Helios Klinik Kipfenberg

BackgroundEven with high standards of acute care and neurological early rehabilitation (NER) a substantial number of patients with neurological conditions still need mechanical ventilation and/or airway protection by tracheal cannulas when discharged and hence home-based specialised intensive care nursing (HSICN). It may be possible to improve the home care situation with structured specialized long-term neurorehabilitation support and following up patients with neurorehabilitation teams. Consequently, more people might recover over an extended period to a degree that they were no longer dependent on HSICN.MethodsThis healthcare project and clinical trial implements a new specialised neurorehabilitation outreach service for people being discharged from NER with the need for HSICN. The multicentre, open, parallel-group RCT compares the effects of one year post-discharge specialized outpatient follow-up to usual care in people receiving HSICN. Participants will randomly be assigned to receive the new form of healthcare (intervention) or the standard healthcare (control) on a 2:1 basis. Primary outcome is the rate of weaning from mechanical ventilation and/or decannulation (primary outcome) after one year, secondary outcomes include both clinical and economic measures. 173 participants are required to corroborate a difference of 30 vs. 10% weaning success rate statistically with 80% power at a 5% significance level allowing for 15% attrition.DiscussionThe OptiNIV-Study will implement a new specialised neurorehabilitation outreach service and will determine its weaning success rates, other clinical outcomes, and cost-effectiveness compared to usual care for people in need for mechanical ventilation and/or tracheal cannula and hence HSICN after discharge from NER.Trial registrationThe trial OptiNIV has been registered in the German Clinical Trials Register (DRKS) since 18.01.2022 with the ID DRKS00027326.

In Germany, neurological-neurosurgical early rehabilitation is well established in the treatment of severe neurological diseases. To develop quality standards, knowledge of the current rehabilitation course is required. Aretrospective analysis was performed on the course of rehabilitation from patients in anearly neurological/neurosurgical rehabilitation program in 16centers from 10German states. The odds for agood or poor outcome were investigated using amultivariate logistic regression model. Seven hundred and fifty-four patients were included in the study. The average age of the patients was 68 ±15years. Of the patients studied, 26 % were on mechanical ventilation commencing their neurological rehabilitation. The average duration of stay was 56 ±51days. Weaning rate from mechanical ventilation was 65 % and the rate of weaning from tracheal cannula was 54 %. Mean improvement in the Barthel Index of 17 points, significant reduction of dysphagia (from 62 to 30 %) and depended walking (from 99 to 82 %), and the achievement of phaseC (the next stage of rehabilitation) in 38 % can still be counted as signs of successful rehabilitation. During their course of stay, near 10 % of the patients died. Of these, 67 % received solely palliative care. In the multivariate logistic models, the absence of the factor "necessity for mechanical ventilation on admission" (odds ratio 0.61; 95 % confidence interval (CI): 0.42…0.89) increased the chance for good outcome and the presence of this factor the risk of dying with an odds ratio of 8.07 (95 % CI: 4.54-14.34). In spite of the severity of neurological deficits, significant functional progress has been made. These results could be interpret as positive proof of the efficacy of neurological/neurosurgical early rehabilitation programs.

Etwa 5% aller in Spezialambulanzen gesehenen Bewegungsstorungen haben einen psychogenen Ursprung. Tremor und Dystonie stellen unter diesen die haufigsten psychogenen Bewegungsstorungen dar. In der Regel ist die Diagnosestellung zeitaufwendig und kostenintensiv, obwohl es eine Vielzahl von positiven klinischen Befunden fur das Vorliegen einer psychogenen Genese der Bewegungsstorung gibt. Insofern kommt der Kenntnis dieser positiven Befunde eine grose Bedeutung zu. Ein prompter Beginn der Erkrankung, die variable Auspragung der Symptomatik, Ablenkbarkeit und spezielle klinische Provokationsmanover konnen bei der Diagnosestellung helfen. Die Zusatzdiagnostik mittels Elektromyografie sowie kinematischer Aufzeichnungsverfahren konnen die Diagnose stutzen als auch, als Verlaufsparameter eingesetzt werden. Im Gegensatz dazu dienen die bildgebenden Verfahren eher der Ausschlussdiagnostik. Die vorliegende Ubersichtsarbeit widmet sich der Anamnese und Klinik, der Differenzialdiagnose und der Zusatzdiagnostik psychogener Bewegungsstorungen.

The cerebellum is involved in sensorimotor operations, cognitive tasks and affective processes. Here, we revisit the concept of the cerebellar syndrome in the light of recent advances in our understanding of cerebellar operations. The key symptoms and signs of cerebellar dysfunction, often grouped under the generic term of ataxia, are discussed. Vertigo, dizziness, and imbalance are associated with lesions of the vestibulo-cerebellar, vestibulo-spinal, or cerebellar ocular motor systems. The cerebellum plays a major role in the online to long-term control of eye movements (control of calibration, reduction of eye instability, maintenance of ocular alignment). Ocular instability, nystagmus, saccadic intrusions, impaired smooth pursuit, impaired vestibulo-ocular reflex (VOR), and ocular misalignment are at the core of oculomotor cerebellar deficits. As a motor speech disorder, ataxic dysarthria is highly suggestive of cerebellar pathology. Regarding motor control of limbs, hypotonia, a- or dysdiadochokinesia, dysmetria, grasping deficits and various tremor phenomenologies are observed in cerebellar disorders to varying degrees. There is clear evidence that the cerebellum participates in force perception and proprioceptive sense during active movements. Gait is staggering with a wide base, and tandem gait is very often impaired in cerebellar disorders. In terms of cognitive and affective operations, impairments are found in executive functions, visual-spatial processing, linguistic function, and affective regulation (Schmahmann's syndrome). Nonmotor linguistic deficits including disruption of articulatory and graphomotor planning, language dynamics, verbal fluency, phonological, and semantic word retrieval, expressive and receptive syntax, and various aspects of reading and writing may be impaired after cerebellar damage. The cerebellum is organized into (a) a primary sensorimotor region in the anterior lobe and adjacent part of lobule VI, (b) a second sensorimotor region in lobule VIII, and (c) cognitive and limbic regions located in the posterior lobe (lobule VI, lobule VIIA which includes crus I and crus II, and lobule VIIB). The limbic cerebellum is mainly represented in the posterior vermis. The cortico-ponto-cerebellar and cerebello-thalamo-cortical loops establish close functional connections between the cerebellum and the supratentorial motor, paralimbic and association cortices, and cerebellar symptoms are associated with a disruption of these loops.

