A refractory pressure ulcer should be treated not only by surgery but also with team medical care in order to avoid recurrence after the initial treatment. At our hospital, plastic surgeons are responsible for organizing the team care. As part of the team care strategy, physical therapists (PTs) and occupational therapists (OTs) provide education to improve the mobility of spinal-cord-injury patients, e.g., improving muscle strength of the upper extremities for adequate transfer and ability to perform wheelchair push ups. For elderly patients, nurses assess the risk of pressure ulcer development using the Braden's scale and set up a nutrition support team. Additionally, if patients have difficulty swallowing, a speech therapist treats the dysphagia. And PTs and OTs treat their impaired activities of daily living. Finally, medical social workers arrange home-health-care services when the patient returns to their home. The management of chronic wounds has progressed from merely assessing the status of the wound to understanding the underlying molecular and cellular abnormalities that prevent the wound from healing. The concept of wound bed preparation, TIME, has simultaneously evolved to provide a systematic approach to removing the barriers to natural healing and enhancing the effectiveness of advanced therapies. Wound bed preparation and the TIME framework are most likely to be successful when used alongside the wound bed preparation care cycle.

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Type 2 diabetes mellitus (DM) doubles the risk of major cardiovascular complications in both patients with and those without established cardiovascular disease (CVD), and the majority of patients with DM die of CVD. Therefore, prevention and early diagnosis for CVD are important for the improvement of quality of life and prognosis of patients with DM. Exercise stress tests, such as a treadmill test, are needed to detect myocardial ischemia, but such stress testing should be done by cardiologists. On the other hand, measurement of ankle brachial index (ABI) is quick and easy and has been used successfully to diagnose peripheral artery disease. Since ABI is known to be a good predictor of the risk of recurrent CV events and death, I strongly recommend that ABI be measured in all DM patients. Dipeptidyl peptidase 4 (DPP-4) inhibitors are oral agents with little risk of hypoglycemia and thus used widely. In 2013, two clinical studies (EXAMINE and SAVOR-TIMI53) showed that DPP-4 inhibitors were generally safe and well-tolerated but did not decrease or increase the rate of CV events in patients with high risk for CV. Although the study periods were short (1.5-2.0 years), it was shown that a reduction of CV events in DM patients with CV risk is difficult with glycemic control alone. Results of the Steno-2 study showed that optimal treatment of hypertension and dyslipidemia in addition to glycemic control are needed to reduce CV events.

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The number of the patients requiring rehabilitation has been rapidly increasing. Rehabilitation patients and their families face various troubles and problems in their illness, their functional state, their convalescence, and a wide range of domains including their at-home life and care burden. And rehabilitation staffs must deal with these problems appropriately and take pride in their efforts and strive to provide continuing reliable care. However, most hospitals and rehabilitation centers only have one or at most a few physiatrists. Thus, most physiatrists and co-medical rehabilitation staff have few advisers and are frustrated by the many kinds of problems faced in providing medical service and management. In this lecture, I discuss how to build safety measures, how to write medical records to prevent future troubles, the proper on-site manner, and the 15 traits of a disliked physiatrist. I hope that this lecture can blow away the frustration from the rehabilitation scene and be helpful not only for patients and their families, but also for physiatrists and co-medical rehabilitation staff.

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Background : Both low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) have been recently reported to be clinically beneficial for post-stroke patients with upper limb hemiparesis. We have already reported that the function of the paralyzed upper limb in the post-stroke hemiplegic patients was improved after a 15-day hospitalization protocol, named NEURO-15. In this present study, we investigated whether two courses (2X) of NEURO-15 were superior to a single one in therapeutic efficacy. Methods: During NEURO-15, each patient was scheduled to receive 21 treatment sessions of 20-min low-frequency rTMS followed by 120-min intensive OT daily. Low-frequency pulses of 1 Hz were applied to the motor cortex of the nonlesional hemisphere. Fugl-Meyer Assessment (FMA), log performance time of the Wolf Motor Function Test (WMFT) and modified Ashworth Scale (MAS) were evaluated on the days of admission and discharge. The first NEURO-15 was given to 16 apoplectic hemiplegic patients whose Brunnstrom Recovery Stage in their fingers ranged from IV to V. After an average of 13.6 months, the second NEURO-15 was administered to all 16 patients. Results : The 2X protocol was completed by all patients without any adverse effects. After the first course of NEURO-15, all patients showed improvement in their paralyzed upper limb function ; improvements which remained until the second NEURO-15 course. The second NEURO-15 course yielded even further improvement in the paralyzed upper limb function. Conclusions : Our proposed combination treatment is a safe, feasible, and clinically useful neurorehabilitative intervention for post-stroke patients with upper limb hemiparesis when administered as both a single application or as a 2X protocol. The effectiveness of the 2X protocol or even more frequent application of NEURO-15 courses needs to be further explored.

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Objective : The Balance Evaluation Systems Test (BESTest) is a new balance assessment set based on systems theory. The purpose was to examine the validity of the Japanese version of the BESTest (J-BESTest) that we translated. Methods : The J-BESTest was produced using a translation and back translation method referenced from a guideline proposed by Guillemin et al. We tested 20 patients with balance dysfunction due to various diseases and 5 healthy persons with the J-BESTest, the Berg Balance Scale (BBS), the Falls Efficacy Scale-International (FES-I) and the Activities-specific Balance Confidence Scale (ABC Scale). We assessed the concurrent validity of the J-BESTest by comparing it with the other measures using Spearman's correlation method. Furthermore, we compared the ability of the J-BESTest to discriminate balance dysfunction with that of the BBS using receiver operating characteristic (ROC) analyses. Results : The J-BESTest was highly correlated with BBS (r=0.84, p<0.01), FES-I (r=-0.61, p<0.01) and ABC Scale (r=0.63, p<0.01). The distribution of the BBS score was more skewed compared with the J-BESTest and had a ceiling effect (6 participants had perfect scores with BBS versus none with the J-BESTest). The area under the ROC curve (AUC) of the J-BESTest was significantly larger than that of BBS (BBS 0.75, 95% confidence interval 0.56-0.94 versus J-BESTest 0.94, 95% confidence interval 0.84.1.0, p<0.05). Conclusion : The J-BESTest was suggested as a clinically useful tool, with good concurrent validity and better sensitivity and specificity than BBS, to identify people with mild balance dysfunction.

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Angles of the shoulder joint are usually defined in each of the sagittal, coronal, and horizontal planes passing through the center of the shoulder joint. One of the problems with this method is the difficulty of describing some positions of the shoulder joint such as the anterolaterally elevated position. In 2005, the International Society of Biomechanics proposed a recommendation on definitions of joint coordinate systems including the shoulder based on Euler/Cardan angles, which have often been used for the purpose of research on shoulder joint movement in daily activities. With this definition, however, it still remains impossible to define the angle of axial rotation in the hanging down position. Also, Codman's paradox, the phenomenon where the rotation angle of the shoulder changes after motions without axial rotation of the arm, remains unsolved. To solve these problems, a new method to define the angle of shoulder axial rotation, the non-singular method, has been proposed. This review describes the history and the problems of the methods used to define shoulder angles, and presents this new method of definition.

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