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脳卒中リハビリテーションの原則
ー急性期を中⼼にー

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藤⽥医科⼤学医学部
リハビリテーション医学I講座

平野 哲

実⽤先進リハビリテーション研究会

⽇本のリハビリテーション医療提供の枠組み
急性期

急性期病棟

回復期

回復期リハビリテーション病棟(地域包括ケア病棟)

在宅生活期

脳卒中の病期

通院
通所
訪問
短期⼊所

⼊院：療養病床
⼊所：介護⽼⼈保健施設

脳卒中後の”改善”Julie Bernhardt et al. Int J Stroke 2017;12:444-450.

Level (ICF)

RecoveryCompensation（システム的解決）

Diseasecondition

障害初期に消失した神経組織の機能を取り戻す

障害前にはない機能を神経組織が獲得

Bodyfunctions/
Structure

障害前に⾏っていたのと同様に，運動（movement）ができることを取り戻す

Activity

時間経過における変化

脳卒中では（相対的）健常部が前提である活動の成⽴(能⼒低下)

⾎流低下し機能が活動停⽌していた、障害部位の周 健常者では通常観察されない脳部位の代替的な活動
囲（penumbra）や関連した組織（diaschisis）における機能が改善することによる運動学習 時間差

新しいやり⽅でかつての運動を⾏う

代替の運動パターン（異なる⾃由度の動員，共収縮
障害前の運動パターン（随意関節運動，時間空間的 など新たな筋収縮パターン，新しい関節協調パター
な関節感の協調）が再出現することによるンなど）の出現することによる四肢や効果器（⼿⾜）を⽤いて，健常者が典型的に 代替する四肢や効果器により課題を遂⾏⾏うように課題達成ができるようになる
袋を⼀つの⼿と⼝であける
⾮⿇痺側や装具・杖などを駆使して歩⾏を遂⾏
MF Levin et al. NNR 2009

中期

初期

代償系
＋ 残存機能
(健常部)
(障害部)

後期

相補性

注：使わなければ代償系も残存機能の低下

評価で重要なポイント：覚醒

Japan Coma Scale (JCS)III.刺激をしても覚醒しない状態(3桁の点数で表現)

300.痛み刺激に全く反応しない
200.痛み刺激で少し⼿⾜を動かしたり顔をしかめる
100.痛み刺激に対し、払いのけるような動作をする
なし
II.刺激すると覚醒する状態(2桁の点数で表現)

30.痛み刺激を加えつつ呼びかけを繰り返すと⾟うじて開眼する
20.⼤きな声または体を揺さぶることにより開眼する
10.普通の呼びかけで容易に開眼する
I.刺激しないでも覚醒している状態(1桁の点数で表現)

3.⾃分の名前、⽣年⽉⽇が⾔えない
2.⾒当識障害がある
1.意識清明とは⾔えない
R:Restlessnes(s 不穏)、I:Incontinence(失禁)、A:Apallic stateまたはAkinetic mutism
たとえば 30Rまたは 30 不穏とか，20Iまたは 20 失禁として表す．

太⽥富雄，他. 脳神経外科 1974; 2: 623-627.

Glasgow Coma Scale (GCS)
1.開眼(eye opening，E)E

⾃発的に開眼4

呼びかけにより開眼
痛み刺激により開眼
2.最良⾔語反応(best verbal response，V)

3
2
V

⾒当識あり
混乱した会話不適当な発語理解不明の⾳声
なし

5
4
3
2
1

3.最良運動反応(best motor response，M)

M

命令に応じて可疼痛部へ逃避反応として異常な屈曲運動
伸展反応(除脳姿勢)
なし

6
5
4
3
2
1

正常ではE，V，Mの合計が15点，深昏睡では3点となる.

リスク／評価／帰結予測

Teasdale GM, et al.Lancet 1974;7872:81–84.

先⼈の⾔葉からみえる急性期病院におけるリハビリテーション治療の最重要役割

評価で重要なポイント：⾮障害部位
例：体幹機能と歩⾏
他動的にベッド上に端座位
で両⼿を膝の上に置き，15
秒以上座位保持可能か評価
可能

不能

4週以内の⼊院期間で独歩可能

6週間の⼊院期間で監視・介助歩⾏
⽯神重信：臨床リハ10:326330, 2001

利⽤可能なシステムがどの程度残存しているのかが，システム的解決（学習・代償）には重要

下肢筋断⾯積（CT）は⿇痺・⾮⿇痺側とも使わないと萎縮⼀度するめにしておいて，それから⽔にいれて烏賊に戻そうとするようなもの 砂原茂⼀先⽣!筋⼒低下, 筋萎縮!関節拘縮, 変形!⾻粗鬆症!最⼤酸素摂取量低下!頻脈, 起⽴性低⾎圧• 沈下性肺炎• 静脈⾎栓症• 尿路系結⽯•褥 瘡• 消化管機能低下• ⽪膚萎縮, 嵌⼊⽖• 耐糖能異常• 意識低下• 精神活動性低下

不動・廃⽤症候群を防⽌する

脳卒中の病期

近藤克則ら. リハ医学 1997;34:129–133.

いつ・どう進めるのか● 早ければ早いほど不動・廃⽤の弊害は減る● 関節可動域の他動運動は問題ない● 早期座位・起⽴・歩⾏開始の⽬安？
● より良好な回復が得られる開始時期・訓練量は?

可塑性に富む時期にできるだけ機能回復を図りたい
Julie Bernhardt et al. Int J Stroke 2017;12:444-450.

早期座位の安全性：SEVEL

早期座位の安全性• ⼊院⽇に意識清明またはJCS1桁の患者で，⼊院当⽇座位にした群と座位にしなかった群に14⽇間の再発・進⾏増加の差はなかった．

• 重症度，病型等で層別化しても同様の結果であった．

近藤克則ら. リハ医学31: 46-53, 1994

再発・進行
11%

なし
90%
⼊院初⽇座位あり群

脳梗塞患者（重症NIHSS>22や病状不安定，頭蓋内動脈狭窄>50%，座位禁忌等を除外）
24時間以内の早期座位群(early sitting)と3⽇⽬に座位へ進める群（progressive sitting)
主要帰結のmRS [0-2]割合は3ヶ⽉時点で差なし（76.2% vs. 77.3%)
Barthel Indexにおいて，早期座位群で良好（96.7 vs. 90.5, p=0.05)

再発・進行
26%

なし
74%

論⽂データより作図
座位訓練中の有害事象も差なし

⼊院初⽇座位なし群

頭部挙上の安全性：HeadPoST

Herisson F, et al. PLoS ONE 2016;11: e0149466.

早期離床と帰結：AVERT II
A very early rehabilitation trial

急性期脳卒中（85%脳梗塞）n=11,093
⼊院後24時間 頭部⽔平 vs. 30度以上の頭部挙上
90⽇後のmRSを⽐較

50m自立歩行患者%

mRS, 誤嚥性肺炎や合併症に差なし．

• 発症24時間以内参加
Very early mobilization (VEM)• VEM:24時間以内に離床Standard care (SC)• 14⽇間 or 退院 (短い⽅)• 起こしてベッド外へ 最低2回／⽇

歩⾏⾃⽴が有意に早まった

CS Anderson et al. N Engl J Med 2017;376:2437-47.

AVERT含めた9試験のメ
タでもほぼ同様の結果
Cochrane Database of Systematic Reviews 2018,
Issue 10. Art. No.: CD006187.

初回離床までの時間
離床セッショ
ン数／⽇
離床時間／⽇• 重篤な合併症差なし

J Bernhardt et al. Stroke 2008;39:390–396
TB Cumming et al. Stroke 2011;42:153–158

早期リハビリテーション治療開始と帰結

早期離床と帰結：AVERT III
2,104名参加の⼤規模ランダム化⽐較試験
3ヶ⽉後のmRS [0-2]の割合はむしろUsual care群が良かった
歩⾏⾃⽴までの期間，合併症差なし

発症からの⽇数• SCの2倍の離床時間

超早期離床群

通常ケア群

n=1054n=105018.5時間22.4時間

6.5回

3回

31回

10分

Lancet 2015;386:46–55

国内の知⾒（PROr）
リハビリテーション科医，PT，OT
リハビリテーション治療開始時期–24時間:Very early mobilization group (VEM)
24–48時間 :Early mobilization group (EM)48– 時間 :Other mobilization group (OM)
24時間以内に開始群で有意にFIM
total, motor FIMの利得が⾼かった．
死亡数，再発例に差はなかった．
リハビリテーション科医が関わる実臨床のやり⽅
であれば24時間以内も効果的
Kinoshita et al. PLoS ONE 2017;12: e0187099.

早期リハビリテーション治療開始と帰結
国内DB解析

DPCデータrt-PA療法を受けた急性期脳梗塞患者6,153例
リハビリテーション治療開始時期
第1, 2病⽇(n=4,266) vs. 第3病⽇(n=1,887)

脳卒中治療ガイドライン2021
脳卒中急性期のリハビリテーションは，
いつから開始することが推奨されるか？

帰結：退院時のmRS [0-2]合併症を予防し，機能回復を促進するために，24–48時間以内に病態に合わせたリハビリテーションの計画を⽴てることが勧められる（推奨A エビデンス⾼）．

第1,2病⽇で有意に⾼い41.2% vs. 36.6% (p<0.01)
多変量解析で調整しても有意死亡や脳出⾎には差がなし．

＊くも膜下出⾎についての早期からのリハビリテーションについてのエビデンスレベルの⾼い検討は報告されていない．

Momosaki et al. Cerebrovasc Dis 2016;42:41–48.

どのくらい頻回にやれば良いのか
AVERTのdose-response解析において，1⽇の離床回数が多いことが良好な帰結と関連 J Bernhardt et al. Neurology 2016;86:2138–45.
⽇本リハビリテーション医学会DBにて，急性期脳卒中患者
8033例において，週7回実施群は週6⽇以下群に⽐較して良好（mRS [0-2])な機能回復であった．
Kinoshita et al. Arch Phys Med Rehabil 2017;98:701–706.

1⽇も週も頻度が⾼い⽅がよい．

リスク管理
リハビリテーション科医がリスクを診断・指⽰•バイタル・神経学的評価•画像（CT，MRI，エコー)，採⾎，⼼電図，X線チェック
注意すべき状態•脳の⾃動調調節能の破綻，主幹動脈狭窄・閉塞•呼吸循環動態が不安定•脳出⾎における⾎圧上昇•神経症状の増悪／頭蓋内圧亢進
•ドレナージなど処置・デバイス管理

急性期リハビリテーション治療の進め⽅
⼗分なリスク管理のもとに，早期座位・⽴位，装具を⽤いた
早期歩⾏訓練，摂⾷・嚥下訓練，セフルケア訓練などを含んだリハビリテーションを，発症後できるだけ早期から⾏うことが勧められる（推奨度A エビデンスレベル中）．
脳卒中急性期リハビリテーションは，⾎圧，脈拍，呼吸，経⽪的動脈酸素飽和度，意識，体温などのバイタル徴候に配慮して⾏うよう勧められる（推奨度A エビデンスレベル中）．
早期離床を⾏う上では，病型ごとに注意すべき病態を考慮しても良い（推奨C エビデンスレベル中）．

まとめ● 早ければ早いほど不動・廃⽤の弊害は減る．
● 頻度は1⽇でも1週間でも⾼い⽅がよい．
● ⼗分なリスク管理のもとに，発症後できるだけ早期からリハビリテーションを⾏うことが推奨される．

● リスクは全疾患平均よりやや⾼い．脳卒中の病態に合わせたリスク管理が必要である．

発表内容，テキスト，画像などの無断転載・無断使⽤を固く禁じます

練習構成から⾒た
脳卒中リハビリテーション

Unauthorized copying and replication of the contents ofthis presentation, text and images are strictly prohibited.

実⽤先進リハビリテーション研究会

藤⽥医科⼤学七栗記念病院
リハビリテーション部 國分実伸

本⽇の内容

練習内容を可視化する⽬的

1. 練習内容を可視化する⽬的（ELF プロジェクト）

ELF プロジェクト（Project of Exercise Log for FHUR）
練習時間の可視化によるリハビリ戦略再考

2. 練習内容可視化⽅法

通常練習の課題

3. 回復期リハビリテーション病棟脳卒中患者の練習内容• 治療効果を判定する際は従来練習と⽐較される
ことが多い

•
•
•
•

4.

⼊院時FIM-mからみた練習内容構成
FIM-m利得と練習内容
⼊院時FIM-mとFIM-cogから⾒た練習構成
STが⾏う嚥下練習の構成• 従来練習の具体的意味は明確にされていない↓
1. 練習の実態を明確化
2. 適正な練習とは何かを考える

まとめ

3. 練習内容及び時間を明⽰的に記載する⽅法

練習内容可視化⽅法 (ST)

練習内容可視化⽅法
練習カテゴリーから選び、毎⽇、5分毎に電⼦カルテに⼊⼒
評価
総合評価
HHD評価
3D評価
⾼次能機能評価その他

排痰 呼吸法Activity練習
書字練習
物理療法
⾃助具調整
装具調整
全⾝調整
ポジショニング
シーティング
指導
その他

IE（機能障害対応練習）
可動域
リラクセーション
筋⼒ 促通
認知賦活
注意課題
失認課題
半側空間無視課題
ロボット練習（BEAR）
UE
上肢促通
上肢機能
ロボット練習(上肢・⼿指）

DE（能⼒低下対応練習）
起居(ベッド)、起居(床)
座位、⽴位
起⽴着座
移乗、セルフケア
IADL練習排泄練習
⾞椅⼦移動 階段
記憶課題
遂⾏機能課題
失語症課題
失⾏課題
WK