Critical illness polyneuropathy is a common disorder in the neurological ICU. Dysphagia is well known to deteriorate outcome in the ICU. The prevalence of dysphagia in critical illness polyneuropathy is not known. The aim of this study was to evaluate the prevalence of dysphagia in critical illness polyneuropathy using fiberoptic endoscopic evaluation of swallowing. Prospective, cohort study. Neurological rehabilitation ICU. Twenty-two patients with critical illness polyneuropathy. Clinical swallowing examination and serial fiberoptic endoscopic evaluation of swallowing (days 3, 14, and 28 after admission). Swallowing of saliva, pureed consistencies, and liquids was tested using fiberoptic endoscopic evaluation of swallowing at three different time points. The penetration-aspiration scale by Rosenbek et al and the secretion severity rating scale by Murray et al were used for grading. Functional outcome after rehabilitation was assessed using the functional independence measure.: Pathologic swallowing was found in 20 of 22 patients (91%). Hypesthesia of laryngeal structures was found in 17 of 22 patients (77%) during the first fiberoptic endoscopic evaluation of swallowing. Over the 4-week follow-up period, laryngeal hypesthesia resolved in 75% of affected cases. Pureed consistencies were swallowed safely in 18 of 22 cases (82%), whereas liquids and saliva showed high aspiration rates (13 of 17 [78%] and 10 of 22 [45%], respectively). Swallowing function recovered completely in 21 of 22 (95%) within 4 weeks. Dysphagia is frequent among patients with critical illness polyneuropathy treated in the ICU. Old age, chronic obstructive pulmonary disease, the mode of mechanical ventilation, the prevalence of tracheal tubes, and behavioral "learned nonuse" may all be contributing factors for the development of dysphagia in critical illness polyneuropathy. Complete recovery occurs in a high percentage of affected individuals within 4 weeks.

Recovery of impaired motor functions following stroke is commonly incomplete in spite of intensive rehabilitation programmes. At 6 months following a stroke up to 60% of affected individuals still suffer from permanent motor deficits, in particular hemiparetic gait, that are relevant for daily life. Novel innovative therapeutic strategies are needed to enhance the recovery of impaired gait function following stroke. This pilot study has investigated the effectiveness of conventional physiotherapy in comparison to an apparative cyclic movement training over a period of 4 weeks to improve (i) power during a submaximal cyclic movement training of the lower limbs, (ii) cardiac fitness, (iii) balance and gait ability, and (iv) quality of life in stroke patients. In comparison to physiotherapy apparative cyclic movement training improved power, balance, cardiac fitness and quality of life to a greater extent. However, there was a statistically significant difference between both intervention groups only for balance but not for the other parameters assessed. The present pilot study should inspire future research with larger patient cohorts to allow appropriate judgement on the effectiveness of apparative cyclic movement training in stroke rehabilitation.

Das Bobath-Konzept ist eine losungsorientierte Vorgehensweise bei der Befundaufnahme und Behandlung von Individuen mit funktionellen Storungen, Bewegungsstorungen und Storungen der posturalen Kontrolle aufgrund einer Lasion des zentralen Nervensystems (IBITA 1996; Panturin 2001; Brock et al. 2002; Raine 2006). Dieser Ansatz zur Rehabilitation Erwachsener mit Storungen des zentralen Nervensystems entstand ursprunglich aus der Arbeit von Berta und Karel Bobath und wird nun bereits seit uber 50 Jahren weiterentwickelt. Als Grundlage fur die praktische Anwendung heute dient der aktuelle Wissensstand uber motorische Kontrolle, motorisches Lernen, neurale und muskulare Plastizitat sowie uber Biomechanik Daruber hinaus fliesen sowohl die Ergebnisse spezialisierter Behandlungserfahrung als auch die Bedurfnisse und Erwartungen der zu Behandelnden in diesen therapeutischen Denkansatz mit ein (Sackett 2000).

Upper limb function is the best predictor of long-term disability after stroke. Despite extensive rehabilitation, recovery of upper limb motor function is frequently incomplete after stroke. We review the pertinent literature on functional reorganization within the cerebral motor network after stroke and noninvasive techniques to modulate brain function towards beneficial plasticity. Direct current stimulation and repetitive transcranial magnetic stimulation are powerful tools to (i) modulate cortical excitability, (ii) induce remote changes within the cortical motor system and (iii) thereby improve upper limb motor function after stroke. Today no relevant side effects have been reported. Neuromodulation, by means of noninvasive brain stimulation techniques, has been shown to be a safe, feasible and effective method to promote recovery of motor function after stroke. However, several methodological and theoretical issues remain to be addressed in future work.