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Background: Standard mirror therapy (MT) is a well-established therapy regime for severe arm paresis after acquired brain injury. Bilateral robot-assisted mirror therapy (RMT) could be a solution to provide visual and somatosensory feedback simultaneously. Objective: The study compares the treatment effects of MT with a version of robot-assisted MT where the affected arm movement was delivered through a robotic glove (RMT). Methods: This is a parallel, randomized trial, including patients with severe arm paresis after stroke or traumatic brain injury with a Fugl-Meyer subscore hand/finger

ZusammenfassungDie S2k-Leitlinie SARS-CoV-2, COVID-19 und (Früh-) Rehabilitation macht auf der Basis einer Güterabwägung Handlungsanleitungen, die sowohl der Infektionsprävention, als auch den therapeutischen Zielen der Patient*innen Rechnung tragen. Die Leitlinie thematisiert in einem ersten Teil das Infektionsschutz-bezogene Vorgehen während der COVID-19-Pandemie generell bei Maßnahmen der Rehabilitation, einschließlich der Frührehabilitation. In einem zweiten Teil geht es um die Versorgung von COVID-19-Patient*innen mit rehabilitativen Therapieverfahren auf Intensivstationen und im Akutkrankenhaus, der Frührehabilitation, der Rehabilitation (Anschluss-Rehabilitation, Heilverfahren) und der ambulanten und Langzeit-Betreuung nach COVID-19, u. a. bei längerer Persistenz von Symptomen (Long- bzw. Post-COVID-19).Bei der aktuellen Version 2 der Leitlinie (Stand 1.11.2021) handelt es sich um eine konsensbasierte Leitlinie mit repräsentativem Gremium sowie einer strukturierten Konsensfindung (S2k-Leitlinie). Insgesamt nahmen 15 Fachgesellschaften an der Leitlinienerstellung und –konsentierung teil. In dieser Kurzfassung der Leitlinie werden alle Empfehlungen im Überblick wiedergegeben.

Neurorehabilitation to alleviate permanent disabilities after stroke is in Germany organised within the so called neurological phase model. This article provides an overview on its organisation and content as well as the restrictions imposed by social law. As an example for therapies, evidence-based motor rehabilitation strategies are presented and linked to their neurophysiological principles. Additionally, the current recommendations for the assessment of fitness to drive are illustrated.

Neurorehabilitation to alleviate permanent disabilities after stroke is in Germany organised within the so called neurological phase model. This article provides an overview on its organisation and content as well as the restrictions imposed by social law. As an example for therapies, evidence-based motor rehabilitation strategies are presented and linked to their neurophysiological principles. Additionally, the current recommendations for the assessment of fitness to drive are illustrated.

Die Funktionelle Elektrostimulation (FES) wird im Rahmen der Neurorehabilitation in den verschiedensten Anwendungsgebieten eingesetzt. Die Vielfalt der neurologischen Symptomauspragungen erfordert die Modifikation der unterschiedlichen therapeutischen Ansatze. Aufgrund dieser Anforderung entstanden die Kombinationen von FES und anderen erfolgreichen Therapien.

A brief survey among members of the German Neurorehabilitation Society aimed to document the hospital capacities (“beds”) for prolonged weaning from a mechanical ventilator for patients with neuro-disabilities that require simultaneous multi-professional neurorehabilitation treatment. Sixty-eight institutions declared to have capacities with a broad distribution across Germany and its federal states. Overall, 1094 “beds” for prolonged weaning (and neurorehabilitation) were reported, 871 together with further information regarding their identification and hence regional location. These units had on average 16.1 beds for prolonged weaning (95% confidence interval 12.6 to 19.6) with a range from 2 to 68 beds per organization. The data indicate substantial capacities for the combined prolonged weaning and neurorehabilitation treatment in Germany. For most “beds” included in this analysis a basic validation was possible. While a reasonable coverage of these specialized service capacities by the survey is likely, the number reported could still be biased by underreporting by non-response. Both the broad variation of number of “beds” for prolonged weaning per unit and their unequal geographical distribution across federal states (per capita rate) warrant a more refined follow-up survey that will provide insights into reasons for the observed pattern of variation for these specialized hospital capacities.