歩⾏(屋内)
歩⾏(トレッドミル)
歩⾏(応⽤, 屋外)
ロボット練習（歩⾏）

評価
評価

⾔語

総合評価 評価

発声・構⾳

嚥下

⾼次脳

評価

評価

意味理解 呼吸練習

唇・⾆・頬の可動域

認知賦活

意味表出 唇・⾆の可動域

唇・⾆・頬の筋⼒増強

構成課題

⾳韻

唇・⾆の筋⼒増強

唇・⾆・頬の協調性

半側空間無視課題

唇・⾆の速度・巧緻性

喉頭挙上筋群の筋⼒増強

セルフケア

IE（機能障害対応練習）統語

評価

発語失⾏ 軟⼝蓋の可動域・筋⼒増強 咽頭収縮筋群の筋⼒増強
喉頭閉鎖筋群の筋⼒増強
頭頸部ストレッチ・⼝腔ケア

談話

DE（能⼒低下対応練習）
その他

発声練習

嚥下反射促通練習

記憶課題

構⾳練習

バルーン拡張練習遂⾏機能課題代償⼿段

嚥下⼿技獲得
直接練習

指導

指導

指導

指導

回復期リハビリテーション病棟脳卒中患者の練習内容

FIMの変化

対象 2015.05.21-2017.03.31までに七栗記念病院回復期リハ病棟に⼊退院した脳卒中患者427例
29.1±11.7

平均⼊院期間66.1±33.5

⿇痺側（右・左）230・197

練習時間の平均値（P/O/S/合計）

204・197・115・483

1⽇単位の平均値

7.3

FIM-m
FIM-c

⼊院時

52.1±25.2

退院時

69.9±23.4

⼊院時

23.1±9.2

退院時

25.9±9.0

退
院 53
時

33
13

7%

-1

13

%

︶

ex起⽴

DE
80

80
60

40

40

20

20

20

0

0

0

53

退院時FIM-m

73

13

33

IE

53

73

UE

80

80

60

60

40

40

20

20

13

33

53

13

73
-20

33

53

73

53

73

0
13

33

33

13

73

60

40

40

33

53

73

⼊院時FIM-mが低い
or ⾼いとWK⽐が低
い

UE
80

60

20

0

0
13

33

53

73

13

33

53

73

FIM利得と練習割合

⼊院時FIM-mから5群に分け中間3群をFIM-m利得により練習内容傾向を確認
FIM-m13n=22

FIM-m14-33
n=110

FIM-m34-53
n=77

FIM-m54-73
n=106

FIM-m74以上
n=112

年齢

79.3±0.5

67.0±11.6

68.1±14.1

67.7±12.762.5±13.3

発症後期
間40.0±11.3

30.1±12.7

29.8±12.0

25.9± 8.924.8±11.2

⼊院期間78.0±36.5

94.1±31.975.6±26.9

58.9±24.3

37.9±17.0

⿇痺側
（右・
左）

11・11

56・54

38・39

54・52

71・41

練習の平
均値
（P/O/S）

205・198・
103・502

287・269・
152・685

238・231・
124・554

191・184・
97・438111・1117・
78・278

WK

13

53

⼊院時FIM-mが低いとDE⽐が⾼い

80

20

53

73

・⼊院時FIMと⽐べ、全体に右に寄るが同様の傾向

0

0

20

0
33

IE

ex座位

ex移乗 着座 ex⽴位

フケア

60

33

20

機能

40

13

20

⼊院時FIM-m

退院時FIM-mと練習割合
評価

40

︶

13

DEとWK合わせて50%→回復期リハ病棟として必要と考えられる

80

60

40

0

DE 31%

割
合 60
︵

60

40

ex起居

ex IADL exセル

80

60

ex⾼次脳
ST IE

WK

DE
80

割
合
︵

IE 23%

(内)

ex階段

次能

ex筋⼒

応)

評価

80

ex可動域 機能STDE

63

床効果と天井効果により
⼊院時FIM-m中間層のFIM利得、FIM効率が⾼くなる

⼊院時FIM-mと練習割合

%

ST評価

WK 20% ex歩⾏

r=-0.07 p=0.133

63

⼊院時FIM-m

⼊院時FIM-m

その他 8% 評価 11%
その他 STその他 ev総合
ev⾼
UE
6%
ex上肢
ex歩⾏(外-20 13

1

練習項⽬の割合機能063

⼊院時FIM-m

UE
⼊院時FIM-mとFIM効率

2

r=-0.39 p<0.0001

40

利 20
得

r=0.84 p<0.0001

WK
19%

13

効
率 0

60

FIM-m

平均発症後期間80
73（除外患者）• 再⼊院例（胃瘻造設、消化器系疾患、DVTなど）• 2週間以内の退院患者• 発症後61⽇
以上
• 再発例
• 両⿇痺

FIM-m

67.2±13.3

FIM-m

年齢

⼊院時FIM-mと利得

FIM-mの変化

・退院時FIM-mが⾼いとDE⽐が低く、UE⽐が⾼い→FIM-m利得により練習割
合に相違

単位平均
値
FIM ⼊院-m 退院
FIM ⼊院
-c 退院

6.5

7.3

7.5

7.4

7.3

13.0

22.6±6.0

44.0±5.8

63.6±5.4

83.5±5.1

19.1±9.947.6±19.9

70.8±12.982.6±7.0

88.9±2.6

7.8±3.615.4±6.7

22.7±7.0

27.0±6.4

30.2±6.1

9.7±4.0

19.1±8.2

26.7±7.1

29.8±6.0

31.6±5.1

⼊院時FIM-motorとcognitiveの練習構成

FIM利得と練習割合
FIM-m34-53

2%

21

100

7%

23%

80

60

60
38%

28%

23%

22%

21%

0

7%

10%

利
得
21
-4
0
利
得
41
以
上

IE

評価 6%

利
得
20
以
下

20

27

33

40

100

8
15

80

21

26

18

20

22

21

27

0

11

11

10

41
以
上

48%

6
8

21
-4
0

DE

6

利
得
20
以
下

40

4
4
26

80

27%

FIM-m54-73

50

64

42

8
9

12
13

24

60

18

21

21

16

11

20
0

13

24

22

40

21
-4
0

UE

22

FIM-m14-33のうち利得41以上の群の練習割合はFIM-m34-53の利得
21-40の練習割合と近い割合→⼊院時ADLが重度〜中等度介助の場合、⾼い利得を得るにはDE・WK割合に双⽅の練習を必要とする

⼊院
時

FIM-cog

練
習
割
合
︵
％
︶

その他
WK 14%

以
下

43

45
100

利
得
20

FIM-m14-33

14-26

5

23

13

DSS 1
n=7

DSS 2
n=49

DSS 3
n=189

DSS 4
n=49

DSS 5
n=28

69.7±6.874.1±11.1

72.3±12.1

68.5±14.1

66.1±12.4

発症後期間

31.6±15.7

32.9±11.7

28.6±11.6

25.4±11.1

27.6±10.1

⼊院期間70.0±31.4

87.6±42.080.2±32.6

68.8±26.2

70.5±25.1

DSS1

DSS2

DSS3

DSS4

入院時FIM-m
40-52 53-65

IE < DE
1介助量軽減
1
移乗獲得

IE、その
他

66-78

79-90

91

IE=DE=WK
早期にADL獲得、
IADL⽬指す

6-10

18

47

5

2

2

DE
17

52

21

10

8

16-20

3

31

32

19

21

18

6

21-25

1

19

29

36

43

IE
WK25
DE

14

IE

1

26-30

4

WK DE

25

39

33

35

4

31-34

DE= WK
1
⽴位を伴う
能⼒獲得

21

34

35

50

6

5

22

32

61

10

35

IE

17

UE

7

UE多
い
3

1

IE

WK

27-39

⾔語聴覚⼠が⾏う嚥下練習の構成

総合評価

UE

11-15

その他

4

11IE

2

IE多い

DE

⼊院時FIM-mとFIM-cogで練習構成の傾向を確認しているが、それ以外の要素も含め練習構成は決まっていく確認は必要⼊院時DSS別の嚥下練習割合

⼊院時DSSにより群分け、⾔語聴覚⼠が⾏なった嚥下練習の構成を確認

年齢

その他 評価PTとOTの合算で傾向を確認

N=7

100%
80%

N=49

N=189

直接練習

N=49

N=28

嚥下⼿技獲得60%

喉頭閉鎖筋群筋⼒増強
嚥下挙上筋群筋⼒増強

嚥下反射促通40%
頭頸部ストレッチ・⼝腔ケア

唇・⾆の協調性練習
唇・⾆の筋⼒増強練習

20%

DSS5

唇・⾆・頬の可動域練習（嚥下）
0%
DSS1
DSS2

構音

嚥下機能評価
DSS3

DSS4

DSS5

高次脳
言語

嚥下
N=7

N=49

N=189

N=49

N=28

年齢に差はないが，DSS 2で最も発症後期間、在棟⽇数が⻑い傾向嚥下練習割合はDSS1と2で最も多い→嚥下以外にも課題があるが嚥下練習に重点をおく傾向

まとめ
1. 回復期リハ病棟の練習割合を評価・IE・DE・WK・UE・その他に⼤分類して傾向を分析
2. DEとWKの合計は50%であり、 FIM-mが低いほどDE⽐率が⾼く、ADL向上が重要課題である回復期リハ病棟としては妥当であると考える
3. FIM-m⾼利得の患者
l 早期ADL⾃⽴後に歩⾏練習に移⾏
l DEとWKの両⽅に時間を費やした
4. STの嚥下練習では⼊院時DSSが低いほど嚥下練習割合が⾼く、嚥下直
接練習が多い傾向｜経⼝摂取の機会をSTで確保
5. 練習構成をみることで達成⽬標に向けたリハビリ戦略を明らかにできるが、現状の練習構成が良い状態なのかよりチャレンジが必要なのかは明確でないことも視野に⼊れるべき

DSS 1では他動的な練習が多い→⾃動運動が困難な症例が多い
DSS1・２では嚥下直接練習割合が⾼い→経⼝摂取の機会をSTで確保
DSS3・4では間接嚥下練習の割合が多い→主栄養が経⼝に移⾏している例が多く、要素別練習で機能向上を図る
DSS5では嚥下練習にかける時間割合が少ない→咀嚼練習については練習時間はそれほど必要ではない上肢練習⽀援ロボットの臨床効果と活⽤

発表内容，テキスト，画像などの無断転載・無断使⽤を固く禁じます
Unauthorized copying and replication of the contents ofthis presentation, text and images are strictly prohibited.

藤⽥医科⼤学七栗記念病院
リハビリテーション部
宮坂裕之

実⽤先進リハビリテーション研究会

本⽇の内容

COI開⽰

• 上肢ロボット研究のReview
開⽰すべきCOI関係にある企業はありません• 回復期脳卒中患者に対する臨床効果⎼ 研究結果の紹介• 上肢ロボットを⽤いた臨床活⽤⎼ ロボット内の保有データの活⽤

上肢ロボットのReviewからみる考察

上肢ロボットの必要性
その他 4%

UE 6%（上肢機能練習）

Zhang（2022）

評価 12%

1⼈あたり33.6単位（11.2時間）

WK 19%（歩⾏練習）

IE 28%（機能障害対応練習）

DE 32%（能⼒低下対応練習）
七栗記念病院回復期リハ病棟のデータ（n=737︓2019.1.1-2021.3.31）

機能改善

⻑期効果

ADL効果

⿇痺levelMode/Other

◯

×

◯

Mild
Moderate

Active、15h以上
Uni>Bi
回復期から慢性期

Wu（2021）◯×–Moderate
SevereFerreira（2018）

△

×

–

–

Veerbeek（2017）

△

–

×

–

End-effectorが効果的

Mehrholz （2015）

◯

︖

◯

­

安全性が⾼いNorouzi-Gheidari （2012） ◯*

×

×

­

*追加訓練で効果的ü ⻑期的な使⽤を推奨
ü 安全性が⾼く、重度⿇痺患者でも適⽤可能
ü 対照群の頻度・強度が同程度の場合は効果低い

◯
△
×
–
︖

効果あり
効果低い
有意差なし
分析なし
不明

InMotion ARMTM Robot

InMotion ARMTM Robot内で使⽤できる評価スコア（Interactive Motion Technologies社）

アルゴリズムに基づいた訓練課題を1⽇約1000回実施

評価モードのスコア

⽇々の訓練のスコア

患者の機能に応じてアシスト
量が変化
随意性あり＝アシスト少ない
随意性なし＝アシスト多い

Point to Point task

肩と肘の屈曲と伸展を交互に繰り返し⾏う︓相反抑制

InMotion ARMTM Robot内に評価モードおよびFeed Backシステムが搭載

80回のリーチ動作の成績がInMotion ARM内に保有される80回×4セット（320回）
320回×3セット（960回）
12個のデータが保有

Circle task

検討1 ロボット療法と電気刺激療法の併⽤効果
対象患者︓30名

ROG (Robot only Group) 15名
REG (Robot with ES Group) 15名

回復期脳卒中患者に対するInMotion ARMTM Robotの臨床効果
1.
2.

REGの電極貼付位置
三⾓筋前部線維上腕三頭筋

電気刺激療法の併⽤
RCTによる検討

パルス幅: 250 μs
周波数: 20 Hz
運動域値下の電気刺激を継続使⽤随意運動と電気刺激の組み合わせは機能をより改善させる

介⼊期間
5 ⽇/週×2週

検討2 ロボット群 × 対照群 RCT(Miyasaka, et al. Med Eng Phys, 2016)

ロボット訓練と通常訓練の⽐較

対象患者︓60名

Pre

RG (Robot Group) 28名
CG (Conventional Group) 32名

介⼊期間
5 ⽇/週×4週

ロボット群
対照群

評価項⽬
Main outcome
Second outcome

OT

PT

ロボット訓練

PT

OT

通常訓練

1h

1h

1h

Fugl-Meyer Assessment（肩・肘/⼿関節/⼿指/合計）
機能評価

能⼒評価

参加評価

肩関節A-ROM
屈曲/外転

WMFT

MAL
（AOU、QOM）(Miyasaka, et al. ISPRM, 2019)

CG (n=32)

RG (n=28)

Gain

Post

Pre

Post

Gain

FMA shoulder / elbow

18.3†
24.3 ** 6.0

18.2

22.1 ** 3.9

FMA wrist

4.9

6.4 ** 1.5

4.5

6.0 ** 1.6

FMA finger

7.7

9.9

**

2.2

7.4

9.4 ** 1.9

FMA total

30.8

40.6

**

9.8

30.1

37.5 ** 7.4

Active ROM
Shoulder flexion

95.5

123.2

**

27.7

100.3

115.3

28.9

103.1

120.9

0.9

1.1

1.9 ** 0.8

Shoulder abduction
MAL-AOU

**

92.0

120.9

0.8

1.7

**

†

†

課題特異的な効果が確認できた

**
**

15.0
17.8

** pre-post 群内⽐較 (p<0.01)† 利得の群間⽐較(p<0.05)

検討3 ⽂献との⽐較

WMFTの結果

ロボット訓練と通常訓練の利得の⽐較

調査⽅法
Ferreira F, et al. (2018, PLOS ONE）のsystematic reviewを調査
Fugl-Meyer Assessmentを使⽤
⽂献検索し、数値が記載されていた論⽂27報

