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Abstracts of the4th World Congress for NeuroRehabilitation

MAIN SYMPOSIA

M1-1 Enhancing Training Effects inNeurorehabilitation after Chronic Stroke:Cortical Stimulation, Drugs, andSomatosensory Input

Leonardo G. CohenNational Institute of Neurological Disorders andStroke, National Institutes of Health, USA

Background: Stroke is the leading cause of long-term dis-ability worldwide and a condition for which there is no univer-sally accepted treatment. The development of new effectivetherapeutic strategies relies on a better understanding of themechanisms underlying recovery of function. Noninvasivetechniques to study brain function including fMRI, PET, TMS,EEG, and MEG led to recent studies that identified some of theseoperating mechanisms, resulting in the formulation of novel ap-proaches to motor rehabilitation based on principles of neuro-plasticity. Recent neuroimaging studies documented the in-volvement of multiple primary and nonprimary motor regionsof both cerebral hemispheres in the process of recovery of mo-tor function after stroke. In general, patients with no residualimpairment show activation patterns close to those exhibited bynormal persons, whereas those with more profound impair-ment activated multiple regions in both cerebral hemispheres.TMS studies have shown that both primary and nonprimary mo-tor regions contribute to functional recovery after stroke. Evi-dence is mounting for the involvement of interhemispheric in-teractions as influential factors in the process of motor recovery.It is clear that functionally relevant adaptive changes take placein the human brain after focal injury. But can we modulatethem? Basic science studies showed that manipulation of envi-ronmental, behavioral, and pharmacologic factors can influ-ence cerebral reorganization. From our knowledge of how thebrain responds to focal injury and how this relates to recoverywe can now generate hypothesis-driven approaches toneurorehabilitation. Methods: Various recent studies from dif-ferent laboratories evaluated the effects of somatosensory stim-ulation applied to the paretic hand, anesthesia of the intacthand, cortical stimulation that enhances plasticity in the af-fected motor cortex or decreases activity in the intact motor cor-tex with transcranial magnetic (TMS) and electrical DC (tDCS)stimulation on motor function in patients with chronic stroke.Results: Somatosensory stimulation applied to the paretic hand,anesthesia of the intact hand, tDCS applied to the motor cortexof the affected hemisphere and downregulation of activity inthe motor cortex of the intact hemisphere elicited behavioralimprovements in motor function of the paretic hand. Conclu-

sion: These results suggest that reduction of somatosensory in-put from the intact hand, increase in somatosensory input fromthe paretic hand, enhancement of activity within the motor cor-tex of the affected hemisphere, down regulation of activitywithin the intact motor cortex and pharmacological interven-tions have the potential of enhancing training effects on motorperformance of a paretic hand. Results from these studiesstarted to provide valuable data for the development of newstrategies in neurorehabilitation.

M1-2 Neuronal Regeneration after Stroke:Studies on a Novel Brain Environment for Repair

S. T. Carmichael, J. Ohab, P. Tsai, and H. WuGeffen School of Medicine at UCLA, USA

Background: Stroke causes localized injury and death butalso a limited degree of neural repair. Recently, it has beenshown that stroke induces newly formed immature neurons(neuroblasts) to migrate from their germinal matrix, thesubventricular zone, to areas of injury. If properly harnessed,this might form a basis for endogenous neuronal regenerationafter stroke. In their normal environment, neuronal stem/pro-genitor cells exist in tight association with blood vessels—a re-lationship that is termed the neurovascular niche. We hypothe-sized that stroke alters blood vessels in the peri-infarct cortex toinduce a novel neurovascular niche which supports neuronalregeneration in peri-infarct cortex. Methods: Small focal strokeswere produced in the somatosensory cortex of young adultmale C57Bl6 and/or erythropoietin receptor conditional knock-out mice. Newly divided neuroblasts were labeled with BrdUadministrat ion after stroke and with double cort inimmunohistochemistry. The following immunohistochemicalmarkers were used to study blood vessels and vascular growthfactors or chemokines: PECAM; angiopoietin 1 and its receptorTie2; SDF-1 and its receptor CXCR4; erythropoietin and the clas-sical erythropoietin receptor. In some cases, endothelial cellswere labeled with intravascular perfusion of tomato lection.The blood brain barrier is open after stroke for at least 7 days inthis model. So growth factors and their antagonists (AMD3100for CXCR4, anti-Tie 2 antibody for tie2 receptor) were adminis-tered systemically with osmotic minipumps after stroke. Micro-scopic results were imaged with confocal and epifluorescentmicroscopy and quantified stereologically. Results: Stroke in-duces migration of newly born neuroblasts from thesubventricular zone to peri-infarct cortex. Over 10 000neuroblasts are present in peri-infarct cortex at day 7poststroke. In peri-infarct cortex, neuroblasts form a tight asso-ciation with vascular endothelial cells. This neuroblast/endo-thelial association occurs at areas of active vascular growth andangiogenesis. These vessels produce angiopoietin 1, SDF-1 anderythropoietin; and migrating neuroblasts express tie2, CXCR4,and the classical erythropoietin receptor. Conditional knockoutof the erythropoietin receptor with a nestin/Cre Lox system re-duces neuroblast survival in peri-infarct cortex, but does not af-fect neuroblast migration after stroke. Systemic administration

Copyright © 2006 The American Society of Neurorehabilitation 51

Abstracts from 2006 4th World Congress for NeuroRehabi-l i tat ion, held February 12-16, 2006 in Hong Kong.Neurorehabilitation and Neural Repair 2006; 20:51-232

DOI: 10.1177/1545968305284198

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of angiopoietin 1 and SDF-1 potentiate neuroblast recruitmentto peri-infarct cortex, producing 16 000 to 20 000 neuroblasts inperi-infarct cortex and altering the migratory pathway from theSVZ. Blockade of CXCR4 with the specific antagonist AMD3100disperses neuroblasts in peri-infarct cortex and alters the migra-tory pathway from the subventricular zone. Ongoing studies areexamining blockade of the angiopoietin 1/tie 2 system and aredetermining the behavioral consequences of inducing or block-ing the poststroke neural stem/progenitor response. Conclu-sion: Stroke induces the formation of a novel neurovascularniche in peri-infarct cortex. This niche links angiogenesis andneurogenesis through specific growth factor systems to pro-mote neuroblast migration and survival after stroke. Becausethis niche exists in area of altered blood brain barrier perme-ability, systemic administration of drugs can selectively influ-ence poststroke neurogenesis. Future studies along these linesmay define treatment avenues that enhance neural repair afterstroke.

M2-1 Understanding the Pattern of FunctionalRecovery after Stroke

G. KwakkelRehabilitation Centre “de Hoogstraat,” UniversityMedical Centre, Utrecht, and VU University MedicalCentre, The Netherlands

Longitudinal studies show that almost all stroke patients ex-perience at least some predictable degree of functional recov-ery in the 1st 6 months after their stroke. However, the nonlin-ear pattern as a function of time is insufficiently understood. Todate, intensive, task-oriented rehabilitation is believed to mod-ulate this logistic pattern of recovery, probably by interactingwith a number of underlying processes, such as recovery ofpenumbral tissues and neural plasticity, including resolution ofdiaschisis. In addition, kinematic studies have shown that func-tional improvement is more than recovery from impairmentsalone, suggesting that patients are able to improve their func-tional skills by using behavioral compensation strategies.Therefore, understanding the impact of task-dependent corticalactivation patterns in noninvasive methods requires not only in-formation derived from longitudinal studies pertaining to func-tional outcomes but also a better understanding of what exactlyis kinematically learned during the acquisition of new skills. Fu-ture studies should also put more emphasis on a better under-standing of the time-dependency of prognostic factors that de-termine functional improvement and outcome after stroke. Inparticular, recently developed longitudinal regression modelsinvestigating changes in time-dependent covariates of func-tional outcome show that improvement in, for example, stand-ing balance control is more important than improvement in legstrength or synergism when it comes to improving walking abil-ity, whereas reduction in visuospatial inattention is independ-ently related to gait improvement. Likewise, it was found thatsome recovery of voluntary finger extension is the most impor-tant factor for the recovery of upper limb function. In these lon-gitudinal regression models, time itself is found to be an inde-pendent covariate which is highly associated with changes inwalking ability and dexterity during the 1st 2 months, suggest-ing that the most pronounced improvements occur early afterstroke. Finally, prediction models that are adjusted for the ef-fects of time after stroke onset also suggest that outcome islargely defined within the 1st weeks poststroke, although func-tional improvement has been found to extend beyond 6 months

poststroke. These findings suggest the existence of a criticaltime window for therapeutic interventions early after stroke. Italso indicates that appropriate patient selection for a meaning-ful intensive practice is essential in optimizing the probability ofsome functional recovery.

