国際生活機能分類(International Classification of Functioning, Disability and Health: ICF)にみた福祉・保健・医療の専門職協働における連携に関する貢献と課題

So far I have attempted to provide a broad framework within which to consider the importance of managerial and organisational integration. Inevitably in so doing I have found it necessary to raise wider educational and training issues which influence not only conceptual skills but also attitude. Indeed I have, on occasion, moved my argument or perspective to even wider considerations; issues pertaining to national culture. Culture, education policy or structure, industrial organisation, all interact in subtle and perhaps devious forms. Thus a cultural framework which is “overly status or class conscious” reflects this in its educational system. Most likely it is more predisposed to segment its secondary and tertiary education systems according to similar principles. It may well encourage separation of the university and technical college or polytechnic system to a degree that is industrially and commercially counterproductive — and integratively devisive. Such an educational system will no doubt require “preselection and filtering” which relies upon early, too early, subject specialisation; it may, subsequently, influence adversely the need for individuals and subgroups to communicate more intimately and to organise themselves more closely. In fact it may ensure the continuance of barriers, hierarchies, and polarised attitudes of class, structure and function all the way across and through commerce and industry.

A National Survey

A 66-year-old man was suddenly unable to speak, follow directions, or move his right arm and leg. He received tissue plasminogen activator within 90 minutes. Four days later, his speech was limited to effortful answers of yes or no. He could not walk or use his right arm, and self-care tasks required maximal assistance. What advice would you offer him and his family regarding rehabilitation for his disabilities?

https://www.nejm.org/doi/pdf/10.1056/NEJMcp043511

Rehabilitation after Stroke

Background and Purpose— There is no consensus concerning the number of patients developing spasticity or the relationship between spasticity and disabilities after acute stroke. The aim of the present study was to describe the extent to which spasticity occurs and is associated with disabilities (motor impairments and activity limitations). Methods— Ninety-five patients with first-ever stroke were examined initially (mean, 5.4 days) and 3 months after stroke with the Modified Ashworth Scale for spasticity; self-reported muscle stiffness; tendon reflexes; Birgitta Lindmark motor performance; Nine Hole Peg Test for manual dexterity; Rivermead Mobility Index; Get-Up and Go test; and Barthel Index. Results— Of the 95 patients studied, 64 were hemiparetic, 18 were spastic, 6 reported muscle stiffness, and 18 had increased tendon reflexes 3 months after stroke. Patients who were nonspastic (n=77) had statistically significantly better motor and activity scores than spastic patients (n=18). However, the correlat...

Spasticity After Stroke Its Occurrence and Association With Motor Impairments and Activity Limitations

Summary Rehabilitation after hemiplegic stroke has typically relied on the training of patients in compensatory strategies. The translation of neuroscientific research into care has led to new approaches and renewed promise for better outcomes. Improved motor control can progress with task-specific training incorporating increased use of proximal and distal movements during intensive practice of real-world activities. Functional gains are incorrectly said to plateau by 3–6 months. Many patients retain latent sensorimotor function that can be realised any time after stroke with a pulse of goal-directed therapy. The amount of practice probably best determines gains for a given level of residual movement ability. Clinicians should encourage patients to build greater strength, speed, endurance, and precision of multijoint movements on tasks that increase independence and enrich daily activity. Imaging tools may help clinicians determine the capacity of residual networks to respond to a therapeutic approach and help establish optimal doseresponse curves for training. Promising adjunct approaches include practice with robotic devices or in a virtual environment, electrical stimulation to increase cortical excitability during training, and drugs to optimise molecular mechanisms for learning. Biological strategies for neural repair may augment rehabilitation in the next decade.

/pdf/strategies-for-stroke-rehabilitation-19ij3gyrkd.pdf

Strategies for stroke rehabilitation

The objective of this study was to present an overview of the prevalence of spasticity after stroke as well as of test instruments and treatments. Recent studies show that spasticity occurs in 20%-30% of all stroke victims and in less than half of those with pareses. Although spasticity may occur in paretic patients after stroke, muscle weakness is more likely to be the reason for the pareses. Spasticity after stroke is more common in the upper than the lower limbs, and it seems to be more common among younger than older people. To determine the nature of passive stretch, electromyographic equipment is needed. However, the Modified Ashworth Scale, which measures the sum of the biomechanical and neural components in passive stretch, is the most common instrument used to grade spasticity after stroke. Treatment of spasticity with physiotherapy is recommended, although its beneficial effect is uncertain. The treatment of spasticity with botulinum toxin in combination with physiotherapy is suggested to improve functioning in patients with severe spasticity. A task-specific approach rather than a neurodevelopmental approach in assessing and treating a patient with spasticity after stroke seems to be preferred.

