[Evidence-based rehabilitation of mobility after stroke]. / Evidenzbasierte Rehabilitation der Mobilität nach Schlaganfall.

BACKGROUND: Approximately two thirds of stroke patients initially suffer from at least impaired mobility. Various rehabilitation concepts have been proposed. OBJECTIVE: Based on the current literature, which rehabilitation methods can be recommended for improvement of gait, gait velocity, gait distance and balance? METHODS: A systematic literature search was carried out for randomized clinical studies and reviews with clinically relevant outcome variables. Formulation of recommendations, separated for target variables and time after stroke. RESULTS: Restoration and improvement of gait function relies on a high number of repetitions of gait movements, which for more severely affected patients is preferentially machine-based. For improvement of gait velocity for less severely affected patients intensive gait training does not necessarily rely on mechanical support. Gait distance can be improved by aerobic endurance exercises with a cardiovascular effect, which have to be performed in a functional context. Improvement of balance should be achieved by intensive functional gait training. Additional stimulation techniques are only effective when included in a functionally relevant training program. DISCUSSION: These guidelines not only provide recommendations for action but also provide pathophysiological insights into functional restoration of stance and gait after stroke.

[Rivermead assessment of somatosensory performance: validation of a German version (RASP-DT)]. / Rivermead Assessment of Somatosensory Performance : Validierung einer deutschen Version (RASP DT).

BACKGROUND: Sensory deficits after stroke are common and impact motor regeneration and the total length of hospital stay as well as quality of life factors including the independence to conduct daily life activities. There is currently no existing reliable and standardized assessment tool to measure somatosensory performance in the German language. The aim of our study was to translate the original version of the Rivermead assessment for somatosensory performance (RASP) into German and to study its reliability in a German-speaking population sample. METHODS: The translation of the English original version followed the protocol of the Medical Outcomes Trust. The German version was assessed with 60 patients with first time presentation of subacute stroke and AC1 coefficients were calculated to measure interrater reliability for the different subtests. RESULTS: The mean AC1 value was 0.75 (range 0.58-0.81). The interrater reliability was good to excellent for all subtests. CONCLUSION: The German version of the RASP (RASP-DT) developed in this study is a reliable assessment instrument for sensory deficits after stroke.

Multiple strokes and bilateral carotid dissections: a fulminant case of newly diagnosed Ehlers-Danlos syndrome type IV.

Ehlers-Danlos Syndrome is a rare group of inheritable disorders resulting in abnormal collagen production, leading to skin fragility, joint hypermobility and easy bruising. Six major subtypes have been identified, of which Type IV most often leads to neurovascular complications, may lead to inner organ rupture and overall has the worst prognosis. Early recognition followed by genetic testing is key, since this diagnosis will guide decision making in the management of complications, influence the choice of antiplatelet medications versus anticoagulants and allow for potentially affected family members to be identified, undergo genetic testing and reproductive counseling. We here report the case of a 50 year old woman with a fulminant presentation of Ehlers Danlos Syndrome Type IV, including bilateral carotid and vertebral artery dissection, multiple strokes and liver rupture. Of note, this patient did not have a known history or obvious clinical features of connective tissue disease. Genetic testing confirmed the diagnosis. Review of her family history revealed multiple family members with a history of aortic dissection or aneurysm rupture. This case illustrates that Ehlers Danlos Syndrome Type IV is an important differential diagnosis even in adult patients without a known history of connective tissue disease and no prior complications.

[Rehabilitation of Parkinson's patients with deep brain stimulation. Experiences of the Neurological Rehabilitation Center Godeshöhe]. / Rehabilitation von Parkinson-Patienten mit Tiefenhirnstimulation. Erfahrungen des Neurologischen Rehabilitationszentrums Godeshöhe.

