Factors influencing patient satisfaction with the first diagnostic consultation in multiple sclerosis: a Swiss Multiple Sclerosis Registry (SMSR) study.

BACKGROUND: Patient satisfaction is predictive of adherence, malpractice litigation and doctor-switching. OBJECTIVE: To investigate which factors of the first diagnostic consultation (FDC) influence patient satisfaction and which topics persons with multiple sclerosis (PwMS) thought were missing. METHODS: Using retrospective patient-reported data of the Swiss Multiple Sclerosis Registry from PwMS with relapsing disease onset, we fitted ordered logistic regression models on satisfaction with FDC, with socio-demographic and FDC features as explanatory factors. RESULTS: 386 PwMS diagnosed after 1995 were included. Good satisfaction with the FDC was associated with a conversation more than 20 min [multivariable odds ratio, 95% confidence interval 3.9 (2.42; 6.27)], covering many topics [1.35 (1.19; 1.54) per additional topic], the presence of a significant others [1.74 (1.03; 2.94) ], and shared decision making [3.39 (1.74; 6.59)]. Not receiving a specific diagnosis was main driver for low satisfaction [0.29 (0.15; 0.55)]. Main missing topics concerned long-term consequences (reported by 6.7%), psychological aspects (6.2%) and how to obtain support and further information (5.2%). CONCLUSIONS: A conversation of more than 20 min covering many MS relevant topics, a clear communication of the diagnosis, the presence of a close relative or significant other, as well as shared decision making enhanced patient satisfaction with the FDC. ClinicalTrials.gov Identifier: NCT02980640.

Effectiveness of telerehabilitation interventions in persons with multiple sclerosis: A systematic review.

BACKGROUND: Telerehabilitation, a service delivery model using telecommunications technology to provide therapy at a distance, is used in persons with multiple sclerosis (pwMS), but evidence for their effectiveness is yet to be determined. OBJECTIVE: To investigate the effectiveness and safety of telerehabilitation intervention pwMS. METHOD: A comprehensive literature search was conducted using medical and health science electronic databases. Three reviewers selected potential studies and independently assessed the methodological quality. A meta-analysis was not possible due to heterogeneity amongst included trials, and a qualitative analysis was performed for best evidence synthesis. RESULTS: Ten RCTs and 2 observational studies (n=564 participants) investigated a wide variety of telerehabilitation intervention in pwMS, which included: physical activity; educational, behavioural and symptom management programmes. All studies scored "low to moderate" on the methodological quality assessment implying high risk of bias. Overall, the review found low level evidence for the effectiveness of telerehabilitation on reducing short-term disability and reducing and/or improving symptoms, such as fatigue. There was low level evidence suggesting some benefit of telerehabilitation in improving functional activities; improving symptoms in the longer-term; and psychological outcomes and quality of life. There is limited data on safety, process evaluation and no data on cost-effectiveness of telerehabilitation. CONCLUSIONS: A wide range of telerehabilitation is used in pwMS, however, the quality of evidence on these interventions was low. More robust trials are needed to build evidence about these interventions.

Telerehabilitation for persons with multiple sclerosis. A Cochrane review.

A wide range of telerehabilitation interventions are trialled in persons with multiple sclerosis (pwMS). However, the evidence for their effectiveness is unclear. Aim of the review was to systematically assess the effectiveness and safety of telerehabilitation intervention in pwMS, the types of approaches that are effective (setting, type, intensity) and the outcomes (impairment, activity limitation and participation) that are affected. The search strategy comprised: Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Review Group Specialised Register (up to 9 July, 2014). Relevant journals and reference lists of identified studies were screened for additional data. Selected studies included randomized and controlled clinical trials that compared telerehabilitation intervention/s in pwMS with a control intervention (such as lower level or different types of intervention, minimal intervention; waiting-list controls, no treatment or usual care; interventions given in different settings). Best evidence synthesis was based on methodological quality using the GRADEpro software. Nine RCTs (N.=531 participants, 469 included in analyses) investigated a variety of telerehabilitation interventions in adults with MS. The interventions evaluated were complex, with more than one rehabilitation component and included physical activity, educational, behavioural and symptom management programmes. All studies scored "low" on the methodological quality assessment. Evidence from included studies provides 'low-level' evidence for reduction in short-term disability (and symptoms) such as fatigue. There was also "low-level" evidence supporting telerehabilitation in the longer term for improved functional activities, impairments (such as fatigue, pain, insomnia); and participation. There were limited data on process evaluation (participants'/therapists' satisfaction) and no data available for cost effectiveness. There were no adverse events reported as a result of telerehabilitation intervention. There is limited evidence to date, on the efficacy of telerehabilitation in improving functional activities, fatigue and quality of life in adults with MS. There is also insufficient evidence to support what types of telerehabilitation interventions are effective, and in which setting. More robust trials are needed to build evidence for the clinical and cost effectiveness of these interventions.

