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Although multidisciplinary rehabilitation programs are commonly used in clinical practice for patients with multiple sclerosis (MS), they are currently underexamined. This study aims to investigate the efficacy and underlying brain mechanisms of an inpatient multidisciplinary rehabilitation. Twenty-four patients with relapse-onset MS underwent a 4-week personalized inpatient multidisciplinary rehabilitation and three assessment sessions including MRI, clinical, cognitive and motor function evaluation. Twenty-four healthy controls underwent two assessment sessions 4 weeks apart. Test performances were compared using repeated measures ANOVA, Tukey and t tests. A motor sequence learning (MSL) task was presented during fMRI and data were analysed using FSL. Patients had less perceived fatigue, improved walking speed and quality of life following the rehabilitation, which could be maintained at follow-up 4 weeks after rehabilitation. After rehabilitation, differences in accuracy of the MSL task between groups diminished, indicating an improved performance in patients. Improved accuracy went along with changes of brain activity in the left cerebellum and right frontal lobe post-rehabilitation, which could be maintained at follow-up. No changes between sessions were observed in controls. Multidisciplinary rehabilitation may improve highly impacting symptoms through more efficient recruitment of brain regions and therefore positively influence MS patients’ quality of life.

Zusammenfassung. Psychosomatische Medizin ist auf der Vorstellung basiert, dass körperliche Erkrankungen von einer Interaktion biologischer, psychologischer und sozialer Faktoren verursacht werden können. Die psychosomatischen Symptome können sich in verschiedenen Organsystemen manifestieren: dem Nervensystem, muskuloskelettalen System, kardiovaskulären System, Atmungssystem, Verdauungssystem, und der Haut. Im Jahr 1995 wurde ein Klassifikationssystem psychosomatischer Symptome vorgestellt, das eine systematische Kategorisierung psychosomatischer Störungen ermöglichen soll (Diagnostic Criteria for Psychosomatic Research, DCPR). Auf Basis der Vorstellung, dass psychosomatischen Erkrankungen körperliche, psychologische und soziale Faktoren zugrunde liegen, wird die Rehabilitation von interdisziplinären Teams durchgeführt. Die medikamentösen und psychotherapeutischen Therapien werden mit Therapien kombiniert, die entspannend wirken und Therapien, die kontrollierte Aktivierung beinhalten (z. B. Physiotherapie, Physiotherapie im Wasser, Medizinische Trainingstherapie, Ergotherapie). Psychosomatische Rehabilitation findet häufig zuerst in einem stationären Rahmen statt und vollzieht sich in mehreren Stufen: Erfassung des Problems (Anamnese und Untersuchungen) (1); Konzeptualisierung des Problems (2); Planung der Rehabilitationsziele (3); Interdisziplinäre Rehabilitationsmassnahmen (4); Überprüfung des Rehaerfolges (5); Vorbereitung der Klinikentlassung (6). Nach der Klinikentlassung wird die Rehabilitation ambulant weitergeführt, um Rückfälle zu vermeiden. Die klinische Effizienz stationärer psychosomatischer Rehabilitation wurde in mehreren Studien nachgewiesen.

Psychosomatic Rehabilitation: An Overview

Although multidisciplinary rehabilitation programs are commonly used in clinical practice for patients with multiple sclerosis (MS), they are currently underexamined.This study aims to investigate the efficacy and underlying brain mechanisms of an inpatient multidisciplinary rehabilitation.Twenty-four patients with relapse-onset MS underwent a 4-week personalized inpatient multidisciplinary rehabilitation and three assessment sessions including MRI, clinical, cognitive and motor function evaluation. Twenty-four healthy controls underwent two assessment sessions 4 weeks apart. Test performances were compared using repeated measures ANOVA, Tukey and t tests. A motor sequence learning (MSL) task was presented during fMRI and data were analysed using FSL.Patients had less perceived fatigue, improved walking speed and quality of life following the rehabilitation, which could be maintained at follow-up 4 weeks after rehabilitation. After rehabilitation, differences in accuracy of the MSL task between groups diminished, indicating an improved performance in patients. Improved accuracy went along with changes of brain activity in the left cerebellum and right frontal lobe post-rehabilitation, which could be maintained at follow-up. No changes between sessions were observed in controls.Multidisciplinary rehabilitation may improve highly impacting symptoms through more efficient recruitment of brain regions and therefore positively influence MS patients' quality of life.

