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歩行障害、転倒

著者: 内藤 寛 伊勢赤十字病院 脳神経内科

監修: 高橋裕秀 昭和大学藤が丘病院 脳神経内科

著者校正/監修レビュー済:2021/02/03
参考ガイドライン:
  1. 日本神経学会(https://www.neurology-jp.org/guidelinem/parkinson_2018.html):パーキンソン病診療ガイドライン2018
  1. 日本神経学会(https://www.neurology-jp.org/guidelinem/sd_mst_2018.html):脊髄小脳変性症・多系統萎縮症診療ガイドライン2018
  1. 日本脳卒中学会 脳卒中ガイドライン委員会編:脳卒中治療ガイドライン2015, 協和企画
  1. 長寿科学総合研究事業転倒予防ガイドライン研究班:高齢者の転倒予防ガイドライン2012 メジカルビュー社 ISBN:9784758304856
患者向け説明資料

概要・推奨   

  1. パーキンソン病の患者は、必ずしも杖でうまく歩けるとは限らない(推奨度2)。
  1. すくみ足は診察室では目立たないことがあり、どのように検出するかが大切である。すくみ足検出のための質問用紙(freezing of gait questionnaire、FOG-Q)が有用である(推奨度2)。
  1. ウェアリングオフがない場合のすくみ足や、オフ時のすくみ足の場合は、ウェアリングオフ対策を含めた抗パーキンソン病薬の用量調節を行う(推奨度2)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
内藤 寛 : 特に申告事項無し[2021年]
監修:高橋裕秀 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、新しい診療ガイドラインに基づき改訂を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 歩行障害、転倒は高齢者の日常生活動作障害の大きな問題である。
  1. 歩行障害は、骨・関節疾患のほかに脳・神経・筋疾患に由来し、動作障害や反応時間の延長、バランス障害、姿勢反射障害などが主な要因となる。
  1. 歩行運動は大脳皮質や基底核、脳幹、小脳、脊髄による運動制御が統合された動きで、さまざまな部位の障害から歩行障害が引き起こされる。
  1. 高齢者では視覚や平衡感覚、筋力の衰えがあり、これらも歩行を不安定にする要因である
  1. 一度でも転倒を経験すると、患者は恐怖のあまり活動を控えるようになり(post-fall syndrome)、自立性の喪失につながる。
問診・診察のポイント  
  1. 歩行障害の病態別分類は以下のパターンに着目して、神経診察を行う。

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文献 

著者: Nir Giladi, Joseph Tal, Tali Azulay, Oliver Rascol, David J Brooks, Eldad Melamed, Wolfgang Oertel, Werner H Poewe, Fabrizio Stocchi, Eduardo Tolosa
雑誌名: Mov Disord. 2009 Apr 15;24(5):655-61. doi: 10.1002/mds.21745.
Abstract/Text To revalidate the Freezing of Gait Questionnaire (FOG-Q), patients with Parkinson's disease (PD) were randomly assigned to receive rasagiline (1 mg/day) (n = 150), entacapone (200 mg with each dose of levodopa) (n = 150), or placebo (n = 154). Patients were assessed at baseline and after 10 weeks using the FOG-Q, Unified Parkinson's Disease Rating Scale (UPDRS), Beck Depression Inventory (BDI), and Parkinson's Disease Questionnaire (PDQ-39). FOG-Q dimensionality, test-retest reliability, and internal reliability were examined. Convergent and divergent validities were assessed by correlating FOG-Q with UPDRS, BDI, and PDQ-39. Comparisons between FOG-Q item 3 and UPDRS item 14 were also made. Principal component analysis indicated that FOG-Q measures a single dimension. Test-retest reliability and internal reliability of FOG-Q score was high. FOG-Q was best correlated to items of the UPDRS relating to walking, general motor issues, and mobility. Correlations between baseline and endpoint suggested that FOG-Q item 3 is at least as reliable as UPDRS item 14. At baseline, 85.9% of patients were identified as "Freezers" using FOG-Q item 3 (> or =1) and 44.1% using UPDRS item 14 (> or =1) (P < 0.001). FOG-Q was a reliable tool for the assessment of treatment intervention. FOG-Q item 3 was effective as a screening question for the presence of FOG.