Neben Akutkliniken sind auch Rehabilitationskliniken zunehmend von der Problematik der multiresistenten Erreger betroffen. Lange Verweildauern und hohe Behandlungsintensitaten stellen dabei besondere Herausforderungen an die Hygiene dar. Systematische Untersuchung eines Ausbruchs mit „Extended Spectrum Beta-Lactamasen“-Klebsiella-pneumoniae (ESBL-K. pneumoniae) in einer Neurorehabilitationsklinik. Gesicherter Fall: Patient mit einem ESBL-K.-pneumoniae-Nachweis im Ausbruchszeitraum und Zugehorigkeit zum Ausbruchsklon, wahrscheinlicher Fall: kein typisiertes Isolat, aber epidemiologischer Link zum Ausbruchsgeschehen. Insgesamt 53 ESBL-K.-pneumoniae-Isolate wurden mittels Next Generation Sequencing (NGS) typisiert. Umgebungsuntersuchungen wurden durchgefuhrt und ein systematisches Screening wurde implementiert. Neben einer Starkung der Standardhygiene wurde eine Kohortierung von Patienten mit ESBL-K.-pneumoniae veranlasst. Insgesamt wurden 30 gesicherte und 6 wahrscheinliche Falle dem Ausbruchsgeschehen zugeordnet (Cluster 1, ST15). In der Typisierung konnten 2 weitere Cluster identifiziert werden: Cluster 2 (ST405) bei 7 Patienten und Cluster 3 (ST414) bei 8 Patienten. Bei 2 Patienten entwickelte der Ausbruchsstamm ST15 weitere Antibiotikaresistenzen (Colistin bzw. Carbapenem). ESBL-K.-pneumoniae wurde in Umgebungsuntersuchungen nicht identifiziert. Der Ausbruch konnte nach strikter Kohortierung beendet werden. Die Erregerausbreitung erfolgte vermutlich von Mensch zu Mensch. Die Ubertragungswahrscheinlichkeit stieg mit dem Grad der Interventionsintensitat, wahrend die Infektionsrate durch die Morbiditat der Patienten bedingt war. Die Identifikation eines Ausbruchsklons mit Entwicklung zusatzlicher Antibiotikaresistenzen und die Entdeckung weiterer Cluster demonstrieren die Relevanz einer Erregertypisierung und eines effektiven Ausbruchsmanagements.

ZusammenfassungIn der Rehabilitation der Mobilität nach Schlaganfall sind technisch unterstützende Verfahren seit vielen Jahren gut etabliert und evaluiert. Belastbare Wirksamkeitsnachweise liegen vor für stationäre Endeffektorgeräte und Exoskeletts sowie für Laufbandtraining mit und ohne Gewichtsentlastung. Neue technische Entwicklungen ermöglichen die frühe Vertikalisierung im funktionellen Kontext bereits auf der (Intensiv-)Station. Zudem existieren mittlerweile verschiedene mobile Exoskelette, deren dezidierte Wirksamkeit allerdings noch belegt werden muss. Im klinischen Einsatz müssen neben einer anzustrebenden hohen Zahl an Repetitionen auch motivationale Aspekte stärker betont werden. Hier bieten sich Techniken der virtuellen Realität an. Für den praktischen Einsatz im klinischen Alltag sind hygienische Aspekte zu berücksichtigen. Für alle Neuentwicklungen ist der Einsatz in einem sinnvollen und reproduzierbaren Gesamtkonzept zu definieren.

Technically assisted rehabilitation of mobility after stroke has been well established for several years. There is good evidence for the use of end-effector devices, exoskeletons and treadmill training with and without body weight support. New developments provide the possibility for functional training during mobilization, even in intensive care units. Mobile exoskeleton devices have been developed, but their clinical effects need still to be evaluated. All devices should not only focus on increasing the number of repetitions, but also include motivational aspects such as virtual reality environments. Hygienic aspects impose a special challenge. All devices should be integrated into a rational and clearly-defined therapy concept.