開始時FMA（中央値︓23.1）

S A

S A

S

A

A

肩/肘機能

S

Lift baskets

Turn key

Fold Towel

Flip 3 cards

Stack 3 checkers

Lift paper clip from table

過去の報告と同等の効果あり

0Lift can to mouth

10

Lift pencil from table

20

Hand to box

30.8

30

Retrieve by elbow flexion

31.2

改善した機能に汎化したパフォーマンが向上
Hand to table

9.8
Extend elbow weight

40

9.7

Forearm to box

A︓急性期
S︓回復期

Extend elbow side50

* p<0.05

検討2の結果FMA利得（中央値︓6.1）

Forearm to table

60

*
*

⼿指機能

重度感覚障害患者への適応
重度感覚障害の定義
SIAS感覚機能の触覚・位置覚が0点

Reach Error
ターゲット

介⼊期間
5 ⽇/週×2週

InMotion ARMTM Robotの臨床活⽤評価項⽬
InMotion Robot内の評価モード
1. Reach Error（RE）
2. Path Error（PE）

InMotion内の保有データを活⽤
1. 感覚障害患者への適応
2. 回復過程の検討

中⼼到達した地点からターゲットまでの平均距離

Path Error

ターゲット

ターゲット

指標

直線経路から
の誤差

14cm
中⼼

軌跡

直線経路
からの平均
誤差

(Miyasaka, et al. Appl Sci; 2019)

InMotion ARMによる評価︓代表値

Reach Error/Path Errorの結果
Reach Error
ターゲットまでの距離

Path Error
軌道の正確さ10
Path Error [cm]12

10
Reach Error [cm]

12

8
6
4

感覚障害は、到達運動、
正確性の改善に影響するF

pre post
Severepre post
Moderate

pre post
Mild

é15

5

0

0

pre post
Mild

健常範囲

5

é5

é10
é15

é10
é15

é15é5
é10 0é5 5 0 105 1510
é15 é10
P2P back
P2P toward

10
5
0

é5

é5
é10

é10
é15

é15

15
10

é5
é10
é15

10
5
0
é5
é10
é15

15

15

15

15 15

10

10

10

10 10

5

5

5

5

0

0

0

0

é5

é5

é5 é5

é10

é10 é10é10é10é15

é15 é15

é15é15é5

é15 é15é10 é10
é5
0
5
é15é5
é10
0 1050 15105 15
é15 é5é10
é5 10
10 é1515 é100
5 0 15105 15
é15 0é5
é10 5é5
10
P2P toward
P2P back
P2P toward
P2P allP2P back
P2P all

15

15

15
10

5

5

0
é5

0
é5

15

15

10

10

5

5

0

0

é5

é5

é10

é10
é10 é10

é15

é15

重度例は、ロボット導⼊を再検討
é15 é10 é50
5 10P2P toward

0

15

5
0

15

15 15

15

15

10

10 10

10

10

5

5 5

5

0

0 0

0

0

é5

é5 é5

é5

é5

15
10
5
0
é5
é10
é15

5

é10 é10é10é10 é10é15 é15é15

é15 é15

é15
é10
0 10
5 1510é15
é10é10
é5 é5
0 0é5
5 510
15
15 é15
P2P all
P2P P2P
towardback

15
é15é15
é10
é5
0 010
5 515
10 1015 15é15 é10
é5 é100 é5 5
P2PP2Pbackall
P2P toward05
é15 é15é10 é10
é5 é5
0
5 10
P2P allP2P back

RawéP2Péallé20140315Saté20140315Sat
RawéP2Péallé20130808Thué20
RawéP2Péallé20130807Wedé20130807Wed
RawéP2Péallé20131018Frié20131018Fri
RawéP2Péallé20130809Frié20130809Fri
RawéP2Péallé20140502Frié20140502Fri

15

0

pre post
Moderate

10

é5

é15

Post

10

pre post
Severe

15

0

é10

15

15

感覚障害（–）の患者の平均値±SD
感覚障害（+）

5

é5

é15 é10 é50
5 10P2P toward

0

10
5

5

0

15

10

10

é10

4

15

15

é5

6

感覚障害 (+) 感覚障害 (-)

RawéP2Péallé20130725Thué20
RawéP2Péallé20140227Thué20140227Thu
RawéP2Péallé20130719Frié20130719Fri
RawéP2Péallé20131003Thué20131003Thu
RawéP2Péallé20140421Moné20140421Mon
RawéP2Péallé20130726 rié20130726Fri

10

0

2

2

Pre
15

5

8

軽度⿇痺例

中等度⿇痺例

重度⿇痺例

感覚障害 (+) 感覚障害 (-) 感覚障害 (+) 感覚障害 (-)é15 é5
é10 0
é5 50 105 1510
é15 é10
P2P back
P2P towardé15 é1515

é15 é15é10 é10é5
0
5
é15 é5
é10
é5
5
0 10
50 15
10
P2P toward
P2P allP2P back

15

15

15

15 15 15

15 15

10

10

10 10 10

10 10

5

5

5

5 5

0

0

0

0 0

é5

é5

é5 é5 é5

é5 é5

é10 é10

é10
é10

é10

é10 é10é10é10 é10é15 é15

é15
é15

é15

é15 é15é15

é15 é15

15

15

10

10

10

5

5

5

0

0

0

é5

é5

é5

é10
é15

15
10
5
0
é5

é15é5
é10
é5 5é50 1050 1510
10 é1515 é1015
é15 0é105 15
10P2P back
P2P toward
P2P allé15 é10 é15
é5 é5
0 0é5
5 510
é10
0 10155 151015 é15 é10P2P P2P
towardP2P allbacké10
é50 é5 05 0 10
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all

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運動⿇痺の回復過程の検討
対象者︓脳卒中患者38名
重度⿇痺17名、中軽度⿇痺21名

重度⿇痺群（FMA肩・肘 10点未満）

駆動回数
（回）
20

アシスト量

介⼊期間
5 ⽇/週×2週（10回）

検討⽅法

4

InMotion ARMによるアシストに⽤いられた電⼒* ** ** *** ** ** **
80

2

40

1
1 2 3 4

FMA肩・肘関節
FMA総合計0

5 6 7 8 9 10（⽇）

1 2 3 4 5 6 7 8 9 10

（⽇）

終了時
開始時
19.6±6.4（21.0） 22.5±5.5（23.0）*
29.4±13.5（30.0） 35.9±13.0（38.0）*0

1 2 3 4 5 6 7 8 9 10（⽇）

上肢ロボットの臨床効果のまとめ• 課題特異的な臨床効果が⾒られた
ü 繰り返し動かした動作が強化される• 他の臨床⼿技との併⽤は有⽤である
ü 運動閾値下の刺激• 過去の報告と同程度の改善が⾒られた

（mW）
150
120

*

150

終了時
開始時
4.4±2.4（5.0） 5.1±3.1（5.0）*
5.7±3.6（6.0） 7.2±5.1（6.0）*

まとめと展望アシスト量の指標値は活⽤可能
繰り返し動作による到達距離や正確性の向上を表している*

1 2 3 4 5 6 7 8 9 10（⽇）

中軽度⿇痺群（FMA肩・肘 11点以上）
•
•

250

50

FMA肩・肘関節
FMA総合計300

各指標値は、初⽇の値をコントロール値として、各⽇の値と⽐較した（Steel法）

（回）
7

（mW）

100
5

（リーチ動作の初動をアシストした回数）

初動時のInMotion ARMの
駆動回数

InMotion ARMによるアシストに⽤いられた電⼒

200
* *

10

2. InMotion ARMによるアシストに⽤いられた電⼒（mW）

6

⿇痺改善は動作開始能⼒を改善しており、指標値として利⽤可能

15

評価項⽬
InMotion Robot内の保有データ
1.初動時のInMotion ARMの駆動回数

5

初動時のInMotion ARMの駆動回数** p<0.01* p<0.05

平均値±SD（中央値）

課題と展望• 適応基準の検討• ロボットが保有するデータの活⽤ü運動軌跡、正確性• 適正な頻度・量の検討* p<0.05
平均値±SD（中央値）

発表内容，テキスト，画像などの無断転載・無断使⽤を固く禁じます
Unauthorized copying and replication of the contents ofthis presentation, text and images are strictly prohibited.

実⽤先進リハビリテーション研究会

実⽤先進リハビリテーションカンファランス2023 winter〜脳卒中リハビリテーションのいま〜

⼯程分析から考える
ADL障害の構造と介⼊戦略
藤⽥医科⼤学
保健衛⽣学部 リハビリテーション学科
北村新

⼊院患者のADL⾃⽴と活動性

移乗・トイレ動作の学習
分離スキル
開始と終了がはっきりしている
ex. 起⽴動作、起居動作

系列スキル
分離スキルが連結
ex. 移乗、トイレ、更⾐、洗体

連続スキル
開始と終了がはっきりしないex. 歩⾏、⾃動⾞運転

移動能⼒/活動性
⼤⾼洋平. 回復期リハビリテーションの実践戦略

活動と転倒. 医⻭薬出版; 2016.

各項⽬に対して３段階（A、B、C）で⾃⽴度を評価
⼀定期間評価をしてパフォーマンスを評価

動作を構成する細かい⼯程（サブタスク）ごとに評価が必要
Schmidt RA, Wrisberg CA. Motor Learning and Performance: A Situation-Based Learning Approach. 4th ed. Champaign, IL: Human Kinetics; 2008.

評価表を使⽤する⽬的

評価表の信頼性・妥当性
30名の脳卒中患者の動作をOT４名で評価• ⾃⽴を妨げている⼯程の明確化• リハプログラムの考案

BTAF（移乗）

TTAF（トイレ）

検者間信頼性

各項⽬ Fleissʼs κκ ≧ 0.66

κ ≧ 0.61• 訓練の効果検証

検者内信頼性各項⽬ Cohenʼs κκ ≧ 0.73

κ ≧ 0.60

内的整合性

0.90 – 0.93

0.94 - 0.95

0.53 – 0.78

0.88 – 0.93

Cronbachʼs α

併存的妥当性• 多職種による評価結果の共有

Spearmanʼs rank coefficient※併存的妥当性︓BTAF - FIM移乗項⽬, TTAF-FIMトイレ動作・トイレ移乗項⽬• ⾃⽴度の判定

κ係数: <0.2 slight, 0.2-0.4 fair, 0.4-0.6, moderate, 0.6-0.8 substantial, 0.8< almost perfect

⽐較的良好な信頼性・妥当性をもって評価が可能
Kitamura S, Otaka Y, Murayama Y, Ushizawa K, Narita Y, Nakatsukasa N, Kondo K, Sakata S. Reliability and Validity of a New Toileting Assessment Form for Patients with Hemiparetic
Stroke. PM R. 2021 Mar;13(3):289-296.
Kitamura S, Otaka Y, Murayama Y, Ushizawa K, Narita Y, Nakatsukasa N, Kondo K, Sakata S. Reliability and Validity of a New Transfer Assessment Form for Stroke Patients. PM R. 2021
Mar;13(3):282-288.

サブタスクごとに⾃⽴度は異なる

縦断調査
取り込み基準・初発脳卒中患者
・⽚⿇痺
・⼊院時に⾞椅⼦利⽤・トイレを利⽤（トイレ調査のみ）
評価
各評価点で移乗・トイレ動作を３⽇間観察【評価終了基準】
回復期リハ病棟
⼊棟

2w

4w

8w

12w

Kitamura S, Otaka Y, Murayama Y, Ushizawa K, Narita Y, Nakatsukasa N, Kondo K, Sakata S. Reliability and Validity of a New Transfer Assessment Form for Stroke Patients. PM R. 2021
Mar;13(3):282-288.

⼊院時の難易度（n=137）

ベッド柵の操作準備動作

移乗準備
⾞椅⼦をベッドへアプローチ

主動作

靴・装具履き⽅向転換(⾞椅⼦→ベッド)※「N︓必要なし」は除外

3. 退院

準備動作

ベッド柵の操作
ナースコール(ベッド)主動作

ナースコール(⾞椅⼦)
ブレーキかけ⾞椅⼦をベッドへアプローチ

⽅向転換(ベッド→⾞椅⼦）

各サブタスクにおいて⼊院時に⾮⾃⽴だった者のうち
⼊院中に⾃⽴した者の割合

フットレスト下肢のせ⾞いすに着座⾞いすから⽴ち上がり
⾞椅⼦駆動
靴・装具脱ぎ※「N︓必要なし」は除外

ベッドに着座

靴・装具履き布団かけ
フットレスト下肢のせフットレスト下肢下ろし
ブレーキ外し靴・装具脱ぎ
⽅向転換(⾞椅⼦→ベッド)
ベッドに寝る⾞いすから⽴ち上がり

ベッドから⽴ち上がり

⽅向転換(ベッド→⾞椅⼦）

ブレーキ外し難易度が⾼い上位項⽬は準備動作が多い

2. 移動⼿段が⾞椅⼦→歩⾏

移乗準備

⾮⾃⽴→⾃⽴の難易度

ブレーキかけフットレスト下肢下ろし

⼊院時の横断的データから
各サブタスクの⾃⽴者割合を算出

1. ⾞椅⼦で⾃⽴

ナースコール(⾞椅⼦)

⼊院時の難易度よりも難易度が⾼い上位項⽬に準備動作が多い

布団かけ
ベッド端坐位保持(移乗後)ナースコール(ベッド)

起き上がり
ベッドから⽴ち上がり
⾞いすに着座
布団はぎ
ベッドに着座

布団はぎ

寝返り

ベッドに寝る
起き上がり

⼊院時に⾞椅⼦やベッド柵の操作ができない患者にとってはその後の動作獲得が難しい

ベッド端座位保持(移乗前)
寝返り

0

10

20

30

⾃⽴者割合

40

Kitamura S, Otaka Y, Murayama Y, Ushizawa K, Narita Y, Nakatsukasa N, Matsuura D,Kondo K, Sakata S.
Difficulty of the subtasks comprising bed-wheelchair transfer in patients with subacute strokes: A cohort study. J Stroke Cerebrovasc Dis. 2022 Oct;31(10):106740.

50(%)

ベッド端坐位保持(移乗後)⾞椅⼦駆動
ベッド端座位保持(移乗前)

0

10

20

30

40

⾃⽴者割合

Kitamura S, Otaka Y, Murayama Y, Ushizawa K, Narita Y, Nakatsukasa N, Matsuura D,Kondo K, Sakata S.
Difficulty of the subtasks comprising bed-wheelchair transfer in patients with subacute strokes: A cohort study. J Stroke Cerebrovasc Dis. 2022 Oct;31(10):106740.