M2-2 Simulation-Based Treatment Planning forGait Abnormalities

S. L. Delp, F. C. Anderson, and A. S. ArnoldStanford University, USA

Background: The outcomes of treatments to correct abnor-mal gait and other disabling movement abnormalities are un-predictable and sometimes unsuccessful. In some cases, spasticmuscles are presumed to contribute to abnormal movement,and botulinum toxin injections or surgical lengthening of themuscles are performed to alter muscle forces. In other cases, di-minished muscle strength is thought to be a factor, and strength-ening exercises or orthoses are prescribed. We believe thattreatments to correct abnormal gait could be designed more ef-fectively if the potential causes of the abnormal gait wereknown, and methods to determine which of these potentialcauses contribute to a person’s gait abnormality were devel-oped. Dynamic simulations offer a powerful framework foridentifying the causes of gait abnormalities in individual sub-jects and for evaluating the effects of potential treatments. Meth-ods: We have generated and analyzed dynamic simulations ofindividual subjects with abnormal gait to determine thebiomechanical cause of their abnormal movements and the po-tential consequences of different treatment options. We repre-sented each subject’s musculoskeletal system by a scaled, 21-degree-of-freedom linkage actuated by 92 muscles. We usedcomputed muscle control to find a set of muscle excitations thatproduced a simulation that closely matched the measured gaitkinematics and kinetics. The predicted muscle excitations weregenerally consistent with the subjects’ measured EMG activity,and the simulated joint angles reproduced the subjects mea-sured kinematics. We identified which muscles were con-tributing to the abnormal moments and evaluated their relativecontributions to the joint motions by altering muscle excitationsin the simulation and computing the resulting changes in bodymotions. Results: Subject-specific dynamic simulations have al-lowed us to identify the causes of abnormal motion and to eval-uate the biomechanical effects of surgical and nonsurgical treat-ments. For example, we evaluated the potential consequencesof botulinum toxin injections by decreasing the excitation of amuscle while leaving its passive force-length properties intact.The motion after the simulated injection provides a clear indica-tion of the effects of diminished muscle excitation on the mo-tion. Conclusion: Subject specific dynamic simulations providea new paradigm for treatment planning. This presentation willdefine the state of the art in dynamic simulation of movement,present case studies in which simulation has been used intreatment planning, and identify challenges for the future.

M3-1 The Development of a Wearable Robot(RUPERT) for Neural Rehabilitation

Jiping HeArizona State University, USA

Background: Recent research has shown that neural plastic-ity in the brain has more capability to recover control of motor

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function after injury than once believed. Functional maps frombrain imaging show that motor cortical representation shrinkswith inactivity after lesions and may expand with subsequentactivities. These findings form the basis for new therapeutictreatment of patients with stroke and traumatic brain injury: re-petitive motor function activities. This type of therapy is mostsuitable for a robotic-assisted approach. However, the develop-ment of robotic systems tends to be on expensive and complexside for practical use. There is a need for a wearable device thatcan be programed to assist a patient to practice coordinatedbimanual activities during therapy sessions at clinic or at hometo take full advantage of the repetitive therapy. Methods: Thedesign goals were to develop an exoskeleton upper extremitytherapeutic device that assists repetitive training of criticalreaching and feeding motions for activities of daily living. Thedevice should also provide measurement of functional perfor-mance for evaluation purpose and guiding the progress of eachtherapy session. The new rehabilitation robot incorporates co-ordinated elbow and shoulder motions and provides active as-sistance at 4 degrees of freedom: shoulder elevation (flexion),elbow extension, forearm pronation, and wrist/hand extension.Rehabilitation of the affected upper extremity thus is orientedtoward restoring the normal sensorimotor relationships be-tween the joints for actually performing activities of daily living.The design is given the acronym RUPERT for robotic upper ex-tremity repetitive therapy device. Position sensors are includedin the shoulder, elbow, and wrist axes. Together with the pres-sure sensors, the information will be used for future design offeedback control and estimation of voluntary muscles torquesfrom the patient in evaluation of recovery and improvement ofmotor function. Results: Two versions of RUPERT have been de-veloped. Eight able-bodied volunteers tried on RUPERT. A widerange of statures was included in the volunteers: from 5-foot-tallfemales to males more than 6 feet. Four stroke survivors havecompleted 3-week therapy protocols using RUPERT I. The pur-pose of these tests is to evaluate the ability of the prototype tofunction in a clinical environment and not focus on patient re-sults. The device physically limits range of motion of individualjoints. Force application is limited by the compliant nature ofthe actuators. Conclusion: Stroke is the leading cause of adultdisability in the United States. Many research studies haveshown that continued recovery of functional skills in stroke pa-tients occurs with forced-use therapy protocols. Robotic de-vices that provide treatment capability in the home and clinicare a way to provide cost-effective therapy to a wider popula-tion for a longer period of time. Preliminary tests showed thatthe design concept of RUPERT will provide such a device.

M3-2 Rehabilitation Robotics and Stroke

H. I. KrebsMassachusetts Institute of Technology and WeillMedical College of Cornell University, USA

Background: The demand for rehabilitation services isgrowing apace with the graying of the population and threatensto impose unprecedented stress on rehabilitation professionals.One novel technology that might ameliorate this situation is re-habilitation robotics. Rather than an assistive technology, reha-bilitation robotics focuses on the development of robotics as atool to enhance the productivity of clinicians in their efforts tofacilitate a disabled person’s recovery. Applications of robots totherapy are fairly recent. Since we pioneered the clinical de-

ployment of this technology in 1994 with a novel robot, MIT-Manus, the field of robotic therapy has seen sustained growthparticularly in recent years. Yet, from the onset we had to ad-dress the fundamental question of whether exercising therapyinfluences brain recovery after stroke. Methods: We tested theMIT-Manus class of robots in several rehabilitation hospitals in-cluding the Burke, Spaulding, and Rhode Island RehabilitationHospitals, and Baltimore and Cleveland Veterans Administra-tion Medical Centers. We delivered robot therapy to more than300 stroke patients, inpatients, and outpatients. Trials typicallylasted 18 robot-therapy sessions, and the inclusion criteria lim-ited the trial to patients with severe to moderate 1st unilateralstrokes to the cortical or basal ganglia territories. Results: 100 in-patients randomly assigned to robotic training or standard ther-apy groups demonstrated that although the patient groups werecomparable at admission, the robot-trained group achieved sig-nificantly greater motor improvement than did the controlgroup. These gains were specific with little generalization. Simi-larly, we have demonstrated that persons with chronic strokerespond to task-specific robotic training. In 110 stroke survi-vors, task-specific robotic therapy lead to sustainable reductionon chronic motor impairments 6 months or longer after stroke.Conclusion: Clinical results to date suggest that rehabilitationrobotics can have a positive influence on neurorecovery after astroke. Our pioneering results are consistent with a prominenttheme of current neuroscience research into the sequelae ofbrain injury, which posits that activity-dependent plasticity un-derlies neurorecovery. Furthermore, our results with more than300 stroke inpatients and outpatients open up a number of op-portunities. It is not far-fetched to envision the rehabilitationclinic of the future as gyms of robots working with differentlimb segments, muscle groups, and functional tasks. At thisgym, the therapist will tailor an exercise routine to the particularpatient’s needs, increasing the clinic’s productivity by oversee-ing several patients at the same time. Productivity may be fur-ther improved by the objective and precise measurementsafforded by robotics and extending treatment to the home.