New rehabilitation strategies for post-stroke upper limb rehabilitation employing visual stimulation show promising results, however, cost-efficient and clinically feasible ways to provide these interventions are still lacking. An integral step is to translate recent technological advances, such as in virtual and augmented reality, into therapeutic practice to improve outcomes for patients. This requires research on the adaptation of the technology for clinical use as well as on the appropriate guidelines and protocols for sustainable integration into therapeutic routines. Here, we present and evaluate a novel and affordable augmented reality system (Augmented Reflection Technology, ART) in combination with a validated mirror therapy protocol for upper limb rehabilitation after stroke.We evaluated components of the therapeutic intervention, from the patients' and the therapists' points of view in a clinical feasibility study at a rehabilitation centre. We also assessed the integration of ART as an adjunct therapy for the clinical rehabilitation of subacute patients at two different hospitals.The results showed that the combination and application of the Berlin Protocol for Mirror Therapy together with ART was feasible for clinical use. This combination was integrated into the therapeutic plan of subacute stroke patients at the two clinical locations where the second part of this research was conducted.Our findings pave the way for using technology to provide mirror therapy in clinical settings and show potential for the more effective use of inpatient time and enhanced recoveries for patients. Implications for Rehabilitation Computerised Mirror Therapy is feasible for clinical use Augmented Reflection Technology can be integrated as an adjunctive therapeutic intervention for subacute stroke patients in an inpatient setting Virtual Rehabilitation devices such as Augmented Reflection Technology have considerable potential to enhance stroke rehabilitation.

Background and purpose: In patients with pathology of one limb, mirror therapy (MT) uses the mirror reflection of the unaffected side to improve function of the affected limb [1]. There is some evidence that Virtual Reality (VR) can substitute the real mirror [2]. To create a standardised VR based mirror therapy as a self-training, several steps of conceptual considerations are essential. The purpose of this project was to understand the therapeutic action of standardised MT and thus to pave the way for a partially automated VR based MT to be executed as a self-training. Methods: A principle of motor learning, called Shaping, is anchored in two existing standardised MT protocols (BeST & BeSTEP) [3], [4] . To understand the shaping process within MT, shaping items and criteria were extracted from the protocols. Additionally, a questionnaire and participatory observation during MT sessions were performed and standardisation rules by means of documentation sheets of MT units were analysed. Results and conclusion: The knowledge about the shaping process during conventional MT, especially in the BeST phase is currently not sufficient to derive machine learning and therefore to create an automated system at this time. Further conceptual investigations to gather this information are necessary and projected.

Using eye-tracking to assess visual attention in head-mounted devices (HMD) opens up many possibilities for virtual reality (VR)-based therapy. Existing therapy concepts where attention plays a major role can be transferred to VR. Furthermore, they can be expanded to a precise real-time attention assessment, which can serve as a foundation for new therapy approaches. Utilizing HMDs and eye-tracking in a clinical environment is challenging because of hygiene issues and requirements of patients with heterogeneous cognitive and motor impairments. In this paper, we provide an overview of those challenges, discuss possible solutions and present preliminary results of a study with patients.

Background A recently updated Cochrane review for mirror therapy (MT) showed a high level of evidence in the treatment of hemiparesis after stroke. However, the therapeutic protocols used in the individual studies showed significant variability. Objective A secondary meta-analysis was performed to detect which parameters of these protocols may influence the effect of MT for upper limb paresis after stroke. Methods Trials included in the Cochrane review, which published data for motor function / impairment of the upper limb, were subjected to this analysis. Trials or trial arms that used MT as group therapy or combined it with electrical or magnetic stimulation were excluded. The analysis focused on the parameters mirror size, uni- or bilateral movement execution, and type of exercise. Data were pooled by calculating the total weighted standardized mean difference and the 95% confidence interval. Results Overall, 32 trials were included. The use of a large mirror compared to a small mirror showed a higher effect on motor function. Movements executed unilaterally showed a higher effect on motor function than a bilateral execution. MT exercises including manipulation of objects showed a minor effect on motor function compared to movements excluding the manipulation of objects. None of the subgroup differences reached statistical significance. Conclusions The results of this analysis suggest that the effects on both motor function and impairment of the affected upper limb depend on the therapy protocol. They furthermore indicate that a large mirror, unilateral movement execution and exercises without objects may be parameters that enhance the effects of MT for improving motor function after stroke.

