Impact of functional independence and sociodemographic factors on post-stroke discharge destination in a super-aged rural community in Japan / Journal of Rural Medicine

Objective: This study aimed to clarify the factors influencing the discharge destination of stroke patients in a super-aged rural community in Japan, focusing on functional independence and sociodemographic factors.Patients and Methods: We enrolled patients recovering from stroke with supratentorial lesions who were admitted to our convalescent rehabilitation hospital. The motor components of the Functional Independence Measure (FIM-motor) were assessed for each patient at admission and discharge as explanatory variables. An increase in the FIM-motor scores during hospitalization was also recorded. Additionally, sociodemographic data such as sex, age, and clinical characteristics, such as type of stroke, history of stroke, days from stroke onset to transfer to our convalescent rehabilitation hospital, total duration of hospital stay including acute care, number of co-resident household members, living with a spouse, and number of children were collected. As target values, discharge outcomes were categorized into two groups: returning home and going to a nursing home. Logistic regression analysis was performed.Results: The study sample comprised 160 patients (mean age ± standard deviation, 74.80 ± 12.19 years). Of these, 114 were discharged to their homes, and 46 were transferred to nursing homes. The results of multivariate logistic regression analysis indicated that higher FIM-motor scores at discharge, greater number of co-resident household members, and living with one’s spouse were the most powerful predictors of a higher probability of returning home.Conclusion: This study demonstrated that functional independence levels and the number of co-resident household members were crucial factors in predicting the discharge destination of patients after stroke in a super-aged rural community in Japan. These findings imply that for older patients with lower functional independence, supportive social networks are essential for home discharge, offering clues for providing long-term healthcare in super-aged rural communities worldwide.

Building Medical Rehabilitation System with Safety and Without Interruption for the Patients with Coronavirus Disease 2019 Using the Functional Resonance Analysis Method (FRAM)

IntroductionCoronavirus disease 2019 (COVID-19) is an indication for rehabilitation medicine, especially in severe cases. However, there has been no systematic development of a safe and uninterrupted provision system of medical rehabilitation for patients and medical staff with COVID-19. The Functional Resonance Analysis method (FRAM) is used to analyze performance in a socio-technical system. In FRAM, each "Function" is viewed from six aspects : Input, Output, Preconditions, Resources, Control, and Time. These aspects define each Function and reveal connections between Functions. In this study, we analyzed a safe and uninterrupted provision system for medical rehabilitation--for severely ill COVID-19 patients using FRAM to prepare for possible problems in the future. MethodsThe subject of analysis was the provision system for medical rehabilitation for patients with COVID-19 at the Rehabilitation Center of Hyogo College of Medicine College Hospital. The analysis was conducted by dividing a 21-month rehabilitation period beginning April 2020 into 5 phases, and analyzing each phase using FRAM. The first four phases were retrospective analyses, and the fifth phase was a prospective analysis. ResultsOur results showed that the number of rehabilitation physicians, consultation systems, and full-time therapists was adjusted and the system providing rehabilitation was modified during each phase. DiscussionElements of Function, such as preconditions, control, and resources, require modification in each phase. In the process of adding and deleting these elements, it became clear that it was necessary to deal with new characteristics of SARS-CoV-2 infection. Retrospective system analysis using FRAM may contribute to the planning of measures necessary for the implementation of rehabilitation medicine prospectively.

Effect of Gait Exercise Assist Robot on Walking Ability in a Patient with Chronic Stroke / The Japanese Journal of Rehabilitation Medicine

We report a case of a patient with chronic stroke who improved his gait ability through weekly gait training using Gait Exercise Assist Robot (GEAR). A man in his 70s, who developed cerebral infarction 27 years ago, presented with right-sided hemiplegia. Before gait training, the patient's gait ability was assessed to be independent, but poor toe clearance was observed on the paralyzed side during the swing phase. Therefore, we started gait training using GEAR with the goal of improving his gait pattern. The patient underwent gait training using GEAR for 20 min/day, 1 day/week for 12 weeks, wherein the treadmill speed was increased as much as possible in order to improve the swing of the paralyzed lower limbs, and the visual and auditory feedback functions were also used to promote the load and swing of the paralyzed lower limbs. As a result, the overground gait velocity, Timed Up and Go Test, and 6-minute walking distance increased after 4 weeks. However, poor toe clearance was observed on the paralyzed side during the swing phase even after 12 weeks of the training. These results suggest that 4 weeks of gait training using GEAR (performed only 1 day/week) may effectively improve the gait ability of patients with chronic stroke. On the other hand, no improvement in gait pattern was observed, and further investigation is required in the future.

