[Therapeutic strategies in stroke aftercare. Contents and effects]. / Therapiestrategien in der Schlaganfallnachsorge. Inhalte und Effekte.

No generally accepted guidelines for stroke aftercare exist in Germany. This literature review summarizes the current evidence regarding the content and the effectiveness of aftercare strategies (exercise therapy, physiotherapy, occupational therapy) and their specific dose (intensity, duration, frequency). Exercise therapy (inter alia physiotherapy, resistance, endurance and gait training) has been shown to be effective for improving physical performance (strength, cardiopulmonary fitness, motor function) resulting in beneficial effects on gait, mobility and activities of daily living (ADL). As for the restoration of ADL and the resumption of social and leisure activities occupational therapy proved to be particularly effective. More research is needed to identify the specific effects of different aftercare strategies and their dose-response relationship to provide physicians a better foundation for therapy prescriptions.

[Sensibility changes of the infraorbital nerve after primary surgery on patients with unilateral cleft lip according to J. Delaire]. / Évaluation à long terme de la sensibilité du nerf infraorbitaire chez les patients porteurs de fente labiale unilatérale complète après traitement primaire selon la technique de J. Delaire.

OBJECTIVE: The aim was to determine the overall sensibility changes in the area of the infraorbital nerve on patients with unilateral clefts lips and unilateral clefts lips and palate who had undergone primary surgical correction according to the principles of Delaire. PATIENTS AND METHOD: Twenty patients (7-20years) with unilateral cleft lips (and palate) who had undergone surgery in infancy according to Delaire were included. Cutaneous sensibilities of the nasolabial fold and of the upper lip were tested using four cutaneous modalities. A tactil superficial sensibility light touch test, a two-point discrimination test (McKinnon-Dellon Disk-Criminator), and the determination of cold and warm detection thresholds (Quantitative Sensory Testing, Medoc Thermal Sensory Analyser). The possible difference of the sensibility between operated and controlateral sides of the face were compared. Results were finally compared to a control group of twenty healthy volunteers. RESULTS: No significant difference could be found between the operated and non-operated side of the cleft group. There was also no difference between the cleft and the control group. Specific difference of perception between nasolabial fold and lip encountered in the literature were confirmed by the experiments. CONCLUSION: The large subperiostal approach according to Delaire during the primary surgical procedure have not affected long term infraorbital sensibility of patients with unilateral complete cleft lip.

[DGRW-update: neurology--from empirical strategies towards evidence based interventions]. / DGRW-Update: Neurologie--Von empirischen Strategien hin zu evidenzbasierten Interventionen.

