Abstract
Table of Contents
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In the following we are publishing the abstracts as submitted by the authors.
The Invited Lectures as well as the Poster Presentations are ordered according to the chronology of the scientific programme.
Missing poster numbers indicate withdrawals as per date of printing.
Keys and abbreviations:
Invited Lectures
Michael P. Barnes Lecture
OL1 Axonal Regeneration in the Central Nervous System: A Retrospective
A. J. Aguayo
Centre for Research in Neuroscience-McGill University, Montreal, QC, Canada
Cajal’s “Degeneration & Regeneration of the Nervous System”, published in 1914, provided one of the earliest comprehensive descriptions of how nerve cells respond to damage. His interpretation of these phenomena anticipated many current ideas in the field.
It is now proven that some interrupted CNS axons can either sprout or regenerate long distances following substrate changes, the administration of growth promoting factors or the blocking of inhibitory molecules residing in myelin, glia or the extracellular matrix. Furthermore, axonal extension can be enhanced by the up-regulation of specific neuronal genes like GAPS, the suppression of others, like PTEN or the transcription factor KLF4. Various examples of this regenerative potential have been provided by a number of laboratories. For instance, in experiments in mature rodents, long segments of peripheral nerve (PN) were grafted as “bridges” that linked the ocular stump of transected optic nerves and the superior colliculus (SC). Approximately six weeks later, up to 12% of the retinal ganglion cells (RGC) had regrown axons along the grafts for distances that were often even greater than in the intact animal. When guided to the SC they tended to innervate appropriate collicular layers and formed terminal arborisations and synapses. These connections were capable of the transsynaptic activation of SC neurons following retinal stimulation by light. However, terminal RGC arbors remained abnormally dense and there was no orderly retinotopic deployment in the colliculus. Furthermore, most axotomized RGC died soon after injury, significantly reducing the possibility of a greater regrowth.
These and other studies underscore the need for further understanding the cell and molecular mechanisms involved in neuronal survival, axonal regrowth, guidance, synaptogenesis and the various compensatory responses that follow neural injury.
PL01 MAIN SYMPOSIUM: Cell Therapies: Hope or Illusion
PL01.1 Cell Therapies in Stroke
G. Nikkhah
Dept. of Stereotactic and Functional Neurosurgery, Neurocenter, University Hospital Freiburg, Germany
Cell therapy interventions into cerebral ischemia induced by stroke have come to the forefront of interest in recent times with the acceleration of research in the stem cell field. In comparison, Parkinson and Huntington (PD/ HD) clinical trials of cell replacement therapy have evolved progressively based on a close coordination between pre-clinical animal models and clinical applications and, importantly, within the context of primary foetal cells. In contrast, cellular intervention therapies for stroke are designed around engineered and/or cultured cells of various sources. For example, pre-clinical work has been reported using immortalized human neural stem cell lines, mesenchymal stem cells/stromal stem cells, hematopoietic stem cells, embryonic stem cells and neuronal progenitor isolated from rodents and humans. Several different cell lines have demonstrated functional efficacy in animal models, and the most promising of these, the NT2N immortalized line, has been taken to Phase I and II clinical trials where they have shown to be safe to use. However, a principle concern with carrying out large clinical trials is that the cells might retain the potential to proliferate and become cancerous over time after transplantation, and this is an issue that concerns any transplanted cells that contain pluripotent cell populations at the time point of implantation. In HD and PD cell intervention therapy is based on direct, central and stereotactic injection strategies intended to replace lost neurones or transmitters, respectively. In the case of stroke, this strategy has been superseded by systemic injection strategies. This implies that the mechanism of action is most likely not based on a direct cellular replacement but on indirect actions of the transplanted cells boosting endogenous neurotrophic effects that enhance sprouting, angiogenesis, neuroprotection, remyelination, as well as immunomodulation, which could have consequences on axonal regeneration. A major challenge for the further development of cell-based therapies for stroke will be to co-ordinate the efforts and generate a standardised framework to guide future pre-clinical and clinical research.
PL01.2 Cell Therapies in Spinal Cord Injury
W. Young
Rutgers University, Cell Biology & Neuroscience, Piscataway, NJ, United States; W M Keck Center for Collaborative Neuroscience, Nelson Labs, Piscataway, NJ, United States
Lithium has long been used to treat manic depression. Its mechanisms of action in manic depression were not understood until quite recently when many studies showed that lithium stimulates neural stem cells to proliferate, to secrete neurotrophins, and to produce more neurons. In fact, people with manic depression who have been treated with lithium have significantly more neurons than people who have similar manic depression but were treated with serotonin uptake blockers. Usually, when neural stem cells are transplanted into injured spinal cords, they tend to respond to the inflammatory environment of the injury site by producing mostly astrocytes. However, in the presence of lithium, neural stem cells produce mostly neurons. Lithium stimulates transplanted umbilical cord blood mononuclear cells to secrete neurotrophins known to promote axonal regeneration. We are now carrying out clinical trials in China (ChinaSCINet) and the United States (SCINetUSA) to assess the effects of lithium on umbilical cord blood mononuclear cell transplant therapy of chronic spinal cord injury. The progress in these trials will be discussed, along with a review of other cell transplant therapies. These developments illustrate an important trend in stem cell therapy of central nervous system disorders. The behavior of stem cells depends on the environment into which they are transplanted. It is not surprising, for example, that neural stem cells transplanted into the injured spinal cords produce mostly glial cells. The injury site requires microglial cells to clean the injury site, astrocytes to repair the blood brain barrier and PNS/CNS barriers, and oligodendroglial cells to remyelinated demyelinated axons. The ability to control the fate and behavior of transplanted cells is key to successful stem cell therapy. Lithium is the first of an important class of stem cell modifying drugs being used to modify transplanted cells and their response to the tissue environment.
PL01.3 Misuse of Cell Therapies?
B. H. Dobkin
University of California Los Angeles, Los Angeles, CA, United States
Cellular interventions are being offered as intravenous and brain/spinal cord injectables at several dozen clinics in China, Thailand, the Caribbean, Brazil, Mexico, Russia, Bulgaria, Ukraine, India, and other stem cell tourism stops. Patients continue to travel to these exploitive, for-profit medical spas in the hope of a cure at US$10,000-$25,000 per visit. Guidelines (www.isscr.org; www.campaignforcure.org) are available to distinguish between innovative testing of cell-based medical therapies within ethical trials and the objectionable selling of hope to vulnerable people and families. The spa-based interventions add nothing to the scientific and disabled person’s knowledge about the efficacy and safety of autologous and non-autologous cell implants and marrow-derived cell transfusions or spinal fluid injections. No specific mechanism of action of the cells-for-sale is established; the same cells are claimed to be a universal tool to “fix” any neurological disease. No credible animal model of disease and repair is relevant to the intervention deployed. No formal pre- and post-testing is performed with standard measures at specific intervals to try to detect change in pre-defined impairments and disability. No specific outcomes are promised—patients simply hope to improve in some aspect of their disability. No adverse responses are reported—if what they do is claimed to be safe, their hospitals and governments tolerate them.
Testimonials at spa Web sites, and several recently reported uncontrolled trials, strongly suggest that cell recipients who believe they are better in some way have engaged in considerable post-intervention rehabilitation. This finding strongly points to the need for considerable pre- and post-intervention rehabilitation aimed at pre-specified impairments and disabilities within prospective, randomized trials with frequent monitoring and blinded observer assessments. Patients should be counseled against medical travel for cell-based interventions unless they are participating in such trials.
S01 Multiple Sclerosis
S01.1 NeuroRehabilitation in MS: Can We Do More to Minimise Disease Impact on the Patient?
A. J. Thompson
UCL Institute of Neurology, London, United Kingdom
The philosophy underpinning rehabilitation seems highly appropriate to the unpredictable and diverse needs of those affected by multiple sclerosis (MS). The key elements of this educational process, which seeks to increase ability, participation and autonomy through the acquisition of knowledge and skills, seem well suited to the management of the multiple symptoms inherent to this condition. One of the major difficulties is accessing the necessary expertise in a timely and responsive manner. When evaluated in the context of randomised controlled trials, there is a reasonable evidence base supporting multi-disciplinary rehabilitation in a number of out-patient and in-patient settings. There is a need to target specific disabling symptoms such as spasticity and fatigue and to improve approaches in particular areas such as vocational rehabilitation and cognitive impairment.
These studies are however limited by the evaluating tools utilised, few if any of which incorporate the patient’s own perception of benefit, a surprising situation considering the central role of the patient in the rehabilitation philosophy. There has been a recent awareness of the need to develop better, more scientifically sound outcome measures which focus on the patients’ view (Patient related outcome measures—PROMS) and to investigate newer measurement techniques such as Rasch analysis and item response theory.
A key question in today’s management of MS is whether we can do more than just adapt to disability: Can we actually reduce impairment? Recent studies targeting both MS and optic neuritis suggest that there is indeed a degree of plasticity which may compensate for the impairment resulting from the pathological process in MS. There is growing evidence that the extent of the response to the initial insult may influence recovery. A better understanding of plasticity could provide a valuable approach to reducing impairment and provide an ideal target to guide and enhance the rehabilitation process.
S01.2 Stem Cell Therapy in Multiple Sclerosis
G. Martino
Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
Since the early 1970s, cell transplantation approaches aimed at restoring the myelin architecture in demyelinating disorders of the central nervous system (CNS), such as multiple sclerosis (MS), have been developed. Different types of myelin-forming cells have been variably transplanted into rodent models of either genetic, chemical or autoimmune CNS demyelination. These approaches showed serious limitations. In particular, lineage-restricted myelin-forming cells—either oligodendrocyte precursor cells (OPCs), Schwann cells, or olfactory ensheathing cells—possess limited growth and expansion characteristics in vitro and drive remyelination only within restricted CNS areas close to the transplantation site in vivo. In more recent years, stem cells—of either embryonic or adult origin—showed functional and morphological properties, both in vitro and in vivo, capable of overcoming such limitations. These cells, nowadays, represent a likely promising alternative cell source for transplantation approaches in CNS-confined diseases like MS. On one hand, the therapeutic use of embryonic stem (ES) cells is still constrained by some key issues—such as feeder-independent growth (expansion) and in vivo terato-carcinoma formation—which need to be solved before proposing any ES cell-based therapy for human applications. On the other hand, adult (or somatic) stem cells might represent a ready-to-use cell source for cell-based therapies, since they can be obtained by different tissues (e.g. bone marrow, epidermis, brain, etc.) and have been already used in both experimental and clinical settings without causing overt toxic/side effects. Different sources of somatic stem cells and different therapeutics strategies to render these cells transplantable in a disease like MS will be discussed.
S02 Drug Delivery System
S02.1 Deep Brain Stimulation Systems for Neurorehabilitation
H. M. Mehdorn and D. Falk
Dept of Neurosurgery University Hospitals Schleswig-Holstein, Kiel, Germany
Deep brain stimulation (DBS) has gained increasing acceptance for movement disorders such as Parkinson’s disease, tremor, and dystonia, due to major advantages over lesional techniques such as variations of stimulation parameters. Recently other indications have also emerged. They may include treatment of a variety of posttraumatic brain dysfunctions such as tremor, pain, drug addiction, and vigilance problems. Further progress concerns miniaturization of the electrical stimulation systems and drug application techniques.
On the basis of personal experience gained in the field of DBS over the last 10 years with movement disorders and previous experiences with lesional surgery of the basal ganglia a review aims to highlight some of the indications for DBS in the field of rehabilitative neurosurgery. Both technical progress and ethical implications will be discussed.
S02.2 Intracerebral Stem Cell and Growth Factor Reservoir in Stroke
T. Brinker
Neurosurgical Dept. INI, Hannover, Germany
Intra-cerebral hemorrhage (ICH) is the most lethal form of stroke with some 50,000 cases annually in the United States. Microsurgical removal of the hematoma and numerous potentially neuroprotective substances so far have failed to improve the outcome in comparison to conservative treatment.
As a novel approach, a clinical Phase I/IIa trial in Germany is currently investigating whether the outcome after surgery can be improved by intracerebral transplantation of human mesenchymal stem cells (hMSC). Such cells are known to exhibit anti-inflammatory and neuroprotective effects after brain injury. For the clinical application the cells are immortalized and genetically engineered to produce the neuroprotective and neuroregenerative substance Glucagon like Peptide-1. Approximately 3000 cells are encapsulated within alginate beads with a diameter of 0.6 mm. The alginate capsules are produced according to the European drug manufacturing regulations and stored at -80°C until clinical use. At surgery approximately 3000 capsules are thawed and, for implantation into the brain cavity after hematoma removal, enclosed within a 1.5*1.5-cm sized polymeric mesh bag. The bag is removed by a second surgery after a treatment period of two weeks.
As such, the treatment aims to achieve local neuroprotective and anti-inflammatory effects, preventing neuronal death in the perihematomal area.
So far five patients have been treated sequentially and recovered from ICH well with no unexpected adverse events. The phase IIa stage is now recruiting and additional hospitals are participating in the approval process.
S02.3 Intrathecal Applications
L. Saltuari
Department of Neurorehabilitation, Hochzirl, Austria
Intrathecal application of pharmacological substances is indicated when enteral and parenteral administration of drugs does not adequately pass the blood-brain barrier. One advantage of intrathecal drug therapy is the fact that the pharmacon acts directly on the CNS without the necessity of high concentration in the extrathecal space.
Another advantage is that therapeutic concentration of the pharmacon can be maintained constant, or in the case of implantation of an electronic administration device, varied during the day according to clinical necessity.
Prior to deciding upon intrathecal therapy, optimal dosage of oral therapy should be achieved. Failing this goal, the patient should undergo evaluation either by simple lumbar puncture with administration of a single bolus, or by external catheter connected with an external pump system with continuous infusion of the drug. This second approach is preferable as the efficacy of the treatment can be observed more precisely and for a longer period of time, and possible side effects can be better objectified. In case of positive response, a pump system will be implanted (gas-driven or electronic devices) and connected with a subcutaneous catheter system leading to the intrathecal space. Refilling of the pump system can be performed transcutaneously; intervals of refills depend on the concentration and daily dosage of the drug.
The main indications for intrathecal treatment at present are pain and spasticity.
S03 Paediatric Neurorehabilitation
S03.1 Neuroplasticity Imaging in Children
M. Staudt
Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Vogtareuth, Germany; Dept. Pediatric Neurology and Developmental Medicine, University Children’s Hospital, Tuebingen, Germany
Motor system: Patients with congenital hemiparesis as a consequence of unilateral lesions acquired pre- or perinatally often control their paretic hands via ipsilateral cortico-spinal projections. The mechanism for the development of these ipsilateral cortico-spinal projections is well understood: At the beginning of the 3rd trimester of pregnancy, descending cortico-spinal motor projections have already reached their spinal target zones, with initially bilateral projections from each hemisphere. During normal development, the ipsilateral projections are gradually withdrawn, whereas the contralateral projections persist. When, during this period, a unilateral brain lesion disrupts the cortico-spinal projections of one hemisphere, the ipsilateral projections from the contra-lesional hemisphere will persist, thus allowing the contra-lesional hemisphere to take over motor control over the paretic extremities. The efficacy of this ipsilateral take-over of motor functions decreases with increasing age at the time of the insult.
Somatosensory system: Ascending thalamo-cortical somatosensory projections have not yet reached their cortical target zones at the beginning of the 3rd trimester of pregnancy, so that these projections can still “react” to brain lesions acquired before or during this period, and can form “axonal bypasses” around periventricular white matter lesions to reach the postcentral gyrus. This can achieve well-preserved somatosensory functions despite extensive white matter damage.
Clinical implications: The methodologies with which these results were obtained (TMS, fMRI, MEG, MR diffusion tensor tractography) can be used to monitor the patterns of reorganization in individual patients with early brain lesions. This can be helpful when brain surgery is considered, e.g. for the relief of pharmaco-refractory epilepsies. Furthermore, the pattern of sensorimotor (re-)organization apparently influences the effects of functional therapies (such as constraint-induced movement therapy), both on a behavioral level and on a cortical level (“neuromodulation”).
S03.3 Pediatric ABI: Developmental Challenges and Functionally Based Interventions
R. DePompei
The University of Akron, Akron, OH, United States
The long-term developmental issues that can compromise the learning and social participation of students are not well described or understood but researchers have identified issues that should be considered with this population. This session will focus on the following:
1. Chapman and others have outlined the progression of potential developmental problems for children and adolescents with TBI. They suggest that there should be efforts for rehabilitation at the time of the injury, when a dip in new learning occurs, and again in later developmental years, where a potential stall for new learning can affect progress in school and social skill development. The effects of this dip and stall will be outlined.
2. There is also growing evidence that the younger the child at the time of the injury, the more likely the child has potential for ongoing problems in learning and with higher levels of language functioning. A summary of the research to date that discusses these issues will be presented.
3. While there have not been long-term studies to determine the best interventions for this population within school and community settings, anecdotal evidence exists for a number of interventions that may be useful. Functionally based strategies will be outlined. A problem-solving activity using the Internet will develop methods for treating educational and social challenges for these children from a functional perspective.
4. Finally, an update regarding the efforts to develop a seamless network of care for children and adolescents with TBI will be provided. The Pediatric Acquired Brain Injury Plan (PABI Plan) was created in 2009 by over 50 specialists and represents an ideal standard of care for children. This plan will be reviewed and suggestions made for adaptation internationally. Additionally, the efforts of the International Pediatric Brain Injury Association will be discussed.
S04 Transcultural Aspects of Neurorehabilitation
S04.1 Transcultural Aspects of Neurorehabilitation: The Indian Perspective
N. Surya
Surya Neuro Centre, Mumbai, India
India is the second most populous country in the world. The enormous vibrant diversity of its populace spreads across several religions, sects, castes, and languages, and it is a country where slums are matched with skyscrapers. Of its 1.7 billion-strong population, 70% resides in rural areas that seldom have access to modern health care amenities.
While the majority of the urban population fulfills its medical needs through private health institutions, the poor have nothing but public health institutions to fall back on. This paradox has led to the synthesis of a unique health care system that draws from both public and private institutions in varying proportions. While modern rehabilitation centers with well-equipped state-of-the-art instruments with teams of skilled therapists are available in major cities, very few skilled therapists are available to members of the rural population.These physiotherapists play a very important role in abridging the rehabilitation services between the urban and rural populations. Families are thereby closely involved in the rehabilitation process as they are instrumental in providing long-term rehabilitation support and community-based rehabilitation.
The ancient techniques of yoga and ayurveda have been practiced for thousands of years in Indian families and have been part of daily rituals such as Suryanamskar. Scientific studies into the impact of yoga in various neurological disorders such as stroke, Parkinson’s disease, and multiple sclerosis have provided evidence of their efficacy and these techniques play a very important role in neurorehabilitation in India.
The Indian model of health based on the principles of yoga and ayurveda has always been centered upon preventive aspects, and the joint family system ensures that the physical, social, and economical burdens of disease and rehabilitation are equally shared.
The most significant aspect of rehabilitation in India is that it is delivered through the harmonious amalgamation of modern and ancient systems of medicine and socially based, community-oriented, family-centered models of rehabilitation and spiritual dimension to the overall rehabilitation efforts.
S04.2 Transcultural Aspects of Neurorehabilitation: The Japanese Perspective
E. Saitoh1 and Y. Kanada2
1Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Aichi, Japan, 2Faculty of Rehabilitation, School of health Sciences, Fujita Health University, Aichi, Japan
In Japan, rehabilitation medicine began as a medical and welfare practice for disabled children around the 1920s. In 1926, the Japanese Orthopedic Association (JOA) was established. At that time, rehabilitation medicine was mainly aimed at treating disabled children by orthopedists.
After World War II, several concepts of rehabilitation medicine came to Japan from the United States. And in 1963, the Japanese Society of Rehabilitation Medicine (JARM) was established with large support from JOA members. The national license system for physical therapists (PT) and occupational therapists (OT) was established in 1965.
In 1982, the Law of Health and Medical Services for the Aged was established and rehabilitation for elderly patients began to gain attention. At that time, the JARM board certification system for physiatrists was started. The national license system of speech language hearing therapist (ST) was established in 1997.
The segment of elderly persons is rapidly growing in Japan. This growth leads to huge social needs for rehabilitation medicine, especially for those with neurological disorders.
At present, more than 150,000 certificated therapists (PT, OT, ST) and about 4,000 certificated physiatrists are participating in rehabilitation medicine. In Japan, rehabilitation medicine is recognized as a basic specialty of clinical medicine. The rehabilitation team collaborates with members of other departments to treat patients with a variety of disabilities in clinical settings. In addition to treatment in acute hospital, Japan also has a unique medical system for subacute or recovery phases of disease that seems to be especially useful for stroke patients.
Of course, neurorehabilitation is one of the most important fields in rehabilitation medicine. Interdisciplinary cooperation at the society level started with support from the WFNR. In January 30, 2010, we established the Japanese Society for Neural Repair and Neurorehabilitation (JSNRNR) was established and and had its first annual scientific meeting in Nagoya. The JSNRNR is expected to facilitate wider and deeper communication among clinicians and scientists involved in neurorehabilitation.
S04.3 Neurorehabilitation in Mexico: Contrasts, Institutions and Vulnerabilities
J. H. Franco
Mexico
The health system in Mexico is functionally organized in socioeconomic groups. It divides the population into two groups: the “insured”, which consists of public and private workers; social security institutes provide care in this group.
The “non government insured” includes the middle and high class groups which can use private hospitals and clinics. The lower classes also belong to this group and the secretary of health provides medical services through its own independent public health system.
Each one of these three systems, social security, private sector and health ministry institutes dictate their own policies and procedures, control their own budgets, and provide services independently, creating most of the time a functional redundancy.
Each system has its own rehabilitation departments, and neurological rehabilitation is provided by physical therapists mainly through the use of neurodevelopment techniques, under the supervision of a physician, rehabilitation specialist. Neurologists are not well integrated into the neurorehabilitation process.
There is no consensus in Mexican neurorehabilitation regarding evaluation scales, a common problematic issue being the application of isolated measurements for spasticity or the presence of synergies, and the lack of use of a standardized functional scale.
Neurorehabilitation professionals in Mexico are not an active research group, limiting the development of evaluation and treatment protocols based on their social, economic and cultural context, tending to copy treatment models from abroad and importing expensive technology
Rehabilitation services are provided to rural areas through so-called “basic rehabilitation units”. Only two out of 31 states in the country have “community-based rehabilitation” programs, which function independent of the three health systems.
It has been suggested that improving education in rehabilitation schools and institutes can make a difference in the training of new generations of physicians and therapists, and improve patient care regardless of the system to which they belong.
SWS Scientific Workshop: Proprioceptive System in Modern Rehabilitation
SWS.1 The Proprioceptive System, Neurophysiological Review
F. Gerstenbrand1,2,3 and S. M. Golaszewski1,2,4
1Karl Landsteiner Institut for Neurorehabilitation and Space Neurology, Vienna, Austria, 2World Federation for Neurology, Research Group for Space and Underwater Neurology, Vienna, Austria, 3Department of Neurology, Medical University, Innsbruck, Austria, 4Department of Neurology and Neuro-Science Institute, Paracelsus University, Salzburg, Austria
For any kind of body movement an efficient function of the proprioceptive system is indispensable. The “sense of locomotion” was described for the first time by J.C. Scaliger in 1557. In 1826, C. Bell created the term “muscle sense” as physiologic feedback mechanisms in a reverse direction after stimulation to the muscles reporting their conditions. H.C. Bastian introduced “kinaesthesia” instead of the term “muscle sense” with the idea that tendons, joints and skin produce stimulation. In 1906, C.S. Sherington introduced the term “proprioception,” which is responsible for the awareness of movement derived from muscles, tendons and articular sources. The responsible receptors are positioned in muscles, joints and ligaments around joints. The receptors help to register tension and stretch. The information is transferred to the brain cortex using the medial lemniscus in the brainstem, the thalamus and the thalamo-cortical projection called a conscious proprioception, contrary to the unconscious proprioception as the second afferent system, but using the dorsal spinocerebellar tract (J. D. Fix, 2002). The sensorimotor area registers the peripheral information, selecting the required afferent stimuli. Every motor activity needs correct information about the position of body and extremities.
The basis for the normal function of the proprioception is the undisturbed gravity of our planet. Disturbances as in weightlessness, the real microgravity, bring disturbed stimulation to the brain causing misinformation for the motor system. This produces the “cosmonaut syndrome” with typical neurological deficits. Counter measures in real microgravity are necessary. Simulated microgravity in an experimental state, but also in patients with long-lasting coma states and with diminished motion, as well as in elderly people, produces the so-called bed rest syndrome.
SWS.2 Brain Imaging in Proprioception
S. M. Golaszewski1,2 and F. Gerstenbrand2,3
1Department of Neurology and Neuroscience Institute, Paracelsus Medical University, Salzburg, Austria, 2Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Vienna, Austria, 3Department of Neurology, Medical University, Innsbruck, Austria
Purpose: The aim of the study was to develop a paradigm for the mapping of the sensorimotor foot region in fMRI with vibrotactile stimulation. Therefore, a proper vibrotactile stimulus was developed and the elicited brain activation pattern was analyzed to find best vibration parameters and an optimized experimental protocol for the applicability of the developed paradigm in clinical functional diagnosis of the brain. Methods: 10 healthy male subjects (25-45yrs) were stimulated with a vibrotactile stimulus within the arch of the right foot. The stimulus was delivered through a fully automated moving magnet actuator with frequency (0-100Hz) and amplitude (0-4mm) control. To avoid adaptation phenomena a stimulus wave form was formed as the product of a fixed vibration carrier signal and a modulation term which varied sinusoidally. The carrier frequency was held constant at 100 Hz at a fixed modulation frequency of 25Hz and a fixed stimulus intensity of 0.05N throughout the fMRI run. Experiments were performed on a 1.5Tesla MR-scanner. For fMRI, we employed T2*-weighted EPI sequences (TR/TE/α=0, 96ms/66ms/90°, matrix=64x64, acquisition time: 2sec, voxel dimension= 4x 4x4mm). Twenty-four slices parallel to the bicommissural plane were simultaneously acquired in an event related design with randomized stimulus presentation with stimulus duration of 1 sec as a 2x2 design with vibration amplitude of 0.5 and 1 mm and a vibration frequency of 25 and 50 Hz. A total amount of 120 volume images was acquired during a single fMRI run. The scan repetition time for the stimulus on/off conditions was 3 s. Post-processing was performed offline with SPM99. A statistical parametric activation map was calculated for each of the 10 subjects and for the group of subjects with an uncorrected p< 0.001 on a cluster level of k>8. Results: FMRI group data of the 10 subjects showed brain activity: (1) bilaterally within the secondary somatosensory cortex located in the inferior parietal lobule, (2) contralaterally to the stimulated side within the primary sensorimotor cortex overlapping the pre- and postcentral gyrus, (3) bilaterally within the supplementary motor cortex within the superior frontal gyrus and (4) on the right hemisphere within the anterior cingular gyrus. The present study supports an increasing stimulus-response relationship between vibrotactile stimuli and the amplitude of the BOLD response within the primary sensorimotor cortex SM to a single vibrotactile event. Stimulus frequency did not significantly influence BOLD amplitude. Conclusion: In the presented study, an fMRI paradigm for vibrotactile stimulation of the foot could be implemented within the MR environment. The vibrotactile stimulus can be well defined and frequency and amplitude can be controlled. The stimulus with a modulation frequency of 25 Hz is able to elicit brain activation within main centers of the sensorimotor cortex for the right foot within a group of 10 subjects. The described fMRI map by vibrotactile stimulation of the foot holds promise for the applicability in neurorehabilitation, especially in patients after head injury or patients in Apallic Syndrome as well as in the planning and functional monitoring in neurorehabilitation.
SWS.3 Clinical and Imaging Effects of the Mechanical Stimulation of Support Zones of Soles
L. A. Chernikova1, R. N. Konovalov1, E. I. Kremneva1, M. V. Krotenkova1, K. A. Melnik2, I. V. Saenko2, and I. B. Kozlovskaya2
1Research Center of Neurology of RAMS, Moscow, Russian Federation, 2SSC RF Institute of biomedical problems, Russian Academy of Sciences, Moscow, Russian Federation
The purpose of this study was to investigate the influence of mechanical support stimulation (MSS) of soles on the recovery of the motor disturbances in poststroke patients and on the sensorimotor cortex activation in healthy subjects. The mechanical support stimulator imitated the afferentation, obtained from feet while slow walking (75 steps/min, 37,5 cycles/min and pressure 0,5±0,15 kg/cm2). Twenty two patients (mean age 59,6±15,0 years) with moderate to severe ischemic stroke (NIHSS at admission 14±3,1) admitted within 72 hours of symptom onset were included into the study. The control group (8 patients) received only standard rehabilitation. The basic group (14 patients) received additionally 10 sessions of MSS (20 min twice a day). Patients were assessed by NIHSS, Rankin Scale, Ashworth Scale, Barthel Index at before and after the course of the MSS, at 1 month after stroke onset. Besides we have used the fMRI (1.5T Symphony, Siemens) to assess the sensorimotor cortex activation during MSS at 11 healthy subjects. fMRI was made in a block-design, with alteration of task condition (30 sec) and the rest condition (30 sec) during 3 minute. The data were analyzed with SPM5. The results indicate that the patients of the basic group had a better recovery than the patients of the control group. It was revealed the activation of the brain areas participating in performance complex locomotion action during the MSS in the slow walking mode in healthy subjects.
SWS.4 Mechanical Support Stimulation as a Countermeasure Against Hypokinetic Motor Disorders
I. B. Kozlovskaya, I. V. Saenko, N. Miller, D. Husnutdinova, and K. Melnik
Russian Federation State Scientific Center Institute for Biomedical Problems of the Russian Academy, Moscow, Russian Federation
Results of long lasting research resulted in the development of well-grounded conceptual understanding of factors, triggering the complex of disturbances in motor system and its control under the microgravity conditions. This complex includes consistent atrophy, atonia, decline in force-velocity properties of muscle; disturbance in spinal mechanisms activities; deep changes in activity of motor control mechanism. The data obtained in experimental studies pointed to the leading role of the support afferents in control of structural-functional properties of the tonic muscle system. It was shown that the support afferents play a role of the trigger in the postural system, that enhances (when the support is present) or inhibits (when the support is withdrawn) the activity of tonic motor units. This conclusion was supported by the fact that mechanical stimulation of the support zones of the soles under supportless conditions fully eliminated all above-mentioned effects of microgravity.
Based on these results method and device for mechanical stimulation of the support zones of the soles was development, which is used as a countermeasure against motor effects of microgravity and now is under going clinical testing in neurorehabilitation.
SWS.5 Application of New Space Technologies to Rehabilitation of Patients With Stroke and Brain Trauma
V. M. Shklovsky, E. Mamitcheva, and E. Lukyanyuk
Center of Speech Pathology and Neurorehabilitation, Moscow, Russian Federation
Kinesitherapy and physical training are usually used to increase the stability and symmetry of vertical posture. One of the new technologies in kinesitherapy comes from space elaboration and is the Regent antigravity costume, which can dosage and create specific proprioceptive afferentation. Theoretical conception: Stimulation of afferent proprioceptive systems of posture and motion promotes rehabilitation of motor stereotype. Goal: To improve efficiency of neurorehabilitation after stroke and TBI by using the Regent antigravity costume. Participants: 339 patients ranging in age from 22 to 73 years, of which 224 had had ischemic stroke and 115 had TBI with damage of the left hemisphere. All of the patients had right hemiparesis and higher mental disorders, including speech. The costume was applied to patients who could move without assistance or with support. Methods: The treatment course included 10-15 sessions of simple and complicated walking up and down stairs in the Regent costume for 30 to 90 min each per day. To evaluate efficiency, the Bartell scale, stabilometry, EEG mapping, direct current potentials, and neuropsychological tests were used before and after the course. Results: We had improvement in all patients in neurological status and quality of life according to the Bartell scale: they have broadened practical skills of self-service and quality of walking. Increased oral and articulation praxis were observed with 86% of patients. Neuropsychological and neurophysiological data correlated with clinical examination. Conclusion: The method of dynamic propriocorrection (using the Regent space costume) can be an effective addition to rehabilitation programs.
SWS.6 Role of Vegetative Nervous System in Pending and Prognosis for Recovery After Ischemic Stroke
S. B. Shvarkov and Z. M. Mizieva
I.M. Sechenov Moscow Medical Academy (MMA), Moscow, Russian Federation
The significance of the vegetative regulation most evidently manifests during the acute stroke period when the survival rate after the cerebral catastrophe depends on it. The clinical-and-physiological analysis of the clinical course and recovery after stroke carried out on 4200 patients confirmed the extremely important role of the adequate vegetative provision on all stages of the clinical course. The dynamics of the vegetative indices depends on the character, localization and severity of the cerebral defect and does not often correlate with the visually observed clinical finding. The valuation methods of the vegetative regulation through the cardiovascular system acting like a sort of the screen allow for efficient estimate the homeostasis and regulation levels. The involuntary nervous system is the first one who reacts to environment factors and stimulates definite responses.
The modality, strength and repetition of the stimulus as well as the initial state of the system are the essential conditions for obtaining predetermined changes in adequate course of behavioral acts. The proprioceptive stimulation relates to the group of such methods. These methods came to the restorative neurology from the space medicine where their application obtained physiological substantiation. They also confirmed their efficiency for the therapy of postinsult paresis of the limbs in the restorative neurology.
Actions through the cerebral proprioceptive afferent systems are accompanied by poly-system reactions. The therapeutic effect becomes evident in the motor, vegetative, cognitive, emotional-and-affective and other systems. The rapid improvement of the clinical presentation as a response to the stimulation appears in the reduction of the paresis strength and spastic muscular tonus, recovery of the motor walking stereotype and the self-service skills.
Against the background of the proprioceptive stimulation, there is a shift of the indexes towards more optimal involvement of different regulation levels. The influence of the ergotropic systems of the suprasegmental level is reduced, the rates of the sympathetic regulation are improved, the usually depressed indexes of the parasympathotonic level are increased. The improvements of vegetative regulations are already observed after first sessions of the proprioceptive therapy. The prolonged treatment makes the shifts stable and the achieved results remain afterwards without stimulations. At this moment, the progress in the gain of motion is revealed clinically. The clinical-and-physiological analysis displayed the features of the recovery process, the role of the regulation and the most essential markers for the treatment and prognosis for the gain of motion in case of ischemic strokes.
SWS.7 Real and Simulated Micro Gravity: Influence to the Motoric System
I. B. Kozlovskaya and A. I. Grigoriev
Institute of Bio-medical Problems, Moscow, Russian Federation
Deterioration of voluntary movement control is a consistent consequence of space flights as well as hypokinetic experiments. Deep changes in locomotor acts structure, disturbance of upright posture, and increased time and decreased accuracy of motor task performance are always observed even after comparatively short-term exposures to real and simulated hypogravity. The data obtained allowed the suggestion that the support unloading acts as a trigger initiating alteration in the activity of motor control systems under these conditions. The support afferentation is deeply involved in the control of activity of spinal extensor motor neurons. In the absence of support load the tonic motoneuron activity is suppressed significantly so the tone of gravitational muscles decreases, initiating changes in different components of the motor system: muscle afferents and motoneuron entities, reflex and motor control mechanisms, as well as trophic apparatus, whose activity, is also determined by the motoneuronal activity.
S05 Low Awareness
S05.1 Do We Need a New Taxonomy for Diminished States of Consciousness?
H. Binder
Neurologisches Zentrum Otto Wagner Spital, Vienna, Austria
Consciousness is an umbrella term that relies on a bundle of primarily subjective experienced conditions of the world and mental states. The content and definition of consciousness is a common challenge that has long been disputed. More and more improving neurophysiologic and neuroimaging methods give insight into brain functions, attempting to find out what’s behind this certain consciousness. In doing this, we were suddenly confronted with the problem of the ambiguous definition of extension and intention of the term consciousness.
Consciousness is one of the most important vital signs in neurology, because it is assumed to provide evidence of a life-threatening process and therefore is of prime importance regarding therapeutic decisions. At first view, it seems easy to decide about failing consciousness, called coma. However, some evidence exists that creates reasonable doubt. For example, we have to accept that consciousness is an individual self-experienced condition. Apart from coma, a term in place of loss of consciousness as well as full consciousness obvious gradations between these extremes are out of question for outsider. It is under discussion between humanities and natural science if and how to evaluate in a given case.
Medicine usually equates consciousness with alertness, but this is the improper approach. One must be aware of an opinion from the third-person point of view only because of easy measurement. Alas an explicit assignment to accurately defined classes of consciousness seems certainly impossible. Because of ambiguous categorization, we have to proceed rather on the assumption of continuous or gradual class belonging. This is the additional problem of measurement if we are confronted with the question if a patient is comatose and further on regarding the extension and intension of returning consciousness.
There is an error to believe in an existing clinically implementable definition and taxonomy regarding consciousness. Taxonomy is a method, rather a measurement or instrument, for classification of objects of a certain area according to certain criteria. The term classification means grading by reference to definite characteristics. While taxonomy in application of strict standards seems impossible for now, implementable definitions from clinical as well as scientific points of view are urgently necessary.
S05.2 How Much Can Imaging Teach Us About Diminished States of Consciousness?
S. Laureys
Belgium
Recent neuroimaging and electrophysiology studies are illuminating the relationships between awareness and: (i) global brain function; (ii) regional brain function; (iii) changes in functional connectivity; and (iv) primary versus associative cortical activation in response to external stimulation. Is awareness lost when overall cortical activity falls bellow a certain threshold? In the vegetative state, global metabolic activity decreases to about 50% of normal levels—similar to what is observed in sleep, anesthesia and coma. However, it seems that some areas in the brain are more important than others for consciousness. Voxel-based statistical analyses have identified a dysfunction in a wide frontoparietal network encompassing the polymodal associative cortices. Consciousness seems not exclusively related to the activity in the frontoparietal network but, as importantly, to the functional connectivity within this network and with the thalami. In addition to measuring resting brain function and connectivity, neuroimaging studies have identified which brain areas still “activate” during external stimulation in vegetative patients. Studies using external (noxious or auditory) stimulation showed robust activation in subcortical and primary sensory cortex which was however isolated and dissociated from the frontoparietal cortical network. Of clinical importance, this knowledge now permits to improve the diagnosis of patients with disorders of consciousness, which remains very challenging at the bedside. Current technology now also permits to show command-specific changes in EEG or fMRI signals providing motor-independent evidence of conscious thoughts. Such brain computer interfaces now permit communication via voluntary EEG or fMRI control, enabling locked-in patients to control their surroundings and giving a voice to minimally conscious state patients.
S05.3 Drugs, Pain and Survival Time: What Do We Really Know?
N. Zasler
Virginia Commonwealth University, Dept. of PM&R, Richmond, VA, United States; Concussion Care Centre of Virginia, Ltd. and Tree of Life Services, Inc., Richmond, VA, United States; Department of PM&R, Virginia Commonwealth University, Richmond, VA, United States
This lecture will review current evidence based medicine and consensus practice regarding three main clinical issues germane to the management of persons with disorders of consciousness. The first will be the utility of pharmacological agents for enhancement of functional status and facilitation of neurorecovery. A proposed hierarchical approach to drug treatment will be proposed examining the existing literature and theoretical basis for treatment with various drug classes including dopaminergic and noradrenergic agonists for facilitation of arousal, recovery and bradykinesia. Other more “novel” medications including Zolpidem, intrathecal baclofen, modafinil/armodafinil, apomorphine and naltrexone. The second area addressed will be the controversies surrounding pain perception in this patient population and the current recommendations for management. Basic concepts related to defining pain and suffering, as well as the neural correlates of pain will be examined. Issues germane to ongoing controversies surrounding potential for subcortical perception of pain and suffering will be explored. Our current knowledge regarding pain and suffering in persons with DOC will then be reviewed with evidence examined for both VS and MCS. Methodologies for pain assessment in DOC will be discussed including methods to optimize assessment quality, as well as inherent limitations in such exams. Medical, as well as ethical considerations in pain treatment will be delineated. Lastly, the literature regarding life expectancy will be examined as related to both clinical and forensic aspects of importance to clinicians working with this special population of patients following acquired brain injury. Nomenclature issues relevant to biostatistics and the neuroscientific investigation of survival after STBI will also be explored. Biostatistical methods used for determining survival time will be reviewed. The latest evidence-based data on morbidity and mortality survival risk factors after STBI as related to the nature of neurologic and functional impairments will be explored. Clinical as well as forensic issues pertinent to prognosticating survival time will also be enumerated. Current literature (i.e., within the last 5 years) examining life expectancy issues after STBI will also be reviewed. Directions for future research in the aforementioned areas will also be discussed.
S06 Neural Repair in Neurorehabilitation
S06.1 Plasticity Enhancement Opens a Window of Opportunity for Successful Rehabilitation
J. W. Fawcett
Cambridge University Centre for Brain Repair, Cambridge, United Kingdom
Recovery of function after damage to the CNS is limited due to the absence of axon regeneration and relatively low levels of plasticity. It is now possible to reactivate plasticity in the adult CNS with treatments such as chondroitinase, which removes glycosaminoglycan (GAG) chains from chondroitin sulphate proteoglycans (CSPGs). Plasticity in the adult CNS is restricted by perineuronal nets (PNNs) around many neuronal cell bodies and dendrites, which contain several inhibitory CSPGs. Formation of these structures and the turning off of plasticity is triggered by environmental influences and impulse activity in neurons. Expression of a link protein by neurons is the event that triggers the formation of the structures, and animals deficient in link protein continue to demonstrate plasticity in the cortex and elsewhere in the CNS into adulthood.
Treatment with chondroitinase removes PNNs and other inhibitory influences in the damaged spinal cord and promotes sprouting of new connections. However, formation of new connections by itself does not necessarily bring back useful behaviour; this only happens when useful connections are stabilised and inappropriate connections removed. For appropriate new connections to form plasticity must be driven by behaviour. Combining a daily rehabilitation treatment for skilled paw function with chondroitinase produces much greater recovery than either treatment alone. The rehabilitation must be specific for the behaviour that is to be enhanced because non-specific rehabilitation improves locomotor behaviour but not skilled paw function. Plasticity-enhancing treatments may therefore open up a window of opportunity for successful rehabilitation.
S06.2 Signaling Axonal Regeneration in the Adult CNS
M. Filbin
New York, NY, United States; Biology Dept., Hunter College, CUNY, New York, NY, United States
A major impediment to axonal regeneration after injury is inhibitors in myelin. Three myelin inhibitors have been identified in NogoA, MAG and OMgp. One approach to overcome these inhibitors to encourage regeneration is to change the intrinsic state of the axon such that it no longer recognizes these molecules as inhibitory. We have shown that if neuronal cAMP levels are elevated MAG and myelin no longer inhibit axonal growth. This effect is transcription dependent and we have identified 4 very different genes that are up-regulated in response to elevation of cAMP. One of these proteins that is up-regulated is the enzyme Arginase I (Arg I), which is key in synthesis of polyamines. We have shown that the polyamine, putrescine must be converted to spermidine to overcome inhibition and to promote regeneration in vivo. Furthermore, we have shown that spermidine overcomes inhibition by activating the kinase CDK5, though the up-regulation of the CDK5 activator, p35. Up-regulation of p35 is transcription-independent and translation-dependent and requires the spermidine-induced activation of the eukaryotic initiation factor, eIF5a, by hypusination. Another protein that is up-regulated with cAMP is secretary, leukocyte, protease inhibitor (SLPI). SLPI overcomes inhibition by MAG and myelin in a dose-dependent manner. In addition, DRG neurons from animals that received SLPI intrathecally for 24 hours also are not inhibited by MAG and myelin when subsequently cultured. SLPI also promotes optic nerve regeneration when injected intraocularly at the same time as the optic nerve is crushed. Recently we showed that MAG-induces the phosphorylation of Smad2, which is necessary for inhibition. Interestingly, SLPI enters the neuron and accumulates in the nucleus, where it suppresses expression of Smad2. This in turn decreases the amount of Smad2 that is available for phosphorylation by MAG and so blocks inhibition.
S07 Dysphagia
S07.1 Rehabilitation of Dysphagia: The Need to Change Strategies
R. Nusser Muller Busch
Unfallkrankenhaus Berlin, Germany
This contribution considers the principles underlying approaches to rehabilitation of adult patients with acquired neurogenic dysphagia and explores the role of implicit knowledge (familiar, everyday experience).
There are three important issues:
1. Those patients with severe dysphagia (in acute stage or chronic) have compromised airways. They are liable to aspiration—and because of this recognised danger—may be NPO/Nil by Mouth, receiving enteral or parenteral nutrition.
2. They may or may not understand verbal instructions. Even if they do understand spoken language, they often are unable to carry out consciously contrived compensation strategies (e.g. Mendelsohn Maneuver) intended to protect the airway, because of impaired sensation and lack of voluntary control of movement.
3. Such compensatory maneuvers are anyway novel and unusual: they are not intuitive and are very different from the automatic swallowing of saliva, food and liquid that adult patients will have practised frequently for a number of years.
We all learn by doing. Movements and activities of daily living, such as eating, drinking, swallowing, and speaking, are learned implicitly. Later the facio-oral functions are used throughout the entire day, (mostly) without thinking about them, consciously.
The objective is to focus on the coordination and the integration of facio-oral functions in nutrition, oral hygiene, nonverbal communication and speech within the therapy situation. Furthermore, the need to change learning and therapy strategies is reflected—from using (explicit) verbal cues to the use of tactile and visual (implicit) cues and situation based motor learning for changing behaviour.
S07.2 A Computational Model of the Central Pattern Generator and Cortical Swallowing
N. Rueffer
Otto-Fricke-Krankenhaus, Bad Schwalbach, Germany
Swallowing is characterized by a sequence of motor events which is controlled in part by the central pattern generator of swallowing localized in the Ponto-Medullary region of the brain stem (CPGS). It is a predominant few in aphasia research that neural control systems for iterative movement like swimming, walking or breathing (iterative CPGs) can serve as a model for the CPGS.
We will discuss some facts challenging the assumption that iterative CPGs are an appropriate model for the CPGS: the swallowing system generates a motor temporal sequence that has—with the exception of mastication—no iterative structure; sensory integration of bolus properties can only in part be explained with change of frequency (modulation); the serial order of the swallowing sequence is not invariant and is influenced by sensory integration of bolus properties: it is only partially fixed, it varies with bolus properties and it varies with the bolus position.
In contrast to the iterative model, we propose a processing model of motor planning and control for swallowing that is based on two fundamental principles, which are not swallowing specific: motor coordination and motor learning. Neurological control of swallowing is based on a combinatory motor temporal planning process that is constrained by biomechanical and functional factors and includes activations of stored motor temporal patterns.
We understand the CPGS as a motor memory, being the result of ontogenetic development of swallowing motor coordination to improve bolus transit efficiency in combination with improvement in airway protection leading to a long-term storage of motor temporal patterns.
Cortical swallowing motor processing integrates the output of the CPGS motor memory into a superior planning process. This opens a window for swallowing rehabilitation.
S07.3 Neurophysiological Swallowing Therapy: Results and Goals
R. O. Seidl
Klinik für Hals-Nasen-Ohrenkranheiten, ukb, Berlin, Germany
Our understanding of the motor rehabilitation process has led to a wider perspective and broader thinking, regarding swallowing therapy. We are familiar with patients who, thanks to spontaneous recovery, are quickly able to learn to swallow again. There are other patients, however, who, due to severe neurogenic disorders, have limited swallowing capability. They are hardly able to or cannot follow verbal, cognitive, instructions at all. These patients require therapy methods which take all aspects of their condition into account. This knowledge has led to the development of new, neurophysiologically determined methods in dysphagia treatment. In this lecture, contemporary evidence (physiological basics, study results) are summarized for determining future goals within dysphagia therapy.
S08 Health Economics in Neurorehabilitation
S08.1 Economic Factors in Neuro Rehabilitation in the Asian Region
L. Li
Division of Rehabilitation Medicine, University Department of Medicine, Tung Wah Hospital, Hong Kong, China
More than 50% of population of the world resides in the Asian region. The economic conditions among the Asian countries varied widely from well-developed to developing countries. Despite the social and cultural aspects, the economic factors in various Asian countries also affect the practice in neurorehabilitation. This could be exemplified by the survey done recently on the care of patients with Spinal Cord Injury among the Asian countries, including Brunei, Bangladesh, Cambodia, China, Taiwan, Hong Kong SAR, India, Indonesia, Iran, Japan, Laos, Malaysia, Philippines, South Korea, Thailand and Vietnam. The GDP (nominal) per capita of these countries varies from US$ 521 to 38,972. The health care systems in these countries are, in principle, covered by public sector and to various extend mixed with private insurance. An observational trend from the survey was that there was a lack of facilities, trained physicians and therapists in provision of neurorehabilitation in the low-income countries. Hospital facilities for neurorehabilitation in these countries are limited and instead community-based rehabilitation programs existed with emphasis on using local resources to enhance the function of the neurologically disabled. On the other hand, the high income countries with health funding from public and private health insurance, the service provided covered comprehensively at the both hospital and community level. However, with the recent economic growth in some developing countries in Asia and health reform proposing by various countries, the impact of economic factors affecting the model of health-care delivery is more obvious with a trend developing a balanced care at the hospital level with an early discharge and carry-on rehabilitation at the community level.
S08.2 Coverage Policies for Neurorehabilitation: An International Comparison
M. Weinrich1 and M. Stuart2
1Bethesda, MD, United States, 2University of Maryland, Baltimore County, Baltimore, MD, United States
Rehabilitation services provided to patients ultimately depend upon coverage policies, i.e., reimbursement for services. This lecture will present an international comparison of coverage policies for neurorehabilitation services. Data will be drawn from the published literature, government documents, and responses to a brief survey questionnaire. Particular attention will be devoted to how insurers and governments make decisions regarding coverage, the availability of data to guide policy makers, and the implications for researchers interested in rehabilitation. Challenges and potential benefits inherent in international comparisons of rehabilitation services and health financing will be illustrated using examples from the authors’ first-hand experiences.
S08.3 Rehabilitation for Stroke: A Case Study in the Challenges and Benefits of International Comparisons
M. Stuart
Baltimore, MD, United States
Challenges and potential benefits inherent in international comparisons of rehabilitation services for stroke will be illustrated, using comparisons from Switzerland, the United States, and Italy. The importance of examining the structure, process, and outcomes of care, as well as financing policy, will be discussed. The importance of rehabilitation for the chronic phase of stroke is illustrated by an innovative strategy to provide Adapted Physical Activity for stroke survivors (APA-stroke), a low-cost ongoing community-based program, being implemented in Italy and the U.S. In Italy this program uses private gyms, with oversight from the rehabilitation service and coordination with general practitioners. Exercise classes are held two to three times a week for one hour in local gyms. Social support reinforces participation. Our Italian community study demonstrated that APA-stroke is safe and efficacious in improving walking speed, balance and social participation.
PL02 MAIN SYMPOSIUM: Sense and Nonsense of Evidence Based Neurorehabilitation
PL02.1 Enhancing Motor Recovery
A. Dromerick
Washington, DC, United States
Abstract not received as per date of printing. Please check the conference website www.wcnr2010.org for possible updates.
PL02.2 Aphasia and Dysarthria Rehabilitation
P. Enderby
United Kingdom
Communication problems are profoundly disabling with individuals who have speech and language problems feeling that they are robbed of their personality. The principles of rehabilitation of speech and language disorders fits well with the International Classification of Functioning as this recognises the importance of addressing not only the impairment but also communication ability, psychosocial consequences and the impact on well-being of both the person and their carer.
The holy grail of evidence-based rehabilitation is rightly pursued by most of us. However it is important to recognise the constraints and restrictions of randomised controlled trials in being the only evidence base for driving forward improved interventions for speech and language disorders.
Systematic reviews can be useful in drawing together the riches of research, making results accessible and summarising evidence; however, it is important to consider that many studies, particularly small scale studies are excluded from these reviews. Considering those studies that are included we must realise that more patients are excluded than included in trials, they tend to address the decontextualised issues, complex interventions are often poorly described and there is frequently poor theoretical underpinning.
Benchmarking studies of the outcomes of patients being treated by speech and language therapists demonstrate great variability in type and quantity of improvement. Given this information along with the generic findings of systematic reviews it is possible to consider particular issues which influence impact of therapy. These include: the timing of therapy, the type of treatment, the amount of treatment, use of technology and the skills of the therapist.
Rehabilitation integrates the scientist with the believer. Speech and language therapy for people with dysarthria and dysphasia whilst driven by our current objective knowledge is also based on a philosophy that states that there are always ways to help our patients even when traditional approaches are exhausted.
PL02.3 Cognitive Rehabilitation
P. J. Eslinger
Penn State Hershey Medical Center, Hershey, PA, United States
Brain-based disorders are the leading cause of disability worldwide and throughout the lifespan. The associated prevalence of brain-based cognitive disorders has created a need for effective cognitive rehabilitation to reduce the burdens and costs of cognitive disability.
This presentation will focus on three controversies in cognitive rehabilitation that are important constraints on identifying and applying effective treatment protocols.
1. Identifying What can be Effectively Rehabilitated. Cognitive rehabilitation can be geared to improving (i) behavior, (ii) cognitive processing, (iii) knowledge structures, (iv) emotion-related processes, and/or (v) surrounding environmental resources. Remediation generally requires multi-level analysis and several treatment approaches. Where does current research and practice indicate a clinician can be most successful in effecting functional change?
2. Finding the Right Fit of Intervention to Deficit. There is a current lack of standardized pathways that guide a clinician from identifying a patient’s deficits to specific treatment protocols. Yet this is a critical phase of treatment standardization. A related constraint is the minimal comparative analysis of treatment protocols.
3. Objective Assessment of Change. Valid and sensitive indices of functional improvement are lacking. What are the most important outcomes that predict return to independence and productivity, and how are they best assessed?
While there is partial information with regard to resolving these controversies, solutions will be attainable with well-designed research and development of clinical practice guidelines.
S09 Stroke
S09.1 Is There a Changing Pattern of Stroke With New Acute Treatment Strategies (e.g. Thrombolysis)?
M. Brainin
Austria
Abstract not received as per date of printing. Please check the conference website www.wcnr2010.org for possible updates.
S10 Brain-Computer Interfaces
S10.1 Non-Invasive Brain-Computer Interfaces: Scope and Limits
G. Curio
Neurophysics Group, Dept. of Neurology, Charité, Berlin, Germany
A major motivation for developing brain-computer interfaces (BCIs) is to support people who are paralyzed. If their brains are uninjured (as in cases with tetraplegia due to late ALS or high spinal cord lesions), they can still plan body movements and even try to execute them. The goal of BCI systems is to use such preserved mental capacities to make up for lost physical abilities. The principle works in three steps: 1) brain activity is recorded during a period of intended movements; 2) user-specific computer programs extract ‘thought-related’ patterns from this data; and 3) the patterns are categorized to control technical devices such as motorized wheelchairs, text programs, and possibly even body-moving exoskeletons.
Many BCI strategies are being explored, including conventional non-invasive EEG recordings, invasive electrocorticography, and intracortical recordings from hundreds of single neurons. These options will enable future BCI users to decide on their personal balance between innocuous but moderately precise non-invasive systems and the higher precision of invasive decoding systems carrying risks of intracranial bleeding and infection.
One non-invasive approach is the Berlin Brain-Computer Interface (www.BBCI.de): Its machine-learning algorithms use diverse EEG signs of intended movements such as slow ‘readiness-potentials’ and movement-related attenuation of EEG ‘idling rhythms’ in brain motor areas. Studies of long-term amputees and posttraumatic quadriplegic patients show that such motor EEG signs are usually preserved when they try to move a ‘phantom limb’. Cognitive BCI-commands can comprise ‘mental rotation’ of a manipulandum or the online detection (and correction) of BCI operation errors. BCI feedback settings include controlling computer cursors, ‘mental typewriters’, gaming applications, virtual prostheses, and—beyond motor rehabilitation—neuroergonomic applications. A recent step towards a realistic BCI application outside of a laboratory is the development of easily manageable EEG systems (no gel, no pressure), based on new concepts of miniaturised or, resp., capacitive electrodes.
S10.2 Turning Thoughts Into Action: Neural Interface Systems to Restore Movement in Humans With Paralysis
J. P. Donoghue
Providence VA Medical Center, Brown Institute for Brain Science, Brown University, Providence, RI, United States
Spinal cord injury, ALS, stroke or amputation leads to an interruption of neural signals from the brain to subcortical structures or to the body with few options to restore function. A neural interface (NI) system, also called a brain computer interface, has the potential to physically reconnect the brain to assistive technology in order to restore independence, communication, as well as movement to those with paralysis. A neural interface system can provide a physical bridge from motor control areas to computers, robotic limbs or muscles (via functional electrical stimulation). Early-stage clinical trials of a pilot intracortical human neural interface system, BrainGate (Caution: Limited by U.S. law to investigational use), show that imagined actions lead to modulation in spiking and local field potential signals in motor cortex years after paralysis onset. Further, the four participants with tetraplegia tested so far (ALS, Stroke or SCI) can use spiking as a control signal for continuous control of a computer cursor. The NI system incorporates a novel 4 x 4 mm intracortically implanted array of 100 microelectrodes that detects neural activity patterns related to intended actions. Signal processors outside the body decode movement intent from neural patterns to generate commands. Participants have demonstrated the ability to use these signals to operate computers and robotic limbs. Recent advances have further demonstrated the ability to provide point and click control more than 3.5 years after implantation, indicating that longlasting intracortical interfaces can be achieved, although signal stability across days can vary. A prototype, fully implantable sensor has also reached preclinical testing. These early-stage developments suggest that NI systems may become a major rehabilitation advance for individuals with paralysis. They also demonstrate the ongoing functionality of motor areas despite damage to motor pathways, which has implications for stroke therapies.
S10.3 Brain-Computer-Interfaces (BCI) in Neurorehabilitation: Communication in Paralysis and Stroke
N. Birbaumer1,2, L. G. Cohen3, A. R. Murguialday1, A. Gharabaghi4, and W. Rosenstiel5
1Institute of Medical Psychology and Beh. Neurobiology, Tuebingen, Germany, 2IRCCS—Ospedale San Camillo, Venezia, Italy, 3NIH, NINDS, Bethesda, MD, United States, 4Dep. of Neurosurgery, Tübingen Univ. Hospitals, Tuebingen, Germany, 5Dep. of Computer Engineering, Tuebingen, Germany
Brain-Computer-Interfaces (BCI) translate electric, magnetic and metabolic brain activity without any motor system activation into signals for a computer and external devices such as neuroprostheses. Reconstruction and classification of complex movements from single cell spike trains, Electrocorticograms from epidural recordings and from EEG/MEG were possible. Application to clinical conditions are few, mostly single case studies. Our laboratory applied BCI from EEG to 40 completely paralysed patients with Amyotrophic Lateral Sclerosis. EEG-BCI worked successfully in most patients and allowed direct brain-communication and letter spelling. Only patients in the completely locked-in state did not learn to use a BCI successfully despite implantation of electrodes in the patients’ brain. New data using classical conditioning of brain activity will be presented and provide hope for communication even in the completely locked-in-state. In chronic stroke without residual movement two controlled studies of our lab will be discussed, showing successful rehabilitation of reaching and grasping with EEG/MEG/ECoG-BCI.
Supported by the Deutsche Forschungsgemeinschaft (DFG), The Bernstein Network on Computational neuroscience of the German Ministry of Education and Research (BMBF) and an European Science Foundation (ESF) grant.
S11 Chronic Pain Management: Updates
S11.1 Pathophysiology and Treatment of Neuropathic Pain
A. H. Dickenson
Dept. Pharmacology, University College, London, United Kingdom
The key criteria for neuropathic pain would be damage or disease to a defined nerve. Damage to a nerve leads to sensory loss—the incidence of spontaneous pain, allodynia and hyperalgesia indicate marked changes in the nervous system that are possible compensations for the sensory loss. Neuropathic pain thus arises from initiating changes in the damaged nerve which then alter function in the spinal cord and the brain located at a number of sites.
Nerve damage increases the excitability of both the damaged and undamaged nerve fibres, neuromas and the cell bodies in the dorsal root ganglion through changes in ion channels. These peripheral changes are substrates for the ongoing pain and the efficacy of excitability blockers such as carbamazepine and lignocaine.
Within the spinal cord, there are increases in the function of calcium channels and the NMDA receptor for glutamate that trigger wind-up and central hyperexcitability. Increases in transmitter release, neuronal excitability and receptive field size result. Ketamine acts on central spinal mechanisms of excitability whereas gabapentin/pregabalin modulate a subunit of calcium channels responsible for the release of pain transmitters into the spinal cord.
In addition to these spinal mechanisms of hyperexcitability, spinal cells participate in a spinal-supraspinal loop that involves parts of the brain involved in affective responses to pain but also engages descending systems that use the monoamines. Descending excitatory pathways become more active after nerve injury whereas inhibitions seem to fail. These systems are the site of action of anti-depressants. Indeed, these central systems may well be the basis for the co-morbidities after neuropathy as well as interacting with opioid mechanisms.
This better understanding of the multiple mechanisms of neuropathic pain should lead to a more effective use of existing drugs and possible novel therapies.
S11.2 The Biopsychosocial Model of Chronic Pain Management
R. Gatchel, N. P. Penson, and J. G. Penson
Department of Psychology, College of Science, The University of Texas, Arlington, TX, United States
The biopsychosocial model is now widely accepted as the most heuristic perspective to the understanding and treatment of chronic pain disorders. This model views physical illnesses such as pain as the result of the dynamic interaction among physiologic, psychological, and social factors, which perpetuates and may even worsen the clinical presentation. Such a comprehensive model of the biopsychosocial interactive processes involved in pain can be quite complex. The goal of this presentation is to provide a review of the major breakthroughs in recent years concerning the basic neuroscience processes of pain (the bio part of biopsychosocial), as well as the psychosocial factors. Indeed, neuroscience research has made major inroads into better understanding basic neural and biochemical mechanisms involved in pain processing. In addition, the emergence of the biopsychosocial model has led to the development of the most effective approach to the management of chronic pain—the interdisciplinary pain management approach. This approach embraces the fact that the comprehensive assessment-treatment of all these dimensions is needed in order to be effective. Such an approach has been demonstrated to be the most therapeutic and cost-effective means of managing the often recalcitrant chronic pain syndromes. Future breakthroughs in the understanding of such biopsychosocial mechanisms will lead to even greater understandings in the areas of etiology, assessment, treatment, and prevention of chronic pain. The role of the genetic factors is also an especially promising new area of research that should provide even greater insights into etiological mechanisms of pain that may account for important individual differences in the pain experience and one’s response to it.
S11.3 Neuromodulation for Pain and Other Nervous System Disorders: History and Frontiers
J. P. Prager
Center for the Rehabilitation of Pain Syndromes (CRPS) at UCLA, Los Angeles, CA, United States
Neuromodulation, the field of implanting devices in the nervous system to control pain, movement dysfunction, and other disorders of the central nervous system, has made significant advances in the current decade. New medications have been discovered, studied, approved and are in use. Microprocessor technology has advanced with greater programming sophistication to enhance reaching new and complex targets. Functional Magnetic Resonance imaging (fMRI) provides significant information regarding potential CNS targets and measures of change. New rechargeable systems now facilitate treatment of problems that previously were untreatable due to high power requirements producing premature battery failure. Clinicians can now manage the patients rather than attempting to manage battery life. Behavioral evaluation is becoming progressively sophisticated to provide better prognostic capability in terms of both pain relief and functional improvement in the chronic pain patient. This session will update the congress participants in the wide ranging progress that is occurring in the field of neuromodulation.
S12 Parkinson’s and Neurodegenerative Diseases
S12.1 Gait Rehabilitation in Parkinson’s Disease
A. Nieuwboer
Belgium
Walking remains possible throughout the course of Parkinson’s disease (PD) but is often severely affected. Therefore, gait rehabilitation takes up a central role in the management of PD. Falling, gait impairment and cognitive decline are clustered within the PD phenotype of PIGD (Postural Instability and Gait Disorder). Freezing of gait (FOG) is one of the characteristic problems of PIGD and manifests itself as: 1) a breakdown of walking during turning or 2) a faulty initiation of gait. Recent work highlights that FOG is possibly associated with an exaggerated executive dysfunction and particularly with a highly deficient shifting ability. Our own work confirms that loading both the cognitive (dual tasking) and the motor system (turning) increases the odds for FOG-episodes.
Like in other neurological conditions, recent evidence supports the use of treadmill training for gait rehabilitation in PD. Treadmill training allows high level intensity of exercise and therefore has the potential to improve over-ground stepping and cardiovascular capacity. While this treatment has a role especially in the early stages of the disease, in the later stages cued gait training may be indicated. Cueing implies making use of sensory stimuli and attention to optimize gait performance and has been shown to be particularly effective in PD. Interestingly and contrary to current clinical thinking both dual tasking and turning have been shown to be trainable with and without cues in PD. Freezing is less amenable to cueing and our recent research shows that cognitive strategies are more effective. Additional work suggests that using sensory feedback and watching a video on preventing FOG are beneficial strategies for ameliorating freezing. We conclude that effective gait rehabilitation in PD not only requires intensity-driven intervention but also strategy-training addressing the interface of motor and cognitive function.
S12.2 Repetitive Transcranial Stimulation in the Rehabilitation of Movement Disorders
J. Rothwell
UCL Institute of Neurology, London, United Kingdom
A large number of studies have shown that rTMS can produce long lasting changes in the excitability of cerebral cortex that outlast the period of stimulation. Some of these effects are thought to be due to LTP- and LTD-like changes in synaptic efficiency in cortical circuits. Given this background, a number of studies have asked whether application of rTMS might improve motor function in patients with movement disorders on the basis that it may assist other parts of the motor system to compensate better for the primary pathology. The analogy would be with Parkinson’s disease in which it is well known that the system can compensate well for loss of 70-80% of nigral dopamine neurones.
The majority of work has been carried out in Parkinson’s disease. Single session studies have shown that high frequency (excitatory) rTMS over motor cortex can transiently improve movement speed. Two studies with repeated application of rTMS over several days have shown sustained improvement of symptoms in both treated and untreated cases. However the gains are little better than the effects of optimal L-Dopa therapy. More interestingly there is evidence that inhibitory rTMS over M1 or SMA might be a useful way to reduce the impact of l-dopa induced dyskinesias, although further studies are needed.
The situation in other movement disorders is less clear. There have been single session studies reporting some improvements in dystonia and tremor. Longer term, but overall mild, benefits have been seen after premotor cortex rTMS in dystonia, and there is one report of some success in Tourette’s syndrome (although single session studies were ineffective).
In conclusion, the evidence so far indicates that the therapeutic effects of rTMS in movement disorders are limited.
S12.3 Dysautonomia in Neurodegenerative Disorders
I. Bodis Wollner
Department of Neurology, State University of NY, Downstate Medical Center, Brooklyn, New York, NY, United States
The autonomic nervous system regulates unconscious body functions, including heart rate, blood pressure, temperature regulation, skin resistance (Bach et al 2009), gastrointestinal secretion, papillary responses and metabolic and endocrine responses to stress. The regulation involves multiple organs and both the cholinergic and catecholamine systems. Based on pathophysiological/anatomical data in Neurodegenerative Diseases (NDD) by Braak and colleagues (2007) and in vivo imaging studies it appears that Autonomic Dysfunction (AuDys) is part of most NDDs.
AuDys may significantly impair quality of life in both ambulatory and hospitalized patients. The autonomic effects of medications used for other purposes need to considered in addition to the underlying NDD.
AuDys may precede by years the so-called cardinal motor symptoms of Parkinson Disease (PD), dementia with Lewy bodies (DLB) and multiple system atrophy (MSA). A cure for NDDs does not exist. Hence early AuDys diagnosis may contribute to the evaluation of potential early neuroprotective therapy.
Exercise and dance may improve mobility and mentation. Animal studies suggest that they may also provide neuroprotection. Unfortunately AuDys restricts the use of some of these promising rehabilitation methods. In particular, orthostatic hypotension and orthostatic intolerance can result in an array of disabilities leading to resistance by some to exercise and dance. Current management of AuDys is symptomatic.
However imaging research elucidated some pathophysiological mechanisms of AuDys symptoms. For instance cardiac parasympathetic dysfunction in NDD is better understood. Research of AuDys may contribute to better diagnosis, lead to “designer” treatments. and open safer avenues of rehabilitation for NDD patients.
S13 Music in Neurorehabilitation
S13.1 Music as a Biological Language of the Human Brain: Implications for Neurorehabilitation
M. H. Thaut
Colorado State University, Fort Collins, CO, United States
The human brain is a multiple language generator. Mental representations—i.e. thoughts—in the human brain operate in multiple language systems, e.g, words, numbers/quantities, and images/percepts. Music is an abstract nonverbal auditory language system that is based on the innate ability to think, perceive, and create sound patterns in complex syntactical rule systems. Evidence for this ability emerges in prehistorical discoveries of musical instruments as early as 40,000 years ago. The ability to communicate via singing may be much older. The arts may actually have contributed significantly to the foundational cognitive ability of the modern human brain to think fluidly in abstraction and develop symbol systems.
Recent neuroscience research in music suggests that the neural systems underlying music are not unique to music but serve general nonmusical functions in regard to linguistic processing, motor control, attention, memory, and executive functions. Thus we can postulate that music can affect general cognitive and motor functions subserved by these brain systems via mechanisms of neural plasticity. Based on this model, a significant number of clinical research projects has indeed substantiated that music can effectively contribute to the rehabilitation of perception, cognition, and motor function via the same mechanisms.
Encoded in the new treatment model of Neurologic Music Therapy (NMT), music can now be considered a clinical modality with considerable evidence for its effectiveness in rehabilitating disorders of the human nervous system. In addition of discussing the scientific bases for NMT, the presentation will also provide a survey of clinical research data in NMT and neurorehabilitation.
S13.2 From Singing to Speaking: Observations in Healthy Singers and Patients Recovering From Nonfluent Aphasia
G. Schlaug1, A. C. Norton2, S. Marchina1, L. Zipse1, C. Wan1, R. Baars2, and L. L. Zhu2
1Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, United States, 2Beth Israel Deaconess Medical Center, Boston, MA, United States
The neural processes that underlie post-stroke language recovery, particularly in non-fluent aphasic patients, remain largely unknown and thus, have not been specifically targeted by aphasia therapies. Two possible pathways to recovery exist; one is through reactivation of perilesional areas in the left hemisphere while the other involves the activation and possibly re-organization of homologous language regions in the right. Because of its potential to engage/unmask language-capable brain regions in the unaffected right hemisphere, Melodic Intonation Therapy (MIT), is well-suited for facilitating language recovery in non-fluent aphasic patients, particularly those with left-hemisphere lesions encompassing large portions of the left frontal (including Broca’s region) and superior temporal lobe. Behavioral and neuroimaging data of patients undergoing an intense therapy program suggest significant improvements in measures of speech output (e.g., more meaningful words/min and increased phrase length) that are correlated significantly with functional and structural imaging changes in a right-hemispheric fronto-temporal network. Furthermore, intensive MIT treatment leads to significant gains in speech production that can be maintained after therapy most likely due to long-lasting functional and structural changes in a right-hemisphere speech-production network.
S13.3 Learning to Play Piano Supports Fine Motor Rehabilitation After Stroke
E. Altenmüller1, S. Schneider1, J. Marco-Pallares2, and T. Münte3
1University of Music and Drama, Hannover, Germany, 2Otto von Guericke University, Magdeburg, Germany, 3Otto v. Guericke University, Magdeburg, Germany
Background and Purpose: In previous studies, it was shown that just three weeks of piano training can induce neuronal representations of skilled finger movements activated by auditory stimulation. In this study, we examined whether this kind of auditory-sensorimotor integration can improve rehabilitation of motor functions following a stroke.
Methods: For this purpose, we evaluated a music-supported training program designed to induce an auditory-sensorimotor co-representation of movements in 32 stroke patients (17 affected in the left and 15 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. As a control, 30 stroke patients (15 affected left and 15 right) undergoing exclusively conventional therapies were recruited. Behavioral pre- and post-treatment motor functions were monitored. Event-related desynchronization and synchronization (ERD/ERS) and event-related coherence from all 62 subjects performing self-paced movements of the right index finger (MIDI-piano) were recorded.
Results: 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. Neurophysiological data showed a significantly larger decrease of EEG signal (power) before time of movement onset in the music-supported training group in the post training register as compared to the control group. The music-supported training group presented a most pronounced enhancement of coherence after the training compared to the control group, especially in the drums conditions.
Conclusion: This innovative therapeutic strategy is an effective approach for the motor skill neurorehabilitation of stroke patients.
S14 Functional Recovery and Translational Research After Stroke
S14.1 Postural Control and Recovery After Stroke: Pathophysiology and Implications for Rehabilitation
A. C. Geurts and V. Weerdesteyn
Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands; St Maartenskliniek, Nijmegen, Netherlands
Insight into the mechanisms underlying balance recovery is necessary to improve rehabilitation for different types of stroke. Yet, longitudinal studies dealing with balance recovery are restricted to rehabilitation inpatients with a unilateral supratentorial stroke. In most cases, quiet stance stability improves, as well as the ability to compensate for external and internal body perturbations and to control posture voluntarily. Although there is evidence of true physiological recovery of the paretic leg in postural control, particularly during the first three months post stroke, substantial balance recovery occurs even when there are no signs of improved support functions or equilibrium reactions exerted through the paretic leg. This type of functional recovery can take much longer than 3 months. Compensatory balance-correcting activity through the non-paretic leg seems to be essential for functional recovery. Indeed, several cross-sectional studies of chronic stroke patients have shown that the non-paretic leg not only bears a greater amount of body weight, but also contributes much more to equilibrium control than the paretic leg. This ‘dynamic asymmetry’ is generally greater than the difference in static weight bearing, which implies that asymmetry in weight bearing is an adequate compensatory strategy to make equilibrium control through the non-paretic leg more effective. In addition, improved trunk control as well as sensory and cognitive adaptation processes may underlie functional balance recovery beyond the period of physiological recovery of the paretic leg. Remarkably, very little information is available about the role of stepping responses as an alternative to equilibrium reactions for restoring the ability to maintain upright stance after stroke. This limits our understanding of falls after stroke, because falls typically occur only when stepping responses fail. Despite a considerable number of intervention studies, no definitive conclusions can be drawn about the best approach to facilitate the natural recovery of standing balance following stroke.
S14.2 Does Knowledge From Non-Invasive Plasticity Assessment Tools Translate Into Better Practice?
V. Hömberg
Germany
Abstract not received as per date of printing. Please check the conference website www.wcnr2010.org for possible updates.
S14.3 Understanding Functional Recovery After Stroke: Where Are We Now and How to Proceed From Here?
G. Kwakkel, on behalf of the EXPLICIT-stroke consortium (www.explicit-stroke.nl)
VU University Medical Centre and UMC Utrecht, Amsterdam, Netherlands
In this specific morning session related with ‘meeting the professor’ existing knowledge about the predictability of the time course of motor and functional recovery after stroke will be reviewed and discussed. At this moment, there is substantial evidence that we are able to modify the natural pattern of functional recovery by early started intensive task-oriented rehabilitation management, however the impact of learning-dependent and intrinsic spontaneous neurological recovery responsible for the observed non-linear improvements in motor skills post stroke are still poorly understood. At least 4 probably interrelated mechanisms are identified that drive motor and functional recovery after stroke. These mechanisms include: 1. salvation of penumbral tissue early post stroke; 2. elevation of diaschisis; 3. neuroplasticity; and 4. behavioral compensation strategies. These mechanisms underlying recovery are not single-acting, but probably highly interactive, operating at different, sometimes limited, time-windows after stroke onset. Due to the absence of a uniform definition of neuroplasticity, it is important to distinguish between ‘true’ neural repair, by restitution of affected neural systems, and behavioral compensation strategies, by substitution of affected systems. Although behavioral compensation strategies rely on adaptive neuroplastic changes in the brain as well, one needs to distinguish between restitution and substitution of functions to understand what and how stroke patients exactly learn during their rehabilitation from perspective of the ICF framework. In line with these mechanisms of recovery a neurobiological model for understanding skill acquisition is presented and emphasis is given for translational research to improve our knowledge about what and how patients learn when they show functional improvement after stroke.
S15 Neglect
S15.1 Neglect in the Acute State: Clinic and Anatomy
H. Karnath
Center of Neurology, University of Tuebingen, Tuebingen, Germany
Spatial neglect is a frequent phenomenon in stroke patients with acute right hemisphere damage. Patients with spatial neglect demonstrate a remarkably strong and consistent bias of spontaneous activity towards the right, ipsilesional side of space. These patients show a spontaneous deviation of eyes and head towards the ipsilesional side and thus ignore objects located on the contralesional side. The talk will address recent developments in the clinical diagnosis of the disorder as well as its underlying anatomy.
S15.2 Prognoses and Treatment Strategies in Neglect
G. Rode, S. Jacquin-Courtois, J. Luaute, P. Revol, D. Boisson, and Y. Rossetti
Université de Lyon, Université Lyon 1, Inserm UMR-S 864, Bron, and Hospices Civils de Lyon, Service de Rééducation Neurologique, Hôpital Henry Gabrielle, Route de Vourles, F- 69230 St Genis Laval, France, Lyon, France
A large proportion of right-hemisphere stroke patients exhibit unilateral neglect, a neurological condition characterised by deficits for perceiving, attending, representing, and/or performing actions within their left-sided space. Unilateral neglect is responsible for many debilitating effects on everyday life, for poor functional recovery, and for decreased ability to benefit from treatment.
This space oriented behaviour disorder is most frequent after damage to the parietal cortex of the right hemisphere, centred around to the inferior parietal lobule (BA 39 and 40), or the white matter anatomical pathways connecting parietal and frontal cortex. The parietal lobe constitutes a sensori-motor interface between space representation and action, involving two levels of representation: a sensorimotor and a cognitive level with interactions between them.
According to level of representation primarily implied, two tracks may be distinguished in rehabilitation of neglect: First, the “top-down” approach requiring active participation of the patient under the guidance of a therapist. The most common approach of this type is visual scanning therapy in which the patient is continually instructed to move the gaze leftward into the neglected space. Second, the “bottom-up” approach not requiring active or conscious participation of the patient, but manipulating stimulus characteristics, sensory input, or the brain directly in an attempt to alter the interhemispheral attentional imbalance. Examples of this approach include vestibular stimulation of the left side, sensory activation of the left limb, eye patching, prism adaptation and TMS of the overactive left hemisphere. Lastly good results with a long-term improvement of neglect and disability were also reported when both rehabilitation approaches have been associated.
S15.3 Guidelines for Neglect Rehabilitation
S. Clarke
Service de Neuropsychologie et de Neuroréhabilitation, CHUV, Lausanne, Switzerland
Unilateral hemineglect is characterised by lack or decrease of attention to stimuli and events in one hemispace following a contralateral hemispheric lesion. In the chronic stage neglect concerns mostly the left hemispace, involves one or several modalities and compromises the activities of daily living and independence of the patient.
Many of the current approaches to neglect rehabilitation are based on cognitive models which postulate i) attentional gradients within each hemispace with differential roles for each hemisphere; ii) role of spontaneous eye movements in originating attention; iii) multimodal representations sustained by parieto-prefrontal networks; or iv) dopaminergic modulation of attention. Several techniques yielded statistically significant improvement measured mostly at the impairment level, more rarely at the disability level. The evidence comes from prospective randomised and non-randomised group studies as well as single and multiple single case studies. A recent Cochrane study analysed 12 randomized controlled trials and confirmed effectiveness at impairment level; the evidence is, however insufficient to support or refute their effectiveness at reducing disability and improving independence (Bowen and Lincoln 2009). There is currently great need for large, multicentre, randomized controlled trials to explore further the promising results demonstrated at the level of impairment.
S16 Neuropharmacology
S16.1 Amphetamine Trials
L. B. Goldstein
Duke University and Durham VA Medical Center, Durham, NC, United States
An extensive series of experiments in laboratory animals show that the short-term administration of d-amphetamine can lead to an enduring enhancement of functional recovery after focal injury to the cerebral cortex. These experiments also show that factors such as drug dose, timing and frequency of administration and concomitant behavioral experience are critical, presenting a challenge for the design of clinical trials intended to determine whether treatment with amphetamine similarly enhances poststroke recovery in humans. The small, underpowered clinical trials conducted to date vary considerably in critical aspects of their designs and are largely negative. For example, the time between stroke onset and treatment, the dose and preparation of the drug, the interval between treatment sessions, the number of sessions, the timing and intensity of physiotherapy, the timing and type of outcome assessments, and other aspects of study design have largely been arbitrarily chosen. Of the 7 trials that have been published, only one has suggested benefit. Systematic evaluation of factors that modulate amphetamine’s putative effect on recovery will be needed to determine whether the approach is clinically useful.
S16.2 Current Status of Neuroprotection After Stroke
M. D. Ginsberg
University of Miami Miller School of Medicine, Miami, FL, United States
Neuroprotection for ischemic stroke refers to strategies, whether applied singly or in combination, that antagonize the injurious biochemical and molecular events that result in irreversible ischemic injury. Three decades of investigative work have defined multiple mechanisms and mediators of ischemic brain injury, which constitute potential targets of neuroprotection; and rigorously conducted experimental studies in animal models of brain ischemia have provided incontrovertible proof-of-principle that high-grade protection of the ischemic brain is an achievable goal. The recent explosion of interest in this field is reflected in over 1000 experimental papers and several hundred clinical articles appearing within the past several years. Nonetheless, many agents have been brought to clinical trial without a sufficiently compelling evidence-based pre-clinical foundation. A recent literature survey (Ginsberg, Neuropharmacology 2008;55:363-389) identified approximately 160 clinical trials of neuroprotection for ischemic stroke. Of the approximately 120 completed trials, two-thirds were smaller early-phase safety-feasibility studies. The remaining one-third were typically larger (>200 subjects) phase II or III trials; but, disappointingly, only fewer than one-half of these administered neuroprotective therapy within the 4-6 hour therapeutic window within which efficacious neuroprotection is considered to be achievable. This fact alone helps to account for the abundance of “failed” trials. This presentation will present an overview of the most extensively evaluated neuroprotective agents and classes and will consider the strengths and weakness of the pre-clinical evidence as well as the results and shortcomings of the clinical trials themselves. Areas of emphasis will include: promising ongoing approaches (e.g., high-dose albumin therapy, hypothermia); the wisdom of combining reperfusion strategies with neuroprotective agents; the therapeutic window for successful neuroprotection and whether it can be extended by imaging-based patient selection; how the translational path for drug-discovery through pre-clinical development to clinical trials might be improved; and whether the search for successful neuroprotectants should emphasize the targeting of specific mechanisms of action.
S16.3 Is There a Future of Neuroprotection?
D. Muresanu
Romania
Abstract not received as per date of printing. Please check the conference website www.wcnr2010.org for possible updates.
PL03 MAIN SYMPOSIUM: Robotics in Clinical Practice—Pro-Con Statement Session
PL03.1 Controversies in Rehabilitation Robotics
H. I. Krebs1,2,3 and W. Z. Rymer4,5
1MIT—Massachusetts Institute of Technology, Cambridge, MA, United States, 2Weill Medical College of Cornell University, White Plains, NY, United States, 3University of Maryland School of Medicine, Baltimore, MD, United States, 4Rehabilitation Institute of Chicago, Chicago, IL, United States, 5Northwestern University, Chicago, IL, United States
Rehabilitation Robotics is a highly promising technology, whose application has shown benefit in several disabling neurological illnesses, particularly in stroke. There are also promising signs that robotics will be useful for treating cerebral palsy, multiple sclerosis, spinal cord injury, and traumatic brain injury as well. While benefits are measurable, the central problem we face is our uncertainty about the appropriate way to use these devices and their potential limitations. We do not understand how to optimize therapy to a particular patient’s need and to maximize the magnitude of long-term improvements resulting from robotic use.
While we agree that the understanding of recovery following a stroke is imperfect and that environmental manipulation is one important tool in neural recovery, we disagree on how to most effectively deploy this technology and develop an optimal framework for training the injured brain or spinal cord. Should we apply the technology in small incremental steps hand-in-hand with our growing understanding of the neuroscience and the neuro-rehabilitation process or should we be bolder and over reach deploying the technology to perhaps foster faster scientific growth? These issues will be discussed.
PL03.2 Pro-Con Statement Session: Con
Z. Rymer
Milwaukee, WI, United States
Abstract not received as per date of printing. Please check the conference website www.wcnr2010.org for possible updates.
S17 Health-Related Quality of Life Following TBI
S17.1 What Do We Mean by Health Related Quality of Life?
M. Bullinger
University Medical Center Hamburg-Eppendorf (UKE), Department for Medical Psychology, Hamburg, Germany
Health related quality of life denotes the patients’ perception of well-being and function in physical, emotional, mental, social and everyday life areas. The term stems from sociological, psychological and anthropological research and has only recently been adapted in medicine. Here it is frequently used as an outcome criterion in clinical studies to evaluate the effect of different therapies on the patient, but also in epidemiological studies as well as health economic research. Approaches to assess quality of life include patients’ self-report versus report by other persons, multidimensional versus unidimensional assessment of well-being and function as well as the use of generic versus condition specific methods.
Since the past 20 years instruments to assess health related quality of life have been developed for adults as well as for children. These instruments comply with psychometric standards concerning the reliability, validity and sensitivity of the scales. They are increasingly used in research (e.g. in clinical trials, epidemiological studies, health economic evaluations) as well as in the practical context (individual patient documentation, quality assurance in health care organisations, medical decision making). More recently condition specific measures have also been developed for neurological diseases and specifically for neurorehabilitation. For adults this includes the work of the quality of life in brain injury group (QOLIBRI). In children, the DISABKIDS group has developed condition-specific modules for children with epilepsy and cerebral palsy. These instruments are examples for quality of life tools, which have been tested and validated cross culturally for use in neurology and neurorehabilitation.
The quality of life area has developed as a major innovation in medicine in terms of including the patients’ perspective not only implicitly in the patient-physician interaction, but also explicitly to incorporate an important dimension with diagnosis, treatment, and quality assessment of care: The patients’ perceptions of his or her own health.
S17.2 Quality of Life After Brain Injury (QOLIBRI): Scale Metrics, Validity and Correlates of Quality of Life
N. von Steinbüchel1, K. v. Wild2, H. Gibbons1, L. Wilson3, M. Bullinger4, A. Maas5, E. Neugebauer6, J. Powell7, G. Zitnay8, J. Truelle9, and the QOLIBRI-Taskforce (international)
1Department of Medical Psychology and Medical Sociology, Georg-August-University, Goettingen, Germany, 2Department of Neurosurgery and Early Neurotraumatological Rehabilitation, Clemens Hospital, Westfalian Wilhelms University of Münster, Münster, Germany, 3Department of Psychology, University of Stirling, Stirling, Germany, 4Department of Medical Psychology, University Hospital Eppendorf, Hamburg, Germany, 5Department of Neurosurgery, University Hospital, Antwerp, Germany, 6IFOM, Private University of Witten/Herdecke, Köln, Germany, 7Goldsmiths College, Department of Psychology, London, United Kingdom, 8Association Martha Jefferson Hospital, Charlottesville, VA, United States, 9Service de Medicine physique et réadaption, C.H.U. Raymond-Poincaré, Garches, France
The QOLIBRI is a novel disease-specific health-related quality of life (hrQoL) instrument specifically developed for traumatic brain injury (TBI) that provides a profile of QoL in six domains with 37 items together with an overall score. It was simultaneously and cross-culturally developed in six languages, and an additional six are currently being validated.
Psychometric properties and factors associated with hrQoL of two international studies will be reported. A total of 1528 and 921 adults with TBI were enrolled (between 3 months to 15 years post-injury). The majority of participants (58%) had severe injuries as assessed by 24-hour worst GCS.
The QOLIBRI scales meet standard psychometric criteria (internal consistency, α= .75 to .89, test-retest reliability, r tt=.78 to .85). Test-retest reliability (r tt= .68 to .87) as well as internal consistency (α= .81 to .91) was also good in participants with lower cognitive performance. The QOLIBRI was developed and validated by exploratory and confirmatory factor analyses and Rasch modelling.
Systematic relationships were observed between QOLIBRI and GOSE, HADS, and SF-36. Within each scale participants with disabilities reported having low QoL in two to three times as many areas as those who showed good recovery. The main correlates of a total QoL score were emotional state (depression and anxiety), functional status (amount of help needed and outcome on the GOSE), and comorbid health conditions. Together these five variables accounted for 58% of the variance in total QoL scores.
The QOLIBRI is the first tool to measure multi-nationally disease-specific health-related QoL after TBI. It assesses novel information not given by other currently available instruments especially valuable to monitor neuro-rehabilitative processes.
S17.3 Health Related Quality of Life
K. von Wild
Dept. of Neurosurgery, Medical Faculty WWU, Münster, Germany
Brain damage can have disastrous consequences for the human brain and the individuals functioning when mental- cognitive and behavioural disabilities are more persistent and constitute more of a handicap than do focal neurological signs. B. Jennett (1975) asked, “In the context of brain damage it is fair, however, to ask, when a life is saved, whether it is a life worth living?” [in: B. Jennett (ed.) Outcome of severe damage to the CNS 1975, p. 6, Ciba Foundation publishers, Basel]. Jennett and Bond introduced their Glasgow Outcome Scale Score (GOS) to assess and measure neuropsychological functioning outcome in addition to survival and physical skills. Physical and mental disabilities combine to produce a social or overall outcome. However, GOS and GOS extended both scores do not reflect the individuals Health Related Quality of Life (HRQOL).
The World Health Organisation (WHO) defined health as a state of complete physical, mental and social well being, and not merely the absence of disease or illness. This definition implies that health is made up of multiple dimensions, including physical, emotional, social, economic and spiritual aspects, and that its qualities can and should be measured. TBI specific HRQOL instruments include patients’ self-report versus report by other persons do not exist so far that could be applied for comparative socio-medical and epidemiological outcome studies.
Participants will learn and know at the end of S17.1What do we mean by health related quality of life (Prof. Dr. Monika Bullinger, University Hospital Hamburg-Eppendorf, Institute for Medical Psychology); S17.2. Quality of Life after Brain Injury (QOLIBRI)—a TBI specific assessment tool (Nicole von Steinbüchel, Professor of Medical Psychology and Medical Sociology University Medical Centre, Gottingen). S17.3 Cross-culture similarities and differences (Leonard Li, Division of Rehabilitation, Tung Wah Hospital, University of Hong Kong)
S17.4 Health Related Quality of Life (HRQoL) Following Traumatic Brain Injury: Cross Culture Similarities and Differences
J. July1, S. Indharty2, F. Senjaya1,3, M. Inggas1,3, and E. J. Wahjoepramono1
1Dept. of Neurosurgery, Medical faculty Universitas Pelita harapan, Siloam Hospital Lippo Village, Tangerang, Indonesia, 2Department of Neurosurgery, Medical Faculty Universitas Sumatera Utara, RS Adam Malik, Medan, Indonesia, 3Department of Neurosurgery, Medical faculty Universitas Air Langga, RS Dr. Sutomo, Surabaya, Indonesia
Moderate and Severe Traumatic Brain Injury often result in physical and mental health problems, and also contribute to social burden. Even mild brain injury could bring several health problems that will not diminish with time. We collect data from four centre of neurosurgical services, three of them are teaching hospitals. Only 30 male patients with moderate brain injury from each service were included. The respondent needs to be reachable by phone, at least 6 months after injury and willing to do the interview. The data are coming from Medan (North Sumatera) representing the Bataknese, Surabaya (East java) representing the Maduranese and Javanese, Bandung (West Java) representing the Sundanese, and others representing the Malays, Chinese, etc. We use the 36 item Short Form Health Survey (SF-36) to measure the HRQoL. All scales from SF-36 show lower scores for the injury group compare to controls (normal). The Bataknese ethnic group shows less tolerable to bodily pain than others (42 ± 23 Vs 65 ± 31), also in general their physical health is lower than other ethnicities after TBI. Family support may play an important role for patient mental health. Overall, the patients’ mental health from this survey is high (82 ± 11), and the control group even less (78 ± 15), probably because of more attention from family to the patients after the accident (culture).
S18 Current Thinking: Aphasia and Dysarthria
S18.1 Current Thinking in Aphasia
R. A. Varley
Department of Human Communication Sciences, The University of Sheffield, Sheffield, United Kingdom
Assessment and intervention for aphasia has shown major development over the last two decades. Within the framework provided by The World Health Organisation, there have been advances in rehabilitation of aphasia at the level of impairment, activity, and participation, together with understanding of the importance of contextual factors such as conversational partners and barriers to communication within the environment. Impairment approaches to aphasia have been dominated by psycholinguistic models that break down language behaviours into sub-component processes. These approaches have resulted in increased diagnostic specificity and development of controlled assessments of lexical and grammatical language function. However, despite major advances in understanding of the neural mechanisms of speech and language gained from functional brain imaging studies, impairment-level approaches to aphasia have continued to address the cognitive-behavioural level, with little consideration of the neurobiological systems underpinning language. This may lead to less than optimal therapeutic strategies. For example, while neural systems are characterised by massive interconnectivity, psycholinguistic models have emphasized the autonomy of sub-processes. As a result, word production impairments might be treated through various output tasks. By contrast, a neurobiologically-inspired approach might note the importance of mirror neuron mechanisms that link sensory-perceptual and output motor systems. As a result, sensory-perceptual stimulation tasks will result in priming of output representations and subsequent improvements in naming.
The value of adding a neurobiological perspective to impairment therapies for aphasia will be explored in a number of areas. Key issues examined are the importance of intensive, massed practice therapy and how use of information technology allows therapy to be delivered in intensive but cost-effective ways; how errorless learning strategies may enhance therapeutic outcomes; a focus on procedural rather than declarative learning strategies, and how a neurobiological perspective has implications for other intervention strategies, such as early use of total communication strategies in activity-based therapies.
S18.2 Current Thinking in Dysarthria: Incorporating New Technologies
B. Murdoch
Australia
For many years clinicians have relied almost exclusively on auditory perceptual judgements of speech intelligibility, articulatory accuracy and subjective ratings of various speech dimensions on which to base their diagnoses of dysarthric speech and plan appropriate intervention. Although perceptual analysis will always remain an essential component of the assessment protocol, it is now evident that perceptual assessments possess a number of inherent inadequacies that limit their ability to guide therapeutic intervention for dysarthria. In particular, perceptual assessments when used alone are unable to provide reliable and valid information as to the pathophysiological basis of the speech disorder. For this reason, recent years have witnessed the development and introduction of a range of physiological techniques to supplement perceptual analysis to more clearly define treatment goals based on a better understanding of the physiological basis of dysarthric speech. A number of these physiological instruments have also been utilized directly in the treatment of dysarthria by way of physiological biofeedback rehabilitation. Recently, a neurophysiological technique called transcranial magnetic stimulation (TMS), which can be used to non-invasively modulate brain activity, has been used in the treatment of dysarthria and to examine the integrity of the corticobulbar tracts in dysarthric speakers. The proposed lecture will describe the major advantages and limitations of perceptual assessments and describe examples of major physiological instruments introduced to improve accuracy of the diagnosis of dysarthria and to better inform treatment planning. Examples of the use of these instruments to provide physiological biofeedback for the treatment of dysarthria will be described. Relevant literature relating to the use of TMS in the treatment of dysarthria and as a tool for elucidating the pathophysiology of dysarthria will be reviewed. The need for clinicians to incorporate physiological and neurophysiological procedures into the assessment and treatment of dysarthria will be emphasized.
S19 Medical Law and Ethics
S19.1 Do Different Religion Beliefs Affect Medical Ethics?
S. J. Baloyannis
Aristotelian University, Thessaloniki, Greece
Medical ethics is the offspring of the amalgamation and harmonization of the modern biomedical technology, with the ethical, philosophical, social and religious principles and beliefs of the society. From the medical point of view medical ethics are imposed by the development of various medical strategies and sophisticated procedures, aimed at sustaining and supporting the human life, mainly in its physical, biological, and functional aspects. From the philosophical point of view, medical ethics have been directly or indirectly influenced by the empiricism, the utilitarianism, the liberalism, the skepticism and individualism. From the point of view of the religion medical ethics are mainly theological rather than philosophical or utilitarian. They serve the integrity and the respect of the human being, as well as the divine economia rather than the interest of the productivity of the human society. The anthropological consideration in the main religions starts from the data of revelation, whereas medicine and science is limited to the present condition of the human nature and tries to ameliorate the quality of the terrestrial life. Theology, generally speaking, incorporates within its scope the quality of the interior life of the soul and the life in eternity of the human being. Most religious doctrines concerning human personhood are based on the mystery of the interpenetration of spirit and matter and the spiritual transfiguration of human beings by the uncreated energies of God. Therefore, the theological background of medical ethics is mainly based on the ultimate meaning of human existence, which is found in the spiritual expectation for eternal life, reflecting therefore the intrinsic value of human life in God. It is well concluded by the main religions, that the moral and spiritual values, which should be respected in all considerations in the area of medical ethics must include (a) the sacral character of human life, which is to be acknowledged and preserved from conception to the grave and beyond, (b) the deep respect of the human being (c) the belief that each human being is the recipient of the infinitive love of God and (d) the concept that the beneficial love of God is the origin and the basis of every human relationship, which reasonably provides ultimate meaning to human existence. These values determine the attitude of the main religious beliefs toward procedures and protocols within the spectrum of medical ethics.
S19.2 Pharahonic Concept for Neurorehabilitation: Historical Remarks and Results
M. R. Awad
Egypt
Abstract not received as per date of printing. Please check the conference website www.wcnr2010.org for possible updates.
S19.3 From Kos to Vienna: Is the Hippocratic Oath Still Valid?
F. Gerstenbrand1,2,3 and S. Huber1
1Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Vienna, Austria, 2Research Group on Neuroethics of the World Federation for Neurology, Vienna, Austria, 3SIG for Neuroethics of the Word Federation for Neurorehabilitation, Vienna, Austria
In the third millennium everyone in the Western industrial society demands that all possibilities of modern medicine have to be available, everyone expects to be relieved of his physical or mental illness and wants that all advances in research are being applied immediately to grant him a longer life. The modern human claims his right to be treated everywhere and any time, even in advanced age and demands his presumed right to have access to all resources of a social welfare system.
Bound by the Hippocratic Oath every physician is obliged to heal. He has to treat the diseases of his patient, but has to interrupt the treatment of a patient who suffers from incurable illnesses. To prolong the life over hours and days in untreatable conditions using special therapeutic measures is not justifiable. The physician has the obligation to heal but as well as to reduce suffering. The maxim never to hurt and always to help has until nowadays carried a great normative weight. The patient has to be informed about all details of his disease and the foreseen diagnostic and treatment programme, and he has to decide if his relatives shall be informed. In state of “unable to consent” the solicitor hat to get the information. Every patient has the right to refuse the planned diagnostic and treatment programme as well as to interrupt such programmes, detailed informed by the physician about all related consequences for his health.
In the Declaration of the World Medical Association, Helsinki 1964, and in the UNESCO Bioethics Declaration on Human Rights, Paris 2005, all details of Hippocratic principles are included, changing the Hippocratic principles to demands with all legal consequences, also obligatory to clinical trials.
Hippocrates’ suggestion “to respect the teacher like his own parent” nowadays is mostly an open recommendation.
S20 Future Perspective for Neurorehabilitation
S20.1 Special Neuro-Rehabilitation for Elderly People?
A. Giustini1,2 and M. Panourgia3
1Italy, 2Rehabilitation Hospital San Pancrazio-S.Stefano Group, Arco(Trento), Italy, 3Expermental Pathology Department, University of Bologna-Casa di Cura del Policlinico, Milano, Bologna, Italy
It is well known that average life expectancy has increased worldwide during the last century: in developed countries, average life expectancy has increased from 46 years in 1955 to 66 years in 2005 with an increase up to 75 years projected for the year 2050, while developing countries, since 1950 have enjoyed a 23-year gain in life expectancy (from 41 to 64 years).
The mean age of incidence and prevalence of neurological disorders, in particularly stroke, reflects the average life expectancy increase and more often in rehabilitation divisions we have to treat a large number of old and very old patients. On the other hand we have increasing problems with chronic neuro-degenerative situations with many, and severe, disabilities for these elderly persons.
Old and very old patients admitted in neuro-rehabilitation departments are often affected by a variety of different chronic-degenerative diseases such diabetes, osteoarthritis, vascular or Alzheimer dementia.
The comorbidity grade of these patients frequently represents a major obstacle for the rehabilitation project and it is very important in order to determine the final goals of the rehabilitation treatment. In addition, geriatric subjects have less physical strength than young adults and they are not able to sustain (and to receive advantages) long/intensive rehabilitation sessions. In elderly people the aims for rehabilitation too are different, for the person, the family and also for the service and the community.
Therefore a new approach (scientific, management,clinical, treatment modalities etc. ) is needed for the elderly in Neuro-Rehabilitation, which must respect the individual specific needs, possibilities, resources and goals to realize suitable and effective rehabilitation care for these persons.
S20.2 Minimizing Undernutrition in Older Inpatients
A. B. Ward
North Staffordshire Rehabilitation Centre, Haywood Hospital, Stoke on Trent, United Kingdom; University Hospital of North Staffordshire, Stoke on Trent, United Kingdom
Poor nutrition following health conditions affecting the nervous system has broad ramifications in all aspects of functioning. Not only does it lead to the obvious physical consequences of weight loss, poor tissue viability and increased risk of inter-current illness, such as infections, it has a profound effect on cognition, mood and behaviour. So, why is it allowed to happen in hospitals across the world? There is good evidence of the calorie requirements following brain and spinal cord injury and of the need for increased nutritional intake, but, as people get older, their ability to utilise food changes after serious illness. Moreover, it is possible that their ability to cope with neurologically-induced dysphagia also changes.
The effect of this may, in part, be due to mood changes and to the direct effect of protein and lipid catabolism, but outcomes are poor unless properly addressed through a multidisciplinary team. Nurses, dietitians and doctors have an important role and developing clinical pathways for the management of swallowing and nutrition is probably the best way to ensure that the correct systems are in place to ensure that elderly people can mount an adequate response to their rehabilitation programme.
S20.3 Neurologists Perspective
V. Hömberg
Germany
Abstract not received as per date of printing. Please check the conference website www.wcnr2010.org for possible updates.
S21 Traumatic Brain Injury
S21.2 One Year Follow Up in TBI and the Role of Rehabilitation
K. von Wild, in cooperation with the Hannover/Münster TBI Study Council
Medical Faculty University of Münster, Münster, Germany
Objective: To review quality management and deficits of functional neurorehabilitation in patients after acute traumatic brain injury (TBI).
Methods: Prospective controlled, population based, multiple centre study on epidemiology and quality management after acute TBI in Germany. Analysis of functional neurorehabilitation and one- year outcome. Follow up by telephone interview of the individual and/or relatives. Catchments areas of inhabitants 2,114 million.
Results: 6.783 acute TBI (58% male). 28% patients were < 1 to 15 years, 18% > 65 years of age. Incidence was 321/100.000 TBI. GCS: 91% mild, 4% moderate, and 5% severe TBI. 5.221 TBI (= 77%) were hospitalised; 1,4% of them died. One year follow-up statistics of 63.5%. Although 778 TBI ( 11.5% of all) are admitted for intensive care only 100 patients (= 1.3% TBI respectively 39% of all neurorehabilitation patients) are treated for early neurorehabilitation (Phase B). All together 258 patients (=3,8% of all TBI, respectively 4.9% of hospitalized TBI ) receive an in- hospital neurorehabilitation (73% male), 68% within one month after injury; 5% are <16 years, 25% >65 years; diagnose of TBI in 10.9%, moderate in 23,4%, and mild in 65.7%. GOS at the end of neurorehabilitation: 1 = 1.7%, 2 = 1.7%, 3 = 21.6%, 4 = 35.8%, and 5 = 39.2. After one year 883 of 4283 TBI patients (20.6%) complain about posttraumatic troubles, about one half is 64 years old or older. Out of 4200 TBI 3.8% can only partially cope with ADL; 2.8% fail when compared with the pre traumatic situation.
S21.3 Long-Term Outcome After Traumatic Brain Injury
C. Hawley
Warwick Medical School, Coventry, United Kingdom
There is substantial literature regarding the problems associated with serious traumatic brain injury (TBI). Studies which have followed patients beyond one year post-injury indicate that these problems can be both persistent and disabling. Longer-term studies have found that some people fare better than others and this paper will discuss outcomes for different populations of TBI survivors. Firstly, predictors of long-term outcome will be explored; secondly, the capacity for positive psychological growth after TBI will be assessed; and finally very long-term outcomes after TBI among military personnel will be discussed.
A large-scale UK study of 603 adult TBI patients examined predictors of early and late outcome. All patients were recruited by 10 specialist centres delivering post-acute rehabilitation. All were interviewed face-to-face and assessed using the Glasgow Outcome Scale (GOS) at first interview, and 566 (93.9%) were subsequently assessed by GOS up to 30 years post-injury. At final follow-up, 35% had severe disability, 45% moderate disability and 18% good recovery. Early and late outcomes on GOS were associated with duration of post-traumatic amnesia (PTA), Glasgow coma score (GCS), abnormal CT scan, neurosurgery, presence of haematoma. Early rehabilitation was significantly associated with positive outcomes.
Positive psychological growth was measured for a cohort of 165 survivors of TBI over 10 years post-injury using the Positive Changes in Outlook Questionnaire (CiOP) and a structured questionnaire. Two thirds had residual disability measured by the GOS (26% severe disability; 44% moderate disability; 30% good recovery). However, presence of disability did not preclude psychological growth. Over half the survivors demonstrated positive growth on the CiOP by agreeing with items such as “I don’t take life for granted anymore”, “I value my relationships much more now”. Early referral to rehabilitation was associated with positive psychological growth.
Finally, a group of military personnel who had received intensive rehabilitation following TBI completed questionnaires 30 years post-injury. Implications for TBI survivors of modern conflicts are discussed.
S22 Treatment of Spinal Cord Injury
S22.1 Treatment of Spinal Cord Injury
K. von Wild
Dept. of Neurosurgery, Medical Faculty WWU, Münster, Germany
Paraplegia means a lifelong sentence of sensory loss, paralysis and dependence.
Complete spinal cord lesions cannot heal in human beings up to now despite intensive experimental research, remarkable efforts and recent achievements in neurorestoratology, bio-technology and re-engineering (1-3). The incidence of SCI is about 30 to 50 per million inhabitants, for Europe about 300.000 paraplegics and in every country between 1000 and 1800 new cases per year with an increasing number of tetraplegics. Traumatic paraplegia is related to the socio-economical situation of the population. Most dramatic is the exponential rise in SCI because of gunshot wounds in regions and countries of social- economic conflicts without access to adequate social-medical healthcare facilities and rehabilitation. Sixty percent of all SCI are injured before age 30. More than 90% of the victims may survive with nearly normal experience of life when put in a wheelchair for the rest of their life. Cross-cultural differences in rehabilitative interventions became obvious. Most patients will recover functionally to some extent over the first year(s). No patient who remained ASIA A (complete loss of motor and sensory functions) for one year will recover to a certain useful extent. Immediate and repeated neurological assessment by an SCI expert is crucial for guiding the acute treatment and rehabilitation as to improve the functional outcome and social re-entry.
Participants will learn from the experts and know at the end of the secession .1 the scenarios of spinal cord repair ( B. Zörner), .2 spinal cord repair: promises and challenges (V. Dietz), and .3 the standard and advanced assessments in SCI (A. Curt).
1.http://www.ianr.org.cn/English/new.asp?id=1067
2.Bejing Declaration of International Association of Neurorestoratology IANR (2009) Cell Transplantation, Vol.18, 487
3.von Wild, K (2009) IANR Deklaration von Peking. Neurologie und Rehabilitation 3, 210-11
S22.2 Scenarios of Spinal Cord Repair
B. Zörner and M. E. Schwab
Brain Research Institute, Zurich, Switzerland
Highly disabling, life-long consequences of spinal cord injury (SCI) in humans include paralysis, loss of sensation and spasticity. In subjects with SCI and in animal models spontaneous recovery can be observed after incomplete lesions. In the absence of long-distance regeneration, short-range sprouting of lesioned and spared fibers probably contributes to spontaneous recovery of motor functions. Blockade of Nogo-A, the most potent known neurite outgrowth inhibitor in the adult central nervous system, induced long-distance regeneration of lesioned fibers and enhanced anatomical plasticity in spared fiber tracts. In rats with SCI, early treatment with Nogo-A blocking antibodies significantly improved function in behavior tasks such as locomotion, swimming or grasping. Importantly, incidence and severity of spastic cramps were reduced after treatment. Manual dexterity of adult monkeys that received an incomplete cervical spinal cord injury improved remarkably after anti-Nogo-A antibody treatment. In collaboration with Novartis, a human anti-human Nogo-A antibody was generated and a clinical trial in acutely injured victims of spinal cord injury is currently ongoing in a European and a North American network of spinal cord injury centers.
S22.3 Spinal Cord Repair: Promises and Challenges
V. Dietz
Spinal Cord Injury Center, University Hospital Balgrist, Zürich, Switzerland
During the past few years, several approaches to spinal-cord repair have been successfully established in animal models. For their use in trials of spinal-cord injury (SCI) in human beings, specific difficulties that affect the success of clinical trials have to be recognised (Dietz and Curt, 2006; Dietz, 2008).
First, transection of the spinal cord is commonly applied in animal models, whereas contusion, which generally leads to injury in two to three segments, represents the typical injury mechanism in human beings. Second, the quadrupedal organisation of locomotion in animals and the more complex autonomic functions in human beings, challenge translation of animal behaviour into recovery from SCI in people. Third, the extensive damage of motor neurons and roots associated with spinal-cord contusion is not addressed in current translational studies. This damage has direct implications for rehabilitation strategies and functional outcome. Fourth, there is increasing evidence for a degradation of neuronal function below the level of the lesion in chronic complete SCI. The relevance of this degradation for a regeneration-inducing treatment needs to be investigated. Fifth, the prerequisites to enable appropriate reconnection of regenerating tract fibres in a postacute stage have still to be established.
Dietz V, Curt A (2006) Neurological aspects of spinal cord repair: Promises and challenges. Lancet Neurology 5:688-694.
Dietz V (2008) Ready for human spinal cord repair? Brain 131: 2240-2242.
http://neurology.thelancet.com Vo15 August 2006
S22.4 Standard and Advanced Assessments in SCI
A. Curt
Spinal Cord Injury Center, University of Zürich, Switzerland
Clinical recovery after spinal cord injury (SCI) can be attributed to mechanisms of functional compensation, neural plasticity and/or repair as has been established for other disorders of the central nervous system (CNS), i.e. stroke. The application of advanced neurophysiological assessments targeted to distinguish between changes within longitudinal and segmental pathways aims for complementing the clinical evaluation. By combined clinical and neurophysiological assessments the relative impact of each of these mechanisms has been explored in a large prospective European multi-centre study in acute traumatic SCI subjects. The combined examination of functional (activities of daily living and ambulatory capacity) and neurological (sensory-motor deficits) measures related to assessments of spinal conductivity (motor- and somato-sensory evoked potentials) followed over 12 months revealed that functional recovery to a large extent occurs by compensation, both in complete and incomplete SCI. But probably also neural plasticity will contribute to some degree to a greater improvement in SCI. Extensive or obvious repair of damaged spinal pathways could not be disclosed, i.e. no signs of re-myelination of delayed evoked potentials. The provided combined assessments might be applicable to estimate treatment effects and to prove biological activities related to drugs or implanted cells (OEC, bone marrow or neural stem cells) as being proposed by preclinical studies and translated into novel interventions in human SCI.
S23 Neuropsychological Rehabilitation: Theory, Therapy and Outcomes
S23.1 Theories of Neuropsychological Therapies
B. Wilson
United Kingdom
Neuropsychological rehabilitation is concerned with the amelioration of cognitive, emotional, psychosocial and behavioural deficits caused by an insult to the brain. Practising neuropsychologists working in adult brain injury rehabilitation use a range of theoretical approaches in their clinical work. In 2002 Wilson published a model of rehabilitation arguing that rehabilitation is one of many fields needing a broad theoretical base incorporating frameworks, theories and models from many different areas. Being constrained by one theoretical model can lead to poor clinical practice. This presentation considers some of the theories and models which have had the most influence on neuropsychological rehabilitation. Included are theories and models of cognitive functioning, learning, assessment, emotion, recovery and plasticity as well as broad based models such as holistic and social models including the “Y-shaped model” by Gracey et al (2009). We also consider how models influence our clinical work both directly and indirectly.
S23.2 Therapeutic Interventions in Neuropsychological Rehabilitation
F. Gracey
Cambridge Centre for Paediatric Neuropsychological Rehabilitation and Oliver Zangwill Centre, Cambridge, United Kingdom
Recent studies and reviews provide evidence in support of the effectiveness of holistic neuropsychological rehabilitation, especially in terms of longer term psychosocial outcome. However, the complexity of this type of intervention is a particular challenge to generation of evidence-based practice guidelines, and a range of models and approaches to guide intervention is required. In order to attempt to address this challenge, we will summarise the key characteristics of holistic neuropsychological rehabilitation interventions. We see these as involving delivery by a specialist interdisciplinary team within a therapeutic milieu to individuals, groups and family members of people with brain injury. Development of skills and strategies across emotion regulation, cognition, communication and physical domains is required. These skills and strategies must be practiced and consolidated in the context of meaningful functional activity to help maximise the client and family’s social participation. Outcomes in this approach explicitly address not only social participation goals but also awareness and identity change. We present selected cases illustrating specific interventions to address cognitive, communication and emotional consequences of brain injury within a holistic programme. We describe the application of the Y-shaped model (Gracey et al, 2009) of rehabilitation to show a method for synchronising specific interventions across the interdisciplinary team so as to facilitate awareness, emotional and social adjustment and social participation.
S23.3 Measuring Outcomes in Neuropsychological Rehabilitation
A. Bateman
Oliver Zangwill Centre for Neuropsychological Rehabilitation, Ely, United Kingdom
Effective neuropsychological rehabilitation impacts on the individual’s cognitive, emotional, psychosocial and behavioural outcomes. It also impacts upon the family (e.g., hopefully reducing carer strain) and wider societal systems (e.g., demands on services). Evaluating benefit of interventions remains challenging because there are not available measures that encompass all of these domains. For this reason, multiple measurement models are appropriate, with a need to consider the benefit to the individual and their wider system. At the Oliver Zangwill Centre we have found it helpful to collate findings across test items, populations of clients and to use multiple domains. Through this findings have emerged that can guide future interventions and research priorities.
In this presentation a range of outcomes will be considered—from an individual’s goal attainment, through psychological self-reported outcomes, to changes in group functioning. The place of modern statistical techniques in supporting our evaluations is emphasised.
S24 Update on CRPS
S24.1 History, Clinical Presentation and Pathophysiology of CRPS
R. Baron
Division of Neurological Pain Research and Therapy, Department of Neurology, Kiel, Germany
Complex regional pain syndromes (CRPS, reflex sympathetic dystrophy, causalgia) are painful disorders that develop after trauma affecting a limb with (type I) or without (type II) nerve injury. Clinical features are pain (spontaneous, hyperalgesia), impairment of motor function, swelling and autonomic abnormalities (changes in sweating and blood flow).
Pain and sensory abnormalities: Spontaneous pain and various forms of hypo- and hyperalgesia at the distal extremity are generated by processes of peripheral and central sensitization and changes in the central representation in the thalamus and cortex. The negative somatosensory signs are explained by central inhibitory processes rather than by degeneration of neurons.
Autonomic abnormalities: A central unilateral inhibition of cutaneous sympathetic vasoconstrictor neurons leads to a warmer affected limb in the acute stage. Secondary changes in the neurovascular transmission and an endothelial damage induce vasoconstriction and cold skin in chronic CRPS.
Pathophysiology of SMP: Cutaneous sympathetic outflow to the painful extremity was experimentally activated to the highest possible physiological degree. The intensity and area of spontaneous pain and mechanical hyperalgesia increased considerably in patients with SMP but not in SIP patients. A pathological interaction between sympathetic vasoconstrictor and afferent neurons within the affected skin is the likely explanation.
Motor abnormalities: During finger tapping of the affected extremity, CRPS patients showed a significant reorganization of central motor circuits, with an increased activation of primary motor and supplementary motor cortices. Furthermore, the ipsilateral motor cortex showed a markedly increased activation. When the individual amount of motor impairment was introduced as regressor in the fMRI analysis, activations of the posterior parietal cortices, SMA and primary motor cortex were correlated with the extent of motor dysfunction. Substantial adaptive changes within the central nervous system may contribute to motor symptoms in CRPS.
Reference: Jänig W, Baron R. Lancet Neurol. 2003;2:687-97.
S24.2 The Rationale for Functional Restoration
R. Harden
Center for Pain Studies, Rehabilitation Institute of Chicago, Northwestern University, Chicago, IL, United States
Complex Regional Pain Syndrome (CRPS) can be a very difficult condition to treat successfully. Not only is the syndrome biomedically multifaceted, comprising both central and peripheral pathophysiology, but it also frequently contains psychosocial components that are additional pivotal diagnostic features (and thus, treatment targets). The array of possible patient presentations and the fact that the presentation often changes over time also complicate successful identification and treatment.1 To further add to the clinical challenges of managing CRPS, the epidemiology and natural history of CRPS are only superficially known; evidence concerning CRPS treatment has developed slowly, due in large part to the vagaries of diagnosis and, moreover, research data— when they are available—are challenging to interpret.2 Given these obstacles to diagnosis, treatment, and research, how is a specialist to embark on a path towards the successful treatment of such a complicated and partially understood condition? The only treatment methodology that can possibly successfully span these gaps in medical science is a systematic and orderly interdisciplinary approach.3 Interdisciplinary treatment is defined (here) as a dedicated, coherent, coordinated, specially trained group of relevant professionals that meet regularly to plan, coordinate care, and adapt to treatment eventualities. It is critical to identify and aggressively treat all spheres of the pain experience. Obsessing with only the biomedical sphere often dooms the clinician and patient to failure, especially in chronic CRPS. The other equally important features for accurate diagnosis and a responsive treatment target in CRPS are psychological factors/co-morbidity. The psychological spheres of the pain experience can now be identified through the many psychometric, quantified measures that have been created and that have demonstrated efficacy in psychological assessment.6-8 Psychological features are sometimes critically important diagnostic components to identify and aggressively treat; psychometric scores are also often employed as secondary outcomes in research. CRPS is not a psychological disorder, however, and it is therefore illogical to designate psychometric outcomes as primary benchmarks of improvement in treatment.
