Neurol Rehabil 2004; 10 (4): 187-216 Tagungen & Kongresse
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Evidence-Based Medicine in Neurorehabilitation
3rd Joint Congress of the Swiss Society of Neurorehabilitation, Austrian Society of Neurorehabilitation, German Society for Neurological Rehabilitation and 1st Regional Meeting of the World Federation for NeuroRehabilitation (WFNR) in association with the German Speaking Medical Society for Paraplegia (DMGP)
Zurich, 30th September – 2nd October 2004
Poster Sessions
P1 ANIMAL MODELS | BS
MULTISENSORIC REHABILITATION MODEL IMPROVES RECOVERY OF NEUROMOTOR FUNCTION AFTER TRAUMATIC BRAIN INJURY IN RATS.
M. Lippert-Grüner, M. Mägele, E.T. Bode, N. Klug, D. Angelov (Köln, D)
The present study was designed to determine whether exposure to multisensorical early rehabilitation model (MRM) after moderate traumatic brain injury (TBI) in rats would promote the recovery of neuromotor function superior to that under standard conditions (SC). Materials and Methods: A total of 28 Sprague-Dawley rats were randomized to one of the following groups: 1) injured/MRM (n=12); 2) sham/MRM (n=2); 3) injured/SC (n=12); 4) sham/SC (n=2). Under anaesthesia, animals were subjected to either a moderate fluid-percussion injury (2,1 atm) or to a sham-injury. Thereafter the injured/MRM and the sham/MRM groups were placed together into specially modified custom made cages (three large cages connected via tunnels) containing various types of bedding and stimulating objects, e.g. balls, robes, running wheel etc.. Along with environmental complexity the animals underwent a specific protocol of motor and multisensoric rehabilitation model. In contrast, the injured/SC and the sham/SC groups were returned to their standard cages where they were housed individually without stimulation. Motor function was assessed by using a composite neuroscore (NS) test battery at 24h, 7, and 15 DPI. Results: Neuromotorfunction assessed by NS was markedly reduced in both injured groups at 24h post-injury being non-significant. However, animals in the injured/RM group performed significantly better when tested for neuromotorfunction as compared to injured/SC animals on 7d and 15d DPI (7d: p = 0,005; 15d: p < 0,05). Conclusion: These results provide experimental evidence that postoperative exposure of rats to multisensoric rehabilitation model (MRM) is associated with significant improvements in the recovery of neuromotorfunction function after TBI. Whether these improvements correlate with reduced CNS scar formation is currently under investigation.
P2 ANIMAL MODELS | BS
THE EFFECTS OF NEUROTROPHIC FACTOR NT-3 ON THE OUTGROWTH AND DIFFERENTIATION OF THE RAT MOTOR NEURON COCULTURED WITH THE HUMAN MUSCLE
S. Pirkmajer, K. Perdan, M. Jevsek, T. Mars, Z. Grubic (Ljubljana, SLO)
Experiments in vitro have several advantages over the in vivo studies. One such advantage is that they permit continuous observation of the investigated process at the cellular level. In the experimental model used here, motor neurons extend from the explants of the embryonic rat spinal cord and form functional synapses with the human myotubes. This coculture system has been extensively characterized and found to reproduce very well the in vivo differentiation of neurons and glia as well as the formation of the neuromuscular junction [1]. Its particular advantage is that it allows quantitation of various aspects of neuronal outgrowth including the ability of motor neurons to form functional neuromuscular junctions with the human muscle.
In our study we employed this system to follow the effects of neurotrophic factor NT-3 on the neuronal outgrowth from the spinal cord and the ability of extending neurons to functionally innervate human muscle in vitro. Several parameters were quantitatively determined: neuronal outgrowth from the embryonic spinal cord explant, percentage of contraction-positive explants, the number of contracting units per explant and the number of clusters of nicotinic receptors. All determinations were carried out during the first two weeks of coculture which is the period of time during which the process of functional innervation is completed. The concentration of NT-3 used throughout the experiments was 10 ng/ml; it was selected as optimal in our initial testing. At this concentration NT-3 significantly increased all the parameters listed above. The approach used here for the quantitation of the effects of NT-3 on the neuronal growth and differentiation may prove useful also in testing of other substances that might have an effect on these parameters.
Reference:
1. Mars T, Yu KJ, Tang X-M, Miranda AF, Grubic Z, Cambi F, King MP: Differentiation of glial cells and motor neurons during the formation of neuromuscular junctions in co-cultures of rat spinal cord explant and human muscle. J Comp Neur 2001; 438: 239-251
P3 CLINICAL TRIAL DESIGN AND OUTCOME STUDIES | C
THE EFFECT OF METHYLPHENIDATE ON ATTENTION IN ACQUIRED BRAIN INJURY AS RECORDED BY USEFUL FIELD OF VIEW
A. Carayannopoulos, D.T. Burke, S. Al-Adawi, A.S.S. Dorvlo, M. K. Shah, J.J. Mello (Boston, USA)
Objectives: To assess the ability of the Useful Field of View (UFOV) test to measure change in attention of patients with acquired brain injury (ABI) when introduced to methylphenidate in an inpatient rehabilitation unit.
Design: This study reviewed data from consecutive patients who were introduced to methylphenidate while being monitored for visual processing speed, divided attention, and selective attention with the UFOV test. Changes in UFOV scores were also compared with changes in Functional Impairment Measures (FIM).
Patients: A series of 16 patients diagnosed with traumatic brain injury (n=12) and subarachnoid hemorrhage (n=4) were followed before and after introduction to methylphenidate as a part of treatment for clinically identified attentional deficit.
Results: The introduction of methylphenidate was correlated with an improvement in processing speed loss, divided attention loss and selective attention loss on the UFOV test. The introduction of methylphenidate was further correlated with improvement on FIM cognition and FIM activity of daily living subscales.
Conclusions: The introduction of methylphenidate to an inpatient population of patients with ABI resulted in a significant improvement in attention and divided attention, which can be measured by the UFOV. This change in attentional ability seems to correlate with improvement in the cognitive and the activity of daily living subscales of the FIM.
P4 CLINICAL TRIAL DESIGN AND OUTCOME STUDIES | C
PRISM ADAPTATION IN NEGLECT INVESTIGATED WITH PSYCHOPHYSICS AND ELECTRO-OCULOGRAPHY
C. Chesaux, M. Murray, C. Bindschaedler (Lausanne, CH)
Short-term adaptation to rightward-deviating wedge prisms has been shown to reduce neglect in right-brain damaged patients on a variety of visuoverbal and visuomotor tasks and has been attributed to changes in spatial representations. Neglect patients are known to be impaired in perceiving contralateral targets and also in initiating contralateral saccadic eye movements [1]. Frassinetti et al. [2] suggested that the improvement seen after prismatic adaptation (PA) may be linked to the ocular system. They suspected that PA may induce eye deviation, which in turn may modify spatial representations.
The present study examined eye movements via electro-oculography (EOG) and discrimination reaction times to laterally-presented visual stimuli performed by a patient with unilateral neglect following a right-hemispheric lesion. The paradigm crossed two factors: target space (left or right of a fixation point aligned on the body midline) and direction of saccade (leftwards or rightwards of a fixation point located right or left of the body midline). Reaction times were measured as well as the latency between the stimulus onset and the end of the saccadic eye movement. The experiment was administered twice; before and after PA to rightward-deviating prisms.