M4-1 Genetic Influences on Outcome FollowingAcute Brain Injury

J. A. R. Nicoll and R. WatersUniversity of Southampton, United Kingdom

Clinical studies have provided evidence that genetic factorsmay be responsible for some of the previously unexplainedvariability in outcome after acute brain injury. Specifically, theε4 allele of the apolipoprotein E (APOE) gene has been associ-ated with poor outcome after traumatic brain injury, spontane-ous intracerebral hemorrhage, cardiac bypass surgery, cerebralischemia after cardiopulmonary resuscitation and in boxing; insubarachnoid hemorrhage the evidence is conflicting; the effectappears not to influence outcome from ischemic stroke. Multi-disciplinary approaches including clinical studies, studies ofhuman neuropathology, and models in genetically modifiedmice have provided evidence of isoform specific differences invarious functions in which apoE participates. These include dif-ferences in neuronal protection, neuroinflammation, repair andremodeling, as well as vascular and hematologic factors. It is tobe expected that future studies will reveal the role of other poly-morphic genes. Clearer understanding of these processes maylead to better prediction of outcome in patients with brain injuryand might possibly identify targets for therapy to reduce the se-

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verity of brain damage or to promote the capacity of the brainfor repair.

M4-2 Genes, Experience, and Neuroplasticity

Mu-ming PooUniversity of California, Berkeley, USA

The development of the nervous system depends on the in-teraction between intrinsic genetic programs and epigenetic in-fluences of the environment. During early embryonic develop-ment, the establishment of initial neuronal connections islargely determined by molecular cues coded by genetic pro-gram, but the maturation of neural circuits requires proper sen-sory experience. The susceptibility of neural circuits to thestructural and functional and refinement by experience endowsthe nervous system the remarkable plasticity that lasts wellbeyond early development. Increasing evidence suggests thatsimilar molecular and cellular mechanisms underlie both devel-opmental and adult neuroplasticity. In this lecture, I will sum-mary our recent studies on the developmental neuroplasticityand discuss possible implications to neuroplasticity in general.Developing a visual system provides the best illustration for therole of early sensory experience in shaping the developingnerve connections. In vivo whole-cell recording from the tec-tum of Xenopus tadpoles showed that correlated spiking of reti-nal ganglion cells and tectal neurons can induce persistentstrengthening or weakening of retinotectal synapses, depend-ing on the order of spiking and the time interval between thepresynaptic and postsynaptic spiking. Such synaptic modifica-tions appear to underlie activity-dependent refinement of thereceptive field properties of the tectal neuron. Furthermore, af-ter repetitive application of moving “conditioning” visual stim-uli of a particular direction across the receptive field of a tectalneuron for a few minutes, we found that the response of thetectal cell became sensitive to light stimuli of the conditioneddirection for a period of at least 60 min. This rapid “learning” re-quires spiking of the postsynaptic neurons and is accompaniedby persistent synaptic potentiation and depression of differentretinotectal synapses. Interestingly, activity-induced synapticmodifications in the developing Xenopus retinotectal systemcan be quickly reversed by either subsequent spontaneous ac-tivity in the tectum or exposure to random visual inputs. This re-versal depends on the burst spiking and activation of the NMDAsubtype of glutamate receptors. Stabilization of synaptic modifi-cations can be achieved by an appropriately spaced pattern ofinduction stimuli. Taken together, these findings underscore theimportance of spike timing–dependent plasticity in the refine-ment of developing circuits and suggest a temporal constrainton the pattern of visual inputs for effective induction of stablesynaptic modifications.

PARALLEL SESSIONS–February 13, 2006

S1A-1 Regulation and Dysregulation ofHuman Behavior

Tatia M. C. Lee,1,2 Leonard S. W. Li,2,3 Peter T. Fox,4

and Jia-Hong Gao4

1Neuropsychology Laboratory, The University ofHong Kong; 2Institute of Clinical Neuropsychology,The University of Hong Kong, and MacLehose

Medical Rehabilitation Centre; 3Tung Wah Hospital,Hong Kong; 4Research Imaging Center, University ofTexas Health Science Center, USA

Background: Human brain is known for its ability to regu-late behavior in accordance with the intentions of the personand the demands of the situation. In doing so, the most advanta-geous choice of behavior essential to human survival could beselected. Method: To understand the neural correlates of cogni-tive regulation of behavior and the effect of normal aging orneurologic conditions on behavioral regulation, a program ofbehavioral and functional imaging studies have been con-ducted. Results: Findings suggest that a coordinated effort ofbrain regions that are closely interacting, but nevertheless ana-tomically dissociable, is essential to effective behavioral regula-tion. Age-related difference in brain activity associated with be-havioral regulation was observed, which was presented as ahigher level of neural activity in the right prefrontal and left in-ferior parietal regions for the older than younger adults. For per-sons presented with impulsive behavior, such as people whohave abused heroin, the attenuation of activity in the anteriorcingulate and the additional recruitment of the right inferior pa-rietal region were noted. Conclusion: Efficient and effectiveregulation of behavior is vulnerable to the effect of normal ag-ing as well as neuropathology. Further theoretical and clinicalimplications of our findings will be discussed.

S1A-2 Rehabilitation of Memory andDysexecutive Disorders

Armin SchniderDivision of Rehabilitation, University Hospital,Geneva, Switzerland

Background: Memory disorders may have diverse mecha-nisms. Whereas some reflect a failure to store new information(pure amnesia), others are accompanied or even provoked bydysexecutive disorders (e.g., disorganized memory), while stillothers reflect the inability to sort out those activated memoriesthat pertain to ongoing reality (spontaneous confabulation).Methods: In this talk, case vignettes of patients having these dif-fering forms of memory disorders will be presented and ap-proaches to their rehabilitation will be discussed. Results: Anumber of techniques exist to alleviate the pure failure of infor-mation storage. Concepts to treat the reality confusion typical ofspontaneous confabulation (behavioral treatment, medication)are emerging. Conclusion: Progresses in the pathogenetic eluci-dation and rehabilitation of memory disorders have been madebut some memory failures are still desperately seeking effectivetreatment.

S1A-3 Luria’s Error: Some Frontal Lobe FunctionsCan Be Rehabilitated

I. H. RobertsonTrinity College Dublin, Ireland

Background: The great Russian neuropsychologist Luriawas pessimistic about the possibility of rehabilitating frontallobe function, as he saw the planning and supervisory functionsof the frontal lobes to be central to the learning and compensa-tory adjustments that underlay recovery of function. He be-lieved that only environmental prosthetics could aid impairedfrontal function. It is now clear, however, that there is a degree



of modularity in frontal functions and that some low level pro-cesses such as arousal can influence high-level executive pro-cesses and vice versa. This paper gives examples of how moder-ate levels of attentional/executive impairment can be modifiedby systematic and theoretically informed procedures. Methods:A series of experimental studies demonstrating howattentional/executive processes subserved in part by the frontallobes can be modified using theoretically derived training pro-cedures. Data from fMRI, EEG, and ERP are produced to demon-strate the probable mechanisms for these effects. More ex-tended training of frontal functions and their impact onexecutive processes are also presented in randomized group tri-als. Results: Data are presented showing how short and longerterm improvements in certain target frontal functions are possi-ble, including sustained attention, planning, and inhibitory con-trol. Conclusion: Although Luria’s pessimism may have beenjustified for severe and global frontal damage, it is clear thatmoderate impairments in frontal function can be rehabilitatedand that these behavioral effects have demonstrable neuralcorrelates.