BACKGROUND: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) has become an important therapeutic option in patients with advanced Parkinson's disease (PD). An increasing number of patients are referred for hospital rehabilitation after initial programming. The role of further DBS and medication adjustments for this rehabilitation therapy is uncertain. METHODS: This study was a retrospective analysis of a hospital rehabilitation program with a systematic algorithm to improve DBS efficacy in PD patients referred within 3 months after electrode implantation. This study analyzed (1) changes of stimulation parameters and medication and (2) changes in the performance of activities of daily living as measured by the Barthel index. RESULTS: After an average of 20.4±10.7 days following surgery 95 PD patients were hospitalized for an average rehabilitation period of 29.0±11.2 days. Technical dysfunctions were found in 3 (3.1%) patients and a bilateral electrode dislocation in 1 (1.1%) patient. Stimulation parameters were adjusted on 7.3±4.0 days, sometimes with several adjustments on the same day. Until discharge the stimulation amplitude was significantly increased from 2.1±0.8 V to 3.0±0.8 V. Moreover, in 70 (73.7%) patients active stimulation contacts were changed. The mean levodopa equivalent dosage decreased from 529±290 mg/die to 300±277 mg/die. The Barthel index increased significantly by 10.3±12.4 points. CONCLUSION: Further DBS and medication adjustments play an important role for hospital rehabilitation of PD patients after initial DBS programming in DBS centers.

Homing in on the specific phenotype(s) of central respiratory chemoreceptors.

To some it may seem that we now know less about respiratory chemoreception than we did 20 years ago. Back then, it was widely accepted that the central respiratory chemoreceptors (CRCs) were located exclusively on or near the surface of the ventrolateral medulla (VLMS). Now, instead, it is generally believed that there are widespread sites of chemoreception, and there is little agreement on when and how each of these sites is involved in respiratory control. However, those in the field know that this actually is progress, primarily because we have gone from simply identifying candidate regions, to identifying specific neuronal subtypes that may be the sensors. In this invited review, we have been asked to discuss some of the current controversies in the field. First, we define the minimal requirements for a cell to be a CRC, and what assumptions can not be made without more data. Then we review the evidence that two neuronal subtypes, serotonergic neurones of the midline raphe and glutamatergic neurones of the retrotrapezoid nucleus, are chemoreceptors. There is evidence supporting a role in respiratory chemoreception for both types of neurone, as well as the other candidates, but there is also information that is missing. Future work will need to focus on which of the candidates are indeed chemoreceptors, what percentage of the overall response each one contributes, and how this percentage varies under different conditions.

The effect of the Ebbinghaus illusion on grasping behaviour of children.

Within the context of the Ebbinghaus illusion, adults regularly misjudge the physical size of a centre disc, yet scale their hand aperture according to its actual size. Separate visual pathways for perception and action are assumed to account for this finding. The dorsal visual stream is said to elaborate on egocentric (visuomotor), while the ventral stream is involved in allocentric transformations (object recognition). This study examines the ontogenetic development of this dissociation between perception and action in 35 children between the ages of 5 and 12 years. We report four major results. First, when children judged object size without grasping the disc, their judgements were deceived by the illusion to the same extent as adults. However, when asked to estimate size and then to grasp the disc, young children's (5-7 years) perceptual judgements became unreliable, while adults were still reliably deceived by the illusion in 80% of their trials. Second, the younger the children, the more their aperture was affected by the illusional surround. Discs of the same size were grasped with a smaller aperture when surrounded by a small annulus, although they were perceived as being larger. Third, young children used the largest safety margin during grasping. Fourth, the reliance on visual feedback decreased with increasing age, which was documented by shorter movement times and earlier maximum hand opening during grasping in the older children (feedforward control). Our results indicate that grasping behaviour in children is subject to an interaction between ventral and dorsal processes. Both pathways seem not to be functionally segregated in early and middle childhood. The data are inconclusive about whether young children predominantly use a specific visual stream for either a perceptual or motor task. However, our data demonstrate that children were relying on both visual processing streams during perceptual as well as visuomotor tasks. We found that children used egocentric cues to make perceptual judgements, while their grasping gestures were not exclusively shaped by viewer-centred but also by object-centred information.