[Multiple sclerosis : rehabilitation and long-term course]. / Multiple Sklerose : Rehabilitation und Langzeitverlauf.

BACKGROUND: Multiple sclerosis (MS) is a highly complex disabling disease with variable pathology and clinical course. Progressive multisystemic involvement of the central nervous system leads to complex functional disturbances and disabilities. Despite disease-modifying therapies and pharmacological symptomatic treatment, the majority of MS patients develop progressive impairments in functions, activities and quality of life in the long-term. Rehabilitation interventions aim at improving symptoms and functional deficits and reducing the negative impact on activities and social participation. OBJECTIVES: To evaluate the impact and value of rehabilitation interventions in MS. METHODS: Specific literature search in PubMed. RESULTS: Good evidence exists for a positive effect of various rehabilitation interventions and multidisciplinary programs. Long-term prognosis is very variable and depends on various influencing factors. Due to an often unpredictable change of disease activity and the high variability, accurate prediction of long-term prognosis in individual MS cases is still challenging. CONCLUSION: Rehabilitation measures should be considered in an early phase of the disease for maintaining functional abilities and reducing the risk of progression of disabilities. Assignment to specific interventions and setting of rehabilitation depend on disease-specific and personal factors and specific goals. Monosyndromic or oligosyndromic impairments in the early phases of the disease can be approached by targeted monodisciplinary ambulatory interventions, whereas more severe and complex disabilities generally necessitate a more intensive multidisciplinary rehabilitation.

Endurance training in MS: short-term immune responses and their relation to cardiorespiratory fitness, health-related quality of life, and fatigue.

The influences of exercise on cytokine response, health-related quality of life (HR-QoL), and fatigue are important aspects of MS rehabilitation. Physical exercises performed within these programs are often practiced in water, but the effects of immersion have not been investigated. To investigate the influences of short-term immune responses and cardiorespiratory fitness on HR-QoL and fatigue during 3 weeks endurance training conducted on a cycle-ergometer or an aquatic-bike. Randomized controlled clinical trial in 60 MS patients. HR-QoL, fatigue, cardiorespiratory fitness, and short-term immune changes (serum concentrations in response to cardiopulmonary exercise test) of brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), interleukin-6, and the soluble receptor of IL-6 (sIL-6R) were determined at the beginning and end of 3 weeks of training intervention. Subjects performed daily 30 min training at 60 % of their VO2peak. SF-36 total (p = 0.031), physical (p = 0.004), and mental health (p = 0.057) scores show time effects within both groups. Between-group effects were shown for FSMC total (p = 0.040) and motor function score (p = 0.041). MFIS physical fatigue showed time effects (p = 0.008) for both groups. Linear regression models showed relationships between short-term immune responses and cardiorespiratory fitness with HR-QoL and fatigue after the intervention. This study indicates beneficial effects of endurance training independent of the training setting. Short-term immune adaptations and cardiorespiratory fitness have the potential to influence HR-QoL and fatigue in persons with MS. The specific immune responses of immersion to exercise need further clarification.

Training in MS: influence of two different endurance training protocols (aquatic versus overland) on cytokine and neurotrophin concentrations during three week randomized controlled trial.

