[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.

[Development of guidelines for rehabilitation of patients with stroke: analysis of therapeutic procedures]. / Aktueller Stand der rehabilitativen Versorgung von Patienten nach Schlaganfall.

The Federal Insurance Institute for Salaried Employees (BfA, Bundesversicherungsanstalt für Angestellte) in Berlin took the initiative to develop evidence-based guidelines for rehabilitation including stroke rehabilitation. In the present study we performed a systematic survey of the scientific literature on stroke rehabilitation and deduced 8 evidence-based therapeutic modules. They were supplemented by 5 practice-based modules to cover the full range of interventions currently applied in stroke rehabilitation. Modules are clusters of various interventions which were aggregated according to the rehabilitative goal they have in common. Data were analysed from 8,876 BfA patients, the total population of "neuro"-patients in 2001 and 2002 with 142,951 interventions and 1,071,885 appointments. Stroke diagnoses covered ICD-10 codes I60, I61, I62, I63, I64 or were coded by G45, G81 and one of these I-codes. Stroke rehabilitation as provided in daily practice was found to be a complex multimodal treatment programme in all hospitals which were studied. On average, patients receive treatments from 7.3 therapeutic modules. A dominating role is played by "motor modules". Obviously, they play a major role in acute stroke rehabilitation in all hospitals compared to cognitive retraining, language therapy and especially improvement of psychic functions, which were significantly less applied. A dramatic variation could be shown to exist between the rehabilitation hospitals (1) with respect to the number of patients who were treated with a given module (e. g., some modules showed variations between 18 % and 100 %), and (2) with respect to treatment intensity and treatment duration per week. Several factors can be taken into account for interpretation of this high variance. Intrinsically, the high variation in symptomatology after stroke can play a major role, as both the deficit profile and the level of severity of a given deficit and the combined severity level can vary from patient to patient. On the other hand, extrinsic factors such as lack of staff may also account for some of the differences. In any case, the results show the necessity to optimize stroke rehabilitation by development and implementation of guidelines. Yet, they also point to a need for further research into rehabilitation interventions and procedures to yield evidence for the approximately 30 % of "only" practice-based interventions.

[Demands for a new, patient oriented rehabilitation]. / Anforderungen an eine patientenorientierte Rehabilitation1.

A new orientation of rehabilitation in Germany has been initiated by the social political representatives in legislation and government, based on conceptualizations of self help movements in Europe and Germany. The goal is to form a new rehabilitation which is dedicated to participation and partnership of citizens with disability ("Nothing about us without us"). Empowerment is envisaged and resources supplied by legislation to allow to implement these new concepts (personal budget). To guarantee these new rights they have been codified in a new, 9th book of the German social code (Sozialgesetzbuch IX, SGB IX). This new perspective gives rise to major evolutionary impulses in rehabilitation, notably disabled persons' participation in self-assessment, in formulating their rehabilitation goals, determining and controlling the rehabilitation process, terminating rehabilitation (co-signing their discharge reports), as well as evaluating the outcome (quality control of rehabilitation results). They have the right to get all their medical information (right of informational independence). Seven guidelines of people with disability are formulated to support implementation of the new rehabilitation.

[Outpatient and inpatient neurological rehabilitation--a follow-up comparison]. / Ambulante und stationäre neurologische Rehabilitation - ein katamnestischer Vergleich.

Since the mid-90s outpatient rehabilitation has been developed by public health insurance companies and pension funds. Outpatient rehabilitation is defined as comprehensive multidisciplinary and medically supervised service which in neurological rehabilitation mostly follows inpatient rehabilitation. In the present paper partial results of a larger study (by Schoenle and Leyhe, 2000) are reported with respect to the follow-up of the effects of outpatient versus inpatient rehabilitation 6 month after termination of the treatment. Major results are the endurance of the effects over the observed time interval and the equivalent effectiveness of the two forms of rehabilitation. Distinct effects were observed for the two patient groups (more progress in the body related functional disturbances for inpatients versus cognitively related progress for the outpatients). The results reflect intrinsic features of neurological rehabilitation and the current organizational status of neurological rehabilitation in Germany.

Dysphonia subsequent to severe traumatic brain injury: comparative perceptual, acoustic and electroglottographic analyses.

