高齢脳卒中患者の早期歩行獲得を目的としたリハビリテーションクリニカルパスの有用性

Effects of the Clinical Pathway in Acute Phase Rehabilitation on Walking Ability Recovery in Elderly Stroke Patients

要旨：高齢脳卒中患者におけるリハビリテーション（以下，リハ）の効率化の観点から，リハ介入後4週間以内の歩行獲得を目標とするクリニカルパス（以下，パス）を作成し，下肢運動麻痺を有する65歳以上の脳卒中急性期患者を対象に，その有用性について検討した．パスを適用した54例のうち37例（68.5％）が目標を達成し，目標達成までの日数はリハ介入後9.6±6.0日であった．脳卒中急性期病棟入院中の歩行能力の改善（Functional Independence Measure歩行点数の増加）をパス導入前の41例と比較すると，改善例の割合はパス導入後のほうが高く（導入前39.0％，導入後66.7％，p＝0.007），改善効率（＝歩行点数増加量/急性期病棟滞在日数）もパス導入後のほうが高かった（導入前0.06±0.09，導入後0.11±0.14，p＝0.024）．多変量解析ではパスの使用は歩行能力の改善に独立して寄与する因子であった（p＝0.042）．パスを導入した急性期リハは高齢脳卒中患者の歩行能力の早期改善に有用である可能性が示唆された．

Abstract : To determine whether the clinical pathway in acute phase rehabilitation contributes to the early recovery of walking ability in elderly stroke patients, we developed a pathway for acute stroke patients over 65 years old who had lower extremity paresis. The pathway goal was to have patients walking within four weeks after the start of physiotherapy. We compared the improvement in walking ability during their stay in the stroke unit, length of stay and discharge destination between the two groups, namely the pre-pathway group that comprised 41 patients admitted before the introduction of the pathway and the post-pathway group that comprised 54 patients admitted after its introduction. In the post-pathway group, 68.5％ of the patients achieved the goal, and the days required to achieve the goal were 9.6±6.0 days after the start of physiotherapy. The proportion of patients whose walking ability improved was significantly higher in the post-pathway group than the pre-pathway group (66.7％ versus 39.0％, p＝0.007). The efficiency of improvement was also higher in the postpathway group (p＝0.024). Logistic regression analysis showed that the use of the pathway was a factor that independently contributed to the improvement of walking ability (odds ratio, 2.80 ; 95％ CI, 1.04 to 7.56 ; p＝0.042). No significant differences were noted between the two groups in length of stay or discharge destination. From these results, it is suggested that the clinical pathway in acute phase rehabilitation promotes the recovery of walking ability in elderly stroke patients.