[Treatment goals in patients with post-stroke upper limb spasticity following injection of botulinum toxin A : Results of the German-Austrian subgroup of the ULIS-II study]. / Therapieziele bei Patienten mit Armspastik nach Schlaganfall nach Injektion mit Botulinumtoxin A : Ergebnisse der deutsch-österreichischen Subgruppe der ULIS-II-Studie.

BACKGROUND: The ULIS-II was an international cohort study (NCT01020500) evaluating current treatment of upper limb spasticity in post-stroke adult patients with botulinum toxin A (BoNT-A) in real-life practice. OBJECTIVE: Post hoc analysis to compare current management of post-stroke adult patients regarding goal setting and attainment with BoNT-A in Germany (D) and Austria (A) with the full cohort of ULIS-II. MATERIAL AND METHODS: The ULIS-II was a global, open-label, prospective, multicenter observational study with 2 visits conducted in 84 centers worldwide. A total of 468 patients aged ≥18 years with post-stroke upper limb spasticity were included. The primary outcome measure was the responder rate defined as achievement of a goal attainment scale (GAS) score of 0, 1 or 2 after 1 cycle of BoNT-A. RESULTS: A total of 57 patients from D/A were included in the efficacy analysis. The number of patients in D/A and the full cohort achieving the primary (78.9% vs. 79.6%) and secondary treatment goal (76.8% vs. 75.6%), respectively, was comparable. Deviating from the full cohort, the most common primary treatment goal in D/A was related to impairment (33.3%). Compared to baseline there was a marked reduction in concomitant therapies at the follow-up visit after 3-5 months in the D/A group: patients receiving oral anti-spastic medication 61.4% vs. 40.4%, positioning 50.9% vs. 36.8% and splinting 43.9% vs. 31.6%. Injection control techniques were less frequently used in the D/A group compared to the global study cohort (electrical stimulation: 26.3% vs. 45.8% and electromyography: 12.3% vs. 29.2%). No adverse events were documented in the D/A cohort. CONCLUSION: A single injection of BoNT-A in adult patients with post-stroke spasticity of the arm led to a high response rate of approximately 80% in both cohorts. The BoNT-A injections in post-stroke adult patients contributed to an improvement in the daily life of patients and their carers beyond simple reduction of muscle tone or spasticity.

Outcome of neurological early rehabilitation patients carrying multi-drug resistant bacteria: results from a German multi-center study.

BACKGROUND: Colonization or infection with multi-drug resistant (MDR) bacteria is considered detrimental to the outcome of neurological and neurosurgical early rehabilitation patients. METHODS: In a German multi-center study, 754 neurological early rehabilitation patients were enrolled and and reviewed in respect to MDR status, length of stay (LOS) and the following outcome variables: Barthel Index (BI), Early Rehabilitation Index (ERI), Glasgow Outcome Score Extended (GOSE), Coma Remission Scale (CRS), Functional Ambulation Categories (FAC). RESULTS: The mean age of the study population was 68.0 ± 14.8 years. Upon admission, the following prevalence for MDRs was observed: MRSA (methicillin resistant staphylococcus aureus) 7.0% (53/754), ESBL- (extended spectrum beta-lactamase) producing bacteria strains 12.6% (95/754), VRE (vancomycin resistant enterococci) 2.8% (21/754). Patients colonized or infected with MDR bacteria (MDR+) were significantly more frequently diagnosed with a critical illness polyneuropathy - CIP - than non-colonized (MDR-) patients: 29.0% vs. 14.8%. In addition, they were more frequently mechanically ventilated (MDR+: 55/138, 39.9%; MDR- 137/616, 22.2%). MDR+ patients were referred to rehabilitation earlier, had a longer LOS in early rehabilitation, lower BI on admission and at discharge, lower ERI on admission and lower CRS at discharge than MDR- patients. There was a highly significant correlation of the BI upon admission with the BI at discharge (rs = 0.492, p < 0.001). GOSE at discharge differed significantly between both groups (χ 2-test, p < 0.01). Perhaps of greatest importance, mortality among MDR+ was higher in comparison to MDR- (18.1% vs. 7.6%). CONCLUSIONS: The outcome of neurological early rehabilitation patients colonized or infected with MDR bacteria including MRSA or ESBL producing strains is significantly poorer than by non-colonized patients. There is some evidence that the poor outcome could be related to the higher morbidity and lower functional status upon admission.

Criterion validity and sensitivity to change of the Early Rehabilitation Index (ERI): results from a German multi-center study.