Stroke, Multiple Sclerosis (MS), traumatic brain injuries (TBI) and neuropathies are the most important diseases in neurological rehabilitation financed by the German Pension Insurance. The primary goal is vocational (re)integration. Driven by multiple findings of neuroscience research the traditional holistic approach with mainly empirically derived strategies was developed further and improved by new evidence-based interventions. This process had been, and continues to be, necessary to meet the health-economic pressures for ever shorter and more efficient rehab measures. Evidence-based interventions refer to symptom-oriented measures, to team-management concepts, as well as to education and psychosocial interventions. Drug therapy and/or neurophysiological measures can be added to increase neuroregeneration and neuroplasticity. Evidence-based aftercare concepts support sustainability and steadiness of rehab results.Mirror therapy, robot-assisted training, mental training, task-specific training, and above all constraint-induced movement therapy (CIMT) can restore motor arm and hand functions. Treadmill training and robot-assisted training improve stance and gait. Botulinum toxine injections in combination with physical and redressing methods are superior in managing spasticity. Guideline-oriented management of associated pain syndromes (myofascial, neuropathic, complex-regional=dystrophic) improve primary outcome and quality of life. Drug therapy with so-called co-analgetics and physical therapy play an important role in pain management. Swallowing disorders lead to higher mortality and morbidity in the acute phase; stepwise diagnostics (screening, endoscopy, radiology) and specific swallowing therapy can reduce these risks and frequently can restore normal eating und drinking.In our modern industrial societies communicative and cognitive disturbances are more impairing than the above mentioned disorders. Speech and language therapy (SLT) is dominant in communicative disorders; the therapists use communicative and/or linguistics-oriented strategies. SLT must begin early after disease onset and with high frequency to elicit good results. PC-assisted (self-)training, possibly telemedically applied, can increase training frequency and time and, hence, improve outcome in aphasia. High-frequency and task-specific training, often PC-assisted, were found to be relevant for improving cognitive functions in all dimensions. Several strategies seem to be efficient in neglect. Visual field deficits can be treated restitutively and compensatingly by PC-assisted training. Attention, memory and executive dysfunctions each require multimodal specific treatment strategies, performed in single and group therapy and in PC-assisted training. Also, education of patients to cope with their impairments and disabilities is another important part. Combined medically and vocationally oriented rehabilitation settings are necessary for raising the rate of return-to-work, especially in patients with motor hand impairments or cognitive disorders. Education of patients and relatives to cope with the chronic neurological diseases and disablements highly improve the sustainability of rehab results and can, in the long run, also reduce mortality and admission to nursing homes. Appropriate physical activity and sports are relevant in the phase of aftercare, by stabilizing both motor coordination and cognitive factors; in MS patients fatigue can be diminished effectively.The main mental comorbidities are anxiety and depression. Pharmacological and psychological treatments have been found to be equally important in this context. Frequently, these mental disorders appear in the phase of aftercare and long-term course only, then worsening outcome sustainability. Efficient concepts to deal with this aspect are still missing. The ambulatory health care system can not cope with it until now.The multitude of evidence-based interventions have over the last 20 years after the Rehab Commission of the Federation of the German Pension Insurance Institutes contributed decisively to even improving primary outcomes and quality of life of neurological patients in spite of shortened length of stay and other restrictions. Neurorehabilitative research, especially the clinically oriented part, had a major influence on the process of professionalization of all members in the neurorehabilitative team. This fact enables new and more efficient organizational structures and working processes within the team; the discussion on this topic has however only just started.

Inspiratory stridor and dysphagia in two newborn infants caused by ectopic thymus tissue.

We report two cases of ectopic cervical thymus, a solid thymic lesion, and a thymus cyst causing inspiratory stridor and mild dysphagia in the neonatal period. Because of the rarity of thymic dystopia, the two masses were initially misdiagnosed as more common entities, namely, lymph node enlargement and lymphangioma, respectively. The correct diagnosis was made only after surgical excision and histopathological examination. This case report is completed by a short review of embryogenic development, diagnostic procedures with differential diagnoses, and therapeutic outcome of ectopic thymus.

Predicting sickness impact profile at six months after stroke: further results from the European multi-center CERISE study.

PURPOSE: To develop prognostic models and equations for predicting participation at six months after stroke. METHODS: This European prospective cohort study recruited 532 consecutive patients from four rehabilitation centers. Participation was assessed at six months after stroke with the Sickness Impact Profile (SIP), which consists of a physical, psychosocial and independent dimension. Twenty-six independent variables on admission to the rehabilitation center and 13 additional variables measured at two months post stroke were included in the analysis. A multiple logistic regression analysis was conducted predicting good participation (SIP < 20%). Sensitivity, specificity, positive and negative predictive values were calculated. RESULTS: The prognostic models for the three dimensions provided independent predictors containing demographics, complications, diagnostic, and disability measures. Sensitivity ranged from 64-84%, specificity 66-85%, positive predictive value 70-78%, and negative predictive value 76-87%. Barthel Index on admission, Euroqol Health State at two months and Caregiver Strain Index at two months were retained in all prediction models. CONCLUSIONS: A combination of variables was found in the prognostic models of the three dimensions of the SIP at six months after stroke. Already from the early beginning of stroke rehabilitation it seems important to focus on personal activities of daily living as well as caregivers' strain. IMPLICATIONS FOR REHABILITATION: Prognostic factors predicting participation, measured by the three dimensions of the Sickness Impact Profile at six months post stroke include demographic variables, post-stroke complications, diagnostic parameters and disability measures. Significant prognostic variables for all three dimensions of the Sickness Impact Profile were a higher Barthel Index score on admission to the rehabilitation center, a higher Euroqol Health State score at two months post stroke and a lower Caregiver Strain Index score at two months post stroke. Early stroke therapy should therefore further emphasize rehabilitation of personal activities of daily living such as mobility, walking, feeding, dressing, and toilet use, as well as considering strategies to reduce caregiver strain such as giving support, providing information and training carers.