Background In the course of neurological early rehabilitation, decannulation is attempted in tracheotomized patients after weaning due to its considerable prognostic significance. We aimed to identify predictors of a successful tracheostomy decannulation. Methods From 09/2014 to 03/2016, 831 tracheotomized and weaned patients (65.4 ± 12.9 years, 68% male) were included consecutively in a prospective multicentric observation study. At admission, sociodemographic and clinical data (e.g. relevant neurological and internistic diseases, duration of mechanical ventilation, tracheotomy technique, and nutrition) as well as functional assessments (Coma Recovery Scale-Revised (CRS-R), Early Rehabilitation Barthel Index, Bogenhausener Dysphagia Score) were collected. Complications and the success of the decannulation procedure were documented at discharge. Results Four hundred seventy patients (57%) were decannulated. The probability of decannulation was significantly negatively associated with increasing age (OR 0.68 per SD = 12.9 years, p

In addition to acute care hospitals, rehabilitation centres are increasingly confronted with multi-resistant pathogens. Long durations of stay and intensive treatments impose special hygienic challenges.We investigated an extended spectrum beta-lactamase-Klebsiella pneumoniae (ESBL-K. pneumoniae) outbreak in a neurorehabilitation centre. We defined confirmed cases as patients who stayed in the centre during the outbreak period and from whom ESBL-K. pneumoniae was isolated with the outbreak sequence type. Probable cases had an epidemiological link to at least one confirmed case but no isolate for typing. Next generation sequencing (NGS) was performed on 53 isolates from patients. Environmental sampling was performed. Systematic microbiological screening was implemented and ESBL-K. pneumoniae-positive patients were cohorted in a designated ward.We identified 30 confirmed and 6 probable cases. NGS revealed three genetic clusters: Cluster 1 - the outbreak cluster - with isolates of 30 cases (sequence type ST15), Cluster 2 with 7 patients (ST405) and Cluster 3 with 8 patients (ST414). In two patients, the outbreak strain developed further antibiotic resistance, one with colistin resistance and the other carbapenem resistance. The outbreak ceased after strict isolation measures.Epidemiology and NGS results paired with the effectiveness of cohorting suggest that transmission occurred mainly from person to person in this outbreak. There was an apparent association of the probability to acquire ESBL-K. pneumoniae and treatment intensity, whereas infection rate was related to morbidity. The identification of the outbreak clone and additional clusters plus the development of additional antibiotic resistance shows the relevance of NGS and highlights the need for timely and efficient outbreak management.

Background: Mirror therapy (MT) was found to improve motor function after stroke. However, there is high variability between patients regarding motor recovery. Objectives: The following pilot study was designed to identify potential factors determining this variability between patients with severe upper limb paresis, receiving MT. Methods: Eleven sub-acute stroke patients with severe upper limb paresis participated, receiving in-patient rehabilitation. After a set of pre-assessments (including measurement of brain activity at the primary motor cortex and precuneus during the mirror illusion, using near-infrared spectroscopy as described previously), four weeks of MT were applied, followed by a set of post-assessments. Discriminant group analysis for MT responders and non-responders was performed. Results: Six out of eleven patients were defined as responders and five as non-responders on the basis of their functional motor improvement. The initial motor function and the activity shift in both precunei (mirror index) were found to discriminate significantly between responders and non-responders. Conclusions: In line with earlier results, initial motor function was confirmed as crucial determinant of motor recovery. Additionally, activity response to the mirror illusion in both precunei was found to be a candidate for determination of the efficacy of MT.

Extended-spectrum β-lactamase (ESBL) producing Klebsiella pneumoniae pose an important threat of infection with increased morbidity and mortality, especially for immunocompromised patients. Here, we use the rise of multidrug-resistant K. pneumoniae in a German neurorehabilitation center from April 2015 to April 2016 to dissect the benefit of whole genome sequencing (WGS) for outbreak analyses. In total, 53 isolates were obtained from 52 patients and examined using WGS. Two independent analysis strategies (reference-based and -free) revealed the same distinct clusters of two CTX-M-15 producing K. pneumoniae clones (ST15, n = 31; ST405, n = 7) and one CTX-M-15 producing Klebsiella quasipneumoniae strain (ST414, n = 8). Additionally, we determined sequence variations associated with antimicrobial resistance phenotypes in single isolates expressing carbapenem and colistin resistance, respectively. For rapid detection of the major K. pneumoniae outbreak clone (ST15), a selective triplex PCR was deduced from WGS data of the major outbreak strain and K. pneumoniae genome data deposited in central databases. Moreover, we introduce two novel open-source applications supporting reference genome selection (refRank; https://gitlab.com/s.fuchs/refRank) and alignment-based SNP-filtering (SNPfilter; https://gitlab.com/s.fuchs/snpfilter) in NGS analyses.