Spasticity After Stroke: An Overview of Prevalence, Test Instruments, and Treatments

Background: There is no consensus concerning the presence of spasticity or the relationship between spasticity and functioning and spasticity and health-related quality of life (HRQL) in the stable phase after stroke. Objective: The aim of the present study was to describe, 18 months after stroke, the frequency of spasticity and its association with functioning and HRQL. Methods: In a cohort of 66 consecutive patients with first-ever stroke, studied prospectively, the following parameters were assessed 18 months after stroke: spasticity, by the Modified Ashworth Scale (0–4 points with 1+ as the modification), muscle stiffness, by self-report, abnormal tendon reflexes, by physical examination, motor performance, by the Lindmark Motor Assessment Scale, mobility, by the Rivermead Mobility Index, activities of daily living, by the Barthel Index, and HRQL, by the Swedish Short Form 36 Health Survey Questionnaire (SF-36). Results: Of 66 patients studied, 38 were hemiparetic; of these, 13 displayed spasticity, 12 had increased tendon reflexes, and 7 reported muscle stiffness 18 months after stroke. Weak (r Conclusions: Few patients displayed spasticity 18 months after stroke. Spasticity might contribute to impairment of movement function and to limitation of activity, but seems to have a less pronounced effect on HRQL.

Spasticity and Its Association with Functioning and Health-Related Quality of Life 18 Months after Stroke

Background and purpose:  There is no consensus concerning the location or severity of spasticity, or how this changes with time after stroke. The purpose was to describe: the location and severity of spasticity, in different muscle groups, during the first 1–2 weeks and at 3 and 18 months after stroke; the association between the severity of spasticity and control of voluntary movements; and the occurrence of spasticity in younger versus older patients.



Methods:  In a cohort of consecutive patients, the following parameters were assessed during the first 1–2 weeks (n = 109) and at 3 (n = 95) and 18 (n = 66) months after first-ever stroke: spasticity, by the Modified Ashworth Scale in different muscle groups; plantar-flexor clonus, by physical examination; and movement function, by the Lindmark Motor Assessment Scale.



Results:  During the first 1–2 weeks and at 3 months after stroke, spasticity was most common in the anti-gravity muscles. The severity of upper extremity spasticity increased over time (P < 0.05). Upper extremity spasticity and movement scores were moderately associated (r = −0.61, P < 0.05). At 3 months, spasticity was more common amongst the younger patients (P < 0.05).



Conclusions:  The results confirm that spasticity is most common in the anti-gravity muscles and is associated with the control of voluntary movements. As the severity of spasticity also increased after 3 months, when neurally mediated spasticity is expected to have passed its peak, intrinsic muscle changes may play a larger role than neural components with the passage of time after stroke.

Location and severity of spasticity in the first 1–2 weeks and at 3 and 18 months after stroke

Objective To describe the recovery of fine hand use and the associations between fine hand use and, respectively, somatosensory functions, grip strength, upper extremity movements and self-care, in the first week and at 3 and 18 months after stroke, and to describe whether these associations change over time. Design Prospective observational study. Patients Sixty-six consecutive patients with stroke. Methods The following parameters were assessed in the first week, and at 3 and 18 months after stroke: fine hand use, grip strength (not assessed in the first week), touch, proprioceptive and upper extremity movement functions; and self-care. Results Seventy percent of all patients had limited fine hand use in the first week, 41% at 3 months and 45% at 18 months after stroke. The associations between fine hand use and the other functioning were moderate to high, but decreased over time for fine hand use and, respectively, somatosensory functions, upper extremity movements and self-care. Conclusion Limited fine hand use is common after acute stroke. Our results suggest that, with time after stroke, upper extremity movements and self-care become less dependent on fine hand use and fine hand use becomes less dependent on touch function, although no ultimate conclusions can be drawn on causality.

/pdf/limited-fine-hand-use-after-stroke-and-its-association-with-308z0gpwm2.pdf

Disa K Sommerfeld

Papers

Spasticity After Stroke Its Occurrence and Association With Motor Impairments and Activity Limitations

Spasticity After Stroke: An Overview of Prevalence, Test Instruments, and Treatments

Spasticity and Its Association with Functioning and Health-Related Quality of Life 18 Months after Stroke

Location and severity of spasticity in the first 1–2 weeks and at 3 and 18 months after stroke

Limited fine hand use after stroke and its association with other disabilities.