BACKGROUND: The influences of exercising on cytokine response, fatigue and cardiorespiratory values are important aspects of rehabilitation in persons with multiple sclerosis (PwMS). Exercise performed within these programs is often practised in water but the effects of immersion on PwMS have not been systematically investigated. OBJECTIVE: The objective of this study is to determine differences in cytokine and neurotrophin concentrations, fatigue and cardiorespiratory values in response to 3 week endurance training conducted on a cycle ergometer or an aquatic bike. METHODS: A randomized controlled clinical trial was conducted in 60 MS patients (Expanded Disability Status Scale range 1.0-6.5). Resting serum levels of brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), Interleukin-6, soluble receptor of IL-6 and tumor necrosis factor alpha, and concentrations in response to cardiopulmonary exercise test (CPET), fatigue and cardiorespiratory values were determined at entry and discharge. Subjects performed daily 30 minute training at 60% of VO2max. RESULTS: Cytokines and neurotrophins showed no significant differences between groups over the training intervention. Within the water group BDNF resting and post-CPET concentrations (p<0.05) showed a significant increase and NGF tended to increase after the training intervention. Short-term effects on BDNF (CEPT) tended to increase at the start and significantly thereafter (p<0.05). No changes occurred in the land group. Other cytokines and fatigue scores remained unchanged over the training period. Cardiorespiratory values improved significantly over time within both groups. CONCLUSION: This study indicates that aquatic training activates BDNF regulation and can be an effective training method during rehabilitation in PwMS.

Design and performance of personal cooling garments based on three-layer laminates.

Personal cooling systems are mainly based on cold air or liquids circulating through a tubing system. They are weighty, bulky and depend on an external power source. In contrast, the laminate-based technology presented here offers new flexible and light weight cooling garments integrated into textiles. It is based on a three-layer composite assembled from two waterproof, but water vapor permeable membranes and a hydrophilic fabric in between. Water absorbed in the fabric will be evaporated by the body temperature resulting in cooling energy. The laminate's high adaptiveness makes it possible to produce cooling garments even for difficult anatomic topologies. The determined cooling energy of the laminate depends mainly on the environmental conditions (temperature, relative humidity, wind): heat flux at standard climatic conditions (20 degrees C, 65% R.H., wind 5 km/h) has measured 423.2 +/- 52.6 W/m(2), water vapor transmission resistance, R (et), 10.83 +/- 0.38 m(2) Pa/W and thermal resistance, R (ct), 0.010 +/- 0.002 m(2) K/W. Thermal conductivity, k, changed from 0.048 +/- 0.003 (dry) to 0.244 +/- 0.018 W/m K (water added). The maximum fall in skin temperature, Delta T (max), under the laminate was 5.7 +/- 1.2 degrees C, taken from a 12 subject study with a thigh cooling garment during treadmill walking (23 degrees C, 50% R.H., no wind) and a significant linear correlation (R = 0.85, P = 0.01) between body mass index and time to reach 67% of Delta T (max) could be determined.

Robot-assisted gait training in multiple sclerosis: a pilot randomized trial.

OBJECTIVE: To evaluate feasibility and perform an explanatory analysis of the efficacy of robot-assisted gait training (RAGT) in MS patients with severe walking disabilities (Expanded Disability Status Scale [EDSS] 6.0-7.5) in a pilot trial. METHODS: Prospective, randomized, controlled clinical trial comparing RAGT with conventional walking training (CWT) in a group of stable MS patients (n = 35) during an inpatient rehabilitation stay, 15 sessions over three weeks. All patients participated additionally in a multimodal rehabilitation program. The primary outcome measure was walking velocity and secondary measures were 6-min-walking distance, stride length and knee-extensor strength. All tests were performed by an external blinded assessor at baseline after three weeks and at follow-up after six months. Additionally, Extended Barthel Index (EBI) at entry and discharge was assessed (not blinded), and acceptance/convenience of RAGT rated by patients (Visual Analogue Scale [VAS]) was recorded. RESULTS: Nineteen patients were randomly allocated to RAGT and 16 patients to CWT. Groups were comparable at baseline. There were 5 drop-outs (2 related directly to treatment) in the RAGT group and 1 in the CWT group, leaving 14 RAGT patients and 15 CWT patients for final analysis. Acceptance and convenience of RAGT as rated by patients were high. Effect sizes were moderate to large, although not significant, for walking velocity (0.700, 95% CI -0.089 to 1.489), walking distance (0.401, 95% CI - 0.370 to 1.172) and knee-extensor strength (right: 1.105, 95% CI 0.278 to 1.932, left 0.650, 95% CI -0.135 to 1.436) favouring RAGT. Prepost within-group analysis revealed an increase of walking velocity, walking distance and knee-extensor strength in the RAGT group, whereas in CWT group only walking velocity was improved. In both groups outcome values returned to baseline at follow-up after six months (n = 23). CONCLUSIONS: Robot-assisted gait training is feasible and may be an effective therapeutic option in MS patients with severe walking disabilities. Effect size calculation and prepost analysis suggest a higher benefit on walking velocity and knee-extensor strength by RAGT compared to CWT. Due to several limitations, however, our results should be regarded as preliminary. Post hoc power calculation showed that two groups of 106 patients are needed to demonstrate a significant moderate effect size of 0.4 after three weeks of RAGT. Thus, further studies with a larger number of patients are needed to investigate the impact of this new treatment option in MS patients.

