Early use of Xeomin neurotoxin for local anti-spasticity therapy for pes equines after acquired brain injury (ABI).

PRIMARY OBJECTIVE: The acute management of spasticity following ABI is challenging. Contractures can occur during the acute phases of illness. The joints most affected are the shoulders and the ankles. RESEARCH DESIGN: A case study of a 48-year-old female patient who received local chemoneurolytic anti-spasticity therapy following a severe subarachnoid haemorrhage for pes equines deformity is presented to illustrate the role of focal neurotoxin therapy. METHODS AND PROCEDURES: The increasing spasticity in her legs was observed and could not be effectively treated with oral anti-spasticity agents or intensive physiotherapy. As spasticity increased (Modified Ashworth Scale 4), mobility of the right foot continued to deteriorate, leading to indication for local anti-spasticity treatment with Xeomin neurotoxin. The spastic pes equinus was injected with Xeomin® using a total dose of 150 U. MAIN OUTCOMES AND RESULTS: On the 6th day after injection, a gradual reduction in spasticity was observed in the injected muscle (Modified Ashworth Scale 1-2) and an increasing improvement in joint mobility. CONCLUSIONS: Early local anti-spasticity treatment with Xeomin is effective treatment. The cost of the intervention would appear to be high, but if one compares it with the costs of conservative treatment, it is not more expensive.

Rehabilitation intervention in animal model can improve neuromotor and cognitive functions after traumatic brain injury: pilot study.

The aim of the present study was to quantify the effect of multisensory rehabilitation on rats' cognition after an experimental brain trauma and to assess its possible clinical implications. The complex intermittent multisensory rehabilitation consisted of currently used major therapeutic procedures targeted at the improvement of cognitive functions; including multisensory and motor stimulation and enriched environment. We have confirmed this positive effect of early multisensory rehabilitation on the recovery of motor functions after traumatic brain injury. However, we have been able to prove a positive effect on the recovery of cognitive functions only with respect to the frequency of efficient search strategies in a Barnes maze test, while results for search time and travelled distance were not significantly different between study groups. We have concluded that the positive effects of an early treatment of functional deficits are comparable with the clinical results in early neurorehabilitation in human patients after brain trauma. It might therefore be reasonable to apply these experimental results to human medical neurorehabilitation care.

Functional outcome at 1 vs. 2 years after severe traumatic brain injury.

PURPOSE: The aim of the study was to evaluate the outcome of patients with severe traumatic brain injury (STBI) after 12 and 24 months (Glasgow Coma Scale GCS < or = 8 points for at least 24 hours). METHODS: A total of 51 patients underwent a multidisciplinary early rehabilitation treatment until they were discharged from hospital and local ambulatory care was deemed sufficient. The follow-up examination took place 12 and 24 months after the STBI. RESULTS: Data revealed a high level of independence in activities of daily living (mean Barthel Index after 1 year 92.7 points, after 2 years 93.7 points). After 1 and 2 years, 74.5% and 80.4% of the patients, respectively, were completely independent of need for care. Nevertheless, more than half of the patients had sensorimotor, behavioural, speech, visual and/or auditory disturbances. Return to work rates improved between 1-2 years after trauma, as evidenced by the rate of patients being back to full time work at 1 year (n = 14, 28%) and 2 years (n = 20, 40%) post-STBI; although none of these changes reached statistical significance. CONCLUSION: In summary, there are still changes in both impairment and disability related areas between 1-2 years post-STBI, but the degree of improvement is variable depending on the area being considered. Clinicians should remain aware of the fact that modulation of impairment and disability appear to continue well beyond 1 year post-STBI, which may impact on decisions regarding the provision and intensity of further rehabilitation efforts.

Early rehabilitation model shows positive effects on neural degeneration and recovery from neuromotor deficits following traumatic brain injury.

This study used an experimental early rehabilitation model combining an enriched environment, multisensory (visual, acoustic and olfactory) stimulation and motor training after traumatic brain injury (via fluid-percussion model) to simulate early multisensory rehabilitation. This therapy will be used by brain injured patients to improve neural plasticity and to restore brain integration functions. Motor dysfunction was evaluated using a composite neuroscore test. Direct structural effects of traumatic brain injury were examined using Fluoro-Jade staining, which allows identification of degenerating neural cell bodies and processes. Animals in the rehabilitation model group performed significantly better when tested for neuromotor function than the animals in standard housing in the 7-day and 15-day interval after injury (7d: p=0.005; 15d: p<0.05). Statistical analysis revealed significantly lower numbers of Fluoro-Jade positive cells (degenerating neurons) in the rehabilitation model group (n=5: mean 13.4) compared to the standard housing group (n=6: mean 123.8) (p<0.005). It appears that the housing of animals in the rehabilitation model led to a clear functional increase in neuromotor functions and to reduced neural loss compared with the animal group in standard housing.