S1B-1 Grading of Persistent Vegetative Stateand the Principle of Its Neurorehabilitation

T. OhtaBrain Function Institute, Iseikai Hospital, Osaka,Japan

Background: Despite the technical advances in modernneurosurgery, many patients with severe brain injury only sur-vive in the vegetative state for many years with rare recovery.These s i tua t ions have forced fami l ies , phys ic ians ,neurorehabilitation staffs, and community to bear an almost in-tolerable burden. A brand-new unpredictable situation neverexperienced so far in the history of human beings has devel-oped. For this clinical syndrome, Jennett and Plum (1972) haveproposed as a new name “persistent vegetative state” from themedicosocial viewpoint and tried to distinguish it from similarconcepts such as permanent, irreversible, or prolonged coma,apallic syndrome, and akinetic mutism. Method: Because of thevarious clinical courses and pathogeneses in the individualcases, more precise definition or more proper concept of thissyndrome seems to be mandatory to cope with the rehabilita-tion of these patients. In this presentation, we are going to intro-duce our classification of “vegetative syndrome” proposed in1975, which has been widely prevailed in Japan. Furthermore,the principles of neurorehabilitation of these patients are pro-posed, which are founded from the viewpoints of phylogenyand ontogeny of the central nervous system. And the chrono-logical changes in the bedsides are observed with the frequencyof the sleep-wake cycle and EEG in addition to the neurologicexamination. Results and Conclusion: The grade of the vegeta-tive syndrome is divided into complete, incomplete, and transi-tional in neurologic examination, primary and secondary fromthe etiologies, and early and persistent from the time course af-ter the insult. Furthermore, the principles of neurorehabilitationfrom the viewpoint of the phylogeny and ontogeny of the cen-tral nervous system are 1) an awake stage should be prolongedand make frequent more and more, 2) to promote their goodfeeling with the stimulation with fine touch of the skin, and ol-factory, visual, gustatory, and auditory sensations, and finally tostimulate their intelligence. The chronological changes of thissyndrome are divided into early and persistent or chronic stages

in between 3 months, and their courses are observed with theneurologic and electroencephalographic examinations.

S1B-2 Advances in Assessment and Managementof Persons in Low-Level Neurologic States,Clinical Caveats, Controversies, and Conundrums

Nathan D. ZaslerConcussion Care Centre of Virginia and Tree of LifeServices, Glen Allen, Virginia; Chairperson,International Brain Injury Association (IBIA);Virginia Commonwealth University, Richmond,Virginia; University of Virginia, Charlottesville,Virginia, USA

There continues to be an ongoing evolution of knowledgeas well as nomenclature relative to the assessment of personswith severe alterations in consciousness following acquiredbrain injury. With the recent publication of the AspenWorkgroup Guidelines for the minimally conscious state (MCS)and the ongoing controversies that surround assessment andmanagement of persons in low-level neurologic states includ-ing coma, vegetative state, and MCS, this lecture will provide at-tendees with an overview of relevant clinical issues germane tothe clinical assessment and management of persons in low-levelneurologic states after acquired brain injury. Issues to be cov-ered will include: 1) review current accepted nomenclature andtrends in terminology evolution; 2) examine current recommen-dations for neurobehavioral assessment of persons with severealterations in consciousness; 3) discuss examination techniquesutilized to elicit responses to support evidence of awareness; 4)delineate clinical findings often misinterpreted by examiners assigns of awareness; 5) elucidate edictally appropriate manage-ment, both medical and rehabilitative, of persons in VS andMCS; 6) review recent developments in assessment and man-agement guidelines; 7) examine current research findings per-taining to evoked potentials, fMRI, and PET scanning in personsin low-level neurologic states; 8) discuss long-term prognosticissues including differences between life expectancy andmedian survival time.

S1B-3 Prolonged Coma, Apallic Syndrome/Vegetative and Minimally Conscious StateMedicolegal Aspects

Robert D. VoogtRobert Voogt & Associates, Inc, Virginia Beach,VA, USA

There are significant differences across cultures and reli-gious orientations regarding patients in persistent vegetativestate/apallic syndrome, minimally conscious or prolongedcoma (PVS/AS/MC/PC). Definitions of these various states havebeen addressed by a variety of researchers and practitioners,but they are full of controversies and interpretation. The case ofCarrie Coons, an 86-year-old woman who woke up after thephysicians and the legal system declared her in a PVS, compelsus to be more vigilant in our understanding. The case of TerrySchiavo, in Florida, involved a protracted battle between familymembers, politicians, and religious leaders. The dialogues be-came intense not only about the medical, moral, ethical, and le-gal issues but also the question of precious financial resources



being used for those in PVA/AS/MC/PC. There remain questionsas to what a person desires should they become unable to com-municate. Others then have to make the choices which createethical, medical, and legal dilemmas. The issue becomes morecomplex as it pertains to withholding and withdrawing treat-ment. Questions arise regarding the decision of nutrition andhydration, as this would preserve life, but does not address theissue of quality of life. This presentation addresses the histori-cal, cultural, and moral context of this debate and themedicolegal aspect of these dilemmas.

S1C-1 Imaging Human Kinesthetic andMotor Functions

Eiichi NaitoKyoto University, Japan

Background: Sensing limb movement is essential for humanmotor control. In particular, kinesthetic information from themuscle spindles plays important roles when we sense our limbmovements. In my talk, first, I demonstrate neuroimaging evi-dence that the motor network of cortical motor areas and cere-bellum participates in the kinesthetic processing. Second, I pro-vide clinical evidence that the spinocerebellum compensatesthe cortical kinesthetic function after a focal damage to theprecentral gyrus. Finally, I introduce the contribution of the kin-esthetic information when we handle external objects or usethem as tools and show that the left inferior parietal cortex inte-grates the kinesthetic information of hand movement and thehaptic information of the touched object. Methods: We vibratedthe tendon of a relaxed limb, which elicits illusory movementsof the limb in the absence of actual limb movements. The ten-don vibration of a muscle excites the muscle spindle afferents,and the brain processes the afferent information to elicit illu-sions. Especially, when the hand is in contact with an externalobject, the tendon vibration elicits the sensation that the objectis also moving along with the hand (hand-object illusion). Byusing functional magnetic resonance imaging (fMRI), we mea-sured brain activity when normal volunteers or a patient experi-enced illusions. Results: 1) Illusory limb (hand, foot) move-ments of the normal volunteers activated somatotopicalsections of the contralateral cortical motor areas and ipsilateralcerebellum that usually participate in the execution of limbmovements. The right frontoparietal cortices were commonlyactivated during illusions irrespective of the limbs, and theseright regions were predominantly activated when comparedwith the left corresponding regions. 2) A focal damage to theleft hand section of precentral gyrus (PMD/M1) severely im-paired the illusory experiences of the patient’s right immobilehand, despite the cutaneous processing remaining relatively in-tact. More than half-year rehabilitative trainings recovered himto vividly experience illusions of right hand. At this stage, illu-sions of right hand activated the spinocerebellum instead ofcortical activations, despite that illusions of left intact hand acti-vated right sensory-motor areas and frontoparietal cortices, asshown in the normal volunteers. 3) When the hand was in con-tact with an external object and the normal participants experi-enced the hand-object illusions, the left parietal cortices, whichmay play important roles during performance of object-manip-ulation, participated in the neuronal integration of the kines-thetic information of hand movements and the haptic informa-tion of the touched object. In this case, the left parietal corticeswere predominantly activated when compared with the rightcorresponding regions. Conclusion: The motor areas (in partic-

ular M1), which normally participate in the execution of limbmovements, play also crucial roles in the kinesthetic sensoryprocessing. The spinocerebellum, which may have the second-ary kinesthetic function, can compensate the cortical kines-thetic processing after rehabilitative trainings. The right parietalregions seem to be specialized for the neuronal processing ofinternal representation of limb movement (body representa-tion), whereas the left parietal regions are specialized forneuronal linkage between the internal representation of limbmovement (body) and the external representations of objects(external world).