Summary The mental status examination is an instrument of behavioural neurology that is used to identify and characterise specifi c disturbances of cerebral function relating to cognitive functions (such as memory and language), emotion and overt behaviour. It is conducted in a systematic fashion but is simple enough to be used at the bedside. Neurological conditions in which the mental status examination can provide clinically important information include stroke, encephalitis, dementia, hypoxic or metabolic encephalopathy, cerebral tumours and traumatic brain injury. This chapter describes methods to assess the following brain functions: level of consciousness, attention, concentration and mental control, language, memory, constructional ability, higher level sensory and motor functions, frontal lobe (executive) functions, and neuropsychiatric control functions.

IntroductionMotor imagery (MI) is a very popular and well-accepted technique in different disciplines. Originating from sport and psychology, MI is now also used in the field of medicine and education. Several studies confirmed the benefits of MI to facilitate motor learning and skill acquisition. The findings indicated that individual’s MI ability might influence the effectiveness of MI interventions. Over the last two centuries, researchers have developed several assessments to evaluate MI’s abstract construct. However, no systematic reviews (SR) exist for MI ability evaluation methods and their measurement properties.Methods and analysisThe SR will evaluate available MI ability assessments and their psychometric properties in four relevant disciplines: sports, psychology, medicine and education. This involves performing searches in SPORTDiscus, PsycINFO, Cochrane Library, Scopus, Web of Science and ERIC. Working independently, two reviewers will screen articles for selection. Then all raw information will be compiled in an overview table—including the articles’ characteristics (eg, a study’s setting or the population demographics) and the MI ability assessment (psychometric properties). To evaluate the articles’ methodological quality, we will use the COSMIN checklist. Then we will evaluate all the included assessments’ quality and perform a best-evidence synthesis. Results of this review will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.Ethics and disseminationThe SR is based on published data, and ethical approval is not required. This review will provide information on assessment performance and equipment, as well as its main focus and usefulness. Furthermore, we will present the methodological quality of all the included articles and assess the included instruments’ quality. Ultimately, this will act as a valuable resource, providing an overview of MI ability assessments for individual clinical settings, treatment aims, and various populations. The SR’s final report will be published in a peer-reviewed journal and presented at relevant conferences.PROSPERO registration numberCRD42017077004

Summary Background Arm hemiparesis secondary to stroke is common and disabling. We aimed to assess whether robotic training of an affected arm with ARMin—an exoskeleton robot that allows task-specific training in three dimensions—reduces motor impairment more effectively than does conventional therapy. Methods In a prospective, multicentre, parallel-group randomised trial, we enrolled patients who had had motor impairment for more than 6 months and moderate-to-severe arm paresis after a cerebrovascular accident who met our eligibility criteria from four centres in Switzerland. Eligible patients were randomly assigned (1:1) to receive robotic or conventional therapy using a centre-stratified randomisation procedure. For both groups, therapy was given for at least 45 min three times a week for 8 weeks (total 24 sessions). The primary outcome was change in score on the arm (upper extremity) section of the Fugl-Meyer assessment (FMA-UE). Assessors tested patients immediately before therapy, after 4 weeks of therapy, at the end of therapy, and 16 weeks and 34 weeks after start of therapy. Assessors were masked to treatment allocation, but patients, therapists, and data analysts were unmasked. Analyses were by modified intention to treat. This study is registered with ClinicalTrials.gov, number NCT00719433. Findings Between May 4, 2009, and Sept 3, 2012, 143 individuals were tested for eligibility, of whom 77 were eligible and agreed to participate. 38 patients assigned to robotic therapy and 35 assigned to conventional therapy were included in analyses. Patients assigned to robotic therapy had significantly greater improvements in motor function in the affected arm over the course of the study as measured by FMA-UE than did those assigned to conventional therapy ( F =4·1, p=0·041; mean difference in score 0·78 points, 95% CI 0·03–1·53). No serious adverse events related to the study occurred. Interpretation Neurorehabilitation therapy including task-oriented training with an exoskeleton robot can enhance improvement of motor function in a chronically impaired paretic arm after stroke more effectively than conventional therapy. However, the absolute difference between effects of robotic and conventional therapy in our study was small and of weak significance, which leaves the clinical relevance in question. Funding Swiss National Science Foundation and Bangerter-Rhyner Stiftung.

