[Future Trends in Medical Rehabilitation in the Context of Multimorbidity - Part I: Definition of Terms, Issues and Challenges]. / Die Zukunft der medizinisch­rehabilitativen Versorgung im Kontext der Multimorbidität ­ Teil I: Begriffsbestimmung, Versorgungsfragen und Herausforderungen.

BACKGROUND: Rehabilitative health care is increasingly focusing its attention on multimorbid people with 2 and more coexistent chronic diseases of sociomedical relevance. METHODS: After defining the term "multimorbidity" in the context of rehabilitative health care, an exploratory overview of the prevalence and clinical implication of this condition as reported in the literature was drafted. Based on a case history, special attention was paid to general as well as special challenges regarding design, configuration and supply of sociomedical rehabilitative care. Consensus was achieved with the Health Advisory Board of the German Federal Rehabilitation Council. RESULTS: The proposed actions necessary for the healthcare of persons with multimorbidity include specific function-oriented individual assessment of needs via the distinctive allocation, selection and performance of rehabilitative procedures as well as post-rehabilitative care until the patient's reintegration into his social environment.

[Correction: Future Trends in Medical Rehabilitation in the Context of Multimorbidity - Part I: Definition of Terms, Issues and Challenges]. / Errata: Die Zukunft der medizinisch­rehabilitativen Versorgung im Kontext der Multimorbidität ­ Teil I: Begriffsbestimmung, Versorgungsfragen und Herausforderungen.

W. SEGER, W. CIBIS, A. DEVENTER, S. GROTKAMP, N. LüBKE, P.-W. SCHöNLE, M. SCHUBERT. DIE ZUKUNFT DER MEDIZINISCH-REHABILITATIVEN VERSORGUNG IM KONTEXT DER MULTIMORBIDITäT - TEIL I: BEGRIFFSBESTIMMUNG, VERSORGUNGSFRAGEN UND HERAUSFORDERUNGEN KüNSTLERISCHE THERAPEUTEN IM GESUNDHEITSWESEN. GESUNDHEITSWESEN 2016;: Bei diesem Beitrag fehlte ein Autor und die zugehörige Institutsangabe. Nachfolgend die ergänzten Autoren und Institute: AUTOREN:: W. Seger1, W. Cibis2, A. Deventer3, S. Grotkamp4, N. Lübke5, P.-W. Schönle6, M. Schmidt-Ohlemann7, M. Schubert2 INSTITUTE:: 1 MDK Niedersachsen, Hannover 2 Bundesarbeitsgemeinschaft für Rehabilitation (BAR), Frankfurt 3 Praxis für Physikalische und Rehabilitative Medizin, Hamburg 4 MDK Niedersachsen, SEG 1, Hannover 5 Kompetenz-Centrum Geriatrie (KCG), Hamburg 6 Maternus Kliniken, Bad Oeynhausen 7 Diakonie Bad Kreuznach, Rehabilitationsklinik, Bad Kreuznach.

Intrathecal Baclofen therapy in Germany: Proceedings of the IAB-Interdisciplinary Working Group for Movement Disorders Consensus Meeting.

Continuous intrathecal Baclofen application (ITB) through an intracorporeal pump system is widely used in adults and children with spasticity of spinal and supraspinal origin. Currently, about 1200 new ITB pump systems are implanted in Germany each year. ITB is based on an interdisciplinary approach with neurologists, rehabilitation specialists, paediatricians and neurosurgeons. We are presenting the proceedings of a consensus meeting organised by IAB-Interdisciplinary Working Group for Movement Disorders. The ITB pump system consists of the implantable pump with its drug reservoir, the refill port, an additional side port and a flexible catheter. Non-programmable pumps drive the Baclofen flow by the reservoir pressure. Programmable pumps additionally contain a radiofrequency control unit, an electrical pump and a battery. They have major advantages during the dose-finding phase. ITB doses vary widely between 10 and 2000 µg/day. For spinal spasticity, they are typically in the order of 100-300 µg/day. Hereditary spastic paraplegia seems to require particularly low doses, while dystonia and brain injury require particularly high ones. Best effects are documented for tonic paraspasticity of spinal origin and the least effects for phasic muscle hyperactivity disorders of supraspinal origin. Oral antispastics are mainly effective in mild spasticity. Botulinum toxin is most effective in focal spasticity. Myotomies and denervation operations are restricted to selected cases of focal spasticity. Due to its wide-spread distribution within the cerebrospinal fluid, ITB can tackle wide-spread and severe spasticity.

Using musical instruments to improve motor skill recovery following a stroke.

