ZEITSCHRIFTEN / Neurologie & Rehabilitation / Archiv / 2004 4 / abstract 1

Neurol Rehabil 2004; 10 (4): 169-178  Tagungen & Kongresse 


Evidence-Based Medicine in Neurorehabilitation

3rd Joint Congress of the Swiss Society of Neurorehabilitation, Austrian Society of Neurorehabilitation, German Society for Neurological Rehabilitation and 1st Regional Meeting of the World Federation for NeuroRehabilitation (WFNR) in association with the German Speaking Medical Society for Paraplegia (DMGP)
Zurich, 30th September – 2nd October 2004

Abstracts Faculty

M.E. Schwab (Zurich, CH)

Spinal cord injuries with very extensive destruction of ascending and descending fiber tracts lead to paralysis without or with only minimal functional recovery (ASIA A,B). In contrast, smaller lesions which spare parts of the white matter can be followed by substantial functional recovery. Extensive rehabilitative training is required to reach an optimal, well adapted level of function. The neuroanatomical basis for this recovery process is not known. Animal experiments show that injured fiber tracts in spinal cord or brain show a spontaneous but small regeneration response. In the case of the pyramidal tract of the adult rat, transected hindlimb fibers sprout into the cervical spinal cord and form new contacts with spared propriospinal axons running from the cervical to the lumbar cord. In this way a new, indirect circuit is formed which allows to transmit information from the motor cortex to the hindlimbs through a cervical relay pathway. This spontaneous nerve fiber growth is limited in distance to about 1 mm, however.
Specific proteins were discovered in the adult spinal cord and brain that inhibit nerve fiber growth in the adult organism. A major factor is found in the myelin sheath of the fiber tracts and is called Nogo-A. The growth-inhibitory effect of Nogo-A can be neutralized by specific antibodies in vitro and in vivo. Infusion of Nogo neutralizing antibodies into the CSF of adult spinal cord injured rats or macaque monkeys leads to a massive enhancement of regenerative fiber growth. Extensive tests of locomotor behavior (rats) and skilled hand movements (monkeys) show a high degree of restoration of function. These findings indicate that adult spinal cord fibers can be stimulated in their regenerative ability, and that these growing fibers are able to form new circuits that mediate functional recovery in the absence of malfunctions. These results in animals form the basis for the development of a new therapeutic approach in spinal cord injured patients.

J.-W. Fawcett (Cambridge, UK)

Recovery from spinal cord injury can be achieved through the regeneration of cut axons, or through enhancing plasticity so that the surviving axons in partial lesions take over additional functions.
Axon regeneration in the spinal cord and other parts of the CNS is prevented by the poor regenerative response of most CNS axons, and by the inhibitory terrain through which they have to grow in the damaged adult CNS. The inhibitory terrain is due to the existence of inhibitory molecules such as NogoA and MAG on oligodendrocytes, and due to the production of inhibitory chondroitin sulphate proteoglycans (CSPGs) by the glial scar tissue that forms at sites of injury. There are at least five inhibitory CSPGs made by astrocytes and oligodendrocyte precursor cells. They are upregulated after injury, and in addition the amount of glycan sugar chain on the molecules is increased, increasing their inhibitory properties. The glycan chains can be digested away by the enzyme chondroitinase. This treatment has been applied to brain and spinal cord injuries, promoting axon regeneration and functional recovery.
The brain and spinal cord are highly plastic early in life during the “critical periods”. These terminate in humans at around 5 years old. CSPGs play a part in the turning off of plasticity at the end of the critical period in the brain, and probably also in the spinal cord. Digesting the CSPGs with chondroitinase can restart plasticity. This treatment should be able to help patients with both acute and chronic spinal injuries, in whom greater degrees of plasticity should aid recovery of function.
There are no treatments in development at present that have the potential to stimulate a complete repair of a spinal cord injury. However, there are a number of treatments that can promote plasticity and regeneration, and which should be able to bring about a significant improvement in the function of patients with spinal cord injury.

V.R. Edgerton (Los Angeles, USA)

There is little issue that the neuromotor system has considerable potential for plasticity with enables significant levels of functional motor recovery following traumatic insults to the nervous system. At the same time, it is remarkable how little we know about the mechanisms that underlie these recoveries. Much progress has been made in understanding the extent that spinal cord plasticity plays in mediating the recovery of load bearing, functional stepping and standing following severe spinal cord injury. In addition, the importance of integration of spinal and supraspinal circuitries is becoming more apparent. In this lecture, the role of activity dependent plasticity will be discussed. Evidence that the spinal cord can learn to step and stand and maintain equilibrium will be presented. Some of the neurotransmitter systems involved in the loss of motor control and its recovery will also be discussed. Given the ability of the neuromotor system to make significant adaptations that can result in improved motor function, the challenge for the immediate future is to identify those mechanisms that can be used in the clinic, which type of patients can take advantage of this information and finally, how much gain of function can be expected for a given patient over some time period.

M. Hallett (Bethesda, USA)

Brain injury, such as stroke, may lead to significant disability. Many patients improve spontaneously, at least to some extent, and after the acute period the principal mechanism appears to be brain plasticity, the capability of the brain to undergo change. There are a number of principles that underlie plastic processes. One is that there is continuous competition between body parts for representation in the central nervous system. A second one is that use of a body part enhances its representation and disuse leads to loss of representation. These principles have been demonstrated in humans most clearly with deafferentation and motor learning. They have begun to be applied in understanding spontaneous recovery from brain injury and in rehabilitation. Spontaneous recovery after stroke leads to plastic changes in both the damaged hemisphere and the undamaged hemisphere (ipsilateral to the weakened body part). Generally, better improvement will result with plasticity of the damaged hemisphere. The undamaged hemisphere seems to play a role early after stroke and achieves an important role if the damaged hemisphere does not recovery well. Physical therapy should help if there is attention to the weakened extremity, and this has been demonstrated by constraint-induced movement therapy. Physiological studies show enhancement of function in the damaged hemisphere after such interventions. Other techniques likely use the same principle such as neuromuscular electrical stimulation, robot-enhanced training and virtual reality training. Sensory stimulation enhances plasticity and can be delivered in a number of ways, from passive movement to cutaneous stimulation with transcutaneous electrical nerve stimulation and even acupuncture. Another principle is that reduction of inhibition enhances plasticity; this has been shown to be relevant with the deafferentation model. Our group has now demonstrated that this can be efficacious in stroke patients. We studied patients with weak hands and more preserved proximal arm function, with a goal of taking over some of the proximal representation in the brain for use by the hand. We coupled anesthesia of the proximal arm with exercise of the hand and showed that this increases hand function more than exercise alone.