Outcome Prediction for Patients With Ischemic Stroke in Acute Care: New Three-Level Model by Eating and Bladder Functions

Objective@#To develop a new prediction model by combining independence in eating and bladder management functions, and to assess its utility in an acute care setting. @*Methods@#Patients with ischemic stroke who were admitted in our acute stroke care unit (n=250) were enrolled in this study. Functional Independence Measure (FIM) scores for eating and bladder management on the initial day of rehabilitative treatment (median, 3 days) were collected as predictive variables. These scores were divided into low (<5) and high (≥5) and categorized as values 0 and 1, respectively. From the simple summation of these two-level model values, we derived a three-level model that categorized the scores as values 0, 1, and 2. The FIM-motor scores at discharge (median, 14 days) were collected as outcome measurements. The three-level model was assessed by observing the distribution patterns of the outcome FIM-motor scores and logistic regression analyses. @*Results@#The median outcome FIM-motor score was 19 (interquartile range [IQR],13.8–45.3) for the value 0 category (n=14), 66.5 (IQR, 59.5–81.8) for the value 1 category (n=16), and 84 (IQR, 77–89) for the value 2 category (n=95) in the three-level model. Data fitting by logistic regression for FIM-motor scores of 41.3 and 61.4 reached 50% probability of values 1 and 2, respectively. @*Conclusion@#Despite the simplicity of the three-level model, it may be useful for predicting outcomes of patients with ischemic stroke in acute care.

Specificities of Rehabilitative Treatments of Brain Disorders：A Survey Using Statistical Analysis of Textual Data from Annual Meeting Abstracts / The Japanese Journal of Rehabilitation Medicine

Objective：Brain disorders are major concerns in rehabilitation medicine in Japan. Of the various categories of brain disorders, rehabilitative treatments for strokes, traumatic brain injuries, and neurodegenerative diseases are different. This study aimed to demonstrate the specificities of the rehabilitative treatments for these three subcategories after statistical analysis of textual data from abstracts indexed during an annual meeting for rehabilitation medicine.Materials and Methods：Abstracts indexed during the 56th annual meeting of the Japanese Association of Rehabilitation Medicine in 2019 were entered into the analytical database. Words associated with each subcategory were extracted using Jaccard's similarity coefficients.Results：The analysies showed that the words strongly associated with strokes were “paresis,” “convalescent,” “admission,” “onset,” “ward,” “function,” “FIM,” “impairment,” “improvement,” and “discharge” (extracted from 402 abstracts；coefficients ranged from 0.36 to 0.23). In parallel, the words such as “trauma,” “traffic,” “higher,” “accident,” “fall,” “brain,” “labor,” “brain-disease,” “hematoma,” and “facility” were related to traumatic brain injuries (extracted from 36 abstracts；coefficients ranged from 0.15 to 0.08). The words strongly associated with neurodegenerative diseases were “cognition,” “MMSE,” “elderly,” “care,” “home,” “nursing home,” “fracture,” “impairment,” “Yahr,” and “disease” (extracted from 96 abstracts；coefficients ranged from 0.18 to 0.09).Conclusions：The specifics of rehabilitative treatments for strokes, traumatic brain injuries, and neurodegenerative diseases were successfully outlined after the analysies of the textual data. This technique may be useful for evaluating information provided in textual forms, such as abstracts of conferences.

