住民のボランティア活動とリハビリテーション専門職のプロボノ活動の協働—地域リハ活動の枠組みの中で介護予防活動を深化できるか—…大田仁史　243

難病患者等に対する障害福祉サービス等の提供について…森岡久尚　246

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目的：脳性麻痺患者における脊柱側弯変形は日常生活動作に著しい障害をもたらす．我々は独自に開発した動的脊柱装具（Dynamic Spinal Brace：DSB）を用いた脊柱側弯変形に対する治療の有効性を患者，介護者の状況の変化において検討した．方法：DSB治療中の脳性麻痺患者222 人を対象に，介護者へのアンケート調査および側弯変形のX線計測を行った．結果：アンケートでは日常生活動作において座位・姿勢で80 ％以上，介助（移乗，移動）・食事のしやすさは50 ％以上で改善を認めた．筋緊張は年齢が18 歳以上の患者において改善を認めた．呼吸・筋緊張は側弯が高度なほど改善を認めた．結論：脳性麻痺患者の脊柱側弯変形に対するDSB治療は患者，介護者の座位・姿勢，介助や食事のしやすさの改善において有効性を認めた．また成長期以降の筋緊張や高度な側弯変形を有する患者の呼吸や筋緊張に対しても有効であると考えられた．

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Osteoarthritis (OA) is a non-inflammatory joint disease that is characterized by cartilage degeneration. OA can develop in any joint with synovium and articular cartilage. OA is a very common disease in old age which can cause patients to become housebound or to require nursing care. Epidemiological research in Japan showed that the estimated number of patients with radiographic knee OA was 25 million and those with radiographic lumbar OA was 38 million. OA induces pain, contracture, hydrarthrosis and joint deformity. These in turn lead to gait disturbance in the lower limb and disorders of ADL in the upper limb. On plain radiography, joint space narrowing, osteophyte formation and bone cysts are observed. Several treatment guidelines for OA were published by several academies associated with OA. Various conservative treatments and surgical treatments are often applied to OA. Patient education, exercise and orthoses are effective in improving pain and functional impairment. As a drug therapy, acetaminophen, NSAIDs and opioids are used to reduce pain in OA. Additionally, steroid and hyaluronic intra-articular injection are widely used in the treatment of OA. If the conservative therapies are not effective, surgical therapies are considered. Surgical therapies are categorized into osteotomy, arthroplasty, arthrodesis and replacement arthroplasty. Recently, total knee and hip arthroplasties are becoming very common. Since exercise and orthosis therapy are effective for OA, rehabilitation doctors should have an understanding of the pathology and treatment of OA. In addition, rehabilitation is very important before and after surgery.

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Understanding the societal and personal impact of immobilization or disuse syndrome is important in Japan with its large elderly population. The indication of disuse syndrome for rehabilitation was narrowed and the fee for disuse syndrome was set at a low level. Muscle strength decreases at a rate of 2.3 % per day in 40 % of the people. Also, the muscle fractional synthetic rate decreased with 10 days rest. Other functional or morphological changes also occur in the neuromuscular junction and the muscle internal structure. Additionally, we must consider the contribution of muscle to the limitation of joint angle after immobilization. Both elasticity and viscosity increase. Cardiac wall thickness and cardiorespiratory fitness decrease during immobilization. Gravitational dependent lung disease or deep vein thrombosis may occur. The brain is also affected by immobilization, leading to condition of learned non-use. The best solution for immobilization is to be active ; however, we must have a detailed knowledge of the pathophysiology of a patient's disease in order increase their activity level. In an acute hospital setting, prevention of immobilization is crucial. The system used in Japan, whereby therapists are assigned full-time in the ward was introduced in April 2014. Furthermore, even though 20.35% of maximal strength training is effective in atrophied muscles, it is ineffective in trained muscles. Another sticking point is that there is no evidence-based recommendation for range of motion exercise. However, rehabilitation intervention in respirator patients improves their ADL. Prophylaxis of deep vein thrombosis is also very important. And learned non-use of the brain may be diminished by the skillful application of vibrations that makes patients feel that their hand is moving even when it is not. Finally, the mechanism of hibernation may be the key to improving our rehabilitation against immobilization in the future.

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