Background. For early inpatient stroke rehabilitation, the effectiveness of amphetamine combined with physiotherapy varies across studies. Objective. To investigate whether the recovery of activities of daily living (ADL, primary outcome) and motor function (secondary outcome) can be improved by dexamphetamine added to physiotherapy. Methods. In a double-blind, placebo-controlled trial, 16 patients, from 918 who were screened, were randomized to the experimental group (EG, dexamphetamine + physiotherapy) or control group (CG, placebo + physiotherapy). Both groups received multidisciplinary inpatient rehabilitation. Dexamphetamine (10 mg oral) or placebo was administered 2 days per week before physiotherapy. ADL and motor function were measured using the Chedoke–McMaster Stroke Assessment (CMSA) twice during baseline, every week during the 5-week treatment period, and at follow-up 1 week, 6 months, and 12 months after intervention. Results. The majority of ineligible patients had too little paresis, were on anticoagulants, or had a stroke >60 days prior to entry. Participants (EG, n = 7, age 70.3 ± 10 years, 5 women, 37.9 ± 9 days after stroke; CG, n = 9, age 65.2 ± 17 years, 3 women, 40.3 ± 9 days after stroke) did not differ at baseline except for the leg subscale. Analysis of variance from baseline to 1 week follow-up revealed significant improvements in favor of EG for subscales ADL ( P = .023) and arm function ( P = .020) at end of treatment. No adverse events were detected. Conclusion. In this small trial that was based on prior positive trials, significant gains in ADL and arm function suggest that the dose and timing of dexamphetamine can augment physiotherapy. Effect size calculation suggests inclusion of at least 25 patients per group in future studies (ClinicalTrials.gov number: NCT00572767).

Background. Functional electrical stimulation (FES) allows active exercises in stroke patients with upper extremity paralysis. Objective. To investigate the effect of motor training with FES on motor recovery in acute and subacute stroke patients with severe to complete arm and/or hand paralysis. Methods. For this pilot study, 23 acute and subacute stroke patients were randomly assigned to the intervention (n = 12) and control group (n = 11). Distributed over 4 weeks, FES training replaced 12 conventional training sessions in the intervention group. An Extended Barthel Index (EBI) subscore assessed the performance of activities of daily living (ADL). The Chedoke McMaster Stroke Assessment (CMSA) measured hand and arm function and shoulder pain. The Modified Ashworth Scale (MAS) assessed resistance to passive movement. Unblinded assessments were performed prior to and following the end of the training period. Results. The EBI subscore and CMSA arm score improved significantly in both groups. The CMSA hand function improved significantly in the FES group. Resistance to passive movement of finger and wrist flexors increased significantly in the FES group. Shoulder pain did not change significantly. None of the outcome measures, however, demonstrated significant gain differences between the groups. Conclusions. We did not find clear evidence for superiority or inferiority of FES. Our findings, and those of similar trials, suggest that the number of sessions should be at least doubled to test for superiority of FES in these highly impaired patients and approximately 50 participants would have to be assigned to each therapeutic intervention to find significant differences.

The process of developing a successful stroke rehabilitation methodology requires four key components: a good understanding of the pathophysiological mechanisms underlying this brain disease, clear neuroscientific hypotheses to guide therapy, adequate clinical assessments of its efficacy on multiple timescales, and a systematic approach to the application of modern technologies to assist in the everyday work of therapists. Achieving this goal requires collaboration between neuroscientists, technologists and clinicians to develop well-founded systems and clinical protocols that are able to provide quantitatively validated improvements in patient rehabilitation outcomes. In this article we present three new applications of complementary technologies developed in an interdisciplinary matrix for acute-phase upper limb stroke rehabilitation – functional electrical stimulation, arm robot-assisted therapy and virtual reality-based cognitive therapy. We also outline the neuroscientific basis of our approach, present our detailed clinical assessment protocol and provide preliminary results from patient testing of each of the three systems showing their viability for patient use.

