Bad Aibling, Germany
Bad Aibling, Germany

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PubMed | DSG and DGN Office, Hospital zum Heiligen Geist, University of Ulm, Goethe University Frankfurt and 7 more.
Type: | Journal: BMC medical education | Year: 2016

Neurogenic dysphagia is one of the most frequent and prognostically relevant neurological deficits in a variety of disorders, such as stroke, parkinsonism and advanced neuromuscular diseases. Flexible endoscopic evaluation of swallowing (FEES) is now probably the most frequently used tool for objective dysphagia assessment in Germany. It allows evaluation of the efficacy and safety of swallowing, determination of appropriate feeding strategies and assessment of the efficacy of different swallowing manoeuvres. The literature furthermore indicates that FEES is a safe and well-tolerated procedure. In spite of the huge demand for qualified dysphagia diagnostics in neurology, a systematic FEES education has not yet been established.The structured training curriculum presented in this article aims to close this gap and intends to enforce a robust and qualified FEES service. As management of neurogenic dysphagia is not confined to neurologists, this educational programme is applicable to other clinicians and speech-language therapists with expertise in dysphagia as well.The systematic education in carrying out FEES across a variety of different professions proposed by this curriculum will help to spread this instrumental approach and to improve dysphagia management.


PubMed | Hannover Medical School, Schon Klinik Bad Staffelstein, Klinik Schloss Pulsnitz, BDH Klinik Elzach and 14 more.
Type: | Journal: BMC research notes | Year: 2016

Evaluation of functional status is difficult in neurological and neurosurgical early rehabilitation patients. The Early Rehabilitation Index (ERI) was introduced in Germany over 20years ago, but since then validation studies are lacking. The ERI (range -325 to 0 points) includes highly relevant items including the necessity of intermittent mechanical ventilation or tracheostomy.The present paper analyzed data from a German multi-center study, enrolling 754 neurological early rehabilitation patients. Together with ERI, Barthel Index (BI), Glasgow Coma Scale (GCS), Glasgow Outcome Score Extended, Coma Remission Scale (CRS), Functional Ambulation Categories and length of stay were obtained.ERI showed significant improvements from admission to discharge (p<0.001). In addition, there were significant correlations of the ERI upon admission and at discharge with BI, CRS and GCS.Evaluation of our study data suggest that the ERI may be used as a valid assessment instrument for neurological and neurosurgical early rehabilitation patients.


Vogel D.,Schon Klinik Bad Aibling | Vogel D.,University of Tübingen | Markl A.,Schon Klinik Bad Aibling | Markl A.,University of Tübingen | And 4 more authors.
Archives of Physical Medicine and Rehabilitation | Year: 2013

Objective: To determine the potential prognostic value of using functional magnetic resonance imaging (fMRI) to identify patients with disorders of consciousness, who show potential for recovery. Design: Observational study. Setting: Unit for acute rehabilitation care. Participants: Patients (N=22) in a vegetative state (VS; n=10) and minimally conscious state (MCS; n=12) during the first 200 days after the initial incident. Interventions: Not applicable. Main Outcome Measure: Further course on the Coma Recovery Scale-Revised. Results: Participants performed a mental imagery fMRI paradigm. They were asked to alternately imagine playing tennis and navigating through their home. In 14 of the 22 examined patients (VS, n=5; MCS, n=9), a significant activation of the regions of interest (ROIs) of the mental imagery paradigm could be found. All 5 patients with activation of a significant blood oxygen level dependent signal, who were in a VS at the time of the fMRI examination, reached at least an MCS at the end of the observation period. In contrast, 5 participants in a VS who failed to show activation in ROIs, did not (sensitivity 100%, specificity 100%). Six of 9 patients in an MCS with activation in ROIs emerged from an MCS. Of 3 patients in an MCS who did not show activation, 2 patients stayed in an MCS and 1 patient emerged from the MCS (sensitivity 85%, specificity 40%). Conclusions: The fMRI paradigm mental imagery displays a high concordance with the further clinical course of patients in a VS. All 5 patients in a VS who showed significant activation of ROIs had a favorable further course until the end of the observation period. We therefore propose the term "functional minimally conscious state" for these patients. They may benefit from rehabilitation treatment. In cases where no significant activation was seen, the method has no prognostic value. Prediction of the clinical course of patients in an MCS by fMRI was considerably less accurate than in patients in a VS. © 2013 by the American Congress of Rehabilitation Medicine.