PMID 19127595  Mov Disord. 2009 Apr 15;24(5):655-61. doi: 10.1002/mds.・・・
著者: Nir Giladi
雑誌名: Mov Disord. 2008;23 Suppl 2:S482-8. doi: 10.1002/mds.21914.
Abstract/Text Freezing of gait (FOG) is frequently considered as one of the dopamine-resistant motor symptoms of Parkinsonism. Recent studies have clearly demonstrated that the Off-related FOG is improved by levodopa (L-dopa) or entacapone treatment. L-dopa can decrease duration of each FOG episode as well as its frequency. On-related FOGs are not common and difficult to diagnose. Only in the most advanced stages of the disease, FOGs are resistant to treatment as many other symptoms. Off-related FOGs are likely to be improved by dopamine agonists (DAs), but this has never been looked at systematically. In contrast, DA treatment might provoke FOG, and in two pivotal studies when DAs were compared to L-dopa in early stages of Parkinson's disease, the DA-treated arms experienced more FOGs. MAO-B inhibitors (selegiline and rasagiline) can decrease FOG frequency or severity, but its clinical significance is still unknown. L-Threo-DOPS has been reported to have a symptomatic beneficial effect in patients with pure freezing syndrome, but small-scale, controlled trials in Parkinson's disease could not support those early observations. Botulinum toxin injected into the calf muscles has been suggested to have a symptomatic benefit. However, double-blind, prospective studies could not support that early observation and increased fall risk in the injected patients has put this direction of treatment on hold. The potential benefit of amantadine, antidepressive drugs, acetylcholine esterase inhibitors, and methylphenidate on FOG has been studied in small-scale studies, and there is a need for prospective studies to understand the future role of those drugs.

(c) 2008 Movement Disorder Society.
PMID 18668620  Mov Disord. 2008;23 Suppl 2:S482-8. doi: 10.1002/mds.21・・・
著者: A Nieuwboer, G Kwakkel, L Rochester, D Jones, E van Wegen, A M Willems, F Chavret, V Hetherington, K Baker, I Lim
雑誌名: J Neurol Neurosurg Psychiatry. 2007 Feb;78(2):134-40. doi: 10.1136/jnnp.200X.097923.
Abstract/Text OBJECTIVES: Gait and mobility problems are difficult to treat in people with Parkinson's disease. The Rehabilitation in Parkinson's Disease: Strategies for Cueing (RESCUE) trial investigated the effects of a home physiotherapy programme based on rhythmical cueing on gait and gait-related activity.
METHODS: A single-blind randomised crossover trial was set up, including 153 patients with Parkinson's disease aged between 41 and 80 years and in Hoehn and Yahr stage II-IV. Subjects allocated to early intervention (n = 76) received a 3-week home cueing programme using a prototype cueing device, followed by 3 weeks without training. Patients allocated to late intervention (n = 77) underwent the same intervention and control period in reverse order. After the initial 6 weeks, both groups had a 6-week follow-up without training. Posture and gait scores (PG scores) measured at 3, 6 and 12 weeks by blinded testers were the primary outcome measure. Secondary outcomes included specific measures on gait, freezing and balance, functional activities, quality of life and carer strain.
RESULTS: Small but significant improvements were found after intervention of 4.2% on the PG scores (p = 0.005). Severity of freezing was reduced by 5.5% in freezers only (p = 0.007). Gait speed (p = 0.005), step length (p<0.001) and timed balance tests (p = 0.003) improved in the full cohort. Other than a greater confidence to carry out functional activities (Falls Efficacy Scale, p = 0.04), no carry-over effects were observed in functional and quality of life domains. Effects of intervention had reduced considerably at 6-week follow-up.
CONCLUSIONS: Cueing training in the home has specific effects on gait, freezing and balance. The decline in effectiveness of intervention effects underscores the need for permanent cueing devices and follow-up treatment. Cueing training may be a useful therapeutic adjunct to the overall management of gait disturbance in Parkinson's disease.