A majority of stroke survivors present with cognitive impairments. Attention disturbance, which leads to impaired concentration and overall reduced cognitive functions, is strongly associated with stroke. The clinical efficacy of acupuncture with Baihui (GV20) and Shenting (GV24) as well as computer-assisted cognitive training in stroke and post-stroke cognitive impairment have both been demonstrated in previous studies. To date, no systematic comparison of these exists and the potential beneficial effects of a combined application are yet to be examined. The main objective of this pilot study is to evaluate the effects of computer-assisted cognitive training compared to acupuncture on the outcomes of attention assessments. The second objective is to test the effects of a combined cognitive intervention that incorporates computer-assisted cognitive training and acupuncture (ACoTrain). An international multicentre, single-blinded, randomised controlled pilot trial will be conducted. In a 1:1:1 ratio, 60 inpatients with post-stroke cognitive dysfunction will be randomly allocated into either the acupuncture group, the computer-assisted cognitive training group, or the ACoTrain group in addition to their individual rehabilitation programme. The intervention period of this pilot trial will last 4 weeks (30 minutes per day, 5 days per week, Monday to Friday). The primary outcome is the test battery for attentional performance. The secondary outcomes include the Trail Making Test, Test des Deux Barrages, National Institute of Health Stroke Scale, and Modified Barthel Index for assessment of daily life competence, and the EuroQol Questionnaire for health-related quality of life. This trial mainly focuses on evaluating the effects of computer-assisted cognitive training compared to acupuncture on the outcomes of attention assessments. The results of this pilot trial are expected to provide new insights on how Eastern and Western medicine can complement one another and improve the treatment of cognitive impairments in early stroke rehabilitation. Including patients with different cultural backgrounds allows a more generalisable interpretation of the results but also poses risks of performance bias. Using standardised and well-described assessments, validated for each region, is pivotal to allow pooling of the data. Clinical Trails.gov ID: NCT02324959 (8 December 2014)

Aus fast 60 eingereichten Arbeiten wurden beim Nationalen Symposium fur Qualitatsmanagement vier Projekte mit dem Swiss Quality Award 2012 ausgezeichnet. Die Gewinner in der Kategorie Management stellen hier ihr "Rheinfelder Patientenmanagement-Modell" vor, die Gewinner der Kategorie Technologie ihre "Onlinepraxis".

Objective: To evaluate the ability of the Frontal Lobe Score (FLS) to differentiate patients with frontal lobe lesions from those with nonfrontal lesions and normal controls. Design: In a prospective, blind setup, the sensitivity and specificity of the Frontal Lobe Score was compared with the Wisconsin Card Sorting Test (WCST) and the Stroop Test. Patients: A sample of 108 subjects (26 patients with cerebral lesions confined to the frontal lobes, 28 patients with cerebral lesions without involvement of the frontal lobes, 31 patients with mixed frontal/nonfrontal lesions, 23 controls without cerebral lesions) was examined. Measures: Frontal Lobe Score, Wisconsin Card Sorting Test, Stroop Test. Results: The Frontal Lobe Score detected pure frontal lesions with a sensitivity of 92.3%. It discriminated patients with frontal lesions from normal controls with a specificity of 100%; differentiation from patients with nonfrontal lesions was obtained with a specificity of 75.0%. For the WCST, sensitivity for detection of pure frontal lesions was 65.4%, while specificity was 60.9% compared with normal controls and 53.6% compared with nonfrontal lesions. The Stroop Test showed a sensitivity of 30.8%, a specificity compared with normal controls of 95.7% and compared with nonfrontal lesions of 92.9%. Conclusion: The Frontal Lobe Score has clinical usefulness for screening of effects of frontal lobe damage superior to that of the WCST and the Stroop Test.