Motor impairment in patients with parietal lesions: disturbances of meaningless arm movement sequences.

The execution of meaningless movement sequences was studied in 12 patients with lesions of the parietal cortex in comparison to the performance of age- and sex-matched controls. Five sequences of increasing complexity had to be performed by imitation and after verbal instruction. The performance errors were qualitatively scored by means of four error categories (temporal or spatial error, addition or omission of movement components). This study examined whether the error scores depended on instruction modality, movement complexity or lesion side. Patients with left parietal lesions produced more errors than those with right parietal lesions and control subjects. While additions or omissions of movement components occurred almost equally in all groups, temporal and spatial errors were more frequent in patients with left parietal lesions only. In addition, only the latter group showed a significant increase of error rates with increasing movement complexity. There were no significant differences between the contra- and ipsilesional hand in any group. These results demonstrate that lesions in the left parietal lobe lead to a disturbed spatio-temporal organisation of movement that becomes increasingly prominent for more complex movements.

Different coupling for the reach and grasp components in bimanual prehension movements.

In this study on functional coupling in bimanual grasping movements, nine normal subjects had to reach and grasp two different objects simultaneously. Both objects could be either small or large, resulting in four different conditions of bimanual grasping. The main dependent variables were the coupling coefficients calculated either between the hand displacements or between the grip apertures of both hands, serving as variables for the coupling of the reach and the grasp component respectively. The correlation was significantly higher for the reach component than for the grasp component, with only the latter one changing significantly with variation of object size. These findings suggest different temporo-spatial coupling modes for the reach and the grasp components of bimanual grasping movements.

Zinc sulphate induces metallothionein in pancreatic islets of mice and protects against diabetes induced by multiple low doses of streptozotocin.

AIMS/HYPOTHESIS: Diabetes is induced by multiple low doses of streptozotocin (MLD-STZ) in male mice of susceptible strains. In this model beta-cell injury and T-cell-mediated inflammatory reactions are induced. Probably, reactive oxygen species (ROS) participate in the destruction of beta cells. The effects of ROS can be counterbalanced by several antioxidant systems. One of these is metallothionein (MT), cytosolic proteins that are induced by zinc ions (Zn2+) and scavenge hydroxyl radicals (OH). The effect of Zn2+ on MLD-STZ-diabetes was studied. METHODS: We gave C57BL/6 and (C57BL/6 x SJL)F1 hybrid mice either MLD-STZ or in addition Zn2+-enriched drinking water. We analysed metallothionein ex vivo in pancreatic islets for protein and mRNA concentration for the isoforms 1 and 2. Pancreatic sections were examined by immunohistochemistry for metallothionein and histologically for insulitis. RESULTS: In both strains, Zn2+-enriched drinking water significantly up-regulated metallothionein and prevented MLD-STZ-diabetes and loss of beta-cell function. In the F1 hybrid mice a variant of MLD-STZ-diabetes was observed. These mice developed hyperglycaemia 10 weeks after the first injection of STZ (in contrast to 2 weeks observed in other mouse strains) and pronounced insulitis. The mRNA of the metallothionein isoforms 1 and 2 were constitutively expressed and slightly up-regulated by Zn2+-enriched drinking water. All islets cells stained for metallothionein. CONCLUSIONS/INTERPRETATIONS: Drinking water enriched with Zn2+ significantly up-regulated metallothionein production in pancreatic islets of mice and prevented diabetes induced with MLD-STZ.

Mirror agnosia and mirror ataxia constitute different parietal lobe disorders.