50

60

70
(%)

ブレーキかけトイレ動作の難易度（n=101）

おむつパッド処理

⽅向転換(⾞椅⼦→便座)

準備動作

下⾐下げ

⾮⾃⽴→⾃⽴の難易度

主動作

⽅向転換(便座→⾞椅⼦)
下⾐上げ
⽴位保持(排泄前)フットレスト下肢のせ
おむつパッド処理
フットレスト下肢下ろし

便座へ着座
ドア開閉(排泄前)
下⾐上げ便座アプローチ

ブレーキ外しナースコール(排泄前)

便座から⽴ち上がり

下⾐下げ※「N︓必要なし」は除外

⾞いすから⽴ち上がり

便座から⽴ち上がり

⾞いすへ着座

難易度が⾼い上位項⽬は下⾐操作や移乗などの主となる動作が多い

主動作

ドア開閉(排泄後)

各サブタスクにおいて⼊院時に⾮⾃⽴だった者のうち
⼊院中に⾃⽴した者の割合

便座アプローチ※「N︓必要なし」は除外

準備動作

後始末
ブレーキかけフットレスト下肢のせ

⽴位保持(排泄後)

⼊院時の横断的データから
各サブタスクの⾃⽴者割合を算出

ナースコール(排泄後)フットレスト下肢下ろし

⾞いすから⽴ち上がり

トイレから出る

難易度が⾼い上位項⽬は周辺機器の利⽤などの準備動作が多い

後始末
便座へ着座
ドア開閉(排泄後)⾞いすへ着座⽅向転換(便座→⾞椅⼦)
⽔洗ボタン押しトイレから出るナースコール(排泄後)ブレーキ外しナースコール(排泄前)⽅向転換(⾞椅⼦→便座)

ドア開閉(排泄前)⽴位保持(排泄後)

便座座位保持(排泄前)

便座座位保持(排泄前)

⽔洗ボタン押し⽴位保持(排泄前)

0

10

20

30

40

50

0

(%)

⾃⽴者割合

10

20

30

Kitamura S, Otaka Y, Murayama Y, Ushizawa K, Narita Y, Nakatsukasa N, Matsuura D,Kondo K, Sakata S.
Differences in the difficulty of subtasks comprising the toileting task among patients with subacute stroke: A cohort study. J Stroke Cerebrovasc Dis. accepted

主動作の
難易度

準備動作の
難易度

⼊院時
けかキーレブ
ブレーキかけ)座便→⼦椅⾞(換転向⽅
⽅向転換（⾞椅⼦→便座）
げ下⾐下
下⾐下げ
)⼦椅⾞→座便(換転向⽅
⽅向転換（便座→⾞椅⼦）
げ上⾐下
下⾐上げ
)前泄排(持保位⽴
⽴位保持（排泄前）)後泄排(持保位⽴
⽴位保持（排泄後）チーロプア座便
便座アプローチ
せの肢下トスレトッフ
フットレスト下肢のせ理処ドッパつむお
おむつパッド処理

しろ下肢下トスレトッフ
フットレスト下肢下ろしし外キーレブ
ブレーキ外しりが上ち⽴らか座便
便座から⽴ち上がり

りが上ち⽴らかすい⾞
⾞椅⼦から⽴ち上がり
座着へすい⾞⾞椅⼦へ着座
る出らかレイトトイレから出る
末始後
後始末

座着へ座便
便座へ着座
)後泄排(閉開アド
ドア開閉（排泄後）)後泄排(ルーコスーナ
ナースコール（排泄後）)前泄排(ルーコスーナ
ナースコール（排泄前）)前泄排(閉開アド
ドア開閉（排泄前）)前泄排(持保位座座便
便座座位保持（排泄前）し押ンタボ洗⽔
⽔洗ボタン押し
)%(

0(%)
5

0
4
40

03
30

02
20

01
10

00

⾮⾃⽴→⾃⽴
おむつパッド処理
おむつパッド処理
ナースコール(排泄後)ナースコール（排泄後）⼊院時
けかキーレブ
ブレーキかけ)座便→⼦椅⾞(換転向⽅
⽅向転換（⾞椅⼦→便座）
げ下⾐下
下⾐下げ
)⼦椅⾞→座便(換転向⽅
⽅向転換（便座→⾞椅⼦）

フットレスト下肢下ろしフットレスト下肢下ろし
後始末
後始末

げ上⾐下
下⾐上げ
)前泄排(持保位⽴
⽴位保持（排泄前）ブレーキかけブレーキかけフットレスト下肢のせフットレスト下肢のせ)後泄排(持保位⽴
⽴位保持（排泄後）チーロプア座便
便座アプローチ

ドア開閉(排泄後)ドア開閉（排泄後）
便座へ着座
便座へ着座

せの肢下トスレトッフ
フットレスト下肢のせ理処ドッパつむお
おむつパッド処理

ドア開閉(排泄前)ドア開閉（排泄前）

下⾐上げ
下⾐上げ

しろ下肢下トスレトッフ
フットレスト下肢下ろし

便座アプローチ
便座アプローチ

し外キーレブ
ブレーキ外しりが上ち⽴らか座便
便座から⽴ち上がり

ナースコール(排泄前)ナースコール（排泄前）

下⾐下げ
下⾐下げ

りが上ち⽴らかすい⾞
⾞椅⼦から⽴ち上がり
座着へすい⾞⾞椅⼦へ着座

便座から⽴ち上がり
便座から⽴ち上がり
⾞いすから⽴ち上がり
⾞いすから⽴ち上がり

る出らかレイトトイレから出る
末始後
後始末

⾞いすへ着座⾞いすへ着座⽅向転換（便座→⾞いす）
⽅向転換(便座→⾞椅⼦)

座着へ座便
便座へ着座
)後泄排(閉開アド
ドア開閉（排泄後）

⽔洗ボタン押し⽔洗ボタン押しトイレから出る
トイレから出る)後泄排(ルーコスーナ
ナースコール（排泄後）)前泄排(ルーコスーナ
ナースコール（排泄前）

ブレーキ外しブレーキ外し⽅向転換（⾞いす→便座）
⽅向転換(⾞椅⼦→便座))前泄排(閉開アド
ドア開閉（排泄前）)前泄排(持保位座座便
便座座位保持（排泄前）⽴位保持（排泄後）
⽴位保持(排泄後)
便座座位保持（排泄前）
便座座位保持(排泄前)し押ンタボ洗⽔
⽔洗ボタン押し⽴位保持（排泄後）
⽴位保持(排泄前)

0
0

10

20
20

30
30

40
40 (%) 50

40

50

⾃⽴者割合

Kitamura S, Otaka Y, Murayama Y, Ushizawa K, Narita Y, Nakatsukasa N, Matsuura D,Kondo K, Sakata S.
Differences in the difficulty of subtasks comprising the toileting task among patients with subacute stroke: A cohort study. J Stroke Cerebrovasc Dis. accepted

(%)

)%(

0(%)
5

0
4
40

03
30

02
20

01
10

00

(%)

⾮⾃⽴→⾃⽴
おむつパッド処理
おむつパッド処理
ナースコール(排泄後)ナースコール（排泄後）フットレスト下肢下ろしフットレスト下肢下ろし
後始末
後始末
ブレーキかけブレーキかけフットレスト下肢のせフットレスト下肢のせ
ドア開閉(排泄後)ドア開閉（排泄後）
便座へ着座
便座へ着座
ドア開閉(排泄前)ドア開閉（排泄前）

下⾐上げ
下⾐上げ
便座アプローチ
便座アプローチ
ナースコール(排泄前)ナースコール（排泄前）

下⾐下げ
下⾐下げ
便座から⽴ち上がり
便座から⽴ち上がり
⾞いすから⽴ち上がり
⾞いすから⽴ち上がり

⾞いすへ着座⾞いすへ着座⽅向転換（便座→⾞いす）
⽅向転換(便座→⾞椅⼦)
⽔洗ボタン押し⽔洗ボタン押しトイレから出る
トイレから出る
ブレーキ外しブレーキ外し⽅向転換（⾞いす→便座）
⽅向転換(⾞椅⼦→便座)
⽴位保持（排泄後）
⽴位保持(排泄後)
便座座位保持（排泄前）
便座座位保持(排泄前)⽴位保持（排泄後）
⽴位保持(排泄前)

0
0

10

20
20

30
30

40
40 (%) 50(%)

発表内容，テキスト，画像などの無断転載・無断使⽤を固く禁じます

Direction-dependent differences in the

脳卒中⽚⿇痺者の上肢運動制御能の回復過程
characteristics of horizontal reaching in pati

Unauthorized copying and replication of the contents ofthis presentation, text and images are strictly prohibited.

Shintaro Uehara1, Akiko Yuasa2, Kazuki Ushizawa2, Shin Kitamura1, Yota Obayashi3

藤⽥医科⼤学 保健衛⽣学部 リハビリテーション学科
1 Faculty of Rehabilitation, Fujita Health University School of Health Sciences, JAPAN2 Department of Rehabilitation MedicineⅠ, Fujita Health University School of Medicine,
上原 信太郎3 Department of Rehabilitation, Fujita Health University Hospital, JAPAN＠PIRRC 2023 Winter
BACKGROUND & AIM

実⽤先進リハビリテーション研究会

RESULTS: mild-to-・ ZĞĂĐŚŝŶŐĨƵŶĐŝƚŽŶŝƐŽŌĞŶŝŵƉĂŝƌĞĚŝŶƉĂƟĞŶƚƐĂŌĞƌƐƚƌŽŬĞ
・ /ƚ ƌĞŵĂŝŶƐ ƵŶĐůĞĂƌ͕ ŚŽǁĞǀĞƌ͕ ǁŚĞƚŚĞƌ ƌĞĂĐŚŝŶŐ ĐŚĂƌĂĐƚĞƌŝƐƟĐƐ ĚŝīĞƌ
2023.01.28

DŽǀĞŵĞŶƚĚĞƚĞƌŝŽƌĂƟŽŶŝŶŽĨƚŚĞŚĂŶĚƐŽƌŽǀĞƌͲƟŵĞĨƵWĂƚŚůĞŶŐƚŚ;ĐŵĚĞƉĞŶĚŝŶŐ ŽŶ ĂŝŵŝŶŐ ĚŝƌĞĐƟŽŶƐ ĂŶĚ ŚŽǁ ƚŚĞǇ ĐŚĂŶŐĞ ĂůŽŶŐ ǁŝƚŚĨƵŶĐƟŶŽĂůŝŵƉƌŽǀĞŵĞŶƚ
・ dŚĞƉƌĞƐĞŶƚƐƚƵĚǇĂŝŵĞĚƚŽĞůƵĐŝĚĂƚĞĚŝƌĞĐƟŽŶͲĚĞƉĞŶĚĞŶƚŬŝŶĞŵĂƟĐĚŝīĞƌĞŶĐĞƐŽĨƌĞĂĐŚŝŶŐŝŶƉŽƐƚͲƐƚƌŽŬĞƉĂƌƟĐŝƉĂŶƚƐ

īĞĐƚĞĚ;dͿF

LF

RESEARCH
MATERIALSQUESTIONS& METHODS

M

LB

B

LB

MB

Movement trajectory

th
ng
le
th
Pa MF

F

L

LF

M

F

LF

10

5
Target
0

th
Pa

le

L

th
ng

LB

14
12
10
8
6

B

5

F

LF
M

14
L 12
10
8
6
LB

MF

B

6

M

Unaffected-Admission
Unaffected-Discharge
LB</EZDǆŽƐŬĞůĞƚŽŶ>Ăď
0.006
-100

0

-50
0
50
100 150200
Angular devia!on (deg)0-200 -150 -100 -50
050
100 150
Angular devia!on (deg)
1200

15

Affected-Admission

Anteroposterior movement (cm)

-150

SD

Mean

-150

-100

-50
0
50
100
Anglar devia!on (deg)
0

200
-200
Total amount of displacement

Affected-Admission
Affected-Discharge
Unaffected-Admission
1200
Unaffected-Discharge

-150

-100

L

B

DŽǀĞŵĞŶƚƚƌĂũĞĐƚŽƌǇ;ƉŽŽůŝŶŐ

80

10
0

īĞĐƚĞĚ;dAͿ

40

-10
-20

,ŽƌŝǌŽŶƚĂůĂĚĚƵĐƟŽŶ͗ϯϬĚĞŐ
0.005

0

-200

F

/ŶĐƌĞĂƐĞƐŝŶƚŚĞƉƌŽƉŽƌƟŽŶŽǀĞƌͲƟŵĞĨƵŶĐƟŽŶĂůŝŵƉƌŽǀ

SD

0

Probability

Probability

0

ϭϬ

M

^ƚĂƌƚƉŽƐŝƟŽŶ

&ůĞǆŝŽŶ͗ϵϬĚĞŐ

-20

ϭϮ

RESULTS: moderat0WĂƟĞŶƚƐŐƌŽƵƉƐ 脳卒中後の上肢運動機能障害
ƚŽƚĂůŽĨϮϴƉŽƐƚͲƐƚƌŽŬĞƉĂƌƟĐŝƉĂŶƚƐǁĞƌĞĚŝǀŝĚĞĚŝŶƚŽƚǁŽŐƌŽƵƉƐďĂƐĞĚŽŶƌĞĂĐŚŝŶŐƉĞƌĨŽƌŵĂŶĐĞĂƚƚŚĞƟŵĞŽĨĂĚŵŝƐƐŝŽŶ͘Affected-Admission

150

LF

F

MF

L

TOTAL

M

B

MB

200

-50
0
50
100
Anglar devia!on (deg)

150

200

Total amount of displacement

Affected-Admission
Affected-Discharge
Unaffected-Admission
Unaffected-Discharge

15

Anteroposterior movement (cm)DŝůĚͲƚŽͲŵŽĚĞƌĂƚĞ͗ĂďůĞƚŽƉĞƌĨŽƌŵƌĞĂĐŚŝŶŐƚŽĂůůƚŚĞĚŝƌĞĐƟŽŶƐ
上肢の運動⿇痺に起因する運動機能障害は，急性期脳卒中患者のおよそ77%に認められる
Number of pa!ents

運動機能を構成する各要素の回復機序は異なる可能性

20

ϭϰ

ϴ

ϭϬĐŵ

Target direc!on
Mean
0.015
Affected-Admission80
10Affected-Discharge
Target direc!onUnaffected-Admission
0
Mean
SD
0.015
Unaffected-Discharge
Affected-Admission
0.01 8040
Affected-Discharge-10
Unaffected-Admission
Unaffected-Discharge-20
0.01
0.005 40SD

Probability

Probability

0-200

お伝えしたいこと͗ƐƐĞƐƐŵĞŶƚ

Unaffected-Admission
Unaffected-Discharge

Discharge: mean FMA = 62.3 (SD 4.7)