H. Hummelsheim (Leipzig-Bennewitz, D)

In recent years, our understanding of motor learning, neuroplasticity and functional recovery after brain lesion has grown significantly. New findings in basic neuroscience provided stimuli for research in motor rehabilitation. Repetitive movement execution and motor activity in a real world environment have been identified in several prospective studies as favorable for motor recovery in stroke patients. EMG initiated electrical muscle stimulation and simultaneous voluntary and electrical muscle activation improves motor function of centrally paretic muscle groups. Furthermore, specific features within training procedures have been identified that render the interventions more efficacious. In particular, the influence of a training close to the patients’ individual limit of motor performance, the role of shaping elements and of repeated motor practice will be discussed.

G. Kwakkel (Amsterdam, NL)

Background and Purpose: To improve the accuracy of early post onset prediction of motor recovery in the flaccid hemiplegic arm, the effects of change in motor function over time on the accuracy of prediction were evaluated, and a prediction model for the probability of regaining dexterity at 6 months was developed.
Methods: In 102 stroke patients, dexterity and paresis were measured with the Action Research Arm Test, Motricity Index, and Fugl-Meyer motor evaluation. For model development, 23 candidate determinants were selected. Logistic regression analysis was used for prognostic factors and model development.
Results-At 6 months, some dexterity in the paretic arm was found in 38%, and complete functional recovery was seen in 11.6% of the patients. Total anterior circulation infarcts, right hemisphere strokes, homonymous hemianopia, visual gaze deficit, visual inattention, and paresis were statistically significant related to a poor arm function. Motricity Index leg scores of at least 25 points in the first week and Fugl-Meyer arm scores of 11 points in the second week increasing to 19 points in the fourth week raised the probability of developing some dexterity (Action Research Arm Test =10 points) from 74% (positive predictive value [PPV], 0.74; 95% confidence interval [CI], 0.63 to 0.86) to 94% (PPV, 0.83; 95% CI, 0.76 to 0.91) at 6 months. No change in probabilities of prediction dexterity was found after 4 weeks.
Conclusions: Based on the Fugl-Meyer scores of the flaccid arm, optimal prediction of arm function outcome at 6 months can be made within 4 weeks after onset. Lack of voluntary motor control of the leg in the first week with no emergence of arm synergies at 4 weeks is associated with poor outcome at 6 months.

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S.M. Golaszewski, K.M. Stephan, C.M. Siedentopf, F. Koppelstätter, F.M. Mottaghy, S.R. Felber, F. Gerstenbrand, R. Seitz, V. Hömberg (Meerbusch, Düsseldorf, Ulm, D; Innsbruck, Vienna, A)

Introduction: Stimulation of proprioceptive pathways using whole-hand electrical stimulation with a mesh-glove has been shown to improve motor performances of stroke patients with chronic neurological deficits. The aim of the study was to elaborate, whether changes in the motorcortex activation patterns can be demonstrated after electrical stimulation of the hand in normal volunteers.
Material and methods: All experiments were performed on a 1.5 Tesla MR-scanner in 10 healthy subjects. The motor-paradigm was self-paced finger-to-thumb-tapping of the left hand. Firstly, a baseline fMRI-examination and secondly subthreshold electrical stimulation with 0.9 mA was applied for 20 minutes outside the magnet to the left hand using a mesh-glove. Thirdly, an identical fMRI run to the baseline and the second run 12 hours post stimulation was performed. Post processing was done with SPM99.
Results: Group-analysis of fMRI-data showed: 1. Baseline fMRI-examinations revealed brain activation of the primary and secondary sensorimotor cortex as previously described. 2. After electrical stimulation of the left hand, there was an increase of activated pixels in these areas. 3. In addition, there was activation of regions not visible on the baseline studies. These involved the ipsilateral inferior parietal lobule, the pre- and postcentral gyrus and the superior parietal lobule. 4. These changes disappeared twelve hours post stimulation.
Conclusions: fMRI reflects an increased BOLD-response due to an increase of local-field-potentials within the sensorimotor cortex due to electrical stimulation. Thus, local-field-potentials can be successfully influenced by subsensory stimulation of afferent pathways. This holds promise for the application of fMRI in the planning of neurorehabilitation strategies.

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J. Kesselring (Valens, CH)

To restore the ability to drive is one aim of the rehabilitation of patients with neurological disabilities. In some instances, an evaluation is required in order to judge a patient’s fitness to drive in today’s traffic. Forty-three patients of the neurorehabilitation unit of the Valens Clinic were assessed by a standard traffic psychological test protocol and a control drive. In 88% there was agreement between the judgments based on each procedure. In 12% the judgements diverged. Four patients had failed either the psychological tests or the control drive but not both. A telephone interview two years after discharge showed that 3 of 4 patients drove anyway. One patient drove uneventfully but 2 patients who had failed the psychological tests had committed several minor traffic offences, one of them in addition a car crash while passing another car. Six patients had failed the psychological test and the control drive. Two drove nevertheless, one reportedly without problems, one having caused a traffic accident without person injury. Three stopped driving and one was lost to follow-up. The traffic psychological tests and control drive yield complementary information on the fitness to drive. However, the assessments need to be improved. New generations of driving simulators may refine the fitness to drive evaluation.