Effect of Gait Exercise Assist Robot on Walking Ability in a Patient with Chronic Stroke / The Japanese Journal of Rehabilitation Medicine

We report a case of a patient with chronic stroke who improved his gait ability through weekly gait training using Gait Exercise Assist Robot (GEAR). A man in his 70s, who developed cerebral infarction 27 years ago, presented with right-sided hemiplegia. Before gait training, the patient's gait ability was assessed to be independent, but poor toe clearance was observed on the paralyzed side during the swing phase. Therefore, we started gait training using GEAR with the goal of improving his gait pattern. The patient underwent gait training using GEAR for 20 min/day, 1 day/week for 12 weeks, wherein the treadmill speed was increased as much as possible in order to improve the swing of the paralyzed lower limbs, and the visual and auditory feedback functions were also used to promote the load and swing of the paralyzed lower limbs. As a result, the overground gait velocity, Timed Up and Go Test, and 6-minute walking distance increased after 4 weeks. However, poor toe clearance was observed on the paralyzed side during the swing phase even after 12 weeks of the training. These results suggest that 4 weeks of gait training using GEAR (performed only 1 day/week) may effectively improve the gait ability of patients with chronic stroke. On the other hand, no improvement in gait pattern was observed, and further investigation is required in the future.

Outcome Prediction for Patients With Ischemic Stroke in Acute Care: New Three-Level Model by Eating and Bladder Functions

Objective@#To develop a new prediction model by combining independence in eating and bladder management functions, and to assess its utility in an acute care setting. @*Methods@#Patients with ischemic stroke who were admitted in our acute stroke care unit (n=250) were enrolled in this study. Functional Independence Measure (FIM) scores for eating and bladder management on the initial day of rehabilitative treatment (median, 3 days) were collected as predictive variables. These scores were divided into low (<5) and high (≥5) and categorized as values 0 and 1, respectively. From the simple summation of these two-level model values, we derived a three-level model that categorized the scores as values 0, 1, and 2. The FIM-motor scores at discharge (median, 14 days) were collected as outcome measurements. The three-level model was assessed by observing the distribution patterns of the outcome FIM-motor scores and logistic regression analyses. @*Results@#The median outcome FIM-motor score was 19 (interquartile range [IQR],13.8–45.3) for the value 0 category (n=14), 66.5 (IQR, 59.5–81.8) for the value 1 category (n=16), and 84 (IQR, 77–89) for the value 2 category (n=95) in the three-level model. Data fitting by logistic regression for FIM-motor scores of 41.3 and 61.4 reached 50% probability of values 1 and 2, respectively. @*Conclusion@#Despite the simplicity of the three-level model, it may be useful for predicting outcomes of patients with ischemic stroke in acute care.

Specificities of Rehabilitative Treatments of Brain Disorders：A Survey Using Statistical Analysis of Textual Data from Annual Meeting Abstracts / The Japanese Journal of Rehabilitation Medicine

Objective：Brain disorders are major concerns in rehabilitation medicine in Japan. Of the various categories of brain disorders, rehabilitative treatments for strokes, traumatic brain injuries, and neurodegenerative diseases are different. This study aimed to demonstrate the specificities of the rehabilitative treatments for these three subcategories after statistical analysis of textual data from abstracts indexed during an annual meeting for rehabilitation medicine.Materials and Methods：Abstracts indexed during the 56th annual meeting of the Japanese Association of Rehabilitation Medicine in 2019 were entered into the analytical database. Words associated with each subcategory were extracted using Jaccard's similarity coefficients.Results：The analysies showed that the words strongly associated with strokes were “paresis,” “convalescent,” “admission,” “onset,” “ward,” “function,” “FIM,” “impairment,” “improvement,” and “discharge” (extracted from 402 abstracts；coefficients ranged from 0.36 to 0.23). In parallel, the words such as “trauma,” “traffic,” “higher,” “accident,” “fall,” “brain,” “labor,” “brain-disease,” “hematoma,” and “facility” were related to traumatic brain injuries (extracted from 36 abstracts；coefficients ranged from 0.15 to 0.08). The words strongly associated with neurodegenerative diseases were “cognition,” “MMSE,” “elderly,” “care,” “home,” “nursing home,” “fracture,” “impairment,” “Yahr,” and “disease” (extracted from 96 abstracts；coefficients ranged from 0.18 to 0.09).Conclusions：The specifics of rehabilitative treatments for strokes, traumatic brain injuries, and neurodegenerative diseases were successfully outlined after the analysies of the textual data. This technique may be useful for evaluating information provided in textual forms, such as abstracts of conferences.

