Published papers

Objective: To test the hypothesis that the structure of fitness in patients with hemiparetic stroke can be categorized into impairment/disability, cardiopulmonary, muscular and metabolic domains, and to study longitudinal changes in their fitness during an inpatient rehabilitation programme. Design: Structure analysis of multiple fitness parameters with principlal component analysis (PCA), and a before and after trial. Setting: Tertiary rehabilitation centre in Japan. Patients: One hundred and seven consecutive inpatients with hemiparetic stroke. Intervention: A conventional stroke rehabilitation programme consisting of 80 minutes of physical therapy and occupational therapy sessions five days a week, and daily rehabilitation nursing for a median duration of 105.5 days. Main outcome measures: Principal component scores extracted from measurement of paresis/daily living (the Stroke Impairment Assessment Set (SIAS) and the Functional Independence Measure (FIM)); muscular (grip strength (GS), knee extensor torque, and cross-sectional areas of thigh muscles); metabolic (body mass index (BMI) and fat accumulation on CT); cardiopulmonary (heart rate oxygen coefficient (HR-O2-Coeff) obtained with a graded bridging activity and a 12-minute propulsion distance). Results: PCA categorized the original 15 variables into four factors corresponding to paresis/activities of daily living, muscular, metabolic and cardiopulmonary domains, and explained 78.1 % of the total variance at admission and 69.6% at discharge. Except the metabolic domain, PCA scores for the other three domains improved significantly at discharge (paired t-test, p < 0.05). Conclusion: The hypothetical structure of fitness was confirmed, and the PCA scores were useful in following longitudinal changes of fitness during inpatient rehabilitation. © Arnold 2004.

In persons with hemiparetic stroke, assessment and promotion of fitness have so far received limited attention, partly because of the lack of appropriate measures applicable to them. Because these mobility-impaired persons are prone to inactivity, disuse and insulin resistance are likely to occur, and can aggravate the already significant health and economic consequences that stroke entails. It is therefore important to assess objectively their fitness to devize effective and efficient fitness promotion programs. Because of physical limitations, however, many persons with stroke cannot perform traditional stress testing using a treadmill or a cycle ergometer, and maximal oxygen consumption, which is regarded as a gold standard, is not a practical measure. In this article, we reviewed the current status of research on fitness in persons with hemiparetic stroke from the perspectives of evaluation, structure analysis of fitness, and longitudinal changes during a rehabilitation program. As a measure of fitness, indices obtainable with a submaximal exercise are proposed, such as anaerobic threshold and heart rate oxygen coefficient. Protocols applicable to persons with hemiparetic stroke with a variety of functional limitations have been developed (basic bedside activities, bridging activity, or single arm ergometry). The structure of their fitness is demonstrated to be described by a fitness model of healthy persons (cardiopulmonary, muscular and metabolic dimensions) if the paresis/activities of daily living dimension is added. Several studies suggest that fitness improves during a conventional stroke rehabilitation program. Studying the changes of the above four dimensions can help develop more effective fitness training programs.

Purpose: To study the status of contribution by non-English speaking countries to international rehabilitation literature taking Japan as an example, and to suggest recommendations to overcome the language barrier. Method: Descriptive study using a systematic MEDLINE search with outcome measures of annual numbers and proportions of articles by Japanese physiatrists published in peer-reviewed English rehabilitation journals, and of categories and types of studies. A database containing 292 relevant articles were used for analysis. Results: The publications have steadily increased annually both in absolute number and in proportion. The number was the largest for Arch Phys Med Rehabil (16.8%), followed by Am J Phys Med Rehabil (12.3%), Prosthet Orthot Int (8.6%), Disabil Rehabil (5.1 %) and so on. The percentage by category was the highest for stroke (26.0%), followed by spinal cord injury (11.6%), neurophysiology (11.6%) and amputation (6.2%), 67.8% of the articles were related to evaluation, 6.5% to outcome studies and 25.7% to therapy. The majority were descriptive studies (45.5%), followed by case control studies (13.0%), before-and-after trials (12.3%), case reports (7.2%) and others. Conclusion: The contribution from Japan to international rehabilitation literature is increasing. Measures were suggested to facilitate more scientific contribution by non-English speaking researchers.

Objectives: To analyse side difference in bilateral trunk muscles in patients with hemiparetic stroke, to relate it with impairment and disability variables and to evaluate longitudinal changes. Methods: In a sample of 83 inpatients with hemiparetic stroke undergoing rehabilitation, we measured the cross-sectional area of the paravertebral muscle and thigh muscles using computed tomography at admission and discharge. Classifying them by paravertebral muscle side difference (group I: contralateral > ipsilateral; II: contralateral = ipsilateral; III: contralateral < ipsilateral) we analysed group difference in the Stroke Impairment Assessment Set, the Functional Independence Measure and walk velocity. Results: In contrast to thigh muscles, the paravertebral muscle cross-sectional area was significantly greater on the side contralateral to the brain lesion. Discharge paravertebral muscle cross-sectional area increased significantly from admission values. The Stroke Impairment Assessment Set, Functional Independence Measure and walk velocity were significantly lower in group I. Conclusion: The contralateral paravertebral muscle cross-sectional area was larger than the ipsilateral ones, and this was related to the degree of impairment and functional limitations.