ANOVAs were conducted with the EOG measure and reaction times, using space (left or right of the body midline), direction of saccade (leftwards or rightwards) and session (prior to or following PA) as within-subject factors. The main finding concerns a significant interaction between space and session for the EOG measure, reflecting the fact the time between the initiation and landing of the saccade was reduced in the left space and increased in the right space following prismatic adaptation. By contrast, PA did not significantly affect reaction times. These data thus support a predominant role of PA in altering eye movements [3], rather than higher-level discrimination abilities.
References:
1. Behrmann M, Ghiselli-Crippa T & Dimatteo I: Impaired initiation but not execution of contralesional saccades in hemispatial neglect. Behavioural Neurology 2001/2002; 13: 39-60
2. Frassinetti F, Angeli V, Meneghello F, Avanzi S & Làdavas E: Long-lasting amelioration of visuo-spatial neglect by prism adaptation. Brain 2002; 125: 608-623
3. Ferber S, Danckert J, Joanisse M, Goltz HC & Goodale MA: Eye movements tell only half the story. Neurology 2003; 60: 1826-1828
P5 CLINICAL TRIAL DESIGN AND OUTCOME STUDIES | C
“CONSTRAINT-INDUCED MOVEMENT THERAPY”: SUCCESSFUL THERAPY-FORM FOR CERTAIN PATIENTS AFTER stroke TO REGAIN FUNCTION OF THE UPPER EXTREMITY.
D. De Clerck, B. Gantschnig, St. Mey, L. Rutz-LaPitz, M. Rutz (Walzenhausen, CH)
“Constraint-induced movement Therapy” (“Forced-use therapy”) is a therapy-form for selected persons with hemiparesis.
In therapy, the paretic arm is trained or lead to function by immobilising the affected hand with a mit, hand-orthesis or similar device, up to 90% of the patients’ waking hours. The affected upper extremity is then intensively trained with task oriented activities as well as used in daily life, for a minimum of six hours a day during two consecutive weeks.
Patients suitable for this kind of therapy must be carefully selected and fulfill certain criteria.
“Constraint-induced movement therapy” requires large efforts by both patients and therapists, but is highly successful.
P6 CLINICAL TRIAL DESIGN AND OUTCOME STUDIES | C
BABINSKI SIGN AND EVIDENCE BASED MEDICINE
J. Opara (Bytom, P)
Purpose: Joseph Felix François Babinski (1857–1932) was one of the most famous physicians of polish origin. He was the co-originator of contemporary neurology and neurosurgery. Babinski`s the most known discovery was the description of the plantar reflex (“toe phenomenon” – now Babinski sign – phénomène des orteils).
Methods: Babinski presented his findings for the first time before the Biological Society of Paris on February 22nd, 1896 as a very short communication “Sur le réflexe cutané plantaire dans certaines affections organiques du système nerveux central”. He wrote: “J’ai observé dans un certain cas d’hemiplégie ou de monoplégie crurale liée à une affection organique du système nerveux central une perturbation dans le réflexe cutané plantaire dont voici en quelques mots la description…”. It is fascinating that the whole communication took just 28 verses! Babinski didn’t use any randomizing, no double-blind trial, no statistical calculations, no citations from literature!
Results: Babinski presented his observation abroad in 1897 during International Congress of Neurology in Brussels, from this time the plantar reflex has been known as Babinski’s sign. Hence since 1898, after publication in “Semaine médicale”, Babinski’s sign became known in all world.
Conclusions: The whole description of the plantar reflex took just 28 verses. There is strong contrast between that and Evidence-Based Medicine. Babinski didn`t use any randomization, no double-blind trial, no statistical calculations, no citations from literature. Living nowadays Babinski whould have no chance for publication.
Reference:
1. Babinski J.: Du phénomène des orteiles et de sa valeur sémiologique. Semaine Médicale, 1898; 18: 321
P7 CLINICAL TRIAL DESIGN AND OUTCOME STUDIES | C
NEUROREHABILITATION OF PATIENTS WITH CONSEQUENCES OF ISCHEMIC BRAIN LESIONS OF DIFFERENT GENESIS DURING THE TREATMENT BY METHOD OF DISTRACTION OSTEOSYNTHESIS OF CRANIAL BONES
A. Khudiaev, E.A. Mikhailova, O.G. Prudnikova (Kurgan, RU)
A surgical technique for stimulation of the cerebral circulation by means of distraction osteosynthesis was developed in RISC “RTO”. A trephine opening is made in the cranial bone in projection of a brain ischemic focus. A separated bone lamina is transformed into a bone fragment, positioned onto the initial place (maternal bed) and fixed with traction devices and their ends are attached to a frame support. As a result of gradual traction at the rate of 0.5 mm/day a bone regenerate forms between the bone fragment and an edge of the maternal bed. This process stimulates the blood afflux to an affected nidus of the brain.
31 patients with consequences of ischemic insults and brain injuries were operated with this technique. Neurologic symptoms declared themselves preoperatively by hemiparesis and aphasia. We distinguished the following stages in a developed scheme of rehabilitation: early, late, restorative postoperative and residual. At the early stage microcircular and thrombotic complications were managed, vascular medicines and nootropics were proscribed, orthostatic loading and respiratory exercises were performed. A non-significant increase of muscle force was noticed. At the late stage electrostimulation of muscles, massage, physical therapy and logopedic exercises were used. The dynamics of neurologic symptoms became more apparent in comparison with the first stage. During the restorative stage locomotive regime of physical therapy was enlarged. At the residual stage patients underwent the above mentioned course of treatment in an interval of 6 months.
In 17 patients the neurologic status corresponded to the restorative stage, in 14 cases a significant regress of aphasic-hemiparetic syndrome was observed. Clinical data was confirmed by data of instrumental methods of investigation: electromyography, esthesiometry, angiography, ultrasound dopplersonography.
P8 CLINICAL TRIAL DESIGN AND OUTCOME STUDIES | C
RELATED IMPACT FACTORS OF THE CHEMONUCLEOLYSIS WITH COLLAGENASE OF LUMBAR DISC HERNIATION
J.-M. Wang (Wuhan, China)
Objective: To study the related impact factors of intradiscal injection with collagenase in patients with lumbar disc herniation.
Methods: All of 168 patients were in-patients. Male,112; Female,56; Age is among 14–73 years old, average 43. 168 patients were divided into two groups depending on size, the type, the number of herniated disc and with or without spinal stenosis respectively. 65 patients with the herniation size less than or equal to 6 mm; 103 patients with the size large than 6 mm. 122 patients with protruded disc, 46 patients with bulge disc. 128 patients with single level herniation, 40 with more than two levels herniation. 154 patients without spinal stenosis, 12 with spinal stenosis. All patients were examined by magnetic resonance imaging (MRI) and discography. Findings of MRI were correlate with the patient’s signs, symptoms, and physical examination. Local anesthesia was used in all patients. The patient was in the prone decubitus position, properly padded under the abdomen. C-arm fluoroscope was used. Both the lateral and anteroposterior views of the spine were monitored. Patients were intradiscal injected with collagenase (1200 U). The collagenase was provided by Shanghai Joy Biopharm. Co., LTD. Assessment was made after 1 week, 3 months and 1 year follow up.
