Comparison of visual and auditory emotion recognition in patients with cerebellar and Parkinson´s disease.

Widespread cortical-subcortical networks are involved in the recognition and discrimination of emotional contents of facial and vocal expression, whereby the cerebellum and basal ganglia are two subcortical regions implicated in these networks with limited evidence to their specific contributions. To investigate this we compared patients with circumscribed cerebellar lesions and patients with Parkinson's disease (PD) on an approved test battery. We studied two groups with subcortical disease, focal cerebellar infarction (n = 22) and PD (n = 22), and a neurological control group with focal supratentorial ischemia (SI) (n = 16) were. Assessments were according to inpatient protocols for neuropsychological routine evaluation, including tests of memory, executive function and attention. Participants completed the Tuebingen Affect Battery, a recognized measure of recognition and discrimination of facial and vocal expression of emotion. As a result, cerebellar lesions were associated with greater impairment than PD and SI in recognition and discrimination of cues of both facial and vocal expressions of differing basic emotions. No confounding effect of other cognitive domains, particularly executive function and attention, was found. Taken together, our findings suggest a specific contribution of the cerebellum to cerebral networks that process facial and vocal emotion expression, related to rapid decisions regulating appropriate behavioral responses in social environments.

Safety and clinical impact of FEES - results of the FEES-registry.

BACKGROUND: At present, the flexible endoscopic evaluation of swallowing (FEES) is one of the most commonly used methods for the objective assessment of swallowing. This multicenter trial prospectively collected data on the safety of FEES and also assessed the impact of this procedure on clinical dysphagia management. METHODS: Patients were recruited in 23 hospitals in Germany and Switzerland from September 2014 to May 2017. Patient characteristics, professional affiliation of the FEES examiners (physicians or speech and language therapists), side-effects and cardiorespiratory parameters, severity of dysphagia and clinical consequences of FEES were documented. RESULTS: 2401 patients, mean age 69.8 (14.6) years, 42.3% women, were included in the FEES-registry. The most common main diagnosis was stroke (61%), followed by Parkinson's disease (6.5%). FEES was well tolerated by patients. Complications were reported in 2% of examinations, were all self-limited and resolved without sequelae and showed no correlation to the endoscopist's previous experience. In more than 50% of investigations FEES led to changes of feeding strategies, in the majority of cases an upgrade of oral diet was possible. DISCUSSION: This study confirmed that FEES, even when performed by less experienced clinicians is a safe and well tolerated procedure and significantly impacts on the patients' clinical course. Implementation of a FEES-service in different clinical settings may improve dysphagia care. TRIAL REGISTRATION: ClinicalTrials.gov NCT03037762, registered January 31st 2017.

Factors influencing weaning from mechanical ventilation in neurological and neurosurgical early rehabilitation patients.

BACKGROUND: Studies analyzing risk factors of weaning failure in neurological and neurosurgical early rehabilitation (NNER) patients are rare. AIM: The aim of this study was to identify clinical factors influencing the weaning of NNER patients. DESIGN: An observational, retrospective data analysis of a German multicenter study was performed. SETTING: German neurological early rehabilitation centers. POPULATION: Inpatient ventilated NNER patients (N.=192) were enrolled in the study. METHODS: Demographical data, main diagnosis, medical devices, special medical care and assessment instruments of functional abilities, consciousness and independence in activities of daily living were accrued and compared between patients with and without successful weaning. The prognostic power of factors associated with weaning success/failure was analyzed using binary logistic regression. RESULTS: In total, 75% of the patients were successfully weaned. Colonization with multi-drug resistant bacteria and the need for dialysis were independent predictors of weaning failure. Successfully weaned patients had a shorter length of stay, better functional outcome, and lower mortality than non-successfully weaned patients. CONCLUSIONS: Successfully weaned patients differ from patients with weaning failure in several clinical variables. All these variables are associated with the morbidity of the patient, indicating that the weaning process is strongly influenced by disease burden. CLINICAL REHABILITATION IMPACT: Functional abilities, level of consciousness, independence in activities of daily living, colonization with multi-drug resistant bacteria, need for dialysis and disease duration might help to predict the weaning process of NNER.

Constraint-Induced Aphasia Therapy in the Acute Stage: What Is the Key Factor for Efficacy? A Randomized Controlled Study.