Anxiety and depression after stroke: a 5 year follow-up.

PURPOSE: The aim was to document the prevalence and predictors of anxiety and depression 5 years after stroke, across four European centres. METHOD: A cohort of 220 stroke patients was assessed at 2, 4 and 6 months and 5 years after stroke. Patients were assessed on the Hospital Anxiety and Depression Scale and measures of motor function and independence in activities of daily living. RESULTS: At 5 years, the prevalence of anxiety was 29% and depression 33%, with no significant differences between centres. The severity of anxiety and depression increased significantly between 6 months and 5 years. Higher anxiety at 6 months and centre were significantly associated with anxiety at 5 years, but not measures of functional recovery. Higher depression scores at 6 months, older age and centre, but not measures of functional recovery, were associated with depression at 5 years. CONCLUSIONS: Anxiety and depression were more frequent at 5 years after stroke than at 6 months. There were significant differences between four European centres in the severity of anxiety and depression. Although the main determinant of anxiety or depression scores at 5 years was the level of anxiety or depression at 6 months, this accounted for little of the variance. Centre was also a significant predictor of mood at 5 years. There needs to be greater recognition of the development of mood disorders late after stroke and evaluation of variation in management policies across centres.

Long-term effects of the intensification of the transition between inpatient neurological rehabilitation and home care of stroke patients.

OBJECTIVE: To investigate an intensified transition concept between neurological inpatient rehabilitation and home care for long-term effects on the care situation two and a half years after stroke patients' discharge. DESIGN: Controlled clinical trial allocating patients to intervention group (intensified transition on ward II) or control group (standard transition on ward I); patients were allocated to whichever ward had a vacancy. The last follow-up assessment was carried out on average 31 months after discharge. INTERVENTION: The intensified transition concept consisted of therapeutic weekend care, bedside teaching and structured information for relatives during the second phase of the rehabilitation. SUBJECTS: Seventy-one patients and their family carers were included, of which one case dropped out. Therefore 70 family carers--35 individuals in each group-- were available for assessment at long-term follow-up. DATA COLLECTION: Family carers were asked via telephone whether the patient was still alive and if so, where he or she is living--at home or in a nursing home. STATISTICAL METHODS: Binary logistic regression analysis with the care situation (home care versus institutionalized care or deceased) as dependent variable. RESULTS: Two and a half years after discharge (T3) in the intervention group significantly fewer patients were institutionalized (2 versus 5) or deceased (4 versus 11) (P = 0.010). Multivariate analysis showed that besides a higher functional life quality at discharge and lower patient's age, the participation in the intensified transition programme is the third significant predictor for home care at T3. CONCLUSION: Effects of an intensified transition programme can persist over a long-term period. They can sustain home care by reducing institutionalization and mortality.

Intensification of the transition between inpatient neurological rehabilitation and home care of stroke patients. Controlled clinical trial with follow-up assessment six months after discharge.