BACKGROUND: Mirror therapy (MT) was found to improve motor function after stroke, but its neural mechanisms remain unclear, especially in single stroke patients. OBJECTIVES: The following imaging study was designed to compare brain activation patterns evoked by the mirror illusion in single stroke patients with normal subjects. METHODS: Fifteen normal volunteers and five stroke patients with severe arm paresis were recruited. Cerebral activations during movement mirroring by means of a video chain were recorded with functional magnetic resonance imaging (fMRI). Single-subject analysis was performed using SPM 8. RESULTS: For normal subjects, ten and thirteen subjects displayed lateralized cerebral activations evoked by the mirror illusion while moving their right and left hand respectively. The magnitude of this effect in the precuneus contralateral to the seen hand was not dependent on movement speed or subjective experience. Negative correlation of activation strength with age was found for the right hand only. The activation pattern in stroke patients is comparable to that of normal subjects and present in four out of five patients. CONCLUSIONS: In summary, the mirror illusion can elicit cerebral activation contralateral to the perceived hand in the majority of single normal subjects, but not in all of them. This is similar even in stroke patients with severe hemiparesis.

Approximately two thirds of stroke patients initially suffer from at least impaired mobility. Various rehabilitation concepts have been proposed.Based on the current literature, which rehabilitation methods can be recommended for improvement of gait, gait velocity, gait distance and balance?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.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.These guidelines not only provide recommendations for action but also provide pathophysiological insights into functional restoration of stance and gait after stroke.

Background. Rehabilitation of the severely affected paretic arm after stroke represents a major challenge, especially in the presence of sensory impairment. Objective. To evaluate the effect of a therapy that includes use of a mirror to simulate the affected upper extremity with the unaffected upper extremity early after stroke. Methods. Thirty-six patients with severe hemiparesis because of a first-ever ischemic stroke in the territory of the middle cerebral artery were enrolled, no more than 8 weeks after the stroke. They completed a protocol of 6 weeks of additional therapy (30 minutes a day, 5 days a week), with random assignment to either mirror therapy (MT) or an equivalent control therapy (CT). The main outcome measures were the Fugl-Meyer subscores for the upper extremity, evaluated by independent raters through videotape. Patients also underwent functional and neuropsychological testing. Results. In the subgroup of 25 patients with distal plegia at the beginning of the therapy, MT patients regained more distal function than CT patients. Furthermore, across all patients, MT improved recovery of surface sensibility. Neither of these effects depended on the side of the lesioned hemisphere. MT stimulated recovery from hemineglect. Conclusions. MT early after stroke is a promising method to improve sensory and attentional deficits and to support motor recovery in a distal plegic limb.

Relatively new evidence suggests that movement representation techniques (ie, therapies that use the observation and/or imagination of normal pain-free movements, such as mirror therapy, motor imagery, or movement and/or action observation) might be effective in reduction of some types of limb pain. To summarize the evidence regarding the efficacy of those techniques, a systematic review with meta-analysis was performed. We searched Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, AMED, PsychINFO, Physiotherapy Evidence Database, and OT-seeker up to August 2014 and hand-searched further relevant resources for randomized controlled trials that studied the efficacy of movement representation techniques in reduction of limb pain. The outcomes of interest were pain, disability, and quality of life. Study selection and data extraction were performed by 2 reviewers independently. We included 15 trials on the effects of mirror therapy, (graded) motor imagery, and action observation in patients with complex regional pain syndrome, phantom limb pain, poststroke pain, and nonpathological (acute) pain. Overall, movement representation techniques were found to be effective in reduction of pain (standardized mean difference [SMD] = −.82, 95% confidence interval [CI], −1.32 to −.31, P = .001) and disability (SMD = .72, 95% CI, .22–1.22, P = .004) and showed a positive but nonsignificant effect on quality of life (SMD = 2.61, 85% CI, −3.32 to 8.54, P = .39). Especially mirror therapy and graded motor imagery should be considered for the treatment of patients with complex regional pain syndrome. Furthermore, the results indicate that motor imagery could be considered as a potential effective treatment in patients with acute pain after trauma and surgery. To date, there is no evidence for a pain reducing effect of movement representation techniques in patients with phantom limb pain and poststroke pain other than complex regional pain syndrome. Perspective In this systematic review we synthesize the evidence for the efficacy of movement representation techniques (ie, motor imagery, mirror therapy, or action observation) for treatment of limb pain. Our findings suggest effective pain reduction in some types of limb pain. Further research should address specific questions on the optimal type and dose of therapy.