M. Keidel (Bayreuth, D)

Whiplash injury (WI) is followed by a posttraumatic syndrome (PTS) [1] which is comparable with the postconcussion syndrome (PCS) after mild traumatic brain injury (MTBI). The PCS describes a constellation of cognitive (e.g. poor memory, attention and concentration), emotional (e.g. irritability, sleep disturbance, nervousness, depressive mood, fatigue or anxiety) and physical (e.g. headache, neck pain, dizziness, vertigo or blurred vision) complaints. The persistent PCS is a major problem in litigation [2]. The factors causing chronicity of the PCS are a major matter of discussion.
Because subjective experiences and expectations, a maladaptive response to pain and stress, personal traits, malingering and a variety of psychosocial or cultural factors may influence the PTS in whiplash injury, one is tempted to consider it as a “fiction” without any necessity of compensation for litigants.
On the other hand evidence from quantitative EEG and MRI studies suggest a diffuse gray matter dysfunction correlated with neuropsychological deficits in PCS after MTBI.
With respect to WI objective “facts” of the “subjective” PTS will be presented (i) regarding electrophysiological correlates [3] and quantification of posttraumatic pain [4] and of vegetative disturbances, (ii) regarding quantification of neuropsychological deficits and of changes in mood, (iii) regarding posttraumatic changes in the (general) pain threshold and (iv) regarding the identification of risk factors for developing a chronic PTS.
Finally practical recommendations [5] will be given to prevent the development of a chronic PTS in WI and to avoid the need for such a multitude of legal expert opinions in this way. For insurance companies [5] and medicolegal purposes [6] in WI it turns out to be of more benefit to act as a preventive doctor rather than as a forensic expert.

1. Keidel M: In: Brandt T et al. (eds.) 2nd edition, Academic Press, Elsevier Science, New York 2003, pp 83-94
2. Keidel M: In: Rauschelbach, H.-H. et al. (eds.) 4th edition; chapter 34. Thieme, Stuttgart, New York 2000, pp 408-421
3. Keidel M et al. Pain 2001; 92: 319-326
4. Nebel K et al. Cephalalgia: in press
5. Strebel HM et al. Schweiz Med Forum 2002; 47: 1119-1125
6. Keidel M: In: Hierholzer G, Peters D (eds.) Springer, Stuttgart, New York 2001, pp 51-64

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C. Price (London, UK)

In this talk, I will highlight the different inferences that can be drawn from functional neuroimaging and neuropsychological studies of aphasia. Functional neuroimaging of neurologically normal subjects indicates that bilateral posterior and anterior regions of the superior temporal gyri are engaged during auditory speech comprehension.
Although damage to this system often impairs speech perception (e.g. patients with classic Wernicke’s aphasia), comprehension deficits are not consistent across patients. Indeed, damage to many areas of the normal system does not impair speech comprehension. Such resilience suggests that multiple neuronal systems might underlie speech comprehension. These systems might be expressed within the normal population or following neuronal reorganisation in patients. I will illustrate how multiple speech comprehension systems can be dissociated using functional imaging studies of patients who have recovered from aphasia.

A. Bellmann Thiran, M. Adriani, S. Clarke (Sion, Lausanne, CH)

A sound that we hear in natural setting allows us to identify the sound source and localise it in space. The two aspects are processed in anatomically distinct cortical networks, as demonstrated with fMRI in normal subjects. Middle temporal gyrus and precuneus bilaterally and posterior left inferior frontal gyrus were more activated in recognition than localisation; lower inferior parietal lobule and posterior middle and inferior frontal gyri were more activated (bilaterally) in sound localisation than recognition (Maeder et al. 2001). Relatively large unilateral right or left lesions of either of these networks were shown to result, in the chronic stage, in selective deficits of sound recognition or sound localisation (Clarke et al. 2000; 2002).
Three observations suggest that major reorganisation takes place within these networks following lesions. First, the correlation between deficit and lesion site is not the same in the acute stage, where we investigated the effects of predominantly small lesions; deficient performance in sound recognition and/or sound localisation was not always associated with the lesion of the corresponding network and, conversely, lesions of specific networks were not always associated with specific deficits (Adriani et al. 2003). The loss of specificity observed in the acute stage disappeared by the early chronic stage (Rey et al. 2004). Second, processing within the intact hemisphere is disturbed by the contralateral lesion, suggesting a key role of interhemispheric connections in the coordination of bilateral networks. This was demonstrated with psychophysical evaluation and fMRI paradigm in patients with unilateral right (Adriani et al. 2003) or left lesions. A decrease in activation in the intact hemisphere contralateral to the lesion was present independently of performance level, while loss of parallel processing within specialised networks correlated with deficient performance. Third, unilateral or bilateral lesions of the ascending auditory pathway at the level of the inferior colliculus or the acoustic radiation were shown to disturb parallel processing within specialised networks, with subsequent reorganisation that was accompanied by functional recovery.

C. Weiller (Hamburg, D)

Recovery of functions of the brain after localised lesions is related to a reorganisation of the brain, which can be influenced by behavioural and pharmacological treatment. A recent study using fMRI, diffusion tensor imaging and transcranial magnetic stimulation suggests two mechanisms of brain activation may be related to recovery of motor function after stroke. Improvement of function is found while activity during fMRI increases in primary areas or with a u-shaped development of activity over time. The latter pattern seems to be more related to normal relearning, reflected by a decreasing stimulation threshold, the former seems to represent a pathological compensatory mechanism, reflected in an increased threshold. The selection between both seems being made in dependency of the connecting tracts.
In recovery from aphasia activation of both, the remaining left hemispheric language related structures as right hemisphere “counterparts” have been put in relation to recovery. In a longitudinal design we found rapidly changing activation patterns in a language task during the first couple of days or weeks of recovery after stroke.

L. Saltuari (Hochzirl, A)

Treadmill training has become an important strategy in locomotion rehabilitation in patients with spinal and supraspinal lesions affecting central motor pathways. The authors present a prospective blinded randomised controlled study of gait rehabilitation in stroke patients using a new driven gait orthosis, Lokomat. Sixteen patients (6 men, 10 women, mean age 60.8, years range 25–86, with ischemic or hemorrhagic stroke were separated in two groups and underwent 9-weeks treatment in an ABA (group I) or BAB (group II) design (A=3 weeks Lokomat training, B=3 weeks conventional physiotherapy). The outcome of locomotion training was assessed with seven scales (EU-walking scale, Rivermead Motor Assessment scale (RMA), 10-m Time Walking Test (10-m TWT), 6-min Time Walking Test (6-min TWT), Motricity Index (MI) for the lower extremities, Oxford scale and Ashworth scale). Results of the EU-Walking scale, RMA, 6-min TWT, Oxford scale, and Ashworth scale demonstrated the superiority of the Lokomat-training to conventional physiotherapy on a significant level (p<0.05 Wilcoxon and Mann-Whitney-U-Test). Both 10-m TWT and MI showed a trend towards improvement in both groups following the phase of Lokomat intervention. Patients walked more symmetrically at higher velocity with improved ankle dorsiflexion during the swing phase, demonstrated a stable stance phase with less spasticity, and developed adequate equilibrium reactions. Improvement was smaller in group I than in group II, indicating a beneficial effect of the Lokomat over conventional therapy, which was proven by pooling 9 weeks of phase A (Lokomat) versus 9 weeks of phase B (conventional physiotherapy).
This driven gait orthosis provides superior possibilities for executing and training physiological gait patterns on a treadmill, and replaces unphysiological work effort on the part of the physio­therapist.