In previous studies, it was shown that there is a need for efficient motor rehabilitation approaches. For this purpose, we evaluated a music-supported training program designed to induce an auditory-sensorimotor co-representation of movements in 20 stroke patients (10 affected in the left and 10 in the right upper extremity). Patients without any previous musical experience participated in an intensive step by step training, first of the paretic extremity, followed by training of both extremities. Training was applied 15 times over 3 weeks in addition to conventional treatment. Fine as well as gross motor skills were addressed by using either a MIDI-piano or electronic drum pads. As a control, 20 stroke patients (10 affected left and 10 right) undergoing exclusively conventional therapies were recruited. Assignment to the training and control groups was done pseudo-randomly to achieve an equal number of left- and right-affected patients in each group. Pre- and post-treatment motor functions were monitored using a computerized movement analysis system (Zebris) and an established array of motor tests (e. g., Action Research Arm Test, Box & Block Test). Patients showed significant improvement after treatment with respect to speed, precision and smoothness of movements as shown by 3D movement analysis and clinical motor tests. Furthermore, compared to the control subjects, motor control in everyday activities improved significantly. In conclusion, this innovative therapeutic strategy is an effective approach for the motor skill neurorehabilitation of stroke patients.

Neuroimaging patterns associated with motor control in traumatic brain injury.

OBJECTIVE: To determine if patients with traumatic brain injury (TBI) and motor deficits show differences in functional activation maps during repetitive hand movements relative to healthy controls. Are there predictors for motor outcome in the functional maps of these patients? METHODS: In an exploratory cross-sectional study, functional magnetic resonance imaging (fMRI) was used to study the blood-oxygenation-level-dependent (BOLD) response in cortical motor areas of 34 patients suffering from moderate motor deficits after TBI as they performed unilateral fist-clenching motions. Twelve of these patients with unilateral motor deficits were studied 3 months after TBI and a 2nd time approximately 4 months later. RESULTS: Compared to age-matched, healthy controls performing the same task, TBI patients showed diminished fMRI-signal change in the primary sensorimotor cortex contralateral to the moving hand (cSM1), the contralateral dorsal premotor cortex, and bilaterally in the supplementary motor areas (SMAs). Clinical impairment and the magnitude of the fMRI-signal change in cSM1 and SMA were negatively correlated. Patients with poor and good motor recovery showed comparable motor impairment at baseline. Only patients who evolved to "poor clinical outcome" had decreased fMRI-signal change in the cSM1 during baseline. CONCLUSIONS: These observations raise the hypothesis that the magnitude of the fMRI-signal change in the cSM1 region could have prognostic value in the evaluation of patients with TBI.

Event-related potential correlates of verbal and pictorial feature comparison in aphasics and controls.

Event-related potentials (ERPs) were recorded from 19 aphasic patients and 18 controls in four versions of a feature comparison task, in which the verbal or pictorial representation of a first stimulus (S1) had to be compared with the verbal or pictorial representation of a second stimulus (S2) presented 2 s later. These tasks were designed to cover some of the discriminatory variance of the token test (TT) including the analytical isolation, encoding and short-term storage of individual features of objects, independent of auditory verbal comprehension. Aphasics made more errors and had longer response latencies than controls in all four tasks, performance being poorest when verbal stimuli had to be processed. ERP analyses - restricted to subjects performing well above chance and to trials with correct responses - were confined to the slow wave (SW) (250-750 ms post-S1-onset) and the contingent negative variation (CNV) preceding the S2. There was no overall group difference that would have suggested that the patients activated different cortical areas than controls on correct performance. A left-hemispheric predominance of the negative SW was found in all four tasks and in both groups, although it was more pronounced in aphasics, and more pronounced in non-fluent than in fluent aphasics. The CNV was characterized by a left-hemispheric accentuation which was more pronounced in controls than in aphasics, particularly in tasks with a verbal S2. Results indicate that successful feature comparisons in the present tasks activate primarily left-anterior cortical areas. During encoding and short-term storage this activation is more pronounced in aphasics than in controls.

Behavioral and neuronal changes during treatment of mixed transcortical aphasia: a case study.

The development of language mechanisms outside the traditional language regions is evidenced by the case of K.S., a patient with chronic mixed transcortical aphasia, that is, good repetition performance compared to all other language abilities. The aphasia was caused by an infarction of the left a. carotis interna that completely destroyed the left perisylvian language region and adjacent structures. Five years post onset the patient underwent intensive aphasia therapy. In the treatment setting chosen, both speech production and comprehension abilities improved as demonstrated by adequacy and reaction time scores. It is argued that the behavioral changes observed are likely to be due to (a) newly acquired communicative strategies and (b) neuronal changes within K.S.'s brain. The behavioral changes are explained in terms of strengthening of synaptic connections and formation of Hebbian cell assemblies corresponding to words.