Long-term outcome in severe traumatic brain injury is significantly influenced by brainstem involvement.

PRIMARY OBJECTIVE: To study the 1-year-outcome of 32 survivors of severe traumatic brain injury with respect to the impact of brainstem injury. RESEARCH DESIGN: Retrospective clinical study performed in a university hospital. METHODS AND PROCEDURES: Thirty-two 1-year-survivors (15 with brainstem injury present) of severe traumatic brain injury were investigated for neurological function, activities of daily living, need for care and professional ability. MAIN OUTCOMES AND RESULTS: Visual impairment, spasticity, co-ordination deficits and organic psychosis were more frequent in the group harbouring brainstem lesions. Professional ability was worse among these patients. CONCLUSION: Brainstem involvement in survivors of severe traumatic brain injury conveys a negative impact on long-term outcome.

Gluteal neuromuscular stimulation in therapy and prophylaxis of recurrent sacral pressure ulcers.

STUDY DESIGN: Case study. OBJECTIVE: Positive influence of electrostimulation on the healing process of the gluteal decubital ulcers. SETTING: Department of Neurosurgery, University of Cologne, Germany. METHOD: The present study reports on the effects of the electrostimulation of the floor-of-the-pelvis-muscles by means of an anal electrode. This procedure was shown to have a positive influence on the healing process of the gluteal decubital ulcers sustained by a patient with incomplete sensomotor paraplegia. Apart from the contraction of the floor-of-the-pelvis-muscles, we observed a contraction of the gluteal muscles on both sides. RESULTS: The ulcers, which had been resisting conventional treatments for months, showed signs of a beginning healing tendency. After 4 weeks both ulcers were completely healed up. CONCLUSION: Because of its easy handling and its good amicability, electrostimulation of the gluteal region - one of the most common localisations of pressure-caused ulcers - by means of an anal electrode might be put to good effect even in prophylaxis in the treatment of paraplegic patients.

Intermediate and long-term outcome in traumatic brain injury is not influenced by additional multiple organ injury.

BACKGROUND: This investigation aims at evaluating the influence of additional multiple organ injury in traumatic brain injury on the outcome in terms of the ability to perform the activities of daily life, of the need of care, and of job ability. METHODS: 62 victims (male to female ratio 4 : 1; age range 15-68 years) of traumatic brain injury were studied. Group 1 (n = 24) consisted of patients who suffered from traumatic brain injury with additional multiple organ injury, group 2 (n = 38) comprised patients with isolated brain injury. Outcome was assessed at 6 and 12 months after trauma by means of different rehabilitation scores. RESULTS: After 6 as well as after 12 months, the majority of both groups were independent in the activities of daily living. Furthermore, no differences were observed concerning the need of care. Job ability was almost equal for both groups. CONCLUSION: Additional multiple organ injury does not pertain to prognosis of traumatic brain injury.

Trauma to the pontomesencephalic brainstem-a major clue to the prognosis of severe traumatic brain injury.

The objective of this study was to assess the significance of an injury to the pontomesencephalic brainstem in severe traumatic brain injury [Glasgow coma score (GCS) below 8]. Forty victims of severe traumatic brain injury with and with out compounding pathologies almost equally distributed among both groups were studied. The outcome (mean follow-up, 11.3 months) was assessed by means of the Glasgow outcome score (GOS) and of the Disability rating scale (DRS). Injury of the brainstem was detected by electrophysiological investigation (evoked potentials, brainstem reflexes) and magnetic resonance imaging (MRI) carried out early after trauma. Statistical analysis (Wilcoxon signed rank test for matched pairs) revealed a significantly worse initial GCS (median 5 versus 6), GOS (median 3 versus 4), and DRS score (median 6 versus 2) for the group with brainstem lesions than for the group without such lesions. Moreover, there was a significant accumulation of lesions of the corpus callosum, the basal ganglia, and the (para-)hippocampal area detected by MRI in the brainstem lesion group. In addition, the finding of an abnormal cortical component of the median nerve evoked somatosensory potential was significantly more frequent in the patients with brainstem injury. Traumatic brainstem lesions diagnosed by MRI a nd/or electrophysiological investigation are associated with injury to other 'deeply' situated parts ofthe brain. The finding of a brainstem lesion influences to the outcome of patients after severe traumatic brain injury.