Constraint-induced Aphasia Therapy in a Case of Chronic Broca's Aphasia / The Japanese Journal of Rehabilitation Medicine

Constraint-induced aphasia therapy (CIAT) is becoming increasingly popular worldwide. It is based on the theory of CI therapy, which is supported by considerable evidence as being useful for rehabilitation after stroke. The CIAT-II protocol (Johnson et al., 2015) was modified to a Japanese version, consisting of intensive training using five expressive language exercises, with shaping and a transfer package for 3 hr/day for 15 consecutive weekdays. We assessed outcomes using the Standard Language Test of Aphasia (SLTA) and Verbal Activity Log (VAL) before and after therapy. We confirmed some improvements in language function using the SLTA and remarkable improvement in VAL amount-of-use scores. Language function and communication skills can be improved using CIAT in patients with chronic aphasia, based on their language function evaluation. The present findings suggest that CIAT might be effective as speech therapy for Japanese patients with chronic aphasia.

Long-Term Outcomes of FIM Motor Items Predicted From Acute Stage NIHSS of Patients With Middle Cerebral Artery Infarct

OBJECTIVE: To outline the association between the National Institutes of Health Stroke Scale (NIHSS) in the acute stage and the Functional Independence Measure (FIM) of motor items several months later. METHODS: Seventy-nine infarct cases with middle-cerebral-artery region transferred to long-term rehabilitation facilities were analyzed. Patients were allocated to either the model-development group or the confirmatory group at a 2:1 ratio. Independent variables were based on the NIHSS during the acute care and on demographic factors such as age and modified Rankin Scale (mRS) before onset. Multivariate logistic analyses were performed to predict the independence of each FIM motor item. These models were evaluated in the confirmatory group. RESULTS: Multivariate logistic analyses in the model-development group (n=53) indicated that at least one NIHSS item was statistically significantly associated with the functional independence of a single FIM motor item. Of the NIHSS items, the affected lower extremity item was the most widely associated with 11 of the FIM motor items, except for eating and shower transfer. The affected upper extremity function was the second widely involved factor associated with 7 of the FIM motor items including eating, grooming, bathing, toileting, bed transfer, toilet transfer, and shower transfer. Age and mRS were also statistically significant contributing factors. The obtained predictive models were assessed in the confirmatory group (n=26); these were successful except for the stairs climb item. CONCLUSION: In combination with age and pre-stroke status, the NIHSS items (especially the affected extremity items) may be useful for the prediction of long-term outcome in terms of activities in daily living.

Constraint-induced Aphasia Therapy in a Case of Chronic Broca's Aphasia / The Japanese Journal of Rehabilitation Medicine

Constraint-induced aphasia therapy (CIAT) is becoming increasingly popular worldwide. It is based on the theory of CI therapy, which is supported by considerable evidence as being useful for rehabilitation after stroke. The CIAT-II protocol (Johnson et al., 2015) was modified to a Japanese version, consisting of intensive training using five expressive language exercises, with shaping and a transfer package for 3 hr/day for 15 consecutive weekdays. We assessed outcomes using the Standard Language Test of Aphasia (SLTA) and Verbal Activity Log (VAL) before and after therapy. We confirmed some improvements in language function using the SLTA and remarkable improvement in VAL amount-of-use scores. Language function and communication skills can be improved using CIAT in patients with chronic aphasia, based on their language function evaluation. The present findings suggest that CIAT might be effective as speech therapy for Japanese patients with chronic aphasia.

Relationship between Pain and Muscle Activities of the Knee Joint during Walking in Patients with Severe Knee Osteoarthritis / The Japanese Journal of Rehabilitation Medicine

Objective：To investigate the relationship between clinical assessment of pain and muscle activity during walking in patients with severe knee osteoarthritis (OA)．Methods：Eleven patients diagnosed as having severe knee OA (13 knees) were evaluated with electromyography and numerical rating scale (NRS) of pain during walking. Electromyography was recorded from the vastus medialis (VM), semitendinosus (ST), vastus lateralis (VL), and biceps femoris (BF) muscles. Co-contraction indexes (CCIs) for the extensor and flexor muscles of the knee joint were calculated as follows：using the VM and ST data for CCI at the medial aspect of the knee and the VL and BF data for CCI at the lateral aspect. Spearman's rank correlation coefficients between the average individual muscle activities or CCI and pain were calculated.Results：During the terminal stance of walking, NRS significantly correlated with the activation patterns of BF (r ＝－0.61, p＜0.05), the CCI of VL-BF (r ＝－0.582, p＜0.05), and the CCI of VM-ST (r ＝－0.596, p＜0.05)．Conclusion：This study suggests that pain severity is reflected in increasing CCI at the medial and lateral aspects during the terminal stance phase in severe knee OA.