Giacino J.T.,JFK Johnson Rehabilitation Institute | Giacino J.T.,Spaulding Rehabilitation Hospital | Whyte J.,Moss Rehabilitation Research Institute | Bagiella E.,Columbia University | And 19 more authors.
New England Journal of Medicine | Year: 2012

BACKGROUND: Amantadine hydrochloride is one of the most commonly prescribed medications for patients with prolonged disorders of consciousness after traumatic brain injury. Preliminary studies have suggested that amantadine may promote functional recovery. METHODS: We enrolled 184 patients who were in a vegetative or minimally conscious state 4 to 16 weeks after traumatic brain injury and who were receiving inpatient rehabilitation. Patients were randomly assigned to receive amantadine or placebo for 4 weeks and were followed for 2 weeks after the treatment was discontinued. The rate of functional recovery on the Disability Rating Scale (DRS; range, 0 to 29, with higher scores indicating greater disability) was compared over the 4 weeks of treatment (primary outcome) and during the 2-week washout period with the use of mixed-effects regression models. RESULTS: During the 4-week treatment period, recovery was significantly faster in the amantadine group than in the placebo group, as measured by the DRS score (difference in slope, 0.24 points per week; P = 0.007), indicating a benefit with respect to the primary outcome measure. In a prespecified subgroup analysis, the treatment effect was similar for patients in a vegetative state and those in a minimally conscious state. The rate of improvement in the amantadine group slowed during the 2 weeks after treatment (weeks 5 and 6) and was significantly slower than the rate in the placebo group (difference in slope, 0.30 points per week; P = 0.02). The overall improvement in DRS scores between baseline and week 6 (2 weeks after treatment was discontinued) was similar in the two groups. There were no significant differences in the incidence of serious adverse events. CONCLUSIONS: Amantadine accelerated the pace of functional recovery during active treatment in patients with post-traumatic disorders of consciousness. (Funded by the National Institute on Disability and Rehabilitation Research; ClinicalTrials.gov number, NCT00970944.) Copyright © 2012 Massachusetts Medical Society.


Koenig A.,ETH Zurich | Koenig A.,University of Zürich | Omlin X.,ETH Zurich | Omlin X.,University of Zürich | And 7 more authors.
Journal of NeuroEngineering and Rehabilitation | Year: 2011

Background: The overall goal of this paper was to investigate approaches to controlling active participation in stroke patients during robot-assisted gait therapy. Although active physical participation during gait rehabilitation after stroke was shown to improve therapy outcome, some patients can behave passively during rehabilitation, not maximally benefiting from the gait training. Up to now, there has not been an effective method for forcing patient activity to the desired level that would most benefit stroke patients with a broad variety of cognitive and biomechanical impairments. Methods. Patient activity was quantified in two ways: by heart rate (HR), a physiological parameter that reflected physical effort during body weight supported treadmill training, and by a weighted sum of the interaction torques (WIT) between robot and patient, recorded from hip and knee joints of both legs. We recorded data in three experiments, each with five stroke patients, and controlled HR and WIT to a desired temporal profile. Depending on the patient's cognitive capabilities, two different approaches were taken: either by allowing voluntary patient effort via visual instructions or by forcing the patient to vary physical effort by adapting the treadmill speed. Results: We successfully controlled patient activity quantified by WIT and by HR to a desired level. The setup was thereby individually adaptable to the specific cognitive and biomechanical needs of each patient. Conclusion: Based on the three successful approaches to controlling patient participation, we propose a metric which enables clinicians to select the best strategy for each patient, according to the patient's physical and cognitive capabilities. Our framework will enable therapists to challenge the patient to more activity by automatically controlling the patient effort to a desired level. We expect that the increase in activity will lead to improved rehabilitation outcome. © 2011 Koenig et al; licensee BioMed Central Ltd.