S1C-2 Neural Mechanisms Underlying LocomotorRecovery after Stroke

I. MiyaiBobath Memorial Hospital, Japan

Background: Locomotor function is one of the keys to dis-charge home in patients with stroke. Especially in severely dis-abled patients, locomotor function is more likely to improvethan is hand function. Although there is accumulating evidencethat functional recovery of the paretic hand is associated withreorganization of the damaged neural networks, neural mecha-nisms underlying locomotor recovery remain unknown. Opticalimaging technique using near-infrared spectroscopy (NIRS) issuitable for assessing cortical activation during normal andpathologic gait because of its flexibility and portability. Its ex-cellent time resolution also enables real-time monitoring ofneurorehabilitation. Methods: Functional NIRS (fNIRS) is basedon modified Beer-Lambert law postulating that absorption ofnear-infrared light is mainly caused by chromophores includingoxygenated hemoglobin (oxyHb) and deoxygenated hemoglo-bin (deoxyHb) in human tissue. Cortical activation can be typi-cally assessed as task-related increase of oxyHb and decrease ofdeoxyHb, although oxyHb appears to be more sensitive to task-related changes. We aimed to characterize cortical activationpatterns during human gait in healthy subjects and hemipareticgait in patients with stroke, and immediate and long-term ef-fects of rehabilitative interventions on the patterns. Results: Inhealthy subjects, walking induced increase of oxyHb levels thatcentered in the medial sensorimotor cortex and supplementarymotor area. Walking or running at higher speed did not neces-sarily increase activation in the sensorimotor cortex but en-hanced activation in other regions such as the premotor andprefrontal cortex. In patients with stroke, cortical activation pat-terns during hemiparetic gait were characterized by asymmetri-cal activation in the sensorimotor cortex and recruitment of thepremotor and prefrontal cortex. Recruitment of the multiple re-gions appeared to depend on the size of lesion and severity ofmotor impairment. Importantly the activation patterns weremodified by rehabilitative interventions. For instance, facilita-tion technique, by which therapists assisted patients to walk bypressing the hip forward and backward to ensure stable stanceand swing the paretic leg, induced enhanced activation in themotor related areas, particularly in the premotor cortex. Partialbody weight support during gait training on the treadmill signif-icantly decreased sensorimotor activation. This finding suggestsa relative shift of locomotor control to the hierarchically lower,subcortical structures including the spinal cord. A longitudinalstudy revealed that locomotor recovery was associated with im-provement of asymmetrical activation in the sensorimotor cor-tex as well as enhanced activation in the premotor cortex. Con-clusion: Locomotor recovery after stroke might depend on



reorganization of neural networks subserving locomotor con-trol. An fNIRS might not only provide a powerful tool to studybrain mechanisms underlying functional recovery after braindamage but also contribute to establishing brain-based as wellas evidence-based strategies for neurorehabilitation.

S1C-3 Tracing Functional Recovery after Strokeby TMS and fMRI

R. J. Seitz,1 C. M. Bütefisch,2 R. Kleiser,3

and V. Hömberg4

1University Hospital Düsseldorf, Germany;2University of West Virginia, USA; 3University ofZürich, Switzerland; 4St. Mauritius Therapy Clinic,Germany

Background: The majority of stroke patients recover fromtheir neurologic deficits. It has been hypothesized that neuro-logic recovery is accommodated by reorganization of functionalrepresentations in the human brain. The orchestration of the in-volved brain areas can be studied noninvasively by functionalmagnetic resonance imaging (fMRI) and transcranial magneticstimulation (TMS). Methods: Neurologic patients with their 1sthemiparetic stroke were investigated from the acute stage to upto 10 weeks after stroke while they were treated initially on theStroke Unit and subsequently in the Neurorehabilitation Unit.Brain scanning with fMRI was performed during visually guidedfinger movements of either hand. Changes in cortical excitabil-ity were studied in the affected and nonaffected hemispherewith paired-pulse TMS. Data from age-matched, right-handedvolunteers served as controls. Results: The patients showedmarked recovery of their affected hand regaining the capacity toperform individual finger movements. Activation data analyzedin re la t ion to f inger movements as assessed wi thelectromyographic surface recordings from the 1st dorsalinterosseus muscles during fMRI scanning showed an activationpattern lateralized to the affected hemisphere in motor andpremotor cortex. Coregistration with perfusion MRI revealed re-activation of brain tissue, which initially was threatened byischemia. Moreover, a small activity increase was found in themotor cortex of the nonaffected hemisphere, even in patientswith strictly unilateral finger movements of the affected hand.In addition, there was activation in the dorsomedial cortex cor-responding to the pre-SMA. TMS revealed an increased corticalexcitability of the motor cortex of both cerebral hemispheres athigher stimulation intensities of the conditioning stimulus whena short interstimulus interval of 2 ms was used. In contrast,intracortical facilitation tested with an interstimulus interval of10 ms was normal. Interhemispheric inhibition from thelesioned motor cortex to the motor cortex of the nonaffectedhemisphere was decreased using a conditioned stimulus on thelesion side and a test stimulus on the opposite side.Interhemispheric inhibition from the nonaffected to the af-fected hemisphere was normal. Conclusion: Recovery fromischemia is a dynamic process which in the initial short period isgoverned by therapeutic measures aimed at restoring arterialand microvascular blood supply. Long-term recovery relies onperilesional and large-scale reorganization of functional repre-sentations in the human brain, as was shown by fMRI. Changesof cortical excitability as evidenced by TMS seem to allow for re-formatting plasticity but also provide clues to understand adap-tive plasticity secondary to focal brain damage. Both aspectsprovide therapeutic challenges for neurorehabilitation.

S1D-1 Evidence-Based Review onStroke Rehabilitation

K. H. MauritzKlinik Berlin & Charité Medical School Berlin,Germany

Background: In stroke rehabilitation, traditional therapeuticapproaches are most common all over the world. These meth-ods are different in various countries and are not validated on ascientific basis. Only recently randomized therapeutic studieswere published in the field of stroke rehabilitation. Methods:The literature was screened for such randomized controlledstudies, for controlled cohort studies, and for meta-analyses andsystematic reviews. Results: Data will be presented on the effi-cacy of inpatient-outpatient settings, stroke rehabilitation units,on various organizations of the therapeutic team (interdisciplin-ary vs. multidisciplinary). Furthermore, comparative studies ofphysiotherapy schools, effects of intensity of training, and effi-cacy of specific rehabilitation techniques (arm rehabilitation,gait rehabilitation, neglect, central visual deficit training meth-ods), the effect of robot assisted training, of functional electricalstimulation and of constrained induced movement therapy) willbe summarized. Conclusion: These studies and review demon-strate that there are effective therapeutical approaches in strokerehabilitation. However, further attempts are necessary in thefuture in order to identify specific patient subgroups for thesetherapies. Other questions, which have not been addressed in ascientific way, are the problem for how long they should begiven and how they should be administered (spread out overtime or condensed).