PL04 MAIN SYMPOSIUM: Early Neurorehabilitation
PL04.1 Philosophy of Early Neurological and Neurosurgical Rehabilitation
H. Binder
Neurologisches Zentrum Otto Wagner Spital, Vienna, Austria
Neurological diseases are chronic diseases with a few exceptions with a covered history till first complaint. Neurological diseases and injuries seldom are finalized incidents. One moment unnoticed but next clearly discernible beginning, the release mechanism is followed from a long lasting cascade of different pathophysiologic processes down to microbiologic domains having an effect not only on structure but also on function, activities and participation. There can be no talk of curative neurology more specifically. But aside of all endeavour of curative medicine to remove causes and their immediate impact it is the upmost challenge to neurorehabilitation to minimize the individual complaints of the patients long acting and this comprises at first all measures for protection and repair of healthy or differently harmed neural tissue simultaneously. But moreover we have to consider that so called early rehabilitation stands at the beginning of a long lasting deterministic as well as stochastic process. It is on the one hand of a deterministic nature because any condition depends undoubtedly causally from the preceding. Therefore it can be separated sharply neither from the so called acute medicine nor from consecutively necessary measures. But at the same time we must consider its stochastic nature not at least because in the long run conditions can predicted only with statistical probability. Therefore early rehabilitation is the space of time not only for specific neurorehabilitative treatment but also for the conception of vital at least medium acting decisions concerning purposes and resultant strategies and required steps. This comprises gathering and specifying of all necessary information, argumentations and correlations, weighting of odds and risks and not at least time, action and resources plan.
PL04.2 Early Rehabilitation: Timing or a Concept?
A. B. Ward
North Staffordshire Rehabilitation Centre, Haywood Hospital, Stoke on Trent, United Kingdom; University Hospital of North Staffordshire, Stoke on Trent, United Kingdom
Starting rehabilitation very early for people following the onset of a neurological health condition has the potential to provide specialist medical interventions during an acute hospital admission and has been developed in response to the need for hospitals to reduce inpatient stays in acute beds. But is there more to early rehabilitation than just timing? The point of entry is defined as when “the priority of care has moved from the definitive acute treatment to one of rehabilitation” and it is at this time that the rehabilitation specialist takes the lead for clinical care. In reality, once definitive care or resuscitation has taken place, a patient’s inpatient stay in hospital is primarily for rehabilitation and dedicating facilities, including beds, for this purpose will bear fruit to meet healthcare priorities.
Early rehabilitation describes rehabilitation interventions within the first month of a hospital admission for a disabling health condition. Its value is set out in a paper, which is shortly to be published and this presentation will describe an evidence based care pathway and the results of a study in which the outcomes of brain injured patients were improved by interventions in the intensive care unit. It will also describe the categories of suitable patients within the definition of early rehabilitation. Below are some examples of how it may be delivered.
i. Transfer of patients to specialist beds in the acute hospital;
ii. Establishment of mobile rehabilitation teams while the patient remains in the referring specialist’s bed;
iii. Daily visits to the acute wards by specialists from a stand-alone rehabilitation facility; and
iv. Establishment of rehabilitation centres to take patients in the very short term.
The presentation will thus go over the advantages and disadvantages of these models and highlight the role of the physician in early rehabilitation.
PL04.3 Is Early Prediction of Functional Outcome After Stroke Feasible?
G. Kwakkel
VU University Medical Centre and UMC Utrecht, Amsterdam, Netherlands
Aims: The present talk will discuss if outcomes in terms of upper limb and lower limb function and ADLs at 6 months after stroke can be predicted at a hospital stroke unit using clinical parameters measured within 72 hours after stroke. In addition, the effect of the timing of post-stroke assessment on the accuracy of prediction was investigated by measurements on days 5 and 9. Methods: Candidate determinants were measured in 188 stroke patients, within 72 hours and at 5 and 9 days post stroke. Logistic regression analysis was used for model development, to predict upper limb function at 6 months, measured with the Action Research Arm Test (ARAT). Results: Patients with an initial upper limb motor deficit who exhibit some voluntary extension of the fingers and some abduction of the hemiplegic shoulder on day 2 have a probability of 0.98 to regain some dexterity at 6 months, whereas the probability was 0.25 for those without this voluntary motor activity. Sixty percent of patients with some early finger extension achieved full recovery at 6 months in terms of ARAT score. Retesting the model on days 5 and 9 resulted in a gradual decline in probability from 0.25 to 0.14 for those without voluntary motor activity of shoulder abduction and finger extension, whereas the probability remained 0.98 for those with motor activity. For the lower limb, sitting balance and lower limb strength were highly predictive for independent gait at six months post stroke, whereas initial Barthel Index measured at 5 days post stroke showed to be the optimal moment for predicting final Barthel Index at 6 months. Conclusions: Based on simple bedside tests, such as finger extension and limb strength functional outcome at 6 months can early be predicted at a hospital stroke unit within the first days post stroke onset.
PL04.4 Special Treatment Problems in Early Rehabilitation
D. Boering
St. Mauritius Therapieklinik, Meerbusch, Germany
Due to technical progress in medicine the number of patients who survive severe acute brain injury and are admitted to early rehabilitation units has increased. For these patients, the first important step is an accurate clinical assignment of disorders of consciousness (DOC), i.e. nonresponsive wakefulness (former VS) vs. minimal responsive wakefulness (former MCS) as an eminent prerequisite to marshal further therapy.
Recent studies outline that standardized neurobehavioral assessments such as CRS-R or DRS are suitable sensitive diagnostic tools and that fMRI of DOC patients may sometimes detect awareness where careful clinical examination fails.
At present, there is no consensus on practice guidelines of treatment for DOC. Research initiatives aimed at developing therapies to facilitate recovery from DOC are constrained at a conceptual level by the absence of a universally accepted definition of consciousness, and by methodological and practical challenges.
During the session we will discuss aspects of actual knowledge on early rehabilitation effects on the recovery from DOC, their limitations and pitfalls. We will focus on medication (therapeutic benefits on arousal/adverse effects on plasticity), verticalisation, early multidisciplinary neurorehabilitation, deep brain stimulation, technology assisted learning setups, etc.
We will further present our experience in everyday practice, especially in an early interdisciplinary approach using ‘therapy blocks’ to better cope with arousal fluctuations and enable a flexible use of stimulation and resting items and pharmacological support.
To solve the complexity of special treatment problems in early rehabilitation, research partnerships need to be developed in order to switch from small single center to multicenter collaborations. The wide integration of special functional neuroimaging techniques into the evaluation process will be a helpful tool in establishing efficient rehabilitative therapy forms.
S25 Motor Learning and Rehabilitation
S25.1 Understanding and Augmenting Motor Learning Processes Using Neurorehabilitation Strategies
P. Celnik
Johns Hopkins University, Baltimore, MD, United States
Is the return of motor function after brain lesions dependant solely on recovery of normal brain activity or is (re)learning of motor skills the main process by which patients improve? While this question remains open, it is likely that a combination of both processes is required. Thus, understanding motor learning is fundamental to develop rational strategies to enhance return of function. In recent years, the use of brain stimulation techniques has started to unveil how different processes underlying motor learning like acquisition, retention and consolidation may involve different brain structures. This knowledge is a first crucial step if the goal is to enhance motor learning processes to allow faster and larger magnitude of motor function return in neurorehabilitation. In this presentation, I will discuss recent studies in healthy individuals investigating the underlying neurophysiological changes occurring in the primary motor cortex (M1) and cerebellum during learning. Specifically, I will address the plasticity changes and contributions of M1 in association to encoding and retention, and the role of the cerebellum in acquisition of different motor tasks. In addition, I will discuss how this knowledge has permitted the testing of interventions to enhance these processes. Ultimately, the goal would be to determine whether patients with brain lesions undergo motor learning in similar manner as healthy individuals, and whether the magnitude of recovery depends of the ability to sustain motor learning. This knowledge will likely have a profound impact on the understanding of recovery of motor function after brain lesions and how neurorehabilitation interventions should be delivered. For instance, it is possible that lesion location can affect more acquisition than retention of motor skills. Thus, interventions that augment this process by specific behavioral training regimens or non-invasive stimulation targeting the responsible neural area should be implemented.
S25.2 Distinguishing Between Motor Recovery and Compensation in Neurorehabilitation
M. F. Levin
School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada; Center for Interdisciplinary Research in Rehabilitation (CRIR), Montreal, QC, Canada
Research on the effectiveness of neurological rehabilitation has seen steady growth over the last decade. Advances in neuroimaging techniques and methods of clinical assessment have helped to make progress in identifying and charting the effectiveness of neurological rehabilitation. These advances have also been facilitated by progress in our understanding of the mechanisms of neuroplasticity and the methods by which sensorimotor rehabilitation can exploit this hitherto unrecognized potential. Nevertheless, there is a lack of consistency amongst researchers and clinicians in the use of terminology related to neuroplasticity that describes changes in motor ability following neurological injury such as stroke. Specifically, the terms and definitions of ‘motor recovery’ and ‘motor compensation’ have been used in different ways which is a potential barrier to effective inter-disciplinary communication and progress in understanding. A theoretical overview of the notions of “recovery” and ‘compensation’ with respect to function at the neuronal, performance and functional levels will be presented and discussed within the framework of the International Classification of Function (ICF) model. Examples of how motor compensations are used during the accomplishment of different tasks, specifically of the upper limb, in individuals with stroke will be presented. The problem of identification of compensatory versus recovered motor patterns within the context of task accomplishment will be discussed as well as how current clinical scales and laboratory-based measurements may or may not meet the challenge of distinguishing between recovery and compensation.
S25.3 How Investigation and Motor Learning in Animal and Human Models Contribute to More Effective Neurorehabilitative Strategies
L. Cohen
Human Cortical Physiology and Stroke Neurorehabilitation Section, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
Neurorehabilitation has seen an important development in the last decade. Basic science animal studies demonstrated that it is possible to evaluate the mechanisms underlying learning and relearning after brain lesions. These studies started to generate exciting information that over the last few years became increasingly important in the design of novel rehabilitative strategies in humans. Importantly, data from clinical studies started to influence the design of animal studies. Human studies in healthy volunteers allowed the formulation of hypothesis on motor rehabilitation applicable to neurorehabilitation following stroke and allowed partial optimization of interventional approaches. Information on the now more fluid interaction between studies designed in animals and humans and their influence in the development of neurorehabilitative protocols following brain injury will be discussed.
S26 Clinical Pathways in Neurorehabilitation
S26.1 Systematic Guideline Preparation
L. Turner-Stokes
King’s College London, London, United Kingdom
Clinical guidelines have become an important tool to support best clinical practice, and are increasingly recognised as an integral component of healthcare culture across the world. For guidelines to achieve their intended purpose of improving the quality of patient care, they must be based on the best available evidence—including not only the best available research-based evidence, but also the best level of clinical experience.
In the last two decades there has been considerable, and perhaps excessive, emphasis on randomised controlled clinical trials (RCTs) as the essential corner stone of ‘evidence based practice’. So much so, that guideline recommendations have often been dictated purely by the availability of experimental evidence, rather than by the clinical needs of patients or the key decisions required of the clinician(s) responsible for their care.
More recently, it has been recognised that other research designs can be at least as important, if not more so, as the source of evidence to underpin these key clinical decisions—providing, of course, that the research is of high quality and the design is the most appropriate to answer the clinical question. Even more radically, there has even been the recognition that good common sense is also a key requisite of clinical guidelines. Some questions could never be answered by randomised trials, but this does not mean that the recommendations are not every bit as important. A number of new methodologies have been developed to incorporate a broader church of research design, and to include the voice of experience—both from professionals and service users.
In this talk I will examine some of the fundamental principles which underlie systematic guideline development, and explore some of the newer tools that can help to ensure the relevance and utility of clinical guidelines as they are developed in the future.
S26.2 Guidelines for Arm Treatment After Stroke
T. Platz
BDH-Klinik Greifswald, Neurological Rehabilitation Centre and Spinal Cord Injury Unit, Department Neuroscience, Ernst-Moritz-Arndt-Universität, Greifswald, Germany
Objective. The German Society for Neurorehabilitation (DGNR) develops evidence-based practice guidelines (EbPG) that are intended to facilitate evidence-based medicine (EbM) and health care (EbHC) in neurorehabilitation.
Methods. The development is based on a systematic literature search, a critical appraisal of individual references, a critical summary of the evidence available for each type of intervention, a rating of the certainty of the estimated therapeutic effect, and consensus-based recommendations derived from the body of evidence (Platz and Quintern, 2009). Among other aspects the methodology includes the use of the Oxford Centre for Evidence based Medicine Levels of Evidence and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
Results. One hundred and nine publications of RCTs and 12 systematic reviews had systematically been assessed. Thereafter, consensus-based recommendations had been derived from the body of evidence (Platz, 2009).
Conclusion. Clinical practice recommendations for arm motor rehabilitation have been provided addressing issues of training intensity, training settings (individual, group, supervised exercises), therapeutic schools, specific therapeutic approaches (including bilateral, impairment-oriented, and task-specific training, CIMT, trunk restraint, mirror and mental training), specific therapies using training devices (including neuromuscular and somatosensory electrostimulation, robot therapy, EMG-biofeedback, rTMS, and acupuncture), as well as medication (L-Dopa, amphetamine).
References
Platz T und Quintern J. Methodik der Leitlinien-Entwicklung der Leitlinien-Kommission der Deutschen Gesellschaft für neurorehabilitation (DGNR). Neurol Rehabil 2009; 15: 75-80.
Platz T. Rehabilitative Therapie bei Armparese nach Schlaganfall. Neurol Rehabil 2009; 15: 81-106.
Acknowledgments. The help of S. Roschka, E.T., B.Sc. with the critical appraisal of the literature and the help of the members of the DGNR guideline commission with the consensus process for recommendations is gratefully acknowledged.
S26.3 Guidelines for Usage of Electrophysiology and Imaging in Neurorehabilitation
K. M. Stephan
St. Mauritius Therapieklinik, Meerbusch, Germany
Planning of neurorehabilitation is mainly based on clinical data and their dynamics over time. Additional electrophysiological and neuroimaging data are often used in order to substantiate the prognosis and establish a more solid basis for monitoring the clinical progress and defining the goal of the rehabilitative process.
As part of the establishment of guidelines for the treatment of stroke patients by the German Society of Neurorehabilitation (Deutsche Gesellschaft für Neurorehabilitation; DGNR; Prof. C.Dettmers, Prof. V. Hömberg, Prof. E.Koenig) we investigated the importance of electrophysiological (Prof. A. Liepert, Allensbach/Freiburg) and neuroimaging data (Dr. K.M. Stephan, Meerbusch/Düsseldorf) for the planning of neurorehabilitation. We were especially interested, in whether these data would provide additional prognostic information for arm and hand functions over and above the information already obtained by clinical examination.
A synopsis of the results will be presented followed by a critical discussion about the role of these techniques during the rehabilitative process. The results have been published detail in German (see Neurol Rehabil 15(2); April, 2009) and are also presented on the homepage of the DGNR.
S27 Physician Education and Training
S27.1 Neurorehabilitation Training in the US
D. I. Katz
Boston University School of Medicine, Boston, MA, United States
Neurorehabilitation is a burgeoning medical subspecialty in the United States and over the last 3 decades there has been an emergence of neurorehabilitation fellowship training programs, and evolution of training curricula and systems of certification. At the residency training level, physiatry residencies have had requirements for minimum experience in various neurologic disorders but neurology residencies have been inconsistent in requirements of exposure to rehabilitation. Neurorehabilitation fellowship training programs have ranged in emphases from primarily clinically oriented programs, to programs aimed at academic neurorehabilitation training, with additional years focused on a research-based curriculum, to those that have an emphasis on particular populations or disorders (e.g., pediatrics, traumatic brain injury, spinal cord injury). The American Board of Physical Medicine and Rehabilitation offers subspecialty certification in specific areas of neurorehabilitation, including neuromuscular medicine, spinal cord injury medicine and pain medicine. As neurorehabilitation evolved as a distinct neurologic subspecialty, the neurologic community in the US has also developed guidelines for subspecialty training and certification. After formation of the Rehabilitation Section (now Neural Repair and Rehabilitation Section) of the American Academy of Neurology in the mid-1980s, the American Society of Neurorehabilitation (ASNR) was founded in 1991. The ASNR developed Training and Assessment guidelines in 1995 and administered an examination and a system of certification for trainees and practitioners of neurorehabilitation in the US. Certification and accreditation are now being transitioned from ASNR to a recently formed organization, the United Council for Neurological Subspecialties (UCNS), founded in 2003 to accredit training programs and certify practitioners in various neurologic subspecialties. Once accepted, neurorehabilitation will be the 9th neurological subspecialty under UCNS. As part of the UCNS application process, an updated, detailed core curriculum and fellowship program requirements have been developed that will be the basis for future standards for neurorehabilitation training and certification in the US.
S27.2 Experience From an Integrated Neurorehabilitation Curriculum
G. Sandrini1, H. Binder2, P. Bülau3, C. Corradini4, V. Homberg5, E. Koenig6, R. Muri7, and L. Saltuari8
1Dept. of Neurorehabilitation IRCCS C. Mondino Foundation Institute of Neurology, University of Pavia, Pavia, Italy, 2Otto Wagner Spital, Wien, Austria, 3Westerwaldklinik Waldbreitbach, Waldbreitbach, Germany, 4Reparto e Servizio di Riabilitazione e Terapia Fisica, Brunico, Italy, 5St. Mauritius Therapieklinik, Meerbusch, Germany, 6Neurologische Klinik Bad Aibling, Bad Aibling, Germany, 7Insleapital Bern Uniklinik fur Neurologie, Bern, Switzerland, 8Abteilung fur neurologische Akutnachsorge, Hochzirl, Austria
Neurological rehabilitation has had in the last years a great development in clinical and research field. Spite of its relevance, large heterogeneity in the curriculum concerning the professionals involved in the rehabilitation team and consequently the care is existing in EC. Some scientific societies (UK, US) proposed a curriculum in the field, but any general consensus exists about the contents. Some EC scientific societies active in Neurorehabilitation (Austria, France, Germany, Holland, Italy, Spain, Switzerland) decided to create the European Network for Education in Neurorehabilitation (ENENR). A curriculum for education and training in neurorehabilitation has been defined by the ENENER and it will be presented here. Prerequisites for the trainer need to include qualification in neurology, neurosurgery and physical medicine and rehabilitation, as well as specific experience in neurorehabilitation. Qualification of the trainers and training institutions were defined and it has to be guaranteed by the national societies. Residency training is relevant in the curriculum and it includes the direct involvement in the case management and in the goal setting and monitoring process during rehabilitation. Continue medical education is supported by National Societies and World Federation of Neurological Rehabilitation. Classroom education is organized in modules according to the common criteria of university education and it includes important topics, such as: 1) basic structures and concepts in rehabilitation; 2) assessment tools and epidemiology; 3) motor rehabilitation; 4) cognition rehabilitation; 5) disorders of communication and autonomic functions; 6) disease specific neurorehabilitation aspects.
S27.3 Should Neurologists Influence Education in Paramedical Professions?
G. Tautscher-Basnett
Gailtal-Klinik, Hermagor, Austria
Changes in health care and on the health labour market necessitate a look at the education and qualification requirements. The first part of this lecture consists of an overview of the current educational situation of paramedical professions in some European countries, with a particular emphasis on the situation in Austria, where presently a process is underway of converting “Akademien” (equivalent to college education) into “Fachhochschulen” (equivalent to university education). This process entails a change in professional qualifications from “Diplomas” to “Bachelor degrees” which is part of an effort to align European standards of professional and scientific qualifications. In the second part the role of neurologists at the different stages of education of paramedical professions is discussed in the light of the various requirements for the tasks. The involvement will differ depending on the role, i.e. the influence of the neurologist depends amongst other things on the professional context, which ranges from being a lecturer in undergraduate (Bachelor degrees) or post-graduate (Master degrees) paramedical studies, to being a contact person or academic advisor during practical work training or acting as supervisor for final-year projects and theses.
S28 Transition of Neurological Disabilities With Age
S28.1 Identify and Reverse Declines With Aging in Patients With Chronic Neurologic Disabilities
B. Dobkin
University of California Los Angeles, Los Angeles, CA, United States
Aging often produces a decline in sensory, motor and cognitive functions that superimpose additional impairments and disabilities on people with chronic neurological diseases. In addition to concurrent health problems that may, for example, affect conditioning, mobility or strength, progressive neural maladaptations may arise. Those that are relevant to mechanisms of plasticity and potentially treatable by rehabilitation include 1) reduced neural inputs and outputs from a fall in behavioral activity leads to diminished skills and difficulty learning new ones; 2) greater noise within neural networks from less salient or unreliable signals degrades motor and cognitive representations; 3) down regulation of physical and chemical systems impairs neuromodulation of inputs and outputs to maintain or increase the strength of synaptic connections; and 4) cognitive/motor decline is accelerated by greater difficulty carrying out usual and modestly challenging behaviors.
Strategies to counter processes that degrade activity-dependent plasticity include 1) exercise to maximize strength, balance and endurance for an expanding variety of physical activities; aerobic exercise to enhance executive and memory functions; practice of cognitive and motor skills using effective web-based training paradigms; 2) refine techniques such as fMRI, connectivity MRI, and structural imaging to quantify network degradation and recovery; develop quantitative neurotransmitter and gene product measurements in vivo within cerebral regions; 3) test drugs to enhance mechanisms of plasticity for learning and memory, such as histone acetylation of chromatin and centrally acting neuro- and immune modulators; 4) develop cellular implant or nanotechnology devices that secrete molecules to replace local production; repair areas of demyelination and axonal injury; implant cellular or chip-based neural networks; and 5) improve existing rehabilitation measurement tools; develop motion and physiological sensors with interpretative algorithms to measure the quantity and quality of activities as monitoring and outcome measures. Much can be done to study and prevent declines with aging.
S28.2 Imaging of Functional Networks in Disease and Normal Aging
A. Guggisberg
University of Geneva, Geneva, Switzerland
Older age is often associated with functional deficits and cognitive decline due to disease and normal aging. There is a need for tools that visualize disturbances in brain organization, provide prognostic information, and guide rehabilitation treatment in these patients. Functional neuroimaging has the potential to provide this information, but traditional imaging studies are often difficult to perform in patients who cannot collaborate because of their deficits.
Spontaneous fluctuations of brain activity at rest are highly organized and coherent within specific neuro-anatomical systems. Thus, a careful analysis of the coherence between brain regions gives access to the functional brain organization. Data can also be registered in patients who are unable to collaborate. Functional connectivity can be derived from recordings of spontaneous brain activity obtained with functional magnetic resonance imaging, electroencephalography, or magnetoencephalography.
Brain pathologies such as tumors, stroke, traumatic brain injury, and Alzheimer’s disease induce a global decrease in functional connectivity between brain regions. The local magnitude of functional connectivity within a network correlates with the behavioral performance in functions dependent on this network. Initial observations suggest that improvement during rehabilitation is accompanied by a local increase in functional connectivity in the corresponding network. Connectivity maps are also able to predict which tumor parts can be surgically resected with low risk of ensuing neurological deficits. Normal aging is associated with decreasing activity in frontal and parietal “default-mode” networks.
Imaging of resting state brain activity thus opens an exciting and accessible window to the intrinsic brain organization with numerous applications in clinical practice as well as for the understanding of brain physiology.
S28.3 Reorganisation of Neural Networks: Is There a Limit?
N. Ward
Sobell Department of Motor Neuroscience, UCL Institute of Neurology, London, United Kingdom
After stroke, treatments aimed at reducing impairment are assumed to work through the promotion of activity dependent plastic change in surviving brain networks. Functional imaging studies in patients with stroke have demonstrated overactivity in a number of cortical motor-related areas, including the premotor cortices and supplementary motor areas (in both hemispheres), but often less task-related activity in ipsilesional primary motor cortex (M1). In general this overactivity is relatively greater in patients with more impairment and greater disruption to the corticospinal system. Furthermore, it appears that in such patients the premotor cortices can take on a new ‘M1-like’ role during modulation of force output. Disruption of activity in these regions with transcranial magnetic stimulation (TMS) can lead to impairment of some motor behaviour in patients but not controls, supporting the idea that the premotor cortices in particular contribute to aspects of recovered function by substitution of function. More recent investigations have examined changes in connection strength between cortical motor regions and are beginning to shed light on changes in the functional relationship between motor regions, in particular dorsal and ventral premotor cortices and M1.
Neuroimaging studies in older healthy volunteers have revealed age-related changes in the organisation of cortical motor regions. In particular, the response of premotor regions to aging appears qualitatively similar to those seen after subcortical stroke. Furthermore, reduced inhibition/greater facilitation between cortical motor regions in the hemisphere ipsilateral to the moving hand is reminiscent of an increased reliance on ipsilateral (contralesional) brain regions after stroke. These data raise the possibility that the degree to which functionally relevant reorganisation in motor networks can successfully support recovered function is diminished with increasing age because of long term adaptive changes. This hypothesis requires urgent consideration as we attempt to understand how far brain reorganisation can be pushed to support recovery after stroke.
S29 Neuromodulation
S29.1 Cortical Stimulation: First Results From the German Multicenter Clinical Trial
F. Hummel
Germany
Abstract not received as per date of printing. Please check the conference website www.wcnr2010.org for possible updates.
S29.2 Somatosensory Stimulation For Post-Stroke Motor Neurorehabilitation
N. Paik
Seoul National University, Seoul National University Bundang Hospital, Seoul, Republic of Korea
The somatosensory and motor cortices are anatomically and functionally interconnected, and both have a capacity of plastic reorganization.
Somatosensory stimulation in the form of peripheral nerve stimulation modulates cortical excitability of the stimulated body part representations and improves motor function in stroke patients, whereas reduced somatosensory input leads to abnormal motor behaviour, and has negative impact on motor recovery after stroke. Therefore, this modality has been used in clinical practice hoping to enhance the beneficial effect of the customary neurorehabilitative treatments. For example, somatosensory stimulation on the paretic hand is reported to transiently enhance pinch muscle power, and to improve daily living like activities in the paretic hand, and stimulation on the pharynx to improve swallowing function after stroke.
Effect of somatosensory stimulation lasts for up to 120 min, and the mechanism underlying the improvement of motor task in stroke patients after somatosensory stimulation is known to be mediated through modulation of intracortical GABAergic pathways.
Combining peripheral nerve stimulation and transcranial magnetic stimulation in the form of paired associative stimulation has been reported to improve gait function in chronic stroke.
We recently combined peripheral nerve stimulation to the paretic hand with non-invasive cortical stimulation in the form of anodal direct current stimulation to the ipsilesional primary motor cortex, and showed that this combination facilitated the beneficial effects of training on motor performance beyond levels reached with each intervention alone, suggesting a possible new strategy for the neurorehabilitation of motor impairments after stroke.
In this session, literature on somatosensory stimulation which are reported to change motor function in patients with stroke, and their underlying mechanisms will be discussed.
S29.3 Modulation of Somatosensory Input
B. Voller
Department of Neurology, Medical University of Vienna, Vienna, Austria
Normal somatosensory input is required for optimal motor behavior including acquisition of new motor skills. Patients with neuropathy show abnormal motor performance and patients with sensory deficits after stroke regain motor function much slower and to a lesser extent.
Neuroplasticity can be modulated either by decrease (deafferentation) or increase (stimulation) of afferent input. As the effects of stimulation will be discussed in a different place, this talk will be focussed on the effects of deafferentation. Peripheral deafferentation e.g. by anesthesia results in bilateral cortical reorganization. On the cortex contralateral to deafferentation representational areas expand. On the ipsilateral cortex, deafferentation leads to a relative increase in activity in homonymous areas, probably due to the reduction of interhemispheric inhibition. The behavioral consequences of these phenomena in healthy test persons and patients with stroke and the implications for neurorehabilitative interventions will be discussed.
S29.4 Recovery of Function in Humans: Pharmacological Treatments in Subacute and Chronic Stroke
A. Floel
Department of Neurology, Universitätsmedizin Charité, Berlin, Germany
Drugs can be used to facilitate recovery from stroke and other diseases of the CNS. This principle has been most thoroughly explored in the motor system. The notion of using drugs to improve language deficits is relatively new and even more controversial than in the motor domain. Both approaches build on similar basic neuroscientific principles, namely that modulation of specific neurotransmitter or neurotrophic systems may facilitate neuronal plasticity and LTP. The talk will give an overview of agents that are currently available, with special emphasis on motor and language recovery. Amphetamines have been repeatedly shown to promote recovery of function in animals, but clinical data remain inconclusive. Other pharmacological agents evaluated for motor recovery include selective norepinephrine re-uptake inhibitors, dopamine, dopamine agonists, cholinergic substances, serotonin re-uptake inhibitors, granulocyte colony stimulating factor, and erythropoietin. Although preliminary data from animal and human experimental studies on these agents are promising, clinical data is as yet not convincing, and larger clinical trials, possibly with better defined patient sub-groups, are needed before any of the available agents may be recommended for routine use.
S30 Spasticity
S30.1 Functional Benefits Resulting From New Treatments of Spastic Paresis
J. M. Gracies
CHU Henri Mondor, Créteil, France
Treatment of spastic paresis has often been reduced to the treatment of spastic muscle overactivity. While a recent trial has compared the effects on active function of botulinum toxin with a systemic synaptic depressor (tizanidine), most trials evaluating botulinum toxin (or any previous treatment assumed to reduce spastic overactivity, such as systemic synaptic depressors, oral or intrathecal) have only emphasized changes in resistance to passive movement (muscle tone), assessing the effects of only one treatment cycle, without associated treatment. Paresis and soft tissue contracture were often not specifically addressed. However, in the subacute and chronic stages, stretch-sensitive (spastic) muscle overactivity emerges as only the third fundamental mechanism of functional impairment, after paresis and soft tissue contracture. None of the three mechanisms of impairment (paresis, contracture, and spastic overactivity) is symmetrically distributed between agonists and antagonists, which generates torque imbalance around joints and limb deformities. Thus, each may be best treated focally on an individual muscle-by-muscle basis.
1. Intensive motor training (e.g. rapid alternating movements and task-related exercises) of the less overactive muscles should disrupt the cycle of paresis-disuse-paresis.
2. Concomitant use of aggressive stretch in the more overactive and shortened antagonists should be added to treatment using focal weakening agents such as botulinum toxin, to break the cycle of overactivity-contracture-overactivity.
In the current health-related economic constraints of most countries, payors are unable to provide for the amount of home physical and occupational therapy that would be required over protracted periods to provide such an amount of daily exercises. However, guided self-rehabilitation contracts may allow persistently implementing the two principles above and may result in meaningful functional improvement, as long as the discipline is maintained over time, covering at least a year span. Examples will be demonstrated.
S30.2 Combining Functional Electrical Stimulation With Spasticity Treatments
J. Burridge1 and J. H. Burridge2
1United Kingdom, 2University of Southampton, Southampton, United Kingdom
Functional Electrical Stimulation is becoming an accepted rehabilitation tool. There is currently more evidence however for its effectiveness as an orthosis, such as correction of drop-foot via stimulation of the common peroneal verve during the swing phase of walking) than as a means to facilitate recovery or treatment for spasticity.
The theoretical argument of FES in the reduction of spasticity is that if electrical stimulation enables an activity to be performed with less effort and with a more ‘normal’ pattern of movement then development of spasticity may be avoided. Currently however there is no evidence to support this.
FES has however been shown in both experimental and in clinical studies to reduce spasticity—the effect is thought not to be through the 1a reciprocal inhibition mechanism but rather in response to a contraction of the agonist (stimulated muscle). These studies have examined the short term effect of stimulation; for it to be clinically useful the effect needs to be long lasting.
In a randomised control pilot study with people who had a spastic drop-foot following stroke (n=19) we compared the combined effect of FES during walking and Botulinum Toxin A injections into the calf muscles with a control group. Statistically significant, between group, differences were measured in Modified Ashworth Score (calf), increase in walking speed and reduction in effort of walking which was maintained at a 12 week follow-up assessment.
More recently in a feasibility study with people with reduced upper limb function following stroke (N=6) we combined upper limb robot training with electrical stimulation of the triceps muscle mediated using iterative learning control and identified not only a reduction in impairment but a more normal pattern of muscle activity during reaching.
Using FES in combination with other approaches may effectively reduce spasticity and facilitate more normal movement.
S30.3 Comparison of the Outcomes Surgical and Non-Operative Treatments for Spasticity
T. Deltombe, T. Gustin, and P. De Cloedt
Cliniques universitaires UCL de Mont-Godinne, Yvoir, Belgium
The treatment of the spasticity is multimodal including physical therapy, orthosis, chemical denervation (botulinum toxin injections and phenol block), functional neurosurgery (intrathecal baclofen and neurotomy) and orthopaedic surgery. The efficacy of these different treatments to reduce the spasticity and to improve the function has been largely studied even with placebo controlled RCT. Surprisingly, only few studies have tried to compare the outcomes obtained with different treatments. The additional effect of electrical stimulation combined with botulinum toxin (BTX) injections and the superiority of BTX injections as compared to phenol block and oral medication has been demonstrated. However, until now, only one study has compared a surgical (neurotomy) and a non-operative (BTX injections) procedure which has demonstrated that neurotomy is more effective than BTX injections to reduce spasticity and to improve gait velocity in cases of spastic foot.
The spastic equinovarus foot is a common deformity among spastic patients which is treatable by non-operative and surgical procedure. In the pre-treatment evaluation, selective diagnostic motor nerve branches blocks of the tibial nerve with local anesthetics are proposed in order to immediately and temporarily suppress the spasticity allowing to differentiate muscle spasticity from fixed contracture. The diagnostic nerve block seems also able to predict the functional benefit from a more permanent treatment of the spasticity such as neurotomy.
Additional multicentric and randomized studies are necessary to compare the outcomes obtained with the available treatment of spasticity. It is mandatory to determine a consensus for the spasticity management according to the neurological pathology and the localization of the disabling spasticity.
S31 New Methodologies in Evaluating Neuropsychological Rehabilitation
S31.1 Ethical and Evidence-Based Practice in Brain Injury Rehabilitation
J. F. Malec
Rehabilitation Hospital of Indiana, Indianapolis, IN, United States; Indiana University School of Medicine, Indianapolis, IN, United States
The goal of evidence-based medicine (EBM) is to develop a scientific basis for choosing interventions that will benefit individuals with defined characteristics under specified conditions. The methodology of EBM attempts to avoid bias inherent in consensus discussions and practice traditions by referencing practice recommendations to the strength of the scientific evidence gleaned from systematic reviews. The randomized controlled trial (RCT) has come to be considered the gold standard for EBM methodology. However, EBM also recognizes that other scientific methods including case controlled or single-subject controlled studies provide a degree of evidence for an assessment or intervention procedure. Strengths as well as risks and weaknesses of RCT-focused EBM will be examined in this presentation. EBM methodology is most consonant with the Medical Model in which the target of the intervention is a disorder within the individual patient. Some rehabilitation assessment and intervention procedures, however, may be more appropriately studied within a Social Model of disability. In the Social Model, the target of intervention is the individual’s environment or social system. Although few would disagree that the pursuit of a scientific basis for practice is an ethical mandate, defining ethical practice in the absence of strong evidence and in the presence of competing methodologies remains challenging. The ethical practice of brain injury rehabilitation requires an awareness of multiple factors that include not only the scientific evidence for a procedure, but also current best practices recommended by professional traditions and consensus, the practice situation, and the individual’s current and evolving situation, needs and preferences.
S31.2 Single-Subject Designs as a Tool for Evidence-Based Clinical Practice: Are They Unrecognized and Undervalued?
R. L. Tate1,2 and M. Perdices3,4
1Rehabilitation Studies Unit, University of Sydney, Sydney, Australia, 2Royal Rehabilitation Centre Sydney, Sydney, Australia, 3Department of Neurology, Royal North Shore Hospital, Sydney, Australia, 4Department of Psychological Medicine, University of Sydney, Sydney, Australia
Background: Is the only road to evidence-based clinical practice the application of results from randomised controlled trials or systematic reviews? Why are single-subject designs (SSDs; also known as n-of-1 trials) generally ignored? Part of the reason is the general misperception that SSDs are not as scientifically robust as group designs, one reason cited being the absence of statistical analysis. Aims: This paper provides empirical data on the quality of SSDs in the published neuropsychological literature. Methods: All full-length articles in Neuropsychological Rehabilitation from inception (1991) to 2008 were surveyed and classified into review papers, non-treatment or treatment studies. Treatment studies were further classified into group designs and SSDs. The latter designs were examined for methodological rigour using Single-case Experimental Design (SCED) Scale and type of data analysis. Results: A total of 89 of the 172 treatment studies (52%) were SSDs. These designs were classified into a hierarchical order of methodological rigour from simple case descriptions (12%), single (7%) and two-phase treatment studies (38%), to complex multi-phase/multiple baseline studies (43%). Statistical analysis was used in 64% of reports. Graphed data were used frequently (78%), yet generally accompanied by either statistical analysis of the graphed data (eg., time series analysis) or supplemented with statistical analysis of the treatment effect. Conclusions: In this sample, the perception that SSD reports do not use statistical analysis was erroneous. Although there is variability in the methodological rigour of SSDs (as there is in randomised controlled trials), the more robust SSDs provide an evidence-based approach and their use in clinical practice is to be encouraged.
S31.3 Defining and Measuring Treatment in Complex Rehabilitation Interventions
T. Hart
Moss Rehabilitation Research Institute, Philadelphia, PA, United States
Rehabilitation research is increasingly challenged to test the efficacy and effectiveness of established treatments, and to develop new interventions targeting specific problems, outcomes, and patient populations. This enterprise requires that we develop more precise and more consistent ways of conceptualizing and measuring the “active ingredients” of treatment. This task is very challenging considering that the majority of rehabilitation interventions are complex, consisting of multiple ingredients that may be difficult or even undesirable to disentangle. Ingredients related to patient effort and learning, the quality of patient-therapist interaction, the involvement of social systems, and the degree to which treatment is individualized may all contribute significantly to outcome, but we lack established metrics to estimate their effects. In this presentation are discussed organizing principles that may help to further the definition of complex rehabilitation interventions, including theories of learning and frameworks for understanding behavior change in interpersonal interaction. Examples of using these frameworks for developing treatment manuals (for experimental studies) and measurement systems (for observational studies) are provided, with special emphasis on applications to neurologic rehabilitation.
S32 Assistive Technology and Telemedicine
S32.1 Instructions for More Appropriate Use of Wheelchairs
R. A. Cooper and R. Cooper
University of Pittsburgh and Human Engineering Research Laboratories, Pittsburgh, PA, United States
Wheelchairs will continue to affect people in different settings to live in their homes, to participate in their communities, and to enhance their quality of life. The setting may be at home, providing personal support and help for daily living; it could be a neighborhood, where the systems help a person to engage in community activities; or it could be more societal where a person commutes to work and contributes to society through employment. In each setting wheelchairs may provide different forms of functionality: enhancing dexterity and mobility, helping with home chores, supporting sports and recreation, providing mobility for school/job functions, and helping to drive vehicles. Wheelchairs touch nearly all aspects of human living for people who use them. Mobility and manipulation are tasks critical to living independently, and are often strongly associated with the ability to continue to live safely in one’s own home. The greatest challenges in wheelchair selection and design are optimizing the interaction between the user and wheelchair, which requires knowledge of materials, biomechanics, ergonomics, anthropometrics, and human physiology, and in motor learning to train the user in developing the skills to gain maximum mobility. User mobility training is an application area for virtual reality, machine learning, remote monitoring, and virtual coaching. Transition to a wheelchair can be a significant personal hurdle for many people; although once the transition is made it can be a liberating experience. A common occurrence among people with neurological conditions is to gradually reduce their sphere of mobility over time, to where they leave the home with decreasing frequency. When the appropriate wheelchair is introduced the environment can once again expand. A thorough assessment of the person’s capabilities, home and work environment and transportation are required to achieve success.
S32.2 Experiences on Telerehabilitation in Rural and Geographically Complex Areas
M. Zampolini
Italy
The development of new communication methods combined with the new technologies has given rise to telerehabilitation as a possibility of application and a promising development for the future. The possibility to reach rural areas far from the rehabilitation center opens new perspectives to extend access to rehabilitation and prolong rehabilitation programs at home after in hospital programs. The problem of deploying telerehabilitation paradigms to rural areas are related to the difficulties to find high speed wired or wireless lines and cultural difficulties to cope with the technologies.
In order to study the possibilities to apply telerehabilitation in rural areas we have developed a project named HCAD (Home Care Activity Desk). This first prototype was set up to provide exercise for the upper limbs, to monitor these exercises, and to transmit the monitored data to a hospital environment. There is also the possibility to interact between the patient and the therapist through a teleconference system.
The acceptance of both the patients and the physiotherapist has been studied. The results show that the acceptance is age-related, the higher the age, the lower the acceptance and is also severity- related, more difficulties there are in doing the exercises the lower the acceptance.
The system and the exercises were based on task-oriented exercises monitored with the sensorised instrument. A multicenter study has been carried out with inclusion of 81 patients with chronic Stroke, TBI and MS patients recruited in Italy, Spain and Belgium. A random allocation was performed creating two groups, one usual care and the second home exercises with the HCAD
The results show that in both groups, patients maintain or even improve on their arm/hand function. The HCAD training for chronic Stroke, TBI and MS patients is shown to be at least as effective as usual care. As usual care takes a lot of effort and time for the therapists as well as the patients travel time, a tele-rehabilitation intervention using HCAD may increase the efficiency of care as it shows similar clinical effects but with less effort and time for the therapists (Journal of Telemedicine and Telecare 2008;14: 249-256).
Another possibility is the use of virtual reality. An RCT has been carried out including 36 patients with mild arm motor impairments due to ischaemic stroke in the region of the middle cerebral artery. The experimental treatment was a virtual reality based system delivered via the Internet, which provided motor tasks to the patients from a remote rehabilitation facility. Both groups significantly improved all outcome scores after treatment, except the Fugl-Meyer that shows benefit with virtual reality groups. (J Rehabil Med 2009;41:1016-1020)
An up-to-date perspective is the application of cognitive rehabilitation to be applied in telerehabilitation. This system allows constant teleconference assistance and a computerized system to perform personalized exercises and specific evaluation.
During the last few years progress has been made in telerehabilitation and the improvement of communication technologies will allow even better application in this field.
S32.3 Smart Homes and Ambient Assisted Living
G. Demiris
University of Washington, Seattle, WA, United States
Smart homes are defined as residential settings equipped with technology to enable monitoring of residents and improvement of their quality of life and overall well-being, as well as detection of emergencies. As technology advances, more sophisticated solutions such as a variety of sensors, can be embedded in the residential infrastructure to address the individual needs of residents including physiological, functional, and cognitive parameters, to facilitate residents’ rehabilitation and to support or even increase their independence. This presentation will provide an overview of ongoing smart home and ambient assisted living applications worldwide and discuss the target audiences, technologies used, and the different stages of development. In spite of the growing number of initiatives in this area, the field is in relatively early stages and is currently lacking an extensive body of evidence. We will additionally showcase an ongoing project targeting community dwelling older adults and discuss user acceptance and the concept of obtrusiveness of smart home technologies. As technological advances enable sophisticated home-based solutions, we need to ensure that the design and implementation of such applications are not determined simply by technological advances but by the actual needs of end users. Furthermore, ethical, practical, organizational and financial implications will be highlighted and future trends will be explored.
Special Closing Lecture
CL1: Repair in the Blue Brain
H. Markram
Switzerland
Abstract not received as per date of printing. Please check the conference website www.wcnr2010.org for possible updates.
Poster Presentations
1 Management
1.1 Epidemiology
P001 An Evaluation of Long-Term Medical Complications in People With Spinal Cord Injury
B. Celik, N. Erden, H. Harman, and K. Ones
Istanbul Physical Medicine Rehabilitation Teaching and Research Hospital, Istanbul, Turkey
The aim of this study was to evaluate the long-term secondary medical complications including spasticity, autonomic dysreflexia, deep venous thrombosis, pulmonary embolism, pressure ulcers, fractures, neuropathic pain, heterotopic ossification in individuals with spinal cord injury (SCI).
33 people with SCI (12 female, 21 male) attending the inpatient clinic were included in the study retrospectively. A data file evaluation including patient history and physical examination was performed.
The mean age and standard deviation was 38.21±14.22 yrs. Time since injury was 5.22±6.47 yrs. 26 patients were classified as paraplegic, 7 as tetraplegic. 19 patients was classified as complete, and 14 patients as incomplete according to ASIA classification. The educational status was less than high school in 73% of patients, and high school in 27%. The economical status was reported to be good in 7.1% of the group, moderate in 71.4%, poor in 14.3% and very low in 7.1%. The cause of SCI was fall in 14 people with SCI, gun shot wound in 7 people with SCI, motor vehicle crash in 6 people with SCI, and metastases, infection in 6 people with SCI. Pressure ulcers were the most frequent secondary medical complications in this group (54.5%). Spasticity was found in 18% of individuals with SCI, neuropathic pain in 39%, deep venous thrombosis and contractures in 12%, autonomic dysreflexia and heterotopic ossification in 3%, respectively.
Pressure ulcers and neuropathic pain were the most common medical complications. Greater attention to these conditions are necessary to reduce their occurrence, and to obtain functional improvement after SCI.
P002 Disability Due to Parkinsonism in Ukraine
V. Golyk, A. Ipatov, O. Zholob, O. Moroz, G. Rusina, and D. Bogouslavskyy
Ukrainian State Institute of Medical and Social Problems of Disability, Dnipropetrovs’k, Ukraine
Parkinson’s disease (PD) is main extrapyramid disorders. For several decades incorrect PD diagnoses (diagnosing “chronic cerebrovascular insufficiency”, CCVI) occurred in formed USSR countries followed by ineffective treatment strategies. The situation influenced on increasing rate of disability. We investigated primary disability rates due to PD (IDC X codes G20, G21) and “CCVI” (IDC X codes I67.2-67.4, I67.8-67.9) in Ukrainian regions. The 2007 PD incidence was 51.4 per 100 000 population (official statistics). Highest rates were observed in Vinnitsa region (106,5), city of Kyiv (106,0), Cherkassy (84,6), Kharkiv (74,1) regions. Lowest rates were reported in Odessa (25,4), Kherson (27,6) and Lugansk (28,7) regions. Disability incidence due PD and parkinsonism (first time in Ukraine, 27 regions and administrative territories) was the following: Panukrainian incidence was 1,5 per 10 000 population (2008), highest incidence: Sevastopol’ (4,7), Odessa region (4,6), Kyiv (3,2) and Vinnitsa region (2,4), lowest positions obtained Donetsk (0,2), Kherson (0,4), Dnipropetrovs’k (0,4) and Ivano-Frankovs’k (0,6) regions. Primary disability incidence range due to “CCVI” among adult Ukrainian population was Panukrainian (incidence 11,4): highest positions in Nikolaev region (26,0), Kyiv (24,2), Odessa (21,3) and Sumy (21,2) regions and lowest ranges in Dnipropetrovs’k region (2,1), Sevastopol’ (2,8) and Donetsk region (3,8). “CCVI” proportion in whole cerebrovascular disorders was highest in Nikolaev (40,0%), Sumi (37,8%), Rivne (37,0%), Chernovtsy (35,1%) and Odessa (33,8%) regions, lowest in Sevastopol’ (4,3%), Dnipropetrovs’k (5,9%), Donetsk (10,0%) and Chernigov (10,3%) regions. Conclusions: revealed data are the subject of primary diagnostic corrections both in clinical and medical-social expertise diagnostics.
P003 Prevalence of Sleep Functions Impairments and Effect of Watching Comedy Movies in Patients With Spinal Cord Lesion
A. Kovindha, T. Attawong, B. Rukpongasoke, J. Suwichai, and S. Buagnern
Faculty of Medicine, Chiang Mai, Thailand
Background: Impaired sleep in patients with spinal cord lesions (SCL) was sometimes reported by nurses. We assessed their sleep functions according to ICF and evaluated whether watching comedy movies affects their sleep functions.
Methods: Firstly, SCL patients (aged > 18 years) reported their sleep functions: amount, onset, maintenance and quality; and completed the Hospital Anxiety and Depression Scales (HADS) questionnaires. Rates of impaired sleep functions were reported. Secondly, extracted and analyzed data of those with impaired sleep functions from those with anxiety or depression scores > 7 and entering the randomized controlled trial of watching 3 comedy movies in the evening for a week, to see whether comedy movies could improve sleep functions.
Results: Of 135 SCL patients, 37.8% reported impairments in amount, 43.7% onset, 48.9% maintenance and 29.6% quality of sleep. Anxiety was related with all components of sleep functions (p< .05). Impaired quality of sleep was found more in post-acute than in chronic patients (p=.033) and related with pain in chronic patients (p=.034). Watching comedy did not improve sleep functions.
Conclusions: Impaired sleep functions were prevalent in patients with spinal cord lesion especially during post-acute rehabilitation and related to anxiety and pain. A week of watching comedy movies did not improve sleep functions.
P004 Clinical Predictors of Efficacy of an Intensive Short-Term Inpatient Rehabilitation Program in Patients With Multiple Sclerosis
F. Martinelli Boneschi1, P. Rossi1, E. Judica1, D. Ungaro1, B. Benedetti1, G. Comi1, R. Gatti2, and M. Comola1
1Neurorehabilitation Unit, Neurology Dept—INSPE. IRCCS Ospedale San Raffaele, Milano, Italy, 2School of Physiotherapy. IRCCS Ospedale San Raffaele, Milano, Italy
Objectives: To identify clinical predictors of efficacy on impairment and disability of a short-term intensive rehabilitative treatment in 145 patients affected by Multiple Sclerosis (MS).
Methods: We considered 186 patients with MS; 41 relapsing patients have been excluded due to the proximity of a clinical relapse, while 145 have been included in this study. Clinical predictors tested were: age, sex, disease course and duration, level of education, basal EDSS and FIM, days of exercise, age of onset, cognitive performance (measured with PASAT), evaluating neurologist. Rehabilitation was considered to be effective on EDSS if associated with an improvement of at least 0.5 (if baseline EDSS>5.5) or of 1.0 point (if baseline EDSS < 5.5) and effective on disability in case of an improvement of FIM of at least 5 points. Logistic regression models have been performed to evaluate predictors of efficacy.
Results: 58.6% of our patients benefited on disability, and 60.4% on impairment. None of the clinical predictors were able to influence the likelihood of efficacy of a rehabilitation treatment in terms of disability. Female gender, a progressive course of MS, later age at onset, more severe disability and more days of rehabilitation were associated with a greater efficacy on impairment.
Discussion: These data confirm that an intensive inpatient rehabilitation course is able to determine a significant improvement of clinical and functional outcome measures. Progressive courses and a more disabled status determine a greater efficacy of motor rehabilitation.
P005 Vascular Risk Assessment in Patients With Ischemic Stroke In Neurologic Rehabilitation: Insights From INSIGHT
D. Sander1, M. Siebler2, T. Brandt3, D. Roemer4, P. Bramlage5, and C. Weimar6
1Department of Neurology, Medical Park Hospital, Bischofswiesen, Germany, 2Neurorehabilitation Center, Essen-Kettwig, Germany, 3Kliniken Schmieder Heidelberg GmbH & Co. KG Speyererhof, Heidelberg, Germany, 4Sanofi Aventis Germany GmbH, Berlin, Germany, 5Institute for Cardiovascular Pharmacology and Epidemiology, Mahlow, Germany, 6Department of Neurology, Universität Duisburg-Essen, Essen, Germany
Background: Neurologic rehabilitation aims at functional recovery after acute ischemic stroke. Vascular risk prediction in this setting is important but has not been validated. The prospective INSIGHT registry will assess the reliability of available risk prediction tools and compares their predictive properties.
Methods: Patient characteristics were acquired together with measurements of the ABI and carotid IMT and origin of stroke classified (TOAST). Patient functioning was assessed with the NIH-SS, modified Rankin Score and Barthel Index. Vascular risk was determined using the ESRS, SPI-II, ESC and PROCAM score.
Results: 1,163 patients (42.5% female) aged 66.3±12.3 years were included. NIH-SS (4.0±3.9), modified Rankin Score (2.4±1.4) and Barthel Index (73.5±30.3) indicated good functional status. 38.2% had an ABI ≤0.9, 13.7% carotid artery stenosis >50% and an average plaque sum score of 8.0±7.3 mm. ESRS was 2.3±1.5, SPI-II was 4.5±2.5, ESC score was 8.6±7.8, and PROCAM score 42.1±10.0. Prediction tools for vascular events correlated well (Pearson/Spearmen correlation coefficient > 0.5). However correlation of ABI was poorly with IMT (r=-0.11 to -0.17), the plaque sum score (-0.14 to -0.20) and slightly better with the carotid stenosis (r=0.19-0.23). Correlation of ABI with ESRS was acceptable given the lower ankle blood pressure was used (r=-0.26).
Conclusion: There was a high degree of correlation between different vascular risk scores. ABI, IMT and stenosis measurement did however not correlate to these risk scores and might indicate that combined use of these parameters might improve predictive value. These assumptions will be validated in the ongoing follow-up.
1.2 Organization
P006 Referral to Rehabilitation After a Severe Traumatic Brain Injury (TBI)
C. Jourdan1, F. Genet1, V. Bosserelle2, C. Fermanian2, P. Aegerter2, J. Weiss3, and P. Azouvi1
1AP-HP hopital Raymond Poincare, Garches, France, 2AP-HP hopital Ambroise Pare, Boulogne, France, 3CRFTC, Hopital Broussais, Paris, France
Objectives: The objective was to assess the predictive factors of decision of referral to rehabilitation of patients with severe TBI.
Methods: Patients with severe TBI were included prospectively in the study by mobile emergency services. Patients referred to a rehabilitation facility were compared to patients directly discharged home.
Results: 269 survivors, out of a total of 518 severe TBI patients, could be included in this study. 166 patients (62%) were referred to a rehabilitation facility, that was considered as specialised in neuro-rehabilitation in 115 cases (43%), and non-specialised in 51 cases (19%). 72 patients (27%) were discharged home directly after the acute car unit, without any rehabilitation support. The logistic regression analysis showed that the following factors were significantly predictive of referral to rehabilitation: not living alone, lack of pre-traumatic alcohol abuse, a low (3-5) initial score at the Glasgow Coma Scale, a high initial Injury Severity Score, and not being referred to a general medical ward after the acute care department.
Conclusions: Patients with more severe injury were more frequently referred to rehabilitation. This raises concerns about patients with apparent good recovery who are discharged home without any rehabilitation support. Injury severity was not the only predictive factors influencing patients’ referral. Patients with poor family support or with pre-injury alcohol abuse were significantly less frequently referred to rehabilitation (Odds ratio respectively 0.29 and 0.31).
P007 Organization of Neuro-Rehabilitation Services in Hungary
G. Fazekas1,2, Z. Denes1, V. Fay3, I. Szel1, and E. Urban4
1National Institute for Medical Rehabilitation, Budapest, Hungary, 2Szent Janos Hospital, Budapest, Hungary, 3Szent Istvan-Laszlo Hospital, Budapest, Hungary, 4Karolyi Sandor Hospital, Budapest, Hungary
There are different models for neuro-rehabilitation in Europe. In Hungary the first steps were made in the 1970s, when special departments for stroke, spinal cord injury and traumatic brain injury rehabilitation were founded at the National Institute for Medical Rehabilitation. There are two opportunities for specialization in rehabilitation medicine: medical doctors having any clinical specialization can apply for board exam after a two-year-long training. Doctors without any specialization have to complete a five-year-long training. Both types of training involves a strong education in neuro-rehabilitation. PhD programmes are also available on this field.
Neuro-rehabilitation services are provided as acute rehabilitation at the acute care units, post-acute rehabilitation at special neuro-rehabilitation units or at general PMR departments. At acute units the rehabilitation team is usually incomplete, physiotherapists and speech therapists are available, but PRM specialists rarely. In post-acute rehabilitation the leader of the team often has specialization both in neurology and PRM. In other cases not the head of the unit, but a team member is specialized in neurology. At some departments there is no neurologist in the team, but available as a consultant.
In accordance with the intention of the PRM Section of the UEMS, rehabilitation services will be based on accredited programmes. A rehabilitation department will not be eligible automatically to provide neuro-rehabilitation, only if it fulfills the personnel and physical requirements.
Reference: Szél I, Bereczki D, Fazekas G, Csiba L, Vekerdy-Nagy Z. Acute care and rehabilitation of patients with stroke in Hungary. Am J Phys Med Rehabil. 2009;88(7):601-4.
P008 ICF Framework Is Helpful for Quality Management in Individual Goal Setting
K. Fheodoroff, S. Ramusch, G. Tautscher-Basnett, and M. Freimüller
Gailtal-Klinik Hermagor, Neurorehabilitation, Hermagor, Austria
Background: The WHO endorses the International Classification of Functioning, Disability and Health (ICF) to describe health status related functioning. Patient-centred neurorehabilitation should aim at enabling participation in interaction and social life.
Objective: To investigate if ICF categories are useful for monitoring and surveying the quality of patient-centred goals in neurorehabilitation.
Methods: Analysis of 6686 goals for 1066 in-patients in a neurorehabilitation clinic (140 beds) categorized by the ICF in terms of goals per patient, goals per category and distribution of categories.
Results: The average number of goals per patient was 6.27 (range: 1-22). Of 6686 goals 30.2% were set at body function level, 69.8% were action and task related. There were 49.9% of goals set at mobility domain, 17.8% at self care domain. 22.2% of goals were addressed at learning/applying knowledge, general tasks/demands and communication, whereas domestic life, interaction, major life areas and social/civic life (together 10.1%) were underrepresented.
Discussion: This goal analysis made apparent that a shift in goal setting from mobility and self care to interaction and major life areas needs to be addressed so as to meet the demands of patient-centred neurorehabilitation. The ICF framework is helpful for monitoring quality and comprehensiveness of goals in neurorehabilitation.
Conclusion: Using ICF categories may be helpful in broadening individual goal spectrums beyond mobility and self care.
P009 Separating Diagnostic Neurology From Management of Long-Term Neurological Conditions: A New Concept of Service Delivery
T. A. Gaber and J. Priest
Bolton PCT, Bolton, United Kingdom
Traditionally, regional neuroscience centres with local satellite clinics oversee both diagnostic neurology and long-term management of the neurological conditions. Neurological rehabilitation services are usually locally organised.
This model has its advantages ensuring the quality and equity of the regional services. On the other hand, a bias towards the diagnostic aspect of the service is prevalent considering the nature of neurology training. This leaves the chronic management not only relatively ad hoc but also lacking collaborative spirit with the locally grounded rehabilitation services.
New service development in Bolton: Pressure to manage waiting lists, inability to provide regular follow up and proven patient dissatisfaction have galvanised Bolton PCT to review the service delivery philosophy.
After wide consultation with the key stakeholders, Bolton PCT decided to commission the diagnostic neurological services to a Centre for Assessment and Treatment (CATS) based in Salford. Management of long-term neurological conditions moved to a new purpose-built community centre where all the members of the neurological rehabilitation team are based.
The key component of the service was based on case management, which is provided by either specialist nurses for conditions such as MS, Epilepsy, and Parkinson’s disease, OT for brain injury and active case manager for complex cases.
The case managers are supported by the neurologists (moving from the acute hospital to the community premises), a rehabilitation consultant, a neuropsychologist and several therapy staff.
Robust audit machinery is in place. If successful, this novel model of service provision may provide an alternative to the current model.
P010 Integrating Multidisciplinary Therapy in Early Stroke Rehabilitation: An Empirical Study
S. Gratzl1, N. Yilmaz-Kaymaz1, E. Beyer1, and M. Brainin2
1Landesklinikum Tulln, Tulln, Austria, 2Landesklinikum Tulln and Danube-University, Tulln and Krems, Austria
Background: The integration of multiple disciplines in early stroke rehabilitation is a necessary requirement and involves doctors, nurses, physiotherapists, occupational therapists, speech therapists, neuropsychologists and social workers. The division of responsibilities concerning important patient procedures is not always clarified between the individual professions, and this can lead to conflicts and grievances.
Objective: This study systematically collects data on the difficulties of multidisciplinary cooperation.
Methods: Standardized questionnaires with closed and open questions were used in the neurological early stroke rehabilitation department Landesklinikum Tulln.
Results: Of the 44 questionnaires, 38 were returned (86% response rate). Participation involved 20 nurses, 9 physiotherapists, 4 occupational therapists, 3 speech therapists, and 2 doctors. Of the 24 activities which demonstrated cross-over between disciplines, only 2 activities were in 100% agreement (dressing the patient before therapy and attaching the nutrition probe after therapy). The most common responsibilities that were not clarified existed between nursing staff and physiotherapists. The predominant discrepancies among both professions were in the domains mobilization, bedding, and transfer of patients.
Conclusion: Seamless interaction of professionals such as between nurses and physiotherapists requires a strict definition of responsibilities for handling and therapy.
P011 Interdisciplinary Progress Report: Improved Communication Between Specialised Neurorehabilitation Hospital and Community Service
T. M. Kristensen
Regionshospitalet Hammel Neurocenter, Hammel, Denmark
In Denmark rehabilitation for adults with acquired severe brain damage is provided at specialised neurorehabilitation hospitals. The community is responsible for providing services for the patient after discharge from hospital. Coordination across the continuum of care is important in order to accomplish a seamless transition from hospital to community living. Discharge communications between hospital and community health care staff is provided by use of an interdisciplinary progress report. In order to ensure that the necessary information is passed on Region Midtjylland—one of five administrative units in Denmark—have prepared a common template to be used by all neurorehabilitation hospitals in the region.
Method: The interdisciplinary progress report is based on: ICF—International Classification of Functioning, Disability and Health, a concept of rehabilitation that holds a holistic approach. The goal is a meaningful way of life for the patient. Different disciplines and sectors (i.e. hospital and community) work together in order to reach common goals. A review of literature within the field was carried out and the template is as well based on experience. The template has been tested by the sender (hospital) and assessed by the receiver (community). Results: The result is a template that covers health issues as well as a description of the patient’s functioning and disabilities. Additionally, a guidebook has been designed that includes definitions and descriptions of the concepts used in the progress report. Conclusion and perspective: The project has shown that using the interdisciplinary progress report improves communication between the mentioned sectors.
P012 Ten Years of Kaifukuki Rehabilitation Ward, a Postacute Rehabilitation Unit Covered by the National Medical Insurance in Japan
I. Miyai1,2, S. Sonoda2,3, S. Nagai2,4, Y. Takayama2,5, Y. Inoue6, A. Kakehi6, M. Kurihara2,7, and M. Ishikawa2,8
1Morinomiya Hospital, Osaka, Japan, 2Kaifukuki Rehabilitation Ward Association, Tokyo, Japan, 3Fujita Health University Nanakuri Sanatorium, Tsu, Japan, 4Kinjo University, Hakusan, Japan, 5Ukai Rehabilitation Hospital, Nagoya, Japan, 6National Institute of Public Health, Wako, Japan, 7Nagasaki Rehabilitation Hospital, Nagasaki, Japan, 8Hatsudai Rehabilitation Hospital, Tokyo, Japan
Background and purpose: A new interdisciplinary postacute rehabilitation unit, Kaifukuki (convalescent) Rehabilitation Ward (KRW) has been developed in the national medical insurance system in Japan since 2000. Over 53,000 beds (42 beds per 100,000 population) are now available nationwide. Furthermore the maximal coverage of rehabilitation increased from 120 to 180 minutes per day in 2006. We aimed to describe basic characteristics and functional outcome of patients admitted to KRW.
Methods: Retrospective cohort study of 70,681 patients from the database of the annual survey for patients admitted to KRW from 2001 through 2008.
Results: Mean (SD) age of the patients was 72.6 (13.8), female gender was 55,0%, and disabling disease comprised stroke (49.1%), orthopedic diseases including hip fracture (34.1%), neurological diseases including traumatic brain injury and spinal cord injury (5.2 %), and others. Mean onset-admission interval (OAI) was 32.3 (19.2) days and length of stay (LOS) was 76.2 (46.7) days. Mean daily rehabilitation session time including the weekend was 78 (32) minutes. Mean scores of admission/discharge Barthel index and the Functional Independence Measure were 49.3 (31.1)/70.6 (32.0) and 75.4 (31.5)/91.7 (31.0), respectively and 68.2% of patients discharged home. Year-by-year comparisons revealed that older age, greater initial disability, shorter OAI and LOS coupled with greater doses of rehabilitative intervention and higher rate of discharge home were prominent in the recent years.
Conclusion: KWR is a unique solution to increasing number of the elderly after acutely disabling diseases.
P013 Guidelines for Cooperation Between Nursing Staff and Therapists in Neurological Rehabilitation
E. Quirbach, B. Brunner, M. Kofler, and L. Saltuari
Hochzirl Hospital, Zirl, Austria
Project name/Project goals: Guidelines for cooperation between nursing staff and therapists in neurological rehabilitation/Improvement of interdisciplinary teamwork through definition and assignment of tasks in the daily workload.
Original status: Relations between nursing staff and therapists were often strained due to lack of a common language in rehabilitation, differing goal settings and expectations, and the assignment of roles in the daily workload.
Brief description: A task force, consisting of six representatives of the nursing and therapist teams, was called into existence in order to formulate guidelines for multi-professional cooperation. The goals were to define role assignments and boundaries of the professions, to clarify misunderstandings on both sides, and to promote an atmosphere of mutual respect and professional satisfaction for all involved. The problems were divided into two groups, as to whether the conflict of interest primarily concerned the nursing staff or the therapists.
Advantages: Working together for the benefit of the patient, without artificial barriers of imagined or real hierarchy.
Final status: Since implementation of the guidelines, interdisciplinary teamwork is no longer an empty cliché, but a reality. The heads of department in nursing as well as in therapy represent commitment to the same ideals, resulting in working better together to enhance the welfare of the patient. Mutual respect between the professions has increased, and with it job satisfaction and a pleasant working atmosphere. When conflicts do occur, they can be solved on a factual instead of an emotional basis.
P014 Medical Care and Services, Technical Aids in Stroke Patients More Than Five Years After Initial Inpatient Stroke Rehabilitation
W. J. Schupp1, U. Hoess2, N. Brinkmann1, and I. Haase3
1Fachklinik Herzogenaurach, Herzogenaurach, Germany, 2Klinikum Rummelsberg, Schwarzenbruck, Germany, 3Klinikgruppe Enzensberg, Füssen, Germany
Aim: CERISE study followed up stroke rehabilitation inpatients in four centres and countries till six months after stroke onset. Living situation and quality of life (Qol) differed due to centre/country, financial resources and political health care system (1,2). Recently, an additional follow up was performed more than five years after study inclusion.
Design: Prospective cohort-study
Methods: All included patients who could be contacted had been assessed again by a trained researcher during a home visit. For the German patients we added a list on medical care and services, used technical aids, filled in by the researcher.
Results: 55 German patients allowed to be assessed again. Almost all had visited in the last year a family doctor, 37 additional different specialists (neurologists, internists, ophthalmologists most frequently). 23 patients had been prescribed PT, 13 OT, 10 massages, 2 logopedics and 1 (neuro) psychology. Nearly all patients had to go to the doctors’ and therapists’ practices, home visits were very rare. Technical aids, repeatedly mostly used, were walking aids, handles in the rooms and aids for toilet and shower. Ten patients received payment or services by social care insurance.
Conclusions: The family doctors were the most important medical persons for the survivors in the German CERISE sample. Therefore, they must be trained with long term neurorehabilitation strategies.
P015 WebRehab: The Swedish Database for Rehabilitation
K. S. Sunnerhagen1, M. Lannsjö2, A. Tölli3, Å. Lundgren Nilsson1, A. Sörbo1, and U. Flansbjer4
1Neuroscience and physiology, Gotehnburg, Sweden, 2Rehabilitation medicine, Sandviken, Sweden, 3Rehabilitation medicine, Stockholm, Sweden, 4Rehabilitation medicine, Lund.Orup, Sweden
We have created a web-based database for inpatient rehabilitation in Sweden, launched in 2007. The aim of the database is to improve 1) quality in the rehabilitation process, 2) use limited resources better, 3) enhance awareness of the ICF model, 4) support the participating units rehabilitation process development, 5) make comparison between units possible, 6) to gather knowledge of rare conditions, and 7) to be used for research.
Twenty of the country’s 21 areas are represented and in 2008 there were 1868 registrations for admittance.
Data are gathered at admittance, at discharge and 1 year after onset of disease/trauma. The database contains information on demographics, diagnoses, and problems within different domains of ICF.
Process measures: time from referral until admission, resources, time of care, whether questions on tobacco, alcohol and drugs have been asked, setting up and using a rehab plan, if assessment for driving has been performed, and use of different assessment instruments.
Result measures: Complication and medical events, ADL in and out, BMI in and out, EQ5D in and out, deceased, discharged to, patient satisfaction with the rehab process, and for acquired brain injury GOSE.
The online registration is working. There is room for improvement in the rehab process; we are not having enough registrations on BMI which can be seen as a measure of quality of care. Sexual problems often are not addressed. Rehab plans are not always set up, however when they are present, they are used. Patient satisfaction is high.
2. Assessment – Basic Research
2.1 Neuropsychology
P016 The Relation Between Memory Self-Efficacy and Psychosocial Factors in Chronic Stroke Patients
L. Aben1, M. M. Visser1, R. W. H. M. Ponds2, J. J. V. Busschbach1, M. H. Heijenbrok-Kal3, and G. M. Ribbers1,3
1Erasmus Medical Center, Rotterdam, Netherlands, 2University Hospital, Maastricht, Netherlands, 3Rijndam rehabilitationcenter, Rotterdam, Netherlands
Objectives: Memory deficits occur frequently after stroke. Most memory training programs for stroke patients are based on compensation techniques and are moderately effective. An increase in effectiveness could be achieved by integrating Memory Self-efficacy (MSE) into training programmes. MSE is an important mediator of actual memory performance and related to psychosocial factors in healthy elderly subjects. This study aims to quantify the relation between MSE and depression, coping and personality in chronic stroke patients.
Material and methods: We included 108 stroke patients who were 18 months or more post onset. We measured MSE, depression, neuroticism and coping with respectively the MIA questionnaire, the CES-D, the EPQ-BV and the assimilative-accommodative coping scale. Memory functioning is measured using the AVLT and two short stories of the RBMT. The data were analysed using univariate and multivariate regression analyses.
Results: As in healthy elderly subjects, depression (ß = -.493; p = .000), neuroticism (ß = -.364; p = .000), and accommodative coping (ß = .263; p = .007) were significantly related to MSE scores. MSE was significantly related to actual memory performance (ß = .231; p = .021). In multivariate analyses, MSE is predicted by depression and in lesser degree by actual memory performance (F = 20,145; p = .000).
Conclusions: Psychosocial factors seem to play an important role in memory complaints after stroke, comparable to other studies with healthy subjects. These findings prove MSE to be a candidate to enhance current memory training programmes for stroke patients.
P017 Learn it With MERLIN: A Software Dedicated to the Teaching of Specific Information With Errorless Learning methods
M. Aeschlimann, S. Clarke, and C. Bindschaedler
Neuropsychology and Neurorehabilitation Service, Vaudois University Hospital Center, Lausanne, Switzerland
Errorless learning has been shown to be a valuable method to teach specific information to patients presenting a variety of deficits such as anterograde or retrograde amnesia, anomia, and agnosia. Variations of the method have been proposed. The original method, or pure errorless learning (EL), requires the patient to repeat and/or copy the entire information during several trials. By contrast, errorless learning combined with fading (ELf) provides the patient with the entire information during the first cycle but with only partial information to be completed during the next cycles, which makes the patient more active.
We developed software, called MERLIN, which allows the therapist to create a database for many patients or learning sessions tailored for one particular patient. Here we first present the design of the software and second illustrate the comparison of both methods on the basis of a single case of anomia for proper names.
Due to the pre-morbid art expertise of the patient, associations between self-portraits and names of painters were chosen as material. Three lists of associated pairs were created: the first list was learned using an EL learning method, the second one with an ELf method, and the third one was used as control. Results showed that, compared to control items, both methods are efficient, with a slight superiority of the second one (ELf). Furthermore, the facilitation of naming for the trained items extended to two complementary naming tasks based respectively on biographical descriptions and other painting of the same artist.
P018 Ecological Assessment of Numerical Competence in Vascular Aphasic Patients
E. Bayen1,2, A. Peskine1,2, C. Prévost1, and P. Pradat-Diehl1,2
1Groupe Hospitalier Pitié-Salpêtrière, Paris, France, 2Unité INSERM UPMC ER 6, France
Aphasic patients after stroke often experience difficulties in dealing with numbers. Nevertheless, such troubles are poorly evaluated and their consequences in daily life activities rarely explored.
We intended to evaluate numerical capacities of aphasic patients after left hemispheric stroke thanks to an Ecological Assessment (EA).
Methods: Twelve right-handed aphasic patients were included in the study. All had returned home after undergoing rehabilitation. They had a neurological and speech evaluation and a cerebral imaging. They were tested by a French published analytic battery of calculation (TLC2) and then by our Ecological Assessment. The latter consists of 11 tasks using numbered data in daily life (handling schedules, dealing with coins) and was formerly normalised in healthy controls.
Results: Patients were of mean age of 44 (22 to 59), 9 had a Barthel score superior to 95, 75% of the patients felt impaired when dealing with numbers in daily activities. Performing the EA lasted an average 55 minutes. Eight patients had pathological scores. 7 out of 11 tasks appeared to be more relevant. Besides, error analyses in both analytic and ecological batteries showed correlation between subtests: transcoding Arabic into alphabetical numbers and check writing; writing down an Arabic number and typing a digicode.
Detecting troubles when handling numerical data in patients suffering from aphasia of variable severity is possible thanks to a rapid ecological test. Correlation between analytic and ecological sub-scores points out both a deficit and a disability. Appreciating this disability allows to orient patients towards specific neurocognitive rehabilitation.
P019 Walking on Eggshells: The Impact of Traumatic Brain Injury on Marital and Relationship Satisfaction
A. Casey1, P. Byrne2, D. Carton1, and D. Quigley3
1National Rehabilitation Hospital, Dublin 6, Ireland, 2National Rehabilitation Hospital, Dun Laoghaire, Co. Dublin, Ireland, 3Trinity College Dublin, Dublin, Ireland
Objective: Adverse cognitive, emotional and behavioural sequelae in those who sustain a Traumatic Brain Injury (TBI) are commonly noted by family members. In addition the impact of TBI on marital and family relationships can be substantial. The aim of this study is to examine marital and relationship satisfaction, coping and use of social supports in those who have sustained a TBI and their partners.
Design: A questionnaire based postal survey was used to investigate relationship and marital satisfaction following a brain injury.
Participants: Thirty four participants (20 female; 14 male), ranging in age from 25-68 years (age 49 years), took part in this study. Sixteen participants (13 male, 3 female) had TBI and eighteen participants (1 male, 17 female) were partners of people with TBI. Participants with TBI who had been inpatients at the National Rehabilitation Hospital (NRH), Dun Laoghaire between the years 2003 to 2007 and their partners were invited to participate in the study.
Outcome Measures: The Marital Satisfaction Questionnaire (MSI-R) and The Brief Cope and Social Supports Questionnaires (SSQ-6) were used to examine marital satisfaction, coping and social supports.
Results: Both patients and partners reported relationship difficulties following brain injury (z = -3.078, p < .05 patients; z = 2.699, p < .05 partners).
Conclusion: This study highlights the significant impact of TBI on relationships for both the TBI survivor and their partners. Practical implications of TBI for couples and for the practice of rehabilitation are discussed.
P020 Metasyndrome Analysis in Neuropsychology
Y. V. MIikadze
Lomonosov Moscow State University, Moscow, Russian Federation
Neuropsychological assessment necessarily precedes neurorehabilitation. Luria’s approach to the assessment of patients with brain lesions consists of first describing the deficits in high-order cognitive functions, secondly determining the damaged brain areas responsible for these symptoms and finally defining a neuropsychological syndrome as a genuine constellation of these symptoms.
Two practical issues come up with the assessment. One is the need of defining the structure of the neuropsychological deficit that guides the development of the rehabilitation plan and evaluation of the progress.
Second is related to the localization of the lesion and more importantly to the detection of functionally affected brain regions that cannot be observed using structural imaging techniques.
Original syndrome analysis proposed by Luria was based on the description of syndromes that result from the well-defined local lesions. Diffuse brain lesions (e.g. TBI, MS) lead to multiple deficits that don’t converge into a unit syndrome but could rather be described as a complex of syndromes associated with affected brain regions.
Global pathological conditions (stroke or epilepsy) secondary disturb the normal functioning of different brain regions functionally and morphologically connected to the prime lesion. These dysfunctions show up in the assessment in form of mild to severe syndromes. Combinations of these syndromes might reveal a stable pattern. A new concept of metasyndrome is introduced in order to describe these repetitive patterns that reflect both the effects of lesion and functionally impaired brain regions on cognition and behavior. It was further applied to the analysis of the focal epilepsy in adolescents.
P021 Preserved Visual Consciousness in a Blindsight Patient: Prospects for Rehabilitation and a New Conception of the Syndrome
M. Overgaard1, K. Fehl2,3, K. Mouridsen4, B. Bergholt5, and A. Cleeremans6
1CNRU, Hammel Neurorehabilitation and Research Center, Aarhus University Hospital, Aarhus University, Hammel, Denmark, 2CNRU, Hammel Neurorehabilitation and Research Unit, Hammel, Denmark, 3Georg-August-Universität Göttingen, Göttingen, Germany, 4CFIN, Aarhus, Denmark, 5Dept of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark, 6Universite Libre de Bruxelles, Bruxelles, Belgium
Blindsight patients, whose primary visual cortex is lesioned, exhibit preserved ability to discriminate visual stimuli presented in their “blind” field, yet report no visual awareness hereof. Blindsight is generally studied in experimental investigations of single patients, as very few patients have been given this “diagnosis”. In this single case study of patient GR, we ask whether blindsight is best described as unconscious vision, or rather as conscious, yet severely degraded vision.
In experiment 1, we find experimental support for the claim that our patient has blindsight. In experiment 2, we successfully replicate the typical findings of previous studies on blindsight that patients are correct when describing stimulus properties in the absence of subjective experience. The third experiment, however, suggests that GR’s ability to discriminate amongst visual stimuli does not reflect unconscious vision, but rather degraded, yet conscious vision. As our finding results from using the Perceptual Awareness Scale (PAS) for obtaining subjective reports that has not previously used in blindsight studies (but validated in studies of healthy subjects and other patients with brain injury), our results call for a reconsideration of blindsight, and, arguably also of many previous studies of unconscious perception in healthy subjects.
As another outcome of the experiments, GR learned that she had vague perceptions in the “blind” field. Her increased ability to notice these experiences points to new ways of training blindsight patients where currently none exist.
P022 Is the Neglected Side of the Visual Field Stationary or Movable in Visuospatial Neglect?
M. Overgaard1 and M. Jensen1,2,3
1CNRU, Hammel Neurorehabilitation and Research Unit, Aarhus University Hospital, Aarhus University, Hammel, Denmark, 2Dept of Philosophy, Aarhus University, Aarhus, Denmark, 3CFIN, Aarhus University, Aarhus, Denmark
Visuospatial neglect is one of the most common cognitive disturbances after brain injury. In their famous experiment, Bisiach and Luzzatti asked patients with left-sided visual neglect to imagine viewing the Piazza del Duomo from two different angles, and found that the neglected part of the visual field changed along with the change of perspective.
In the here described experiment, patients with left-sided visuospatial neglect will be compared to healthy subjects when presented to a stimulus display consisting of a virtual scenery with an avatar and red balls around him having to be counted, if visible, “as you see them” or “as the avatar sees them”. It will be assumed that neglect patients, when taking on a first person perspective, will neglect the left sided red balls. However, when taking on the perspective of the avatar figure, it is an open question whether the left-sided balls will be neglected still, or whether the neglected part of the visual field will “move around” with the avatar figure as he changes his position in space. The experiment will give important information to the classical debate whether neglect is related to perception or to a spatial aspect of mental representations. Furthermore, if left-sided objects become visible to the patients the moment they take on the perspective of, say, a figure facing the opposite way, this indicates new methods to train with the patients.
P023 Rehabilitation of Attentional and Working Memory Deficits Using Hypnosis: A New and Potentially Strong Tool in Cognitive Neurorehabilitation
M. Overgaard1, J. Lindeløv1,2, and R. Overgaard1
1CNRU, Hammel Neurorehabilitation and Research Unit, Aarhus University Hospital, Aarhus University, Hammel, Denmark, 2Dept of Psychology, University of Aalborg, Aalborg, Denmark
Over the past decade, research involving hypnosis has made important contributions to cognitive neuroscience. The advent of sophisticated functional neuroimaging in particular has made it possible to localize task-related, regionally specific brain activity associated with hypnosis. One compelling line of research exploring attention has involved the suppression of the Stroop effect using hypnotic suggestion and the elimination of the flanker compatibility effect by hypnotic suggestions that increased focal attention.
Given the extensive and growing knowledge of the cognitive architecture for many neuropsychological disorders and the ability of hypnotic suggestion to reliably modulate performance at cognitive, behavioural and experiential levels, an underexploited opportunity remains for using hypnosis to make a meaningful contribution to neuropsychological interventions in the remediation of cognitive disorders.
In the here described, currently ongoing experiment, patients with minor attentional deficits are treated with hypnotic inductions to increase attention and working memory capacity. Patients are tested for short- and long term effects testing their ability to recapitulate a brief text as exactly as possible. To evaluate their general outcome, patients are tested before and after using the working memory index of WAIS-III. The patient group is tested against a matched group of patients given a relaxing hypnosis without attention or working memory-relevant inductions.
P024 Prevalence and Determinants of Cognitive Complaints After Aneurysmal Subarachnoid Haemorrhage
P. E. C. A. Passier1, J. M. A. Visser-Meily2, M. J. E. van Zandvoort3, M. W. M. Post4, G. J. E. Rinkel5, and C. van Heugten6
1Rehabilitation Centre De Hoogstraat, Utrecht, Netherlands, 2University Medical Centre Utrecht, Utrecht, Netherlands, 3Psychological Laboratory, Helmholtz Institute, Utrecht University, Utrecht, Netherlands, 4Rehabilitation Centre De Hoogstraat, Research department, Utrecht, Netherlands, 5University Medical Centre Utrecht, department of Neurology and Neurosurgery, Utrecht, Netherlands, 6Department of Neuropsychology and Psychopharmacology, Maastricht, Netherlands
Background: To investigate the prevalence of cognitive complaints after subarachnoid haemorrhage (SAH) and the relationships between cognitive complaints and cognitive impairments, disability and emotional problems.
Methods: Cognitive complaints were assessed with the Checklist for Cognitive and Emotional consequences following stroke (CLCE-24) in 111 persons who visited our outpatient clinic 3 months after SAH. Associations between cognitive complaints and cognitive functioning (memory, attention, executive and visuospatial functioning), demographic characteristics, disability (Glasgow Outcome Scale) and emotional problems (depression and anxiety) were examined using Spearman correlations and linear regression analysis.
Results: Most frequent reported cognitive complaints were mental slowness (60.4%), short-term memory problems (48.6%) and attention deficits (attending to things: 44.1%, doing two things at once: 36.9%). Results of the bivariate and multivariate analyses are displayed in Table 1. In the final regression model, memory functioning (beta value -0.20), disability (-0.21) and depressive symptoms (0.45) were significant determinants of cognitive complaints, together explaining 32.4% of the variance.
Bivariate and Multivariate Analyses of Independent Variables and CLCE-24 Cognition Score After SAH. (N = 111)
SAH: subarachnoid haemorrhage; CLCE-24: Checklist for cognitive and emotional consequences following stroke; GOS: Glasgow Outcome Scale; STAI-DY-1: State Trait Anxiety Inventory, BDI-II-NL: Beck Depression Inventory.
Conclusion: Cognitive complaints are common after SAH and associated with memory deficits, disability and depressive symptoms. Rehabilitation programs should focus on these symptoms and deficits.
P025 Hemispheric Stroke and Calculation Disorders
M. Rousseaux, F. Szewczykowski, M. Lequertier, and W. Daveluy
CHRU of Lille, Lille, France
Introduction: Calculation has been investigated in patients with focal hemispheric lesions, mostly parietal. Little is know about disorders in extended middle (MCA) or anterior (ACA) cerebral arteries stroke.
Patients and methods: Inclusion: 35 patients in the first months following a stroke of the left ACM (16), right ACM (13) or ACA (6). Exclusion: severe aphasia or neglect. Calculation assessment (TLC2): lexical decision, matching, transcoding, counting, understanding the magnitude, completion of operations, grammaticality judgement, calculation, problem solving, numeral knowledge and ecological use of number. Other: language, spatial attention, executive functions and working memory.
Results: Lexical decision, matching, counting, completion of operations and grammaticality judgement were preserved in comparison (p<0.05) with controls. LMCA strokes impaired transcoding (dictation of numbers written in letters, dictation of numbers written in Arabic numbers, transcribing Arabic numerals/verbal written, transcribing verbal written numerals/Arabic), understanding the magnitude (estimating a result), calculation (mental calculation, written operations to solve), problem solving, knowledge about numbers and their ecological use. RMCA stroke altered estimating a result, written operations to solve and ecological use. ACA strokes impaired written operations to solve and problem solving. Significant correlations: between executive function or digit span and estimating a result, grammaticality judgement and problem solving; between BDAE subtests and transcoding, understanding the magnitude and mental calculation. Conclusion: Transcoding operations are essentially under the control of lateral structures of the left hemisphere. Calculation and problem solving is processed within a multi-modular system in the left and right lateral hemispheres and frontal structures.
P026 Brain Activity During a Prism Adaptation Task in Patients With Right Cerebral Hemisphere Injury: A Study Using Functional Near-Infrared Spectroscopy
H. Taniguchi1,2, T. Tominaga2, K. Oue2, M. Kono2, Y. Yukawa1,2, N. Sueyoshi1,2, and S. Morioka1
1NeuroRehabilitation, Kio University, Kitakaturagi-gun, Nara, Japan, 2Rehabilitation, Murata Hospital, Osaka, Japan
Objective: Prism adaptation (PA) is used for the treatment of unilateral spatial neglect (USN), and the task is reported to cause a significant increase in the activity of the right parietal lobe. Subjects: In this study, we used functional near-infrared spectroscopy (fNIRS) to measure the brain activity during a PA task in patients with right cerebral hemisphere injury (3 patients had recovered and 6 had not recovered USN) and analyzed it. Methods: We used prism glasses that shift the region receiving visual inputs to 10° rightward. Each patient was asked to sit in front of a target placed 45 cm away, and was asked to point out the target quickly with the right index finger. We used hemoglobin oxygenation level as the parameter for analysis. Results: Patients who had recovered showed a significant increase in the activity in the right frontal-parietal lobe (p < 0.01), whereas patients with persistent USN showed a significant increase in the activity in either the right frontal lobe or the right parietal lobe (p < 0.01). Some of the patients with persistent USN did not show any increase in the activity. Discussion: The network of the right frontal-parietal lobe is related to the improvement in the visual and somatic sensation brought about by the PA task; it seems that the network dysfunction in the right frontal-parietal lobe is one of the factors that lead to the persistence of USN.
P027 The Neuropsychological Sequelae of Cranioplasty: A Case Study
S. J. Weatherhead1, G. J. Newby1, and C. Pinder2
1Community Care Western Cheshire, Chester, United Kingdom, 2Wirral University Teaching Hospital NHS Foundation Trust, Wirral, United Kingdom
Introduction: Cranioplasty is regularly used to repair large cranial defects resulting from trauma or surgery. Common materials used include bone, plastics, or titanium. Published research indicates post-surgery improvements in cerebral blood flow regulation, neurological and general functioning. Analysis of neuropsychological functioning, has focused on the Syndrome of the Trephined. However, there is limited research that includes a comprehensive neuropsychological assessment before and after surgery.
Methods: A single case study is presented of an adult male who incurred a traumatic brain injury following a quad bike accident. Craniotomy was conducted to evacuate an acute haematoma. Post surgery CT scans also indicated fronto-temporal damage. Approximately one year later, successful cranioplasty surgery was carried out. A full neuropsychological assessment was administered pre and post surgery.
Results: Following cranioplasty, a moderate increase was noted in verbal comprehension. Slight increases were evident in general intellect, processing speed and verbal executive functioning tasks. Psychological improvements were noted in perceptions of self-image and self-esteem, with reduced levels of fatigue. A number of simple partial seizures occurred post surgery and at the time of writing, epilepsy status is medicated but unstable.
Discussion: This case study highlights some of the neuropsychological gains that can occur as a result of successful cranioplasty. However these are balanced against the risk of epilepsy, which can have negative neuropsychological effects. Indeed the cognitive dulling from medication may mask additional gains. Robust research utilising a comprehensive neuropsychological assessment would add significant understanding to the potential gains and risk factors following cranioplasty.
P028 Brain Activity During Vibration-Induced Illusory Movements in Hemiplegic Stroke Patients
Y. Yukawa1,2, T. Tominaga2, S. Ichimura2, K. Oue2, M. Kono2, H. Taniguchi1,2, N. Sueyoshi1,2, and S. Morioka1
1NeuroRehabilitation, Kio University, Kitakatsuragi-gun,Nara, Japan, 2Rehabilitation-Murata Hospital, Osaka, Japan
Introduction: Previous studies have revealed that when a limb senses vibration-induced illusory movements (VIM) motor-related areas like the primary motor cortex on the opposite side become active and brain activity resembling motor imagery is displayed in healthy individuals. However, whether or not hemiplegic stroke patients can sense VIM is unclear. Methods: Using functional near-infrared spectroscopy (fNIRS), the current study examined brain activity with regard to the tendon of the flexor carpi radialis muscle of the wrist of the hemiplegic limb during tasks involving VIM performed by hemiplegic stroke patients who had mild sensory deficit (Patients 1-6) and similar patients who had severe sensory deficit (Patients 7 and 8). Results: Results revealed that Patients 1-6 had significantly increased blood flow (p<0.01) in motor-related areas like the primary sensorimotor cortex on both sides or on the opposite side while Patients 7 and 8 had no significant increase in blood flow in those areas. Discussion: In cases of mild sensory deficit, significantly increased blood flow was noted in motor-related areas as a result of vibratory stimulation, suggesting that hemiplegic stroke patients who have mild sensory deficit may be able to sense VIM with the hemiplegic limb. Thus, sensing of VIM by hemiplegic stroke patients may help with motor imagery.
P029 Spatial-Numerical Associations in a Patient With Multimodal Right-Sided Hemineglect
H. Zauner1, G. Wood2, K. Moeller3, C. Haider1, G. Alfred1, and H. Nuerk3
1SKA-RZ der PV Großgmain, Großgmain, Austria, 2University Salzburg, Salzburg, Austria, 3University Tübingen, Tübingen, Germany
Objectives: Is there a common cognitive mechanism underlying all spatial-numerical associations? Typically, healthy participants associate small numbers with the left side and larger numbers with the right. Accordingly, left-side hemineglect patients present with difficulties assessing the representation of small numbers, in accordance with their impaired representation of the left side. Here we investigate how right-side hemineglect affects spatial numerical associations. Subjects and methods: We examined patient D (69 years, left handed) after peri-interventional left-parietal stroke (ischemic areas in arteria cerebri media and arteria cerebri posterior) and multimodal right-sided hemineglect. We assessed the patient’s performance in magnitude classification, detection of numbers in a visual detection task (reactions assessed by eye tracker) and line bisection tasks with numeric flankers (compared to 24 healthy controls). Results: In the magnitude categorization and visual detection tasks patient D showed a statistically robust preference for the (atypical) association small-right/large-left. Patient D detected visual stimuli on the right side much more accurately when a small number was used as a visual cue. In contrast, in the line bisection task patient D showed a bias toward the larger number as healthy controls do. Discussion: We conclude that spatial numerical associations are not all controlled by the same cognitive mechanism but rather by specific individual preferences. Evidence provided by patient D suggests that different cognitive mechanisms in neglect underlie the spatial numerical association in choice reaction time and eye-tracking tasks on the one side, and line bisection with numeric flankers task, on the other side.
2.2 Neuroimage
P030 Stroke Patients With Left Hemispheric Infarcts Display Stronger Activation During Action Observation and Imagery Than Those With Right Hemispheric Infarcts
V. Nedelko1, T. Hassa2, J. Liepert2, F. Binkofski3, C. Weiller4, A. Schoenfeld5,5, and C. Dettmers1
1Kliniken Schmieder, Konstanz, Germany, 2Kliniken Schmieder, Allensbach, Germany, 3Neurologische Universitätsklinik, Lübeck, Germany, 4Neurologische Universitätsklinik, Freiburg, Germany, 5Neurologische Universitätsklinik, Magdeburg, Germany
Background/aim: Motor imagery has been reported to engage the primary motor cortex of the unaffected hemisphere in left-hemispheric stroke patients, but not in right-hemispheric ones (Stinear et al. 2007). Aim of the present study was to replicate this finding.
Method: Patients: Nine left-hemispheric and 9 right-hemispheric patients—all right handed—with exclusively first ever basal ganglia or subcortical infarction of the MCA. During scanning video sequences with objected related actions were displayed. Subjects were instructed to observe the actions, or to imagine these actions from a first person perspective.
Data acquisition using a 1.5 T Philips Gyroscan NT and T2*-sensitive gradient-echo echoplanar imaging (EPI). Data of right hemispheric strokes were flipped at the midline.
Results: Action observation and action imagery induce a strong, symmetrical pattern within the superior and inferior parietal cortex, the dorsal and ventral premotor cortex, visual cortices and frontal cortex. Comparison of left versus right-hemispheric strokes revealed stronger activation in the left-hemisphere in stroke patients, particularly in the right visual cortex and fusiform gyrus as well as in the left dorsal premotor cortex.
Discussion: Two major mechanisms may contribute to the prominent activation in left hemispheric strokes: 1. Right hemispheric patients may be hampered by subtle attentional deficits ( suggested by right visual cortex and fusiform gyrus of left hemispheric strokes). 2. Primary motor cortices are inhibited by transcallosal fibres of the contralateral side. This inhibitory effect is stronger in the non-dominant right hemisphere. This may contribute to the diminished activation in right hemispheric strokes.
P031 Functional Reorganization During Walking in Subcortical Stroke
S. Y. Joo1, D. Kim1, S. J. Yoo1, E. S. Kim2, H. J. Park3, and J. D. Lee3
1Dept. and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea, 2Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea, 3Department of Diagnostic Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea
Introduction: Most post-stroke hemiplegic patients have abnormal gait patterns. However, studies about functional reorganization related to post-stroke gait have been still limited. The aims of this study were to investigate the functional reorganization during walking in hemiplegic patients with subcortical stroke using 18F-FDG Positron Emission Tomography (PET).
Materials and Methods: Ten hemiplegic patients with subcortical stroke who could walk independently for 45 minutes were included. Age and sex-matched healthy people were included as controls. During the walking session, subjects walked on treadmill at 1.5 km/hour for 15 minutes before isotope injection. After the injection, they walked for 30 minutes, and underwent PET. During the resting session, they rested for 40 minutes and underwent PET. Data analysis was performed using a SPM 2. We compared FDG uptake difference between the walking and the resting session using paired t-test for each group. We also compared FDG uptakes between the groups using t-test with an uncorrected threshold of p<0.001.
Results: (1) While both the control and patient groups showed increased activity of bilateral primary motor areas, bilateral occipital lobes and cerebellar vermis, activity increased was also noted in ipsilesional cerebellar hemisphere in the patient group. (2) The subcortical stroke group showed more intensive uptake during walking in ipsilesional cingulated gyrus, cerebellar vermis than controls.
Conclusion: The brain regions related to walking in hemiplegic patients with subcortical stroke may be different from those in healthy people.
This work was supported by National Research Foundation of Korea Grant funded by the Korean Government (2009-0073).
P032 Cerebral Cortex Activity When Listening to Footsteps Accompanying Walking: A Study on the Use of Audiovisual Mirror Neurons in Rehabilitation
S. Nobusako1,2, S. Shimizu1,2, S. Shinkuma2, K. Miki3, H. Tamaki3, and S. Morioka1
1Graduate School of Health Sciences, Kio University, Kitakatsuragi-gun, Nara, Japan, 2Department of Rehabilitation, Higashi Osaka Yamaji Hospital, Higashiosaka-city, Osaka, Japan, 3Neurocognitive Rehabilitation Center, Setsunan General Hospital, Kadoma-city, Osaka, Japan
Purpose: A number of recent reports have indicated the efficacy of action observation therapy using the properties of mirror neurons (MNs) that are activated both when performing action and observing action. In addition, reports have also revealed the existence of MNs that respond to observed action as well as audiovisual MNs that respond to sound accompanying action. Thus, this study investigated the presence of areas displaying such activation when walking, when observing walking, and when listening to footsteps accompanying walking, and this study explored the possibility of action observation/hearing therapy.
Methods: Subjects were 10 healthy adults. Functional near-infrared spectroscopy (fNIRS) was used to measure cerebral blood flow and oxygen consumption. Task conditions were: 1) walking, 2) observing walking, 3) viewing video of random figures, 4) listening to footsteps, and 5) listening to a metronome.
Results: Significant activation of the bilateral inferior frontal gyrus (p < 0.05) was noted under Conditions 1, 2, and 4 in comparison to Conditions 3 and 5.
Discussion: Results suggested the existence of audiovisual MNs specifically for walking in the bilateral inferior frontal gyrus, indicating that instructional materials in sync with the sound of footsteps as part of observing walking in action observation therapy (i.e. action observation/hearing therapy) may better facilitate improvement in walking.
P033 Conditions for Actuation of the Canonical-Neuron System: A Study of the System’s Use in Rehabilitation
S. Shimizu1,2, S. Nobusako1,2, S. Shinkuma2, K. Miki3, H. Tamaki3, S. Morioka1
1Graduate School of Health Sciences, Kio University, Kitakatsuragi-gun, Nara, Japan, 2Department of Rehabilitation, Higashi Osaka Yamaji Hospital, Higashiosaka-city, Osaka, Japan, 3Neurocognitive Rehabilitation Center, Setsunan General Hospital, Kadoma-city, Osaka, Japan
Purpose: When tools are visually presented and their use is silently named, neurons displaying activity in the brain similar to that when the tools are actually used are found in the anterior intraparietal area and ventral premotor area; the system for motor control by these sites in the brain is known as the canonical-neuron system (CNS). Using functional near-infrared spectroscopy (fNIRS), this study examined the effects of silent naming of the uses of tools on the CNS; this study also investigated the use of the CNS in rehabilitation.
Methods: Subjects were 8 healthy right-handed adults. Cerebral blood flow and oxygen consumption were studied under Conditions 1 and 2. Under Condition 1, tools were visually presented and the subject silently named their use. Under Condition 2, the subject silently named the use of tools but tools were not visually presented.
Results: Under Condition 1, significant activation (p < 0.05) was noted in comparison to Condition 2 from the anterior intraparietal area to the ventral premotor area, both of which are found in the CNS.
Conclusion: Results revealed that silent naming of visually presented tools is appropriate for activation of the CNS.
P034 Prefrontal Cortex Activity Varies With the Difficulty of Digit Span Tasks: A Functional Near-Infrared Study
A. Sogo1,2, S. Morioka1, J. Kubo2, E. Yamada2, S. Tanaka3, N. Arima2,4, and T. Yamamoto2,4
1Department of NeuroRehabilitation, Graduate School of Health Sciences, Kio University, Nara, Japan, 2Department of Rehabilitation, Faculty of Medicine, Kagawa University Hospital, Kagawa, Japan, 3Department of Physical Therapy, Faculty of Health and Welfare, Prefectural University of Hiroshima, Hiroshima, Japan, 4Department of Orthopaedic Surgery, School of Medicine, Kagawa University, Kagawa, Japan
Objective: Near-infrared spectroscopy (fNIRS) is an optical method for determining changes in the oxygenated (Oxy-Hb) and deoxygenated hemoglobin concentrations in the human cerebral cortex. The purpose of this study was to examine the hemodynamic response of the prefrontal cortex (PFC) during the performance of a working memory (digit span) paradigm in 10 volunteers by using fNIRS.
Methods: The subjects were asked to rest on a seat for 20 seconds, and then perform a digit span task. Subjects in the control group were instructed to report the number “1” for 40 seconds, whereas those in the working memory task group were instructed to report the number 3, 5, 7, or 9 randomly. Effect size (Zi) was calculated from the Oxy-Hb concentrations obtained by NIRS (Zi = (Xi - X)/SD), and the effect sizes of each channel were compared between the control and digit span task groups.
Results: The activity of the PFC was induced by the 5, 7, and 9 digit tasks, but not by the 3 digit task. Highest PFC activity was noted in the 7 digit task.
Conclusion: The results suggest that moderately difficult tasks induce maximum brain activity.
2.3 Neurophysiology
P035 Intermanual Transfer of Sensorimotor Memory for Grip Force When Lifting Objects: The Role of Wrist Angulation
D. Bensmail1, A. Sarfeld2, G. Fink2, and D. Nowak3
1R. Poincare Hospital, Garches, France, 2Uniklinik Köln, Cologne, Germany, 3Hospital for Neurosurgery and Neurology, Kipfenberg, Germany
Objective: The mechanisms underlying sensorimotor memory for grip forces (GF) when lifting objects are still under debate. While some authors argue that sensorimotor memory reflects an internal sense of effort related to the most recent action, others argue in favour of the idea that mechanical features of objects, e.g. the weight, are remembered to guide future motor commands.
Methods: Here we investigate the mechanisms underlying the intermanual transfer of sensorimotor memories when lifting an object. Twenty right-handed healthy subjects grasped and lifted an object with constant mechanical properties with the right hand (RH) first and then with the left hand (LH). Ten of the subjects lifted the object with the RH in a regular wrist angulation (RWA) (at 15 degree wrist extension), followed by lifts with the LH in a RWA. The remaining 10 subjects lifted the object with the RH in a hyperflexed wrist angulation, followed by lifts with the LH in a RWA.
Results: Subjects generated greater peak GF rates and greater grip and lift forces when lifting the object with the wrist in a regular angulation compared to lifts with the wrist in hyperflexion. Importantly, subjects transferred the predictive scaling of GF (as measured by the peak rates of GF increase) from the right to the left hand, regardless of wrist angulation.
Conclusions: These data suggest that the predictive scaling of GF rather reflects an internal sense of effort (modulated by the angulation of the wrist) than an internal representation of the mechanical object properties.
P036 Impact of Transcranial Direct Current Stimulation (tDCS) on Spinal Network Excitability in Healthy Subjects
B. Bussel1, N. Roche1, R. Katz2, and V. Achache3
1Hopital R Poincare, Garches, France, 2UPM ER6, Paris, France, 3UPM ER6, Paris, France
Transcranial Direct Current Stimulation (tDCS), when applied over the motor cortex, modulates excitability dependent on the current polarity. The impact of this cortical stimulation (1,75mA during 20min) on spinal cord network excitability has rarely been studied. In this series of experiments, performed in 13 healthy subjects, we show that anodal tDCS increases disynaptic inhibition directed from Extensor Carpi Radialis (ECR) to Flexor Carpi Radialis (FCR) with no modification of presynaptic inhibition of FCR Ia terminals and FCR-H reflex recruitment curves. These effects, clearly observed after 10min of stimulation don’t persist after the end of stimulation. We also show that cathodal tDCS does not modify spinal network excitability. Our results suggest that the increase of disynaptic inhibition observed during anodal tDCS relies on an increase of disynaptic interneuron excitability. These results are in accordance with previous findings obtained in animals and in humans after a single transcranial subthreshold anodal stimulus. Our results also indicate that anodal tDCS applied over the motor cortex in human subjects induces effects on spinal network excitability. In consequence they highlight the fact that the effects of tDCS should be considered in regard to spinal motor circuits and not only to cortical circuits.
P037 Reorganisation of Movement-Related Intracortical Inhibition (SICI) in Acute to Chronic Stroke
V. Hörniss, G. Liuzzi, P. Lechner, K. Heise, M. Zimerman, J. Hoppe, C. Gerloff, and F. C. Hummel
BINS Lab, Department of Neurology, Hamburg, Germany
Background: In chronic stroke patients, reduced modulation of intracortical inhibitory circuits has been linked to deficits in motor control. However, the development of movement-related inhibitory modulation from acute to chronic stroke in relation to motor improvement has not been investigated yet.
Methods: We tested GABAergic short intracortical inhibition (SICI) in the lesioned primary motor cortex of patients with acute subcortical stroke (n=11; 63.2 ± 3.0 years). SICI was measured during the preparation of a simple movement with the paretic hand at 5 days, 6 weeks, 3 months and 1 year after stroke.
Results: The main finding was that movement-related SICI was similar to healthy controls in the acute stage (day 5 and 6 weeks). However, at 3 months after stroke, SICI was reduced and less modulated compared to controls (p=0.006). In the chronic phase (1 year), SICI modulation showed a tendency towards healthy levels.
Conclusions: A continuous decrease of SICI modulation from acute to subacute stroke accompanies motor recovery early after stroke and shows a tendency towards reconstitution in the chronic phase. The present findings might provide a basis for post stroke phase specific therapeutic interventions (e.g., brain stimulation) targeting the stroke hemisphere.
P038 Evaluation of Swallowing Using 320-Detector Row Multislice CT: Kinematic Analysis of Laryngeal Closure During Normal Swallowing
Y. Inamoto, N. Fujii, E. Saitoh, M. Baba, S. Okada, D. Kanamori, K. Katada, and Y. Ida
Fujita Health University, Toyoake, Aichi, Japan
Purpose: To determine if 320-detector row computed tomography (320-MSCT) can be used to depict normal dynamic swallowing, and to measure the temporal characteristics of laryngeal closure associated with hyoid elevation and the pharyngoesophageal segment (PES) opening.
Method: After informed consent, six healthy volunteers received a 320-detector row CT scan while swallowing of a 10-ml portion of honey-thick liquid (5%w/v) in a 45° reclining position on Aquilion ONE (Toshiba, Japan) scanner. The scanning range was 160mm from the skull base to the upper esophagus. The scan parameters were 0.5-mm thickness by 320 rows, 0.35sec/rotation, 120kv and 60mA. Three-dimensional images were created in 29 phases at an interval of 0.10 seconds over a 2.90-second duration. We then measured the timing of movements of hyoid bone, epiglottis, laryngeal vestibule, true vocal cords (TVCs), and PES.
Results: We could depict 4D images of swallowing (3D-dynamic images) and measured the dynamic movement of each structure clearly. The sequence for laryngeal closure was the following: first, the hyoid started to elevate, second, the PES opened, third, TVCs closure and laryngeal vestibule closure occurred almost simultaneously during the hyoid elevation, and last, the epiglottic maximum inversion occurred after the hyoid maximum displacement.
Discussion: We could successfully produce the world first 3D dynamic images of swallowing that were clear enough to observe the target structures’ movement. Moreover, we could measure the laryngeal closure’s event, a critical element during swallowing, distinctively and accurately. 320-MSCT is an innovative tool with great potential for further promoting our knowledge of swallowing mechanism.
P039 Animal Model for Human Investigation and Rehabilitation in Alzheimer Type Cognitive Deficits
M. B. Jablonski1, A. Kiryk2, M. Ulamek3, S. Januszewski3, R. Pluta3, and L. Kaczmarek2
1Lublin Medical University, Lublin, Poland, 2Nencki Institute of Experimental Biology, Warsaw, Poland, 3Mossakowski Medical Research Centre, Warsaw, Poland
The role of brain ischemia and molecular mechanisms emerging from ischemic blood-brain barrier seems to be crucial for development of Alzheimer’s disease. First, we discuss ischemic brain changes, including vascular degeneration that contributes to different stages of Alzheimer’s disease. Then we assess the role of the ischemic blood-brain barrier, a key β-amyloid peptide transportation system in- and outside brain, whose pathology is observed early in Alzheimer’s disease. Finally, we present characteristic behavioral changes for Alzheimer’s disease following rat ischemic brain injury. After brain ischemia, similarly to humans, locomotor hyperactivity positively correlated with increased hippocampal neuronal changes. Following brain ischemia impairment in habituation and reduced anxiety (human-like) were observed together with reference and working memory deficits. Moreover, ischemic brain injury in experimental animals led to progression of spatial memory for up to 1 year. These behavioral abnormalities were related to significant brain atrophy, associated with diffuse neuronal loss in the brain cortex, and in the CA1 sector of the hippocampus. Taken together supportive evidence from both experimental and clinical studies indicates that the decline in progressive cognitive activities could not be explained only by direct contribution of primary ischemic brain injury but rather by a progressive result of the additive effects of the ischemic lesions, Alzheimer’s factors and finally aging. Most importantly data from our animal model has shown that senescent systems retain some capacity for regeneration and functional recovery after ischemic injury what could be basis for neurorehabilitation process.
P040 The Changes of F-Wave and H-Reflex on Gastrocnemius Muscle After ESWT
M. Sohn, K. Cho, S. Jee, and Y. Kim
Chungnam National University Hospital, Daejeon, Republic of Korea
Introduction: To investigate the electrophysiologic mechanism of extracorporeal shock wave therapy(ESWT) by observing changes of F-wave and H-reflex recording from gastrocnemius muscle.
Method: We included 10 healthy participants and 10 stroke patients. ESWT stimulation was on the medial head of gastrocnemius. The intensity was 0.1mJ/mm2. The stimulation number was 1,500. We measured F-wave, H-reflex, and MAS before and after the stimulation.
Results: The minimal latency was 37.63±2.82ms before ESWT in normal. The latency was 28.27±1.66ms and H-M ratio was 3.74±1.64 before ESWT in normal. There was no significant changes in all the parameters after ESWT. The minimal latency was 41.82±3.89ms before ESWT in stroke patients. The latency was 30.77±1.17ms and H-M ratio was 5.63±2.98 before ESWT in stroke patients. There was no significant changes in all the parameters after ESWT, too. In stroke group, modified Ashworth scale (MAS) of plantarflexor spasticity was 2.67±1.15 before ESWT. After the ESWT, MAS was decreased 1.22±1.03. There was significant changes in plantarflexor spasticity (p <0.05).
Conclusion: There was significant decrease on plantarflexor spasticity after ESWT. There were no significant changes in F-wave and H-reflex. We think that there need further evaluation about the spasticity decreasing mechanism of ESWT
P041 Effects of Exercise on Cognitive Function in Chronic Cerebral Hypoperfusion Rat Model
S. Lee1, H. Yun1, H. Sun1, J. Han1, I. Choi1, and R. Bian2
1Research Institute of Medical Sciences, Gwangju, Republic of Korea, 2Sir Run Run Show Hospital, Zhejiang University School of Medicine, Hangzhou, China
Objective: We aimed to investigate the effects of exercise on cognitive function in chronic cerebral hypoperfusion rat model.
Methods: Thirty-six male Sprague-Dawley rats were used. Chronic cerebral hypoperfusion was induced by ligation of bilateral common carotid arteries (BCCAO). All rats were randomly divided into 4 groups: normal rats (group A); normal rats with exercise (group B); BCCAO rats (group C); BCCAO rats with exercise (group D). Group B and D rats were subjected to daily 30-min treadmill exercise for 4 weeks. Cognitive function was evaluated by Morris water maze test. The activities of superoxide dismutase (SOD) were analyzed. The neuron cells were microscopically analyzed on cresyl violet stain.
Results: 1) After exercise, group A, B, and D showed shorter escape latencies than group C (p<0.05). 2) There were no significant differences among 4 groups before and after exercise in the time resting on hidden platform (p>0.05). 3) There was significant difference in the number of crossings among 4 groups after exercise (p=0.040). 4) After exercise, the activities of SOD significantly increased in all groups. Group A and D were significantly higher than group C (p=0.030). 5) Histopatholgical study displayed the formation of apoptotic bodies and pyknotic cells in group C and D. There were more normal neuron cells in group D than group C (p=0.032).
Conclusion: We suggest that treadmill exercise is helpful in improving cognitive function in chronic cerebral hypoperfusion rat model. Therefore, treadmill exercise would be a useful strategy for treating chronic neurodegenerative diseases.
P042 Rehabilitation Model Shows Positive Effects on Neuronal Degeneration and Recovery From Neuromotor Deficits
M. Lippert-Grüner1, M. Maegele2, J. Pokorny3, O. Svestkova4, and D. Angelov5
1Neurochirurgische Uniklinik, Köln, Germany, 2Department of Surgery KHS Merheim, Köln, Germany, 3Institute of Physiology, Prague University Hospital, Prague, Czech Republic, 4Department of Rehabilitation, Prague University Hospital, Prague, Czech Republic, 5Anatomisches Institut Uni Köln, Köln, Germany
In the present study we used an experimental early rehabilitation model in the form of combining an enriched environment, multisensoric (visual, acoustic and olfactory) stimulation and a motor training after traumatic brain injury (via Fluid-percussion-model) in analogy to an early multisensoric rehabilitation therapy used by brain injured patients to improve neuronal 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 FluoroJade staining, which allows identifying degenerating neuronal cell bodies and processes.
Animals in the rehabilitation model group performed significantly better when tested for neuromotor function as compared to standard housing animals in the 7 and 15 days interval DPI (7d: p = 0,005; 15d: p < 0,05). Statistical analysis (T-test) revealed significantly lower numbers of FluoroJade positive cells (degenerating neurons) in the rehabilitation model group (n=5: mean 13.4) compared to standard housing group (n=6: mean 123.8) (p < 0,005).
We assume that housing of animals in rehabilitation model led to a clear functional increase of neuromotor functions and to the reduced neuronal loss, when compared with the animal group in the standard housing.
P043 Changes in Upper Extremity Muscle Activation During the Sub-Acute Phase After Stroke: Preliminary Results of a Case Series Study
M. A. Luijkx1, G. B. Prange2, M. J. A. Jannink2, J. H. Buurke2, and G. J. Renzenbrink1
1Roessingh Centre for Rehabilitation, Enschede, Netherlands, 2Roessingh Research & Development, Enschede, Netherlands
Introduction: Impaired arm function after stroke accounts for a substantial compromise of functional performance. Understanding changes in muscle activation after stroke might clarify therapeutic focus in rehabilitation practice. The objective is to examine changes in muscle activity during reach and its relation to changes in strength and arm movement ability during recovery of sub-acute stroke patients.
Methods: Five stroke patients (S) were recruited from rehabilitation centre Het Roessingh. Surface EMG of anterior and posterior deltoid, biceps, triceps, wristflexor and wristextensor muscles and elbow angle were recorded during a standardized reaching task at 3, 6, 9 and 12 weeks post stroke. Global strength (MRC) and arm movement ability (motricity index (MI) and Fugl-Meyer score (FM)) were scored.
Results: Arm movement ability, strength and elbow extension generally increased (Table). This was predominantly accompanied by an increase in the level of muscle activity in EMG of anterior deltoid and wrist extensors and a decreased co-activation at the wrist during reach.
Discussion: An increasing reach performance was observed, predominantly accompanied by increased agonist activation at the shoulder and wrist. These improvements were accompanied by increased arm strength, indicating that improved arm function after stroke may be mainly related to an increased ability to control and activate strong agonist muscles. This implies that focus on optimizing prime mover activation is promising to stimulate recovery of arm function after stroke.
P044 “Mental Time Travel” Disorder and Restoration in Brain-Injured Patients: Kinetographic Approach
O. A. Maksakova and V. I. Lukianov
Burdenko Neurosurgical Institute, Moscow, Russian Federation
“Mental time travel” phenomenon (MTT) appears when an individual images himself in past or future with wishes and motives that are independent of the present motivational state. Some recent publications analyze brain activity patterns during the mental time travel with functional MRI.
The possibilities of the kinetographic method for analysis of “mental time travel” phenomenon in healthy persons and in brain-damaged patients are presented. The authoring method of kinetography uses a “sitting” version of stabilography as a tool and data processing with relation to complex system theory.
Parameters of energy, entropy, and stability of the kinetographic signal were used for individual functional state estimation. The spectral analysis of energy lets to show up meaningful phases of the personal time during examination. Healthy volunteers (12 persons, 23-59 years old) and patients in different periods after BI (17 persons, 19-65 years old) were compared according to complex system characteristics. Part of patients passed the MTT-test with kinetography twice or more. Kinetographic results demonstrated how events of the past and the future do become actualizing during recovery process after severe brain injury. Two main groups of MTT-restoration are revealed in connection with outcome of severe brain injury. Recurrent change of functional state on the distant past stage promises rather fine course of restoration in spite of confusion and memory disorder during the first MTT-test in the first group. Next step of rehabilitation evaluates with significance of near-term future. Casual fluctuations of functional state in MTT-test predict lingering emotional-cognitive recovery in the second group.
P045 Determination of Functional Impairments Using the Methods of Computational Intelligence
T. Sarkodie-Gyan1, M. Alaqtash1, H. Yu1, C. MacDonald1, E. Spier2, and R. Brower1
1Department of Electrical and Computer Engineering, University of Texas at El Paso, El Paso, TX, United States, 2Highlands Regional Rehabilitation Hospital, El Paso, TX, United States
The recognition of muscle patterns during gait offers insight into the control of skeletal position, joint stiffness, vibrations of the soft tissue packages, stability during ground contact, and propulsion for the movement task. A pilot study was performed on 6 able-bodied subjects and on 4 impaired subjects. Measurements of the ground reaction forces (GRF), the corresponding gait phases and the muscle activity patterns were recorded.
For the acquisition of the dynamic gait data, wearable inertial-sensors were used. The sensors were placed on hips, thighs, shanks and feet. Motion data were acquired in conjunction with electromyographic data (EMG) and GRF from an instrumented treadmill.
A computational algorithm, based on a fuzzy relational matrix approach was developed to evaluate the relationships between the activation patterns of the muscles and the gait phases, and the relationship between the segmental accelerations and gait phases. The relational matrix depicts the strength of association or interaction between the muscles within the gait phases, and between the segmental accelerations and the gait phases, respectively. In fact, the relational matrices established for able-bodied subjects may be used as a reference pattern within a knowledge-based diagnostic system. The correlation between an input relational matrix (patient) and the knowledge based-matrices (able-bodied subjects) will provide an assessment of the neurological state of the patient. Objective evaluation of gait patterns will assist physicians in the determination of the pathological status of a patient, and also assist in the determination of the functional characteristics of neurological impairment.
P046 Motor Recovery After Experimental Stroke Does Not Depend on Protein Synthesis in Motor Cortex
M. R. Schubring-Giese, B. Hertler, C. O. Atiemo, and A. R. Luft
University of Zurich, Zürich, Switzerland
Recovery of movement after an ischemic stroke is commonly assumed to involve brain mechanisms that also enable movement learning in the healthy. One of these mechanisms is neural plasticity that requires the expression of genes and proteins to mediate lasting modifications to neural network function and structure. We have previously shown that learning a novel motor skill requires intact protein synthesis in primary motor cortex (M1) (Luft et al. J Neurosci 2004;24:6515). Here, we hypothesized that the same would be true for motor recovery after an M1 stroke. Three groups of rats were subjected to 7 days of training a forelimb reaching skill. Two groups received a ~1mm photothrombotic lesion in the forelimb representation contralateral to limb used for reaching. Sham animals (n=5) were operated but not lesioned. Stroke rats were injected with the protein synthesis inhibitor anisomycin at two injection points inside normal tissue along the lesion’s edge (n=7) or vehicle (n=6) after post-lesion training sessions 1 and 2 (days 4 and 5 after stroke). Sham rats also received ANI injections. Recovery training was continued until session 10. All groups learned the reaching skill achieving similar pre-lesion performance levels (p>0.5). Lesioned rats showed a marked reaching deficit in comparison with sham (performance loss 90%, p=0.001). ANI had no effect on recovery (p=0.4) or performance of sham animals. Motor recovery after an M1 lesion does not require protein synthesis in the peri-infarct tissue. This finding points to substantial differences in the plasticity mechanisms that mediate motor recovery and learning.
