Background: Team-based approaches involving the cooperation of various professionals have the power to improve the quality of medical care by utilizing the specialized knowledge and skills of each professional. A multidisciplinary pain, agitation, and delirium (PAD) management team was established in Hiroshima University Hospital. Herein, we describe smooth patient mobilization achieved by enabling discussions among members of this multidisciplinary management team. Case: The patient was a 72-year-old Japanese woman with acute exacerbation of interstitial pneumonia and respiratory failure. We identified a suspected alveolar hemorrhage by bronchofiberscopy on the patient’s first day in the intensive care unit (ICU). This finding required the patient to be placed on bed rest. Therefore, her physiotherapy program was restricted to mobilization. In team rounds during the patient’s 5th day in the ICU, we discussed her mobilization. Discussions among the multidisciplinary medical staff led to mobilization and a reduction in sedation medication administered because of the suspected alveolar hemorrhage. The patient underwent a second bronchofiberscopy by emergency medical doctors to assess the alveolar hemorrhage immediately after PAD rounds. The suspected alveolar hemorrhage was not confirmed. Therefore, the physiotherapy program was amended to include standing exercises and sitting in a wheelchair; the new program was initiated the same day. The patient did not experience worsening symptoms during her hospitalization and was discharged from the hospital 95 days after initial admission. Conclusions: By discussing treatment options within a multidisciplinary medical team, we achieved smooth patient mobilization and administered reduced levels of sedation medication.

Objective: Radiotherapy is an essential component of curative or palliative therapy for patients with uterine cervical cancer. Although advances in radiotherapy have led to longer survival, survivors may consequently be at risk of pelvic insufficiency fracture (PIF). We retrospectively reviewed medical records and clinical outcomes to assess the impact of PIF on walking disability. Methods: Between January 2002 and December 2009, 145 uterine cancer patients treated with radiotherapy in our hospital were reviewed. Among these, 15 patients (10.3%) were diagnosed with PIF. The types of fractures were identified according to the AO/OTA classification system. Medical records were examined to establish the time to first diagnosis of PIF, the type of fracture, and clinical outcomes. Disability was assessed using Barthel index mobility scores. Results: The median time to PIF detection was 16 months. Of the 15 patients with PIF, 14 had type B fractures (7 cases of B2 and 7 cases of B3) and 1 had a type C fracture. Among 11 patients with pelvic pain, 6 achieved pain control but 5 patients with bilateral lesions in the posterior arch or lateral compression of the sacrum developed pain that finally resulted in walking disability and a lower performance status. Conclusions: PIF causes severe motor disturbance in patients with unstable fracture types. Routine imaging checkups were useful during the 5 years after completion of radiotherapy; in nine patients the fracture progressed for longer than 1 year. In cancer rehabilitation for PIF patients, continuous assessment is essential for predicting walking disability.

Background: Magnetic resonance diffusion tensor imaging (DTI) is a new technique that evaluates neural fiber integrity within the brain. We conducted DTI in patients exhibiting aphasia during the acute stage post-infarct and investigated the neural tracts responsible by comparison with DTI data from age-matched controls. Methods: Fractional anisotropy (FA) maps were generated from diffusion tensor brain images obtained from aphasic patients 14−21 days following their first infarct. Tract-based spatial statistics (TBSS) analysis was then applied. In addition, regions of interest (ROIs) were set within the right and left arcuate fasciculus, and mean FA values were extracted from individual TBSS data. The ratios between FA values in the left and right hemispheres were compared with those of the control group. Results: The study examined 10 aphasic patients and 21 age-matched controls. Brain maps from TBSS analysis revealed significantly reduced FA in the left arcuate fasciculus of the patient group compared with that in the control group. Further ROI analyses confirmed significantly lower left/right arcuate fasciculus FA ratios in aphasic patients versus controls (median [range]: 0.955 [0.739−1.023] vs. 1.006 [0.982−1.088]; P = 0.0001 by Wilcoxon rank sum test). Conclusions: These results suggest that FA in the left arcuate fasciculus decreased in association with aphasia after cerebral infarct. Because patients in the acute stage have not yet experienced the neural recovery that occurs in the chronic stage, the findings indicate that the left arcuate fasciculus is a crucial neural structure in aphasia.