Results: The overall success rate after 1 week, 3 months, and 1 year following the therapy was 22.62%, 89.29% and 92.26%; 7 patients were operated, One of them developed cauda equina syndromes at the third day after the injection and were operated immediately. It is found that the size of herniation did not affect the treatment when smaller than 10 mm. The protruded disc got better result than bulge disc after 1 week following the chemonucleolysis (P<0.01). Patients manifesting single disc herniation had a better outcome than those manifesting more than two discs herniation (P<0.05) after 3 months/ (P<0.01) after 1 year. The total effective rate in patients without spinal stenosis was higher than that in patients with spinal stenosis (P<0.01). 52 patients suffered from severe pain for about 4 days after the treatment. Anaphylaxis did not occur.
Conclusion: Intradiscal therapy with collagenase is effective. The stenosis can affect the treatment negatively. The herniation bigger than 10mm is better to be operated.
P9 COGNITIVE REHABILITATION | C
DIE NEUROPSYCHIATRISCHE BEHANDLUNG VON PATIENTEN MIT SCHWEREN HIRNORGANISCHEN PSYCHOSYNDROMEN IN DER NEUROCHIRURGISCHEN FRÜHREHABILITATION
M. Amend, W. Mandrella, W. Ischebeck (Hattingen-Holthausen, D)
Über die Behandlung schwerster deliranter und amnestischer Psychosyndrome in der neurochirurgischen Frührehabilitation wurde bisher wenig publiziert.
Ziel der Untersuchung ist die Darstellung der rehabilitativen Behandlungsziele und des Outcomes.
Die untersuchte Stichprobe umfasst 1293 Patienten, die auf zwei geschlossenen Stationen der neurochirurgischen Frührehabilitationsklinik Holthausen in einem Zeitraum von 11,7 Jahren (1993–2004) behandelt wurden.
In die Untersuchung wurden die neurochirurgischen Grunddiagnosen, Altersstruktur, Geschlecht, neuropsychologische Testergebnisse, die klinische Einschätzung der sozialen und beruflichen Reintegrationsfähigkeit, Entlassungsziele und bei aSAB-Patienten die Versorgungsmethode (Coil/Clip) bzw. Shuntpflichtigkeit währen der Behandlung, einbezogen.
Die führenden neurochirurgischen Grunddiagnosen verteilen sich wie folgt: SHT 38,4%, aSAB 32,4%, spontane ICB 11,8%, Hirntumoren 5,7%. Das Durchschnittsalter der Patienten beträgt 52 Jahre. Geschlechtsspezifisch überwiegen Männer mit 71%. Bei 28,6% der Patienten bestand die Indikation zu Shuntanlage.
Mit einem multiprofessionellen interdisziplinären Therapiekonzept verbesserte sich die hirnorganische Symptomatik in bezug auf Kognition, Mnestik und soziale Integrationsfähigkeit, so dass 57,2% der Patienten in ihr häusliches Umfeld reintegriert werden konnten, 18,1% wurden in AHB-Kliniken überwiesen, 4,4% in Tageskliniken teilstationär weiter behandelt und 21,2% in Pflegeeinrichtungen verlegt.
Die Ergebnisse zeigen, dass die neuropsychiatrische Frührehabilitationsbehandlung von Patienten mit schwersten deliranten und amnestischen Psychosyndromen ein notwendiger und lohnender Bestandteil des postoperativen Behandlungsmanagement ist und das Outcome possitiv beeinflusst.
P10 COGNITIVE REHABILITATION | C
NEUROPSYCHOLOGISCHE REHABILITATION VON ORGANISCHEN GEDÄCHTNISDEFIZITEN
H. Hildebrandt, M. Ebke, G. Schwendemann (Bremen, D)
Gedächtnisdefizite spielen als Folgen neurologischer Erkrankungen eine nicht unerhebliche Rolle. Die Erforschung der Rehabilitation von Gedächtnisdefiziten ist dagegen überwiegend auf die Behandlung schwerer Amnesien konzentriert. Es werden vier Studien vorgestellt, in deren Zentrum die neuropsychologische Behandlung von nicht-amnestischen, aber gedächtnisgestörten Patienten steht: eine erste Studie, die drei verschiedene, für Patienten der Phase D der neurologischen Rehabilitation entwickelte Gruppentherapien mit einer Kontrollgruppe vergleicht. Eine zweite Studie, die für zwei analoge Patientengruppen ein funktionelles Training mit einem Strategietraining vergleicht. Die dritte Studie basiert auf dem Vergleich einer computerisierten Form des funktionellen Trainings mit einer Kontrollgruppe (beide Gruppe Patienten mit schubförmiger MS). Und eine letzte Studie, die wiederum bei Phase D Patienten die computerisierte Form des funktionellen Trainings mit einer Kontrollgruppe vergleicht.
Alle Studien kommen zu dem Ergebnisse, dass die Behandlung der Nichtbehandlung überlegen ist. Beim Zwischengruppenvergleich zeigt aber regelmäßig nur das funktionelle Training eine signifikante Überlegenheit gegenüber den Kontrollgruppen.
Die spezifische Form des funktionellen Trainings (inkl. der in ihm geleisteten Vermittlung von einfachen Basisfähigkeiten bzw. -strategien) sollen diskutiert werden, wie auch die Frage, ob auch für die Gedächtnisrehabilitation repetitive Stimulation eine gewisse Rolle spielt.
P11 COGNITIVE REHABILITATION | C
STUDIE ÜBER DIE EFFIZIENZ NEUROLOGISCHER REHABILITATION AM BEISPIEL ALLTAGSRELEVANTER KOGNITIVER FÄHIGKEITEN MIT DEM MESSINSTRUMENT VAT (VALENSER ALLTAGSORIENTIERTE THERAPIE)
M. Keller, N. Keller-Hahn, J. Kool, J. Kesselring (Valens, CH)
Das in der Klinik Valens entwickelte und publizierte Messinstrument VAT (Valenser alltagsorientierte Therapie) dient zur Erfassung der Selbständigkeit bei neurologischen Patienten in der erweiterten Alltagsaktivität. Um die Effizienz in der neurologischen Rehabilitation erfassen zu können, untersuchten wir eine Gruppe von Patienten (CVI, SHT, Hirnblutungen) zu Beginn des stationären Aufenthaltes (Messzeitpunkt 1) sowie im Anschluss an ein dreiwöchiges stationäres Therapieprogramm (Messzeitpunkt 2). Dabei interessierte uns welche der Funktionen sich nach der dreiwöchigen intensiven Therapie verbessern.
Neben der Absolvierung des VAT-Tests wird der Mini-Mental-State (als Ausschlusskriterium für eine Demenz) sowie die Anzahl der erfolgten Therapien (Rekreation, Ergo-, Physiotherapie, neuropsychologische und logopädische Behandlung) erfasst. Dabei interessierte die Frage, ob die Anzahl der Therapien im Zusammenhang mit möglichen Verbesserungen im VAT-Parcour stehen.
Wir untersuchten bisher 16 Patienten (Durchschnittsalter 51 Jahre). Davon sind 10 Patienten zum ersten Mal zu einem Rehabilitationsaufenthalt sowie 6 Patienten zum wiederholten Mal in einer Reha-Klinik. Alle Personen absolvierten den VAT-Test, einen Parcours mit folgenden Unteraufgaben: einen Kaffeeautomaten bedienen, ein Büro nach Plan finden, einen Brief versenden, am Kiosk Preise vergleichen und eine Kaufentscheidung treffen, einen Parkautomat bedienen (Zeit und Gebühr lesen, Rechnen) etc..
In einer ersten Auswertung der Erst- und Zweitmessungen zeigt sich insgesamt eine signifikante Steigerung. Vor allem die Leistungen in den Unteraufgaben Kaffeeautomat, Personalbüro finden, Brief versenden, Aufgaben am Kiosk lösen sowie das Gehen mit und ohne Hindernisse haben sich signifikant verbessert.
