Stefan Hesse

Ausgangspunkt Vorgestellt wird das externe Lidloading mittels eines aufgeklebten Bleiplättchens zur temporären Behandlung des Lagophthalmus infolge einer Plegie bzw. Parese des M. orbicularis oculi. Die erstmals 1993 beschriebene Technik ist simpel und effektiv, aber offensichtlich in Vergessenheit geraten. Methodik Statt eines Uhrglasverbandes tagsüber wird nach Entfettung des Lides ein individuell zugeschnittenes Bleiplättchen auf das Lid mit einem doppelseitigen Klebeband befestigt. Der Patient soll das Lid schließen können, eine Spontanptose zeigt ein zu schweres Plättchen an. Die Lidhebung als Funktion des M. levator palpebrae ist unbeeinträchtigt. Der Effekt ist schwerkraftabhängig, sodass der Patient einen Uhrglasverband oder eine Augenklappe nachts trägt. Im Falle einer persistierenden Parese des M. orbicularis oculi ist ein operatives Verfahren angezeigt. Insgesamt wurden 152 Fälle seit 1997 behandelt, in der Mehrzahl nach Hirnstamminfarkt bzw. OP eines Akustikusneurinoms. Ergebnisse Sofort konnten alle Patienten mithilfe des Plättchens das Lid schließen, ca. 45 % mussten bei Schlupflidern das Plättchen mehrfach am Tage befestigen, die Compliance war hoch, eine rasche Rückbildung der Parese erfolgte in ca. 60 % der Patienten. In Einzelfällen war die Rückbildung des M. orbicularis oculi schneller als die des oris. Schlussfolgerung Das externe Lidloading mittels Bleiplättchen im Falle eines Lagophthalmus ist simpel und effektiv, im Vergleich zum Uhrglasverband kosmetisch ansprechend, schaltet das Auge nicht aus und ist mit dem Führen eines Autos vereinbar. Background The introduction of an external lid loading with the help of a lead weight for the treatment of lagophthalmos is presented. This simple and effective approach was first described in 1993 but obviously not frequently used in the therapy for lagophthalmos. Methods Instead of wearing a monoculus throughout the day, the patient wears an indivdually tailored adhesive lead weight; its aim is a complete lid closure, in case of a too heavy lead weight a spontaneous ptosis occurs. With the M. levator palpebrae intact, lid lifting is no problem. The effect of the lead weight is gravity dependent, so that the patient has to wear the monoculus at night. To minimise the risk of lead intoxication, we varnished the surface of the weight with nail varnish. In the case of a persistant paresis of the M. orbicularis oculi, an implantation of a gold weight can follow. A total of 152 cases with lagophthalmos have been treated with the external lid loading since 1997. Results All patient could perform lid closing immediately after lead weight application. Approximately 45 % of the patients had to re-adjust the lead weight per day. Compliance was high and a partial or complete restoration of the function of the M. orbicularis oculi was observed in 60 %. In some cases the restoration of the M. orbicularis oculi was faster than in the M. orbicularis oris. Conclusion The external lid loading with a lead weight is a simple and effective approach in the treatment of lagophthalmos in comparison to a cosmetically unattractive monoculus. When wearing the lead weight the vision is not blurred so that car driving may be possible.

Every year, more than 200 000f people in Germany suffer a stroke. Restoration of walking ability and arm/hand function is an essential objective of rehabilitation. Three months after the stroke, about a quarter of the patients are still bound to the...

Restoration and improvement of gait after stroke are major aspects of neurorehabilitation. Mobilization out of the bed into the wheelchair and verticalisation with the help of a standing frame are first steps. With the patient cardiovascular stable,

Description and case series on a new mechanical arm trainer with three degrees of freedom (DoF), the REHA-SLIDE (RS), for stroke rehabilitation are presented. Similar to a rolling pin, it consists of two handles at either side of a connecting rod, the handles are bilaterally moved forward and backward, sideways, and rotated, the base plate is inclinable. A computer mouse attached to the rod enables playing games offering computer-biofeedback. Two patients, 6 and 5 weeks after a first-time supratentorial stroke, suffering from a flaccid non-functional upper extremity have been studied. Interventions performed were additional 30 min of RS-training every workday for 6 weeks; one session included 400 repetitions evenly distributed between the forward backward movement and drawing a circle clock- and counter clockwise. Afterwards the patients could play games. Upper extremity portion of the Fugl-Meyer Motor Assessment Score (FM, 0-66), and muscle strength by a Medical Research Council (MRC) sum score (0-45), the FM assessment was blinded. In the 2 patients, the FM (0-66) improved from 7 to 37, and from 17 to 43, their initial (terminal) MRC sum scores were 6 (36) and 13 (31). With the REHA-Slide (RS), severely affected patients practiced a bilateral 3 DoF movement. No conclusions can be drawn so far and a controlled clinical study must be the next step.