Kerkhoff G.,Saarland University | Reinhart S.,Saarland University | Ziegler W.,Neuropsychologische Klinik | Artinger F.,Karlsruhe University of Applied Sciences | And 2 more authors.
Neurorehabilitation and Neural Repair | Year: 2013

Background. No treatment for auditory neglect and no randomized controlled trial evaluating smooth pursuit eye movement therapy (SPT) for multimodal neglect are available. Objective. To compare the effects of SPT and visual scanning therapy (VST) on auditory and visual neglect in chronic stroke patients with neglect. Methods. A randomized, prospective trial was conducted. Fifty patients with left auditory and visual neglect were randomly assigned. Twenty-four patients completed SPT therapy and 21 patients VST. Five patients (4 VST, 1 SPT) were lost. Each group received 1-hour sessions of neglect therapy for 5 consecutive days totaling 5 hours. Outcome measures in visual neglect (digit cancellation, visuoperceptual- and motor line bisection, paragraph reading) and auditory neglect (auditory midline) were assessed twice before therapy, thereafter, and at 2-week follow-up. The SPT group practiced smooth pursuit eye movements while tracking stimuli moving leftward. The VST group systematically scanned the same but static stimuli. Both groups were divided into subgroups, and effects were separately investigated for mild and severe neglect. Results. Both groups did not differ before therapy in clinical/demographic variables or neglect severity (auditory/visual). After treatment, the SPT group showed significant and lasting improvements in all visual measures and normal performance in the auditory midline. Neither visual nor auditory neglect impairments changed significantly after VST. Moreover, the treatment effect sizes (Cohen's d) were considerably higher for visual and auditory neglect after SPT versus VST, both for mild and severe neglect. Conclusions. Repetitive contralesional, smooth pursuit training induces superior, multimodal therapeutic effects in mild and severe neglect. © The Author(s) 2013.


Krewer C.,Schon Klinik Bad Aibling | Krewer C.,Ludwig Maximilians University of Munich | Riess K.,Schon Klinik Bad Aibling | Riess K.,Ludwig Maximilians University of Munich | And 7 more authors.
Gait and Posture | Year: 2013

Some stroke patients with hemiparesis exhibit a so-called pusher behaviour, i.e., they actively push away from the unaffected side and lean towards the hemiparetic side. This impairs their postural balance to such a degree that they are often unable to sit or stand. Pusher behaviour thus substantially hampers the rehabilitation of these patients. So far only a few case studies on treatment strategies have been performed. This study investigated the immediate after-effects of galvanic vestibular stimulation (GVS), machine-supported gait training with the Lokomat, and physiotherapy with visual feedback components (PT-vf). Fifteen pusher and 10 non-pusher patients participated in an observer-blinded cross-over pilot study. Patients were measured on the scale for contraversive pushing (SCP) and on the Burke lateropulsion scale (BLS) immediately before and after a single-session of the specific intervention. Compared to PT-vf, Lokomat therapy had a significant effect on the BLS of pusher patients but no significant effect on the SCP values. GVS had no significant effect on these values on either scale. BLS is more useful than SCP to detect small changes for clinical trials and routine treatment. Forced control of the upright position during locomotion seems to be an effective method for immediately reducing the pushing behaviour of stroke patients, probably because it recalibrates a biased sense of verticality, via the somatic graviception. This finding, however, does not allow prediction of its long-term effects. Furthermore, it would be interesting to evaluate repetitive, multi-session DGO therapy and the amount of therapy needed to effectively reduce the pusher behaviour. © 2012 Elsevier B.V.


Kopczak A.,Schon Klinik Bad Aibling | Von Rosen F.,Schon Klinik Bad Staffelstein | Krewer C.,Schon Klinik Bad Aibling | Schneider H.J.,Ludwig Maximilians University of Munich | And 2 more authors.
European Journal of Endocrinology | Year: 2011

Objective: The insulin tolerance test (ITT) is the gold standard for the diagnosis of GH deficiency (GHD) and hypocortisolism. As hypopituitarism is a common disorder after traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH), the test is increasingly used in patients with pre-existing brain damage. Design: A cross-sectional, observational study. Methods: Fifty-six patients (41 TBI and 15 SAH) were tested with the ITT (0.15 IE/kg body weight, mean glucose 33 mg/dl). In 38 patients, the test was performed in a supine position; the other 18 patients were in a sitting position during the ITT. Results: Hypocortisolism and GHD were more often diagnosed in a supine than in a sitting position (hypocortisolism: 55.3% supine versus 0% sitting, P<0.0001; GHD: 42.1% supine versus 11.1% sitting, P=0.03). Patients in a sitting position suffered more often from symptoms such as tachycardia (61.1% sitting versus 15.8% supine, P=0.001), trembling (22.2 vs 7.9%, NS), and sweating (66.7 vs 28.9%, P=0.007). There were no significant differences between the groups in drowsiness (72.2% sitting versus 65.8% supine, NS), dizziness (44.4 vs 44.7%, NS), and fatigue (33.3 vs 15.8%, NS). Because of somnolence, the hypoglycemic state could only be stopped with i.v. administration of glucose in 25 supine patients (66%). In contrast, none of the 18 patients (0%) tested in a sitting position got somnolent or was in need of i.v. application of glucose (P<0.001). Conclusions: In patients with brain injury, posture might affect rates of diagnosing GHD and hypocortisolism and sympathetic symptoms in the ITT. These findings are exploratory and need replication in a standardized setting. © 2011 European Society of Endocrinology.