Literatur:
1. Keller M., Kool J., Keller-Hahn N., Kesselring J. Valenser Alltagsorientierte Therapien (VAT) – Validierung eines neuen Verfahrens zum Messen der Selbständigkeit von neurologischen Patienten. Neurol Rehabil 2002; 8 (5): 239-246
P12 COGNITIVE REHABILITATION | C
BIO-PHYSICAL HEALTH TECHNOLOGIES IN THE REHABILITATION OF PATIENTS SUFFERING CONSEQUENCES AFTER BRAIN INJURIES
K.V. Lyadov, I.V. Sidyakina, T.V. Shishova, T.V. Baidova (Moscow, RU)
A brain injury can be a starting point in the development of a traumatic brain disease. According to different authors, after a brain injury, a psycho-vegetative syndrome, followed by vegetative diseases such as headaches, feeling dizzy, getting tired quickly, memory problems and a decrease in work abilities, dominates in 78% of cases.
This work was aimed at studying a complex effect of bio-physical technologies by Professor Fomin M.I. among patients suffering a post traumatic syndrome.
The work was based on the results of observation of 28 patients (17 women and 11 men, age18–64).8 patients had aesthenic syndrome, 14 people had vegetative-distonic syndrome,6 people suffered celebral-oriented syndrome.
All patients received a complex consequent treatment, without any breaks using “Anotron”, “Barocyclon”, “Molecule-cell regulato” and vibro-massagers (all the equipment was patented by Fomin M.I).
These technologies allow a complex approach in patient’s rehabilitation,detoxication of the whole organism; affect central and distant mechanisms of the pathological process regulation, improving microcirculation and cell metabolism. All these approaches together improve each other’s effectiveness. The complex treatment lasts 1,5–2 hours. The parameters of the effect and the position of electrons were chosen individually due to the patient’s prevailing complex of symptoms; as a rule, one pair of electrodes was set trans-cerebrally to influence the central brain structures. The patients went through the procedures well, they felt relaxed, sleepy and experienced after treatment effect (3–4 hours later) – they felt active and that feeling became more stable by the end of the treatment. After the complex treatment, a positive tendency among all the patients was noticed: a decrease in their complaints about insomnia, headaches, anxiety, and annoyance. They started to tolerate psycho-emotional and physical exercises more easily. The effectiveness of the treatment went along with a better result in psychological testing.
After the treatment a decrease of the latent period R300 was noticed among 85,7% of the patients.
Thus, health technologies by Professor Fomin, influencing the organism and activating the processes of self-regulation and adaptation can be used successfully in treatment of patients suffering consequences after brain injury.
P13 COGNITIVE REHABILITATION | C
SOUND OBJECT SEGREGATION FOLLOWING HEMISPHERIC LESIONS
C. Nikolov, M. Adriani, P. Maeder, St. Clarke (Lausanne, CH)
Brain-damaged patients often complain of hearing difficulties in noisy surroundings. This suggests putative disturbances of sound segregation mechanisms, the most powerful of which is the use of spatial cues. We report here on the capacity to use spatial cues for the identification of sound objects in noisy surroundings and for explicit sound localisation following brain damage. Eleven patients with unilateral or bilateral hemispheric lesions (stroke, head-injury, colloidal cyst with hydrocephalus, sequelae of meningitis), aged between 23 and 67 years, who participated in our rehabilitation program and had a full neuropsychological evaluation with detailed assessment of auditory cognitive functions. The latter included recognition of environmental sounds, sound localisation, sound motion perception and capacity to segregate sound objects by means of spatial cues (spatial-release-from-masking=SRM). Sound localisation was tested with a task that simulated five different azimuthal positions by means of varying interaural time differences (ITD). Subjects were instructed to indicate the perceived position on their head with their ipsilesional hand. Normative data have been obtained from 60 normal subjects (and published previously; Clarke et al. 2000). Sound object segregation based on spatial cues was tested using the SRM paradigm (a soft noise that is masked by a louder noise of similar frequency range can be perceived with increasing spatial separation between the target sound and the masking noise). In our test spatial removal of the masking noise was simulated by ITD (and thus, each ear continued to receive the same frequencies at a same intensity level). Normative data have been obtained from 60 normal subjects (and published previously; Bellmann Thiran and Clarke 2003). Four patients had a normal performance in sound localisation and presented correctly the SRM effect. Three other patients were deficient in sound localisation and did not present the SRM. The remaining four patients presented dissociation between these two capacities. Two were deficient in sound localisation, but presented correctly the SRM effect, the other two had the reverse profile, with normal sound localisation and absent SRM effect. In conclusion, the capacity to use spatial cues for the identification of sound objects in noisy surroundings can be impaired following brain damage, either in isolation or in association with deficits in explicit sound localisation.
P14 COMA | C
COMA FOLLOWING A SEVERE TRAUMATIC BRAIN INJURY – FUNCTIONAL OUTCOME AFTER 12 MONTHS.
M. Lippert-Grüner, C. Wedekind, N. Klug (Köln, D)
Introduction: In the last years there has been significant progress in medical technology and treatment, leading to a considerable increase in the number of severe traumatic brain-injury (TBI) survivors. Most of them show severe functional deficits. For rehabilitation treatment, coma-patients present a special challenge.
Material and methods: The aim of the study is to improve the 12-months outcome in 24 severe brain injured patients with a coma duration for more than seven days. All patients had received an uninterrupted rehabilitative treatment, starting in the acute phase of illness and including Multimodal-Early-Onset-Stimulation (MEOS). Outcome after 12 months was assessed by means of Glasgow Outcome Scale (GOS) and Functional Independence Measure (FIM).
Results: 12 Months after trauma: six (25%) of the patients had died (GOS=1), three (12.5%) continued to be in a vegetative state (GOS=2), six (25%) were severely disabled (GOS=3), six (25%) were moderately disabled (GOS=4) and three (12.5%) achieved a good recovery with only minimal disability (GOS=5). Mean FIM was 88.3 (range 18–126).
Discussion and conclusion: The early onset rehabilitation is one of the most important factors for the outcome of the severe brain injured patients with a prolonged phase of coma. If patients survive the critical stage of TBI, mortality rate during the first year is still very high. Patients who survive and receive early and continuous rehabilitative treatment, despite of high number of severe neurological deficits, it is possible to get a high degree of autonomy and independence on care.
P15 COMA | C
A NEW SHOULDER RANGE OF MOTION SCREENING MEASUREMENT, ITS RELIABILITY IN THE ASSESSMENT OF THE PREVALENCE OF SHOULDER CONTRACTURES IN PATIENTS WITH IMPAIRED CONSCIOUSNESS DUE TO SEVERE BRAIN DAMAGE
M. Pohl, J. Mehrholz (Kreischa, D)
Objective: To determine reliability of a new shoulder joint range of motion (ROM) measurement for unconscious patients, and to assess the prevalence of shoulder joint contractures in such patients.
Design: Prospective cohort survey.
Setting: An early rehabilitation center for adult persons with neurological disorders.
Subjects: 50 patients with impaired consciousness due to severe cerebral damage of various etiologies. In addition, normal reference values were measured in 60 healthy adults.
Intervention: Shoulder ROM was assessed by measuring the distance between olecranon and underlay while the patient was lying supine on a solid surface and the patient’s hands were passively positioned behind the neck. Distances between olecranon and underlay were measured first manually by the rater and second, for control, digitally by a blinded person from a digital photo taken while a constant force was applied on the elbow.