0.006

MB

MB

B
Admission: mean FMA = 59.0 (SD 5.7)

Target direc!on
Mean
20
Affected-Admission
80
Affected-Discharge
Unaffected-Admission
Target direc!on0
0.018
Unaffected-Discharge
Affected-Admission
40
Affected-Discharge
Unaffected-Admission-20
Unaffected-Discharge
0.012
0

0.012

M

Unaffected sideF

Discharge:
mean FMA = 62.3 B(SD 4.7)
Affected-Admission

0.018

ŝƐĐŚĂƌŐĞ;dͿ

14
MF
LF
12
M ͲϴƚĂƌŐĞƚƐǆϴƚƌŝĂůƐсϲϰƚƌŝĂůƐŝŶƚŽƚĂů
10ͲƐŬĞĚƚŽƉĞƌĨŽƌŵƌĞĂĐŚŝŶŐĂƐƋƵŝĐŬůǇĂŶĚĂĐĐƵƌĂƚĞůǇĂƐƉŽƐƐŝďůĞ
8
L
M
6
MB
dĂƌŐĞƚĂƚϴůŽĐĂƟŽŶƐ

8
MF

B
Admission:LBmean FMA = 59.0 (SDMB5.7)

Affected-Discharge

ϭϲ

MF

0

LB

F
14
12
10

LF sideAffected

MF

L
MB

LB
Affected-Admission
Affected-Discharge

10/ŶƚĞŶƐŝǀĞZĞŚĂďŝůŝƚĂƟŽŶtĂƌĚ
Unaffected sidesŝƐƵĂůůǇͲŐƵŝĚĞĚƌĞĂĐŚŝŶŐƚĂƐŬ
L

F

LF

L

Start posi!on

MB

BF

LF

hŶĂīĞĐƚĞĚ;dͿhŶĂīĞĐƚĞĚ;dAͿ

Sort by target loca!ons

M

MB

B

B

・・・ ^ƚƌŽŬĞĂƌĞhŶŝƚAffected side
LB

MF

Trial-by-trial analysis

ĚŵŝƐƐŝŽŶ;dAͿ

Start posi!on
M

L

MB

Sort by target loca!ons

TargetPath length
(cm)

MF

WĂƚŚůĞŶŐƚŚ;ĐŵͿ

Trial-by-trial analysis

F

Path length(cm)

Movement trajectory

ϭ
ϭ
ϴ
6

MF

L

ǆƉĞƌŝŵĞŶƚĂůƉƌŽƚŽĐŽů
WŽƐƚͲƐƚƌŽŬĞ ƉĂƌƟĐŝƉĂŶƚƐ ŝŶ ƚŚĞ ƌĞĐŽǀĞƌǇ ƉŚĂƐĞ ƉĞƌĨŽƌŵĞĚ ƚŚĞ ŚŽƌŝǌŽŶƚĂůĂƌŵͲƌĞĂĐŚŝŶŐƚĂƐŬĂƚƚŚĞƟŵĞŽĨĂĚŵŝƐƐŝŽŶĂŶĚĚŝƐĐŚĂƌŐĞ͘
LF

ϭϮ
ϭϬ
ϴ
6

īĞĐƚĞĚ;dAͿ

600

Number of pa!ents

Affected-DischargeDŽĚĞƌĂƚĞͲƚŽͲƐĞǀĞƌĞ͗ƵŶĂďůĞƚŽĐŽŵƉůĞƚĞƌĞĂĐŚŝŶŐƚŽĐĞƌƚĂŝŶĚŝƌĞĐƟŽŶƐ
Canning et al., Clin Rehabil, 2004
600

600
Mediolateral movement (cm)0ϲϰ͘ϳ;ϭϰ͘ϬͿ

0

0

1200

ϲϮ͘Ϯ;ϭϬ͘ϲͿmean FMA = 28.9 (SD 14.4)
mean FMA = 19.4 (SD 14.4)

600
Mediolateral movement (cm)1200ϭϯΈϴϲ͘ϳйΉϮΈϭϯ͘ϯйΉϭϬΈϳϲ͘ϵйΉϯΈϮϯ͘ϭйΉϵ;ϲϬ͘ϬйͿϲ;ϰϬ͘ϬйͿϴ;ϲϭ͘ϱйͿϱ;ϯϴ͘ϱйͿϭϭ;ϳϯ͘ϯйͿϰ;Ϯϲ͘ϳйͿϲ;ϰϲ͘ϮйͿϳ;ϱϯ͘ϴйͿdǇƉĞŽĨƐƚƌŽŬĞ
/ŶĨĂƌĐƟŽŶ͕Ŷ;йͿ,ĞŵŽƌƌŚĂŐĞ͕Ŷ;йͿīĞĐƚĞĚƐŝĚĞ>ĞŌ͕Ŷ;йͿZŝŐŚƚ͕Ŷ;йͿ

0

0

Reac!on forceWƌŽƉŽƌƟŽŶŽĨŵĞĚŝŽůĂƚĞƌĂůͬĂdƌŝĂůͲďǇͲƚƌŝĂůĂŶĂůǇƐŝƐ

ŶŐƵůĂƌĚŝīĞƌĞŶĐĞĨƌŽŵƚŚĞƚĂ^ŽƌƚďǇƚĂƌŐĞƚůŽĐĂƟŽŶƐ

īĞĐƚĞĚƐŝĚĞdĂƌŐĞƚ
L

LB,ĂŶĚǀĞůŽĐŝƚǇ

hŶĂīĞĐƚĞĚƐŝĚĞ

x

LF

F
ϭϬ
ϱ
Ϭ

B

ŶĚ

M ͗DĞĚŝĂů
MF ͗DĞĚĚŝĂůĨŽƌǁĂƌĚ
F ͗&ŽƌǁĂƌĚ
LF ͗>ĂƚĞƌĂůĨŽƌǁĂƌĚ
L ͗>ĂƚĞƌĂů
LB ͗>ĂƚĞƌĂůďĂĐŬǁĂƌĚ
B ͗ĂĐŬǁĂƌĚMB ͗DĞĚŝĂůďĂĐŬǁĂƌĚ

MF
M
MB

^ƚĂƌƚƉŽƐŝƟŽŶ

Ϯ͘DŽǀĞŵĞŶƚƟŵĞ;ƐĞĐͿϮ͘DŽǀĞŵĞŶƚƟŵĞ

Ϭ͘ϲ
Ϭ͘ϰ
Ϭ͘Ϯ
Ϭ

FUGLǦMEYERASSESSMENTOFSTROKERECOVERYϯ͘EƵŵďĞƌŽĨǀĞůŽĐŝƚǇƉĞĂŬƐ

CannotbeϯϮ
performedORϭpatientcannotgetϬpastASISwithout
compensation
1Ǧ HandpassedASIS
without
compensation
(gravitationaltricks)
lumbarspinewiththumbpointingΎZŝŐŚƚͲĂƌŵĚĂƚĂǁĂƐŇŝƉƉĞĚƚŽĐŽƌƌĞƐƉŽŶĚƚŽůĞŌͲĂƌŵĚĂƚĂup.
2Ǧ Performedfaultlessly
0Ǧ





Compensationat

startofmovement
SCORESCORINGCRITERIANOTESSCORE
(armabducted,elbow
LEFT c.Pro/supinationof
RIGHT
b. Shoulderflexiontoflexed)
90°,Elbowat0°
UPPER
EXTREMITY
forearm,elbowat0°,
NOTE:StartPositionelbow0°,
1Ǧ Compensationlater
UNLESSOTHERWISESPECIFIED,PREFERABLESTARTPOSITIONISPATIENTSITTINGWITHHANDSINLAP.
shoulderbetween30°Ǧ90°.
shoulderbetween30Ǧ
inmovementBiceps:Handinlap,forearm
90°offlexion
2Ǧ Faultlessmotion
supine.Supportarmatelbowwith
I. Reflexes0Ǧ
Cannotbethumbfirmlyincreviceofelbow

上肢運動機能障害の回復

共同運動の程度の臨床的評価

Brunnstrom の回復段階^ƚĂƌƚ・dŚĞƉĞƌĨŽƌŵĂŶĐĞŽĨŚŽƌŝǌŽŶ

ƉŽƐƚĞƌŝŽƌĚŝƌĞĐƟŽŶŝƌƌĞƐƉĞĐƟ
ŝŶƉĂƌƟĐŝƉĂŶƚƐǁŝƚŚŵŝůĚͲƚŽͲ

・dŚŝƐ ĚŝƌĞĐƟŽŶͲĚĞƉĞŶĚĞŶƚ ĚŝŵƉĂĐƚƚŚĞƉĂƩĞƌŶŽĨŵŽǀĞĞƌĂƚĞͲƚŽͲƐĞǀĞƌĞŚĞŵŝƉĂƌĞƐŝƐ

0Ǧ

1ǦCompensationat
startorcannotbe
performed(startpositioncannotbe
attainedorno
pro/supination)
Performedpartly(startingposition
maintainedbutnot
completerangeofmotion)
Faultlessmotion

performed(cannot
attainstarting
positionorno
2Ǧ
2Ǧ
pro/supination)
0Ǧ Atleast2ofthe3NOTE:StartPositioniselbow
1Ǧ Performedpartly
phasicreflexesare
90°,shoulderat0°.
b. Triceps(extensor)(startingposition
共同運動を許容した粗⼤運動
ONLYassessediftotalscorein
hyperactiveORnot
sectionVis6.
attainedand
assessedII. FlexorSynergy
VI.Normalreflex
pro/supinationwithin
90°andshoulderat0°1Ǧ 1reflexishyperactive,
Assesswhetherreflexesarenormal,
a. ShoulderElevation
activity
limitedrangeofEnsurethatelbowiskeptclosetooratleast2reflexes
livelyorhyperactive.
(raisingtrapezius)
motion)
trunk. arelively
Hyperactive:3+
b. ShoulderRetraction
2Ǧ Performed
a.Biceps,fingerflexors (spreadstoothermusclegroups)
2Ǧ Nomorethanone
0Ǧ Cannotbe(rollingtheshoulderback)
Startingwithpalmdown,move
faultlessly(completeLively:Between2+and3+
andtriceps
reflexislivelyand
performed
handtoear,armakimbo(forearmc. ShoulderAbduction
pro/supinationand
Normal:2+
nonearehyperactive
supinated).
1Ǧ Performedpartly(On1,2+,3+scale)
correctstarting(atleast90°)共同運動から逸脱した肩関節運動
2Ǧ Performed
(movingarm90°from
position)
Maximumrangeofmotioninthe
faultlessly
midline)
0Ǧ Compensationat
elbowandshoulderjointsis
TOTALSCOREǦ
UpperExtremity
d. ExternalRotation
startorcannotbe
assessed. V. MovementoutofMaximumUpper
Scoreeachaspectoftest.
(elbowcreasefacing
performed(initialsynergy____/36 ____/36
ExtremityScore=36
forward)
elbowflexionoccurs,e. ElbowFlexion
ordeviationfrom
a. Shoulderabduction
(elbowfullyflexed)
forearmpronation)
to90°,elbowat0°,and
f. ForearmSupination
1Ǧ Compensationlater
forearmpronated.
(palmback)
Wrist:ExaminerMayAssistpatientbysupportingarminrequiredpositionifneeded.
orperformedpartly
However,elbowflexorshouldbeactivatedduringelbow90°,andelbowextensorsshouldbeactivatedduringelbow0°.
2Ǧ Faultlessmotion
III. ExtensorSynergy
共同運動から逸脱した⼿関節運動0Ǧ

andtapownthumb.
FingerFlexors:Examinerplaces
fingersoninsideofhandandtap
ownfingers.Triceps:Upperarmabductedby
examiner,elbowinpassiveflexion.
c. Pro/supinationof
Tapjustaboveelbow.
forearmwithelbowat

Noreflexactivitycanbeelicited
Reflexactivitycanbe
elicitedFugl-Meyer Assessment Score for upper extremity (FM-UE)：共同運動の程度を数値化

痙縮を伴う異常な共同運動が出現し，それが徐々に分離していく過程を表現
Brunnstrom (1970)

共同運動からの逸脱程度を点数化

StageⅠ： 弛緩性⿇痺
StageⅡ： 共同収縮下の最⼩限の運動に進化StageⅢ： 共同収縮依存の随意運動

a. Shoulder
adduction/internalrotation(upperarmmovesacrossbody)

StageⅣ： 多少の共同収縮の残留

b. Elbowextension(elbowfullyextended)

StageⅤ： ほとんど共同収縮と無関係な運動

c. ForearmPronationCompensationat

startorcannotbe
NOTE:StartPositionelbow90°,
a.Stabilityofwrist
performed(initial
shoulder0°.
NOTE:StartPositionshoulder
dorsiflexedto15°,
0Ǧ Cannotbeflexionofelbowor
90°Ǧ180°,forearminmidǦposition
performed
elbowat90°,shoulder
ResistanceisONLYappliedif shoulderabduction)
betweenpro/supination
1Ǧ Performedpartlyat0°
patientcanmaintain15°. 1Ǧ
Compensationlater
2Ǧ Performed

Examinerappliesslight

pro/supination

Examinerkeephandlightlyunder
patient’stoensurethatthe
movementisnotonlydueto
gravity.

resistance

faultlessly

2Ǧ

b.Flexion/extensionofwrist,elbowat90°,
shoulderat0°

0Ǧ
1Ǧ

2Ǧ

orperformedpartly
Faultlessmotion

NOTE:StartPositionelbow90°,
shoulder0°.

Duringthewristextensionfingers
canbesomewhatflexed.
Cannotattain
startingposition
Startingposition
maintained,butno
resistanceistaken
Startposition
maintainedwithsome(slight)resistanceScoreeachaspectoftest.