We tested the applicability of the Goettinger Hoarseness Diagram (GHD) for quantitative evaluation of voice disorders after severe traumatic brain injury (TBI) and compared the obtained data with those from established voice analysis systems such as the Multi-Dimensional Voice Program (MDVP), electroglottography (EGG) and perceptual ratings using sustained vowel productions from 10 patients with TBI dysarthrophonia at late stages postinjury and of 10 healthy control speakers. Statistical analyses revealed significant intergroup differences with respect to various acoustic and perceptual measures, i.e., irregularity component, noise component, noise-to-harmonic ratio, shimmer, jitter, roughness, creakiness, strained-strangledness, hypernasality. By contrast, the considered EGG estimates, i.e., open quotient and speed quotient, did not allow for separation of patients and controls. In addition, the two GHD components exhibited close correlations to perceived roughness and creakiness, on the one hand, and breathiness and, to some degree, nasality, on the other, whereas the MDVP parameters failed to differentiate between these two perceptual modes of phonation.

Syntactic and semantic processing in the healthy and aphasic human brain.

A syntactic and a semantic task were performed by German-speaking healthy subjects and aphasics with lesions in the dominant left hemisphere. In both tasks, pictures of objects were presented that had to be classified by pressing buttons. The classification was into grammatical gender in the syntactic task (masculine or feminine gender?) and into semantic category in the semantic task (man- or nature made?). Behavioral data revealed a significant Group by Task interaction, with aphasics showing most pronounced problems with syntax. Brain event-related potentials 300-600 ms following picture onset showed different task-dependent laterality patterns in the two groups. In controls, the syntax task induced a left-lateralized negative ERP, whereas the semantic task produced more symmetric responses over the hemispheres. The opposite was the case in the patients, where, paradoxically, stronger laterality of physiological brain responses emerged in the semantic task than in the syntactic task. We interpret these data based on neuro-psycholinguistic models of word processing and current theories about the roles of the hemispheres in language recovery.

[Early rehabilitation in Baden-Wurttemberg--a study of all Baden-Wurrtemberg early rehabilitation centers]. / Frührehabilitation in Baden-Württemberg--Eine Untersuchung aller Frührehabilitationseinrichtungen Baden-Württembergs.

Over a period of 12 months, all persons among the 10.4 million inhabitants of the state of Baden-Württemberg were included in the study who had suffered severe brain damage and were treated in special early rehab units, comprising 147 beds for adults and 43 for children. With 830 patients admitted, the incidence of severe brain damage was 7.98/100.000 in adults and 1.11/100.000 in children. 50 to 70 year old patients were over-represented, those older than 70 years were underrepresented due to geriatric rehab facilities for the latter. Male patients dominated, while female were somewhat younger. 54% of the patients were admitted from the hospital which had performed primary care, with an average stay of 67 days. Average early rehab duration was 53 days (arithmetic average; median 40 days, some patients required up to one year). 32.8% of the patients had suffered traumatic brain damage (ICD 851, 852, 854) and 40.9% non-traumatic brain affection (ICD 430, 431, 433-438, 310, 348), including 12.2% CVA (ICD 433-438), 8.5% subarachnoid and 12.3% intracerebral hemorrhage. Severity as indexed by the early rehab Barthel index improved from an initial average of -119 to -34 at discharge. 80% of the patients showed an overall improvement (71% of them by up to 200 points and 46% by up to 100 points).

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.

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.

Speech disorders following severe traumatic brain injury: kinematic analysis of syllable repetitions using electromagnetic articulography.

Using electromagnetic articulography, the lips, the tip of the tongue, and the tongue dorsum were tracked during repetitions of the syllables [pa], [ta] and [ka] in 10 speakers with dysarthria following severe traumatic brain injury and in 10 age-matched control subjects. When asked to produce the syllable trains as fast as possible, the patient group showed a rather homogeneous pattern of movement abnormalities including prolonged syllable durations and reduced peak velocity/amplitude ratios. Most presumably, limited speed generation gives rise to the impaired ability to increase speech rate. During the habitual speaking condition, reduced velocity/amplitude ratios were restricted to the tongue tip and tongue dorsum. Obviously, the tongue and the lips are differentially affected in dysarthria following severe traumatic brain injury.

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.

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.

[Computer-assisted neuropsychological training in neurological rehabilitation]. / Computerunterstütztes Hirnleistungstraining in der neurologischen Rehabilitation.

Using computer-assisted cognitive training to treat patients with cognitive disorders has proved a useful tool in neurological rehabilitation. This has been shown by positive experience in many rehabilitation clinics but also in numerous control studies investigating the efficiency of such training. Patients with attention deficits show the most pronounced improvements as the computer with its technical possibilities is an ideal training instrument because of stimulus representation and reaction time measures. In other areas, computer training has become an essential therapeutic means complementing other therapies. In a clinical environment it seems that computer training is essential because it enables attaining the necessary therapeutic density. However, training must be integrated and become part of a global therapeutic framework.