Main outcome measures: Prevalence of contractures defined as increased distance between olecranon and underlay or impossibility of positioning the hands passively behind the neck, and intra- and interrater-reliability of the two different shoulder ROM measurements with the interclass-coefficient (ICC).
Results: Measurement of shoulder ROM showed a high intra- (ICC: 0.78–0.91) and interrater-reliability (ICC: 0.77–0.90) for manual measurement, a high intra- (ICC: 0.91–0.95) and interrater-reliability (ICC: 0.90–0.94) for the digital analysis, and a high interclass correlation for both methods (ICC 0.87). The prevalence of shoulder contractures was found in 56 percent of the patients and in 50 percent of all shoulder joints.
Conclusion: The described method provides a reliable measurement for reduced shoulder ROM and appears to be a useful screening method to demonstrate the prevalence of shoulder joint contracture in these patients.
P16 FUNCTIONAL IMAGING | C
THE NEURAL MECHANISMS OF MIRROR TRAINING
C. Dohle, K.M. Stephan, R. Kleiser, J. T. Valvoda, T. Kuhlen, R.J. Seitz, H.-J. Freund (Bonn, Düsseldorf, Aachen, D)
It has been proposed that rehabilitation of hemiparesis after stroke can be improved by viewing the non-affected limb as the affected one by means of a vertical parasagittal mirror (‘mirror training’, Altschuler et al., Lancet, 353 (1999): 2035-36). Here, we describe two neuroimaging experiments (reported previously) which might help to understand the mechanism of this training procedure. In the first experiment, six right-handed normal subjects performed finger movements with either hand under visual control via a video chain while lying in a functional magnetic resonance (fMR) scanner. In a second experiment with positron emission tomography (PET), ten right-handed normal subjects performed movements with their right arm that were displayed in real-time as a computergraphic model of a human arm via a virtual reality system. In half of the trials of both experiments, the visual image was inverted horizontally, thus that the subject’s right hand / arm was viewed as a left hand/arm and vice versa. Imaging analysis was performed employing Brain Voyager 4.9 (fMR) and SPM 99 (PET) respectively, each thresholded at a level of significance of p<0.01 (corrected for multiple comparisons). In both experiments, inversion of the visual image lead to an activation of the hemisphere contralateral to the visual image. In the fMR experiment, these activations were found in the primary and higher order visual areas (Dohle et al., J. Neurophysiol, 91(2004): 2376-9). In the PET experiment, the activation focus was in the precuneal region (Dohle et al., Soc Neurosci Abstr 163.7, San Diego, 2002). Taking both findings together, the beneficial effect of mirror training in hemiparetic patients might be caused by the activation of the damaged hemisphere through the inverted visual image. Possible reasons for the differences in the activation patterns in both experiments and the implications for the implementation of mirror training procedures will be discussed.
P17 LEGAL ISSUES | C
CLINICAL PATHWAYS FÜR DIE STATIONÄRE NEUROLOGISCHE REHABILITATION
P.-J. Hülser, R. Weber, Th. Holler, H.P. Müller (Elzach, Wangen, D; Aarau, CH)
Das therapeutische Vorgehen in der Neurologischen Rehabilitation ist weniger abhängig von der ätiologisch orientierten Diagnose als viel mehr von den entstandenen Funktions- und Fähigkeitsstörungen. Um hier clinical pathways (Behandlungspfade) als Abbild und Dokumentationsinstrument des unter den im klinischen Alltag gegebenen Randbedingungen bestmöglichen Ablaufs aufzustellen, müssen diagnoseunabhängige, fähigkeitsorientierte Parameter der Erkrankungsmanifestation betroffener Patienten beschrieben werden. Dafür wurde ein komplexer Algorithmus entwickelt, der auf empirischer Grundlage ermittelte, aufwandrelevante Komponenten („Behandlungspfeile“) umfasst. Jeder Behandlungspfeil beschreibt die bei Vorliegen bestimmter Funktionsstörungen (z.B. Bewusstseinsstörung, Sprachstörung, Hemiparese, Tetraparese, Dysphagie) erforderlichen Behandlungsprozesse, basierend auf den Prinzipien der evidence-based medicine, einschließlich der Erhebung des personellen und Sachmittel-Aufwandes. Kombiniert mit einem zentralen „Planungs- und Entscheidungspfeil“ kann die an den im individuellen Falle eines betroffenen Patienten vorliegenden Beeinträchtigungen orientierte Auswahl der zutreffenden Behandlungspfeile den Ablauf des Rehabilitationsprozesses adäquat abbilden.
Der Planungs- und Entscheidungspfeil enthält unter anderem Zieldefinitionen, das Zeitraster für Ergebniskontrollen und Handlungsanweisungen im Falle des Erreichens oder Verfehlens von Vorgaben. Zudem ist diese Darstellung der rehabilitativen Prozesse nicht nur hinsichtlich der Reha-Methoden, sondern auch des erforderlichen Aufwands nachvollziehbar und überprüfbar. Da innerhalb der Behandlungspfeile der personelle und Sach-Aufwand differenziert beschrieben wird, lässt sich der für einen individuellen Patienten erforderliche Aufwand in Abhängigkeit seiner Funktionsstörungen im Längsschnitt durch Zusammenfassung der einzelnen Behandlungspfeile ermitteln, was für die Kalkulation etwa von DRG oder anderen Fallpauschalen herangezogen werden kann. Im Querschnitt ergibt sich die in einem bestimmten Zeitkorridor erbrachte Leistung. Deren Umfang kann in Beziehung gesetzt werden zu dem in Deutschland eingeführten Phasenmodell der Neurologischen Rehabilitation. Eine derartige Abbildung soll nicht zuletzt zu der von gesundheitspolitischen Entscheidungs- wie von Kostenträgern gewünschten Leistungstransparenz in der Neurologischen Rehabilitation beitragen.
P18 LOCOMOTION | C
A PRELIMINARY NON-RANDOMISED STUDY TO EVALUATE THE SAFETY AND PERFORMANCE OF THE ACTIGAIT IMPLANTED DROP-FOOT STIMULATOR IN ESTABLISHED HEMIPLEGIA: PATIENTS’ PERCEPTIONS
J. Burridge, M. Haugland, Th. Sinkjaer, B. Larsen, N. Svaneholm, H. Iversen, P. Brogger (Southampton Hampshire, UK; Aalborg, Bronderslev, Glostrup, Hammel, DK)
Correction of drop-foot using surface functional electrical stimulation has been shown to be effective, particularly in stroke [1]. Despite benefits in walking, patients reported problems with electrode positioning, skin irritation and the inconvenience of external leads and electrodes. Implanted systems have failed to achieve as good improvement in walking partly because of their inability to control inversion and eversion, as components of normal ankle lift during walking, The ActiGait is an implantable drop-foot stimulator comprising a stimulation implant (nerve cuff and receiver), external control unit and transmitter, wireless heel switch and clinical station (PC based programming of stimulation parameters) (Fig 1). The system allows independent adjustment of output from four channels of stimulation via one nerve cuff, placed around the common peroneal nerve just proximal to its bifurcation into the deep and superficial branches. This design avoids many of the inconvenient aspects of external systems.
A prospective non-randomised trial to evaluate safety, performance and patients’ perception of the device was conducted. All subjects who had a drop-foot following a stroke at least six months prior to recruitment gave informed consent. The study was approved by the Local Ethical Committees. Patients’ perception was evaluated via an independently administered questionnaire based on one used with a surface system [2]. The questionnaire comprised 31 multiple choice questions and opportunity for comments.