The improved pendulum test of Wartenberg provides reliable and reproducible data in spastic patients. The R2 index calculated from the pendulum curve is the most useful single value to quantify spasticity of the legs. During a drug trial with the 1,4- benzodiazepine tetrazepam, the R2 indicates faithfully the changes in spasticity. It is also useful in deciding when a dose increase is needed in individual cases. Compared with the Ashworth Scale, it is independent of the raters' impression and expressed in digital values. Its current limitation is that it can be used only for the lower extremi ties. Its decisive advantage over other methods is that it expresses the degree of spas ticity in a single value. Tetrazepam was applied in increasing doses to nine patients and proved to be an effective antispastic drug with good tolerability and only minor side effects. The changes in the R2 index during a 5-day trial were statistically significant.

Following an extended infarction in the territory of the left anterior cerebral artery including the anterior corpus callosum, a 66-year-old right-handed man exhibited an alien hand syndrome on the right side and an ideomotor apraxia of the left hand. In addition to other typical symptoms of frontal lobe lesions, he presented with an interesting difference in the manifestation of perseveration in either hand. In the right hand, the perseveration was part of the alien hand syndrome, whereas in the left hand perseveration showed in the inability to switch promptly from one movement to another on instruction during praxis testing.

Background The Australian Whiplash Disability Questionnaire (WDQ) was cross-culturally translated, adapted, and tested for validity to be used in German-speaking patients. The self-administered questionnaire evaluates actual pain intensity, problems in personal care, role performance, sleep disturbances, tiredness, social and leisure activities, emotional and concentration impairments with 13 questions rated on an 11-point rating scale from zero to ten. Methods In a first part, the Australian-based WDQ was forward and backward translated. In a consensus conference with all translators and health care professionals, who were experts in the treatment of patients with a whiplash associated disorder (WAD), formulations were refined. Original authors were contacted for clarification and approval of the forward-backward translated version. The German version (WDQ-G) was evaluated for comprehensiveness and clarity in a pre-study patient survey by a random sample of German-speaking patients after WAD and four healthy twelve to thirteen year old teenagers. In a second part, the WDQ-G was evaluated in a patient validation study including patients affected by a WAD. Inpatients had to complete the WDQ-G, the North American Spine Society questionnaire (NASS cervical pain), and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) at entry in the rehabilitation centre. Results In the pre-study patient survey (response rate 31%) patients rated clarity for title 9.6 ± 0.9, instruction 9.3 ± 1.4 and questions 9.6 ± 0.7, and comprehensiveness for title 9.6 ± 0.7, instruction 9.3 ± 1.4 and questions 9.8 ± 0.4. Time needed to fill in was 13.7 ± 9.0 minutes. In total, 70 patients (47 females, age = 43.4 ± 12.5 years, time since injury: 1.5 ± 2.6 years) were included in the validation study. WDQ-G total score was 74.0 ± 21.3 points (range between 15 and 117 points). Time needed to fill in was 6.7 ± 3.4 minutes with data from 22 patients. Internal consistency was confirmed with Cronbachs’s α = 0.89. Concurrent validity showed a highly significant correlation with subscale pain and disability (NASS) at r = 0.74 and subscale pain (SF-36) at r = 0.71. Conclusions The officially translated and adapted WDQ-G can be used in German-speaking patients affected by a WAD to evaluate patients’ impairments in different domains. The WDQ-G is a self-administered outcome measure showing a high internal consistency and good concurrent validity., Health and Quality of Life Outcomes, 11, ISSN:1477-7525