3 Assessment – Clinical Practice (Part I)
3.1 Neuropsychology
P047 Supporting the Mothers of Adult ABI Survivors: A Narrative Therapy Group
P. Calvert1 and S. Weatherhead2
1University of Liverpool, Liverpool, United Kingdom, 2West Cheshire Primary Care NHS Trust, Chester, United Kingdom
Introduction: Research on parenting a person with an Acquired Brain Injury (ABI) has largely focused on paediatric cases, neglecting the experiences of parents of adult survivors, despite them often being a main carer. This narrative therapy group intervention was offered to mothers of adults with an ABI, all of whom were primary carers. Aims were to facilitate group support, new coping strategies, shared stories, and development of narratives not solely focused on the caring role.
Method: The mothers attended six, weekly sessions and a follow-up approximately three weeks later. Each session aimed to build on the previous session and identify the mother’s narratives relating to their experience of parenting an adult child with an ABI, being a parent and being themselves. Later sessions focused on noticing and developing a richer more affirmative narrative description of these three areas.
Results: Pre and Post standardised and idiosyncratic measures of intra- and interpersonal factors were administered. These highlighted a slight improvement in the group members’ sense of well being, a change in parenting locus of control and quality of relationships. Qualitative feedback also suggested that the aims had been met.
Conclusions: Mothers are often involved in their adult children’s care after an ABI. Groups such as the one described here, based on Narrative Therapy principles can be an appropriate way of supporting these family members. They offer recognition and exploration of the difficulties mothers experience as parents and individuals. Further research into this area is required and recommendations for further groups are discussed.
P048 Dance and Movement Therapy in Rehabilitation of Individuals Surviving Traumatic and Non-traumatic Brain Injuries
T. Gueye1,2 and N. Šebková1,2
1Department of Rehabilitation Medicine, Prague 2, Czech Republic, 2The First Faculty of Medine Charles University, Prague, Czech Republic
Dance and Movement Therapy (DMT) is a psychotherapeutic use of the movement as a process for improving the emotional, cognitive, social and physical integration of the organism. Patients after brain injury (BI) suffer from problems in all those areas. In the Department of Rehabilitation Medicine (DRM) in Prague interdisciplinary team of professionals struggles to address patients’ problems in a complex way. Our clients are individuals after mild to severe brain trauma, as well as stroke survivors, or patients after other brain damage. DMT is an important part of diagnostics as well as therapy of those patients, as it works on more levels at the same time. We use movement to influence psychosocial area and vice versa, through deliberation of emotional potential we tent to influence physical and motoric expressions. The therapeutic aim is to explore, sense and recognize owns body, body image, body borders and movement repertoire in connection to emotions. Motoric dysfunctions, as paresis of the limb, poor stabilization of the trunk, spasticity, ataxia, involuntary movements and tremors, disturbed flow of the movement, coordination, disturbed rhythm and initialization or ending of the movement, can be influenced. DMT works with regressions to a lower movement patterns seen often by BI patients. Group therapy enables communication and socialization in the group in nonverbal and verbal way, work on self-esteem, self-trust and self-admitting.
P049 Long-term experience of early psychological rehabilitation after severe traumatic brain injury (TBI)
S. Gusarova and N. Ignatyeva
Burdenko Neurosurgical Institute, Moscow, Russian Federation
The majority of clinicians connect psychological neurorehabilitation with a patient’s ability to keep verbal communication. This form of treatment is used on social adaptation stage, or neurotic syndromes of late posttraumatic phase might be a target.
Psychologist must begin his work with a patient being in different states of consciousness—coma, vegetative state, confusion—in our model of rehabilitation management that took shape and was used with more than 130 patients surviving brain damage.
The psychologist operates in intensive care unit as part of rehabilitation team. His works might begin before other team participants on day 3-4 after severe TBI.
Goals of psychological rehabilitation on this phase are strengthening of patient’s ability to survive, and integration of bodily processes and consciousness.
As verbal channel could be used only one-way direction namely from a psychologist to a patient, communication field is mediated via patient bodily processes.
Principal methods of psychological work with unconsciousness adopt Body-oriented psychotherapy, namely somatic therapy biosynthesis (D.Boadella) and Process-oriented psychotherapy (A.Mindell).
There are used techniques of work with minimal signals, “switch of channels”, “capture of state”, grounding, centering, etc. A psychologist ought to build up and to extend safe space of a patient, to strengthen his internal experience of support and security.
These activities create opportunities to increase contact with the patient and form the field for maximal display of his process. The main concept and the set of techniques of early (urgent) psychological neurorehabilitation of TBI patients resulting 15 years’ experience will be demonstrated in this report.
P050 Cats Test: Normative Data for Diagnosing Visual Neglect With a Screening Test
T. J. Haid, M. Hoch-Städele, C. Pech, M. Kofler, E. Quirbach, and L. Saltuari
ÖLKH Hochzirl, Zirl, Austria
Patients with visual neglect demonstrate typical limitations in visual exploration, especially contralesional omissions and ipsilesional start of exploration. Clinical experience shows that the limitations can be observed better when targets are hidden between “non-targets”, and no spatial organisation in the arrangement is obvious.
We therefore developed a simple clinical test, the “Cats Test”. Approximately 240 silhouettes (dogs, houses, clocks, etc.) are scattered on a DIN A4 sheet of paper (horizontal format) without an obvious spatial pattern. Among these silhouettes, 24 cats are located as target stimuli (12 on both the left and right 40% of the page, no targets in the central 20%-column).
For standardisation, we instructed 192 neurologically healthy volunteers (50-86 years of age, 50% > 68 years) to cross out the cats on the sheet without a time limit. Parameters such as the number and positions of omissions (including the difference between omissions on the left and right side) and position of the first four cats crossed out were recorded. Important findings for the clinical use of the test are as follows: difference between left- and right-sided omissions never exceeded three targets (the maximum number of omissions on both sides was five); 98% of the subjects crossed out at least one of the first four targets on the left half of the page; correlation of age and number of omissions was not significant.
Test form, instruction, and statistical data are obtainable free of charge by e-mail (
P051 Five Points Test: First Normative Data for the Elderly
T. J. Haid, M. Hoch-Städele, C. Pech, M. Kofler, E. Quirbach, and L. Saltuari
ÖLKH Hochzirl, Zirl, Austria
Spontaneous cognitive flexibility is often clinically measured by fluency tests. These count among the executive function tests and can be divided into verbal and figural fluency tasks. Normative data for the elderly are lacking for one of the most prominent figural fluency tests, the Five Points Test (5PT). We developed a version of the 5PT with well defined instructions, administration, and scoring. In order to compile normative data, we tested 109 neurologically healthy persons between the ages of 60 and 88 years (50% > 68 years) with completed mandatory schooling but without university-entrance diploma. No significant deviation from normal distribution was found for the number of correct designs (Correct; Mean = 27.9, SD = 7.7), the total number of designs (Total; Mean = 33.2, SD = 9.8) or the percentage of correct designs (%Correct = Correct * 100/Total; Mean = 85.4, SD 11.7). Age did not significantly correlate with Total (p = .843; r = -.019) or Correct (p = .093; r = -.162); the correlation is significant but weak (p = .005; r = -.268) with %Correct. With respect to these findings we present first normative data for the entire age group. Test forms, instructions, and statistical data are obtainable free of charge by e-mail (
P052 Diagnosis and Treatment of an Obsessive-Compulsive Disorder Following Traumatic Brain Injury: A Single Case Study
H. Hofer1, S. Frigerio1, D. Gassmann2, and R. Müri1
1Departement of Neurology, Bern, Switzerland, 2Departement of Psychology, Bern, Switzerland
Cognitive impairments following traumatic brain injury may result in behavioral patterns indistinguishable from those associated with obsessive-compulsive disorder. This creates potential difficulties in obtaining a differential diagnosis. We describe a 27-year-old patient who suffered severe traumatic brain injury with residual lesions mainly in the bilateral orbitofrontal area. He developed neuropsychiatric symptoms corresponding to severe obsessive-compulsive disorder with great impact on activities of daily living. He underwent a detailed diagnostic examination, which was followed with cognitive behavioral therapy and medical therapy that are recommended for obsessive-compulsive disorder. These improvements were maintained after 6 months. Our case illustrates the importance of a detailed diagnostic process to create a differential diagnosis for choosing appropriate therapeutic interventions. Further case studies are required to underline our concept.
P053 Pen-and-Paper Tests of Visual Neglect and Neglect in Activities of Daily Living
I. Klepo, D. Tršinski, and V. Šepec
Special hospital for medical rehabilitation Krapinske Toplice, Krapinske Toplice, Croatia
Introduction: Unilateral visual neglect is a common neuropsychological deficit as a result of cerebrovascular accident, most often when the right hemisphere is affected. It has significant implications on the person’s ability to participate in activities of daily living (ADL).
Objective: The purpose of this paper is to correlate the objective tests of the visual neglect with the performance of the three ADL. Methods: The presence of visual neglect was tested in three patients (2 male; 1 female) with right cerebrovascular accident using the star cancellations and design copy tasks. The participants performed three ADL in the area of personal and extrapersonal space: shaving (male), washing face and hands and applying hand cream (female), writing a postcard and reading a notice on door. Results: The star cancellations and design copy tasks confirmed the presence of the visual neglect. Activities of shaving and washing didn’t show neglect of personal space (body neglect) but two patients demonstrated neglect of the reaching area. All participants indicated the elements of neglect in the activities of writing a postcard (reaching area). Also, one patient neglected a far space in the reading a notice on the door. Conclusion: Pen-and-paper tests are good predictors of the neglect of reaching space in ADL but aren’t good predictors of ADL that include personal space (body neglect). Also, objective tests have proved to be predictors of neglecting the far space in person with severe neglect.
P054 Computer-Assisted Errorless Learning for Memory Training in Chinese Elderly With Alzheimer’s Disease: A Pilot Study
G. Y. Y. Lee1, D. W. K. Man2, E. C. S. Yu3, and C. C. K. Yip2
1Occupational Therapy Dept., Kwai Chung Hospital, Kwai Chung, Hong Kong, 2Dept. of Rehabilitation Sciences, the Hong Kong Polytechnic University, Hung Hom, Hong Kong, 3Psychogeriatric Team, Kwai Chung Hospital, Kwai Chung, Hong Kong
Introduction/Objectives: The effects of two computer-assisted memory training programme (errorless and errorful learning) and a therapist-led, errorless training programme for Chinese persons with early Alzheimer’s Disease were compared.
Participants, Materials/Methods: Chinese early Alzheimer’s disease persons for pilot study were recruited from two Psychogeriatric Day Hospitals of Kwai Chung Hospital in Hong Kong during the period of 2008 to 2009. They should achieve a score 1 on the Chinese version Clinical Dementia Rating Scale Score of 1 and a score of less than 8 in the Cantonese version of Geriatric Depression Scale—Short Form. A randomized controlled trial research design was adopted such that subjects were randomly assigned into the three intervention programmes and a control group. Primary outcome measures included The Chinese Mini Mental State Examination (MMSE-CV), Chinese Mattis Dementia Rating Scale (CDRS) and Hong Kong List Learning Test (HKLLT). Data collected from pre-and-post training assessment and a three- month follow-up were analysed.
Results: 17 persons with early Alzheimer’s Disease completed the study protocol. By non parametric Friedman tests, time effect was found to be statistically significant for MMSE-CV (p=.004), CDRS (p=.032), HKLLT (p=0.0012) by comparing the score at pre-and-post treatment assessment and three month follow up.
Conclusion: Positive changes were initially found in the cognitive functioning of early Alzheimer’s patients after receiving therapist/computer-assisted errorless training and computer-assisted errorful training when compared with control. A larger sample will be recruited from multi-centres in the main study to further confirm the relative effectiveness of treatment programmes.
P055 Evaluation of Driving Capacity in Older Drivers
S. Park, E. Choi, M. Lim, E. Kim, S. Hwang, K. Choi, H. Yoo, and K. Lee
National Rehabilitation Center, Seoul, Republic of Korea
Objective: To assess the driving capacity of older drivers, their cognitive-perceptual function, visual function, motor function and driving performance were evaluated.
Method: Subjects were 56 drivers aged 65 years or older. Cognitive perceptual function was evaluated with a computer-based test tool named ‘Cognitive Perceptual Assessment for Driving (CPAD)’ and clock drawing test. Visual function test included visual acuity, visual field, color vision and contrast sensitivity. For motor function, muscle strength and range of motion were evaluated. Driving performance was evaluated in the virtual reality(VR)-based driving simulator. For comparison, 50 younger drivers aged between their late twenties and early forties underwent the same evaluation.
Results: 1) Among older drivers, 20 subjects (37.0%) passed CPAD test, 2 subjects (3.7%) failed, and 32 subjects(59.3%) fell into borderline group. Mean CPAD score was 51.08±4.64, which was significantly lower than that of younger drivers. Eighteen subjects (32.1%) in older drivers group failed in clock drawing test.
2) In visual function test, 40 subjects (71.4%) had visual acuity less than 20/30, 3(5.8%) had visual field narrower than 140° bilaterally, and 6(10.7%) had abnormal color identification. Contrast sensitivity was significantly decreased in older drivers.
3) In motor function assessment of older drivers, 4 subjects (7.1%) in older drivers group showed hemiparesis secondary to stroke.
4) In VR-based driving simulator, 22 subjects (40.0%) in older drivers failed while only 4 subjects(8.5%) in younger drivers did.
Conclusion: Older drivers showed significantly higher incidence of visual and cognitive-perceptual dysfunction, and poorer driving performance compared to younger drivers.
P056 Evaluation of a Neuropsychological Rehabilitation Program
G. Pusswald1, C. Mildner2, K. Zebenholzer1, and K. Vass1
1Medical University Vienna—Neurology, Vienna, Austria, 2KFJ Hospital Vienna, Vienna, Austria
Objective: The purpose of our study was to evaluate a neuropsychological rehabilitation program for patients suffering from MS. Knowing that the cognitive impairments often influence patients’ quality of life and job, we stress the importance of an intervention which takes several health related domains into account, according to the ICF. Therefore we compounded a rehabilitation program consisting of restitution training as well as a compensatory approach.
Methods: The sample was composed of 20 MS outpatients, 4 men and 16 women with a mean age of 44 (26-57). Most of the MS patients (16) had a MS of relapsing remitting with mild to moderate disabilities EDDS= 3,5), MS was diagnosed more than 13.43 years ago. The subjects were randomised in two groups, the intervention (TG) and the waitlist control group (WG) showed no significant differences in their clinical and sociodemographic characteristics.
The intervention consisted of a restitution training (home based PC-training) and a compensatory training (workshop).
Results: Comparison of the domain alertness with signal revealed a significant group difference between TG and WG (p=.026). Further on a significant improvement of the TAP divided visual attention task could be achieved p=.034. There was a moderate correlation between the reaction time with signal and the mental fatigue (r=−0,45) significant at p=.04. There was a tendency of improvement of mental fatigue and quality of life.
Conclusion: This study stresses the importance of a neuropsychological rehabilitation program which includes restitution and compensation.
P057 The Effectiveness of Neurofeedback and Biofeedback in the Treatment of Fibromyalgia
M. Rincon1 and D. Angulo2
1Fundación Cardio Infantil, Universidad Militar Nueva Granada, El Bosque, Del Rosario, Bogotá, Colombia, 2Fundación Cardio Infantil Universidad El Bosque, Bogotá, Colombia
Objective. To examine the effects of Neurofeedback and Biofeedback with Galvanic Skin Response (BF-GSR) on The Fibromyalgia Impact Questionnaire (FIQ).
Methods. Nine patients with Fibromyalgia were enrolled in the study. Eight female and one male, with an average age of 56.67 ± 5.8 (range, 47-62y). They were trained in Neurofeedback which is a behavioural training for self-regulation of brain activity (increase alpha and reduce beta waves) and trained to reduce the GSR, twice a week during two months. The FIQ was compared before and after sixteen sessions of Neurofeedback and BF-GSR. Any intervention is considered favorable if the FIQ reduces the total score in 20%.
Results. All patients completed the treatment and there were no reported side effects.
Significant improvement was found on the FIQ (p=0.01). Six patients reduced the total score in 20% and 7 patients reduced the total score.
Some items of the FIQ, including stiffness, depression, anxiety and average pain intensity, showed a significant improvement at the post treatment assessment.
Conclusion. The results of this study show that the clinical manifestations of Fibromyalgia improve with the application of Neurofeedback and BF-GSR. A substantial number of the items of the FIQ, as well as its total score, showed a favorable evolution in seven of the patients after 16 sessions, indicating an improvement in their physical capacity, and impact on the daily life of the patients. Our results support the use of these techniques as part of the multidisciplinary rehabilitation in the treatment of Fibromyalgia.
P058 Beyond Aphasic Syndromes: On-Line Evaluation of Neural Networks Processing Words and Sentences
L. M. Schneider1, L. Spierer1, F. Grosjean2, and S. Clarke1
1Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland, 2University of Neuchâtel, Neuchâtel, Switzerland
Language comprehension relies on the integration of hierarchically organized linguistic levels ranging from phonetic to pragmatic aspects. While growing neuroimaging literature suggests that partially segregated specialized brain networks underlie the encoding of the different levels of spoken language. The lack of neuropsychological evidence for the fine anatomo-functional organization of language processing comes from the limited specificity of the off-line comprehension tests used in clinical evaluation of aphasia. On-line comprehension paradigms resolve this issue by allowing to recruit selectively language processing levels of interest.
Using a voxel-based lesion-symptom mapping method, we investigated the neural underpinnings of on-line language comprehension in 30 right-handed aphasic brain-damaged patients with a first unilateral left-hemispheric lesion. On-line comprehension paradigms assessed i) low-level phonetic processing using a syllable discrimination task; ii) lexical processing with word recognition tasks, one assessing access to word form and the other to word meaning; and iii) morpho-syntactic and semantic-pragmatic (sentence) levels with a word monitoring task.
The anatomo-clinical correlations revealed clear associations between lesion locations and most of the tests of our on-line comprehension battery. Lesions to Broca’s area were associated with impairment in phonetic processing; sylvian damage with impaired word form recognition; and posterior cortico-subcortical damage with impaired word meaning recognition.
The on-line battery revealed no specific performance pattern associated with classical aphasia syndromes determined with off-line testing. This suggests that any linguistic level can be impaired in different aphasia syndromes.
Our results support evidence for segregated specialized brain networks that underlie the encoding of the different levels of spoken language.
P059 Coping Styles of Patients and the Family System in Relation to Cognitive Rehabilitation and Quality of Life After Brain Injury
G. Wolters1, S. Stapert2, I. Brands3, J. M. A. Visser-Meily4,5, and C. van Heugten1,2
1Faculty of Health, Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands, 2Faculty of Psychology, Department of Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, Netherlands, 3Neurology Department, Rehabilitation centre Blixembosch, Eindhoven, Netherlands, 4Rehabilitation Centre De Hoogstraat, Utrecht, Netherlands, 5Rudolf Magnus Institute of Neuroscience, University Medical Centre, Utrecht, Netherlands
Objective: This study investigated the changes in coping styles of patients with acquired brain injury who underwent cognitive rehabilitation, and the effects of these changes on their quality of life. In addition, the influence of family functioning and coping styles on functional outcome of both the family and the patient was examined. Design: Prospective longitudinal study. Setting: Outpatient rehabilitation centre. Participants: One hundred and ten patients, who were more than 6 months post injury, and the family systems of 80 patients. Measures: Utrecht Coping List, Life Satisfaction Questionnaire-9, Stroke-Adapted Sickness Impact Profile-30, Family Assessment Device, and the Caregiver Strain Index. Results: Active problem-focused coping styles decreased and passive emotion-focused coping styles increased significantly in the patients over the course of outpatient cognitive rehabilitation. Increases in active problem-focused coping styles and decreases in passive emotion-focused coping styles predicted a higher quality of life in the long term. Caregivers who had a preference for passive coping were prone to lower family functioning, lower quality of life and higher strain. However, families’ coping styles or functional outcome did not influence patients’ quality of life. Conclusion: From this study, we conclude that the preference for a coping style influences functional outcomes, but families’ coping styles did not predict patients’ functional outcomes. Therefore, an intervention aimed at enhancing family functional outcome should focus on decreasing the use of passive coping styles in families. To improve patient functional outcome, clinicians should focus on changing the patients’ own coping styles.
P060 Managing Caseload Complexity in a Community ABI Service: Three Models of Group Working
S. J. Weatherhead1, G. J. Newby1, and P. Calvert2
1Community Care Western Cheshire, Chester, United Kingdom, 2Liverpool University, Liverpool, United Kingdom
Three diverse, but effective group therapy interventions that have had positive outcomes are discussed as ways of managing a complex caseload in a small specialised, community based ABI service.
1) A Narrative Therapy Group for men struggling to adjust to life after an ABI—Four men, with a range of difficulties who had previously accessed neuropsychological support, attended the group. All had ongoing neuropsychological and functional problems. Narrative Therapy methods such as externalisation, exploring unique outcomes, and the use of metaphor were embedded within the intervention. Standardised and subjective assessments indicated positive outcomes and improved adjustment.
2) A Parenting Group for Fathers with an ABI—The intervention covered five areas; play, child development, keeping calm, timing praise and silence, and talking to children about brain injury. Learning methods included role-play, discussion, and homework assignments. Outcome measures highlighted improved confidence and enjoyment of parental tasks, with an unanticipated secondary gain of improved behaviour in their children.
3) Supporting the Mothers of Adult ABI Survivors: A Narrative Therapy Group—Literature has focused heavily on parenting a child with an ABI, neglecting the challenges of parenting an adult survivor. This group was for mothers who were primary carers for their adult sons/daughters. The group was designed to facilitate group support, new coping strategies, shared stories, and development of narratives not solely focused on the caring role. Standardised and subjective measures showed an improved sense of well being, a change in parenting locus of control and the quality of relationships.
P061 Narrative Therapy With ABI Survivors: Individual, Systemic, and Group Work
S. J. Weatherhead1, G. Newby1, and P. Calvert2
1Community Care Western Cheshire, Chester, United Kingdom, 2Liverpool University, Liverpool, United Kingdom
Narrative Therapy has developed in the last 25 years as a useful intervention with a full range of problems including anger, attention, mental health diagnoses, and relationship difficulties.
The effects a brain injury has on a person’s sense of self, as well as the neuropsychological sequelae of that injury mean that a therapy such as this, which prioritises each person’s narrative, whilst deconstructing problematic stories, has the potential to be of great use to the people who have suffered a brain injury, as well as those who support them.
Narrative Therapy is built on a poststructuralist philosophy, which highlights the complex interplay of knowledge, power, and language. The therapeutic approach proposes that we all live by stories constructed from the experiences we have had, and that at times problematic stories can become so dominant that any contrary experiences are neglected, and can become lost. Despite Narrative Therapy being applied in a variety of health and psychological settings, it is an under-utilised approach in brain injury services.
In addition to introducing the model, a number of examples from clinical practice in a community-based acquired brain injury service, are discussed. Case studies and systemic interventions are presented, including individual, group, and family work. These are appropriately evaluated to evidence the usefulness of the approach in this setting, and include examples relating to, violence, relational problems, adjusting to life after a brain injury, and caring for a person with a brain injury.
P062 Supporting Dads: A Parenting Group for Fathers With an Acquired Brain Injury
S. J. Weatherhead and G. J. Newby
Community Care Western Cheshire, Chester, United Kingdom
Parental brain injury can have a negative impact on the parent-child relationship. It can lead to behavioural and emotional problems for the child, as well as psychological and practical difficulties for the parent. Parenting classes are widely available for the general population, to assist with these types of problems, but are not specifically tailored towards brain-injured parents. This work presents an opportunistic parenting course developed for fathers who accessed a local ABI service.
The course was spread over six one-hour weekly sessions. Learning methods included role play, discussion and homework assignments. Content was guided by the facilitators; clinical experiences of parenting programmes, and neuropsychological theory. Topics included: Non-Directive Play, Child Development, Keeping Calm, Timing of Praise and Silence, Talking to Children about Brain Injury, and Open Discussions.
There was 100% attendance, and evaluation methods showed the group to have a positive impact on the relationships between the fathers and their children. It also had the unanticipated impact of provided structure to the attendees’ week, peer support, and an increase in confidence for attendees.
Opportunistic group work such as this provides a possible beneficial approach to community-based therapy. It can be a useful tailored adjunct to general service provision. Both quantitative and qualitative measures highlighted the benefits of the group. Furthermore follow-up with the group, and their partners encouraged continued contact between attendees.
P063 Adjusting to Life After a Brain Injury: A Narrative Group Therapy Intervention
S. J. Weatherhead and G. Newby
Community Care Western Cheshire, Chester, United Kingdom
It is well documented that self-concept can be heavily impacted upon by ABI. Residual cognitive, emotional, behavioural, and psychological effects can have a devastating influence on a person’s past, present and future understanding of themselves. Despite a growing neuropsychotherapy literature base in this field, Narrative Therapy is a relatively under-studied approach. However, clinical experience indicates that a Narrative Therapy group may be a useful intervention.
This intervention targeted four men who had particular problems adjusting to life after a brain injury. They had all accessed neuropsychological support, and had varying degrees of neuropsychological deficits. The group took place over six sessions, plus a follow-up session. Narrative therapeutic techniques were adopted including externalising the problem, thickening narratives, and using therapeutic documents to reinforce therapeutic gain. Standardised and non-standardised measures highlighted positive outcomes in quality of life, emotional functioning, functional presentation, and personal narratives.
At a clinical level group interventions can be particularly useful in services where staff resources are limited. More importantly than this, they provide a space for sharing and developing personal and group narratives. Narrative Therapy can be particularly useful in brain injury services, because an ABI has such an impact on a person’s sense of self. The group format still allowed space for incorporating Narrative Therapy techniques, and forms of question asking. Indeed the shared language that develops in a group arena provides the perfect vessel for narrative practice.
3.2 Neuroimage
P064 Investigation of Regional Cerebral Flood Flow by Using Cerebral Perfusion Scan With SPECT in Patients With Neurological Manifestations
S. T. Chang
Department of Physical Medicine & Rehabilitation, Tri-Service General Hospital, NDMC, Taipei, Taiwan
Researchers have demonstrated a strong relationship between movement disorders and regional cerebral blood flow (rCBF).
Methods: Brain images with single photon emission computed tomography (SPECT) were obtained after injection of ethyl cysteinate dimer (Tc-99m-ECD).
Results: Five cases with neurological manifestations were investigated with SPECT. First, a right-hemispheric stroke patient developed complex regional pain syndrome (CRPS) in the right upper limb, and the rCBF showed contralateral increase of tracer uptake in the left thalamus accompanied by crossed cerebellar diaschisis (CCD) in the left cerebellum. Second, a patient with thoracic cord lesion suffered from intractable neuropathic pain, treated with gabapentin. He developed right hemichorea in high dosage of gabapentin, and rCBF showed a perfusion defect in contralateral basal ganglion (BG). Third, we report a rare case of a 90-year-old female who exhibited rabbit syndrome, although she had never taken antipsychotics. SPECT revealed increased rCBF in the right BG, and returned to baseline after Madopar. Fourth, we present a female with primary writing tremor, whose rCBF showed a defect in the contralateral BG. Fifth, a combined appearance of CCD and parakinesia brachialis oscitans (PBO) occurred in a patient with putaminal hemorrhage. The occurrence of CCD and PBO share the same posterior limb of internal capsule and the corticopontocerebellar fibers, so the co-existing fact raise a valuable prediction of stroke recovery.
Conclusion: Brain rCBF with SPECT plays an important role in differential diagnostics of movement disorder.
P065 Resting-State Network Connectivity According to Motor Recovery
Y. Kim, W. Chang, C. Park, E. Shim, and P. Lee
Department of Physical and Rehabilitation Medicine, Stroke and Cerebrovascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine
Introduction: Functional magnetic resonance imaging (fMRI) during the resting-state is applicable to stroke patients with severe motor impairment. In the current study, we performed longitudinal resting-state fMRI during motor recovery in ischemic stroke patients.
Methods: Sixteen ischemic stroke patients (seven males, 55.7 years old) with cortical or subcortical lesions participated. In all patients, resting-state fMRI data were longitudinally acquired over three sessions using 3.0TMR scanner; shortly after onset (within 2 weeks), and at one and six months after onset. According to changes in motor impairment as indexed by Fugl-Meyer assessment (FMA) scores, the patients were divided into two groups: the poor recovery and good recovery groups. The sensorimotor network (SMN) was extracted from the resting-state fMRI data using correlation methods.
Results: The pattern of the SMN was contrasted between the poor and good recovery group: an asymmetric pattern was shown at onset and remained even after six months in the poor recovery group, whereas a symmetric pattern was preserved at onset and after six months in the good recovery group. The laterality index at onset was significantly different in both groups.
Conclusion: The preservation of a symmetric pattern in the SMN of the resting-state fMRI at onset is considered to give information for predicting successful motor recovery at six months. During motor recovery, temporal changes of the resting state networks reveal neuroplastic changes at the system level. (Supported by the Samsung Biomedical Research Institute grant (C-A7-407-1) and the Korea Science and Engineering Foundation grant (M10644000022-06N4400-02210).)
P066 Spinal Cord White Matter Integrity in Patients With Cervical Spondylosis Is Related to Degree of Spinal Canal Stenosis: A Combined MRI and Diffusion Tensor Imaging Study
P. Lindberg1,2, M. A. Maier1, F. Rannou2, and A. Feydy2
1Université Paris Descartes, Paris, France, 2Hôpital Cochin, Paris, France
Objectives: We used DTI to test the hypothesis that degree of spinal canal stenosis is related to the degree of spinal white matter integrity in patients with cervical spondylosis.
Methods: 15 patients with cervical spondylosis and 10 healthy subjects of similar age were studied. DTI was used for quantification of spinal white matter integrity (fractional anisotropy, FA; Apparent Diffusion Coefficient, ADC) of whole spinal cord at C2-C3, C4-C5, and C6-C7 levels. Sagittal T2-weighted imaging allowed for calculation of spinal canal stenosis (ratio) at C3, C5 and C7 levels.
Results: The patients had lower FA than controls at C2-C3 (0.52±0.05 vs 0.56±0.04) and C4-C5 (0.51±0.05 vs 0.55±0.04) levels (p=0.05), but not at C6-C7. Patients also had increased spinal canal stenosis at C3, C5 and C7 levels compared to controls (p<0.05). The group difference in FA was not present when the degree of stenosis was controlled for in a multiple regression analysis. When averaged across all cervical levels the mean degree of spinal canal stenosis correlated with mean FA (R=0.69, P<0.001), i.e., patients with least cervical canal space had lowest FA values of the whole cervical spinal cord.
Conclusions: DTI can quantify spinal cord white matter degeneration related to spinal canal stenosis in patients with cervical spondylosis. Spinal DTI may prove useful for guiding treatment in cervical spondylosis.
P067 fMRI as Rehabilitative Tool for Low Levels of Consciousness Patients
S. Marino1, R. Morabito1, S. Guerrera1, B. Spanò1, A. Baglieri1, A. Federico2, N. De Stefano2, and P. Bramanti1
1IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy, 2Department of Neurological and Behavioural Sciences, University of Siena, Siena, Italy
Objective: Vegetative State (VS) and Minimally Conscious State (MCS) are considered different clinical entities, but their bedside differential diagnosis remains challenging. The aim of this study was to assess the differences in neural responses of brain activation in patients in VS and MCS using the functional magnetic resonance imaging (fMRI).
Methods: We studied 50 patients with severely damaged brain 4 to 7 months after the brain injury. By using multiple validated behavioural scales such as the Glasgow Coma Scale and the Clinical Unawareness Assessment Scale, the patients were grouped in VS (n=23) and MCS (n=27). We then digitally recorded and adapted a story segment told by a first-degree family, which was administered by a MRI-compatible noise attenuated headphones, while an fMRI examination was acquired by using a “block” design.
Results: Conventional MRI examinations showed lesions localized on right temporal and frontal cortex in 15 patients (VS=7, MCS=8), left temporal and parietal cortex in 15 patients (VS=8, MCS=7) and diffuse abnormalities in 20 patients (VS=13, MCS=7). The fMRI examination showed significant activation of the primary auditory cortex during the acoustic stimuli in both with VS and MCS. However, only MCS showed significant activation also of associative temporal areas in hierarchically order.
Conclusions: The brain activity could help in discerning if the status of wakefulness in VS is also accompanied by partial awareness as found MCS.
P068 Cortical Reorganization in a Patient Affected by Multiple Sclerosis After Intrathecal Baclofen Implantation
S. Marino, S. Guerrera, A. Furnari, C. Pastura, G. D’Aleo, and P. Bramanti
IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy
Objectives: To assess the role of intrathecal baclofen (ITB) in the cortical reorganization in a patient affected by multiple sclerosis (MS).
Background: Spasticity is often observed in patients with MS. Baclofen, as an antagonist at gamma-amino butyric acid receptors, is, therefore, a neuroinhibitor and one of the mainstay treatments of severe spasticity due to MS (1). Studies of Functional Magnetic Resonance (fMRI) suggest that, in MS patients, a cortical reorganization may occur, but it never studied in MS patients treated with ITB.
Materials and Methods: We reported a case of a 59 year old woman affected by secondary progressive MS and severe spasticity. We performed an fMRI examination, before and a month after the ITB implantation, using a finger tapping task.
Results: Conventional MRI examination confirmed a MS pattern with periventricular lesions in the white matter. On finger-tapping fMRI examinations, the brain regions activated during motor tasks were similar in SM patient and NC. Each subject showed contralateral motor cortex activation after motor task. In addition, MS patient, after a month of ITB implantation, also showed ipsilateral motor cortex activation and more significant activation in somatosensory cortex and ipsilateral and contralateral activation in posterior parietal cortex when compared to the first fMRI examination.
Discussion/Conclusions: This is the first study, even if only to one patient, that shows the role of ITB in cortical reorganization. The application of fMRI seems to support the hypothesis of a central influence which might lead to cortical reorganization in patients who undergo therapy with ITB.
P069 Tendency to Fall Is Associated With Delayed Response in the Lateral Prefrontal Cortex During Gait in Patients With SCD: A Functional NIRS Study
M. Mihara1, N. Hattori1,2, M. Hatakenaka1, H. Yagura1, and I. Miyai1
1Neurorehabilitation Research Institute, Morinomiya Hospital, Osaka, Japan, 2PREST, Japan Science and Technology Agency, Saitama, Japan
Patients with spinocerebellar degeneration (SCD) show progressive deterioration of balance ability and high incidence of falls. But precise pathphysiology of falls is still unclear.
In this study, we investigated the cortical activation during gait on the treadmill in 27 patients with SCD including SCA6 (13 patients), 16qADCA (4 patients), and isolated cerebellar atrophy (10 patients), using a functional near-infrared spectroscopy (fNIRS) system. Cortical activation patterns and clinical characteristics were compared between patients with (fallers) and without (non-fallers) episodes of falls for the last eight weeks.
The fallers and non-fallers were comparable in age, disease duration, and gait speed, but Scale for the Assessment and Rating of Ataxia were significantly higher in the fallers. Region of interest analysis of fNIRS revealed similar changes in the oxygenated hemoglobin (oxyHb) signals in the supplementary motor area, medial sensorimotor cortex, and medial prefrontal cortex (PFC). In the lateral PFC, the fallers showed lower oxyHb signals in the early phase and higher signals in the late phase of 30 second walking on the treadmill.
These findings provide further support for the previous studies implying an important role of the PFC in the control of balance and ataxic gait due to cerebellar damage after stroke (NeuroImage 2007; 37: p1338-1345, NeuroImage 2008; 43: p329-336).
P070 Analysis of the Cortical Thickness and the Subcortical Connectivity in Patients With Diffuse Axonal Injury
S. Ohn1, H. Choi1, C. Park2, D. Park1, K. Jung1, and W. Yoo1
1Department of Physical Medicine and Rehabilitation Hallym University College of Medicine, Anyang, Republic of Korea, 2Department of Physical Medicine and Rehabilitation, Stroke and Cerebrovascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
Disruption of the cytoskeletal network and axonal membranes characterizes diffuse axonal injury (DAI) after traumatic brain injury. Clinical courses and outcomes are variable in these patients in spite of their small lesion in conventional magnetic resonance imaging (MRI). Recent advances in neuroimaging technique, structural changes could be verified comprehensively either in terms of the cortical gyri and subcortical white matter tract. We aimed to differentiate this variable clinical pattern using diffusion tensor imaging (DTI) and structural MRI. Eight patients with traumatic brain injury and eight control subjects were included. Cortical thickness and subcortical connectivity were compared between control and TBI patients using structural MRI and DTI. Long tracts such as corpus callosum and thalamocortical tract showed low fractional anisotropy in DTI. Cortical thickness was decreased in the area where the tract was involved. We applied comprehensive analytic methods for DAI in traumatic brain injury, which showed changes in projection and association fibers especially the thalamocortical tract.
P071 Integrity of Thalamocortical Tract Affect Antalgic Effect of rTMS on Central Post-Stroke Pain
S. Ohn1, W. Yoo1, C. Park2, S. Kim3, W. Chang2, and Y. Kim2
1Department of Physical Medicine and Rehabilitation Hallym University College of Medicine, Anyang, Republic of Korea, 2Department of Physical Medicine and Rehabilitation, Stroke and Cerebrovascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea, 3Department of Diagnostic Radiology and Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
Introduction: Repetitive transcranial magnetic stimulation (rTMS) over primary motor cortex (M1) is known to be effective on the relief of central post-stroke pain (CPSP). Diffusion tensor imaging (DTI) is a method to be used for detecting pathological changes of neural tract. We investigated the relationship between antalgic effect of rTMS and integrity of thalamocortical tract (TCT).
Methods: Ten CPSP patients (5 women, age 58.9 years) were recruited. Duration of pain was 25.3±18.2 months. 10Hz rTMS for 5 seconds with 80% of resting motor threshold was applied over M1 followed by resting period for 55 seconds. rTMS train and resting block were repeated 20 times for 5 consecutive days. After rTMS, participants were divided into responder group and non-responder group by antalgic effect. DTI was obtained before rTMS using 3T Achieva® MRI scanner (Phillips, US). Tractography was performed using MedINRIA® software (INRIA Sophia Antipolis, France). FA, ADC, and delineation ratio of TCT volume were calculated.
Results: VAS was decreased in responder group (n=6) from 7.2 to 5.0, and increased in non-responder group (n=4) from 6.3 to 7.5. In responder group, volume of superior TCT was higher and ADC was lower than those of non-responder group (p<0.05). VAS change was correlated with ADC and delineation ratio of TCT volume (R2=0.6, p<0.01).
Conclusion: rTMS over M1 was effective on CPSP. The effect was better when superior TCT was preserved. (Supported by a KOSEF grant funded by the Korean government (No. M10644000022-06N4400-02210) and by a grant from the Korean Research Foundation (#2004-041-E002))
P072 Modulation of Cognitive Network by Transcranial Direct Current Stimulation
J. Yoo1, C. Park1, W. Chang1, O. Bang2, P. Lee1, and Y. Kim1
1Department of Physical and Rehabilitation Medicine, Stroke and Cerebrovascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 2Department of Neurology, Stroke and Cerebrovascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine
Introduction: Previous research has shown that applying anodal transcranial direct current stimulation (tDCS) to the left dorsolateral prefrontal cortex (DLPFC) can improve accuracy of the working memory task. However, its neural mechanism of was not clearly delineated. In this study, we observed modulation of cognitive networks induced by tDCS in healthy subjects using functional MRI.
Methods: Twelve healthy subjects participated. Anodal tDCS was applied to the scalp over the left DLPFC with an intensity of 1.0 mA for 20 minutes. The fMRI was performed using 3T MR scanner and single-shot echoplanar sequences. Total 100 whole brain volumes were obtained at resting state and during ‘3-back verbal working memory’ task before and after application of tDCS. We extracted default mode network (DMN) and executive network and from the resting-state fMRI data using group independent component and correlation analysis.
Results: After applying tDCS, resting-state fMRI showed increased connectivity with the cingulate cortex, contralateral DLPFC, and visual cortex for DMN and executive network. Corresponding to these, cognitive task-based fMRI showed decreased activation of the cingulated cortex, right DLPFC, and visual cortex after tDCS.
Conclusion: Stimulation of the prefrontal cortex by tDCS modulated functional networks during resting state and cognitive task state. Effective modulation of functional networks by tDCS might be a determinant to obtain behavioral changes and functional improvements in healthy person and patients with brain disorder. (Supported by the Korea Research Foundation Grant funded by the Korean Government (KRF-2008-1093- 000) and by a KOSEF grant funded by the Korean government (M10644000022-06N4400-02210)).
3.3 Neurophysiology
P073 Complex Recovery of Patients With Bell’s Palsy in Order to Prevent Facial Spasticity (Clinical, Electrophysiological and Kinetotherapeutical Correlations)
E. Gavriliuc1, L. Munteanu2, and V. Lisnic2
1University of Medicine, Chisinau, Republic of Moldova, 2Institute of Neurology and Neurosurgery, Chisinau, Republic of Moldova
Objectives: Bell’s palsy arises from an acute inflammatory process that damages the nerve in its intra-osseal portion. Electrophysiological studies of the facial nerve commonly include standard nerve conduction studies and blink reflex. We used these techniques to localize the exact site of lesion, and provide information on the severity and prognosis of facial palsy.
Methods: We evaluated 37 patients referred to consultation room with Bell’s palsy. For all patients, nerve conduction study and blink reflex were performed. In correlation with electrophysiological indices we applied complex kinetic exercises within 10 days after income in hospital. Inclusion criteria were: acute unilateral facial paralysis, onset and deterioration within 48 hours. All patients were given prednisolone, 60 mg orally for 10 days, after which medication was stopped. The mean age of the patients at the onset of palsy was 45 ± 12 years (range, 29-67).
Results: 30 patients from 37 after treatment with prednisolone and complex kinetic exercises achieved full facial muscles recovery within 30 days. Nerve conduction study, EMG and blink reflex were performed repeatedly in these patients and the results were normal. 7 patients developed unilateral first grade spasticity of facial muscles after 2 month of the onset (3 of them were diagnosed with Herpes simplex I)
Conclusion: Correlation of electrophysiological studies and complex kinetic exercises in patients with acute facial palsy prevent development of facial spasticity. Due to early application of kinetotherapy and pharmacological treatment the frequency and grades of spastic complications dramatically decrease.
P074 Factors Influencing Finger Tapping Performance in Cerebellar Ataxia
M. Hatakenaka1, M. Mihara1, N. Hattori1,2, H. Yagura1, and I. Miyai1
1Neurorehabilitation Research Institute, Morinomiya Hospital, Osaka, Japan, 2PREST, Japan Science and Technology Agency, Saitama, Japan
To evaluate characteristics of finger movement accuracy in cerebellar ataxia, forty patients with spinocerebellar degeneration (SCA6/LCCA/16qADCA = 20/15/5, male/female = 18/22, mean age ± SD = 63 ± 11, all right-handed) performed unimanual and bimanual finger tapping tasks. The tasks included self-rated, unimanual, bimanual in-phase, and bimanual anti-phase tapping with and without coupling of working memory task (the Paced Auditory Serial Addition Test: PASAT). The performance was monitored using a magnetic sensing system (Kandori et al. Neurosci Res 2004;49:253). Based on the scores of the Scale for the Assessment and Rating of Ataxia (SARA), the patients were divided into moderate (SARA ≥ 9, n=27) and mild (< 9, n=13) ataxia. The standard deviation (SD) was used as an estimate of movement pattern stability.
The mean amplitude and frequency of unimanual tapping was comparable between patients with mild and moderate ataxia. However the SDs were significantly greater with visual information of the task performance than without visual information in patients with moderate, but not mild ataxia. In bimanual in-phase task, the SD of relative phase difference in patients with moderate ataxia was larger than those with mild ataxia. The performance of bimanual anti-phase task was poor in both groups. The PASAT loading had detrimental effect on both uni- and bimanual tasks in either group.
These findings suggest that visuomotor integration and working memory load may interfere with motor control of fine finger movements especially in patients with moderate ataxia.
P075 Implicit vs. Explicit Learning in Hand Rehabilitation
R. Horst
Institute for Further Education, Private Practice for Physical Therapy, Ingelheim, Germany
The goal of this lecture is to introduce a modern evidence-based concept to enhance motor strategies for daily life activities, using man’s most unique tool of the mind: the hand.
Traditional neurological rehabilitation concepts have placed the emphasis on sensory input for initiating voluntary movement, on the basis of reflex theories. Verbal instructions and passively initiated movements were aimed toward enhancing the individual’s concentration and perception of “normal” movement.
Current evidence has proven that internally focused movements do not lead to the supposed improvement of motor control, but rather an external focus leads to better learning capabilities. External focus is required for the action-goal of the distal body part while proximal body parts act subconsciously. Both need to act together automatically enabling an enormous amount of flexibility. Modern evidence calls for modern intervention methods.
Within the N.A.P.—Concept the therapist uses his hands as a specific tool to stabilize or mobilize body structures, as it would occur within the healthy system, during the action goal of the client. Fundamental neurophysiological, functional anatomical and biomechanical knowledge is required for this. In order to develop safe and economical strategies the individual needs to learn to use input specifically, according to the situation.
By experiencing positive motor strategies the patient extinguishes adaptive avoidance strategies. In this way the brain can restore its existing motor programs in the sense of resetting the brain.
P076 Analysis of Balance Skills Improvement on Patients After Brain Injury
K. Kotkova and K. Mikesova
Department of Rehabilitation Medicine, First Faculty of Medicine and General Teaching Hospital, Prague 2, Czech Republic
The followed up patients suffered from stroke or traumatic brain injury. The control of balance is a complex neuronal mechanism, based on unconditioned and conditioned reflexes, as well as on the actual cognitive processes. Training of the posture support mechanisms can provide a highly effective tool for rehabilitation.
We followed up the process of improvement of balance skills during long term multimodal rehabilitation including training of equilibrium skills with visual biofeedback on stabilometric platform. The presented group of patients was measured during the rehabilitation process (from 3 month to 2 years) at our department, results were received periodically: at the beginning and after daycare centre therapy, and subsequently during outpatient regular rehabilitation. Data were obtained by analyzing various types of biosignal from stabilometric platform Posturograph STP-06: velocity and length of trajectory of gravity center of the body, and from RS Scan Footscan balance plate: location and changes of foot pressures while standing on the plate, both in two basic situations—open or closed eyes.
Patients improved during our study, the way of improving differed according to initial impairment. Patient’s stability changes we recorded as a gravity center less fluctuating and better coordination of reach tasks.
Results of our observation are used for evaluation and further planning of physiotherapy and occupational therapy. The designed system help us to classify balance disorders, to measure the dynamic of their improvement during rehabilitation and to use this data for the prognostic and patient motivating purposes.
P077 The Cutaneous Silent Period in Cervical Radiculopathy
A. A. Leis1, M. Kofler2, I. Stetkarova3, and D. S. Stokic1
1Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson, MS, United States, 2Department of Neurology, Hochzirl Hospital, Zirl, Austria, 3Department of Neurology, Na Homolce Hospital, Prague, Czech Republic
Electromyographic (EMG) activity from voluntarily contracting hand muscles undergoes transient suppression following nociceptive fingertip stimulation. This suppression is mediated by a spinal inhibitory reflex designated the cutaneous silent period (CSP). In theory, conditions that interrupt the afferent pathways arising from digits should abolish or delay the CSP. In practice, the CSP is relatively preserved in peripheral nerve syndromes because afferent impulses are carried by smaller ‘injury-resistant’ A-delta fibers or because the afferent signal is amplified in the spinal cord. Hence, we hypothesized that the CSP would not detect conduction abnormalities produced by cervical radiculopathies. Noxious stimulation was applied to thumb (C6 dermatome), middle (C7) and little (C8) fingers of 23 patients with cervical radiculopathy. Four or more CSP responses were recorded in abductor pollicis brevis muscle following stimulation to each digit. All patients had C6, C7, or C8 radiculopathy documented by EMG. Ten patients had C6, seven had C7, and six had C8 radiculopathy. Complete CSPs were elicited in 21 of 23 patients irrespective of digit stimulated. There was no significant difference in CSP onset latencies or durations that correlated with radiculopathy. In two, CSPs were not clearly defined regardless of digit stimulated. In theory, the CSP can be used to monitor afferent impulses traveling through cervical roots. In practice, radiculopathy is rarely associated with CSP abnormalities. CSP testing is of little use in detecting cervical radiculopathies.
P078 New Approaches in Rehabilitation of Patients With Vestibular Disorders After Stroke
K. Lyadov, L. Sidyakina, I. Ganichkina, and T. Shapovalenko
Center of Restoration Medicine and Rehabilitation, Moscow, Russian Federation
Balance disorders are one of the main incapacitating factors among post stroke patients. A search for new methods of restoration of coordination function remains actualized.
We researched the balance function among 37 patients after stroke in vertebrobasilar system with balance disorders on the dynamic stabiloplatform “Balance Manager”, Neurocom, USA. The time of stroke—from 3 weeks to 6 months. The average age of patients was 52,8 years old. According to the results of sensory organization test (SOT), average Score Equilibrium was 33,6%, which is 39,4% lower than the average level of the age norm. The degree of balance was estimated in each of 18 tests according to the formula of Equilibrium.
All patients had rehabilitation of vestibular function using “Brain Port”. This method includes translingual electric stimulation with biofeedback and information about centre of gravity for patient can to “check” vestibular apparatus. Rehabilitation exercise was 1-2 times a day (about 15 to 90 exercises) in sit or stand condition.
The device is a small resource of electric impulses which contacts the front surface of tongue. At sight deprivation, a patient, orienting towards a stimulus, had to complete some rehabilitation tasks.
According to the results of SOT after the course of rehabilitation procedures the average result of the effectiveness of balance work increased by 28,5% and was 62,1% which is just 9,9% lower than the average age norm. Besides, some positive effects were noticed—articulation improvement, decrease in the expression of bulbar disorders and paresis of mimic muscles.
P079 Using of Transcranial Magnetic Stimulation During the Treatment of Patients in Persistent Vegetative State
K. Lyadov, T. Shapovalenko, T. Baydova, I. Sidyakina, and T. Isaeva
Center of Restoration Medicine and Rehabilitation, Moscow, Russian Federation
Increasing of quantity of patients in “vegetative state” stipulates the necessity of creating of treatment algorithm and differentiation of methodical approaches according to the initial neurophysiologic parameters. An essential meaning has studying of intracortical processes and an ability to influence the restoration of psychical activity.
We observed 31 patients with infringement of consciousness 7-9 points GCS. The cause of persistent vegetative state was traumatic brain injury, stroke, hypoxia. The age was from 18 to 50. The period of such condition was from 2 to 6 months. Besides basic check-up (CT, MRI, EEG, evoked potentials) the patients got diagnostic transcranial magnet stimulation using twin stimuli. 3 groups were formed: the 1st—patients with intracortical inhibition and no facilitation (17 people), the 2nd—patients with intracortical facilitation and no inhibition (14 people), the 3rd—controlled group (19 people not examined by the TMS method). The average primary GCS point in the 1st group was 8,27; in the 2nd—8,32; in the 3rd—8,65. Patients of the 1st and the 2nd groups got a course of rhythmical TMS (10 procedures 3 times pro week).
In the 1st group the tendency of consciousness increase as compared with the controlled group (p<0,1) to 0,83 points in average. In the 2nd group there were no essential differences and dynamics according to Glasgow scale as compared with the 3rd group (change of average GCS-point was 0,31 point); in the 3rd—0,34 point.
Presence of intracortical inhibition and loss of intracortical facilitation at the same time can be the evidence of prescription for rhythmical TMS during the persistent vegetative state. If there is no inhibition and there is intracortical facilitation the rehab TMS doesn’t influence essentially dynamic psychical processes of patients in vegetative condition.
P080 Controlling the Velocity of Linear Passive Manual Movements in Upper and Lower Limb Joints: A Pilot Study in Healthy Subjects
L. Marinelli1, G. Vigo2, L. Mori1, G. Checchia3, C. Lentino3, M. Bove4, C. Trompetto1, and G. Abbruzzese1
1Institute of Neurology, Department of Neuroscience, Ophthalmology and Genetics, Genova, Italy, 2Department of Rehabilitation, Santa Corona Hospital, ASL2 Savonese, Pietra Ligure, Italy, 3Department of Rehabilitation, Santa Corona Hospital, ASL2 Savonese, Pietra Ligure, Genova, Italy, 4Institute of Human Physiology, Department of Experimental Medicine, University of Genova, Genova, Italy
Objective: To investigate, in healthy subjects, the reliability of a manual technique that, starting from sinusoidal movements, would consent to achieve passive linear movements at pre-set target velocities.
Materials and methods: The technique was based on the synchronisation of the movement with two repetitive auditory signals played at different tone intervals (TIs) by a metronome. Wrist, elbow, knee and ankle passive movements were recorded with a motion analyzer system in six healthy subjects. The investigated TIs ranged from 1.50 to 0.25s.
Results: In all joints, movements were highly reproducible, their duration was similar to the TI played by the metronome and the range of motion during the movement was slightly reduced compared to the range of motion measured at rest (79-96% depending on the joint). The velocity profile of passive movements was bell shaped for all joints and TIs. The peak velocity depended on both the TI and the range of displacement according to a linear function, for all the tested joints.
Discussion: The possibility to perform manual passive stretches of joint muscles through a range of velocities is very important in neurology and neuro-rehabilitation. While repetitive stretches at various velocities can be obtained using sinusoidal movements, the velocity of linear displacements is more difficult to control. Sinusoidal movements can favour the appearance of paratonia. Linear displacement can be more suitable to detect spasticity. Controlling the velocity of both sinusoidal and linear passive displacements without unwieldy equipment could be a major advantage in routine muscle tone examination.
P081 Effect of the Use of a New Upper Limb Prosthesis on Motor Representations and Phantom Sensations
C. Mercier1,2, J. Dubé1,2, C. Vincent1,2, J. Bouffard1,2, E. Boulianne3, and S. Lajoie3
1Centre interdisciplinaire de recherche en réadaptation et en intégration sociale (CIRRIS), Quebec, QC, Canada, 2Université Laval, Quebec, QC, Canada, 3Institut de réadaptation en déficience physique de Québec (IRDPQ), Quebec, QC, Canada
It has been suggested that the intensive use of a prosthetic hand can decrease phantom limb pain and reverse amputation-induced sensorimotor reorganization. Not all studies, however, have found an association between prosthesis use and pain and/or reorganization. Moreover, studies that did find an association used transversal or retrospective designs, which make it difficult to ascertain whether this association reflects a causal relationship. The aim of this pilot study using transcranial magnetic stimulation is to perform a longitudinal follow-up of new prosthesis users (either a first prosthesis or a new type of prosthesis) in order to verify whether prosthesis-related pain reduction and reversal of amputation-induced reorganization can be demonstrated in the first weeks of intensive prosthesis use. Results obtained in four patients with a traumatic below-elbow amputation suggest that amputation-induced motor reorganization is partially reversed in new prosthesis users. This reversal was evident as a change in inter-hemispheric symmetry of muscle thresholds, with prosthesis use leading to greater symmetry. For the muscles on the amputated side the prosthesis generally decreased corticospinal excitability for proximal muscles and increased excitability for distal muscles. Interestingly, this parallels changes recently described in a patient who received a bilateral hand allograft. It is noteworthy, however, that these neurophysiologic changes were not accompanied by a decrease in pain. A larger cohort of patients is needed in order to be able to better assess the relationship between neurophysiologic and clinical changes while taking into account between-patient variability in prosthesis use, initial phantom sensations, and initial amount of reorganization.
P082 Complex Rehabilitation of Patients With Discal Pathology and Degenerative Lumbar Stenosis (Clinical-Imagistic and Electrophysiological Aspects)
E. Gavriliuc1, M. Gavriliuc2, L. Munteanu2, and D. Lisii2
1University of Medicine “N. Testemitanu”, Chisinau, Republic of Moldova, 2Institute of Neurology and Neurosurgery, Chisinau, Republic of Moldova
Objectives: Radiculalgia is mainly caused by discal pathology and degenerative lumbar stenosis. Lumbar stenosis has a major impact on the daily activity of the patient and is a frequent cause of social disability. We tried to find out whether nerve conduction study may help to refine the diagnostics and tactics of kinetotherapy in patients with discal pathology associated with lumbar stenosis.
Methods: We evaluated 154 patients referred to consultation room with radiculalgia secondary to discal pathology. For all patients, nerve conduction study (NCS) and EMG (electromyography) were performed in completion to clinical examination and MRI exams. We used Williams program kinetic exercises for assuring remobility to the spinal column after surgical intervention.
Results: In 22 patients from 154, through MRI examinations we found out the coexistence of unilateral or bilateral spinal stenosis with a discal pathology. For 16 patients from these 22, NCS showed latency and amplitude values below the normal levels. All these patients underwent surgical intervention. The EMG and clinical evaluation was fulfilled before and after operation. The EMG results and Clinical Evaluation were elaborated with Williams program kinetic exercises, in 3 phases, individually for each patient.
Conclusion: Correlation of EMG and clinical evaluation of the patients, fulfilled before and after surgical intervention, plays an important role in the elaboration of complex programs of kinetic rehabilitation exercises patients with discal pathology and degenerative lumbar stenosis. The volume and phases of kinetic exercises were applied individually for each patient, according to the EMG and clinical evaluations.
P083 Cortical Processing of Electrocutaneous Stimuli in Chronic Stroke Patients: A Relationship With Post-Stroke Shoulder Pain
M. Roosink1, J. R. Buitenweg1, G. J. Renzenbrink2, A. C. H. Geurts3, and M. J. IJzerman1
1University of Twente, Enschede, Netherlands, 2Roessingh Rehabilitation Center, Roessingh Research & Development, Enschede, Netherlands, 3Radboud University Medical Center, Nijmegen, Netherlands
Cerebral stroke is often associated with changes in cognitive-evaluative and somatosensory functions which may play a role in the development and maintenance of post-stroke pain. The neurophysiological mechanisms underlying these changes may be objectively assessed using cortical evoked potentials (EPs). However, amplitudes and latencies of late EP components (N90, N150, P200, P300) have rarely been investigated in stroke patients. In this study, EPs were evoked in the electroencephalogram using electrocutaneous stimuli at the affected and unaffected hand in stroke patients with persistent post-stroke shoulder pain (PSSP, n=6), pain-free stroke patients (n=14) and healthy controls (N=20). In addition, cognitive (mini mental state exam, MMSE) and somatosensory (clinical examination, quantitative sensory testing) functions were assessed. Stroke was associated with reduced EP amplitudes (N150, P300) and increased EP latencies (N90, N150 and P300). Although MMSE scores were normal, these changes were most likely related to disturbed cognitive-evaluative processes (attention, stimulus discrimination), since they occurred after stimulation at both hands. In addition, PSSP was associated with increased N90 latencies and electrical sensation thresholds at the affected hand (loss of integrity of the ascending somatosensory tract) and with increased P200 and N150-P200 peak-to-peak latencies (reduced perception of stimulus intensity). In conclusion, EPs extended the clinical examination, providing objective information about sensory-discriminative and cognitive-evaluative dysfunctions in stroke patients. In addition, the results implicated that PSSP may be more than ‘simply’ nociceptive shoulder pain and necessitate further investigations of central mechanisms in PSSP.
P084 Which Features of Spasticity Are Present During Gait After Acquired Brain Injury?
D. S. Stokic, J. W. Chow, and S. A. Yablon
Methodist Rehabilitation Center, Jackson, MS, United States
Background: Current controversy regarding the contribution of spasticity to gait impairment after acquired brain injury (ABI) may stem from inadequate characterization of features of spasticity during gait.
Objective: Characterize velocity-dependent increase in EMG activity during lengthening of the medial gastrocnemius (MG) muscle and co-contraction between tibialis anterior (TA) and MG during gait after ABI.
Methods: EMG in TA and MG was recorded in 24 subjects with moderate-to-severe spasticity due to ABI and 34 age-matched healthy controls walking at comparable speeds. The direction and gain of EMG-lengthening velocity relationship (EMG-LV) in MG during stance represent a velocity-dependent feature of spasticity whereas co-activation index (CoAI) indicates a degree of TA-MG co-contraction.
Results: Gain of EMG-LV slopes across all gait cycles was on average positive (78%/Ls/s) on the more affected side (MA) but negative (-101%/Ls/s) on less affected side (LA) and in controls (-97%/Ls/s). After excluding negative and non-significant EMG-LV slopes, the gains no longer differed. CoAI significantly differed between MA, LA, and controls (0.97, 0.77, 0.35) during initial double support, and for MA (.51) and LA (.37) compared to controls (0.33) during late double support, but not during single support or MG lengthening. The higher the CoAI, the higher the gain of EMG-LV significant positive slope (r=.53).
Conclusion: Co-contraction between ankle muscles better characterizes gait after ABI than velocity-dependent increase in EMG during MG lengthening. Their correlation suggests that velocity-dependent increase in EMG during MG lengthening cannot be ascribed solely to stretch but rather to central motor influence, resulting in ankle co-contraction.
P085 Rehabilitation in Parkinson’s Disease: Cueing-Dependent Changes in Brain Activity
E. E. H. van Wegen1,2, A. N. Vardy1, A. Daffertshofer1, and G. Kwakkel1,2
1Research Institute MOVE, Amsterdam, Netherlands, 2Dept. Rehabilitation Medicine, VU University Medical Centre, Amsterdam, Netherlands
Cueing training using external rhythms has been shown to improve gait, balance, freezing and fear of falling in people with Parkinson’s disease (PD), and gradually cueing techniques and strategies are becoming standard elements of the rehabilitation treatment of PD. Why external cueing by means of flashes of light, auditory beats, or rhythmic vibrations enhances motor performance (e.g. gait) in PD is essentially unknown. It has been suggested that external rhythms compensate or augment defective internal timekeeping mechanisms of the basal ganglia circuitry. We hypothesized that the rhythmicity (i.e. predictability) of cues is related to motor improvement in PD. We therefore compared sequences of predictable regular cues with sequences of irregular unpredictable cues that are not equidistant in time.
We examined the cortical activity before and after a bout of rhythmic hand movements under two types of tactile cueing, regular and irregular, using magnetoencephalography (MEG) in 20 PD patients and 15 controls. We found increased motor related beta activity lasting 5 to 10s after rhythmic movement in both groups. In addition, a late and more sustained increase in alpha band activity 40 s after movement termination was found which was absent in PD patients. A phenomenon called ‘motor perseverance’ may be responsible for this absence of increase in alpha power in PD patients. The sustained depression of alpha activity in the PD group may reflect longer lasting activation of alternative motor related brain circuitry following rhythmic cueing, and may provide a (partial) explanation for the Parkinson specific effects of external cueing.
P086 Short-Term Effects of Transcutaneous Electrical Stimulation Combined With Locomotion-Like Movement on Reciprocal Inhibition in Healthy Persons
T. Yamaguchi1, T. Fujiwara2, S. Tanabe3, Y. Muraoka4, K. Saito5, R. Osu6, Y. Otaka5, and M. Liu2
1Keio University Graduate School of Medicine, Shinjuku-ku, Tokyo, Japan, 2Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan, 3Fujita Health University School of Health Sciences, Faculty of Rehabilitation, Toyoake, Aichi, Japan, 4National Hospital Organization Murayama Medical Center, Clinical Research Center, Musashimurayama, Tokyo, Japan, 5Tokyo Bay Rehabilitation Hospital, Narashino, Chiba, Japan, 6Advanced Telecommunications Research Institute International, Keihanna Science City, Kyoto, Japan
Pedaling Exercise (PE) could facilitate phasic and coordinated muscle activities and reduce lower extremity spasticity in persons with stroke or spinal cord injury. It is also well known that Transcutaneous Electrical Stimulation (TES) could have beneficial effects to increase reciprocal inhibition and to reduce spasticity. In this study, we investigated whether Transcutaneous Electrical Stimulation combined with Pedaling Exercise (PE-TES) might induce changes in the strength of a specific spinal interneuronal circuit, namely spinally mediated reciprocal inhibition. Seven healthy subjects participated in the study. At intervals of over one week, they received PE-TES, TES alone or PE alone in random order. TES was applied to tibialis anterior muscle during the extension phase of the pedaling cycle. PE employed a servo-dynamically controlled ergometer with a trunk support, and the participants pedaled at a resistance of 5 N-m at their comfortable speed. Each session lasted for 7 minutes and included no break. We assessed reciprocal inhibition of the soleus H-reflex. The magnitude of the reciprocal inhibition was measured before, immediately after, 15 min and 30 min after each intervention. The PE-TES brought a statistically significant increase in the reciprocal inhibition when compared with the other two groups (PE-TES versus TES: p=0.04, PE-TES versus PE: p<0.01). Furthermore, PE-TES enhanced reciprocal inhibition for at least 15 min afterward. Both TES and PE had only immediate effects. These results demonstrate the presence of short-term plasticity within spinal inhibitory circuits and suggest that PE-TES may also reduce spasticity in patients with stroke or spinal cord injury.
3.4 Biochemical
P087 Hyperuricemia and Functional Outcome on Short Term at Patients With Stroke
G. Galbeaza, D. Cinteza, D. Poenaru, C. Teleianu, V. Marcu, S. Popescu, S. Diaconescu, and A. Dima
National Institute of Physical Medicine and Rehabilitation, Bucharest, Romania
Introduction: uric acid is the final product of purinic catabolism. The raised level of seric uric acid was linked with dislipidaemia, diabetes, hypertension and metabolic syndrome. The link between seric uric acid and the risk for coronary heart disease and stroke is uncertain.
Aim: The present study wants to determine if there is a direct link between the level of seric uric acid and functional outcome of patients with stroke.
Material and methods: Prospective study over a 4-month period of patients with recent stroke who were at their first admission in a rehabilitation centre. A total of 21 patients were included. They were evaluated clinically, biologically (seric uric acid, cholesterol, triglyceride, glycemia, VSH), EKG, and functionally (FIM at admission and after 2 weeks).
Results: Out of the 21 patients 20 were with hypertension, 7 had diabetes, 9 had dislipidaemia, 5 had a raised seric uric acid level and 1 had a low seric uric acid level. The patients with hyperuricemia had a better FIM score both at admission and release. The patients with more comorbidities had a lower FIM level.
Conclusions: Hyperuricemia seemed to be linked with a better functional outcome after stroke. The disability level is linked with the number of comorbidities. Study limitations: the small number of patients and the short term evaluation. Future research is needed to determine whether functional outcome in stroke is linked with the level of seric uric acid.
4 Treatment: Basic Research
4.1 Neuropharmacology
P088 Standard of Complex Management of Spasticity After Stroke in the Czech Republic
E. Ehler1, E. Vaňásková2, and I. Tětkářová3
1Department of Neurology, Hospital Pardubice, Pardubice, Czech Republic, 2Department of Rehabilitation, Hradce Králové, Czech Republic, 3Department of Neurology, Prague, Czech Republic
Spasticity is a frequent consequence of stroke, with various severity, and may present the main problem of a patient. After acute phase of stroke most patients are regularly checked for hypertension, heart disease, and stroke prevention. Only a small number of patients have the opportunity to get regular long-lasting rehabilitation or even more complex management of spasticity.
The flexion-pronation type of spasticity in the upper extremity and extension type in the lower extremity is common. Spasticity should be managed whenever it is a problem. In patients after the stroke there is a focal spasticity that presents problems in the region of one or two joints. Patophysiological mechanisms of focal spasticity are the same as in the generalized one, but the therapeutical effect of local botulinum toxin is substantially more significant. The most important role in therapy of spasticity is to have a neurorehabilitation specialist or neurologist, cooperating with physiotherapist or ergotherapist.
The first step of the process is treatment of all complications and factors that could worsen the spasticity. The second step is physio- and ergotherapy, with some indications for splinting. Peroral anti-spastic therapy is not very effective in poststroke spasticity and undications for it are restricted. Local therapy with botulinum toxin is very effective in focal poststroke spasticity with focal clinical problems. For rational use of botulinum toxin in focal spasticity special knowledge and skills of treating doctors are unavoidable. Some patients are indicated for surgical release of spastic muscles or for tendon transfer.
The decision for termination of poststroke spasticity treatment is based on lack of evidence of such treatment, that the patient is not improving anymore, or we reached the therapeutic goal.
For evaluation of patients with poststroke focal spasticity we recommend the modified Ashworth scale, goniometry, functional independence measure (FIM), instrumental ADL, disability assessment scale, SF-36, and KCF.
P089 Repeated Application of High Dose Botulinum Neurotoxin Type A (Xeomin®) in Cynomolgus Monkeys
K. Fink, C. Janaitis, and J. Bluemel
Merz Pharmaceuticals, Frankfurt, Germany
Xeomin® is a botulinum neurotoxin type A preparation free of complexing proteins. In a previous study on cynomolgus monkeys 16 LD50U Xeomin®/kg injected 4-weekly caused bodyweight reductions. The aim of this study was to determine for this dose the shortest injection interval not causing systemic side effects.
Cynomolgus monkeys (male and female, 4/sex/group) were treated with Xeomin® four times. Xeomin® (16 LD50U/kg i.m.) was injected into the left gastrocnemius and biceps muscles. Administration interval was 4, 8 or 12 weeks. Animals were monitored for bodyweight, muscle mass, underwent full toxicological assessment and detailed histopathology of treated muscles.
Treated muscles were atrophic after the third (4-weekly) or second (8- and 12-weekly) administration. Terminal body weights were reduced in the 4-weekly injected group.
Weight of treated muscles in all groups was ~50% reduced as compared to controls or the respective contralateral muscles, an effect which was slightly more pronounced in animals treated 4-weekly than in those treated 8- or 12-weekly. Histopathologically a muscular atrophy was observed in all treated muscles accompanied by secondary changes (variability of myofiber size, increase in collagen and adipose tissue) which were slightly more pronounced in the 12-weekly injected group. In the corresponding right muscles variability of myofiber size was observed in all treated groups, but most severe in the 4-weekly injected group. The weight of the contralateral muscles was reduced in the 4-weekly injected group.
Based on bodyweight as a parameter for systemic side effects, 16 LD50U/kg administered every 8 weeks can be considered as no-observed-adverse-effect level.
P090 Single Case Report: Cerebrospinal Fluid Shunt Infection: A Combined Antibiotic, Surgical and Neurorehabilitative Approach
C. Haider1,2, M. Krombholz-Reindl3,4, H. Zauner1,2, and A. Gassner1
1Rehabilitation center Grossgmain, Grossgmain, Austria, 2Department for Neurorehabilitation, Austria, 3Christian Doppler Clinic, Salzburg, Austria, 4Department for Neurosurgery, Austria
Two thirds of shunt infections develop within the first two months after surgery; most cases are due to staphylococcus.
In a pediatric study Thompson et al concluded that the vulnerable period for bacterial colonization of shunts may not be restricted to the operative procedure as is commonly believed, but may extend throughout the postoperative period of wound healing.
Our findings stress this hypothesis because 7 weeks after shunt insertion, the first symptoms of possible shunt infection, such as elevated temperature and sinus tachycardia, were monitored.
The microorganisms detected in the parietal postoperative wound after this latency period during postacute neurorehabilitation were plasma coagulase negative and methicillin-resistant staphylococcus.
Our young patient had a severe open head injury and severe brain damage that had occurred 15 weeks before, followed by a complicated course with craniotomy, removal of bony fragments, epidural drainage, late onset hydrocephalus, cerebrospinal MEDOS shunt and reconstructive cranioplasty. The patient was treated with vancomycin intravenously for 2 weeks, and then the MEDOS shunt system was explanted. The additional rehabilitation procedure was very successful, as measured by Rivermead motor assessment (at admission 0, at discharge 18 points) and basic activities of daily living scale (admission 0, discharge 13).
P091 Neuroprotective and Consequent Neurorehabilitative Outcomes, in Elderly With Severe Brain Conditions, Treated With Neurotrophics: Actovegin and/or Cerebrolysin: Preliminary Results
G. Onose1, M. Haras1, C. Chendreanu-Daia1, A. Mihaescu1, A. Anghelescu1, L. Onose2, D. Mardare1, and T. Spircu3
1The Physical & Rehabilitation Medicine (PRM) Clinic Division of the Teaching Emergency Hospital “Bagdasar-Arseni”, Bucharest, Romania, 2The Medical Service of Metrorex, Bucharest, Romania, 3The University of Medicine & Pharmacy “Carol Davila”, Bucharest, Romania
Background: assessment of outcomes obtained in our PRM Clinic with Actovegin®, Cerebrolysin® or combined-neurotrophic therapy.
Material & methods: Four homogeneous lots of elderly (60 years old or more) admitted between 2007-2009: 41 treated only with Actovegin® (28 M, 13 F), 24 only with Cerebrolysin® (18 M, 6 F), 43 with Actovegin® + Cerebrolysin® (24 M, 19 F) and 70 controls—that were not treated with Actovegin® or Cerebrolysin® (29 M, 41 F). All patients received aside an equivalent pharmacological and physical therapy. The etiological distribution within the total group of patients (178) was: stroke (98 ischemic and 52 hemorrhagic), traumatic brain injury (13) and brain compressive conditions of different etiologies (15). The main of the 13 parameters assessed at admission/ discharge was the Functional Independence Measure (a/d FIM).
Results: In the Actovegin® lot, the improvement of the FIM score, from admission (a) to discharge (d), was at the statistical significance limit, compared to the witness lot (p = 0.051). In the Cerebrolysin® lot the a/d FIM score evolution was statistically comparable to the controls (p = 0.158). In the Actovegin® + Cerebrolysin® lot, it resulted a strong statistically significant better evolution of the a/d FIM score, vs. the control lot (p = 0.000).
Discussions & Conclusions: The study groups were small—these are preliminary results. Our initial study in elderly emphasized statistical significant efficiency of the combined use of Actovegin® and Cerebrolysin®: simultaneously or sequentially—no matter the order of administration.
P092 Our Experience Concerning the Use of Extracorporeal Shockwave Therapy for the Spasticity Management, in Children With Cerebral Palsy: Preliminary Results
L. Padure1, G. Onose2, C. Chendreanu-Daia2, A. Mirea3, M. Bejan1, L. Onose4, M. Haras2, and A. Anghelescu2
1The National Clinical Center for Pediatric Rehabilitation, Bucharest, Romania, 2The Physical & Rehabilitation Medicine Clinic Division of the Teaching Emergency Hospital “Bagdasar-Arseni”, Bucharest, Romania, 3The University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania, 4The Medical Service of Metrorex, Bucharest, Romania
Background: The medical use of Shock Waves is called Extracorporeal Shock Wave Therapy (ESWT). Our purpose was to evaluate the response to ESWT in cerebral palsy spasticity.
Material & Methods: 50 spastic children (20 Males, 30 Females; 2-9.1 years old). We applied focused ESWT, targeting the mainly affected muscles, with the same parameters (energy: 0,15 mJ/mm2; shot dose: 500 shocks/ min; frequency: 10 Hz). Each patient received 1 therapy session. All had evaluations—global: segmental mobility, based on active range of motion ) and analytical, based on Ashworth modified scale scores—at 3 days and at 2 weeks (± 5 days) afterwards; additionally, we evaluated global patient’s or his/her adult attendant’s related appraisal.
Results: ESWT proved statistically efficient on the global functioning in both, the upper (p=0.0046) and lower (p=0.0004) limbs. It resulted in a significant decrease of the Ashworth modified scale level for triceps suralis (p= 0.000) and for adductors (p=0.010), as only the number of these muscles was large enough for reliable mathematical assessment. Regarding adult attendant’s related appraisal, its average (2.3) placed it towards the “good” established interval.
Discussions & Conclusions: ESWT improved spasticity in affected children. Further studies are needed for a more reliable statistical assessment and to improve the methodology. In this respect, we have recently started a study concerning the effects of ESWT on spasticity in adults, implying a unitary and more adaptive to the range of spasticity methodology (statistical results not available yet).
P093 Neuroprotective and Consequent Neurorehabilitative Clinical Outcomes, in Patients Treated With the Pleiotropic Drug Cerebrolysin®
G. Onose1, D. Muresanu2, C. Chendreanu-Daia1, C. Popescu1, A. Mihaescu1, D. Mardare1, A. Dumitrescu1, and I. Colibaseanu1
1The Physical & Rehabilitation Medicine (PRM) Clinic Division of the Teaching Emergency Hospital “Bagdasar-Arseni”, Bucharest, Romania, 2The Neurological Clinic of the ‘Iuliu Hatieganu’ University of Medicine and Pharmacy, Cluj-napoca, Romania
Background: Discovery of neurotrophic factors resulted in better approaching central nervous system lesions. Cerebrolysin® is a peptide mixture that penetrates the blood-brain barrier in significant amounts and mimic the effects of NGF.
Methods: Comparative analysis: Cerebrolysin® treated (10 ml x 2/ day, i.v. x 3 weeks) vs. non-treated, inpatients (all received aside, a rather equivalent pharmacological and physical therapy). Two lots of patients, admitted in our PRM Clinic Division, during 2007-2009: 69 treated with Cerebrolysin® (22 F, 47 M) and 70 controls (41 F, 29 M) were studied. The total number of assessed items was 13: most contributive in relation with the score of Functional Independence Measure at discharge (d FIM), were: admission (a FIM), number of physical therapy days, number of hospitalization days, age (A) and days till the first knee functional extension. Concomitantly, the main neuromotor parameters have been assessed regarding the speed in achieving their functional recovery.
Results: Concerning d FIM, there have not been objectified significant differences between the two lots (p=0.245) but regarding most of the neuromotor parameters—mainly for KE (p=0.000) and days till the first time recovery of the ability to walk between parallel bars (WPB - p=0.000)—resulted highly significant differences in favor of Cerebrolysin® lot.
Conclusion: Cerebrolysin administration, proved to hasten, statistically significant the improvement of some critical functional parameters. We have now initiated a comprehensive national, retrospective (in the last decades) multicenter—based on unitary data acquisition frame and mathematical apparatus—such a study.
P094 Cardiovascular Alterations Following Intrathecal Baclofen Bolus: Two Cases
C. Rifici1, G. D’Aleo1, M. Kofler2, P. D’Aleo1, L. Saltuari2, and P. Bramanti1
1IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy, 2Department of Neurology, Hospital Hochzirl, Zirl, Austria
Baclofen may cause respiratory failure, epileptic seizures, coma, and autonomic disturbances. Cardiovascular side effects are most pronounced during anesthesia or overdose. To date, a single therapeutic dose of oral baclofen has produced heart conduction problems in a tetraplegic patient, there are no reports, however, on cardiac dysfunction during intrathecal baclofen screening tests. We describe two patients in whom serious bradycardia and hypotension occurred after ITB bolus testing. Both patients suffered from severe spasticity (patient 1: traumatic brain injury, patient 2: spinal cord injury). Medical history and diagnostic exams revealed no previous cardiological problems. Ten minutes following a 50 µg ITB bolus, patient 1 developed bradycardia (58 bpm) and incomplete right branch block, which lasted 3 hours. In patient 2, a 20 µg ITB bolus was followed after 5 minutes by severe bradycardia (30 bpm) and hypotension (60/30 mmHg), without loss of consciousness, lasting for 10 minutes. Exaggerated muscle tone was alleviated after 2 hours by the applied doses. Both patients were continued on oral baclofen and did not undergo implantation of a permanent pump system. In both patients presented here, cardiac dysfunction became clinically evident for the first time during ITB test bolus application, and subsequently both patients died of fatal cardiac arrhythmias during oral baclofen therapy. Hence, ITB-related cardiac dysfunction could have served as a red flag for subsequent avoiding GABAergic treatment. Careful cardiological examination before and during ITB application is advised, in order not to miss this rare complication of baclofen treatment.
P095 The Medium Latency Reflex Response and Its Contribution to Spasticity Following the Administration of Tizanidine
P. W. Stubbs1,2, T. Sinkjær2, J. F. Nielsen1, and N. Mrachacz-Kersting2
1Hammel Neurorehabilitation and Research Center Hospital, Hammel, Denmark, 2Aalborg University, Aalborg, Denmark
Tizanidine is administered to reduce spasticity. The aim of this study was to assess (i) the passive stiffness of the affected soleus muscle (SOL) pre and following two weeks administration of Tizanidine and (ii) the changes in the reflex components while walking relating these to clinical measures.
Five chronic stroke patients were seated with their foot attached to a moveable plate (n=3) or walking with their foot attached to a portable robotic actuator (n=2). Dorsiflexion perturbations were imposed in sitting (velocity: 8-80°/s, amplitude: 4-6°, hold time:500ms) and in walking (velocity: 300°/s, amplitude: 6°, hold time: 200ms). Clinical measures included the 10 meter walk test (10MWT), Fugl Meyer Lower limb (FMLL), Tardieu and Ashworth scales.
Following Tizanidine, the passive stiffness remained unchanged. The Medium Latency Reflex (MLR) was delayed (pre: 80ms, post: 85ms) and reduced in both tasks (by 24%). There were no differences in the 10MWT (23.83s vs.24.82s), FMLL (16 vs. 16.6), Tardieu (V1: 1 vs. 0.8; V3: 2.2 vs. 2.2) and Ashworth (2.4 vs. 2.2) scales. The results suggest that Tizanidine does not reduce passive stiffness or change clinical measures after two weeks. However, it is successful in reducing and delaying the MLR response during walking. As these are preliminary findings, the implications of this data are not yet established.
P096 Downregulation of Oxido-Inflammatory Cascade in Alcoholic Neuropathic Pain by Epigallocatechin-3-Gallate
V. Tiwari, A. Kuhad, and K. Chopra
University Institute of Pharmaceutical Sciences (UIPS), Chandigarh, India
Alcoholic neuropathy is one of the devastating complications of long term alcohol consumption which involves decreased nociceptive threshold characterized by spontaneous burning pain, hyperalgesia and allodynia. Alcoholic neuropathy has been associated with behavioral alterations, increase in oxidative-nitrosative stress and pro-inflammatory cytokines. The present study was designed to explore the protective effect of epigallocatechin-3-gallate against alcoholic neuropathy in rats. Chronic alcohol (35%) treated rats developed neuropathy after 6 weeks, which was evident from decreased tail flick latency (thermal hyperalgesia), paw withdrawal threshold in Randall-Sellito test (mechanical hyperalgesia) and von-Frey hair test (mechanical allodynia) along with enhanced in oxidative-nitrosative stress and inflammatory mediators (TNFα, IL-1β and TGF-β1 levels). Co-administration of epigallocatechin-3-gallate significantly and dose-dependently prevented behavioral, biochemical and molecular changes associated with alcoholic neuropathy. In conclusion, the current findings suggest the neuroprotective potential of epigallocatechin-3-gallate in attenuating the behavioral and biochemical alterations associated with alcoholic neuropathy through modulation of oxido-inflammatory cascade.
4.2 Neurobiologic (Stem Cells)
P097 Experiences With a Follow-Up Study of Stem-Cell-Therapy Treated Patients
G. Filiczki1, K. Rábai2, and A. Kelemen1
1International Pető Institute, Budapest, Hungary, 2Semmelweis University, Budapest, Hungary
Fifteen cerebral paretic children treated by conductive education were examined, and their parents were interrogated after stem-cell-therapy at the International Pet Institute. Our hypothesis was that the parents were partial and more subjective. Their subjective opinions were compared with clinical findings. During the interviews the following questions were asked:
Who did the patients ask for information about stem-cell-therapy?
To their knowledge what kind of cells did the patients get?
How were the stem-cells got into the patients’ body?
Did the patients get rehabilitation treatment during the stem-cell-therapy?
Did any complication appear in connection with the stem-cell-therapy?
Did the patients get information about what kind of changes and improvements should they observe?
How did the patients judge the effect of stem-cell-therapy?
How did the conductor judge the effect of stem-cell-therapy?
The patients’ neurological status and results of their functional appraising tests, before and after the stem-cell-therapy, were compared after the interviews.
Experiences: Parents judged the effect (or inefficiency) of the treatment as objective as conductors did it, or as it turned out from neurological examinations and functional tests. However they didn’t discuss their experiences with other parents or with the specialist treating the children. Parents got contradictory opinions during the consultancy because the knowledge of specialists treating and examining the cerebral paretic children was incomplete about stem-cell-therapy.
Suggestion: The patients deliberating stem-cell-therapy and specialists should get acquainted with the handout of The International Society for Stem Cell Research about the possibilities with stem-cell-therapy.
P098 Effect of Exercise on Cognitive Function and Neurogenesis in Vascular Dementia Rat Model
J. Lee1,2, D. Choi1, M. R. Hasan1, J. Han1, H. Y. Kim1, C. Y. Shin1, and S. Han1
1Center for Geriatric Neuroscience Research, IBST, Konkuk University, Seoul, Republic of Korea, 2Department of Rehabilitation Medicine, Konkuk University Medical Center, Seoul, Republic of Korea
Background and Purpose: Exercise can enhance learning and memory, and delay age-related cognitive decline. Whether exercise has preventive or therapeutic role in vascular dementia is not well documented yet. We investigated to determine whether exercise could recover cognitive deficit and promote neurogenesis in vascular dementia rat models.
Materials and Methods: Male Wistar rats (8 weeks, 275-300 g, n = 5~6 each group) were subjected to bilateral common carotid artery occlusion (BCCAo) and were randomly divided into two groups: no exercise (BCCAo) and treadmill exercise (BCCAo+exercise). Sham operated rats were also divided into control and exercise group. Exercise groups underwent treadmill exercise daily at 15 m/min for 30 minutes for 4 weeks starting from 3rd week to 7th week. BrdU injection was administered i.p. daily (50 mg/Kg) during 3rd and 4th weeks to observe neurogenesis. All rats were subjected to Morris Water Maze Test (MWMT) 5 trials daily for the last 4 days during 7th week. Double immunohistochemistry staining was done to observe neurogenesis.
Results: Exercise groups with or without BCCAo showed decreased latency and search error in MWMT. Latency of control, exercise, BCCAo and BCCAo+exercise groups were 74.0 ± 0.91, 56.0 ± 5.29, 33.6 ± 4.99 and 28.0 ± 5.83 seconds respectively, while search error was 32.2 ± 1.10, 26.3 6.24, 41.4 ± 6.07 and 33.6 ± 4.99 meters respectively. Exercise increased neurogenesis both in BCCAo and sham groups.
Conclusion: Our data suggest that exercise may delay cognitive decline in vascular dementia and promote neurogenesis.
4.3 Interventional (Destruction, Stimulation, Brain Computer Interface)
P099 EEG-Based Brain-Computer Interface in Chronic Quadriplegics Using Robotic Arm Device as Functional Assistive Technology: Clinical Survey and Posttrial Follow-Up
G. Onose1, A. Anghelescu1, C. Grozea2, C. Chendreanu-Daia1, A. Mirea1, S. Fazli3, M. Danoczy3, and F. Popescu4
1The Physical & Rehabilitation Medicine (PRM) Clinic Division of the Teaching Emergency Hospital “Bagdasar-Arseni”, Bucharest, Romania, 2The Fraunhofer FIRST Institute, Berlin, Germany, 3Technical University Berlin, Machine Learning Group, Berlin, Germany, 4The Fraunhofer FIRST Institute, Berlin, Germany, Berlin, Germany
Background: To assess the feasibility and effectiveness of using an advanced, combined non-invasive electro-encephalography (EEG-) based brain-computer interface (BCI) and a mechatronic/robotic arm device, towards the assistive purpose of improving the postcervical SCI chronic severe disabling, neuro-motor condition.
Material & Methods: In the 9 quadriplegic studied patients group cluster analysis was performed. Multiple regression method emphasized contribution to the dependent variable (EEG-BCI performance error) of the following independent variables: age, motor and sensitive AIS scores, and preferentially collected most discriminative frequency bands.
Results: The analysis of the EEG mapping based spectrograms of the studied quadriplegics, pointed out the highest performance level of control could be associated to the shift of the cerebral waves towards the fast frequencies, mainly to the beta-spectral power.
In a formula that gives the dependent EEG-BCI variable, the most important contribution is brought by the age (coefficient 1.41; p = 0.024) then by the AIS motor score (coefficient = 0.74; p = 0.034, positively).
Discussions & Conclusions: According to our preliminary results, the motivation for quadriplegics to use EEG-BCI based mechatronic/robotic devices, is mainly related to their proficiency, determination and age, offering a valuable perspective to improve the severe activity limitations, post SCI paralyzed people encounter in managing activities/instrumental (activities) of daily living (ADL/ IADL) including by possibly thus outfitting an original conception of ours—mechatronic orthotic/exoskeleton device, to assist/rehabilitate orthostatism and walk in complete paraplegia and/or other conditions seriously affecting locomotion.
P100 Can Intrathecal Pumps With Blocked Catheters Be Re-Used?
M. Cirasanambati, S. Bandi, B. Mayilvaganan, B. Alexandra, J. Singh, and A. B. Ward
Haywood Hospital, Stoke-On-Trent, United Kingdom
Aim of study: To investigate the efficacy of intrathecal drug delivery systems following prolonged periods of catheter blockage.
Background: Catheter blockage is a major cause of intrathecal drug delivery pump dysfunction, requiring system revision. Manufacturers advise that stopping pumps for longer than 48 hours may damage internal pump tubing systems and affect drug delivery. It is unclear, from literature review and manufacturer data, how prolonged periods of catheter blockage affect the function of the pump and whether catheter replacement alone could allow their continued use in the same patient.
Method: Four explanted Synchromed II (Medtronic, Inc.) pumps with objective evidence of catheter blockage were used. Open system volumetric analysis of the four pumps with minimal, intermediate and maximal flow rates were performed, which was compared against closed system volumetric analysis to compensate for the evaporation losses.
Results: The mean period from diagnosis of catheter blockage to explantation was 4.2 months (range 3- 6 months). Variation of actual outflow volume in comparison with expected outflow for the set rate ranged from -4% to 8% at minimal rate, -1% to 7% at mid flow rate and -5% to 7% at maximal flow rate for all four pumps. All were within the manufacturer’s acceptable range of ± 14.5% of the expected outflow.
Conclusion: This study demonstrates that pump function is retained within an acceptable range following prolonged outflow blockage. There is potential for the continued use of these pumps for the remainder of their battery life by replacement of the catheter system alone.
P101 Can Task-Related Eye Movements During Motor Imagery Training Enhance Its Effect?
E. Heremans1, B. Smits-Engelsman1, P. Feys2, A. Nieuwboer1, and W. Helsen1
1K.U. Leuven, Heverlee, Belgium, 2Universiteit Hasselt, Hasselt, Belgium
Motor imagery (MI), defined as mental rehearsal of a motor act in the absence of overt motor output, is a promising rehabilitation tool for patients with neurological disorders. Although the evidence regarding its beneficial effects is growing rapidly, to date very little attention has been paid to how imagery training can be applied most effectively. In a previous study, we found a close coupling between eye and imagined hand movements, similar to the eye-hand coupling in physically executed hand movements. Therefore, in the present study we investigated whether visual MI training can be enhanced by the making of task-related eye movements. 36 young healthy participants were divided in three groups. Two groups received four sessions of 30 minutes visual MI training of a Virtual Radial Fitts task, performed with their non-dominant hand. In the first group spontaneous eye movements were allowed during MI training, while the second group was instructed to fixate on a central point while imagining. The third group (control group) received no training at all. The results show that the correlation between movement times of imagined and real movements increased over training if MI training was performed in the presence of eye movements, while it decreased if eye movements were suppressed. These findings indicate that the use of task-related eye movements may optimise the quality of MI practice. Furthermore, the effects of eye movements during MI training on the spatial and kinematic aspects of the arm movements will be presented and related to rehabilitation aspects.
P102 Modulation of Flexor Muscle Activity During Resisted Walking in Motor Incomplete Spinal Cord Injured Individuals Compared to Controls
A. Houldin and T. Lam
University of British Columbia, Vancouver, BC, Canada
Hip and knee flexor muscle activity during the swing phase of walking is influenced by proprioceptive feedback from flexor muscle afferents. The application of a velocity-dependent resistance against the hip and knee has been shown to result in an immediate, feedback-mediated increase in flexor activity during swing. The purpose of this study is to determine whether people with chronic motor-incomplete spinal cord injuries (m-iSCI) can modulate motor output in response to different levels of resistance during treadmill walking, compared to able-bodied controls. Subjects walked on a treadmill with the Lokomat robotic gait orthosis. The Lokomat was programmed to apply different levels of a velocity-dependent resistance, calculated as a percentage of each individual’s maximum voluntary contraction of the hip and knee flexors. Each condition consisted of 20 steps against resistance followed by 20 steps without. Electromyography and kinematics of the lower limb were recorded. Individuals with m-iSCI have weak modulation of the magnitude of muscle activity in response to different levels of resistance. However, in the control group, we observed that there was greater rectus femoris muscle activity during swing as the level of resistance increased. Controls also responded to the removal of resistance with a high step. The size of the high step appeared to be proportional to the amount of resistance. This high stepping response appeared attenuated in persons with m-iSCI. This research will add to our current understanding of the neurological mechanisms of walking and has implications for rehabilitative programs for individuals with m-iSCI.
P103 The Effect of Low Frequency rTMS on Right Broca’s Homologue in Global Aphasia: Pilot Study
S. Kang, H. Park, K. Seo, D. Kim, S. Kim, and J. Seo
Chung-Ang University, College of Medicine, Department of Physical Medicine & Rehabilitation, Seoul, Republic of Korea
Object: We applied 1Hz repetitive transcranial magnetic stimulation(rTMS) to right Broca’s homologue (right inferior frontal gyrus) to evaluate whether suppression of right Broca’s homologue by rTMS can improve speech recovery, which was known as maladaptive strategy.
Method: The patient with global aphasia after left middle cerebral artery infarction received low frequency rTMS. To determine location of stimulation site, we used neuronavigation system, which is an image-guided, frameless and localization system. We applied 1Hz, intensity of 80% of motor threshold for 11 min (5min stimulation - 1min resting - 5min stimulation, 600 pulses) rTMS on right Broca’s homologue 3-days a week for 3 weeks. The patient was tested with Korean Version-Western Aphasia Battery (K-WAB) and Parallel Short Forms for the Korean-Boston Naming Test (K-BNT) before and after stimulation for outcome measure. Safety was assessed using electroencephalogram before and after stimulation.
Results: Significant improvement was observed in fluency and comprehension at post rTMS. The Aphasia Quotient score was improved from 3.4 to 33.2 after rTMS in K-WAB, K-BNT score was improved from 0 to 2 after rTMS. Electroencephalogram were not changed significantly throughout the trial in patient.
Conclusion: Speech therapy with low frequency rTMS could improve aphasia.
P104 Modulation of Mu Rhythm Desynchronization During Motor Imagery by Transcranial Direct Current Stimulation in Chronic Patients With Hemiparesis
Y. Kasashima1, Y. Matsushika2, T. Fujiwara1, J. Ushiba2, T. Tsuji1, K. Hase1, and M. Liu1
1Department of Rehabilitation Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan, 2School of Fundamental Science and Technology, Graduate School of Keio University, Kanagawa, Japan
Non-invasive electroencephalogram (EEG)-based brain-machine interface (BMI) has been developed based on recent advances in analysis of brain signals. The event-related desynchronization of 8-13Hz EEG (mu ERD) is interpreted as the desynchronized activities of the activated neurons and appears during motor imagery. It is, therefore, applied to BMI. We assessed mu ERD induced with motor imagery in two patients with severe hemiparesis and examined the modulation of ERD with anodal transcranial direct current stimulation (tDCS) combined with rehabilitation. Methods: The participants received anodal tDCS(10min, 1mA) for 10 min a day just before their occupational therapy for 5 days a weak. Before and after the intervention, Electroencephalograms (EEGs) were recorded near the injured M1 area during imagery of their paretic hands grasping. mu ERD by the imagery was assessed. Results: After the intervention of anodal tDCS, mu ERD of the affected hemisphere increased in both cases. Conclusion: Anodal tDCS combined with rehabilitation may be useful tool to enhance the capability of mu ERD based BMI.
P105 Effects of Single tDCS on Lower Limb Motor Activity and Mobility in Chronic Stroke
W. Kitisomprayoonkul and S. Utarapichat
Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
Background: Weakness of lower limb causes walking difficulty and increases falling in stroke patients. Any method to enhance motor activity facilitates walking ambulation and may decrease falling.
Methods: Ten chronic ischemic stroke patients participated in a single-blind cross-over randomized sham-controlled trial. Each patient participated in 2 stimulation conditions, i.e. transcranial direct current stimulation (tDCS) and sham stimulation, with at least 48 hours washout period. Anodal tDCS (2 mA × 10 minutes) was applied over the lower limb motor area of the infarcted cortex. Ten seconds ramp-up and ramp-down was used in sham stimulation.
Results: Mean age of participants is 57.1 ± 12.2 years. Onset is 34.1 ± 18.9 months. Repeated ANOVA indicated a significant effect of tDCS and time on root means square (RMS) amplitude of vastus medialis muscle of hemiparetic limb (p = 0.04). Post hoc analysis revealed RMS amplitude increases from 88.40 to 100.25 μV in tDCS group (p = 0.03) and from 87.44 to 94.08 μV in sham group (p = 0.15). RMS of tibialis anterior muscle, median frequency of vastus medialis and tibialis anterior muscles were not significant change (p > 0.05). Timed Get-Up-and-Go test of tDCS group was decreased from 16.00 to 15.82 sec. (p = 0.54).
Conclusion: Motor activity of vastus medialis muscle of hemiparetic limb in chronic stroke significantly increases immediately after a single 10-minute tDCS. Further study is needed to find out an optimal duration and number of repetition for clinical implication.
P106 Establishment and Gene Expression Characterization of a Rat Model for Unilateral Repetitive Transcranial Magnetic Stimulation
S. Lee, T. R. Han, J. Beom, M. S. Bang, K. H. Park, and B. Oh
Seoul National University Hospital, Seoul, Republic of Korea
Objective: To establish an animal model for unilateral hemispheric application of repetitive transcranial magnetic stimulation (rTMS) and characterize rTMS-induced changes of gene expression
Method: Twenty-nine adult male Sprague-Dawley rats were subjected to a single session of rTMS with low- (1 Hz, n=12), high-frequency (20 Hz, n=12), or sham (n=5) stimulation. Low- and high-frequency groups were subdivided into 10-, 20-, and 30-minute application groups. Stimulation was applied using 25 mm figure-of-8 coil. We also developed a hydraulic cooling system. Five minutes after applying rTMS on the left hemisphere, we obtained the brain tissue from the left cortex and striatum, and contralateral cortex. Levels of phosphorylation of Akt and endothelial nitric oxide synthase (eNOS), and vascular endothelial growth factor were measured using Western blot. Real-time PCR was conducted on arc, fos, akt1, bdnf, angpt, ntrk, tek, vegfa and pik3cg genes.
Results: In western blot, the stimulated cortex showed greater phospho-Akt expression than the contralateral cortex in both low- (optical density ratio, 4.5±3.3 vs. 1.0±0.8, P<0.05) and high-frequency (3.3±0.9 vs. 0.7±0.5, P<0.05) groups. Low-frequency rTMS reduced phospho-eNOS expression in the contralateral cortex (0.5±0.5) compared to the sham (1.4±0.6, P<0.05) and high-frequency (1.4±0.8, P<0.05) groups. In real-time PCR, low-frequency group showed significantly lower level of akt, ntrk, tek and vegfa transcription in the stimulated cortex than in the contralateral cortex.
Conclusion: We established a small animal model of unilateral hemispheric rTMS and confirmed its differential molecular effects on the stimulated and contralateral cortices.
P107 Changes in Thigh Muscle Area and Fiber Type Composition Following Progressive Resistance Training After Stroke
J. Lexell1, U. Flansbjer1, and F. Kadi2
1Department of Rehabilitation Medicine, Lund University Hospital, Lund, Sweden, 2School of Health and Medical Sciences, Örebro University, Örebro, Sweden
Muscle weakness is a prominent impairment after stroke and interventions to improve muscle strength are important in stroke rehabilitation. Progressive resistance training (PRT) has been shown to lead to improvements in knee muscle strength, gait performance and participation in post-stroke individuals (J Rehabil Med, 2008, 40:42-48). In this study, the mechanisms underlying the improvements in strength were evaluated. Fifteen men and women (mean age 61 years) with post-stroke weakness (19 months post-stroke) participated in progressive resistance training (80% of maximum load) of the thigh muscles, twice weekly for 10 weeks. Before and after the training period, strength was measured dynamically and isokinetically, magnetic resonance imaging was used to measure the anatomical thigh muscle area of both lower limbs and muscle biopsies were taken from the vastus lateralis of the paretic leg to determine the mean area and proportion of different fiber types. The mean improvement in dynamic strength was between 40% and 70% (p<0.001) and in isokinetic strength between 14% and 64% (p<0.01). The mean cross-sectional area of the extensor and the flexor muscles increased on 4% to 6% (p<0.001) in both lower limbs. There was a significant increase in the cross-sectional area of Type IIA fibers (10%) (p<0.05), but no other significant changes in fiber area or fiber type proportion. Improvements in muscles strength following PRT in chronic stroke can be partly explained by increased muscle mass and muscle fiber cross-sectional area.
P108 Short Term Behavioural Changes Indicating Treatment Effect During Guided Interaction Therapy: The Affolter Model® for Adults With Acquired Brain Damage: A Case Study With 5 Participants
L. Lund, A. B. Andersen, K. Hastrup Arentsen, and T. Kristensen
Hammel Neurorehabilitation and Research Centre, Hammel, Denmark
Purpose: The purpose of this study was to clarify whether persons with acquired, very severe brain damage may change behaviour during treatment, and if so, to identify favourable and differentiated treatment responses. The authors’ vague observations over years of these patients’ changeability during individually tailored therapy led to application of guided interaction therapy according to the Affolter model® to clarify the question.
Data collection: Each participant was guided once a day in three upon each other following days. The interventions were double camera videotaped.
Inclusion criteria: A general state allowing daily participation in the general neurorehabilitation service at HNRC; a Rancho Los Amigos Score of 2, 3 or 4 at first intervention; consecutively admitted to neurorehabilitation at HNRC.
Exclusion criteria: Congenital or earlier brain injuries; other neurological or psychiatric diagnoses.
Processing data: Favourable changes in behaviour were identified and categorized by 5 different persons, through individual and more consensus analyses.
Results: The participants’ changes in behavior represent 45 different subtypes, appearing in patterns. They are classified in the categories: Normalisation of tone, Decrease/cease of hyperactivity, Relevant changes in the direction and expression of glance, Signs of understanding of/participation in activity. The behavioural changes are interpreted as favourable changes in perceptual and cognitive functioning.
Conclusion: These 5 severely disabled participants in neurorehabilitation seem to present differentiated categories of favourable, behavioural changes elicited by guided interaction therapy. The categories seem consistent with short term changes observed and mentioned in publications dealing with applying the model to different or less specified populations.
P109 The Immediate Effects of EMG-Triggered Neuromuscular Electrical Stimulation on Cortical Excitability and Grip Control in People With Chronic Stroke
J. A. Rosie
Health and Rehabilitation Research Institute, AUT University, Auckland, New Zealand
Aim: The aim of this study was to identify the immediate effects on cortical excitability and grip control of a short intervention of EMG-triggered neuromuscular electrical stimulation, compared to voluntary activation of the finger flexor muscles, in people with chronic stroke.
Participants: Fifteen people with chronic stroke participated.
Intervention: Participants performed a simple force tracking task with or without EMG-triggered neuromuscular electrical stimulation of the finger flexor muscles.
Main outcome measures: Cortical excitability was measured by single and paired-pulse transcranial magnetic stimulation. Multi-digit grip control accuracy was measured during ramp and sine wave force tracking tasks. Maximal grip strength was measured before and after each intervention to monitor muscle fatigue.
Results: No significant increases in cortico-motor excitability were found. Intracortical inhibition significantly increased following the EMG-triggered neuromuscular electrical stimulation intervention immediately post-intervention (t = 2.466, p = .036), and 10 minutes post-intervention (t = 2.45, p = .04). Accuracy during one component of the force tracking tasks significantly improved (F(1, 14) = 4.701, p = .048) following both interventions. Maximal grip strength reduced significantly following both interventions, after the assessment of cortical excitability (F(1, 8) = 9.197, p = .16), and grip control (F(1, 14) = 9.026, p = .009).
Conclusions: EMG-triggered neuromuscular electrical stimulation during short duration force tracking training does not increase cortical excitability in participants with chronic stroke. Short duration force tracking training both with and without EMG-triggered neuromuscular electrical stimulation leads to improvements in training-specific aspects of grip control in people with chronic stroke.
P110 Brain Activity Before and After a Perception Task in a Stroke Patient With Hemiplegia
N. Sueyoshi1,2, T. Tominaga2, K. Oue2, H. Taniguchi1,2, Y. Yukawa1,2, and S. Morioka1
1NeuroRehabilitation, Kio University, Kitakatsuragi-gun, Nara, Japan, 2Rehabilitation, Murata Hospital, Osaka, Japan
Introduction: Motor imagery plays a crucial role in the recovery of motor function in stroke patients with hemiplegia. Perceptions are reportedly involved in increasing the vividness of motor imagery (Malouin et al. 2009). To increase the vividness of motor imagery, we devised a task involving perception of the direction of skin friction (denoted here as a “perception task”) and reported finding that motor paralysis improved. This study sought to examine brain activity during motor imagery and during actual movement before and after a perception task. Methods: The subject was a patient presenting with left hemiplegia due to a lacunar infarct in the right pons. Brain activity was measured using functional near-infrared spectroscopy. Brain activity was recorded during motor imagery and during actual movement in the form of dorsiflexion of the ankle joint before and after performance of the perception task. Results: Prior to the perception task, a significant increase in Oxy-Hb was noted in the right prefrontal cortex during both motor imagery and actual movement. After the perception task, such an increase was noted in the same area during both motor imagery and actual movement, but a significant increase in Oxy-Hb (p < 0.01) was also noted in the bilateral premotor cortex and the primary sensorimotor cortex as well. Conclusion: Results clearly revealed that after the perception task Oxy-Hb in motor-related areas increases during both motor imagery and actual movement. Findings suggested that these areas are involved in motor imagery (Ehrsson et al. 2003).
P111 The Effect of Sensory Electrical Stimulation on Brain Activity and Hand Sensation
N. C. M. Towersey, D. Taylor, and G. Lewis
Health and Rehabilitation Research Institute, Auckland, New Zealand
Background: Prolonged sensory electrical stimulation provides sensory input to the central nervous system and has been shown to prime the brain and enhance upper limb functional improvements following stroke. Despite these positive outcomes, the application of prolonged sensory electrical stimulation in the clinical setting is problematic. The laboratory equipment used in previous studies is not readily available to therapists and the application of one or two hours of stimulation would be impractical in the clinical setting.
Purpose: The purpose of this study was to evaluate the use of 30 minutes of sensory electrical stimulation, using a standard electrical stimulation machine, on the activity of motor pathways, the sensory cortex and index finger sensory thresholds in healthy adults.
Methods: A within subject design with experimental and control interventions. 12 healthy participants (20-70 years) received three interventions; sensory electrical stimulation applied at the median nerve at the wrist with attention directed towards the simulation, sensory electrical stimulation with attention diverted away from the stimulation, and sham stimulation. Cortico-motor excitability, measured by transcranial magnetic stimulation, excitability of the sensory cortex measured by somatosensory evoked potentials, and sensory threshold of the index fingers measured by Semmes Weinstein Monofilaments were assessed twice at baseline, immediately following and 15 minutes following the intervention.
Results: Data analysis is currently underway and preliminary findings will be presented.
P112 Phenol Block for Focal Dystonia After Brachial Plexus Injury With Assistance of Ultrasound: A Case Report
Y. Tsai1,2, S. Huang1,2, and H. Cheng1,2
1Center for Neural Regeneration, Taipei Veterans General Hospital, Taipei, Taiwan, 2National Yang Ming University, Taipei, Taiwan
Setting: Human electrophysiological laboratory.
Patient: A 45-year-old Caucasian male with dystonia of left arm and chest wall after brachial plexus injury (BPI) and repair surgery.
Case Description: The patient developed severe dystonia involving left pectoralis major and minor, brachioradialis, triceps and biceps brachii, after recovery from left BPI (C5-7 roots to trunk lesions, severe complete at C5) and humeral head fracture, caused by a traffic accident three years ago. Repetitive involuntary shoulder internal rotation caused avascular necrosis of humeral head. Due to poor response to oral medications and two trials of Botulinum toxin injection performed by a Neurologist, left arm amputation was suggested by the Orthopaedic surgeon.
Assessment/Results: Because the patient could not afford another trial of Botulinum toxin therapy, he was referred to our lab for phenol block. To overcome the difficulty in bringing the needle to the motor points caused by repetitive involuntary muscle contraction, ultrasound was applied along with electrical stimulation. Sono-guide also helped avoiding penetration of the pleura. After four weekly phenol blocks, the range of the involuntary movement decreased from 75° to 20° in elbow flexion/extension, from 45° to 10° in shoulder internal rotation. The patient also reported decreased pain and better sleep.
Discussion: To our knowledge, focal dystonia involving arm and chest wall after BPI has not been described in the literature. In this case, the effect of phenol block was not inferior to Botulinum toxin injection.
Conclusion: With appropriate devices and injection skills, phenol block could be an effective treatment for focal dystonia.
P113 Arm Laboratory to Efficiently Increase the Therapy Intensity of the Severely Affected Arm After Stroke: An Open Study
C. Werner1, R. Buschfort2, A. Heß2, A. Waldner3, and S. Hesse1
1Charité University Medicine Berlin, Medical Park Berlin, Berlin, Germany, 2Klinik am Stein, Zentrum für NeuroGeriatrie und Rehabilitationsmedizin, Olsberg, Germany, 3Villa Melitta, Bozen, Italy
Objectives: To assess the acceptance, utilization and clinical results of an arm studio to intensify the treatment of the severely to moderately affected arm after stroke. In line with a distal bilateral approach, it consists of four workstations, one finger trainer, and three machines for bilateral training of selected distal and proximal movements.
Design: Open study
Subjects: Out of 119 treated subacute stroke patients, 30 filled in a questionnaire and 24 were assessed
Methods: 15 additional sessions of 30 - 45 min, each patient practiced with two workstations, based on the impairment level three groups (A,B, C) were distinguished: plegic (A), proximal and distal movements but hand non-functional (B), and able to grasp and release an object (C). Motor functions were assessed with the Fugl-Meyer Score (FM, 0-66) in group A (n=6) and B (n=6), and the Action Arm Research Test (ARAT, 0-57) in group C (n=12).
Results: No relevant side effects occurred, the patients were positive, the initial (terminal) FM was 8.5 ± 3.3 (21.2 ± 4.4.) in group A, 25.3 ± 6.9 (44.3 ± 9.1) in group B, and for the ARAT 33.3 ± 11.2 (43.5 ± 10.7) in group C.
Conclusion: The arm studio efficiently intensify the upper limb rehabilitation after stroke, a controlled study is currently being conducted.
P114 Is Voluntary Postural Control Training the Trigger Factor for Restoration of Integrative Brain Functioning in Patients With Severe Traumatic Brain Injury?
L. Zhavoronkova1, A. Zharikova2, O. Maksakova2, I. Flerov2, and V. Naydin2
1Institute of Higher Nervous Activity and Neurophysiology RAS, Moscow, Russian Federation, 2Burdenko Neurosurgery Institute RAMS, Moscow, Russian Federation
Introduction: Patients with consequences of severe traumatic brain injury (TBI) have been suffering from disintegration of brain activity and standing balance training (SBT) with visual biofeedback could be rehabilitative procedure enhancing integrative brain functioning. The aim of our study is to investigate the mechanisms of restoration of brain functioning during rehabilitation course with SBT.
Patients and methods: 20 patients with posture balance disturbances after acute TBI involved into rehabilitation program were included. SBT séance consisted of statical Romberg test and 3 dynamical tests. SBT course contained 8-12 séances during 3-4 weeks. Standing balance characteristics, EEG-coherence and differentiate Mayo-Portland Adaptability Inventory-3 scores were analyzed and compared with those in 20 healthy volunteers matched by age and gender.
Results: Before SBT all characteristics of patients were significantly worse comparing to healthy volunteers. After SBT course statistically significant reduction of center of pressure (CP) sway area occurred. Length of CP path and CP fluctuation velocity decreased in static test while quality of performance in dynamical tests increased. These findings were accompanied by increase of value of power in alpha-band and interhemispheric EEG-coherence predominantly in central and parietal areas involved in voluntary motor activity and postural control. Simultaneously motor, cognitive, emotional functions have improved.
Conclusion: Rehabilitation course with SBT improved posture characteristics and was accompanied by clinical recovery of motor, cognitive and emotional state in patients with TBI. These findings accompanied by EEG power and coherence enhancing in specific areas may reflect formation of integrative processing in the brain after rehabilitation with SBT.
4.4 Robotics
P115 Feasibility of Dynamic Entrainment With Ankle Mechanical Perturbation to Treat Human Locomotor Deficits
J. Ahn and N. Hogan
MIT, Cambridge, MA, United States
Dynamically entraining human gait with periodic torque from a robot may provide an approach to walking therapy that is uniquely supportive of normal biological function. Based on a patient’s performance, a robot may entrain the patient’s walking frequency and gradually “drag” it towards a normal walking frequency. To test the feasibility of this approach we perturbed the gait of unimpaired human subjects using Anklebot, a therapeutic robot module, to apply ankle torque at various frequencies. With a properly designed perturbation, 10 subjects out of 12 exhibited entrained gaits: their gait frequency adapted to match that of the mechanical perturbation. Remarkably, their gait synchronized (“phase-locked”) with the robot perturbation so that it assisted the propulsive (“push-off”) phase of gait.
Dynamic entrainment differs from most current robot-aided locomotor therapy in several ways:
1. Most current robot-aided therapy attempts to control lower-limb trajectories. In contrast, our results suggest that an embedded neural oscillator interacting with peripheral musculo-skeletal mechanics plays a prominent role in human locomotion. If so, current robot-aided walking therapy may interfere with normal locomotor function. Instead of imposing kinematic patterns, rehabilitation by entraining an embedded oscillator might provide an essential but hitherto neglected element of walking therapy.
2. By controlling robotic torque frequency and amplitude, assistance may be adjusted continuously to promote patient participation, an essential element of successful upper-extremity neuro-restoration.
3. Entraining an embedded oscillator in lumbar spinal cord may be able to promote recovery with minimal involvement of supraspinal input, especially important for rehabilitation after Spinal Cord Injury.
P116 Visuomotor Ankle Robot Training Improves Hemiparetic Gait After Stroke: A Preliminary Report
L. W. Forrester1,2, A. Roy3,4, H. I. Krebs3,5,6, and R. F. Macko3,4
1University of Maryland School of Medicine, Departments of Physical Therapy & Rehabilitation Science and Neurology, Baltimore, MD, United States, 2VA Maryland Exercise & Robotics Center of Excellence, Baltimore, MD, United States, 3University of Maryland School of Medicine, Department of Neurology, Baltimore, MD, United States, 4VA Maryland Exercise & Robotics Center of Excellence, MD, United States, 5Massachusetts Institute of Technology, MA, United States, 6Weill Medical College of Cornell University, Department of Neurology and Neuroscience, NY, United States
Background/Objectives: Stroke is a leading cause of disability with hemiparetic gait limiting daily activities. Task-oriented therapies such as treadmill exercise can improve gait velocity, but abnormal gait patterning persists, suggesting a need for other strategies to improve gait biomechanics. We report effects of a 6-week visuomotor-based impedance controlled ankle robotics intervention on paretic ankle motor control and gait function in chronic stroke.
Design: Single-arm pilot study; sample of convenience, repeated measures ANOVA, paired t-tests, Wilcoxon sign-rank test as required.
Participants and Setting: Stroke survivors (n=8) with chronic hemiparetic gait in a Human Motor Performance Laboratory.
Materials/Methods: Assessments included paretic ankle ranges of motion, strength, motor control, and overground gait function. Subjects played dorsi-and plantar-flexion video games with the robot during 3 x1 hour training sessions weekly, amassing 560 targeted repetitions per session.
Results: Improved paretic ankle motor control was seen as increased target success (20.5 to 34.3; p<0.003), faster movements (mean: 4.8 to 9.9 deg/sec, p = .008; and peak: 41.4 to 48.2 deg/sec, p = .032) and smoother movements (jerk: 302.7± 18.8 to 209.4 ± 20.5 s-3, p = .009). Walking velocity increased (.51 to .62 cm/s, p=.03), while durations of paretic single support increased (p<.03) and double support decreased (p=.01).
Conclusions/Significance: Ankle robotics training improved paretic ankle motor control that transferred to improved floor walking. Improvement in walking speeds were comparable to those reported from other task-oriented approaches, suggesting a focus on ankle motor control may provide a valuable adjunct to other gait therapies.
P117 The Effect of Straight Reaching and Circle Line Exercise of Upper Limb Rehabilitation Program Using Haptic-Robotic Device in Hemiplegic Patients: Pilot Study
S. Kang1, K. Seo1, D. Kim1, Y. Kim2, S. Lee2, M. Song2, and H. Lee3
1Chung-Ang University, College of Medicine, Department of Physical Medicine & Rehabilitation, Seoul, Republic of Korea, 2Chung-Ang University, Department of Mechanical Engineering, Seoul, Republic of Korea, 3Department of Human Environment Design, Faculty of Human Life Design, Toyo University, Tokyo, Japan
Objective: To develop and evaluate the effect of an upper limb rehabilitation program using Haptic-robotic device in hemiplegic patients.
Methods: The subjects were 12 patients after stroke with weakness on their hemiplegic arm. Inclusion criteria was Brunnstrom stage >3. The patients were assigned to the upper limb rehabilitation program using Haptic-robotic device designed to repeat straight reaching and circle line exercise, for three sessions per week, 20 minutes per session for 3 weeks. Changes of speed and error during the tasks were recorded. We measured Fugl-Meyer score at beginning and end of the training.
Results: The mean velocity of straight reaching exercise was not increased significantly (p>0.05), but the error of the task was decreased significantly (p<0.05) in both straight reaching and circle line exercise. In assist-mode which the robotic device assist the motion with 2.5N forward and backward, the errors were significantly decreased (p<0.05), but the velocity was not increased significantly (p>0.05) in both exercise. Fugl-Meyer score was significantly increased at the end of the training (28.17±18.36 to 48.83±7.91, p<0.05). Additional result is that the patients were satisfied with additional exercise program with this device, because of limited availability of conventional occupational therapy.
Conclusion: Upper limb rehabilitation therapy with Haptic-robotic device could be one of therapeutic options in hemiplegic patients. Further study about the specific mode of the tasks with this device to improve the activities of daily living is necessary.
P118 Changes in Function and Spasticity Using Robot-Assisted Therapy in Pediatric Patients
B. Ladenheim1,2, J. Mast1,2,3, L. Monterroso1, S. Birnhak1, H. I. Krebs4,5,6
1Blythedale Children’s Hospital, Valhalla, NY, United States, 2New York Medical College, Valhalla, NY, United States, 3Weill Medical College of Cornell University, New York, NY, United States, 4Massachusetts Institute of Technology, Cambridge, MA, United States, 5Burke Medical Research Institute, White Plains, NY, United States, 6University of Maryland School of Medicine, Baltimore, MD, United States
Background: Robot-assisted therapy has been shown to produce long-lasting and replicable increased mobility and decreased spasticity in adults following stroke. Given the plasticity of their nervous system, children should show gains equal or greater than in adults. Here are the results of a randomized controlled study comparing passive versus active participation in robot-assisted therapy.