(palmdown)

StageⅥ： 通常の速度の正常な運動

0Ǧ

VII.Wrist

b. Shoulderflexion,
90°Ǧ180°,elbowat0°
andforearminmidǦ
NOTE:StartPositionisflexor
position. positionbetween

0Ǧ


1Ǧ
2Ǧ

Cannotbe
performed
Performedpartly
Faultlessmotion

0Ǧ

Cannotattain

Li & Francisco, Front Hum Neurosci , 2015
c.Stabilityofwrist
dorsiflexedto15°,
elbowat0°,shoulderat30°Supplementary materials in Hadjiodsif etstartingposition
al., J Neurophys, 2022
NOTE:StartPositionelbow0°,
1Ǧ Startingposition
shoulder30°.
maintained,butnoResistanceisONLYappliedifpatientcanmaintain15°.


tϯ
tϮ

TEST

a. BicepsorFinger
Flexors(flexor)dŽƚĂdĂƌŐĞƚ

DĞĚŝŽůĂƚĞƌĂů

40Ǧ

Makesuresubjectmaintains
uprightpositiontoavoidtϮtϭConclusionsϯ͘EƵŵďĞƌŽĨƉĞĂŬƐ

Explaintasksverballyanddemonstrate.Patientshouldperformtasksontheunimpairedsidefirstandtasksshouldbescoredagainst
IV. Movementcompensatorymovements.
unimpairedside(ifpossible).Repeateachtaskthreetimesandscoreforbestperformance.
combiningsynergies AnteriorǦSuperiorIliacSpine
Unlessotherwisespecified:(ASIS):Topofhipbone.o ExaminerMAYassistpatientinattainingstartpositionanduprightpositioninchair.
a. HandtolumbarToscorea1,armmustpasstheo ExaminerMAYNOTassistpatientinattainingfinalposition.
Onset
KīƐĞƚ
spine
midlineonthewaytotheback.
o Scoreonrangeofmotionorwhetherpatientcanattainfinalposition(pointsshouldbelostfortone/contracture).
Backofhand(dorsalside)against
o Eachtaskmustbeperformedasadistinctunitwithatleast3secondsseparatingalltasks.

ILLUSTRATIONŶƚĞƌŽƉŽƐƚĞƌŝŽƌ

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x

dŝŵĞ

dŝŵĞ

/ŶĐƌĞĂƐĞƐŝŶƚŚĞƉƌŽƉŽƌƟŽŶ
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ϭϱ͘ϴ;ϭϭ͘ϳͿ Ϯϱ͘Ϭ;ϭϬ͘ϵͿ<ŝŶĞŵĂƟĐƉĂƌĂŵĞƚĞƌƐŽĨƌĞĂĐŚŝŶŐ

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合⽬的的運動&DͲh͗&ƵŐůͲDĞǇĞƌĂƐƐĞƐƐŵĞŶƚĨŽƌƵƉƉĞƌĞǆƚƌĞŵŝƚǇ

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ŵĞĂŶƐĐŽƌĞ;^Ϳϱϲ͘ϴ;ϳ͘ϵͿ ϲϭ͘ϯ;ϱ͘ϭͿDŽǀĞŵĞŶƚƚƌĂũĞĐƚŽƌǇ
;Ğ͘Ő͘ŵŝůĚͲƚŽͲŵŽĚĞƌĂƚĞĐĂƐĞͿ

dŽƚĂů

ŶĚ
ŶƚĞƌŽƉŽƐƚĞƌŝŽƌ

'ĞŶĚĞƌ
DĂůĞ͕Ŷ;йͿ&ĞŵĂůĞ͕Ŷ;йͿ

陽性徴候

LB

mean FMA = 28.9 (SDĚŵŝƐƐŝŽŶ
14.4)
ĚŵŝƐƐŝŽŶ ŝƐĐŚĂƌŐĞ
ŝƐĐŚĂƌŐĞ
Lawrence et al., Stroke, 2001
mean FMA = 19.4 (SD 14.4)

ŐĞ͕ŵĞĂŶ;^Ϳ（⼒発揮 ＋ 巧緻的制御）− 共同運動
陰性徴候

Affected-Discharge

⿇痺側上肢の運動機能 ＝0DŝůĚͲƚŽͲŵŽĚĞƌĂƚĞ;ŶсϭϱͿDŽĚĞƌĂƚĞͲƚŽͲƐĞǀĞƌĞ;ŶсϭϯͿ
脳卒中患者の能⼒低下にsĂƌŝĂďůĞ 最も影響を及ぼす機能障害の⼀つ

2

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resistanceistaken
Startposition
maintainedwithsome(slight)resistance

3

indicated impaired trajectory kinematics for patients withstroke compared with controls (average ± SEM AMD2 for all
patients: 61.4 ± 7.5; for all controls: 8.13 ± 0.56). Interestingly,
however, subacute patients tended to show markedly worse
kinematics than chronic patients despite similar or higher
FM-UE scores, as illustrated in Fig. 4B. Because very few participants in the subacute stage had low FM-UE scores, resulting in a higher average FM-UE for the subacute groupcompared with the chronic group (on average, FM-UE of
50.0 ± 3.0 for the subacute vs. 37.4 ± 4.0 for the chronic
group, see Fig. 4B), we performed additional analysis on
patients with moderate and mild impairment [FM-UE ! 26,
the cut-off is based on previous work (19, 25)]. For thesepatients (24 subacute and 16 chronic), despite similar FM-UE(54.3 ± 2.0 for the subacute vs. 51.5 ± 3.2, means ± SE for thechronic patients, respectively, P = 0.47), trajectory abnormalities were substantially greater in the subacute group (AMD2of 60.5 ± 10.2 vs. 21.5 ± 4.1, P < 10"4, Fig. 5). These two groups
were signiﬁcantly different (P = 0.0002) even when the subacute participant with the highest AMD2 (174.9, Fig. 5B) was
excluded as a potential outlier. We also considered whether
this AMD2 difference between subacute and chronic patients
could be due to FM-UE capturing different types of abnormality in each group. In other words, despite similar overall
FM-UE scores, could there be systematic differences in subcomponents of the FM-UE between subacute and chronic
patients? We thus isolated and compared 1) the part of the
FM-UE focusing on movement of the proximal arm (see
MATERIALS AND METHODS) and 2) the part of the FM-UE

subgroups (subacute vs. chronic mild/moderate patients).
We found no signiﬁcant differences (proximal part: 30.8 ± 1.0
vs. 29.7 ± 1.6 for subacute vs. chronic, P = 0.56; out-of-synergy
part: 10.2 ± 0.5 vs. 9.7 ± 0.8 for subacute vs. chronic, P = 0.59),
ruling out that AMD2 differences could be explained by differences speciﬁc to the synergy subcategory of the FM-UE
that are not apparent when taking the whole score into
account.
The difference in arm dexterity despite similar FM-UE
that we observed suggests that impaired arm dexterity (anegative sign) is dissociable from abnormal synergies (a positive sign on which FM-UE is based)—one is not causing theother. This failure on part of the FM-UE to capture differences in the quality of motor control during the subacute recovery stage further suggests that additional assessments
may be needed to capture the full spectrum of the poststroke
motor control phenotype, and/or recovery of motor control
within the subacute stage may lag behind corresponding
improvements in FM-UE.
Finally, we examined whether our ﬁnding could be
explained by larger lesion volume in the subacute group.
trajectory
Trial-by-trial
For theMovement
part of mild/moderately
impaired patients
who analysis
also had imagingF available, we still observed similar FMUE scores (53.4 ± 2.4 for the 19 subacute vs. 46.3 ± 4.1 forthe 10LFchronic patients, P MF
= 0.14) and signiﬁcantly largerth
AMD2 in the subacute group (65.1 ± 12.0 vs. 16.4 ± 3.1, P g<nle10"4). Yet, lesion size was larger in the chronic subgroupth[61,029 ± 25,540 voxels for chronic (n = 10) vs. 9,269P±a 3,206
LM
voxels for subacute (n = 19), P = 0.0138], suggesting that

共同運動の程度と運動巧緻性との間の関係性
同程度の共同運動を呈する患者群でも運動の巧緻性は異なる

F

5POSITIVE AND NEGATIVE STROKE SIGNS REVISITED
共同運動の程度が軽度の患者は⼤きな運動出⼒を発揮できるL
M
0Shoulder (horizontal) adduction

A

B

B

62.8

14
12
10
8
6

LF 7. Relationship of weakness
MFand FuglFigure
Meyer scale for the upper extremity (FM-UE).
49.1
Comparing strength (expressed as a % of nonparetic strength) with each patients’ FM-UE
scores revealed strong correlations between
FM-UE and shoulder abduction strength, elbow
M
ﬂexion strength, and elbow extension strength,
but not shoulder adduction strength (which was
relatively high across the whole patient population). For each panel, each dot represents apatient [red: subacute (n = 11); blue: chronic, at
the time of examination (n = 14)].

10cm

80

L

60
35

40

160
140

高

100

29.4
te

0

cu
c
f

ba

40

LB

20

d

Su

te
ba

cu

60

20

b

25

80

f

a

30

120

C
hr
on
ic

c

e

C
hr
on
ic

180

MB

Affected-Admission
Affected-Discharge

29.5

B

LB

100

Unaffected sideF
14
LF
12 R =0.15, pMF= 0.46
0
0
20 10
40
60
FM-UE
8
L
M
6
50

LB

Rs=0.56, p = 0.0036

0

20

40

We ﬁrst assessed the quality of reaching movements using
our two-dimensional (2-D) reaching task. Examples of participants’ trajectories with the paretic arm are shown in Fig. 4A.
We made two primary observations. First, subacute patients
had markedly worse trajectories compared with chronic
patients for similar FM-UE scores. Second, there was convergence onto the shape of trajectories of the control populationas patients’ FM-UE scores improved.
To formally assess reaching trajectories in patients withstroke and generate a scalar comparison metric, we used theAMD2 metric obtained through functional
557 principal component analysis (fPCA, see MATERIALS AND METHODS). Consistent

J Neurophysiol " doi:10.1152/jn.00447.2021 " www.jn.org
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861

共同運動の程度と運動巧緻性の回復機序は異なる可能性
697034
research-article2017

Cortes et al

NNRXXX10.1177/1545968317697034Neurorehabilitation and Neural RepairCortes et al

共同運動の程度と運動出⼒の回復過程は類似する⼀⽅で、運動巧緻性の回復過程は異なる
Figure 5. Normalized time course for all outcome variables:
AMD2, Action Research Arm Test (ARAT), Fugl-Meyer
Assessment of the upper extremity (FMA-UE), and biceps
Neurorehabilitation anddynamometry (strength) Z-score. The dotted line indicates the
Neural Repair
normalized
value of the recovery achieved between the first and2017, Vol. 31(6) 552–560
the second visit for each measure, which is 1. AMD2 plateaued© The Author(s) 2017
Reprints and permissions:at week 5, while all clinical measures continued to improvesagepub.com/journalsPermissions.nav
through the first year after stroke.
https://doi.org/10.1177/1545968317697034
DOI:
10.1177/1545968317697034

Original Research Article

A Short and Distinct Time Window for
Recovery of Arm Motor Control Early
After Stroke Revealed With a Global
Measure of Trajectory Kinematics

-150

15

Anteroposterior movement (cm)Cortes et al

0-200

RESULTS
Patients with Subacute Stroke Had Worse Reaching
Dexterity Compared to Patients with Chronic Stroke
despite Similar Fugl-Meyer Scores

Number of pa!ents

The functional principal component analysis described earlier compares patients’ trajectories with the population ofcorresponding trajectories from healthy controls. Because ofvariability within the reference population itself, AMD2scores would be nonzero for controls themselves. To estimate an AMD2 value for this baseline, we calculated AMD2
between the trajectories of each control participant compared and the trajectories of all other controls.

60

Rs=0.81, p = 1.1×10-6

0

0

20

60

40

Hadjiodsif et al., J Neurophys, 2022

FM-UE

Target direc!on

0.015

SD

Mean

Affected-Admission
Why would FM-UE not be that suitable for assessing reachAffected-Discharge
ing dexterity deﬁcits?
The primary reason is that is not what it
Unaffected-Admission
was designed for—instead,
it was created to assess synergies
Unaffected-Discharge
outside the context
of reaching or any other kind of functional
0.01
movement (11). Recent work has shown that reaching dexter-

80

10
0

40

Probability

0.006

力発揮

共同運動

50

its constituent components. Given the prevalence and ity in patients with stroke is improved with weight support; -10
impact of hemiparesis, it-20
is important to assess speciﬁc post- conversely, without weight support, dexterity might bestroke motor impairments with quantitative metrics to ena- masked by weakness and abnormal synergies. Beer et al. (16) -20
that external arm support allowed for signiﬁcantly
ble clinicians to reliably characterize the initial0deﬁcit and to found 0.005
predict and track recovery. This knowledge may help opti- greater peak torques when moving to distal targets requiring
mize rehabilitation (27–29) and also enable researchers to elbow extension and/or shoulder ﬂexion, i.e., arm support
compare the effectiveness of different experimental treat- facilitated movements that required breaking out of ﬂexor
ments and interventions to enhance recovery. The FM is synergy. At the same time, there was little, if any, effect ofwidely used in tracking poststroke motor recovery, in fact it external arm
0 support for movements to proximal targets thatis the de facto impairment measure from the International involved elbow ﬂexion and shoulder extension. A subsequent-100 -50
0 of Functioning,
50
100 Disability,
150 and
200Health used for study by the-200-150also-100-50while providing
050
same group
found that,arm 100
Classiﬁcationelbow extension
studiesdevia!onand trials(deg)(12, 27, 30–40). Here, however, we have support allows for greater range and speed
AngularAnglarofdevia!on(deg)shown that FM-UE might miss one of the components of (15), this improvement was independent of reduced shoulder
hemiparesis—reaching dexterity loss—even though it might strength or elbow ﬂexor/extensor strength imbalance. This
well capture weakness and abnormal
synergies.
ﬁnd- suggested that abnormal synergies—and not merely weakness
Total amountof Ourdisplacement
ings, showing a 1200
poor correspondence between these two per se—were the sign alleviated by arm support. This ﬁnding
types of impairment, suggest
the need for more careful mirrored earlier results for 3-D movements (14), which
Affected-Admission
matching between the rehabilitation intervention being showed a critical effect of synergy intrusion in the absence ofAffected-Discharge
tested in clinical studies and the chosen primary outcome weight support. Thus, tasks that require the patient to makeUnaffected-Admission
measure: hemiparesis—or upper motor neuron syndrome— multijoint movements in 3-D without support, like most of
Unaffected-Discharge
is too vague a term, as it lumps
weakness, synergies, and the test components of the FM-UE, will primarily reﬂect
dexterity loss.
weakness and synergies, masking residual dexterity.

0

150

200

Figure 2. Lesion distribution overlay for chronic (top, n = 10) and subacute (bottom, n = 19) patients with moderate/mild Fugl-Meyer scale for the upper ex! doi:10.1152/jn.00447.2021 ! www.jn.org
864
J Neurophysiol
tremity (FM-UE) impairment(FM-UE ! 26). Averaged lesion distribution
mapped toJohns Hopkins University-Montreal Neurological Institute (MNI)
Downloaded
fromindicatesjournals.physiology.org/journal/jn
at Fujita Health University (202.236.174.013) on March 24, 2022.
space, with lesion ﬂipped to one hemisphere.
Color barpatient count.