Developing the ICF Core Sets for multiple sclerosis to specify functioning.

Functioning is increasingly being taken into account for evaluating the impact of multiple sclerosis (MS) on the individual and the effectiveness of treatment and rehabilitation. With the International Classification of Functioning, Disability and Health (ICF), we can now rely on a globally-agreed-upon framework and system for classifying the typical spectrum of problems in functioning of persons given the environmental context in which they live. ICF Core Sets are lists of ICF categories selected to capture those aspects of functioning that are most likely to be affected by specific diseases. The objective of this document is to outline the development process for the ICF Core Sets for MS. The ICF Core Sets for MS will be defined at an ICF Core Set Consensus Conference, which will integrate evidence from preparatory studies, namely: a) a systematic review on parameters reported in MS studies; b) a qualitative study using focus groups and individual interviews with individuals with MS; c) an expert survey with international health professionals participating and d) an empirical cross-sectional study. The ICF Core Sets for MS are being designed with the goal of providing useful standards for research and clinical practice.

Advanced lightweight cooling-garment technology: functional improvements in thermosensitive patients with multiple sclerosis.

Cooling of thermosensitive patients with multiple sclerosis (MS) can improve clinical symptoms. In order to study the effectiveness of an advanced lightweight cooling-garment technology based on aquatic evaporation, a single-blinded balanced crossover study was performed on 20 patients with an Expanded Disability Status Scale score < or =6.5. The results using a tight-cuff cooling-garment prototype for peripheral cooling suggest improvement of a timed-walking test, leg-strength, fine-motor skills and subjective benefits. Preliminary data of the heart rate variability (HRV) including six patients suggest that the MS patients show an abnormal HRV after sham condition, which is normalized after cooling. Technical information was gained about the cooling activity and the practicability and handling of the device. These encouraging findings promote further adaptations of the prototype to increase its cooling properties and ameliorate the practicability of the cooling garment.

New technologies and concepts for rehabilitation in the acute phase of stroke: a collaborative matrix.

The process of developing a successful stroke rehabilitation methodology requires four key components: a good understanding of the pathophysiological mechanisms underlying this brain disease, clear neuroscientific hypotheses to guide therapy, adequate clinical assessments of its efficacy on multiple timescales, and a systematic approach to the application of modern technologies to assist in the everyday work of therapists. Achieving this goal requires collaboration between neuroscientists, technologists and clinicians to develop well-founded systems and clinical protocols that are able to provide quantitatively validated improvements in patient rehabilitation outcomes. In this article we present three new applications of complementary technologies developed in an interdisciplinary matrix for acute-phase upper limb stroke rehabilitation - functional electrical stimulation, arm robot-assisted therapy and virtual reality-based cognitive therapy. We also outline the neuroscientific basis of our approach, present our detailed clinical assessment protocol and provide preliminary results from patient testing of each of the three systems showing their viability for patient use.

Escalating immunotherapy of multiple sclerosis--new aspects and practical application.

Recent clinical studies in multiple sclerosis (MS) provide new data on the treatment of clinically isolated syndromes, on secondary progression, on direct comparison of immunomodulatory treatments and on dosing issues. All these studies have important implications for the optimized care of MS patients. The multiple sclerosis therapy consensus group (MSTCG) critically evaluated the available data and provides recommendations for the application of immunoprophylactic therapies. Initiation of treatment after the first relapse may be indicated if there is clear evidence on MRI for subclinical dissemination of disease. Recent trials show that the efficacy of interferon beta treatment is more likely if patients in the secondary progressive phase of the disease still have superimposed bouts or other indicators of inflammatory disease activity than without having them. There are now data available, which suggest a possible dose-effect relation for recombinant beta-interferons. These studies have to be interpreted with caution, as some potentially important issues in the design of these studies (e. g. maintenance of blinding in the clinical part of the study) were not adequately addressed. A meta-analysis of selected interferon trials has been published challenging the value of recombinant IFN beta in MS. The pitfalls of that report are discussed in the present review as are other issues relevant to treatment including the new definition of MS, the problem of treatment failure and the impact of cost-effectiveness analyses. The MSTCG panel recommends that the new diagnostic criteria proposed by McDonald et al. should be applied if immunoprophylactic treatment is being considered. The use of standardized clinical documentation is now generally proposed to facilitate the systematic evaluation of individual patients over time and to allow retrospective evaluations in different patient cohorts. This in turn may help in formulating recommendations for the application of innovative products to patients and to health care providers. Moreover, in long-term treated patients, secondary treatment failure should be identified by pre-planned follow-up examinations, and other treatment options should then be considered.