H. Schröter-Morasch (München, D)

Schlucken bedeutet die Aufnahme und Beförderung von Nahrung und Flüssigkeit von den Lippen bis zum Magen, aber auch den Abtransport von Speichel und Sekret aus Mundhöhle und Rachen. Dafür sind mehrere sensomotorische Funktionskomponenten wesentlich: (1) die Wahrnehmung der entsprechenden Substanzen (Geruch, Geschmack, Beschaffenheit, Konsistenz, Temperatur und Menge) zur Auslösung reflektorischer Funktionen (Speichelfluss, Schluckreflex) (2) kontraktile und propulsive Muskelbewegungen zur Erzeugung der entsprechenden Schubkräfte sowie (3) zeitgerechte Klappenfunktionen für die Einhaltung des korrekten Passageweges. Da sich Luft- und Speisewege im Rachen überkreuzen, ist insbesondere der adäquate Verschluss des Kehlkopfes während des Schluckvorganges essentiell.
Schluckstörungen treten bei einer Vielzahl von neurologischen Erkrankungen auf, am häufigsten nach Schlaganfall (initial >40%), Schädel-Hirn-Trauma, Tumoren und nach Langzeitintensivbehandlung. Stehen in der Akutphase die Sicherstellung von Atmung und Ernährung im Vordergrund (Schröter-Morasch 2003), muss in der Rehabilitation darüber hinaus nach klinischer und instrumenteller Diagnostik eine störungsspezifische Funktionelle Therapie erfolgen (Bartolome et al. 1999). Sie lässt sich in 3 Hauptkategorien unterteilen:
(1) Die restituierenden Methoden beinhalten krankengymnastische Techniken, übertragen auf den speziellen oropharyngealen Bereich. Dazu gehören Stimuli (z.B. die taktil-thermale Stimulation der vorderen Gaumenbögen zur Verbesserung der Schluckreflexauslösung), sowie ein sensomotorisches Training am Schlucken beteiligter Muskeln wie Zunge, Mundboden, Gaumensegel, Rachen und Kehlkopf durch gezielte schluckverwandte Einzelbewegungen oder Bewegungssequenzen (Bartolome 2004). Die Therapie kann durch Biofeedbacktherapie mittels Oberflächen-EMG ergänzt werden.
Da diese Therapieverfahren außerhalb des Schluckablaufes zur Anwendung kommen, werden sie auch als „indirekte Therapie“ bezeichnet.
(2) Kompensatorische Verfahren umfassen willkürlich initiierte Verhaltensänderungen während des Schluckablaufs (daher auch „direkte Therapie“ benannt), d.h. der reflektorische Schluckvorgang wird durch willkürliche erlernte Bewegungen modifiziert. Sie betreffen Haltungsänderungen und spezielle Schlucktechniken, welche zum Ziel haben, trotz defizitärer Wahrnehmung und/oder Muskelfunktion sicheres aspirationsfreies effektives Schlucken zu ermöglichen. So führt eine Kopfdrehung zur kranken Seite zur Verengung des paretischen Rachenraumes und der Speisebolus kann über die gesunde Seite abgeschluckt werden. Die wichtigsten Schlucktechniken sind kräftiges Schlucken, das sog. supraglottische und super-supraglottische Schlucken (zum willkürlichem Verschluss des Kehlkopfes) und das Mendelsohn-Manöver, das durch verlängerte Kehlkopfhebung eine verbesserte Öffnung des Speiseröhreneinganges ermöglichen soll.
(3) Adaptive Verfahren umfassen die die diätetische Anpassung sowie spezielle Ess- und Trinkhilfen. Eine individuell angepasste Dysphagiekost muss als wichtigste Kriterien die Bolusgröße und die Nahrungskonsistenz (flüssig, breiig, fest) berücksichtigen, welche effektives, sicheres Abschlucken ermöglichen, wozu auch die Applikationsform beitragen kann (z.B. spezielle Löffel, Tassen).
Zur Kontrolle der Effektivität der gewählten Therapiemethoden sind instrumentelle Untersuchungsverfahren wie Videoendoskopie und Videofluoroskopie unverzichtbar (Kuhlemeier et al. 2001).
Randomisierte doppelblinde Kontrollstudien zur Wirksamkeit der Funktionellen Dysphagietherapie lassen sich aus ethischen Gründen nicht durchführen. Plastische Modulationen des menschlichen Schluckkortex sind im Spontanverlauf nach Schlaganfall mit kortikaler Läsion nachgewiesen (Hamdy et al. 1998), die Wirksamkeit elektrischer Stimulation des Pharynx wurde 2002 von Fraser et al. belegt. Weiterhin existieren inzwischen zahlreiche Studien zur Wirksamkeit einzelner spezielle Übungen und Therapieverfahren.
Die Wiedererlangung einer ausreichend effektiven und sicheren oralen Nahrungsaufnahme bedeutet eine Vermeidung von lebensbedrohlichen Folgekomplikationen, eine verkürzte stationäre Verweildauer mit entsprechender Kostensenkung sowie eine nicht hoch genug einzuschätzende Verbesserung der Lebensqualität des Patienten.

