not only in muscle spasticity but also in upper limb motor function after two BoNT-A injections. It is suggested that repeated BoNT-A injections followed by a comprehensive rehabilitative program would be an effective treatment for limb spasticity after a stroke.

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Purpose : The purpose of this study was to investigate the risk factors for falls among wheelchair users who were institutionalized in a long-term care health facility. Subjects : The participants were 62 new residents (mean age, 85.4±7.9) of a long-term care health facility. Methods : A longitudinal study of 6 months follow-up for falls was carried out. Baseline data were obtained regarding age, history of falls, functional status, psychological variables, physiological function, medical treatments and economic status. Risk factors for falls were analyzed by logistic regression. Results : During the follow-up, falls by 29 patients (46.8% of participants) were reported. Our analysis showed that four risk factors were significantly associated with falls : the patient had a bent back, a high FIM score, polypharmacy and benzodiazepine use. Logistic regression analysis revealed that a bent back was the best predictor of falls (OR 4.11 ; CI 95% 1.25-13.5).

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Peripheral nerve injuries are usually caused by trauma and are different from peripheral neuropathy. Clinical signs include flaccid paralysis, sensory loss and rapid muscle atrophy. Peripheral nerve lacerations are best treated by early microsurgical repair. There are several defining characteristics of peripheral nerve laceration and regeneration, namely, the degeneration of distal axons (Wallerian degeneration), the misdirection of regenerating axons, slow axonal regeneration and rapid muscle atrophy. Following nerve laceration, distal axons fall into axonal degeneration and leave empty Schwann tubes. Afterwards, several regenerating axons sprout from each proximal axon and they then regenerate into distal Schwann tubes in an almost random fashion. When sprouting axons migrate into different Schwann tubes other than their original tubes, misdirection occurs and functional recovery will not occur. The speed of axonal regeneration is usually from 1 to 2 mm a day. Denervated muscle atrophy progresses rapidly and becomes irreversible after one year. Therefore, muscles more than 36 cm distal to the nerve laceration site, for example, the hand muscles after a brachial plexus injury or the foot muscles after a sciatic nerve injury will not recover even after perfect nerve repair is accomplished. So far, neither Wallerian degeneration nor axonal misdirection can be prevented via pharmacological means. At present, the best functional recovery can be obtained by microsurgical nerve repair with correct funicular matching in order to prevent joint contracture and muscle atrophy, which can be prevented to a certain degree with stretching and electro-stimulation of the affected muscles. Additionally, sensory re-education can be used to improve object recognition.

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