Methods: 15 children, age 4 to 18, with upper extremity spasticity as a result of acquired brain injury, were randomly assigned to therapy groups. Criteria included injury having occurred at least 6 months prior and the cognitive ability to play a video game. Subjects had 16 (twice weekly) therapy sessions using the MIT-MANUS robot. Active participants used a joy-stick to move a cursor to targets; the robot assisting as needed. Passive participants watched an unrelated video while the robot moved their hand. Mobility and function were evaluated for each subject before and after therapy. Primary measures were the Pediatric Evaluation of Disability Inventory, the upper extremity Fugl-Meyer Motor Assessment (F-M) and the Modified Ashworth Spasticity Scale.
Results: Gains were seen for both groups in almost all measures; active participants generally showing greater gains. This difference was particularly robust for the F-M (12% vs. 2%), and Ashworth (-31% vs. -10%).
Conclusions: Active participation appears to be an important factor in robot-assisted therapy in children. This can have wide-reaching implications for pediatric rehabilitation. Reduction in impairment at an early age may influence development and decrease the lifetime morbidity associated with spasticity such as surgeries and equipment needs.
P119 ARMOR: New Therapeutic Approach to Neuromuscular Upper Extremity Improvement Following Stroke
S. Mayer, A. Mayr, E. Quirbach, M. Kofler, and L. Saltuari
Hospital Hochzirl, Zirl, Austria
Considering the complex symptoms of the upper motor neuron syndrome, robot-assisted training may provide valuable enhancement of therapeutic strategies to improve control of the paretic arm and hand.
The aim of this study is to investigate whether the use of a novel robotic device can reduce motor impairment and enhance functional recovery the hemiparetic upper limb more efficiently than conventional physical therapy. Further points of interest were optimum timing of therapy and duration of the therapeutic effect.
Forty hemiparetic patients with a first unilateral ischemic stroke were randomized into two groups to receive either passive robot-assisted therapy or conventional physical therapy for at least 30 minutes per day. Outcome measures included a three-dimensional movement analysis, resistance measurements conducted at three different speeds, and strength development against a preset resistance, obtained at baseline, each week during the 4 week intervention period, and 6 months later.
Preliminary results of ARMOR training showed a significant reduction of pathological muscle tone and non-significant improvement in dexterity as compared to the group receiving physical therapy. Muscle tone was insignificantly reduced in the ARMOR group as compared to conventional therapy group.
Automatized training led to greater improvement in the earlier rather than later phases following stroke, and positively influenced time course recovery.
Extensive clinical testing with ARMOR has shown that robotic training can improve clinical outcomes if used as a support to conventional treatment of acute and subacute patients.
P120 The Effect of Lokomat Gait Retraining in Stroke Patients: A Prospective Randomized Controlled Trial
A. Mayr, E. Quirbach, M. Kofler, and L. Saltuari
Hospital Hochzirl, Zirl, Austria
Lokomat training has become an acknowledged strategy in gait rehabilitation. To further investigate its efficacy for stroke patients, the authors present a prospective randomized controlled trial for gait retraining.
Seventy-four stroke patients were randomized into two groups (A = add-on Lokomat training, B = add-on conventional physical therapy) for 8 weeks of treatment. Inclusion criteria were a first ischemic lesion of the medial cerebral artery no longer than five weeks ago, cardiovascular stability, and the ability to walk with assistance of no more than one therapist. Outcome measures were the modified Emory Functional Ambulatory Profile, Hochzirl Walking Aids Profile, Rivermead Motor Index, Mobility Milestones, and gait analysis.
Both groups demonstrated significant improvement during treatment (group A: P= .000; group B: P= .003). Group A showed highly significant improvement of walking speed in the early training phase (p= .000), whereas group B revealed significant improvement in the early and later phases of gait rehabilitation (P= 0.002; P= .001). Although no significant between-group differences were found, the Lokomat group showed more functional gait improvement than the control group. Gait analysis revealed better pelvic tilt, hip flexion and dorsal extension of the foot during gait in group A as compared to group B.
The present data suggest that the Lokomat enhances the efficiency of functional gait training, especially in the early phase, thus possibly shortening the duration of hospitalization.
P121 An Electromechanical Device for Distal Upper Limb Training: Preliminary Results
A. Mayr1, A. Kollreider2, D. Ram2, and L. Saltuari1
1Hospital Hochzirl, Zirl, Austria, 2Tyromotion, Graz, Austria
Functional improvement in the paretic hand after stroke continues to be a challenge in neurorehabilitation. The development of a new electromechanical device for the distal upper limb, the Amadeo, may help to improve hand function in neurological patients.
Thirty-two stroke patients (23 with ischemia, 9 with hemorrhage) were randomized into one of three treatment groups (A = add-on active Amadeo training, B = add-on passive Amadeo training, C = Jacobson progressive muscle relaxation technique). The feasibility and potential efficacy of the new device, which imitates the hand’s grasping movement, was evaluated over ten weeks (two weeks baseline, four weeks intervention, follow-up at week ten). Resistance measurements were conducted with four different speeds (v=2 mm/s, 20 mm/s, 40 mm/s, 200 mm/s), strength was tested in flexion and extension against a preset resistance of the system (R=40N/finger), and range of motion (ROM) was measured passively. The Action Research Arm Test (ARAT) served as a functional outcome measurement.
Resistance measurements were found to be greater at lower than at higher speeds. Muscle strength did not improve in any group. ROM remained unchanged in each finger. ARAT revealed little improvement in hand function in all three groups.
The Amadeo is a novel electromechanical device, which allows for objectification of kinematic parameters of active and passive movements of individual fingers, repetitive training, and assessment of the therapeutic intervention.
P122 Optimizing Parameters for Testing Muscle Tone With the Lokomat Robotic Assistive Device
A. Mayr1, R. Kiechl2, L. Lünenburger2, and L. Saltuari1
1Hospital Hochzirl, Zirl, Austria, 2Hocoma, Volketsvil, Switzerland
Objectivity in the measurement of muscle tone is difficult to achieve. The development of robotic devices in neurorehabilitation offers new possibilities.
Resistance in the hip and knee joints to passive movement in the Lokomat, with varying angular velocities, was measured by the system in 30 healthy subjects of different age groups (young: 22-34 years, middle-aged: 35-47, older: 51-62). The subjects underwent 6 measurements with different predefined velocities (hip: 160, 90, 30°/s; knee: 240, 120, 30°/s) in predefined ranges of motion (hip: -4 to 42; knee: 0° to 80°) for the hip and knee joints, and with different lengths of the time intervals between tests (180, 90, 45, 15, 5, 0 s).
Between-test analysis revealed clear differences in resistance at higher velocities (hip: v=160°/s, 90°/s and hip: v=240°/s, 120°/s) in contrast to lower velocities (30°/s in both joints), and between longer (180, 90, 45 s) and shorter (15, 5, 0 s) intervals. EMG data and resistance were highly correlated. The older age group showed more reflex activity and more resistance than younger subjects. Regression analysis revealed lesser resistance in women than in men. The differences in resistance between young and older groups could be explained by a decrease in motor control and/or an increase in muscle or joint stiffness with age.
The Lokomat system can supply objective data for measuring resistance to passive stretch and may be a relevant tool for measuring muscle tone in patients with differing pathological conditions, as well as for monitoring therapeutic interventions.
P123 Force Feedback Training in a Robotic Device for the Hemiparetic Arm: Preliminary Results
B. I. Molier1, G. B. Prange1, A. H. A. Stienen2, H. van der Kooij3, M. J. A. Jannink1,3, and H. J. Hermens1,3
1Roessingh Research and Development, Enschede, Netherlands, 2Northwestern University, Chicago, IL, United States, 3University of Twente, Enschede, Netherlands
Introduction: To stimulate restoration of arm function after stroke, rehabilitation therapy is important to induce motor relearning. An emphasis on movement error in rehabilitation therapy may be helpful by stimulating patients to generate more appropriate movement patterns. Such emphasis may be applied through force-feedback about undesired movements during reach training by means of a robotic device. The objective of this study is to determine whether arm function of stroke survivors improves after robotic force-feedback training.
Methods: Five stroke survivors participated in the force feedback training, 3 times per week for 30 minutes for 6 weeks. During the training sessions subjects performed active reaching movements, which were performed over a pre-defined path. When deviating from the path force feedback was applied to the shoulder and elbow joints by a robotic device. During baseline and evaluation sessions Fugl-Meyer(FM), Motricity Index(MI) and Action Research Arm Test(ARAT) were measured.
Results: At baseline the FM-score varied between 21-51 points, the MI between 58-77 points, and the ARAT between 5.5-49 points. Four subjects showed an increase in FM-score of 1-9.5 points. Two subjects showed an increase in MI-score of 8 and 13 points. Four subjects increased on the ARAT-scale with 1-5 points.
Conclusion: Force-feedback training for stroke survivors seems to improve arm function after 6 weeks of training. Despite the small subject group, the results based on the clinical scales are promising. Further analysis into the kinematics is ongoing. These findings imply that sensory feedback may be a suitable way to stimulate motor relearning after stroke.
P124 Modelling a Virtual Reality Environment for Gait Training on a Robotic Gait Trainer
F. Müller1, M. Sapa1, C. Krewer1, A. König2, R. Riener2, L. Luenenburger3, L. Zimmerli4, and M. Bolliger5
1Neurolog. Klinik, Bad Aibling, Germany, 2ETH, Zürich, Switzerland, 3HOCOMA, Voketswil, Switzerland, 4HOCOMA, Volketswil, Switzerland, 5Uniklinikum Balgrist, Zürich, Switzerland
Gait training in hemiplegic stroke patients is going through significant changes. After a transition from focus on muscle tone to repetitive exercises of gait cycles on the treadmill recently robotic gait training has evolved. We report on the combination of robotic gait training with the use of virtual reality for enhancing motivation and involvement of patients in a gait trainer.
Virtual reality is the use of computer modeling and simulation that enables a person to interact with an artificial environment. Its application in neurorehabilitation immerses the patient in a computer-generated environment to produce a more realistic and demanding exercise situation.
The EU funded project MIMICS uses real-time acquisition of behavioral and physiological data to adaptively and dynamically change the display of a virtual reality system, while the patient is exercising gait on the Lokomat training system. Several models of augmented feedback have been tested. Model 1 included the difference in torque of each leg during the gait to control the straight path of a walking person on a virtual trail. While this was useable for patients with various symmetrical muscular disabilities, e.g. spinal cord lesions or polyradiculitis, patients with hemiplegia were unable to maintain (the adjustable) balance between both sides to control the avatar. Therefore model 2 was designed that uses only one-dimensional maneuvering by the patient to accelerate or decelerate the avatar by the patient’s effort as measured by the torque sensors. Preliminary results are presented that show the increase in patient’s motivation and endurance.
P125 A Methodology to Quantify Alterations in Human Upper Limb Movement During Co-Manipulation With an Exoskeleton
J. V. G. Robertson1,2, N. Jarrassé3, M. Tagliabue4, A. Maiza5, V. Crocher3, G. Morel3, and A. Roby-Brami1,2
1Laboratory of Neurophysics and Physiology—CNRS UMR 8119—Université Paris Descartes, Paris, France, 2Department of Physical Medicine and Rehabilitation, Hôpital R. Poincaré, Garches, France, 3Institute of Intelligent Systems and Robotics—CNRS UMR 7222—Université Pierre et Marie Curie, Paris, France, 4Laboratory of Neurobiology and Sensory-motor Networks—CNRS UMR 7060 – Université Paris Descartes, Paris, France, 5Laboratoire de Neurophysique et Physiologie-CNRS UMR 8119-Université Paris Descartes, Paris, France
Recently, rehabilitation exoskeletons have begun to emerge. Their principal advantage is the possibility to control the segments of the upper limb and thus directly influence movement synergies, known to be perturbed following stroke. Improving inter-joint coordination may improve functional ability. However, the complex interactions between an upper limb exoskeleton and its wearer reveal new problems, including the capacity of robot not to alter the patient’s movement.
Currently, no common performance indicators or general methodology exist for the assessment of robot-human interactions making systems very difficult to evaluate. We propose a general methodology for the evaluation of the ability of an exoskeleton to interact finely and in a controlled way with a human through a set of simple indicators. These include the measurement of interaction forces at the point of contact between the exoskeleton and the subject, several kinematic parameters relating to end point motion, as well as joint rotations during the movement. We tested our methodology in a pilot study with 4 healthy subjects.
Our results demonstrate that human-robot interactions are indeed complex and cannot be resumed by the measurement of only one type of parameter. The analysis of forces exchanged and different levels of kinematics (endpoint and joint level) is necessary for a complete understanding of the nature of the interactions. In this way, potential unnatural perturbations to movement which could influence motor learning processes can be minimized.
P126 Modern Approach to the Gait Restoration in Patients With Acute Stroke
N. A. Rumiantseva, E. A. Kovrazhkina, A. N. Starizin, A. U. Suvorov, G. E. Ivanova, and V. I. Skvortsova
Russian State Medical University, Moscow, Russian Federation
Purpose. Working out complex program of gait restoration using robotic devices. Methods. Were investigated 53 non-ambulatory patients (mean age 59±10,4 years) with acute stroke (main group). Mean time from the stroke onset till beginning of physiotherapy with robotic devices was 14±1,6 days and depended on adequacy of functional tests. The program of rehabilitation lasts 2 weeks and includes: 30 minutes of traditional physiotherapy (ontogenetic caused kinesiotherapy, PNF, Feldenkrais therapy) and 20 minutes of training with robotic devices (Gait Trainer I, Motomed Viva 2) daily with continuous monitoring of blood pressure and heart rate. The control group include 25 patients, received only 30 minutes daily of traditional physiotherapy. Results. By the end of 2nd week dynamics of the standing balance test, Berg balance test, functional ambulation categories and Barthel index was better in main group in comparison with control group (p < 0,01), all the patients from main group acquired the possibility of independent walking. Also, we note significant regression (p<0.05) abnormalities of proprioceptive sensation (from 37,7 till 9,4%) and ataxia (from 37 till 11,3%) in this group, with no dynamics in control group. Conclusions: Usage of complex program of rehabilitation including ontogenetic caused kinesiotherapy and physiotherapy with robotic devices leads to significant improvement functionality and level of independence of acute stroke patients. This program is especially effective for patients with proprioceptive sensation abnormalities and ataxia.
P127 Virtual Realities as Motivational Tools for Robotic Assisted Gait Training
T. Schuler1,2, K. Brütsch1,3, R. Müller2, and A. Meyer-Heim1
1Rehabilitation Center, University Children’s Hospital, Affoltern am Albis, Switzerland, 2Institute of Human Movement Sciences, ETH Zurich, Zurich, Switzerland, 3Institute of Psychology, Division Neuropsychology, University of Zurich, Zurich, Switzerland
Background: Patient’s cooperation and motivation have been recognised as important factors for a favourable outcome in paediatric rehabilitation. Real-time running virtual realities (VR) were developed for the therapy with the paediatric robotic driven gait orthosis (DGO) Lokomat. These allow more interaction during robotic assisted gait training (RAGT) and enhance the gaming aspect of tasks. The aim of this study was to evaluate VR as motivational tools during RAGT.
Method: Nine handicapped and eight healthy children participated in the practical experiment. Muscular effort was assessed by surface electromyography (sEMG) on four muscles during a training protocol with six different randomly applied task conditions. These tasks included: normal walking in the DGO, walking with therapist’s motivational instructions, a VR soccer scenario, the soccer game with additional therapist’s instructions, a VR landscape scenario and walking on a treadmill without the DGO. The outcome measures of interest were the motor output expressed by mean muscle activity and the participant’s motivation assessed by two different questionnaires. Comparisons were drawn through repeated measurement Analysis of Variance (ANOVA) and parametric paired t- tests.
Results: The EMG activity output in both groups was significantly higher during tasks with VR than during the normal walking condition (P<0.001 for the soccer game), whereas therapist’s motivational instructions played an important role as well. An agreement between self reported motivation, effort and fun (questionnaires) and behavioural indices (muscle activity) was observable.
Conclusion: The results support that VR scenarios seem to be an efficient motivational tool to increase children’s muscular effort during RAGT.
P128 Direction-Dependent Visual Processing During Robot-Mediated Arm Reaching
X. Tang and D. L. Turner
University of East London, London, United Kingdom
Visual cortical processing during finger movement is selective for features of the visual stimulus and direction and is often accompanied by gamma band power changes suggestive of “visuomotor binding”. Here, we hypothesised that early visual processing would involve direction-dependent activation of visual cortex during arm reaching. Nine right handed subjects performed visually cued, planar reaching against a 0 N inertial force-field, induced by a robotic device (IMT, Boston, MA) to 2 different directions (away/left - 135° and towards/midline - 270° from a central start point; pathlength = 15 cm). Visual scalp event-related desynchronization/synchronization (ERD/ERS; log power change from pre-cue baseline) was recorded (O1, Oz, O2, PO1 and PO2 on 10/20 EEG template; sample rate 1kHz; >75 artefact-free, common referenced trials). Direction-dependent differences in ERD/ERS amplitude were analysed in the timeframe periods (4ms duration) before reaching onset (405 ms; all sig. diffs. p < 0.05). Significantly greater ERS occurred in response to reaching to 135° than 270° in O1, Oz, O2 and PO2 electrodes but not PO1. The greatest direction-dependent significant difference in ERS peaked at 342ms (O1; +0.7±0.4 vs. 0.0±0.2 loguV2), 382ms (Oz; +0.9±0.4 vs. -0.10.2), 317ms (O2; +0.9±0.4 vs. -0.7±0.2) and 281ms (PO2; +0.3±0.2 vs. -0.3±0.1). The results suggest that a direction-dependent “signature” in visual cortex occurs before reaching away/towards the body and may be involved in unilateral visual neglect after stroke. Furthermore, this direction “signature” could be incorporated into design of a visuo-prosthesis for those with visual impairments.
P129 Gait Robots for the Repetitive Practice of Floor Walking and Stair Climbing and Descending in Non-Ambulatory Patients
C. Werner1, A. Waldner2, C. Tomelleri2, A. Kollreider3, D. Ram3, and S. Hesse1
1Charité University Medicine Berlin, Medical Park Berlin, Berlin, Germany, 2Villa Melitta, Bozen, Italy, Bozen, Italy, 3Tyromotion Graz, Graz, Austria
Background: Stair climbing up and down is an essential part of everyday mobility. To enable wheelchair-dependent patients the repetitive practice of this task, a novel gait robot, G-EO (EO, Lat: I walk), based on the end-effector principle has been designed. The trajectories of the foot plates are freely programmable and the movement of the centre of mass is controlled. The article presents the design, compares the lower limb muscle activation pattern of hemiparetic subjects during the real and simulated walking condition, and reports a single case.
Methods: The muscle activation pattern of eight lower limb muscles of six hemiparetic patients during free and simulated walking on the floor and stair climbing was measured via dynamic electromyography. Eleven non-ambulatory, sub-acute stroke patient additionally trained on the machine every workday for five weeks.
Results: During floor walking, the onset (duration) of the thigh muscle activation was delayed (prolonged) on the machine across all subjects. During stair climbing, the shank muscle activation was more phasic and timely correct in selected patients on the device. The severely affected subjects regained walking and stair climbing ability.
Conclusions: The G-EO is an interesting new option in gait rehabilitation after stroke. The lower limb muscle activation patterns are comparable, and the positive case report warrants further clinical studies.
4.5 Assistive Technology
P130 A Pilot Randomised Controlled Trial of Virtual Reality Mediated Therapy Compared to Physiotherapy in the Rehabilitation of the Upper Limb After Hemiplegic Stroke
J. H. Crosbie1, S. Lennon1, S. McDonough1, and M. Michael2
1University of Ulster, Newtownabbey, United Kingdom, 2University of Ulster, Coleraine, United Kingdom
Objective: To assess the feasibility of a randomised controlled trial investigating effectiveness of virtual reality (VR) mediated therapy compared to conventional physiotherapy in the motor rehabilitation of the upper limb following stroke.
Study design: Assessor blinded RCT.
Participants: People with stroke recruited from two hospital stroke units and members of local stroke clubs.
Outcomes: Upper Limb Motricity Index, Action Research Arm Test were completed at baseline, post-intervention and 6 weeks follow-up.
Results: 77 potential participants contacted and screened for inclusion, 18 being randomised into one of two study groups. Outcome data were obtained from 95% of randomised participants at the end of treatment and at follow-up. One participant withdrew consent. Compliance in both groups was high and only two people reported side effects of transient dizziness and headache from VR exposure. Both groups reported some small changes to their upper limb impairment and activity levels, as assessed by the Upper Limb Motricity Index (MI) and the Action Research Arm Test (ARAT). The VR group improved by a median of 7 points on MI and 3 points on ARAT. The conventional group improved by a median of 8 points on MI and 3 points on ARAT. VR intervention was acceptable to participants.
Conclusion: This study demonstrated the feasibility of a randomised controlled trial of virtual reality mediated therapy for the upper limb compared to conventional therapy. Small differences in MI and ARAT scores may be explained by lack of sensitivity of the chosen outcome measures in this relatively small group.
P131 An Exploration of Stakeholders’ Perceptions of the Barriers to Clinical Use of Assistive Technologies in Services for Upper-Limb Stroke Rehabilitation
A. Hughes1, J. H. Burridge1, S. H. Demain1, C. Ellis-Hill1, D. F. Jenkinson2, A. D. Pandyan3, I. D. Swain4,5, and L. Yardley6
1University of Southampton, Southampton, United Kingdom, 2Stroke Unit, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, United Kingdom, 3Keele University, Keele, United Kingdom, 4Salisbury NHS Foundation Trust, Salisbury, United Kingdom, 5Department of Design Engineering & Computing, Bournemouth University, Bournemouth, United Kingdom, 6School of Psychology, University of Southampton, Southampton, United Kingdom
Introduction: Half of all patients commencing stroke rehabilitation have marked impairment of the hemiplegic arm, with only 14% regaining useful function. Assistive technologies (ATs) have been developed and evaluated yet currently reach only a fraction of patients. The NIHR funded a five year research programme to generate understanding necessary to develop cost-effective stroke services in upper-limb rehabilitation. This stage aims to understand the potential advantages and disadvantages to the clinical use of ATs, and the needs and priorities of stakeholders.
Method: Participants include people with a stroke (n=40), their carers (n=20), health care professionals (n= 40), budget holders (n=15) and service commissioners (n=15). An interactive exhibition was held at the University of Southampton in October 2009 where stakeholders tested a range of ATs. Focus groups with each stakeholder group will be conducted within three months of the exhibition to discuss personal involvement in AT use, and positive and negative views on the AT presented.
Results: Results will be categorised in terms of barriers and facilitators to the use of upper-limb technologies addressing issues such as user comfort and acceptability, cost-benefit, evidence of effect and funding provision.
Conclusion: Getting research implemented in practice is challenging. This novel approach explores the barriers to using new technologies from the perspective of all key stakeholders. These findings will be combined with those of a national survey, and systematic review to inform a clinical trial resulting in a recommended care pathway for upper-limb rehabilitation.
P132 How Many People Are Able to Control a P300-Based Brain-Computer Interface (BCI)?
G. Krausz1, C. Guger1, and E. Sellers2
1g.tec medical engineering GmbH, Graz, Austria, 2East Tennessee State University, Johnson City, TN, United States
An EEG based brain-computer interface (BCI) can be used to control systems such as computers, wheelchairs or virtual environments. One of the most important applications is a spelling device to aid severely disabled individuals with communication.
In this study, 100 subjects tested a P300 based BCI system to spell a 5-character word with only 5 minutes of training. 8 EEG signals were acquired while the subject looked at a 36 character matrix (6x6) to spell the word WATER. Two different spelling methods were used: the RC (row-column) and the SC (single character) spelling mode. The BCI system classifier was trained on the data collected for the word WATER. During the real-time phase of the experiment, the subject spelled the word LUCAS.
The results showed that 72.8% (N=81) were able to spell with 100% accuracy in the RC paradigm and 55.3% (N=38) spelled with 100% accuracy in the SC paradigm. Less than 3% of the subjects did not spell any character correctly.
This study shows that high spelling accuracy can be achieved with the P300 BCI system using approximately five minutes of training data for a large number of non-disabled subjects, and that the RC paradigm is superior to the SC paradigm. Eighty-nine percent of the 63 RC subjects were able to spell with accuracy of 80% - 100%. A similar study using a motor imagery BCI with 99 subjects showed that only 19% of the subjects were able to achieve accuracy of 80% - 100%.
P133 Paediatric Interactive Therapy System (PITS): Effects on Finger and Hand Dexterity and Attention: A Single Case Study
K. Wick1, K. Eng2, L. Holper2, E. Chevrier2, P. Pyk2, D. Kiper2, L. Jaencke3, and A. Meyer-Heim1
1Rehabilitation Centre, Affoltern am Albis, University Children’s Hospital Zurich, Switzerland, 2Institute of Neuroinformatics, University of Zurich and ETH Zurich, Switzerland, 3Institute of Neuropsychology, University of Zurich, Switzerland
Background: Conventional rehabilitation therapy programmes like physiotherapy and occupational therapy may be upgraded by including virtual-reality-based interactive therapy systems. A wide range of studies in adults are available but little is known about the training effects of virtual-reality-based therapy strategies in children suffering cerebral palsy.
A single subject design was used to investigate the training effects of the virtual-reality-based Paediatric Interactive Therapy System (PITS) on hand dexterity and different aspects of attention.
Method: Prior to and after the three-week PITS intervention (four 45-minutes sessions per week), assessments were administered. The PITS-training was integrated in the conventional rehabilitation therapy programmes of a 17 year old adolescent with tetraspastic right accentuated cerebral palsy. Three different entertaining and motivating interactive game scenarios were used to practice various hand movements in a repetitive way.
Results: test scores for finger- and hand dexterity (Nine Hole Peg Test and Box and Block Test) showed improvements of the affected limb. Moreover, progress was achieved in some aspects of attention (reduced error counts both in selective and divided attention and reduced number of omissions in selective attention). No improvements were made in grip and pinch strength and in reaction rates of alertness and selective attention.
Conclusion: These findings are promising, although there is certainly a need for further research in this developing field. PITS may be an effective additive therapy strategy to conventional rehabilitation therapy programmes.
5 Treatment: Clinical Practice
5.1 Neuropharmacology
P134 The Treatment of Patients With Neuromuscular Contractures of Knee With Botulinum Toxin A (Botox)
Bakran1, S. Butkovic’-Soldo2, I. Banicˇek1, I. Dubroja1, and M. Bakran3
1Special Hospital for Medical Rehabilitation Krapinske Toplice, Krapinske Toplice, Croatia, 2Teaching Hospital, Osijek, Croatia, 3General Hospital Zabok, Zabok, Croatia
Aim: To explore efficiency of physiotherapy and Botox in rehabilitation of patients with spastic knee contracture who were not clinically better after physiotherapy.
Methods: Patients with traumatic brain injury (TBI) and spastic muscular contracture in the knees were included in this investigation. Physiotherapy, baclofen, paracetamol and tramal did not give evident progression in the range of movement (ROM) and reduction of spasticity during three months of rehabilitation. Botox was then injected into the gastrocnemius, biceps femoris, semitendinosus and semimembranosus muscles. The patients received 100 to 200 m.u. of Botox. ROM and spasticity were measured in the beginning of rehabilitation, three months later, and three months after Botox was injected.
Results: 26 patients were included in this study, and were 32.2 years old on average. A total of 30 knees were treated. The most common cause of TBI was traffic accidents (80%). There were statistically significant differences in passive and active ROM in the knees between the first and third measurement, and between the second and third measurement. There were statistically significant differences in spasticity in muscles treated with Botox between the first and third measurement and between the second and third measurement. The data had normal distribution. For testing statistical differences, analysis of variance and Duncan test were used. Statistical testing was carried out at the 95% level of significance (p<0.05).
Conclusion: The research pointed out that physiotherapy together with Botox successfully reduces spasticity and improves range of movement, even obstinate contracture by patients with TBI.
P135 Flexed-Abducted-Externally Rotated Hip Associated to Gluteus Medius Spasticity: A Case Report
L. Berna1 and F. Cubillos2
1Pedro Aguirre Cerda National Rehabilitation Institute, Santiago, Chile, 2University of Chile Clinical Hospital, Santiago, Chile
Objectives: To show an alternative treatment of a refractory flexed-abducted-externally rotated hip in a severe spastic Cerebral Palsy patient.
Case: We report a 13-year-old girl with a severe tetraplegic Cerebral Palsy. She had difficulty with adequate hip positioning due to her spasticity, bilateral coxa valga and a bilateral hip subluxation. She received oral and focal spasticity treatment, and surgical procedures (on adductor muscles, iliopsoas, tensor fasciae latae and femoral neck osteotomy) to get better hip positioning, wheelchair transfers and QoL. However, she developed a flexed, abducted and externally rotated hip position, worsening her transfers and orthosis use.
Materials-Methods: After considering it was a spastic gluteus medius involved, she received Lidocaine infiltration test at this level, showing a satisfactory hip alignment through a neutral position. Therefore, a Botulin toxin A (Botox ©) infiltration, 2 U/kg dosage, one-site injection, following anatomical guidance, was done.
Results: The patient showed a good response, getting a functional passive range of motion, allowing better alignment without any difficulty or pain. No adverse effects were reported.
Discussion: This assessment gives an alternative handling on this kind of refractory condition, which can be applied early to avoid hip subluxation when an unbalanced force occurs after adductors tenotomy.
Conclusions: We should consider gluteus medius activity on flexed-abducted-externally rotated hip. Its blockage becomes a reliable, simple and effective procedure to perform a differential diagnosis between involved muscles, especially before programming a definitive surgical technique.
P136 Intrathecal Baclofen for Spasticity in Cerebral Palsy of Children and Young Adults
B. Bussel1, O. Remy-Neris2, and D. Selmane1
1Hopital R Poincare, Garches, France, 2Hopital Brest, Brest, France
This study promoted by the French Ministry of Health was carried out by 16 French teams from 2005 to 2009. This study involved 109 patients (7 to 30 years old), 91 of whom were followed for one year and 78 for three years. The role of preliminary tests is questionable since in over 96% of cases, if there was an initial intention to treat, the pump was implanted. We found a large and constant reduction in spasticity of the lower limbs, and to a lesser degree, of the upper limbs which persisted, unchanged, at 2 years. The daily dose of baclofen, mostly injected continuously), increased a little over time (120µg at the start and 200µg at 2 years). The main goals (facilitate passive mobilization, sitting position and avoid orthopedic complications) were achieved in 90% of cases. Improvements in gait were the goal for 15 patients and were achieved in all 15. We found a very interesting effect on the excessive response to startle which has never been studied before. The number of serious undesirable events i.e. those requiring further surgical intervention was quite high: 22 events in 20 patients. Pain, measured by VAPS, present in 1/2 patients was significantly reduced at 3 months and remained so at 2 years. The effect on functional independence (tested with the FIM) and quality of life, as measured by the SF 36, did not change significantly. However, the large majority of patients and their families expressed great satisfaction with the treatment.
P137 Safety of NT 201 (Xeomin(R); Botulinum Neurotoxin Type A Free From Complexing Proteins) for the Treatment of Upper Limb Spasticity: A Pooled Data Analysis
J. Ferreira1, P. Kanovsky2, S. Grafe3, I. Pulte3, A. Hanschmann3, and P. Minnasch3
1Institute of Molecular Medicine, Lisbon, Portugal, 2Palacky University Medical School, Olomouc, Czech Republic, 3Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany
Objectives: To assess the safety of NT 201 (Xeomin®; Botulinum neurotoxin type A, free from complexing proteins) in the treatment of patients with upper limb spasticity, using a pooled data analysis.
Methods: Data were pooled from two randomised clinical studies. In one study, patients with upper limb post-stroke spasticity (n=148) received one set of injections with either NT 201 or placebo (double-blind). In the other study, patients with upper limb spasticity of various aetiologies (n=192) received one set of injections with NT 201 at either 50 U/ml or 20 U/ml dilution (observer-blind). Post-injection, patients in both studies were followed for up to 20 weeks. Upper limb muscles were treated as clinically indicated; maximum intended dose, 400 U. Safety was assessed by the incidence rates of adverse events (AEs).
Results: The pooled safety population consisted of 340 patients (NT 201, n=265; placebo, n=75). The median dose of NT 201 was 300 U (maximum 495 U). AEs were reported by 35.5% (94/265) of patients receiving NT 201, and 26.7% (20/75) of patients receiving placebo. In the NT 201 group, 7.6% (20/265) of patients had AEs judged to be related to the study medication, most commonly injection site haematoma (1.5%, 4 patients) and muscular weakness (1.1%, 3 patients). No serious AEs, or AEs leading to study drop-out, were judged as medication-related.
Conclusions: Pooled data from two clinical studies demonstrate the good safety and tolerability of NT 201, at doses up to 495 U, in the treatment of upper limb spasticity.
P138 Use of Chemical Neurolysis With Phenol in Reducing Serious Spasticity and Work Load for Individuals in Vegetative State: A Randomized Clinical Trial
A. Giattini, A. Bonamartini, K. Cerquetti, E. Calderisi, and M. Vallasciani
Istituto S. Stefano, Porto Potenza Picena, Italy
Individuals in vegetative state are often affected by a serious and diffuse spasticity which is an important obstacle in caring, in particular in nursing operations. Phenol is one of the most used substances in treating local spasticity, also if its use is limited to the principal nerves of the limbs. The aim of this study is to verify if the treatment of spasticity with phenol is useful in increasing Range of Motion (ROM) of respective joints, improving position in a wheelchair and reducing work load and time in nursing operation. We enrolled 11 patients in vegetative state caused by acquired cerebral damages who had been admitted in two centers. They were affected by a serious spasticity of upper and lower limbs and treated, by physiotherapists using passive mobilization, from the beginning of their disease, at least once a day. Patients of group A (6) were treated with injections of 5 ml of aqueous phenol solution at 6%, in tributary nerves of muscles of the limbs interested of the spasticity. Before the injection, patients were evaluated in their ROM of more limited joints and in calculating nursing time (washing, wound dressing and getting dressed). In group B, patients (5) were enrolled, evaluated and treated with phenol 6 months later. Then we reversed the treatment (cross-over) for 6 months. Immediately after the injections almost all the patients had a significant increasing of ROM not observed in non-treatment period. The statistic correlation of other parameters gave a significant reduction in nursing time.
P139 Repeated NT 201 (Xeomin(R); Botulinum Neurotoxin Type A Free From Complexing Proteins) Treatments for Up to 89 Weeks in Upper Limb Post-Stroke Spasticity
P. Kanovsky1, I. Pulte2, G. Comes2, S. Grafe2, for the NT 201 group
1Palacky University Medical School, Olomouc, Czech Republic, 2Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany
Objectives: To assess the long-term use of NT 201 (Xeomin®; Botulinum neurotoxin type A, free from complexing proteins) for the treatment of patients with upper limb post-stroke spasticity.
Methods: Patients with upper limb post-stroke spasticity were randomised to receive one set of injections with either NT 201 or placebo (double-blind), with a 12-20-week follow-up. Subsequently, patients entered a 48-69-week open-label phase, receiving up to five additional sets of NT 201 injections. Upper limb muscles were treated as clinically indicated with an intended maximum dose, 400 U.
Results: 148 randomised patients. Mean duration of exposure to NT 201 was ~15 months (63.6 ± 17.6 weeks); median dose, 374 U; and mean cumulative dose 1.333 ± 494 U. The majority of patients (100/147; 68.0%) received ≥4 injections. Ashworth Scale scores were improved for thumb, finger, wrist and elbow flexors and forearm pronators (p<0.0001). After the first injection 45.2% of the NT 201 patients had an improvement of 1 on the disability assessment scale (21.3% for placebo; p≤0.0002). The same improvement was experienced by 52.9% of patients after the 5th injection (p<0.05). Ninety patients (61%) reported ≥1 AE, all of mild to moderate intensity, within up to 89 weeks. 18 patients (12.2%) reported an AE considered related by the investigator. There were no clinically relevant laboratory test changes, and no patients developed neutralising antibodies.
Conclusions: NT 201 was efficacious and well-tolerated in the long-term treatment of upper limb post-stroke spasticity for up to 89 weeks of repeated injections.
P140 Improvement in Gait Pattern Using Botox in Longstanding Spasticity of Tumoral Cause: A Case Report
A. Moyano, L. Berna, and F. Cubillos
University of Chile Clinical Hospital, Santiago, Chile
A 47-year-old male patient with history of right parietal meningioma operated, with untreated spastic paretic right leg 2 years of evolution, which determines gait interference due to dynamic equine-varus secondary to spastic soleus and tibialis posterior muscles. His main complaint was a painful compensatory genu recurvatum, in addition to significant weakness of ankle dorsiflexors. No rehabilitation program was performed after his surgery.
Neuromuscular blockade was performed with lidocaine test in soleus and tibialis posterior which is successful in reducing genu recurvatum and foot inversion. Also a knee flexion at bearing weight during standing phase at gait cycle was observed, which was interpreted as a manifestation of weakness quadriceps soleus masked by spasticity.
With this background, focal anti-spasticity management was done with Botox ® using a total of 150 units (80U in soleus, 50U in posterior tibial and 20U in gastrocnemius).
After infiltration physiotherapy treatment was done focused on paretic-limb muscle strengthening (with emphasis on quadriceps) and inhibition of spasticity techniques, working on gait rehabilitation with technical assistance (cane and GRAFO).
After 4 months of training, quadriceps and sural triceps normal strength and tone was obtained, therefore GRAFO was changed to leaf spring AFO (LAFO). The patient achieves painless and faster gait, without having recurvatum, and with better performance (less fatigue, greater distance flown).
P141 Improved Hand Functionality Using Phenol in the Median Nerve: A Case Report of Spasticity Post TBI
A. Moyano, L. Berna, and F. Cubillos
University of Chile Clinical Hospital, Santiago, Chile
We present a 16-year-old male patient, who suffered a stabbing wound and traumatic brain injury, complicated with left parieto-temporal cephalohematoma and abscess, surgically drained. After that he developed right spastic facio-brachio-crural hemiparesis, provoking impaired gait pattern and worsening hand activation, interfering with functional independence in self-care activities (clothing, toileting, feeding) and transfers.
A neuromuscular blockade lidocaine test on the right flexor digitorum superficialis was performed, diminishing spasticity from grade 2 to grade 1 in modified Ashworth scale. This flexor tone decrease allowed a slightly better voluntary extensor of third and fourth fingers (MMT 2).
Considering that fact, a phenol 6% antispastic focal treatment on right median nerve was made, under electrical stimulation guidance. Following injection, occupational therapy was started to increase muscular strength and manual skills.
After two weeks of physical and occupational therapy, a better interphalangeal active range of motion was observed, finger and wrist extensors muscular strength (MMT 4) was increased, which has improved his performance of hand functions with fewer muscular compensations.
P142 Very Early Implant of Intrathecal Baclofen Pump in Acquired Brain Injured Patients
F. Posteraro1, F. Logi1, R. Galli1, B. Calandriello1, and L. Bordi2
1Auxilium Vitae Rehabilitation Centre, Volterra (Pisa), Italy, 2Neurosurgical Unit—AOUP Careggi, Florence, Italy
Objective: To evaluate the results of very early implant of Intrathecal baclofen (ITB) pump in patients with acquired brain injury (ABI).
Materials and Methods: A consecutive series of 8 ABI patients (6 male, 2 female. Mean Age 31.5 years) who received ITB within 4 months from acute event (Mean time 90.1 days, range 31-123) were enrolled in the study.
Global outcome measure: GOS, DRS, LCF. Specific outcome measures: MAS, Frequency Spasm Scale.
Intrathecal baclofen test was not performed and only oral therapy (until 75 mg/day) was used for evaluate drug tolerability.
Criteria to implant were: MAS > 2 in more than 3 joints, severe vegetative dysregulation.
Dosage of baclofen ranged from 160 to 480 micrograms/day.
Results: MAS and Frequency Spasm Scale decreased in all patients. GOS, LCF and DRS improved. On the basis of informal observation, decrease in pain, improving in nursing and ROM were also recorded. Dysautonomic disorders were controlled. Outcome measures for patients implanted earlier (within 2 months) were not worst than other. No adverse effects have been recorded.
Conclusion: ITB at very early stage is effective on decreasing spasticity and on preventing secondary impairment. ITB seem to be effective on neurovegetative disorders and it did not adverse functional recovery in patients with ABI. Intrathecal bolus test is not compulsory and it increases costs. It is often useless, it could be responsible for false negative (ABI patients float). Intrathecal continuous test with external device can be responsible for infections and implanting delay.
P143 Agitation and Associated Features in Traumatic Brain Injury
R. Singh, G. Venkateshwara, S. Nair, R. Munjal, and D. Datta
Department of Neurorehabilitation, Sheffield Teaching Hospitals, Sheffield, United Kingdom
Objective: Agitation after traumatic brain injury is common and often interferes with recovery, rehabilitation and community re-integration. Incidence varies from 10-96% representing the lack of agreement in diagnosis. All studies of incidence and features of agitation have been from the USA with one in Australia. There are no published studies from the United Kingdom and we sought to look at features of agitation and outcome.
Methods: consecutive TBI admissions with agitation were studied. Demographic details, clinical features, CT findings and treatment received were recorded and associations sought.
Results: from 2005-08, 53 patients were identified with CB. Mean age was 41.2 yrs (SD 15.2), 34 (64%) were male and 26 (49%) had previous psychiatric history including alcohol dependence. Average CB duration was 39.2 days (SD27.8) including those discharged with CB remaining. Based on behaviour type and frequency, 22 had severe CB, 21 moderate and 10 mild.
Only 26 had good outcome in terms of resolution of symptoms or discharge destination with relatively easy management by family or carers.
Factors associated with worse outcome were type of injury, alcohol excess, severity of initial behaviour, treatment with antipsychotics and duration of symptoms (all p<0.001)
Using a stepwise logistic regression technique, further analysis showed that pathology, behaviour severity and duration of symptoms were all independent predictors for outcome (p<0.001)
Conclusion: CB is common after TBI and can be difficult to treat. Little research has been done on outcomes in CB but our study has found a number of features that predict worse outcome and may assist management.
P144 Intrathecal Baclofen in Spinal Cord Injury: A Retrospective Study of 48 Patients on Complications, Long Term Daily Dose and Catheter Tip Level
K. Vermeersch1, M. Schreurs1, C. Godderis1, B. Nuttin2, and C. Kiekens1
1University Hospitals Leuven, Pellenberg, Belgium, 2University Hospitals Leuven, Leuven, Belgium
Study design: A retrospective study of 48 spinal cord injury (SCI) patients with a programmable intrathecal baclofen (ITB) pump.
Objectives: (1) To study the rate and nature of the complications of ITB. (2) To study the mean daily dose after long term follow-up (1, 3, 5, 8 and 10 years) and study any correlation to the catheter tip level.
Methods: Medical records of all SCI patients who received an implantable ITB pump in the University Hospitals Leuven department during 1991-2009, were reviewed.
Results: Fourty-eight SCI patients (representing 303 pump years) were included. Mean follow up was 75.8 months (6 - 222 months). Mean daily dose was 119 µg/day (48 patients) after implantation which increased towards 329 µg/day (41 patients), 437 µg/day (30 patients), 393 µg/day (24 patients), 410 µg/d (17 patients) and 464 µg/d (15 patients) respectively after 1, 3, 5, 8 and 10 years. Range of dose varied between 23 g/day and 1492 µg/day. There was no significant difference in daily dose if the catheter tip is used as an independent parameter, nor with regard to the SCI level. Thirty of the 48 patients (62.5%) experienced a total of 49 complications. Thirty-six out of 49 complications were catheter related. The complication incidence was one complication every 6.2 pump years.
Conclusion: Mean daily dose of intrathecal baclofen administration seems to stabilize between 1 and 3 years after implantation. No correlation between the catheter tip level and mean dose was found. Sixty-five % of the patients experienced a complication, mostly catheter related.
P145 Intrathecal Baclofen Withdrawal Due to Catheter Malfunction During Pregnancy: A Case Report
S. A. Yablon1, D. S. Stokic2, K. H. Goodson2, and K. K. Ramsey2
1Baylor Institute for Rehabilitation, Dallas, TX, United States, 2Methodist Rehabilitation Center, Jackson, MS, United States
Pregnancy in patients with intrathecal baclofen (ITB) pumps is rare. We found only 9 published reports describing ITB administration during pregnancy. All reported successful deliveries without life-threatening complication to the mothers or newborn children, prompting suggestions that ITB administration during pregnancy is safe. Catheter-related complications occur frequently in clinical practice with ITB infusion systems, however, and may cause severe symptoms including a potentially fatal withdrawal syndrome. We report a case of ITB withdrawal due to catheter malfunction that occurred during pregnancy. A 20-year-old female, with a 2-year history of severe traumatic brain injury, underwent implantation of an ITB infusion pump (Synchromed II, Medtronic, Minneapolis USA) for left-sided hypertonia that impaired walking. Thirteen months later, at stable dose of 170mcg/24h (simple continuous administration mode) and 18 weeks into her first pregnancy, she presented with new onset of tremulousness, hyperreflexia, worsened hypertonia, and difficulty walking. Previously unmeasurable H-reflex/M-wave (H/M) ratios now exceeded pre-implant values, indicating interrupted ITB delivery and consistent with withdrawal. After admission to the high-risk obstetrical unit, oral baclofen was administered for approximately 10 days on a weaning schedule after attenuation of withdrawal symptoms. The ITB catheter was not repaired. A healthy baby was successfully delivered 20 weeks later. This is the first reported case of ITB withdrawal occurring during pregnancy. Pregnant patients with ITB infusion systems are susceptible to catheter-related complications. If a malfunction occurs, prompt diagnosis and intervention with supportive measures is required. Adjunctive H/M ratio measurement facilitates confirmation of ITB withdrawal without fetal radiation exposure risk.
P146 Persistent Intrathecal Baclofen Withdrawal After Rostral Repositioning of a New, Functioning Subarachnoid Catheter: A Case Report
S. A. Yablon1, D. S. Stokic2, and K. H. Goodson2
1Baylor Institute Rehabilitation, Dallas, TX, United States, 2Methodist Rehabilitation Center, Jackson, MS, United States
Continuous intrathecal baclofen (ITB) administration provides long-term relief of spasticity after brain or spinal cord injury. ITB diffusion in the cerebrospinal fluid is incompletely understood. ITB primarily flows rostrally, with lumbar segments showing higher concentration gradients and accordingly greater lower limb (LL) tone reduction. Catheter tip location may influence regional ITB diffusion, however, prompting recommendations for upper thoracic or cervical catheter positioning when more upper limb (UL) tone relief is needed. Few studies confirm the utility of this practice, or whether LL tone reduction is compromised. We report a case of ITB withdrawal and complete loss of LL tone control after rostral repositioning of a new, functioning catheter. A 25-year-old male underwent ITB pump implantation 11 months after traumatic brain injury for treatment of severe hypertonia, with satisfactory trunk and LL tone relief (dose: 500mcg/24h; mode: simple continuous; catheter tip: T-12). Six years later, the patient experienced abrupt onset of pruritus, hyperreflexia, and worsened hypertonia, consistent with catheter malfunction. The surgeon replaced both pump and catheter, but moved the catheter tip rostrally (T-2) to enhance UL response. Symptoms persisted, however, and programmed boluses (50, 100mcg) yielded no clinical or neurophysiologic (H-reflex/M-wave ratio) evidence of response. Indium I-111 radioscintigraphy showed rapid tracer diffusion to the cerebral cisterns confirming “normal” rostral ITB flow. Caudal repositioning to T-12 brought prompt symptom resolution and return to previous levels of satisfactory tone control. We caution clinicians that rostral catheter repositioning may compromise thoracolumbar ITB diffusion and LL tone control, with potential ITB withdrawal risk.
5.2 Interventional (Destruction, Stimulation, Brain Computer Interface)
P147 Synergistic Effect of Mellow Music to Tendon Pressure in Decreasing Spasticity in Cerebral Palsy
L. V. Adorable1 and L. S. Vismanos2
1Sacred Heart Hospital, Cebu, Philippines, 2Southwestern University, Cebu, Philippines
The study determined the synergistic effect of mellow music to tendon pressure in decreasing spasticity in cerebral palsy. Nine spastic cerebral palsy patients were divided into two groups. The study had two phases. In first phase, the Tardieu spasticity grade and angle of muscle action of elbow flexor were measured before treatment in both groups, after treatment with tendon pressure with mellow music in group 1 and with tendon pressure only in group 2. In second phase, the same measurements were obtained with group 1 receiving tendon pressure only and group 2 with tendon pressure with mellow music. Tendon pressure was applied for three minutes. Mellow music was played for two minutes ahead of tendon pressure application and sounded off after application. The match pair test was used to find the difference between pretest and posttest measurement of a group and the two-sample test was used to find the significance of the difference between two means with p value set at 0.05. The differences in angle of muscle action before and after treatment using tendon pressure with mellow music in two groups were significant. It was not significant when tendon pressure was used alone in two groups. There was significant difference in the angle after tendon pressure only and after tendon pressure with mellow music in group 2 but not in group 1. The combination of mellow music and tendon pressure further decrease the spasticity on the elbow flexor among cerebral palsy patients than with tendon pressure only.
P148 Clinical Trial of Neuromuscular Electrical Stimulation on Shoulder Subluxation, Shoulder Pain and Arm Function After Stroke
L. V. Adorable1 and A. O. Dulap2
1Sacred Heart Hospital, Cebu, Philippines, 2Southwestern University, Cebu, Philippines
The study determined the effect of neuromuscular electrical stimulation (NMES) on shoulder subluxation, shoulder pain and arm function after stroke. Seventeen hemiplegic patients with shoulder subluxation were divided into three groups. Two groups were subjected to four weeks of NMES on supraspinatus or NMES-1 group and deltoid or NMES-2 group. The third group was used as control. Each subject in NMES-1 and NMES-2 was treated five times a week, once a day for 10 minutes in first treatment and extended by four minutes each day over the first week. It lasted 30 minutes by beginning of second week up to end of study. All groups received proprioceptive neuromuscular facilitation. Measured in each subject before and after four weeks of treatment were shoulder subluxations using anteroposterior view x-ray of the shoulder, shoulder pain using visual analogue scale (VAS) and arm function using manual muscle testing (MMT), and active and passive ranges of shoulder flexion, abduction and external rotation. The study used Wilcoxon Signed Rank test for VAS and MMT results, and paired t-test for ranges of motion and shoulder subluxation with p value set at 0.50. There was significant reduction in shoulder subluxation in NMES-1 and 2, and significant reduction in shoulder pain and improvement of arm function in NMES-2 only. There were no significant changes in the control group. Thus, neuromuscular electrical stimulation of the supraspinatus and deltoid is effective for reducing shoulder subluxation and shoulder pain, and improving arm function after stroke.
P149 Continuous Infusion of Intrathecal Baclofen for Spasticity and Pain
D. Al Khudhairi1, A. Shug’a Aldin1, Y. Hamdan2, A. Rababah2, M. Hafid2, J. Pazdirek2, and J. Abdulsalam2
1Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia, 2Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia
Spasticity is a disorder of muscle function that causes muscle tightness or spasm. This may result from traumatic or pathological causes of the brain or spinal cord. Baclofen has been widely used for spasm since 1967 but has side effects which could result from oral doses due to central depressant properties including sedation, ataxia, weakness and fatigue. Intrathecal Baclofen is an alternative therapy when oral Baclofen is ineffective or with side effects.
Thirty three patients were selected to have intrathecal Baclofen pump implantation after positive effects of intrathecal Baclofen diagnostic test.
Baclofen diagnostic test 50-100 mcg was given as a bolus intrathecally, and the effect was monitored for the next 20 hours, and when Ashworth scale of spasm improved by 2 scales, then the patient was eligible for pump implantation.
All patients had good to excellent results after implantation and spasticity was reduced significantly. The doses of continuous intrathecal Baclofen was between 50-840 mcg/day. There were few complications, two pumps were explanted due to infection and one needed changing of the catheter only.
For spasticity and pain, Baclofen intrathecally is an excellent alternative when oral Baclofen is ineffective or cannot be tolerated, although it is initially expensive due to the high cost of equipment but could be cost effective in the long term.
P150 The Potential Use of rTMS in SCI Rehabilitation
N. Alexeeva and B. Calancie
SUNY Upstate Medical University, Syracuse, NY, United States
There is a growing body of evidence on cortical motor reorganization following spinal cord injury (SCI). However, traditional methods for SCI rehabilitation address motor function at or caudal to the level of injury. In the present study we used a novel quadro-pulse repetitive transcranial magnetic stimulation (rTMSQP) of the motor cortex for supraspinal targeting of motor function in persons with chronic, neurologically-incomplete SCI. Trains of 4 monophasic pulses at 2 ms interstimulus interval were applied every 5 s. Post-stimulation measures of: 1) hand dexterity; 2) cortical excitability assessed by single- and double-pulse TMS); and 3) spinal excitability assessed by tendon reflexes were compared to pre-stimulation values. In two cervical SCI subjects, 250-360 trains of rTMSQP at 0.9 x resting threshold (RT) to single-pulse TMS evoked reproducible and lasting (~ 30 min) after-effects: a better motor performance of the treated hand during Purdue Pegboard and Minnesota dexterity tests, increased motor evoked response and reduced spinal reflex amplitudes. The effect of rTMSQP on hand dexterity appeared to be stronger with daily (5 per week) sessions. In addition, overall dexterity scores of the weaker hand improved over time. Regardless of rTMSQP protocol, subjects reported less ‘stiffness’ of the treated limbs and no adverse effects. We demonstrate that cortical rTMSQP can benefit motor function affected by chronic, motor-incomplete SCI presumably by optimizing motoneuronal excitability at the cortical (upregulation) and spinal (downregulation) levels. These findings, together with observation that rTMSQP after-effects outlast the stimulation duration, underscore rTMS as a potential SCI treatment modality.
P151 The Effect of a Video Game System on Balance and Gait After Stroke
A. N. Garcia, A. Carvalho, M. M. F. Vieira, C. Torriani, S. R. Alouche, and F. N. Cyrillo
Universidade Cidade de São Paulo, São Paulo, Brazil
Objective: The purpose of this study was to evaluate the influence of using the console Nintendo Wii® as a complement for the physiotherapy sessions in subjects post-stroke. Method: Two groups, aged between 20-60 years, composed by ten chronic stroke patients (more than six months since stroke) were studied. The control group (CG) received a sixty minutes conventional physical therapy treatment in group, once a weak. The experimental group (EG) received in addition to the group treatment ten sessions with the Nintendo Wii twice a week per twenty minutes. The training using Wii balance software included yoga, balance and aerobic practice. Patients were assessed by the Orpington Severity Scale, the Berg Balance Scale, the Dynamic Gait Index, the Functional Reach Test and the Timed Up and Go Test. Results: The results showed a significantly improvement in the Berg Balance Scale (p=0,02) and in the Dynamic Gait Index (p=0,04) for both groups after the treatment. No significant differences were found between the experimental and the control groups (p=0,62). Conclusion: The use of a video game system as a complement of the conventional physiotherapy treatment for stroke patients demonstrated the same effects of the therapy alone but can be considered as a motivational instrument that can contribute for the patients’ adhesion in therapy.
P152 Neural Correlates to Constraint-Induced Movement Therapy: A Case Study
T. Askim1,2, B. Indredavik1,2, A. E. Dahl2, R. Stock2, E. Langørgen2, and A. K. Håberg1
1Norwegian University of Science and Technology, Trondheim, Norway, 2Trondheim University Hospital, Trondheim, Norway
Background: Constraint-induced movement therapy (CIMT) has been shown to be efficacious in chronic stroke patients. The aim of the present study was to investigate the neuronal correlates to CIMT.
Methods: Four patients with arm paresis after subcortical or cortical stroke were included. Two patients were allocated to ten days with CIMT and two controls, matched according to stroke site, received standard treatment during the same period. Assessment at inclusion and after two weeks intervention included Wolf Motor Function Tests (WMFT) and functional MRI of finger tapping at 1Hz.
Results: On the WMFT, the patient with subcortical stroke improved from 14.3 to 4.0 sec after CIMT, the control improved from 7.8 sec to 4.4 sec. The patient with cortical infarction improved from 18.0 sec to 9.0 sec after CIMT, the control improved from 30.6 to 21.5 sec. On functional MRI, the patient with subcortical stroke had increased activity in ipsilesional hand area and decreased activity in contralesional hemisphere after CIMT. The control had increased activity in ipsilesional hand area and contralesional pre- and postcentral gyri. The patient with cortical stroke receiving CIMT revealed decreased ipsilesional hand area activity, but no other clear changes, while the control showed increased activity in contralesional pre- and postcentral gyri.
Discussion: Functional outcome improved in all patients following intervention, but CIMT seems to improve function by decreasing contralesional activity in subcortical strokes and decreasing ipsilesional activity in cortical strokes. This conclusion is based upon a limited selection of patients and should therefore be tested out in a larger study.
P153 Recruitment and Baseline Characteristics of Subjects Enrolled in the Locomotor Experience Applied Post-Stroke (LEAPS) Trial
A. L. Behrman1, K. A. Sullivan2, S. P. Azen2, S. S. Wu1, S. E. Nadeau1, B. H. Dobkin3, and P. W. Duncan4
1University of Florida, Gainesville, FL, United States, 2University of Southern California, Los Angeles, CA, United States, 3University of California Los Angeles, Los Angeles, CA, United States, 4Duke University, Durham, NC, United States
The purpose of the LEAPS trial is to determine the difference in walking recovery at 1 year in three intervention groups: home-based exercise program (HEP) delivered at 2 months, locomotor training program (LTP) at 2 (early, E-LTP) or 6 months post-stroke (late, L-LTP). The goal was to recruit 400 adults within 30 days post-stroke with moderate to severe walking limitations and who would be community-dwellers at 2 months post-stroke.
Methods: Recruitment was executed with financial and administrative support. Patients were screened via chart review and interviews on admission to 5 inpatient rehabilitation facilities. Subjects excluded if stroke > 30 days, pre-stroke were ADL-dependent, demented or residual deficits from prior stroke, and major medical co-morbidities limited exercise. Eligible subjects were screened at 2 months post-stroke to determine if community-dwellers, walking difficulty (speed < 0.8m/sec), and exercise tolerance.
Results: From 4/06 - 8/09 and 5289 stroke admissions, 4909 individuals were screened and 4501 were excluded. Primary reasons for exclusions: 1) stroke not primary diagnosis 2) > 30 days post-stroke and 3) major co-morbidities. Primary reasons for failing second 2 month screen: 1) walking ≥ 0.8m/sec or 2) no residual lower extremity paresis. Four hundred eight individuals (mean age 62±12.7, 45% female, 42% minority) were randomized at 2 months post-stroke to HEP (n=126), E-LTP (n=139), or L-LTP (n=143). Ninety-nine percent were Rankin 2-4, walking speed 0.3838±.22, 53.4% walked < 0.4m/sec, 93% were community-dwellers.
Conclusions: Our recruitment methods produced our desired sample, random allocation across groups, and strata of walking recovery.
P154 Effect of Facilitatory rTMS on Upper Limb Spasticity in Hemiparetic Stroke Patients
D. Bensmail1, A. Sarfeld2, G. Fink2, and D. Nowak3
1R. Poincare Hospital, Garches, France, 2Uniklinik Köln, Cologne, Germany, 3Hospital for Neurosurgery and Neurology, Kipfenberg, Germany
The aim of our study was to assess the effect of rTMS in spastic chronic stroke patients. We hypothesized that facilitation of cortico-spinal pathways may induce an increase of inhibitory inputs to spinal cord producing an inhibition of spinal reflex activity and thus reducing spasticity.
Method: 13 patients with chronic stroke were included in the study. Each patient participated in two different experimental sessions. One session included a 20 Hz rTMS over the lesioned primary motor cortex (M1) and another session included a sham 20 Hz rTMS over the lesioned M1. The stimulation intensity was set at 90 % of the resting motor threshold (RMT) in patients with elicitable MEP on the lesioned hemisphere and at 120 % of the RMT of the healthy hemisphere in patients without any elicitable MEP on the lesioned hemisphere. Some parameters were assessed before and after each session: Ashworth score, Tendon reflex amplitude of the biceps brachialis (BB) muscle and the stretch-reflex response of the BB muscle (phasic and tonic phase).
Results: The Ashworth score decreased significantly after rTMS and SHAM stimulation. We did not observed any significant modification of tendon reflex amplitude or the phasic part of the stretch reflexes after facilitatory rTMS. A significant increase of the tonic part of the stretch reflexes was observed after rTMS.
Conclusion: A single session of facilitatory rTMS does not seem to reduce spasticity in hemiparetic stroke patients. It could be interesting to assess the effect of inhibitory rTMS.
P155 Rehabilitation After Dorsal Root Rhizotomy: A Preliminary Experience
L. Berna1, S. Chahuan1, A. Cubillos2, V. Ferrada1, and X. Neculhueque1
1Pedro Aguirre Cerda National Rehabilitation Institute, Santiago, Chile, 2Roberto del Rio Hospital, Santiago, Chile
Background: Selective dorsal rhizotomy (SDR) is a surgical technique developed to manage patients with spastic cerebral palsy (CP). However, in our country it is new and we don’t have knowledge about their outcomes after this surgery.
Objective: To show our preliminary experience in Rehabilitation after SDR for treatment of spastic CP.
Materials and Methods: Prospective study. We evaluated two children with Spastic Diplegia who met inclusion criteria to SDR. We started a comprehensive multidisciplinary rehabilitation treatment based on a biopsychosocial focus in our Institute. Gross Motor Function Classification System level, grade of spasticity, muscle strength, range of motion, and bladder function before and after procedure were registered, and side effects as well.
Results: Both were premature 4-year-old kids, undergoing several spasticity treatment with poor functional outcome. In the first case, a GMFCS IV level was registered, major involvement was at L2-L3, meanwhile the second case had a GMFCS III level and S1-S2 involvement. After 5 months, there was a significant reduction on muscle tone, and range of motion improvement. There was no improvement in GMFCS, but a better performance in gross motor skills were observed. Both patients had transient neurogenic bladder, and no pain was observed.
Discussion: This preliminary report at 5 months SDR postoperative shows it is a safe and effective method for reducing spasticity. A comprehensive preoperative and postoperative standard method to register and follow this process is necessary and it has been a learning period for all the rehabilitation team involved.
P156 Impact of tDCS on Motor Function in Acute Stroke
A. Brem1,2, I. Speight1, and L. Jäncke2
1Zentrum fuer ambulante Rehabilitation, Zurich, Switzerland, 2Department of Neuropsychology, Zurich University, Zurich, Switzerland
Transcranial direct current stimulation (tDCS) is a non-invasive technique which allows modulation of neuronal excitability. Until today no studies have been conducted regarding the effects of tDCS on motor rehabilitation in acute stroke. On the supposition that excessive activity of the unaffected hemisphere represents a maladaptive process, we investigated whether the inhibition of the healthy hemisphere will lead to a similar motor improvement as the activation of the lesioned hemisphere.
Three right-handed patients with acute stroke (< 5 weeks) received either anodal, cathodal or sham stimulation (20 minutes, 1mA) twice a day on 5 consecutive days. Immediately after the stimulation the patients underwent either physiotherapy or occupational therapy while the excitability of the motor cortex was still altered. Motor function was assessed by the Fugl-Meyer Arm Subtest and the Nine-Hole-Peg-Test (NHPT).
Whereas 10 sessions of anodal and cathodal stimulation resulted in a distinct difference in the NHPT (19% and 25% respectively), sham stimulation led only to little improvement (5%). The outcome of Fugl-Meyer was less marked (anodal 17%, cathodal 20%, sham 12%). The more pronounced gain after cathodal stimulation may indicate a more even distribution of the current and thereby stronger effect on undamaged brain tissue. Future studies should investigate whether the combined activation and inhibition of the affected and unaffected hemispheres would lead to even more pronounced effects. Furthermore they should aim to find the ideal moment to start supporting the brain in its processes of spontaneous recovery and research the impact on adaptive post-stroke neuroplasticity.
P157 Goal-Oriented Cognitive Rehabilitation for People With Early-Stage Alzheimer’s Disease: A Single-Blind Randomized Controlled Trial of Clinical Efficacy
L. Clare1, D. Linden1, R. Woods1, and R. Whitaker2
1School of Psychology, Bangor University, Bangor, United Kingdom, 2North Wales Organisation for Randomised Trials in Health and Social Care, Bangor University, Bangor, United Kingdom
This single-blind randomized controlled trial compared cognitive rehabilitation (CR) with relaxation therapy (RT) and no treatment (NT) in order to provide evidence regarding the clinical efficacy of cognitive rehabilitation (CR) in early-stage Alzheimer’s disease (AD). Participants were 69 individuals (41 female, 28 male; mean age 77.78, sd 6.32, range 56-89) with a diagnosis of AD or mixed AD and vascular dementia and an MMSE score of 18 or above, and receiving a stable dose of acetylcholinesterase-inhibiting medication. Forty-four family carers also contributed. Participants randomised to the CR group received 8 weekly individual home-based sessions of CR incorporating work on personally-relevant goals supported by components addressing practical aids and strategies, techniques for learning new information, practice in maintaining attention and concentration, and techniques for stress management. The primary outcomes were goal performance and satisfaction, assessed using the Canadian Occupational Performance Measure. Questionnaires assessing mood and quality of life, and a brief neuropsychological test battery, were also administered, and carers completed a measure of carer strain. A subset of participants underwent functional magnetic resonance imaging (fMRI). Following intervention the CR group showed significant improvement in ratings of goal performance and satisfaction, while scores in the other two groups did not change. At six-month follow-up, the CR group rated their memory performance more positively than did RT and NT. Behavioural changes in the CR group were supported by fMRI data for a sub-set of participants. The findings provide preliminary support for the clinical efficacy of CR in early-stage AD.
P158 Randomised, Controlled Study for Evaluation of Home Based Video-Training in the Treatment of Arm Paresis Following a Stroke
V. Nedelko1, T. Hassa1, C. Rothmeier2, K. Starrost1, J. Liepert1, F. Binkofski3, C. Weiller4, and C. Dettmers2
1Kliniken Schmieder, Allensbach, Germany, 2Kliniken Schmieder, Konstanz, Germany, 3Neurologische Universitätsklinik, Lübeck, Germany, 4Neurologische Universitätsklinik, Freiburg, Germany
Aim: Evaluation of the effect of six weeks of home-based video training to support recovery of hand function after stroke.
Method: Inclusion criteria: Patients who needed further treatment for their hand paresis. Exclusion criteria: Age < 18 or > 80; clinically obvious neglect, apraxia, aphasia or serious cognitive deficits, complete paralysis of the hand or only minimal deficit; serious depression.
Intervention: Observation and imitation of ten simple, object related movements, 1 hour daily at home, for six weeks following inpatient rehabilitation. Appropriate motor sequences carefully selected from 45 possible tasks.
Control intervention: Identical exercises described in a videotext. A second control group without specific home work.
Design: Prospective, randomized study with three arms and two control groups.
Main outcome parameter: Blinded evaluation of the videotaped Wolf-Motor-Function-Test (WMFT) before and after training. Additional outcome parameter: Nine-Hole-Peg-Test (NHPT), Motor Activity Log (MAL) and Stroke Impact Scale (SIS)
Results: Patient recruitment has been completed (December 2007 to September 2009). Fifty-four patients, 18 per group, have been included. Questionnaires were distributed six months after completion of training. These have not yet been completed.
Discussion: Video training has a high acceptance in stroke patients. It is possible to perform without professional supervision. It is an easy method to make patients exercise for an hour daily. The training method is cheap and easily available. Completion of the results is expected in the very near future.
P159 A Multi-Site Randomized Controlled Trial of Stroke Inpatient Rehabilitation Reinforcement of Walking Speed (SIRROWS)
P. Plummer-D’Amato1, B. H. Dobkin2, and R. Elashoff2
1Northeastern University, Boston, MA, United States, 2University of California Los Angeles, Los Angeles, CA, United States
Based on recommendations of the World Federation for NeuroRehabilitation, we aimed to test the feasibility of conducting a multi-site, international randomized clinical trial (RCT) of a practical and easily managed intervention within the context of usual inpatient stroke rehabilitation care. Patients with hemiplegic stroke admitted for initial rehabilitation, once able to take at least 5 steps with not more than maximum assistance of one person, were randomized to receive daily verbal reinforcement of walking speed during a 10-m walk once a day or no reinforcement of walking speed. All participants received the site’s standard therapy. The primary outcome was self-selected fast walking speed for 50 feet at discharge. Eighteen sites in 8 countries entered 184 eligible patients in 21 months. No differences were found between groups for age, time post stroke or initial gait speed (mean 0.45m/s). At discharge, the experimental group walked faster than the control group (0.91 v 0.71 m/s; p<0.01); they also walked further in 3 minutes (132 v 112 m, p<0.05). The significant difference in gait speed was retained 3 months later. Regardless of intervention, individuals with initial gait speed >0.5 m/s had significantly shorter lengths of stay than slower walkers. Thus, daily verbal reinforcement had a profound impact, allowing community-level walking speeds at discharge. Feedback from investigators was highly favorable about their opportunity to participate in an RCT that might alter how they managed their patients, despite no funding. The group aims to continue carrying out trials using Web-based interactions and welcomes additional participants.
P160 Mirror Neuron System: A RCT in the Upper Limb Rehabilitation of Acute Stroke: Preliminary Report
M. Franceschini1 and B. Stefano1, on behalf of NESPERIA2
1Neuro-Rehabilitation Department, Roma, Italy, 2Multicenter Group Cooperation, Italy
Recent neurophysiological studies revealed mirror neurons in the human premotor-area discharging during the observation of hand/arm actions. The aim of the study was to investigate whether the observation of upper limb actions may provide a useful strategy in acute stroke rehabilitation.
A RCT enrolled 102 subjects (53 Experimental Group, 49 Control Group) at 30±3 days of first stroke. Patients with dementia, visual impairment, neglect, fluent aphasia were excluded. All subjects received conventional rehabilitation treatment, moreover ExG patients were asked to watch video-records showing daily upper limb activities, while CG watched, in addition, a static imagine without moving individuals. Functional changes were looked for using: Fugl Meyer, Box and Block (B&B), Frenchay Arm Test, Barthel Index and FIM. All evaluations were taken at the beginning (T0), at the end of 4-week treatment (T1) and at 4-month follow-up (T2).
No between-group differences were found at baseline with respect to age, Token Test Scores, Bells Test, Spinler’s Test, and MMSE. After adjusting for baseline scores and age, the preliminary analysis demonstrated a significant improvement in all parameters in both groups from T0 to T1 (p<0.001) and from T0 to T2 (p<0.001). Furthermore, a significant “time x treatment” effect was shown in the B&B Test, favouring a higher impact of Experimental treatment on upper limb recovery (p<0.001, T0 to T1, and p=0.02, T0 to T2, respectively).
A rehabilitation strategy exploiting the paradigm of mirror neurons may reveal useful in promoting motor dexterity recovery in the acute phase of stroke.
P161 Hybrid Assistive Neuromuscular Dynamic Stimulation (HANDS) Therapy for Patients With Chronic Stroke: Nonrandomized Control Cohort Study
T. Fujiwara1, K. Honaga1, K. Abe1, T. Tsuji1, K. Hase1, A. Kimura2, and M. Liu1
1Keio University, Shinjuku, Tokyo, Japan, 2Keio University Tsukigase Rehabilitation Center, Izu, Japan
Objectives: We devised a therapeutic approach to facilitate the use of the paretic UE in daily life by combining integrated volitional control electrical stimulation (IVES) with a wrist splint, the hybrid assistive neuromuscular dynamic stimulation (HANDS). The aim of this study is to assess its effects on selected measures of hand function and impairments.
Materials and Methods: Nonrandomized controlled, cohort before-after, single blinded trial conducted with 36 chronic stroke patients with hemiparesis. Twenty-two patients were assigned to HANDS therapy and 14 patients were assigned to home-program based training with splint (control). Both were conducted for 3 weeks. In HANDS therapy, the patients wore a wrist-hand splint and carried a portable IVES in a waist-bag for 8 hours during the daytime. The system was active for 8 hours, patients were instructed to use their paretic hand as much as possible while wearing the HANDS system. Their non-paretic upper extremity was not restrained. The patients were also instructed to practice bi-manual activities in their daily lives. Before and after trial, motor function of paretic arm was assessed with Fugl-Meyer test (FM) and the amount of paretic hand use in their daily life was assessed with Motor Activity Log (MAL).
Results: The FM and MAL score were significantly improved in both HANDS group and control group. The improvement of FM and MAL score, however, were greater in HANDS group than in control group. Conclusion: The HANDS therapy may offer a promising option for the management of the paretic UE in patients with stroke.
P162 Severe Chronic Brain Injury and Reintegration Into the Society: A Prospective Evaluation of a Residential Rehabilitation Programme
G. J. Geurtsen1, C. M. Heugten2,3, and J. D. Martina1
1Medical Rehabilitation Centre Groot Klimmendaal, Arnhem, Netherlands, 2Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands, 3Department of Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, Netherlands
Introduction: Many severe brain injury patients regain community reintegration but some of them face multiple problems which hamper community functioning. Besides the direct consequences of the brain injury patients develop secondary problems such as psychiatric complaints and behavioural problems. Moreover, some develop alcohol and drugs dependency. Through the compilation of huge problems patients get stuck in life. This is an important challenge for the patient, their caregiver and the society, which needs intervention to prevent further accumulation of problems that could lead to an admission to a neuropsychiatry department.
The Brain Integration Programme is a residential community integration programme which focuses on reintegration of this complex patient group in the areas of living, day spending and social contacts.
Methods: A controlled prospective cohort study was performed. Seventy chronic brain injury patients were assessed 3 months before start of treatment, at start and end of treatment and at one-year follow-up. A three-year follow-up will be undertaken.
Results: In the waiting list period there are no significant changes. Both the emotional well-being increases and community integration increases too. After treatment more than 70% of the patients live on their own instead of living with their parents. The number of patients working increases and the hours work increases. The clinical and statistical significant improvements after treatment remain at follow-up.
Discussion: The improvements after treatment indicate that the Brain Integration Programme is effective in resolving the needs of this complex chronic brain injury patient group and leads to a sustained reduction in problems.
P163 Comprehensive Rehabilitation Programmes in the Chronic Phase After Severe Brain Injury: A Systematic Review
G. J. Geurtsen1, C. M. Heugten2,3, and J. D. Martina1
1Medical Rehabilitation Centre Groot Klimmendaal, Arnhem, Netherlands, 2Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands, 3Department of Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, Netherlands
Objective: The aim of this study (accepted for publication in J Rehabil Med) was to perform a systematic review on the effectiveness of comprehensive rehabilitation programmes for adults in the chronic phase after severe acquired brain injury.
Method: We searched Pubmed, PsychInfo and Psychlit for articles covering 1990-2008 and performed a quality assessment. The comprehensive programmes were subdivided into neurobehavioral interventions, residential community reintegration and day treatment programmes. The extracted data included study characteristics, patient characteristics and intervention characteristics.
Results: Thirteen studies met pre-established criteria. Two studies were randomized controlled trials, five were controlled comparative studies and six were uncontrolled longitudinal cohort studies. Overall, their methodological quality was limited. The investigated programmes led to substantial improvement in daily life functioning and community integration of severe chronic brain injury patients, with lasting effects at follow up. Day treatment programmes had the highest level of evidence.
Conclusions: Comprehensive rehabilitation programmes appear effective in terms of a reduction of psychosocial problems, a higher level of community integration and an increase in employment. Although this is the first review to differentiate between specific programmes, clear-cut clinical recommendations are not possible yet due to the limited methodological quality and the poor description of patient and intervention characteristics. Specific recommendations for future studies and publications are given.
P164 Effects of Aerobic Treadmill Exercise in Chronic Stroke Survivors: A Randomized, Controlled Trial
C. Globas1,2, C. Becker1, J. Cerny1, U. Lindemann1, J. M. Lam3, R. F. Macko4, and A. R. Luft2
1Clinic of Geriatric Rehabilitation, Robert Bosch Krankenhaus, Stuttgart, Germany, 2Department of Neurology, University Hospital of Zurich, Zurich, Switzerland, 3Clinic of Neurology, University Tübingen, Tübingen, Germany, 4Department of Neurology, University of Maryland, School of Medicine, Baltimore, MD, United States
Objective: To investigate the effects of 3 months of aerobic treadmill training in chronic stroke survivors on cardiovascular fitness, ambulatory function, balance, leg strength, mobility function and quality of life.
Methods: 38 chronic stroke patients (time since stroke> 6 months) with residual hemiparetic gait disturbance were randomized to either 3 months (3x/week) progressive graded, high intensity aerobic treadmill exercise (T-EX) or control group receiving conventional care physiotherapy. Outcome measures were peak cardiovascular fitness (VO2 peak), sustained walking capacity in six-minute-walks (6MW), gait velocity in 10-m timed walks, balance (Berg Balance), leg strength (5 chair- rise), mobility (Rivermead Mobility Index) and quality of life (SF-12)
Results: 36 patients completed the study (18 T-EX, 18 controls). As compared with controls, T-EX lead to greater improvements in peak exercise capacity (VO2 peak; 30% vs. -1%; p<0.0001), 6MW (22% vs. -1%; p<0.0001) maximum walking speed (FCWS, 13% vs. -6%; p=0.01), RMI (p<0.05) and mental sum score of SF12 (p<0.05). Gains in VO2 peak (r=0.59; p=0.01) and 6MW (r=0.56; p<0.05) in T-EX were predicted by increasing training intensity up to 80% HRR whereas increasing treadmill velocity predicted improvements in walking function (6MW: r=0.77; p<0.001; FCWS: r=0.64; p<0.01) but not cardiovascular fitness.
Conclusion: This randomized controlled trial shows that aerobic treadmill exercise effectively improves cardiovascular fitness, gait performances, balance and quality of life in chronic stroke survivors. Gains in fitness are determined by the aerobic intensity of training Improvements in gait were related to the number of repetitions (=steps) as expected from task-specific training.
P165 Intensive Orthosis-Based Home Training of the Upper Limb Leads to Pronounced Improvements in Patients in the Chronic Stage After Brain Lesions
K. Heise, G. Liuzzi, M. Zimerman, C. Gerloff, and F. Hummel
Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
Background: Recovery of hand function after central brain lesions is often insufficient especially in patients who cannot actively extend their fingers. Here, the aim was to test whether self-administered training with a dynamic training orthosis (DTO), supporting hand and finger extension, is feasible to actively improve the hand function in patients after brain lesion.
Methods: 12 patients with upper limb (UL) hemiparesis in the chronic stage (10 stroke, 1 SHT, 1 cavernoma resection, 9-120 months post lesion, 51.3±13.9 yoa) with initial severe impairment of UL function, i.e. inability to actively extend fingers and wrist, were trained over five consecutive days to apply and use a DTO for a daily self-administered training at home thereafter. Primary outcome was upper limb active range of motion, evaluated with the Fugl-Meyer assessment (UEFMA) at baseline, before, immediately after, 4 weeks and 3 months after initial training phase.
Results: Patients showed a stable non-functional level prior to the onset of DTO training (UEFMA 23.2±6.9, z=-.170, p=.87). All patients improved significantly over time (Χ2 = 17.904, df = 4, p=.001). Functional improvement in the UEFMA was significant at all time points in relation to the functional level before training (UEFMA post 27.7±7.1, 4wFU 29.78.7 p<.01, 3mFU 31.2±10.1 p<.05). Grip and pinch force improved in the affected (p<.05) hand but not in the unaffected hand (p=.80).
Conclusion: Patients with stable moderate to severe impairment of UL function after receiving common neurorehabilitative therapy can further improve their hand function with intensive self-initiated and regularly supervised DTO-based home training.
P166 The NETS Trial: Study Design of a European Multicenter Trial to Evaluate the Effect of a Combination of Anodal Transcranial Direct Current Stimulation and Functional Training in the Subacute Stage After Stroke
K. Heise1, K. Wegscheider2, C. Gerloff1, and F. Hummel1
1Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, 2Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
Based on proof-of-principle studies the combination of non-invasive brain stimulation and motor training might be a promising intervention to enhance functional recovery in stroke patients. To evaluate whether early application of transcranial direct current stimulation (tDCS) combined with functional training will enhance recovery of upper limb function in the subacute phase after stroke multicenter sham-controlled trials are needed. Here we describe the design of the ‘Neuroregeneration Enhanced by TDCS in Stroke (NETS) trial’—a randomized, placebo-controlled, double-blind, multicenter clinical trial addressing this question.
The study design features two stages, (a) an early intervention phase over ten consecutive days starting between 5th and 30th day poststroke and (b) a follow up period until 12 months post intervention. During intervention, patients receive 20 minutes of anodal tDCS applied to the motor cortex of the lesioned hemisphere during standardized rehabilitative training of hand motor function.
The primary outcome measure is the improvement in upper limb function measured with the Fugl-Meyer Assessment. Secondary outcomes address all three domains of the International Classification of Functioning and Disability (WHO). The sample size required is 125 patients in each group (total: 250), patients will be recruited in 12 centres in Austria, France, Germany, and Switzerland.
The NETS Trial is the first randomized pivotal trial on efficacy and safety of non-invasive brain stimulation delivered during functional training in the early phase after stroke. The data will provide evidence for an interventional strategy of tDCS combined with training as a basis to translate it into clinical application.
P167 The Effects of Transcranial Direct Current Stimulation in the Acute Treatment of Patients With Migraine
S. Jung1,2, H. Kim1,3, and M. Kim1,3
1Seoul National University College of Medicine, Seoul, Republic of Korea, 2Seoul National University Boramae Medical Center, Seoul, Republic of Korea, 3Seoul National University Hospital, Seoul, Republic of Korea
Objective: To assess the efficacy of transcranial direct current stimulation (tDCS) in the acute treatment of patients with migraine attack
Design: A randomized, double-blind, sham-controlled, parallel-group study
Methods: Fourty-one migraineurs were recruited. Among them, 22 patients received real tDCS with a 2mA current for 20 minutes over the primary motor cortex on the same side of migraine. Nineteen patients were allocated to the sham stimulation group. The sham tDCS was done same as the real tDCS except the stimulation duration of 10 seconds. Patients were instructed to record their headache severity on headache diary after tDCS. The severity of headache was evaluated according to the grading system of international headache society as 0 (no headache), 1 (mild), 2 (moderate), or 3 (severe). We also checked pre- and post-tDCS level of cognition, depression, and anxiety for the information of the safety.
Results: The severity of headache is significantly decreased 60 and 90 minutes after tDCS (p = 0.017, by paired t-test) compared to baseline. Three patients felt dizziness and one patient complained howling. However, there was no deterioration of cognitive function and no difference in level of depression and anxiety between pre- and post tDCS.
Conclusions: A motor cortex tDCS was found to result in a significant headache relief to patients with acute migraine attack. The effect began 1 hour after stimulation. We suggest that tDCS is applicable as a safe treatment tool of acute migraine attack.
P168 Low-Frequency rTMS Plus Intensive Occupational Therapy Improves Motor Function and Reduces Spasticity of Paretic Upper Limb in Post-Stroke Patients: A Pilot Study
W. Kakuda, M. Abo, K. Kobayashi, R. Momosaki, A. Yokoi, A. Fukuda, A. Ishikawa, and H. Ito
Jikei University School of Medicine, Tokyo, Japan
Purpose: To determine the effects of daily application of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with intensive occupational therapy over 15 days on motor function and spasticity in hemiparetic upper limb in post-stroke patients. Methods: Ten post-stroke patients with spastic upper limb hemiparesis categorized as Brunnstrom stages 3-5 for hand-fingers were subjected. They were assessed as to have reached a plateau stage of functional recovery in spite of conventional occupational therapy. Each patient received 22 sessions of 20-min 1-Hz rTMS applied to the contralesional cerebral hemisphere followed by intensive occupational therapy (60-min one-to-one training and 60-min self-training). The motor function in the affected upper limb was evaluated by Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) at admission and discharge. The spasticity of the affected upper limb (flexors of fingers, wrist and elbow) was also evaluated with modified Ashworth scale (MAS). Results: Our 15-day protocol was well tolerated by all patients without any complications. At discharge, all patients had increased FMA score (range of score increase: 1-12). Shortening of the performance time on WMFT was noted in 8 patients, although 2 patients with Brunnstrom stage for hand-fingers of 3 did not show any shortening of the time. MAS score decreased in 7 patients (3 with Brunnstrom stage for hand-fingers of 4-5 and 4 patients with stage of 3). Conclusions: Our 15-day protocol of combination treatment seems feasible not only for improving motor function but also for reducing spasticity in the affected upper limb in post-stroke hemiparetic patients.
P169 Vibrotactile Stimulation in the Control of Muscle Tone in Children With Spastic Cerebral Palsy
A. Katusic1 and V. Mejaski-Bosnjak2
1Day care center for rehabilitation Little House, Zagreb, Croatia, 2Children’s Hospital Zagreb, Medical School, University of Zagreb, ZAGREB, Croatia
Afferent signals from the muscle’s proprioceptors play an important role in the control of muscle tone. Vibrotactile stimulation excite muscle’s proprioceptors which than send sensorimotor information to brain. In this way peripheral afferent pathways enable the restoration of connections with supraspinal structures and include mechanism of synaptic inhibition in the control of muscle tone.
The goal of this study is to evaluate the effects of vibrotactile stimulation on spasticity in children with spastic cerebral palsy. The primary objective was to determine whether vibrotactile stimulation could improve gross motor functions.
Subjects included in this study were 30 children with spastic cerebral palsy aged 4-6 years. Children were randomly assigned to control group (n=15) or to intervention group (n=15). Intervention group was treated with vibrotactile stimuli in duration of 25 minutes twice a week during 3 months. Control group subjects continued with their usual physical therapy for 12 weeks. The primary outcome measure was the Modified Ashworth scale and the secondary measure was the Gross Motor Function Measure (GMFM-66). The measures were taken prior to randomization and after 12 weeks.
Treatment with vibrotactile stimuli provided a significantly greater improvement in both the GMFM and Modified Ashworth scale compared with usual physical therapy. The improvement in motor performance has been seen in the facilitation of rotations, better postural trunk stability and head control and in greater selectivity of movements. The result of study indicated that vibrotactile stimulation may have positive influence on spasticity and enhance gross motor performance in children with cerebral injury.
P170 Does Pharyngeal Electrical Stimulation Improve Swallowing Function in Patients With Bihemispheric Lesions?
C. Ledl
Neurologische Klinik Bad Aibling, 83043 Bad Aibling, Germany
Objectives: Pharyngeal electrical stimulation (PES) has been shown to alter cortical plasticity and to improve swallowing function after monohemispheric brain injury (Fraser et al. 2002). In normal subjects, improved pharyngeal excitability was observed in the left and the right motorsensory cortices. Patients with monohemispheric lesions exhibited topical changes in the undamaged hemisphere.
Our study aimed to investigate if PES could be successfully applied to patients suffering from bihemispheric lesions.
Method: 12 patients with bilateral hemispheric lesions were included in a prospective randomized study. All patients suffered from hypoxic brain injuries and were in a minimally conscious or in a vegetative state. Six patients received PES (10 stimulations), another six patients were attributed to a sham group. Flexible endoscopic evaluation of swallowing (FEES) was conducted in all patients before and after the stimulation/ sham block. Penetration/ aspiration ratings, and ratings of pharyngeal residue were performed. Swallowing frequency was measured before and during PES/sham, one day after and one week after the stimulation/sham block.
Results: Swallowing frequency increased significantly during PES. It fell to its initial value when the stimulation block had ended. The sham group showed no change in swallowing frequency. FEES showed no significant functional profit concerning the penetration/ aspiration ratings and pharyngeal residue.
Discussion: PES has not been effective in patients with bihemispheric lesions. Improvements in monohemispheric lesions were due to cortical changes in the undamaged hemisphere. Functional improvements associated with PES therefore seem to depend on the possibility to recruit intact cortical structures.
P171 Combined Transcranial Direct Current Stimulation (tDCS) and Body Weight Support Robotic Training (BWSRT) for Gait Rehabilitation in Stroke Patients
D. León1, Ú. Costa1, D. Edwards2, R. Pelayo1, J. M. Tormos1, M. Bernabeu1, J. Medina1, and A. Pascual-Leone3
1Institut Guttmann., Badalona, Spain, 2Burke Rehabilitation Hospital., New York., NY, United States, 3Berenson-Allen Center for Noninvasive Brain Stimulation, Boston, MA, United States
Background and purpose: Preliminary reports suggest that the efficacy of robot-supported therapy for upper limb motor recovery after stroke can be enhanced when coupled with tDCS. Modulating lower limb motor cortex excitability to gait training might promote the efficacy of BWSRT. This pilot study examines the safety and possible clinical effects of multiple sessions of tDCS combined with BWSRT in sub-acute stroke patients.
Subjects: Fifteen mixed cortical-subcortical stroke patients (X age; 46,47 SD:12,44, male; 11, female; 4), participating in a gait rehabilitation program with BWSRT. Results were compared to fifteen (X age; 49,93 SD:13,77, male;10, female; 5) controls from our retrospective BWSRT stroke database.
Intervention: Twenty daily sessions over 4 weeks, each involving 30 minutes of BWSRT. During the firsts 20 minutes of each session, 2mA anodal tDCS was applied over the ipsilesional motor cortex.
Assessment: Detailed side effect and neurological assessment, Functional Ambulatory Categories (FAC), 10m walking test and Tinnetti scale for gait and balance were assessed pre and post intervention.
Results: All patients tolerated the intervention well, with no adverse effects, other than minor scalp itching from the tDCS. In this small cohort, the efficacy of BWSRT was not enhanced by tDCS as compared to the historic control group.
Conclusions: Combination of tDCS with BWSRT is safe and easy to use in a clinical setting. A sham controlled, double-blind, randomized study is needed to assess the effect of tDCS in gait recovery after stroke.
P172 Comparison of Constraint-Induced Therapy Outcomes for Home Program Versus In-House Training
K. E. Light1, S. Fritz2, and M. Malcolm3
1University of Florida, Department of Physical Therapy, Gainesville, FL, United States, 2University of South Carolina, Department of Physical Therapy, Columbia, SC, United States, 3Colorado State University, Department of Occupational Therapy, Fort Collins, CO, United States
Constraint-Induced Therapy has been established as an effective upper-limb rehabilitation when provided within the guidelines established by the EXCITE trial. The EXCITE trial consisted of in-laboratory training 6 hours/ day for 2 weeks with direct supervision and massed practice. This therapy is expensive and not realistic in today’s healthcare arena. Would a less expensive program, employing 1 hour/day of direct training followed by 5 hours of structured home practice and daily telephone supervision, be equally effective? The purpose of this project was to determine if CIMT results in better outcomes when the training and practice occur onsite with the trainers as opposed to brief, daily, onsite training followed by home practice and telephone supervision. Subjects: Fifty subjects with the diagnosis of chronic stroke were included in this preliminary analysis. Procedures: Two groups, a lab-trained group (N=25, Mean age = 61 years) and a home-trained group (N=25, Mean age = 62 years) participated. Testing: The primary outcome measure was the Wolf Motor Function Test (WMFT) which consists of 15 timed tasks and two strength tasks. Results: Repeated measures ANOVA of the WMFT reveals a significant difference (p< .05) and significant interaction between groups on the pretest and posttest. The in-laboratory trained group improved significantly more on both the time and strength measures of the WMFT than did the home-trained group. Conclusion: Providing CIMT training in-house, with constant supervision and instruction, is significantly more effective than providing the CIMT training for an equivalent amount of time in a home-program setting.
P173 A Comparative Study of Constraint-Induced Therapy Versus Bilateral Arm Training for Stroke Rehabilitation
K. Lin1, L. Chuang1, and C. Wu2
1School of Occupational Therapy, National Taiwan University College of Medicine, Taipei, Taiwan, 2Department of Occupational Therapy, Chang Gung University, Taoyuan, Taiwan
Background and Objective. This study compared the effects of distributed constraint-induced therapy (dCIT), bilateral arm training (BAT), and control treatment (CT) on motor control, motor function, and functional use of the affected arm in stroke patients. Methods. Sixty-six patients were randomized to dCIT, BAT, or CT groups. Each group received intensive training for 2 hours/day, 5 days/week, for 3 weeks. Pretreatment and posttreatment measures included kinematic variables of reaching movement in unilateral and bilateral tasks, the Wolf Motor Function Test (WMFT), and the Motor Activity Log (MAL). Results. The dCIT and BAT groups performed smoother reaching trajectories in both unilateral and bimanual tasks relative to the CT group. The BAT group also generated greater force at movement initiation during the unilateral and bimanual tasks than the CT group. The difference between the BAT and dCIT groups on force at movement initiation (peak velocity) in the bimanual tasks approached significantly (P = .056). Moreover, patients receiving dCIT had greater WMFT functional ability score than the CT group and achieved better performance in the amount and quality of use of the limb using the MAL than the BAT and CT groups. Conclusions. Relative to CT, dCIT and BAT generated smoother movement and BAT exhibited greater force to initiate movement for stroke patients during the unilateral and bimanual reaching. The dCIT is also superior to the CT in enhancing functional ability of motor functions and functional use of the affected arm.
P174 Transfer Effects of Mental Training After Stroke: A Pilot Study
F. Malouin1, C. L. Richards1, and A. Durand2
1CIRRIS, Quebec City, QC, Canada, 2IRDPQ, Quebec City, QC, Canada
Background and purpose: The aim of this presentation is to examine the transfer effects of motor imagery or mental training combined with a small amount of physical training (P) on untrained tasks in persons with chronic stroke. Methods: Five persons (3 men) with a mean age of 61.3 (±7.2) years with a chronic stoke (1 to 5 years) were investigated. After 12 training sessions of mental training combined with a small amount of physical training, all participants had relearned to increase the loading on their paretic leg during rising from a chair and sitting down (R-S). For this presentation we report the changes in the vertical forces recorded under each foot during two untrained tasks: 1) quiet standing with eyes open (EO) and 2) with eyes closed (EC) before and after R-S training. Changes in the vertical impulse during 15 s of quiet standing EO and EC were calculated and converted in percent of body weight. Results: All participants improved the loading on the paretic side during the two untrained postural tasks. Significant (P=.025) gains ranged from 7% to 36% (EO: mean 15.5% ±12.9%) and from 4% to 22% (EC: mean 12.23% ±8.2%). Conclusion: The gains obtained after training a dynamic task (R-S) with mental training combined with a small amount of physical training were also observed for untrained postural tasks. Present findings suggest that transfer effects can be expected when the untrained motor tasks require similar motor strategy (limb loading).
P175 Cortical Effects of Polyneuropathy and Potential Consequences for Conventional Rehabilitation
J. Meijer
Rehabilitation Center Breda/Revant Rehab Centers, Netherlands
In polyneuropathy, sensory and motor nerve function is disturbed, which influences the central nerve system as shown on fMRI scans. Brain plasticity refers to the brain’s ability to change its structure and function during learning and recovery as a result of peripheral and central alterations of input. Learning and recovery depends on the information provided by sensori-motor efferent-afferent feedback loops. The efficiency and speed of the motor (recovery) process depends on sensory information provided by motor activity. Due to deafferentation, these cortical alterations take place in polyneuropathy, influencing cortical motor programs and learning.
On expert opinion, functional training in polyneuropathy is performed, to stimulate the disturbed feedback loops. This might explain the marginal results of the current rehabilitation programmes. Further knowledge of the peripheral and central mechanisms regulating the long-term recovery, might prompt newer and more efficacious strategies.
A promising treatment is motor imagery. Motor imagery is the active process to relive sensations with or without external stimuli. Motor recovery and learning are based on response-produced sensory information. By active exercise, a flow of sensory information is created. Numerous studies have indicated that motor imagery result in the same plastic changes on the same areas in the motor system as actual physical practice.
Motor imagery trespasses the inadequate efferent-afferent feedback loops of learning by direct stimulation of the cortex. The time is there to evaluate and implement these new insights in rehabilitation.
P176 Vibratory Stimulation as Additional Therapy in Stroke Patients: A Preliminary Study
G. Müller-Putz1 and P. Grieshofer2
1Rehab-Assist, Bad Goisern, Austria, 2Rehabilitation Clinic Judendorf Strassengel, Judendorf Strassengel, Austria
Recent studies showed that therapeutic electrical stimulation can improve the recovery of the upper extremity of patients after stroke (Peurala et al. 2002, de Kroon et al. 2002, Clinical Rehabilitation). In this work we report on first results after applying vibratory stimuli to a group of stroke patients.
Twenty stroke patients (aged 20 to 81years, mean 57, 10 men, 7 women) participated in this study, whereby they suffer from hemiparesis after lesions either at the left (8) or at the right hemisphere (9). Patients were recruited in the Rehabilitation Clinic Judendorf-Strassengel, Austria and the application of a vibration device (Rehab-Assist, Bad Goisern, Austria) was included within the therapeutic plan, individually adjusted.
Patients received the vibratory stimuli at the contralateral hand of the lesion. For those patients who have a flaccid palsy, a tether was used to fix the vibratory part in the same kind. The stimulation intensity and type of stimulation (pulsatile or continuous) was adjusted in a way, that patients did not feel uncomfortable.
The study was conducted during ongoing therapies, general parameters can be summarized: in total, the stimulation was applied 11 times (median, 10.6 times mean) for 10 min in each patient. We report on preliminary results of simple measures and the patients’ impressions and feelings.
P177 Muscle Vibration Decreases Spasticity in Spinal Cord Injury
N. Murillo1, H. Kumru1, J. Valls-Solé2, J. Medina1, and J. Vidal1
1Institut Guttmann, Badalona, Spain, 2Hospital Clinic, Barcelona, Spain
Objective: Spasticity is common after spinal cord injury (SCI). Increased sensitivity to Ia muscle afferent input may contribute to the development of these spasms. The possibility that mechanical stimulation of selected muscles can act directly on the nervous system inducing changes of motor performances was explored.
Methods: Nineteen spinal cord injury (SCI) patients with spasticity and nine healthy control subjects were studied in sitting position. In baseline and test conditions, we determined the score in the Ashworth Scale, the Knee ROM, cycle and duration of clonus (for SCI group). Neurophysiological studies were performed: the Hmax/Mmax ratio and withdrawal.
The test condition consisted in applying vibration at 50 HZ during 10 minutes on the rectus femoris.
Result: Vibration induced a significant reduction in: MAS, ROM of knee extension, number of cycles and total duration of clonus in SCI group (p<0.003 for each comparison).
Hmax/Mmax ratio decreased in both groups (p< 0.001).
The size of the bursts in TA and SOL activity was reduced significantly (p<0.03 for both muscles in SCI group and healthy control group).
Discussion: The improvement in spasticity is likely to be mediated by changes at the Ia synapse or motoneuron because vibration altered the magnitude of the soleus H reflex. Vibration-evoked depression of clinical and electromyographic activity may be clinically useful in controlling involuntary muscle contractions after SCI.
P178 Rehabilitation of Dysphagia: The Need to Change Strategies
R. Nusser-Müller-Busch
Unfallkrankenhaus Berlin, Berlin, Germany
Please see abstract content at
P179 The Effect of Transcranial Direct Current Stimulation on Attention After Traumatic Brain Injury
E. Kang1,2, D. Kim3, J. Lim1, and N. Paik1
1Seoul National University Bundang Hospital, Seongnam, Republic of Korea, 2Seoul Bukbu Geriatric Hospital, Seoul, Republic of Korea, 3Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
Objective: To test whether a single session of anodal transcranial direct current stimulation (tDCS) to the left dorsolateral prefrontal cortex (DLPFC) can improve attention in traumatic brain injury (TBI).
Method: Ten patients with attention deficit after TBI performed computerized contrast reaction time task before and after the administration of real (2mA for 20 min) or sham tDCS (2mA for 1 min) to the left DLPFC in a double blind, crossover manner.
Results: TDCS led to a significant shortening in reaction time relative to baseline (p<0.05), whereas sham stimulation did not. However, response accuracy were not changed for both stimulations (p>0.05).
Conclusion: Non invasive anodal tDCS applied to the left DLPFC was found to improve attention versus sham stimulation in TBI patients, which suggests the potential role of non-invasive cortical intervention to improve attention during rehabilitative training after TBI.
P180 Botulinum Toxin Type A (BoNT-A) and Treatment of Obstetric Brachial Plexus Palsy
S. I. Pascual-Pascual, M. Martinez Moreno, A. Lovic, and J. Lopez-Gutierrez
Hospital Universitario La Paz, Madrid, Spain
Objectives: Up to 30% of obstetric brachial palsies (OBP) leave permanent sequelae despite an adequate physical rehabilitation. Most common deformities are (upper OBP,C5-C6) fixed internal rotation, limited arm abduction-elevation, hyperpronation. The usual cause of sequelae in most cases is not weakness but early imbalance of agonist-antagonist muscles due to several causes: axonotmesis, abnormal axon regeneration or to an abnormal dystonic type learning of movement. Early BoTx-A infiltrations to non damaged muscles help to strengthen the most serevely affected, reaching better function of the arm. Pathophysiology and rationale for treatment is presented.
Methods: Review of all axonal injured OBP treated in our hospital. Sixty-one cases were treated according to a multiprofessional protocol: When axonotmesis is diagnosed after 3rd m, BoNT-A and/or surgery is indicated, added to physiotherapy. During follow up (average 30 months) they received 3.2 infiltrations (average), mainly in subscapularis and teres major. Also in biceps, triceps, pronator teres and pectoralis major). Twenty-five cases got 1-2 surgeries, preceded and/or followed by BoNT-A injections.
Results: BoNT-A gives excellent results in 25%, good in 50%, moderate in 10% of cases. Better results for arm elevation and abduction. Better results in early treatments (p<.01). The maximum improvement is reached after 18 months of treatment. Conclusion: BoNT-A has an important role in early management of OBP. It prevents or reduces the development of contractures improving the balance and function of the arm. Late treatment gives lower results. Video-recording is a crucial tool in evaluation.
P181 Does Cranioplasty Improve Consciousness in Patients With Craniectomy After Traumatic Brain Injury? An Exploratory Pilot Study
H. Stelling1, C. Dafe2, P. Mitchell3, and L. A. Graham2
1University of Newcastle, Newcastle upon Tyne, United Kingdom, 2Walkergate Park Centre for Neurorehabilitation, Newcastle upon Tyne, United Kingdom, 3Neurosurgery Department Newcastle General Hospital, Newcastle upon Tyne, United Kingdom
Background: Cranioplasty (CP), reconstruction of skull deficit following decompressive craniectomy, is traditionally viewed as a cosmetic procedure having no effect on neurological function after severe brain injury. However, cases of dramatic improvement in conscious level after CP have been observed in clinical practice.
Aim: To investigate whether cranioplasty is associated with consistent change in conscious level.
Method: Neurosurgical notes of patients undergoing cranioplasty from Jan 2007 -Jan2009 were retrospectively reviewed. Four measurements were taken between decompressive craniectomy & CP and four following CP. Each measurement included total Glasgow Coma Scale (GCS), individual GCS components, pupil size & limb power. Pre & post CP values were compared. Data were collected and analysed using Microsoft excel & SPSS.
Results: Twenty three patients, 16 male, mean age 37 years (range 16-64) were studied. There was a significant improvement in GCS over time (p<0.01). To test the specific impact of CP, immediate pre & post CP GCS values were compared, assuming time based improvement over this interval is minimal & improvement is attributable to CP. No significant change in immediate pre & post CP GCS was found.
Discussion: Improvement in consciousness attributable to CP has significant implications for clinical practice. This study found no evidence that cranioplasty has any effect on GCS in addition to expected time based recovery. The results were limited by small numbers & the pseudo- ordinal neurosurgical outcome measure used. Further study using detailed outcome measures is needed to further investigate the effects of cranioplasty after decompressive craniectomy.
P182 Anterior Versus Posterior Plastic Ankle Foot Orthoses for Ankle Spasticity: Which One Is Better?
A. Suputtitada, W. Chatkungwanson, N. Chaiprakit, and J. Theamprasit
Department of Rehabilitation, Faculty of Medicine, Bangkok, Thailand
Objectives: To compare the effectiveness of anterior plastic ankle foot orthosis (AFO) and posterior plastic AFO for treatment of ankle spasticity in stroke patients.
Study design: A randomized crossover design.
Methods: Ten stroke patients with ankle spasticity MAS score ≥ 1+ were recruited. Five were treated with anterior plastic AFO before posterior plastic AFO and five were treated with opposite sequence. Apply each orthosis for 30 minutes in 1 week interval. Outcomes measurement was performed by using passive range of motion (PROM), Modified Ashworth scale(MAS), walking velocity, stretch reflex surface EMG and walking surface EMG of medial gastrocnemius muscles and patient satisfaction.
Results: The results compared between two types of orthoses revealed statistically significant improvement of walking velocity and walking surface EMG of medial gastrocnemius muscles in anterior plastic AFO more than posterior plastic AFO. But there is no statistically significant in outcomes of PROM of ankle dorsiflexion, MAS and stretch reflex surface EMG of medial gastrocnemius muscle when compared between two orthoses. Patient satisfaction of anterior plastic AFO was statistically significant higher than posterior plastic AFO.
Conclusion: This study revealed that anterior plastic AFO is more effective in reducing calf muscle spasticity during walking than posterior plastic AFO.
P183 Evidence of Neuroplasticity in Hand Motor Control After Intensive Rehabilitation in Subjects With Chronic Stroke
I. M. Tarkka1, M. Könönen2,3, and K. Pitkänen4
1Department of Health Sciences, Jyväskylä, Finland, 2Department of Clinical Neurophysiology Kuopio University Hospital, Kuopio, Finland, 3Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland, 4Brain Research and Rehabilitation Center Neuron, Kuopio, Finland
Cerebrovascular stroke is the leading cause of long-term disability world-wide. Despite improved management of stroke during the acute phase, the majority of survivors are disabled and they need effective and long-term rehabilitation. Constraint-induced movement therapy (CIMT) is one of the therapies for subjects with stroke concentrating the rehabilitative efforts on the affected hand and arm. Here the effects of two-week long CIMT on behavioral, neuroimaging and neurophysiologic measures in subjects with chronic stroke were studied. The behavioral data on hand function of 88 subjects (mean age 50±12years) with chronic stroke (mean duration since stroke onset 36±18 months) who participated in two-week long CIMT is presented. Behavioral gains were observed in hand function of the subjects with stroke and we found that neither the time since stroke not the affected hemisphere nor the gender of the subject had any significant effect on the degree of functional gain achieved in the therapy. A small subgroup of subjects participated also in functional MRI (fMRI) and transcranial magnetic stimulation (TMS) studies. Changes were observed in fMRI activations of the affected hand fist making movements after therapy and they varied in accordance with the individually achieved functional changes. In addition, hand muscle responses to TMS showed modifications after therapy. They were larger in amplitude and elicitable more laterally in the affected hemisphere in these subjects. Neurophysiologic and functional imaging results are taken as evidence for use-dependent plasticity in subjects with chronic stroke.
P184 Effects of Sensory Intraoral Stimulation in the Swallowing Process
R. Tobar, S. Tapia, A. Helo, P. Arecheta, and L. Toledo
Universidad de Chile, Santiago, Chile
Background: Dysphagia is a high incidence complication in stroke patients. Approximately 51% of patients with an acute stroke have dysphagia. This condition increases the risk of malnutrition, pneumonia, dehydration, social role impairment and death. Dysphagia is frequently associated with decreased sensibility. For this reason, the intraoral sensory stimulation is often used in rehabilitation. However, there is not enough evidence to prove its efficacy.
Objective: To determine the effect of intraoral sensory stimulation of swallowing ability in patients with neurogenic dysphagia diagnosis, secondary to stroke.
Method: Subject: 15 healthy Chileans between 50 and 80 years old, with a diagnosis of neurogenic dysphagia, secondary to stroke.
Procedures: First, an anamnesis and history review was performed. Swallowing was then clinically examined with a standard protocol and the Swal-QOL was completed. Subsequently, intraoral sensory therapy was applied. This therapy was conducted during one month by a speech pathologist who trained a caregiver in the procedures. The caregiver performed these activities every day, 3 times a day, and the speech pathologist oversaw the procedures, 2 times per week.
Results: All of the patients improved their swallowing abilities to some extent. The most important improvements were in intraoral sensibility and swallowing parameters. Moreover, all patients improved their quality of life when measured with the Swal-QOL test.
P185 Experience of First Baclofen Pump Insertion in Abu Dhabi
S. A. Wasti and M. Mansur
Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
Insertion of Baclofen pump for severe generalized lower limb spasticity is now an accepted treatment in most developed health care systems. Patients from emerging affluent countries often go overseas for management of spasticity and sometime have the baclofen pump inserted. On return there are difficulties with follow up care such as effect and dose monitoring and pump refilling. We present our experience of first locally inserted baclofen and difficulty with follow up compliance.
A 34-year-old female with cerebral palsy had been a resident in a long-term care facility for 12 years. Case review revealed that lower limb spasticity and spasms made care difficult and heavy. After careful evaluation by multidisciplinary team decision was made to insert baclofen pump. Family was briefed about the procedure and follow up requirements. After the insertion and dose titration the spasticity and spasms improved. Her care needs became easier to manage and patient was discharged home. Since discharge however, there has been a regular failure to attend for follow up appointments making it difficult to monitor response, titrate dose and refill the pump. Family has been counseled on several occasions.
Our experience indicates that follow up care after baclofen pump insertion can be difficult to maintain. This may be particularly true for patients from families with limited educational background. Perhaps careful choice of patients and a community based specialist nurse surveillance and monitoring service is the best way to ensure effective follow up.
P186 Evaluation of a Shoulder Orthosis in the Rehabilitation of the Severely and Flaccid Arm After Stroke: A Prospective Study
C. Werner1, A. Bardeleben2, I. Rembitzki3, and S. Hesse1
1Charité University Medicine Berlin, Medical Park Berlin, Berlin, Germany, 2Medical Park Berlin, Berlin, Germany, 3Otto Bock Health Care, Duderstadt, Germany
Within study we evaluated clinical and gait analysis data on the orthosis OmoNeurexa, a new shoulder orthosis to prevent and treat a painful shoulder (PS) after stroke. A shoulder brace of soft material connects to a forearm cuff to promote elbow extension and supination. Out of 26 subjects, 23 patients used the device continuously for four weeks and three put the orthosis off within three days (too tight, no effect anticipated, fear of flexor spasticity). The comfort was good, transpiration minimal, and 15 patients reported a beneficial effect of the orthosis on their activities, e.g. they felt more secure during transfer tasks and mobility. Eleven patients reported a relevant pain reduction. The gait analysis of 10 patients revealed a more dynamic gait pattern reflected by a significant reduction of the relative double stance phase. Furthermore the paretic quadriceps muscle was facilitated during the initial stance phase in selected patients. The therapists reported that they could intensify their functional therapy approach in seven subjects. The shoulder subluxation decreased, spasticity of the initially plegic patients only slightly increased, and the shoulder range of motion did not change. The orthosis is an interesting component in the prevention and treatment of PS after stroke, controlled trials are justified.
P187 The Effectiveness of Light Therapy on Agitated Behaviours in Institutionalized Older Adults With Dementia: A Systematic Review
M. Wu1,2, H. Sung1, W. Lee1, and S. Tsai1
1Tzu Chi College of Technology, Hualien, Taiwan, 2Tzu Chi University, Hualien, Taiwan
Background: Agitated behaviours are common in older adults with dementia and can cause negative impact on those with dementia themselves and their caregivers if these behaviours are not appropriated managed. Studies have shown that light therapy has positive impact on emotional and psychological well-being of older adults; however, the evidence of the effectiveness of light therapy on agitated behaviours of those with dementia in long-term care facilities is unclear.
Objective: This systematic review aimed to determine the best available evidence regarding the effectiveness of light therapy on agitated behavior in older adults with dementia in long-term care facilities.
Methods: Search of CINAHL, Medline, PsychInfo, Cochrane, and Chinese publication databases were conducted. The search was limited to articles published in English and Chinese between the year 1990 and 2009.
Results: Only four articles met the inclusion criteria: randomized controlled trial, older adults with dementia residing in long-term care facilities, light therapy as the intervention, and agitated behaviours as the primary outcome. This review of four RCT studies reported that light therapy overall has positive impact on reduction of agitated behaviours in institutionalized older adults with dementia.
Conclusions: Light therapy can be a simple and effective complementary therapy to reduce occurrence of agitated behaviours in those with dementia, so health care professionals can apply this therapy for those with dementia in long-term care facilities to reduce their agitated behaviours in order to promote the health and the quality of life in older adults with dementia in long-term care facilities.
P188 The Long Term Efficacy of Extracorporeal Shock Wave Therapy in Stroke Patients With Spasticity
S. Yoo1, H. Kim2, J. Park1, D. Kim1, and P. Jung1
1East West Neo Medical Center, College of Medicine, Kyung Hee University, Seoul, Republic of Korea, 2College of Medicine, Kyung Hee University, Seoul, Republic of Korea
Objectives: We investigate the effect of extracorporeal shock wave therapy (ESWT) on muscle spasticity of elbow flexor and forearm pronator affected by stroke. Few studies have examined various treatment protocols depending on patients with stroke.
Methods: We studied 65 patients (treatment 35 case, control 30 case) affected by stroke with spasticity in upper limbs. Mean onset period was 9.2 months and mean age was 58.9 years. Inclusion criteria were a more than 4-month history of stroke and scores of higher than 2 points on the modified Ashworth scale (MAS). The shock wave (Vitera, hydraulic) was applied on biceps and flexor carpi radialis. Stimuli were given to the site of treatment 1000 times; 4 Hz; 0.069 mj/mm2. The patients were evaluated by K-NIHSS, MAS, Modified Tardieu Scale (MTS), and active elevation of upper limb. Treatment was performed 1 time/week, total 3 times in each muscle. Patients were evaluated at baseline, after sham stimulation, 4 weeks, 8 weeks and 12 months after treatment using MAS, MTS, and active elevation.
Results: On MAS, MTS and active elevation after ESWT, patients showed significant decrease in spasticity of elbow flexor and forearm pronator after the 1st, 4th, 8th weeks and 12 months compared with control, baseline and sham stimulation(p<0.05). At 8th weeks, the treatment effect using MTS and active elevation were peak.
Conclusion: The repeated treatment increased its effect. Following ESWT, assessment using MAS and MTS showed a decreased spasticity. ESWT can be used to treat patients with the spasticity in the upper limbs.
P189 Inhibition of Contralesional Motor Cortex Improves Motor Sequence Learning in Chronic Stroke Patients
M. Zimerman1, K. F. Heise1, N. Freundlieb1, J. Hoppe1, L. G. Cohen2, C. Gerloff1, and F. C. Hummel1
1Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany, 2Human Cortical Physiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH), Bethesda, MD, United States
Background: Motor learning mechanisms interact with rehabilitative training and are a key component for stroke recovery. Recent studies demonstrated that decreasing activity in ipsilateral motor cortex could be beneficial to transiently improve motor function after stroke. However, the question remains open whether this intervention will also improve motor learning The purpose of this study was to test the hypothesis that down-regulation of the contralesional motor cortex (cM1) by the paretic hand will enhance the learning process of a motor sequence task in chronic stroke patients.
Methods: 12 chronic stroke patients (59 ± 4.3 SE) were tested in a double-blind, sham-controlled, cross-over design. All subjects attended two training sessions during which either cathodal transcranial direct current stimulation (tDCS) or Sham was applied to the cM1 with an inter-session interval of at least one week. Motor performance was evaluated before, 90 min. and 24h after training.
Results: We found a significant improvement in correct sequences with tDCS relative to Sham that outlasted the stimulation period by at least 24h post training (F= 5,68; p<0.02).
Conclusion: These results indicate that cathodal tDCS over cM1 can enhance the effects of motor training and might provide a promising interventional strategy in combination with regular rehabilitative training.
5.3 Robotics
P190 Virtual Reality Enhances Walking Performance in Robotic Assisted Gait Training of Children
K. Brütsch1,2, A. König3, L. Zimmerli3,4, L. Lünenburger4, S. Mérillat (-Koeneke)1, R. Riener3, L. Jäncke1, and A. Meyer-Heim2
1University of Zurich, Institute of Neuropsychology, Zurich, Switzerland, 2Rehabilitation Center Affoltern a. A., University Children’s Hospital Zurich, Affoltern a. A., Switzerland, 3Sensory-Motor Systems Laboratory, ETH Zurich, Zurich, Switzerland, 4Hocoma AG, Volketswil, Switzerland
Virtual reality (VR) offers novel options to provide therapy within a functional, purposeful and motivating context. Combining robotic assisted gait training (RAGT) with VR technologies seems to be a promising possibility for rehabilitation therapy. However, the effectiveness of RAGT in children is strongly influenced by their motivational state during the intervention. Therefore, we developed VR-based scenarios that provided interactive elements to engage patients during RAGT. The aim of this study was to compare the immediate effect of different supportive conditions (VR versus non-VR conditions) on motor output in patients and healthy children while training with the driven gait orthosis Lokomat®.
Thirteen patients (six males, seven females, mean age 12.31 years, SD. 2.39 years) with different neurological disorders and 14 healthy children (seven males, seven females, mean age 11.79 years, SD. 2.72 years) participated in this study. Firstly, they were instructed to walk in the Lokomat with three different activity levels to ascertain the individual degree of active involvement. Secondly, four randomly presented conditions have been presented: two different VR-based conditions, therapist instructions to promote active walking and watching their favourite DVD. The measured motor output is expressed by force exertion provided by the Lokomat.
Biofeedback values of the swing phase correlated highly with the instructed activity levels of the participants (p<0.01). Active participation in children increased significantly when supported with VR scenarios compared to other supportive conditions (p<0.05).
In summary, VR represents a valuable tool for patients and healthy subjects to keep motivation high during RAGT.
P191 Improvement of Gross Motor Function in Children With Cerebral Palsy After Robotic Gait Training
A. Czernuszenko1, M. Bonikowski1, J. Kwasiborski1, A. Stęplowska1, E. Żak2, M. Jóźwiak3, F. Manikowska3, and S. Snela4
1Mazovian Neuropsychiatric and Rehabilitation Center for Children and Youth, Wiązowna, Poland, 2Department of Rehabilitation, Medical University of Silesia, Katowice, Poland, 3Klinika Ortopedii i Traumatologii Dziecięcej Uniwersytet Medyczny im K. Marcinkowskiego, Poznań, Poland, 4Children Orthopedic and Traumatology Department Country Hospital No 2, Rzeszów, Poland
Purpose: This randomized study evaluated the effect of 4 weeks of robotic-assisted (Lokomat) gait training additional to conventional therapy in diplegic children.
Materials and methods: 21 children aged 6-14 (mean 12.13) with a diagnosis of spastic diplegia due to cerebral palsy (CP) GMFCS level II to III were divided into 2 groups. Intervention group (n=12) participated in a 4-week robotic-assisted walking training involving max. Twenty sessions (45 min per session). Both groups participated in the same conventional rehabilitation program.
Pre- and post-training evaluations were performed with GMFM 88. Mean data of the 21 subjects were pooled and pre- and post-training comparisons were made.