A major criterion for the application of rehabilitation robots in gait therapy is the question to what extent the machine is able to facilitate physiologically correct muscle activation patters in the patients leg muscles in order to achieve an optimal gait training effect. The EMG data presented in this paper is based on intermediate results of a study with 8 healthy subjects (5 male, 3 female) to evaluate the end-effector based gait rehabilitation robot HapticWalker in position controlled mode. The study investigated two different walking trajectories (floor, upstairs) at three different cadences (45, 60, 90 steps/min) in three different modes (free walking, HapticWalker with vertical CoM motion, HapticWalker without vertical CoM motion). Results show that muscle EMGs measured from all relevant leg muscles have the same phasic and rhythmic muscle activation patterns on the HapticWalker as with free walking. Even though there are differences in patterns of dedicated muscles, we observed reduced amplitudes and slightly delayed activation on the HapticWalker compared to free walking. No differences in EMGs were observed between the two different HapticWalker modes (with vertical CoM motion, cancelled CoM motion), which might eliminate the need for an active trunk suspension system in the latter case. A passive patient lifter would significantly reduce the complexity of the machine construction, all advanced training modes (e.g. dynamic body weight reduction) could then be accomplished via compliant behavior of the freely programmable footplates. Numerous EMG measurements with healthy subjects and non-ambulatory stroke patients were performed on the predecessing electromechanical Gait Trainer GT I and showed that physiologically relevant findings from healthy subjects (e.g. correct phasic muscle activation) can be transferred to a certain extent to stroke patients, but nevertheless studies with stroke patients on the robotic gait trainer HapticWalker are needed to confirm the results presented in this paper.

Gait restoration is an integral part of rehabilitation of brain lesioned patients. Modern concepts favour a task-specific repetitive approach, i.e. who wants to regain walking has to walk, while tone-inhibiting and gait preparatory manoeuvres had dominated therapy before. Following the first mobilization out of the bed, the wheelchair-bound patient should have the possibility to practise complex gait cycles as soon as possible. Steps in this direction were treadmill training with partial body weight support and most recently gait machines enabling the repetitive training of even surface gait and even of stair climbing. With treadmill training harness-secured and partially relieved wheelchair-mobilised patients could practise up to 1000 steps per session for the first time. Controlled trials in stroke and SCI patients, however, failed to show a superior result when compared to walking exercise on the floor. Most likely explanation was the effort for the therapists, e.g. manually setting the paretic limbs during the swing phase resulting in a too little gait intensity. The next steps were gait machines, either consisting of a powered exoskeleton and a treadmill (Lokomat, AutoAmbulator) or an electromechanical solution with the harness secured patient placed on movable foot plates (Gait Trainer GT I). For the latter, a large multi-centre trial with 155 non-ambulatory stroke patients (DEGAS) revealed a superior gait ability and competence in basic activities of living in the experimental group. The HapticWalker continued the end effector concept of movable foot plates, now fully programmable and equipped with 6 DOF force sensors. This device for the first time enables training of arbitrary walking situations, hence not only the simulation of floor walking but also for example of stair climbing and perturbations. Locomotor therapy is a fascinating new tool in rehabilitation, which is in line with modern principles of motor relearning promoting a task-specific repetitive approach. Sophisticated technical developments and positive randomized controlled trials form the basis of a growing acceptance worldwide to the benefits or our patients.

Background and Purpose: Preliminary reports suggest that central stimulation may enhance the effect of conventional physical therapies after stroke. This pilot study examines the safety and methodology of using transcranial direct stimulation (tDCS) with robot-assisted arm training (AT), to inform planning a larger randomised controlled trial. Subjects: Ten patients, after an ischaemic stroke 4–8 weeks before study onset, no history of epilepsy, participated. Eight had a cortical lesion and 2 had subcortical lesions: all had severe arm paresis and, co-incidentally, 5 had severe aphasia. Methods: Over six weeks, they received thirty 20 min-sessions of AT. During the first 7 minutes, 1.5mA of tDCS was applied, with the anode over the lesioned hemisphere and the cathode above the contralateral orbit. Arm and language impairment were assessed with the Fugl-Meyer motor score (FM, full range 0–66) and the Aachener Aphasie Test. Results: No major side effects occurred. Arm function of three patients (two with a subcortical lesion) improved significantly, with FM scores increasing from 6 to 28, 10 to 49 and 11 to 48. In the remaining seven patients, all with cortical lesions, arm function changed little, FM scores did not increase more than 5 points. Unexpectedly, aphasia improved in 4 patients. Conclusions: These procedures are safe, and easy to use in a clinical setting. In future studies, patients should be stratified by degree of arm weakness and lesion site, also the unexpected aphasia improvement warrants following-up.

The group at Klinik Berlin/Charite University Hospital in Berlin, Germany, began studies to promote motor recovery after stroke in the early 1990s. Following the introduction of treadmill training with partial body-weight support, the group designed an electromechanical gait trainer, GT I, based on movable foot plates that relieve therapist effort (e.g., when assisting the movement of the paretic limbs) and intensify patient gait training (GT). Preliminary results of a recent multicenter trial of 155 acute stroke patients showed that the GT I effectively promotes gait ability and competence in activi ties of daily living. The experimental group received 20 min of GT and 25 min of physiotherapy (PT) and the control group received 45 min of PT every day for 4 weeks. The laboratory's next step was the HapticWalker, a robotic walking simulator with freely programmable foot plates so that patients can, for example, additionally train for stair climbing and perturbations. The foot plates can be operated in full guidance or compliance control modes, thus reducing foot support according to the patient's learning success. For the severely affected upper limb, the laboratory's computerized arm trainer, called the Bi-Manu-Track, enables bilateral practice of forearm pronation/supination and wrist flexion/extension. Compared with electrical stimulation of the paretic wrist extensors, acute stroke patients with severe arm paresis (n = 44) had significantly more upper-limb muscle strength and control at the end of the 6-week intervention period and at follow-up. The laboratory's most recent and cost-effective development, the Nudelholz, is a purely mechanical device that bilaterally trains the shoulder, elbow, and wrist joints. It is intended for home therapy.