Background The literature suggests a beneficial effect of motor imagery (MI) if combined with physical practice, but detailed descriptions of MI training session (MITS) elements and temporal parameters are lacking. The aim of this review was to identify the characteristics of a successful MITS and compare these for different disciplines, MI session types, task focus, age, gender and MI modification during intervention. Methods An extended systematic literature search using 24 databases was performed for five disciplines: Education, Medicine, Music, Psychology and Sports. References that described an MI intervention that focused on motor skills, performance or strength improvement were included. Information describing 17 MITS elements was extracted based on the PETTLEP (physical, environment, timing, task, learning, emotion, perspective) approach. Seven elements describing the MITS temporal parameters were calculated: study duration, intervention duration, MITS duration, total MITS count, MITS per week, MI trials per MITS and total MI training time. Results Both independent reviewers found 96% congruity, which was tested on a random sample of 20% of all references. After selection, 133 studies reporting 141 MI interventions were included. The locations of the MITS and position of the participants during MI were task-specific. Participants received acoustic detailed MI instructions, which were mostly standardised and live. During MI practice, participants kept their eyes closed. MI training was performed from an internal perspective with a kinaesthetic mode. Changes in MI content, duration and dosage were reported in 31 MI interventions. Familiarisation sessions before the start of the MI intervention were mentioned in 17 reports. MI interventions focused with decreasing relevance on motor-, cognitive- and strength-focused tasks. Average study intervention lasted 34 days, with participants practicing MI on average three times per week for 17 minutes, with 34 MI trials. Average total MI time was 178 minutes including 13 MITS. Reporting rate varied between 25.5% and 95.5%. Conclusions MITS elements of successful interventions were individual, supervised and non-directed sessions, added after physical practice. Successful design characteristics were dominant in the Psychology literature, in interventions focusing on motor and strength-related tasks, in interventions with participants aged 20 to 29 years old, and in MI interventions including participants of both genders. Systematic searching of the MI literature was constrained by the lack of a defined MeSH term., BMC Medicine, 9, ISSN:1741-7015

Background Motor imagery (MI) when combined with physiotherapy can offer functional benefits after stroke. Two MI integration strategies exist: added and embedded MI. Both approaches were compared when learning a complex motor task (MT): 'Going down, laying on the floor, and getting up again'. Methods Outpatients after first stroke participated in a single-blinded, randomised controlled trial with MI embedded into physiotherapy (EG1), MI added to physiotherapy (EG2), and a control group (CG). All groups participated in six physiotherapy sessions. Primary study outcome was time (sec) to perform the motor task at pre and post-intervention. Secondary outcomes: level of help needed, stages of MT-completion, independence, balance, fear of falling (FOF), MI ability. Data were collected four times: twice during one week baseline phase (BL, T0), following the two week intervention (T1), after a two week follow-up (FU). Analysis of variance was performed. Results Thirty nine outpatients were included (12 females, age: 63.4 ± 10 years; time since stroke: 3.5 ± 2 years; 29 with an ischemic event). All were able to complete the motor task using the standardised 7-step procedure and reduced FOF at T0, T1, and FU. Times to perform the MT at baseline were 44.2 ± 22s, 64.6 ± 50s, and 118.3 ± 93s for EG1 (N = 13), EG2 (N = 12), and CG (N = 14). All groups showed significant improvement in time to complete the MT (p < 0.001) and degree of help needed to perform the task: minimal assistance to supervision (CG) and independent performance (EG1+2). No between group differences were found. Only EG1 demonstrated changes in MI ability over time with the visual indicator increasing from T0 to T1 and decreasing from T1 to FU. The kinaesthetic indicator increased from T1 to FU. Patients indicated to value the MI training and continued using MI for other difficult-to-perform tasks. Conclusions Embedded or added MI training combined with physiotherapy seem to be feasible and benefi-cial to learn the MT with emphasis on getting up independently. Based on their baseline level CG had the highest potential to improve outcomes. A patient study with 35 patients per group could give a conclusive answer of a superior MI integration strategy. Trial Registration ClinicalTrials.gov: NCT00858910

Background Standardised translation and cross-cultural adaptation (TCCA) procedures are vital to describe language translation, cultural adaptation, and to evaluate quality factors of transformed outcome measures. No TCCA procedure for objectively-assessed outcome (OAO) measures exists. Furthermore, no official German version of the Canadian Chedoke Arm and Hand Activity Inventory (CAHAI) is available. Methods An eight-step for TCCA procedure for OAO was developed (TCCA-OAO) based on the existing TCCA procedure for patient-reported outcomes. The TCCA-OAO procedure was applied to develop a German version of the CAHAI (CAHAI-G). Inter-rater reliability of the CAHAI-G was determined through video rating of CAHAI-G. Validity evaluation of the CAHAI-G was assessed using the Chedoke-McMaster Stroke Assessment (CMSA). All ratings were performed by trained, independent raters. In a cross-sectional study, patients were tested within 31 hours after the initial CAHAI-G scoring, for their motor function level using the subscales for arm and hand of the CMSA. Inpatients and outpatients of the occupational therapy department who experienced a cerebrovascular accident or an intracerebral haemorrhage were included. Results Performance of 23 patients (mean age 69.4, SD 12.9; six females; mean time since stroke onset: 1.5 years, SD 2.5 years) have been assessed. A high inter-rater reliability was calculated with ICCs for 4 CAHAI-G versions (13, 9, 8, 7 items) ranging between r = 0.96 and r = 0.99 (p < 0.001). Correlation between the CAHAI-G and CMSA subscales for hand and arm was r = 0.74 (p < 0.001) and r = 0.67 (p < 0.001) respectively. Internal consistency of the CAHAI-G for all four versions ranged between α = 0.974 and α = 0.979. Conclusions The TCCA-OAO procedure was validated regarding its feasibility and applicability for objectively-assessed outcome measures. The resulting German CAHAI can be used as a valid and reliable assessment for bilateral upper limb performance in ADL in patients after stroke.