PMID 17229744  J Neurol Neurosurg Psychiatry. 2007 Feb;78(2):134-40. d・・・
著者: Maaike Bakker, Rianne A J Esselink, Marten Munneke, Patricia Limousin-Dowsey, Hans D Speelman, Bastiaan R Bloem
雑誌名: Mov Disord. 2004 Sep;19(9):1092-9. doi: 10.1002/mds.20116.
Abstract/Text Postural instability and gait disability (PIGD) are disabling signs of Parkinson's disease. Stereotactic surgery aimed at the internal globus pallidus (GPi) or subthalamic nucleus (STN) might improve PIGD, but the precise effects remain unclear. We performed a systematic review of studies that examined the effects of GPi or STN surgery on PIGD. Most studies examined the effects of bilateral GPi stimulation, bilateral STN stimulation, and unilateral pallidotomy; we, therefore, only performed a meta-analysis on these studies. Bilateral GPi stimulation, bilateral STN stimulation, and to a lesser extent, unilateral pallidotomy significantly improved PIGD, and more so during the ON phase than during the OFF phase.

PMID 15372604  Mov Disord. 2004 Sep;19(9):1092-9. doi: 10.1002/mds.201・・・
著者: E A Pereira, K A Muthusamy, N De Pennington, C A Joint, T Z Aziz
雑誌名: Br J Neurosurg. 2008;22 Suppl 1:S41-4. doi: 10.1080/02688690802448335.
Abstract/Text Deep brain stimulation (DBS) of the pedunculopontine nucleus (PPN) is a novel neurosurgical therapy developed to address symptoms of gait freezing and postural instability in Parkinson's disease and related disorders. Here, we summarize our non-human primate and neuroimaging research of relevance to our surgical targeting of the PPN. We also describe our clinical experience of PPN DBS with greatest motor improvements achieved by stimulation at low frequencies.

PMID 19085352  Br J Neurosurg. 2008;22 Suppl 1:S41-4. doi: 10.1080/026・・・
著者: Ann Ashburn, Louise Fazakarley, Claire Ballinger, Ruth Pickering, Lindsay D McLellan, Carolyn Fitton
雑誌名: J Neurol Neurosurg Psychiatry. 2007 Jul;78(7):678-84. doi: 10.1136/jnnp.2006.099333. Epub 2006 Nov 21.
Abstract/Text OBJECTIVE: To evaluate the effectiveness of a personalised home programme of exercises and strategies for repeat fallers with Parkinson's disease (PD).
METHOD: Patients with a confirmed diagnosis of idiopathic PD, independently mobile, living at home in the community, experiencing more than one fall in the previous 12 months and with intact gross cognitive function were invited to participate in this randomised controlled trial. Usual care was compared with a personalised 6 week, home based exercise and strategy programme. The primary outcomes were rates of falling at 8 weeks and 6 months. Whether participants had repeat fallen, nearly fallen or experienced injurious falls were also examined. Functional Reach, the Berg Balance Test, PD Self-assessment Scale and the Euro Quol were rated by a blinded assessor.
RESULTS: Participants were randomised to the exercise (n = 70) and control (n = 72) groups. There was a consistent trend towards lower fall rates in the exercise group at both 8 weeks and 6 months and lower rates of injurious falls needing medical attention at 6 months. Lower rates of repeat near falling were evident for the exercise group at 8 weeks (p = 0.004) and 6 months (p = 0.007). There was a positive effect of exercises at 6 months on Functional Reach (p = 0.009) and quality of life (p = 0.033). No significant differences were found on other secondary outcomes measures.
CONCLUSION: There was a trend towards a reduction in fall events and injurious falls with a positive effect of exercises on near falls and quality of life.