BACKGROUND: Constraint-induced aphasia therapy (CIAT) has proven effective in patients with subacute and chronic forms of aphasia. It has remained unclear, however, whether intensity of therapy or constraint is the relevant factor. Data about intensive speech and language therapy (SLT) are conflicting. OBJECTIVE: To identify the effective component of CIAT and assess the feasibility of SLT in the acute stage after stroke. METHOD: A total of 60 patients with aphasia (68.2 ± 11.7 years) were enrolled 18.9 days after first-ever stroke. They were randomly distributed into 3 groups: (1) CIAT group receiving therapy for 3 hours per day (10 workdays, total 30 hours); (2) conventional communication treatment group, with same intensity without constraints; and (3) control group receiving individual therapy twice a day as well as group therapy (total 14 hours). Patients were assessed pretreatment and posttreatment using the Aachener Aphasia Test (primary end point: token test) and the Communicative Activity Log (CAL). RESULTS: Pretreatment, there were no between-group differences. Posttreatment, all groups showed significant improvements without between-group differences. CONCLUSION: It was found that 14 hours of aphasia therapy administered within 2 weeks as individual therapy, focusing on individual deficits, combined with group sessions has proven to be most efficient. This approach yielded the same outcome as 30 hours of group therapy, either in the form of CIAT or group therapy without constraints. SLT in an intensive treatment schedule is feasible and was well tolerated in the acute stage after stroke.

Choosing the optimal trigger point for analysis of movements after stroke based on magnetoencephalographic recordings.

The aim of this study was to select the optimal procedure for analysing motor fields (MF) and motor evoked fields (MEF) measured from brain injured patients. Behavioural pretests with patients have shown that most of them cannot stand measurements longer than 30 minutes and they also prefer to move the hand with rather short breaks between movements. Therefore, we were unable to measure the motor field (MF) optimally. Furthermore, we planned to use MEF to monitor cortical plasticity in a motor rehabilitation procedure. Classically, the MF analysis refers to rather long epochs around the movement onset (M-onset). We shortened the analysis epoch down to a range from 1000 milliseconds before until 500 milliseconds after M-onset to fulfil the needs of the patients. Additionally, we recorded the muscular activity (EMG) by surface electrodes on the extensor carpi ulnaris and flexor carpi ulnaris muscles. Magnetoencephalographic (MEG) data were recorded from 9 healthy subjects, who executed horizontally brisk extension and flexion in the right wrist. Significantly higher MF dipole strength was found in data based on EMG-onset than in M-onset based data. There was no difference in MEF I dipole strength between the two trigger latencies. In conclusion, we recommend averaging in respect to the EMG-onset for the analysis of both components MF as well as MEF.

Repetitive training of complex hand and arm movements with shaping is beneficial for motor improvement in patients after stroke.

OBJECTIVE: Repetitive training of simple upper limb movements is effective in stroke rehabilitation. For the repetitive training of complex movements, however, results are inconsistent. The aim of this study was to determine whether repetitive training of complex upper limb movements, focussing on strength and velocity as shaping elements, is effective in stroke rehabilitation. DESIGN: Longitudinal study, A-B-A design. PATIENTS: Fifteen first-ever stroke patients. METHODS: Phases (A): "house-typical" therapy and repetitive training of: (i) grasping and transport movements; and (ii) sawing movements of the affected arm with shaping elements and focussing on velocity over 10 min each, twice daily, 5 days per week. Phase B: "house-typical" occupational and physiotherapy. Each phase lasted 3 weeks. RESULTS: Patients experienced continuous functional improvement. Voluntary forces improved significantly during the first training phase. Sawing movement improved significantly only during phases A. The grasping and transport movement improved considerably during phase A with a trend of further improvement during the other phases. The transported weight clearly increases only during phases A. CONCLUSION: Repetitive training of complex movements results in motor improvement in stroke patients without relevant transfer to functional improvement if strength and velocity are to be enhanced as shaping elements.

Isotonic and isometric contractions exert the same amount of corticomotor system excitability in healthy subjects and patients after stroke.

OBJECTIVE: Active, voluntary training of the centrally paretic upper limb is crucial for functional recovery after brain damage. The aim of this study was to determine whether the type of voluntary contraction has a differential influence on corticomotor system excitability in healthy subjects and patients after stroke. DESIGN: Experimental cross-sectional study. SUBJECTS: Fifteen healthy volunteers and 15 patients after stroke. METHODS: Participants performed dynamic isotonic and isometric voluntary wrist extensions with the non-dominant or the paretic hand, respectively, with force levels of 10%, 20% and 30% of the maximum voluntary surface electromyogram. Excitability was measured by comparing the amplitude of motor evoked potentials elicited by transcranial magnetic stimulation. RESULTS: The type of contraction did not have any effect on the amplitude of motor evoked potentials, either in healthy subjects or in patients after stroke. CONCLUSION: Dynamic isometric and isotonic voluntary contractions seem to have the same effect on the excitability of the corticomotor system.

Early prediction of functional outcome after stroke.