A magnetic measurement device for the kinematic analysis of unrestrained human hand movements.

A magnetic measurement device is described which was constructed to study human hand- and finger-movements. The system overcomes some problems frequently arising in the study of finger grip movements. It allows the simultaneous recording of several positions which cannot be observed with optical devices because they are hidden by other parts of the limb. Trajectories are recorded using small receiver coils moving in an alternating magnetic field of 3 transmitter coils. The performance of subject's movements is not significantly disturbed. A high sampling rate and a lack of mechanical damping permit a high temporal resolution which can analyze rapid movements. Subjects are not exposed to any biological risk or discomfort. Thus, a recording session can be repeated numerous times. The results obtained from this type of apparatus may allow quantification of the course of progressing diseases and to study the effects of remediation.

Effect of cannabinoids on spasticity and ataxia in multiple sclerosis.

The chronic motor handicaps of a 30-year-old multiple sclerosis patient acutely improved while he smoked a marihuana cigarette. This effect was quantitatively assessed by means of clinical rating, electromyographic investigation of the leg flexor reflexes and electromagnetic recording of the hand action tremor. It is concluded that cannabinoids may have powerful beneficial effects on both spasticity and ataxia that warrant further evaluation.

Central motor conduction time to bulbocavernosus muscle: evaluation by magnetic brain stimulation and testing of bulbocavernosus reflex.

Magnetic brain stimulation and bulbocavernosus reflex (BCR) testing were performed to evaluate the central motor conduction time (CMCT) to the bulbocavernosus muscle (BC). In six healthy subjects CMCT ranged from 13.81 ms to 16.9 ms with a mean value of 15.77 ms (SD 1.38 ms). This equals a central motor conduction velocity of about 40 m/s, which can only be realized in fast conducting pyramidal tract fibres. Testing of pyramidal tract function by BC-CMCT might improve the diagnosis of male sexual dysfunction.

Stroke following chiropractic manipulation of the cervical spine.

We analyzed the clinical course and neuroradiological findings of ten patients aged 27-46 years, with ischemic stroke secondary to vertebral artery dissection (VAD; n = 8) or internal carotid artery dissection (CAD; n = 2), all following chiropractic manipulation of the cervical spine. The following observations were made: (a) All patients had uneventful medical histories, no or only mild vascular risk factors, and no predisposing vascular lesions. (b) VAD was unilateral in five patients and bilateral in three. VAD was located close to the atlantoaxial joint in all eight patients and showed additional involvement of lower sections in six, as well as temporary occlusion of one vertebral artery in three. (c) Nine of ten patients had brain infarction documented by magnetic resonance imaging or computed tomography. (d) Onset of symptoms was immediately after the manipulation (n = 5) or within 2 days (n = 5). (e) Progression of neurological deficits occurred within the following hours to a maximum of 3 weeks. (f) Maximum neurological deficits were severe in nine of ten patients. (g) Outcome after 4 weeks-3 years included no or mild neurological deficits in five patients, marked deficits in three, persistent locked-in syndrome in one, and persistent vegetative state in one. (h) Informed consent was obtained in only one of ten patients. Thus, patients at risk for stroke after chiropractic manipulation may not be identified a priori. Neurological deficits may be severely disabling and are potentially life threatening.

Hesitation vowels: a motor speech respiration hypothesis.

In spontaneous speech the relation of hesitation vowels 'ah' and 'mh' (filled pauses) and respiration was studied in 16 healthy native speakers of German. Hesitation vowels did not occur randomly in expiration during speech. When expiratory duration was divided into four segments of equal length, the highest incidence of hesitation vowels was to be found at early loci during expiration. As speech respiration is reset to vegetative breathing as soon as speech production stops, hesitation vowels act as phonomotoric subroutines during halting speech production to prevent the respiratory system from uneconomic air loss and to keep it in the speech respiration mode.

Losing the error related negativity in the EEG of human subjects: an indicator for willed action.

When people make errors in a discrimination task, a negative-going waveform can be observed in scalp-recorded EEG that has been coined the error-related negativity (ERN). We hypothesized that the ERN only occurs with slips, that is unwilled action errors, but not if an error is committed willingly and intentionally. We investigated the occurrence of the ERN in a choice reaction time task that has been shown to produce an ERN and in an error simulation task where subjects had to fake errors while the EEG was recorded. We observed a loss of the ERN when errors were committed in willed actions but not in unwilled actions thus supporting the idea that the production of the ERN is tied to slips in unwilled actions but not mistakes in willed actions.