We describe two new clinical syndromes, mirror agnosia and mirror ataxia, both characterized by the deficit of reaching for an object through a mirror in association with a lesion of either parietal lobe. Clinical investigation of 13 patients demonstrated that the impairments affected both sides of the body. In mirror agnosia, the patients always reached toward the virtual object in the mirror and they were not capable of changing their behavior even after presentation of the position of the object in real visual space. In mirror ataxia (resembling optic ataxia) although some patients initially tended to reach for the virtual object in the mirror, they soon learned to guide their arms toward the real object, all of them producing many directional errors. Both patient groups performed poorly on mental rotation, but only the patients with mirror agnosia were impaired in line orientation. Only 1 of the patients suffered from neglect and 3 from apraxia. Magnetic resonance imaging showed that in mirror agnosia the common zone of lesion overlap was scattered around the posterior angular gyrus/superior temporal gyrus and in mirror ataxia around the postcentral sulcus. We propose that both these clinical syndromes may represent different types of dissociation of retinotopic space and body scheme, or likewise, of allocentric and egocentric space normally adjusted in the parietal lobe.

The role of ventral medial wall motor areas in bimanual co-ordination. A combined lesion and activation study.

Two patients with midline tumours and disturbances of bimanual co-ordination as the presenting symptoms were examined. Both reported difficulties whenever the two hands had to act together simultaneously, whereas they had no problems with unimanual dexterity or the use of both hands sequentially. In the first patient the lesion was confined to the cingulate gyrus; in the second it also invaded the corpus callosum and the supplementary motor area. Kinematic analysis of bimanual in-phase and anti-phase movements revealed an impairment of both the temporal adjustment between the hands and the independence of movements between the two hands. A functional imaging study in six volunteers, who performed the same bimanual in-phase and anti-phase tasks, showed strong activations of midline areas including the cingulate and ventral supplementary motor area. The prominent activation of the ventral medial wall motor areas in the volunteers in conjunction with the bimanual co-ordination disorder in the two patients with lesions compromising their function is evidence for their pivotal role in bimanual co-ordination.

Force regulation is deficient in patients with parietal lesions: a system-analytic approach.

By means of a quantitative system-analytic investigation strategy, the postural motor control of the fingers was evaluated, to characterise the possible deficit of force regulation in patients with parietal lesions. In spite of a normal response to short torque pulses, the parietal-lesion patients had difficulties in returning to the preload level after the application of an additional step torque load to fingers II-IV of their left or right hands. The control offset (measured 500 ms after step torque application) was significantly larger in the patient group. This deficit in the investigated patients with parietal lesions to compensate for step torque loads was not due to a paresis, but rather resulted from a disturbance in the generation of a sufficient counterforce against the applied step torque within an adequate time window and motor pattern. This distinct force-regulation deficit was found in patients with left- and right-sided parietal lesions.

Human anterior intraparietal area subserves prehension: a combined lesion and functional MRI activation study.

It has been shown in nonhuman primates that the posterior parietal cortex is involved in coordination of arm and eye movements in space, whereas the anterior intraparietal area in the anterior lateral bank of the intraparietal sulcus plays a crucial role in fine finger movements, such as grasping. In this study we show by optoelectronic movement recordings that patients with cortical lesions involving the anterior lateral bank of the intraparietal sulcus have selective deficits in the coordination of finger movements required for object grasping, whereas reaching is much less disturbed. Patients with parietal lesions sparing the cortex lining the anterior intraparietal sulcus showed intact grasping behavior. Complementary evidence was obtained from functional MRI in normal control subjects showing a specific activation of the anterior lateral bank of the intraparietal sulcus during grasping. In conclusion, this combined lesion and activation study suggests that the anterior lateral bank of the intraparietal sulcus, possibly including the human homologue of the anterior intraparietal area, mediates the processing of sensorimotor integration of precisely tuned finger movements in humans.

Virtual holography in diagnosis and therapy of sensorimotor disturbances.

It has been shown that VR techniques can be usefully applied in the field of sensorimotor disturbances. Virtual scenarios can be created in which patients perform specific motor tasks. Using an optoelectronic position tracking system for motion recording as well as for interaction with virtual objects, and using Virtual Holography as an adequate visualization technique, we are now developing and testing suitable scenarios. Furthermore, an advanced visualization and animation tool using VR technology for diagnosis purpose and therapy planning has been developed, which the physician can profit from during motion analysis.