600

from our analysis. This case was rare: in the main session,
targets were excluded in only two out of 53 patients. From
the remaining trajectories, we excluded movements in which
1) movement direction at peak speed was !90" away fromtarget direction, 2) the participant had not moved beyond
30% of the target distance (the criteria used in Ref. 12 andpreviously Ref. 22), or 3) the movement onset analysis
described in the previous paragraph failed to provide an

557

estimate of movement onset (as in when the peak velocity
was lower than the 2 cm/s onset criterion; these movements
were clearly abortive). For the second training block that we
focus on in this paper, these criteria excluded 3.72% of
patients’ movements with the paretic arm; for healthy controls, the corresponding value was 0.07% for the left and
FMA =(these
28.9are(SDrightmeanarms together
the 14.4)
percentages calculated after a small number of targets were excluded altogether due

共同運動の程度が変化しても巧緻性に顕著な変化は⾒られない

0

Estimation of baseline value for AMD2 in controls.

Probability

pal component analysis (fPCA), a method that applies principal component analysis to functional data (23). In summary,this data-driven analysis allows trajectories to be evaluated
without prior assumptions about which trajectory features
ought to be emphasized. Here, we used fPCA to estimate theMahalanobis distance (MD) of patients’ trajectories from thereference population of healthy, age-range-matched controls.
Here, MD can be understood as a generalization of the z-score;
it is large when the movement is impaired (i.e., it is dissimilar
to the healthy controls used as a reference) and small whenthe movement is similar to healthy controls. For each patient,
we averaged these distances across trials and target directions
into the average squared Mahalanobis distance (AMD2) separately for session T1 and for session T2. Additional details areprovided in Supplemental Materials, adapted from a previous
report (12).

Downloaded from journals.physiology.org/journal/jn at Fujita Health University (202.236.174.013) on March 24, 2022.

group. This provided estimates of the two-tailed P values wereport. We opted to use bootstrap over more typical t tests, as
the latter require assumptions of normality that may nothold for our data, especially for the distribution of AMD2
across participants. For simplicity, we used a similar bootstrap method for all other comparisons in the paper (otherthan the analysis used for Fig. 7) and also to calculate all
SEMs reported. To examine the relationship between weakness and FM-UE (Fig. 7), we used Spearman’s rank correlation to avoid assumptions about linearity.

Affected-Admission

Functional principal component analysis.

SD

20
Affected-Admission
80
DISCUSSION
Downloaded from journals.physiology.org/journal/jn at Fujita Health UniversityAffected-Discharge(202.236.174.013) on March 24, 2022.
Signiﬁcance of Our Findings for Assessing Poststroke
Statistical comparisons.
Unaffected-Admission
To compare AMD2 between subacute and chronic patients,
Motor Impairment
0
Unaffected-Discharge
or changes in AMD2 between T1 and T2, we used a bootstrap
0.012
Here, we sought to dissect the hemiparesis 40
phenotype into
procedure (24) using 10,000 permutations within each sub-Affected-Discharge

exclusion criteria 1) and 2), showing qualitatively identical

0022-3077/22 Copyright © 2022 the American
PhysiologicalSociety. of kinematics, we www.jn.org
To assessthe quality
used functional princi-

60

巧緻的制御

100

FM-UE

Mean

0.018

40

FM-UE

Unaffected-Admission
Unaffected-Discharge

50

0Hadjiodsif et al., J Neurophys, 2022

856

20

Elbow extension

MB

100

worse motor control (higher AMD ) for subacute patients compared with chronic patients, despite similar FM-UE. White circles indicate mean values andﬁndings (see Supplemental Fig. S3).
* A. M. Hadjiosif and M. Branscheidt contributed equally to this work.
Correspondence: A. M. Hadjiosif (alkis@jhmi.edu).
Submitted 5 October 2021 / Revised 23 December 2021 / Accepted 12 January 2022

Rs=0.70, p = 0.00010150Discharge: mean FMA = 62.3 (SD 4.7)

n = 26) groups. Note the higher AMD2 for subacute patients, especially the ones with moderately and mildly impaired FM-UE (!26). The lowercase letJ Neurophysiol # doi:10.1152/jn.00447.2021
www.jn.org
ters (a–f) point to #thecorresponding trajectories on A. The black dashed line indicates baseline calculated based on control data (n = 17); the gray band
J Neurophysiol # doi:10.1152/jn.00447.2021 # www.jn.org
results
in somedegreeof(202.236.174.013)
motor95%
impairment(2–4),
which
Downloaded
from journals.physiology.org/journal/jn at Fujita
HealthUniversityon
March
24, 2022.
INTRODUCTION
indicatesthecorresponding
conﬁdence
intervalestimatedusing bootstrap. 862
makes activities of daily living harder, compromising qualityof life (5, 6). Hemiparesis (or upper motor neuron syndrome)
to mechanicalconstraints).
In theinterest of completenessis clinicallyquite recognizable
but remains
undercharacterizedandin terms
of its behavioral
components.our
It hasbeentransparency,
we repeatedanalyses
without the

50

Elbow flexion

Figure 4. Subacute patients had worse kinematics compared with chronic patients for similar Fugl-Meyer scores. A: exemplar movement trajectories,
a starting position (pink). Vision of the hand was occluded; instead, during movement,a cursor was displayed on screen on the plane of the arm. thicklines indicate
means
C: reaches
for two patients closest to the mean AMD2 for each subgroup. Numbers indicate speciﬁc AMD2 scores.POSITIVE AND NEGATIVE STROKE SIGNS REVISITED
using the paretic arm, for three subacute patients (red), three chronic patients (blue),andblack
three controls(gray). B: scatter
plot±ofSE.
kinematic
abnormality
dexterity; hemiparesis; motor control; stroke; synergy
Target direc!on(average squared Mahalanobis distance, AMD2) vs. Fugl-Meyer scale for the upper extremity (FM-UE) for the subacute (red, n = 27) and chronic (blue,

Stroke is one of the leading causes of disability globally,
with an estimated 13.7 million individuals suffering a strokeeach year (1). A large fraction of strokes (up to 70%–80%)

100

0

150

B
Admission: mean FMA = 59.0 (SD 5.7)

Figure 5. Subacute patients had worse kinematics compared with chronic patients despite similar Fugl-Meyer scores. Violin plots of Fugl-Meyer scale forShoulder (horizontal) abduction
150

MB

s

NEW & NOTEWORTHY Motor impairment is common after stroke and comprises reduced dexterity, weakness, and abnormal
0
extremity(FM-UE)
Mahalanobis distance (AMD2) (B) for chronic (n = 16) and subacute (n = 24) patients with moderate/
2030
40(A) and
50average
0 the upper
10
60 squared
66
muscle synergies. Here we report that, when matched on an established synergy and weakness scale (Fugl-Meyer), patients
Figure 3. Task design andtrajectories.
A:reachingillustrationof thanthe chronic
experimental(Kinarm,
BKIN Technologies,
ﬁgure
withexample
subacute stroke
have worse
dexterity
ones. This apparatus
result suggeststhat the componentsof hemiparesisKingston, ON, Canada,mild(FM-UE ! 26)FM-UE
impairment. Note how, for this FM range, where both subacute and chronic patients were adequately represented, we found much2and have separable
mechanisms
and, thus, may requiredistinctassessments
and treatments.
adapted from Ref. 55). B:arethedissociabletask: participants
had tomake point-to-point
outwardreaching
movements
to eight different targets (cyan) beginning from860

B

Strength [% of unaffected]

100

200

Su

Most patients with stroke experience motor deﬁcits, usually referred to collectively as hemiparesis. Although hemiparesis is oneof the most common and clinically recognizable motor abnormalities, it remains undercharacterized in terms of its behavioral
subcomponents and their interactions. Hemiparesis comprises both negative and positive motor signs. Negative10cm
signs consist of
weakness and loss of motor control (dexterity), whereas positive signs consist of spasticity, abnormal resting posture, and intrua How positive and negativebsive movement synergies (abnormal muscle co-activations during voluntary movement).
signs interact,cm
and whether a common mechanism generates them, remains poorly understood. Here, we used10
a planar,arm-supported reaching task to assess poststroke arm dexterity loss, which we compared with the Fugl-Meyer stroke scale; a measure primarilyStart
reﬂecting abnormal synergies. We examined 53 patients with hemiparesis after a ﬁrst-time ischemic stroke. Reaching kinematics
were markedly more impaired in patients with subacute (<3 mo) compared to chronic (>6 mo) stroke even for similar FuglMeyer scores. This suggests a dissociation between abnormal synergies (reﬂected in the Fugl-Meyer scale) and Cursor
loss of dexterity,
which in turn suggests different underlying mechanisms. Moreover, dynamometry suggested that Fugl-Meyer scores capture
weakness as well as abnormal synergies, in line with these two deﬁcits sharing a neural substrate. These ﬁndings have two imd
ewhich component of
portant implications: First, clinical studies that test for efﬁcacy of rehabilitation interventions
shouldHand
is specifyTarget
hemiparesis they are targeting and how they propose to measure it. Metrics used widely for this purpose may not always be
occludedchosen appropriately. For example, as we show here, the Fugl-Meyer score may capturesome hemiparesis components (abnormal synergies and weakness) but not others (loss of dexterity). Second, there may be an opportunity to design rehabilitationinterventions to address speciﬁc subcomponents of hemiparesis.

F

40

220

AMD2

Abstract

Affected side

120

巧緻性

2

Rehabilitation, Johns Hopkins University, Baltimore, Maryland; 3Department of Neuroscience, Johns Hopkins University,
Baltimore, Maryland; 4Cereneo Center for Research and Neurorehabilitation, Weggis, Switzerland; 5Kennedy Krieger Institute,
Baltimore, Maryland; and 6Santa Fe Institute, Santa Fe, New Mexico

150

B

140

FM-UE

1

160

低

Start posi!on

MB

LB

Strength [% of unaffected]

60

Neuroscience of Disease

from our analysis. This case was rare: in the main session, estimate of movement onset (as in when the peak velocity
targets were excluded in only two out of 53 patients. From was lower than the 2 cm/s onset criterion; these movements 55
were clearly
abortive).
For the second training block that wethe remaining trajectories,
we excluded
movements
which
Dissociation
betweenabnormalin
motorsynergies
and impaired
reaching
1) movement direction
at peak
speed
was !90" away from focus on in this paper, these criteria excluded 3.72% of
dexterity
after
stroketarget direction, 2) the participant had not moved beyond patients’ movements with the paretic arm; for healthy con- 50
30% of the target distance (the criteria used in Ref. 12 and trols, the corresponding value was 0.07% for the left andAlkis M. Hadjiosif,1* Meret Branscheidt,2,4* Manuel A. Anaya,2 Keith D. Runnalls,2 Jennifer Keller,5POSITIVE AND NEGATIVE STROKE SIGNS REVISITED
previously Ref. 22), orAmy3)J. Bastian,the movement
onset analysis right arms together (these are the percentages calculated af3,5
Pablo A. Celnik,2 and John W. Krakauer1,2,3,645
ter a small
numbertargets
described in the previous
paragraph
to provide
an Maryland;
Departmentof Neurology,failed
Johns Hopkins
University, Baltimore,
Departmentof Physicalof
Medicine
and were excluded altogether due

CStrength [% of unaffected]

B 180

Strength [% of unaffected]

A 65

AMD2

J Neurophysiol 127: 856–868, 2022.

Figure 2. Lesion distribution
overlayFebruary
for chronic(top, n = 10) and subacute (bottom, n = 19) patients with moderate/mild Fugl-Meyer scale for the upper exFirst published2, 2022; doi:10.1152/jn.00447.2021
tremity (FM-UE) impairment (FM-UE ! 26). Averaged lesion distribution mapped to Johns Hopkins University-Montreal Neurological Institute (MNI)
space, with lesion ﬂipped to
one hemisphere.
Color bar indicates patient count.
RESEARCH
ARTICLEA

Sort by target loca!ons

Target
LF
MF
共同運動の程度と⼒発揮との間の関係性
10Path length(cm)

POSITIVE AND NEGATIVE STROKE SIGNS REVISITED

0

A

軽度FMA
の運動障害を有する⽚⿇痺患者(n = 13)mean= 19.4 (SD 14.4)

600
1200
⽬標点に向かう到達運動の軌跡⻑を評価
MediolateralBmovement (cm)