New rehabilitation strategies for post-stroke upper limb rehabilitation employing visual stimulation show promising results. Cost-efficient ways to provide these techniques are still a challenge. Virtual and Augmented Reality Technologies could be suitable for this endeavor. Recent technological advances often are not translated into therapeutic practice and improved outcomes for patients because of a lack of research on their practical usage, coupled with the inexistence of appropriate guidelines and protocols. Here we present a novel and affordable augmented reality system that was developed and evaluated in combination with a validated mirror therapy protocol for upper limb rehabilitation after stroke. We evaluated the components of the therapeutic intervention from both the patients' and the therapists' points of view. In particular, we provide evidence that the combination and application of the Berlin Protocol for Mirror Therapy together with Augmented Reflection Technology is feasible for clinical use. This paves the way to a broader use of technically-supported mirror therapy with the possibility of higher therapy frequencies and enhanced recovery for patients.

Purpose: Mirror therapy can improve motor and sensory functions, but effects of the mirror illusion on primary motor and somatosensory cortex could not be established consistently. Methods: Fifteen right handed healthy volunteers performed or observed a finger-thumb opposition task. Cerebral activations during normal movement (NOR), mirrored movement (MIR) and movement observation (OBS) by means of a video chain were recorded with functional magnetic resonance imaging (fMRI). Activation sizes in movement > static conditions were identified using SPM8 (p < 0.001, unc.) and attributed to predefined areas employing the Anatomy toolbox 1.8. Laterality indices for the responsive areas were calculated on the basis of the number of activated voxels. Results: Relevant bilateral BOLD responses were found in primary motor (M1) and somatosensory (S1 - BA 2, 3b and 3a) cortex, premotor and parietal areas and V5. When comparing MIR to NOR, no significant change of contralateral activation in M1 was found, but clearly at S1 with differences between hands. Conclusion: The mirror illusion does not elicit immediate changes in motor areas, yet there is a direct effect on somatosensory areas, especially for left hand movements. These results suggest different effects of mirror therapy on processing and rehabilitation of motor and sensory function.

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.

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.

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.

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.

Given the rising number of strokes worldwide, and the large number of individuals left with disabilities after stroke, novel strategies to reduce disability, increase functions in the motor and the cognitive domains, and improve quality of life are of major importance. Physical activity is a promising intervention to address these challenges but, as yet, there is no study demonstrating definite outcomes. Our objective is to assess whether additional treatment in the form of physical fitness-based training for patients early after stroke will provide benefits in terms of functional outcomes, in particular gait speed and the Barthel Index (co-primary outcome measures) reflecting activities of daily living (ADL). We will gather secondary functional outcomes as well as mechanistic parameters in an exploratory approach. Our phase III randomised controlled trial will recruit 215 adults with moderate to severe limitations of walking and ADL 5 to 45 days after stroke onset. Participants will be stratified for the prognostic variables of “centre”, “age”, and “stroke severity”, and randomly assigned to one of two groups. The interventional group receives physical fitness training delivered as supported or unsupported treadmill training (cardiovascular active aerobic training; five times per week, over 4 weeks; each session 50 minutes; total of 20 additional physical fitness training sessions) in addition to standard rehabilitation treatment. The control intervention consists of relaxation sessions (non-cardiovascular active; five times per week week, over 4 weeks; each session 50 minutes) in addition to standard rehabilitation treatment. Co-primary efficacy endpoints will be gait speed (in m/s, 10 m walk) and the Barthel Index (100 points total) at 3 months post-stroke, compared to baseline measurements. Secondary outcomes include standard measures of quality of life, sleep and mood, cognition, arm function, maximal oxygen uptake, and cardiovascular risk factors including blood pressure, pulse, waist-to-hip ratio, markers of inflammation, immunity and the insulin-glucose pathway, lipid profile, and others. The goal of this endpoint-blinded, phase III randomised controlled trial is to provide evidence to guide post-stroke physical fitness-based rehabilitation programmes, and to elucidate the mechanisms underlying this intervention. Registered in ClinicalTrials.gov with the Identifier NCT01953549 .