Ataxic breathing during alternating forearm movements of various frequencies in cerebellar patients.

Breathing was analyzed at rest and during sinusoidal tracking movements of the forearm of the dominant side at various frequencies in 11 patients with a cerebellar impairment and in 9 healthy subjects. In the patients, breathing movements were always rhythmical as in normal subjects during rest, but sometimes were interrupted by intermittent breathing-arrests during tracking (breathing ataxia). In 9 of the 11 cerebellar patients, the normal phase relationships between breathing and forearm movements at target frequencies in the spontaneous breathing rate range were absent. Thus patients with cerebellar lesions not only show disturbed skeletomotor movements, but also show an impaired coordination between breathing and limb movements.

Virtual reality for physically disabled people.

This paper demonstrates how physically disabled people can benefit from the innovative virtual reality techniques. Several specific examples show the applicability of virtual reality to the therapy and rehabilitation of people with various disabilities. In addition, the paper describes how physicians can use virtual reality as an advanced visualization tool for the diagnosis of physical disabilities. Finally, possible display techniques and input devices for diagnosis and rehabilitation purposes are discussed briefly.

Prevention of high- and low-dose STZ-induced diabetes with D-glucose and 5-thio-D-glucose.

To induce hyperglycemia in mice by administration of STZ, two experimental protocols that involve different pathogenic pathways are being used. First, the intraperitoneal injection of a single high dose (HD-STZ) exerts direct toxicity on beta-cells, which results in necrosis within 48-72 h and overt permanent hyperglycemia. Second, injections of multiple low doses of STZ (LD-STZ), administered intraperitoneally on 5 consecutive days, induce both beta-cytotoxic effects and STZ-specific T-cell-dependent immune reactions. In LD-STZ models, only a combination of toxic and immunological effects result in gradually increasing hyperglycemia, provided male mice of susceptible strains are being used. In this study, we found that 5-T-G, a glucose analogue that has sulfur for oxygen in the pyranose ring, prevented, in a dose-dependent way, both HD-STZ- and LD-STZ-induced hyperglycemia and that D-G, which was only tested in the LD-STZ system, was also protective, albeit somewhat less so than 5-T-G. This protective effect was achieved by intraperitoneally injecting 5-T-G and D-G, respectively, right before each STZ injection. Protection against hyperglycemia was already achieved with a total of 3 injections of 5-T-G, 1 injection each given before the first 3 of 5 LD-STZ injections. By means of OGTT, it was determined that pretreatment with 5-T-G afforded protection from substantial beta-cell damage in vivo.(ABSTRACT TRUNCATED AT 250 WORDS)

T cell-dependent class II major histocompatibility complex antigen expression in vivo induced by the diabetogen streptozotocin.

Immune reactions are involved in the low-dose streptozotocin (STZ)-model of hyperglycemia (1). By means of the popliteal lymph node assay, we demonstrated that T cell-dependent lymphoproliferation can be evoked by STZ (2). The present report shows that class II MHC antigen expression is readily inducible in multiple organs by a single dose of STZ injected subcutaneously (s.c.) into BALB/cJ mice. An increment of class II-positive cells of the lymphocyte and monocyte/macrophage lineage is discernible in the endocrine pancreas, kidney, and liver, but not the brain. In addition, renal tubular and bile duct epithelium express strong class II positivity. Class II antigens are not visible on pancreatic endocrine cells and hepatocytes. These immune phenomena are T cell-dependent, as assessed in tissues from BALB/cJ nu/nu recipients and their +/nu counterparts. STZ-induced class II antigens develop transiently and are not necessarily associated with organ dysfunction. The present STZ-induced MHC class II antigen aberrancies are in agreement with observations described recently by COCKFIELD et al. (3). In addition, we found that injection of methylnitrosourea, the aglycone of STZ, also resulted in class II MHC molecule induction in the liver, whereas the diabetogen alloxan failed to exert any effect on class II antigens.