High-intensity lower limb endurance training in chronic respiratory disease

High-intensity endurance training is mainly undertaken during pulmonary rehabilitation for patients with chronic respiratory disease. High-intensity endurance training is recommended in many clinical management guidelines. High-intensity endurance training involves training generally at an intensity of at 60-80％ of the patient’s peak work capacity or higher. The effects of high-intensity lower limb endurance training have mostly been investigated in chronic obstructive pulmonary disease （COPD） patients. High-intensity endurance training is more effective than low-intensity endurance training in terms of achieving physiologic gains. According to meta-analyses of studies in patients with chronic respiratory disease, this type of training results in improvements in range of exercise measures, health-related quality of life and dyspnea. There is also some evidence to support the benefits of highintensity endurance training patients suffering from chronic respiratory diseases other than COPD, such as in idiopathic pulmonary fibrosis and pulmonary arterial hypertension patient

Intensive care unit acquired weakness の概要と評価法

解説Perspective　医療の進歩に伴い集中治療室入室患者の生存率は向上している．生存した重症患者の中で，新たな問題が報告されている．集中治療室退室後に生存可能であった患者の中には，運動機能障害が残存する患者がいる事がわかっている．運動機能障害の中で問題になっている筋力低下は，Intensive care unit acquired weakness（ICU-AW）と報告されている．近年，ICU におけるリハビリテーションガイドラインが発表され，集中治療室での重症患者に対する早期リハビリテーションが重要とされている．ICU-AW は日常生活動作や健康関連QOL に影響するだけでなく，患者の生命予後に強く影響する因子となっており，その診断は重要である．診断にはMRC score の使用が推奨されているが，意識状態により評価の可否や評価時期に影響が生じる．集中治療室で測定される骨格筋評価とその問題点について，ICU-AW とMRC score を中心に論述する．　Advances in medical care have contributed to improved survival rates in patients admitted to intensive care units (ICUs). However, newer issues are being observed in critically ill patients. For example, motor impairment is observed among critically ill patients who survive after being discharged from the ICU. Motor impairment in the ICU causes muscle weakness, which is described as ICU-acquired weakness (ICU-AW). Recently, guidelines have been issued for the rehabilitation of patients in the ICU. Early rehabilitation of critically ill patients is important as ICU-AW not only affects the activities of daily living and quality of life of these patients but also significantly affects their survival rates; hence, the diagnosis of ICU-AW is important. Herein, we discuss the evaluation and measurement of skeletal muscle function in patients admitted to the ICU while focusing on ICU-AW and the Medical Research Council score

痛みの神経生理学的機構に基づく理学療法の重要性

総説Review articles　日本人の多くが痛みを経験するが，現代のリハビリテーション医療では，治療効果が得られにくい患者もおり，症状の慢性化に至る例も少なくない．慢性疼痛の原因は，痛みを長期間，頻回に受けることにより，痛みの神経生理学的機構における中枢神経系の可塑的変化が生じることにより起きている．痛み治療において，集学的アプローチが重要であり，医師の薬物治療は，痛みの神経生理学的機構に基づいて行われて，効果を発揮している．本稿では，現在解明されている痛みの神経生理学的機構とその破綻による慢性疼痛のメカニズムについて概要し，痛みの神経生理学的機構に基づいた理学療法の重要性について，論述した．　A large number of Japanese people have experienced pain, however modern rehabilitation treatment is less likely to treat their pain completely, and the pain may lead to chronic symptoms. A primary cause of chronic pain is the mechanism of occurrence of plastic changes in the central neuro system. The neurophysiological plastic change results from repeated pain in a long period. As to pain therapy, a multimodal approach is essential for the therapeutic effect and physician’s medication based on the neurophysiological mechanism of pain makes more effective results rather than the modern medical treatment. In this article, we expounded the outline of neurophysiological mechanism of pain and the existing problem of mechanism of chronic pain. Finally, we discussed the importance of the current physical therapy based on the neurophysiological mechanism of pain

せん妄の早期発見・予防と理学療法の重要性

総説Review articles　せん妄は急性期病院だけでなく医療現場全体に渡る問題である．せん妄の発症はADL やQOL の低下に関連するだけでなく，生命予後の独立不良因子である．せん妄は早期発見と予防が重要であるが，現状では正確にせん妄を評価することができておらず見逃されることが多い．せん妄と評価される手前の閾値下せん妄は，症状の出現が分かりづらく，発見が遅れるといった問題がある．せん妄の発症メカニズムは脳内ネットワークの障害があり，理学療法評価・治療によりせん妄の早期発見・予防ができる可能性がある．せん妄を症状のみから捉えるのではなく，発症メカニズムに基づいて脳の反応から捉えることが必要である．本稿では，せん妄発症による問題点と，発症メカニズムの仮説から理学療法がせん妄の早期発見・予防にとって重要であることを，早期発見ツール・発症予防プログラムの開発の観点から論じる．　Delirium, a common clinical problem in hospitalized individuals, has been found to be a strong independent prognostic factor in critically ill patients, with a large effect on the impairment of their activities of daily living and quality of life. Early diagnosis and prevention are important strategies for delirium; however, it is often not diagnosed accurately. Subsyndromal delirium is difficult to evaluate clinically. Evaluating the dysfunction and restriction of the brain network, which is thought to be the cause of delirium, may provide new strategies for its prevention. We discuss the properties of a tool for the screening and early diagnosis of delirium based on the discontinuation and restriction of the brain network. Furthermore, we focus on the importance of physiotherapy as a new treatment strategy for delirium