Objective: To review the psychometric properties of the Stroke Impairment Assessment Set (SIAS), which was developed in 1990 as a comprehensive instrument to assess stroke impairment. Method: Articles related to the SIAS were retrieved from the MEDLINE and the Folia Centro Japonica. Results: Thirty-five articles were retrieved and analyzed. 1) Scale quality: Rasch analysis demonstrated the unidimensionality of the SIAS. Factor analysis produced 6 factors corresponding to the 6 SIAS subscales. 2) Interrater reliability: The weighted kappas were high except for the unaffected side quadriceps item for which the score distribution was skewed. 3) Concurrent validity: Significant correlations were found between a) SIAS motor items and the Motricity Index or the Brunnstrom stage, b) SIAS lower extremity scores and the Functional Independence Measure (FIMSM) locomotion scores, c) trunk scores and abdominal manual muscle testing, d) visuospatial scores and line bisection and copying task scores, and e) speech scores and the FIMSM communication scores. 4) Predictive validity: Three studies attempting to predict discharge functional status demonstrated that adding the SIAS as one of the predictors enhanced the predictive power. 5) Responsiveness: The SIAS was more responsive to changes than the Motricity Index, the Brunnstrom stage, or the National Institutes of Health Stroke Scale. Conclusion: The SIAS is a useful measure of stroke impairment with well-established psychometric properties.

This study was designed to examine the scale quality of our newly developed short behavior scale and to identify its role in predicting the functional outcome of stroke patients. The short behavior scale consists of six items that assess cognitive function related to the daily behavioral status of a patient in activities of daily living and exercise. It can be scored quickly through observation of a patient's behavior. We assessed 190 stroke inpatients, who had a mean age of 61 years. The mean days and length of stay from onset were 47.3 and 138.2, respectively. We examined internal consistency with the Cronbach's alpha coefficient. Interrater reliability was tested by having two examiners evaluate 30 patients independently. We studied how the short behavior scale correlated with the admission Functional Independence Measure, Mini-Mental State Examination scores, and speech and visuospatial functions. We also studied how the short behavior scale contributed to the prediction of discharge Functional Independence Measure raw scores with stepwise multiple regression analysis. In another group of 116 patients, we cross-validated our predictive equation. The Cronbach's alpha coefficient was 0.88. The intraclass correlation coefficient was 0.84 for total score. The short behavior scale correlated significantly with cognitive Functional Independence Measure scores and Mini-Mental State Examination scores. We could explain 70.8% of the variance of discharge Functional Independence Measure scores from the Short Behavior Scale, days from onset to admission, age, speech scores, and admission Functional Independence Measure scores. Stability of the predictive equation was shown in cross-validation to a second sample of 116 patients. In conclusion, our newly developed short behavior scale proved reasonable and would be useful to enhance the precision of outcome prediction in stroke rehabilitation.

Objectives: To compare bone mineral densities (BMDs) of the affected and unaffected limbs in stroke patients at multiple sites; to study longitudinal changes during a 3-month rehabilitation program; and to relate BMDs to demographic, impairment, and disability variables. Design: Descriptive study. Setting: Tertiary rehabilitation center. Patients: One hundred four consecutive hemiplegic inpatients, 69 men, age 56.5 ± 13.2yrs, 47 with left- sided brain lesion. Median days from onset to admission and median length of stay days were 83 and 105.5, respectively. Main Outcome Measures: BMDs of proximal humerus, distal radius, femoral neck, and calcaneus bilaterally, and third lumbar vertebra, measured with dual-energy x-ray absorptiometry (DXA), were compared between affected and unaffected sides at admission and discharge. Results: Stroke Impairment Assessment Set (SIAS) motor scores, Functional Independence Measure (FIM) scores, grip strength, and awake/sleep heart rate counts (activity index) improved significantly at discharge. Affected/unaffected BMD ratios were 88.3% to 98.4% at admission and 79.6% to 98.8% at discharge, lowest for the humerus. Discharge/admission ratios were 89.1% to 97.8% for the affected and 97.4% to 100% for the unaffected side. All BMDs were intercorrelated (R = .438 to .873). They correlated significantly with age, body weight, grip strength, FIM scores, and activity index. Factors selected to explain BMD with multiple regression analysis differed according to the site and timing of the measurement. Conclusions: BMDs of the affected side were lower and most marked in the humerus. Longitudinally, not only the affected but the unaffected BMDs decreased. Age, sex, duration of stroke, anthropometric measurements, motor paralysis, muscle strength, and activity level contributed differently to bone loss according to the site and timing of the measurement.