Result: Post-training evaluations revealed improvements in B, D and E domain of GMFM in the Lokomat group (mean (SD) 2,99 (5,0), 5.14 (5,7) and 5.8 (3,4) percent respectively) and increase in B and E domain of GMFM in control group (mean (SD) 3,5 (1,1) and 1,56 (2,5) % respectively). The difference in improvement in E domain of GMFM between Lokomat and control groups was statistically significant.
Conclusion: The present study supports recent findings that robotic-assisted gait training can lead to improvement of gait function in ambulatory children with cerebral palsy (CP).
P192 Complex Step-by-Step Rehabilitation Program With Robotic Mechanotherapy in Acute MCA Ischemic Cerebral Stroke
V. S. Feshchenko, E. A. Pavlova, G. E. Ivanova, O. M. Samsygina, and A. Y. Suvorov
Department of Physical Therapy and Sports Medicine, Russian State Medical University, Moscow, Russian Federation
Goal: To study efficacy of a complex step-by-step inpatient rehabilitation program in acute MCA ischemic stroke patients. The study included 24 patients (aged 40-80), who were monitored using clinical and neurological examination, the minor stress response functional testing (MSRFT) and the Rivermead ADL (RADL). The MSRFT results attributed the patient to one of four steps of treatment protocol and, when have met next step inclusion criteria, moved to the next one. Group 1 (n=1, initial RADL=1, hyperventilation test passed) followed a step 1 treatment protocol with very early mobilization (tilt table), the ontogenetic-based kinesotherapy stage 1+2 (in supine, side-lying, prone) and bilateral arm exercises as cardiotraining. Group 2 (n=6, initial RADL=2-3, semiorthostatic test passed) used a step 2 protocol, including cycling as cardiotraining (Motomed Viva2), CPM leg exercises (Con-Trex LP) and active sitting and passive standing exercises. Group 3 (n=5, RADL=4-5, orthostatic test passed) followed a step 3 protocol comprising standing balance and weight transfer exercise (COBS), passive- to-active and active lower-extremity training exercise (Con-Trex LP), cardiotraining and gait training (GT-1). Group 4 (n=12, RADL>= 6, orthostatic test passed) used a step 4 protocol with standing balance and weight transfer exercises (COBS), active lower-extremity training exercises (Con-Trex LP) and walking speed and cardiotraining (treadmill with HR monitoring). A 14 days inpatient rehabilitation resulted in an increase of physical tolerance and a 3-4 point rise of RADL score in all groups. This step-by-step program is consistent with neuromotor reeducation principles and may contribute to ADL rehabilitation in acute cerebral stroke patients.
P193 Armeo as Training Tool to Improve Upper Limb Functionality in Multiple Sclerosis: A Pilot Study
D. Gijbels1, G. Alders2, I. Lamers2, E. Knippenberg2, L. Kerkhofs3, and P. Feys1
1REVAL PHL-Uhasselt, Hasselt, Belgium, 2REVAL PHL, Hasselt, Belgium, 3MS and Rehabilitation Center, Overpelt, Belgium
Background: Little research in MS has focused on physical rehabilitation of upper limb dysfunction, though it strongly influences the performance of important activities of daily living (ADL). Further, the use of rehabilitation technology for improving arm function has not yet been documented in patients with MS.
Objective: This pilot study was aimed at establishing the effects of a 8-week mechanical-assisted training program on upper limb muscle strength and ADL function in MS patients with moderate to severe paresis.
Methods: A case series was applied, with provision of a training program (3x/week, 30 minutes/session) supplementary on the conventional therapy, by employing a gravity-supporting exoskeleton apparatus (Armeo®). Ten high-level disability patients (EDSS 7.0-8.5) performed actively exerted movements in a virtual, real life-like learning environment receiving visual, auditory and performance feedback. Tests were administered before and after training, and at 2-month follow-up. Muscle strength was determined through the Motricity Index (MI) and Jamar hand-held dynamometer; ADL function was assessed using the TEMPA, Action Research Arm Test (ARAT) and 9-Hole Peg Test (9HPT).
Results: Muscle strength remained unchanged. Significant improvements were particularly found in ADL function parameters. After training, performance of the TEMPA progressed (p=0.02), while a trend towards significance was found for the 9HPT (p=0.05). Remarkably, at follow-up, results on the TEMPA as well as ARAT indicated on further progression relative to baseline, both being significant (p=0.01, p=0.02 respectively).
Conclusions: The results suggest that arm functionality is trainable in high-level disability MS patients by means of a technology-enhanced physical rehabilitation program.
P194 Toy-Based Devices to Increase Functional Recovery in Children With Cerebral Palsy
K. L. Kerman1, B. Therrien2, C. O’Rourke2, A. Shaikhouni2, and J. J. Crisco2
1Warren Alpert Medical School, Brown University/Rhode Island Hospital, Hasbro Children’s Hospital, Dept. Pediatrics, Providence, RI, United States, 2Warren Alpert Medical School, Brown University/Rhode Island Hospital, Hasbro Children’s Hospital, Dept. Orthopaedics, Providence, RI, United States
Cerebral palsy (CP) includes a group of non-progressive clinical syndromes of children characterized by motor dysfunction. Physical therapy, orthotics, electrical stimulation, pharmacotherapy and surgery are major treatments to increase function. Constraint and robotic therapy data suggest that increased skilled use of disabled muscles may promote functional restoration through direct effects on muscle and changes within the CNS. Our objectives are (1) create new toy-based devices for children with CP that enhance the total amount and frequency of therapy outside of limited clinical sessions; (2) demonstrate that increasing therapy improves functional outcomes. Toy controllers encourage the use of affected upper limb muscles in order to operate remote controlled, motorized toys. Controllers record relative joint motion and toy use. Limb function is evaluated by standard functional measures (AHA, SHUEE, PEDI, Ashworth) as well as quantitatively in a visuomotor step tracking task. In the ongoing pilot study children (ages 5-12) are assigned to an experimental group who use toy controllers or a control group with standard controllers (e.g. joysticks). Limb function is measured at enrollment,1, 2, 3 and 6 months. Our long term goal is to translate these prototypes into inexpensive rehabilitation toys with wide availability. This approach may lead to a community-based extremity therapy for a wide range of neuromotor impairments.
P195 Changes in Circle Area After Gravity Compensation Training in Chronic Stroke Patients
T. Krabben1, G. B. Prange1, J. de Boer1,2, H. J. Hermens1,3, H. van der Kooij4, and M. J. A. Jannink5
1Roessingh Research & Development, Enschede, Netherlands, 2Roessingh Rehabilitation Center, Enschede, Netherlands, 3University of Twente, Department of Electrical Eng., Mathematics and Computer Science, Enschede, Netherlands, 4University of Twente, Department of Biomechanical Engineering, Enschede, Netherlands, 5Oost NV, The Development Agency East Netherlands, Enschede, Netherlands
Introduction: After stroke, many people experience difficulties to selectively activate muscles. Shoulder abduction is often accompanied by elbow flexion. Gravity compensation reduces the activation level of shoulder abductors which limits the amount of involuntary elbow flexion. The objective of the present study is to examine whether training in a gravity compensated environment can lead to increased range of motion during unsupported movement.
Methods: During six weeks, eight chronic stroke patients received 18 half hour sessions of gravity compensation training. The training consisted of reaching exercises needed to play the computer game ‘FurballHunt’. Gravity compensation was applied through a passive device called Freebal. Motor status and movement performance were evaluated before and after training. Motor status was evaluated with the Fugl-Meyer (FM) assessment, and movement performance with an unsupported circle drawing task. During this task shoulder and elbow angles were measured by a robotic exoskeleton called Dampace. The area of the circles was calculated.
Results: After training, FM scores increased on average 3.3 points. Circle area increased with an averaged increase of 113 cm2 (34.4%).
Discussion and conclusion: The majority of chronic stroke patients increased motor status and movement performance after training. Training in a gravity compensated environment can lead to an increased range of motion as represented by the increased circle area. Similar results were reported after instantaneous application of gravity compensation. Gravity compensation training by means of a simple robotic device can induce improvements in arm function.
P196 Actual Experience With the “Armeo” Mechanized System for the Rehabilitation of Patients With Upper Limbs Paresis
K. Lyadov, T. Shapovalenko, I. Sidyakina, V. Ivanov, and A. Albegova
Center of Restoration Medicine and Rehabilitation, Moscow, Russian Federation
“Armeo” is a rehabilitation complex with support for an affected hand. It was developed for functional therapy of patients with upper limbs pareses.
In “Armeo” complex following principles are realized: 1) reduction of weight of the paretic limb and facilitation of active movements; 2) biological feedback allowing the patient to self-control his actions; 3) organization of training as a game of variable complexity which raises patient’s motivation for successful task realization.
We examined 20 patients (average age was 51,6 ±18,6 years) with various pathology (stroke, spinal and craniocerebral injury, vertebrogenic myelopathy; encephalitis aftereffects).
Estimation of functional abilities of an upper limb was done according to the scale of estimation of hand paresis (Upper Extremity Motion) by Bard and Hirschberg; scale for hand function estimation (Frenchay Arm Test) by D. Wade. Muscular tonus was estimated according to six-score scale for spasticity estimation (Modified Ashworth Scale of Muscle Spasticity) by R. Bohannon, V. Smith.
Testing was done before the beginning of the training and after completing of the course on “Armeo” complex.
Conclusions: 1) inclusion of the “Armeo” device in complex treatment promotes intensification of rehabilitation program; 2) this study showed that for the patients with pareses of the hand training on “Armeo” complex promotes the raising of an arbitrary activity in proximal and distal section; 3) training including “Armeo” device does not lead to significant intensification of paretic limbs spasticity.
P197 Electromechanical and Robot-Assisted Arm Training for Improving Arm Function and Activities of Daily Living After Stroke: A Systematic Cochrane Review of the Evidence
J. Mehrholz1,2, T. Platz3,4, J. Kugler5, and M. Pohl6
1Wissenschaftliches Institut, Kreischa, Germany, 2SRH FH Gera, Gera, Germany, 3BDH-Klinik Greifswald, Department Neurowissenschaften des Universitätsklinikums, Greifswald, Germany, 4Ernst-Moritz-Arndt Universität, Greifswald, Germany, 5Department of Public Health, Faculty of Medicine, TU Dresden, Dresden, Germany, 6Klinik Bavaria Kreischa, Kreischa, Germany
This systematic review examined the effectiveness of electromechanical and robot-assisted arm training for improving activities of daily living and arm function and motor strength of patients after stroke.
We searched the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, AMED, SPORTDiscus, PEDro, COMPENDEX and INSPEC. We also handsearched relevant conference proceedings, searched trials and research registers for randomised trials. The primary outcome was activities of daily living.
This review identified 11 trials, which included 328 participants. Electromechanical and robot-assisted arm training did not improve activities of daily living (SMD = 0.29; 95% confidence interval (CI) -0.47 to 1.06; P = 0.45; I2 = 85%). Arm motor function and arm motor strength improved (SMD = 0.68, 95% CI 0.24 to 1.11; P = 0.002; I2 = 56% and SMD = 01.03, 95% CI 0.29 to 1.78; P = 0.007; I2 = 79% respectively). Electromechanical and robot-assisted arm training did not increase the risk of patients to drop out (RD) (fixed-effect model) = 0.01; 95% CI -0.05 to 0.06; P = 0.77; I2 = 0.0%) and adverse events were rare.
Patients who receive electromechanical and robot-assisted arm training after stroke are not more likely to improve their activities of daily living, but arm motor function and strength of the paretic arm may improve. However, the results must be interpreted with caution because there were variations between the trials in the duration, amount of training and type of treatment, and in the patient characteristics.
P198 Electromechanical-Assisted Training for Walking After Stroke: What Is the Evidence?
M. Pohl1, C. Werner2, J. Kugler3, and J. Mehrholz4,5
1Klinik Bavaria, Kreischa, Germany, 2Abteilung Neurologie, Medical Park Berlin, Klinik Humboldtmühle, Berlin, Germany, 3Department of Public Health, Faculty of Medicine, TU Dresden, Dresden, Germany, 4Wissenschaftliches Institut der Klinik Bavaria, Kreischa, Germany, 5SRH FH Gera, Gera, Germany
The aim of the present study was to investigate the effect of automated electromechanical and robotic-assisted gait training devices for improving walking after stroke.
We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, EMBASE, CINAHL, AMED, SPORTDiscus, PEDro, COMPENDEX and INSPEC. We handsearched conference proceedings and trial registers in an effort to identify further randomised trials.
The primary outcome was the proportion of patients walking independently (without assistance or help of a person) at follow up.
Seventeen trials (837 participants) were included in this review. Electromechanical-assisted gait training in combination with physiotherapy increased the chance to walk independently (odds ratio (OR) 2.21, 95% confidence interval (CI) 1.52 to 3.22; P < 0.001), but did not increase whether walking velocity (MD = 0.04 m/sec, 95% CI -0.05 to 0.13; P = 0.39) nor walking capacity significantly (mean difference (MD) = 7 metres walked in six minutes, 95% CI -32 to 46; P = 0.073). Patients who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are more likely to achieve independent walking than patients receiving gait training without these devices. However, further research should address specific questions, for example, which frequency or duration of electromechanical-assisted gait training might be most effective and at what time after stroke, and follow-up studies are needed to find out how long the benefit lasts. Future research should include estimates of the costs (or savings) due to electromechanical gait training.
P199 Effects of Different Robot-Aided Approaches for the Upper Limb Rehabilitation in Neurological Impaired Patients
S. Mazzoleni1, M. C. Carrozza1, P. Dario1, S. Micera1,2,3, and F. Posteraro4
1ARTS Lab Scuola Superiore S. Anna, Pisa, Italy, 2Neuroprosthesis Control Group, Institute for Automation, Swiss Federal Institute of Technology, Zurich, Switzerland, 3Rehabilitation Institute and Technology Center, Zurich, Switzerland, 4Auxilium Vitae Rehabilitation Centre, Volterra (Pisa), Italy
Objective: The objective of the present study is to present the results of the upper limb robot-aided rehabilitation in hemiparetic patients using different approaches.
Methods: Seventy-one chronic hemiparetic subjects were altogether recruited in experimental clinical trials using different approaches.
Fifteen patients were recruited in a study aimed at assessing the effects of divergent force fields scenario, twenty patients in a second study aimed at assessing the effects of a convergent force field scenario, thirty-four patients in a third study aimed at comparing two different rehabilitation scenarios, two patients (and four healthy subjects) in a forth study aimed at assessing the preliminary reliability of an innovative method of assessment using EEG signals synchronicity with robot parameters.
The InMotion2 robotic system (Interactive Motion Technologies, Inc., Cambridge, MA, USA), designed for clinical and neurological applications, was used for this study. All subjects were asked to perform goal-directed, planar reaching tasks that emphasized shoulder and elbow movements, using different scenarios.
Results: The results of different studies show that a) the application of divergent force fields seems to improve the effectiveness in mild impaired patients; b) the effectiveness of robot-aided therapy for the upper limb rehabilitation in chronic hemiparetic patients can continue even more than one year after the acute event; c) the execution of active movements reduces, and not increases, spasticity in neurologically impaired patients; d) synchronized EEG measurements highlight an increased ipsilateral hemispheric activation in each patient at the end of the treatment.
P200 First Results on Feasibility and Efficacy of a Robotic, Home-Based Locomotion Therapy in Chronic, Incomplete Spinal Cord Injured Subjects
H. Plewa1, M. Knestel2, E. P. Hofer2, C. Schuld1, and R. Rupp1
1Orthopaedic University Hospital, Heidelberg, Germany, 2 Institute of Measurement, Control and Microtechnology, University of Ulm, Ulm, Germany
Introduction: In incomplete spinal cord injured (iSCI) subjects task oriented training regimes are applied for enhancement of neuroplasticity to improve gait capacity. A sufficient training intensity can only be achieved in clinics with the use of complex gait robots. For continuation of the automated locomotion training at home the compact, pneumatically driven orthosis “MoreGait” has been developed, which generates the key afferent stimuli for activation of the spinal gait pattern generator. The objective of this study is to test the feasibility and efficacy of this novel device.
Methods: Eight chronic (time since injury: 8,5 ± 6.94 y) SCI (1 tetraplegic, 7 paraplegic) individuals (5 female, 3 male, mean age: 44 ± 9.48 y) with an incomplete lesion (4 ASIA C, 4 ASIA D) have been included.
Training was performed for 8 weeks (45 min./day for a min. 4 days/week). Primary outcome measures were 10m and 6-min. walk tests.
Statistical analysis was done with Wilcoxon matched-pair-test and Bonferroni-correction for multiple comparisons.
Results: All participants performed the training on a daily basis. Only one adverse event (pressure ulcer) directly related to the device occurred.
A significant (p<0.025) increase of the mean gait speed (4 weeks: 42%, 8 weeks: 80%) compared to baseline has been observed. Mean gait endurance improved by 44% (4 weeks) and 68% (8 weeks).
Conclusions: A home-based robotic training with the novel MoreGait is feasible and well accepted by the users. The outcomes in iSCI individuals are at least comparable to those of complex locomotion robots used in clinics.
P201 Efficacy of Complex Inpatient Rehabilitation Program With Robotic Mechanotherapy for Restoration of Upper Extremity Function in Acute Ischemic Stroke Patients
O. M. Samsygina1, G. E. Ivanova1, A. Y. Suvorov1, and E. A. Kovrazhkina2
1Department of Physical Therapy and Sports Medicine, Russian State Medical University, Moscow, Russian Federation, 2Department of Fundamental and Clinical Neurology and Neurosurgery, Russian State Medical University, Moscow, Russian Federation
Goal: To investigate efficacy of robotic mechanotherapy for upper extremity used in complex with conventional step-by-step rehabilitation program. A study group included 7 patients in acute phase of ischemic atherothrombotic stroke (mean age 58±12, Left MCA -3, Right MCA -4), who followed a complex step-by-step rehabilitation program with robotic mechanotherapy. The control group included 30 patients (mean age 61± 14, Left MCA 19, right MCA-11), who followed conventional complex step-by-step ontogenesis-based rehabilitation (including eye movement exercises, cardiotraining with bilateral symmetrical arm lifting and cycling, step-by-step ontogenetic kinesotherapy). The study protocol included a transition from passive exercises to active concentric and eccentric contractions, performed in conventional and scapular planes (Con-Trex Multijoint, Working Simulation) in addition to conventional program. Assessment included active and passive ROM, the shoulder shrug test (positive in all patients), the Fugl-Meyer upper extremity total score (FMUETS) with routine clinical and neurological examination (muscle strength and tone), the minor-stress response functional testing. There was a marked difference in FMUETS at discharge with 36 for the study group (initial 14) and 24 for the control group (initial 13), also seen as a difference between the study and control group in active/passive ROM of the shoulder and elbow (a contribution of 23%/36% for shoulder flexion and 16%/18 for external rotation, 15%/18% and 17%/19% for forearm pronation and supination in study group), muscle strength - 16% and muscle tone - 31%. These enabled the study group patients to incorporate the hemiplegic arm into activities of daily living.
P202 Repetitive Locomotor Therapy After Stroke With the Help of an Electromechanical Gait Trainer: Review on the Controlled Trials
C. Werner1, A. Bardeleben2, and S. Hesse1
1Charité University Medicine Berlin, Medical Park Berlin, Berlin, Germany, 2Medical Park Berlin, Berlin, Germany
Gait rehabilitation is a major concern after stroke. Modern concepts of motor learning favour a task specific repetitive approach, i.e. an individual who wants to regain walking ability has to walk. The Gait Trainer GT I is an end-effector-based electromechanical device enabling the wheelchair-bound subject to repetitively practice complex gait cycles. The harness-secured patient is positioned on two foot plates whose movements simulate stance and swing phases. Controlled trials have been conducted so far in Germany (multicentre trial, n= 165; Pohl et al., 2007), Hong Kong (monocentre trial, n=50; Tong et al., 2006), Finland (monocentre trial, n=56, Peurala et al., 2009), and Portugal (monocentre trial, n=; 40, Dias et al, 2007). The meta analysis on the studies revealed a superior effect of the machine in combination with physiotherapy on gait function and on gait speed in non-ambulatory stroke patients. The net therapy time was comparable in both groups. The higher number of steps practiced in each single session (uo to 1000 on the GT I) was the major explanation. The studies and the meta analysis will be presented.
5.4 Assistive Technology
P203 Effects of Closed Kinetic Chain Exercise on Balance and Gait Ability Using Sliding Rehabilitation Machine in Chronic Stroke Patients
S. Byun1, T. Jung2, and D. Kim2
1Department of Rehabilitation Medicine, Dae-gu Fatima Hospital, Dae-gu, Republic of Korea, 2Department of Rehabilitation Medicine, Kyung-pook National University College of Medicine, Dae-gu, Republic of Korea
The purpose of this study was to investigate if the sliding rehabilitation machine, which makes the stroke patients use of their affected lower limb, can be a useful tool for the improvement of balance and gait ability in chronic stroke patients.
Thirty chronic stroke patients were involved in this study. They were divided into two groups. The one group (group A, n=15) underwent the sliding rehabilitation machine training and conventional training, then underwent only the conventional training for next 2 weeks. The other group (group B, n=15) underwent trainings in reversed order. Experimental group was defined as sum of 2 weeks period used the machine in each group (group A&B), and control group was defined as sum of 2 weeks period not used the machine in each group. Functional Ambulation Category (FAC), Berg Balance Scale (BBS), 6 minute Walking Test (6mWT), Timed Up and Go (TUG), modified Barthel Index (MBI), modified Ashworth scale (MAS), and manual muscle test (MMT) were used for evaluating balance and gait abilities. All participants were assessed three times, ie before training, at 2 weeks, and 4 weeks of training.
Statistically significant improvements were observed in all parameters in experimental group after 2 weeks training (p<0.01), otherwise statistically significant improvements were observed only in 6mWT (p<0.05) in control group after 2 weeks training. There were statistically significantly larger changes of parameters in experimental group in all parameters, comparing the control group.
P204 Music Cueing Effects on Treadmill Training in Mild to Moderate Parkinson’s Disease
D. Chaiwanichsiri, W. Kitisomprayoonkul, and R. Bhidayasiri
Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
Background: Cueing techniques have been introduced for gait and balance training in Parkinson’s disease (PD).
Objective: To study the effects of music cueing on treadmill walking program in PD patients.
Methods: Randomized single blind controlled trial was conducted. Thirty male PD patients, aged 60-80 years with Hoehn & Yahr stage 2-3 without freezing, were recruited from Chulalongkorn Comprehensive Movement Disorders Center, King Chulalongkorn Memorial Hospital. The participants were randomly allocated into 3 groups for a 4-week training program: A = treadmill with music cueing 3 days/week and home walking 3 days/week, B = treadmill training 3 days/week and home walking 3 days/week, C = home walking 6 days/week. Participants were assessed with UPDRS, Timed Up and Go (TUG), Expanded Timed Up and Go (ETUG), Single leg stance (SLST), and six -minute walk test (6-MWT). Step length, stride length, cadence, and walking speed were calculated. Outcome measures were compared at pre-program, at 4th week post program, and at 8th week follow up.
Results: Group A significantly gained most improvement at 4th week and continued by home practice to 8th week. Compared among group A: B: C, stride length gained = 12%: 5.2%: 6.7% (p = 0.042), walking speed gained = 8.6%: 6.5%: -2.4%, 6-MWT gained = 10.2%: 5.4%: 2.9%, and dynamic balance tested with TUG improved = 14.2%: 12.5%: 7.6%. Cadence, SLST and UPDRS showed no significant change.
Conclusions: Music cueing on treadmill training enhanced gait and balance performances in early stage PD patients.
P205 Motivating Mobility: An Exploration of Developing Upper Limb Rehabilitation Technology Tailored to Individual Stroke Patients’ Needs
A. Hughes1, J. H. Burridge1, M. Balaam2, E. C. Harris2, S. R. Egglestone3, T. Nind4, A. Wilkinson5, and S. Mawson5
1School of Health Sciences, Southampton, United Kingdom, 2University of Sussex, United Kingdom, 3University of Nottingham, Nottingham, United Kingdom, 4University of Dundee, United Kingdom, 5Sheffield-Hallam University, Sheffield, United Kingdom
Introduction: Half of all patients commencing stroke rehabilitation have marked impairment of the hemiplegic arm, with only 5% of those with severe paralysis regaining useful function. Current opinion in motor learning, reinforced by clinical evidence supports the use of repetitive movement practice, feedback and goal orientation to improve rehabilitation. This study aims to motivate people to practise their rehabilitation by extending their activities using a combination of technology and interactive personal games. The multi-disciplinary team comprises physiotherapists, design engineers and computer scientists.
Method: Two chronic hemiplegic stroke participants were selected via an interview and screening criteria. Ethical approval and written informed consent were obtained. Participative user centered design techniques were used over three months to assess patients’ rehabilitation aims, movement abilities and interests. Notes, photos and video were recorded.
Results: Two prototype technologies were designed:
i) A device enabling a severely impaired patient to play with her toddler using her hemiplegic arm to guide balls down a shute.
ii) A chess game in which the participant uses his hemiplegic hand to select a piece using a pressure sensitive sensor, whilst the unaffected hand keys in the move.
Conclusion: A user centered approach enabled technologies to be designed with stroke patients which addressed their rehabilitation aims as well as their real life interests. These technologies will now be deployed in the home for one month with physiotherapy outcome measures being taken before and after the deployment along with a semi structured interview to assess users’ perceptions of comfort, usability and acceptability.
P206 Inhibitor Bar Relieves Toe Pain of Patients After Stroke
I. Kondo1, T. Teranishi1, Y. Wada1, H. Miyasaka1, S. Sonoda2, W. Narita2, E. Saitoh2, and K. Ohta3
1Fujita Memorial Nanakuri Institute, Tsu, Japan, 2Fujita Health University, Toyoake, Japan, 3Matsusaka Chuo Hospital, Matsusaka, Japan
Objective: Severe toe pain occurs sometime with tonic toe flexion reflex during the chronic stage after stroke and often restricts the patient’s ability of walking. The purpose of this study was to examine the effect of inhibiter bar for the patients with toe pain occurred with tonic toe flexion reflex after stroke. Materials and Methods: Subjects were thirteen patients who were referred to the brace clinics of three hospitals, because of severe toe pain with tonic toe flexion reflex. The onset of pain was from three months to 168 months after stroke. Their age was from 54 to 74 (Ave: 62.8, SD: 6.67). Nine had hemorrhagic pathology and four had cerebral infarction. Five patients were using plastic ankle foot orthosis (AFO) and eight patients were using double upright AFO with orthopaedic shoe. All of the patients were treated toe pain with inhibitor bar. Inhibitor bar was fixed at the portion between toe and MP joint on the insole of plastic AFO or orthopaedic shoe. It was made of foam rubber and was cut and carved according to the each patient’s toe shape. Results: Within four weeks after the fixture of inhibiter bar, the toe pain completely disappeared except one patient who had also post-stroke pain. One patient, who could not walk before the treatment, recovered his ability of locomotion. Conclusion: This result suggested that the inhibiter bar would be an option of the treatments for the patient with severe toe pain after stroke.
P207 Improved Walking Ability and Reduced Therapeutic Stress With an Electromechanical Gait Device: A Randomised Controlled Trial
S. Freivogel1, D. Schmalohr1, and J. Mehrholz2
1Neurological Rehabilitation Hospital, Hegau-Jugendwerk, Gailingen, Germany, 2Wissenschaftliches Institut, Kreischa, Germany
To evaluate the effectiveness of repetitive locomotor training using a newly developed electromechanical gait device, compared to treadmill training/gait training with respect to patient’s ambulatory motor-outcome, necessary personnel resources, and discomfort experienced by the therapists and patients.
In this randomized, controlled, crossover trial all patients sequentially received two kinds of gait training. Study intervention A: 20 treatments locomotor training with an electromechanical gait device; control intervention B: 20 treatments locomotor training with a treadmill or task-oriented gait training. Primary variable was walking ability (Functional Ambulation Category/FAC). Secondary variables included gait velocity, Motricity-Index, Rivermead-Mobility-Index, Berg-Balance-Scale, modified Ashworth-Scale, distance walked during training sessions, the number of therapists needed, and discomfort and effort of patients and therapists during training sessions.
16 non-ambulatory patients with stroke, severe brain or spinal cord injury were included in our trial. Gait ability (intervention A: 0.9; B: 0.5 mean FAC improvement) and the other motor-outcome related parameters improved for all patients; but there was no significant difference between the kinds of intervention.
However, the number of therapists needed was significantly lower during intervention A. In addition, the occurrence of therapist discomfort and the level of their effort during training sessions were significantly lower during intervention A.
Intensive locomotor training either with a treadmill/gait training on the floor or with the electromechanical gait device resulted in improved gait ability. However, locomotor training with the electromechanical gait trainer required less therapeutic assistance, reduced the level of therapist discomfort, and was well tolerated by patients.
P208 Treadmill Training for Patients With Parkinson’s Disease: What Is the Evidence?
J. Mehrholz1,2, R. Friis3, J. Kugler4, A. Storch5, and M. Pohl6
1Wissenschaftliches Institut, Kreischa, Germany, 2SRH FH Gera, Gera, Germany, 3California State University, Long Beach, CA, United States, 4Department of Public Health, Faculty of Medicine, TU Dresden, Dresden, Germany, 5Department of Neurology, Technical University Dresden, Dresden, Germany, 6Klinik Bavaria Kreischa, Kreischa, Germany
Our objectives were to assess the effectiveness of treadmill training to improve gait function of patients with Parkinson’s Disease, and the acceptability and safety of this type of therapy.
We searched the Cochrane Movement Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE.
We also handsearched relevant conference proceedings, searched trials and research registers, for randomised trials comparing treadmill training with no treadmill training in patients with Parkinson’s Disease.
We included 8 trials (203 participants) in this review. Treadmill training did improve gait speed (SMD = 0.53; 95% confidence interval (CI) 0.20 to 0.87; P = 0.002; I2= 0%; fixed effect model), stride length (SMD =0.42; 95% CI 0.00 to 0.84 ; P = 0.05; I2= 0%), walking distance (MD = 358 metres ; 95% CI 289 to 426; P <0.0001; I2= 30%), but cadence did not improve (MD = 1.06 ; 95% CI -4.32 to 6.44; P = 0.70; I2= 0%) at the end of study. Treadmill training did not increase the risk of patients to drop out (RD) (random effect model) = -0.07; 95% CI -0.18 to 0.05; P = 0.26; I2= 51%) and adverse events were not reported.
Patients with Parkinson’s disease who receive treadmill training are more likely to improve impaired gait hypokinesia. However, the results must be interpreted with caution because there were variations between the trials in patient characteristics, the duration, amount of training, and type of treatment. It is, additionally, not known how long these improvements may last.
P209 The Effect of Repetitive Arm Cycling on Motor Performance and Recovery in Persons With Subacute Stroke
T. K. W. Ng1, W. W. M. Cheuk1, C. Y. L. Chao1, V. Y. W. Ng2, H. K. Y. Cheung2, E. Y. W. Wong1, A. T. K. Luy1, and P. M. Y. Lau1
1Physiotherapy Department, Kowloon Hospital, Hong Kong, 2Department of Rehabilitation, Kowloon Hospital, Hong Kong
Introduction: Restoration of the upper extremity function after stroke remains unpromising. Bilateral arm training has been proposed as potentially beneficial treatment intervention. However, few studies have used repetitive arm cycling as bilateral training protocol and its benefits on subacute stroke patients are not well-substantiated.
Objective: To determine whether training on an arm ergometer could reduce motor impairment and enhance recovery of the hemiparetic arm in persons with subacute stroke.
Methodology: A single-blinded, randomized controlled trial was conducted. Twenty-four subacute stroke patients with severe upper limb weakness were randomly allocated into either the experimental group (n=12) or control group (n=12). Both study groups participated in a conventional stroke rehabilitation program, 5 days a week, 3 hours a day, for 4 weeks. The experimental group received additional 30 minutes of repetitive arm cycling program. The outcome measures were the Fugl-Meyer Assessment upper limb section (FMA), Action Research Arm Test (ARAT), active range of motion of the shoulder abduction, elbow and wrist extension, and Modified Ashworth Scale (MAS). Assessments were done at baseline, 2nd week and end of training.
Results: The experimental group demonstrated greater improvement (all p< 0.05) in FMA, ARAT, and active range of motion of shoulder and elbow when compared with the control group at 2nd week and end of training. The MAS over the wrist was significantly reduced at end of 4 weeks of training (p=0.023).
Conclusion: Repetitive arm cycling early after stroke is an effective method to enhance motor and functional recovery in a severe hemiparetic arm.
P210 Can We Improve Balance in Parkinson’s Disease? Yes, “Wii” Can
E. Pelosin1, L. Avanzino2, R. Marchese1, L. Marienelli1, C. Trompetto1, M. Bove2, and G. Abbruzzese1
1Departement of Neurosciences, Ophthalmology & Genetics, Genova, Italy, 2Department of Experimental Medicine, Section of Human Physiology, Genova, Italy
Introduction: Balance impairment is a common problem in idiopathic Parkinson’s disease (PD) often responsible for increased risk of falls, mobility restriction and loss of independence. Conventional exercises are often repetitive and may induce patients to lose their interest and to interrupt physical therapy at home. This study was aimed at evaluating the effectiveness of a low-cost, commercially available playing system (Wii-Fit®)) to improve balance in PD. The inclusion of a form of play in the rehabilitation program might increase patient’s motivation to perform functional exercises.
Methods: Seven patients with PD and seven age-matched normal subjects (NS) were recruited and performed 30 minutes exercises playing with Wii-Fit® every day for one week. Subjects were evaluated by means of static posturography. Sway-Path (SP), Sway-Area (SA), Antero-Posterior (AP) and Latero-Lateral (LL) displacements of centre of foot pressure (COP) were measured before and after training in the eyes-open (EO) and eyes-closed (EC) conditions.
Results: Statistical analysis (RM-ANOVA) showed in the PD group a significant improvement of all parameters in the EC condition, while in EO condition a significant improvement was observed only for the SA and LL values. Significant improvements of all parameters were observed in the NS group exclusively in the EO condition.
Conclusions: These preliminary results suggest that a video game-based approach can exert a positive effect improving static balance in PD patients. The great compliance and the friendly use of the Wii-Fit® device suggest that this treatment approach is promising in PD rehabilitation, with a wide range of applicability.
P211 Ballistic Propriocorrection as a Means of Rehabilitation in Acute Left MCA Cerebral Stroke
S. N. Churilov, G. E. Ivanova, and O. M. Samsygina
Department of Physical Therapy and Sports Medicine, Russian State Medical University, Moscow, Russian Federation
Goal: To study influence of ballistic propriocorrection on motor rehabilitation poststroke. The study included 80 patients (left MCA ischemic stroke, mean age 61,3±0,3). All patients underwent minor stress response functional tests (MSRFT) and motor assessment (passive and active ROM, muscle strength and tone). The MSRFT results attributed to one of 4 activity levels with a step-by-step increase of functional activity. Step 1a (n= 48(60%), hypoventilation test passed) protocol included ballistic exercises (BE) for eye movement and neck muscles exercises in supine. Step 1b (n= 26(32,5%), hyperventilation test passed) included step 1a and BE for the hip and shoulder in supine and side-lying. Step 2a (n= 6(7,5%), semiorthostasis test passed) included steps 1a-b and BE for the knee and elbow in supine, side-lying and prone on the elbows. Step 2b included steps 1a-2a with BE for the ankle and wrist in supine, side-lying, prone on the elbows and quadrupeds on the elbows and hand-and-knees. Step3a (orthostatic test passed) included steps 1a-2b with BE to restore coordination of the upper and lower limbs in kneeling and standing. At discharge the passive ROM reached 87,52% of normal compared to initial 62,48%, the active ROM - 79,68% compared to 16,33%, the muscle strength - 92, 43% of normal compared to initial 24,3%, the muscle tone - 74,68% compared to 19,2%. The initial MSRFT and motor assessment could enable to select an optimal rehabilitation program. The ballistic propriocorrection may contribute to an increase of active ROM, muscle strength and elasticity and ameliorate joint degeneration.
P212 The Effects of an Ankle Foot Orthosis in People With Stroke: A Systematic Review
S. F. Tyson1 and R. M. Kent2
1University of Salford, Salford, United Kingdom, 2University of Leeds, Leeds, United Kingdom
An ankle foot orthosis (AFO) is often prescribed after stroke but their use remains controversial. Consequently we reviewed the evidence so evidence-based choices could be made.
Search Strategy: Relevant Cochrane Groups, Database of Systematic Reviews, Central Register of Controlled Trials; Database of Abstracts of Reviews of Effects; MEDLINE: EMBASE: CINAHL: AMED: PsycINFO; RECAL; HTA Database; National Research Register; Current Controlled Trials Register and PEDro were searched.
Included Trials: English-language randomised controlled trials comparing an AFO on impairments or activity limitation to no treatment; normal care or placebo in adults with stroke.
Selection of Trials and Analysis: Titles, abstracts and full text were independently screened against the inclusion criteria and the methodological quality of selected trials was assessed for potential for bias. Those with low risk of bias were included in the meta-analysis. Where possible, results were combined using mean difference and 95% confidence intervals by a fixed-effect model.
Results: 12 cross-over trials, involving 314 patients were selected. Meta-analysis demonstrated that an AFO can improve walking speed, step length, functional mobility and weight distribution but only the immediate, short-term effects were assessed.
Conclusion: Current evidence supports the use of an AFO to improve walking and balance in people with stroke.
P213 Effect of a Foot Drop Neuroprosthesis on Walking in Chronic Stroke Patients
J. D. M. Vloothuis1, D. I. van Riet Paap1, A. Beelen1,2, F. Nollet2, and L. Heijnen1
1Rehabilitation center “De Trappenberg”, Huizen, Netherlands, 2Department rehabilitation academic medical center Amsterdam, Amsterdam, Netherlands
Introduction: Ankle foot orthosis (AFO) and orthopaedic shoes (OS) are usual practice to correct foot drop. Functional electrical stimulation neuroprosthesis provides an alternative approach.
Aim: To evaluate the effects of a neuroprosthesis (Ness L300©) compared to an AFO/OS on walking capacity, energy cost, walking activity and patient satisfaction in chronic stroke patients.
Patients: Twenty patients with chronic stroke and foot drop using an AFO or OS.
Methods: Using a pre-post intervention design, walking speed, daily physical activity, energy cost and patient satisfaction were measured at baseline with AFO/OS and after 8 weeks using the L300©. Patient satisfaction with long-term use was assessed at 26 and 52 weeks.
Results: Sixteen patients completed the short-term study. Four stopped due to pain or fear of falling. No significant differences were found in walking speed (0,77 pre versus 0,80 m/s post) or energy cost (4,31 pre versus 4,32 J/m post). Daily physical activity was significantly lower with the L300© (7728 pre versus 6292 steps/day post). Participants were more satisfied about quality of gait, walking effort and climbing stairs with the L300©. Eight patients continued the use of the L300© after 8 weeks: four completed the long-term study and four stopped (three due to skin problems). All completers were satisfied with the L300©.
Conclusions: Although patients are more satisfied with the use of the L300©, no beneficial effect on walking speed, daily physical activity, and energy cost was found when compared with conventional devices. Prolonged use of L300© neuroprosthesis may be restricted by skin problems.
P214 Using Motivational Theories to Inform Design of Assistive Technology for Motivating Rehabilitation
A. Wilkinson1, S. Mawson1, S. Rennick Egglestone2, A. Hughes3, T. Nind4, M. Balaam5, E. C. Harris5, and J. Burridge3
1Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, United Kingdom, 2University of Nottingham, Nottingham, United Kingdom, 3University of Southampton, Southampton, United Kingdom, 4University of Dundee, Dundee, United Kingdom, 5University of Sussex, Sussex, United Kingdom
Introduction: Stroke is the largest single cause of disability in the UK. Active participation and engagement have been demonstrated to promote recovery. Post-stroke patients can experience reduced motivation. (Stroke Association, 2008) Motivation is reported to affect both rehabilitation and the outcomes of rehabilitation. (Maclean, 2000) In order to develop appropriate technology to encourage motivation of patients to continue completing exercises, motivational theories must be understood and applied during the design process.
Method: A literature search of motivation theory and factors influencing motivation led to development of a framework. The framework provided factors which needed to be incorporated into user centred design sessions. These are presented as a mind map and include internal, clinical and social factors. Key aspects were then used to develop prototypes along with user feedback.
Results: A motivational framework has been developed to inform the prototype development. A prototype has been designed to enabling the user to read an e-book whilst completing exercises—in order to go to the next sentence an exercise must be completed with the upper limb.
Conclusion: Motivational theories can offer a framework to inform the design of health technologies addressing patient and therapist aims as well as incorporating individual interests to enhance motivation. Identifying influences highlight that each user is likely to have different expectations and needs from a technology system to promote rehabilitation. Increased understanding of motivation and self-efficacy and the numerous factors affecting them can lead to improvements in health technology designs with greater patient engagement in technology mediated rehabilitation.
6 Ethics
P215 Estimating the Burden of Informal Care for Persons With a Severe Traumatic Brain Injury (TBI) in the Parisian Area (France)
E. Bayen1,2, V. Bosserelle3, C. Fermanian4, J. Weiss3, P. Aegerter4, P. Azouvi2,5, P. Pradat-Diehl1,2, and M. Joël6
1Groupe Hospitalier Pitié-Salpêtrière, Paris, France, 2Unité INSERM UPMC E6, Paris, France, 3CRFTC, Paris, France, 4Unité de Recherche Clinique (URC), Hôpital A Paré, Paris, France, 5Hôpital R Poincaré de Garches, Paris, France, 6Laboratoire d’Economie et de Gestion des Organisations de Santé (LEGOS), Université Paris-Dauphine, France
Informal Care, in opposition to professional care, is related to time and money provided by family, friends or neighbours for outpatients with chronic illness. Such private and “free” caregiving for adults with disability is neither studied nor recognized in France.
We try to value Informal Care in a prospective cohort including 269 survivors after Severe TBI occurring between 2005 and 2007 in the Parisian area (SBIP study).
Methods: Informal carers were interviewed twice : 1) One year after the TBI, caregivers were administered a written postal survey with SF-36 (a) Zarit (b) and questions about life adjustment 2) Three years after the TBI, caregivers sustaining some of the most severe outpatients were asked on phone about time spent (thanks to RUD questionnaire (c)), family distress, quality of life, financial resources.
Results: 1) 61 informal caregivers returned the written survey : mainly women (2/3) (44% parent, 40% spouse), of mean age 50, for outpatients aged 36 usually after car-accident (71%). Both SF-36 and Zarit revealed health problems, exhaustion, stress, withdrawal from work and leisure activities. 2) Interviewing 12 carers orally proved that measuring care time for Activity of Daily Life, Instrumental ADL and supervision time is tricky. Economic valuation of Informal Care remained a challenge on both methodological and practical level: opportunity costs, proxy good and Willingness-to-pay methods must be further discussed.
We need more sociological light on this invisible care in our society and further evaluation of the economic impact of Informal Care and its monetary compensation.
P216 From the Neurorehabilitation Physiology to Allocation Resources: An Ethical View and Responsibility of the Physiatrist
M. Rincón1 and D. P. Martinez2
1Fundación Cardio Infantil Instituto de Cardiología, Universidad Militar Nueva Granada, El Bosque, Del Rosario, Bogotá, Colombia, 2Clínica Juan Luis Londoño SaludCoop, Medellín, Colombia
We have questions in relation to the responsibility of our medical actions and allocation of health resources in a third world country. We ask our sense of belonging and social responsibility, about rehabilitation for patients with neurological diseases, which in our system is a high cost, but from the ethical point of view should be considered involving the health system and a responsible family. Neurorehabilitation, a process of support aid and growth, from the Physiological which is demonstrated with evidence based Medicine, but also from the realm of ethics, where patients with disabilities have to be treated fairly. One has to consider the allocation of health resources, where all the necessary ones are not there. Every human being has the right for health services to be given with quality, but also must have an ethical demand on economic reality. The Physiatrist, has to reflect ethically on the use of services and the best costs, so that today in involving the patient, his family in the Neurorehabilitation, help is given to the patients with disabilities in a cost effective manner.
The rehabilitation is not simply based on the application of techniques or the implementation of technological apparatus; it is a PHILOSOPHY OF RESPONSIBLE MEDICINE, which assumes that the patient is a person of dignity.
Our work is to achieve highest self-sufficiency and functional performance of our patients, without forgetting, that they have responsibilities for their own care, and our social responsibility to use carefully the resources in our health system.
7 Assessment: Clinical Practice (Part II)
7.1 Clinical
P217 Recovery of Upper Extremity Function After Stroke in Regard to Eligibility and Need for Intensive Functional Training
I. C. Brunner and L. I. Strand
University of Bergen, Bergen, Norway
Background: Intensive functional training of the affected arm after stroke is in line with current knowledge of motor learning, and is addressed in modalities like Constraint Induced Movement Therapy (CIMT) and Arm Ability Training. The objective of this study was to examine the share of patients eligible for intensive functional training in the subacute phase after stroke.
Method: A prospective repeated measures design was applied. A total of 100 consecutive patients with persistent paresis of an arm, 1-2 weeks post-stroke, were screened for ability to participate, only including patients who were medically stable and cognitively intact. Motor function was assessed by the Action Research Arm Test (ARAT) and the Nine Hole Peg Test at 1-2 weeks, 4 weeks, and 3 months post-stroke. Eligibility for intensive functional training was defined by a score between 11-51 on ARAT.
Results: Among the 100 patients, 54 were excluded from further assessment, mostly due to cognitive impairments. Of the remaining 46 patients, 21 (46%) were eligible for intensive functional training 1-2 weeks post-stroke, while motor function in the others was either too good or too poor. The share of patients eligible for intensive functional training declined to 30% after 4 weeks and 11% after 3 months. Of the initial 46 eligible patients, 52% reached reasonable dexterity within 3 months, all receiving standard rehabilitation.
Conclusion: Cognitive impairment is a major limitation for intensive functional training in patients with upper extremity paresis, and intensive functional training seems suitable for only a selected group of patients.
P218 Evaluation of Effectiveness and Indications for Use Constraint-Induced Movement Therapy in Patients Affected by Multiple Sclerosis
M. Bigoni1, F. Menegoni1, E. Milano1, S. Baudo1, C. Trotti1, A. Boghi2, M. Galli3, and A. Mauro1,2
1Istituto Auxologico Italiano, Piancavallo (Verbania), Italy, 2Università di Torino, Torino, Italy, 3Politecnico di Milano, Milano, Italy
Objective. Perform an evaluation in multiple sclerosis (MS) patients pre- and post Constraint Induced Movement Therapy (CIMT). Methods. 12 MS patients (mean EDSS 6.2) with impairment in use of upper limb were recruited: 6 patient performed constraint protocol (CIMT group) while 6 performed exercises being free to use booth arms (nCIMT group). Patients were evaluated with clinical scales, kinematic analysis, transcranial magnetic stimulation (TMS) and functional magnetic resonance (fMRI). Results. After treatment: Medical Research Council values increased at arm and hand (p < 0,043 and p < 0,028 respectively) and Nine-hole-peg test values decreased (p < 0,033) at the most compromised limb in all patient. Kinematic analysis of tri-dimensional movement showed improvement of peak velocity (p < 0,043) for the most compromised limb in CIMT group and improvement of smoothness parameter (index of curvature, p < 0,043) for both arm in nCIMT group. TMS showed only a reduction of silent period (p < 0,05) in the most compromised side in CIMT group, whereas a qualitative evaluation of fMRI results showed an overall reduction of areas of activation during a standardized active movement in booth groups. Conclusions: CIMT had positive effects that differ only in few aspects from the intensive rehabilitation program (nCIMT group), some indexes of functional rearrangement of cortical network were found suggesting a restore of cortical inhibition mechanisms; nevertheless CIMT does not appear as the most specific and effective rehabilitation treatment for MS patient.
P219 A One-Year Follow-Up After Shortened Constraint Induced Movement Therapy With and Without Mitt After Stroke
C. Brogårdh and J. Lexell
Department of Rehabilitation Medicine, Lund University Hospital, Lund, Sweden
Constraint Induced Movement Therapy (CIMT) is a promising rehabilitation intervention after stroke to improve upper extremity function and self-reported use of the more affected hand in daily activities. There is however a need to explore the long-term benefits of CIMT and the importance of the different components of the therapy. The aim of this study was to investigate the arm and hand function and self-reported use of the more affected hand one year after participation in a shortened CIMT programme. The sCIMT consisted of 3 hours of training/day for 2 weeks in the subacute phase after stroke, where the patients had been randomized to a mitt group or a non-mitt group. Twenty post-stroke patients (15 men and 5 women; mean age 58.8 years; on average 14.8 months post stroke) with mild to moderate impairments of hand function were assessed at the follow-up. Outcome measures used were the Sollerman hand function test, the modified Motor Assessment Scale and the Motor Activity Log test, and all assessments were made by blinded observers. One year after sCIMT, participants within both the mitt group and the non-mitt group showed statistically significant improvements in arm and hand motor performance and on self-reported motor ability compared to before and after treatment. However, no significant differences between the groups were found in any measure at any time. In conclusion, sCIMT seems to be beneficial up to one year after training, but the restraint does not enhance upper motor function.
P220 Clinical and Evolutive Characteristics in Elderly Spinal Cord Injuries Neurorehabilitation
C. Chendreanu-Daia1, G. Onose1, A. Mihaescu1, L. Onose2, and M. Renta3
1Physical & Rehabilitation Medicine (PRM) Clinic Division of the Teaching Emergency Hospital Bagdasar, Bucharest, Romania, 2The Medical Service of Metrorex, Bucharest, Romania, 3The University of Medicine and Pharmacy “CAROL DAVILA”, Bucharest, Romania
Scope, Background: In this study we try to evaluate the characteristics and the efficiency of the rehabilitation program applied to the elderly with spinal cord injuries (SCI) compared to the adults with the same pathology.
Material & Methods: We analyzed 59 patients admitted in our clinical division between January 2009 - June 2009, divided in two groups; the underlying cause of addition was spinal cord injury; the study lots comprise 31 patients over 60 years (med 68); the controls were 28 (med 33.5). We analyzed the follow parameters: admission/ discharge Functional Independence Measure (a/d FIM), (global) status at discharge (ES), number of physical therapy days (PT), hospitalization length (H), days until the recovery of functionally (gait enabling) and quality of life score (QoL)
Results: We observe that in the degree of motor score is negative correlate to the age (p=0.000). In the study lots the number of incomplete lesion (87%) was higher than controls (76%). The main etiology for SCI was falling (62%) in study lot instead car accident (46%) in the control group. The presence of pressure sore was similar (87% vs 79%). The functional evolution FIM quantified was excellent in both lots (med. a FIM/d FIM study: 63,516/73,483; controls: 59,821/77,428; p=0.000). No statistical evidence between neurological level, PT (19,225 vs 23,035), H (28,451 vs 32,214) or QoL (med. 41,8 vs 44) in both group.
Discussions & Conclusions: Age might be a good protector versus the severity of SCI. Further studies are needed.
P221 Prediction of Later Emergence From Vegetative State Using the Behavioural Observation Component of the SMART Assessment
L. F. da Conceicao Teixeira and H. Gill-Thwaites
Royal Hospital for Neurodisability, London, United Kingdom
The management of disorders of consciousness such as vegetative state (VS) is a major clinical challenge. At the present there are no validated prognostic markers apart from age, aetiology and time spent in VS. It is hence, difficult to predict which of these patients will progress to greater degrees of consciousness. This study explores whether the behavioural component of the Sensory Modality Assessment and Rehabilitation Technique (SMART) can predict emergence from VS. It also tries to establish if there is a difference in the movement patterns of the patients that emerge from VS and those who do not emerge.
In this quantitative, case-matched retrospective study, 14 participants were divided into two different groups (group1: emerged from VS; group2: remained VS). Four categories of behaviour (no movement, reflexive, spontaneous and purposeful movements) were compared.
Results are currently being analysed but initial evaluation suggests that the patients that emerged from VS demonstrate a larger behaviour repertoire and more spontaneous behaviours than the participants that remained in VS.
Finding an accurate prognosis predictor is of major importance in the neurorehabilitation field as it will contribute to improve our understanding of this disorder of consciousness. Furthermore, it would help in the treatment and management of this patient population. Most importantly, would help in any major decisions about withdrawing or withholding treatment of these patients.
This research was conducted with the support from Brunel University and Neuro-disability Research Trust.
P222 Robotic Ambulatory Training (RAT) in Patients With Spinal Cord Injuries (SCI): Initial Experience in Abu Dhabi
L. Davidson, R. Namlal, and S. A. Wasti
Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
Robotic ambulatory training (RAT) in patients with Spinal Cord Injuries (SCI):
Initial experience in Abu Dhabi
Studies have shown that RAT benefits patients with long standing SCI. Mechanized therapies are considered effective by large number of our patients and many seek to travel to rehabilitation centers overseas to receive such therapies. We have recently acquired robotic therapy equipment in our rehabilitation facility at Sheikh Khalifa Medical City. We trialed two of our long-term spinal cord injured patients to evaluate response to RAT using the new equipment.
Case 1—Female, 30 years, C7 incomplete spinal cord (ASIA-D) injury, with moderate spasticity of right lower limb and right ankle contracture. She exhibited trunk flexion pattern during gait.
Case 2—Male, ASIA C, post laminectomy T6-T9. He had suffered with progressive weakness of lower limbs over past two years. He had spastic paraparesis and his walking speed was reduced.
Our early experience suggests that RAT improves walking in ambulatory SCI patients. This has been reported in the literature. Our patients are keen to utilize RAT and find the robotic equipment comfortable. We plan a formal review of client satisfaction with RAT.
P223 Effect of Repetitive Arm Cycling Following Botulinum Toxin for Post-Stroke Spasticity: Evidence From fMRI
K. Diserens1, D. Ruegg2, R. Kleiser3, N. Perret4, P. Vuadens5, E. Fornari1, F. Vingerhoets1, R. J. Seitz3, and D. Ruegg2
1University Hospital Lausanne, Lausanne, Switzerland, 2Department of Medicine, Fribourg, Switzerland, 3Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany, 4Fondation Plein Soleil, Lausanne, Switzerland, 5Clinique romande de réadaptation, Sion, Switzerland
Background and Objective: Investigations were conducted to establish whether arm cycling enhances the antispastic effect of intramuscular botulinum toxin (BTX) injections in post-ischemic spastic hemiparesis. Effects on cerebral activation were evaluated by functional magnetic resonance imaging (fMRI).
Methods: Eight chronic spastic hemisyndrome patients (49 ±10 years) after middle cerebral artery infarction (5.5± 2.7 years) were investigated. BTX was injected into the affected arm twice 6 months apart. Four patients were randomly assigned to repetitive arm cycling training 3 days a week for 3 months, while four patients received control intervention. After a free 3-month interval, patients were crossed. Spasticity was assessed using Ashworth scale and Range of motion before and 3 months after BTX injections. Images were analyzed using Brain Voyager QX 1.8, and fMRI-signal changes were corrected for multiple comparisons (qFDR <0.05).
Results: During passive movements of affected and non-affected hands, fMRI-activity increased bilaterally in sensorimotor cortex (MISI), secondary somatosensory areas (SII), and supplementary motor area predominantly in contralesional hemisphere compared with rest. Following repetitive arm cycling, fMRI-activity increased in MISI of lesioned hemisphere and SII of contralesional hemisphere. For patients with residual motor activity, training-related fMRI-activity increases were associated with reduced spasticity; in completely plegic patients, there was no fMRI-activity change in SII but increased spasticity after training.
Conclusion: Increased activity in SII of contralesional hemisphere and in MISI of lesioned hemisphere probably reflects a training-induced effect. It is hypothesized that increased BOLD activity results from increased afferent information related to the BTX antispastic effect reinforced by training.
P224 Daily Activity Wireless Network: The DAWN of New Monitoring and Outcome Measures
B. H. Dobkin, W. Kaiser, and M. Batalin
University of California Los Angeles, Los Angeles, CA, United States
Researchers in neurologic rehabilitation have sought direct, ecologically valid, continuous measures of upper and lower extremity daily activities. Measurement tools of movement and activity outside of a laboratory cannot monitor compliance with prescribed motor interventions or provide information about the types, quantity, and quality of mobility and upper extremity actions. To create more precise and clinically meaningful measures, a collaboration of engineers, computer scientists, and clinicians have begun to incorporate wireless sensors, called Personal Activity Monitors (PAMs), into research studies. PAMs include triaxial accelerometers that can be integrated with microgyroscopes, GPS data to distinguish indoor from outdoor activity, voice recorders, and heart rate monitors. The sensors are low cost, compact, rugged, require little power, and allow data downloading by a USB connector. The signal processing and state classification system are a fundamental advance over conventional activity monitoring systems, with components for automated sensor data collection, transport to a remote secure database repository, individualized subject model development, and subject state classification based on new Bayesian sensor fusion methods. We have distinguished purposeful from nonpurposeful activities such as waking, standing up, climbing, reaching for items, grooming, eating, exercising, etc, at home and in the community. A PAM on each ankle can determine cadence, walking speed, and asymmetries in temporal and spatial aspects of gait. PAM technology allows community-based trials, decreases research and clinical care costs by enabling home- and telerehabilitation-based interventions, and provides new outcome measures to detect progress over time. If interested in collaborating, contact
P225 Risk of Fall in Patients With Tropical Spastic Paraparesis/HTLV-I Associated Myelopath (TSP/HAM)
L. D. Facchinetti, G. L. Chequer, M. F. Azevedo, and M. A. Lima
FIOCRUZ, Rio de Janeiro, Brazil
Introduction: Falls are one of the most important complains of TSP/HAM patients. The aim of the study is to identify the incidence of falls in a TSP/HAM population and the factors associated with their occurrence.
Methods: A cross-sectional study with TSP/HAM patients followed at the HLTV clinic Instituto de Pesquisa Clínica Evandro chagas, Brazil. Fifty-nine patients were interviewed about clinical and epidemiological data; duration of disease (DD); HTLV-I proviral load (PL); number of falls and practice of exercise. However, only 19 of the individuals with Expanded Disability Status Scale (EDSS) ≤ 6.5 were submitted to a functional evaluation, which included: lower limb motor score of ASIA, ambulatory motor index (AMI), timed get up and go (TUG), Berg scale and EDSS.
Results: Most of the patients were women (64%); mean age was 53.2 years (SD ± 12.06), DD was 9.9 years (SD ± 8.53) and PL was 8.9% (SD ± 5.6). 43% of the patients reported at least one fall in the past six months and 55% of these informed two or more falls. 58% did not practice exercises. The mean lower limb motor score of ASIA, IMA, TUG, Berg scale and EDSS were respectively, 39.4 (SD± 9.39); 81.6% (SD ± 21.30); 21.1 s (SD ± 13.52); 46.9 (SD ± 12.13) and 3.7 (SD ± 1.64).
Conclusion: TSP/HAM patients have an elevated incidence of falls and impaired functional variables. Most of them did not practice any kind of exercise. It would be important to identify which of these aspects discriminate between fallers and non- fallers.
P226 The Influence of the Perceptual Training in the Weight-Bearing Rate of the Lower Limbs in Stroke Patients
H. Fujita1, S. Morioka1, M. Fujimoto2, and H. Nakano3
1Graduate School of Health Sciences, Kio University, Nara, Japan, 2Hakuho women’s College, Nara, Japan, 3Neurocognitive rehabilitation Center, Setsunan General Hospital, Osaka, Japan
The purpose of this study was the influence of the perceptual training of the weight-bearing rate of the lower limbs in stroke patients.
The subjects were 14 hemiplegic patients who agreed to participate in the experiment. Hemiplegic patients without a higher brain function disorder were selected. The subjects were given different sponges of five kinds of hardness, and made to memorize hardness with a side of hemiplegic foot sole. Then, 10 trials during a given were administered according to the random sampling table where the subjects were required to estimate the hardness of sponges upon questioning. The perceptual training was administered with eyes closed in the standing position for each day for 10 days. The weight was measured using a healthmeter as the indicator for the weight-bearing rate.
The weight-bearing rate was measured for 5 sec with eyes opened before and after the perceptual training. Furthermore, the walk velocity was measured as a parameter of a physical function. And, paired t test was used for the statistical analysis on this study.
The weight-bearing rate of the lower limb of the hemiplegic before training showed a significant increase compared to the weight after training in the perceptual training (p<0.05).
These results were suggested that not only the increase of the weight-bearing rate of the lower limbs but also contributes to the lower limbs function by the perceptual training.
P227 Validation of a Biomechanical Model for Quantification of “Spasticity” in Chronic Stroke Patients
J. Gäverth1,2, P. Lindberg1,3, M. Islam1, A. Fagergren1, J. Borg3, and H. Forssberg1
1Karolinska Institutet, Stockholm, Sweden, 2Department of Physiotherapy, Karolinska University Hospital, Stockholm, Sweden, 3Department of Rehabilitation Medicine, Danderyd Hospital, Stockholm, Sweden
Background: Spasticity is a common symptom after stroke and is often evaluated according to the modified Ashworth scale.
Objective: The aim of this study was to validate a new model for quantification of muscle tone that in addition allows estimation of the mechanical (muscle and tissue) and neural (reflex) components.
Method: A biomechanical model of the hand composed of different factors that contribute to passive wrist movement was constructed, consisting of (i) inertia, (ii) elastic resistance (E, length-dependent), (iii) viscous resistance (V, velocity-dependent) and (iv) reflex mediated muscle contractions (Neural component (NC), velocity-dependent). We measured resistance and EMG during 50º passive wrist extension across four controlled velocities (5, 71, 142, and 236º/s) in stroke patients and healthy subjects. In a subgroup of patients, repeated measures before and after ischemic nerve block were obtained.
Results: The model was validated in four ways. i) NC was abolished or reduced drastically after the ischemic nerve block; ii) NC correlated strongly to the EMG activity, both in the same subject during the ischemic nerve block procedure and in the patient group; iii) The total resistance, and NC, correlated to the modified Ashworth score; iv) NC was also velocity dependent. The profile of mechanical neural factors contributing to the resistance differed among patients.
Conclusions: The results indicate that the model is valid for quantification of neural component of increased muscle tone in chronic stroke patients. The method may be developed to be used clinically to measure muscular and neural components of muscle hypertonus, i.e., “spasticity”.
P228 Improvement in Activities of Daily Living (ADL) in Ischaemic Stroke (IS) Patients Younger or Older Than 65 Years
J. Jansa, K. Angleitner, S. Korosec, S. Susteric, and Z. Sicherl
University Medical Centre Ljubljana, Ljubljana, Slovenia
Introduction: To compare duration of occupational therapy (OT) and followed-up functional outcome in group of IS patients younger or older than 65 years.
Methods: IS patients were consecutively included into OT within acute hospital stay; 24 with R-hemiplegia, 26 with L-hemiplegia; 31 males, 19 females. We used Assessment of Motor and Process Skills (AMPS) during OT intervention and at three months follow-up. We used AMPS software and SPSS for analysis.
Results: 25 IS patients were younger than 65yrs (mean 55yrs, range 39-65) and 25 older than 65yrs (mean 73yrs, range 67-81). Mean OT duration in younger group was 15 days (range 4-54); mean OT duration in older group was 8 days (range 2-28). Difference was statistically important (p<0,007). During hospital stay in younger group mean AMPS-motor score was-0,18 (range-2,5-1,7); mean AMPS-process score was 0,18 (range -1,06 -1,24). Mean AMPS-motor score during hospital stay in older group was -0,20 (range -2,7 - +1,5); mean AMPS-process score during hospital stay was 0,15 (range-1,0-1,3). After month 3 mean AMPS-motor score in younger group was 0,18 (range-1,06-1,24); mean AMPS-process score 0,47 (range -0,77-+1,4). Mean AMPS-motor score in older group was -0,21 (range-2,1-+1,5); mean AMPS-process score 0,42 (range-0,60-1,38). AMPS-motor and AMPS-process skills correlated in both groups (r=0,6-0,7). Correlations were at p<0,05; no statistically important differences among groups in initial or follow-up assessment (p=0.28; p=0.67).
Conclusion: Quality of ADL performance within early hospital stay has improved. There were no statistically important changes among groups although the younger group received more OT during hospital stay.
P229 Comparison of the Short Physical Performance Battery (SPPB) Between Stroke Patients and Control Group
T. Kim1, S. Kim1, J. Lee1, S. Park2, S. Han1, K. Lee1, and M. Kim1
1Hanyang University College of Medicine Dept. of Rehabilitation, Seoul, Republic of Korea, 2The Rusk Memorial Medical Center, Seoul, Republic of Korea
Objective: Recently, National Institute of Aging (NIA) reported the validity of Short Physical Performance Battery (SPPB) for assessing lower extremity function and predicting mortality in elderly. Our purpose is to assess the usefulness of the SPPB in stroke patients and to determine difference of the SPPB between stroke patients and control group.
Methods: One hundred and fifty-nine stroke patients hospitalized in three rehabilitation facilities and 159 sex, age-matched control subjects were included. All subjects were enrolled to interview and administer the SPPB. The SPPB included assessment of standing balance, walking speed (timed 4 m walk), and chair stand (timed test of rising 5 times from a chair). Each part scored 0 to 4 points, total 12 points maximum.
Results: The SPPB score in stroke patients was significantly lower than control group (p<0.01).Within control group, male showed higher SPPB score than female, and the age was highly correlated with SPPB score (R=-0.629, p<0.01). Within stroke patients, there was no significant difference between male and female, or right and left hemiplegic patients. The age was not correlated with SPPB score in stroke patients and duration of stroke was weakly correlated with SPPB score.
Conclusions: The stroke patients showed significantly lower SPPB score than control group. The age, sex, direction of affection, and duration of stroke did not influence SPPB score respectively. We expect that SPPB in stroke patients may be helpful tool for assessing lower extremity physical function.
P230 Relationship Between Short Physical Performance Battery (SPPB) and FIM, MBI in Stroke Patients
T. Kim1, S. Kim1, K. Lee2, S. Han1, S. Jang1, and S. Park1
1Hanyang University College of Medicine Dept. of Rehabilitation, Seoul, Republic of Korea, 2The Rusk Memorial Medical Center, Seoul, Republic of Korea
Objective: In 1994, National Institute of Aging (NIA) reported the validity of Short Physical Performance Battery (SPPB) for assessing lower extremity function and predicting mortality in elderly. Our purpose is to examine the relationship between the SPPB and Functional Independence Measure (FIM), Modified Barthel Index (MBI) in stroke patients.
Methods: One hundred and fifty-nine stroke patients were enrolled to interview and administer the SPPB, FIM, and MBI. The SPPB included assessment of standing balance, walking speed (timed 4 m walk), and chair stand (timed test of rising 5 times from a chair).
Results: The motor subtotal score of FIM was moderately correlated with all parts of SPPB score. The cognitive subtotal score was weakly correlated with SPPB. The MBI was weakly correlated with standing balance, chair stand, and total score of SPPB, but was not correlated with walking speed.
Conclusions: In this study, SPPB was significantly correlated with FIM and MBI, especially motor subtotal score of FIM. These results suggest that SPPB may be useful tool to assess and predict the physical function in stroke patients
P231 Evidence on the Efficacy of Integrated Care
T. Larsen
CAST, Odense C, Denmark
Purpose: The fragmented delivery of health and social services for large groups of patients with chronic conditions was put on the research agenda in 2002 by WHO. The FP7-IHC-project (www.integratedhomecare.eu) aims to develop a turn-key-solution for better clinical continuity to European health regions.
Method: Systematic review of the literature on clinical continuity as complemented by trials and surveys within this project.
Preliminary results
1. Integrated home care (IHC) is the most promising approach to better clinical continuity from the point of view of cost-effectiveness. IHC is characterized by 1) delivery form, 2) funding/administration, 3) organization and 4) clinical focus.
2. Stroke, COPD and heart failure (HF) are diseases of first priority regarding IHC with poor outcomes as a common indicator of efficacy. Alone, for these 3 chronic diseases more than 1 million new patients per year in EU might benefit from IHC.
3. As IHC improves activities of daily living (ADL) which implicates long term savings in social care services the working hypothesis is that IHC is a health economic dominant intervention. This enables a meso-strategy of dissemination focusing European health regions with direct contact between clinical and funding levels instead of national legislative levels.
4. The practical efficacy of IHC is closely related to the combination of patient-centric procedures with multidisciplinary expertise across administrative sectors.
5. Barriers in funding across sectors and over time slow down implementation wherefore a special study of these problems and their solution is ongoing specific to each EUcountry.
P232 Validity and Reliability of a New Clinical Measure of Spasticity Based on Tonic Stretch-Reflex Threshold Excitability
M. F. Levin and A. Calota
McGill University, School of Physical and Occupational Therapy, Montreal, QC, Canada
According to the well-known theory of motor control, the equilibrium-point (λ model), the central nervous system (CNS) regulates muscle activation levels and produces movement by shifting motoneuronal thresholds via the tonic stretch reflex threshold (TSRT). The TSRT is expressed within a biomechanical frame of reference and related to the joint angle instead of in terms of latency. Disorders in TSRT regulation would therefore be related to disordered motor control and the appearance of spasticity. In this study, the excitability of the TSRT was investigated as the conceptual unit of measure of spasticity. We investigated intra- and inter-evaluator reliability of TSRT measurement to quantify spasticity in 20 subjects with chronic stroke-related spasticity using a portable device and the Modified Ashworth Scale (MAS). Evaluations were done on 2 days, by 3 evaluators. Biceps brachii EMG signals and elbow displacement were recorded during 20 elbow stretches applied at different velocities for each evaluation. Velocity-dependent dynamic stretch reflex thresholds (angle where EMG signal increased in the biceps for a given velocity of stretch) were recorded. These values were used to compute TSRT (excitability of motoneurons at 0°/sec). Reliability was moderately good for subjects with moderate to high spasticity (intra-evaluator: 0.46-0.68 and inter-evaluator: 0.53-0.68). The TSRT measure did not correlate with resistance to stretch (MAS). Our results suggest that the TSRT may be a more representative measure of moderate to high spasticity. Further improvements are suggested for the portable device in order to quantify all levels of spasticity.
P233 Short-Term Synchronization of Low Frequency (Subdelta) Oscillations After Ischemic Stroke in Humans
G. Liuzzi, P. Lechner, P. Sauseng, K. Heise, J. Hoppe, M. Zimerman, F. C. Hummel, and C. Gerloff
BINS Lab, Department of Neurology, Hamburg, Germany
Background: Based on animal models of ischemic lesions, it has been proposed that synchronous neuronal activity in the low frequency range (subdelta) serve as a signal for neuronal sprouting from the contralateral non-lesioned cortex. To assess synchronization of brain activity in humans, we examined oscillatory activity in patients in the acute stage after ischaemic stroke with EEG.
Methods: 19 channel EEG-recordings were used to investigate spontaneous synchronous neuronal activity at rest in a group of 10 patients in the acute stage after stroke and in age- and sex-matched healthy controls. Measurements were taken at 1, 3 and 5 days after the stroke event.
Results: Coherence in the subdelta frequency range showed higher synchronization in the immediate (day 1) and intermediate (day 3) phase after stroke. Oscillatory activity was in particular synchronized across hemispheres. At day 5, the level of synchronization returned to the level of the healthy control group.
Discussion: The present study supports the view that low frequency brain oscillations show higher synchronization in a short time frame after ischemic stroke, especially across hemispheres. In the light of animal studies, it can be speculated that enhanced synchronization of subdelta oscillatory activity might reflect axonal sprouting after ischemic lesions of the brain.
P234 Relevant Posturography Descriptive Measures in Hemiplegic Standing Balance Assessment: A Pilot Study
P. Marque1, M. Labrunée1, X. de Boissezon1, E. Castel-Lacanal1, R. Montoya2, P. Dupui2, I. Tack3, and D. Gasq1,4
1Service de Médecine Physique et de Réadaptation, CHU Rangueil, Toulouse, France, 2Service d’Explorations Fonctionnelles Physiologiques, CHU Rangueil, Toulouse, France, 3Service d’Explorations Fonctionnelles Physiologiques, CHU Rangueil, Toulouse, France, 4Université Paul Sabatier, Toulouse III, UFR STAPS, Laboratoire Adaptation Perceptivo-Motrice et Apprentissage, Toulouse, France
Posturography is a widespread quantitative measure of postural instability, allowing to record a vast number of descriptive measure. Our work consists in selecting the most relevant parameters in term of validity and reliability in 20 hemiplegic patients (age: 49.7±15.5 years). The validity is assessed with regard of the unipedal stance ability on the paretic limb. Reliability is assessed with Small Real Difference of individual coefficient of variation (SRD-CVind), expressed in percentage. We used a three strain gauge force platform (40 Hz, Win-posturo© Medicapteurs©), and the PosturoPro© software for time-frequency analysis. The parameters are obtained in static condition with eyes closed (except for average speed). Alpha error is corrected with a Bonferroni procedure. The relevant stability parameters are three power spectral density parameters (IPX1 between 0.05 - 0.5 Hz, IPX2 between 0.5 - 1.5 Hz, and IPX3 > 1.5 Hz) obtained with a time-frequency analysis in the frontal plane (p values are respectively 0.012 for IPX1, 0.0005 for IPX2, 0.0009 for IPX3), the average speed of the centre of pressure with eyes open (p=0.0025), the CP length in frontal plane (p=0.0025), and the area of the CP displacements (p=0.0019). Maximal DMS-CVind between three consecutive recordings are respectively 13%, 15% and 20% for IPX1, IPX2 and IPX3, 31% for average speed of CP, 33% for CP length in frontal plane, and 79% for area of the CP displacements. To determine the real interest of this parameters in the follow-up of the rehabilitation, it will be necessary to estimate their sensibility to change.
P235 Running Nose and Stroke: Crossingpoint Neurology and Cardiology
B. J. Mayr-Pirker, N. Geringer-Manakanatas, R. Alber, H. Zauner, and A. Gassner
Neurorehabilitation, Großgmain, Austria
Hypereosinophilic syndrome is a rare disorder which can cause ischemic stroke. Herein we describe a patient with persistent hypereosinophilia with recurrent ischaemic strokes focusing on the importance of taking a careful anamnesis.
A 63-year old female patient with leukoencephalopathy and a subcortical right cerebral ischemic stroke 2 months before was referred to our department for rehabilitation. It was noticeable that the patient suffered from a running nose since 6 months. Moreover she showed a polyneuropathy of unknown origin.
Hematological test revealed a moderate leukocytosis with hypereosinophilia formed by mature eosinophils and conservation of other hematopoietic series. An echocardiogram showed an atypical occupation of the ventricles and an endocardial thickening. The bone marrow analysis confirmed the diagnosis of a hypereosinophilic syndrome. The patient was started on prednisone with a resolution of the pathological echocardiogram, the eosinophile and the neuropathy.
In conclusion a hypereosinophilic syndrome is great challenge for doctors and requires realising careful anamnesis, performing overstandard examinations and good cooperation with consultants of other specialities.
P236 Speech-Language Pathologist Intervention With Adult Patients With Severe Traumatic Brain Injury
A. Nielsen1 and I. Jacobsen2
1Traumatic Brain Injury Unit, Copenhagen University Hospital, Glostrup, Denmark, 2Traumatic Brain Injury Unit, Copenhagen University Hospital, Glostrup, Denmark
Introduction: This abstract describes the criteria used for Speech-Language Pathologist intervention (SLPi) in patients with severe traumatic brain injury (TBI) in a sub acute unit.
Methods: In the unit many patients cannot cooperate with SLPi. The patients demonstrate reduced levels of consciousness, confusion, cognitive deficit, and a wide range of communication deficit. The average stay for patients is 104 days and the duration of Post Traumatic Amnesia (PTA) > 28 days in 81% of the patients.
To ensure that patients who profit from SLPi actually do receive it, we have stated both objective and subjective criteria on the basis of which the communicative intervention is established. The objective criteria are neuroscientifically based, corresponding primarily to Ranchos Los Amigos score > 6 and the patients having emerged from PTA. The subjective criteria are based on observations and opinions by the interdisciplinary team and by the SLP based on a neurobehavioral and communicational checklist.
Results: By relying on these two criteria it is possible to standardize the SLPi, thereby ensuring that patients with communicational needs and the ability to cooperate with intervention are not overlooked. At the same time SLP resources are economized.
Discussion: The subjective and objective criteria often lead to the same conclusion. When this is not the case, the subjective criteria prevail over the objective criteria because they take individual differences into consideration (e.g. the patient in PTA who is able to cooperate). Both types of criteria are therefore of great importance when establishing SLPi with severe TBI patients.
P237 Physical Limitation in Adults With HIV Neurologic Disease in a Brazilian Reference Center for HIV/AIDS
R. L. Oliveira, M. R. Cruz, L. D. Facchinetti, G. L. Chequer, A. M. Rocha, B. G. J. Grinsztejn, and M. T. T. Silva
Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
Background: Antiretroviral therapy (ART) has a significant impact on reducing the incidence of opportunistic infections and increasing survival of AIDS patients. HIV neurological disorders (HND) are frequent and recognized as a major cause of disability and death. Physical impairments associated with HND have profound effects on quality of life (QOL) and functional abilities.
Objectives: Characterize physical limitation in HND patients.
Methods: Cross-sectional study of 43 patients admitted due to active HND from May to September 2009. Clinical, demographic and physical-functional data were evaluated. Performance Status (PS) on the last month and Barthel Index (BI) at admission were used to measure functional status.
Results: The main HND were cerebral toxoplasmosis (25.6%), neurosyphilis (16.3%), and cryptococcus meningitis (7.0%). Mean age was 37.9 years (SD 9.2) and 81.4% was male. In 51.9% patients, CD4 count was less than 200cels/mm3. Medium length of hospitalization was 21.7 days (SD 23.1). During the follow up, 69.8% had independent gait, 7.0% needed orthosis, and 34.9% were on rehabilitation program. Regarding functional capacity, about one third of patients presented any kind of bed restriction. The mean score of BI was 81.9 (SD 32.4).
Conclusion: HND-inpatients had few functional limitations in this preliminary study. Despite neurological disorder may result in functional disability, physical impairments could be associated with other factors such as previous functional status, advanced age, staging of AIDS, and history of irregular use of ARV. Early rehabilitation should be offered to these patients to fast recovering, to prevent additional disabilities, and to improve QOL.
P238 A Novel Test to Measure Upper Limb Motor Function: Instrumented Peg-in-Hole Technique
B. Omran1,2, M. P. Barnes2, L. Graham3, and G. R. Johnson1
1Centre for Rehabilitation and Engineering Studies, Newcastle upon Tyne, United Kingdom, 2Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom, 3Walkergate Park Centre for Neurorehabilitation and Neuropsychiatry, Newcastle upon Tyne, United Kingdom
A novel measurement technique is presented for the quantification of upper limb motor function. In this test, participants, sitting on standard height table, were asked to move a peg between two holes (left and right holes) as fast as they could. The difficulty of the test was changed by using four pegs of different diameter (p1, p2, p3, p4). The principal outcome measure was the insertion time (time spent inside each hole per insertion).
30 patients, with reported activity limitation in one or both upper limbs, completed the test. 29 of the participants repeated the test after 10 minutes. All participants also completed the Action Research Arm test (ARA). The ARA scores ranged between 0 and the maximum of 57 (median= 51.5).
The mean (SD) values for the insertion time of the right hole (measured in seconds) were 0.73 (0.48), 0.52 (0.37), 0.48 (0.37), and 0.40 (0.24), for pegs 1, 2, 3 and 4, respectively.
This insertion time was reduced significantly with decreasing the peg diameter (ANOVA, p=0.002). Moreover, the paired t-test demonstrated no significant difference between the two repeated measurements for any of the four pegs. Furthermore, the insertion time, for all four pegs, showed negatively strong and significant correlation with ARAT. The correlation coefficients (Spearman’s test) were -0.793, -0.725, -0.714, -0.697 for pegs 1, 2, 3 and 4, respectively (P<0.001 in all pegs).
This measurement method may (with the use of optical timing system) potentially provide a low cost portable assessment device suitable for use in busy clinics.
P239 Clinical and Baropodometric Evaluation of Posture and Gait of Stroke Patients After Upper Limb Infiltration With Botulinum Toxin
A. F. C. G. Placido Bramanti
IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy
Background: Objective of this study is to evaluate the efficacy of upper limb infiltration with Botulinum Toxin (BTX) through a clinical and an instrumental evaluation. Materials and Methods: We enrolled ten stroke patients matched for sex, age and severity of disease and randomly divided them into two groups of treatment: the first group (group-A, 5 patient) performed a conventional neuro-rehabilitative treatment lasting six weeks (five sessions/for week lasting 1hour), the second one (group-B, 5 patient) performed the conventional rehabilitative treatment in association to the upper limb infiltration with BTX. Clinical evaluation: neurological examination, administration of clinical rating scales (Barthel Index (BI), Ashworth scale (As), Tinetti Test (TT); instrumental evaluation: (static/dynamic analysis). Results: Group A(b/d):BI:50/53; As(8/6); TT: 14/17; Group B (b/d): BI:48/55 ; As:(9/5);TT: 13/19 Group A(b/d): plantar surface (%)(n/p): (62.4-37.6)/(60.1-39.9); semi-step length (cm)(n/p): (24.6-13.3)/(26.3-15.1); gait speed (cm/sec)( n/p): (23.2-11.1)/(24.5-12.6); cadence (step/min): (44.1-33.2)/(45.2-35.2): Group B (e/r): ps (%)(n/p): (64.7-35.3)/(60.1-39.9); semi-step length (cm) (n/p): (30-14.6)/(33.4-18.2); gait speed (cm/sec) (n/p): (25.4-14)/(28.5-17.4); cadence (step/min) (n/p): (40.9-33.4)/(44.1-37.3). Discussion and Conclusion: Through these preliminary data we want to show as the upper limb infiltration with BTX in subjects affected by Stroke improves global motor performances and in particular posture and gait through an improvement of limbs motor coordination. Will be required further studies with enlargement of population and follow-up over time to assess the efficacy of this treatment for posture and gait so to standardize as a useful aid for the rehabilitation of patients with upper motor neuron lesion.
P240 The Relationship Between ApoE Genetic Status and Outcome After Traumatic Brain Injury
J. L. Ponsford1, M. Schoenberger1, A. McLaren2, D. Rudzki2, J. Olver1, and M. Ponsford3
1Monash University and Monash-Epworth Rehabilitation Research Centre, Melbourne, Victoria, Australia, 2Monash University, Clayton, Victoria, Australia, 3Epworth Hospital, Richmond, Victoria, Australia
In recent years there has been growing interest in the role of the Apolipoprotein (ApoE) gene in influencing outcome following traumatic brain injury. ApoE plays a role in cell maintenance and nervous system response to injury. Its three isoforms, e2, e3 and e4, show differing responses to brain injury; with e4 allele carriers having an altered neurochemical metabolism and reduced cholesterol, potentially resulting in impaired reinnervation, greater cell death and poorer recovery. Some previous studies have found poorer outcomes in e4 allele carriers, but others have not. Most studies have had limited statistical power. The current study examined whether presence of the ApoE ε4 allele was associated with lower Glasgow Coma Scores (GCS), longer post-traumatic amnesia (PTA) duration and poorer long-term functional outcome measured on the Glasgow Outcome Scale -Extended (GOSE). Participants were 654 individuals with TBI (67.4% male). ApoE genotyping was determined from saliva samples by one-stage PCR method. The ApoE ε4 allele was carried by 166 (25.3%) participants, most having the 3/4 allele combination. Of non-ApoE ε4 carriers, most had the 3/3 combination. Only three participants had the 2/2 combination. The GOSE was completed a mean of 1.9 years post-injury (SD=1.3). We found the hypothesized relationship between ApoE ε status and functional outcome on the GOSE. There was no significant relationship between initial injury severity, measured by GCS or PTA duration and genetic status. It would appear that the presence of the ApoE e4 allele may influence long-term functional outcome. Possible mechanisms underpinning this relationship will be discussed.
P241 Do Long-Term L-Dopa Side-Effects Occur in Patients With Traumatic Brain Injury?
E. Pucks-Faes, D. Noori, R. Schauer, M. Kofler, and L. Saltuari
Hochzirl Hospital, Austria
Levodopa is a frequently used pharmacological stimulant treatment in neurorehabilitation of patients with severe traumatic brain injury (TBI). In patients with Parkinson’s disease long-term levodopa therapy often results in motor complications, such as motor fluctuations and dyskinesias. The aim of this study was to investigate the occurrence of motor complications in patients with TBI treated with levodopa. In a retrospective study, 28 patients (20 men, 8 women, median age 31 years, range 16-69 years) with TBI and treatment with levodopa were examined between 2004 and 2009. We assessed duration of treatment, administered dosage of levodopa and improvement of cognitive disturbances in terms of alertness, emotional reactivity and impulsion as well as the occurrence of motor complications. Mean duration of treatment with levodopa was 3.7±0.9 years (range 1.2-4.6 years), 10/28 patients received levodopa for more than 4 years. The mean daily dose of levodopa was 429±213 mg (range 125-1000 mg). In 21 patients, levodopa led to an improvement of alertness (n=8), emotional reactivity (n=6) and impulsion (n=14) at last clinical follow-up. In this small series, patients with TBI treated with levodopa did not develop motor complications after long-term therapy. The lack of motor complications in these TBI patients suggests, that motor complications otherwise seen in patients with IPD are rather disease-related than pharmacon-related.
P242 The Validity of Block Anesthesia in Neurorehabilitation to Estimate Spasticity Versus Fibromuscular Contracture
E. Pucks-Faes, H. Matzak, R. Schauer, and L. Saltuari
Hochzirl Hospital, Zirl, Austria
In neurorehabilitation muscle contracture caused by spasticity is one of the major problems. By clinical investigation it is frequently not possible to distinguish between an increased resistance to passive stretch and a fibromuscular or even skeletal contracture. In respect to treatment it is essential to be able to differentiate between a fixed (organic) and functional reversible contracture. An option for the differential diagnostic consideration is a block anesthesia of the muscle innervating nerve. The block anesthesia is performed sonographically guided, the position of the injection needle reconfirmed by electrical stimulation. So far we have five patients examined systematically, all received 15-20ml bupivacaine, 0,25% as a depot in the nerve region proximally to the nerve’s muscle supply. Functional tests (ROM) were performed after complete pareses of the nerve/muscle; evaluation has been done interdisciplinary. In four patients clear discrimination in etiology related to impairment of ROM could be carried out, in these patients fibromuscular alteration was not the causing etiology; one patient fibromuscular contraction was the main cause for impairment of ROM whereas spasticity presumably contributed just the same, yet to lesser degree. To our opinion and to our experience nerve block anesthesia is a suitable means to differentiate between spasticity and fixed fibromuscular contraction in impaired ROM in neurorehabilitation.
P243 Grasping Strategies in Hemiparetic Stroke Patients
A. Roby-Brami1,2, J. V. G. Robertson1,2, and D. Bensmail1,2
1University Paris Descartes, CNRS, Paris, France, 2Hopital Raymond Poincaré, Garches, France
As proposed by Jeannerod, prehension consists of two components: reaching and grasping. Upper limb disability in hemiparetic stroke patients is multifactorial. Impairments of upper limb control may be the direct consequence of the pyramidal tract lesion on hand dexterity: lack of selective finger command, disruption of precision grip, weakness, spasticity, or may result from more proximal impairments which perturb reaching and thus the positioning of the hand near the object: weakness, spasticity, abnormal synergies. These impairments may be worsened by trophic disorders. Conversely, patients may develop compensatory reaching and grasping strategies in order to perform daily living tasks. The aim of the present study was to provide a naturalistic description of grasping strategies spontaneously used by hemiparetic patients. To that purpose, we used video recordings and kinematic analysis (Polhemus sensors) of a grasping task involving four simple geometrical objects in 9 healthy subjects and 15 spastic hemiparetic patients. Follow-up of Botulinum toxin therapy (before, 1 and 4 months after BTT) was used to investigate how the reduction of spasticity might modify the grasping strategy. The analysis presented here focuses on global finger posture and 3D hand position and orientation at the time of grasping. BTT influenced hand orientation at the time of grasping (particularly improving hand elevation).We propose i) a preliminary taxonomy of grasping posture in hemiparetic patients and ii) a heuristic diagram of the complex chain of causality influencing reaching and grasping after stroke as a framework for future physiopathological investigations and therapeutic evaluation.
P244 Measuring Communicative Effectiveness in Severe Aphasia
A. C. Van der Meulen1, W. M. E. Van de Sandt-Koenderman1,2, H. J. Duivenvoorden3, and G. M. Ribbers1,2
1Rijndam rehabilitation centre, Rotterdam, Netherlands, 2Erasmus MC, Dept. Rehabilitation Medicine, Rotterdam, Netherlands, 3Erasmus MC, Dept. Medical Psychology and Psychotherapy, Rotterdam, Netherlands
In aphasia rehabilitation, treatment is disorder-oriented (aiming at the underlying linguistic deficit) or functional (learning patients to communicate in a different, often non-verbal, way despite this deficit). Efficacy studies in aphasia mainly consider disorder-oriented interventions. Group studies on aphasia interventions on the activity or participation level are scarce (Van de Sandt-Koenderman, 2004). An important reason for this lack is the paucity of validated instruments that can serve as outcome measure.
We show that the recently developed Scenario Test can be used for this goal. The test assesses daily-life communicative effectiveness in aphasia and is innovative in that it (1) systematically examines patients’ verbal and non-verbal communicative abilities; (2) examines patients’ level of dependence on a communicative partner. Both are crucial for planning and evaluating functional aphasia therapy. A study on the psychometric qualities of the Scenario Test (N=122 aphasic patients, 25 non-aphasic controls) showed good reliability, validity and sensitivity to change (Van der Meulen et al., in press). The test enables clinicians to target functional communication training to the individual’s specific context and to measure the effect of this training on patients’ communicative effectiveness in daily functioning. Further, it allows much needed future efficacy studies on activity-level oriented aphasia interventions.
References
Van de Sandt-Koenderman WME. High-tech AAC and aphasia: Widening horizons? Aphasiology. 2004;18:245-263
Van der Meulen AC, Van de Sandt-Koenderman WME, Duivenvoorden HJ, Ribbers GM, Measuring verbal and non-verbal communication in aphasia: reliability, validity, and sensitivity to change of the Scenario Test. Int J Lang Comm Dis. In press.
P245 Rehabilitation in Alien Environment May Negatively Affect Outcome
S. A. Wasti
Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
Rehabilitation when delivered in a culturally and linguistically alien environment may not be effective. In emerging affluent countries health systems are not yet fully developed and medical care is sometimes outsourced. Whilst treatments such as cardiac surgery may deliver good results, outcome of rehabilitation is often unsatisfactory. Following two cases highlight the shortcomings of rehabilitation outcome in alien environment.
Case 1. A 70-year-old female with left middle cerebral artery infarct commenced rehabilitation in our unit. She started to improve in ADLs and transfers, needing help of one. She was then sent overseas for continued rehabilitation. She returned after 7 months having gained nearly 10 kg in weight, needing two persons help and hoist transfers. She became depressed in the alien unit and did not engage in her rehabilitation.
Case 2. A 6-months pregnant 28-year-old female was diagnosed with meningioma. She underwent excision and started rehabilitation for ambulatory and functional deficits. She responded well, started to attend to her own ADLs and standing. She was then sent overseas for rehabilitation. After delivering her baby she became depressed and self aborted the rehabilitation to return home. She was 14 kg heavier and unable to walk due to back pain. Rehabilitation locally has resulted in improved walking and ADL skills.
These cases illustrate that rehabilitation in unfamiliar environment effects outcome. Depression is often main underlying cause of negative response. Evidence exist that patients respond unsatisfactorily in culturally alien environment and perform better in familiar setup. Further multicentre studies are needed for comparative evaluation.
P246 Strict Pre-Agreement on Goals in Long-Term ABI Patients Improves Outcome and May Reduce Demands for Recurrent Rehabilitation
S. A. Wasti, M. Pillay, and R. Namlal
Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
Patients with ABI and their families pursue repeated episodes of rehabilitation and often travel far for this purpose. No controlled studies exist on effectiveness of recurrent rehabilitation in distant centres. There may be emotional cost of distance from home, social and linguistic alienation and also the discharge process is often flawed. We managed four patients in our local centre. All had undergone several previous episodes of rehabilitation, many overseas. We established a strict pre-admission goals agreement and pursued goal directed rehabilitation. All patients responded well and achieved the set goals.
Four patients 3 males, 1 female (ages 18, 20, 27, 39) with past diagnosis of SAH, TBIx2 and posterior circulation infarct were reviewed in clinic. All requested further episodes of rehabilitation overseas. We offered rehabilitation in the local centre but with strictly agreed goals. These were explained and agreed prior to admission. Each patient was set at least three goals, including improved gait, walking distance, speech intelligibility, continence and improved ADL skills. In 3 patients all goals were attained. In one patient none of the goals was attained as inpatient but continued pursuance by the family after discharge resulted in attaining two of the three goals. One patient progressed further and took entrance test for school.
In our experience strict agreement on goals prior to rehabilitation in patients with long-term disability improved outcome. In patients who repeatedly seek and shop for rehabilitation, pre-agreed goals must be set before commencement of rehabilitation program.
P247 Do Event Related Potentials of Vegetative and Minimally Conscious State Patients Correlate With Coma Recovery Scales?
M. Wieser1,2, J. Haefeli1,2, L. Buetler1,3, and R. Riener1,2
1ETH Zurich, Institute of Robotics and Intelligent Systems (IRIS), Zurich, Switzerland, 2Spinal Cord Injury Center, University Hospital Balgrist, Zurich, Switzerland, 3Humaine Clinic Zihlschlacht, Zihlschlacht, Switzerland
Clinical scales are the state of the art describing the level of alertness and awareness of vegetative and minimally conscious state patients. Previous findings showed that cognitive event related potentials as the P300 are good predictors for awakening from coma. In this study we investigated the clinical course of patients by matching a quantitative value based on P300 measurements to the score of a qualitative clinical scale.
A classical P300 tone paradigm was used to evaluate the response of six patients in a vegetative and minimally conscious state over eight weeks. Supplementary, the JFK Coma Recovery Scale was used. Additional to the visually detected P300 response, a topographical analysis as well as a statistical t-test (p=0.05) was performed. The identified latency was classified into three groups: “abolished” for no P300 response, “pathologic” for latencies longer than the double standard deviation based on a healthy control group (n=19) and “normal” for all the others. This rating for all three electrodes Fz, Cz and Pz was combined and compared to the clinical scale.
The results of the event-related potential analysis show an approximation to the clinical progress known from the clinical scale. By means of the P300 latency we might have found a promising tool to quantify the changes of alertness in these patients. However, to strengthen the quantitative description we have to include more patients. Furthermore, we will combine the P300 results with additional neurological and physiological recordings.
P248 Body Weight Percentile of the Children With Cerebral Palsy
E. Yilmaz Yalcinkaya, A. B. Ayna, F. Karaagac, and K. Ones
Istanbul Physical Therapy and Rehabilitation Training and Education Hospital, Istanbul, Turkey
Cerebral palsy (CP) describes a group of disorders of the development of movement and posture causing activity limitation that is attributed to non-progressive disturbances that occurred in the developing fetal or infant brain.
The purpose of this study is to determine if the associated problems like epilepsy and feeding competencies influence the body weight percentile of children with cerebral palsy (CP). One hundred nineteen children, aged between 0 and 16 years, were studied.
Data were collected in our cerebral palsy policlinic from the patients’ files between March 2008-October 2009.
The following data for every patient were obtained: gender, body weight percentile, age of the patient (at present time), age that the problem had been first noticed, etiologic risk factors, clinical type and some CP associated medical problems were noted.
Statistical analysis was made by using SPSS 15.0 program.
The mean age of 119 patients was 6.03 years (0-16 years). Of these, 78 (65,5%) were boys and 41(34.5%) were girls. Body weight percentile (BWP) mean was 25.61±32.07 and 66 (55.5%) patients were underweight (<10 percentile). BWP was significantly correlated with mother age and it was not correlated with caregivers’ education years. According to gender, epilepsy and mental retardation presence BWP were not significantly different.
The patients who have drooling problems were in low body weight percentile, but it was not statistically significant p=0.460). Also the patients with dysphagia problems were in low body weight percentile, but it was not statistically significant (p=0.380).
P249 Rehabilitation of Targeted Daily Life Competences as Situated Learning: Intensive Rehabilitation of Patients With Severe Traumatic Brain Injury
L. L. Aadal1 and M. M. Kirkevold2
1Hammel Néurorehabilitation- and Research Centre, Hammel, Denmark, 2Department of Nursing Science, University of Aarhus, Århus, Denmark
Background: In Denmark annually about 120 people need highly specialized neurorehabilitation after a severe traumatic brain injury (TBI). Given that patients with severe TBI have changed abilities to (re)learn, and that the objective of neurorehabilitation is to regain an independent and meaningful everyday life, two levels of pedagogical challenges exist: Helping the patient regain or compensate for changed learning abilities and supporting the patient in relearning or compensating for lost competencies.
Objective: To develop a model that may foster participation by synthesizing insights from “situated learning” theory with neuropsychological research that illuminates the patients’ changed learning abilities.
Methods: Qualitative study. Theoretical analysis and synthesis of “situated learning theory”, neuropsychological theory and empirical studies of cognitive and emotional functioning following a TBI. Lave and Wenger’s “situated learning” theory describes learning as a relational process situated in a practice community. A severe TBI can change both the competencies involved in the learning process and the ability to participate. Considering rehabilitation as relearning requires that the special learning competencies of patients with severe TBI are determined.
Results/conclusion: Because of their changed abilities to (re)learn, patients with severe TBI pose challenges in terms of being active participants in the “rehabilitation practice community.” This study highlighted six main categories that need to be considered in developing a practice which fosters relearning: Perception, attention, memory, language, physical competencies and emotion/model of behaviour.
P250 Structured Rehabilitation Intervention With Multidisciplinary Approach for Outpatient Stroke Patients in Malaysia: A Pilot Project
N. Aziz, A. Fadilah, H. Nashriah, F. A. Aznida, A. Maryam, and M. A. Katijjah
University Kebangsaan Malaysia, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia
Background: Structured rehabilitation is proven to improve long-term outcome in functional performance and overall quality of life. At present, there is no agreed consensus on how best post-discharged outpatient rehabilitation should be provided. Our centre has taken an initiative in starting of a new service of combined-based rehabilitation clinic (CSRC) with multidisciplinary approach to stroke patients attending outpatient rehabilitation.
Methodology: The CSRC provided assessments, problem identification and setting-up individual plans for each patient. The aim of this study was to determine the outcome of stroke patients attending this new unit. Data on sociodemographic, stroke profile, intervention sessions and outcomes were obtained from May 2008 to September 2009. Statistical analysis using cross-tabulation and chi-square analysis were performed
Results: A total of 34 patients attended CSRC over the period of 16 months The mean age was 62.6 years (SD 12.7) with mean stroke duration of 17.8 months (SD10.9) during assessment. The mean post-stroke duration the patients were referred to CSRC was 10.5 months (SD 9.44). Mean number of assessments was 1.5 sessions (SD 0.7) over 12 month’s intervention. 25.0% were able to be discharged, 15.6% were started on group therapy and 50.0% were still on individual therapy. Post-CSRC intervention, 53.1% were on dual-therapy, 28.1% on triple-therapy and 9.4% maintain single therapy.
Conclusion: Initial data show that regular assessments performed by a multi-disciplinary team in outpatient rehabilitation resulted in better outcome and planning of long-term stroke patients. This service may thus be an excellent complement to existing stroke pathway.
P251 One-Year Outcome After a Severe Traumatic Brain Injury (TBI) in the Parisian Area
V. Bosserelle1, C. Fermanian1, P. Aegerter1, J. Weiss2, and P. Azouvi3
1AP-HP, Boulogne, France, 2CRFTC, Hopital Broussais, Paris, France, 3AP-HP, Garches, France
Objectives: A prospective observational study was undertaken to assess the care network, both at the acute and the rehabilitation stages, and the outcome one-year after a severe TBI in the Parisian area.
Methods: Severe TBI patients were included prospectively by mobile emergency services. Surviving patients were contacted by telephone one year after the injury. Global disability was assessed with the GOS-Extended (GOS-E). Cognitive and behavioural modifications in everyday life were assessed with the Dysexecutive Questionnaire (DEX). Quality of life was assessed with the Euro-QOL.
Results: 518 patients were included. Among the 274 survivors, 135 (49.2%) could be contacted for the one-year follow-up interview. Fifty-five patients (40.7%) had returned to work at one-year, but most of them experienced difficulties. According to the GOS-E, 18.6% were classified as “Good Recovery”, 43% as “Moderate Disability”, and 37% as “Severe Disability”. The most frequent cognitive and behavioural changes were the following: deficits in decision-taking abilities; poor emotional appraisal; poor planning abilities, impulsivity. Injury severity, as assessed with the Glasgow Coma Score, was poorly predictive of one-year disability. The most frequent impact on quality of life, as assessed with the Euro-QOL was related to mood changes and to everyday life activities.
Conclusions: The results showed a high level of persistent disability one year after the injury, that was only poorly predicted by injury severity measures.
P252 Outcome in Patients With Stroke Due to Atrial Fibrillation: A Retrospective Case-Control Study
C. Boccagni, A. Sant’Angelo, S. Bagnato, F. Rubino, F. Dispensa, and G. Galardi
Rehabilitation Department, Cefalù, Italy
Introduction. Cardioembolic stroke due to atrial fibrillation (AF) accounts for about 20% of ischemic strokes. Its prognosis is usually regarded as poor, because of high case-fatality rates and high risks of recurrence. Moreover, stroke caused by AF has a poor outcome in terms of function recovery compared to stroke due to non cardio-embolic causes. The aim of this study was to evaluate the outcome after a standard neurorehabilitative treatment in patients with ischemic stroke due to AF compared to patients with non cardio-embolic stroke.
Methods. We studied 41 consecutive patients admitted in our Rehabilitation Department to carry out a standard neurorehabilitative treatment after a stroke due to AT. The functional independence measure (FIM) was evaluated at admission and at the end of the hospitalization. Each patient was matched for sex and age with patients affected by non cardio-embolic stroke admitted in our Department in the same period. Statistical analysis was performed using a repeated measures ANOVA with the factor TIME (FIM score at admission vs FIM score at the end of hospitalization) as within-subject factor and the factor GROUP (patients with AF vs patients without AF) as between-subjects factor.
Results. A significant improvement of FIM score was found in both groups of patients at the end of the hospitalization (factor TIME: F(1,80)=164, p<0.0001); factor GROUP: F(1,80)<0.001; p=1); TIME*GROUP: F(1,80) = 2.29, p = 0.14).
Conclusions. Functional outcome is comparable in patients with stroke due to AF and in patients with non cardioembolic stroke.
P253 Tunisian Hereditary Spastic Paraplegias: Clinical Variability Supported by Large Genetic Heterogeneity
A. Boukhris1, G. Stevanin2, I. Feki1, N. Elleuch1, M. I. Miladi1, M. Damak1, A. Brice2, and C. Mhiri1
1Habib Bourguiba Hospital, Department of Neurology, Sfax, Tunisia, 2the INSERM, U975, Paris, France
Background: Hereditary spastic paraplegias (HSP) constitute a clinically and genetically heterogeneous group of neurodegenerative disorders characterized by slowly progressive spasticity of the lower extremities. In addition to pure forms, complicated forms involving additional neurological features have also been reported. Objective: To perform the first clinical, epidemiological and genetic study of HSP in Southern Tunisia. Results: We investigated 88 patients belonging to 38 unrelated Tunisian HSP families. We could establish the prevalence of HSP in the district of Sfax to be 5.75/100,000. Thirty one percent of families had a pure HSP, whereas 69% had a complicated form. Genetic studies revealed significant or putative linkage to known HSP loci in 13 families (34.2%) to either SPG11 (7/38, 18.4%), SPG15 (4/38, 10.5%) or to SPG4 and SPG5 in one family each. The linkage results could be validated through the identification of two recurrent truncating mutations (R2034X and M245VfsX246) in the SPG11 gene, three different mutations (Q493X, F683LfsX685 and the novel S2004T/r.?) in the SPG15 gene, the recurrent R499C mutation in the SPG4 gene as well as the new R112X mutation in the SPG5 gene. Conclusions: We report the largest series of North African HSP families of Arab origin investigated so far and establish its prevalence in South Tunisia. Our study confirms the marked heterogeneity in clinical presentation supported by the large underlying genetic heterogeneity, even within homogeneous phenotypic entity. Recessive complicated HSP is the more frequent subtype of HSP in Southern Tunisia with SPG11 and SPG15 as the major responsible genes.
P254 Experience of Spasticity Overcoming and Movement Restoration in a Long Time After Stroke
S. Boyko and A. Boyko
Burdenko Neurosurgical Institute, Moscow, Russian Federation
Plasticity of nervous system is a background for brain connections’ re-building in years after brain damage.
An important factor of successful CNS-reorganization (movement retraining) is the patient’s learning ability including: ability to recognize movement task; ability “to hear” own body and to correct wrong movement; high motivation. Complicative conditions: altered elastic tissues; wrongly formed spastic motion pattern.
Two patients had Bobath physiotherapy courses of 20 sessions in 23 and 16 years after stroke accordingly. Once or twice a week they participated in out-patient physiotherapeutic program at Burdenko Neurosurgical Institute with obligation to every-day homework. Similarity: long term after severe intracerebral bleeding; right-hemisphere damage; rehabilitation program not later than three years after stroke; compensatory physiotherapeutic strategy; never got Bobath physiotherapy.
Differences: milieu integration; structure of values and attitudes; movement experience before and after stroke.
Outcomes of rehabilitation courses: Patient K., 46, F: significant improvement of walking pattern, positive stabilographic change; motor links got into gear that weren’t enabled previously; spasticity decrease in left paretic arm. Patient C., 52, F: short term spasticity decrease in left extremities. Muscle tone increased in months to baseline.
Conclusion: 1. Spasticity decrease is possible in a very distant time after stroke. 2. Muscle tone of paretic extremities reduces according to movement re-learning, postural control, and selectivity of motion just as in earlier rehabilitation. 3. Motivation, milieu integration, and learning ability have decisive importance of successful therapy in remote period.
P255 eHealth in Stroke Rehabilitation Using 3D Computer Games
J. Broeren1,2,3, L. Pareto4, B. Johansson2, S. Zeller2, C. Ljungberg4, K. S. Sunnerhagen1, and M. Rydmark3
1Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden, 2NU-Hospital Organisation, Department of Research and Development, Trollhättan/Uddevalla, Sweden, 3Institute of Biomedicine, Mednet, University of Gothenburg, Gothenburg, Sweden, 4Laboratory of Interaction Technology, University West, Trollhättan, Sweden
We have designed and initiated testing of an e-health system for stroke rehabilitation in a rural area in Sweden, i.e. NU Hospital Group Area. The rehabilitation method is based on computer generated environments and objects. The scenario is that the user sits in front of a computer monitor with stereoscopic 3D visualization and holds a haptic stick (a robotic arm which mediates a feeling of touch and force feedback) with which the user trains using “serious games”. Assessment and training is carried out by the motor activity of the hand and arm. The pattern of movement is detected and analyzed continuously. This gives an objective quantitative and qualitative measure of the user’s progress and will give decision support for choice of suitable exercises as well as individually adapted adjustment of difficulty based on individual needs. For collection of daily assessments, game allocation and tuning of difficulty and audiovisual communication between therapists and users the e-health system will have bidirectional contact with the home-based units. Our study investigates users and spouses’ experiences of home based training and distance meetings. Our proposed system will enable many persons with neurological deficits to prolong their rehabilitation period. Modern e-Health technologies may as well function as a communication port regarding stroke rehabilitation, and also have the potential to become a health care portal in the community. Such a portal has the potential to improve the quality of life for elderly people with physical and mental impairments as well as for their care giving relatives.
P256 Qualitative Gait Analysis and Its Correlation With Fatigue in MS Patients During Inpatient Rehabilitation
R. Bussmann1, R. Sacco2, P. Oesch1, J. Kesselring1, and S. Beer1
1Rehabilitation Centre Valens, Valens, Switzerland, 2Neurological Sciences Department, Second University of Napoli, Napoli, Italy
Introduction: Gait impairment and fatigue are two of the most common and disabling problems in multiple sclerosis (MS). Some evidence exists for beneficial effects of physical training on mobility: gait assessments, however, were done only by simple quantitative tests providing very limited quantitative and no qualitative information.
Objective: The main goal of this study was to characterize the spatio-temporal gait parameters in MS patients before and at the end of a three week inpatient rehabilitation program, and to analyze the correlation with fatigue.
Patients and methods: 27 patients with definite MS with a stable phase of disease admitted for an inpatient rehabilitation able to walk without aids for at least 10 meters were evaluated using GAITRite® Functional Ambulation System. Subjects were tested before and at the end of a 3 week inpatient rehabilitation and were asked to complete a self-rating fatigue scale (Würzburger Erschöpfungsinventar WEIMuS). In a pre-post-analysis spatio-temporal gait parameters and correlation with fatigue were analyzed.
Results: After a 3-week intensive inpatient training there was a significant increase of walking velocity together with a longer stride length and a decrease of coefficient of variation indicating improved gait stability, and fatigue scores decreased significantly correlating strongly with improvement of gait parameters.
Conclusions: Our study indicates that gait analysis by GAITRite® is a useful tool for objective measurement of treatment effects on qualitative gait parameters in MS patients. Inpatient rehabilitation training was found to have beneficial effects on different gait parameters and fatigue scores.
P257 Correlation Between Sensory Impairment and Upper Extremity Function in Subacute Stroke Patients
R. Chanubol1, P. Wongphaet2, and N. Chavanich2
1Prasat Neurological Institute, Bangkok, Thailand, 2Department of Rehabilitation Medicine, Ramathibodhi Hospital, Mahidol University, Thailand
Background: Despite the accepted prognostic importance, systematic sensory assessment and scoring of stroke patient is not commonly used because it is time consuming and too complex to carry out in many instances.
Objective: To study correlation between a newly developed abbreviated sensory impairment score and upper extremity function recovery after stroke.
Method: 33 first-ever subacute stroke patients from Prasat Neurological Institute were recruited. Only patients without severe cognitive and language impairment were included. At their admission to rehabilitation department and one month later, each stroke patients were assessed for arm motor, sensory impairment and disability in activities of daily living. Their arm motor function were assess with Action Research Arm Test, arm motor function subscale of Fugl-Meyer Stroke Scale, and Block and Block Test. A sensory impairment score were given according to performance in tactile localization and joint position distance discrimination ability. The highest possible score of 4 is for patients with normal sensory function. Those who can not detect touch and passive joint movement get the lowest possible score of 0. Patients with partial sensory function get the score 1 up to 3.
Result: Sensory impairment score at admission to rehabilitation is correlated with upper extremity motor function outcome (p<0.001, r =0.67-0.69) one month later.
Conclusion: The newly developed sensory impairment score at admission to rehabilitation is correlated with hand and arm motor function outcome one month later.
P258 Gait Rehabilitation in Poststroke Patients: Task Oriented Treadmill Exercises Versus Step Over Obstacles Training
D. Cinteza, S. Diaconescu, S. Popescu, G. Galbeaza, V. Marcu, D. Poenaru, and A. Dima
National Institute of Physical Medicine and Rehabilitation, Bucharest, Romania
Background: Stroke is a leading cause of long-term and severe disability. Gait rehabilitation is the most important aim for both patients and professionals. Negotiating obstacles during gait in real life requires many adaptations and could enhance the risk of falls; crossing obstacles is a challenge in activities of daily living of stroke survivors.
Objectives: To compare efficiency of two methods for gait rehabilitation, treadmill training and obstacles crossing exercises, in order to provide a safe low-energy-costing gait in hemiparetic stroke patients.
Materials and Methods: This is a prospective randomized uniblinded study. We followed 20 patients included in a rehabilitation poststroke program. Subgroup A (10 subjects) was trained on the treadmill for gait improvement, and we used a personalized set of “steps-over-obstacles” exercises for subgroup B. All of the patients met the inclusion and exclusion criteria of the study. The parameters of gait (speed, symmetry, length of step) and other functional scales were used to asses the walking capacity after 3 weeks of treatment and after 3 months. Spasticity and motor deficit were also assessed.
Results: After 3 weeks the gait parameters were similarly improved in both groups. The functional scales for gait capacity and the overall patients’ impressions were significantly better for the subgroup B. After 3 months, the subjects from subgroup B presented lower risk for falling and a better ADL evaluation.
Conclusions: This work suggests that steps-over-obstacles training offers a better quality of walking for poststroke patients, with a safer gait and lower energy expenditure.
P259 Italian McGill Ingestive Skills Assessment (I-MISA): Translation and Validation of Italian Version Scale
M. Collina1, A. Giattini1, E. Calderisi1, M. Ricci1, M. Torresi1, F. Ciarrocchi1, A. Giorgini2, and H. Lambert3
1Istituto Santo Stefano, Porta Potenza Picena, Italy, 2Istituto Santo Stefano, Porta Potenza Picena, Italy, 3Centre for Health Services and Policy Research, Queen’s University Kingston, ON, Canada
Swallowing disorders are a common condition in the general population, but the prevalence increases with age. The 80% of elderly people with swallowing disorders are associated with increased mortality and morbidity, first of all pneumonia. Not rare the elderly with dysphagia has aspiration, dehydration, pneumonia, malnutrition, functional decline and institutionalisation. To be effective, management of dysphagia requires a multidisciplinary team approach and a careful assessment of the patient’s oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. The McGill Ingestive Skills Assessment (MISA) was developed to facilitate the reliable and valid bedside assessment of elderly persons with feeding difficulties regarding clinical and functional swallowing evaluation, patient’s mobility, cognition and behaviour. The aim of this study is to create an Italian version of MISA able to give prognostic and rehabilitative guidelines for the clinical practice. Translation and transcultural adaptation of original scale are conducted according to guide lines available in the literature. The Italian version of MISA, FIM and DOSS were administered to 20 individuals, 65 years of age and older, residing in a Rehabilitation Institute, at admission, at the day-after admission and at discharge. We statistically evaluated reliability, validity and sensitivity. Results showed a high correlation between I-MISA and FIM, and between I-MISA and DOSS. Our findings support the validity, efficacy and sensitivity of I-MISA to use with the elderly people with swallowing disorders like the English version.
P260 Body Weight Support and Treadmill Training: Influence on Parkinson’s Disease
C. L. Corrêa1, L. L. Takano2, and A. Rosso2
1Universidade Federal do Paraná, Caiobá, Brazil, 2Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
Objective: To analyze the effects of Body Weight Support (BWS) associated to treadmill in patients with Parkinson’s Disease (PD) because gait disturbances are frequent in Parkinson’s disease. Design: prospective study. Setting: University-based clinical and research facilities. Participants: 9 individuals with PD in stage 2 and 3 of the Hoehn and Yahr staging under stable medication and 46 healthy individuals as control group. Intervention: Participants were divided into two groups (control and experimental groups) to treadmill training at speed from 1.0 to 3.0 km/h with 10% and 20% of their body weight supported. Participants received 10 minutes of training using 20% of their body weight supported, 5 minutes rest interval and plus 10 minutes using 10% of their body weight supported per session for 24 sessions followed by 3 months. Main outcome measure: Hoehn and Yahr Scale, cadence, gait speed and Borg scale. Statistical analysis was done using t test and ANOVA (p <0.05). Results: There were significant difference to values of Borg scale between control and experimental groups at 10th min (p=0,03). Experimental group presented cadence lower than control group during initial walking (p=0,007). According to increase of speed gait the cadence was similar between groups. Conclusions: These findings suggest that to train subjects with PD could be improve physical conditions, specially, breathlessness and cadence.
P261 Management of Urinary Tract Infections (UTI) in Patients With a Urinary Catheter: How Are We Doing in Neurological Rehabilitation?
G. Juknevicius, M. H. Desai, and E. C. Davis
International Centre for Neurological Rehabilitation and Neuropsychiatry, Newcastle upon Tyne, United Kingdom
Catheter-associated UTI is the source of 8% of hospital-acquired bacteraemia. This audit aimed to identify the neurorehabilitation centre’s current management strategies and compare them with the SIGN recommendations.
Methods: 100 case notes were retrospectively reviewed. The number of patients with an indwelling urethral catheter, the prevalence of catheter-associated symptomatic UTI, the investigations carried out and the treatments used were identified.
Results: 29/100 patients had a long-term catheter, 55% male and 45% female; 34% patients had a stroke, 27% Traumatic Brain Injury and 10% a SCI; 51% had a diagnosis of UTI documented in the notes and were treated with antibiotics. Positive urine dipstick testing was the main reason for initiating treatment. Urine culture results showed mixed growth in 65% (19) cases. The main choice of empirical antibiotic was Trimethoprim (8 cases). Twenty-four cases had asymptomatic bacteriuria and were asymptomatic when urine samples were collected. Systemic illness arose in 20% (6) of the cases.
Conclusions and Recommendations: All long-term urinary catheterised patients are bacteriuric unless proved otherwise. Urine dipstick examination has no role in diagnosing asymptomatic bacteriuria. Haematological investigations and urine C&S should support a diagnosis of a UTI. Trimethoprim 200mg BD OR Cephalexin 500 mg TDS is the treatment of choice until the C&S is available. For recurrent UTI, the same antibiotics from previous reports should be used until further results are available. Care protocol was created for use in the unit after presentation in the multidisciplinary meeting.
P262 Management of Depression in an Adult Acquired Brain Injury (ABI) Rehabilitation Centre: A Comparison to National Guidelines
M. H. Desai, K. Collinson, E. Naidu, and J. Macfarlane
International Centre for Neurological Rehabilitation and Neuropsychiatry, Newcastle upon Tyne, United Kingdom.
Background: Depression is common after ABI with national guidelines published in 2005 to highlight its importance and set standards of care.
Assessment and management of depression in these patients is complex as some tools and measures can not be used due to the impaired communication, visual and/ or cognitive function.
Quality Issues: 1) Is our service delivering the standards of care for depression outlined in the guidelines? 2) To identify means to address any shortfall in meeting the standards.
Method: A checklist was developed from the guidelines and retrospective analysis of 25 patients’ notes over previous 18 months.
Results: All 25 patients had mood assessment within 1 week with 23/25 at admission. Doctors diagnosed depression in 5/25 (20%) and the psychologist in 16/24 (66%) of patients, with 7/16 having suicidal ideation.
Three patients were referred to psychiatry services. 9/25 patients were on antidepressants at some stage, 8/16 had CBT sessions, and 3/16 had meditation and relaxation from psychologist as intervention.
Risk factors, scaling tools, communication, actions, consent, long term treatment plan and withdrawal of medication were poorly documented.
Conclusion: The true rate of depression probably lies between the figures above and highlights the difficulty in diagnosing depression.
Patients should be reviewed regularly to identify risk factors for depression and any new or changing symptoms. Medics should be trained to carry out mood screening and suicide risk assessment.
A care pathway is designed as a part of co-ordinated multi-disciplinary framework to identify and manage low mood.
Re-audit is planned.