OBJECTIVES: (I) To obtain biomechanical parameters and assessment scores applied at a very early stage after stroke that predict best the functional outcome after rehabilitation. (II) To evaluate the predictive value of changes (i.e. increase or decrease) of these parameters during the first week in relation to the predictive value of their absolute scores. DESIGN: Prospective outcome study. SUBJECTS: Forty-one stroke patients, admitted to the stroke unit within 24 hours. MAIN OUTCOME MEASURES: Barthel Index, Rivermead Motor Assessment, Motor Club Assessment and Functional movement activities, NIH-Stroke scale (NIH-SS), Grip strength. RESULTS: Parameters assessed within the first hours after stroke correlated only weakly with the outcome. The best model predicting functional outcome and independence in activities of daily living of stroke patients after 6 months was that including NIH-SS, grip strength, age and previous stroke explaining 79% of the variance. These parameters assessed on day 7 post-stroke are more predictive than the difference between stroke onset and day 7 post-stroke. CONCLUSION: Parameters for predicting outcome should not be assessed before day 7 post-stroke.

Central compensation at short muscle range is differentially affected in cortical versus subcortical strokes.

BACKGROUND AND PURPOSE: The active force generated by a single muscle fiber is greatest in midrange. In healthy subjects, the reduced muscle force at short muscle length is partially compensated by modified patterns of muscle activation, probably central in origin. These patterns are presumed to be deficient after stroke. We examined the excitability muscle-length relation in stroke patients and healthy controls and hypothesized about its alteration in stroke patients. METHODS: Corticospinal excitability was assessed in 31 stroke patients (19 subcortical, 12 cortical) and 19 healthy volunteers by transcranial magnetic stimulation. We recorded the motor evoked potentials (MEPs) simultaneously from the biceps brachii and the triceps brachii muscles at 0 degrees, 20 degrees, 40 degrees, 60 degrees, 80 degrees, 100 degrees, and 120 degrees degrees of elbow flexion (0 degrees being full elbow extension). RESULTS: Normal subjects revealed a significant increase in MEP amplitudes at shortened muscle lengths for both the flexor and extensor muscles (P<0.001). Multivariate variance analysis revealed that the MEP-angle curves of cortical stroke patients were significantly different from those of the control group for both muscles, lacking an increase of corticospinal excitability at short muscle length. Yet the MEP-angle curves for the subcortical stroke patients did not show a statistically significant difference from the control group for either muscle. CONCLUSIONS: Cortical and subcortical strokes differentially affect the corticospinal excitability muscle-length relation. This may account for the reported disproportionate decrease in muscle strength at shortened range after stroke.

Change of facilitation during voluntary bilateral hand activation after stroke.

BACKGROUND AND PURPOSE: The relearning of daily activities after stroke also involves performance of bimanual tasks. This raises the possibility that concurrent activation of the healthy hemisphere interferes with reorganization processes in the affected hemisphere due to inhibitory pathways between homologous motor cortex representations. This study investigated the effect of voluntary, simultaneous activation of both hands upon the non-dominant (healthy subjects) or affected (stroke patients) hemisphere. METHODS: Eleven healthy subjects and 16 stroke patients were investigated using transcranial stimulation (TMS). TMS was applied over the non-dominant/affected hemisphere during performance of an isometric pinch grip at different force levels (10% or 50% of maximal voluntary contraction) with the contralateral hand. The ipsilateral hand had to perform the pinch grip at various force levels (10%, 50%, or 100% of maximal voluntary contraction) simultaneously. Peak-to-peak amplitudes of motor evoked potentials (MEPs) were compared to assess differences in motor cortex excitability. RESULTS: Unilateral activity of either hand alone exerted a facilitatory effect upon the non-dominant or affected hemisphere. In healthy subjects, the activation of the ipsilateral hand simultaneously with the contralateral hand did not produce any significant change of the MEP amplitudes compared to unilateral activation of the contralateral hand. In patients, however, the additional activation of the ipsilateral hand caused an additional increase of the peak-to-peak amplitudes. CONCLUSION: In healthy subjects voluntary activation of the ipsilateral hand does not change the excitability of the motor cortex of the non-dominant hemisphere, when the contralateral hand is simultaneously activated. The facilitation of the contralateral hand seems to gate further facilitation by the ipsilateral hand. However, in stroke patients simultaneous activation of both hands causes an additional facilitation compared to activation of the affected hand alone.

Enhanced motor cortex excitability during ipsilateral voluntary hand activation in healthy subjects and stroke patients.

BACKGROUND AND PURPOSE: It is still a matter of debate whether the ipsilateral voluntary hand activation has a facilitatory or inhibitory effect on the nondominant or affected hemisphere. To give an answer to this question is of great importance for the rehabilitation of stroke patients, because they often use the unaffected hand for compensation. METHODS: Ten healthy volunteers and 11 stroke patients were investigated using transcranial magnetic stimulation (TMS). TMS was applied to the dominant/unaffected hemisphere during performance of different tasks (simple index finger abduction, pinch grip, and power grip) at various force levels (5%, 10%, 50%, and 100% maximal voluntary contraction) with the ipsilateral hand. Peak-to-peak amplitudes of motor-evoked potentials were used as measure for motor cortex excitability. RESULTS: Both simple and complex tasks led to a facilitation of the contralateral corticospinal system at all levels of applied force. Not only the facilitatory effect in general but also the slope of the relationship between force level and MEP amplitude were significantly lower in stroke patients indicating that both the general activation level of the impaired motor system and the bandwidth of possible activation levels are diminished. CONCLUSIONS: Voluntary activation of the hand does not exert an inhibitory effect on the excitability of the ipsilateral hemisphere in healthy volunteers or in stroke patients.