Fifteen subjects were recruited from three stroke rehabilitation centres. Results showed statistically significant improvement in walking parameters and no changes in nerve conduction velocity. Thirteen subjects who completed the trial were sent the questionnaire. Twelve replies that have been received identified that 91% of subjects used the stimulator everyday and 82% for over 9 hours each day. 82% could don the stimulator without help, 63% in less than three minutes, the remainder in less than six. Compared with Taylor et al’s study of a surface stimulator, patients used the stimulator more often (91% everyday as opposed to 53%) and for longer (82% as opposed to 58% for 9 hours or more) and no problems were encountered with electrode positioning or skin irritation. The most ‘popular’ reason for using the stimulator was to make walking less effort and 90% of subjects said they were less likely to trip or fall.
In conclusion: the ActiGait system is as effective as the surface stimulator, is used more regularly, for longer periods and has fewer practical problems.
References:
1. Burridge JH: Does the drop-foot stimulator improve walking in hemiplegia? Neuromodulation 2001; 4 (2): 77-83
2. Taylor PN, Burridge JH, et al.: Patient’s perceptions of the Odstock Dropped foot Stimulator (ODFS). Clinical Rehabilitation 1999; 13: 439-446
P19 LOCOMOTION | C
COMPARISON OF FOUR DIFFERENT TECHNIQUES FOR LOMOMOTOR TRAINING AFTER SCI: FUNCTIONAL AND REFLEX OUTCOMES
E. Field-Fote, M.T. Khan, S.D. Lindley (Miami, USA)
Background: In individuals with chronic (>1 yr) incomplete spinal cord injury (SCI), body weight supported (BWS) locomotor training has been shown to improve walking ability and other functions. However, optimal methods and parameters for training have not been established. Additionally, PLASTICITY of spinal reflex circuitry may be associated with changes in function and this relationship has not been investigated fully.
Methods: Eighteen (18) individuals with chronic motor-incomplete SCI were assigned to 1 of 4 different BWS locomotor training protocols. Training was performed 5 days per week for 3 months using either: 1) treadmill training with manual assistance (TM), 2) treadmill training with peroneal nerve stimulation (TS), 3) treadmill training with robotic assistance (Lokomat robotic orthosis; LR), or 4) overground training with peroneal nerve stimulation (using a WalkaideII stimulator; OG). Prior to and following participation we assessed walking speed, balance, lower extremity strength, EMG patterns and selected spinal reflexes.
Results: All groups demonstrated improvements in overground walking speed: TM: +31.4%, TS: +30.8%, OG: +29.3%, LR: +42.9%. Mean initial strength scores (based on ASIA lower extremity motor scores; max= 50) were statistically different among training groups: TM= 36.2, TS= 27.8, OG= 39.8, LR= 20.5. There was a significant inverse correlation between change in walking speed and initial strength scores (r= -0.83). Mean balance scores (Berg Balance Scale max= 48) improved in 2 of the 4 groups: TM= 2, TS= 0, OG= 5, LR= 0. EMG patterns were more robust following training in all groups based on analysis of walking-related RMS values. Reciprocal inhibition was increased following training (16%; pooled data); there was a trend toward increased presynaptic (D1) inhibition and low frequency depression but this trend was not significant (likely do to small samples size).
Conclusions: Locomotor training is associated with improvements in walking function regardless of the form of training. Individuals with the greatest deficits in lower extremity strength made the greatest improvements in walking function. Overground training was associated with the greatest improvement in balance score. Changes in spinal reflex activity may be associated with changes in motor function. Supported by: NIH grant grant #HD41487, the Schumann Foundation and The Miami Project to Cure Paralysis.
P20 LOCOMOTION | C
EFFECTS OF LOCOMOTION TRAINING WITH ASSISTANCE OF A DRIVEN GAIT ORTHOSIS IN HEMIPARETIC PATIENTS AFTER STROKE
B. Husemann, F. Müller, C. Krewer, A. Laß, Chr. Gille, S. Heller, J. Quintern, E. Koenig (Bad Aibling, D)
Aims: The results of gait rehabilitation after stroke is strongly dependent on exercising walking. However, in the beginning patients are often unable to practice walking due to their disability. In the last ten years it was assumed that treadmill training is effective to improve walking capabilities, partially with the assistance of graded body weight support.
During the early stages of treadmill training the paretic leg has to be moved manually on the treadmill. The physical capabilities and the individual experience of the therapists usually limit this training in severely handicapped patients.
To aid the therapists, a driven gait orthosis has been developed for paraplegic patients.
The apparatus is capable of moving the legs of a patient in a symmetric and physiologic way on the moving treadmill, while securing the patient at the level of pelvis and trunk. Actuators at the knee and hip joints are controlled by a position controller and produce angular movements of the joints. We report our experiences and measurements when transferring the use of the LOKOMAT to hemiplegic patients.
Design: Randomized controlled trial, pilot study.
Participants: 29 acute stroke survivors 14 in the treatment group and 15 in control group.
Intervention: Treatment group received daily approximately 30 min Lokomat therapy and control group 30 min daily regular physiotherapy based on proprioceptive neuromuscular facilitation and Bobath concepts. In addition both groups received 30 min regular physiotherapy daily. Participants were tested at baseline and after completing 20 units Lokomat therapy and 20 units physiotherapy or 40 units physiotherapy.
Main outcome measures: Time-walking-test and functional ambulation category.
Results: The walking speed after 4 weeks therapy in the Lokomat group and in controls was significantly improved compared to the baseline speed but there was no significant difference between the groups. The functional ambulation category shows in both groups an significant gain in the walking ability but did not reveal any statistical significant differences between the therapy and control group.
Conclusions: This pilot study indicates that the Lokomat therapy is a promising intervention for gait rehabilitation. There is no difference in effect compared to patients, who receive only physiotherapy, when intensity of treatment is controlled. Lokomat training eases hard work of therapist when exercising with severely handicapped patients. There is a subgroup, patients staring with a functional ambulation category score higher than 2 who showed more than average improvement. However, a larger trial is needed to define patients who would show more pronounced effects.
P21 LOCOMOTION | BS
COMPARISON OF SURFACE EMG PATTERNS IN HEMIPLEGIC PATIENTS DURING TREADMILL TRAINING WITH AND WITHOUT ASSISTANCE OF A DRIVEN GAIT ORTHOSIS
B. Husemann, F. Müller, C. Krewer, A. Laß, S. Heller, J. Quintern, E. Koenig (Bad Aibling, D)
Aims: Restitution of gait after hemiplegia due to a stroke is strongly dependent on exercising walking. However, in the beginning patients are usually unable to practice walking due to their disability. Different technical apparatus have been developed to assist gait training during the early period. There is evidence, that regular treadmill training is an effective measure to improve walking capabilities, partially with the assistance of graded body weight support. During the early stages of treadmill training the paretic leg has to be moved manually by therapists or assistants during walking movements on the moving treadmill. The physical capabilities and the individual experience of the therapists usually limit this training in severely handicapped patients. In addition, asymmetric walking can be alleviated by body weight support, yet not completely prohibited.
A driven gait orthosis (LOKOMAT) has been developed for gait exercises in paraplegic patients. The apparatus is capable of moving the legs of a patient in a symmetric and physiologic way on the moving treadmill, while securing the patient at the level of pelvis and trunk. Actuators at the knee and hip joints are controlled by a position controller and produce angular movements of the joints. We report our experiences and measurements when transferring the use of the Lokomat to hemiplegic patients.
