Repetitive transcranial magnetic stimulation (rTMS) and deep transcranial magnetic stimulation (dTMS) were approved as a novel therapy for patients with depression who did not respond to medications in Japan. As for a neuromodulation for neuropsychiatric disorders, this article presented the findings of a systematic review and network meta-analysis of non-surgical brain stimulation for the treatment of depressive episodes, and subsequently outlined the recent topics of theta burst stimulation (TBS) for depression, dTMS for obsessive-compulsive disorder (OCD), and rTMS for a depressive episode of bipolar disorder. To expand the clinical use of rTMS as a treatment by health insurance in Japan, it needs to promote the appropriate use under the approved indication and equal accessibility to medical institutions providing rTMS as well as to evaluate the cost-effectiveness of rTMS in the treatment of depression compared to existing therapies.

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Undoubtedly, in the field of rehabilitation medicine, nutritional support plays an important role. Nowadays, most of rehabilitation physicians in Japan recognize clinical importance of nutritional support for the patients receiving rehabilitation management. Especially, to increase muscle volume and strength in the rehabilitation training, not only muscle strengthening training but also nutritional support are necessary. At the acute hospitals, some special protocols such as prehabilitation and Enhanced Recovery After Surgery (ERAS) are clinically introduced. The purpose of the introduction of these protocols is to enhance functional recovery after surgery. In both of these protocols, nutritional support is regarded as an important element. Furthermore, in terms of the prevention of Hospitalization-Associated Disability (HAD) and Intensive Care Unit-Acquired Weakness (ICU-AW) which can develop at the acute hospital, we have to be careful about nutritional status of the patients. The importance of nutritional support for the patients admitted to convalescent rehabilitation wards has been already reported and confirmed with some clinical studies. It seems that good nutritional status at the time of admission and nutritional improvement during the hospitalization at convalescent rehabilitation wards could lead to the facilitation of functional recovery. In the management of sarcopenia and frailty, nutritional support is needed as well as muscle strengthening training. It is recommended to take a sufficient amount of protein for the prevention of these pathological conditions associated with aging. Recently, some researchers have reported that nutritional support had the possibility to prevent the development of Alzheimer’s disease. For example, Mediterranean diet is expected to prevent the disease. It has been also reported that some nutrients could enhance neural plasticity through the increase of BDNF secretion.

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In the current study, we tested the change of the arms function of the patients whom we performed low-frequency iterative transcranial magnetic stimulation for the postapoplectic hemiplegia and combination therapy (following, NEURO-15) of the intensive rehabilitation in several times in the long term. Among the patients admitted to this hospital during, we presented with postapoplectic arms paralysis, and finger flexure, extension movement intended for possible 49 people (paralysis side 26 handedness, non-handedness 23). We used a part of the study data which this study obtained the approval of this hospital Ethical Review Board (approval number 15) and conducted. We explained study contents to subjects by a document and word of mouth and obtained an agreement of the enforcement.The inpatient care followed the protocol of the Jikei University School of Medicine method and performed it and evaluated the arms item of FMA in before and after therapy. A total number of points of FMA was severe with 0-19 points by evaluation results and was moderate with 20-46 points and divided 47-66 points into mild three groups. Furthermore, the paralysis side divided it into two groups of handedness and the nonhandedness. We divided each into 5 or more groups and 4 or less groups according to the number of enforcement of the treatment and examined it. In the FMA moderate degree group, we recognized a significant difference in 5 or more groups. Also, significant improvement was found, in category A, handedness group is 5 or more groups and 4 or less groups, in category B, handedness group and non-handedness group are 5 or more groups. Category C is 5 or more groups in non-handedness group. It was confirmed to be able to expect the long-term maintenance, improvement of the arms function by performing NEURO-15 than this study several times.