OBJECTIVE: An intensified transition concept between neurological inpatient rehabilitation and home care was investigated for effects on the functional status of stroke patients and the physical and emotional health of their carers. DESIGN: Controlled clinical trial allocating patients to intervention group (intensified transition on ward II) or control group (standard transition on ward I); patients were allocated to whichever ward had a vacancy. Follow-up assessment was carried out six months after discharge. SUBJECTS: Seventy-one patients and their family carers were included, of which nine cases dropped out. Therefore 62 stroke patients with persisting disability and their family carers were available for assessment at follow-up--33 patients in the intervention group, 29 patients in the control group. INTERVENTION: The intensified transition concept consisted of therapeutic weekend care, bedside teaching and structured information for relatives during the second phase of the rehabilitation. MAIN MEASURES: Patients were assessed with the Barthel Index, Functional Independence Measure, Ashworth Spastic Scale, Frenchay Arm Test, and Timed Up and Go Test. The carers completed SF-36, and were assessed using the Giessen Symptom List, Depression Scale and Burden Scale for Family Caregivers. RESULTS: The intensified transition did not lead to significant change in the functional status of the patients or in the physical and emotional health of the family carers. Within the first four weeks after discharge, the patients in the intervention group had fewer new illnesses. In the observation period the use of outpatient care services was more frequent in the intervention group than in the control group. CONCLUSION: Even though there are few differences of moderate intensity between the two groups the intensified transition programme does not affect either the functional status of the stroke patients or the health of the carers.

[Current aspects of neurologic and neurosurgical rehabilitation in ambulatory medicine]. / Aktuelle Aspekte der neurologischen und neurochirurgischen Rehabilitation für die ambulante Medizin.

Nearly all neurological and neurosurgical diseases can cause lasting disabilities. Therefore, neurorehabilitation is needed. The German Pension Insurance Association has developed a concept of phases working as a chain of treatment, rehabilitation and care. This was confirmed as the one official system by the German Federal Society for Rehabilitation consisting of all social insurances and wellfare sponsors. The goals and tasks of each phase are defined by the functional status of the patients and their requirements for recovery. The costs are mostly determined by the social health or the social pension insurances. Different professions (physicians, nurses, physiotherapists, occupational therapists, speech therapists, (neuro-)psychologists, social workers) have to cooperate as a "therapeutic team" to improve the patient's impairments, disabilities and handicaps and to make full use of their individual resources of recovery. Only this can be the basis for valid prognostic decisions. In the long term treatment and care of the general practitioner, stroke patients are the most important group. Special problems are seen after traumatic brain injuries. Other relevant diagnoses are Parkinson's syndrome, multiple sclerosis, diseases and injuries of the spinal cord or the peripheral nervous system. In many patients, special aids have to be prescribed for several aspects of human living.

[Concept for a functional status and handicap-adjustment treatment and rehabilitation service chain in neurologic and neurosurgical management in Germany ("phase model")]. / Konzept einer zustands- und behinderungsangepassten Behandlungs- und Rehabilitationskette in der neurologischen und neurochirurgischen Versorgung in Deutschland ("Phasenmodell").

The German medical service and social support network for patients with neurological diseases and disabilities are publicly criticized as inadequate. However, the German social laws give everybody the legal right to be admitted not only for acute medical treatment but also for rehabilitation measures if they are going to be disabled and at risk of becoming dependent on care or of losing the ability to work. Rehabilitation beginning in the early stage of illness is required. Institutions are now being built up to close the gap between acute medical treatment and the beginning of comprehensive rehabilitation, especially in those neurologically severely disabled patients who need "rehabilitation before care". As a basis for planning to improve the situation, a study group set up by the German Pension Insurance Association (Verband Deutscher Rentenversicherer) has developed the following concept of phases in neurological and neurosurgical treatment, rehabilitation and care. The aims and tasks of each phase are defined by the patient's functional status and requirements for recovery: 1. Acute medical treatment and care in intensive care units or normal clinical wards; 2. Early rehabilitation of patients who are not really conscious or cooperative and need intermediate care services should complications arise ("early rehabilitation"); 3. Rehabilitation of patients who are conscious and able to cooperate but depend upon care for functions in activities of daily living (ADL) ("comprehensive" or "post-primary rehabilitation"); 4. Rehabilitation of patients who are independent in ADL functions but need comprehensive treatment for further recovery ("medical rehabilitation" in a traditional sense); 5. Institutional or outpatient rehabilitational aftercare for vocational and/or social reintegration ("aftercare"); 6. Private or institutional care aimed at maintaining the patients' functional status ("permanent care"). Patients with severe traumatic brain injury or cerebral hypoxia often require phase B care, while those who have had a stroke and those with some other neurological diseases (e.g. multiple sclerosis) often require institutions offering phase C rehabilitation. Acute treatment, rehabilitation, care and aftercare must be connected as a chain of services. Problems of sharing the costs among the different parts of the German social insurance system has hitherto led to gaps in that chain.