P263 Post-Stroke Depressive Disorder: Associations With Lesion Location and Functional Recovery
S. R. Draca
Clinic for rehabilitation “Dr M.Zotovic”, Neurorehabilitation Unit, Belgrade, Serbia
Post-stroke depression (PSD) is a common consequence of stroke. Injury to specific brain areas appears to increase the risk of developing PSD. Depression was assessed in a total of 80 patients, 3-5-months after the first, unilateral stroke. The patients were subdivided in 4 groups: left or right cortical lesion, and left or right subcortical lesion. All patients were tested by self-rating depression scale Beck Depression Inventory (BDI)-II with a cut off point of 14. The prevalence of PSD was 33%. The highest rate of PSD was found in the group with left subcortical stroke (48%). The highest rate of moderate depression (score 20-28) was found in the group with left subcortical stroke (19%), while the highest rate of severe depression (score 29-63) was found in the group with left cortical stroke (21%). The results also demonstrated a significantly higher median value of BDI-II score in a group with left subcortical stroke compared to a group with right subcortical stroke (p<0,01). No significant difference was found between the other groups of patients.
We also found a significant negative correlation (p<0,001) between the severity of depressive symptoms as measured by BDI-II in the whole group of patients and the severity of functional impairment as measured by Barthel Index, indicating that patients with PSD had lower functional status. This study showed a correlation between PSD and a left-sided hemispheric lesion. It is important to make an accurate diagnosis of PSD as treatment may reduce morbidity.
P264 External Auditory Cueing Methodology: Progressively Increasing and Decreasing Cueing Rates During Mobility Training in Persons With Parkinson’s
M. Ford, O. R. Olokode, T. T. Babatope, N. A. Shannon, J. N. Thompson, and K. D. Williamson
The University of Alabama at Birmingham, Birmingham, AL, United States
Mobility training with external auditory cues (EAC) has shown to be effective at increasing walking speed, stride length, and cadence in persons with Parkinson’s disease (PD). The question remains as to what is the best incremental increase in EAC rate during training. The purpose of this study was to describe a novel approach to determining the dosage of EAC during mobility training. 5 ambulatory individuals with PD participated in this pilot study. Participants trained for 30 min./session, 2 sessions/week, for 3 weeks. EAC cueing progressed from comfortable speed in 10 bpm increments, while investigators assessed walking speed, stride length, and cadence. EAC progression stopped (training plateau) when stride length began to decrease in lieu of increasing cadence and EAC rate (Table 1). EAC was then decreased in 5 bpm increments to examine the relative changes in walking speed, stride length, and cadence. Comfortable and fast over-ground walking speed (without EAC) increased .05 m/s after training. EAC are typically increased during training with an aim to improve spatial and temporal movement coordination, as well as walking speed. These preliminary data showed that incremental increases and decreases in EAC rate, based on changes in gait parameters, can still lead to increases in over-ground walking speed. Further study is required to understand the possible dosage (intensity) of EAC that can improve function, as well as fitness in persons with PD.
Mean Walking Speed, Stride Length, and Cadence During Specified Training Sessions
P265 Management of Eating and Drinking After Acquired Brain Injury: A Functional Approach
R. Gerry and A. Graham
Frenchay Brain Injury Rehabilitation Centre, Frenchay Hospital, Bristol, United Kingdom
Swallowing difficulties are common following an acquired brain injury and their assessment can be challenging particularly with associated cognitive and behavioural problems. The traditional Clinical Bedside Assessment (CBA) of swallowing is the first phase in the determination of swallowing difficulties and usually follows a very structured approach. This, however, is often not appropriate for patients with challenging behaviour and cognitive impairment, in addition to their mechanical swallowing difficulties, who not only may not engage in the assessment, because they do not understand it, but also may feel threatened by the hands on approach.
This paper presents a structured, functional approach to swallowing assessment and management of patients with an acquired brain injury, and their outcomes, at Frenchay Brain Injury Rehabilitation Centre.
P266 Experienced Emotional Burden in Caregivers: Psychometric Properties of the Involvement Evaluation Questionnaire in Caregivers of Chronic Brain Injured Patients
G. J. Geurtsen1, R. Meijer1,2,3, C. M. Heugten4,5, and J. D. Martina1
1Medical Rehabilitation Centre Groot Klimmendaal, Arnhem, Netherlands, 2Department of Rehabilitation, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands, 3Department of Research Development and Education St. Maartenskliniek, Nijmegen, Netherlands, 4Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands, 5Department of Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, Netherlands
Objective: To examine psychometric properties (internal consistency, discriminant validity, and responsiveness) of the Involvement Evaluation Questionnaire for Brain Injury (IEQ-BI) measuring emotional burden in caregivers of patients with severe chronic acquired brain injury.
Design: An inception cohort study.
Subjects: Caregivers of severe chronic acquired brain injury patients.
Measures: Besides the IEQ-BI, the Family Assessment Device (FAD) and the General Health Questionnaire (GHQ) were used.
Methods: Ninety-eight caregivers filled out all questionnaires, of which 41 caregivers did this twice, before and after the persons they cared for had started a residential community reintegration programme. Cronbach’s alpha and Intra class Correlation Coefficient (ICC) were calculated for internal consistency. Pearson correlation coefficients were used for discriminant validity and ICC and Cohen’s d were calculated to determine responsiveness.
Results: The internal consistency of the IEQ-BI was good (α = .73 - .84; ICC = .69 - .76). As expected, low correlations were found between the IEQ-BI and either the GHQ (r= .11 - .40) or the FAD subscales (r= -.29 - .19). Regarding responsiveness of the IEQ-BI, a moderate effect size was found (Cohen’s d = .36) while the ICC was good (.80).
Conclusions: The IEQ-BI measures the experienced emotional burden in caregivers of patients with severe chronic acquired brain injury and seems to be a promising new instrument with good internal consistency, discriminant validity and good responsiveness.
P267 High Aerobic Intensity Interval Training Improves Peak Aerobic Power and Walking Economy in Chronic Stroke Patients
T. Gjellesvik1,2, J. Hoff2,1, and J. Helgerud2,3
1Department of Physical Medicine and Rehabilitation, St. Olav University Hospital, Trondheim, Norway, 2Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway, 3Hokksund Medical Rehabilitation Center, Hokksund, Norway
Background: Peak aerobic power (VO2peak) is found to be the strongest predictor of mortality independent of existing cardiovascular disease. However, little attention has been given to this topic despite reports of chronic stroke patients being severely deconditioned. Research has shown a superior effect of aerobic high intensity training compared to moderate intensity to improve VO2peak. The aim of this study was thus to determine the effect of a 4-week aerobic high intensity training programme on chronic stroke patients. Design: Baseline control trial. Methods: 4 men and 4 women mean 48.9 (±10.6) years with chronic stroke trained 5 days/week for 4 weeks preceded by a 4-week control period. Training consisted of treadmill walking in 4x4 minute work periods at 85%-95% of peak heart frequency with 3 minutes active breaks between intervals. Results: VO2peak improved 11.6 % from 2.32 (±0.44) L · min-1 to 2.60 (±0.55) L · min-1 (p=0.013) after training. Walking economy (Cw) improved by 8.1 % from 1.12 (±0.15) to 1.04 (±0.18) L · min-1 (p=0.004). In addition, functional improvements were found in distance walked in 6 minutes by 9.6 % (p=0.006), 10 metre walk test 8.3 % (p=0.006) and the timed up and go test 11.9 % (p=0.006). Conclusion: Aerobic high intensity interval treadmill training is well tolerated in these patients and significantly improves both VO2peak and walking economy. Furthermore, walking speed and distance increased after 4 weeks of training. No adverse effects were registered during the course of this study.
P269 Posttraumatic Agitation in Brain Injury During Acute Care
F. A. Hanapiah, R. B. A. Rahim, V. Mathaneswaram, and L. H. M. Khazri
University Malaya Medical Center, Kuala Lumpur, Malaysia
Objective: To determine the incidence of posttraumatic agitation during acute traumatic brain injury (TBI) care, its associated variables, common management and outcome on discharge.
Method: Thirty acute traumatic brain injured inpatients referred to the rehabilitation team underwent the Agitated Behaviour Scale (ABS) assessment. Patients were categorised into brain injury severity by the presenting Glasgow Coma Score (GCS) and the duration of Posttraumatic Amnesia (PTA). Common practices in managing posttraumatic agitation via behavioural and environmental modification with pharmacological intervention were evaluated. The ABS and Modified Barthel Index (MBI) scores on discharge measured outcome of these interventions.
Results: 63.3% of the TBI patients suffered posttraumatic agitation during acute care. Half were of moderate severity with disinhibition being the most prominent factor. Severity of injury and presence of posttraumatic amnesia were associated with posttraumatic agitation. Simple measures such as the use of orientation board and singled room nursing appeared to have better outcome with improved discharge mean MBI scores. The use of medication was also associated with better MBI scores on discharge and lowered ABS scores.
Out of the thirty patients, nine were discharged in agitation while fifteen were discharged in PTA.
Conclusion: Posttraumatic agitation during acute care is very common and is associated with injury severity and PTA. Good management via environmental and pharmacological intervention was associated with reducing agitation and improved independence on discharge. Due to the high rate of patients discharged in agitation and amnesia, outpatient treatments and approaches addressing these issues are essential.
P270 Dysautonomia After Severe Traumatic Brain Injury
H. T. Hendricks1,2, A. H. Heeren1, and P. E. Vos3
1Department of Rehabilitation Medicine, Radboud University Medical Centre, Nijmegen, Netherlands, 2Groot Klimmendaal, Rehabilitation Centre, Arnhem, Netherlands, 3Radboud University Medical Centre, Institute of Neurology, Nijmegen, Netherlands
Background: Dysautonomia after traumatic brain injury (TBI) is characterized by episodes of increased heart rate, respiratory rate, temperature, blood pressure, muscle tone, decorticate or decerebrate posturing, and profuse sweating. It develops generally during the early recovery phase. In clinical practice, dysautonomia is often misinterpreted. The reported incidence rates vary considerably. The prognostic importance is still unclear. This study addresses the following research questions (1). What is the incidence of dysautonomia in patients with TBI? (2). Which clinical variables are associated with the occurrence of dysautonomia? (3). Is the functional outcome of patients who suffered from dysautonomia worse than comparable patients without dysautonomia?
Methods: A historic cohort study in patients with severe TBI (GCS ≤ 8 on admission).
Results: 76 of 119 patients survived and were eligible for follow up. The incidence of dysautonomia was 11.8%. Episodes of dysautonomia were prevalent during a mean period of 20.1 days (range 3-68), and were often initiated by discomfort. Patients with dysautonomia showed significant longer periods of coma (24.78 versus 7.99 days) and mechanical ventilation (22.67 versus 7.21 days). Dysautonomia was associated with diffuse axonal injury (DAI) (RR 20.83, CI 4.92-83.33) and the development of spasticity (RR 16.94, CI 3.96-71.42). Patients with dysautonomia experienced more secondary complications. They tended to have poorer outcome.
Conclusions: Dysautonomia occurs in approximately 10% of patients surviving severe TBI and is associated with DAI and the development of spasticity at follow up. The initiation of dysautonomia by discomfort supports the Excitatory: Inhibitory Ratio model as pathophysiological mechanism.
P271 Health Status and Functional Recovery in Patients With Critical Illness Polyneuromyopathy
D. Intiso1, L. Amoruso2, F. Di Rienzo1, T. Lombardi3, M. Zarrelli2, G. Maruzzi1, M. Basciani1, and G. Grimaldi3
1Scientific Institute “Casa Sollievo della Sofferenza”, Neurorehabilitation Unit, San Giovanni Rotondo, Italy, 2Scientific Institute “Casa Sollievo della Sofferenza”, Neurology Unit, San Giovanni Rotondo, Italy, 3University, Rehabilitation Medicine Unit, Foggia, Italy
Background: Critical illness polyneuromyopathy (CIPNM) is a frequent neurological complication in intensive care unit patients (ICU). By impeding recovery, it can be a significant burden for both patients and clinicians. The objective of the present study was to investigate the long-term outcome and health status of patients with CIPNM.
Method and Subjects: Patients suffering from CIPNM admitted to an intensive rehabilitation setting were identified. The Barthel (BS) and modified Rankin Scales (mRS) were administered to all patients at baseline, discharge and follow-up (mean 31.7±15.8 months). Neuromyopathy and strength of the related paretic muscle were ascertained by the EMG and MRC scale, respectively. SF-36 questionnaire was administrated to ascertain the health status. All patients underwent to individual tailored rehabilitation treatment.
Results: Twenty-two subjects (19M, 3F, mean age 58.4±13.9) were identified. Tetraparesis or tetraplegia was the prevalent neurological impairment (86.3%). Overlapping Central Nervous System (CNS) lesions were detected in 11 (50%) subjects. The mean Barthel scores at baseline, discharge and follow-up, respectively, were 16.6±10.6; 78.2±19.5 and 88.5±19.4 (p <0.001) and the median mRS scores were 5 (IQR: 5-5), 3 (IQR: 1-5) and 2.5 (IQR: 0-5). At discharge, 81.8% of patients with alone CIPNM achieved good recovery. The SF-36 questionnaire showed significant low values compared to Italians and US norms.
Discussion and conclusion: Rehabilitation treatment in ICU patients with CIPNM produced good functional long-term outcome. Despite complete recovery, they experienced significant difficulties in the health status. The patients with alone CIPNM had better recovery than subjects with CIPNM and coexistent cerebral lesions.
P272 Functional Recovery in Decompressive Craniectomized Patients With Intractable Intracranial Pressure After Severe Cerebral Lesions
D. Intiso1, T. Lombardi2, G. Grimaldi2, A. Del Gaudio3, A. Iarossi1, M. Tolfa1, M. Russo1, and F. Di Rienzo1
1Neuro-rehabilitation Unit, Scientific Institute “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy, 2University, Rehabilitation Medicine Unit, Foggia, Italy, 3Intensive Care Unit, Scientific Institute “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
Background. Severe cerebral lesions can lead to refractory intracranial pressure (ICP) and sub-sequent brain swelling and death. Decompressive craniectomy (DC) remains a controversial therapeutic strategy. The long-term functional recovery and quality of life in a sample of decompressive craniectomized patients are reported.
Method and Subjects. Patients with Glasgow Coma Scale (GCS) < 8 and refractory ICP following traumatic brain injury (TBI) and cerebro-vascular accidents were screened. All decompressive craniectomized patients were enrolled. In all patients admitted to a rehabilitation setting modified Rankin (mRS) and Barthel Scale (BS) were administered at admission, discharge and follow-up. The quality of life was evaluated with SF-36 questionnaire at follow-up (41.116.6 months).
Results. Of the 375 subjects screened, 39 (13F, 26M, mean age 46.4±20.5) patients were enrolled: 12 patients (2F, 10M) with TBI and 27 (11F, 16M) with cerebral hemorrhage. The mean GCS score resulted 6±2.1. Early craniectomy within 24 hours were performed in 30 (85.7%) subjects. The mortality rate was 31.4%. The mean Barthel values at admission, discharge and follow-up, respectively, resulted 2.7±5.3; 43.07±30.03 and 77.1±27.34 (p<0.001), and the median mRS values were 5 (IQR 4-5), 5 (IQR 2-5), and 2 (IQR 1-3). Globally 17 (43.5%) patients gained good recovery and 2 (5.7%) presented a persistent vegetative state. The SF-36 questionnaire showed significant abnormalities in all domains of health status.
Conclusion. DC patients achieved good long-term outcome, but they experienced significant difficulties in the health status. Although the mortality remains high, DC can represent an efficacious therapeutic strategy in patients with intractable ICP.
P273 The Use of FAVRES™ in Clinical Evaluation of Persons With Cognitive Communication Disorders After Traumatic Brain Injury
I. Jacobsen and L. Siert
Traumatic Brain Injury Unit, Copenhagen University Hospital, Glostrup, Denmark, Denmark
Objective: The objective of this study is to clarify whether the new formal Canadian test of cognitive communication disorders Functional Assessment of Verbal Reasoning and Executive Strategies, FAVRES, can provide other information about cognitive communication disorders after severe traumatic brain injury than the formal linguistic and non-verbal executive tests that are frequently used in the evaluation of these disorders today.
Participants: The participants are 10 subjects with severe traumatic brain injury (TBIs) (duration of PTA > 28 days) and 10 normal control subjects matched by age, sex and educational level (Controls). Experienced speech-language pathologists had diagnosed the TBIs with cognitive communication disorders.
Method/procedure: All subjects were tested with FAVRES, 3 linguistic tests and 4 non-verbal executive tests.
Results: TBIs performed poorly on FAVRES but close to Controls on the linguistic and executive tests and a higher level of significance (3 out of 4 p-values ≤ 0,0001) was obtained when FAVRES was used to distinguish between the two groups. There was found no significant correlation between the TBIs’ scores on FAVRES and on the linguistic and executive tests.
Conclusion and perspectives: By detecting the communication problems at a very high level of significance, FAVRES provides other information about cognitive communication disorders after severe traumatic brain injury than the formal linguistic and non-verbal executive tests used by speech-language pathologists today. Thereby FAVRES seems to be a useful tool for clinical evaluation of persons with cognitive communication disorders and perhaps also for further research of the underlying cognitive causes of the disorders.
P274 Slip-Related Plantar Pressure Changing Patterns: Parameters for Early Detection of Slip Event
S. Jang and M. Kim
Department of Rehabilitation Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
Introduction: Falls induced by slip event are a serious public health. We investigated the changing patterns of dynamic plantar pressure during normal gait and unpredictable slip event.
Method: Eleven healthy adult male volunteers walked onto a 100 cm × 480 cm wooden tile. After walking on the dry wooden tile, two layers of 50 cm × 70 cm oily vinyl sheets were placed to induce slip. Each slipping trial on the oily sheet was categorized as slip (S) if the subject totally loses his balance, recovered (R) if the subject had temporarily lose his balance.
In-shoe dynamic plantar pressure was measured by Pedar-X ® (Novel, Germany). Plantar pressures were assessed in four regions (M0: total area, M1: toe, M2: metatarsal head, M3: arch, M4: heel). In three circumstances (N; normal step, R, and S), plantar pressure changes were analyzed.
Results: Contact time in M4 of recovered step was significantly longer than other steps, and peak pressure and contact time in M 1, 2, 3 were significantly different between three group (N, R, S in descending order). Instant of peak pressure (IPP) showed unique difference between three steps, IPP in M4 and other regions showed opposite order. We calculated the IPP of metatarsal head to heel ratio, and it showed the most different nature between three steps.
Conclusion: Plantar pressure distribution according to response to slip event showed different changing patterns. It was found that IPP of metatarsal head to heel ratio is useful parameters for early detection of slip event.
P275 Uric Acid Levels and Functional Outcome of Patients With Stroke and Brain Injury
B. D. Jordan, K. Bonistall, D. Sutton, and M. Peterson
Burke Rehabilitation Hospital, White Plains, NY, United States
Background: Uric acid represents a naturally occurring antioxidant and free radical scavenger.
Objective: To determine if plasma uric acid levels were associated with acute rehabilitation outcome following stroke and brain injury.
Methods: Retrospective chart analysis of 233 consecutive patients with stroke and brain injury who admitted to an acute rehabilitation unit. Patients were divided into 2 groups based on low and normal/elevated uric acid levels. The main outcome measures were the Functional Independence Measures (FIM), the Mini-Mental Status Examination (MMSE), the Galveston Orientation and Amnesia Test (GOAT), the Standardized Assessment of Concussion (SAC), and the 6 Item Cognitive Impairment Test (6CIT) scores.
Results: Among the 233 patients 19 (8 %), exhibited low uric acid levels. Patients with low uric acid presented with lower admission total (37.26 v 53.6) (p = .001), motor (22.95 v 33.93) (p= .002) and cognitive (14.32 v 19.67) (p=.006) FIM scores compared to those individuals with normal/high uric acid levels. However, there were no differences in FIM efficiency or discharge FIM scores between the groups. Patients with low uric acid also demonstrated lower GOAT scores on admission (49.38 v 76.74) (p=.003) and discharge (69.63 v 82.95) (p=.05), lower SAC scores on admission (11.25 v 17.88) (p=.014) and discharge (13.54 v 19.12) (p=.039), and higher 6CIT scores on admission (20.78 v 11.49) (p=.006).
Conclusions: Patients with low uric acid on admission tended to have a less favorable cognitive outcome following acute inpatient rehabilitation. However, this may reflect a lower level of function on admission.
P276 Aging With a Spinal Cord Injury: Prevalence of Cardiovascular Risk Factors in Older Individuals More Than 10 Years Post Injury
S. Jörgensen and J. Lexell
Department of Rehabilitation Medicine, Lund University Hospital, Lund, Sweden
Individuals with a spinal cord injury (SCI) have increased morbidity and mortality from cardiovascular disease. Our knowledge about the prevalence of risk factors for cardiovascular disease, such as increasing age, obesity, hypertension and dyslipidemia, in this population is incomplete. The aim of this study was to investigate the prevalence of cardiovascular risk factors in older spinal cord injured individuals more than 10 years post injury. Twenty-three individuals (16 men and 7 women; 51-76 years, mean 63 years) with a complete SCI (13-54 years post injury; mean 27 years), were assessed. Anthropometric measurements, blood pressure and blood analyses of lipid profiles and fasting plasma glucose were recorded. All individuals were interviewed about lifestyle, diet and physical activity habits. Four individuals were obese (Body Mass Index, BMI >30) and six were overweight (BMI >25). Five individuals had hypertension, three had elevated fasting glucose levels but all individuals had normal or lowered lipid profiles. Only three individuals were obese or overweight and had elevated fasting glucose levels. There was no relationship between lifestyle, diet and physical activity habits and blood analyses. In conclusion, these data suggest that older spinal cord injured individuals more than 10 years post injury do not appear to have an increased risk profile for cardiovascular disease.
P277 Effect of Intensive Rehabilitation on Spasticity and Pain in Multiple Sclerosis
D. Ungaro1, E. Judica1, F. Martinelli Boneschi1, M. Comola1, R. Gatti2, G. Comi1, E. S. Perego1, and P. Rossi1
1Neurorehabilitation Unit, Neurology Dept—INSPE. IRCCS Ospedale San Raffaele, Milano, Italy, 2School of Physiotherapy, IRCCS Ospedale San Raffaele, Milano, Italy
Background: Spasticity is a common symptom which occurs in most of the patients affected by multiple sclerosis (MS). It is a major cause of long-term disability and significantly impacts daily activities and quality of life and is only partially influenced by traditional spasmolytic drugs. Furthermore spasticity is often associated with pain principally characterized by the presence of spasm and painful muscle contraction.
Objective: The aim of this study was to evaluate the impact of spasticity and related pain in patients with MS and their modifications after intensive rehabilitation treatment. Methods: We considered 180 subjects with MS who underwent to a programme of rehabilitation in our Neurorehabilitation Unit. We excluded patients who received steroid treatment in previous three months and/or changed antispastic drugs during hospitalization and in the 30 days before. We measured entity of spasticity of lower limbs with the Ashworth Scale (AS) administered at the beginning and at the end of rehab treatment of. We evaluated pain due to spasticity by Visual Analogue Scale (VAS).
Results: 87 subjects of the 180 patient were enrolled in the study in respect to selection criteria. Rehabilitation determined reduction of AS of about 70.5% (p<0.0001). At the end of rehab treatment we registered an improvement of VAS for pain of 68.9% which is strongly significative (p<0.004).
Conclusions: Rehabilitation through an intensive and specific training of exercises and muscular stretching could significantly improve objective spasticity and related pain in MS and could be considered as a strong support in spasticity therapy.
P278 Effect of Decannulation on Pharyngeal Movement in Post-Stroke Tracheostomized Patients
S. J. Jung1, D. Y. Kim1, J. H. Chang1, S. J. Yoo1, C. Park1, and Y. S. Baek2
1Dept. and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea, 2School of Mechanical Engineering, Yonsei University, Seoul, Republic of Korea
Introduction: Tracheostomy is known to disturb the swallowing, but its influence on the pharyngeal movements is still unclear. We investigated the effects of decannulation through the video analysis of videofluorographic swallow study (VFSS).
Materials & methods: We included 11 chronic post-stroke patients with tracheostomy (7 males, 4 females) who indicated for decannulation. VFSS was performed in four phases: T1 (over 14 days before decannulation), T2 (just before decannulation), T3 (just after decannulation), and T4 (over 14days after decannulation). We tried 12% semisolid, 6% semisolid, and liquid in small (5cc) and large (15cc) amounts. Starch food thickener was used in VFSS for concentration. We measured the temporospatial data such as pharyngeal transit time, stage transition duration, hyoid bone movement, laryngeal prominence movement, larynx-to-hyoid approximation through the video analysis using spatial analysis program (GraphClick, Arizona-software, Phoenix, U.S.A).
Results: No significant differences were found for all temporospatial data between T1 and T2. Larynx-to-hyoid approximation was significantly decreased in T3 compared to T2 in small amount of 12% semisolid, 6% semisolid and liquid (p<0.05). Other parameters had no significant changes between T2 and T3. No significant differences were also found for all temporospatial data between T3 and T4.
Conclusion: Decannulation may not affect hyoid bone and laryngeal movement except larynx-to-hyoid approximation, and swallowing related temporal parameters in pharyngeal phase.
This work was supported by the Korea Science and Engineering Foundation (KOSEF) grant funded by the Korea government (MEST) (No. 2009-0080591).
P279 Rehabilitation After Temporal Lobe Epilepsy Surgery
A. Kelemen1,2, G. Filiczki1, and C. Borbély2
1The András Pető Institute of Conductive Education and College for Conductor Training, Budapest, Hungary, 2National Institute of Neurosciences, Budapest, Hungary
Sixty to seventy percent of temporal lobe epilepsy (TLE) patients become seizure free after surgery. Apart from seizure outcome, neuropsychological, psycho-social (quality of life) and psychiatric outcome are equally important issues. We present conceptual framework of rehabilitation after epilepsy surgery. The different difficulties and rehabilitation needs are described in patients with favorable and less favorable outcome. The rehabilitation survey (patient’s state, expectations and aims) and the rehabilitation plan are part of the preoperative investigation. Rehabilitation means supporting the patients to attain their goals. We present the psychological, psychiatric and social difficulties of patients after temporal lobe epilepsy surgery and their consequences. Different types of rehabilitation procedures (medical, psychiatric, psycho-social, occupational) are discussed. Cognitive rehabilitation (CR) is a therapeutic approach designed to improve cognitive functioning after central nervous system insult. After TLE surgery different types of memory deficit develop. For cognitive rehabilitation of memory deficits we use retraining in individual sessions, duration of 10-12 weeks, 1,5hour/week, using Fe-Psy test battery tasks and compensation training in group sessions, 4-6 patients/group, duration of 4-6 weeks, 1,5 hour/week, teaching patients different learning and memory strategies.
Epilepsy surgery complications may need neurorehabilitation.
Epilepsy surgery is a cost effective method only when combined with the best possible rehabilitation.
P282 Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and Videofluoroscopic Swallowing Study (VFSS): Assessment of Penetration, Aspiration and Residues
S. Jung1,2 and J. Kim1,3
1Seoul National University College of Medicine, Seoul, Republic of Korea, 2Seoul National University Boramae Medical Center, Seoul, Republic of Korea, 3Seoul National University Hospital, Seoul, Republic of Korea
Objectives: To investigate the concordance of penetration, aspiration and pharyngeal residues evaluated using videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES), and to know whether adding FEES to VFSS improves the diagnostic sensitivity.
Materials and Methods: A single-group, prospective study was performed. VFSS and FEES were performed and interpreted independently by 2 different examiners, who were blinded to the results of the other study. Foods for examination were 5ml of semi-blended diet (SBD), plain yogurt, boiled rice (NRD), 2ml (small fluid, SF) and 5ml (large fluid, LF) of diluted liquid barium. The concordance of penetration-aspiration scale (PAS) and pharyngeal residue severity scale (PRS) evaluated with VFSS and FEES was analyzed using intraclass correlation coefficient (ICC). Detection of penetration and aspiration and pharyngeal residue was compared using McNemar test.
Results: Thirty-four individuals were included. The PAS grading was concordant between VFSS and FEES in SF and SBD (ICC 0.865 and 0.760 respectively). Evaluation was concordant in all solid foods for vallecular residue (VR) and in LF, SBD and yogurt for pyriform sinus residue (PRS, ICC>0.7). Combining FEES with VFSS raised detection rates of penetration in SBD, YOP, and NRD (p-value<0.05) and raised detection rates of VR and PSR were raised in all foods.
Conclusions: There was concordance between VFSS and FEES in evaluating penetration/aspiration in SF and SBD, and pharyngeal residues in solid foods. Combining FEES with conventional VFSS raised diagnostic sensitivity of penetration and pharyngeal residues compared to the evaluation using VFSS only.
P283 Characteristics of Gait in Charcot Marie Tooth Disease Type IA According to Disease Severity
D. Y. Kim1, B. O. Choi2, S. Y. Joo1, J. H. Chang1, D. S. Lee1, and C. Park1
1Dept. and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea, 2Department of Neurology, Ewha Womans University, School of Medicine, Seoul, Republic of Korea
Objectives: Charcot-Marie-Tooth disease (CMT), a group of inherited sensory motor polyneuropathies, progresses motor and sensory dysfunction centripetally over time followed by the development of abnormal gait patterns. We investigated characteristics of the gait in patients with CMT type 1A and differences of gait patterns by disease severity.
Patients and method: We recruited 24 patients with CMT 1A. The control group was comprised 24 healthy people without gait impairment. Patients with a neuropathic score equal to or less than 10 were classified into the mild group, while those scoring 11 or above were classified into the moderate group. The temporospatial, kinetic, and kinematic data were obtained using three-dimensional gait analyzer, Vicon 370 (Oxford Metrics Ltd., Oxford, UK). The ANOVA test was applied to analyze the difference between the three groups. The significant difference was defined by p < 0.05.
Results: CMT patients showed significantly greater maximal hip flexion angle at swing, ankle plantar flexion angle at initial contact and terminal swing than controls (p<0.05). No significant difference was found in temporospatial, kinetic, and kinematic data between the mild and control groups. Compared to the control group, the moderate group showed the increased hip flexion and ankle plantar flexion moment at stance, maximal hip flexion angle at swing, plantar flexion angle at initial contact and terminal swing, decreased gait speed (p<0.05).
Conclusion: The characteristic gait patterns in CMT IA patients according to disease severity could be revealed through the three-dimensional gait analysis.
P284 Safe Initiating of Oral Intake in Patients With Acquired Brain Injury: Organizing a Randomised Controlled Study of Assessment Methods
A. Kjaersgaard1, L. Hedemann Nielsen2, and B. H. Sjölund3
1Research Initiative for Occupational Therapy, University of Southern Denmark, Odense C, Denmark, 2Hammel Neurocenter, Hammel, Denmark, 3Department of Public Health, University of Southern Denmark, Odense C, Denmark
Standardised assessment of dysphagia is believed to give a dramatic reduction of aspiration pneumonias in patients with stroke. The current recommendation is to evaluate all patients before initiating oral intake. The most frequently used clinical assessment of dysphagia in Denmark is based on Facial-Oral Tract Therapy (F.O.T.T.™). It is a structured approach to assessment and treatment of neurogenic dysphagia. The aim of this prospective randomized controlled study is to examine whether the FOTT based clinical assessment gives results comparable to those with instrumental assessment through Fiberoptic Endoscopic Evaluation of Swallowing (FEES). We will include 118 patients > 18 years with acquired brain injury (ABI) admitted to Hammel Neurocenter. All patient prerequisites for initiating oral intake will be evaluated with standard assessment procedures within 24 hours after admission. Then patients are randomized to either FOTT or FEES. Hereafter, all patients will get the same FOTT based treatment and follow-up data will be collected 90 days after admission. The primary outcome measures are the number of aspiration pneumonias in the two groups during rehabilitation and if there is an agreement between FOTT and FEES for initiating oral intake. Secondary outcome measures are e.g. number of days from injury to oral intake, as well as BMI, FIM, RLAS and FOIS at admission and at follow up. So far, 28 patients have been included. The study is expected to be completed within 2 years and may provide new knowledge about clinical evidenced based practice initiating safe oral intake within neurorehabilitation of patients with ABI.
P285 Pharyngeal Obstruction With Unusual Foreign Body Caused Dysphagia
I. Kondo1, T. Teranishi1, Y. Wada1, H. Miyasaka1, J. Katoh2, T. Honda2, Y. Kubota2, and K. Ohta3
1Fujita Memorial Nanakuri Institute, Tsu, Japan, 2Kizankai Memorial Hospital, Iida, Japan, 3Matsusaka Chuo Hospital, Matsusaka, Japan
A 92-year-old man was evaluated for a complaint of dysphagia. Videofluorography (VF) revealed a large foreign body attached on the epiglottis. It was removed during VF examination and turned out to be a conglomeration of sputum debris and food residue. Its size was 5x3x2cm. VF After the removal of the conglomeration, his dysphagia was gradually improving. His past history was remarkable for an infectious illness and a sore throat, possibly epiglottitis. We speculated that this unusual case most likely represented a sensory disturbance of oro-pharyngeal region occurred with the lowered arousal level. We are going to present this case, radiographic findings, and a discussion of the differential diagnosis.
P286 Effects of Obesity on Cardiopulmonary Function in Chronic Stroke Patients
S. Lee, M. Lee, J. Kim, J. Han, and I. Choi
Research Institute of Medical Sciences, Gwangju, Republic of Korea
Objective: We aimed to investigate the effects of the obesity on cardiopulmonary function of chronic stroke patients.
Methods: Twelve chronic stroke patients with Functional Ambulation Categories Classification greater than 3 grade, and Brünnstrom stage of lower extremity greater than 4 stage were recruited. They were classified into 2 groups based on Body Mass Index (BMI); obese group (BMI 27.5±1.2 kg/m2; 4 men, 2 women; age 58.3±8.9 years; duration of disease 10.2±3.5 months) and control group (BMI 23.5±0.6 kg/m2; 3 men, 3 women; age 60.0±5.1 years; duration of disease 9.8±2.8 months). The patients with previous history of unstable angina, uncontrolled arrhythmia, heart failure, and restrictive pulmonary disease were excluded. On a bicycle ergometer (Lode B.V®, LODE medical technology, The Netherlands), loads were gradually increased by Ramp protocol. Heart rate and blood pressure were measured before and after maximal stress test. Respiratory gas and heart rate were analyzed with a respiratory gas analyzer (Quark b2®, Cosmed Inc., USA).
Results: 1) Heart rate and minute ventilation at rest were not significantly different between two groups, respectively (p>0.05). 2) Peak heart rate and rate pressure product during exercise were not significantly different between two groups, respectively (p>0.05). 3) Maximal oxygen consumption was not significantly different between two groups (p>0.05). 4) Anaerobic threshold was significantly lower in the obese group (p=0.041).
Conclusion: Our results showed higher oxygen consumption and lower anaerobic threshold during exercise in obese chronic stroke patients. Therefore, individualized, patient-tailored exercise prescription should be considered.
P287 Rehabilitation of Patients in Acute Period of Stroke
K. Lyadov, T. Shapovalenko, I. Sidyakina, V. Ivanov, and T. Isaeva
Center of Restoration Medicine and Rehabilitation, Moscow, Russian Federation
Among all diseases, stroke holds the leading position as a cause of death and primary incapacitation, which are the reasons for the high medical and social importance of this problem.
Accordingly, development of rehabilitation standards for patients at different stages of treatment, starting from the first 24 hours after stroke, seems extremely important.
It is necessary to differentiate the rehabilitation program according to the somatic state of the patient and his or her consciousness.
Rehabilitation is contraindicated to very severe patients in shock of various genesis, atonic coma (a score of less than 4 points according to the Glasgow coma scale), with stroke heaviness due to NIHSS more than 36 points, raising dislocation symptoms demanding resuscitation, or in the case of urgent surgery necessity.
Starting from the first 24 hours after stroke, it is sensible to do the following: regulation of body position, setting of paretic limbs, passive therapeutic exercises, classical massage of paretic hand, drainage massage of thorax, and neuromuscular stimulation of distal paretic hand muscles.
At the next stage, sitting is added, together with verticalisation on a “Erigo” verticalizer, neuro-muscular simulation of distal paretic hand muscles, cyclic training for lower extremities on a “Motomed” trainer, and mechano(vibro)stimulation of foot support points in a cyclogram in pacing mode. Transition to broader rehabilitation program criteria include: 1) exclusion of phlebothrombosis with areas of floating thrombi of lower extremities vessels; 2) central hemodynamics stability: systolic arterial pressure 110-220 mm Hg (in case of hemorrhage stroke: 110-180 mm Hg); and 3) lack of negative dynamics in neurological state.
Thus, performing early rehabilitation while maintaining formulated principles allows for the prevention of possible aftereffects in the acute period of stroke, and promotes acceleration of motion and cognitive function restoration by influencing neuroplastic processes of brain. Developed criteria may serve as an algorithm of treatment of patients with stroke in a resuscitation department or neurology unit.
P288 Posterior Tibial Tendon Transfer Through Interosseous Membrane in Adult Spastic Equinovarus Foot Is Not Associated With Flat Foot Deformity
P. Marque1, H. Bensafi2, P. Gilbert1, X. de Boissezon1, F. Molinier2, J. Pujet2, and D. Gasq1,3
1Service de Médecine Physique et de Réadaptation, CHU Rangueil, Toulouse, France, 2Service de Chirurgie Orthopédique et Traumatologique, CHU Rangueil, Toulouse, France, 3Université Paul Sabatier, Toulouse III, UFR STAPS, Laboratoire Adaptation Perceptivo-Motrice et Apprentissage, Toulouse, France
Equinovarus foot is a common disabling complication in spastic hemiplegic adults, which sometimes requires surgical correction. In our experience, the posterior tibial tendon transfer through interosseous membrane, according to Watkins procedure, is usually proposed in equinovarus foot adult patients, combined with lengthening of the Achilles tendon. It is a controversial surgical procedure because of secondary flatfoot and valgus deformities observed in cerebral palsy patients. Moreover, involvement of tibial posterior dysfunction in adult hemiplegic, assessed with intramuscular electromyography, is always controversial. In a retrospective cohort study, twenty one adults (age: 51.3±10.4 years), who had spastic equinovarus foot after stroke or cranial traumatism (4.4±5.4 years since disease occurrence), were reviewed at a four-year mean follow-up (4±2.5 years, from 5 to 97 month). Foot deformities were assessed using two technics (radiology and baropodometry), and compared to contralateral foot. Radiological parameters are Djian’s angle for the hindfoot valgus and Djian-Annonier’s angle for medial foot arch, obtained with bilateral radiographs with the patient standing. There is no difference exists between the two feet for this radiographic parameters (respectively, p=0.93 and p=0.46), and the values of Djian-Annonier’s angle shows hollow foot (113±8.7°). The baropodometric parameter is footprint area, which is lesser in involved foot (58.4±28.4 cm² vs 98.1±22.1 cm², p=0.002), because of midfoot (isthmus) disappearance. This result confirms the hollow foot tendency. Most of patients are satisfied about surgery and functional improvement in term of walking ability. Our results confirm interest of Watkins procedure in adult spastic equinovarus.
P289 Effect of Fiber-Enriched Nutrition in Patients With Dysphagia and Tube-Feeding Due to Severe Brain Damage
H. Matzak1, M. Mittlböck2, M. Kofler1, K. Poustka1, and L. Saltuari1
1Hospital Hochzirl, Hochzirl, Austria, 2University of Medicine, Vienna, Austria
Patients with severe cerebral lesions often develop dysphagia rendering enteral tube-feeding necessary in order to prevent pulmonary aspiration, and to provide for adequate alimentation. Impaired intestinal function, reduced bowel movements, and increased fecal impaction occur frequently during tube-feeding. Some patients may even develop subileus. Concomitant formation of bowel gases, malabsorption, and idiosyncratic reactions against common nutritional preparations may produce altered consistency of faeces, either too compact or too liquid. We performed a randomized, double-blind, prospective study in order to investigate whether a fiber-enriched tube-feeding preparation is able to minimize bowel malfunction during a 55 day observation period. Seventy-four patients, median age 49, range 14-71, with traumatic brain injury, cerebral hypoxia, ischemic stroke, subarachnoid or intracranial hemorrhage, were recruited between 2004-2007. All required tube-feeding due to severe dysphagia. Patients received randomly either 1500ml/day (1500kcal/day) of a fiber-enriched tube-feeding preparation (BeneFiber®), or a conventional tube-feeding preparation (Nutrison Standard®). Daily assessment included stool consistency, use of laxative substances, and presence of diarrhea. There were no significant differences between verum and placebo group (Wilcoxon rank sum test) with regard to laxative substance use (66.7% versus 65.7% of patients), absence of diarrhea (25.9% versus 43.3%), and fecal consistency (watery: 24.0% versus 27.9%; normal: 11.1% versus 10.1%). Fiber-enriched nutrition did not decrease the frequency and amount of commonly encountered intestinal dysfunctions during tube feeding in patients with dysphagia secondary to severe cerebral lesions.
P290 Overview About a New Approach in Dysphagia Management in Estonia
M. Mumma
East-Tallinn Central Hospital, Tallinn, Estonia
Introduction/Objectives: The Neurological Rehabilitation Department in East Tallinn Central Hospital offers complex post-acute rehabilitation to adults with CNS disorders, mostly stroke patients. Dysphagia may occur in approximately one third of post-stroke patients. The aim of this work is to introduce the short history of the evaluation of swallowing disorders using videofluoroscopy in our department. The videofluoroscopic evaluation of swallowing first started in East-Tallinn Central Hospital in February 2007, being the first hospital in Estonia to use such precise method to diagnose and treat swallowing disorders.
Materials/Methods: All inpatients with signs of swallowing difficulties were assessed on videofluoroscopy by a speech and language therapist during 2007-2009. Fluids with different viscosity and solids were introduced during the assessment, to determine the food consistencies, way of intake and treatment plan suitable for the patient.
Results: Fifty patients were included in the study. 16 women, mean age 73,2 and 34 men, mean age 66,2 years. 92% were stroke patients, 84% of which in post-acute state, and 8% six months to 1,5 years post-stroke. Also, patients with traumatic subdural haemorrhage, Parkinson’s Disease, operated brain tumor and cervical myelopathy were included. All of the patients received speech therapy intervention before and after the videofluoroscopic assessment of swallowing. Therefore, aspiration pneumonia was avoided and individual plan for swallowing rehabilitation was compiled for each patient.
Conclusions: Videofluoroscopic evaluation of swallowing has proved to be an informative method in preventing aspiration and in helping to find the best therapy methods in dysphagia management in our department.
P291 Alien Hand Syndrome: A Report of 2 Cases and Interpretation of Symptoms From the Viewpoint of NeuroRehabilitation
W. Narita1, I. Kondo2, S. Sonoda1, R. Kanamori1, N. Shibata1, M. Hayashi1, K. Ohta3, and E. Saitoh2
1Nanakuri Sanatorium, Tsu, Japan, 2Fujita Health University, Toyoake, Japan, 3Department of Rehabilitation Medicine, Matsusaka Chuo Hospital, Matsusaka, Japan
The term “alien hand syndrome (AHS)” comprises many clinical signs of which the common features are the abnormal movement of the affected limb. Two major types of AHS were previously classified, callosal and frontal types. Case 1: A man aged 54 years old with dominance of right hand displayed abnormal behavior after hematoemesis from gastric ulcer. Magnetic resonance imaging revealed that the cerebral infarction of whole part of callosal body and bilateral parietal lobes. He was referred to our hospital for the purpose of rehabilitation. The disconnect syndrome was observed at admission and the main problem in activities of daily living was diagnostic apraxia. Case 2: A man aged 55 years old usually used right hand for feeding and writing. He had subarachnoid hemorrhage caused by aneurysm rapture of anterior communicating artery. After subarachnoid hemorrhage, there was cerebral ischemia at the region of anterior cerebral artery, anterior part of callosal body, and parietal lobe. Forced grasp of his right hand and the difficulty of coordinated movement of both hands were observed at admission. Although most of the activities had become to be able to perform under small amount of assistance or supervision in both cases, it was difficult to know how each symptom of AHS, such as diagnostic apraxia, affected to have got the functional ability in daily life. It was suggested that it should divide symptoms according to the characteristics of movement and also the relation to the environment under which the patients should perform activities.
P292 Surface EMG Pattern of Movement of Spastic Upper Extremity in Patients With Stroke
S. Ohn, W. Ko, G. Kang, J. Choi, K. Jung, and W. Yoo
Department of Physical Medicine and Rehabilitation Hallym University College of Medicine, Anyang, Republic of Korea
Objective: The purpose of this study is to evaluate the specific movement pattern of spastic hemiplegic upper extremity after stoke using dynamic electromyography.
Method: Nine patients with spastic hemiplegia after stroke and eight normal persons were recruited. Participants’ tasks to be evaluated with dynamic EMG were individual grasp of both hand and shoulder flexion. The muscular activities of upper trapezius, anterior deltoid, biceps brachii, triceps brachii, flexor digitorum superficialis, and extensor digitorum communis were investigated. Participants’ hand and arm functions were evaluated with Fugl-Meyer motor assessment (FMA) before test. Parameters evaluated by dynamic EMG were co-contraction ratio (CCR), initial contraction time (ICT) of muscle, maximal voluntary contraction force, root mean square of each muscle. We compared the difference of CCR, ICT of each muscle between patients and normal persons. Correlation between FMA and Co-contraction ratio was analyzed.
Results: Initial contraction times of flexor digitorum superficialis and extensor digitorum communis muscle were different between two groups (p<0.05). Muscle co-contraction ratio was more increased in the spastic hemiplegia patients. Low FMA score was related with increased proximal muscle tone of hemiplegic upper limbs.
Conclusion: Increased proximal tone is related to poor functional outcome of the hand. These findings are important clue to manage the patients who are suffering spasticity. Muscles tested in the present study might be selected as the points of Botulinum toxin injection or motor block for functional recovery.
P293 Functional Outcome After Out of Hospital Cardiac Arrest: A Prospective Study From the Intensive Care Unit to the Rehabilitation Unit
A. Peskine1, C. Luyt2, F. Baronnet3, and P. Pradat-Diehl4,5
1AP-HP Groupe Hospitalier Pitié Salpêtrière Medecine Physique et de réadaptation, Paris, France, 2AP-HP Groupe Hospitalier Pitié Salpêtrière Réanimation Médicale, Paris, France, 3AP-HP Groupe Hospitalier Pitié Salpêtrière Urgences cérébrovasculaires, Paris, France, 4Université UPMC Paris 6, Paris, France, 5APHP Groupe Hospitalier Pitié Salpêtrière Médecine Physique et de Réadaptation, Paris, France
Background: Cardiac arrest survivors may experience hypoxic brain injury that results in cognitive impairments which frequently remains unrecognised. Cognitive deficiencies may lead to limitations in daily life activities. We propose a prospective study. Our aim is to describe the functional status of cardiac arrest survivors, 6 months after the onset.
Methods: In this prospective study, all adult patients admitted alive after an out of hospital cardiac arrest in our hospital have been consecutively included between March 2008 and March 2009. All patients were included within the first week after onset; follow up consisted of consults with the PMR specialist. The primary outcome measure was the Glasgow Outcome Scale Extended GOS E 6 months after the cardiac arrest. Neuropsychological assessment was proposed when possible as well as behavioural assessment.
Results: 13 patients have been included. Three died before the 6 months assessment. At 6 months, 2 patients presented with minimally conscious state, 2 presented with severe limitations, consistent with a GOS E score 4, 3 patients were autonomous for daily life activities but needed hep for elaborate activities, (GOS E 6) and 3 patients were autonomous for life activities but presented with neuropsychological sequelae preventing them to returning to their premorbid level of functioning, notably vocational, (GOS E 7). None of the patients scored 8 that is good recovery without limitation.
Discussion: Cardiac arrest leads to neurological sequelae that need systematic assessment. In this study, 60% of the survivors presented with neuropsychological impairments that needed specific assessment and rehabilitation.
P294 Long-Term Follow-Up of Patients Treated With Intrathecal Baclofen Pump (IBP) for Generalized Spasticity
K. Petropoulou, C. Rapidi, M. C. Micha, E. Kandylakis, and M. Venieri
B’ Department, National Rehabilitation Center, Athens, Greece
Aim: To demonstrate the therapeutic effect of implanted IBP for spasticity management and application of individualized long-term rehabilitation program
Materials and Methods: A retrospective study of 42 patients (26 men), with severe spasticity of spinal origin (N=25, multiple sclerosis: 48%, spinal cord injury: 36%, myelitides: 16%) and cerebral origin (N=17, traumatic brain injury: 58.8%, cerebral palsy: 23.5%, infections:11.7%,hypoxemic encephalopathy: 5.9%). Mean duration disease: 12.5 years, mean follow- up time since implantation: 3.6 years, daily baclofen dose: 227.1 μg /day. Continuous pump was implanted in 12 patients and programmable pump in 30. Setting : After positive screening test, the implantation of baclofen pump took place in a neurosurgery department. Three days after the implantation, the patients were readmitted to our clinic, where the daily dose of baclofen was adjusted. The main targets for implantation were: facilitation of proper posture, prevention of decubitus ulcers, pain alleviation, performance of intermittent catheterizations and hygiene and enhancement of orthotic wear. In incomplete lesions, the recovery and functional outcome were excellent.
Results: The management of generalized spasticity with IBP implantation contributes significantly to the accomplishment of rehabilitation goals. The proper implantation timing, the daily dose and the mode, continuous or flex, depend absolutely on short and long- term rehabilitation targets, as well as the patient’s and his caregivers’ needs. In incomplete lesions, the potential mobility is unmasked for functional purposes.
Conclusions: As long as the goals of rehabilitation are set up post implantation, there is a significant spasticity reduction, improving many aspects of patients’ lives.
P295 Meta-Analysis of Walking Training RCTs in Patients With Stroke
S. H. Peurala, T. Sjögren, J. Paltamaa, and A. Heinonen
University of Jyväskylä, Jyväskylä, Finland
Purpose: To analyze the effectiveness of walking training in stroke in randomized controlled trials (RCT). Methods: A systematic literature search was performed from five databases (1966 - 7/2008) and by hand. Analysis: The methodological quality of the RCTs was rated height-level, acceptable or poor based on the 11 items related to selection, performance, attrition and detection bias and the number of patients included. Search and selection method, methodological quality and content analysis were evaluated by two blinded and independent assessors. Results: Forty-three RCTs fulfilled the inclusion criteria. Methodological quality of 12 high-level RCTs was mean 7.0 (range 6 - 8), of six acceptable 4.8 (4 - 5) and of 19 poor 4.3 (3 - 6). In chronic stage of stroke, specific walking training didn’t increase walking speed (n5, p=0.09), but increased walking distance (n3, p=0.0007) compared to no/placebo treatment. Specific walking training increased walking speed (n7, p=0.005), but not walking distance (n3, p=0.65) or walking independency (n2, p=0.30) at different stage of stroke compared to overall physiotherapy. Specific walking training increased walking speed and walking independency at acute (n7, p<0.0001 and n4, p=0.01) and subacute (n7, p=0.008 and n3, p=0.001) stage of stroke and walking distance at different stage of stroke (n5, p=0.03), but it didn’t increase walking speed at chronic stage of stroke (n2, p=0.28) compared to conventional walking training of the same intensity. Conclusion: Specific walking training, e.g. with treadmill and electromechanical devices, electrical stimulation, music motor and biofeedback during walking should be used when available.
P296 Sleep Disturbance and Melatonin Levels Following Traumatic Brain Injury
J. L. Ponsford1, S. Rajaratnam2, J. Shekleton2, D. Parcell2, J. Redman2, and J. Phipps-Nelson2
1Monash University and Monash-Epworth Rehabilitation Research Centre, Clayton, Victoria, Australia, 2Monash University, Clayton, Victoria, Australia
Sleep disturbances commonly follow traumatic brain injury (TBI), and contribute to ongoing disability. However, there are no conclusive findings regarding changes to sleep quality and sleep architecture measured using polysomnography in TBI patients. Possible causes of sleep disturbances include disruption of circadian regulation of sleep-wake cycles, psychological distress and/or neuronal response to injury. We sought to investigate the mechanisms of sleep-wake disturbance in TBI patients. Twenty-three participants with TBI (429.7±287.62 days post injury; 22.7 ± 17.7 days PTA) and 23 age- and gender-matched controls were compared on polysomnographic sleep parameters, salivary dim light melatonin onset (DLMO) time and self-reported anxiety and depression. TBI patients had significantly higher self-reported anxiety (HADS-A) and depressive symptoms (HADS-D), and sleep disturbance (PSQI). Polysomnography data showed significantly decreased sleep efficiency (SE) and significantly increased wake after sleep onset (WASO) in the TBI group. No significance group differences were reported on sleep architecture. Controlling for anxiety and depression scores, TBI group showed significantly higher levels of slow wave sleep. There was no significant difference in self reported sleep timing or salivary DLMO time. The TBI group had significantly lower levels of overall melatonin production, which significantly correlated with REM sleep but not SE or WASO. The lowered evening melatonin production is indicative of disruption to the circadian regulation of melatonin synthesis. The study results suggest at least two factors contribute to sleep disturbances in TBI patients: that depression is associated with reduced sleep quality, and increased slow wave sleep with the effects of mechanical brain damage.
P297 Role of Sensory Integration Therapy With Children With Neuro-Developmental and Motor Difficulties: Occupational Therapists Perspective
S. Radic, I. Bekic, and M. Grubisic
Special Hospital for Care of Children With Neurodevelopmental and Motor Difficulties, Zagreb, Croatia
Appropriate integration of sensory information is one component of developing and creating the self image, and image of the world which is for most children, a basic factor that influences the acquisition and development of necessary living skills. However, the progress of children with neurodevelopmental delay significantly is undermined and subsequent delayed among else because of sensory integration problems. These problems can directly affect the socio-emotional, cognitive and behavioral development of the child so sensory integration therapy can be essential for successfully meeting the needs and tasks which a child has to fulfill.
The purpose of this paper is to show 2 examples of sensory integration therapy with children with neuro-developmental and motor difficulties provided at our hospital.
Sensory integration therapy approach was developed by Jean Ayres, PhD, and is intended for children who have problems with processing of received information in the right way and because of that, they have more developmental difficulties, learning or behavioural problems. By influencing, on three body sensory systems—tactile, vestibular and proprioceptive, and five senses, at the right time and intensity with right stimuli therapist enables the children to organize sensory information’s and have adoptive response in meaningful way.
Conclusion is that sensory integration therapy approach enables a child to establish a peaceful state of awareness, strengthens organization of received stimuli in concrete, usable information and ensures adoption of the fundamental learning concepts, an essential factor for integration of children with neurodevelopmental and motor difficulties in “normal” process of daily living.
P298 Evidence for Central Pain Mechanisms in Persistent Post-Stroke Shoulder Pain
M. Roosink1, G. J. Renzenbrink2, J. R. Buitenweg1, R. T. M. Van Dongen3, A. C. H. Geurts3, and M. J. IJzerman1
1University of Twente, Enschede, Netherlands, 2Roessingh Rehabilitation Center, Roessingh Research & Development, Enschede, Netherlands, 3Radboud University Medical Center, Nijmegen, Netherlands
Traditionally, post-stroke shoulder pain (PSSP) is regarded as a peripheral, nociceptive pain. However, treatment is often unsatisfactory and many stroke patients report persistent PSSP. In addition to the biomechanical explanation of PSSP, both the stroke lesion as well as neuroplasticity may alter the function of the pain system and may act as central contributors to the development and maintenance of persistent PSSP. The objective of this study was to assess peripheral and central pain mechanisms associated with persistent PSSP. Somatosensory and supra-spinal endogenous inhibitory functions were assessed in stroke patients with persistent PSSP (n=19), pain-free stroke patients (PF, n=29) and healthy controls (HC, n=23), using clinical examination and quantitative sensory testing combined with a cold pressor test. Sensory abnormalities were more frequently observed and more severe in patients with PSSP, including spinothalamocortical tract (STT) lesions, a feature commonly associated with neuropathic pain. Moreover, signs of central sensitization, such as allodynia at the affected side and generalized hyperalgesia at the unaffected side, were more frequently observed in the patients with PSSP. Supra-spinal inhibitory function was similar in stroke patients and healthy controls. PSSP was not related to the severity of paresis, glenohumeral subluxation or spasticity. This study implies that sensory loss, in particular of the STT, and central sensitization play a role in PSSP that is larger than traditionally assumed. Prevention and treatment might be improved by recognizing both peripheral and central causes of PSSP. Future research should further establish the role of central mechanisms in the development of persistent PSSP.
P299 A Prospective and Follow-Up Study to Quantify the Functional Outcome of Intensive Rehabilitation in Multiple Sclerosis Ssing MS Functional Composite Score (MSFC)
P. Rossi1, F. Martinelli Boneschi1, E. Judica1, D. Ungaro1, G. Comi1, R. Gatti2, V. Martinelli1, and M. Comola1
1Neurorehabilitation Unit, Neurology Dept—INSPE. IRCCS Ospedale San Raffaele, Milano, Italy, 2School of Physiotherapy, IRCCS Ospedale San Raffaele, Milano, Italy
Background: Rehabilitation is recognized to be effective in improving clinical features in Multiple Sclerosis. Nevertheless is still debated which outcome measure is better to use in identify efficacy on functional outcome. FIM and BI seems in fact to not be useful to measure functional improvement following intensive rehabilitation treatment in MS.
Objective: To determine the impact of rehabilitation on functional skills of patients affected by MS as measured with MS Functional Composite Score.
Methods: We considered 108 subjects with MS who underwent to a programme of rehabilitation in our Neurorehabilitation Unit. The MSFC score has been collected at baseline and at the end of hospitalization. This is a standardized scale which collects data from three different functional test which explore single ability. 9-Hole-Peg Test for upper limb ability, time to walk 10 meters to measure walking performance and PASAT to determine entity of cognitive impairment. Each single measure are then converted in an unique standardized numeric value which reflect the whole patient’s functional ability.
Results: At the end of rehab period MSFC significantly improved with a difference of -3.582 points (p<0.0001). This data is still observed even after a follow-up period of 3 months. At this point patients still continue to have an improvement on MSFC compared with baseline of -2.938 (p<0.003) while no significant difference have been detected in respect of end of treatment (-0.684, p=NS).
Conclusions: These data support the evidence that MSFC could be considered useful to quantify functional improvement following intensive rehabilitation in patients with MS.
P300 Effect of One Hippotherapy Session on the Gait of Patients With Stroke Disabilities
R. P. Holzhey1, A. Schuh1, and R. B. Santos2
1FMU—Faculdades Metropolitanas Unidas, São Paulo, Brazil, 2Clube Hípico de Santo Amaro, São Paulo, Brazil
Introduction: Stroke is the third cause of death, the main cause of disability, and has the most expensive treatment for the public care services in the industrialized countries. Hippotherapy is a treatment much used as an alternative for the treatment of many neurological diseases. Spite of this, only few trials, especially with adults, has been realized in this area. Objective: Evaluate the immediate effects of the hippotherapy on the gait of patients after stroke. Method: It was applied the Timed Up and Go Test (TUGT) before and five minutes after a thirty-minute hippotherapy session on ten patients. Results: Two statistical analysis showed that the TUGT time was reduced and pointed statistical significance. On the first analysis it was calculated the average of the first and second time before and after the hippotherapy. This analysis showed that 7 of 10 patients improved the TUGT time after hippotherapy and three patients had higher TUGT times in spite of fatigue and unexpected pain after hippotherapy. Discussion: The reduction in the TUGT time of the patient after the hippotherapy session can be related to reduction in spasticity, improvement in motor control of the trunk, improvement of abnormal movement patterns, increased sensory integration and reduction in energy expenditure during gait as positive effects of hippotherapy. This study proves that these effects also be applied to stroke patients. Conclusion: A hippotherapy session reduced TUGT time of stroke patients, improving the gait pattern of the patients.
P301 Dual-Task Performance in Cerebral Palsy
C. B. M. Monteiro1,2, Â. M. Dias2, M. Nascimento3, L. C. S. Poyares2, S. R. P. Malheiros2, and R. B. Santos4
1Universidade de São Paulo, São Paulo, Brazil, 2UniFMU, São Paulo, Brazil, 3AACD, São Paulo, Brazil, 4Clube Hípico de Santo Amaro, São Paulo, Brazil
Introduction: Cerebral Palsy (CP) is defined as a disorder of posture and movement, persistent and non-progressive, caused by lesion in the developing encephalon. Due to motor alterations, physiotherapeutic treatment is important, and to facilitate daily life activities, the physiotherapist can train the patient to perform under dual-task conditions. Under normal circumstances it is a prerequisite for an individual to have a normal life. Objective: This work has as objective to verify the motor-cognitive dual-task performance in cerebral palsy. Method: For the accomplishment of this work, the Timed Up & Go (TUG) test was used, which measures the functional mobility to get up, sit down and gait. The test was applied to four children with spastic diplegia (ages 6 to 12). The patients were asked to do the TUG test and simultaneously sing a song. The measurement of time and number of steps was obtained, respectively, through chronometer and pedometer and the occurrence of difference was verified in the execution of the task without singing and singing a song of the child’s preference. Results: Measurements using the mean showed reduction of time, from 11.63s (± 2.65s) to 9.38s (±1.46s), and in steps, from 15.75 (± 3.91) to 11.08 (± 5.26). Conclusion: This study demonstrates the existence of a mean statistically significant difference between the situation to sing and not to sing, as much in time as in steps. It is noted that in both variables there was a reduction in the values when the singing activity took place.
P302 Swallowing Medication: A Challenge for Neurological Patients With Chronic Dysphagia: An FEES Study
S. Schwarz and M. Rupp
Klinik und Kurhotel Pirawarth, Bad Pirawarth, Austria
Objective: Dysphagia is a frequent problem in neurological patients. Impaired oral control, clearance of the hypopharynx, penetration and aspiration of bolus parts into the airways are well known problems. Swallowing a medication is a challenge for dysphagic patient. Extensive medication results in increased risk of both reduced compliance and aspiration. Our aim was to evaluate the risk of retention and aspiration of oral medication.
Design: 127 consecutive neurorehabilitation inpatients with chronic swallowing problems rated by the Bogenhausen Dysphagie Skala (BODS) underwent a functional endoscopic examination study (FEES). They were presented with different consistencies including a placebo medication.
Results: Among the severely disturbed patients who had no PEG-tube, more than half (17/24) showed problems like retention in the valleculae or recessus piriformis for more than two swallowing efforts, which means a higher risk of aspiration. Among the patients with minor swallowing problems, 34 out of 73 had problems swallowing medication. Among the patients without clinical signs of dysphagia, five out of 23 were symptomatic. Five patients who were rated as very severely disturbed, they received all their food and medication through PEG-tube.
Conclusion: This study shows a significant proportion of patients, (nearly half) have problems swallowing medication. This would indicate a need to consider this aspect of dysphagia within the routine assessment of Dysphagia.
P303 Long Term Outcome After TBI: Is Mild Injury Really Mild?
R. Singh, G. Venkateshwara, S. Nair, R. Munjal, and D. Datta
Department of Neurorehabilitation, Sheffield Teaching Hospitals, Sheffield, United Kingdom
Introduction: Mild traumatic brain injury (MTBI) is generally considered to have a good outcome compared to moderate or severe TBI. We followed a head injury cohort to compare difference in outcomes after one year.
Methods: All head injury admissions remaining in hospital after 24 hours were followed. We looked at this population with predominantly MTBI, at one year using the Extended Glasgow Outcome Score. Severity of TBI was measured by initial Glasgow Coma Score.
Results: In one year we had 127 admissions with head injury staying beyond 24 hours. We were able to follow up 88 after one year of whom 86% were white, 28% had alcohol implicated in their injury and 7% were on warfarin and had been admitted as a precaution. Median age was 37.5 yrs (13-95) and length of stay was 3 days (0-30).
MTBI made up 39 (44%) of cases, moderate 39 (44%) and severe 10 (11%)
The majority of patients had a good outcome at one year with 32 (36.4%) in Good upper range, 28 (31.8%) in Good lower, 23 (26.1%) in Moderate upper, 2 (2.3%) in Moderate lower, 2 (2.3%) in Severe outcome and one patient had died.
Comparison showed that 30(78.9%) of mild had a good outcome, 25(64.1%) of moderate TBI had a good outcome and 5(50%) of severe TBI had good outcome. While this suggests a trend, analysis found that χ2=18.7, df15, p=0.227 suggesting that there was no significant difference between severity of brain injury and outcome.
Conclusions: Previous work suggests that MTBI has better outcome than moderate or severe injury. To date, our study does not show a difference between severity of TBI but the sample to date is small and we are continuing the study with ongoing follow up.
P304 Mild Traumatic Brain Injury: Do Injury Beliefs and Understandings Influence Clinical and Functional Outcomes?
D. L. Snell1,2, L. J. Surgenor3, E. J. C. Hay-Smith1, and R. J. Siegert4
1Rehabilitation Teaching and Research Unit, University of Otago, Wellington, New Zealand, 2Canterbury District Health Board, Christchurch, New Zealand, 3Department of Psychological Medicine, University of Otago, Christchurch, New Zealand, 4King’s College London, Department of Palliative Care, Policy and Rehabilitation, School of Medicine at Guy’s, King’s College and St Thomas’ Hospitals, London, United Kingdom
Background: Mild traumatic brain injury (MTBI) can result in persisting disability in a significant minority of cases but factors influencing such outcomes remain poorly understood. Research in other health conditions suggests that patient beliefs about symptoms and recovery can have powerful explanatory utility. The applicability of these concepts to MTBI has not been explored.
Objectives: To examine the extent to which illness beliefs predict clinical outcomes six to nine months after MTBI.
Method: Using a prospective study, participants (n=147) were recruited within three months following a MTBI and seen again six months later. Clinical and demographic information was collected and participants completed a battery of questionnaires at both time points that included the Revised Illness Perceptions Questionnaire, Brief COPE, Rivermead Post-Concussion Symptoms Questionnaire, Rivermead Follow-Up Questionnaire, and HADS. Multiple regression evaluated the extent to which injury/illness perceptions, coping styles, and emotional distress shortly after injury predicted outcome at follow up.
Results: Preliminary analysis suggested functional and social outcomes at follow-up were significantly predicted by baseline emotional representations (p<.05), positive reframing (p<.01), and depression (p<.01). Number of post-concussion symptoms was significantly predicted by baseline perception of more severe consequences of having a head injury (p<.01), use of instrumental support (p<.05), and anxiety (p<.01).
Conclusion: It would seem that increased emotional distress, perceiving the injury as having more severe consequences (unrelated to measured consequences) and avoidant/ passive coping styles are particularly important in predicting social, functional and post-concussion symptom outcome. Current reassurance-based interventions may be improved by targeting these variables.
P305 Are There Any Predictors in the Assessment of the Clinical Outcome in Patients With the Diagnosis Vegetative State?
C. Stepan
Neurological Department, Vienna, Austria
In the daily clinical practise the term “vegetative state” is currently used incorrectly. This is mainly due to a lack of cross-linked basic information about this clinical picture. There are no exact data about the incidence and only little about the prevalence. Many aspects of the pathophysiology, mainly concerning reduced consciousness as a cardinal symptom, are still unclear. There is no approved hypothesis about developing vegetative state, upon which a causal or at least a symptomatic therapy could be based. Up to now, only limited research of the effect and outcome of neurological rehabilitation on patients with vegetative state has been done, neither for the acute phase nor for long term consequences.
For this reason basic information and guidelines for documentation and treatment are needed.
To resolve these problems a database was established by our department. We will provide fundamental information about the incidence of vegetative state and its associated variables, primarily for the metropolitan area of Vienna. Another aim of this study is to collect suitable data to achieve a precise definition of the often variable clinical picture. Furthermore, the latest diagnostic techniques will be used to form and to test a well-founded hypothesis about the pathogenesis and the pathophysiology of the marked clinical picture and his remission.
Prospectively, this data base will be used as a basis for the systematic analysis of the Public Health Service facing medical care of patients with vegetative state (“Health Service Research”).
P306 An Interesting Case of Opercular Syndrome
N. Surya1, G. Hattangadi2, V. Dangra3, and H. Attari4
1Surya Neuro Centre, Mumbai, India, 2BYL Nair Hospital and Topiwala National Medical collage, Mumbai, India, 3Bombay Hospital Institute of Medical Sciences, Mumbai, India, 4BYL Nair Hospital and Topiwala National Medical Collage, Mumbai, India
Opercular or Foix Chavany Marie syndrome is a congenital or acquired condition characterized by involvement of either unilateral or bilateral opercular area of cerebral cortex or its connections. In this syndrome there is bilateral paralysis of facial, lingual, pharyngeal, masticatory muscles and dysarthria with automatic- voluntary dissociation.
We present a 17 year old male football player from Yemen who had right sided weakness with difficulty in speaking following a fall at 5 months of age.
His right lower limb weakness improved over a period but left with persistent right hand dystonia, sialorrhoea, dysphagia and anarthria. He had lower facial weakness with inability to protrude his tongue and excessive drooling. His mode of communication is non verbal through gestures.
He underwent EEG, BERA, and MRI brain and was treated with antiepileptic drugs along with speech and swallowing therapy. He has shown significant improvement in drooling and swallowing after two weeks of therapy.
We highlight a case of opercular syndrome who is functionally independent, riding the bike, playing football and attending his school despite his disability.
P307 A Discriminative Measure for Static Posture-Keeping Ability to Prevent In-Hospital Falls: Reliability and Validity of the Standing Test for Imbalance and Disequilibrium (SIDE)
T. Teranishi1, I. Kondo1, Y. Wada1, H. Miyasaka1, M. Okada2, H. Sakurai2, W. Narita3, and S. Sonoda3
1Fujita Memorial Nanakuri Institute, Fujita Health University, Tsu, Mie, Japan, 2School of Health Sciences, Fujita Health University, Toyoake, Aichi, Japan, 3Fujita Health University Nanakuri Sanatorium, Tsu, Mie, Japan
The standing balance test for imbalance and disequilibrium (SIDE) is a discriminative measure developed with the purpose of preventing falls by classifying static standing balancekeeping ability. The purposes of this study were to determine the inter-rater reliability of SIDE, and to examine criterion-related validity by comparing evaluation results to the Berg Balance Scale (BBS). Subjects comprised 30 patients (18 men, 12 women) with a mean (± standard deviation) age of 57.4 ± 16.97 years (range, 25-85 years). The 30 patients included 15 cases with cerebral hemorrhage, 7 with cerebral infarction, 3 with traumatic brain injury, 3 with spinal cord injury, 1 after total knee arthroplasty and 1 with disuse syndrome. In the reliability study, two physiotherapists, members of the treatment team for patients, independently classified the level of static posturekeeping ability. Inter-rater reliability was analyzed using the kappa statistic, a measure of chance corrected agreement. To determine criterion-related validity, functional balance-keeping ability was evaluated using the BBS for the same patients. The kappa statistic was 0.76 for the inter-rater reliability study. The Spearman rank-correlation coefficient between levels on SIDE and scores on BBS was 0.93 (p<0.01). These results suggest that balance-keeping ability can be classified simply and accurately by physiotherapists who are already familiar with SIDE, and that SIDE has ample concurrent validity in balance evaluation as compared to BBS.
P308 Validity Study of Standing Test for Imbalance and Disequilibrium (SIDE): Is the Amount of Body Sway in Adopted Posture Consistent With Item Order?
T. Teranishi1, I. Kondo1, Y. Wada1, H. Miyasaka1, M. Okada2, H. Sakurai2, G. Tanino3, and S. Sonoda3
1Fujita Memorial Nanakuri Institute, Fujita Health University, Tsu, Mie, Japan, 2School of Health Sciences, Fujita Health University, Toyoake, Aichi, Japan, 3Fujita Health University Nanakuri Sanatorium, Tsu, Mie, Japan
The standing balance test for imbalance and disequilibrium (SIDE) is a discriminative measure developed for the purpose of preventing falls. The purpose of this study was to determine the validity of item order of SIDE in reference to body sway. Subjects are comprised of 60 healthy young adults (30 men, 30 women) with a mean (± standard deviation) age of 21.3±2.4years, height of 164.5±8.2cm, weight of 57.7±9.3kg. The center of pressure (COP) was measured by an Anima’s stabilimeter G6100 recorded for 30 seconds with 20 Hz sampling frequency. The measurement postures that were similar to postures adopted in the SIDE were standing with 20cm apart feet position, standing with close the legs with inside of both feet touching together, two tandem standings (with dominant foot forward and backward), two single-leg standings (with dominant foot and non dominant foot). We calculated locus length from the data of COP. Statistical differences of means were determined with repeated measure ANOVA and Bonferroni’s post hoc test. In the results, the order of total locus length in each posture was consistent with the item order of SIDE. There was significant difference between the means of total locus length in each posture (p<0.001) with the exception of both tandem standings and both one-leg standings. It was suggested that the item order of SIDE had the concurrent validity in reference to the amount of body sway in adopted postures.
P309 Evolution of Tracheal Aspiration in Severe Traumatic Brain Injury-Related Oropharyngeal Dysphagia: One-Year Longitudinal Follow-Up Study
R. Terré, M. Bernabeu, D. León, D. Guevara, S. Laxe, and F. Mearin
Institut Guttmann, Badalona, Spain
Aims: To ascertain the clinical evolution and prognostic factors of aspiration recovery and feeding outcome in patients with severe traumatic brain injury (TBI) and a videofluoroscopic (VFS) diagnosis of tracheal aspiration. Methods: Twenty-six patients with severe TBI and videofluoroscopic diagnosis of tracheal aspiration were prospectively evaluated. Clinical evaluation of oro-pharyngeal dysphagia and videofluoroscopic examination were performed at admission and repeated at 1, 3, 6 and 12 months of follow-up. Results: At admission all patients had VFS aspiration. During follow-up, an improvement was observed in both oral and pharyngeal function, with the number of patients with aspiration decreasing progressively. The most significant change occurred in the examination made at 3 months. At one year, only 23% of patients had aspiration. No patient had clinically significant respiratory infections during the follow-up period. Persistent aspiration at one year of follow-up correlated with baseline variables: Rancho Los Amigos Level Cognitive Function Scale score, Disability Rating Scale score, tongue control alteration, velopharyngeal reflex abolition and delay in triggering swallowing reflex. Conclusion: Swallowing physiology in severe TBI greatly improved during follow-up and the number of aspirations decreased progressively, with the most significant reduction at between 3 and 6 months of evolution. This study revealed several prognostic factors for persisting aspiration: neurologic involvement (evaluated with the Rancho Los Amigos Level Cognitive Function Scale and Disability Rating Scale), tongue control alteration, oropharyngeal reflex abolition and delay in triggering swallowing reflex at baseline.
P310 Balance Ability and Fall in Active and Inactive Elderly
T. Thaweewannakij, S. A. D. Amatachaya, and P. A. D. Peungsuwan
Faculty of Associated Medical Sciences, Muang, Thailand
Objective: To assess balance ability, incidences and consequences of fall in inactive and active elderly
Methodology: The study recruited 120 well-functioning older adults, aged 65 to 80 years with a BMI of 20-30 kg/m2 from several communities in Thailand. The subjects underwent the process of screening tests in order to classify them into 3 groups which were inactive, lifestyle active and exercise groups. Subjects were tested balance ability by using the time up and go test (TUGT) and interviewed fall history during the past 6 months by using a questionnaire. Findings of these subjects were compared by using ANOVA and post-hoc test (p<0.05).
Results: The time required to complete the TUGT were 12.22±3.16s, 10.98±1.51s and 10.39±1.47s for inactive, lifestyle active and exercise subjects respectively. The significant differences of TUGT were found between inactive and active (lifestyle active and exercise) subjects (p<0.01). However, there were no significant differences between lifestyle active and exercise subjects. Six inactive subjects reported falls. Causes of fall included impaired balance, hazard environment, inattention during movements and inappropriate footwear. Consequences of fall were identified as mild injury and increased movement awareness.
Conclusion: Inactive subjects had significantly poorer balance control than active subjects. Longer time needed to complete the test may imply that inactive subjects had greater deterioration of reaction time, leg strength and walking ability than active subjects. The results correlated to falls that were experienced by inactive subjects. Thus, exercise and physical activity are important to safely and effectively perform daily functional tasks.
P311 A Concept to Guide the Choice of Measurement Instruments for Evaluation of Technology-Supported Task-Oriented Training Interventions
A. A. A. Timmermans1,2, A. I. F. Spooren1,3, H. Kingma2,4, and H. A. M. Seelen1,5
1Adelante Center of Expertise in Rehabilitation and Audiology, Hoensbroek, Netherlands, 2Eindhoven University of Technology, Biomedical Technology, Eindhoven, Netherlands, 3PHL University College, Hasselt, Belgium, 4Maastricht University Medical Center, Department of ORL-HNS, Maastricht, Netherlands, 5Maastricht University, Research School Caphri, Department of Rehabilitation Medicine, Maastricht, Netherlands
Introduction: Task-oriented training can improve arm-hand skill performance (AHSP) after stroke. Implementation of rehabilitation technology based exercises has started. To identify the benefits of different training systems, outcome measures representative of essential AHSP components should be used. Aim was to describe a conceptual framework that may guide the classification and choice of outcome measures to be used in technology-supported training interventions, based on information from existing non-technologically oriented clinical studies.
Methods: A systematic literature search was performed to identify RCTs evaluating the effects of task-oriented arm-training on AHSP after stroke. The methodological quality of the studies was assessed by two reviewers. Fifteen studies were selected for data extraction.
Results: Twenty-nine assessment tools were used, averaging 4 tests per study. Eight framework components were identified, i.e.: assessment of 1) function, 2) participation, 3) complex skills, 4) arm skills, 5) hand skills, 6) bilateral skills, 7) exact measures and 8) real-life relevance. On average 5.5 (SD=1.6) components were measured per study. Treatment addressed on average 4 (SD=1.3) components. Regarding specific measurements of AHSP, 13 studies showed agreement between arm-hand training components and assessment components. However, in only 55% of the studies all trainings components were measured. Generalized effects were most evaluated for complex skills (8 studies), function (5 studies) and participation level (5 studies). Most used outcome measures were Box-and-Block Test (n=4), Barthel Index (n=6), Nine-Hole-Peg-Test (n=4), Fugl-Meyer (n=5) and Jamar dynamometer (n=4).
Conclusion: A concept was developed to classify instruments and guide the choice for a specific intervention. AHSP assessment includes the evaluation of both training specific and generalized effects.
P312 Pituitary Insufficiency After Traumatic Brain Injury or Subarachnoid Haemorrhage
A. Tölli1, C. Höybye2, B. Bellander3, A. Hulting2, and J. Borg1
1Department of Clinical Sciences, Division of Rehabilitation Medicine, Karolinska Institute, Stockholm, Sweden, 2Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden, 3Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
Introduction: Traumatic brain injury (TBI) or subarachnoid haemorrhage (SAH) might cause pituitary insufficiencies but the prevalence and clinical implications of these are far from clear. The purpose of this study is to investigate: the prevalence, their relation to neurological and cognitive function during recovery, their relation to outcome with regard to function, activity and participation.
Method: Patients with TBI or SAH, aged >17 and admitted to Neurointensive care are eligible for inclusion. Within ten days post injury/SAH, a Synacthene test is performed and thyroid function examined. Follow-up at 3, 6 and 12 months includes detailed screening of clinical function according to protocol. Hormonal screening at 3 months include S-TSH, S-fT4, S-fT3 and S-Cortisol and at 6 and 12 months S-TSH, S-fT4, S-fT3, S-IGF-I, P-GH, S-Prolactin and S-Cortisol. In addition, S-Estradiol, S-FSH and S-LH are examined in females and S-Testosterone and S-SHBG in males.
Results: Until now, 38 patients have been included, 7 have been lost due to fatal outcome. Until now no conclusive impairments in pituitary function have been observed. However, although most patients had a normal thyroid function, some had disturbances at day 10. In addition, at three months post TBI/SAH a disturbance in cortisol secretion was seen in some.
Conclusions: Preliminary data from this ongoing study demonstrate thyroidal disturbances early after TBI/SAH and cortisol disturbances at three months post injury. Data collection will continue until around 200 consecutive patients have been included, which will elucidate the possible impact of hormonal disturbances on the clinical recovery course and outcome.
P313 Hypercalciuria in Spinal Cord Injury Patients: Favourable Results With Alendronate Therapy
N. Turhan and A. K. Özkan
Başkent University Faculty of Medicine, Ankara, Turkey
Osteoporosis is common in patients with spinal cord injury (SCI). One of the metabolic consequences of bone loss is hypercalciuria. Hypercalciuria and related polyuria, cause severe obstacles in urinary rehabilitation by challenging the early use of clean intermittent catheterization (CIC). Aim of the study was to assess the effect of weekly alendronate treatment to control hyperuricemia.
Materials and Methods: Eleven male patients with SCI and hypercalciuria were studied. The mean patient age was 30.20±7.07 and the mean observation period was 9.40±5.20 weeks. Hypercalciuria was considered as daily excreted calcium levels (mg) as high as 3 times the body weight (Kg) or more. Distribution of lesion levels were 4 cervical, one high thoracic, 4 lower thoracic and 2 lumbar.
Results: In 4 of the patients hypercalciuria was first observed on follow ups. Detection time of hypercalciuria were 2 weeks, 10 weeks (in 2 patients), and 17 weeks from the onset of injury. In the remaining 7 patients hypercalciuria was already present on admission (6-22 weeks from the injury). Patients were treated with weekly alendronate. Respond was a prompt reduction in calcium loss and urine volumes which happened within a few days. The mean value of calciuria levels were 387.30±125.48 mg/day (207-659 mg/day) and 108.80±64.96 mg/day (21-204 mg/day) before and after the onset of treatment respectively. In 5 of the patients CIC could only be managed by controlling hypercalciuria related polyuria.
Conclusion: Early prescription of biphosphonates after SCI in order to prevent bone loss related hypercalciuria should be seriously considered.
P314 Functional Outcome Six to Twelve Months After Subarachnoid Hemorrhage: A Systematic Review on Prognostic Determinants
M. A. van Kessel1,2, G. M. Ribbers1,2, A. P. Verhagen2, F. van Kooten2, and H. J. Stam2
1Rijndam Rehabilitation Centre, Rotterdam, Netherlands, 2Erasmus Medical Centre, Rotterdam, Netherlands
Objective. To define prognostic determinants of functional outcome six to twelve months after subarachnoid haemorrhage
Data sources. The Pubmed, Embase and Psy-info databases were searched between 1994 and 2008 for studies on prognostic determinants of outcome at the levels of activity and participation as defined by the International Classification of Functioning, Disability and Health.
Study selection. Time to follow-up had to be at least 6 months and type of treatment had to be stated. Two reviewers independently reviewed 180 abstracts and assessed the quality of the selected full-text articles.
Data extraction. 36 articles were included in this review. Data on patient and study characteristics, inclusion, exclusion criteria, prognostic determinants, outcome measurements, univariate and multivariate results were extracted by one reviewer and randomly checked by a second reviewer.
Data synthesis. A best-evidence synthesis was performed to determine the strength of each prognostic factor mentioned in two or more studies. Strong evidence of prognostic value was found for persistent intracranial pressure elevation and Hunt&Hess grade. Strong evidence of no association with outcome was found for sex, hypertension, time before surgery, acute hydrocephalus, glucose levels, aneurysm location, number of aneurysms, intraoperative rupture, seizures and Glasgow Coma Scale (GCS). All other possible prognostic factors showed inconclusive results.
Conclusion. Outcome at a 6 to 12 months post SAH is predicted by persistent intracranial pressure elevation and the Hunt&Hess grade. Sex, hypertension, time before surgery, acute hydrocephalus, glucose levels, aneurysm location, number of aneurysms, intraoperative rupture and GCS have no prognostic value.
P315 A New Three-Minute Screen of Apraxia in Stroke: The Apraxia Screening Test (AST)
T. Vanbellingen1, B. Kersten2, M. Bellion1, F. Baronti1, R. Müri3, S. Bohlhalter3
1Klinik Bethesda, Tschugg, Switzerland, 2Department of Psychology, University of Bern, Bern, Switzerland, 3Division of Cognitive and Restorative Neurology, Department of Neurology, University Hospital Bern, Bern, Switzerland
Background and Purpose: Most tests for apraxia are time consuming and their scoring systems often rely on video analysis. For clinicians a quick, valid screening instrument for apraxia is still lacking. The present study aimed to assess the reliability and validity of newly developed bedside test, apraxia screening test (AST) based on a comprehensive standardized test for upper limb apraxia (TULIA).
Methods: In phase I an item reduction of the TULIA (48 Items) was performed. First, less internally consistent items (rit < 0.60) and items with floor and ceiling effects were removed. Second, from the remaining 17 items 12 were selected according to expert opinion. Finally, factor and reliability analyses were performed on the remaining 12 items. In phase II 21 stroke patients were assessed prospectively by both TULIA and the 12-item AST. In addition, language comprehension was assessed by a Token Test, the Bell’s Test was used to assess neglect symptoms.
Results: First, internal consistency was high for the total AST (Cronbach’s alpha > 0.90). A factor analysis of the AST confirmed two dimensions which were also internally consistent (Cronbach’s alpha > 0.80). Second, a binary classification display showed that accuracy was almost perfect: Whereas specificity was perfect (9 true negatives), sensitivity (12 true positives) was slightly higher in the AST because a single patient was classified as mild apractic by TULIA, but severe by AST.
Conclusions: The present findings demonstrate that AST offers a reliable and valid bedside test to identify apraxia in stroke.
P316 Observational Study on the Management of Overactive Bladder Syndrome With Urge Incontinence in Early Stroke-Rehabilitation
W. N. Vance, D. Galle, and J. Wissel
Neuro-Urologie, Beelitz-Heilstätten, Germany
Introduction: In more than 40% of stroke survivors disturbances in central bladder control caused by dysregulation from the corticoreticular system for voiding and bladder control alters neurorehabilitation (Griffith 1992). The most frequent neurourological dysfunction in early rehabilitation following stroke is the overactive bladder syndrome with urge incontinence. Goal of the study was to identify the major factors which contribute in regaining urine and bowel continence.
Methods: Prospective observation study in stroke. If patients showed an overactive bladder syndrome they were included in an incontinence management including trospium chloride, physio-therapeutic training and nursing program. All indwelling catheters (IC) were taken out as early as possible.
Results: 262 patients were included, most of them enters the unit with IC. 120 (45.8%) showed spontaneous urinary continence. 66 (55%) were faecal continent at admission, another 24 (20 %) reached faecal continence before discharged. 56 (21.4%) became urinary continent after incontinence management, 86 (32,8 %) remained urinary incontinent Those were managed with catheters (mostly suprapubic) and diapers.
Conclusion: This study showed that in 2/3 of stroke survivors urinary and faecal incontinence is reversible and there is no reason for IC in most of them. Early removal of an IC therefore is recommended. The most important factor to achieve the goal continence is an implemented incontinence management and a coordinated working relationship between nurses, physicians, physiotherapists as well as care givers.
P317 Comparison of Electronystagmography Results With Clinical Balance Test Results in Patients With Vertigo and/or Instability
L. E. Vereeck1,2, B. Damen1, S. Truijen1, F. L. Wuyts3, and P. H. Van de Heyning2
1Artesis University College of Antwerp, Merksem—Antwerp, Belgium, 2Department of Otolaryngology, University Hospital Antwerp, University of Antwerp, Antwerp, Belgium, 3Faculty of Sciences, University of Antwerp, Antwerp, Belgium
Objective: To investigate whether clinical balance test results differ between patients with and without asymmetry on caloric and/or rotational electronystagmography results.
Patients and methods: This was a retrospective chart review of 67 patients with vertigo and/or instability. The results of static (Romberg with Jendrassik manoeuvre, standing on foam, tandem Romberg and single leg stance with eyes open and closed) and dynamic (Timed Up and Go test, tandem walking and Dynamic Gait Index) clinical balance tests were compared among patients with normal caloric and rotational findings (n=9), patients with asymmetry on caloric test results and normal rotational findings (n=20) and patients with abnormal caloric and rotational findings (n=38).
Results: Significant differences between the three groups were found on standing on foam with eyes closed (Kruskal Wallis test: p<0.01) and on the summed score of the static balance tests (Kruskal Wallis test: p=0.03). Post hoc analysis (Mann-Whitney U test) revealed that patients with asymmetrical caloric and rotational findings performed significantly poorer than patients with either both normal caloric and rotational findings (standing on foam eyes closed: p=0.02; summed score of the static balance tests: p=0.08) or abnormal caloric but normal rotational findings (standing on foam eyes closed: p<0.01; summed score of the static balance tests: p=0.02).
Conclusion: This study demonstrates that patients with symmetrical central vestibular compensation findings, irrespective of peripheral vestibular system status, perform better on static clinical balance tests when compared with patients with asymmetry on rotational testing.
P318 Sensitivity and Specificity of Clinical Balance Tests for Identifying Subjects With Vertigo and/or Instability
L. E. Vereeck1,2, A. Bastiaensen3, N. Verboven3, S. Truijen3, F. L. Wuyts4, and P. H. Van de Heyning2
1Artesis University College of Antwerp, Merksem—Antwerp, Belgium, 2Department of Otorhinolaryngology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium, 3Artesis university College of Antwerp, Merksem—Antwerp, Belgium, 4Faculty of Sciences, University of Antwerp, Antwerp, Belgium
Objective: To assess whether clinical balance tests can discriminate asymptomatic adults from patients with vertigo and/or instability.
Patients and methods: Data, based on a retrospective chart review of 399 patients with vertigo and/or instability, were compared with balance test results of 318 asymptomatic adults. Both populations were split into three age groups. Static balance tests were Romberg with Jendrassik manoeuvre (ROMJ), standing on foam (SOF), tandem Romberg (TR) and single leg stance (SLS). Except for ROMJ (eyes closed only), static balance tests were performed with eyes open and closed (EC). Furthermore tandem walking, Dynamic Gait Index (DGI) and Timed Up&Go test (TUG) were performed.
Results: The best static balance test for decades 3&4 is SLS-EC (overall sensitivity/specificity: 85%; sensitivity: 86%; specificity: 84%) using a cut-off score of 30 seconds. For decades 5&6 the most appropriate test is TR-EC with a cut-off score of 20 seconds (90.5; 89; 92) and for decades 7&8 this is SOF-EC with a time limit of 10 seconds (82; 82; 82). When using functional balance tests, the TUG seems the best option using different time limits per age group (decades 3&4: 6 seconds (93; 96; 90), decades 5&6: 7 seconds (89.5; 86; 93), decades 7&8: 9 seconds (83.5; 78; 89)).For the oldest group, a cut-off score of 22 (maximum score: 24) on the DGI provides a similar result (83.5; 85; 82).
Conclusion: When age of the subjects was taken into account, excellent sensitivity and specificity values could be obtained. Different tests were suggested per age group.
P319 Age and Gender Specific Normative Data of the Dutch Version of the Dizziness Handicap Inventory
L. E. Vereeck1,2, S. Truijen1, F. L. Wuyts3, and P. H. Van de Heyning2
1Artesis University College of Antwerp, Merksem—Antwerp, Belgium, 2Department of Otorhinolaryngology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium, 3Faculty of Sciences, University of Antwerp, Antwerp, Belgium
Objective: To provide age and gender specific normative data of the Dutch version of the Dizziness Handicap Inventory (DHI).
Patients and methods: Adults (n=296) aged 20 years or older, who perceived their balance to be normal, were included in the study. Exclusion criteria were: actual complaints or a history of vertigo or dizziness; neurologic, otologic, orthopaedic, or other medical conditions impeding balance; nursing home residents; dependence on the assistance of another person or the assistance of another person or an supportive device; a fall within the last six months. The Dutch version of the DHI-questionnaire was completed independently by each subject before they participated in a balance assessment session. DHI-scores range from 0 to 100. The higher the score, the greater the perceived handicap.
Results: Age and gender specific data of the DHI are shown in tables 1 and 2. Except for decade 8 (p=0.025; Mann Whitney U test), no gender differences could be detected.
Age Related Normative Data of the Dizziness Handicap Inventory for Men
Age Related Normative Data of the Dizziness Handicap Inventory for Women
Conclusion: This study demonstrates that DHI-scores increase with age. No gender differences could be shown, except for decade 8. Women, aged 70 or more had significantly higher DHI-scores when compared with men in the same age group.
P320 Investigating the Internal Validity of the Trunk Impairment Scale (TIS) Using Rasch Analysis: The TIS 2.0
G. Verheyden and P. Kersten
University of Southampton, Southampton, United Kingdom
Aim: To examine the internal validity of the static sitting balance, dynamic sitting balance, and coordination subscales of the Trunk Impairment Scale (TIS), a reliable and valid scale measuring trunk performance and sitting balance in people after stroke.
Methods: A total of 162 people after stroke were included in the study. Participants were recruited from an acute unit and in- and outpatient rehabilitation setting. To examine internal validity of the subscales of the TIS, we conducted a Rasch analysis by means of the Partial Credit Model. For each subscale, we examined whether the distribution of scores fitted the theoretical Rasch model. If a scale meets the expectations of the Rasch model (i.e. fit), the observed raw ordinal score gained through summation of the set of items can be transformed into interval scale measurement.
Results: The first item of the static sitting balance subscale had to be removed since it had a large ceiling effect. The remaining static sitting balance subscale did not fit the Rasch model (Chi-square=7.03, p<.0001 with Bonferroni adjusted p-level=0.01). Both the dynamic sitting balance (Chi-square=42.65, p=.0052 with Bonferroni adjusted p-level=0.005) and coordination subscales (Chi-square=7.87, p=.4461 with Bonferroni adjusted p-level=0.01) fitted the Rasch model.
Conclusion: Internal validity of the dynamic sitting balance and coordination subscales was confirmed and conversion tables of ordinal scores into interval scores for these two subscales were proposed. Based on our results, we present the Trunk Impairment Scale, version 2.0 (TIS 2.0).
P321 Investigating the Sequence and Head and Trunk Posture of People With Stroke When Performing a Lateral Reach
G. Verheyden, M. Burnett, J. Littlewood, D. Hyndman, and A. Ashburn
University of Southampton, Southampton, United Kingdom
Introduction: Preliminary results from our centre suggested differences between people with stroke (PwS) and healthy controls (HC) in the four phases of a lateral reach (initiation, reach, return and recovery) and in the distance reached. The aim of this study was to examine these hypotheses in our main cross-sectional study.
Methods: In sitting, participants were asked to reach sideways as far as possible without losing balance. Three-dimensional movement analysis of the lateral reach was performed using CODAmotion, recording the four phases of the reach as well as head, trunk and pelvis position at the point of maximum reach. We compared the normalised lateral reach graphs between the groups visually and used inferential statistics to examine between-group differences.
Results: Our sample included 24 PwS (mean (SD) age 66 (15) years, mean (SD) 6 (4) weeks after stroke) and 20 HC (mean (SD) age 66 (5) years). We noted apparent visual differences for the lateral reach graphs and that PwS took significantly longer to perform a lateral reach (p=.012), but no differences in timing of the four phases of the lateral reach between groups (p>.05). Head, trunk and pelvis angles relative to the room were all significantly lower in PwS (p<.036).
Conclusion: Our results confirmed that PwS reached less far than HC. They also took more time to perform the task. Together with our previous longitudinal findings, we suggest that lateral reach impairments are linked to poorer balance control and justify inclusion of lateral reach performance in clinical practice early after stroke.
P322 Balance Assessments in Patients With Incomplete Spinal Cord Injuries
J. Wannapakhe1, S. A. D. Amatachaya1, P. A. D. Arrayawichanon2, and W. A. D. Siritaratiwat1
1Faculty of Associated Medical Sciences, Muang, Thailand, 2Faculty of Medicine, Muang, Thailand
Introduction: Independent ambulatory incomplete spinal cord injury (iSCI) patients face with a high risk for fall. However, there was no report of balance impairment in these patients.
Objective: To investigate the balance ability in patients with iSCI who were able to walk independently
Methodology: Twenty patients with iSCI (AIS C and D) who were able to walk independently with or without walking devices were recruited in the study. Subjects were tested their balance ability by using the Berg Balance Scale (BBS), Timed Up and Go Test (TUGT), and Functional Reach Test (FRT).
Result: Subjects with the mean age of 45.60±15.72 years participated in the study. There were mostly males (17 subjects) and at a chronic stage of injury (17 subjects). Nine subjects were tetraparesis and 11 were paraparesis. The results of BBS, TUGT and FRT were 34.25±14.62 scores, 43.98±18.20 seconds, and 22.06±8.57cm respectively.
Conclusion: The findings suggested that independent ambulatory iSCI subjects had poor balance control which may be an important factor leading them to encounter a high risk for fall. Thus rehabilitation procedures for such patients should emphasize on the improvement of balance ability.
P323 Reduced Ankle Power Generation at Push Off Rather Than Postural Instability Leads to Slow Gait Following Traumatic Brain Injury (TBI)
G. Williams1, M. E. Morris2, A. Schache2, and P. McCrory2
1Epworth Hospital, Melbourne, Australia, 2University of Melbourne, Melbourne, Australia
It has been hypothesized that reduced gait speed following TBI is a consequence of increased caution and postural instability, but reduced ankle power generation at push-off may also play a contributing role.
The aim of this study was to identify the reasons why people with TBI walk at a reduced gait speed.
A sample of 55 TBI participants receiving therapy for gait disorders was recruited. 3D motion analysis of self-selected and maximum safe walking speed was conducted and compared to a group of 10 healthy controls (HCs).
TBI participants walked at a reduced gait speed when compared to age appropriate norms. When matched to HCs for speed, TBI participants displayed reduced ankle power generation at push off and increased peak hip power generation during initial and terminal stance compared to the HCs. The majority of TBI participants had equivalent ability to accelerate to faster gait speeds, but used an alternative method to HCs. Hip flexor power generation was significantly increased compared to HCs in order to accelerate. Postural instability was significantly increased for the TBI participants but did not deteriorate with increasing gait speed.
The primary cause of reduced gait speed following TBI seems to be reduced ankle power generation for push off. Reduced distal power generation was partially compensated for proximally with increased hip power generation. Postural instability, as measured by lateral COM displacement, whilst present in this population, was unchanged at faster speeds and did not seem to be the primary reason for reduced gait speed.
P324 Aphasia in Patients With Stroke
E. Yilmaz Yalcinkaya, K. Ones, N. Erden, H. Harman, and E. Taraman
Istanbul Physical Therapy and Rehabilitation Training and Education Hospital, Istanbul, Turkey
Stroke is one of major cause of disability and abnormality in the elderly. Our objective was to evaluate certain characteristics and functional status of stroke patients in outpatient clinic. There were 117 enrolled stroke patients in the present study, that was performed at the Istanbul Physical Therapy and Rehabilitation Center, Training and Research Hospital, 3rd Clinic of Physical Therapy and Rehabilitation Center of the hospital, outpatients clinic, between January 2008 and June 2009. The mean age of 117 patients was 61,42 ± 12,70 years (17-88 years). Of 58 (49,6%) were men and 59 (50,4%) were women. 27 (23,1%) patients had aphasia. Functional independent Measure (FIM) and Brunnstromm stage are shown in Table 1.
FIM and Brunnstrom Stage of the Patients
Aphasic patients have significantly lower score than nonaphasic patients according to FIM (p<0.05). Also aphasic patients were in lower stage according to upper lower extremity and hand Brunnstromm (p<0.05).
P325 Effect of Nasogastric Tubes on Incidence of Aspiration in Dysphagia Patients
J. Yun and E. Choi
Daejeon St. Mary’s hospital, Daejeon, Republic of Korea
Objective: Is it safe to feed orally with nasogastric (NG) tube inserted state? Method: 40(male: 27, female: 13, age: 70.9±11.7 years) dysphagia patients with NG tube feeding were included. The Videofluorographic swallow study (VFSS) was performed with NG tube inserted and repeated after removing the NG tube. Five types of food were supplied, and each of them performed twice. Result: Aspiration rate was increased in 6 patients with NG tube inserted state and in 11 patients without NG tube, compared with removed state. 23 patients showed no differences along with the NG tube. Among 6 patients who showed the increased aspiration rate with the NG tube, two patients were observed malpositioning of NG tube (pharyngeal coiling), the other 4(stroke: 2, Traumatic brain injury: 1, unknown cause: 1) were revealed to have no other reason besides the NG tube.11 patients out of 40, there was no penetration or aspiration, but retention in vallecular fossa and pyriformis sinus with thick barium. On the other hand, with plain barium, penetration and aspiration were observed. These patients had not increased in aspiration rate with NG tube comparing with no NG tube. Hence we tried oral feeding with small amount but not large amount for dysphagia training. Following up, neither aspiration symptom nor pneumonia was developed. Conclusion: It will be safe and useful to feed small amount orally for training with maintaining almost of nutrition by NG tube in the patients who were possible to feed per oral small amount but would have risk in large amount.
8 Quality of Life
8.1 Extrapyramidal (Parkinson)
P326 Is Impact of Fatigue an Independent Factor Associated With Physical Activity in Patients With Idiopathic Parkinson’s Disease?
R. G. Elbers1, E. E. H. van Wegen2,3, L. Rochester4, V. Hetherington5, A. Nieuwboer6, A. Willems6, D. Jones7, and G. Kwakkel2,3
1University of Applied Sciences Leiden, Leiden, Netherlands, 2VU University Medical Center, Amsterdam, Netherlands, 3Research Institute MOVE, Amsterdam, Netherlands, 4Newcastle University, Newcastle upon Tyne, United Kingdom, 5St. Nicholas Hospital, Newcastle upon Tyne, United Kingdom, 6Katholieke Universiteit, Leuven, Belgium, 7Northumbria University, Newcastle upon Tyne, United Kingdom
Objectives: To investigate the longitudinal association between fatigue and physical activity in Parkinson’s Disease (PD) and determine whether this association is distorted by potential confounders.
Methods: Data from baseline, 3, 6, and 12 week assessments in a single blind randomized clinical trial with cross-over design were used (N=153).
The Multidimensional Fatigue Inventory (MFI) was used to assess fatigue and an activity monitor to measure the amount of physical activity (defined as % dynamic activity during each monitoring session). Time-independent and time-dependent factors were investigated for their possible univariate association with physical activity.
Random coefficient analysis was applied. Candidate confounders were successively added to the longitudinal association model to determine if the association between physical activity and fatigue was distorted. A change beyond 15% was considered significant.
Results: Fatigue was significantly associated with physical activity (β=-0.099, SE=0.032, p=0.002). This association was not significantly distorted by type of intervention, age, gender, social support, disease duration, disease severity, motor impairment, cognition, anxiety, or medication intake. Depression caused proportional change of 22.2% in the regression coefficient of MFI. After controlling for depression, a significant association between MFI and dynamic activity remained (β=-0.121, SE=0.036, p=0.000).
Conclusion: The association found between fatigue and physical activity suggests that patients who experience higher levels of fatigue are less physically active. However, the total explained variance of physical activity by fatigue alone was small, suggesting that fatigue is only a minor factor in the complex of behavioral aspects that affect the amount of physical activity in patients with PD.
P327 Progressive Mobility Training With Rhythmic Auditory Stimulation
M. P. Ford1,2, L. A. Malone2, I. Nyikos2, R. Yelisetty1, and C. S. Bickel1,2
1The University of Alabama at Birmingham, Birmingham, AL, United States, 2Lakeshore Foundation, Homewood, AL, United States
Training with a rhythmic auditory stimulus (RAS) has shown to be effective at improving walking speed, stride length, and cadence. Progression of RAS during mobility training is typically based on initial walking speeds and the ability to synchronize with the RAS. The aim of this study was to examine the use of frequently measured walking speed, stride length, and cadence, as the basis for progressively increasing RAS during mobility training with individuals with PD. A convenient sample of 12 individuals with medical diagnosis of idiopathic PD (Hoehn and Yahr 1 - 3) participated. Individuals trained for 30 min/session, 3 sessions/week, for 8 weeks. Music rhythm rates were produced with Finale at the Center for Biomedical Research in Music at Colorado State University. Participants began training with RAS set at their comfortable walking rate. During each training session participants’ walking was assessed at a rate 10 bpm higher than previous training session. The RAS training rate increased when stride length and walking velocity increased, and cadence did not decrease more than 15 bpm below the RAS rate. Comparing pre- and post-training gait parameters we found increases in walking velocity, stride length, and cadence. The results of this study showed that a systematic assessment of gait parameters during RAS mobility training can serve as guidelines for progressing mobility training in persons with PD.
Pre/Post Walking (Without Music)
An * indicates significant (p< .05) differences.
P328 External Auditory Cueing and Mobility Training in Persons With Parkinson Disease
M. Ford1,2, C. S. Bickel1, L. A. Malone2, and I. Nyikos2
1The University of Alabama at Birmingham, Birmingham, AL, United States, 2Lakeshore Foundation, Homewood, AL, United States
The purpose of this study was to examine the effects of an 8 week mobility training program that utilized external auditory cueing (EAC) on persons with Parkinson’s disease (PD). We hypothesized that a program using EAC in an effort to exercise at intensities that could evoke physiological changes would positively impact measures of physical fitness, QOL, and PD symptoms. 14 individuals (ages 50 - 79 years; 9 males and 5 females) with a diagnosis of PD (Hoehn and Yahr 1 - 3) participated in this study. Participants walked 30 minutes per session, 3 sessions per week. EAC was systematically increased over the 8 week training period. Along with significant improvements in walking speed, the 6 min. walk test was significantly improved from 464 ± 120m to 563 ± 93m (p < 0.05). The SF-36 showed a significant change in self-reported health status for the physical function subscale only. The UPDRS showed significant reductions in section I (mentation, behavior, and mood), section II (activities of daily living), and section III (motor examination) (Table 1). An 8-week walking program that utilized music with embedded EAC served as exercise resulting in improvements physical function, fitness, and reduced symptoms associated with PD. Further research is required to better understand the dosage of training and the long-standing benefits EAC with persons with different severities of PD.
Average UPDRS scores for Individuals Pre and Post Walking (n=12)
P329 Step Activity and Community Mobility in Persons With Parkinson’s Disease
M. Ford and S. Pearson
The University of Alabama at Birmingham, Birmingham, AL, United States
Parkinson’s disease (PD) can lead to a significant decline in physical activity, community mobility, and quality of life (QOL). The purpose of this report is to describe the relationship between PD severity, physical activity, community mobility and QOL in persons with PD. This report is part of prospective study examining the natural history of mobility and QOL decline in persons with PD. This preliminary baseline data are from 12 individuals with PD (Hoehn & Yahr 1 - 3) who agreed to participate in this longitudinal study. Investigators used the Stepwatch step activity monitor (SAM) to count the daily steps taken over a 7 day period. The Life Space Mobility Assessment was used to describe the level of community mobility and the Parkinson’s Disease Questionnaire-39 was used to capture perceived QOL at baseline assessment.
Baseline Data
P330 Improvement of Motor Aquatic Schemes Aimed at Further Increasing Balance in Patients Affected by Parkinson’s Disease (PD) in the Intermediate Stage
A. P. C. Loureiro1, T. G. Gnoato1, J. R. Viana1, J. Sabino1, L. G. F. Cruz1, L. Cidade1, and V. L. Israel2
1Pontifícia Universidade Católica do Paraná, Curitiba, Brazil, 2Universidade Federal do Paraná- Litoral, Matinhos, Brazil
Introduction: Among PD motor disabilities, we empathize postural and balance alterations. Exercises executed in water helped on the straitening reaction and balance. In water, the body is constantly submitted to instabilities. The fact that there is no natural support in water, and that in water the body provokes turbulence, the patient have to have postural adjustments continuously in order to keep its stable balance, and this may happen caused by the different physical effects of the water.
Aim: Improve motor abilities in water to augment balance in patients with PD.
Methods and materials: Seven PD patients (age 59.85 _+7.92 years old, time of lesion 7.85±3.80 years) participated in this study. Was opted a clinical-quality method using aquatic physiotherapeutic evaluation at the beginning and at the end. Ten group interventions where made, in warm pool, using the 3 phases, mental adaptation, balance and movement, and 10 points for the Halliwick Concept.
Results: The Wilcoxon statistic test from the motor aquatic abilities related to balance, we detach floating in the following axes: prone (p=0.04*); supine (p=0.04*), sagittal (p=0.133), combinational (p=0.073), right longitudinal (p=0,041*), left longitudinal (p=0.041*), transversal/supine/prone (p=0.248) and transversal/prone/supine (p= 0.248).
Conclusion: :The evolution of the participants, related to floating, may be associated to constantly trying to keep the balance when forced out of balance due to pulling and gravity, also by the corporal stability acquired by the hydrostatic pressure. We believe that physiotherapy in water may be one more tool for secondary prevention and treatment for the PD symptoms.
P331 Is Motor and Cognitive Functioning Related to Employment Status in Persons With Parkinson’s Disease? A Clinic-Based Cross-Sectional Study
F. Björk, B. Johnels, and Å. C. Lundgren Nilsson
Neuroscience and Physiology, Göteborg, Sweden
Objective: The purpose of this study was to identify variables associated with and predictors of employment status among patients with Parkinson’s disease in working age at a rehab clinic.
Methods: Assessment of the current employment status of 100 persons with Parkinson’s disease in working age. Cognitive functioning was evaluated with the Barrow Neurological Institute Screen (BNIS), Digit span of Wechsler Adult Intelligence Scale III (WAIS-III) and Visual Span of the WAIS-III, Swedish version (WAIS-III NI), part A and B of the Trail Making Test (TMT A and B). Motor symptoms of Parkinson’s disease were rated using the Unified Parkinson’s Disease Rating Scale, motor examination (UPDRS-III). Parkinson’s disease questionnaire (PDQ-39) was used to assess health-related quality of life.
Results: Forty-six percent had no current work activity, 25 percent worked low part-time (25% or 50%), and 29 percent high part-time or full-time (75% or 100%). The best predictive variables to account for the variance between the high-working reference group and the group with no work/low-working group was motor function and cognitive functioning on a screening level and attention set-shifting (TMT B-A).
Conclusions: Rehabilitation/Vocational programs for persons with Parkinson’s disease would benefit from inclusion of a formal motor and cognitive assessment, the later including screening and different aspects of working memory especially attention set-shifting, to better assess work potential and to study the predictors of work-related outcomes to direct the best treatment effort in rehabilitation to keep persons in work.
P332 Client Satisfaction With Intraintestinal L-Dopa Therapy
G. Tautscher-Basnett, V. Tomantschger, and M. Freimueller
Gailtal-Klinik Hermagor, Hermagor, Austria
Background: Continuous dopaminergic stimulation (CDS) delivered by intraintestinal L-Dopa therapy in the advanced stages of Parkinson’s disease (PD) has become increasingly established. The aim of this retrospective survey was to gain information on client satisfaction with this type of therapy and to find out which problems users encounter.
Methods: 18 patients were switched from oral medication to CDS in the period 01/2006 to 07/2009 at the Gailtal-Klinik. At the point of this survey 15 patients were receiving treatment; one patient had died, one decided to go back to oral medication and one patient was switched to Apomorphine pump. The survey consisted of a questionnaire with 11 questions (ten potential problems, one open question) and a self-reporting scale regarding client satisfaction with three sub-parts. The questionnaire was sent to the 15 patients still receiving CDS with the pump. The rate of return was 100%.
Results: Of the ten potential problems nine were in fact experienced by the patients, one problem (“faulty pump”) had not been encountered at the time of the survey. Despite various problems, client satisfaction with using the pump, with the effects of intraintestinal CDS and with the personal and telephone support for users were mainly rated with “very satisfied” or “satisfied”.
Summary: Technical systems used by laypersons (patients and carers) have to show a low error-proneness in order to be used effectively in everyday life. If the therapy is effective and continuous multidisciplinary care functions well, then even technical problems are accepted by users.
P333 The Effect of Continuous Intraintestinal L-Dopa Therapy on Non-Motor Symptoms in Parkinson’s Disease
V. Tomantschger, G. Tautscher-Basnett, and M. Freimueller
Gailtal-Klinik Hermagor, Hermagor, Austria
Background: The effects of non-motor symptoms (NMS) on quality of life in Parkinson’s disease is being increasingly discussed. This study investigates how continuous dopaminergic stimulation (CDS) delivered by intraintestinal L-Dopa therapy affects non-motor symptoms (NMS) in patients with Parkinson’s disease.
Methods: Eleven patients participated. Inclusion criteria: CDS for 6 months continuously; ability to walk a few steps; no severely limiting co-morbidities. Five NMS were investigated: frequency of falls, sleep quality, digestion, hallucination, mood. Instruments used: structured interview, geriatric depression scale (GDS), UPDRS, PDQ39. Answers of interview correlated with Tinetti test for frequency of falls; interview for sleep quality; mood measured with GDS and compared with PDQ39 (questions 17-19). Hallucination measured with PDQ39 (question 33) and UPDRS (question 2).
Results: The following changes could be observed: a) frequency of falls: reduced in 10 patients; b) sleep quality: improved in 8 patients, no change in 2 patients, worse in 1 patient; c) digestion: positive changes reported by 8 patients, no changes by 3 patients; d) hallucination: positive changes in 10 patients, condition worsened in 1 patient; e) mood: according to GDS positive changes in all patients, according to PDQ39 positive in 9 and no change in 2 patients.
Summary: The results suggest that L-Dopa therapy delivered intraintestinally by CDS influences NMS positively, i.e. the mode of delivery may play a part in the management of NMS in the course of Parkinson’s disease. Paying increased attention to NMS addresses important issues concerning quality of life of patients and their careers.
8.2 Inflammatory (MS)
P334 Different Rehabilitation Settings Impact on SM Patients’ Quality of Life
R. Acito, A. Falappa, L. Bacci, R. Santoni, A. Morgantini, R. Raspa, L. D’Angelantonio, T. Zaccari, and G. Pirani
Istituto di Riabilitazione Santo Stefano, Ancona, Italy
Background: Rehabilitation treatment may reduce disability and improve Quality of Life in MS patients.
Objectives: Verify if there are different results about quality of life acting the same treatment (time of treatment and treatment technique) in different settings (outpatients, inpatients, DH patients)
Methods: 30 SM patients of 115 were selected using specific inclusion and exclusion criteria and divided into three groups by a randomization program. Patients of each group were treated for twenty sessions lasting 45 minutes, using the same rehabilitation technique but in different settings; quality of life has been measured using SF - 36 score at the beginning of treatment and at the end; standing balance also has been evaluated using Berg score.
Results: Outcome scores were analyzed in terms of change scores between latter and former evaluation using SPSS 13.0 for Windows; ANOVA test also has been used. We found a significative statistical improvement of SF - 36 score in the three groups; best scores were reached in two items (physical activity and physical pain) and in the inpatients and DH patients in particular.
Conclusion: Rehabilitation training betters the self perception in all patients treated; better results are reached by recovery and DH training, and particularly in increasing physical activity and reducing pain.
P335 Does Attentional Training Have a Positive Effect on Quality of Life of Multiple Sclerosis Patients?
L. Bacci, L. Pierfederici, L. Catena, and A. Morgantini
Istituto di Riabilitazione Santo Stefano, Ancona, Italy
Cognitive impairment is a well-known feature of Multiple Sclerosis (MS) and often can be detected at early stage of the disease. Some studies have demonstrated that these problems strongly affect patients’ ability to work, social relationships, activities of daily living and quality of life (QoL), sometimes despite minimal physical disability. The most frequently impaired cognitive domains are memory, attention and information processing speed and executive function. Currently studies regarding cognitive rehabilitation in MS are limited and report heterogeneous results. Some researches have shown that QoL questionnaires more broadly measure the impact of MS than do the most frequently used measures of disease activity.
The aim of this study is to evaluate the efficacy of an attentive training and to observed the impact on QoL using Functional Assessment o Multiple Sclerosis (FAMS), MS-specific QoL instrument.
We selected 14 out-patients with definite MS who complained of cognitive disturbances evidenced by the Brief Repeatable Battery of Neuropsychological test. All participants underwent neuropsychological assessment consisting of attention, memory tests and a QoL instrument (FAMS) at baseline and at the end of the rehabilitation treatment.
Significant improvements on memory deficits were showed immediately after treatment. Otherwise there was a near significant improvement on attentional abilities, especially for mental flexibility and on QoL.
This study shows the efficacy of the attentional training especially on memory abilities and the positive effect on QoL after a cognitive treatment. It also confirm the FAMS sensibility on revealing psychosocial consequences of MS.
P336 Advanced Lightweight Cooling-Garment Technology: Functional Improvement in Patients With Multiple Sclerosis and Thermosensitivity
S. J. Albert1, P. Stützer2, J. Kool3, S. Beer1, and J. Kesselring1
1Department of Neurology and Neurorehabilitation, Valens, Switzerland, 2Department of Psychiatry, Chur, Switzerland, 3Zürcher Hochschule für Angewandte Wissenschaften, Winterthur, Switzerland
In spite of ongoing progress in the medical treatment addressing to the progress of Multiple Sclerosis (MS), symptomatic therapy aiming at the improvement of quality of life and relief of symptoms remains one of the corner stones of therapeutic interventions in clinical practice. In the present study we evaluated the effectiveness of cooling garment in MS patients with a history of thermal sensitivity.
Thirty subjects were randomized to two days of testing under thermal conditions (29 ° C) and normal temperature (19 ° C) with and without activated cooling garment. Results: The use of the cooling garment showed significant improvements of gait speed, when applied in hot conditions. The results are statistically significant concerning a walking time of three 3 minutes. After a minute, was already a trend yet without statistical significance. The fine motor skills and coordination in the hands Six Spot Step Test (SSST) and Nine-Hole-Peg Test (NHPT) were not significantly improved by cooling. Since the test duration of SSST and NHPT compared to the walking test was relatively short, possibly not a sufficient exhaustion could be provoked by these tests. The cooling-garment is regarded as effective and its use showed to be feasible.
P337 The Experiences of Patients With Multiple Sclerosis Who Participated in a 10-Week Group Exercise Programme: A Focus Group Study
R. Clarke and S. Coote
University of Limerick, Limerick, Ireland
Introduction: Evidence shows that exercise has positive effects on physical outcomes in a MS population, however its effect on quality of life (QOL) is uncertain. Quantitative methods of assessing QOL may not be a true indicator of a patient’s experience. This qualitative study explored the effect of participating in a 10-week group exercise programme.
Methods: A focus group methodology was used. Focus groups were audio-taped and transcribed verbatim. A summary and debrief between moderators took place to verify data.
Thematic-analysis was used to analyze the data. Themes were grouped according to their frequency, extensiveness and intensity. Themes were then confirmed by the assistant moderator and verified by member checking.
Results: 14 people were recruited from those who had participated in the “Getting the Balance Right” study. Three focus groups took place and common themes arose. The Psychological Benefits discussed were feelings of empowerment, confidence, hope and motivation. Physical Benefits were described as increased energy levels and functionality. The Increase in Knowledge relating to appropriate exercises was also a significant discussion point. The most frequent and emotive theme was the role of group participation as a vital component with positive implications for adherence and motivation.
Conclusions: People with MS experience many psychological and physical improvements in response to group exercise which impact on their QOL and functional capacity with the role of the group a significant factor. The results of the focus group are supported by the results of the randomised controlled trial using the MSIS 29 to measure participation restrictions.
P338 Are We Addressing the Hidden Symptoms in Multiple Sclerosis?
M. H. Desai1, B. J. Chandler1, and E. C. Davis2
1International Centre for Neurological Rehabilitation and Neuropsychiatry, Newcastle upon Tyne, United Kingdom, 2International Centre for Neurological Rehabilitation and Neuropsychiatry, Newcastle upon Tyne, United Kingdom
Background: Multiple Sclerosis patients can experience a wide range of problems/symptoms during their life, some will last for a short time or may continue or develop over a life time.