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To investigate the clinical effect of multiple course of repetitive transcranial magnetic stimulation (rTMS) combined with intensive occupational therapy (IOT) in the post-stroke patients with upper limb hemiparesis. NovEl Intervention Using Repetitive Transcrarnial magnetic stimulation and Intensive Occupational Therapy: NEURO-15, which performs rTMS followed by IOT during the 15-day hospitalization period, was applied multiple times to 18 patients with upper limb hemiparesis after stroke, and the clinical utility of such procedure were examined. Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT) and Simple Test for Evaluating Hand Function (STEF) as the upper limb function evaluation items, and Jikei Assessment Scale for Motor Impairment in Daily Living (JASMID) and Visual Analog Scale (VAS) as evaluation criteria for the paralyzed upper limb were used, respectively. In 12 out of 18 cases, an improvement in the frequency of use of the upper limb function of JASMID was observed in the second course compared to the first course of NEURO- 15. In addition, significant improvements in the frequency of use of the upper limb function of JASMID, VAS, STEF and ARAT were also observed at the second and subsequent NEURO-15, but FMA did not. Furthermore, in 18 cases who received multiple courses of NEURO-15, there was no correlation between an improvement in the frequency of use of the upper limb function of JASMID ARAT, but in 12 cases excluding 6 cases with ARAT≧50, positive correlation between both criteria was observed. Clinical utility of multiple course of NEURO- 15 for the post-stroke patients with upper limb hemiparesis were confirmed. Also, patients with higher improvement in the frequency of use of the upper limb function of JASMID at the second course of NEURO-15 tend to have higher ARAT scores. Therefore, it was suggested that such criteria would be useful in determining whether multiple courses of NEURO-15 is clinically relevant.

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Repetitive transcranial magnetic stimulation (rTMS) has been shown to be beneficial for hemiparesis in patients with acute and chronic stroke. However, few studies have examined the usefulness of apply rTMS of convalescent rehabilitation wards. The purpose of this study was to evaluate the application status, outcomes and methods of rTMS for post-stroke upper and lower limb hemiparesis in the convalescent rehabilitation wards. The subjects were post-stroke upper and lower limb hemiparesis admitted to the convalescent rehabilitation wards, who received a combined therapy of rTMS with physical therapy, occupational therapy, and speech therapy. Lowfrequency rTMS of 1Hz was applied to the upper limb hemiparesis, and a high-frequency rTMS of 10Hz was applied to the lower limbs, followed by one to one training and self training. Each patient received treatment for 12 days. Functional evaluations were performed before and after the treatment intervention to judge the efficacy. Approximately 30% of the 49 stroke patients who were hospitalized during the study period from April 1 to July 8, 2019 were treated combined therapy with rTMS. It was showed that applying high-frequency rTMS early after admission to the convalescent rehabilitation wards, was effective for lower limb hemiparesis Although positive therapeutic results were obtained by applying low-frequency rTMS to upper limb paralysis, it was suggested that the treatment could be more effective by evaluating cortical activity patterns.

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In recent years, the use of electrical stimulation therapy durinGSwallowing training has been shown to be effective in improvinGSwallowing function. In this study, we aimed to combine indirect and direct traininGS with Gentle Stim (GS), a form of interferential current stimulation therapy, to examine changes in swallowing function and attain withdrawal from tube feeding. The participants were patients receiving nasal tube feeding. They were categorized into the GS and control groups and compared on the basis oFTheir results in the repetitive saliva swallow test, modified water drinking test, and food test (FT) before and aFTer the intervention. We found that both the GS and control groups showed a significant improvement aFTer the intervention. A significant difference in FT was observed between the GS and control groups. Furthermore, the proportion of patients who were able to meet nutrition needs by oral intake oFThree meals alone at discharge was also increased, which suggests that the combined use of GS may promote withdrawal from tube feeding.

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The aim of this study was to evaluate the age-stratification of the Japanese version of Southampton Hand Assessment Procedure (SHAP). SHAP was performed on 132 adults without disabilities, the index of function (IOF) and scores of profiles by function of dominant or non-dominant hands of subjects were analyzed by agestratification. The IOF scores of dominant hand in the 20s, 30s, and 40s years group were significantly higher than those in the 70s and above groups in SHAP. IOF scores of non-dominant hand were significantly higher in the 20s and 30s groups than in the 60s and over groups. In addition, significantly differenced scores of grasping profile were found according to each age group. The results of this study suggest that the motor function of the dominant and nondominant hands decreases with age. It is suggested that the profile according to the gripping function is influenced by various factors such as age-related change of individuals and environmental factors.