PMID 17119004  J Neurol Neurosurg Psychiatry. 2007 Jul;78(7):678-84. d・・・
著者: M E Morris
雑誌名: Phys Ther. 2000 Jun;80(6):578-97.
Abstract/Text People who are diagnosed with idiopathic Parkinson disease (PD) experience movement disorders that, if not managed, can lead to considerable disability. The premise of this perspective is that physical therapy for people with PD relies on clinicians having: (1) up-to-date knowledge of the pathogenesis of movement disorders, (2) the ability to recognize common movement disorders in people with PD, (3) the ability to implement a basic management plan according to a person's stage of disability, and (4) problem-solving skills that enable treatment plans to be tailored to individual needs. This article will present a model of physical therapy management for people with idiopathic PD based on contemporary knowledge of the pathogenesis of movement disorders in basal ganglia disease as well as a review of the evidence for physical therapy interventions. The model advocates a task-specific approach to training, with emphasis on treating people with PD-related movement disorders such as hypokinesia and postural instability within the context of functional tasks of everyday living such as walking, turning over in bed, and manipulating objects. The effects of medication, cognitive impairment, the environment, and coexisting medical conditions are also taken into consideration. An argument is put forward that clinicians need to identify core elements of physical therapy training that apply to all people with PD as well as elements specific to the needs of each individual. A case history is used to illustrate how physical therapy treatment is regularly reviewed and adjusted according to the changing constellation of movement disorders that present as the disease progresses.

PMID 10842411  Phys Ther. 2000 Jun;80(6):578-97.
著者: Roberta Marchese, Marco Bove, Giovanni Abbruzzese
雑誌名: Mov Disord. 2003 Jun;18(6):652-8. doi: 10.1002/mds.10418.
Abstract/Text To analyse the effect of concomitant cognitive or motor task performance on balance control in Parkinson's disease (PD), we performed a posturographic study in 24 PD patients and in 20 sex- and age-matched control subjects. Postural sway was measured with eyes open (EO) and eyes closed (EC) during quiet stance and during performance of calculation or motor sequence of thumb opposition to the other fingers. No difference of centre of foot pressure (COP) parameters was observed during quiet standing (either EO or EC) between patients and controls, but visual deprivation induced in both groups a worsening of postural stability. COP area was significantly increased in PD patients during dual task performance, whereas no difference of COP path and x-y axes was observed. The effects induced by the performance of cognitive or motor task were significantly more evident in PD patients with clinical evidence of postural instability (presence of prior falls in the history). This study demonstrates that dual task interference on postural control can be observed in PD patients during performance of cognitive as well as motor tasks. The balance deterioration during dual task performance was significantly enhanced in patients with history of prior falls. These findings have some implications for the strategies to be used in reducing the risk of fall in PD.

Copyright 2003 Movement Disorder Society
PMID 12784268  Mov Disord. 2003 Jun;18(6):652-8. doi: 10.1002/mds.1041・・・
著者: Yutaka Naito
雑誌名: Brain Nerve. 2014 Sep;66(9):1049-55.
Abstract/Text Continuous infusion of intrathecal baclofen (ITB), via implanted pump, is a powerful tool in the management of severe spasticity in neurological disorders. The advantages of ITB therapy are that it is non-destructive, reversible, and programmable, allowing for neuromodulation. Patients reported significant subjective improvements and decreases in muscle tone after baclofen injection, but excessive doses of ITB resulted in motor weakness. Few complications and adverse effects were reported. ITB therapy appears to be a promising treatment to improve residual motor control in patients with severe spasticity.

PMID 25200576  Brain Nerve. 2014 Sep;66(9):1049-55.

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