Fatigue is experienced by 90% of patients, cognitive dysfunction by 54-65% and memory problems by 55%. 50% complain of bowel dysfunction and nearly 75% experience bladder dysfunction at some stage. Depression is observed in 10-57%, pain in 28-86%, and sexual dysfunction in 70% of patients.
Doctors should systematically address, whether the person with MS has a hidden problem contributing to their clinical condition.
Aims and Objectives: 1) To identify compliance with NICE guidelines on the Care of patients with Multiple Sclerosis. 2) To improve quality of care.
Method: Analysis of rehabilitation clinic letters & notes, (12 month period)
Results: Discussion of symptoms was: 22% for fatigue, 74% continence issues, 28% Cognitive function, 48% mood, 42% skin integrity, 62% pain symptom, 96% spasticity, 36% speech & swallowing and 6% for sex and relationship issues.
Conclusion: Identification of issues such as depression, fatigue, pressure areas, cognitive dysfunction, sex & relationships needs to be improved. If required, direct questioning should be used. It is important to find the balance between too much questioning and not enough, and between relying on patient to highlight problems and using direct questioning.
Recommendations: We have developed a checklist tool of these hidden symptoms for use at annual review to find out, whether problems are picked up specifically by asking using checklist, rather than being volunteered by patients.
P339 Gait Analysis for Objective Assessment of Motor Fatigue in Patients With Multiple Sclerosis
C. Dettmers1, A. Khusnullina2, M. Roth2, and M. Vieten2
1Kliniken Schmieder, Konstanz, Germany, 2Fachbereich Sportwissenschaften, Uni Konstanz, Konstanz, Germany
Background/aim: Motor and cognitive fatigue in patients with multiple sclerosis (MS) has an enormous impact on productivity and quality of life. In contrast to its enormous impact on productivity, fatigue is difficult to assess. There is no objective way to measure fatigue. The aim of the present study was to analyze gait parameters in MS patients with motor fatigue during exhaustion and treadmill training.
Method: Patients: Fourteen patients with definite MS complaining of fatigue.
Protocol: Patients were asked to walk on the treadmill till they were seriously tired and requested rest.
Gait analysis: Komplettsystem AS 200, Firma LUKOtronic, recorded the gait. Eleven active infrared sensors were attached to the heals, achilles tendons, knees, buttoms, thoracic spine and medial side of scapula. The following movements and joints were analysed: step size, step broadness, step altitude, circumduction, angle at the knees and sway. Gait was also videotaped.
Self esteem of patients fatigue was assessed by Fatigue Scale of Motor and Cognition (FSMC, Penner IK et al 2005).
Results: Twelve patients had serious motor fatigue according to the questionnaire, 1 moderate and 1 only cognitive fatigue. Average distance on the treadmill was 110 meter (63 to 692). All eight gait parameters were significantly altered during exhaustion. Variability of parameters increased during exhaustion.
Interpretation: Careful analysis of gait parameter is a promising tool for detection and assessment of motor fatigue in patients with MS.
P340 Exercise Significantly Reduces the Impact of Fatigue in People With MS With Minimal Gait Impairment
M. Garrett1, A. Larkin2, J. Saunders1, N. Hogan1, and S. Coote1
1University of Limerick, Limerick, Ireland, 2Multiple Sclerosis Ireland, Ireland
Background: Fatigue limitations are experienced by most people with MS. Exercise is an important component the management of MS. Trials to date have mixed outcomes regarding the effect of exercise on fatigue and have many methodological limitations.
Aim: To compare the effect of different exercise interventions on the impact of fatigue, in people with MS, with minimal gait impairment.
Methodology: Participants were block randomised to a physiotherapist led exercise class, a fitness instructor (FI) led exercise class, yoga or a control group. Participants attended for 1 hour a week for 10 weeks. Blind assessments were conducted before and after the intervention, using the Modified Fatigue Impact Scale. Data was normally distributed, thus, analysed using parametric statistics.
Results: 250 participants were eligible for analysis. The physiotherapist led group (N=64) showed a mean improvement of 7.14 (95%CI 3.45, 10.82, p = 0.000). The yoga group (N=63) had a mean improvement of 6.11 (95% CI 2.72, 9.49, p = 0.001). The FI group (N=69) showed a mean improvement of 7.36 (95% CI 3.88, 10.84, p = 0.000). The control group (N=54) had a mean improvement of 1.02 (95%CI - 2.08, 4.13 p = 0.514). The reductions in the impact of fatigue from baseline were 18%, 18.8%, 15.5% for the exercise interventions respectively and 2.7% in the control.
Conclusion: The ten week exercise interventions of physiotherapist led exercise, fitness instructor led exercise and yoga showed reductions in fatigue which were statistically significant.
P341 Cognitive Dysfunction in Multiple Sclerosis and Its Relationship to Mood Disturbance and Fatigue: Testing a Model to Guide Rehabilitation
H. L. Gill1, J. Fleming1, S. Bennett1, and D. Shum2
1School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia, 2School of Psychology, Griffith University, Brisbane, Australia
Cognitive dysfunction is known to affect 40-70% of individuals with multiple sclerosis (MS). Evidence suggests prominent impairments in memory, sustained attention, planning, and speed of information processing, all of which having implications for effective daily functioning. Cognitive dysfunction influences individuals’ functional independence and role fulfillment in the contexts of work, family life and social activities. Consequently, cognitive dysfunction has an adverse impact on community participation. However, it is important to consider the role of mood disturbance and fatigue, as these symptoms have also been shown to lead to poor functional outcomes. Further, there is conflicting evidence regarding the association of these constructs with cognitive dysfunction in MS. This study utilized structural equation modeling (SEM) to investigate the interplay between cognitive dysfunction, mood disturbance and fatigue on community participation in a sample of 80 community-dwelling individuals with diagnosed MS. Cognitive dysfunction was measured using a battery of standardized neuropsychological tests. Mood disturbance, fatigue, and participation were measured through self-report questionnaires. The hypothesized model was found to have good fit. Results suggested that cognitive dysfunction was the only direct predictor of community participation, with greater dysfunction predicting less participation. However, both fatigue and mood disturbance were found to have indirect effects on community participation. Specifically, the effect of fatigue on participation was mediated by cognitive dysfunction, while mood disturbance had an indirect effect through fatigue and cognitive dysfunction. These findings underscore the complex interplay between different symptom domains in MS and their association with functional outcomes. Implications for intervention will be discussed.
P342 The Effect of Group Physiotherapy, One on One Physiotherapy and Yoga on Balance in People With MS Who Use at Least Bilateral Assistance to Walk
N. Hogan1, M. Garrett1, S. Coote1, A. Larkin2, and J. Saunders1
1University of Limerick, Limerick, Ireland, 2Multiple Sclerosis Society, Ireland
Introduction: Balance impairment is one of the most commonly reported symptoms in people with MS(PwMS). This, along with other symptoms of MS, challenges a person’s mobility and their ability to ambulate safely in their home or community, therefore, increasing their risk of falling. This can lead to injuries, an increased fear of falling and a decrease in activity levels, confidence and social participation for PwMS.
Aim: To assess the effect of two physiotherapy interventions and yoga on balance in PwMS
Methods: 146 participants were assessed and allocated to group physiotherapy which consisted of balance and strength exercises, one on one physiotherapy, group yoga or control. Participants received one hour of therapy for ten weeks. They were assessed before and after the intervention using the Berg Balance Scale (BBS). An increased score on the BBS indicates an improvement.
Results: Data for 112 participants were analysed. Group physiotherapy (n=48) showed a mean change of 5.69 (95%CI 3.58 - 7.79), one on one physiotherapy showed a mean change of 3.67 (95%CI 1.0 - 6.31) and yoga showed a mean change of 5.3 (95%CI 3.06 - 7.54). These improvements were all statistically significant with p values of 0.000, 0.013 and 0.007 respectively. The control group had a mean change of -3.11 (95%CI -8.99 - 2.77).
Conclusion: All three intervention groups had statistically significant improvements in balance scores, whereas, the control group’s scores worsened. Twenty five percent of participants who took part in group physiotherapy went from having a moderate risk of falls to having a low risk of falls.
P343 Effects of Rehabilitation on Quality of Life and Fatigue in Multiple Sclerosis
E. Judica, F. Martinelli Boneschi, D. Ungaro, M. Comola, G. Comi, V. Martinelli, and P. Rossi
Neurorehabilitation Unit, Neurology Dept—INSPE. IRCCS Ospedale San Raffaele, Milano, Italy
Background: In multiple sclerosis research has proven the effectiveness of rehabilitation in reducing disability and improving the quality of life, as well as improving physical fitness and helping to achieve a lower level of perceived fatigue.
Objective: To determine the impact of rehabilitation over a short time period and the effect of fatigue on the quality of life (QoL) in people with multiple sclerosis (MS).
Methods: We considered 96 subjects with MS who underwent to a programme of rehabilitation in our Neurorehabilitation Unit. The outcome measurements evaluated at the beginning and at the end of rehab period were quality of life (MSQoL54), disability (EDSS) and fatigue (Fatigue Severity Scale). We measured quality of life by MSQOL-54 at the beginning and one month after the end of rehab treatment.
Results: At the end of rehab period EDSS significantly improved from 5.9 to 5.2. Changes from baseline to follow-up were significant for most scale and subscale scores except for sexual function, sexual satisfaction and cognitive function subscales of MSQOL-54. Physical health composite and Mental health composite, evaluated one month after the end of rehabilitation period, significantly improved (p<0.0001). We found a relationship between increase in all domains of MsQol and reduction of fatigue.
Conclusions: These data support the evidence that rehabilitation can improve quality of life in patients with MS over a short time period. Moreover this improvement seems to correlate with a significant reduction of subjective fatigue, supporting for the role of rehabilitation in improvement of quality of life and fatigue.
P344 Impact of Family Role in Quality of Life of People With Multiple Sclerosis
L. Pedro1 and J. Pais Ribeiro2
1ESTESL, Lisbon, Portugal, 2FPCE-UP, Porto, Portugal
Objective: Multiple sclerosis (MS) it is a chronic neurological disease, characterized by demyelisation, and a broad spectrum of physical, emotional and social impairment.
The aim of the present study is to examine the Impact of family role perception in quality of life in patients with MS.
Material: We use the domain of family role (7 items) of the IPA (Impact on Participation and Autonomy) questionnaire, that measures several aspects of participation and autonomy, and the Multiple Sclerosis Quality of Life scale (MSQol-54) a multidimensional quality of life questionnaire.
Methods: 280 patients with MS were recruited via their physician at a neurology department of a Central Hospital in Lisbon. The mean age was 40 years (range 18- 65), 71.3% were women, 61.1% were currently married, 63% active workers, mean school level of 12 years, and scores of EDSS is 2.8.
Methods: the study is cross-sectional and correlational.
Results: The correlations between family role and the domains of MSQOL-54: Physical Health (r=0.70, p<0.01), Physical Role Limitations (r=0.71, p<0.01), Emotional Role Limitations (r=0.52, p<0.01), Pain (r=0.49, p<0.01), Well-being (r=0.47, p<0.01), Energy (r=0.58, p<0.01), Health in General (r=0.44, p<0.01), Social function (r=0.60, p<0.01), Cognitive Function (r=0.30, p<0.05), Health Distress (r=0.55, p<0.01), Overall Qol (r=0.52, p<0.01), Sexual function (r=0.41, p<0.01), Change Health (r=0.30, p<0.05), and Satisfaction with sexual function (r=0.41, p<0.01),.are all statistic signification.
Conclusion: There is a statistically significant correlation between the variables, suggesting that family role can play an important perspective in the quality of life of patients with MS.
P345 Relationships Between the Perception of the Severity of Disease and Quality of Life in People With Multiple Sclerosis
L. Pedro1 and J. Pais Ribeiro2
1ESTESL, Lisbon, Portugal, 2FPCE-UP, Porto, Portugal
Multiple sclerosis (MS) is a chronic neurological disease, with onset typically in early adult life. Although its course is unpredictable, potentially severe consequences may develop during the course of the disease.
The aim of the present study is perception of the severity of disease in quality of life in patients with MS.
Material: We use the Multiple Sclerosis Quality of Life scale (MSQol-54) a multidimensional quality of life questionnaire and one question about disease perception “What’s your perceptions about the severity of your illness (multiple sclerosis)”?
Methods: 280 patients with MS were recruited via their physician at a neurology department of a central hospital in Lisbon. The mean age was 40 years (range 18- 65), 71.3% were women, 61.1% were currently married, 63% active workers, mean school level of 12 years, and scores of EDSS is 2.8.
Methods: the study is cross-sectional and correlational.
Results: The correlations between the perception severity of disease and the domains of MSQOL-54: Physical Health (r=0.26, p<0.05), Physical Role Limitations (r=0.22, p<0.05), Emotional Role Limitations (r=0.14, p<0.05), Pain (r=0.19, p<0.05), Well-being (r=0.21, p<0.05), Energy (r=0.19, p<0.05), Health in General (r=0.42, p<0.01), Social function (r=0.23, p<0.05), Cognitive Function NS, Health Distress (r=0.30, p<0.05), Overall Qol (r=0.37, p<0.05), Sexual function (r=0.16, p<0.05), Change Health (r=0.28, p<0.05), and Satisfaction with sexual function (r=0.16, p<0.01),.are moderate statistic signification.
Conclusion: Results show that there is a statistically significant correlations between the variables, suggesting that quality of life can play an important role in the adjustment to the disease.
P346 Using a Musical Instrument to Improve Motor Skill Recovery in Subjects With Multiple Sclerosis
V. Petrillo1, S. Lambiase2, P. Rossi2, M. C. Saccuman3,4, D. Spada5, M. Comola2, A. Tettamanti1,2,4, and R. Gatti1,2,4
1School of Physiotherapy, Vita-Salute San Raffaele University, Milan, Italy, 2San Raffaele Hospital, Neurorehabilitation Unit, Milan, Italy, 3Faculty of Psychology, Vita-Salute San Raffaele University, Milan, Italy, 4Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy, 5Department of Biomedical Sciences and Technologies, Psychology Section, School of Medicine, Universita’degli Studi, Milan, Italy
Background: Some studies have shown that playing a musical instrument can have an important role in the recovery of the hand in stroke patients, as it is an extremely complex process of integration between auditory and motor systems with plastic adaptation in different cerebral regions. We designed a study that entailed active music making in the rehabilitation of subjects with Multiple Sclerosis to improve hand motor skill recovery.
Materials and methods: 13 hospitalized subjects were randomized in two groups: 7 played repetitive isolated fingers’ movements sequences on keyboard (Experimental Group=EG) and 6 performed the same exercises on a drawn keyboard (Control Group=CG); training was applied half an hour per day for 15 days.
Pre and post-treatment motor functions were evaluated with Nine-Hole PegTest (9HPT), Jamar and Pinch dynamometers. Ethical committee approved the study.
Results: In both groups there were significant differences between in-score and out-score in the 9HPT for both limbs (EG: right hand p=0.018, left hand p=0.017; CG: right hand p=0.028, left hand p=0.042). The analysis of only the most affected side showed significant results in all tests for EG (9HPT p=0.018, Jamar p=0.026, Pinch p=0.078) and only in 9HPT for CG (p=0.042).
Comparing the two groups, EG showed a higher increment in Jamar both considering the left side (p=0.051) and the most affected side (p=0.043).
Conclusions: Playing a musical instrument appears to be beneficial for the hand rehabilitation of subjects with Multiple Sclerosis. Results are encouraging and further studies will be carried on with a larger sample.
P347 Sport Therapeutic Strength Training in the Course of a Neurological Inpatient Rehabilitation on the Health Related Quality of Life of Patients With Disseminated Encephalomyelitis
R. Spiesberger, M. Aimet, G. Haudum, J. Lampichler, J. Pelikan, R. Skopetz, and A. Pfeiffer
Klinik Pirawarth, Bad Pirawarth, Austria
Introduction: At present there are different opinions concerning physical strain and health related quality of life in patients with disseminated encephalomyelitis.
Points of discussion are fatigue during therapy and possible negative effects on the progression of the disease. The core of this study is to ascertain the influence of a sports science based strength training on the health related quality of life of patients with disseminated encephalomyelitis during a neurological inpatient rehabilitation.
Methods: For this purpose patients (n=93) were rationed into groups of 40, 50 and 70 percent of their one repetition maximum, tested on weight machines. The strength training was accomplished two to three times weekly over a period of four weeks. The health related quality of life was assessed with the Sf - 36 in the beginning, at the end and after three months of rehabilitation. Results: The conclusion of this study is that a strength training with 40 percent of the one repetition maximum shows a significant improvement of the health related quality of life at the end of an inpatient rehabilitation in opposite to patients without a certain training. The recommendation is a strength training with 40 percent of the one repetition maximum because of the positive impact concerning health related quality of life and the reduction of possible negative effects.
P348 Plyometric Exercise to Reduce Plantar Flexor Spasticity in Subjects With Multiple Sclerosis
A. Tettamanti1,2, C. Ghislanzoni3, A. Gemelli1, L. Tagliabue1, P. Rossi3, M. Comola3, and R. Gatti1,3,2
1School of Physiotherapy, Vita-Salute San Raffaele University, Milan, Italy, 2Lab of Analysis and Rehabilitation of Motor Function, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy, 3San Raffaele Hospital, Neurorehabilitation Unit, Milan, Italy
Background: Increased levels of cocontraction are a common and impairing problem in subjects affected by spasticity. The aim of this study is to observe differences in cocontraction levels of leg muscles in subjects with multiple sclerosis (MS) and healthy subjects, after isotonic (ISO) and plyometric (PL) strength training of plantar flexors.
Methods: 8 subjects with MS, hyperreflexia of plantar flexors, voluntary activation of dorsal flexors, at least 10° of dorsal flexion were recruited and compared with 8 sex and age matched healthy subjects. The subjects with MS were divided into 2 training groups: isotonic and plyometric, trained twice a day for 2 weeks. Plantar and dorsiflexors surface EMG during isometric maximal contraction and maximal isometric strength were acquired pre training and 24 hours after the last training session. The same assessment was performed with healthy subjects. Co-activation level of antagonist muscles was computed from sEMG signal. Ethical committee approved the study.
Results: Hypertonic plantar flexors are weaker than healthy ones (median: healthy= 825N, MS= 268N, p<0.001). Coactivation of gastrocnemius during dorsal flexion after training reduces (Δmedian: ISO= +29.62%, PL= -14.04%, p=0.083), and strength of plantar flexors increases (Δmedian: ISO= -2.19N, ΔPL= +27.39N, p=0.021) only in plyometric group.
Conclusions: MS subjects are weaker than healthy subjects above all in plantar flexion. Plyometric training seems to be more efficacy, than isotonic one, both to increase strength and to decrease co-activation levels of plantar flexors during voluntary maximal dorsal flexion. Other studies on larger sample and with neurophysiological data are advisable.
8.3 Vascular (Stroke)
P349 Group of Physical Therapy in Hemiparesia Post-Stroke
M. Alves, V. Guimarães, S. Nique, and V. Striebel
Metodist University Center IPA, Porto Alegre, Brazil
With the growing number of individuals with sequela of stroke, who need physiotherapy treatment for long periods, the objective of this study is to present, discuss, and encourage the participation of individuals with post-stroke sequelae who is making physical therapy group.
Eight hemiplegic individuals, with a age mean of 57.8 years and duration of post-stroke sequelae mean 2.1 years, which was attend at Physiotherapy Clinic of Metodist University Center IPA, located at Parque Belém Hospital, in Porto Alegre, Brasil, were recruited following the criteria of inclusion (mental state and balance) and subjected to pre-established program, with specific exercises twice a week, lasting 45 minutes. Subjects were evaluated before and after application of the program, calls for a total of 14 meetings, the following parameters: motor function (Fugl-Meyer), balance (EEFB), mental state (MMSE) and function (MIF).
The exercise program consists of: heating, stretching, specific activities for the day, relax and at the end of the session, we use music. The score of all individuals improved at the end of calls.
The therapy group is an effective therapeutic option that can ease the complications of stroke. Based on the tendency to first try to reduce the functional limitations and, subsequently, increase social integration and adaptation in the environment by offering people the opportunity to feel that it is not the only one having problems. Besides resulting in greater functional independence and less risk of falls, there was greater motivation and greater adherence to the proposed activities.
P350 Applicability of Constraint-Induced Movement Therapy for Lower Extremity in Stroke Patients
R. D. Assis, H. C. Borges, A. C. Alves, and T. R. Chamlian
Lar Escola São Francisco—centro de reabilitação, São Paulo, Brazil
Introduction: The Constraint-induced Movement Therapy (CIMT) is an intensive rehabilitation treatment for patients with acquired encephalic lesions to overcome the learned nonuse phenomenon. Although there are several studies for upper extremity rehabilitation, fewer studies tried to apply this technique for lower extremity (LE). Objective: Describe the therapeutics effects of CIMT for LE in stroke patients. Methods: Eight patients with chronic stroke made individually the one week protocol of CIMT for LE. The protocol consisted in five consecutives days of treatment with three hours of shaping (“walk” and “climb up the stairs”) plus domiciliary exercises. The outcomes: Time up and Go (TUG), Berg Balance Scale (BBS), Physiological Cost Index (PCI) and Dynamic Gait Index (DGI) were applied, by another therapist, in the first and last day of treatment. Also, the patients were filmed during the protocol. Results: We observed an increase on score at BBS and DGI, a decrease in TUG, and minimal variation on PCI, demonstrating that the patients had an improvement in their equilibrium and become more faster to walk. The video analysis showed an improvement in the body weight-bearing on a paretic LE. Conclusion: The protocol of CIMT for LE can be used as a complementary treatment for the rehabilitation process.
P351 The Impact of Depression on Quality of Life in Post-Stroke Patients
G. I. Chiriţi, D. Dimulescu, and A. Marin
National Institute of Rehabilitation, Physical Medicine and Balneoclimatology, Bucharest, Romania
Objectives: Studying the impact of depression on quality of life in post-stroke patients hospitalized in the Rehabilitation Clinic.
Materials and Methods: The study, realized at the National Institute of Rehabilitation, Physical Medicine and Balneology, included two groups of post-stroke patients: 1 - case group and 2 - control group, with 30 patients each, of both sexes (predominantly female), aged over 50. We applied to hospitalized patients Beck depression scale: in group 1 were included patients with a score over 29 points (severe depression) and in group 2 were included patients with a score below 29 points (low and average depression).
Following clinical and functional parameters were assessed for in and out-patients: pain (VAS scale), physical dysfunctions (joints and muscles examination), disabilities (ADL 24, Tinetti gait scale, Tinetti balance scale), quality of life.
Results: At the end of the physical-kinetic treatment, patients in the two groups achieved following improvements: 19,53%(group 1) vs.28,46%(group 2)- for the pain; 13,60% (group 1) vs. 19,22% (group 2)- for the physical dysfunction; 16,25%(group 1) and 25,17% (group 2)- for disabilities; 16,46% (group 1) and 24,28% (group 2)- for quality of life.
Conclusions: The results of this study demonstrated the impact of depression on quality of life in post-stroke patients, advocating for the association to the rehabilitation treatment for the antidepressant medication and psychological evaluation.
P352 Quality of Life and Its Meaning: Perspectives of Community-Dwelling Stroke Survivors in Singapore
H. M. Chua1, C. Lim1, T. Ng2, S. Seow3, and Y. M. Soh1
1Tan Tock Seng Hospital, Singapore, Singapore, 2Asian Women’s Welfare Society, Singapore, Singapore, 3KK Women’s and Children’s Hospital, Singapore, Singapore
Background: This study aimed to (i) determine the global and domain specific quality of life (QOL) of Singapore stroke survivors (ii) identify the relationship between QOL and functional status and depression (iii) analyse activity participation rates and (iv) explore participants’ experience of stroke.
Methods: Cross-sectional survey study was conducted on participants who survived stroke for at least one year. Short Form 36 (SF-36), Modified Barthel Index (MBI), Zung Depression Scale and Activity Card Sort-Singapore were used to measure QOL, functional status, depression and activity participation respectively. Pearson correlation was performed. Lived experience of stroke participants were gained through in-depth interviews using an idiographic approach. Qualitative results were coded for themes and triangulated with field notes and quantitative data.
Results: 33 participants (mean age 49.13±12.71 years) from a voluntary welfare organisation were interviewed at mean 4.58 years post-stroke. Mean MBI was 89.65±16.36. Participants’ mean SF-36 scores were lower than Singapore norms. Depression had the highest correlation to SF-36. High-demand physical activities (27.3%) were the least retained while low-demand physical activities were rated as most important. 5 themes emerged from the qualitative interviews—“exercise gives hope”, “family and friends”, “financial woes”, “seeking meaningful work” and “creating resources to support changes”.
Conclusion: Stroke affects occupational participation. There was no direct relationship between bodily functions and QOL. We propose that rehabilitation professionals should extend beyond physical impairments restoration to multi-dimensional perspective in psycho-education and developing programs to empower stroke survivors to reinstate themselves in valued occupations.
P353 The Utility of a Bladder Scan Protocol Using a Portable Ultrasonographic Device in Stroke Patients
M. H. Chun1, H. J. Kim1, E. Y. Han2, and J. H. Yi1
1Asan Medical Center, Seoul, Republic of Korea, 2Jeju National Medical Center, Jeju, Republic of Korea
Objective: To evaluate the clinical usefulness of a bladder scan protocol for urinary retention using the portable ultrasonographic device (PUD) in stroke patients.
Design: Twenty-six stroke patients whose post-void residual urine volume (PVR) was more than 100 ml, were enrolled as case group. They were managed using our bladder scan protocol until the PVR was less than 100 ml and intermittent urinary catheterization (IC) was performed if PVR was more than 400 ml using the PUD. The control group (n=26) was also managed using the PUD but they were not applied to this protocol.
Results: The period of scanning in days was similar in the two groups, but more patients in the control group were scanned longer after the PVR lowered to less than 100 ml (2.3 vs. 8.5 days) and discontinued scanning before PVR lowered to 100 ml (1 vs. 7). IC volume was significantly higher in the case group without bladder overdistension (407.3 vs. 344.9 ml), and urinary tract infection did not occur during this period.
Conclusions: Our bladder scan protocol for urinary retention after stroke might be useful as it allows catheterization of an adequate urine volume and reduces unnecessary bladder scanning.
P354 Anxiety-Negative Factor in Improving Physical Dysfunctions and Disabilities in Patients Post-Stroke
D. Dimulescu, G. Chiriţi, and A. Marin
National Institute of Rehabilitation, Physical Medicine and Balneoclimatology, Bucharest, Romania
Objectives: Showing the influence of anxiety on the results achieved in improving physical dysfunctions and disabilities after a rehabilitation program applied to post-stroke patients.
Material and method: The study has included two groups of post-stroke patients: 1 - case group and 2 - control group, with 25 patients each, of both sexes, aged between 40 and 70 years.
We performed a psychological screening to hospitalized patients using STAI anxiety scale: in group 1 were included patients with scores higher than 49 points (above average and high anxiety), while in group 2 were included patients with scores under 49 points (low and average anxiety).
Clinical and functional parameters that we evaluated were physical dysfunctions (that included spasticity - Ashworth Scale; joint mobility of the affected segment) and disabilities (that included balance and gait disorders - Tinetti Balance Scale, Tinetti Gait Scale, ADL 24; addiction).
Results: After the physical-kinetic treatment, we achieved following improvements: spasticity -16.82% (group 1) and 23.50% (group 2), joint mobility -20.25% (group 1) and 26.43% (group 2), balance disorders - 17.45% (group 1) and 24.73% (group 2), gait disorders - 22.81% (group 1) and 29.46% (group 2), ADL 24 - 8.60% (group 1) and 17.85% (group 2), addiction -17.27% (group 1) and 23.73% (group 2).
Conclusions: The presence of anxiety (more than 49 points on the STAI scale) has negatively influenced recovery treatment outcomes - physical dysfunctions and disabilities - in post-stroke patients. Anxiolytic therapy and psychological counseling is needed in such cases.
P355 Afferent Paresis: A Case Report
R. P. Guimarães, A. C. Santana, C. de Camargo, T. D. Oberg, and N. M. F. V. Lima
UNICAMP, Campinas, Brazil
Introduction: Postcentral cortical lesions after stroke can result in deficits on the superior limb (SL), characterized by slowness and inaccuracy in object’s manipulation in the absence of sight. Luria called this condition afferent paresis.
Methods: Case report of a 39 years old female patient, who had a stroke 4 years ago. Fugl-Mayer Assessment (FMA), Bell’s test, Nottingham Scale, Motor Sequence Test, functional tests with and without visual feedback were used as measurement tools.
Results: The Bell’s test excluded hemineglect, FMA showed scores of 54 at motor function and 9 at sensibility, both on the SL. At the Nottingham Scale the scores were 1 for tactile sensation, proprioception and stereognosis. At the motor sequence test, with eyes open, the score was 0, and with eyes closed 5; The functional test with eyes open had a score 1 with eyes open and 26 without visual feedback.
Conclusion: Without visual information the ASL showed poorer scores on functional tests, confirming the correlation between sensibility and functionality on the SL. All the functional tests demonstrated poor scores on the study subject showing the necessity of specific treatments for these deficits in order to improve the patient’s abilities.
P356 Effects of a Treadmill Training Using Load in the Unaffected Lower Limb in Chronic Hemiparetic Patients
L. I. de Nadai, R. P. Guimarães, C. M. Stivali, A. N. Bovi, G. R. Faria, T. D. Oberg, and N. M. F. V. Lima
UNICAMP, Campinas, Brazil
Introduction: The weight-bearing and the sensory motor function at the affected lower limb (ALL) in post-stroke patients are in deficit. Repetitive exercises on treadmill can improve the functional abilities of the ALL in hemiparetic patients. Previous studies reported the benefits of the unaffected upper limb restriction in hemiparetic patients, however unaffected lower limb restrictions are poorly described.
Objective: Our aim was to analyze the effects of using load in the unaffected lower limb on weight-bearing and motor function of the paretic lower limb.
Methods: Prospective and longitudinal study with 7 hemiparetic patients. The ABC scale, Fugl-Mayer Assessment (FMA), Ashworth modified scale, PASS, Time Up and Go, 10 meters gait and the Barthel Index were used as measurement tolls, and we also assessed the weight-bearing on the ALL. The patients underwent a 12 session treatment with addition of 1Kg on the unaffected ankle.
Results: There were variations between the three evaluations for gait time (p=0,005), FMA (p=0,002), ABC scale (p=0,007) and PASS (p=0,042).
Conclusion: The therapy with treadmill and load addition at the unaffected lower limb did not change the weight-bearing at the ALL but showed improvements at the motor function, balance in upright position and gait speed.
P357 Knee Hyperextension: Functional Correlations on Hemiparesis
R. P. Guimarães, M. Taranto, T. A. Camilotti, A. N. Bovi, T. D. Oberg, and N. M. F. V. Lima
UNICAMP, Campinas, Brazil
Introduction: Knee hyperextension (KH) in hemiparetic patients usually leads to postural and mobility abnormalities and its possible causes are quadriceps paresis and spasticity of the triceps surae.
Objectives: Our aim was to asses the KH incidence and its correlations to hemiparetic patient’s functionality.
Methods: We evaluated 26 hemiparetic patients assessing weight-bearing, knees and ankles goniometry, Ashworth modified scale, manual muscular testing, Fugl Mayer assessment (FMA) and Time Up and Go.
Results: We encountered 19 patients with KH in upright position (8,15 ± 2,98 degrees) and in supine position (7,89 ± 3,05 degrees). The KH group showed better hip extensor’s strength at the affected limb (p-0,009); greater algic complaints at the affected limb (p=0,001) and less knee flexor’s strength at the affected limb (p=0,05). There were no differences between the groups concerning to weight-bearing at the affected limb, muscle tone, gait speed, balance and mobility.
Conclusion: On this sample we found a high incidence of KH but it did not correlate to paresis or spasticity of the quadriceps or triceps surae at the affected limb.
P358 Isotonic and Isometric Strengthening for the Extensor Knee Muscle: Effects on Spasticity, Balance and Gait for Chronic Hemiparetics
R. P. Guimarães, A. N. Bovi, W. M. Castro, A. Pennachi, G. A. Gomes, M. Taranto, N. M. F. V. Lima, and T. D. Oberg
UNICAMP, Campinas, Brazil
This study objective was to analyze the results of isotonic and isometric strengthening for the extensor knee muscle on the affected limb in post stroke chronic hemiparetic patients and assess its effects on spasticity, inferior limb motor function, balance and mobility. The subjects were divided into three groups: isotonic strengthening (n=6), isometric strengthening (n=6) and control group (n=6). The Ashworth scale for knee extensors and hamstrings, Fugl-Mayer Assessment Scale (FMA), Time up and go (TUG) and Berg Balance Scale (BBS) were used as assessment tools. The results revealed that the isotonic and isometric strengthening program showed post-treatment variations for total FAM (p=0,001) and TUG (p=0,006), and the isometric strengthening group was the only one that showed improvement on the BBS scores (p=0,014). The control group had no significant improvements on FAM, TUG and BBS. There were no muscle tone increase on knee extensors or hamstrings right after the isometric or isotonic training, however, we found a tone increase 30 days after treatment. The knee extensor’s selective muscle strengthening, specially the isometric training, led to motor function, balance and mobility improvement associated with reduction or maintenance of muscle tone in almost every subject.
P359 A Psychometric Comparison of the Stroke Impact Scale 3.0 and Stroke-Specific Quality of Life Scale
K. Lin1, T. Fu1, C. Wu2, Y. Hsieh1, and P. Lee3
1School of Occupational Therapy, National Taiwan University College of Medicine, Taipei, Taiwan, 2Deaprtment of Occupational Therapy, Chang Gung University, Taoyuan, Taiwan, 3Department of Occupational Therapy, Chung Shan Medical University, Taichung, Taiwan
Purpose: This study compared the responsiveness and criterion-related validity of the Stroke Impact Scale (SIS) and Stroke-Specific Quality of Life Scale (SS-QOL) for patients after stroke rehabilitation.
Methods: The SIS and SS-QOL, along with 5 criterion measures—the Fugl-Meyer Assessment, the Motor Activity Log, the Functional Independence Measure, the Frenchay Activities Index, and the Nottingham Extended Activities of Daily Living Scale—were administered to 74 stroke patients before and after a 3-week intervention. Responsiveness was examined using the Wilcoxon signed rank test and standardized response mean (SRM). Criterion-related validity was investigated using the Spearman correlation coefficient (ρ).
Results: Whereas the SS-QOL subscales were nonresponsive to changes, the SIS hand function showed medium responsiveness (SRM = 0.52, Wilcoxon Z = 4.24, P < .05). Responsiveness of the SIS total also was significantly larger than that of the SS-QOL total (SRM difference, 0.36; 95% confidence interval, 0.02-0.71). Criterion validity of the SIS hand function was good (ρ = 0.51-0.68; P < .01), but that of the SS-QOL was only fair (ρ = 0.25-0.31; P < .05).
Conclusion: Because the SIS had better overall responsiveness and the SIS hand function showed medium responsiveness and good criterion validity, the SIS appears to be more suited for assessing changes after stroke rehabilitation.
P360 Aphasia and Predictors of Health-Related Quality of Life
R. Martín Mourelle1, M. Lata Caneda1, J. Barrueco Ejido1, C. Villarino Díaz-Jimenez1, L. González Cabezas de Herrera1, L. Gestoso do Porto1, and R. Meijide Faílde2
1Physical and Rehabilitation Service of Universitary Hospital Complex A Coruña, A Coruña, Spain, 2Department of Medicine University A Coruña, A Coruña, Spain
Background and Purpose: Assessing aphasics’ quality of life is a crucial issue in rehabilitation medicine and health-related quality of life (HRQL) measures are increasingly used to help us to understand the impact of the disease and to plan a treatment. The Spanish version of Stroke and Aphasia Quality of Life-39 Scale (SAQOL-39) is a questionnaire aimed to assess the quality of life of aphasics. This study aimed to evaluate the HRLQ of people with aphasia and the most relevant predictors.
Methods: Long-term aphasic patients due to stroke were recruited from the records of our Neuro-Rehabilitation Unit. Diagnosis was performed by Boston Diagnostic Aphasia Examination. All patients were submitted to the Spanish adaptation of SAQOL-39 involving physical, psychosocial, communication and energy domains. Data analysis was performed by SPSS 16.0.
Results: A total of 40 participants agreed to take part. The sample comprised 27 males and 13 females. Mean age was 59.1 years. Most patients were non-fluent aphasics (84.6%). The Spanish SAQOL-39 showed good internal consistency analysis (Cronbach’s alpha 0.952). There was good acceptability demonstrated by minimal floor/ceiling effects. The mean score for the full scale was 3.64. Aphasia severity on discharge was significantly related to SAQOL-39 score (Spearman’s rho: 0.422, P<0.01). There was also a high significant relation with Depression.
Conclusions: The Spanish SAQOL-39 questionnaire is accessible and acceptable to people with aphasia and seems to be suitable for clinical practice.
Aphasia severity and the presence of Depression seem to be relevant facts in our aphasic patients’ quality of life.
P361 Which Is More Valid for Stroke Patients: Generic or Stroke-Specific Quality of Life Measures?
M. O. Owolabi
University of Ibadan, Ibadan, Nigeria
Background: It remains unclear whether generic or specific HRQOL measure is more valid for stroke. The aim of this study is to compare the validity of SF-36, a generic measure, and HRQOL in stroke patients (HRQOLISP), a stroke- specific measure, for assessing post-stroke HRQOL. Methods: The validity of HRQOLISP and SF-36 were compared in a cross-sectional study of 100 stroke survivors. The stroke levity scale (SLS) and modified Rankin scale (mRS) were applied to measure stroke severity and disability respectively. Results: Both measures exhibited adequate ‘known groups’ and construct validity. However the SF-36 lacked content validity for cognitive domain and personal constructs including spiritual functioning. Most SF-36 subscales had substantial floor or ceiling effects. The HRQOLISP demonstrated better content and internal consistency validity and no significant floor or ceiling effect. Conclusions: Like other stroke-specific measures, HRQOLISP was better than SF-36 in most parameters of validity considered. The SF-36 is designed for comparison among different diseases and may not be suitable for clinical trials or studies of internal adaptation, cognitive or spiritual functioning in stroke. This is because it lacks content validity for these domains and may underestimate health changes in most subscales.
P362 What Are the Consistent Predictors of Generic and Specific Post-Stroke Health-Related Quality of Life?
M. O. Owolabi
University of Ibadan, Ibadan, Nigeria
Background: In order to improve post-stroke health-related quality of life (HRQOL), it is crucial to focus scarce health care and research resources towards its consistent determinants. Disparities in reported determinants of post-stroke HRQOL may be due to the use of different instruments (generic or specific) in different populations. This is the first study to identify factors which consistently influenced both generic and specific post-stroke HRQOL in the same study population.
Methods: One hundred consecutive consenting stroke survivors were assessed using the stroke levity scale (SLS), modified Rankin scale (mRS), SF-36, and health-related quality of life in stroke patients (HRQOLISP) measure. Employing multiple regression analysis (R2=0.63), potential predictors were sought among age, gender, socioeconomic class (SEC), aphasia, post-stroke duration, side, type and number of strokes, SLS, mRS, social support, and Likert scale graded responses to laughter and negative feelings frequency.
Results: Gender, SEC and stroke type had no significant impact on HRQOL. The consistent independent statistical predictors of several facets of generic and stroke-specific HRQOL were stroke severity, disability, laughter and negative feelings frequencies.
Conclusions: While stroke severity, a component of physical health, impaired psychological health, psychological dysfunction in turn negatively influenced physical and other domains of health, thereby creating a vicious cycle. These multidirectional interactions may involve neural, social and existential mechanisms which remain to be confirmed, elucidated and exploited.
P363 Rehabilitation Outcome of Chronic Dysphagia Due to Brainstem Stroke
Y. Ozeki, H. Kagaya, E. Saitoh, M. Baba, M. Yokoyama, and S. Okada
Fujita Health University, Toyoake, Japan
We investigated the rehabilitation outcome of chronic dysphagia due to brainstem stroke. Twenty-nine patients who had brainstem stroke at least 3 months ago were admitted to our department to treat dysphagia. Severity of dysphagia was assessed by using Dysphagia Severity Scale (DSS); a 7-point ordinal scale consisting of: 1) saliva aspiration: 2) food aspiration; 3) water aspiration; 4) occasional aspiration; 5) oral problem; 6) minimum problem; and 7) within normal limits. At admission, all patients were fed by tube only and DSS distributions were 6 saliva aspirations, 18 food aspirations, 3 water aspirations, and 2 occasional aspirations. Based on the findings of videofluoroscopic examination of swallowing and video endoscopic evaluation of swallowing, we tried direct and/or indirect therapy including thermal-tactile stimulation, supraglottic swallow, Shaker’s exercise and Mendelsohn maneuver. The median length of stay in the hospital was 94 days. At discharge, 19 patients became possible to eat from their mouth and 11 out of 19 patients did not need to use tube feeding. Fifteen patients improved DSS. Two patients became to eat without any aspirations. Eleven out of 18 food aspiration patients improved DSS, while only 2 out of 6 saliva aspiration patients improved DSS. In conclusion, rehabilitation after 3 months from onset is still useful for patients with chronic dysphagia due to brainstem stroke.
P364 Predictors of Health-Related Quality of Life in Patients With Aneurysmal Subarachnoid Haemorrhage
P. E. C. A. Passier1, J. M. A. Visser - Meily2, M. J. E. van Zandvoort3, M. M. W. Post4, G. J. E. Rinkel5, and E. Lindeman6
1Rehabilitation Centre De Hoogstraat, Utrecht, Netherlands, 2University Medical Centre Utrecht, Department of Rehabilitation and Sports Medicine, Utrecht, Netherlands, 3Psychological Laboratory, Helmholtz Institute, Utrecht University, Utrecht, Netherlands, 4Rehabilitation Centre De Hoogstraat, Research Department, Utrecht, Netherlands, 5University Medical Centre Utrecht, Department of Neurology and Neurosurgery, Utrecht, Netherlands, 6University Medical Centre Utrecht, Department of Rehabilitation and Sports Medicine, Utrecht, Netherlands
Background: Many patients who survive an aneurysmal subarachnoid haemorrhage (SAH) experience decreased health-related quality of life (HRQoL). Our aim was to describe HRQoL and to examine predictors of HRQoL one year after SAH.
Methods: In a longitudinal study in 115 patients living at home one year after SAH, we assessed HRQoL with the Stroke Specific Quality of Life scale (SSQOL). At three months after SAH, we recorded demographic characteristics (age, gender, education level), disability (Glasgow Outcome Scale), subjective complaints (cognitive and emotional complaints, depressed mood, anxiety) cognitive impairments and passive coping style.
Results: Results of the bivariate and multivariate logistic analyses are displayed in table 1. Disability, cognitive complaints, impairments in visuospatial functioning and passive coping style were significant determinants of SSQOL scores in multivariate logistic regression analysis, together explaining 53.2 % of the variance.
Logistic Analyses of Determinants and SSQOL-Total Score One Year After SAH
SSQOL: Stroke Specific Quality of Life; SAH: subarachnoid haemorrhage; CLCE-24: Checklist for cognitive and emotional consequences following stroke; GOS: Glasgow Outcome Scale; STAI-DY-1: State Trait Anxiety Inventory; BDI-II-NL: Beck Depression Inventory; UCL-P: Utrecht Coping List.
p <0.2, **p<0.05
Conclusion: Disability, cognitive complaints, impairments in visuospatial functioning and passive coping style assessed at 3 months after SAH predicted decreased HRQoL 1 year after SAH. These results can be used to tailor rehabilitation programs in patients with SAH.
P365 Comparisons Between the Effect of Early Versus Delayed Stroke Rehabilitation on the Quality of Life in Stroke Survivors: A Multi-Center Study in Thailand
K. Piravej1, N. Konjen2, V. Cowintaveewat2, V. Kuptniratsaikul3, and P. Srisa-an Kuptniratsaikul4
1Rehabilitation Medicine Department, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 2Rehabilitation Center, Thai Red Cross Society, Bangkok, Thailand, 3Rehabilitation Medicine Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, 4Rehabilitation Medicine Department, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Background: Stroke can cause permanent neurological damage and serious long-term disability. Unlike delayed stroke rehabilitation, early rehabilitation after stroke can improve recovery and functional outcomes. However, there are no data on effects of early versus delayed rehabilitation on quality of life(QoL) in stroke survivors in Thailand.
Objective: To assess influence of early versus delayed rehabilitation after onset of stroke on patient’s QoL.
Study design: Multi-center, prospective study.
Material and Methods: From Thai Stroke Rehabilitation Registry (TSRR) database, 376 stroke patients from 9 main tertiary hospitals in Thailand were screened between March-December 2006. 327 patients met the inclusion criteria but only 281 patients completed rehabilitation. 264 patients completed WHOQOL BREF-THAI questionnaires and were divided into three groups based on time after onset of stroke to start of rehabilitation: <1 month (early), 1-6 months (intermediate), and >6 months(delayed). WHOQOL BREF-THAI questionnaires, consisting of four domains (physical, psychological, social relationships and environment), were given to the patients pre- and post- rehabilitation to assess QoL.
Results: Demographic characteristics, BI and HADS scores between all groups pre-rehabilitation were comparable. Comparisons within groups showed significant improvement in physical and psychological domains, and environment post-rehabilitation. This improvement was no longer significant when compared across groups. Comparisons within groups post-rehabilitation showed significant improvement for social relationships in early and intermediate groups. Delayed group showed significant worsening for social relationships.
Conclusion: Stroke rehabilitation can improve QoL in all groups but not for social relationships in the delayed group.
P366 Quality of Daily Life of Disabled Stroke Patients One Year After
N. Porubcova and J. Hvizdakova
Department of Rehabilitation, Bratislava, Slovakia
The aim of this study is to demonstrate how a patient’s life is one year after a stroke occurs - what their basic needs are, and what could be improved in terms of medical and social care in the future.
Methods: 78 stroke patients completed a questionnaire containing 19 questions one year after their stroke. The answers showed us the level of the patients’ physical and mental state, social adaptation, their needs and requests.
Results: Mostly the answers revealed a lack of rehabilitation after discharge from the hospital. The home environment, including close family in some cases, was not prepared for patients’ limited mobility. The patients began to feel isolated in their own surroundings, socially secluded, and depressed.
Conclusion: As the quality of medical care during the acute state improves, it gives patients a chance to survive a stroke, but often they remain disabled. Another step of medical care - helping stroke survivors handle their handicap, to build a new way of life amongst family, friends, and at work is very important too. By comparing our results with international data, we can see that the problem of long term rehabilitation for stroke patients, including home visits, rehabilitation, and social care still needs much improvement in Slovakia.
P367 Life Satisfaction and Return to Work After Aneurysmal Subarachnoid Haemorrhage
M. W. M. Post1, P. E. C. A. Passier1, J. M. A. Visser-Meily2, G. J. E. Rinkel2, and E. Lindeman2
1De Hoogstraat, Utrecht, Netherlands, 2University Medical Center Utrecht, Utrecht, Netherlands
Objective: To investigate life satisfaction and employment status after aneurysmal subarachnoid haemorrhage (SAH) and to explain the variance of life satisfaction with demographic, disease-related and personality characteristics.
Methods: Patients with SAH (n=141) living at home 2-4 years after SAH responded to a mailed questionnaire. Outcomes were life satisfaction (LiSat-9) and employment status. Determinants of life satisfaction in multiple regression analysis were demographic and SAH characteristics, subjective complaints (mood disorder, fatigue, cognitive complaints) and personality characteristics (neuroticism, passive coping style).
Results: Of all patients, 46.7% had a GOS score of V (good outcome) at discharge, mean age was 51.4 (sd 12.3) years and mean time after SAH was 36.1 (sd 7.9) months. Only 35.2% completely resumed their work. Life satisfaction was generally good with a mean LiSat-9 score of 4.8 (SD 0.8) on a 1-6 scale. Patients were least satisfied with their vocational situation (51.9%) and sexual life (51.7%), and were most satisfied with their relationships (75.2% - 88.7%) and their self-care ability (88.6%). Good outcome at discharge and return to work were significantly associated with life satisfaction (p<0.01). Age (beta value 0.17), work after SAH (0.19), disability at hospital discharge (0.25), mood (-0.37) and passive coping (-0.25) together explained 47.2% of life satisfaction scores.
Conclusion: Not returning to work, disability, depression and passive coping were associated with reduced life satisfaction. Vocational reintegration after SAH needs more attention in rehabilitation.
P368 Building of a Comfort/Discomfort Scale and Validation in Stroke Patients
M. Rousseaux, F. Beaucamp, G. Wigneron, and W. Daveluy
CHRU of Lille, Lille, France
Introduction: Comfort is composed of all the conveniences and amenities that produce material well-being. Comfort is an important component of quality of life (QoL). However, in the QoL scales, C/D is severely underestimated.
Patients and methods: We built a scale with two parts. It first assesses C/D in 11 personal activities of daily living (pADL) using a visual analogue scale (10-0): food intake, cleaning and dressing the upper and lower parts of the body, urinary and faeces elimination, transfers, positioning in armchair and bed, and sleeping. Then it assesses factors promoting C/D (10-0), motor deficit, fatigue, spasticity and spasms, pain, sphincter problems, visual disorders, ataxia, and depression. Two independent observers conducted two interviews of 45 stroke patients (mean age 61, FIM 84). We also investigated 27 normal subjects (C).
Results: In C subjects, the mean perception of comfort was above 9.2/10 for most items, except toileting the lower part of body, dressing the lower part of body, and especially sleeping. In patients, discomfort was most severe (p<0.05) for food intake, toileting the upper and lower parts of the body, dressing the upper part, urine elimination, installation in chair. Main D factors were motor deficit, stiffness, spasticity, imbalance and communication disorders. We found fair inter-rater and intra-rater reproducibility for both parts of the scale. Global C/D level correlated with the FIM.
Discussion: This scale showed fair sensitivity, reproducibility and external validity. Nearly two-third of stroke patients showed discomfort in pADL, mainly resulting from motor disorders. C/D scale helps defining adapted treatments.
P369 The Influence of Additional Trunk Exercises on Static and Dynamic Balance of Stroke Patients
W. Saeys1,2,3, L. Vereeck1,2,3, K. Boddaert2, G. Leemans2, C. Lafosse3, S. Truijen2, F. L. Wuyts1, and P. Van de Heyning1
1University of Antwerp, Antwerp, Belgium, 2Artesis University College of Antwerp, Antwerp, Belgium, 3Rehabilitation Hospital Hof Ter Schelde, Antwerp, Belgium
Goal: The aim of this study is to examine the influence of extra selective trunk training on both the static as dynamic balance in stroke patients.
Methods: This study is a prospective randomized controlled trial with participation of 22 stroke patients, admitted for rehabilitation in rehabilitation hospital Hof Ter Schelde (Antwerp, Belgium). These patients were divided in a control (n=10) and an experimental group (n=12). The experimental group received besides the conventional rehabilitation of Hof Ter Schelde during 8 weeks additional trunk training consisting of power and coordination exercises and specific exercises aimed at improving sitting balance. The control group received besides the conventional rehabilitation also during 8 weeks extra arm training consisting of electrostimulation in combination with passive mobilisation techniques without involvement of the trunk. The patients have been evaluated both during intake and after 8 weeks with the Trunk Impairment Scale, Romberg test both Eyes Open as Eyes Closed, Four Test Balance Scale, Berg Balance Scale, Dynamic Gait Index, Rivermead Motor Assessment Scale en Tinetti Test.
Results: There was a significant intervention effect found for TIS dynamic (p=0.001), TIS coordination (p<0.001), TIS total (p<0.001), FTBS (p=0.024), RMAB Gross Function (p=0.008), RMAB Leg and Trunk (p=0.004), RMAB Total (p=0.031), Tinetti Gait section (p=0.004) and Tinetti Total (p=0.005).
Conclusion: Eight weeks of additional trunk training does improve both static and dynamic balance in stroke patients.
P370 Influence of Sensory Loss on the Perception of Verticality in Stroke Patients
W. Saeys1,2,3, L. Vereeck1,2,3, K. Janssens2, S. Scheirs2, C. Lafosse3, S. Truijen2, F. L. Wuyts1, and P. Van de Heyning1
1University of Antwerp, Antwerp, Belgium, 2Artesis University College of Antwerp, Antwerp, Belgium, 3Rehabilitation Hospital Hof Ter Schelde, Antwerp, Belgium
Goal: Spatial orientation in relation to gravity is crucial to maintain upright body posture. Perception of verticality is influenced by somatosensory performance, therefore the aim of this study was to evaluate the influence of somatosensory deficits on the perception of verticality, measured by SVV (Subjective Visual Vertical) and SPV (Subjective Postural Vertical), in stroke patients.
Methods: In 32 stroke patients SVV and SPV were measured with the head in upright position. Patients were asked to respectively adjust the laser bar or chair to the earth vertical position. Furthermore, the RASP (Rivermead Assessment of Somatosensory Performance) was assessed to evaluate somatosensory loss.
Results: A higher total score on the RASP corresponds with a lower mean deviation on SVV and SPV. A larger amount of somatosensory loss, on the other hand, corresponds with a higher mean deviation on SVV and SPV. There is a moderate correlation between the results of SPV and total score on the RASP (r = 0.622). The correlation between SVV and total score on the RASP is smaller (r = 0.428). When patients are divided in 5 groups based on RASP-scores. There is a significant difference in SPV- and SVV scores between the different groups based on total RASP score, respectively p = 0.014 Kruskal Wallis Test) and (p = 0.048 Kruskal Wallis Test).
Conclusion: Somatosensory deficits exert a negative influence on the perception of verticality in stroke patients.
P371 Home Care: Risk of Falls and Health Related Quality of Life One Year After Inpatient Stroke Rehabilitation
W. J. Schupp1, R. Schmidt1, and E. Grässel2
1Fachklinik Herzogenaurach, Herzogenaurach, Germany, 2Clinic for Psychiatry, Erlangen, Germany
Aim: Health related quality of life (QOL) is predictive for long term living and staying at home after stroke rehabilitation. In another sample of our stroke rehabilitation inpatients we studied their, risk of complications, esp. falls, and their health related quality of life.
Design: Prospective cohort-study.
Patients and methods: In 2006 we included 260 inpatient stroke patients (phase B or C) being discharged home with (partially) dependency on care. Structured telephone interviews were performed at one and at 2,5 years after asking for actual living place, complications in home care, especially falls and health related quality of life, using EQ5D.
Results: One year after, 230 patients or relatives could be contacted: 26 patients had died, 12 had been transferred to nursing homes, 192 lived at home. Questions on complications like falls and EQ5D had been answered by n=186. 18 told about recent falls mainly causing hematoma or contusion. Falls also induced anxiety (61%), mobility restrictions (50%) and pain (33%). Their health related QOL was depressed in all dimensions (compared with normal population), mainly in extended ADL and mood. Recent falls correlated with more pain/physical complaints.
Conclusions: Results confirmed findings in other patient samples of our clinic regarding their living place up to one year after discharge. Their QOL is reduced. Falls additionally caused problems. The data of the 2,5 years follow-up had now been collected.
P372 Application of Constraint Induced Movement Therapy to the Lower Limb in Subjects With Stroke
A. Tettamanti1,2, V. Sirtori3, E. Castelli3, A. Beghelli1, S. Mammi3, M. Comola3, and R. Gatti1,2,3
1School of Physiotherapy, Vita-Salute San Raffaele University, Milan, Italy, 2Lab of Analysis and Rehabilitation of Motor Function, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy, 3San Raffaele Hospital, Neurorehabilitation Unit, Milan, Italy
Background: Constraint induced movement therapy (CIMT) is a rehabilitative therapy, used for the recovery of upper-limb in post-stroke subjects, based on the restraint of the healthy limb.
The aim of this study is to analyze the possibility to apply the CIMT to the lower limb (L-CIMT).
Methods: Eight post-stroke subjects, able to walk without assistance for 10 meters, were recruited. This randomized cross-over study compared the effect of one day of L-CIMT with one of control. During L-CIMT subjects performed 6 hours of exercises (walking, standing posture, mini-squat, sitting up and down) wearing a knee orthesis blocked in extension and an in-line skate on the healthy limb (restraint), and a wedge heel shoe on the affected limb. In control day subjects performed the same exercises without restraint. Before and after treatment an electromyographic gait analysis (Tibialis Anterior, Gastrocnemius, Rectus Femoris, Vastus Medialis, Gluteus Medius and Biceps Femoris) was performed. Gait cycle was divided in 6 periods, the presence or absence of muscular activation was recorded and the quantity of wrong activities was computed referring to normative data. Treatment effect was computed as the increase of correct activations between pre and post treatment using McNemar test and Relative Risk. Ethical committee approved the study.
Results: L-CIMT group achieved a greater improvement in the correctness of muscle activation than the control group (McNemar p=0.002; Relative Risk=2.05, 95%CI: 1.28-3.31).
Conclusion: L-CIMT can improve the correctness of lower limb muscles activation during walk in post-stroke subjects. Larger studies are advisable.
P373 Translation and Clinical Validation of an Instrument Used to Measure the Quality of Life in Patients With Neurogenic Dysphagia
L. Toledo1, A. Helo1, P. Arecheta1, S. Tapia1,2, and R. Tobar1,3
1Universidad de Chile, Santiago, Chile, 2CRS Cordillera, Chile, 3Hospital del Trabajador, Chile
Introduction: The prevalence of swallowing disorders in the general population has not been established. In Chile, suffering a stroke is the main cause of dysphagia in adults, also it is estimated that each year about 16,000 adults will present dysphagia due to a stroke. Neurogenic dysphagia may produce malnutrition, dehydration and aspiration pneumonia affecting people’s health as well as their quality of life (QOL). In Chile there is no instrument used to measure the impact of the dysphagia in the patients’ quality of life. Considering this situation, the objective of this study was to translate and validate the SWAL-QOL (McHorney, 2000) to the Spanish language.
Methodology: The methodology adopted in this study consisted in the application of the SWAL-QOL, which was previously translated according to the international standards and then applied in a pilot study. The sample consisted of 2 groups of 40 subjects. The first group consisted in 40 healthy subjects and the second group was completed with 40 patients with dysphagia due to a stroke. The questionnaire was applied after written consent was obtained from all the subjects. To determine the reliability of the instrument the second group completed the test-retest and internal consistency was measured with α’s Cronbach coefficient.
Results: The translated version of SWAL-QOL was considered adequate and comprehensible. The results evidence that the patients with dysphagia got significantly worse scores. This result can be translated as a worse QOL for those patients. The instrument also showed an adequate internal consistency and reliability.
P374 Stroke in Children and Rehabilitation
K. Triebl-Roth1, M. Peichel1, G. Schweintzger2, R. Linderl1, G. Brunner1, A. Kerber1, E. Wutz1, and P. Grieshofer1
1Klinik-Judendorf-Strassengel, Judendorf-Strassengel, Austria, 2LKH-Leoben, Leoben, Austria
Stroke in children is a severe disease. It is a great challenge for the rehabilitation-team to manage the child and his parents during the follow-up time. Rehabilitation and education need a lot of sensitive experience in a very careful way. Since 2005 we have treated 12 children with strokes in our clinic. The median range of age at diagnosis was 5 years (3 months - 13 years). The male-female-ratio was 1:1. In 4 patients there was a history of febrile infectious disease. 12 children suffer from hemiparesis (5 rightside, 7 leftside). All of our children are able to go; every school-child is able to read and write, only one child needs special treatment at school.
Two children have a severe dysphasia. 3 of 12 children suffer from complex seizures, 4 have a severe neglect.
None of our children has a recurrence of stroke, 10 of them get prophylaxis with orally acetyl-salicyl-acid, one gets oral anticoagulation-therapy. We combine conservative therapy-options (physiotherapy, occupational therapy, speech-therapy) with locomotion-therapy, psychological-treatment and education at inpatient-school. Complications of intensive locomotion-therapy did not occur, except mild alterations to the skin (blisters on the heel) in 7 cases. We mean that early beginning of rehabilitation is an essential fact for the outcome of movement and behaviour.
P375 Occupational Therapy and Cognitive Therapy With the Severe Impairment of Brain Caused by a Stroke
M. Vitkova
Boskovice Hospital, Boskovice, Czech Republic
The quality of life of the patients who suffered a stroke, brain injury or other diseases affecting the brain depends on immediate and prompt neurological rehabilitation.
Neurorehabilitation is important for the patients from the very beginning—from hospitalization up to their integration into the normal social and working life and their families. Occupational therapy is an important part of the complex rehabilitation. Its main goal is reaching the maximum possible level of the patients’ self-sufficiency and improving the quality of their lives. I would like to present the results of the cognitive therapy with a patient (1950, widow, with 2 daughters) after a severe stroke. She came to the OT department with serious cognitive disorders, spastic weeping and spastic right arm and leg. Results of tests: MMSE - 4 points (now 30); ADL - 0 points (now 95); ADL I - 0 points (now 65). She had 168 hours of OT. Now she can walk with walking sticks, she is independent and self-sufficient. She goes to the theatre, exhibitions, concerts. She has a part-time job in the library in her village. In her free time she makes Christmas decorations (she learned the technology during the therapy), with her left hand. This woman, who was severely disabled at the beginning, now lives a full-value life, even with her handicap, thanks to the timely and effective therapy, as well as the cooperation of the her family, which is always necessary for good results of the therapy.
8.4 Traumatic (Brain, Spinal, Peripheral NS)
P376 Quality of Life Among the Traumatic Spinal Cord Injured Patients
P. Dajpratham, R. Kongkasuwan, and W. Phutakumnerd
Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
Objectives: To study the quality of life among the traumatic spinal cord injured patients and to identify the factors related with the quality of life of such patients.
Method: The traumatic SCI patients who had been treated in the Department of Rehabilitation Medicine, Siriraj Hospital, Bangkok, Thailand since 2003 until June 2009 were interviewed for the demographic data. The injury related data was obtained from the medical records. The WHOQOL-Bref was used to acquire the QOL score which would be interpreted as poor, fair, and good QOL level according to the questionnaire. The Center for Epidemiologic Studies -Depression scale and the modified Barthel Index (BI) were used to assess depression, and functional disability respectively.
Results: Sixty nine patients (51 males and 18 females) with mean age 36.54 ± 11.46 years old participated the study. They suffered from traffic accident 67.2%, fall from height 11.9%, gun shot 16.4% and others 4.5%. The injury levels were cervical 31.3%, thoracic 50.7%, lumbosacral 18%. Most of them (60.6%) had incomplete lesion. Eighteen patients (26.1%) reported depression. The mean BI score was 69.71 ± 29.42. Most of them (73.1%) had their QOL score in the fair level. The sufficient income (OR 13.67, 95%CI: 3.1-60.22, p=0.001), having no depression (OR 7.6, 95%CI: 1.17-49.22, p=0.033), and being employed (OR 6.88, 95%CI: 1.44-32.94, p=0.016) were significantly related with the good QOL.
Conclusion: Most of the SCI patients determined their QOL as fair level. Sufficient income, having no depression, and being employed were associated with the good QOL.
P377 Living . . . Again! Residential Rehabilitation: Establishing and Maintaining a Quality of Life for People With a Brain Injury: A 5 Step, Community Based Model
T. P. Donovan
Robin Hill Farm Brain Injury Program, Hillsboro, NH, United States
Since 1983, this model has established, developed and maintained programming which promotes quality of life for people who have sustained long term, life-long issues as a result of a brain injury. This presentation focuses on our 5 level continuum of care model (ranging from a nursing component in the home to individual apartments) which allows for choice and integrity in a community based program. The audience will be educated on:
1. the importance of providing services specifically for people with a brain injury
2. understanding the importance of rehabilitative goals in a residential setting to ensure the continuation of quality of life
3. the definition and benefit of this models licensed “ community based treatment and rehabilitation” regarding health and safety.
Often times, people who have sustained a brain injury have little to no idea how to utilize or gain skills after being discharged from an active rehabilitation program. Our model (Robin Hill Farm Brain Injury Program) has focused on post-active rehabilitation specifically for people with brain injuries. This paper will present cases of people who have used our services for over 23 years.
Summary: This paper/presentation will educate the viewer of the history, development and case study of people who have experienced “living” after a brain injury. This paper focuses on psycho-social, physical, cognitive issues that have been presented in the past 26 years.
P378 The Lived Experience of Return to Work Rehabilitation Following Traumatic Brain Injury: What Actually Helps
M. Hooson
North Wales Brain Injury Service, Colwyn Bay, United Kingdom
Traumatic brain injury (TBI) is increasingly prevalent in an age of increased motorization and violence. The majority of patients are young adults previously in paid employment. The reported statistics for successful return to work (RTW) vary from 15% to 77%. However no literature was sourced which examines or discusses the most central component of successful return to work rehabilitation - what the individuals themselves have found to be of assistance clinically.
This study explored the lived experience of return to work rehabilitation from the perspective of individuals with TBI who had actively engaged in a specialist RTW rehabilitation programme. A phenomenological approach, with an interpretative focus, was utilized to explore and obtain an enhanced understanding from data obtained from semi-structured interviews conducted with ten participants. The interviews were audio-recorded. Interpretative Phenomenological Analysis (IPA) was undertaken to elicit themes to enhance my understanding.
Whilst all participants verbalized positive experiences of the outcomes of RTW rehabilitation, none had returned to their previous employment resuming previous roles. The core message from this research is that participants experience a distinct grief reaction to their employment status during RTW rehabilitation which is, at best, poorly acknowledged and addressed within RTW rehabilitation programmes. RTW rehabilitation needs to include both group and one to one rehabilitation, and clinical liaison with work. In addition, facilitated long-term peer and clinical support is required to ensure individuals maintain success in their attempts to RTW. Clinicians need to adopt a flexible interdisciplinary team approach in their delivery of RTW rehabilitation.
P379 Diagnosis and Successful Management of CRPS
B. Kuegelgen and C. Kuegelgen
Therapiezentrum Koblenz, Koblenz, Germany
Twenty-six patients suffering from CRPS are treated in a cooperation for posttraumatic chronification with the Unfallkasse Rheinland- Pfalz. Even in guidelines there is no unique concept of illness. Our diagnosis of CRPS: following clinical criteria: limb-fixing in the past, not-understandable pain, under work first, then under moving only, then in rest without moving, finally fixing hand at the thorax, combined with additional vegetative dysfunction: change of blood flow, swallowing, color, temperature). Non-systematical lesion of sensitivity, change in passive moving, diminished moving caused by pain occur, real paresis only in case of CRPS II.
Our hypothesis: cerebral change of function that is correctable by intensive moving. The movements should be high in frequency but short in length, additional pain management (psychological and physiotherapetic pain therapy).
Otherwise movements are hardly acceptable for these patients, the therapy has to take place without any medical narcotics.
Process: 1. Improvement of vegetative dysfunction, 2. decrease of pain under movement, 3. under work. Too intensive therapy leads regularly to deterioration. If patients cooperate the process is predictable and consistent. Continued anaesthetization prevents the remission of cerebral change of function. Treatment-Duration: 8-12 weeks. Weekly common round with the Unfallkasse Rheinland-Pfalz.
Results (n=26): complete remission: 11, small impairment (without handicap) 10, relevant impairment, compared to start of the treatment improved: 04, no change, treatment finished: 03.
Medication by narcotics: none at start of the treatment: 10, quit during treatment 15, not quit during treatment 1 (treatment finished). Under work 19, retirees/without work 4, not workable 3.
P380 Diagnosis and Successful Management of Whiplash Injury
B. Kuegelgen and C. Kuegelgen
Therapiezentrum Koblenz, Koblenz, Germany
In a cooperation for posttraumatic chronifications with the Unfallkasse Rheinland-Pfalz 24 therapy-resistant patients suffering from chronic whiplash injury are treated. Even in guidelines there is no unique concept of illness. We diagnose whiplash injury in case by following clinical criteria: immediate or up to one day retarded neck pain, pain provocable by active or passive moving in the active or stretched muscle, swallowings over the cervical spine joints later.
These findings only check without narcotics can discover. These are only supposed to be found under examination in non-narcotic- status. It is a muscular pain caused by overstraining in retaining, additionally after few weeks deconditioning and disturbance in coordination because of immobility. There is no distortion. The original muscular lesions are common functional lesions (strain or overstretching of non-trained muscles) as they are frequent in car accidents but also otherwise produced. Chronification is promoted by yellow flags. Therapy consists in treatment of muscular lesions by physiotherapy and improvement of endurance and coordination, education and psychological pain therapy. This therapy leads to success only without narcotics. Overtaxing may cause vertigo and vomiting.
Weekly common round with the Unfallkasse Rheinland-Pfalz.
Results (n=24): complete remission: 12, small impairment (without handicap) 08, relevant impairment, compared to start of the treatment improved: 01, no change, treatment finished: 03.
Medication by narcotics: none at start of the treatment: 16, quit during treatment 05, not quit during treatment 3 (treatment finished). Under work 21, treatment finished 03.
P381 Health Related Quality of Life and Life Satisfaction 6 to 15 Years After Traumatic Brain Injuries in Northern Sweden
J. Lexell1, L. Jacobsson2, and M. Westerberg3
1Department of Rehabilitation Medicine, Lund University Hospital, Lund, Sweden, 2Department of Health Sciences, Luleå University of Technology, Luleå, Sweden, 3Department of Business Administration and Social Sciences, Luleå University of Technology, Luleå, Sweden
The aim of this study was to assess health related quality of life (HRQoL) and life satisfaction in individuals with a traumatic brain injury (TBI). A total of 67 individuals were assessed 6-15 years after their TBI. All individuals completed the Swedish versions of the Short Form (36) Health Survey (SF-36) and Satisfaction with Life Scale (SWLS), along with structured questions about their appraisal of the TBI. The time since injury was on average 10 years. The mean age was 44 years (18-65 years). Thirty-two individuals had a mild TBI and 35 had a moderate to severe TBI. The HRQoL was significantly (P<0.001) lower on all of the SF-36 subscales compared with a Swedish age- and sex-adjusted general population. Life satisfaction was also significantly (P<0.001) lower compared with healthy individuals. Multivariate regression analysis showed that sex and injury severity were of minor importance predicting HRQoL and life satisfaction several years after injury. Working or studying was strongly related to self-reported physical health. Higher rated life satisfaction was more common among those who were married and productive at follow-up, which in turn were more likely in individuals that were older at the time of injury, had more severe injuries, and perceived a relatively low impact of the TBI on their life. In conclusion, current vocational situation and self-appraisal seem to be more important than sex, age at time of injury, and injury severity for subjective HRQoL and life satisfaction among individuals with a TBI many years after the injury.
P382 Early Rehabilitation of Comatose Patients After Traumatic Brain Injury
M. Lippert-Grüner1, O. Svestkova2, and S. Grüner3
1Neurochirurgische Uniklinik, Köln, Germany, 2Department of Rehabilitation Medicine, Prague, Czech Republic, 3Praxis Dr. Grüner, Köln, Germany
Introduction: As a result of improvements in the rescue system and progress in intensive care therapy, an increasing number of patients have survived severe traumatic brain injury in recent years. An early and consistent administration of the correct rehabilitation programme is of crucial importance for the restoration and improvement of cerebral function, as well as social reintegration. Prospective study conducted at the neurosurgical department of a university hospital to assess the 1-year outcome of comatose patients after severe traumatic brain injury.
Patients and Methods: 27 patients were included. Patients received multimodal early-onset stimulation and continuous inpatient and outpatient rehabilitation therapy.
12-months outcome was assessed by means of Glasgow outcome scale, Barthel index, Functional independence measure (FIM) and need of care.
Results: 7 patients died, 4 remained in a vegetative state, 7 were severely disabled, 6 were moderately disabled, and 3 achieved a good recovery 12 months after injury. Mean Barthel index was 66.7 and mean FIM was 85.2. The majority of patients still were at least intermittently dependent on care.
Conclusions: Despite intensive rehabilitation treatment, severe traumatic brain injury is still burdened with significant mortality and morbidity.
P383 Variations of Intracranial Pressure and Brain Perfusion Pressure During Lung Expansion Procedures in Patients With Severe Traumatic Brain Injury
S. A. Ferreira1, V. L. Israel2, L. R. Aguiar3,1, and A. P. C. Loureiro3
1Hospital Universitário Cajuru, Curitiba, Brazil, 2Universidade Federal do Paraná- Litoral, Matinhos, Brazil, 3Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
Introduction: The respiratory system affects the brain’s hemodynamic, respiratory physical therapy plays an outstanding and acknowledged role in the adequate care in severe traumatic brain injury patients. Aim: The aim was to verify how the chest compression-decompression maneuver affects the intracranial pressure (ICP) and the brain perfusion pressure (BPP). Material and Method: There was fifteen patients (age 29 ±13 years old) in the study, all ventilator- dependent on mechanical ventilation (MV) and having their ICP monitored (maximum value was 20 mmHg). The patients were seen during 3 consecutive days, lying in dorsal decubitus position, the headboard at 30 degrees. The chest compression-decompression maneuver was applied for 10 to 15 minutes on average. The ICP and the BPP were registered at five different times: before the maneuver, immediately 1, 5, 15 and 10 minutes after the maneuver. Results: The data obtained were submitted to a variance analysis statistical test with repeated measurements (ANOVA). The results have shown that the ICP values had minimal variations dropping from 2 to 3 mmHg while the maneuver was being applied, with a statistical significance of p=0,000, persisting on the 1st minute and, later, there was a gradual increase until 30 minutes, when the ICP reached values close to the initial ones at rest, and the BPP remained within or close to normal. Conclusion: The chest compression-decompression physical therapy maneuver do not promote cerebral hemodynamic repercussion related to the ICP and BPP in sedated and anesthetized mechanically ventilated patients with severe head injury.
P384 Return to Work Following Vocational Rehabilitation for Traumatic Brain Injury (TBI) Patients: An Overview
S. Marnetoft1 and A. M. Assucena2
1Mid Sweden University, Östersund, Sweden, 2PRM Department, Hospital de Requena, Requena, Spain
Introduction: Return to work is a very important issue for people with traumatic brain injury (PwTBI), and so is for the society. PwTBI need a means to community reintegration, self worth and independence. The society needs individuals with working ability, and social cost reduction. The consequences of sickness absence for individuals are, among others, a weakened financial position. Research has shown that it can also lead to isolation and exclusion from the labour market. It is also often an entrance to other disorders, and sick cases may end up in a disability pension.
Aim: The aim of the study was an overview of vocational rehabilitation and its outcome for PwTBI.
Method: Studies were identified through a systematic keyword search in a number of relevant databases. For inclusion, TBI, vocational rehabilitation, work, return to work and employment had to be in focus and studies had to be published between 2000 and September 2009.
Results: Around 20-50% of PwTBI return to work depending on the severity of the injury. Unemployment rates are consequently high among PwTBI.
Conclusion: These results show a low return to work in PwTBI and the need for more effective vocational rehabilitation services for PwTBI.
P385 Continuous Care After Prevocational Training for Persons With Higher Brain Dysfunction Due to TBI in Relation to Maintenance of Employment
K. Ota1, S. Sonoda2, and H. Kanda3
1Department of Rehabilitation Medicine, Matsusaka Chuo Hospital, Matsusaka, Japan, 2Department of Rehabilitation Medicine II, School of Medicine, Fujita Health University, Toyoake, Japan, 3Mie Prefectural Welfare Center for Physically Disabled, Tsu, Japan
Objective: Higher brain dysfunction due to traumatic brain injury (TBI) usually results in social behavioral disorders, which, with cognitive dysfunction, is problematic in obtaining or maintaining employment. In Japan, an ongoing program coordinates services to individual TBI patients through a support coordinator beginning early after TBI (continuous care). We investigated employment outcome in those who received continuous care after prevocational training.
Subjects: 100 persons with higher brain dysfunction due to TBI who received prevocational training at a welfare center after medical rehabilitation (86 males, 15 females, age 40.4±11.8)
Procedure: The employment rate was evaluated at the end of training and from 2 to 8 years after training by telephone interviews or mailed questionnaires. Results of the Community Integrated Questionnaire (CIQ) and cognitive scales, such as FIQ (WAIS-R), Trail Making Test, were compared between employed subjects and those who lost employment.
Results: Of the 100 subjects, 40 became employed after training. Of these, 13 subsequently lost their jobs; however, 7 of the 13 gained new employment. Of the remaining 60 subjects, 8 later found and maintained employment through services provided by continuous care. Thus, 42 of 100 subjects (42%) maintained employment. Cognitive scales and CIQ scores did not differ according to continued employment. However, those with job loss had more social behavioral disorders.
Conclusion: The rate of 42% in maintaining employment among these 100 patients indicates that the continuous care program is of benefit to persons with higher brain dysfunction after TBI.
P386 Assessment of Community Integration, Comparing Two Groups of People Who Have Suffered Moderate to Severe Brain Trauma, Using the Questionnaire of Community Integration (CIQ)
R. Tobar, N. Droguett, and J. Dote
Hospital del Trabajador, Santiago, Chile
Introduction: At the Hospital del Trabajador de Santiago, since 2005, exists an interdisciplinary team in neurorehabilitation (UNRH) in patients who suffered a brain injury (TBI) in inpatient program, continuing multidisciplinary outpatient treatment, after which, patients should ideally be re-employed or return to their home and social environment. At the end of the treatment, are evaluated by their functional sequelae, with an % loss of profit, and a financial compensation.
Objectives: To compare aspects of quality of life and % return to work, between two groups of patients who have suffered TBI, before and after implementation of UNRH, based on the results of the CIQ, % return to work, and percentage of loss of profit.
Methods: CIQ was applied in two groups of patients treated in the periods 1998-1999 and 2005-2007. Both groups received neurorehabilitation treatment and were evaluated by its sequelae with a percentage of disability. Recorded sex, age at time of accident, % of loss of profit, final functionality in DRS, work activity, financial compensation and CIQ results.
Results: Better results are observed in the patient group 2005-2007, validated by CIQ, especially in sub-scores: home and social integration and productivity; with a reduction in total treatment time and better percentage of return to work.
Conclusions: The integration of people who have suffered TBI, has improved with an early interdisciplinary intervention, and a multidisciplinary outpatient treatment, which is reflected in the differences obtained on the % in return to work and results of CIQ, at the end of treatment.
8.5 Other
P387 Quality of Life in Caregivers of Patients Receiving Intrathecal Baclofen Treatment
G. D’Aleo1, M. Kofler2, C. Rifici1, A. Furnari1, C. Pastura1, L. Saltuari2, and P. Bramanti1
1IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy, 2Department of Neurology, Hospital Hochzirl, Zirl, Austria
Intrathecal baclofen (ITB) infusion has become the treatment of choice in patients with severe spasticity. Increased quality of life (QoL) in patients treated with ITB has previously been demonstrated; however, to date no study has been undertaken concerning QoL of caregivers looking after patients treated with ITB. The aim of this study was to assess the effects of ITB on caregiver QoL.
We studied 51 caregivers (39 males, 12 females, mean age 32.4 years) of patients with an implanted Synchromed pump for ITB treatment. The patients (34 males, 17 females, mean age 37.2 years) suffered spasticity secondary to perinatal damage, traumatic or anoxic brain injury, cerebrovascular accident, multiple sclerosis, transverse myelitis, spinal cord injury, spinal cord lipoma exeresis, cervical or lumbar canal stenosis, Strümpell-Lorrain disease, or syringomyelia. Clinical examination of the patients included Modified Ashworth Scale, Spasm Frequency Scale, Visual Analog Scale for assessing mood, rehabilitative goal attainment, ability to independently change posture, ambulation (independent, with walking aids, with assistance), nursing, type and amount of rehabilitative treatment, and perineal hygiene facilitation). The Caregiver Burden Interview (CBI) was administered to assess QoL of caregivers. All scales were administered one month before and six months after pump implantation. Statistical analysis was carried out by paired t-test.
All caregivers had a significant total score reduction in CBI (p < 0.001). The data also showed significant improvement of nursing, rehabilitative treatment, and perineal hygiene. We conclude that ITB treatment improves QoL of caregivers mainly through facilitation of nursing and rehabilitation.
P388 Practice Performance of the Physiotherapist in the Inclusion of Children With Cerebral Palsy Elementary School in the City of Curitiba in the Year 2009
R. R. N. Santos1, S. M. Silva1, C. G. Ribas1, and A. P. C. Loureiro1,2
1Pontifícia Universidade Católica do Paraná, Curitiba, Brazil, 2CHR Ana Carolina Moura Xavier, Curitiba, Brazil
Practice performance of the physiotherapist in the inclusion of children with cerebral palsy elementary school in the city of Curitiba in the year 2009. This study aims to show how physiotherapists can act effectively in the process of inclusion of children with cerebral palsy in the regular education system. This research was conducted in three public schools l, belonging to a regional city of Curitiba. Each school was visited five times between March and April 2009. The sample consisted of three children diagnosed with cerebral palsy, cognitive preserved, literate, aged between 9 and 16 years. To assess the students were used Observation Protocol Form and Neurological Assessment of the Qualitative and Descriptive of the Pequeno Cotolengo do Paraná. Through the results have been established goals of physiotherapy performance and carried out specific actions in accordance with the needs presented by each child. Fifteen teachers in total were tested in order to check the level of knowledge about cerebral palsy. After the study, we found that the physical therapy through adjustments of the furniture and materials, removal of architectural barriers and guidelines for teachers, created conditions for the development of children with cerebral palsy within the school environment.
P389 The Impact of Disability on Health-Related Quality of Life in Greek Patients
M. C. Micha1, A. G. Mathiopoulos2, and K. D. Petropoulou3
1B’Department, National Rehabilitation Center, Athens, Greece, 2Doctor of Physical Medicine and Rehabilitation, Athens, Greece, 3B’Department,National Rehabilitation Center, Athens, Greece
Objectives: The assessment of health-related quality of life (HRQοL) among Greek patients with motor disability, the identification of associated factors and the comparison of these estimates with other specific population norms.
Materials-Methods: 92 patients with motor disability were evaluated, caused by stroke (39.1%), multiple sclerosis (18.5%), pathological spinal lesion(12%), spinal cord injury(17.4%) and peripheral neuropathies (13%). SF-36 and Barthel index for the evaluation of activities of daily living (ADL) were used. Demographics and clinical characteristics of the patients were also recorded. Data was modelled using multiple linear regression analysis.
Results: Mean age of patients: 54.7 years, mean duration of disease: 11.8 years. The mean scores on SF-36 dimensions ranged from 23.4 (physical functioning) to 53 (role emotional). Multiple analysis revealed that more than two coexistent somatic diseases were independently associated with physical functioning (β=−11.8, SE=4.31), bodily pain (β=−28.5, SE=7.7) and general health dimensions (β=-32.4, SE=7.9). Furthermore, psychiatric disorders were associated with lower scores on physical functioning (β=−8.9, SE=2.2) and mental health (β=−12.3, SE=5.3). In addition, advanced age was associated with lower scores on social functioning dimension. Lower scores on bodily pain were found for patients with neuropathic pain and heterotopic ossifications. Being bedridden or wheelchair user were also independent predictors for most of the SF-36 dimensions. Conclusions: HRQoL was related to potentially modifiable factors that, if addressed by rehabilitation team specialists, may lead to QoL parameters improvement. HRQοL was found substantially lower compared to Greek and foreign general population and comparable to disease-specific populations of other countries.
P390 The Neuronal Correlates of Mirror Therapy: An fMRI Study on Mirror Induced Visual Illusions in Stroke Patients
M. E. Michielsen1, M. Smits1, G. M. Ribbers2, H. J. Stam1, J. N. van der Geest1, J. B. J. Bussmann1, and R. W. Selles1
1Erasmus MC University Medical Center, Rotterdam, Netherlands, 2Rijndam Rehabilitation Center, Rotterdam, Netherlands
Background and Aim: We investigated the neuronal basis for the effects of mirror therapy in stroke patients, hypothesizing that observing a mirror reflection of the unaffected hand in place of the affected hand would increase neuronal activity in the affected hemisphere.
Methods: Twenty-two stroke patients participated in this study. We used functional magnetic resonance imaging to investigate neuronal activation patterns in two experiments. In the unimanual experiment, patients moved their unaffected hand, either while observing it directly (no mirror condition), or while observing its mirror reflection (mirror condition). In the bimanual experiment, patients moved both hands, either while observing the affected hand directly (no mirror condition) or while observing the mirror reflection of the unaffected hand in place of the affected hand (mirror condition).
Results: Data of 18 participants were suitable for analysis. Random effects analysis showed no differences between the mirror and the no mirror condition in either of the two experiments. A region of interest (ROI) based analysis only showed an increase in activity in the affected hemisphere as a result of the mirror illusion was during the bimanual experiment in the superior temporal sulcus (STS).
Conclusion: In this first study on the neuronal correlates of the mirror illusion in stroke patients we found no unequivocal evidence for the mirror illusion to increase activity in the affected hemisphere. While clinical studies have found positive effects of mirror therapy in stroke, the underlying neuronal mechanisms remain poorly understood.
P391 Klippel-Trenaunay-Weber Syndrome: A Case of Successful Rehabilitation and Surgical Treatment of Paraplegia Causing Rupture of an Intramedullary Cavernoma
K. Rábai1, R. Veres2, B. Both3, A. Klauber3, and P. Cserháti3
1Semmelweis University, Budapest, Hungary, 2State Health Centre, Budapest, Hungary, 3National Institute for Medical Rehabilitation, Budapest, Hungary
Introduction: KTW-syndrome described in 1900 includes cutaneous capillary malformations, tissue hypertrophy, arteriovenous fistulas. According to literary data this malformation was noticed in spinal cord in 24 cases. We present an other, unique case.
Case report: Hypertrophy and deformity were noticed of both lower extremities of a 28-year-old man since his birth. At the age of two extraction of a wide intraabdominal vascular malformation and right nephrectomy were done. Progressive paraplegia and urinary retention exfoliated in three days during his studies in the USA. MRA demonstrated rupture of cavernoma at the level of T8 in the background of these symptoms, proving the diagnosis of KTW syndrome. The patient got back to Hungary for rehabilitation. He was moving with wheelchair and was applying a permanent catheter. MRA done before physiotherapy proved recurrence and even progress of the cavernoma at the previous level. After discussing with the patient, open surgical treatment was done. With increasing the strain the patient is able to walk with sticks. Patient is doing intermittent self catheterization five times a day; there is no hydronephrosis in his kidney and there is no incontinence by usage of oxybutynin.
Discussion: The case presenting all symptoms of KTW-syndrome was unique because of rupture and then recurrence and progress of intramedullary vascular malformation. Therefore the otherwise suggested endovascular embolization wasn’t possible. MRA done in the USA proved there wasn’t any similar malformation in other segments of spinal cord, so complex rehabilitation might go on after the open surgical treatment with fine functional result.
P392 Familiar Music Listening During Lunch Time to Reduce Behavioural and Feeding Problems Among Institutionalized Older Adults With Cognitive Impairment
H. Sung1,2, W. Lee1, T. Li3, R. Watson4, H. Liang5, and H. Lee6
1Tzu Chi College of Technology, Hualien, Taiwan, 2Tzu Chi University, Hualien, Taiwan, 3National Dong-Hwa University, Hualien, Taiwan, 4University of Sheffield, Sheffield, United Kingdom, 5Taipei Inner connection Music association, Taipei, Taiwan, 6Tzu Chi General Hospital, Hualien, Taiwan
Older adults with cognitive impairment often display behavioural problems which can affect their activities of daily living. Behavioural problems can also cause difficulty in feeding and further result in malnutrition among those with cognitive impairment. Studies reported that music appears to have beneficial effects on behavioural and emotional problems of those with cognitive impairment caused by dementia; however, little is known about the effect of familiar music listening on behavioural and feeding problems of those with cognitive impairment in nursing homes. This one-group pre and post-test study aimed to examine the effect of familiar music listening during meal time on behavioural and feeding problems of older adults with cognitive impairment residing in nursing homes. Thirteen participants received one-hour familiar music listening via CD player during lunch time in the dining room everyday over 3-week period. Behavioural problems were assessed by the Cohen-Mansfield Agitation Inventory (CMAI), and feeding problems were assessed by the Edinburgh Feeding Evaluation in Dementia Scale (EdFED Scale) at baseline and week 3. Wilcoxon signed rank test result indicated that the participants who received 3 weeks of familiar music listening during lunch time had a significant reduction on their behavioural and feeding problems (p< .05). Familiar music listening during lunch time can be a potential non-pharmacological intervention for managing behavioural and feeding problems of older adults with cognitive impairment in nursing homes. The reduction of behavioural and feeding problems may improve the health and quality of life of those with cognitive impairment in long-term care setting.
P393 A Systematic Review of Preferred Music Listening for Behavioural and Psychological Symptoms in Institutionalised Elders With Dementia
H. Sung1,2, W. Lee1, and H. Liang3
1Tzu Chi College of Technology, Hualien, Taiwan, 2Tzu Chi University, Hualien, Taiwan, 3Taipei Inner Connection Music Association, Taipei, Taiwan
Music listening can be a feasible and inexpensive intervention to manage behavioural problems in elders with dementia. Music that is preferred by the listener has been suggested to have the most beneficial effects on relaxation and stress reduction. However, the current available evidence about the effectiveness of preferred music listening on behavioural and psychological symptoms in elders with dementia is unclear. This systematic review aimed to evaluate preferred music listening for managing behavioural and psychological symptoms of those with dementia in long-term care facilities and to provide implications for future research and practice. A review was undertaken by searching English and Chinese electronic databases with specified search terms for the period of 1993-2009. Nine research-based articles met the inclusion criteria and were included in the review. The findings from these studies indicate that preferred music listening have positive impact in reducing the occurrence of behavioural and psychological symptoms in elders with dementia in long-term care facilities. However, the majority of these studies were non-RCTs. The small sample sizes and lack of randomisation in some of these studies mean that caution is needed in drawing conclusions from these studies. This review concludes that preferred music listening has positive impact in reducing behavioural and psychological symptoms in elders with dementia; however, the methodological limitations indicate the need for further research. The incorporation of preferred music listening intervention into activity programmes in long-term care facilities has the potential to improve mental health and the quality of life of elders with dementia.
P394 Medical, Prevocational, Vocational Rehabilitation After Brain Damage: Equal Project
O. Svestkova1,2, Y. Angerova1,2, P. Sladkova1,2, and K. Svecena1,2
1General Teaching Hospital, Prague 2, Czech Republic, 2First faculty of medicine, Charles University, Prague, Czech Republic
The Department of Rehabilitation Medicine in co-operation with the Prague Labour Office (LO) was involved in the assessment of psychosensorimotor potential of people with disabilities.
In 2004 the contract between the General Teaching Hospital and LO concerning this assessment was signed and the LO was obliged to pay for this assessment.
With this experience we participated as principal investigators in the Community Initiative EQUAL project with 48 partners, including 7 rehabilitation departments, labour offices, social agencies, NGO for employment of people with disabilities, Confederation of Industry, and the Ministry of Labour and Social Affairs. The aim was to develop a standardized tool for evaluation of the ability for employment of people with disabilities and reintegration of people with disabilities to the labour market.
The multi-professional rehabilitation team of rehabilitation specialists (physicians, physiotherapists, occupational therapists, psychologists, speech therapists, and social workers) selected and translated standard methods for assessment of potential for employment. The tests have been divided into sets forming two levels: (1) set for general first-level use and (2) set for second-level use. Tests for second-level use were for people with moderate, severe, and very severe disability. We introduced these tests to everyday practice using uniform case records and check-out reports for GP, labour offices and social departments.
The examination of physical abilities for work of 270 people was performed.
Results were applied in vocational programs of the corresponding labour offices. Selected methods were accepted by the Ministry of Labour and Social Affairs and Labour Offices.
P395 Effectiveness of Physical Therapy in Subjects Affected by Peripheral Sensorial Ataxia
S. Faccendini1, M. Cassola2, N. Riva1, M. Comola1, R. Fazio1, A. Tettamanti2,1, and G. Rabaiotti1
1San Raffaele Hospital, Neurorehabilitation Unit, Milan, Italy, 2School of Physiotherapy, Vita-Salute San Raffaele University, Milan, Italy
Background: Polyneuropathy may lead to ataxia: it provokes deficits in balance, gait and functional activities. The aim of the study is to assess both the effectiveness of physiotherapy and possible additional benefits of treatment with Whole Body Vibration (WBV) in peripheral sensorial ataxia patients.
Methods: 18 in-patients affected by peripheral sensorial ataxia (15 idiopathic, 1 diabetic, 1 alcoholic, 1 Guillain-Barrè) were divided into two groups: NO WBV (n=13) and WBV (n=5), underwent a three-week-lasting program of 2 daily sessions based on balance and walking resistance. WBV group performed a daily session (5 series of 2 minutes) of WBV (Power Plate PR05). The treatment lasts 50 minutes for both groups.
Functional Impairment Measurement, Berg Balance Scale and Six Minute Walking Test were used as outcomes measurements in four evaluations (pre-treatment, post-treatment, follow-up at 3 months and 6 months). Ethical committee approved the study.
Results: Considering all patients, statistically significant improvements (p<0,05) were found in the three outcomes at the end of 3 weeks of treatment; there aren’t statistically significant differences between the period of discharge and the first follow-up nor between this one and the second follow-up. There aren’t statistically significant differences, comparing two groups, in any functional scale, in any control period.
Conclusions: Three weeks of physiotherapy improve balance, functional activities and walking resistance; this result seems to be maintained until 6 months. These results are obtained with both the physiotherapy treatment under study.
P396 The Effectiveness of Special Care Units on Neuropsychiatric Symptoms of Elders With Dementia: A Systematic Review
S. Y. Tsai, H. C. Sung, and M. C. Wu
Tzu Chi College of Technology, Hualien, Taiwan
Neuropsychiatric symptoms are common in elders with dementia and viewed as one of the challenging care problems for caregivers in long-term care setting. Special Care Units (SCUs) offer a modified physical environment and supportive social environment to accommodate the special needs of those with dementia and have potential to reduce neuropsychiatric symptoms of elders with dementia residing in long-term care facilities. However, the current evidence of the effectiveness of SCUs for those with dementia is unclear. This study aimed to review the evidence of the effectiveness of SCUs on neuropsychiatric symptoms of elders with dementia. Search of CINAHL, Medline, PsychInfo, Cochrane, and Chinese publication databases were conducted. Studies in which the neuropsychiatric symptoms of elders with dementia residing in SCUs were compared against traditional units in long-term care facilities were included. The search was limited to articles published in English and Chinese between the year of 1990 and 2009. Seven research-based articles met the inclusion criteria and were included in this review. All seven articles were non-RCT studies and reported conflicting results about the effectiveness of SCUs on neuropsychiatric symptoms in elders with dementia. Some variations in the features of SCUs in these studies made it difficult to compare the effectiveness of the SCUs across studies. There is limited evidence to support that the effectiveness of SCUs on neuropsychiatric symptoms of elders with dementia. Studies using more rigorous research designs with comparison groups are needed to evaluate the effectiveness of SCUs for elders with dementia.
P397 A Systematic Review of Special Care Units on Quality of Life in Older Adults With Dementia
S. Y. Tsai, H. C. Sung, and M. C. Wu
Tzu Chi College of Technology, Hualien, Taiwan
Special care units were designed to provide a supportive environment for older adults with dementia. The features of a typical special care unit can include a modified physical environment and activity programs, special staff pattern, family involvement, and caregivers with special training. Some studies found that special care units can reduce disability and improve quality of life in those with dementia; however, the current evidence of special care units on quality of life of those with dementia is unclear. This study aimed to review the effectiveness of special care unit on quality of life for older adults with dementia. Search of electronic databases in English and Chinese were conducted. The search was limited to articles published in English and Chinese between the year of 1990 and 2009. Researched-based papers in which the quality of life of those with dementia residing in special care units compared to that of those with dementia residing in traditional nursing units in long-term care facilities were included. Five articles met the inclusion criteria. None of these five studies were randomized controlled trials. These study results indicated that special care units overall have positive impact on quality of life of those with dementia compared to those residing in traditional units. There is some evidence to support the effectiveness of special care units on quality of life in those with dementia. However, small sample sizes and variations in the features of special care units mean that caution is needed in drawing conclusion from these studies.
P398 Ecological Test of San Pellegrino Terme
C. Valiante, G. P. Salvi, A. M. Quarenghi, L. Manzoni, L. Smirni, P. Quarenghi, A. Previtali, and R. Bonaldi
Neurorehabilitation Unit, San Pellegrino Terme, Italy
Objectives: to find an ecological test that can prove the evolution of the motor, cognitive and behavioral abilities in patients affected by sequelae of severe craniocerebral accident (trauma, hemorrhage or brain surgery) during their everyday life activities.
The purpose of the test is to optimize and personalize the rehabilitation strategies.
Methods: Every patient had a preliminary physiatric, neurological and neuropsychological evaluation, in order to consider their motor and cognitive deficiencies, their self-consciousness of their condition and their motivation to follow the program. Each patient is tested outside the Clinic. The test is based on 10 activities. Judging how each activity is carried out, a score is given.
During the test the examiner takes note of any possible cognitive problems in order to work out the most appropriate rehabilitation treatment.
Results: we achieved better consciousness of the patients and their relatives about the difficulties to carry out everyday life activities; strategies for the reinstatement of the patients at home, at school and at work; possible emotional and behavioral disorder presents.
Conclusions: The test is ecological because it involves everyday-life activities carried out outside the Clinic. The test completes the work that is done in the ClinicIt helps to verify whether the goals are achieved and how are the patients’ abilities to do everyday-life activities while they are staying in the Clinic. It also gives useful advice to give to the patients’ relatives about how to handle patients once they are back home.
P399 Facilitating Motor Learning in Elders by Anodal Polarization of the Primary Motor Cortex
M. Zimerman, K. F. Heise, G. P. Liuzzi, M. Nitsch, J. Hoppe, N. Freundlieb, C. Gerloff, and F. C. Hummel
Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
Background: Healthy aging is accompanied by declines in motor performance and learning affecting daily life activities and independence. Recent studies demonstrated improvements in motor functions induced by transcranial direct current stimulation applied to the motor cortex (M1) in young healthy adults. Here, we tested whether anodal tDCS applied to M1 in healthy elderly persons facilitates i) performance of a skilled motor task (Jebsen-Taylor hand function test, JTT) and ii) skill acquisition within an explicit motor learning task.
Methods: Both studies were performed within a double-blinded, sham-controlled, cross-over design. In i) healthy elderly persons (n=10) performed the JTT with anodal tDCS or sham. Performance of JTT was evaluated before and after application of tDCS or sham. In ii) an explicit finger sequence task was tested in 14 elderly, subjects attended a training sessions during which either anodal tDCS or Sham were applied.
Results: i) revealed a significant improvement in JTT with tDCS relative to Sham outlasting the stimulation for at least 30min. It is of interest that the older the subject were the more prominent the tDCS effect was. ii) With tDCS, elder subjects showed a significant improvement during training with persistently enhanced of performance for up to 24hrs.
Conclusion: non-invasive cortical stimulation by anodal tDCS can facilitate motor performance and enhance skill acquisition, function impaired during healthy ageing.
9 Other
P400 Evaluation of Applicability to Home Exercises Guide for Stroke Patient Submitted to Rehabilitation Process
F. O. Albieri, I. K. Naki, and M. C. S. Moreira
Institute of Physical Medicine and Rehabilitation, Sao Paulo, Brazil
Introduction: Neurorehabilitation process needs educative attention aiming autonomy and independence for exercises outside therapy for post stroke patients. In Brazilian literature there are few programs focused on no supervised exercises or guides with home exercises for stroke patient.
Objective: The aim of this study was evaluating the understanding, retention and adherence of practice of home physical exercises based on a guide with orientations for stroke patients during the rehabilitation process.
Methods: 9 subjects with hemiparesis, both genders, under a neurorehabilitation program with 2 appointments of physical therapy per week. Each subject received one home physical exercises orientation guide with 15 exercises to be done 3 times/week. Each exercise had picture and subtitle. During one therapy, subjects were introduced and trained to practice the same exercises at home. To measure understanding, retention and adherence of practice, two questioners were applied in the 15th day and after one month training.
Results: The understanding rate was 89% and their evaluation of the guide (0 to 10) was 9.56±0.49; all subjects considered the pictures compatible with exercises subtitle; 78% of subjects took into account pictures to be done the exercises and 78% of subjects performed the requested number of repetition. Within a week, the average of practice was 2.67±1.12. A mean of 4 exercises was spontaneously remembered after one mouth. The others were called on the guide.
Conclusion: The use of home exercises guide had a high understanding rating and was considered a reference to adherence of no supervised exercises practice.
P401 Effect of Ipsilateral, Contralateral or Bilateral Upper Limb Motor Training in Patients With Chronic Stroke
F. O. Albieri1, P. Avila2, and M. E. P. Piemonte2
1Institute of Physical Medicine and Rehabilitation, Sao Paulo, Brazil, 2Physical Therapy Department, Faculty of Medicine, Univ. Sao Paulo, Sao Paulo, Brazil
Introduction: Motor learning studies with sequential tasks have been showing the intermanual relations in stroke. However, there are not many evidences comparing different kinds of training (ipsilateral, contralateral or bilateral) in the same study aiming the better form of application of neurorehabilitation process.
Objective: The objective of this study was comparing the effects of different kinds of training of a new motor ability in patients with chronic stroke.
Methods: 49 subjects (25 stroke, 24 healthy) of both genders divided in 3 groups defined by training: ipsilateral (IG), contralateral (CG) and bilateral (BG). Each group was divided in stroke (SG) and health (HG) subgroups. The subjects memorized a numeric sequence and reproduced it with upper limb movements on a numeric table. The training consisted in reproducing 4 times the same sequence until 600 movements with paretic upper limb in IG, no paretic upper limb in CG and with both in BG. Each group performance was evaluated in 4 different moments: before training (AT), 5 minutes (DT), 48 hours (48hDT) and 7 days (7dDT) after training. Statistics was evaluated with ANOVA.
Results: IG had the highest performance in DT, but the worst retention of learning (p=0,007) for new motor ability. Both paretic and no paretic upper limb had similar initial performance in all SG.
Conclusion: All kinds of training showed improvement to immediately learning. The BG and CG were more effective to retention of learning.
P402 Influence of the Complaint Surface on Gait Pattern in Parkinson’s Disease
G. D. P. N. Silva1, A. Agulhon1, L. B. Bagesteiro2, and S. R. Alouche1
1Universidade Cidade de São Paulo, São Paulo, Brazil, 2Universidade Federal do ABC, São Paulo, Brazil
Introduction: An efficient gait depends on the simultaneous and coordinated activity of multiple systems to supply the demands of the task and unpredictable environments. In Parkinson’s disease (PD) patients the impairment of the postural control is evident; the gait is stereotyped and characterized by movement depletion. The purpose of this study was to verify the influence of compliant surface on the gait pattern of PD patients. Method: PD patients walked at self-selected speed on a 10m-walkway. Kinematic data from the hip, knee and ankle joints in the sagittal plane and from the shoulder and pelvic segments in the frontal plane were recorded using 60 Hz cameras. We compared the joint angles under three conditions: walking on stable ground, walking on a foam mat (5cm thick and 33kg/m3 density) and back at the stable ground. The walking speed and stride length were measured. Conditions (pre exposure/ exposure/ post exposure) were compared using analyses of variance. Significance level used was 5%. Results: PD patients showed a higher ankle, knee and hip joint amplitudes (p<0.01) and were slower while walking on unstable surface. The stride length was larger in post-exposure condition. Conclusion: PD patients are able to modify their gait pattern when walking over a complaint surface in a similar way than healthy subjects. After this exposition, patients improve their performance making larger steps.
P403 High Orthopaedic Shoes Improve Functional Mobility, Walking Speed and Gait Characteristics in Hemiplegic Gait
M. C. Borgerhoff Mulder1,2, M. M. E. M. Eckhardt1, H. L. D. Horemans2, M. H. Heijenbrok-Kal1,2, and G. M. Ribbers1,2
1Rijndam Rehabilitation Centre, Rotterdam, Netherlands, 2Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
Objective: To evaluate the effect of stabilizing the ankle and knee of the paretic leg with a temporary high orthopedic shoe on walking ability of stroke patients in the early stage of regaining walking ability. Furthermore, interference of attentional demands was studied.
Design: Clinical experimental study.
Subjects: Nineteen stroke patients (mean age 55.5 (SD 10.0), male to female ratio 12:7, mean time post stroke 3,6 months (SD 1.4), 12 right hemispheric and 7 left hemispheric) with a spastic paresis of the lower extremity (Modified Ashworth Scale score of 1 or more of the plantar flexors of the foot).
Methods: Functional mobility, measured with the timed up and go test, walking speed and gait characteristics, measured with clinical gait analysis, were evaluated while walking with a high orthopaedic shoe and with normal shoes (control condition). Both conditions were performed with and without a verbal dual-task.
Results: Walking with the high orthopaedic shoe resulted in improved functional mobility (21%; p = .00), increased walking speed (38%; p = .00) and increased bilateral step length (10-33%; p < .02). Also during dual-task performance functional mobility (18%; p = .00) and walking speed (33%; p = .00) improved significantly.
Conclusion: In the early recovery phase after stroke, when regaining walking ability, a temporary high orthopaedic shoe can improve hemiplegic gait, even with dual task interference.
P404 Neurological Complications Following Cardiopulmonary Transplantation: A Rehabilitation Perspective
M. Bowman
St Vincents Hospital, Sydney, Australia
Aim: Organ transplantation is now mainstream therapy for end stage cardiopulmonary disease, with more than 7000 new procedures reported annually worldwide. Neurological complications occur in between 30 - 60 % of transplant recipients, and are a significant cause of disability. Complications may occur in the central or peripheral nervous system, and commonly in both. The more common causes are critical illness neuropathy/myopathy, peri-operative cerebral anoxia, immunosuppressant toxicity, cerebrovascular disorders, opportunistic CNS infections, and CNS malignancy due to immunosuppression.
The purpose of this paper is to provide an overview of the rehabilitation management of this condition.
Method: Case series of 86 consecutive heart or lung transplant patients admitted for inpatient rehabilitation.
Results: The most common neurological complications noted in this case series were tremor (due to Calcineurin inhibitors), and peripheral neuropathy. Seven patients had suffered a stroke, and 2 had suffered from hypoxic brain injury. Challenges to rehabilitation included associated cardiorespiratory deconditioning, steroid myopathy, and non-neurological complications. Interruption to rehabilitation occurred in 40% of patient admissions, and 9 patients died in hospital.
Discussion: The past decade has seen improvements in heart and lung transplantation management, with a significant increase in patient survival. Neurological impairment is a common co-morbidity following heart and lung transplantation. The role of rehabilitation in the management of this condition is likely to increase accordingly.
P405 The Trunk Exercises to Decrease Spasticity of Extremities
A. Bukowska1,2 and M. Terlecka2
1University School of Physical Education, Krakow, Poland, 2Votum RehaPlus - Functional Rehabilitation Clinic, Krakow, Poland
Spasticity is a real problem of patients after stroke or traumatic brain injury.
It is a hyper muscle tonus, mostly of upper or lower extremities during any movements or activities. This effect is called associated reactions.
In our research we tried to show how to decrease spasticity of limbs using exercises of trunk.
The hypothesis is: Stabilization and strengthening of the trunk decrease hyper muscle tonus.
The research included 25 patients with a similar problem, whose spasticity was a result of damage on upper-motor neuron system. They mostly had the spasticity of one lower limb, rarely an upper limb was involved too. During one hour treatment sessions, every day for a month, patients were treated with the variety of techniques of Proprioceptive Neuromuscular Facilitation Concept (PNF) and some sensorimotor techniques of Neurology Music Therapy (NMT).
A diagnostic session was taken before and after a month’s therapeutic programme. Therapy outcome was valued both qualitatively and quantitatively. Changes in spasticity level were evaluated with modified Ashworth Scale at all patients in a supine position. Decrease of associated reactions was also estimated visually during gait tests. On the level of patient’s function we assessed the time and amount of strides during “up and go” test. Measurements of trunk muscles strength were made with electronic devices - Muscle Lab.
Functional tests were also taken before and after every single session to see possible changes of associated reactions.
Satisfactory results, based on all tests and measurements, were noted at the end of the programme.
P406 The Effect of Virtual Reality Training on Unilateral Spatial Neglect in Stroke Patients
M. H. Chun and Y. M. Kim
Asan Medical Center, Seoul, Republic of Korea
Objective: To investigate the effect of virtual reality training on unilateral spatial neglect in stroke patients.
Method: Twenty two stroke patients (13 males and 8 females, mean age=62.1) who had unilateral spatial neglect as a result of right hemisphere stroke were recruited. All patients were randomly assigned to one of two groups, the virtual reality (VR) group (n=11) or the control group (n=11). The VR group received Virtual reality (IREX system, Vivid Group Inc., Canada) training which stimulated the left side of their bodies. The control group received conventional therapy such as visual scanning training. Both groups received therapy for 30 minutes a day, five days per week for three weeks. Outcome measurements included star cancellation test, line bisection test, left response and raw score of motor-free visual perception test (MVPT), and Korean version of modified Barthel index (K-MBI). These measurements were checked before and after treatment.
Results: Following three weeks of therapy, the change of raw score of MVPT in the VR group was significantly higher than that of the control group. The change of star cancellation score in the VR group tended to be higher than that of the control group (p=0.09). The changes of line bisection score, left response scores of MVPT, and the K-MBI in the VR group were higher than those of the control group, but the differences were not statistically significant.
Conclusion: This study suggests that virtual reality training may be a beneficial therapeutic technique on unilateral spatial neglect in stroke patients.
P407 Management of Spasticity With Botulinum Toxin Type A (BT-A): A One Year Follow-Up Prospective Study
A. Clemenzi1,2, A. Tonini1, L. Pace1, M. Matteis1, G. Comanducci1, M. G. Grasso1, R. Formisano1, and P. Cicinelli1
1Fondazione Santa Lucia I.R.C.C.S., Rome, Italy, 2II Faculty of Medicine - “Sapienza” University, Rome, Italy
We retrospectively reviewed 60 patients with spasticity related to different neurological disorders: vascular 50%, traumatic brain injury 21.7, demyelinating 21.6%, degenerative disorders 1.7%, and spinal cord lesion 5%. Patients were repeatedly treated with Botulinum Toxin type A (BT-A; Botox®) for one year. All the patients experienced spasticity for a mean time of 8.2 years (SD 8.1; range 0-31). BT-A injections were performed every 3 months or longer according to patients clinical condition (injections mean 2.7/year; SD 0.7; range 2-4/year). Both functional (Barthel Index) and spasticity scales (modified Ashworth) were recorded before each injections. Patients’ clinical characteristics were independently associated to the neurological disorders at baseline. A mean of 350 U of BT-A (SD 141.5 U; range 100 - 600 U) showed to be effective in ameliorating Barthel and Ashworth scores. Functional and spasticity scores showed a significant improvement after the first treatment (p<0.05) in upper and lower limbs. They also improved during the follow-up period without reaching a statistically significant level.
BT-A showed to be more effective in those patients treated earlier after spasticity onset (p<0.05), regardless of the injection number performed in one year. None of the patients experienced adverse event attributable to BT-A.
In conclusion, though the clinical benefits of BT-A primarily depend on its peripheral actions, more distant long-term effect altering sensory inputs to CNS might be involved. Further studies are needed to determine whether those effects may be lasting and useful in early spasticity treatment.
P408 Measuring Physical Activity and Energy Expenditure in People With MS: Do Devices Concur?
S. Coote, E. Ermacora, and A. Bleotu
University of Limerick, Limerick, Ireland
Introduction: One aim of physiotherapy for people with MS (PwMS) is to deliver programmes in a way that changes physical activity behaviours and reduces energy expenditure. Measures of physical activity and energy expenditure are needed in clinical trials. To date accelerometers or pedometers have estimated physical activity. Recently the Body Media Sensewear arm band (SWA) has added galvanic skin response and heat flux to estimate energy expenditure. This study aimed to compare the output of the ActivPal (AP) accelerometer and the SWA in an ambulatory PwMS.
Methods: Participants were recruited from the MS Society following ethical approval. 11 participants wore the SW and AP simultaneously for a period of 7 days.
Results: The ICC value for step counts by the SWA and AP was 0.73 (95%CI 0.27, 0.92). The SWA reported an average of 14,152 steps more. The ICC value for METs from SWA and AP was not significant (r=0.13, p=0.34). The SWA was on average 0.12 MET greater than the AP.
Discussion: There is a relationship between the step counts of the two devices, however the SWA systematically reports more steps. The placement of the devices, thigh and arm, may account for some of the differences in step count. The relationship between the MET estimations by the AP and SWA is poor. Further research is needed to compare both devices to indirect calorimetry or double labelled water and to step counts. This will establish which device gives a more accurate assessment of energy expenditure and physical activity.
P409 Which People With MS Access Physiotherapy Services, and How Much Treatment Do They Receive? A Survey in Ireland
S. Coote1, G. McKeown2, and M. Shannon3, on behalf of PIMS4
1University of Limerick, Limerick, Ireland, 2Dublin Physiotherapy Clinic, Dublin, Ireland, 3Beaumont Hospital, Dublin, Ireland, 4Physiotherapists Interested in MS, Nationwide, Ireland
Introduction: It is estimated that 7,000 people with MS (PwMS) live in Ireland. As the average age of onset is 27, and life expectancy is normal, the number of rehabilitation years and demand on services is high. PwMS felt that their greatest need was for physiotherapy services (Landsdowne Survey, 2006) but services are reported to be limited and treatment times low.
Methods: This was a prospective profiling study of PwMS attending physiotherapy services between September 1st and November 30th 2008. PwMS were given an information leaflet, gave consent, and had their data recorded.
Analysis: Data was analysed in an Excel spreadsheet using descriptive statistics and proportions. Qualitative responses were analysed for themes, then counted.
Results: Data for 295 patients attending 17 services was collected. 5.76% of PwMS had no difficulty walking, 20.00% mild gait difficulty, 14.92% walked with stick, 16.95% walked with bilateral aid, 15.59% primarily used a wheelchair but could still walk with assistance and 26.10% were non ambulatory. Average treatment time was 3.6 hours in 3 months, with 25.9% having 1 hour or less and 5.52% having the amount similar to those studies where therapeutic benefits have been found. The most reported main problem was balance (18.2%) with 14.4% reporting fatigue, 13.7% walking, 10.3% mobility and 9.9% weakness.
Conclusion: Physiotherapy services were delivered to people with a wide range of mobility problems at a range of locations. Treatment time is exceptionally low and must be increased to ensure effectiveness. The main problems reported are relevant for physiotherapy intervention.
P410 Constraint-Induced Movement Therapy for Children With Central Hemiparesis: What Makes It Work?
W. Deppe, K. Thümmler, J. Fleischer, C. Berger, and S. Pelz
Rehabilitationszentrum für Kinder und Jugendliche, Kreischa, Germany
Background: The efficacy of CIMT in children with cerebral palsy has been proven. Yet it is unclear what the main principles of efficacy are - restraint, structured therapy or high therapy intensity? To clarify the importance of restriction we have developed an equally intensive well-structured bimanual program and compare it with our kid-CIMT program.
Methods: Prospective, randomized, controlled intervention study.
Pre- and post-assessment instruments: Melbourne Assessment of Unilateral Upper; Limb Function; Assisting Hand Assessment (AHA).
(kid)-CIMT group: Restraint of the non-involved arm 4 hrs daily over 3 weeks during therapy. In week 4 bimanual training of daily activities.
Bimanual control group: Bimanual program over 4 weeks (4hrs daily) with emphasis on daily activities.
Results: In an interim evaluation of N = 28 patients ( 14 CIMT, 14 bimanual) both groups showed significant improvement. For the Melbourne Assessment changes in the CIMT group are significantly higher :+10,6 vs +4,2 (p = 0.05). In contrast there are no significant differences in the bilateral AHA: +3,5 vs +4,7 (n.s.).
Conclusions: Our interim evaluation demonstrates improvements for both methods. For isolated functions of the involved arm the CIMT group shows better results, in bimanual functions there is no difference.
Thus the restraint seems actually to be a main principle for the development of new unilateral motor functions in CIMT, but children do not benefit from this advantage in spontaneous bimanual activities.
In our congress presentation we will be able to demonstrate final results of the larger definite sample (N = 45).
P411 Supporting Daily Living Activities of Patients With Stroke
S. Tölgyesy1, G. Fazekas1,2, T. Vamos1, and I. Szel1
1National Institute for Medical Rehabilitation, Budapest, Hungary, 2Szent Janos Hospital, Budapest, Hungary
Stroke influences several fields of the daily living activities (ADL). Rehabilitation is based on the patient’s active participation and completed by a multi-professional team. Occupational therapist is a basic member of this team.
Occupational therapy (OT) aims to improve the activities on the fields of self-care, productivity (profession-housework-learning) and recreation. Possible solutions for supporting execution of these functions: adaptation of the action, adaptation of the environment, application of assistive devices. In case of patients with stroke the aim is to activate the affected arm, or—if it is not possible—to teach the patient the one-handed way of life. OT involves—among others—solutions for dressing (wide clothes with simple closing methods, keeping a correct order when dressing), eating (putting non-slip material under the plate, using cutleries with thicken handle), personal hygiene (handrails and special seats in the bathroom), communication, working activities, hobby. The personalized programme is based on the necessities of each patient.
Conclusion: OT can provide useful support to the patient in re-learning and training ADL functions under the conditions of the real life. It is substantial to make use of these solutions in the rehabilitation of patients with stroke.
Reference: Govender P, Kalra L. Benefits of occupational therapy in stroke rehabilitation. Expert Rev Neurother. 2007;7(8):1013-9.
P412 Is It Constraint or Repetitive Task Practice? Intensive Training Without Constraint Is Effective: A Team Approach Working With an Individual With Cognitive Problems and Ten Years Post Head Injury
D. Fischer and C. Birkett
Walkergate Park, Newcastle upon Tyne, United Kingdom
Background: Mr T is a 30-year-old who sustained a TBI in 1999. He had not used his left hand during ADLs since then. Constraint Induced Movement Therapy (CIMT) discourages the use of the unaffected arm by restraining it for up to 90% of waking hours combined with intensive training of the paretic arm 6 hours/day, 5 days/week, over a 2-week period. Mr T met the upper limb criteria of most CIMT studies but would have been excluded from some due to balance and cognitive problems, and length of time since injury.
Results: Mr T achieved all his functional goals and demonstrated remarkable improvement in quality of movement during functional tasks. His family noted increased motivation to learn new skills, and confidence in meeting people, by him joining an enabling programme. Action Research Arm Test and Berg Balance Scale improved. He did not tolerate wearing his constraint outside of the 6 hour programme.
Conclusion: Many CIMT studies demonstrate effective results, but its principles are difficult to carry out in practice due to constraints on time and resources, and because inclusion criteria in studies often exclude more complex patients. Our case study showed that an individual with cognitive problems can be motivated to participate in an intensive training programme, and significant functional gains can be made 10 years post injury. It appears that the important part of CIMT was the intensive training, not the constraint. The application of this intensive training programme was only possible within a committed MDT.