To identify objective clinical examinations for the diagnosis of whiplash syndrome, whereby we focused on trigger points.A cross-sectional study with 1 measurement point.A quiet treatment room in a rehabilitation center.Patients (n=124) and healthy subjects (n=24) participated in this study. Among the patient group were patients with whiplash-associated disorders (n=47), fibromyalgia (n=21), nontraumatic chronic cervical syndrome (n=17), and endogenous depression (n=15).Not applicable.Each patient and control subject had a manual examination for trigger points of the semispinalis capitis, trapezius pars descendens, levator scapulae, scalenus medius, sternocleidomastoideus, and masseter muscles bilaterally.Forty (85.1%) of the patients with whiplash had positive trigger points in the semispinalis capitis muscle. The patients with whiplash had a significantly higher prevalence of positive trigger points in the semispinalis capitis muscle than any of the control groups (P.05). For the other examined muscles, the prevalence of trigger points in the patients with whiplash did not differ significantly from the patients with fibromyalgia or nontraumatic chronic cervical syndrome. It did differ from the patients with endogenous depression and the healthy controls.Patients with whiplash showed a distinct pattern of trigger point distribution that differed significantly from other patient groups and healthy subjects. The semispinalis capitis muscle was more frequently affected by trigger points in patients with whiplash, whereas other neck and shoulder muscles and the masseter muscle did not differentiate between patients with whiplash and patients with nontraumatic chronic cervical syndrome or fibromyalgia.

Background: In patients with Ribbing's disease (RD)—a form of multiple epiphysal dystrophy—hypertension is frequent, often severe, and accompanied by a relevant cardiac dysfunction. Hypothesis: This study was undertaken to evaluate the contribution of the calcium antagonist amlodipine and of the angiotensin-converting-enzyme inhibitor enalapril to blood pressure regulation by studying their effect on neurohormonal activation. Methods: Fifty hypertensive patients with RD were studied. After a placebo run-in period of 4 to 6 weeks, patients were randomly assigned to receive either amlodipine (10 mg once daily) or enalapril (20 mg once daily) for 6 months. Results: Both drugs significantly lowered blood pressure. Enalapril did not result in activation of the sympathetic system (as determined by measurement of the plasma norepinephrine level). On the other hand, the hypotensive effect of amlodipine occurred with an increase in heart rate and in the levels of plasma norepinephrine and angiotensin II. Conclusion: It is unclear whether amlodipine may reduce cardiac dysfunction in patients with RD.

• The accuracy of computed tomography, electroencephalography, and clinical features in the differential diagnosis of senile dementia was studied prospectively. Out of 50 demented patients, autopsy revealed 32 cases with either senile dementia of the Alzheimer's type (SDAT), multi-infarct dementia (MID), or a combination of both. Eighteen patients had dementia caused by other diseases. Based on a combination of computed tomography, electroencephalography, and clinical features, senile dementia of the Alzheimer's type was differentiated from all 50 patients, with a specificity of 83% and a sensitivity of 80%. Focusing on senile dementia of the Alzheimer's type, multi-infarct dementia, or a combination of both, specificity decreased to 65% and sensitivity to 47%. Comparing the different methods, multi-infarct processes were diagnosed with a higher sensitivity by the clinical features (73%) than by computed tomography (18%) or electroencephalography (18%). None of the methods validly differentiated multi-infarct dementia from a combination of multi-infarct dementia and senile dementia of the Alzheimer's type.