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To clarify the factors related to the improvement of the Action Research Arm Test (ARAT) after the stratification for the baseline ARAT score. One hundred eighty-four stroke patients were stratified into three groups based on the total ARAT score before the NEURO treatment. Multivariate logistic regression analysis was performed to assess the relationship between the improvement of ARAT and other factors. In the severe group, the improvements in FMA-A and C items were significantly associated with those of ARAT. None of the factors in the moderate and mild groups had a significant relationship. In severe group, the treatment designed to improve “shoulder/elbow/forearm” and “finger” function was considered as useful. On the other hand, there would be a divergence between the improvement of motor function and activity level of upper extremities in the moderate and mild group.

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Not a few clinical researchers have already applied repetitive transcranial magnetic stimulation (rTMS) as a therapeutic tool for stroke patients. So far, this intervention has proved to be significantly effective for improving hemiparetic symptoms in stroke patients. However, to the authors’ knowledge, there is no information on the therapeutic applicability of low-frequency rTMS in patients with infectious diseases of the central nervous system. We therapeutically provided combined protocol of low-frequency rTMS and intensive rehabilitative training for a hemiparetic patient who has progressive multifocal leukoencephalopathy (PML). During the 15-day hospitalization, the patient received 11 treatment sessions consisting of low-frequency rTMS over the non-lesional hemisphere (40 minutes), one-to-one training (120 minutes) and free exercises (120 minutes). The motor function of the affected upper limb was serially evaluated with Fugl-Meyer Assessment, Action Research Arm Test and Modified Ashworth scale. With this 15-day therapeutic protocol, motor function of the affected upper limb significantly improved without any adverse events. This case shows that low-frequency rTMS combined with rehabilitative training might be effective for hemiparesis caused by PML as well as that after stroke. In the future, this combined protocol is desired to be therapeutically introduced for some patients with infectious brain diseases.

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We studied the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive rehabilitation on cerebral palsy patient．A 40 years old male with cerebral palsy was studied. The patient was independent in activities of daily living and able to walk alone with a wheeled pickup walker. Of the four-week hospitalization，only intensive rehabilitation was performed for the first two weeks，and the combined therapy of rTMS and intensive rehabilitation was followed for the following two weeks． Since spasticity was predominantly observed in the right upper limb and lower limb，rehabilitation and self-training were performed for 1 hour respectively after applying rTMS on the right cerebral primary motor field of finger region．As a result of the combination therapy of rTMS and intensive rehabilitation，it became able to attach and detach gloves and to hold coins because the spasticity of the upper limbs was reduced and the finger separation movement was improved． The effect of combined therapy of rTMS and intensive rehabilitation was suggested even in a patient with cerebral palsy．

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This study examined the effects of NEURO^® on gait for the purpose of improving upper limb function. We report a case of a change in gait due to improvement of upper limb function. The case was a man in his 40s， 2 years after left putamen hemorrhage. Brunnstrom Recovery Stage was Ⅲ-Ⅲ-Ⅳ， and he used a short leg brace during walking. As a characteristic of walking， knee joint extension-flexion-extension movement similar to clonus occurred in the swing phase. We analyzed changes in walking before and after NEURO^® using VICON. The task was natural walking， and we compared the joint angles before and after NEURO^® during one walking cycle. As a result， the forward tilt of the trunk during walking was reduced， and the range of motion of shoulder joint extension on the non-paralyzed side was expanded. And， the hip extension angle at the end of stance of the paralyzed leg was increased. Also， during the swing phase of the paralyzed side， the knee joint extensionflexion- extension movement resembling clonus disappeared. This study suggests that improvement of upper limb function by NEURO^® stabilizes trunk function during walking. And I think that this has improved the range of motion for hip extension at the end of the stance and made it possible to swing out the lower limbs smoothly.

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Action research arm test (ARAT) is used to determine the effect of NovEl intervention using repetitive transcranial magnetic stimulation and intensive occupational therapy (NEURO^®) and is suitable for detecting changes in upper limb function in patients with chronic stroke. The evaluation can be applied to motor paralysis of a wide range of severity. The first evaluation item of Gross movement of ARAT subtest “Hand to back of head” is related to the grooming activity that the patient wants to acquire, but it requires a wide range of motion of shoulder and elbow joints, so it is a difficult evaluation item. In some cases, it is difficult to show improvement of upper limb function. In this study, 3 trials before and after NEURO^® were recorded with a 3D motion analyzer, and shoulder flexion angles were obtained. Before NEURO®, the angle change of shoulder flexion was a gradual bimodal, but after NEURO^®, the angle change became clear bimodal. From the quantitative evaluation using three-dimensional motion analysis, the movement pattern of “Hand to back of head” was captured. This is thought to be due to the improvement of voluntary improvement of the upper limbs and attenuation of spasticity caused by NEURO^®, suggesting that the cooperative movement of the shoulder and elbow joints improved.