Most virtual rehabilitation environments rely on visual feedback. However, little is known on the optimum characteristics of these feedbacks. Here, we present first results of a systematic literature review to assess and compare visual feedback types in virtual reality (VR) based neurological motor rehabilitation of the upper limb. Overall we identified 104 relevant publications. Within these some applied multiple visual feedback types. We found six main visualization groups: Avatar Feedback (N=52), Augmented Reality Feedback (N=16), Abstract Feedback (N=40), Tracking Feedback (N=13), Performance Evaluation Feedback (N=2), and Combined Feedback (N=7). However, there is insufficient evidence for the choice of a specific visual feedback in relation to motor outcome. Thus, further research is necessary.

Mirror therapy is a therapy to treat patients with pain syndromes or hemiparesis after stroke. However, the underlying neurophysiologic mechanisms are not clearly understood. In order to determine the effect of a mirror-like illusion (MIR) on brain activity using functional near-infrared spectroscopy, 20 healthy right-handed subjects were examined. A MIR was induced by a digital horizontal inversion of the subjects' filmed hand. Optodes were placed on the primary motor cortex (M1) and the occipito-parietal cortex (precuneus, PC). Regions of interest (ROI) were defined a priori based on previous results of similar studies and confirmed by the analysis of effect sizes. Analysis of variance of the ROI signal revealed a dissociated pattern: at the PC, the MIR caused a significant inversion of a hemispheric lateralization opposite to the perceived hand, independent of the moving hand. In contrast, activity in M1 showed lateralization opposite to the moving hand, but revealed no mirror effect. These findings extend our understanding on interhemispheric rivalry and indicate that a MIR is integrated into visuomotor coordination similar to normal view, irrespective of the hand that is actually performing the task. (C) 2013 Society of Photo-Optical Instrumentation Engineers (SPIE)

Objective: To compare lateralized cerebral activations elicited during self-initiated movement mirroring and observation of movements. Subjects: A total of 15 right-handed healthy subjects, age range 22-56 years. Methods: Functional imaging study comparing movement mirroring with movement observation, in both hands, in an otherwise identical setting. Imaging data were analysed using statistical parametric mapping software, with significance threshold set at p

Lesions of human cortex areas often lead to elementary as well as higher-order disturbances of motor behaviour. In a cooperation between the Institute of Technical Computer Science in Aachen and the Department of Neurology in Dusseldorf, a system based on Virtual Reality (VR) techniques is being developed for the diagnosis of patients suffering from such sensorimotor disturbances. The use of VR comprises two aspects: firstly, VR can be used as an advanced visualization tool for motion analysis by the physician. Secondly, patients can be brought into virtual scenarios where they can perform specific motor tasks for diagnosis and therapy purposes.