In paraplegic patients, amputation illusions and anosognosia with phantom position illusions are distinct phenomena which do not concur in any one patient. A permanent amputation illusion regularly follows a complete spinal injury with concomitant brain concussion, whereas all patients who are conscious during their spinal trauma remain aware of their paralyzed limbs in definite phantom positions which are clearly related to the position of the body at the moment of injury.

Copyright @ 2009 Schuster et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background: Two different approaches have been adopted when applying motor imagery (MI) to stroke patients. MI can be conducted either added to conventional physiotherapy or integrated within therapy sessions. The proposed study aims to compare the efficacy of embedded MI to an added MI intervention. Evidence from pilot studies reported in the literature suggests that both approaches can improve performance of a complex motor skill involving whole body movements, however, it remains to be demonstrated, which is the more effective one.Methods/Design: A single blinded, randomised controlled trial (RCT) with a pre-post intervention design will be carried out. The study design includes two experimental groups and a control group (CG). Both experimental groups (EG1, EG2) will receive physical practice of a clinical relevant motor task ('Going down, laying on the floor, and getting up again') over a two week intervention period: EG1 with embedded MI training, EG2 with MI training added after physiotherapy. The CG will receive standard physiotherapy intervention and an additional control intervention not related to MI.The primary study outcome is the time difference to perform the task from pre to post-intervention. Secondary outcomes include level of help needed, stages of motor task completion, degree of motor impairment, balance ability, fear of falling measure, motivation score, and motor imagery ability score. Four data collection points are proposed: twice during baseline phase, once following the intervention period, and once after a two week follow up. A nested qualitative part should add an important insight into patients' experience and attitudes towards MI. Semi-structured interviews of six to ten patients, who participate in the RCT, will be conducted to investigate patients' previous experience with MI and their expectations towards the MI intervention in the study. Patients will be interviewed prior and after the intervention period.Discussion: Results will determine whether embedded MI is superior to added MI. Findings of the semi-structured interviews will help to integrate patient's expectations of MI interventions in the design of research studies to improve practical applicability using MI as an adjunct therapy technique.

Background The Whiplash Disability Questionnaire (WDQ) poses a validated tool for the assessment of patients who experience whiplash-associated disorders. A German translation and cross-cultural adaptation was recently produced and presented high validity and internal consistency. As a follow-up, the presented study tests the translated Whiplash Disability Questionnaire’s (WDQ-G) retest reliability and responsiveness to change. Methods The WDQ-G was assessed on three different measurement events: first upon entry (ME1), second four days after entry (ME2), and third at discharge (ME3). Test-retest reliability data from ME1 and ME2 was analysed in a group of stable patients to obtain the intraclass correlation coefficient (ICC) and the standard error of measurement (SEM). To test the instrument’s responsiveness, WDQ-G change data were compared to concurrent instruments. The probability of each instrument, to correctly distinguish patients of the stable phase (ME1 to ME2) from patients who deemed to have improved between from ME1 to ME3, was analysed. Results In total, 53 patients (35 females, age = 45 ± 12.2) were recruited. WDQ-G scores changed from ME1 to ME2 by 5.41 ± 11.6 points in a stable group. This corresponds to a test-retest reliability of ICC = 0.91 (95% CI = 0.80–0.95) with a SEM of 6.14 points. Minimal Detectable Change, at 95% confidence, was calculated to be 17 points change in scores. Area under Receiver Operator Characteristics of the WDQ-G’s responsiveness revealed a probability of 84.6% (95% CI = 76.2%–93%) to correctly distinguish between improved and stable patients. Optimal sensitivity (73.2%) and specificity (76.2%) was established at 11-point change. Conclusions High retest reliability and good responsiveness of the WDQ-G support clinical implementation of the translated version. The data suggest, that change in total score greater than eleven points can be interpreted as clinical relevant from a patient’s perspective. Minimal Important Change is suggested at 15 points where there is still high specificity and a 90% confidence MDC., Health and Quality of Life Outcomes, 11, ISSN:1477-7525