Objective: Neuromyelitis optica spectrum disorders (NMOSD) are immune-mediated chronic inflammatory disorders of the central nervous system that are predominantly characterized by attacks of optic neuritis and/or transverse myelitis. The aim of this study was to investigate the clinical rehabilitation course of patients with NMOSD. Methods: We carried out a retrospective evaluation of 20 cases of NMOSD in which the patients underwent multidisciplinary inpatient rehabilitation intervention starting within 2 months after acute exacerbation. Rehabilitation outcomes were assessed using the modified Rankin Scale, the Expanded Disability Status Scale (EDSS), and the Functional Independence Measure (FIM). Results: A total of 19 cases were finally included in this study. The average EDSS scores ranged from 5.9 to 7.1 during hospitalization. Lower age significantly correlated with improved EDSS scores. Changes in the EDSS score during rehabilitation varied in patients experiencing their first attack; however, improvements in the EDSS score of ≥ 1.5 were observed only in patients who had experienced two or less attacks. During rehabilitation, the FIM significantly improved from 81.4 to 101.7, with a gain of 20.3 and efficacy of 0.2/day. Conclusion: Multidisciplinary rehabilitation may improve functional recovery after NMOSD attacks. Younger age and two or less attacks were associated with better outcomes in this study.

Background: Iatrogenic injuries to the spinal accessory nerve (SAN) are not uncommon during cervical lymph node biopsy. Many operative treatments for SAN injury in the posterior cervical triangle have been reported, but there are no guidelines regarding the choice between operative and nonoperative treatments. Because it is believed that the nerve seldom spontaneously regenerates, some articles suggest surgical intervention within 3 months from the nerve injury to achieve good postoperative results. However, we experienced a case of spontaneous accessory nerve recovery more than 3 months after accessory nerve injury. It is necessary to carefully exclude similar patients from unnecessary surgery. Case: A 41-year-old woman underwent cervical lymph node biopsy at an otolaryngology clinic. She experienced pain across her neck and weakness of the shoulder in abduction just after the biopsy. Three months after the biopsy, her symptoms persisted and she was referred to our hospital for surgical treatment. On careful examination, we detected signs of accessory nerve regeneration. Consequently, we prescribed physical therapy and a rehabilitation program, including active and passive range-of-motion exercises of the shoulder and muscle strengthening exercises. Six months after the injury, there was a dramatic improvement of the trapezius muscle function and the patient became pain free. Discussion: When the biopsy incision is more than one finger’s breadth away from the normal course of the SAN, and when Tinel-like signs advance along the trapezius muscle over time, spontaneous SAN recovery can be anticipated.

Objective: Pressure injuries seriously impact the quality of life of patients and increase public and private healthcare costs. Electrical stimulation therapy is recommended for wound contraction, and some clinical studies have shown that the application of a monophasic pulsed microcurrent can help to reduce the treatment period. However, the optimal stimulus conditions are unclear. The purpose of this study was to investigate the effect of different frequencies of monophasic pulsed microcurrent stimulation on the number and viability of human dermal fibroblasts. Methods: Human dermal fibroblasts were electrically stimulated in vitro (intensity: 200 μA; frequency: 1, 2, 4, 8, 16, 32, and 64 Hz; duty factor: 50%) for 1 h three times every 24 h. Controls were unstimulated. Cell numbers and cell viability were assessed after each electrical stimulation session. Results: In the 1-, 2-, 4-, and 8-Hz groups, cell numbers were significantly higher than those in the control group, whereas electrical stimulation at 64 Hz resulted in a decrease in cell numbers at 24 h after the third treatment (p < 0.05). Cell viability was high in both the control and low-frequency stimulation groups, with no significant differences between groups. Conclusion: Application of 1–8 Hz monophasic pulsed microcurrent stimulation increased the number of human dermal fibroblasts in vitro, and is proposed as the optimal condition for accelerating the healing of pressure injuries.

Objective: The purpose of this research was to investigate the real-world effectiveness of speech therapy time on cognitive recovery in older patients with acute stroke. Methods: The participants of this retrospective cohort study were hospitalized patients with acute stroke registered in the Japan Rehabilitation Database between December 2005 and September 2014. The patients were divided into two groups according to the amount of time they spent undergoing speech therapy, i.e., a high-intensity speech therapy group and a control group. Multivariate linear regression analysis was performed to assess the association between cognitive Functional Independence Measure efficiency and high-intensity speech therapy. Results: Of the 3341 eligible stroke patients (mean age: 77 years) extracted from the database, 53% received high-intensity speech therapy. Patients in the high-intensity speech therapy group had significantly higher cognitive Functional Independence Measure efficiency scores than those in the control group (mean, 0.17 vs. 0.10, respectively; P < 0.001). Multivariate regression analysis showed that cognitive Functional Independence Measure efficiency was significantly and positively correlated with high-intensity speech therapy (coefficient, 0.03; 95% confidence interval, 0.004–0.056; P = 0.026).