The aim of this study was to find out weather automated treadmill training in the Lokomat induces a muscle activation how the EMG pattern differs in hemiparetic patients and healthy subjects during manual and automated treadmill training.
Methods: 7 Healthy controls and 9 hemiplegic stroke patients were measured while walking on a treadmill with assistance of a driven gait orthosis (LOKOMAT) as well as on a normal treadmill with facilitation techniques by therapists. We present data of movement recordings by surface EMG muscle patterns from muscles tibialis anterior, gastrocnemius, quadriceps and biceps femoris.
Results: Our results indicate in healthy subjects and on the unaffected side of patients, that the use of an extrinsically given cyclic leg movement will induce typical muscular walking patterns. Faster velocities induced higher amplitudes of muscular patterns. Not surprisingly, patterns and EMG amplitude were reduced on the affected side. Rather astonishing, most recordings on the treadmill without the use of the Lokomat, only with the assistance of a facilitating physiotherapist would induce less pronounced muscular patterns.
Conclusion: Our experiences support the idea, that a close to normal rhythmic locomotor pattern can be elicited when a driven gait orthosis is used for inducing cyclic leg movements in healthy controls and hemiplegic subjects.
P22 LOCOMOTION | C
ENERGY EXPENDITURE OF HEMIPARETIC PATIENTS AND HEALTHY SUBJECTS: WALKING IN A LOKOMAT VS. ON A TREADMILL
C. Krewer, F. Müller, B. Husemann, S. Heller, J. Quintern, E. Koenig (Bad Aibling, D)
Purpose: This study examined the oxygen and energy expenditure for normals and severely disabled hemiparetic patients while walking in a driven gait orthosis (Lokomat) and in comparison to walking on treadmill.
Methods: 5 hemiparetic patients (age 50±15, Body Mass Index 25±3, FAC 4) and 5 healthy subjects (age 46±14, Body Mass Index 26±4) were measured during walking in the Lokomat and on treadmill at a speed of 1 and 2 kilometer per hour. Patients who could not walk with 2 km/h on treadmill, walked with there maximum speed. Reference was measured while standing in the Lokomat and on treadmill with 30% Body weight support.
Measured parameters are VO2 [ml×min¯¹], VCO2 [ml×min¯¹] received breath-by-breath and heart rate [beats per minute]. To describe energy expenditure the terms O2cost [ml×kg¯¹×m¯¹] and O2rate [ml×kg-¹×min-¹] are used. The rate of O2 consumption (O2rate) relates to the level of physical effort and the O2cost determines the total energy required to perform a task of walking. For statistical analysis the parameters were averaged over the last 30 seconds of each condition and each person.
Results: For patients oxygen consumption is higher on treadmill than in the Lokomat, this already in the reference condition, indicating that standing in a treadmill is physically more demanding for patients, while for controls it is the opposite. Healthy subjects show significant higher energy level on the treadmill when walking at 2 km/h. At 1 km/h patients have significant higher values for O2rate and O2cost than normals on the treadmill, while there are no significant differences in the Lokomat.
Conclusions: Energy expenditure is higher for treadmill than for Lokomat exercise. But to calculate total expenditure for one Lokomat therapy session or one treadmill therapy session, the average duration of 30 min for Lokomat and 10 min for treadmill therapy have to be considered.
P23 LOCOMOTION | C
DIFFERENT WALKING STRATEGIES IN THE LOKOMAT: MEASUREMENT OF ENERGY EXPENDITURE
C. Krewer, F. Müller, B. Husemann, S. Heller, J. Quintern, E. Koenig (Bad Aibling, D)
Purpose: This study investigated the oxygen uptake and energy expenditure of hemiparetic patients and controls while walking in a driven gait orthosis (Lokomat) at several robotic strategies.
Methods: 10 hemiparetic patients (age 54±14, Body Mass Index 26,3±2,6) and 10 healthy subjects (age 48±12, Body Mass Index 25,3±4,3) were measured while they were walking in the Lokomat. They underwent different robotic strategies, in permuted order between subjects. Baseline was measured while standing in the Lokomat with 30% body weight support (BWS). Robotic strategies were walking with 100% BWS at a speed of 1 vs. 2 km/h, walking with 30% BWS at a speed of 1 vs. 2 km/h. A complete different control option allows to reduce the force that supports the moving leg, to allow more active movements. We measured this option by reducing the driving force to 60% or to 0% of either side.
Each robotic strategy was executed for 3 minutes, separated by 2-minutes resting periods. Measured parameters are VO2 [ml×min¯¹], VCO2 [ml×min¯¹] received breath-by-breath and heart rate [beats per minute]. To describe energy expenditure the terms O2cost [ml×kg¯¹×m¯¹] and O2rate [ml×kg¯¹×min¯¹] are used. The rate of O2 consumption (O2rate) relates to the level of physical effort and the O2cost determines the total energy required to perform a task of walking. For statistical analysis the parameters O2rate and O2cost were averaged over the last 30 seconds of each period and each person.
Results: For patients all Lokomat strategies with 30% body weight support are significantly different from baseline, but there are no significant differences between baseline and walking with 100% body weight support. In contrast for healthy subjects 30% BWS with 100% unilateral force reduction is significantly different from baseline. This indicates, that for healthy controls typical walking conditions in the Lokomat are not physically demanding. Both groups show no significant difference between walking with 1 and 2 km/h for O2rate, leading to a reduction of O2cost for higher speed in both groups.
Conclusions: Walking in the Lokomat is not passive according to the measurement of oxygen consumption. Improved activity is an effect of an active stance phase (walking with 30% BWS), not of the passive leg movement (walking with 100% BWS). For the amount of oxygen consumption within a therapy unit speed is no relevant parameter.
P24 LOCOMOTION | C
EFFECTIVE GAIT TRAINING ON THE TREADMILL AND THE LOKOMAT: COMPARISON OF ACHIEVABLE TRAINING TIME AND SPEED
F. Müller, S. Heller, C. Krewer, B. Husemann, E. Koenig (Bad Aibling, D)
Introduction: Physiotherapy is the mainstay of rehabilitation approaches for impairments in motor function. Only during the last few years the application of treadmill training has helped to improve the possibility of gait training in severely impaired patients. Due to the high effort for therapists when exercising with stroke patients or paraplegic patients on the treadmill, new robotic devices have been developed to assist and even increase the effect of training sessions. The most advanced apparatus is the Lokomat, which has been developed to enable completely paralyzed patients to walk on a treadmill without the physical help of therapists. The patients are walking in a driven gait orthosis, with actuators at hip and knee joints of either side inducing cyclic gait patterns.
Methods: We compared the effective training time and walking speed as well as the increment from begin to end of therapy sessions of groups of stroke and spinal patients during their physiotherapy who were either exercising on a treadmill (n=50) or in the lokomat (n=44). To make sure that comparable efforts were requested from the patients, we restricted our analysis to our three most experienced physiotherapists. An identical goal of the sessions was to achieve the maximum walking speed as well as to continue exercising as long as the patients could tolerate it. Sessions had to be limited to a maximum of 45 minutes effective training time for logistic reasons, which only came into effect for Lokomat training.
Results: On the average, patients could continue gait exercise on the treadmill to a maximum of 13 minutes, leading to a distance of 460 meters per session at the end of the rehabilitation period. In contrast, patients treated on the Lokomat ended their walking endurance at 37 minutes average, with a resulting distance of 1230 meters per session. Groups were comparable in terms of the motor items of the Barthel Score.
