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.

The functional anatomy of motor imagery after sub-acute stroke.

BACKGROUND: The neural correlates of motor imagery (MI) are tightly coupled with the cortical motor control network. Therefore MI may have therapeutic potential for patients with motor deficits after an ischemic stroke. OBJECTIVE: The aim of our study was to assess the hemispheric balance of the cortical motor network during motor imagery (MI) in patients recovering from stroke in the sub-acute stage. METHODS: We studied 17 patients after cerebral ischemic stroke (sub-acute stage) and 12 healthy subjects using functional Magnetic Resonance Imaging (fMRI) during motor imagery and performance of isometric grip force movements (5 Newton). Laterality indices (LI) were calculated from regional activation analysis to assess hemispheric distribution of activity in pre-specified motor areas. RESULTS: Laterality index (LI) revealed a more balanced cortical activity in MI for both controls (-0.03) and patients (-0.12) in the premotor cortex compared to movement execution (0.48 controls; 0.12 patients) and a trend towards a shift in contra-lesional activity in stroke patients. CONCLUSIONS: Our results indicate a preserved interhemispheric balance of patients in the sub-acute stage when activating the cortical motor areas during MI. This could provide a reasonable physiologic baseline for using MI as an additional rehabilitative therapy for improving functional recovery in the sub-acute stage after stroke.

Advances in adjuvant pharmacotherapy for motor rehabilitation: effects of levodopa.

Hemiparesis is common after stroke and often severely disabling. Until very recently, the only therapeutic option for motor recovery was physiotherapeutic training. Experimental animal studies have shown that when applied in addition to exercises pharmacological interventions that affect the norepinephrine system can enhance the rate of functional motor recovery. These effects were observed when an increase in norepinephrine concentration in the CNS was pharmacologically induced. We recently showed that 3 weeks of single daily doses of 100 mg L-dopa, which is metabolized into norepinephrine in the brain, increase the efficacy of physiotherapy in hemiparetic stroke patients. Two additional randomized controlled trials with stroke patients also demonstrated the clinical relevance of this approach for motor recovery and independence in activities of daily living. Modifying effects of other frequently occurring clinical symptoms such as spasticity, neglect, and attention were also investigated. Thus, in view of its minimal side effects, L-dopa can be recommended in conjunction with exercise therapy to improve the functional outcome in stroke rehabilitation.