Conclusions: These data suggest that a large amount of speech therapy time in older patients with acute stroke is a significant predictor of good cognitive recovery. Increased amounts of speech therapy for such patients may lead to better cognitive recovery after stroke.

Background: Magnetic resonance diffusion-tensor imaging (DTI) is a tool for the assessment of neural fiber integrity. We applied DTI in a patient with hearing loss that developed after bilateral putaminal hemorrhage. Case: A 59-year-old woman was referred to our outpatient clinic for sequelae diagnosis. Six years earlier, she had suffered a left putaminal hemorrhage, but almost fully recovered. Four years later, she suffered a right putaminal hemorrhage, resulting in severe left hemiparesis and hearing loss. After receiving conservative acute care treatment, she was transferred to a long-term rehabilitation facility and returned home 7 months later, when her Functional Independence Measure score was 103 points. Although the patient could not respond to auditory stimuli, her writing and reading abilities were intact. Auditory examinations indicated that the brainstem response was normal, but pure tone audiometry was at the low end of the scale (105 dB). We examined the patient’s brain using DTI, and the lesions were assessed in reference to the standard brain map transformed into her individual brain space. Fractional anisotropy and color brain maps indicated that the lesions were located within bilateral acoustic radiations. In addition, we applied fiber tracking analysis in which voxels of the medial geniculate bodies in the standard brain map were transformed into the patient’s individual brain space and then taken as seeds for the fiber tracking. The resulting image showed bilateral disruption of acoustic radiation fibers. Conclusion: By applying DTI, we identified the neuroanatomical pathology of hearing loss that developed after bilateral putaminal hemorrhage.

Objective: The aim of this study was to measure the initiation of pharyngeal swallowing during discrete swallowing and during chew-swallowing in younger and older healthy subjects and to determine the normal range of the stage transition duration (STD) for different food boluses. The correlations between STDs were investigated. Methods: Twenty-eight younger subjects (< 60 years old) and 25 older subjects (≥ 60 years old) were enrolled. While in the sitting position, the subjects swallowed 10 ml of thin liquid barium (LQ), 8 g of corned beef hash with barium (CB), 8 g of cookie with barium (CK), and a two-phase mixture of 4 g of corned beef hash with barium and 5 ml of thin liquid barium (MX). A videofluoroscopic examination of swallowing was performed at 30 frames/s in the lateral projection. The delay in pharyngeal swallowing (i.e., STD) was measured. The normal range (mean ± 2SD) of STDs for each bolus type was determined, and correlations were calculated to examine the relationship among STDs. Results: The median STDs for LQ, CB, CK, and MX in all subjects were 0.0, 1.2, 2.4, and 1.9 s, respectively. The STDs were prolonged for CB, CK, and MX compared with LQ. Additionally, the median STD was longer for LQ, CB, and CK in older than in younger subjects. No significant correlations were found between STDs except for those between CB and CK. Conclusions: A delayed pharyngeal response is commonly observed during chew-swallowing. Liquids, solids, and two-phase mixtures exhibit independent timings of pharyngeal swallow initiation.

1) The unit of Cadence in Table 2:

(Incorrect)

cm

(Correct)

steps/min

2) The addition to Figure 2 legend: (D)

(Incorrect)

toe clearance versus toe elevation at midswing.

(Correct)

toe clearance versus toe elevation at midswing (D).

Objective: Although previous studies have evidenced the value of three-dimensional gait analysis (3DGA) for evaluating gait disorder, the time-consuming measurement process and space requirement has hampered its use in the clinical setting. The aim of this study was to examine the feasibility of a simplified 3DGA system for stroke patients. Methods: Thirteen pairs of stroke patients and age- (± 1 year), gender-, and gait speed- (± 0.5 m/s) matched controls were drawn from the Fujita Health University gait analysis database. 3DGA was performed using the KinemaTracer^® treadmill gait analysis system. Comparisons of the spatiotemporal and kinematic parameters were performed between stroke patients and matched controls. The correlations between items from the Wisconsin Gait Scale (WGS) and 3DGA data in stroke patients were also investigated. Results: 3DGA measurements clearly showed reduced toe clearance, hip flexion, and knee flexion in stroke patients compared with the matched controls. In contrast, significant increases were observed in hip elevation, shoulder elevation, shoulder lateral shift, and step width in stroke patients. For the four items drawn from the WGS, a significant correlation with three 3DGA parameters was observed: stance time on the impaired side, stance width, and knee flexion from toe off to midswing. Conclusions: In this study, significant differences in gait parameters of stroke patients and age-, gender-, and speed-matched controls were found using a simplified 3DGA system. A significant correlation with WGS was also observed. These results support the validity of the clinical measurement of gait parameters using a simplified 3DGA system.