S1D-2 Functional Outcomes in StrokeRehabilitation

H. RingPM&R, Loewenstein Hospital Rehabilitation Center,Raanana Sackler Faculty of Medicine, Tel AvivUniversity; Chairman, National RehabilitationCouncil, Ministryof Health, Israel

Measurement of function has become a cornerstone of therehabilitation work helping not only in the clinical and researchwork but also in monitoring and analyzing patients’ recovery,performing cost-effectiveness analysis and also in the decision-making process. Quantification of function outcomes has beenmade possible thanks to the development of valid and reliabletools. The stroke patients’ population considered in this studywas admitted to our department from all over the country andconsisted on a total of 929 patients, 64.1% after a 1st stroke,19.8% after a recurrent stroke, and 15.8% “other”, namely func-tional decline, postneurosurgery, etc. They had an average ageof 60 years for 1st stroke (25-90 years), with about one-third ofthe patients above age 65. Male patients represented 62.4% inthe 1st stroke group. Between 83% and 88.6% of patients weremarried; 91.6% of the 1st stroke patients returned home after therehabilitation. The effectiveness, efficiency, and efficacy valuesof these samples according to our computerized database willbe presented with the help of the Functional IndependenceMeasure (FIM), a global measure of disability developed by theAmerican Academy of PM&R and managed now by the UniformData System (UDSMR) from Buffalo. Effectiveness is the gain



(“delta”) between FIM admission and FIM discharge scores. Ef-ficiency is the gain divided by the length of stay (LOS) in the de-partment. Absolute efficacy is the ratio between the actual andthe theoretical possible achievement, and relative efficacy is theabsolute value divided by the LOS or, in other words, the imple-mentation of the “rehabilitation potential,” which is the differ-ence between the FIM score on admission and the maximal pos-sible score (126). All these will be presented using a clinicalrational described by us in the literature, namely, the functionalresults should be presented according to the site of lesion andsyndromatic assignment: right hemisphere damage with orwithout the neglect syndrome and left hemisphere damage withor without the aphasia syndrome.

Patients with these special syndromes had statistically signifi-cant lower FIM admission scores (neglect, 58.9; aphasia, 63.1;no-neglect, 82.1; no-aphasia, 85.4), showed better gains(neglect, 33.3; aphasia, 28.4; no-neglect, 22.4; no-aphasia, 22.2)but needed longer length of stay (LOS) periods: neglect, 130days; aphasia, 108 days; no-neglect, 89 days; no-aphasia, 89days, under the “up to plateau” policy, signaling that braininjury recovery is a time-dependent process. Moreover, accord-ing to our results patients with these syndromes had better over-all efficiency, mainly during the 1st month of treatment: about0.60 in the neglect/aphasia patients as opposed to 0.40 to 0.49in the patients without these syndromes. However, the absoluteand relative efficacy (implementation of rehabilitation potentialwithout or with LOS consideration) was much higher in patientsfree of these syndromes and more markedly so in patients witha 1st stroke. The results may guide rehabilitation policy.

S1D-3 Application of Mental Imagery toRehabilitation of Post-Stroke Patients:Why and How Does It Work?

C. C. H. Chan,1 K. P. Y. Liu,1 C. W. Y. Hui-Chan,1

L. S. W. Li,2 and T. M. C. Lee3

1The Hong Kong Polytechnic University, 2Tung WahHospital, 3The University of Hong Kong,Hong Kong

Background: Mental practice is a very common methodused in rehabilitation for functional retraining. This method in-volves patients to think through the ways of which a task is to beperformed before its actual execution. A series of randomizedclinical trials was conducted to explore the extent to which thetheory of mental imagery could be applied to enhance the func-tional regain of poststroke patients. It is hypothesized that men-tal imagery could improve the function of daily tasks and, at thesame time, promote generalization of the relearned skills. Thispaper also covers a few of the behavioral and psycho-physiologic studies conducted by the same research group onstudying individual differences in the styles and abilities of vi-sual and vibrotactile imagery. Method: There are a total of 4 clin-ical studies: 1st 2 studies are large-scale randomized clinical tri-als, whereas the 2nd 2 studies are smaller scale follow-upcontrolled trials. The outcome measures used included stan-dardized complicated daily function assessment and physicaland cognitive instruments. The other 2 studies are experimentalstudies using laboratory-based visual and vibrotactile imagery.The outcome measures were response time and accuracy ratefor the behavioral study and amplitude and latency of ERPs forthe psychophysiologic study. The participants of most of thestudies were poststroke patients suffered from cerebral infarc-tion receiving active rehabilitation in subacute rehabilitationhospital settings. Results and Conclusion: Functional retraining

based on the motor relearning principle was found effective forimproving complicated daily tasks among poststroke patients.However, the skills acquired through this technique were taskspecific and not readily generalized to novel or previously un-trained tasks. Findings from our studies on the use of imagerytechniques suggest that they are useful for both the regaining ofthe lost functions after a stroke and the generalizations of theskills learned to other unlearned tasks. Results of our studiesfurther demonstrate that mental imagery processes involved aninitial phase of attention and memory retrieval (denoted byN400 ERPs), followed by a later phase of image generation, ma-nipulation, and maintenance (denoted by P600 ERPs). Subjectswere found to possess different preference of and ability on ob-ject vs. spatial visual imagery. All these findings are essential forrefining the application of mental imagery theory to rehabilita-tion of poststroke patients.

S2A-1 Cognitive/Linguistic ImpairmentSubsequent to Mild Traumatic Brain Injury

B. E. MurdochUniversity of Queensland, Australia

Background: Mild traumatic brain injury (mTBI), associatedwith an absence of frank neurologic disturbance, has beenlinked to persistent physical, cognitive, and affective distur-bance. Although the cognitive sequelae of this syndrome havebeen relatively well documented, the legacy of such injuries onlanguage abilities has until recently been largely unknown. Thefindings of recent research suggest mTBI may impart significantand long-standing effect on language skills, with evident impli-cations for vocational, social, and educational success. Meth-ods: This presentation will review the reported evidence forlong-term cognitive/linguistic impairments occurring subse-quent to mTBI and discuss possible neural mechanismswhereby injury of this type may disrupt language processing. Inaddition, the findings of a study aimed at profiling the nature oflinguistic abilities in persons subsequent to mTBI will be re-ported and discussed. Specifically, the performance of a groupof persons with mTBI on a battery of tests capable of assessingcognitive, general, and high-level language function, includingsemantic processing tasks, will be reported and compared witha group of nonneurologically impaired controls matched forage and gender. Results: Disruption to high-level linguistic pro-cesses post-mTBI was evidenced in the literature by reports ofdeficits on tasks of verbal fluency, story recall, verbal memory,and anomaly detection. Analysis of the group data revealed thepresence of deficits in attention, lexical access, complex lexical-semantic manipulation, response monitoring, and organizationin the mTBI group. Conclusion: The findings suggest that high-level language deficits may represent a long-term and debilitat-ing effect of mild brain trauma, necessitating a reevaluation ofcontemporary clinical management strategies for this purpose.

S2A-2 Distraction, Competition, andInterference: How Do People with BrainDamage Navigate in a Sea of Distraction?

Leonard L. LaPointe, Charles G. Maitland, Julie A. G.Stierwalt, Tonya Toole, Adrienne B. HancockFlorida State University, USA

Background: One of the most frequent observations ofbrain-damaged persons with cognitive and language impair-ment is that their language, attention, and memory performance



is severely stressed under conditions of visual and auditory dis-traction. Cognitive resource allocation models suggest that per-sons have a limited capacity to perform simultaneous multipletasks or deal with interference or competition without cognitiveor language degradation. Recent evidence has suggested that si-multaneous language or cognitive tasks can degrade other so-matic systems as well, such as the motoric systems used in am-bulation. Little is known about the effects of everydaydistractions (such as cafeteria noise or 4-speaker babble) onlanguage and cognitive processing, especially in clinical popu-lations of stroke, multiple sclerosis, and Parkinson’s disease.The aim of this review is to present data from representativestudies of participants with neurogenic disorders, specificallymultiple sclerosis and Parkinson’s disease on the effects of dis-traction or simultaneous multitasking on walking, as well as lin-guistic and cognitive processing under conditions of auditorydistraction. Methods: For study 1, various types of auditory dis-traction were presented to persons with multiple sclerosis orParkinson’s disease during performance of an array of cognitivetasks, such as simple reaction time, choice reaction time, work-ing memory, lexical decision making, and form discrimination.For study 2, measurements of gait and balance were made dur-ing conditions of walking and walking with low, medium, andhigh cognitive-linguistic load. A gait pad equipped with sensorsthat measured duration, velocity, and quality of gait was usedwith appropriate software to determine the effects of cognitive-linguistic load on gait pattern. Results: In study 1, statisticallysignificant change across several cognitive domains were foundduring selected conditions of auditory distraction in both partic-ipants with multiple sclerosis or with Parkinson’s disease. Instudy 2, statistically significant effects of cognitive-linguisticload were found on multiple parameters of gait performanceduring conditions of medium and heavy load. Heavy cognitiveworking memory demands were particularly disruptive to si-multaneous gait performance. Conclusion: Distraction, compe-tition and interference has a particularly deleterious effect oncognitive performance, even in participants with mild to mod-erate multiple sclerosis or Parkinson’s disease. In Parkinson’sdisease, medium or heavy cognitive-linguistic loading duringsimultaneous walking affects speed, duration, and quality ofambulation, suggesting that some aspects of simultaneouswalking and talking could place persons with Parkinson’sdisease at a greater risk for falls.