胸部外科手術後のPeak cough flow とMaximum phonation time の関係

研究論文Original Articles　手術後の肺活量（VC）が咳嗽力（PCF）に影響を及ぼすことは明らかだが，最大発声持続時間（MPT）で評価される声門閉鎖機能低下がPCF に及ぼす影響は明らかとなっていない．本研究では呼吸器外科手術後の患者28 例においてMPT とPCF の関係を明らかにすることを目的とし，手術後1 日目〜5 日目にPCF，MPT，VC を測定した．手術後5 日目までPCF およびMPT は，手術前と比較し有意に低下した（p <0.05）． またPCF とMPT の回復率には手術後1 日目のみに相関関係を認めた（r= 0.53，p <0.05）．PCF とVC の回復率は手術後1 日目〜5 日目まで相関を認めた（r = 0.41-0.27，p <0.05）．手術後の声門閉鎖機能低下が咳嗽力に及ぼす影響は，人工呼吸器離脱後１日目までで，その後はVC の影響を強く受けると考えられた．　The vital capacity（ VC） after thoracic surgery affects peak cough flow（ PCF）.　However, the influence of glottic closure deterioration evaluated by maximum phonation time （MPT） on PCF is not clear. We clarified the relationship between coughing and vocal cord function in 28 patients after thoracic surgery. We measured the PCF, MPT, and VC on postoperative days 1 to 5. On postoperative day 1, the mean PCF decreased to 58.0% and the mean MPT decreased to 62.5%. The mean PCFs and MPTs on postoperative days 1 to 5 were significantly lower than the preoperative PCF and MPT, respectively （p < 0.05）. There was a positive correlation between the rates of change in the PCF and MPT only on postoperative day 1 （r = 0.53, p < 0.05）. There was also a positive correlation between the rates of change in the PCF and VC on postoperative days 1 to 5 （r = 0.41–0.27, p < 0.05）. Cough intensity was affected by the vocal cord function on postoperative day 1. However, after postoperative day 2, the cough intensity was not influenced by the vocal cord function. Declining glottal closure function（ vocal cord function） immediately after surgery affects the cough intensity and vocal function. The influence of reduction in glottic closure function after surgery on coughing decline was observed up to 1 day after the withdrawal of ventilatory support. After the secondpostoperative day, the PCF was strongly influenced by the VC

The severity of nutrition and pneumonia predicts survival in patients with aspiration pneumonia: A retrospective observational study

Abstract Introduction Aspiration pneumonia is a common problem among older adults; it has a high mortality rate and the prevalence is increasing. Reports on the risk factors for mortality in patients with aspiration pneumonia are limited. This study aimed to evaluate the risk factors for 90‐day survival in patients with aspiration pneumonia. Methods This retrospective observational study was conducted at Seirei Mikatahara General Hospital between 1 April 2015 and 31 March 2016. Patients with aspiration pneumonia who had dysphagia or aspiration confirmed by modified water swallow test or VideoEndoscopic examination of swallowing were included. The primary endpoint was 90‐day survival. We performed univariate and multivariate logistic regression analyses with survival and non‐survival at 90 days as the independent variables. Results A total of 276 patients were recruited for this study. The A‐DROP score (odds ratio [OR] = 2.440; 95% confidence interval [CI], 1.400–4.270; p < 0.01), Geriatric Nutritional Risk Index score (OR = 0.383; 95% CI, 0.178–0.824; p < 0.05) and sex (OR = 0.365; 95% CI, 0.153–0.869; p < 0.05) were independent early predictors of mortality. Conclusion The results suggest that nutritional status and the severity of pneumonia are important factors that predict life expectancy in patients with aspiration pneumonia

Risk factors for decreased walking ability in hospitalized patients with aspiration pneumonia

Objective To evaluate the factors that influence walking ability in patients hospitalized due to aspiration pneumonia. Methods This retrospective observational study evaluated patients hospitalized with aspiration pneumonia. The primary endpoint was preservation of walking ability. Univariate and multivariate logistic regression analyses were performed with the preservation of walking ability as the dependent variable. Results A total of 143 patients were enrolled in this study. The patients were divided into two groups: those whose walking ability decreased after hospitalization ( n  = 61) and those whose walking ability was maintained after hospitalization ( n  = 82). Multivariate logistic regression analyses showed that A-DROP (odds ratio [OR] 3.006; 95% confidence interval [CI] 1.452, 6.541; P  < 0.01), the Geriatric Nutritional Risk Index (OR 0.919; 95% CI 0.875, 0.960; P <  0.001) and days to initial mobilization (OR 1.221; 95% CI 1.036, 1.531; P <  0.05) were the independent early predictors for preservation of walking ability. Conclusion Nutritional status and early mobilization were important risk factors affecting the maintenance of walking ability in patients hospitalized due to aspiration pneumonia. Thus, a combination of nutrition and early rehabilitation is needed for these patients. Registry of Research Studies involving Human Subjects This study was registered with the University Hospital Medical Information Network Clinical Trial Registry (UMIN 000046923)