0

10cm

巧緻的制御 ×Movement trajectory

journals.sagepub.com/home/nnr

Trial-by-trial analysis

Sort by target loca!ons

力発揮

Start
F
stroke participants’ reaching trajectories and trajectories fromF
the dominant arm of healthy controls. The main finding was
TargetCursorLF
MF
LF
MF
that improvement in motor control for the paretic arm was10halmost all over by five weeks, whereas FMA-UE and ARAT
gt
Juan C. Cortes, MD1, Jeff Goldsmith, PhD2, Michelle D. Harran3, Jing Xu, PhD1,
Hand isTargetscores continued to show robust improvements up to 14
en
1
4
5
1
5
l
occludedNathan Kim , Heidi M. Schambra, MD , Andreas R. Luft, MD , Pablo Celnik, MD ,hweeks poststroke. Furthermore, these two clinical measures,at
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M
along with arm strength, continued to show improvements
L
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0
Cortes et al
557 the first year post-stroke. The results presented here
Trial-by-trial analysis
Sort by target loca!ons
Movement trajectory
556
Neurorehabilitation and Neural Repair 31(6)through
Total N = 28F
not only suggest that there is a limited time-period for recovery
Figure 3. Task design and example
A: illustration of the experimental apparatus (Kinarm, BKIN Technologies, Kingston, ON, Canada, ﬁgure
LF 10 MF
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loca!onsof motor control,
but also that this recovery process is distinct
運動出⼒
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th
adapted from Ref. 55). B: the task: participants had to make point-to-point outward
reaching
Clinical Motor Scores Continued to Improve
Abstract 共同運動の程度
5
0
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Targetng
Start
MB on the plane of the arm.
LB
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t
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coursefor alldynamometry
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control, increases in strength, and acquisition of compensatory strategies. Objective. To isolate and characterize the timeThe critical question raised
B
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J Neurophysiol # doi:10.1152/jn.00447.2021 # www.jn.org
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and
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precise time course of this recovery, however, depends on thatRehabilitation,
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Hopkins
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weeks
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by meatarget loca!ons
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4port the hypothesis
motor Sort
control,14
Dept.
of NeurologyFurthermore,and Rehabilitationthese
Medicine,
York University,
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2 The results presented here
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motor
control,
also
that
this
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analysis
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measures did
Neurorehabilitation& Neural
88control, but
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that website.
this recovery process
distinct that a subset of stroke participants, specifing
strength and motor control, the latter being defined as the of motor
the ishypothesis
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Corresponding Author:
that for eachclinicalL measure M
thePments.12 Motor control, and not just strength, is essential for ment,
activity
limitation,andstrength.
M
Mean
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Juan C. Cortes, MD, Johns Hopkins University School of Medicine,
207
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or beyond.
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limitation,
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20
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delta fromand
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5 to week 54 is roughly 100% of the deltaMBMBskilled use of the limb and may determine how much it is
Affected-Admission
Carnegie,
559 North
Wolfe raised
Street, Baltimore,
21287,isUSA.
The
criticalquestionby our MD
results
why, at participantstheAffected-Admission
purpose,were split into “high” and “low” AMD2
80
from weekraised
1.5 to week
This isresults
not the casethe motor
Email:
juancamilo@jhu.edu
used in everyday activities. The Fugl-Meyer Assessment of group
The
criticalby5. ouris forwhy,
at thelevel,
did recovery of motor control plateau
at five
Affected-Discharge
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the median
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potential
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B
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the results indicated >99% power to detectsuch a delta.
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with
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about
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Discharge:
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F the outcome
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0.005
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In a recent study in more than 200 stroke participants,
is important
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MF
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they
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0.018
20
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robot. This kinematic measure was found to benonparetic
more sensi10 did not
10arms during early recovery (up to week 5 post80
80
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10
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tive than FMA-UE in detecting motor recovery
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stroke),duringlate8
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clinicalTargetdirec!onTarget direc!on 8
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Figure 4. Time course of clinical scales: Fugl-Meyer
first three months post-stroke.36 Furthermore,
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0
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20
0
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6 Affected-Admission
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teau in recovery
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80
80
10
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0.012-200 -150-100 -500
50
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40
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impairment
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detect changes after robotic therapy in chronicinitialstrokethat
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to determine
time courseof recovery of aa recent
study
in we
more
200thestroke
participants,
Z-score (C) for individual stroke participants (gray), and mean
-10
24
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detect loca!ons
were undetectable with Trial-by-trial
either FMA-UE oranalysis
ARAT.
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motor control after stroke using a 2D reaching task that
Movement
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Angular devia!on (deg)Anglar devia!on (deg(black) with standard error bars. The
dotted lines in trajectory
A and B00 effects
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possible interaction
between initial impairment
severityand Unaffected-Discharge
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-20
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time toplateau. Still, any changes beyond
week 5This
would
only
of
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andcompensation.
The
globalkinematic
mea40
small differences in motor behavior than standard
clinical
UE = 66, ARAT = 57). For all clinical measures, improvement40
robot.
kinematic
measure
was
found
to
be
more
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LB
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F
0
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represent
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was seen beyond week 5.
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0.005
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陰性兆候

c

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LF
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tive than
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theB
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Figure 4. Time course of clinical scales:
first three months
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haveAffected-Discharge
0
ng
0
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100 150200-200 -150 -100
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50
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24
were undetectable with either FMA-UE or ARAT. Thus
Angular devia!on (deg)Anglar devia!on (deg)(black) with standard error bars. The dotted lines in A and B00の運動障害を有する⽚⿇痺患者 (n = 15)の運動障害を有する⽚⿇痺患者(n = 13)2D
continuous
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Mean
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0.018
20
FMAスコアの改善に伴い運動の範囲・量は増⼤する
FMAスコアは有意に増加するが到達運動の軌跡⻑は変わらない
Affected-Admission
seen beyond week 5.
measures.24,34 Moreover, it is also 80highly unlikely that theAffected-Admission
B was
80
10

共同運動の程度が変化しても巧緻性に顕著な変化は⾒られない
L

15

20

0

Affected-Discharge

0.012

Target direc!onAffected-Admission
Affected-Discharge
Unaffected-Admission
Unaffected-Discharge

Mean

SD
80

40

-20
0

0.006

0
-200

0.01

-200

-150

Unaffected-Discharge

-100

-50
0
50
100 150
Mean length
Anglar devia!on(deg) of stay0

0

mean FMA = 28.9 (SD 14.4)
mean FMA = 19.4 (SD 14.4)
600
Mediolateral movement (cm)Target direc!onAffected-Admission
10
Affected-Discharge
Unaffected-Admissionmean FMA = 28.9 (SD 14.4)
0mean FMA = 19.4 (SD 14.4)
Unaffected-Discharge
0600
Mediolateral movement (cm)

1200-10

SD

Mean
80

40

-20

0.005

0
-150

-100

-50
0
50
100
Angular devia!on (deg)

150

200

-200

1200

600

0

-150

-100

-50
0
50
100 150 200
Anglar devia!on (deg)Reac!on force

0

Discharge

Affected-Admission
Affected-Discharge
Unaffected-Admission
Unaffected-Discharge

運
動
量
の
増
⼤

15

Affected-Admission

200= 53.0 days

Total amount of displacement

1200
Anteroposterior movement (cm)Affected-Admission

Affected-Discharge
Unaffected-Admission
Unaffected-Admission
Unaffected-Discharge00

Total amount of displacement

MB 1200

0.015

600

40

-20

Number of pa!ents

200

Probability

Number of pa!ents

15
150

Admission

0

B
Admission: mean FMA = 59.0 (SD 5.7)

0

0
-10

Affected-Discharge

LB

Discharge: mean FMA = 62.3 (SD 4.7)

0.018

-50
0
50
100
Angular devia!on (deg)Number of pa!ents

B

-100

0

Affected-Admission
Affected-Discharge

MB

-150

-20

Anteroposterior movement (cm)

LB

-200

40

0

M

Anteroposterior movement (cm)MF

Probability

L

14
12
10
8
6

Affected-Discharge
Total amountof displacement
Unaffected-Admission
Unaffected-Discharge
Affected-Admission
0.01
Affected-Discharge
Unaffected-Admission
Unaffected-Discharge
0.005

1200

0

Unaffected side
F
14
MF
LF
12
0.006
10
8
L0
M
6

Affected-Admission

LF

Affected-Admission

F

Affected-Discharge
Unaffected-Admission
Unaffected-Discharge

0.012

共同運動の程度が変化しても巧緻性に顕著な変化は⾒られない
中等度〜重度Affected-Discharge

Affected side

Probability

軽度

LB

Probability

Probability

TargetMF

Probability

LF

Probability

Probability

Path length(cm)

Reac!on force

600

0mean FMA = 28.9 (SD 14.4)
mean FMA = 19.4 (SD 14.4)
0600
Mediolateral movement (cm)

1200

150

200

M

L

TOTAL

L

LB

ƐĞǀĞƌĞ;ŶсϭϯͿŝƐĐŚĂƌŐĞ

B

LB

MB

M

th
Pa

M

Start posi!on ϭϯ

MB
B

LB

MB

B

;ϭϬ͘ϲͿ

Affected side
F

ϲϬϬ

ϮϬ

B

B
Admission: mean FMA = 59.0 (SD 5.7)

まとめ

Unaffected-Admission
Unaffected-Discharge

Discharge: mean FMA = 62.3 (SD 4.7)

DĞĚŝŽůĂƚĞƌĂů;ĐŵͿ

Target direc!onŶŐƵůĂƌĚŝīĞƌĞŶĐĞĨƌŽŵƚŚĞƚĂƌŐĞƚůŽĐĂƟŽŶ
0.018
Affected-Admission
Affected-Discharge

dŽƚĂů

tϭ
^ƚĂƌƚ

dĂƌŐĞƚ

īĞĐƚĞĚ;dͿ
Unaffected-AdmissionAīĞĐƚĞĚ;dͿ
Unaffected-Discharge
0.012 hŶĂīĞĐƚĞĚ;dAͿϬ͘ϬϭϮhŶĂīĞĐƚĞĚ;dͿ

SD

0.015

80

^ƚĂŶĚĂƌĚŽĨĚĞǀŝĂƟŽŶ

MeanϮϬ

o ⿇痺側上肢の共同運動、運動巧緻性、⼒発揮の回復機序は異なる可能性が

Mean

20
ϴϬ

0
40

Ϭ
ϰϬ

-20

ͲϮϬ

Ϭ͘ϬϬϲ

0

Ϭ

0.006

ProbabilitytϮWƌŽďĂďŝůŝƚǇ
ProbabilityŶƚĞƌŽƉŽƐƚĞƌŝŽƌ

ŶĚ

0.01

Target direc!onAffected-Admission
Affected-Discharge
Unaffected-Admission
Unaffected-DischargeSD
Mean
ある（共同運動の程度と⼒発揮の回復過程は類似）
80

10
0

40
-10
o 運動巧緻性に対しては異なる介⼊戦略を⽴てる必要があるかもしれない
-20

0

0.005

tϯ

DĞĚŝŽůĂƚĞƌĂů
tϮ

ConclusionsƌĞƐƉŽŶĚƚŽůĞŌͲĂƌŵĚĂƚĂϰϬ

⽬標点に向かう運動の割合は変わらないĞŶƚƟŵĞ;ƐĞĐͿ

4
ϯ
Ϯ
ϭ
Ϭ

Unaffected side
F
14
MF
12
10
8
M
6

Ϭ の運動障害を有する⽚⿇痺患者
Ϭ
中等度〜重度(n = 15)ϬϲϬϬϭϮϬϬDĞĚŝŽůĂƚĞƌĂů

Ϭ͘Ϭϭϴϯ͘EƵŵďĞƌŽĨƉĞĂŬƐ

L

B/ŶĐƌĞĂƐĞƐŝŶƚŚĞƉƌŽƉŽƌƟŽŶŽĨĂŶƚĞƌŽƉŽƐƚĞƌŝŽƌŵŽǀĞŵĞŶƚŵĂǇŶŽƚŶĞĐĞƐƐĂƌŝůǇŝŶĚŝĐĂƚĞŝŶĐƌĞĂƐĞƐŝŶƉƵƌƉŽƐĞĨƵůŵŽǀĞŵĞŶƚ

ƌŐĞƚůŽĐĂƟŽŶƐ

Ϭ͘ϲ
Ϭ͘ϰ
Ϭ͘Ϯ
Ϭ

LF

MB

ϲϬ

īĞĐƚĞĚ;dͿAffected-Admission
Affected-DischargedŽƚĂůM ͗DĞĚŝĂů
MF ͗DĞĚĚŝĂůĨŽƌǁĂƌĚ
F ͗&ŽƌǁĂƌĚ
LF ͗>ĂƚĞƌĂůĨŽƌǁĂƌĚ
L
͗>ĂƚĞƌĂů
LB ͗>ĂƚĞƌĂůďĂĐŬǁĂƌĚ
B ͗ĂĐŬǁĂƌĚMB ͗DĞĚŝĂůďĂĐŬǁĂƌĚ

ϴϬīĞĐƚĞĚ;dAͿ

dŝŵĞ

dŝŵĞ

ϵϰ͘ϱ;ϰϮ͘ϭͿϮϱ͘Ϭ;ϭϬ͘ϵͿ

Ϭ

M

0

LB
LB
MB
MB
共同運動の程度が変化しても巧緻性に顕著な変化は⾒られない^ƚĂƌƚDĞĚŝŽůĂƚĞƌĂů

ŶƚĨŽƌƵƉƉĞƌĞǆƚƌĞŵŝƚǇ

WƌŽƉŽƌƟŽŶŽĨŵŽǀĞŵĞŶƚ;йͿƌĞĂŬĚŽǁŶ

ϭϬϬ

LŶŐůĞ;ĚĞŐͿϲ͘ϮйͿ
ϯ͘ϴйͿ

ŶƚĞƌŽƉŽƐƚĞƌŝŽƌ;ĐŵͿŶƚĞƌŽƉŽƐƚĞƌŝŽƌ

ϭ͘ϱйͿ
ϴ͘ϱйͿ

hŶĂīĞĐƚĞĚ;dAͿdŽƚĂůƉĂƚŚůĞŶŐƚŚ

ϭϮϬϬ
dŽƚĂů

ŶĚ

5
L

LB

14
MF
12
ŶƚĞƌŽƉŽƐƚĞƌŝŽƌ
10
8
M
6

WƌŽƉŽƌƟŽŶŽĨŵĞĚŝŽůĂƚĞƌĂůͬĂŶƚĞƌŽƉŽƐƚĞƌŝŽƌŵŽǀĞŵĞŶƚƐ
LF

ϲ͘ϵйΉ
ϯ͘ϭйΉ

10

th
ng
le

EƵŵďĞƌŽĨƉĂƟĞŶƚƐ

TOTAL

hŶĂīĞĐƚĞĚ;dͿLŽŶƐĚŝƌĞĐƟŽŶƐ

Path length(cm)ŐƌŽƵƉƐďĂƐĞĚŽŶϬͲϮϬϬ ͲϭϱϬ ͲϭϬϬ

0
-200

-150

ͲϱϬ
Ϭ
ϱϬ
ŶŐůĞ;ĚĞŐͿ

-100

ϭϬϬ

ϭϱϬ

ϮϬϬ

-50
0
50
100
Angular devia!on (deg)

0
150

200

⽬標点に向かう運動・dŚĞƉĞƌĨŽƌŵĂŶĐĞŽĨŚŽƌŝǌŽŶƚĂůƌĞĂĐŚŝŶŐƚĞŶĚƐƚŽĚĞŐƌĂĚĞŝŶƚŚĞĂŶƚĞƌŽͲƉŽƐƚĞƌŝŽƌĚŝƌĞĐƟŽŶŝƌƌĞƐƉĞĐƟǀĞŽĨƚŚĞŚĂŶĚƐŽƌĨƵŶĐƟŽŶĂůŝŵƉƌŽǀĞŵĞŶƚŝŶƉĂƌƟĐŝƉĂŶƚƐǁŝƚŚŵŝůĚͲƚŽͲŵŽĚĞƌĂƚĞŚĞŵŝƉĂƌĞƐŝƐ

・dŚŝƐ ĚŝƌĞĐƟŽŶͲĚĞƉĞŶĚĞŶƚ ĚŝīĞƌĞŶĐĞ ŝŶ ƚŚĞ ĚŝĸĐƵůƚǇ ŽĨ ƌĞĂĐŚŝŶŐ ŵĂǇŝŵƉĂĐƚƚŚĞƉĂƩĞƌŶŽĨŵŽǀĞŵĞŶƚĂƉƉĞĂƌĂŶĐĞŝŶƉĂƌƟĐŝƉĂŶƚƐǁŝƚŚŵŽĚͲĞƌĂƚĞͲƚŽͲƐĞǀĞƌĞŚĞŵŝƉĂƌĞƐŝƐ

-200

-150

-100

-50
0
50
100
Anglar devia!on (deg)150200