Aspects of speech motor control: programing of repetitive versus non-repetitive speech.

The aim of the present study was to investigate whether time to program repetitive speech movements (RS) would be distinct from time to program non-repetitive speech movements (NRS) when the length of sequences is kept constant. Using an oral reading task, latencies for the initiation of RS and NRS were measured under two conditions which allowed delineation of the time necessary for perceptual processing separated from actual motor programing. The results show that latencies for NRS were significantly longer than for RS, indicating that the nature of an utterance, not simply its length, is a determinant of program complexity.

Changes of transcranially evoked motor responses in man by midazolam, a short acting benzodiazepine.

The present study investigated the effects of midazolam, a short acting benzodiazepine, on muscle responses elicited by magnetic brain stimulation. During continuous midazolam infusion (0.3 mg/kg/h for up to 30 min) amplitudes and durations of transcranially elicited compound muscle action potentials decreased progressively while latencies remained unchanged. The results can be accounted for by midazolam enhancement of the inhibitory action of GABAergic cortical interneurons, which decreases the excitability of pyramidal cells and reduces the number of neurons available for generation of descending pyramidal tract activity.

Monitoring brain activity of human subjects during delayed matching to sample tasks comparing verbal and pictorial stimuli with modal and cross-modal presentation: an event related potential study employing a source reconstruction method.

The time course of the event related potentials evoked within a delayed matching to sample task employing verbal and pictorial stimuli was analyzed with a source reconstruction method (minimum norm method). During signal stimulus presentation pictorial stimuli evoked more activity than verbal stimuli. Activity was particularly prominent in left frontal areas for the match of verbal-verbal stimulus pairs and over right posterior regions for the match of verbal-pictorial stimuli. Anticipation of the to-be-matched stimulus produced more pronounced activity for pictorial stimuli and generally stronger left and frontal activity. Results are discussed referring to a biological model of language processing.

Syntactically and semantically based computations: processing of prepositions in agrammatism.

Six Broca's and six Wernicke's aphasics were tested for their processing of prepositions in different linguistic tasks which placed increasing emphasis on the use of syntactic knowledge. Subjects performed a variety of tasks involving the production and perception of sentences containing prepositions. Agrammatics' production performance was very poor. Although their comprehension performance was superior to production when asked to complete a sentence selecting the target item out of four prepositions their comprehension performance was no longer superior to production in tasks where correct performance strongly depends upon the knowledge of sentence form. These results support the view of a general incapacity of agrammatics to use knowledge of sentence structure in production and in comprehension.

Memory and skill acquisition in Parkinson's disease and frontal lobe dysfunction.

Animal experiments and human neuropsychological studies have provided evidence for the hypothesis that skill acquisition may be regulated by the basal ganglia. In the present studies, perceptual and cognitive skill acquisition as well as a number of explicit verbal memory functions were investigated in patients in early and more advanced stages of Parkinson's disease (PD) and in patients with frontal lobe lesions. Patients in more advanced stages of PD were impaired at cognitive skill acquisition as well as during recall conditions that involved active semantic organisation of the stimulus material. Similar explicit memory deficits were present in frontally lesioned patients. PD patients with unilateral symptoms showed a selective impairment in acquiring a cognitive skill. Perceptual skill acquisition was preserved in all groups. The overall pattern of memory impairment in PD is largely consistent with dysfunction of fronto-striatal circuitry.

Obturator nerve injuries during intra-abdominal surgery.

Selective obturatory nerve lesions are described to occur relatively infrequent. In the present paper two patients developing signs and symptoms of an obturatory neuropathy as a result of abdominal surgery were reported. In a 48-year-old woman a bilateral obturator neuropathy occurred after bilateral ovarectomy with a weakness of the adductor muscles, typical electromyographic findings and sensory deficits in the medial aspect of the thigh. Similar unilateral signs and symptoms were seen in a 65-years-old man as a result of an aortofemoral bypass operation. Symptomatology and differential diagnosis of obturator nerve lesions are discussed.

Autoimmune thyroiditis and myopathy. Reversibility of myopathic alterations under thyroxine therapy.

A female patient with Hashimoto's autoimmune thyroiditis and myopathic symptoms is reported. Besides a myopathic pattern, widespread spontaneous pathological activity was found in the affected musculature. Under thyroxin therapy, both the clinical picture and the electromyographic findings normalized completely within a few weeks.