Functional independence measure for elderly patients undergoing aortic valve replacement.

OBJECTIVE: This study aimed to evaluate the efficacy of the Functional Independence Measure to assess preoperative frailty for elderly patients undergoing surgical aortic valve replacement. METHODS: Eighty-five patients >65 years who survived elective isolated aortic valve replacement from January 2008 to October 2015 were included. The mean age at the operation was 78 ± 6 years old (n = 28 males, n = 57 females). The patients were divided into two groups according to their status at discharge: impossible to discharge home or hospitalization for >30 days (compromised group, n = 8), or unaffected (unaffected group, n = 77). Preoperative frailty was evaluated with the Functional Independence Measure, which comprises 18 items divided into six domains: self-care, sphincter control, mobility, locomotion, communication, and social cognition. RESULTS: The preoperative total Functional Independence Measure score was significantly lower in the compromised group (79 ± 32) than in the unaffected group (120 ± 9, p < 0.01). The preoperative motor Functional Independence Measure score was significantly lower in the compromised group (45 ± 24) than in the unaffected group (85 ± 9, p = <0.01). The duration of postoperative intubation, intensive care unit stay, and postoperative hospitalization were significantly longer in the compromised group than in the unaffected group (48 ± 67 vs 16 ± 12 h, p < 0.01; 6.7 ± 5.3 vs 3.4 ± 2.0 days, p < 0.01; 34 ± 27 vs 23 ± 11 days, p = 0.02, respectively). CONCLUSIONS: The preoperative Functional Independence Measure is effective for assessing preoperative frailty in elderly patients undergoing aortic valve replacement in terms of predicting operative morbidity.

Three Cases of Chronic Stroke Patients Receiving 4-weeks of Intensive Rehabilitation Following Botulinum Toxin Type A Treatment for Lower Limb Spasticity / The Japanese Journal of Rehabilitation Medicine

Botulinum toxin type A (BTXA) has been shown to be an effective treatment in reducing muscle tone and managing spasticity in poststroke patients. However, its effectiveness in improving function in lower limb spasticity has been more controversial. In this report, we present our findings in three cases of chronic stroke patients with lower limb spasticity wherein we examine the effectiveness of a 4-week intensive rehabilitation program following BTXA treatment. For each patient, BTXA was injected into spastic muscles of the affected lower limb and a rehabilitation program was provided for the patient in-hospital for 4 weeks. Before BTXA treatment (baseline) and at 2 and 4 week follow-ups after each treatment, the Stroke Impairment Assessment Set (SIAS), the Modified Ashworth Scale (MAS) and the Range of Motion (ROM) of the ankle, the 10 Meter Walking Test (10MWT), the 6 minutes walking distance (6MD), the Timed Up and Go Test (TUG), the Berg Balance Scale (BBS), and the Functional Independence Measure (FIM) were all assessed. In each patient, ankle MAS and ROM, 10MWT, 6MD, TUG, and BBS after 4 weeks improved from the baseline. Furthermore, the ankle MAS and ROM improved significantly within 2 weeks, as did the 10MWT and 6MD over the total 4 weeks. In conclusion, it is suggested that a better improvement of ambulation and balance, as well as spasticity, would be found with intensive rehabilitation following BTXA treatment for lower limb spasticity.

Two Cases of Poststroke Hemiplegic Patients Whose Gate Ability Was Improved by Using Twister Orthoses / The Japanese Journal of Rehabilitation Medicine

Twister orthoses are used to correct in-toeing and out-toeing, and consist of a pelvic band, a twister cable, and an ankle-foot orthosis (AFO). The twister cable is made of spiral coiled springs and connects the pelvic band with the AFO. Twister orthoses are used for children with lower limb paralysis who in many cases present with a rotation deformity of the hip joint ; however, their use in adults has not yet been reported. We report our experience treating two cases of adult poststroke hemiplegic patients whose gate ability was improved by using twister orthoses.