1. Bartolome G: Neurogene Dysphagie. Tectum Verlag, Marburg 2004
2. Bartolome G, Buchholz D, Feussner H, Hannig C, Neumann S, Prosiegel M, Schröter-Morasch H, Wuttge-Hannig A: Schluckstörungen–Diagnostik und Rehabilitation. Urban & Fischer, München 1999
3. Fraser C, Power M, Hamdy S, Rothwell JC, Hobday D et al.: Driving plasticity in human adult motor cortex is associated with improved motor function after brain injury. Neuron 2002; 34: 831-840
4. Hamdy S, Aziz Q, Rothwell JC, Power M, Singh KD, et al.: Recovery of swallowing after dysphagic stroke relates to functional reorganization in the intact motor cortex. Gastroenterology 1998; 115: 1104-1112
5. Kuhlemeier KV, Palmer JB, Rosenberg D: Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients. Dysphagia 2001; 16: 119-122
6. Schröter-Morasch H: Medizinische Basisversorgung bei Dysphagie. In: Grohnfeldt M (Hrsg.) Lehrbuch der Sprachheilpädagogik und Logopädie, Bd. 4. Kohlhammer, Stuttgart 2003

R. Wise (London, UK)

It is known from studies on primate neuroanatomy that there are multiple reciprocal connections between the temporal lobe and prefrontal cortex. It is now suggested, from studies that combine auditory physiology with anatomy, that there are two or more “streams” of auditory processing in the rhesus macaque, and that these separate “streams” have different targets in their connections with prefrontal cortex. Functional neuroimaging studies, in both normal and aphasic subjects, are indicating that there are also several streams of auditory verbal processing in the human brain. In particular, there is considerable evidence that intelligible speech is processed in rostral temporal lobe regions, in the superior temporal sulcus, temporal pole and inferotemporal cortex; and that their connections are with ventrolateral and rostral prefrontal cortex via the uncinate fasciculus. Activity in the caudal superior temporal gyrus and sulcus is more closely associated with dorsolateral prefrontal cortex via the superior longitudinal fasciculus. I suggest there is evidence that one function of a caudal-dorsal stream of auditory verbal processing is to support speech rehearsal (repetition). Mimicry is a critical skill for the acquisition of language, and one not possessed by non-human primates. Rostral and caudal streams of auditory processing are likely to be intimately connected, and it is known that there are strong anatomical interconnections along the length of the superior temporal sulcus. The role of rostral and inferotemporal cortex in language comprehension is becoming evident from studies on the temporal variant of fronto-temporal dementia (semantic dementia), and disorders of speech production and repetition with caudal temporal lobe lesions are well recognised from the stroke literature. Although the study of pharmacotherapy in the treatment of aphasia is, to date, very limited and unconvincing, it is becoming apparent that changing monoaminergic function of the prefrontal cortex, especially in elderly subjects, may influence skill at language tasks even in the absence of brain pathology. Recognising the different anatomical and functional connections between the rostral-caudal and dorsal-ventral extent of the human temporal lobe and the ventrolateral, dorsolateral and rostral regions of prefrontal cortex will inform both behavioural and pharmacological interventions in chronic aphasic stroke.

G. Rode (Lyon, F)

Neglect is a neurological deficit for perception, attention, representation, and/or performing action within the contralesional space. This space-oriented behaviour disorder is predominantly consecutive to a damage of the right hemisphere syndrome, particularly the inferior parietal lobule (BA 39 and 40). Other areas, as BA 6, 8 and 44 and superior temporal sulcus are also involved11. The inferior parietal lobule 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 theoretical tracks may be distinguished in rehabilitation of neglect: a “top-down” approach including visual scanning training, cueing or sustained attention training, and a “bottom-up” approach including the sensory manipulations, eye patching method and prism adaptation. For the last method, improvement of neglect in visuomotor tasks may be explained by the sensori-motor post-effect consecutive to adaptation. Several results also suggest a high level cognitive post-effect as demonstrated the reduction after prism adaptation of representational neglect, number mental representation bias, dichotic listening and tactile extinction, underlying the bottom-up track of prism adaptation. Moreover in two recent studies, these two tracks were associated: visual scanning training with posterior neck muscles vibration or trunk rotation with a long-term improvement of neglect and disability. Lastly following a lesion of the right cerebral hemisphere, the different damaged cognitive processes: deficit of attention, intention, global-local processing, spatial memory and mental representation can all contribute to the clinical picture of neglect as well as the motor or sensory deficits. All these must be integrated in rehabilitation which has to be considered as a rehabilitation of spatial cognition disorders rather than rehabilitation of a focal deficit.

A. Schnider (Geneve, CH)

Much like other cognitive failures, the rehabilitation of memory disorders starts with the understanding of their mechanisms. Although most cases of memory disorder reflect an inability to store enough information (true amnesia), others reflect a disorganized memory (frontal memory failure) or even inadequate suppression (filtering) of memories (spontaneous confabulation). In this lecture, diverse approaches to the rehabilitation of memory disorders will be discussed. Amnesic patients profit from internal strategies that also improve memory in healthy subjects: deep encoding, vanishing cues, visual imagery, or errorless learning. In more severe amnesia, such strategies are insufficient and compensatory strategies have to be employed, such as, taking notes and developing strict everyday habits. An external memory aid with proven efficacy, both for insufficient storage and disorganized memory, is the use of a pager system. Future systems are likely to be much more practical and versatile. No controlled study has been done on the rehabilitation of spontaneous confabulation, a profound confusion of ongoing reality based on a deficient early filtering mechanism, which normally adapts thought to ongoing reality even before the content of an upcoming memory becomes conscious. This disorder probably requires limitation of sensory stimulation in order to prevent the provocation of false memories. Dopamine antagonists (neuroleptics) may be helpful.