Quantification of Uhthoff's phenomenon in multiple sclerosis: a magnetic stimulation study.

OBJECTIVE: To quantify temperature induced changes (=Uhthoff phenomenon) in central motor conduction and their relation to clinical motor deficits in 20 multiple sclerosis (MS) patients. METHODS: Self-assessment of vulnerability to temperature and clinical examination were performed. We used motor evoked potentials to measure central motor conduction time (CMCT) and applied the triple stimulation technique (TST) to assess conduction failure. The TST allows an accurate quantification of the proportion of conducting central motor neurons, expressed by the TST amplitude ratio (TST-AR). RESULTS: Temperature induced changes of TST-AR were significantly more marked in patients with prolonged CMCT (P=0.037). There was a significant linear correlation between changes of TST-AR and walking velocity (P=0.0002). Relationships were found between pronounced subjective vulnerability to temperature and (i) abnormal CMCT (P=0.02), (ii) temperature induced changes in TST-AR (P=0.04) and (iii) temperature induced changes in walking velocity (P=0.04). CMCT remained virtually unchanged by temperature modification. CONCLUSIONS: Uhthoff phenomena in the motor system are due to varying degrees of conduction block and associated with prolonged CMCT. In contrast to conduction block, CMCT is not importantly affected by temperature. SIGNIFICANCE: This is the first study quantifying the Uhthoff phenomenon in the pyramidal tract of MS patients. The results suggest that patients with central conduction slowing are particularly vulnerable to develop temperature-dependent central motor conduction blocks.

Fitness to drive with neurological disabilities.

To restore the ability to drive is one aim of the rehabilitation of patients with neurological disabilities. In some instances, an evaluation is required to judge a patient's fitness to drive in today's traffic. Forty-three patients of the neurorehabilitation unit of the Valens Clinic were assessed by a standard traffic psychological test protocol and a control drive. In 88%, there was agreement between the judgments based on each procedure. Four patients had failed either the psychological tests or the control drive but not both. Six patients had failed the psychological test and the control drive. Two drove nevertheless, and three patients stopped driving. Nineteen of 32 patients cleared to drive were followed up. Eleven drove without accidents or traffic fines. The traffic psychological tests and control drive yield complementary information on the fitness to drive. However, the assessments need to be improved. New generations of interactive driving simulators may refine the fitness to drive evaluation and become useful tools in driving rehabilitation.

Fatigue in MS is related to sympathetic vasomotor dysfunction.

The authors studied standard autonomic function tests and measures of heart rate variability in 60 patients with multiple sclerosis (MS) and correlated results with the Fatigue Severity Scale and the Modified Fatigue Impact Scale. The authors found that autonomic responses correlated with fatigue resembling a hypoadrenergic orthostatic response, possibly due to a sympathetic vasomotor lesion with intact vagal heart control. Treatments to control sympathetic dysfunction for MS-associated fatigue deserve further study.

Effects of a short-term exercise training program on aerobic fitness, fatigue, health perception and activity level of subjects with multiple sclerosis.

Multiple sclerosis (MS) patients of an inpatient rehabilitation program have been randomly assigned to an exercise training (MS-ET) or nontraining group (MS-NI). Before and after 4 weeks of aerobic exercise training, a graded maximal exercise test with measurement of gas exchange and a lung function test was administered to all 26 patients fulfilling the inclusion criteria. Activity level, fatigue and health perception were measured by means of questionnaires. Twenty-six healthy persons served as control group and were matched in respect of age, gender and activity level. Training intervention consisted of 5x30 min sessions per week of bicycle exercise with individualised intensity. Compared with baseline, the MS training group demonstrated a significant rightward placement of the aerobic threshold (AT) (VO2+13%; work rate [WR])+11%), an improvement of health perception (vitality+46%; social interaction+36%), an increase of activity level (+17%) and a tendency to less fatigue. No changes were observed for the MS-NI group and the control groups. Maximal aerobic capacity and lung function were not changed by either training or nontraining in all four groups. Overall compliance to the training program was quite low (65%), whereas incidence of symptom exacerbation by physical activity has been lower than expected (6%).