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Infrequent repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy were administered to a hemiplegic patient who continued rehabilitation after stroke in this study. As the results, the patient’s motor function in upper extremity and work ability were improved. Using JASMID, frequency of use of upper extremity was maintained at a hige score, but quality of movements were decreased. The patient was able to tackle new work tasks while maintaining a willingness to use in daily life while complaining of poor quality of upper extremity movement. This result was attributed to the improvement of upper limb function, which enabled patients to perform complex tasks, and changed the patient’s perception of “unable tasks” to ”difficult tasks”. In fact, the patient was able to acquir movements that were close to his wishes. The patient’s motivation was maintained and a new approach could be started by himself. This study suggests that how to use to use the function of the upper extremity on the paralyzed side in daily life has a significant effect on how a patient is aware of the need and uses it continuously.

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We report on the effect of double therapy using both low-frequency repetitive transcranial magnetic stimulation (rTMS) to the primary motor area for the lower limb on the non-lesional hemisphere and intensive physical therapy (PT) in a stroke patient with lower limb hemiplegia. The patient was a 66-year-old man with lower left hemiplegia 22 months after stroke onset, using a wheelchair to move. The primary motor area for ankle dorsiflexion on the non-lesional hemisphere was identified by functional MRI prior to rTMS application. One treatment session comprised 20 min of low-frequency rTMS with 1 Hz application and 60 min of PT. In total, 21 sessions were applied during 15 days. One year later, a second course of treatment was performed. FRT, TUG, and walking time were improved after the second course compared to after the first course. Although walking ability did not meet the criteria shown by Kakuda et al., double therapy appears effective.

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We had a patient who underwent a combination protocol of repetitive Transcranial Magnetic Stimulation (rTMS) and intensive aphasia therapy four times in five years after a stroke. He was in his 70s and showed motor aphasia caused by a widespread cardiogenic cerebral infarction. He had difficulty speaking at the first combination protocol, but became able to utter short sentences after the fourth combination protocol. This article analyzes rehabilitation records and aphasia evaluation results of this case. Nakagawa et al. (2012) said that functional recovery may be restricted in two to three years when widespread foci are found in a patient over 40 years old. As the result of this case, contrarily, we could expect recovery from aphasia caused by widespread foci at chronic stage if patients undergo a combination protocol of rTMS and aphasia therapy multiple times and continue voluntary training.

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Because we chased the HRQOL change of the case treated with multiple injections of botulinum toxin type A （BoNT-A） preparation this time, we report it. Left putamen cerebral hemorrhage occurs before X-9 year. Brunnstrom recovery stage is upper limb III, finger II, lower limb III. Modified Ashworth Scale is ankle dorsiflexion 2. The 10m gait speed is 57.7 seconds. We evaluated SF-36 for an index of HRQOL. The BoNT-A preparation is treated with each eight times of time 350 units. The standard that HRQOL about the body function to the fifth was improved with improvement of the gait speed, but is psychological is a tendency to decrease. Furthermore, HRQOL did not have a change and was maintained as we repeated times.

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We experienced a case in which the administration of botulinum neurotoxin Type A (BoNT-A) and long-term rehabilitation led to the self-reliance of single-piece Lofstrand crutch from a difficult state due to inward equinovarus position of foot caused by severe spasticity after stroke． The patient was in his 50s with cerebral hemorrhage and cerebral infarction， which caused paralysis of the upper left and lower limbs． BoNT-A was administered to the upper left and lower limbs in the convalescent period， and to the upper left limb in the chronic stage． In rehabilitation， the mode of walking was changed progressively according to the standing and walking conditions， and the approach to the upper left limb was also carried out． Four years after the onset， he became self-reliance of walking with a walker， and in five years he became self-reliance of single-piece Lofstrand crutch． There is a possibility of long-term and gradual improvement by administration of BoNT-A multiple times from the early onset and long-term rehabilitation．

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