M. Weinrich (Bethesda, USA)

The idiomatic phrase for predictions of impending disaster is “gloom and doom”. I think that the outlook for neurorehabilitation is more accurately captured by the phrase “gloom and boom”. Many of us, both in the clinical and research arenas, are experiencing little growth or even declines in the real funds available. Modest growth in national economies coupled with rapidly increasing expenditures for medical goods and services have strained the health care budgets for most of the industrialized world. We are poised on the threshold of an exciting new era in medicine, an era in which the promise of biotechnology is fulfilled with advances ranging from “designer” chemotherapy to tissue engineered replacement parts. These exciting developments, especially in acute care, inevitably compete for resources devoted to rehabilitation. So, there is little doubt that in the short-term, investigators in neurorehabilitation will face increased difficulties in securing research grants, and that clinicians providing rehabilitative care will face increased pressure from both public and private payers to curtail services and reduce costs.
However, there are a number of powerful forces working that I believe will ultimately expand neurorehabilitation greatly. The population in the industrialized world is aging rapidly. This means that there will be an increased emphasis on maintaining a productive, older workforce, and that there will be an advantage for health systems that can develop strategies to reduce disabilities, maintain individuals’ function and control costs. Many of us believe that neurorehabilitation interventions can accomplish these ends. It is now time for us to prove that they can and to ruthlessly eliminate those interventions that do not.
While there is increased competition for resources from other disciplines, neurorehabilitation has a new set of tools that can begin to create the kind of scientific excitement and major clinical advances that we have seen in other fields. These include functional imaging, gene therapies, tissue engineering, biomechanical modeling, to name just a few. We also are seeing a new generation of investigators and clinicians emerging that are taking on the challenge of developing effective treatments for stroke, brain injury and spinal cord injury.
There will continue to be major stresses on this field. Perhaps the largest stress will be cultural. Science is rapidly moving away from the “cottage industry” of the individual investigator working in an isolated laboratory to the collaborative, multidisciplinary model of “big science”. Medicine has embraced the concept of “evidence-based” practice, yet at the same time that the U.S. public spends as much on alternative medicine as it does on out-of-pocket expenditures for traditional medical treatment. To survive, neurorehabilitation must maintain the pace of scientific and clinical innovation while also retaining the essential elements of successful clinical interaction. I believe that we can do this by focusing on the traditional values of rehabilitation: patient centered, outcomes oriented, and self-critical. These values are not necessarily aligned with professional self-interest.
Neurorehabilitation will “boom” in the coming years, but not all of our current practices, and perhaps not all of our current professions, will survive. There will be no substitute for developing the evidence on which to base clinical practice, and there will be no denying the evidence.

S. Cappa (Milan, I)

The burden associated with cognitive dysfunction due to neurological disorders is enormous. Even limiting our consideration to the consequences of focal brain damage in adults, the impact of cognitive disorder on long-term functional prognosis is well-known. Cognitive rehabilitation has a long-standing clinical tradition in some areas of intervention (for example aphasia), and a more recent story in others (such as unilateral neglect or memory disorders following to closed head injury). The last decades have been characterised by an increased sophistication of research in the theoretical background of cognitive rehabilitation, and, to a lesser degree, in the neurological underpinnings of recovery. However, the basic issue of effectiveness remains highly controversial. In the recently published guidelines of the task force on cognitive rehabilitation established by the EFNS, a group of experts from different European countries have provided a critical evaluation of the available evidence, and have considered the specific methodological difficulties associated with evidence-based reviews in this area of clinical medicine. These include the problems associated with the organization of randomised clinical trials of rehabilitation of cognitive disorders, as well as the possible additional contribution of other weaker sources of evidence, such as single case studies.

N. Hogan (Cambridge, USA)

This presentation will review a decade of work focused on creating novel interactive robots to treat and understand motor impairment and disability. An initial pilot study of acute-phase in-patients recovering from stroke was successful and prompted (1) a larger study which showed that these results could be replicated and (2) a follow-up study which showed that the benefits were durable.
Subsequent studies demonstrated that similar and durable benefits could be obtained with chronic-phase stroke victims. Because interactive robotic treatment was administered to these stroke victims long after the period when recovery is usually considered to be complete, this is a striking and promising result. Equally important, interactive robotic therapy evoked a significant reduction of chronic pain which also proved to be durable.
Robotic tools also facilitate fundamental studies of neurorecovery. Kinematic studies of the recovery process showed that, similar to the development of motor behavior in infants, it begins with stereotyped submovements and proceeds by progressively merging these to approach unimpaired motor performance.
Exploration of the likely biology of recovery suggested a way to improve robotic treatment: performance-based progressive robotic therapy is aimed at accelerating a process akin to motor learning postulated to underlie recovery. Initial studies of this new treatment method showed a dramatic improvement over the previous successes.
Initial efforts to extend interactive robotic therapy to a wider range of upper-extremity functions will be reviewed.

J. Dewald, M.D. Ellis, B.G. Holubar, T. Sukal, A.M. Acosta (Chicago, USA)

Disturbances in movement coordination are the least well understood but often the most debilitating with respect to functional recovery following stroke. These deficits in coordination are expressed in the form of abnormal muscle synergies and result in limited and stereotypic movement patterns that are functionally disabling. The result of these constraints in muscle synergies is an abnormal coupling between shoulder abduction and elbow flexion, which significantly reduces a stroke survivor’s reaching space when he/she lifts the weight of the impaired arm against gravity. Whether or not abnormal muscle co-activation and associated joint torque patterns are responsive to intervention is an important issue for stroke rehabilitation given their detrimental impact on the workspace of the impaired arm in individuals with chronic severe impairment. We attempted to reduce abnormal elbow/shoulder joint torque coupling and enhance functional torque pattern production by implementing an isometric protocol that trained individuals to generate complex elbow and shoulder joint torque patterns away from the constraining patterns. Following only 8 weeks (3 sessions per week) of the multi-DOF (degree of freedom) protocol, subjects demonstrated a significant reduction in abnormal elbow flexion torque coupling during maximum shoulder abduction and a subsequent significant increase in ability to generate torque patterns away from the abnormal elbow/shoulder-coupling pattern. Based on these encouraging results we are currently implementing the testing of an Arm Coordination Training 3-D device (ACT 3D) for the measurement and rehabilitation of stroke-induced movement discoordination. The device is designed to deliver novel interventions that train individuals with a broad spectrum of upper extremity reaching impairment to progressively overcome the negative effects of gravity during 3-D reaching and retrieval movements. The ACT 3D also provides high-resolution measurements of physiological (strength and coordination) and functional performance (reaching workspace) evaluating the effectiveness of rehabilitation interventions. Therefore, quantitative outcome measures will be obtained and may be used to evaluate patient progress. Potential underlying neural mechanisms and clinical implications of our approach will be discussed.