Paresis, historical therapy in the perspective of Caelius Aurelianus, with special reference to the use of hydrotherapy in antiquity.

Caelius Aurelianus provides in his work Tardarum sive chronicarum passionum, based on Soranos' famous, but lost, work about acute and chronical illnesses, a remarkably detailed description of the physio-therapy of paresis, which covers the complete therapeutic spectrum of the groundwork of a combined therapy. His view that rehabilitative treatment should be started from the second day of illness sounds almost revolutionary. Also, modern early rehabilitation makes a specific use of combined therapy in a way that is analogous to that described by Caelius Aurelianus. Even today, the view is taken that fast mobilisation of the patient is the top priority of therapy. The three-stage mobilisation therapy involving exercises in rolling-in-bed as well as practice in trying-to-sit-up is quite similar to what is common practice today.

Early rehabilitative concepts in therapy of the comatose brain injured patients.

OBJECTIVES: To evaluate the changes of vegetative parameters and behavioural assessment in comatose patients after severe brain injury during the Multimodal-Early-Onset-Stimulation (MEOS) in early rehabilitation. MATERIAL AND METHODS: We studied 16 predominantly male (3:1) patients, age mean 43.6 (16-77) years. Mean coma duration was 22.2 (8-41) days, therapy duration (MEOS) 9.8 (1-30) days. The initial GCS was 6.6 (3-9), KRS 5.3 (0-15). Including criteria for therapy: Severe head trauma, coma for at least 48 hours (GCS < 8), vegetative stability, normal intracranial pressure, abandon of mechanical ventilation, sedation and severe infections. MEOS was finished in achieving GCS > 9, follow-up investigations were made after 2 years. RESULTS: We identified significant changes in two vegetative parameters (heart/respiratory frequencies), even in deep coma (GCS 3-4). Most significant changes were caused by tactile and acoustic stimulation. Standardized behavioural assessment turned out to be particularly advisable in cases of medium coma (GCS 5-7). Stimulation of tactile and acoustic senses resulted mainly in mimical, head and eye movements. Follow-up was possible in 14 patients: One remained in a vegetative state (GOS 2), two exhibited severe neurologic/neuropsychologic deficits, depending on care (GOS 3), six substained major functional deficits (GOS 4), at though they were able to perform the tasks of daily life on their own, three patients reached GOS 5. Two returned to their former jobs. DISCUSSION AND CONCLUSION: The present results indicate that stimulation therapy should be based on a close observation of patterns of behaviour, and, at least in deep coma stages, involve the registration of vegetative parameters. It may be sensitive to identify parameters predicting a favourable or unfavourable outcome. Preliminary data seem to support the hypothesis that the absence of any response to external stimuli is indicative of an unfavourable outcome.

[Self-help groups as a component of ambulatory community-based rehabilitation after acquired brain damage]. / Selbsthilfegruppen als Bestandteil der ambulanten wohnortnahen Rehabilitation nach erworbener Hirnschädigung.

Self-help groups are communities of people with chronic illness or disabilities and their families who join in an effort to cope with their condition and/or psychosocial live problems through mutual help. Their areas of work range from therapeutically focussed support to legal and social counselling and support to the personal help an individual member may need. Self-help groups for the various health conditions or disabilities are considered an important component of ambulatory rehabilitation at community level. Along with social, cultural and leisure activities, health education plays an important role in terms of prevention. For survivors of stroke or brain injury, however, the availability of self-help offers continues to be highly inadequate despite a huge need for assistance, counselling and follow-along services after discharge from rehabilitation in this very patient group.

[Early stimulation, a component of an early rehabilitation treatment concept on the neurosurgical intensive care unit]. / Frühstimulation, ein Bestandteil des frührehabilitativen Behandlungskonzeptes auf der neurochirurgischen Intensivstation.

Restitution or improvement of impaired brain function following severe head trauma essentially depends on immediate and systematic application of adequate rehabilitation measures. In an collaborative study of the University of Cologne Rehabilitation Centre and Clinic for Neurosurgery, the question is investigated whether early-onset stimulation therapy might have a favourable effect on the course of recuperation, including possible acceleration in regaining consciousness. For 60 minutes at least twice a day, auditory, tactile, olfactory, visual, gustatory and kinesthetic stimulation is administered to the patient, under medical supervision and with the help of nursing personnel, physiotherapists and the patient's family. In order to record the patient's reactions to these stimuli, heart rate, frequency of respiration, skin resistance, and muscle activity are measured and the patient's behaviour is observed using standardized assessment instruments.