BACKGROUND: Evaluation of functional status is difficult in neurological and neurosurgical early rehabilitation patients. The Early Rehabilitation Index (ERI) was introduced in Germany over 20 years ago, but since then validation studies are lacking. The ERI (range -325 to 0 points) includes highly relevant items including the necessity of intermittent mechanical ventilation or tracheostomy. METHODS: The present paper analyzed data from a German multi-center study, enrolling 754 neurological early rehabilitation patients. Together with ERI, Barthel Index (BI), Glasgow Coma Scale (GCS), Glasgow Outcome Score Extended, Coma Remission Scale (CRS), Functional Ambulation Categories and length of stay were obtained. RESULTS: ERI showed significant improvements from admission to discharge (p < 0.001). In addition, there were significant correlations of the ERI upon admission and at discharge with BI, CRS and GCS. CONCLUSIONS: Evaluation of our study data suggest that the ERI may be used as a valid assessment instrument for neurological and neurosurgical early rehabilitation patients.

[Course of rehabilitation in early neurological/neurosurgical rehabilitation. Results of a 2014 multi-center evaluation in Germany]. / Rehabilitationsverlauf von Patienten in der neurologisch-neurochirurgischen Frührehabilitation.

BACKGROUND: In Germany, neurological-neurosurgical early rehabilitation is well established in the treatment of severe neurological diseases. To develop quality standards, knowledge of the current rehabilitation course is required. PATIENTS AND METHODS: A retrospective analysis was performed on the course of rehabilitation from patients in an early neurological/neurosurgical rehabilitation program in 16 centers from 10 German states. The odds for a good or poor outcome were investigated using a multivariate logistic regression model. RESULTS: Seven hundred and fifty-four patients were included in the study. The average age of the patients was 68 ± 15 years. Of the patients studied, 26 % were on mechanical ventilation commencing their neurological rehabilitation. The average duration of stay was 56 ± 51 days. Weaning rate from mechanical ventilation was 65 % and the rate of weaning from tracheal cannula was 54 %. Mean improvement in the Barthel Index of 17 points, significant reduction of dysphagia (from 62 to 30 %) and depended walking (from 99 to 82 %), and the achievement of phase C (the next stage of rehabilitation) in 38 % can still be counted as signs of successful rehabilitation. During their course of stay, near 10 % of the patients died. Of these, 67 % received solely palliative care. In the multivariate logistic models, the absence of the factor "necessity for mechanical ventilation on admission" (odds ratio 0.61; 95 % confidence interval (CI): 0.42 … 0.89) increased the chance for good outcome and the presence of this factor the risk of dying with an odds ratio of 8.07 (95 % CI: 4.54-14.34). DISCUSSION: In spite of the severity of neurological deficits, significant functional progress has been made. These results could be interpret as positive proof of the efficacy of neurological/neurosurgical early rehabilitation programs.

Event-related potentials indicating impaired emotional attention in cerebellar stroke--a case study.

The cerebellum has been implicated in affective and attentional processes, but little is known about corresponding neural signatures. We investigated early and late components of event-related potentials (ERPs) to emotionally arousing pictures, with and without competing attentional tasks, in a patient with an ischemic right posterior cerebellar infarction, at two months post infarct and two year follow-up. The early posterior negativity (EPN) response to highly arousing emotional cues in the competing visual attention condition revealed that the augmentation over occipital areas, as typically seen in normals, was absent post-infarct but was restored after two years. The late positive potentials (LPP) response to highly arousing emotional cues showed augmentation over frontal areas post-infarct, and over centro-parietal regions after two years. These ERP findings suggest a specific pattern of disruption of neural function associated with emotional-behavioral disturbances following cerebellar lesions, which can revert to normal with long term recovery.

[Immediate effects of therapeutic interventions on the central motor system and their practical consequences]. / Unmittelbare Effekte therapeutischer Interventionen auf das zentrale motorische System und deren Konsequenzen für die Praxis.

Physiotherapy and occupational therapy have changed over recent years influenced by our growing neurophysiological knowledge especially about motor learning. Understanding the direct effects of therapeutic interventions on the central motor system is crucial for further development of therapeutic approaches. Recent studies are discussed dealing with the facilitatory effects of different therapeutic interventions and the question whether or not the activation of the healthy upper limb has a facilitatory or inhibitory net-effect on the damaged central motor system. In a controlled study using transcranial magnetic stimulation (TMS) we could show that motor system excitability is not influenced by the contraction type (isometric or isotonic), neither in healthy nor in stroke patients. Two TMS-studies could show that voluntary exercises of the non-affected hand alone or in bimanual tasks do not have an inhibitory effect on the damaged central motor system. However, the strongest facilitation of the damaged motor area could be achieved by voluntary activation of the affected extremity. The therapeutic approach in severely or completely paretic upper limbs should, hence, be focussed on functional compensation. As soon as voluntary activity is obtainable intensive voluntary exercises should however be preferred, with contraction type (isometric or isotonic) seeming not to be important.