[Spastic movement disorders: non-medicamentous therapies based on neurophysiologic principles]. / Spastische Bewegungsstörungen: nichtmedikamentöse Therapien auf neurophysiologischer Grundlage.

Lesions of the upper motor neurons cause a spastic syndrome and a central paresis. The consequence of these "plus" and "minus" symptoms on locomotor function is a spastic movement disorder. Strategies of physical therapy for the spastic movement disorders are discussed in relation to research findings in neurophysiology and muscle physiology. The main therapeutic technics are physiotherapy, functional electrical stimulation (FES) and biofeedback training (BFB). Various methodological problems which arise in carrying out and evaluating therapeutic studies are described. Valid prognostic criteria are essential in order to achieve an optimal use of the different therapeutic procedures. This review underlines the need for further research, since some important questions remain open.

[A comparison of the clinical and instrumental functional findings in subjects with Angle class II/2 versus a eugnathic group]. / Vergleich der klinischen und instrumentellen Funktionsbefunde bei Probanden mit einer Angle-Klasse II/2 gegenüber einer Eugnathengruppe.

On the basis of a clinical and functional analysis, the diagnosis of a group of patients with Angle class II/2 malocclusion is compared with a control group with normal occlusion in a statistical study. The present study confirms the tendency revealed in the literature for patients with an Angle class II/2 malocclusion to more frequently show symptoms of a myoarthropathy. However, our results failed to confirm the assumption made in previous studies that class II/2 patients have a steep condylar axis. In particular in patients with relatively vertical upper incisors and a deep bite, a functional analysis should be done at the start of treatment. In the event of problems being found, the primary aim of therapy is the correction of the upper incisor angle.

[Health and handicap profile of patients with cerebrovascular diseases in an inpatient rehabilitation center]. / Krankheits- und Behinderungsprofil von Patienten mit zerebrovaskulären Erkrankungen in einer stationären Rehabilitationseinrichtung.

In order to get more precise information on the staffing and structural capacities needed in the care and rehabilitative treatment of patients with cerebrovascular diseases (CVD), the profiles of illness and disability were studied retrospectively on the basis of the medical histories of CVD patients who had been treated at a neurological rehabilitation centre in 1987 and had mostly come from the facility's assigned catchment area. Due to insufficient documentation of certain profile data in the patients histories, the same data were recorded in a complementary study for all patients in this target population admitted in the first half of 1988. The classification of patients into nursing care categories, already practiced in everyday clinical routines, turned out a valid global estimate for the total nursing, medical and therapeutic efforts required in the individual patient. A high correlation exists between the nursing care category assigned and the numbers of necessary care interventions as well as functional disorders requiring rehabilitative attention. The nursing care interventions needed concentrate on certain situations during the day, which has to be taken into account in staff planning. Given the multitude of impairments and disabilities seen, comprehensive management in a neurological rehabilitation unit presupposes a team of diverse diagnostic and therapeutic specialists, which, apart from medical specialists and nursing staff, should at least comprise physio- and Occupational Therapists, neuro-linguistic or logopedic specialists, as well as psychologists. In view of the high incidence of accompanying internal diseases, a stroke rehabilitation unit must have access to an internal medical service at least on a consultancy basis, and available on an extended time scale.