R. Riener, G. Colombo (Zurich, CH)

Background: Manually assisted treadmill training has been used for many years in rehabilitation. It could be shown that this training improves walking capabilities in patients with different neurological diseases. The success of locomotor training seems to be dependent on an appropriate afferent stimulation of neuronal centres within the central nervous system.
Objectives: The Lokomat was developed too improve the possibilities of the locomotor training and to reduce workload of the therapists that are assisting the leg movements during manually assisted training. This device allows automatic movements of the legs of non-ambulatory patients during locomotion therapy. In addition the instrumented robot has the possibility to assess different motor functions of the patients during training.
Methods: With the Lokomat several performance variables can be determined in order to assess the motor function and biomechanical status of the patient. The measured variables will range from gait performance, spasticity and range of motion to voluntary motor control. The outcome measures obtained will be validated against standard clinical and functional measurement methods. It is expected, that the accuracy of this kind of measurements will be higher than standard manual measurements.
Also “patient-cooperative” techniques were developed, where the technical system considers the patient intention and efforts rather than imposing any predefined movement. It his hypothesized that cooperative approaches have the potential to improve the therapeutic outcome as they motivate the patient to actively contribute to the leg movement.
Findings: It has been shown that the Lokomat can be applied to different patient groups and there is already some evidence for functional improvements with some patient groups. Lokomat-based motor assessment techniques could successfully be implemented and are currently being evaluated in a clinical study. Cooperative control strategies have also been implemented and were tested on single subjects.
Conclusion: More intensive treadmill training in terms of duration and load can be performed in certain neurological patients with considerably less workload for the therapists. The induced gait pattern is more physiologic then in manually assisted therapy and the functional benefit for some patient groups could clearly be shown. The Lokomat has the potential to assess motor functions and to better incorporate patient activity.

M. Hadders-Algra (Groningen, NL)

Early intervention in infants with neurological dysfunction aims at 1) promotion of social, emotional, intellectual, motor and physical development, 2) prevention of secondary problems and 3) support of the family. However, no consensus exists about the best way to achieve these goals. This holds true for young infants being taking care of in the hospital, for instance in the neonatal intensive care unit (NICU), but also for older infants cared for at home.
In the NICU environment intervention varies between stress reducing programmes such as Kangaroo Care and Newborn Individualized Developmental Care and Intervention Program (NIDCAP), stimulation and developmental programmes, including NeuroDevelopmental Treatment (NDT), and programmes consisting of a mix of stimulation and stress reduction. The effect of these programs is heterogeneous, with the NIDCAP intervention having the best documented results. Evidence suggests that NIDCAP has a positive effect on the infant’s cognitive development, but not on motor development.
Programs for management of infants with neurological dysfunction in the home environment vary between infant stimulation programs such as the Portage Program and physiotherapeutical programs such as NDT or Vojta. The principle of the infant stimulation programs is that a trained paraprofessional home visitor uses an individual assessment of the infant to develop short- and long-term objectives for developmentally sequenced behaviours in six areas: infant stimulation, cognition, language, self-help, motor and socialization. Various studies indicated that infant stimulation programs have a beneficial effect on infant development. However, up till now it could not be demonstrated that NDT or Vojta have a positive effect on infant motor development. The absence of effect is remarkable as animal research suggests that intervention in early life can have a positive developmental effect. Possibly the absence of beneficial effect of early NDT and Vojta are due to the contents of these therapies, which aims at normalization of motor behaviour and reflex inhibition. Novel concepts on normal and abnormal motor development, such as the neuronal group selection theory suggest that keywords in early intervention in motor disorders might be variation and stimulation, whilst disregarding the aspect of normality of motor behaviour. Current research aims at testing the efficacy of this approach.

D.A. Johnson (Edinburgh, UK)

The concept of evidence-based medicine in pediatric neurorehabilitation carries a number of assumptions:
1. A complete recovery does not occur after injury to the developing brain
2. Clinical prognosis is accurate and meaningful
3. Rehabilitation services exist in hospital, school and community sectors.
4. Longitudinal follow-up continues into adulthood.
Unfortunately, the present state of knowledge offers little support for those assumptions. Essential evidence is sadly lacking for both evidence-based practice and, more fundamentally, pediatric rehabilitation generally.
Whilst the meta-analytic approach of evidence-based medicine may be appropriate for adult neurorehabilitation, the problem for pediatrics is the absence of interaction between scientists and clinicians, in the context of persistent misunderstanding and ignorance.
This presentation will consider the problems underlying these assumptions. Further, the ethical, moral and legal perspectives of continued professional and scientific neglect will be discussed in relation to an ageing population.

J. Evans (Glasgow, UK)

Technology has great potential for enabling people with memory impairments to compensate for their deficits, but to date has been under-utilised. In this paper I will review the range of “off-the-shelf” technological aids that are available, the evidence for their effectiveness with people with memory impairment and discuss their limitations. Adaptations of available technology offer greater promise of meeting the needs of people with memory impairment and two examples of such adaptations will be presented. NeuroPage, a paging based reminding system, is the only technological memory aid evaluated in a large scale randomised controlled trial, and is now available as a national reminding service in the UK. MemoJog, which is based on a Personal Digital Assistant platform, uses a new interface designed around the specific needs of people with memory impairment. Finally applications of alerting technology for improving prospective memory and “goal management” in patients with deficits in executive functioning will be discussed.

A. Dove, T. Manly (Cambridge, UK)

Executive functions refer to a range of high-level abilities that includes planning, using goals to guide our behaviour in everyday life, and the control of attention. These capacities are thought to be particularly dependent on the integrity of the frontal lobes – structures that are rather vulnerable in traumatic brain injury. Deficits in executive function can be subtle and difficult to measure using standard neuropsychological tests and yet have disastrous consequences for everyday functioning. Such difficulties may also undermine the effective use of other capacities that may be relatively intact. As the very functions that may support recovery and adaptation to injury (e.g. mental flexibility, insight) are compromised, rehabilitation in this area is inherently challenging.
One way to look at executive functioning deficits is not that these capacities are completely absent, rather that they are used unreliably or too intermittently. In a series of ongoing studies we have used environmental and technological manipulations to see whether we can increase the frequency of patients’ “executive moments”. Beginning with a computerised measure – that, for example, can be used in brain scanning studies – we have examined in detail the effect of periodic environmental cues for patients to maintain their attention. We have subsequently extrapolated these effects to more complex, life-like measures and shown that the performance of patients can be effectively normalised by such manipulations. Such effects are useful in assessing the level at which patients are experiencing difficulty and in suggesting useful rehabilitative techniques. Our current work is examining whether these effects can be reliably extended into patients’ everyday lives.