Rapidly induced changes in neuromagnetic fields following repetitive hand movements.

Sensory feedback plays a major role in movement execution and motor learning, particularly in motor rehabilitation. Whilst elaborating therapeutic strategies, it is of interest to visualize the effect of a therapeutic intervention at the moment of its application. We analyzed the effect of repeated execution of a simple extension and flexion movement of the wrist on the sensorimotor cortex of seven healthy subjects using magnetoencephalography. Spatial filtering based on current dipoles was used to quantify the strength of cortical activation. Our results showed an increase of cortical activation reflecting activity of efferent neurons, whereas the activity of proprioceptive afferent neurons was not affected. Since only efferent activity increased, it is suggested that this reflects phenomena of long-term potentiation.

[Functional outcome after decompressive craniectomy: a retrospective and prospective clinical study]. / Funktionelles Outcome nach dekompressiver Kraniektomie: eine retro- und prospektive klinische Studie.

Decompressive craniectomy has been revived as a radical surgical treatment in increased ICP. While the life saving effect is undisputable, reports about the functional outcome are controversial. Furthermore, there are no data comparing the outcome of craniectomised patients with different aetiologies. In a retrospective and prospective study we assessed the functional outcome of craniectomised patients (41 stroke and 24 traumatic brain injury (TBI) patients). The majority of patients considerably benefits from the rehabilitation process. Nevertheless, most of them remained dependent upon caregivers. In stroke patients there was a significant negative correlation between age and outcome. Even though TBI were younger than stroke patients there were no outcome differences between these groups. We found no correlation between the side of the hemisphere injured and outcome.

[Diagnostic problems in juvenile Huntington chorea]. / Diagnostische Probleme bei einer juvenilen Chorea Huntington.

Huntington's disease (HD) may cause considerable diagnostic problems because of the highly variable clinical features, especially at the beginning of the illness. We report the case of a 21-year-old woman with definite HD whose main symptoms were psychopathological changes that were misinterpreted as schizophrenia for 7 years. One reason for this misdiagnosis was the unusual, very early onset and the remarkable earlier age of onset of HD compared with that of other affected relatives. The phenomenon of earlier onset within one affected family is well documented in the literature in cases with the paternally transmitted mutated gene. Diagnostic landmarks were consideration of the initially mild disturbances of movement and the once again repeated detailed examination of the family history.

Effects of an early postnatal hypoxia on the development of spontaneous head movements in rabbits.

The early detection of minor brain dysfunctions resulting from perinatal hypoxia is very important since the prognosis of the affected children can be substantially improved by a prompt treatment. Therefore, this paper deals with the influence of an early postnatal hypoxia on the postnatal development of spontaneous head movements and the influence of the visual system on head movements in normal and hypoxic disturbed ontogenesis. Head movements were recorded in 12 unrestrained spontaneously behaving alert rabbits from 6 litters with the sensor coil technique. One rabbit of each litter was exposed to a single acute hypoxia (FiO2 = 0.05) for 3 h at the 1st day of life. The siblings were regarded as a control group. The most important characteristic of the postnatal development of the head movements is the forming of horizontal saccadic movements during the second postnatal week and their perfection by an increase in mean velocity up to the 20th postnatal day. The early postnatal hypoxia leads to a decrease of the mean velocity of saccadic head movements. But this is only true if the rabbits have open eyes. Blind-folding the rabbits of the control group during the recordings was followed by a decrease of the mean velocity (14th and 20th postnatal day) and the amplitude (at the 20th postnatal day) of the saccadic head movements. In contrast to the non-hypoxic rabbits, blind-folding had no perceptible influence on head movements in hypoxic rabbits until the 3rd postnatal week. Our results suggest that early postnatal hypoxia causes a

A follow-up study of perinatally hypoxic rabbits.

Rabbits, surviving a severe 3-hours-lasting hypoxia (FiO2 = 0.05) during the 1st day of life, grew up together with their littermates. In animals aged 10 and 20 days, respectively, the vestibular induced tonic eye deviations were investigated during tilting around the three orthogonal body axes. The spontaneous head-body-motor coordination was analysed by means of a search coil technique in 14 days old rabbits. Perinatally hypoxic rabbits exhibit a compensation of initially reduced torsional tonic eye deviation and an overcompensation of the vertical ones at the 20th postnatal day in comparison to controls. Moreover, we found reduced amplitudes and velocities of spontaneous head saccades in perinatally hypoxic animals 14 days old. We assume a retarded development of the neuronal nets of the brain stem reticular formation in the hypoxic rabbits accompanied by an insufficient visuo-vestibular interaction.