理学療法ジャーナル39巻3号

2005年03月発行

特集 脳科学からみた理学療法の可能性と限界

脳損傷患者の運動学習の可能性

著者： 沼田憲治¹

所属機関： ¹昭和大学保健医療学部

ページ範囲：P.223 - P.229

脳卒中患者のリハビリテーション効果に関してこれまでに多くの論議がなされてきた．しかし，その実証が困難であることなどから効果に関しては多くが否定的な見解を示すものであった^1）．しかしこの十数年の間に，神経生理学や分子生物学などをはじめとした分野から，中枢神経の可塑性や神経再生について驚異的な数の報告が提出され，これらの基礎的な知見を基にした研究から，近年リハビリテーション効果に関する新たな見直しがなされるようになってきた．すなわち，これまで実証困難であった，脳卒中患者の麻痺肢に対するある種の運動療法によって明らかな機能的回復を認めるとともに，それを裏付ける皮質の新たな再構築（可塑性）を認める多くのエビデンスが報告されていることである．これまでの中枢神経疾患の理学療法は運動学的観点が主体であり，麻痺や運動回復の神経学的メカニズムに関してはブラックボックスとして扱ってきた．しかしこれらの報告によって，従来の理学療法のあり方が脳科学を根拠とした立場へと方向修正が迫られる状況になっていると言っても過言ではない．

　本稿では，これまでに報告された脳損傷後の運動障害に対するいくつかの運動療法とそれに伴う中枢神経の可塑性（treatment-induced neuroplasticity）について焦点を当て概説する．

参考文献

1）Dobkin HB：Focused stroke rehabilitation program do not improve outcome. Arch Neurol 41：701-703, 1989

2）Hess G, et al：Long-term potentiation of horizontal connections provides a mechanism to reorganize cortical motor maps. J Neurophysiol 71：2543-2547, 1994

3）Hess G, et al：Long-term potentiation and long-term depression of horizontal connections in rat motor cortex. Acta Neurobiol Exp 56：397-405, 1996

4）Plautz EJ, et al：Effects of repetitive motor training on movement representation in adult squirrel monkeys：role of use versus learning. Neurobiol Learn Mem 74：27-55, 2000

5）Remple MS, et al：Sensitivity of cortical movement representations to motor experience：evidence that skill learning but not strength training induces cortical reorganization. Behav Brain Res 123：133-141, 2001

6）Klein JA, et al：Synaptogenesis and Fos expression in the motor cortex of the adult rat after motor skill learning. J Neurosci 16：4529-4535, 1996

7）Biernaskie J, et al：Enriched rehabilitative training promotes improved forelimb motor function and enhanced dendritic growth after focal ischemic injury. J Neurosci 21：5272-5280 2001

8）Nudo RJ：Adaptive plasticity in motor cortex：Implications for rehabilitation after brain injury. J Rehabil Med 41：7-10, 2003

9）Johansson BB：Environmental influence on recovery after brain lesions-experimental and clinical data. J Rehabil Med 41：11-16, 2003

10）Thickbroom GW, et al：Motor outcome after subcortical stroke correlates with the degree of cortical reorganization. Clin Neurophysiol 115：2144-2150, 2004

11）Nudo RJ：Recovery after damage to motor cortical areas. Curr Opin Neurobiol 9：740-747, 1999

12）Biernaski J, et al：Enriched rehabilitative training promotes improved forelimb motor function and enhanced dendritic growth after focal ischemic injury. J Neurosci 21：5272-5280, 2001

13）Kleim JA, et al：Motor learning-dependent synaptogenesis is localized to functionally reorganized motor cortex. Neurobiol Learn Mem 77：63-77, 2002

14）Liepert J, et al：Motor cortex plasticity during forced-used therapy in stroke patients：a preliminary study. J Neurol 248：415-321, 2001

15）Ostendorf CG, et al：Effect of forced use of the upper extremity of a hemiplegic patient on changes in function. a single-case design. Phys Ther 61：1022-1028, 1981

16）Wolf SL, et al：Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Exp Neurol 104：125-132, 1989

17）Taub E, et al：Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 74：347-354, 1993

18）Taub E, et al：New treatments in neurorehabilitation founded on basic research. Nat Rev Neurosci 3：228-236, 2002

19）Levy CE, et al：Functional MRI evidence of cortical reorganization in upper-limb stroke hemiplegia treated with constraint-induced movement therapy. Am J Phys Med Rehabil 80：4-12, 2001

20）Schaechter JS, et al：Motor recovery and cortical reorganization after constraint-induced movement therapy in stroke patients：a preliminary study. Neurorehabil Neural Repair 16：326-338, 2002

21）Fridman EA, et al：Reorganization of the human ipsilesional premotor cortex after stroke. Brain 127：747-758, 2004

22）Feydy A, et al：Longitudinal study of motor recovery after stroke：recruitment and focusing of brain activation. Stroke 33：1610-1617, 2002

23）Ward NS, et al：Neural correlates of outcome after stroke：a cross-sectional fMRI study. Brain 126：1430-1448, 2003

24）Milter WHR, et al：Effects of constraint-induced movement therapy on patients with chronic motor deficits after stroke；a replication. Stroke 30：586-592, 1999

25）Stinear JW, et al：Rhythmic bilateral movement training modulates corticomotor excitability and enhances upper limb motricity poststroke：a pilot study. J Clin Neurophysiol 21：124-131, 2004

26）Stinear JW, et al：Distinhibition in the human motor cortex is enhanced by synchronous upper limb movements. J Physiol 543：307-316, 2002

27）Carel C, et al：Neural substrate for the effects of passive training on sensorimotor cortical representation：a study with functional magnetic resonance imaging in healthy subjects. J Cereb Blood Flow Metab 20：478-484, 2000

28）Miyai I, et al：Longitudinal optical imaging study for locomotor recovery after stroke. Stroke 34：2866-2870, 2003

29）Miyai I, et al：Premotor cortex is involved in restoration of gait in stroke. Ann Neurol 52：188-194, 2002

30）Carey JR, et al：fMRI analysis of ankle movement tracking training in subject with stroke. Exp Brain Res 154：281-290, 2004

31）Barbro BJ：Enviromental influence on recovery after brain lesions-experimental and clinical data. J Rehabil Med Suppl 41：11-16, 2003

32）Comery TA, et al：Increased density of multiple-head dendritic spines on medium-sized spiny neurons of the striatum in rats reared in a complex environment. Neurobiol Learn Mem 66：93-96, 1996

33）Ohlsson A-L, et al：Enviroment influences functional outcome of cerebral infarction in rats. Stroke 26：644-649, 1996

34）Zhao LR, et al：Enviromental influence on brain-derived neurotrophic factor messenger RNA expression after middle cerebral artery occlusion in spontaneously hypertensive rats. Neuroscience 97：177-184, 2000

35）Johansson BB, et al：Neuronal plasticity and dedritic spines：effect of environmental enrichment on intact and postischemic rat brain. J Cereb Blood Flow Metab 22：89-96, 2002

36）Landers M：Treatment-induced neuroplasticity following focal injury to the motor cortex. Int J Rehabil Res 27：1-5, 2004

37）Butefisch CM, et al：Enhancing encoding of a motor memory in the primary motor cortex by cortical stimulation. J Neurophysiol 91：2110-2116, 2004

38）Adkins-Muir DL, et al：Cortical electrical stimulation combained with rehabilitative training：enhanced functional recovery and dendritic plasticity following focal cortical ischemia in rats. Neurol Res 25：780-788, 2003