M. Laganaro (Geneva, CH)

Among the factors predicting the outcome of therapy for aphasia, the treatment intensity seems to be an important predictor (Basso & Caporali, 2001; Bhogal, Teasell, & Speechley, 2003; Denes, Perazzolo, Piani, & Piccione, 1996). Intensity can be conceived either in terms of number of therapy sessions over a given period of time, or in terms of intensity of task and item repetition during therapy. Both issues of intensity can be addressed by the introduction of computer assisted treatment (CAT) in therapy for aphasia. Studies on computer assisted therapy (CAT) have shown encouraging outcome with chronic aphasic speakers, especially when the CAT programs focus on specific aphasic impairments, anomia for example (Pedersen et al. 2001, Fink, Brecher, Schwartz and Robey, 2002). In a preliminary study (Laganaro, Di Pietro and Schnider, 2003) we showed that individually adapted CAT can be effective as an adjunct to clinical therapy for anomia, not only with chronic aphasic out-patients but also in acute in-patients. In that study CAT proved to be a useful means to increase the number of therapy sessions. In a further study (Laganaro, Di Pietro and Schnider, subm.) we directly addressed the question of intensity in CAT for anomia. Our results suggested that the effect of therapy for anomia also depended on the number of treated items. This is probably linked to the fact that the speed of recovery depends on the linguistic properties of the treated items and can vary according to the anomia type. Perspectives on the introduction of CAT in order to increase treatment intensity and number of items in therapy for anomia are discussed.

J. Hollenweger (Zurich, CH)

In 1980, the World Health Organisation (WHO) published a new framework to clarify the nature of disabilities. Just one year later – the International Year of Persons with Disabilities – the ICIDH (International Classification of Impairments, Disabilities and Handicaps) provoked criticism, mainly from consumer and advocacy groups – the emerging voice of persons with disabilities themselves. The initial ICIDH model will be described along with the successive criticisms mainly by disability advocates. This eventually led to its revision.
The first version of the revised classification which was widely circulated was the Beta-1 version of the ICIDH-2. A Beta-2 version followed with some conceptualisations altered and improved. International field trials were carried out and the results analysed. Particular attention was accorded to the distinction between the conceptualisation of activities and participation. These considerations led to encompassing these two dimensions into a single domain. This development and the guiding principles that underpinned the revision process will be explored.
As a result of these efforts, the ICIDIH-2 was approved in 2001 by the World Health Assembly in 2001 and renamed “International Classification of Functioning, Disability and Health”. The philosophy of the ICF along with its purposes and limitations will be explored in this paper.

K. Theodoroff (Hermagor, A)

The “International Classification of Functioning, Disability and Health” (ICF) provides a description of situations with regard to human functioning and its restrictions. It may serve as a framework to organize this information. It structures the information in a meaningful, interrelated and easily accessible way.
ICF organizes information in two parts. Part 1 deals with Functioning and Disability, Part 2 covers Contextual Factors. Each part has two components.
Part 1: Functioning and Disability: The Body component comprises 2 classifications: one for functions of body systems and one for body structures. The chapters in both classifications are organized according to the body systems.
The Activities and Participation component covers the complete range of domains denoting aspects of functioning from both an individual and a societal perspective (i.e. activity and participation.
Part 2: Contextual Factors: A list of Environmental Factors is the first component of Contextual Factors. Environmental factors have an impact on all components of functioning and disability.
Personal Factors are also component of Contextual Factors but they are not classified in ICF because of the large social and cultural variance associated with them.
The components of Functioning and Disability can be expressed in two ways. On the one hand they can indicate nonproblematic (i.e. neutral) aspects of health-related states summarized under the umbrella term “functioning”; on the other hand they can be used to indicate problems (e.g. impairment, activity limitation or participation restriction) summarized under the umbrella term “disability”.
A person’s functioning and disability is conceived as a dynamic interaction between health conditions (diseases, disorders, injuries, etc.) and contextual factors (including both personal and environmental factors). The basic construct of the Environmental Factors component is the facilitating or impeding impact of features of the physical, social and attitudinal world.
All components classified in ICF are quantified using the same generic scale (qualifying terms: 0=none, -1=mild, -2=moderate, -3=severe, -4=complete). Having a problem may mean an impairment, activity limitation, participation restriction or barrier depending on the construct. For quantification to be used in a specific manner, assessment procedures need to be developed.

P. Frommelt (Schaufling, D)

This presentation will focus on the use of the ICF in clinical neurorehabilitation. It will outline our own approach in incorporating the ICF into goal-setting and as a tool for assessing work-related disabilties in persons with neurological disorders. As others have noted the introduction of the ICF in daily practice is neither easy nor is the benefit immediately evident for those who are expected to use this classification. One of the pioneering work has been presented by Rensch and his team from Luzern.
Why is it useful to introduce the ICF into clinical practice? The main gain is the theoretical construct on which the ICF is based. It shifts the focus from a medical model of rehabilitation towards a social perspective in which person and social context interact. The inclusion of the component of context transforms the traditional individualised perspective of disease. In a way the ICF facilitates a movement towards an community based rehabilitation. The social model of chronic diseases as outlined by the ICF and operationalised in the component of participation has not been the dominant disease-model in professional training at least not in Germany. Training staff in the philosophy of ICF can be used to form a new common paradigm of neurorehabilitation and establish basic concepts shared by different professions. In practical application the goal setting based on the ICF changes the process from a symptom- to a participation-orientation. In a bottom-down approach the long-term goals referring to preferred social roles are defined and then in a deductive process the lower level functional goals which lead towards the participation goals. The workshop will provide practical examples for the goal-setting process. While the framework of ICF is finding increasing support by large professional organization e.g. the American Psychological Association, there are different obstacles which impeded the use of the item-list and its coding. The volume with over 1100 items makes it nearly impossible to include the total catalogue into busy clinical practice. In addition, the terminology is often different from traditional professional language. A further obstacle is the lack o

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