Conclusion: This analysis confirmed subjective impressions, that effective training time can be enhanced two- to threefold by the use of robotic assistance. Although the net time of gait exercise may not be the only parameter to control the rehabilitation outcome what locomotion is concerned, it certainly is an important factor.
P25 LOCOMOTION | C
VERGLEICH DER AEROBEN ÜBUNGSINTENSITÄT BEI PATIENTEN NACH SCHLAGANFALL – GANGTRAINER VERSUS KONVENTIONELLE PHYSIOTHERAPIE. EINE RANDOMISIERTE UND KONTROLLIERTE LONGITUDINALSTUDIE
M. Pohl, J. Mehrholz, C. Werner, S. Hesse (Kreischa, Berlin, D)
Einleitung: Obgleich die Erkrankungen Schlaganfall und Herzkrankheit gemeinsame Risikofaktoren und pathophysiologische Prozesse besitzen, existierten nur wenige Untersuchungen bezogen auf die kardiorespiratorische Belastung in der Rehabilitation von Patienten nach Schlaganfall. Die aktuellen AHA-Leitlinien empfehlen ein Trainieren der aeroben Kapazität von 20-60 Minuten pro Tag an mindestens 3 Tagen der Woche. Die vorliegenden Studie vergleicht die Übungsintensität im Verlauf der physiotherapeutischen Behandlung von Patienten nach Schlaganfall.
Methoden: Insgesamt 150 Patienten nach Schlaganfall (Intervall <60 Tage, Barthel Index 25–60) wurden im Rahmen der multizentrischen Studie DEGAS (DEutsche GAngtrainer-Studie) zwei Gruppen zugewiesen. Die Experimentalgruppe erhielt jeden Werktag 20 min Gangtrainer (GT) plus 25 min Physiotherapie (PT) und die Kontrollgruppe (KG) 45 min PT für jeweils 4 Wochen. Mit einem Pulsmessgerät (POLAR S410) wurden bei den Studienpatienten des Zentrums Kreischa (n=71) einmal wöchentlich die Parameter Ruheherzfrequenz (HR rest), mittlere Herzfrequenz beim Üben (HR mean), höchste Herzfrequenz (HR peak) und der Anteil der Übungszeit im aeroben Trainingsbereich in einer Behandlungseinheit kontinuierlich gemessen. Die Parameter des aeroben Trainingsbereiches wurden mit der adaptierten Karvonnen-Formel berechnet.
Ergebnisse: In der GT-Gruppe wurde länger pro Tag im empfohlenen Trainingsbereich trainiert als in der KG-Gruppe (15,8 min vs. 5,3 min; p<0,05; Anteil der Übungszeit im aeroben Trainingsbereich 34% vs. 11%; p<0,05). Im Vergleich mit der KG-Gruppe fanden wir signifikante Unterschiede zugunsten der GT-Gruppe in den Parametern HR mean:103 b/min vs. 93 b/min und HR peak:122 b/min vs. 112 b/min; p<0,05. Kein Patient wurde kardial überbelastet.
Schlussfolgerungen: Das repetetive Gehtraining mit dem Gangtrainer von Patienten nach Schlaganfall (integriert in die physiotherapeutische Behandlung) ist ein adäquater Reiz, um in der Frührehabilitation das kardio-respiratorische System ohne Überbelastung der oft multimorbiden Patienten zu trainieren.
Die Auswertung der DEGAS-Studie wird zeigen, ob sich die Vorteile in der kardio-respiratorischen Belastung auch auf die funktionellen Outcome-Parameter der Gehens und der Alltagsselbständigkeit auswirken.
P26 MOTOR REHABILITATION | C
RELIABILITY OF A VIDEO-BASED MODIFIED FUGL-MEYER SCALE FOLLOWING stroke AND UPPER-LIMB MOTOR DEFICITS
G. Alon, K.S. McBride, A.F. Levitt (Maryland, USA)
The Fugl-Meyer Assessment Scale (F-M) is a commonly used to document motor impairment of the upper-limb following a stroke. The scale’s intra- and interrater reliability while the raters are attending the patients are documented. However, the utility of the test in randomized controlled clinical trials is questioned due to the difficulty of concealing rater knowledge of subjects’ group assignment. The purpose of this methodological study was to establish intra- and interrater reliability of a video-based scoring of a modified F-M. Five raters of varied disciplines scored four videotapes of patients performing the F-M test. The order of tape reviews was randomized in each of three sessions separated by five to eight days. All raters participated in a two-hour training session prior to testing. An independent data manager conducted analysis of variance (ANOVA), inter- and intraclass correlation coefficients (ICC) and a Tukey post-hoc analysis using SPSS software. There were no significant differences of tester scores across sessions but significant difference between testers (P < .05). Post-hoc analysis identified that two raters with previous experience with the F-M test, scored higher than those with no previous experience (14.5 ± .25 vs. 11.47 ± .19 points). Four raters’ intrarater ICC was 0.99 and one was 0.95 yielding a group mean of 0.98. Coefficient of variation (CV) ranged from 0.049 to 0.084. We concluded that a video-based Fugl-Meyer assessment scale is reliable and can be used by an independent evaluator in randomized clinical trials provided they have similar experience administering the test.
P27 MOTOR REHABILITATION | C
THE EFFICIENCY OF IMPULSE MAGNETO STIMULATION IN REHABILITATION OF THE PATIENTS WITH MOVEMENT DISORDERS AFTER DISCECTOMY
V. Daminov, K. Lavrentiev, A. Kuznetsov (Moscow, RU)
Purpose of this study is to estimate the efficiency of inductive impulse magneto therapy in the patients within early period after discectomy.
Materials and methods: Magneto stimulation was applied in 104 patients with paresis of foot flexor or foot extensor on the 2th–5th day after discectomy (L5 or S1) (group 1). Stable and scanning methods were used with induction 0.5–1.7 Tl daily during 12–18 days. The control group consisted of 62 age- and gender matched patients with the similar severity of disease (group 2). The patients of control group were conducted by usual rehabilitation (massage, kinesiotherapy, laser therapy). We used Muscular Force Scale of R. Braddom, MOS SF-36 and ENMG before and after the treatment.
Results: There was significant regress of degree of paresis by 1–2 marks in 74% of the patients of the group 1 (p<0.05). Only 51% of patients of the group 2 had the same changes. SF-36 scores were considerably improved in group 1. The patients of control group had not considerably improved dynamics of these scores. Significant increase (on 50% and more) of initially reduced peak parameters was registered in stimulating ENMG in 45% of the patients of group 1 and in 29% of the patients of group 2. In the group 1 motor nerve conduction velocity on fibular nerve increased in 42% of the patients, on tibial nerve – in 51%. The factor of dynamics was 15–22%. Significant changes of nerve conduction parameters were not registered in the patients of group 2.
Conclusion: Additional magneto stimulation therapy heightens the efficiency of rehabilitation in the patients within early postoperative period after discectomy.
P28 MOTOR REHABILITATION | C
MULTICHANNEL PROGRAMMABLE ELECTRICAL STIMULATION IN REHABILITATION OF THE PATIENTS WITH GUILLAIN-BARRé SYNDROME
V. Daminov, K. Lavrentiev (Moscow, RU)
Purpose of this study is to estimate efficiency of multichannel programmable electrical stimulation in rehabilitation of the patients with Guillai |