S2A-3 Treatment for Naming Disorders inCantonese Aphasic Persons with DifferentUnderlying Impairments

S. P. Law, W. Wong, and E. WongUniversity of Hong Kong, Hong Kong

Background: Anomia is one of the most common features oflanguage disorders subsequent to brain injuries. Because of itspervasiveness and persistence, numerous studies of differenttreatment approaches have been conducted on anomic patientswith deficits to different loci in the lexical system. A compre-hensive and critical review of anomia treatment studies showsthat while most therapies are able to enhance a patient’s namingperformance, they vary greatly in terms of their effect to gener-alize to untreated stimuli or whether the effect is long-lasting.To better our understanding of the interaction between task andimpairment, which is essential to the development of a theoryof rehabilitation, Howard (2000) has proposed applying the

same treatment to patients with different underlying impair-ments and examining how they respond to the therapy. In thepresent study, the same treatment protocol combining semanticfeature analysis and semantic priming was performed on 5 Can-tonese-speaking anomic patients with different degrees of dis-ruption to naming, semantic processing, phonological process-ing, phonological STM, and verbal learning. Methods: Amultiple baseline treatment design was used. During the base-line, the subjects were asked to name a set of 256 line drawingsof objects belonging to 18 categories. Those items that the sub-jects failed to name on 2 of 3 occasions were selected for assign-ment to treated, untreated generalization, and control items.Four subjects were trained on stimuli of high and low familiarityin the 1st and 2nd treatment phases, respectively. The othersubject received training on naming inanimate items followingby animate objects. Subjects who successfully completed bothtreatment phases would proceed to the maintenance phase. Toevaluate the effects of treatment, generalization, and repeatednaming attempts, the McNemar’s test was used to contrast thehighest accuracy during baseline with that in a treatment ses-sion for treatment probes and to compare the best performancein a baseline session with that over the entire treatment periodfor generalization and control probes. Results: Two patientswith relatively milder semantic impairment completed the treat-ment by reaching the criterion of at least 85% accuracy on treat-ment items during 3 consecutive sessions. They both demon-strated generalization to untreated probes semantically relatedto the treatment items, but only 1 of them was able to maintainthe treatment gain for more than 1 month. Two patients with se-vere semantic deficits failed to complete the 1st treatmentphase. The other patient, who suffered moderate to severe se-mantic disruption but showed the highest pretreatment namingperformance, benefited from the therapy. Although he couldmaintain treatment gains, treatment effects were limited totrained items. Conclusion: The various patterns of treatmentoutcomes were interpreted in light of the subjects’ underlyingimpairments. Both the extent of semantic deficits and namingdisorder may predict the effectiveness of this semanticallybased intervention. On the other hand, neither phonologicalSTM nor verbal learning ability seems to have any role in affect-ing treatment results. Finally, the maintenance of treatmentprogress may depend on whether the patient can perform homepractice.

S2B-1 Diagnosis and Management of NeurogenicOrthostatic Hypotension

Pietro CortelliUniversity of Bologna, Italy

Background: Orthostatic hypotension (OH) is a frequentcause of syncope and may contribute to morbidity, disability,and even death because of the potential risk of substantial in-jury. It may be the initial and most incapacitating symptom inmany primary and secondary autonomic nervous system (ANS)disorders (e.g., pure autonomic failure [PAF], multiple systematrophy [MSA], diabetic autonomic neuropathy). It occurs fre-quently in elderly patients because of therapy (vasoactivedrugs, antidepressants), reduced fluid intake, and decreasedANS function. In Parkinson’s disease the prevalence of OH maybe as high as 60%. Characteristic symptoms of OH include light-headedness, visual blurring, dizziness, generalized weakness,fatigue, cognitive slowing, leg buckling, coat-hanger ache, and



gradual or sudden loss of consciousness. Frequent falls with in-juries may result. Orthostatic hypotension is defined as a de-crease in systolic blood pressure (BP) of at least 20 mmHg and/or diastolic BP of at least 10 mmHg within 3 minutes after stand-ing up and/or passive head-up tilt. Neurogenic OH results froman impairment of the sympathetic system to increase vascularresistance, resulting in pooling of venous blood in the lower ex-tremities and splanchnic vessels and a consequent reduction instroke volume, cardiac output, and cerebral perfusion. Thesemechanisms differ from nonneurogenic OH caused by lowintravascular volume (blood or plasma loss, fluid or electrolyteloss), impaired cardiac function, and vasodilatation (drugs, al-cohol, heat, etc.). Objectives: OH is an underdiagnosed disor-der. Many new treatment options, pharmacologic andnonpharmacologic, have been published in recent years. Evi-dence-based guidelines for the clinical and laboratory diagnos-tic workup and therapeutic management of OH are provided forneurologists.

S2B-2 Botulinum Toxin Treatment ofSecretory Disorders

Markus Naumann1 and Christopher Mathias2

1Klinikum Augsburg, Germany; 2Imperial CollegeLondon at St Mary’s Hospital & National Hospitalfor Neurology & Neurosurgery, & Institute ofNeurology, University College London, UnitedKingdom

Botulinum toxin A (BoNT-A) has become a valuable tool inthe treatment of neurologic disorders associated with increasedmuscle tone and is increasingly used to treat a variety of auto-nomic disorders resulting from neurogenic hyperactivity of se-cretory glands, i.e., focal hyperhidrosis, hypersalivation, orpathological tearing. Within the past few years, several openand 2 large placebo-controlled studies documented the benefi-cial effect of BoNT-A in the treatment of focal axillaryhyperhidrosis. BoNT-A has been shown to be a safe and highlyeffective treatment option for this disabling disorder, which hasa long duration of benefit of 6 to 12 months and leads to amarked improvement of quality of life. Repeated treatmentsover 16 months showed very stable and predictable resultswithout formation of antibodies. BoNT-A is also a very usefultreatment of palmar or facial hyperhidrosis and Ross syndrome.BoNT-A has become the treatment of choice in gustatory sweat-ing, as it is safe and long lasting. A few smaller open and con-trolled studies evaluated the role of BoNTA in the treatment ofsialorrhea in Parkinson’s disease or ALS. The intraglandular in-jection of the toxin (parotid gland, submandibular glands) mayreduce salivation and could be a useful additional treatment op-tion for patients in whom other treatment strategies had failed.There are some encouraging reports on BoNTA in the treatmentof pathologic tearing (crocodile’s tear syndrome) and chronicrhinitis, but more data are needed to judge its role in theseconditions.