P413 A Child-Friendly, Interdisciplinary Constraint-Induced Movement Therapy Program (Kid-CIMT) for the Treatment of Children With Central Hemiparesis
J. Fleischer, K. Thümmler, C. Berger, S. Pelz, S. Philipp, and W. Deppe
Klinik Bavaria Zscheckwitz, Kreischa, Germany
Background: In the rehabilitation of adult stroke patients Constraint-induced movement therapy (CIMT) has been shown to be effective for improving upper extremity function and everyday use. To introduce CIMT in the treatment of children with hemiparesis including cerebral palsy, traumatic brain injury and stroke the program has to be child-friendly and suitable for an interdisciplinary team. For this purpose we developed the kid-CIMT program.
Patients: Our kid-CIMT is addressed to children between 3 and 12 years of age with hemiparesis.
Requirements: Minimal active mobility of shoulder, elbow, wrist and fingers; stable sitting posture, standing position and gait; sufficient language and task comprehension, attention, endurance and compliance
Structure and practice: Restraint of the non-involved arm for a minimum of 4 hours daily (during therapy) over 3 weeks; in week 4 integration of new acquired unilateral functions into everyday and play activities. The program involves physiotherapists, occupational, sport and music therapists. Children get psychological support during the treatment course. The program consists of 3 parts:
Mobilisation program: improvement of muscle and joint mobility (passive mobilisation)
Sensibility program: Promotion of tactile and proprioceptive perception
Activity program: Sequential structure depending on the child’s abilities starting from trunk and shoulder stabilisation proceeding to abilities of hand and finger manipulation as highest level
Conclusion: Our CIMT program is characterized by child-friendly modifications, high intensity, interdisciplinary and a sequential structure of the therapies. Moreover our program emphasizes the integration of the new unilateral functions into bimanual use.
P414 Respiratory Therapy (Bagging) for Patients in Early Neurorehabilitation
U. Frank1 and K. Frank2
1University of Potsdam, Linguistic Department, Potsdam, Germany, 2Aatalklinik Bad Wuennenberg, Bad Wuennenberg, Germany
Objective: In a pilot project a respiratory intervention technique (bagging) was adapted for patients with respiratory deficits in early neurorehabilitation. We present preliminary data evaluating this technique. Specifically, we examined whether a continuous and stable improvement of oxygen saturation (SPO2) can be established.
Methods: The ‘bagging’ method implies adding air into the lungs during the inspiration phase by using a resuscitation bag. Subsequently the patient is requested to cough, and is given manual support on the chest by the therapist. As a result of the increased intrapulmonary volume and forced coughing, there is an improvement of mucociliary clearance.
We examined a group of 11 patients who received 1-2 bagging interventions/day over a period of 12 days. Outcome measure was oxygen saturation (SPO2) before and after every intervention.
Results: By applying the bagging method a continuous and stable improvement of oxygen saturation could be accomplished for all patients (mean: 90% before - 95% after intervention). Furthermore the initial values before intervention at each intervention day were higher than the day before which indicates a sustained improvement. A single case analysis confirmed this effect for each patient. Furthermore we observed an improvement of the patients’ vigilance, improved quality of bronchial secretion and marked improvements in swallowing and phonation.
Conclusion: The bagging method is an easy-to-learn and inexpensive method that leads to a stable and sustained increase in oxygen saturation and to improvement of further clinical parameters. Modifications of the method and further evaluations are presently in preparation.
P415 Decannulation Management for Patients With Dysphagia and Respiratory Deficits: A Multidisciplinary Approach
U. Frank, H. Sticher, F. Maetzener, C. Czepluch, S. Wilmes, S. Hadert, H. Wilhelm, and M. Maeder
REHAB Basel, Basel, Switzerland
Objective: Current approaches to decannulation management often fail to account for patients with combined dysphagia and respiratory deficits. We present a standardized interdisciplinary decannulation management that has been developed in our rehabilitation center for this group of patients.
Methods: We developed an interdisciplinary protocol and decision chart for weaning patients off the tracheotomy tube and subsequent decannulation. Furthermore, we defined criteria to identify those patients who are at risk for respiratory failure after decannulation. If a patient meets these predefined criteria, a tracheostomy button is applied prior to final decannulation. The button is inserted during a laryngoscopic examination and left in situ in a 1-day and subsequently in a 3-day trial. These trials are evaluated by the following measures: ABG-analyses, pulse rate, and respiratory frequency clinical stress indicators. After three days of observation the decision is made for or against permanent decannulation.
Results: We present preliminary data of our present evaluation and a case study. Our first evaluation shows that by establishing clinically based interdisciplinary criteria it is possible to wean patients off the tracheostomy tube and decannulate them successfully. In all patients we observed a marked increase in swallowing frequency and effectiveness.
Conclusion: The multidisciplinary treatment and decannulation management approach leads to a safe decannulation, even for patients who would otherwise be difficult to wean because of severe respiratory deficits.
P416 Mental Retardation and Hyperactivity: Case Study
S. M. Golubovic1 and V. Stoilkovic2
1Faculty of Special Education and Rehabilitation, Belgrade, Serbia 2Institution for Children Without parental Care, Belgrade, Serbia
This case study describes a boy born in 2000 by caesarian section, which caused the infant to suffer asphyxia and hypotonia. He started to walk at the age of 23 months, and his walk is discordant. He has periodical autoaggressive behavior, presence of pica, polyphagia, polydipsia, enuresis and encompasses and sleep disorder. Paroxysms of high-voltage slow activity register on the EEG. At the social scale of matureness, he complies with the age of 3,8 years, or SQ - 56. He is mentally retarded, as is his mother. Because of hyperactivity (uncontrolled anger and aggression with children, objects and adult persons), he drinks Rissar. His behavior is getting worse, he rejects demands of the teachers, and is biting children and spitting. Intervention of the pedagogists has no effect, whereby whole behavior repeats with higher intensity. He recognizes themes and objects with which he has previous immediate contact, repeats words that are spoken, pronounces more simple sentences, and speaks more understandably. He sometimes spontaneously makes more difficult sentence construction, which is supported with adequate reward. His nonverbal abilities are better. He shows objects, is interested, tries to show with drawing what he wants, but drawing is immature for his age, he scribbles and does not know how to hold the pencil. What he visually perceives connects with happenings and persons that are related to that perception. Now, he is physically stronger, and his motor coordination is better. He demonstrates institutional syndrome, and repeats words that he has heard from adult persons but he does not understand their meaning, which is not in accordance with his age.
P417 Dyslexia and Dysgraphia: Identification and Support
S. M. Golubovic1 and Z. Z. Golubovic2
1Faculty of Special Education and Rehabilitation, Belgrade, Serbia, 2Faculty of Mechanical Engineering, University of Belgrade, Belgrade, Serbia
A dyslexic and dysgraphic student has very different possibilities in different countries in Europe. According to information from some faculties, professors themselves recognize students who have difficulties with reading, writing and /or reading comprehension problems. It is necessary to provide more information about the phenomenon of dyslexia and dysgraphia, particularly during the secondary education and before preliminary exams and university education. Secondly, students who proceed with university education should be provided with all the necessary information about their problem through all means of communication (f.e. web sites of the faculty or university, free assessment for those who have doubts about dyslexia ). Thirdly, those students who are diagnosed as dyslexic should have certain benefits similar to the benefits of students with other types of needs—prolonged time for finishing the task, assistants for written exams, possibilities of auditive presentation of the literature. Around 30% of University students identified as dyslexic have not been previously diagnosed through the school system. The problem is that the level of support in those countries, underpinned by sound policies and guidelines, has not been replicated elsewhere. There are many reasons for this, including the lack of support given to hidden handicaps, awareness and understanding of dyslexia, and priority within the respective countries, including social unrest and economic reform.
P418 Seizures and Driving: A Systematic Review of the Evidence
C. A. Hawley1 and J. L. Hutton2
1Warwick Medical School, Coventry, United Kingdom, 2University of Warwick, Coventry, United Kingdom
Introduction: Seizures affect up to 10% of the population at some point during their lifetime. Driving Licensing authorities in most countries apply restrictions on those who have seizures, but the seizure-free period required before a driving licence is restored varies between countries. These restrictions are based on judgements of the risk of further seizures which could affect road safety. In the UK an unprovoked seizure triggers a 12 month driving ban, yet drivers do not always report their seizures to their GP or to DVLA, non-reporters are generally younger with correspondingly increased accident risk.
Aims: Systematic review of the evidence for current medical standards of fitness to drive after seizure.
To estimate risk of subsequent seizures after an initial seizure.
Method: Electronic databases (including Medline; Cochrane; EMbase) were searched (1966-present) including foreign language articles. Two independent researchers screened all abstracts. Data was extracted to identify the probabilities of recurrent seizures over varying time periods.
Results: 9,330 anonymised abstracts were screened and 343 full text articles selected for data extraction. Seizure recurrence was the main focus of study for only 39 papers. The quality of published reports was low.
Conclusion: The world-wide variation in the seizure-free interval before driving can resume reflects the limited scientific data available on driving with seizures or epilepsy. We found no better evidence on which to base policy or practice than was available when the UK standards based on risk criteria were set. New studies are needed which assess seizure risk among those with predisposing factors.
P419 Stroke Rehabilitation Services and Outcomes: Differences Between University Hospitals and Rehabilitation Centers in Thailand (TSRR-I)
P. Wattanapan1, N. Inthnu2, K. Piravej2, A. Kovindha3, and V. Kuptniratsaikul4
1Department of Rehabilitation Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand, 2Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 3Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, 4Department of Rehabilitation Medicine, Faculty of Medicine, Mahidol University, Bangkok, Thailand
Objective: To study the differences in rehabilitation services and outcome between university hospital and rehabilitation center in Thailand
Materials and Methods: Data was gathered from TSRR I among 6 university hospitals and 3 rehabilitation centers. All participants were assessed using Barthel index, Hospital Anxiety and Depression scale (HADS), WHOQOL-BREF-Thai questionnaire and Brunnstrom stage at admission and discharge. Total cost of treatments including treatment units (1 unit=20 min) were recorded.
Results: There were 327 patients: 200 in university hospitals and 127 in rehabilitation centers. There was no difference in age, gender, onset-admission interval, Barthel score, admission QOL and HADS score. The patients in university hospitals had better admission Brunnstrom stages of hand, arm and leg (p 0.003, 0.006 and 0.003). Length of stay for university hospitals and rehabilitation centers were 3.80 (SD=1.65) and 5.28 (SD=3.22) weeks respectively (p<0.001). There was no significant difference in units of rehabilitation services whereas total cost of rehabilitation treatments in university hospital (10347.62, SD=8661.23 baht) was higher than rehabilitation center (6088.33, SD=4491.09 baht) significantly (p<0.001). After the end of the program, there were significant improvements of functional outcome and QOL score but not of motor recovery in both groups. However there were no differences in outcome between groups.
Conclusion: In-patient rehabilitation program helps to improve functional outcome and QOL of patients after stroke. Length of stay in rehabilitation centers was shorter while cost of rehabilitation treatments was higher in university hospitals. There were no differences in motor recovery, functional outcome and QOL between groups.
P420 The Ability of Sit to Stand and Functional Balance Post Task Specific Training in Children With Cerebral Palsy
W. Kumban, S. Amatachaya, P. Peungsuwan, and W. Siritaratiwat
Faculty of Associated Medical Sciences, Khon Kaen, Thailand
Purpose: To investigate the effects of task specific training: sit to stand on an ability of sit to stand and functional balance in children with cerebral palsy.
Method: Ten school children with cerebral palsy aged between 6 to 15 years were recruited in this quasi-experimental study. Main outcomes were measured immediately before and after the trainings. Subjects were tested their abilities of sit to stand using the Motor Assessment Scale (MAS: sit to stand item). Five times sit to stand (FTSST), functional reach test (FRT) in sitting and standing posture and pediatric balance scale (PBS) were outcomes indicated functional balance. Subjects attended 20-minute task specific training of sit to stand 3 times a week for 6 weeks. Wilcoxon Signed Rank test (p<0.05) was used to analyze the outcome differences between pre and post training.
Results: The mean(±SD) score of sit to stand item in MAS was significantly improved from 3.2(±1.62) to 4(±1.94) (ρ=0.034). The mean of FTSST was significantly decreased from 41(±29.13) to 25(±13.23) seconds (ρ=0.005). Mean distance of FRT during sitting was significantly increased from 23.2(±9.87) to 28.3(±11.8) cm (ρ= 0.015) but FRT during standing was not significantly different (ρ=0.06). PBS scores were significantly increased from 31.6(±20.91) to 33.2(±21.79) (ρ=0.041).
Conclusion: Specific sit to stand training improved an ability of sit to stand and functional balance in children with cerebral palsy. Results from this study imply the applicability of specific sit to stand training for cerebral palsy rehabilitation.
P421 Effect of Simple Balancing Training Program in Elderly Patients
V. Kuptniratsaikul, R. Praditsuwan, P. Assantachai, T. Ploypetch, and S. Udompunturuk
Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
Objective: To study the effectiveness of easily-performed balancing exercise to prevent falls in the elderly during November 2008-July 2009.
Methods: Demographic data with age, sex, underlying diseases, fall history, walking ability, turning, ability to go outside by himself, and fear of fall history were assessed. The balancing abilities were evaluated before and every follow-up period including Timed Up and Go Test (TUGT), 5-time chair stand, Functional reach, 180 degree turn, Berg balance scale-short form. Then, participants were demonstrated how to perform easy balancing exercise and asked to practice and record for exercise compliance. They were reevaluated the balancing abilities at 3, and 6 months. The new event(s) of fall and fear of fall were evaluated at follow up periods.
Results: 155 subjects were recruited, 123 female (79.4%) with mean age of 66.9 years. Most of them (96.1%) had history of previous falling and the number was decreased to be 56% at 6-month follow up period. All the outcomes of balancing abilities were significantly improved (p<0.001) especially at 3-month period. Concerning the compliance of exercise, most subjects (74.3-80.0%) performed with fair to good level at 3-month and 6-month follow up periods. There was evidence that compliance may have effect on balancing ability. About 20 % of participants had adverse events from exercise including mild knee or back pain, fatigue, and knee crepitus during exercise.
Conclusion: Balancing training in the elderly can decrease falling rate within 6 months of training. Strategy to emphasize elderly in performing exercise regularly may improve balance.
P422 Comparative Analysis of Physical Therapy Intervention Uses the Principles of the Neurodevelopment Treatment and Concept Snoezelen in Children With Cerebral Palsy With Multiple Disabilities and Children With Motor Delay in Development
C. G. Ribas1,2, C. C. C. Lima2, A. P. C. Loureiro1,3, C. Bressan1, L. P. Siquinel1, A. B. Silva1, and L. C. Resnauer1
1Pontifícia Universidade Católica do Paraná, Curitiba, Brazil, 2AMCIP, Curitiba, Brazil, 3CHR Ana Carolina Moura Xavier, Curitiba, Brazil
The Snoezelen is a multisensory environment that seeks to stimulate many sensory perceptions. It has grown, offering space with lights, smells, tactile surfaces, moving images, and other sensory experiences that can able people to relaxation experience and well being in order and pedagogical therapy, involving cognitive, motor and emotional development, in order to able and recover the children in these capacities.
The goal of physical therapy in this study when using the Snoezelen environment was seeking through its various resources, activities that facilitate the movement and the acquisition of new motor skills. We selected two groups, one with two children with a clinical diagnosis of cerebral palsy and the second of two children with a clinical diagnosis of delayed motor development. Ten interventions were proposed for each participant, being carried out 2 times a week lasting 30 minutes each. The motor performance of children was measured using Gross Motor Function Measure (GMFM) before and after intervention. Three subjects in the study presented important developments, and a child with cerebral palsy does not have an evolutionary trend as significant because of the accommodation stimulus.
P423 Morphological Analysis of the Soleus Muscle of Rats Submitted to Neonatal Hypoxia-Ischemia and a Muscle Stretching Protocol
A. P. C. Loureiro1, A. S. Pagnussat2, C. G. Ribas1, L. Stolfa1 B. L. Piassetta1, A. C. A. Hoffmann1, W. C. Moraes1, and J. L. Ywazaki1
1Pontifícia Universidade Católica do Paraná, Curitiba, Brazil, 2Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
The perinatal hypoxia-ischemia is a major cause of mortality and morbidity in humans, resulting in cognitive and motor damages. This study aimed to investigate the possible morphological changes suffered by the musculature of an animal model of rats with neonatal hypoxia-ischemia. Were used 24 Wistar rats randomly divided into four groups (A) sham (SHAM), (B) hypoxia-ischemia (HI), (C) hypoxia-ischemia + stretching (HI +STRET) (D) stretching (STRET). At 7 days post natal, the rats were submitted to ischemia, with permanent occlusion of the right common carotid artery. Then the animals were exposed to hypoxic environment, consisting 2% of O2 and 92% of N2. The muscle stretching protocol was performed in intermittently left soleus muscle of animals in groups C and D, 3 times a week for 3 weeks, consisting of 5 repetitions of 30sec to 45 sec range. After 12 weeks all animals were euthanized for the removal of the soleus muscle of both legs. Partial results concerning body weight, muscle weight and muscle length, using the nonparametric Kruskal-Wallis indicated: p-values not significant for initial body weight in the weight of the final comparison groups HI x SHAM gave values of p * = 0.0172, p values for muscle weight of both the right foot and the left were not significant, the muscle length of the left paw showed the following values p compared the following groups: HI x STRET - p = 0.05 and STRET x SHAM - p = 0.05.
P424 Role of Transdisciplinary Rehabilitation Team in Consciousness Restoration: Complicated Way to Reality
O. A. Maksakova, S. Gusarova, N. Ignatieva, V. Maksakov, V. Bykova, S. Boyko, and I. Yashkova
Burdenko Neurosurgical Institute, Moscow, Russian Federation
Brain-damaged patients’ levels of recovery depend on their participation in rehabilitation process that is very different and poorly gaugeable. Urgent rehabilitation dealing with comatose or vegetative patients depends on the resource of transdisciplinary team approach which might be very important for unconscious condition.
Process of consciousness retrieval in 70 surviving BI persons who passed early, postponed or outpatient treatment was the subject of inquiry. Team discussion significant information, “Mental time travel”-test, results of stabilotraining, Galveston Orientation and Amnesia Test, Mayo-Portland Adaptability Inventory were used as measurement tools.
The key stage of rehabilitation process namely the restoration of consciousness, realized by means of build-up of the patient’s contacts with his own body and outward things is considered.
The basic working principle is the feedback to any minimal movement or vegetative signal of the patient beyond specific professional targets. The net of feedbacks with the patient and inter-professional ones builds up the team as Non-linear Complex System. Characteristics of “Team-Patient” system status are energy, entropy, and complexity. Increase of complexity is a powerful tool for propulsion of recovery process for instance by way of simultaneous actions of several team workers.
Conclusions: 1. Formation of Complex system “Patient—Team” may lead to integration of consciousness. 2. Analysis of communications in this system is useful for creation of common theory of consciousness as team work allows connecting First Person and Third Person Views. 3. Set of chronotops a patient perceives as his own reality should be considered as a measure of consciousness.
P425 Clinical Neurorehabilitation: Implications of the Reorganization of Elementary Functions (REF) Model
H. Malá1,2 and J. Mogensen3
1The Unit for Cognitive Neuroscience, Copenhagen K, Denmark, 2The Center for Rehabilitation of Brain Injury, Copenhagen, Denmark, 3The Unit for Cognitive Neuroscience, University of Copenhagen, Copenhagen K, Denmark
The REF (Reorganization of Elementary Functions) model suggests mechanisms of posttraumatic reorganization, and resolves the contradiction between localization and functional recovery (Mogensen & Malá, 2009). In the process of developing this model, we have reconceptualised the term ‘function’ and introduced a concept of strictly localized, basic processing modules, which we term ‘elementary functions’ (EFs). Uniting the EFs into functional networks gives rise to ‘algorithmic strategies’ (ASs), which constitute the information flow and processing mediating a particular behavioural surface phenomenon traditionally defined as ‘function’. After brain injury, the EFs of the affected structure are irreversibly lost. However, during neurorehabilitation, the remaining EFs are reorganized into novel ASs. Creation and utilization of these ASs constitutes the basis for functional recovery. The degree to which recovery appears possible is a reflection of how successful the new AS-network is in achieving the surface phenomenon under consideration. This model has several implications relative to clinical neurorehabilitation. One of these concerns the degree to which results of rehabilitation training can be expected to generalize across situations and cognitive domains. Since novel ASs are created and selected according to situation dependent feedback mechanisms, dissimilar external conditions may call for different ASs. Consequently, therapeutically established ASs may not be adequate in the settings of daily life. Additionally, upon the loss of a particular brain structure, the structure and networks mediating recovery will not be identical in case of different cognitive and situational demands. Therapeutically, an important implication is that rehabilitative training should include as naturalistic settings as possible.
P426 Impact of Different Treatment Approaches on Recovery of Arm and Hand Function in Stroke Patients: A Randomized Controlled Trial
C. Meier Khan1, P. Oesch1, U. Gamper1, J. Kool2, and S. Beer1
1Rehabilitation Center, Valens, Switzerland, 2Zurich University of Applied Science, School of Physiotherapy, Winterthur, Switzerland
Background: In hemiplegic stroke only a small part of patients regains full arm function, leaving the major part with severe impairment in the long-term. Different rehabilitative concepts have shown some benefits, their specific impact however is unclear.
Objective: The primary goal was to compare the impact of Conventional Neurological Therapy (CNT), Constraint Induced Movement Therapy (CIT) and Therapeutic Climbing (TC) on arm and hand function in stroke patients.
Methods: All stroke patients admitted for inpatient rehabilitation with minimal upper extremity function, no shoulder-pain, and some gait-function were randomly assigned to CNT, CIT and TC. Primary end points were arm function (Wolf Motor Function Test, WMFT and the Motor Activity Log, MAL) rated by a blinded assessor at entry, at discharge and after 6 months. Mann-Whitney test assessed differences between the treatment groups, effect sizes (ES) were calculated.
Results: 44 stroke patients got included. All groups showed significant improvements at discharge and 6 months follow-up in all primary outcomes. ES for WMFT and MAL were larger in CNT and CIT than in TC. Additionally WMFT was significantly better in CIT and CNT compared to TC at discharge and at 6 months (ES= .56- to .76). Finally CIT patients were less at risk to develop shoulder pain (ES= 0.82-1.79).
Conclusions: CIT and CNT were more effective in restoring arm function than TC. CIT treated patients were less prone to develop shoulder pain. Finally self training may be an efficient component in CIT saving therapist resources.
P427 NMT-Based Interdisciplinary Group Concept for Effective Motor Training in Neurorehabilitation
K. Mertel
Klinik Bavaria Zscheckwitz, Kreischa, Germany
Research over the past 15 years has shown impressively that the use of music, especially rhythm, induces predictable neurologic responses. Various rhythmic stimuli can trigger motor function, utilizing the rich connectivity between auditory pathways and motor pathways. Studies comparing musicians and nonmusicians have documented how auditory rhythm is processed in distributed and parallel fashion cortically and subcortically. For example, research has shown the critical involvement of audiospinal pathways via the reticular formation. Based on advances in neuroscience the use of music as a therapeutic tool for persons with neurologic diseases has now tremendous potential because of the many ways the individual properties of music i.e. rhythm, melody, and harmony induce predictable neurologic responses. Based on these findings Neurologic Music Therapy (NMT) developed evidence-based and standardized motor training techniques. In our institution, Klinik Bavaria, Center for Neurorehabilitation for children and adolescents in Germany, we have successfully applied NMT within an interdisciplinary team consisting of physio-, occupational- and neurologic music therapists. Four groups of 4-5 patients suffering from cerebral palsy or TBI complete their motor single sessions by weekly provided NMT-based group training. The patients specifically exercise upper and lower extremities to gain better performance in ADL sequences or proceed with gait training. Within the sessions, goal oriented music training led to better performance and endurance compared to single PT or OT sessions. Now the NMT groups are a permanent part of our treatment plan which bring together interdisciplinary team competence for an intensive high frequency motor training during inpatient conditions.
P428 Functional Improvements and Cortical Reorganization After Mirror Therapy in Chronic Stroke Patients: A Randomized, Controlled Trial
M. E. Michielsen1, R. W. Selles1, J. N. van der Geest1, M. Eckhardt2, H. J. Stam1, M. Smits1, G. M. Ribbers1, and J. B. J. Bussmann1
1Department of Rehabilitation Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands, 2Rijndam Rehabilitation Center, Rotterdam, Netherlands
Background and Purpose: To evaluate clinical effects and cortical reorganization after mirror therapy in a group of chronic stroke patients.
Methods: Forty chronic stroke patients (mean time post-onset=3.9 years) were randomly assigned to the mirror group (n=20) or the control group (n=20) and then joined a 6-week training program. Both groups trained once a week under supervision of a physiotherapist at the rehabilitation center and practiced at home 1 hour per day, 5 times a week. The primary outcome measure was the Fugl-Meyer assessment (FMA), but we also measured grip force, spasticity, pain, dexterity, hand-use in daily life and quality of life at baseline, posttreatment, and 6 months’ follow-up. Changes in neural activation patterns were assessed with functional magnetic resonance imaging (fMRI) at baseline and posttreatment.
Results: Posttreatment, improvement on the FMA was greater in the mirror group than in the control group (3.6±1.5, P<.05). This improvement did not persist at follow-up, and no improvements were found on the other outcome measures (all P>.05). fMRI results showed a shift in activation balance within the primary motor cortex toward the affected hemisphere in the mirror group, which did not occur in the control group (weighted laterality index difference = 0.40±0.39, P<.05).
Conclusion: This study showed the effectiveness of mirror therapy in a group of chronic stroke patients and is the first to associate mirror therapy with cortical reorganization. Future research has to determine the optimum practice intensity and duration for improvements to persist and generalize to other functional domains.
P429 Additional Aerobic Bicycle Ergometer Training for Post Cerebral Stroke Patients in Rehabilitation: Does It Have Adverse Effects on Spasticity?
G. Pirstinger, B. Gappmayer, C. Haider, H. Zauner, A. Gaßner, and R. Alber
SKA-RZ Großgmain, Großgmain, Austria
Objectives: In the process of rehabilitation after cerebral stroke, sport therapeutic aspects gain in importance. Exercising in the aerobic range improves the cardiopulmonary capacity. Eich et al. showed that aerobic treadmill training leads to enhanced walking performance (walking distance and speed). The current guidelines of the American Heart Association recommend aerobic exercises of about 20 to 60 minutes three days a week for post-cerebral-stroke patients. We examined wether a 20 minutes training (Lactate 2 - 4 mmol/l), 3 times a week increases the spasticity of the affected limbs.
Methods: In this study 35 patients (31 male, mean age: 60.6, SD 11.5) post cerebral stroke (time since onset: maximum 12 month) were randomly assigned to a treatment and a control group. Mean duration of rehabilitation was 29 days (SD 5.8). Eighteen patients received lactate-controlled bicycle-ergometer training 3 times a week for 20 minutes, and were compared to 17 patients without any extra treatment beyond standard rehabilitation program. Outcome was assessed with 6-Minutes-Walking-Distance-Test (6MWD), Ashworth-Scale for muscular tonicity and EuroQol-Visual Analogue Scale for quality of life.
Results: There was significant increase in walking distance (6MWD) for both groups (p<.001), for the treatment group however significantly higher than for controls (p<.001), without provoking an increase in tonicity at the affected limbs. Quality of life scores showed equal significant increase in both groups (p<.001).
Conclusion: Applying an additive low-cost cycle ergometer intervention on post-stroke patients increased the walking distance without negative influences on the spasticity of the affected limbs.
P430 Articulation Disorders in Children Born After Bombing
M. Risovic1 and S. M. Golubovic2
1Health Center Krusevac, Krusevac, Serbia, 2Faculty of Special Education and Rehabilitation, University of Belgrade, Belgrade, Serbia
Background. Articulation disorder is a disorder of sounds pronunciation in children with normal physiological hearing, normal enervation of speech organs, normal developmental of other language abilities, and normal intellectual capacities.
Method. The capability of articulation were researched in pre-school children whose intra-uterine development lasted in 1999. year during in bombing from city Krusevac, Serbia. Children were investigation from city Krusevac (N 318) and from village (N 200) with Global of Articulation Test in Serbian language.
Results. Articulation disorders have 30,5% children (34.3% male and 26.4% female). Pathology articulation have 28.95 % children from city and 33% from village. From total number of tested children 301 (58.1%) of them managed analysis of sounds, 134 (25.9%) didn’t and 83 (16%) managed fragmentally. Girls were more successful on this test than boys, which is shown by statistically important difference. Research result of capabilities of articulation misarticulated sounds tend to be those typically acquired letter in development. These include the sounds l, r, s, z.
Conclusion. Results of research capabilities of articulation sounds in children born in 1999 show that there is difference in this capability related to children born in 1998 and earlier.
P431 Suppression of the E-Effect During the Subjective Visual and Postural Vertical Test in Healthy Subjects
W. Saeys1,2,3, L. Vereeck1,2,3, A. Bedeer2, C. Lafosse3, S. Truijen2, F. L. Wuyts1, and P. Van de Heyning1
1University of Antwerp, Antwerp, Belgium, 2Artesis University College of Antwerp, Antwerp, Belgium, 3Rehabilitation Hospital Hof Ter Schelde, Antwerp, Belgium
Introduction: In this study the influence of head-on-body and starting roll position of a laserbar and chair was investigated on the perception of respectively the visual and postural vertical. Sixty-one subjects, between 21 and 82 years, participated in this study.
Results: Results show that head-on-body and starting roll position of laser bar or chair have an influence on outcome for both subjective visual vertical test (SVV) and subjective postural vertical test (SPV). When head-on-body and starting roll positions are combined the E-effect (a deviation of the SVV-SVV opposite to the head-on-body tilt, when the roll tilt of the head is < 60 to 70 degrees) is observed in the anti-parallel condition, but is suppressed when starting roll position of laser bar or chair are relatively parallel to the length axis of the tilted head.
Discussion: We suggest that in the assessment of the SVV, when the laser bar is aligned with the length axis of the head (parallel condition), the oblique effect occurs.
In the assessment of the SPV, the E-effect is also suppressed in the parallel condition. We hypothesize that in the parallel conditions, the gravitational reference frames of head and trunk are more aligned with each other providing similar information. On the other hand, the reference frames of head and trunk are malaligned in the anti-parallel condition and providing contradictory input. Conclusions: It seems that SVV- and SPV measurements are influenced by head-on-body and starting roll positions and has to be taken into account in further studies.
P432 PeLoBASE: Online Accessible Research Database for the Pediatric Lokomat
T. Schuler and A. Meyer-Heim
REHABResearchGroup, Rehabilitation Center University Children’s Hospital, Affoltern am Albis, Switzerland
Background: Feasibility of gait restoration using the robotic driven gait orthosis Lokomat has been investigated in the rehabilitation of children with central gait impairments. However, evidence as well as the optimal training setup as frequency, duration, velocity and dose dependency needs further research. There is a lack of knowledge regarding indications, age, severity and possible combinations with other therapy options like botulinum toxin, orthopaedic surgery or augmented feedback/ virtual reality training systems. Research questions are so numerous that they should be addressed by a multi-centre approach, which also would allow comparing different therapeutical settings.
Objectives of the PeLoBASE are installation and maintenance of a clear, structured, global and safe online database; collection and storage of anonymous patient- and training data of multiple centres that can be statistically analysed; consolidated findings about treatment outcome, optimal indications and therapeutical application of robotic assisted gait training. A PeLoBASE account is cost-free and offers easy data collection tool for single and multicentre studies and RCT; online access and data storage; comprehensive patient description of anatomical and clinical parameters; transfer of logged Lokomat data; data collection of additional therapeutical interventions; internationally usable assessment standard forms; screen and filter functions; access to a world wide network of Pediatric Lokomat users. To date, seven rehabilitation centres worldwide are joining the PeLoBASE network. For more information please go to: http://www.kispi.uzh.ch/af/ForschungLehre/RehabResearchGroup/Projects/PeLoBASE_en.html.
P433 An Evidence-Based Preferred Music Listening for Managing Feeding Problems in Community-Dwelling Elders With Cognitive Impairment
H. Shih1, H. Sung2, M. Lee3, Z. Lin4, and H. Lee5
1Graduate Institute of Nursing, Tzu Chi University, Hualien, Taiwan, 2Department of Nursing, Tzu Chi College of Technology & Tzu Chi University, Hualien, Taiwan, 3Department of Curriculum Design and Human Potentials Development, National Dong-Hwa University, Hualien, Taiwan, 4Department of Nursing, Tzu Chi College of Technology, Hualien, Taiwan, 5Department of Psychiatry, Tzu Chi Medical Centre, Hualien, Taiwan
The benefits of evidence-based practice are their potential to improve quality of care and patient outcomes. Preferred music listening has been suggested to have positive impact on behavioural problems of elders with cognitive impairment caused by dementia. Feeding problem is frequently reported by caregivers as one of the challenging problems in elders with cognitive impairment. However, little is known about the utilisation and effectiveness of an evidence-based preferred music listening protocol for feeding problems in cognitive-impaired elders. This study aimed to evaluate the effectiveness of an evidence-based preferred music listening delivered by trained family caregivers on feeding problems in community-dwelling elders with cognitive impairment. A one-group pre-test and post-test design was used. Eleven participants were assessed for their music preferences and then received a music listening intervention based on their music preferences via a CD player provided by the trained family caregivers during dinner time for 1 hour daily for 4 weeks at home. Feeding problems measured by Edinburgh Feeding Evaluation in Dementia Scale (EdFED Scale), nutrition status measured by Mini Nutritional Assessment (MNA), and body weight of each participant was measured at baseline and week 4. Wilcoxon signed rank test result indicated that the participants who received 4 weeks of preferred music listening had a significant reduction on the feeding difficulties (p< .003), and significant increase on their nutrition status and body weight (p<.05). Preferred music listening has the potential to reduce feeding problems and further improve nutrition status and quality of life of community-dwelling elders with cognitive impairment.
P434 The Effectiveness of Folic Acid on Cognitive Functions in People With Epilepsy
L. Tang and H. Sung
Tzu Chi College of Technology, Hualien, Taiwan
Background: Folic acid is essential for the development of central nervous systems; insufficient folic acid can result in high blood levels of the amino acid and homocysteine that have been found to be associated with cognitive decline and neurological damage. People with epilepsy need to be long-term on anti epileptic drugs (AEDs) to control seizure attack. Side effects from AEDs have been reported such as impairment on cognitive functions, sleep disorder, and emotional disorder. The effects of folic acid on cognitive functions were tested in studies.
Objectives: The aim of the review was to analyze the effectiveness of folic acid on cognitive functions in people with epilepsy.
Search strategy: Clinical trials were identified from a search of PubMed and the Cochrane library from March 2002 to March 2008 using the terms: folic acid, folate, cognition, cognitive functions, cognitive impairment, epilepsy, seizure, and epileptic disorder.
Selection criteria: All double-blind controlled randomized trials with participants of people with epilepsy disorder, intervention of folic acid as add-on supplements, compared with people without folic acid, and cognitive functions as outcome were included in the review. Two RCT fit with criteria were included and analyzed.
Data collection and analysis: The reviewers independently selected qualified studies, and analyzed the data.
Author’s conclusions: Using folic acid as add-on supplement is safe and without adverse effects, it was tested to improve the cognitive functions in people with epilepsy and treated with either phenytoin or carbamazepine. Further analysis needed to confirm the effects of folic acid on cognitive function.
P435 Ketogenic Diet Used on Seizure Control for People With Epilepsy
L. Tang and H. Sung
Tzu Chi College of Technology, Hualien, Taiwan
Purpose: The aim of this review was to determine the effectiveness of ketogenic diet on seizure control.
Methods: Complementary and Alternative Medicine (CAM) is a group of diverse medical and health care system and practice. Some studies indicated that CAM was used to conjunct with traditional medicine to lead improvement of seizure control. Ketogenic diet (KD) is one of the modalities suggested and used. KD was demonstrated to have greater than 50% reduction in seizure frequency and reduction in the number of antiepileptic drugs used. However, KD like other treatment might have adverse effects.
Results: This review paper included 1 systemic review, 2 randomized controlled trail studies, and 2 clinical trails. KD is a diet high in fat but low in carbohydrate, and has been considered as a potent antiepileptic treatment for children. The review showed that the different ratio of lipid to nonlipid diet had different antiepileptic efficacy, seizure-free outcome, dietary tolerability, and degree of gastrointestinal symptoms. The duration of initiating KD also indicated to have different outcome. Compared with the standard (24-48 hours fast) KD initiation, the gradual KD initiation had fewer adverse effects and better tolerability
Conclusions: The results revealed the ratio of lipid in diet and the time of initiation had influence on efficacy of seizure control. None of the studies indicated the details of adverse effects from KD. The subjects of the four studies were age between 1-14 years old children. The efficacy of KD on adult needs to be further determined in future study.
P436 Interdisciplinary Management of Neurogenic Dysphagia During Neurorehabilitation
G. Tautscher-Basnett, V. Tomantschger, R. Krassnig, and M. Freimueller
Gailtal-Klinik Hermagor, Hermagor, Austria
Background: Neurogenic dysphagia is common in neurological disorders and can lead to potentially life-threatening aspiration pneumonia. At the Gailtal-Klinik interdisciplinary procedures were developed in a team including medical doctors, nurses, a speech-language therapists (SLT) and a neurolinguist.
Methods: Interdisciplinary procedures (depicted on a colour-coded poster) have been in place since 12/2008. Two observation periods (i.e. pre and post introduction) were compared in terms of total number of patients, number of patients receiving dysphagia treatment, and number of aspiration pneumonias. Since introduction of these procedures virtually all patients were screened by neurologists with the 50ml-water-test; a limited number of patients were screened by nurses completing specifically developed swallowing protocols and some patients, who could not or would not adhere to the swallowing recommendations, were invited to wear a white armband to remind themselves and their environment of their swallowing difficulties.
Results: The comparison of the two observation periods (1.3.-31.8.2008: 668 in-patients; 1.3.-31.8.2009: 678 in-patients) showed that in 2008 5% of all patients received dysphagia treatment by SLTs and in 2009 7%. In 2008 five patients were diagnosed with an aspiration pneumonia (i.e. 0,75%) and in 2009 three patients (i.e. 0,44%), which means a reduction of 40%.
Conclusion: Interdisciplinary management of neurogenic dysphagia seems to reduce the risk of developing potentially life threatening aspiration pneumonia. Whether the reduction was due to these interdisciplinary procedures, the generally heightened awareness of all staff, or the higher % of dysphagia treatment is at this point not clear.
P437 Limb Immobilisation After Botulinum Toxin Injection in Patients With Delayed-Onset Posthemiplegic Dystonia
C. Trompetto, L. Avanzino, L. Marinelli, L. Mori, E. Pelosin, and G. Abbruzzese
Departement of Neurosciences, Ophthalmology & Genetics, Genova, Italy
Introduction: Using Transcranial Magnetic Stimulation (TMS) in patients with delayed-onset posthemiplegic dystonia, we recently found an increased excitability of the corticospinal projections targeting the affected hand muscles. We think that this motor hyper-excitability could play a role in the pathogenesis of dystonia. As it has been proven in healthy subjects that arm immobilisation is able to decrease corticospinal excitability, in the present research we investigated the effect of prolonged arm immobilisation in patients with delayed-onset posthemiplegic dystonia.
Patients and Methods: Two patients (a 50-year-old woman and a 46-year-old man) were studied, both presenting with a rest hemi-dystonia, predominant on the upper limb. TMS of the motor cortex showed a clear hyper-excitability of the affected corticospinal system in both the patients. Two weeks after the injection of botulinum toxin type A (BoNT-A) in the upper limb dystonic muscles, the affected forearm and hand were immobilised with a plastic splint for 6 weeks. Before BoNT-A injection (baseline) and at various intervals after immobilisation (4 and 8 weeks after), muscle strength and dystonia were scored using Medical Research Council (MRC) scale and the session for the distal arm and hand of then Unified Dystonia Rating Scale (UDRS).
Results: At the final evaluation, when MRC scores regained the baseline values, UDRS scores were still decreased in both the patients, showing a clinical effect overlasting the chemo-denervation induced by the toxin.
Discussion: These preliminary results suggest that prolonged arm immobilisation after BoNT-A injection could be an useful treatment in patients with delayed-onset posthemiplegic dystonia.
P438 A Comparative Study on the Treatment Periods of Patients With Walking Difficulty Developed as a Result of Brain Injury With Similar Localization and Size, Caused by Different Pathogenic Factors
E. Urban1 and S. Vasarhelyi-Toth2
1Karolyi Sandor Hospital, Budapest, Hungary, 2State Health Center, Budapest, Hungary
Background: Brain plasticity is the background of the functional reorganization processes after focal brain injuries.
Objectives: In our study we have investigated whether there is any numerical difference that may be the consequence of different brain plasticity during the period of learning to walk.
Methods: We have reviewed the documentation of 224 patients who were discharged from our Department between 01 Jan and 30 June 2008. The cases were selected based on our special criteria, i.e. similar localization and size of the brain injury and the same neurological deficit upon admission. As a result of this screening, 11 cases were identified and analyzed according to the following: gender and age of patient, brain CT, neurological symptoms, Barthel and FIM scores at the time of admission and discharge. The duration of treatment required for learning to walk was compared in the retrospective processing of the data collected from the patients’ medical records.
Results: Walking difficulty caused by hemiparesis developed as a result of acute brain injuries with similar localization and size, did not improve in the same extent and rate during similar treatment protocols.
Conclusion: The best outcome in rehabilitation was achieved in cases of traumatic brain injury. If the injury was caused by cerebrovascular disorder, the extent of motor function improvement and the duration of treatment were influenced by the accompanying diseases such as depression, brain atrophy, chronic alcoholism, diabetes and dementia. These factors may play a role in the different plasticity.
Author Index
A
Aadal, L. L.: P249
Abbruzzese, G.: P080, P210, P437
Abdulsalam, J.: P149
Abe, K.: P161
Aben, L.: P016
Abo, M.: P168
Achache, V.: P036
Acito, R.: P334
Adorable, L. V.: P147, P148
Aegerter, P.: P006, P215, P251
Aeschlimann, M.: P017
Aguayo, A. J.: OL1
Aguiar, L. R.: P383
Agulhon, A.: P402
Ahn, J.: P115
Aimet, M.: P347
Al Khudhairi, D.: P149
Alaqtash, M.: P045
Albegova, A.: P196
Alber, R.: P235, P429
Albert, S. J.: P336
Albieri, F. O.: P400, P401
Alders, G.: P193
Alexandra, B.: P100
Alexeeva, N.: P150
Alfred, G.: P029
Alouche, S. R.: P151, P402
Altenmüller, E.: S13.3
Alves, A. C.: P350
Alves, M.: P349
Amatachaya, S. A. D.: P310, P322, P420
Amoruso, L.: P271
Andersen, A. B.: P108
Angelov, D.: P042
Angerova, Y.: P394
Anghelescu, A.: P091, P092, P099
Angleitner, K.: P228
Angulo, D.: P057
Arecheta, P.: P184, P373
Arima, N.: P034
Arrayawichanon, P. A. D.: P322
Ashburn, A.: P321
Askim, T.: P152
Assantachai, P.: P421
Assis, R. D.: P350
Assucena, A. M.: P384
Atiemo, C. O.: P046
Attari, H.: P306
Attawong, T.: P003
Avanzino, L.: P210, P437
Avila, P.: P401
Awad, M. R.: S19.2
Ayna, A. B.: P248
Azen, S. P.: P153
Azevedo, M. F.: P225
Aziz, N.: P250
Aznida, F. A.: P250
Azouvi, P.: P006, P215, P251
B
Baars, R.: S13.2
Baba, M.: P038, P363
Babatope, T. T.: P264
Bacci, L.: P334, P335
Baek, Y. S.: P278
Bagesteiro, L. B.: P402
Baglieri, A.: P067
Bagnato, S.: P252
Bakran, M.: P134
Bakran, Ž.: P134
Balaam, M.: P205, P214
Baloyannis, S. J.: S19.1
Bandi, S.: P100
Bang, M. S.: P106
Bang, O.: P072
Baniček, I.: P134
Bardeleben, A.: P186, P202
Barnes, M. P.: P238
Baron, R.: S24.1
Baronnet, F.: P293
Baronti, F.: P315
Barrueco Ejido, J.: P360
Basciani, M.: P271
Bastiaensen, A.: P318
Batalin, M.: P224
Bateman, A.: S23.3
Baudo, S.: P218
Baydova, T.: P079
Bayen, E.: P018, P215
Beaucamp, F.: P368
Becker, C.: P164
Bedeer, A.: P431
Beelen, A.: P213
Beer, S.: P256, P336, P426
Beghelli, A.: P372
Behrman, A. L.: P153
Bejan, M.: P092
Bekic, I.: P297
Bellander, B.: P312
Bellion, M.: P315
Benedetti, B.: P004
Bennett, S.: P341
Bensafi, H.: P288
Bensmail, D.: P035, P154, P243
Beom, J.: P106
Berger, C.: P410, P413
Bergholt, B.: P021
Berna, L.: P135, P140, P141, P155
Bernabeu, M.: P171, P309
Beyer, E.: P010
Bhidayasiri, R.: P204
Bian, R.: P041
Bickel, C. S.: P327, P328
Bigoni, M.: P218
Binder, H.: PL04.1, S05.1, S27.2
Bindschaedler, C.: P017
Binkofski, F.: P030, P158
Birbaumer, N.: S10.3
Birkett, C.: P412
Birnhak, S.: P118
Björk, F.: P331
Bleotu, A.: P408
Bluemel, J.: P089
Boccagni, C.: P252
Boddaert, K.: P369
Bodis Wollner, I.: S12.3
Boering, D.: PL04.4
Boghi, A.: P218
Bogouslavskyy, D.: P002
Bohlhalter, S.: P315
Boisson, D.: S15.2
Bolliger, M.: P124
Bonaldi, R.: P398
Bonamartini, A.: P138
Bonikowski, M.: P191
Bonistall, K.: P275
Borbély, C.: P279
Bordi, L.: P142
Borg, J.: P227, P312
Borgerhoff Mulder, M. C.: P403
Borges, H. C.: P350
Bosserelle, V.: P006, P215, P251
Both, B.: P391
Bouffard, J.: P081
Boukhris, A.: P253
Boulianne, E.: P081
Bove, M.: P080, P210
Bovi, A. N.: P356, P357, P358
Bowman, M.: P404
Boyko, A.: P254
Boyko, S.: P254, P424
Brainin, M.: P010, S09.1
Bramanti, P.: P067, P068, P094, P387
Bramlage, P.: P005
Brands, I.: P059
Brandt, T.: P005
Brem, A.: P156
Bressan, C.: P422
Brice, A.: P253
Brinker, T.: S02.2
Brinkmann, N.: P014
Broeren, J.: P255
Brogårdh, C.: P219
Brower, R.: P045
Brunner, B.: P013
Brunner, G.: P374
Brunner, I. C.: P217
Brütsch, K.: P127, P190
Buagnern, S.: P003
Buetler, L.: P247
Buitenweg, J. R.: P083, P298
Bukowska, A.: P405
Bülau, P.: S27.2
Bullinger, M.: S17.1, S17.2
Burnett, M.: P321
Burridge, J. H.: P131, P205, S30.2
Burridge, J.: P214, S30.2
Buschfort, R.: P113
Busschbach, J. J. V.: P016
Bussel, B.: P036, P136
Bussmann, J. B. J.: P390, P428
Bussmann, R.: P256
Butković-Soldo, S.: P134
Buurke, J. H.: P043
Bykova, V.: P424
Byrne, P.: P019
Byun, S.: P203
C
Calancie, B.: P150
Calandriello, B.: P142
Calderisi, E.: P138, P259
Calota, A.: P232
Calvert, P.: P047, P060, P061
Camilotti, T. A.: P357
Carrozza, M. C.: P199
Carton, D.: P019
Carvalho, A.: P151
Casey, A.: P019
Cassola, M.: P395
Castel-Lacanal, E.: P234
Castelli, E.: P372
Castro, W. M.: P358
Catena, L.: P335
Celik, B.: P001
Celnik, P.: S25.1
Cerny, J.: P164
Cerquetti, K.: P138
Chahuan, S.: P155
Chaiprakit, N.: P182
Chaiwanichsiri, D.: P204
Chamlian, T. R.: P350
Chandler, B. J.: P338
Chang, J. H.: P278, P283
Chang, S. T.: P064
Chang, W.: P065, P071, P072
Chanubol, R.: P257
Chao, C. Y. L.: P209
Chatkungwanson, W.: P182
Chavanich, N.: P257
Checchia, G.: P080
Chendreanu-Daia, C.: P091, P092, P093, P099, P220
Cheng, H.: P112
Chequer, G. L.: P225, P237
Chernikova, L. A.: SWS.3
Cheuk, W. W. M.: P209
Cheung, H. K. Y.: P209
Chevrier, E.: P133
Chiriţi, G.: P351, P354
Cho, K.: P040
Choi, B. O.: P283
Choi, D.: P098
Choi, E.: P055, P325
Choi, H.: P070
Choi, I.: P041, P286
Choi, J.: P292
Choi, K.: P055
Chopra, K.: P096
Chow, J. W.: P084
Chua, H. M.: P352
Chuang, L.: P173
Chun, M. H.: P353, P406
Churilov, S. N.: P211
Ciarrocchi, F.: P259
Cicinelli, P.: P407
Cidade, L.: P330
Cinteza, D.: P087, P258
Cirasanambati, M.: P100
Clare, L.: P157
Clarke, R.: P337
Clarke, S.: P017, P058, S15.3
Cleeremans, A.: P021
Clemenzi, A.: P407
Cohen, L. G.: P189, S10.3, S25.3
Colibaseanu, I.: P093
Collina, M.: P259
Collinson, K.: P262
Comanducci, G.: P407
Comes, G.: P139
Comi, G.: P004, P277, P299, P343
Comola, M.: P004, P277, P299, P343, P346, P348, P372, P395
Cooper, R. A.: S32.1
Cooper, R.: S32.1
Coote, S.: P337, P340, P342, P408, P409
Corradini, C.: S27.2
Corrêa, C. L.: P260
Costa, Ú.: P171
Cowintaveewat,RN, V.: P365
Crisco, J. J.: P194
Crocher, V.: P125
Crosbie, J. H.: P130
Cruz, L. G. F.: P330
Cruz, M. R.: P237
Cserháti, P.: P391
Cubillos, A.: P155
Cubillos, F.: P135, P140, P141
Curio, G.: S10.1
Curt, A.: S22.4
Cyrillo, F. N.: P151
Czepluch, C.: P415
Czernuszenko, A.: P191
D
da Conceicao Teixeira, L. F.: P221
Dafe, C.: P181
Daffertshofer, A.: P085
Dahl, A. E.: P152
Dajpratham, P.: P376
D’Aleo, G.: P068, P094, P387
D’Aleo, P.: P094
Damak, M.: P253
Damen, B.: P317
D’Angelantonio, L.: P334
Dangra, V.: P306
Danoczy, M.: P099
Dario, P.: P199
Datta, D.: P143, P303
Daveluy, W.: P025, P368
Davidson, L.: P222
Davis, E. C.: P261, P338
de Boer, J.: P195
de Boissezon, X.: P234, P288
de Camargo, C.: P355
De Cloedt, P.: S30.3
de Nadai, L. I.: P356
De Stefano, N.: P067
Del Gaudio, A.: P272
Deltombe, T.: S30.3
Demain, S. H.: P131
Demiris, G.: S32.3
Denes, Z.: P007
DePompei, R.: S03.3
Deppe, W.: P410, P413
Desai, M. H.: P261, P262, P338
Dettmers, C.: P030, P158, P339
Di Rienzo, F.: P271, P272
Diaconescu, S.: P087, P258
Dias, Â. M.: P301
Dickenson, A. H.: S11.1
Dietz, V.: S22.3
Dima, A.: P087, P258
Dimulescu, D.: P351, P354
Diserens, K.: P223
Dispensa, F.: P252
Dobkin, B.: P153, P159, P224, PL01.3, S28.1
Donoghue, J. P.: S10.2
Donovan, T. P.: P377
Dote, J.: P386
Draca, S. R.: P263
Droguett, N.: P386
Dromerick, A.: PL02.1
Dubé, J.: P081
Dubroja, I.: P134
Duivenvoorden, H. J.: P244
Dulap, A. O.: P148
Dumitrescu, A.: P093
Duncan, P. W.: P153
Dupui, P.: P234
Durand, A.: P174
E
Eckhardt, M. M.: P403, P428
Edwards, D.: P171
Egglestone, S. R.: P205
Ehler, E.: P088
Elashoff, R.: P159
Elbers, R. G.: P326
Elleuch, N.: P253
Ellis-Hill, C.: P131
Enderby, P.: PL02.2
Eng, K.: P133
Erden, N.: P001, P324
Ermacora, E.: P408
Eslinger, P. J.: PL02.3
F
Faccendini, S.: P395
Facchinetti, L. D.: P225, P237
Fadilah, A.: P250
Fagergren, A.: P227
Falappa, A.: P334
Falk, D.: S02.1
Faria, G. R.: P356
Fawcett, J. W.: S06.1
Fay, V.: P007
Fazekas, G.: P007, P411
Fazio, R.: P395
Fazli, S.: P099
Federico, A.: P067
Fehl, K.: P021
Feki, I.: P253
Fermanian, C.: P006, P215, P251
Ferrada, V.: P155
Ferreira, J.: P137
Ferreira, S. A.: P383
Feshchenko, V. S.: P192
Feydy, A.: P066
Feys, P.: P101, P193
Fheodoroff, K.: P008
Filbin, M.: S06.2
Filiczki, G.: P097, P279
Fink, G.: P035, P154
Fink, K.: P089
Fischer, D.: P412
Flansbjer, U.: P015, P107
Fleischer, J.: P410, P413
Fleming, J.: P341
Flerov, I.: P114
Floel, A.: S29.4
Ford, M. P.: P327
Ford, M.: P264, P328, P329
Formisano, R.: P407
Fornari, E.: P223
Forrester, L. W.: P116
Forssberg, H.: P227
Franceschini, M.: P160
Franco, J. H.: S04.3
Frank, K.: P414
Frank, U.: P414, P415
Freimueller, M.: P332, P333, P436
Freimüller, M.: P008
Freivogel, S.: P207
Freundlieb, N.: P189, P399
Frigerio, S.: P052
Friis, R.: P208
Fritz, S.: P172
Fu, T.: P359
Fujii, N.: P038
Fujimoto, M.: P226
Fujita, H.: P226
Fujiwara, T.: P086, P104, P161
Fukuda, A.: P168
Furnari, A.: P068, P387
G
Gaber, T. A.: P009
Galardi, G.: P252
Galbeaza, G.: P087, P258
Galle, D.: P316
Galli, M.: P218
Galli, R.: P142
Gamper, U.: P426
Ganichkina, I.: P078
Gappmayer, B.: P429
Garcia, A. N.: P151
Garrett, M.: P340, P342
Gasq, D.: P234, P288
Gassmann, D.: P052
Gassner, A.: P090, P235
Gaßner, A.: P429
Gatchel, R.: S11.2
Gatti, R.: P004, P277, P299, P346, P348, P372
Gäverth, J.: P227
Gavriliuc, E.: P073, P082
Gavriliuc, M.: P082
Gemelli, A.: P348
Genet, F.: P006
Geringer-Manakanatas, N.: P235
Gerloff, C.: P037, P165, P166, P189, P233, P399
Gerry, R.: P265
Gerstenbrand, F.: S19.3, SWS.1, SWS.2
Gestoso do Porto, L.: P360
Geurts, A. C. H.: P083, P298, S14.1
Geurtsen, G. J.: P162, P163, P266
Gharabaghi, A.: S10.3
Ghislanzoni, C.: P348
Giattini, A.: P138, P259
Gibbons, H.: S17.2
Gijbels, D.: P193
Gilbert, P.: P288
Gill, H. L.: P341
Gill-Thwaites, H.: P221
Ginsberg, M. D.: S16.2
Giorgini, A.: P259
Giustini, A.: S20.1
Gjellesvik, T.: P267
Globas, C.: P164
Gnoato, T. G.: P330
Godderis, C.: P144
Golaszewski, S. M.: SWS.1, SWS.2
Goldstein, L. B.: S16.1
Golubovic, S. M.: P416, P417, P430
Golubovic, Z. Z.: P417
Golyk, V.: P002
Gomes, G. A.: P358
González Cabezas de Herrera, L.: P360
Goodson, K. H.: P145, P146
Gracey, F.: S23.2
Gracies, J. M.: S30.1
Grafe, S.: P137, P139
Graham, A.: P265
Graham, L. A.: P181
Graham, L.: P238
Grässel, E.: P371
Grasso, M. G.: P407
Gratzl, S.: P010
Grieshofer, P.: P176, P374
Grigoriev, A. I.: SWS.7
Grimaldi, G.: P271, P272
Grinsztejn, B. G. J.: P237
Grosjean, F.: P058
Grozea, C.: P099
Grubisic, M.: P297
Grüner, S.: P382
Guerrera, S.: P067, P068
Guevara, D.: P309
Gueye, T.: P048
Guger, C.: P132
Guggisberg, A.: S28.2
Guimarães, R. P.: P355, P356, P357, P358
Guimarães, V.: P349
Gusarova, S.: P049, P424
Gustin, T.: S30.3
H
Haase, I.: P014
Håberg, A. K.: P152
Hadert, S.: P415
Haefeli, J.: P247
Hafid, M.: P149
Haid, T. J.: P050, P051
Haider, C.: P029, P090, P429
Hamdan, Y.: P149
Han, E. Y.: P353
Han, J.: P041, P098, P286
Han, S.: P098, P229, P230
Han, T. R.: P106
Hanapiah, F. A.: P269
Hanschmann, A.: P137
Haras, M.: P091, P092
Harden, R.: S24.2
Harman, H.: P001, P324
Harris, E. C.: P205, P214
Hart, T.: S31.3
Hasan, M. R.: P098
Hase, K.: P104, P161
Hassa, T.: P030, P158
Hastrup Arentsen, K.: P108
Hatakenaka, M.: P069, P074
Hattangadi, G.: P306
Hattori, N.: P069, P074
Haudum, G.: P347
Hawley, C.: P418, S21.3
Hayashi, M.: P291
Hay-Smith, E. J. C.: P304
Hedemann Nielsen, L.: P284
Heeren, A. H.: P270
Heijenbrok-Kal, M. H.: P016, P403
Heijnen, L.: P213
Heinonen, A.: P295
Heise, K. F.: P189, P399
Heise, K.: P037, P165, P166, P233
Helgerud, J.: P267
Helo, A.: P184, P373
Helsen, W.: P101
Hendricks, H. T.: P270
Heremans, E.: P101
Hermens, H. J.: P123, P195
Hertler, B.: P046
Heß, A.: P113
Hesse, S.: P113, P129, P186, P202
Hetherington, V.: P326
Heugten, C. M.: P162, P163, P266
Hoch-Städele, M.: P050, P051
Hoess, U.: P014
Hofer, E. P.: P200
Hofer, H.: P052
Hoff, J.: P267
Hoffmann, A. C. A.: P423
Hogan, N.: P115, P340, P342
Holper, L.: P133
Holzhey, R. P.: P300
Hömberg, V.: S14.2, S20.3, S27.2
Honaga, K.: P161
Honda, T.: P285
Hooson, M.: P378
Hoppe, J.: P037, P189, P233, P399
Horemans, H. L. D.: P403
Hörniss, V.: P037
Horst, R.: P075
Houldin, A.: P102
Höybye, C.: P312
Hsieh, Y.: P359
Huang, S.: P112
Huber, S.: S19.3
Hughes, A.: P131, P205
Hughes, A.: P214
Hulting, A.: P312
Hummel, F. C.: P037, P165, P166, P189, P233, P399, S29.1
Husnutdinova, D.: SWS.4
Hutton, J. L.: P418
Hvizdakova, J.: P366
Hwang, S.: P055
Hyndman, D.: P321
I
Iarossi, A.: P272
Ichimura, S.: P028
Ida, Y.: P038
Ignatieva, N.: P424
Ignatyeva, N.: P049
IJzerman, M. J.: P083, P298
Inamoto, Y.: P038
Indharty, S.: S17.4
Indredavik, B.: P152
Inggas, M.: S17.4
Inoue, Y.: P012
Inthnu, N.: P419
Intiso, D.: P271, P272
Ipatov, A.: P002
Isaeva, T.: P079, P287
Ishikawa, A.: P168
Ishikawa, M.: P012
Islam, M.: P227
Israel, V. L.: P330, P383
Ito, H.: P168
Ivanov, V.: P196, P287
Ivanova, G. E.: P126, P192, P201
Ivanova, G. E.: P211
J
Jablonski, M. B.: P039
Jacobsen, I.: P236, P273
Jacobsson, L.: P381
Jacquin-Courtois, S.: S15.2
Jaencke, L.: P133
Janaitis, C.: P089
Jäncke, L.: P156, P190
Jang, S.: P230, P274
Jannink, M. J. A.: P043, P123, P195
Jansa, J.: P228
Janssens, K.: P370
Januszewski, S.: P039
Jarrassé, N.: P125
Jee, S.: P040
Jenkinson, D. F.: P131
Jensen, M.: P022
Joël, M.: P215
Johansson, B.: P255
Johnels, B.: P331
Johnson, G. R.: P238
Jones, D.: P326
Joo, S. Y.: P031, P283
Jordan, B. D.: P275
Jörgensen, S.: P276
Jourdan, C.: P006
Jóźwiak, M.: P191
Judica, E.: P004, P277, P299, P343
Juknevicius, G.: P261
July, J.: S17.4
Jung, K.: P070, P292
Jung, P.: P188
Jung, S. J.: P278
Jung, S.: P167, P282
Jung, T.: P203
K
Kaczmarek, L.: P039
Kadi, F.: P107
Kagaya, H.: P363
Kaiser, W.: P224
Kakehi, A.: P012
Kakuda, W.: P168
Kanada, Y.: S04.2
Kanamori, D.: P038
Kanamori, R.: P291
Kanda, H.: P385
Kandylakis, E.: P294
Kang, E.: P179
Kang, G.: P292
Kang, S.: P103, P117
Kanovsky, P.: P137, P139
Karaagac, F.: P248
Karnath, H.: S15.1
Kasashima, Y.: P104
Katada, K.: P038
Katijjah, M. A.: P250
Katoh, J.: P285
Katusic, A.: P169
Katz, D. I.: S27.1
Katz, R.: P036
Kelemen, A.: P097, P279
Kent, R. M.: P212
Kerber, A.: P374
Kerkhofs, L.: P193
Kerman, K. L.: P194
Kersten, B.: P315
Kersten, P.: P320
Kesselring, J.: P256, P336
Khazri, L. H. M.: P269
Khusnullina, A.: P339
Kiechl, R.: P122
Kiekens, C.: P144
Kim, D. Y.: P278, P283
Kim, D.: P031, P103, P117, P179, P188, P203
Kim, E. S.: P031
Kim, E.: P055
Kim, H. J.: P353
Kim, H. Y.: P098
Kim, H.: P167, P188
Kim, J.: P282
Kim, J.: P286
Kim, M.: P167, P229, P274
Kim, S.: P071, P103, P229, P230
Kim, T.: P229, P230
Kim, Y. M.: P406
Kim, Y.: P040, P065, P071, P072, P117
Kimura, A.: P161
Kingma, H.: P311
Kiper, D.: P133
Kirkevold, M. M.: P249
Kiryk, A.: P039
Kitisomprayoonkul, W.: P105, P204
Kjaersgaard, A.: P284
Klauber, A.: P391
Kleiser, R.: P223
Klepo, I.: P053
Knestel, M.: P200
Knippenberg, E.: P193
Ko, W.: P292
Kobayashi, K.: P168
Koenig, E.: S27.2
Kofler, M.: P013, P050, P051, P077, P094, P119, P120, P241, P289, P387
Kollreider, A.: P121, P129
Kondo, I.: P206, P285, P291, P307, P308
Kongkasuwan, R.: P376
König, A.: P124, P190
Konjen,MD, N.: P365
Kono, M.: P026, P028
Könönen, M.: P183
Konovalov, R. N.: SWS.3
Kool, J.: P336, P426
Korosec, S.: P228
Kotkova, K.: P076
Kovindha, A.: P003, P419
Kovrazhkina, E. A.: P126, P201
Kozlovskaya, I. B.: SWS.3, SWS.4, SWS.7
Krabben, T.: P195
Krassnig, R.: P436
Krausz, G.: P132
Krebs, H. I.: P116, P118, PL03.1
Kremneva, E. I.: SWS.3
Krewer, C.: P124
Kristensen, T. M.: P011
Kristensen, T.: P108
Krombholz-Reindl, M.: P090
Krotenkova, M. V.: SWS.3
Kubo, J.: P034
Kubota, Y.: P285
Kuegelgen, B.: P379, P380
Kuegelgen, C.: P379, P380
Kugler, J.: P197, P198, P208
Kuhad, A.: P096
Kumban, W.: P420
Kumru, H.: P177
Kuptniratsaikul, V.: P365, P419, P421
Kurihara, M.: P012
Kwakkel, G.: P085, P326, PL04.3, S14.3
Kwasiborski, J.: P191
L
Labrunée, M.: P234
Ladenheim, B.: P118
Lafosse, C.: P369, P370, P431
Lajoie, S.: P081
Lam, J. M.: P164
Lam, T.: P102
Lambert, H.: P259
Lambiase, S.: P346
Lamers, I.: P193
Lampichler, J.: P347
Langørgen, E.: P152
Lannsjö, M.: P015
Larkin, A.: P340, P342
Larsen, T.: P231
Lata Caneda, M.: P360
Lau, P. M. Y.: P209
Laureys, S.: S05.2
Laxe, S.: P309
Lechner, P.: P037, P233
Ledl, C.: P170
Lee, D. S.: P283
Lee, G. Y. Y.: P054
Lee, H.: P117
Lee, H.: P392, P433
Lee, J. D.: P031
Lee, J.: P098, P229
Lee, K.: P055, P229, P230
Lee, M.: P286, P433
Lee, P.: P065, P072, P359
Lee, S.: P041, P106, P117, P286
Lee, W.: P187, P392, P393
Leemans, G.: P369
Leis, A. A.: P077
Lennon, S.: P130
Lentino, C.: P080
León, D.: P171, P309
Lequertier, M.: P025
Levin, M. F.: P232, S25.2
Lewis, G.: P111
Lexell, J.: P107, P219, P276, P381
Li, L.: S08.1
Li, T.: P392
Liang, H.: P392, P393
Liepert, J.: P030, P158
Light, K. E.: P172
Lim, C.: P352
Lim, J.: P179
Lim, M.: P055
Lima, C. C. C.: P422
Lima, M. A.: P225
Lima, N. M. F. V.: P355, P356, P357, P358
Lin, K.: P173, P359
Lin, Z.: P433
Lindberg, P.: P066, P227
Lindeløv, J.: P023
Lindeman, E.: P364, P367
Lindemann, U.: P164
Linden, D.: P157
Linderl, R.: P374
Lippert-Grüner, M.: P042, P382
Lisii, D.: P082
Lisnic, V.: P073
Littlewood, J.: P321
Liu, M.: P086, P104, P161
Liuzzi, G.: P037, P165, P233, P399
Ljungberg, C.: P255
Logi, F.: P142
Lombardi, T.: P271, P272
Lopez-Gutierrez, J.: P180
Loureiro, A. P. C.: P330, P383, P388, P422, P423
Lovic, A.: P180
Luaute, J.: S15.2
Luenenburger, L.: P124
Luft, A. R.: P046, P164
Luijkx, M. A.: P043
Lukianov, V. I.: P044
Lukyanyuk, E.: SWS.5
Lund, L.: P108
Lundgren Nilsson, Å.: P015, P331
Lünenburger, L.: P122, P190
Luy, A. T. K.: P209
Luyt, C.: P293
Lyadov, K.: P078, P079, P196, P287
M
Maas, A.: S17.2
MacDonald, C.: P045
Macfarlane, J.: P262
Macko, R. F.: P116, P164
Maeder, M.: P415
Maegele, M.: P042
Maetzener, F.: P415
Maier, M. A.: P066
Maiza, A.: P125
Maksakov, V.: P424
Maksakova, O. A.: P044, P114, P424
Malá, H.: P425
Malcolm, M.: P172
Malec, J. F.: S31.1
Malheiros, S. R. P.: P301
Malone, L. A.: P327, P328
Malouin, F.: P174
Mamitcheva, E.: SWS.5
Mammi, S.: P372
Man, D. W. K.: P054
Manikowska, F.: P191
Mansur, M.: P185
Manzoni, L.: P398
Marchese, R.: P210
Marchina, S.: S13.2
Marco-Pallares, J.: S13.3
Marcu, V.: P087, P258
Mardare, D.: P091, P093
Marienelli, L.: P210
Marin, A.: P351, P354
Marinelli, L.: P080, P437
Marino, S.: P067, P068
Markram, H.: CL1
Marnetoft, S.: P384
Marque, P.: P234, P288
Martín Mourelle, R.: P360
Martina, J. D.: P162, P163, P266
Martinelli Boneschi, F.: P004, P277, P299, P343
Martinelli, V.: P299, P343
Martinez Moreno, M.: P180
Martinez, D. P.: P216
Martino, G.: S01.2
Maruzzi, G.: P271
Maryam, A.: P250
Mast, J.: P118
Mathaneswaram, V.: P269
Mathiopoulos, A. G.: P389
Matsushika, Y.: P104
Matteis, M.: P407
Matzak, H.: P242, P289
Mauro, A.: P218
Mawson, S.: P205, P214
Mayer, S.: P119
Mayilvaganan, B.: P100
Mayr, A.: P119, P120, P121, P122
Mayr-Pirker, B. J.: P235
Mazzoleni, S.: P199
McCrory, P.: P323
McDonough, S.: P130
McKeown, G.: P409
McLaren, A.: P240
Mearin, F.: P309
Medina, J.: P171, P177
Mehdorn, H. M.: S02.1
Mehrholz, J.: P197, P198, P207, P208
Meier Khan, C.: P426
Meijer, J.: P175
Meijer, R.: P266
Meijide Faílde, R.: P360
Mejaski-Bosnjak, V.: P169
Melnik, K.: SWS.3, SWS.4
Menegoni, F.: P218
Mercier, C.: P081
Mérillat (-Koeneke), S.: P190
Mertel, K.: P427
Meyer-Heim, A.: P127, P133, P190, P432
Mhiri, C.: P253
Micera, S.: P199
Micha, M. C.: P294, P389
Michael, M.: P130
Michielsen, M. E.: P390, P428
Mihaescu, A.: P091, P093, P220
Mihara, M.: P069, P074
MIikadze, Y. V.: P020
Mikesova, K.: P076
Miki, K.: P032, P033
Miladi, M. I.: P253
Milano, E.: P218
Mildner, C.: P056
Miller, N.: SWS.4
Minnasch, P.: P137
Mirea, A.: P092, P099
Mitchell, P.: P181
Mittlböck, M.: P289
Miyai, I.: P012, P069, P074
Miyasaka, H.: P206, P285, P307, P308
Mizieva, Z. M.: SWS.6
Moeller, K.: P029
Mogensen, J.: P425
Molier, B. I.: P123
Molinier, F.: P288
Momosaki, R.: P168
Monteiro, C. B. M.: P301
Monterroso, L.: P118
Montoya, R.: P234
Morabito, R.: P067
Moraes, W. C.: P423
Moreira, M. C. S.: P400
Morel, G.: P125
Morgantini, A.: P334, P335
Mori, L.: P080, P437
Morioka, S.: P026, P028, P032, P033, P034, P110, P226
Moroz, O.: P002
Morris, M. E.: P323
Mouridsen, K.: P021
Moyano, A.: P140, P141
Mrachacz-Kersting, N.: P095
Müller, F.: P124
Müller, R.: P127
Müller-Putz, G.: P176
Mumma, M.: P290
Munjal, R.: P143, P303
Münte, T.: S13.3
Munteanu, L.: P073, P082
Muraoka, Y.: P086
Murdoch, B.: S18.2
Muresanu, D.: P093, S16.3
Murguialday, A. R.: S10.3
Müri, R.: P052, P315
Muri, R.: S27.2
Murillo, N.: P177
N
Nadeau, S. E.: P153
Nagai, S.: P012
Naidu, E.: P262
Nair, S.: P143, P303
Nakano, H.: P226
Naki, I. K.: P400
Namlal, R.: P222, P246
Narita, W.: P206, P291, P307
Nascimento, M.: P301
Nashriah, H.: P250
Naydin, V.: P114
Neculhueque, X.: P155
Nedelko, V.: P030, P158
Neugebauer, E.: S17.2
Newby, G. J.: P027, P060, P062
Newby, G.: P061, P063
Ng, T. K. W.: P209
Ng, T.: P352
Ng, V. Y. W.: P209
Nielsen, A.: P236
Nielsen, J. F.: P095
Nieuwboer, A.: P101, P326, S12.1
Nikkhah, G.: PL01.1
Nind, T.: P205, P214
Nique, S.: P349
Nitsch, M.: P399
Nobusako, S.: P032, P033
Nollet, F.: P213
Noori, D.: P241
Norton, A. C.: S13.2
Nowak, D.: P035, P154
Nuerk, H.: P029
Nusser Muller Busch, R.: P178, S07.1
Nuttin, B.: P144
Nyikos, I.: P327, P328
O
O’Rourke, C.: P194
Oberg, T. D.: P355, P356, P357, P358
Oesch, P.: P256, P426
Oh, B.: P106
Ohn, S.: P070, P071, P292
Ohta, K.: P206, P285, P291
Okada, M.: P307, P308
Okada, S.: P038, P363
Oliveira, R. L.: P237
Olokode, O. R.: P264
Olver, J.: P240
Omran, B.: P238
Ones, K.: P001, P248, P324
Onose, G.: P091, P092, P093, P099, P220
Onose, L.: P091, P092, P220
Osu, R.: P086
Ota, K.: P385
Otaka, Y.: P086
Oue, K.: P026, P028, P110
Overgaard, M.: P021, P022, P023
Overgaard, R.: P023
Owolabi, M. O.: P361, P362
Ozeki, Y.: P363
Özkan, A. K.: P313
P
Pace, L.: P407
Padure, L.: P092
Pagnussat, A. S.: P423
Paik, N.: P179, S29.2
Pais Ribeiro, J.: P344, P345
Paltamaa, J.: P295
Pandyan, A. D.: P131
Panourgia, M.: S20.1
Parcell, D.: P296
Pareto, L.: P255
Park, C.: P065, P070, P071, P072, P278, P283
Park, D.: P070
Park, H. J.: P031
Park, H.: P103
Park, J.: P188
Park, K. H.: P106
Park, S.: P055, P229, P230
Pascual-Leone, A.: P171
Pascual-Pascual, S. I.: P180
Passier, P. E. C. A.: P024, P364, P367
Pastura, C.: P068, P387
Pavlova, E. A.: P192
Pazdirek, J.: P149
Pearson, S.: P329
Pech, C.: P050, P051
Pedro, L.: P344, P345
Peichel, M.: P374
Pelayo, R.: P171
Pelikan, J.: P347
Pelosin, E.: P210, P437
Pelz, S.: P410, P413
Pennachi, A.: P358
Penson, J. G.: S11.2
Penson, N. P.: S11.2
Perdices, M.: S31.2
Perego, E. S.: P277
Perret, N.: P223
Peskine, A.: P018, P293
Peterson, M.: P275
Petrillo, V.: P346
Petropoulou, K.: P294, P389
Peungsuwan, P.: P310, P420
Peurala, S. H.: P295
Pfeiffer, A.: P347
Philipp, S.: P413
Phipps-Nelson, J.: P296
Phutakumnerd, W.: P376
Piassetta, B. L.: P423
Piemonte, M. E. P.: P401
Pierfederici, L.: P335
Pillay, M.: P246
Pinder, C.: P027
Pirani, G.: P334
Piravej, K.: P419
Piravej,MD, K.: P365
Pirstinger, G.: P429
Pitkänen, K.: P183
Placido Bramanti, A. F. C. Giuseppe Paladina.: P239
Platz, T.: P197, S26.2
Plewa, H.: P200
Ploypetch, T.: P421
Plummer-D’Amato, P.: P159
Pluta, R.: P039
Poenaru, D.: P087, P258
Pohl, M.: P197, P198, P208
Pokorny, J.: P042
Ponds, R. W. H. M.: P016
Ponsford, J. L.: P240, P296
Ponsford, M.: P240
Popescu, C.: P093
Popescu, F.: P099
Popescu, S.: P087, P258
Porubcova, N.: P366
Post, M. M. W.: P364
Post, M. W. M.: P024, P367
Posteraro, F.: P142, P199
Poustka, K.: P289
Powell, J.: S17.2
Poyares, L. C. S.: P301
Pradat-Diehl, P.: P018, P215, P293
Praditsuwan, R.: P421
Prager, J. P.: S11.3
Prange, G. B.: P043, P123, P195
Previtali, A.: P398
Prévost, C.: P018
Priest, J.: P009
Pucks-Faes, E.: P241, P242
Pujet, J.: P288
Pulte, I.: P137, P139
Pusswald, G.: P056
Pyk, P.: P133
Q
Quarenghi, A. M.: P398
Quarenghi, P.: P398
Quigley, D.: P019
Quirbach, E.: P013, P050, P051, P119, P120
R
Rababah, A.: P149
Rábai, K.: P097, P391
Rabaiotti, G.: P395
Radic, S.: P297
Rahim, R. B. A.: P269
Rajaratnam, S.: P296
Ram, D.: P121, P129
Ramsey, K. K.: P145
Ramusch, S.: P008
Rannou, F.: P066
Rapidi, C.: P294
Raspa, R.: P334
Redman, J.: P296
Rembitzki, I.: P186
Remy-Neris, O.: P136
Rennick Egglestone, S.: P214
Renta, M.: P220
Renzenbrink, G. J.: P043, P083, P298
Resnauer, L. C.: P422
Revol, P.: S15.2
Ribas, C. G.: P388, P422, P423
Ribbers, G. M.: P016, P244, P314, P390, P403, P428
Ricci, M.: P259
Richards, C. L.: P174
Riener, R.: P124, P190, P247
Rifici, C.: P094, P387
Rincon, M.: P057, P216
Rinkel, G. J. E.: P024, P364, P367
Risovic, M.: P430
Riva, N.: P395
Robertson, J. V. G.: P125, P243
Roby-Brami, A.: P125, P243
Rocha, A. M.: P237
Roche, N.: P036
Rochester, L.: P326
Rode, G.: S15.2
Roemer, D.: P005
Roosink, M.: P083, P298
Rosenstiel, W.: S10.3
Rosie, J. A.: P109
Rossetti, Y.: S15.2
Rossi, P.: P004, P277, P299, P343, P346, P348
Rosso, A.: P260
Roth, M.: P339
Rothmeier, C.: P158
Rothwell, J.: S12.2
Rousseaux, M.: P025, P368
Roy, A.: P116
Rubino, F.: P252
Rudzki, D.: P240
Rueffer, N.: S07.2
Ruegg, D.: P223, P223
Rukpongasoke, B.: P003
Rumiantseva, N. A.: P126
Rupp, M.: P302
Rupp, R.: P200
Rusina, G.: P002
Russo, M.: P272
Rydmark, M.: P255
Rymer, W. Z.: PL03.1
Rymer, Z.: PL03.2
S
Sabino, J.: P330
Sacco, R.: P256
Saccuman, M. C.: P346
Saenko, I. V.: SWS.3, SWS.4
Saeys, W.: P369, P370, P431
Saito, K.: P086
Saitoh, E.: P038, P206, P291, P363, S04.2
Sakurai, H.: P307, P308
Saltuari, L.: P013, P050, P051, P094, P119, P120, P121, P122, P241, P242, P289, P387, S02.3, S27.2
Salvi, G. P.: P398
Samsygina, O. M.: P192, P201, P211
Sander, D.: P005
Sandrini, G.: S27.2
Santana, A. C.: P355
Sant’Angelo, A.: P252
Santoni, R.: P334
Santos, R. B.: P300, P301
Santos, R. R. N.: P388
Sapa, M.: P124
Sarfeld, A.: P035, P154
Sarkodie-Gyan, T.: P045
Saunders, J.: P340, P342
Sauseng, P.: P233
Schache, A.: P323
Schauer, R.: P241, P242
Scheirs, S.: P370
Schlaug, G.: S13.2
Schmalohr, D.: P207
Schmidt, R.: P371
Schneider, L. M.: P058
Schneider, S.: S13.3
Schoenberger, M.: P240
Schoenfeld, A.: P030
Schreurs, M.: P144
Schubring-Giese, M. R.: P046
Schuh, A.: P300
Schuld, C.: P200
Schuler, T.: P127, P432
Schupp, W. J.: P014, P371
Schwab, M. E.: S22.2
Schwarz, S.: P302
Schweintzger, G.: P374
Šebková, N.: P048
Seelen, H. A. M.: P311
Seidl, R. O.: S07.3
Seitz, R. J.: P223
Sellers, E.: P132
Selles, R. W.: P390, P428
Selmane, D.: P136
Senjaya, F.: S17.4
Seo, J.: P103
Seo, K.: P103, P117
Seow, S.: P352
Šepec, V.: P053
Shaikhouni, A.: P194
Shannon, M.: P409
Shannon, N. A.: P264
Shapovalenko, T.: P078, P079, P196, P287
Shekleton, J.: P296
Shibata, N.: P291
Shih, H.: P433
Shim, E.: P065
Shimizu, S.: P032, P033
Shin, C. Y.: P098
Shinkuma, S.: P032, P033
Shklovsky, V. M.: SWS.5
Shug’a Aldin, A.: P149
Shum, D.: P341
Shvarkov, S. B.: SWS.6
Sicherl, Z.: P228
Sidyakina, I.: P079, P196, P287
Sidyakina, L.: P078
Siebler, M.: P005
Siegert, R. J.: P304
Siert, L.: P273
Silva, A. B.: P422
Silva, G. D. P. N.: P402
Silva, M. T. T.: P237
Silva, S. M.: P388
Singh, J.: P100
Singh, R.: P143, P303
Sinkjær, T.: P095
Siquinel, L. P.: P422
Siritaratiwat, W.: P322, P420
Sirtori, V.: P372
Sjögren, T.: P295
Sjölund, B. H.: P284
Skopetz, R.: P347
Skvortsova, V. I.: P126
Sladkova, P.: P394
Smirni, L.: P398
Smits, M.: P390, P428
Smits-Engelsman, B.: P101
Snela, S.: P191
Snell, D. L.: P304
Sogo, A.: P034
Soh, Y. M.: P352
Sohn, M.: P040
Song, M.: P117
Sonoda, S.: P012, P206, P291, P307, P308, P385
Sörbo, A.: P015
Spada, D.: P346
Spanò, B.: P067
Speight, I.: P156
Spier, E.: P045
Spierer, L.: P058
Spiesberger, R.: P347
Spircu, T.: P091
Spooren, A. I. F.: P311
Srisa-an Kuptniratsaikul,MD, P.: P365
Stam, H. J.: P314, P390, P428
Stapert, S.: P059
Starizin, A. N.: P126
Starrost, K.: P158
Staudt, M.: S03.1
Stefano, B.: P160
Stelling, H.: P181
Stepan, C.: P305
Stephan, K. M.: S26.3
Stęplowska, A.: P191
Stetkarova, I.: P077, P088
Stevanin, G.: P253
Sticher, H.: P415
Stienen, A. H. A.: P123
Stivali, C. M.: P356
Stock, R.: P152
Stoilkovic, V.: P416
Stokic, D. S.: P077, P084, P145, P146
Stolfa, L.: P423
Storch, A.: P208
Strand, L. I.: P217
Striebel, V.: P349
Stuart, M.: S08.2, S08.3
Stubbs, P. W.: P095
Stützer, P.: P336
Sueyoshi, N.: P026, P028, P110
Sullivan, K. A.: P153
Sun, H.: P041
Sung, H. C.: P396, P397
Sung, H.: P187, P392, P393, P433, P434, P435
Sunnerhagen, K. S.: P015, P255
Suputtitada, A.: P182
Surgenor, L. J.: P304
Surya, N.: P306, S04.1
Susteric, S.: P228
Sutton, D.: P275
Suvorov, A. U.: P126
Suvorov, A. Y.: P192, P201
Suwichai, J.: P003
Svecena, K.: P394
Svestkova, O.: P042, P382, P394
Swain, I. D.: P131
Szel, I.: P007, P411
Szewczykowski, F.: P025
T
Tack, I.: P234
Tagliabue, L.: P348
Tagliabue, M.: P125
Takano, L. L.: P260
Takayama, Y.: P012
Tamaki, H.: P032, P033
Tanabe, S.: P086
Tanaka, S.: P034
Tang, L.: P434, P435
Tang, X.: P128
Taniguchi, H.: P026, P028, P110
Tanino, G.: P308
Tapia, S.: P184, P373
Taraman, E.: P324
Taranto, M.: P357, P358
Tarkka, I. M.: P183
Tate, R. L.: S31.2
Tautscher-Basnett, G.: P008, P332, P333, P436, S27.3
Taylor, D.: P111
Teleianu, C.: P087
Teranishi, T.: P206, P285, P307, P308
Terlecka, M.: P405
Terré, R.: P309
Tettamanti, A.: P346, P348, P372, P395
Thaut, M. H.: S13.1
Thaweewannakij, T.: P310
Theamprasit, J.: P182
Therrien, B.: P194
Thompson, A. J.: S01.1
Thompson, J. N.: P264
Thümmler, K.: P410, P413
Timmermans, A. A. A.: P311
Tiwari, V.: P096
Tobar, R.: P184, P373, P386
Toledo, L.: P184, P373
Tolfa, M.: P272
Tölgyesy, S.: P411
Tölli, A.: P015, P312
Tomantschger, V.: P332, P333, P436
Tomelleri, C.: P129
Tominaga, T.: P026, P028, P110
Tonini, A.: P407
Tormos, J. M.: P171
Torresi, M.: P259
Torriani, C.: P151
Towersey, N. C. M.: P111
Triebl-Roth, K.: P374
Trompetto, C.: P080, P210, P437
Trotti, C.: P218
Tršinski, D.: P053
Truelle, J.: S17.2
Truijen, S.: P317, P318, P319, P369, P370, P431
Tsai, S. Y.: P396, P397
Tsai, S.: P187
Tsai, Y.: P112
Tsuji, T.: P104, P161
Turhan, N.: P313
Turner, D. L.: P128
Turner-Stokes, L.: S26.1
Tyson, S. F.: P212
U
Udompunturuk, S.: P421
Ulamek, M.: P039
Ungaro, D.: P004, P277, P299, P343
Urban, E.: P007, P438
Ushiba, J.: P104
Utarapichat, S.: P105
V
Valiante, C.: P398
Vallasciani, M.: P138
Valls-Solé, J.: P177
Vamos, T.: P411
Van de Heyning, P. H.: P317, P318, P319, P369, P370, P431
Van de Sandt-Koenderman, W. M. E.: P244
van der Geest, J. N.: P390, P428
van der Kooij, H.: P123, P195
Van der Meulen, A. C.: P244
Van Dongen, R. T. M.: P298
van Heugten, C.: P024, P059
van Kessel, M. A.: P314
van Kooten, F.: P314
van Riet Paap, D. I.: P213
van Wegen, E. E. H.: P085, P326
van Zandvoort, M. J. E.: P024, P364
Vaňásková, E.: P088
Vanbellingen, T.: P315
Vance, W. N.: P316
Vardy, A. N.: P085
Varley, R. A.: S18.1
Vasarhelyi-Toth, S.: P438
Vass, K.: P056
Venieri, M.: P294
Venkateshwara, G.: P143
Venkateshwara, G.: P303
Verboven, N.: P318
Vereeck, L.: P317, P318, P319, P369, P370, P431
Veres, R.: P391
Verhagen, A. P.: P314
Verheyden, G.: P320, P321
Vermeersch, K.: P144
Viana, J. R.: P330
Vidal, J.: P177
Vieira, M. M. F.: P151
Vieten, M.: P339
Vigo, G.: P080
Villarino Díaz-Jimenez, C.: P360
Vincent, C.: P081
Vingerhoets, F.: P223
Vismanos, L. S.: P147
Visser-Meily, J. M. A.: P016, P024, P059, P364, P367
Vitkova, M.: P375
Vloothuis, J. D. M.: P213
Voller, B.: S29.3
von Steinbüchel, N.: S17.2
von Wild, K.: S17.2, S17.3, S21.2, S22.1
Vos, P. E.: P270
Vuadens, P.: P223
W
Wada, Y.: P206, P285, P307, P308
Wahjoepramono, E. J.: S17.4
Waldner, A.: P113, P129
Wan, C.: S13.2
Wannapakhe, J.: P322
Ward, A. B.: P100, PL04.2, S20.2
Ward, N.: S28.3
Wasti, S. A.: P185, P222, P245, P246
Watson, R.: P392
Wattanapan, P.: P419
Weatherhead, S. J.: P027, P047, P060, P061, P062, P063
Weerdesteyn, V.: S14.1
Wegscheider, K.: P166
Weiller, C.: P030, P158
Weimar, C.: P005
Weinrich, M.: S08.2
Weiss, J.: P006, P215, P251
Werner, C.: P113, P129, P186, P198, P202
Westerberg, M.: P381
Whitaker, R.: P157
Wick, K.: P133
Wieser, M.: P247
Wigneron, G.: P368
Wilhelm, H.: P415
Wilkinson, A.: P205, P214
Willems, A.: P326
Williams, G.: P323
Williamson, K. D.: P264
Wilmes, S.: P415
Wilson, B.: S23.1
Wilson, L.: S17.2
Wissel, J.: P316
Wolters, G.: P059
Wong, E. Y. W.: P209
Wongphaet, P.: P257
Wood, G.: P029
Woods, R.: P157
Wu, C.: P173, P359
Wu, M. C.: P396, P397
Wu, M.: P187
Wu, S. S.: P153
Wutz, E.: P374
Wuyts, F. L.: P317, P318, P319, P369, P370, P431
Y
Yablon, S. A.: P084, P145, P146
Yagura, H.: P069, P074
Yamada, E.: P034
Yamaguchi, T.: P086
Yamamoto, T.: P034
Yardley, L.: P131
Yashkova, I.: P424
Yelisetty, R.: P327
Yi, J. H.: P353
Yilmaz Yalcinkaya, E.: P248, P324
Yilmaz-Kaymaz, N.: P010
Yip, C. C. K.: P054
Yokoi, A.: P168
Yokoyama, M.: P363
Yoo, H.: P055
Yoo, J.: P072
Yoo, S. J.: P031, P278
Yoo, S.: P188
Yoo, W.: P070, P071, P292
Young, W.: PL01.2
Yu, E. C. S.: P054
Yu, H.: P045
Yukawa, Y.: P026, P028, P110
Yun, H.: P041
Yun, J.: P325
Ywazaki, J. L.: P423
Z
Zaccari, T.: P334
Żak, E.: P191
Zampolini, M.: S32.2
Zarrelli, M.: P271
Zasler, N.: S05.3
Zauner, H.: P029, P090, P235, P429
Zebenholzer, K.: P056
Zeller, S.: P255
Zharikova, A.: P114
Zhavoronkova, L.: P114
Zholob, O.: P002
Zhu, L. L.: S13.2
Zimerman, M.: P037, P165, P189, P233, P399
Zimmerli, L.: P124, P190
Zipse, L.: S13.2
Zitnay, G.: S17.2
Zörner, B.: S22.2
Keyword Index
A
A.R.Luria: P020
ABI: P047
accreditation: P007
achilles tendon lengthening: P281
Acquired brain injury: P142, P262
Acquired, very severe brain damage: P108
Action Research Arm Test: P257
activities of daily living: P053
activity limitation: P291
activity participation: P352
activitymonitor: P224
Actovegin: P091
acute stroke: P126, P192
Acute Treatment: P167
adaptation: P411
adjustment: P063
aerobic training: P164, P429
aging: P276, S28.1
Agitated behaviours: P187
Agitation: P143
alcoholic neuropathy: P096
alendronate: P313
algorithm of treatment: P287
Alien environment: P245
alien hand syndrome: P291
Allocation Resources: P216
Alzheimer’s disease: P039, P157
Amadeo: P121
Amphetamine: S16.1
AMPS: P228
Amyotrophic Lateral Sclerosis: S10.3
Analgesia: S11.1
Angiogenesis Modulating Agents: P106
Animal model: P039
animal studies: S25.3
ankle foot orthosis: P212
Anomia: P017
anterior AFO: P182
antibiotics: P261
anxiety: P354
aphasia: P058, P103, P244, P324, P360, S13.2, S18.1
Aphasia/dysarthria: PL02.2
Apolipoprotein E: P240
Apraxia: P315
aquatic physical therapy: P330
arm: P043, P197, P201
arm dysfunction: P193
arm function: P161, P426
arm rehabilitation: P113, P186
Armor: P119
Armparesis: P158
articulation: P430
Asia: S08.1
aspiration: S07.3
aspiration pneumonia: P436
assessment: P228, P244, P273, P311, P339, S23.3
Assessment scale: P368
Assistive technology: P131, P205, P214
ataxia: P069, P074
Atrial fibrillation: P252
attention: P023, P179
attention deficits: P056
Attentional training: P335
audiovisual mirror neurons: P032
Auditory sensorimotor integration: S13.3
automated locomotion therapy: P200
Automobile driving: P055
axon regeneration: S06.2
Axonal regeneration: OL1
B
Baclofen: P149
Baclofen pump: P185
Bagging: P414
balance: P151, P210, P310, P317, P318, P322, P330, P342, P369, S14.1
Balance and gait: P203
balance skills: P076
balance training: P114
balancing exercise: P421
baropodometric evaluation: P239
basal ganglion: P064
BCI: P132, S10.1
behavioural and psychological symptoms: P393
behavioural problems: P392
Bell’s palsy: P073
Benchmarking: PL02.2
Bilateral arm cycling: P209
biofeedback: P078, P196
Biomechanics: P227
biopsychosocial: S11.2
Bladder scan: P353
blindsight: P021
block-anesthesia: P242
Bobath therapy: P254
body weight: P248
body weight support: P260
bombing: P430
Botox: P134, P140
Botulinum neurotoxin: P137, P139
botulinum neurotoxin A: P089
botulinum toxin: P088, P135, P180, P239, P437, S30.1
botulinum toxin therapy: P243
Botulinum Toxin type A: P407
botulinum toxone: P223
bowel malfunction: P289
brachial plexus injury: P112
Brain: P091
brain activity: P026, P028, P110
brain computer interface: S10.2
brain damage: P291, S17.3
Brain Imaging: SWS.2
brain injury: P015, P042, P044, P048, P049, P059, P076, P084, P114, P163, P266, P382, P424, S21.3, S23.2, S31.1
brain injury rehabilitation: S31.3
brain language: S13.1
brain plasticity: P175, P438, S13.2
Brain stimulation: S25.1
brain trauma: SWS.5
Brain-Computer Interface: P099, P132, S10.1
brain-machine interface: P104
brainstem stroke: P363
C
Calculation: P025
canonical-neuron system: P033
cardiopulmonary: P404
Cardiopulmonary function: P286
cardiovascular alterations: P094
cardiovascular risk factors: P276
caregiver: P387
caregiver burden: P266
case study: P412
catecholamines: S29.4
catheter: P261
Catheter Block: P100
CDS: P332, P333
Cell Therapies: PL01.2, S02.2
Cell Transplantation: S01.2
Central post-stroke pain: P071
cerebral anoxia: P293
Cerebral Ischemia: P041
Cerebral Palsy: P092, P097, P133, P135, P136, P147, P169, P191, P194, P248, P281, P301, P388, P420, S03.1
Cerebrolysin: P093
cerebrospinal fluid shunt infection: P090
Cerebrovascular accidents: P173, P359
certification: S27.1
cervical myelopathy: P066
child-friendly: P413
children: P127, P374, P410, P432, S03.1
Children with Neurodevelopmental Problems and Impa: P297
Children, Adolescents and Adults: S17.1
chronic pain: S11.2
chronic stroke: P164
Claw toe: P206
client satisfaction: P332
Clinical pathways: S20.2
clinical trial: P158
Clinimetrics: P359
CMT: P283
cognition: P331
cognitive: P024
Cognitive Communication Disorders: P273
cognitive disorders: PL02.3
cognitive dysfunction: P265, P341, P385
Cognitive function: P041, P434
Cognitive Impairments: S17.1
cognitive network: P072
cognitive rehabilitation: P023, PL02.3
Cognitive-perceptual function: P055
coma: P382
coma recovery scales: P247
Community Brain Injury: P060
community integration: P162, P386
Community-Based: P377
comorbidity: S20.1
compensatory training: P056
Complex Regional Pain Syndrome: S24.2
complications: P145, P146
comprehensive rehabilitation: P163
Computational Intelligence: P045
computer-assisted neurocognitive rehabilitation: P054
consciousness: P021, P049, S05.1
constraint induced movement therapy: P372, P412
Constraint Induced Therapy: P219
constraint-induced movement therapy: P218, P350, P410, P413
Constraint-Induced Therapy: P172
content: P378
contracture: P242
Contractures of knee: P134
Cooling garment: P336
Coping: P059
Cortical excitability: P109, P111
cortical thickness: P070
Costs: P215
coverage: S08.2
CPGS: S07.2
craniectomy: P181
cranioplasty: P027, P181
craniotomy: P027
Critical illness polyneuromyopathy: P271
Cross Culture: S17.4
cross-over in disciplines: P010
CRPS: S24.2
cueing: P085
Curriculum: S27.2
cutaneous silent period: P077
D
daily living activities: P411
Dance: P048
data base: P305
deafferentation: S29.3
decompressive craniectomy: P272
Deep brain stimulation: S02.1
degeneration: P042
delayed stroke rehabilitation: P365
Dementia: P187, P392, P393, P396, P397
Depression: P262, P263, P351
developmental: S03.3
Device: P206, P207
diagnostic: P052
diffuse axonal injury: P070, P270
Diffuse brain lesions: P020
diffusion tensor imaging: P066
digit span: P034
diplegic: P155
disabilities: P351, P354
disability: P002, P366, P389
discal: P082
discharge from hospital: P011
Disease Specific Questionnaires: S17.2
disorders: P430
Dizziness Handicap Inventory: P319
DOC: PL04.4
driven gait orthosis Lokomat: P432
driving: P418
drooling: P248
dual-task: P301
dysarthria: S18.2
dysautonomia: P270, S12.3
Dyscomfort: P368
dyslexia and dysgraphia: P417
dysphagia: P170, P259, P278, P284, P285, P302, P309, P325, P363, P373, P436, S07.3
dysphasia: P306
dystonia: P180, P437
E
E-effect: P431
e-Health: P255
Early Alzheimer’s Disease: P054
Early neurorehabilitation: P414
Early rehabilitation: PL04.1, PL04.2
early stroke rehabilitation: P010, P365
Ecological battery: P018
ecological test: P398
economic factor: S08.1
Education: S27.2
educational: S03.3
EEG: P099, P233
effect: P097
efficacy: P244
Elderly: P091, P220, P310, P399, P421, S20.1, S20.2
electrical stimulation: P161
electroencephalography: P114
electromyography: P077
electronystagmography: P317
EMG: P043, P292
employment: P367, P385
employment status: P331
energy expenditure: P408
Engineering: S32.1
entrainment: P115
epigallocatechin-3-gallate: P096
Epiglottitis: P285
Epilepsy: P434, P435
epilepsy surgery: P279
equinovarus foot: S30.3
equinus deformity: P281
Errorless learning: P017
errorless learning training: P054
ESWT: P040, P188
Ethics: P216, S19.3
evaluation: P125
evaluation methodology: P307, P308
event related potential: P247
every day life activities: P398
evidence: P418, S26.1
Evidence base: PL02.2
Evidence-based medicine: S31.1
evoked potentials: P083
executive functions: P051
Exercise: P041, P098, P225, P267, P337, P340
exoskeleton: P125
External auditory cueing: P264
Extracorporeal Shock Wave Therapy: P092
eye movements: P101
F
F.O.T.T.: P284
facio-oral functions: P178
fall: P225, P274, P310, P322
fall prevention: P421
families: P062
family role: P344
fathers: P062
fatigue: P256, P326, P339, P340, P343
FAVRES: P273
Fees: P284
fellowship: S27.1
Fiberoptic Endoscopic Evaluation of Swallowing: P282
Fibromyalgia: P057
figural fluency: P051
FIM: P252, P324
finger movements: P074
finger training: P121
five points test: P051
flexor muscle activity: P102
fMRI: P072, P183, P390, S05.2
fNIRS: P034
focal brain injury: P438
focal dystonia: P112
Folic acid: P434
Follow-up: P219
foot deformity: P288
foot drop: P213
force feedback: P123
functional MRI: P152
functional balance: P420
Functional Connectivity: S28.2
functional electrical stimulation: P213, S30.2
Functional Impairments: P045
Functional Independence Measure: P093, P230
Functional magnetic resonance imaging: P065, P067, P068
functional MRI: P218
functional near-infrared spectroscopy: P032, P033
functional outcome: P087, P314
functional prognosis: PL04.3
functional recovery: P165, P166, P194, P425, S22.2
functional RMI: P223
G
Gait: P031, P069, P084, P140, P159, P171, P198, P283, P295, P300, P301, P323, P402, S12.1
gait analysis: P256, P339
gait and posture: P239
gait rehabilitation: P129, P202, P258
gait restoration: P126
gait retraining: P120
gait training: P124, P327, P328
Gene Expression: P106
Geriatric assessment: P055
GMFM 88: P191
goal attainment: P157
Goals: P246
Graduate Institute of nursing: P433
Grasping: P035, P243
Gravity compensation: P195
Gravity-support: P193
Grip control: P109
Grip force: P035
group: P349
Group Therapy: P060
group work: P063
guide: P400
Guided interaction therapy: P108
Guideline development: S26.1
H
H-reflex: P040, P086
hand function: S29.3
Hand Rehabilitation: P075
haptic device: P117
head injury: P383
health care: S27.3
Health Related Quality of Life (HRQoL): P347, P381, S17.4
Healthy human: P036
hemineglect: S15.3
hemiparesis: P410, P413
hemiplegic: P234
hemiplegic stroke patients: P028
hemispace: S15.3
Hemispatial neglect: P406
Hereditary spastic paraplegia: P253
Hidden symptoms: P338
Hippocratic Oath: S19.3
hippotherapy: P300
history: S04.2
HIV/AIDS: P237
home care: P371
home exercises: P400
home rehabilitation: S32.2
home-based training: P200
HRQOLISP: P361
HTLV-I: P225
hyperactivity: P416
hypercalciuria: P313
hypereosinophilia: P235
hypnosis: P023
hypokinetic motor disorders: SWS.4
I
ICF: P011, P015
ICF framework: P008
identification: P417
illness perceptions: P304
Immobilization: P437
impairment: P024, P321, S18.1
implicit learning: P178
inclusion: P388
incontinence: P316
India: S04.1
Informal Care: P215
informatics: S32.3
insurance: S08.2
integrated care: P231
Integrity: P377
Intensity: P267
intensive functional training: P217
interaction: P125
interdisciplinary: P436, S04.2
interdisciplinary care: S11.2
interdisciplinary group concept: P427
interdisciplinary teamwork: P013
interlimb coordination: P074
Intermanual transfer: P035
International Comparison: S08.3
Intra thecal baclofen: P136
intracortical inhibition: P037
intracranial pressure: P383
intrathecal: P149
Intrathecal application: S02.3
intrathecal baclofen: P094, P142, P144, P145, P146, P387
intrathecal baclofen pump: P294
ischemia: S16.2
Ischemic brain: P039
ischemic stroke: P005, SWS.6
IT Pump: P100
J
Japan: S04.2
K
Ketogenic diet: P435
kinematics: P243, P402
Klippel-Trenaunay-Weber Syndrome: P391
L
Larynx: P038
learning: S31.3
learning to walk: P438
levodopa: P241
life satisfaction: P381
Life space assessment: P329
Light therapy: P187
location: P263
locked-in syndrome: S05.2
locomotion: P115
locomotion-therapy: P374
locomotor adaptations: P102
Lokomat: P102, P191
Lokomat gait orthosis: P120
Lokomat robotic assistive device: P122
long term care: P014
long term effect: P241
long term rehabilitation: P076, P250
Long-term neurological conditions: P009
long-term safety: P139
lower extremity: P116
lower limb: P372
M
magnetoencephalography: P085
manual movements: P080
Marital Satisfaction: P019
Master student: P433
measurement: P232, P238, S25.2
mechanical stimulation: SWS.3
mechanotherapy: P192, P201
medical ethics: S19.1
medical services: P014
Medium latency response: P095
melatonin: P296
Melodic Intonation Therapy: S13.2
memory: P157
Memory Self-efficacy: P016
mental retardation: P416
Mesenchymal Stem cells: S02.2
meta-analysis: P295
Mexico: S04.3
micro gravity: SWS.7
Migraine: P167
Mild traumatic brain injury: P303, P304
minimally conscious state (MCS): P067, P181, S05.3
Mirror neurons: P160
Mirror Therapy: P390, P428
MISA: P259
mobility training: P264
model: P009
Models: S23.1
Models of care: PL04.2
Motivation: P190, P205
Motivational Theories: P214
motor activity: P105
Motor Control: P173
motor cortex: P128
motor function: P150, P156
Motor imagery: P030, P101, P175
motor imagery training: P174
Motor Learning: P075, P189, P399, P401, S25.1, S25.3
motor memory: S07.2
Motor observation: P030
motor plasticity: P081
motor recovery: P046, P065, P199, S29.2
motor training: P427
motoric system: SWS.7
movement disorder: P064
movement disorders: S12.2
MS: S01.1
MSFC: P299
MTBI: P303
multidisciplinary approach: P250, P415
multidisciplinary therapy: P010
Multiple Sclerosis: P004, P068, P193, P218, P256, P277, P299, P335, P337, P338, P340, P341, P342, P343, P344, P345, P346, P347, P348, P408, P409, S01.2
music: P147, P346, S13.1
Music cueing: P204
music listening: P392
myelin inhibitors: S06.2
N
n-of-1 trials: S31.2
Narrative: P047
Narrative Therapy: P061
nasogastric tube: P325
Near-Infrared Spectroscopy: P069
neglect: P029, S15.2
neglect rehabilitation: S15.3
Nerve grafts: OL1
neural networks: S28.3
Neuro rehabilitation: P262, S20.1
neuro-recovery: PL03.1
neuro-urology: P316
neurodegenerative disorders: S12.3
Neurofeedback: P057
Neurogenesis: P098
Neurogenic Dysphagia: P184, S07.1
neuroimaging: S26.3
Neurologic disease: P237
Neurologic Music Therapy: P427
neurologic rehabilitation: P005
neurological: P404
Neurological disorders: P190
neurologists: S27.3
neuromodulation: S11.3
neuromuscular electrical stimulation: P148
neuropathic pain: S24.1
Neuropathy: S11.1
neurophysiological therapy: S07.3
neuroplasticity: PL01.3, S01.1, S14.3, S28.1
neuroprosthesis: P213
neuroprotection: S16.2
neuropsychiatric symptoms: P396
neuropsychological: P293
Neuropsychological assessment: P020
neuropsychological rehabilitation: S31.2
neuropsychology: P018, S23.1, S23.2
Neuropsychotherapy: P060, P061
neurorehabilitation: P033, P220, P302, P425, S01.1, S02.1, S04.1, S04.3, S08.1, S13.1, S13.3, S21.2, S25.3, S27.2
neurotechnology: S10.2
neurotomy: S30.3
neurotrophins: S29.4
Nogo-A: S22.2
non-motor symptoms: P333
Normative data: P319
numbers: P018
numerical representation: P029
Nursing: P138
nutrition: P289, S20.2
O
Obesity: P286
obsessive compulsive disorder: P052
obstetric brachial palsy: P180
Obstruction: P285
Occupational therapy: P297, P411
on-line comprehension: P058
online research database: P432
operculum: P306
Orthopaedic shoe: P403
orthosis: P186
orthosis-based home training: P165
oscillatory activity: P233
outcome: P012, P162, P240, P245, P246, P251, P272, P419, S23.3
Outcome Predictors: P004
outcomes: P224, S21.3
outpatient: P250
P
P300: P132
Paediatric Interactive Therapy System: P133
pain: P206, P277, S11.1, S11.3
Pain Management: P379, P380
paralysis: S10.2
paramedical professions: S27.3
Paraplegia: S22.1
parenting: P062
Parents: P047
paresis: P196, P358
parietal lobe: S15.2
Parkinson: P085, P208, P210, P331
Parkinson’s disease: P204, P264, P326, P327, P328, P329, P330, P332, P333, P402, S12.1, S12.2
Parkinsonism: P002
pathology: P082
pediatric ABI: S03.3
pediatrics: P118
Peg-in-Hole Technique: P238
pen-and-paper tests: P053
perception: P110
Perception of verticality: P370, P431
Perceptions: P131
perceptual training: P226
peripheral neuropathy: P096
peripheral sensorial ataxia: P395
phantom limb: P081
pharmacotherapy: P088, S05.3
pharyngeal electrical stimulation: P170
Phenol: P138, P141
phenol block: P112
philosophy: S19.1
Physical activity: P326, P408
physical dysfunctions: P354
Physical limitation: P237
physical therapy: P260, P349, P355, P356, P357, P388, P395, P422, P423
physiological instrumentation: S18.2
Physiotherapy: P134, P152, P207, P342, P409
Pituitary insufficiency: P312
plantar pressure: P274
Plasticity: P075, P086, S06.1, S13.3, S25.2
Pleiotropic: P093
plyometric exercise: P348
PNF and NMT treatment: P405
policy: S08.2
polyamine: S06.2
polyneuropathy: P175
Post-stroke spasticity: P139
posterior AFO: P182
poststroke spasticity: P223
Posttraumatic agitation: P269
posttraumatic amnesia: P269
posttraumatic plasticity: P425
postural balance: P307, P308
posture: P431
power: P323
practice guideline: S26.2
predictors: P360, P362, P364, S21.3
Preferred music listening: P393
pregnancy: P145
prescription of TMS: P079
Prevalence: P003
prevention: P073
prevention of falls: P307, P308
prevocational assessment: P394
principles: S07.1
prism adaptation: P026
Problem solving: P025
processing model: S07.2
prognosis: P221, P314, S26.3
progress report: P011
progressive resistance training: P107
proprioception: SWS.2
proprioceptive system: SWS.1
propriocorrection: P211
prostheses: P081
psyhological treatment: P049
protein synthesis: P046
psychometric properties: P266
psychosensorimotor: P394
Q
QST: S24.1
Quadriplegia: P099
Quality: P377
quality control: P015
quality management: P008
Quality of life: P059, P328, P334, P335, P337, P341, P343, P344, P345, P351, P352, P359, P360, P361, P362, P364, P365, P367, P368, P373, P375, P376, P384, P386, P387, P389, P397, S17.1, S17.2, S17.3
quantitative sensory testing: P298
R
radiculopathy: P077
RAS: P327
Rasch: S23.3
Rasch Analysis: P320
rats hypoxia-ischemia: P423
Re Use of IT Pump: P100
Recent use: S19.3
Recommendations: S26.1
recovery: P271, S14.1, S16.1
Regeneration: PL01.1, S06.1, S22.3
Rehabilitation: P004, P006, P057, P082, P153, P155, P159, P160, P173, P190, P199, P211, P214, P216, P231, P245, P249, P271, P272, P279, P299, P305, P311, P334, P338, P350, P363, P378, P379, P380, P382, P391, P419, P426, P428, PL04.4, S06.1, S07.1, S12.1, S14.3, S15.2, S18.1, S21.2, S23.2, S26.2, S31.1, S32.1, SWS.5
rehabilitation robotics: PL03.1
Rehabilitation settings: P334
rehabilitation software: P017
rehabilitation strategies: P398
rehabilitation team: P424
rehabilitation unit: P012
Relationship satisfaction: P019
religions: S19.1
Reorganization: P031, P042, S03.1
repetitive magnetic stimulation: P150
Repetitive transcranial magnetic stimulation: P071
residential community integration programme: P162
Respiratory Deficits: P415
respiratory physical therapy: P383
Respiratory therapy: P414
Resting State: S28.2
Resting-state Network: P065
restitution training: P056
Retina: OL1
return to work: P379, P380
rhizotomy: P155
right cerebral hemisphere injury: P026
rilke: P050
rising and sitting: P174
risk of falls: P371
robot: P197, P198
robot-aided therapy: P115
robotic: P124
Robotic Ambulatory Training: P222
robotic assisted gait training: P127
robotic devices: P126
robotics: P113, P116, P117, P118, P123, P129, P195, P199, P202
Role of Rehabilitation Physician: PL04.2
RSD: S24.2
rTMS: P103, P154
S
safety: P137
SAH: P312
scale: P259
SCI: S22.4
Screening: P315
seizure control: P435
seizures: P418
self rehabilitation contract: S30.1
sensation: P111
sensitivity and specificity: P318
Sensorimotor systems: P045
sensors: P224
sensory electrical simulation: P111
sensory impairment: P257
Sensory integration therapy approach: P297
Sensory loss: P370
sensory perceptions: P422
Sensory Stimulation: P184
Serious Games: P255
service delivery: P009
services: P007
Severity Disease: P345
SF-36: P389, S17.4
Short physical performance battery: P229, P230
Short term behavioural changes: P108
shoulder pain: P298
shoulder subluxation: P148
sialorrhea: P306
single-subject designs: S31.2
sit to stand: P420
Sitting Balance: P320, P321
Situated Learning: P249
skeletal muscle: P107
Sleep disturbance: P296
Sleep function: P003
Sliding Rehabilitation Machine: P203
slip: P274
SLP Intervention: P236
smart homes: S32.3
Snoezelen: P422
soles: SWS.3
soleus muscle: P423
somatosensory input: S29.3
Somatosensory stimulation: S29.2
spastic equinovarus foot: P288
Spastic paresis: S30.1
Spasticity: P040, P068, P073, P080, P084, P088, P092, P094, P095, P118, P122, P135, P138, P140, P141, P144, P146, P147, P149, P154, P169, P177, P182, P185, P188, P196, P227, P232, P242, P253, P254, P277, P292, P294, P348, P358, P375, P405, P407, P429, S30.2, S30.3
spatial attention: S15.1
spatial neglect: S15.1
spatial perception: P022
spatial representation: P029
special care units: P396, P397
SPECT: P064
SPG: P253
spinal cord: P066, P086, P391
spinal cord injury: P001, P144, P150, P177, P200, P220, P222, P276, P313, P322, P376, PL01.2, S22.1, S22.2, S22.3, S22.4
Spinal cord lesion: P003
spinal cord repair: S22.3
Spinal Cord Stimulation: S11.3
Spinal network: P036
splint: P161
sporttherapeutic based strength training: P347
stabilometry: P234
Stem cells: PL01.1, PL01.3, S01.2
stem-cell: P097
Step activity: P329
stretch reflex: P080
Stroke: P012, P016, P025, P030, P031, P043, P046, P078, P083, P087, P104, P105, P107, P109, P110, P113, P116, P117, P119, P120, P121, P129, P131, P148, P151, P152, P153, P154, P156, P159, P160, P168, P171, P172, P174, P176, P183, P186, P188, P189, P195, P201, P202, P203, P205, P209, P211, P212, P217, P219, P227, P228, P229, P230, P231, P232, P233, P252, P254, P255, P257, P258, P263, P267, P275, P278, P286, P287, P295, P298, P300, P315, P316, P320, P321, P324, P349, P350, P352, P353, P355, P356, P357, P358, P362, P366, P369, P370, P372, P373, P374, P375, P390, P400, P401, P403, P406, P419, P426, P428, PL03.1, PL04.3, S02.2, S08.3, S14.1, S14.3, S16.1, S16.2, S25.1, S25.2, S26.2, S26.3, S28.2, S28.3, S29.2, S30.2, SWS.5
stroke arm rehabilitation: P123
stroke outcome: P361
stroke patients: P226
stroke recovery: P037
stroke rehabilitation: P014, P130, P371, P429
stroke unit: PL04.3
stroke/SCI/TBI/CP: S28.1
stroke/SCI/TBI/MS: PL01.3
subacute stroke: P166
subarachnoid haemorrhage: P024, P364, P367
subarachnoid hemorrhage: P314
subcortical connectivity: P070
Subjective and objective assessment criteria: P236
support: P417
Swallowing: P038, P265
swallowing disorders: P178, P290
swallowing medication: P302
Swallowing process: P184
sympathetic: S24.1
Symptomatic treatment: P336
systematic review: P163
systemic side effects: P089
T
taxonomy: S05.1
TBI: P236, P303, P312, P385, S17.2, S21.2
tDCS: P036, P156, P171
technology: P311, S32.3
telerehabilitation: S32.2
temporal lobe epilepsy: P279
testing muscle tone: P122
Thalamocortical tract: P071
Theories: S23.1
therapy: P063
Thermosensitivity: P336
tibial posterior transposition: P288
time-frequency analysis: P234
Tizanidine: P095
TMS: P037, P183
tracheostomy: P278, P415
training: P007, P197, P198, P208, P401, S27.1, S29.4
transcranial direct current stimulation: P072, P104, P105, P166, P167, P179, P189, P399
Transcranial Magnetic Stimulation: P106, P168, S12.2, S18.2
transcultural aspects: S04.1
transplantation: P404, PL01.1
traumatic: P376
Traumatic Brain Injury: P006, P019, P052, P143, P179, P215, P240, P241, P249, P251, P269, P270, P275, P296, P309, P323, P381, P384, P386
Treadmill: P208, P260
treadmill exercise: P164
Treadmill training: P204
treatment: P416, PL04.4
treatment duration: P409
treatment protocols: PL02.3
treatment theory: S31.3
Trunk: P405
trunk performance: P369
tube-feeding: P289
Two years treatment: P136
U
Ukraine: P002
unconsciousness: P424
Upper Extremity: P172, P292
upper extremity function: P217
upper limb: P130
upper limb hemiparesis: P168
Upper Limb Motor Function: P238
Upper limb spasticity: P137
upper limb training: P119
upper-limb hemiparesis: P165
uric acid: P087, P275
Urinary retention: P353
UTI: P261
V
Vascular dementia: P098
vegetative and minimally conscious state patients: P247
vegetative nervous system: SWS.6
vegetative state: P067, P079, P221, P305, S05.2, S05.3
vestibular disorder: P317, P318
vestibular disorders: P078
VFSS: P325
vibration: P177
vibration-induced illusory movements: P028
vibratory stimulation: P176
vibrotactile stimulation: P169
video game: P151
video training: P158
Videofluoroscopic Swallowing Study: P282
videofluoroscopy: P290, P309
virtual realities: P127
virtual reality: P124, P130, P406, S32.2
visual cortex: P128
visual exploration: S15.1
visual imagery: P022
visual neglect: P022, P053
visual neglect and stroke: P128
vocational: P378
vocational assessment: P394
Vocational rehabilitation: P384
voxel-based lesion symptom mapping: P058
W
walking: P032, P153, P207
Walking ability: P403
Walking Speed: P222
weight-bearing rate of the lower limbs: P226
Wheelchair: S32.1
whole body vibration: P395
Wii-Fit®: P210
working memory: P034
320-detector row CT: P038