Bauer P.,Schon Klinik Bad Aibling | Bauer P.,Paracelsus Medical University | Krewer C.,Schon Klinik Bad Aibling | Golaszewski S.,Paracelsus Medical University | And 2 more authors.
Archives of Physical Medicine and Rehabilitation | Year: 2015

Objective To determine whether functional electrical stimulation (FES)-assisted active cycling is more effective than active cycling without FES concerning walking and balance. Specifically, walking ability was classified as to the amount of personal assistance needed to be able to walk and balance was evaluated for static and dynamic balance tasks. Design Monocentric, randomized, single-blinded, controlled trial. Setting Neurologic rehabilitation hospital. Participants Patients with severe hemiparesis due to stroke (N=40). Interventions Twenty minutes of active leg cycling with or without FES applied to the paretic vastus medialis and rectus femoris of quadriceps and to the biceps femoris and semitendinosus muscles, 3 times/wk for 4 weeks. Main Outcome Measures Functional ambulation classification (FAC) and performance-oriented mobility assessment (POMA) were the primary outcome measures. The leg subscale of the motricity index (MI) and the modified Ashworth scale were the secondary outcome measures. Evaluation was done before and after the intervention period and after an additional 2 weeks. Results After the intervention, the FAC, POMA, and the MI (P<.016) for both intervention groups improved significantly. The FAC of the control group increased by a median of 1 category and that of the FES group by 2 categories. The median change in POMA was 2 and 4 points for the control group and the FES group, respectively. The Mann-Whitney U test between-group comparisons revealed that these gains were significantly better in the FES group for both the FAC (U=90; z=-2.58; P=.013; r=-.42) and the POMA (U=60; z=-3.43; P<.0004; r=-.56). Because of missing data and slightly decreased effect sizes during the follow-up phase (FAC, r=-.33; POMA, r=-.41), differences did not reach statistically significant P values. The MI leg subscale showed significant improvements in both groups. However, there were no significant differences between the groups at any time. No changes were observed on the modified Ashworth scale. Conclusions FES-assisted active cycling seems to be a promising intervention during rehabilitation in patients with stroke. © 2015 American Congress of Rehabilitation Medicine.


PubMed | Ludwig Maximilians University of Munich and Schon Klinik Bad Aibling
Type: Journal Article | Journal: Topics in stroke rehabilitation | Year: 2016

The subjective postural vertical (SPV), i.e., the perceived upright orientation of the body in relation to gravity, is disturbed in patients with pusher behavior. So far, the SPV has been measured only when these patients were sitting, and the results were contradictory as regards the side of the SPV deviation.The objective was to investigate the SPV in patients with different degrees of severity of pusher behavior while standing.Eight stroke patients with pusher behavior, ten age-matched stroke patients without pusher behavior, and ten age-matched healthy control subjects were included. The SPV (SPV error, SPV range) was assessed in the pitch and the roll planes. Pusher behavior was classified with the Burke Lateropulsion Scale (BLS).In the pitch plane, the SPV range was significantly larger in pusher patients than in patients without pusher behavior or healthy controls. The SPV error was similar for groups. In the roll plane, the SPV error and the SPV range were significantly larger and more ipsilesionally tilted in the pusher group than in the other two groups. There was a significant correlation between the SPV error in the roll plane and the BLS score.The study revealed that patients with pusher behavior had an ipsilesional SPV tilt that decreased with decreasing severity of the behavior. The large uncertainty in verticality estimation in both planes indicates that their sensitivity for the perception of verticality in space is generally disturbed. These findings emphasize the importance of specific rehabilitation approaches to recalibrate the impaired inner model of verticality.

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