Neuroscience and clinical practice: a personal postscript.

For such complex endeavours as understanding functions of the nervous system and treating patients with impairments of such functions, a continuous exchange of ideas in mutually understandable language is needed between researchers and clinicians. Neither of them is capable in the long run of doing justice to the scientific aspects of neuroscience and neurology and to the expectation of the patients on his or her own. It should become possible to bridge the gap between caring for patients and a scientific understanding of the mechanisms by which certain therapies work and the measurement of performance and outcome which is important for the credibility of interventions. The scientific approach to neurology has led to remarkable improvements in understanding some of the disease processes and to some valuable new therapies. There is no fundamental contradiction, however, between this approach and the pastoral aspects of medical care.

Impact of neurorehabilitation on disability in patients with acutely and chronically disabling diseases of the nervous system measured by the Extended Barthel Index.

To study the impact of rehabilitation on disability in an unselected patient group with acutely and chronically disabling neurologic diseases, the Extended Barthel Index (EBI) was determined at the beginning and at the end of the rehabilitation stay in all patients admitted to our Neurorehabilitation Centre in Valens, Switzerland. Patients who reached the highest possible EBI score at entry ("ceiling effect"), with a short stay (<1 week), or with a deterioration due to other medical complications were excluded. Finally EBI data of 743 patients could be analyzed. The mean EBI at entry was 45 and 51 at discharge. The mean increase of the EBI score per week was 1.1 (SD, 1.7). The change of the EBI score was analyzed independently in patients with acute neurologic diseases admitted in the postacute phase (acute group) and patients with chronically disabling neurologic diseases (chronic group). As expected, the increase of the EBI score was higher in the acute group than in the chronic group; 80.8% of the acute group patients and 42.5% of the chronic group patients showed an increase of the EBI score at discharge. Both groups showed a significant EBI gain with a marked shift to higher EBI scores at discharge. The mean gain per week was 1.6 in the acute group and 0.5 in the chronic group, respectively. Analysis of EBI changes considering the different underlying diseases showed the highest increase in patients with stroke and traumatic brain injury.

Neurorehabilitation: a bridge between basic science and clinical practice.

A true paradigm shift or revolution of thinking is taking place in the field of neurology. Earlier, it was regarded as the science of exact diagnosis of incurable illnesses, according to the resigned dogma that damage to the central nervous system could not be repaired: "Once development is complete, the sources of growth and regeneration of axons and dendrites are irretrievably lost. In the adult brain the nerve paths are fixed and immutable: everything can die, nothing can be regenerated" (Cajal, 1928). Even then one could have countered this with what holds today: "Rehabilitation does not take place in the test tube!", and one would have been supported only a short time later by a most authoritative source, if one had read and quoted what the professor of neurology and neurosurgery in Breslau, Otfried Foerster, wrote in a 100-page article about therapeutic exercises that appeared in the Handbuch der Neurologie. From his introduction, only three sentences are quoted, which illustrate his opinion of the importance of therapeutic exercises and are closer to our views of brain functions today (Foerster, 1936): There is no doubt that most motor disturbances caused by lesions of the nervous system are more or less completely compensated as a result of a tendency inherent to the organism to carry out as expediently as possible the tasks of which it is capable under normal circumstances, using all the forces still available to it with the remaining undamaged parts of the nervous system, even following injury to its substance. This happens spontaneously, when neither a reversal of the noxa nor a regeneration of the destroyed tissue is possible, simply by means of a reorganization of the remaining parts of the nervous system, which is not a machine composed of individual parts that stands still when one part fails; rather, it possesses an admirable plasticity and exhibits an astonishingly extensive adaptability, not only to changed external conditions but also to disruptions of its own substance. Therapeutic exercises influence the course of spontaneous restoration; they support it, strengthen it. Not infrequently, in fact, they actually set it in motion when the forces essential to restoration lie fallow and are not deployed by the organism.