Background Mirror therapy is used to improve motor function after stroke. During mirror therapy, a mirror is placed in the person's midsagittal plane, thus reflecting movements of the non-paretic side as if it were the affected side. Objectives To summarise the effectiveness of mirror therapy compared with no treatment, placebo or sham therapy, or other treatments for improving motor function and motor impairment after stroke. We also aimed to assess the effects of mirror therapy on activities of daily living, pain, and visuospatial neglect. Search methods We searched the Cochrane Stroke Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, PsycINFO and PEDro (last searched 16 August 2017). We also handsearched relevant conference proceedings, trials and research registers, checked reference lists, and contacted trialists, researchers and experts in our field of study. Selection criteria We included randomised controlled trials (RCTs) and randomised cross-over trials comparing mirror therapy with any control intervention for people after stroke. Data collection and analysis Two review authors independently selected trials based on the inclusion criteria, documented the methodological quality, assessed risks of bias in the included studies, and extracted data. We assessed the quality of the evidence using the GRADE approach. We analysed the results as standardised mean differences (SMDs) or mean differences (MDs) for continuous variables, and as odds ratios (ORs) for dichotomous variables. Main results We included 62 studies with a total of 1982 participants that compared mirror therapy with other interventions. Of these, 57 were randomised controlled trials and five randomised cross-over trials. Participants had a mean age of 59 years (30 to 73 years). Mirror therapy was provided three to seven times a week, between 15 and 60 minutes for each session for two to eight weeks (on average five times a week, 30 minutes a session for four weeks).When compared with all other interventions, we found moderate-quality evidence that mirror therapy has a significant positive effect on motor function (SMD 0.47, 95% CI 0.27 to 0.67; 1173 participants; 36 studies) and motor impairment (SMD 0.49, 95% CI 0.32 to 0.66; 1292 participants; 39 studies). However, effects on motor function are influenced by the type of control intervention. Additionally, based on moderate-quality evidence, mirror therapy may improve activities of daily living (SMD 0.48, 95% CI 0.30 to 0.65; 622 participants; 19 studies). We found low-quality evidence for a significant positive effect on pain (SMD −0.89, 95% CI −1.67 to −0.11; 248 participants; 6 studies) and no clear effect for improving visuospatial neglect (SMD 1.06, 95% CI −0.10 to 2.23; 175 participants; 5 studies). No adverse effects were reported. Authors' conclusions The results indicate evidence for the effectiveness of mirror therapy for improving upper extremity motor function, motor impairment, activities of daily living, and pain, at least as an adjunct to conventional rehabilitation for people after stroke. Major limitations are small sample sizes and lack of reporting of methodological details, resulting in uncertain evidence quality.

Background and Purpose— Previous stroke performance measures consider aspects of postacute treatment, but there are only few specific quality indicators or standards for poststroke rehabilitation. The purpose of this study was to develop a set of indicators for measuring the quality of postacute stroke rehabilitation in inpatient and outpatient facilities using a standardized evidence-based approach. Methods— Quality indicators were developed between January 2009 and February 2010 by an interdisciplinary board of healthcare professionals from rehabilitation centers cooperating in the Berlin Stroke Alliance. The Berlin Stroke Alliance is a regional network of >40 providers of acute treatment, rehabilitation, and aftercare aiming to improve stroke services within Berlin and Brandenburg. The indicators were developed according to published international recommendations and predefined methodological requirements. The applied standards included a systematic literature review, a rating of published evidence, an external peer review, and the evaluation in a pilot study before implementation. Results— Of an initial list of 33 indicators, 20 indicators were rated as being appropriate. After completion of the pilot phase, we agreed on a set of 18 indicators. The indicators measure processes (9 indicators), outcomes (5 indicators), and structures (4 indicators) in the following domains of stroke rehabilitation: completion of diagnostics; secondary prevention; cognition and affect; speech and swallowing; management of complications; sensorimotor functions and mobility; discharge status; and aftercare. Conclusions— Documentation of evidence-based quality indicators for stroke rehabilitation in clinical routine is feasible and can serve as a first step toward implementing standardized cross-institutional quality assurance programs for stroke rehabilitation.

Arm movements can easily be adapted to different biomechanical constraints. However, the cortical representation of the processing of visual input and its transformation into motor commands remains poorly understood. In a visuo-motor dissociation paradigm, subjects were presented with a 3-D computer-graphical representation of a human arm, presenting movements of the subjects’ right arm either as right or left arm. In order to isolate possible effects of coordinate transformations, coordinate mirroring at the body midline was implemented independently. In each of the resulting four conditions, 10 normal, right-handed subjects performed three runs of circular movements, while being scanned with O15-Butanol-PET. Kinematic analysis included orientation and accuracy of a fitted ellipsoid trajectory. Imaging analysis was performed with SPM 99 with activations threshold at P