Shoulder Joint Motion Analysis of Daily Living Activities Using a Global Coordinate System / The Japanese Journal of Rehabilitation Medicine

Objective : With clinical application in mind, we developed a method to measure the movement of a selected joint three-dimensionally as a conic domain (joint sinus cone). The method was applied to shoulder joint motion during daily living activities exercises in a group of hemiparetic poststroke patients. The results were compared to the exercise range of physically unimpaired persons. Methods : The subjects dressed in jackets and performed certain other tasks in a sitting position and the range of motion of the shoulder joint in three dimensions was measured using a 6-dimensional electromagnetic tracking system. Measurement results were analyzed with a plane display using a Lambert Azimuthal equal area. Results : This method was able to determine findings difficult to see with the naked eye, such as the narrow range of motion in a paralyzed shoulder joint and poor functionality also in the contralateral shoulder. Conclusion : The dressing measurement was achieved using magnetic measurement equipment. By displaying the results through a map projection it was possible to appreciate the whole range of the motion. Because this method facilitates the expression of complex joint exercise ranges, it will be useful in the analysis of daily behavior restrictions due to impairment.

Predictive Factors for Good Functional Recovery and the Effect of Constraint-induced Movement Therapy on Motor Function : An Assessment of Upper Extremity Function using STEF in a Large Sample / The Japanese Journal of Rehabilitation Medicine

Background : Constraint-induced movement therapy (CI therapy) is a rehabilitation treatment that effectively improves upper extremity function in patients with chronic hemiparesis after stroke. In Japan, no previous studies have shown the effects of CI therapy in a large size sample, and the Simple Test for Evaluating Hand Function (STEF), a standard assessment tool for upper extremity function, is rarely used to evaluate the effects of CI therapy. Little is known regarding the factors capable of predicting the outcome of CI therapy. The present study aimed to examine potential predictors of outcomes after CI therapy and the effects of CI therapy using STEF. Methods : This study included patients with hemiparesis in the chronic stage of stroke (≥180 days from onset). We compared upper extremity function before and after CI therapy intervention, which involved 5 hours per day for 10 consecutive weekdays of training. We assessed upper extremity function using the STEF, Wolf Motor Function Test-functional ability scale (WMFT-FAS) before and after intervention, and investigated potential predictors (age, gender, time since stroke, type of stroke, side of stroke, hand dominance, spasticity). Results : There were 107 subjects. Our comparison revealed that both STEF and WMFT-FAS scores improved significantly following intervention, from means of 31.3 to 42.7 points and 51.8 to 57.0 points, respectively. No significant predictors that influenced the functional outcome were identified. Conclusion : CI therapy is effective for improving upper extremity function. It is important not to exclude people from CI therapy based on any supposed predictors.

Cancer Rehabilitation in the Regional Hospital for Cancer Treatment / The Japanese Journal of Rehabilitation Medicine

Background & Purpose : For cancer patients and survivors, some rehabilitation seems to be required in order for them to function properly and to maintain their ADL and QOL. To improve outcomes, the subject of cancer rehabilitation in our hospital, one of Japan's regional centers for cancer treatment, was examined. Methods:Our section met 246 patients who were admitted to our hospital for cancer treatment from April, 2008 to March, 2010. We assessed their age, cancer origin, disability, the term between admission, operation and consultation, the period of hospitalization and rehabilitation, and the outcome. Results:Most patients had some deficits due to their cancer, which included neurological defects, bone and joint troubles, especially bone metastasis, or dysphasia. “Disuse syndrome” was found in 101 patients who had been lying in bed without these deficits. Owing to their treatment, 139 patients were discharged home with some functional inconvenience. Their length of stay in our hospital was suggested to be shortened by early consultation with our section (<i>R</i>=0.84). Despite their efforts, 90 patients died. They enrolled in some program for an average of 56.4±6.3 days, and continued their rehabilitation for 7.6±1.2 days on average before their deaths. Conclusion:Patients who are suffering from cancer need rehabilitation in all stages of their disease, which are preventive, restorative, supportive and palliative. Both in a hospital setting and in community-based medicine, a better rehabilitation system is required for most cancer patients, not only the survivors, especially those falling into “disuse syndrome” unnecessarily, but also terminally ill patients.