Is the repetitive training of complex hand and arm movements beneficial for motor recovery in stroke patients?

OBJECTIVE: To determine whether a repetitive training of complex movements of arm and hand contributes to functional recovery in stroke patients. DESIGN: Prospective, longitudinal, multiple baseline design across individuals. SETTING: Neurological rehabilitation centre. SUBJECTS: Twenty-one patients with stroke in the middle cerebral artery territory. INTERVENTIONS: Baseline phase: 'house-typical' occupational and physiotherapy; training phase: 'house-typical' therapy supplemented by repetitive training of (1) grasping and transport movements and (2) sawing movements of the affected arm over 10 minutes each, twice daily, five days per week. MAIN OUTCOME MEASURES: Rivermead Motor Assessment (RMA, arm section), grip strength, rapid isotonic hand extension, three-dimensional motion analysis. RESULTS: Patients experienced a continuous functional improvement of the affected arm (RMA score from initial 4.9 +/- 2.1 to 8.0 +/- 4.6, p < 0.001) and an increase of grip strength during the baseline and the training phase (from initial 102.4 +/- 43.3 N to 150.6 +/- 118.9 N, p < 0.05). Movement analysis revealed a trend to a more precise movement execution. The repetitive training of complex movements did not result in an additional benefit. CONCLUSION: The repetitive training of complex movements does not further enhance the functional recovery of the affected arm and hand in stroke patients compared with functionally based occupational and physiotherapy.

Is the reduction of spasticity by botulinum toxin a beneficial for the recovery of motor function of arm and hand in stroke patients?

To determine the functional benefit of botulinum toxin A (BtxA) in spasticity of arm flexors, we conducted an open-label study with 10 stroke patients. 480 mouse units BtxA (Dysport((R))) were injected into flexor muscles. Outcome measures were done by the Modified Ashworth Scale, Rivermead Motor Assessment (arm section), active and passive ranges of motion (ROM), grip strength and a 3-dimensional motion analysis. The functional capacity of the entire arm, even of the shoulder, and the ROM of fingers and wrist increased. Despite a diminution of muscle tone, grip strength remained unchanged or increased. An improvement of forearm extension was only observed in cases of preserved voluntary extensor motricity. Injection of BtxA into spastic distal flexor muscles may lead to a functional improvement of the entire arm. Grip strength is not necessarily reduced.

Cortical neuromagnetic fields evoked by voluntary and passive hand movements in healthy adults.

Neuromagnetic fields were recorded from the left cerebral hemisphere of six healthy right-handed subjects under three different conditions: (1) externally triggered rapid voluntary extension and flexion of the right hand, (2) passive extension and flexion of the right hand, and (3) stimulation of the skin of the right index finger by means of air pressure. Location analysis using the current density analysis did not reveal any differences between motor evoked field I (MEF I) in active and passive movements, and met the maximum of cerebral activation in the contralateral precentral region. In contrast, the sensory evoked field was located clearly in the contralateral postcentral region. Additionally, a significantly shorter latency of MEF I (with respect to movement onset) was observed in flexion compared with extension in both passive and active movements. These results support the assumption that MEF I is generated by cortical activation resulting from proprioceptive, probably muscle spindle, input. The current density analysis has proved to be an appropriate method for investigating movement-related fields. Furthermore, the described method seems to be appropriate for evaluating the processes of cortical reorganization and the influence of neurorehabilitation within longitudinal studies in patients with lesions in motor centers of the brain.

Evidence-based physiotherapeutic concepts for improving arm and hand function in stroke patients: a review.

In recent years, our understanding of motor learning, neuroplasticity and functional recovery after the occurrence of brain lesion has grown significantly. New findings in basic neuroscience provided stimuli for research in motor rehabilitation. Repeated motor practice and motor activity in a real world environment have been identified in several prospective studies as favorable for motor recovery in stroke patients. EMG initiated electrical muscle stimulation -- but not electrical muscle stimulation alone -- improves motor function of the centrally paretic arm and hand. Although a considerable number of physiotherapeutic "schools" has been established, a conclusive proof of their benefit and a physiological model of their effect on neuronal structures and processes are still missing. Nevertheless, evidence-based strategies for motor rehabilitation are more and more available, particularly for patients suffering from central paresis.