S2B-3 The Pathophysiological Basis andManagement, Including Neurorehabilitation,in Neurally Mediated Syncope

Christopher J. MathiasImperial College London at St Mary’s Hospital &National Hospital for Neurology & Neurosurgery, &

Institute of Neurology, University College London,United Kingdom

Neurally mediated syncope is a common autonomic condi-tion with clusters among young and older people. The syncopalepisodes are characterized by autonomic dysfunction that is in-termittent and often short lived, causing bradycardia because ofoveractivity of cardiac parasympathetic (vagus) nerves (thecardioinhibitory form) and hypotension due to underactivity ofsympathetic nerves to blood vessels (the vasodepressor form).In the majority, the 2 occur together; some may have predomi-nantly the cardioinhibitory or vasodepressor form. There arepredominantly 3 subgroups: vasovagal syncope, which is themost common and can affect the young; carotid sinus hypersen-sitivity, which is clustered around the elderly; and miscella-neous causes including situational syncope, which can occur inany age group in certain situations. Examples of the latter in-clude micturition and cough syncope. This lecture will focus onthose aspects of neurally mediated syncope relevant to diagno-sis and management. There will be an emphasis on understand-ing the pathophysiologic basis of the problem and how suchknowledge aids neurorehabilitation strategies relevant to evi-dence-based management.

S2C-1 Trial Designs for Neurorehabilitation

D. C. GoodPenn State College of Medicine Milton S. HersheyMedical Center, USA

Compared to other areas of medicine, rehabilitation hasbeen relatively slow to embrace evidence-based treatment.However, we are now in a new era of critical evaluation of inter-vention strategies for neurorehabilitation. Much of this is drivenby new insights into the basic neurobiology of recovery afterneurologic illness and injury. In this presentation, design issuesfor rehabilitation trials to test new interventions will be dis-cussed, with an emphasis on the emerging importance of ran-domized clinical trials (RCTs). Several examples of recentlycompleted or ongoing trials in stroke rehabilitation will be dis-cussed. Specific characteristics that distinguish rehabilitationfrom other areas of medicine present challenges to trial design.In medical domains, the primary goal is to alter disease pathol-ogy or impairment, and treatments involve a defined interven-tion. In rehabilitation, the goal is to alter activities or participa-tion. As a result, interventions and outcomes are often complexand multifaceted. Rehabilitation is often perceived as a process,and treatments require provider-subject interaction, making ithard to ensure that a rehabilitation intervention is uniformacross subjects. Control subjects may receive standard care,which may itself include complex interventions. It is particu-larly important that key elements of the experimental interven-tion are not also included in the control group. Another chal-lenge is that for many rehabilitation trials, a double-blindeddesign may be difficult or impossible to achieve. The great het-erogeneity in type and severity of neurologic deficits in neuro-rehabilitation patients and the coexistence of other medical co-morbidities may affect outcomes. Psychosocial variables thatare difficult to control and hard to measure may also confoundoutcomes. Because of these issues, a careful delineation of thestudy population is critical. On the other hand, if inclusion andexclusion criteria are too narrowly defined, there is a risk thatstudy results may not be generalizable to a real-world clinicalpopulation. The spectrum of studies of clinical interventions inneurorehabilitation ranges in complexity from simple clinicalobservations to small cross-sectional or descriptive studies to



observational prospective follow-up studies (cohort or casecontrolled) to RCTs. The efficacy of a potential new interventionis often tested through progressively more rigorous trials. Ap-propriate trial methodologies, especially for preliminary studiesusing small numbers of patients, include pre- and posttreatmentcomparison studies using multiple baseline or crossover de-signs. Well-designed observational studies have a clear role inrehabilitation research, but there is the concern that investigatorbias may overestimate the magnitude of treatment effect. RCTsare considered the gold standard by which any medical treat-ment is evaluated. RCTs have been relatively infrequent in reha-bilitation, and most have involved relatively small numbers ofsubjects at a single site. Rigorously conducted multicenter RCTsare definitely a new development in neurorehabilitation, but anumber of these trials have recently been completed or are cur-rently in progress. Despite the complexity, expense, and logisti-cal difficulties of multicenter RCTs, they are the best way to en-sure that a treatment is widely generalizable across differentsites and patient populations. Examples of multicenter RCTs in-clude studies of constraint-induced movement therapy, robotictraining, and treadmill training with partial body weight sup-port. A large multicenter trial to assess the benefit of amphet-amine to enhance motor training in hemiparesis and a trial of di-rect cortical stimulation coupled with physical training are nowunderway. Other promising treatment strategies are candidatesfor RCTs in the future. As the search for more effectiverehabilitation interventions accelerates, the future forneurorehabilitation research is bright.

S2C-2 Can Clinicians Induce Plasticity-AssociatedBehavioral Gains with Rehabilitation?

B. H. DobkinUniversity of California Los Angeles, USA

Background: Similar neural adaptations during the acquisi-tion of cognitive and motor skills in response to injury and withtask-oriented rehabilitation have been demonstrated at the mo-lecular, cellular, and physiologic level in neurons and their syn-apses, as well as being reflected in the brain maps that representthese skills. The potential impact of being able to manipulatethe biological mechanisms associated with practice and learn-ing is great, but the translation from animal models is no simplematter. Methods: Brain-behavior relationships that changed inassociation with rehabilitation techniques after a brain or spinalcord injury were explored in animal models and human reports.Studies that based their outcomes on repeated measures to es-tablish time-dose-response relationships were especially exam-ined. Results: Few longitudinal studies with repeated interimmeasures of changes in skills and in cerebral morphology,physiology, gene expression, or imaged activations have beenreported. Animal models of repair and plasticity may seembetter able to accommodate such studies, but they have inher-ent problems, such as different responses within and acrossspecies, limitations in behavioral testing, and the applicabilityof the injury and repair interventions to translational humanstudies. These models are best at examining an isolated biologi-cal perturbation. Pre- and posttests for a given intervention inpatients are the most frequent approach. Interim measures re-lated to how the intervention is altering behavior or representa-tional plasticity are rare. Conclusion: Plasticity can be inducedas behavioral improvements are made during the rehabilitationof neurologic impairments and disabilities. One-to-one rela-tionships, however, are difficult to discern. Present experimen-tal designs may not establish the optimal dose of a pharmaco-

logic, biologic, and physical or cognitive therapy that producesthe most clinically meaningful response. Further progress maybe made by capturing snapshots of the cascades of gene expres-sion and cellular changes that unfold over the time after injuryand during a rehabilitation intervention in animal models. Inclinical trials, functional neuroimaging may capture changes inpatterns of activation as the response to a specified intensity ordose of intervention is measured. The duration of the interven-tion in pilot studies may need to be open-ended to allow sub-jects to reach a plateau in both behavioral change and brainmap adaptations. By using this approach, brain-behavior rela-tionships may become more closely matched. Functionalneuroimaging may then help identify the subjects who are mostlikely to benefit from a given strategy based on their early treat-ment imaging-behavioral responses. Imaging may also offerpredictions, based on the evolution of activation patterns oninterim scans, about the optimal duration of the strategy for aparticular subject.

S2C-3 The Importance of Outcome Measuresof Acute Stroke Trials

K. S. Lawrence WongChinese University of Hong Kong, Hong Kong

Clinical trials for acute stroke therapies have been plaguedby repeated negative results. There are many explanations suchas poor drug selection. However, one of the most important les-sons learned is the appropriate use of outcome measures. Un-like trials in nephrology in which blood levels of creatinine areused or in hepatology in which liver function tests are used,stroke trial demands clinical outcome in terms of death or de-pendency to document the efficacy of specific therapy. Such“hard” outcome measures are very insensitive to the interven-tion tested because of the possibility of confounders such ascomorbidity. Experience in multiple sclerosis trials have sup-ported the use of surrogate markers for efficacy measures. Itmay save millions of dollar on phase III trials if the preliminaryMRI findings on plaque regression are not promising. Similarly,in stroke trial there are many possible surrogate markers.Microembolic signal detection may be very useful for testingantithrombotic agents, and growth of infarct size may be usefulfor neuroprotection. More important, appropriate selection ofclinical outcome measures that is sensitive is essential to proveefficacy. An example is the FISS—tris study which use BarthelIndex rather than modified Rankin Scale.

S2D-1 Intracerebral Grafts and Memoryin Animals

Bruno Will, Sarah Schimchowitsch, Christian Kelche,and Jean-Christophe CasselUniversité Louis Pasteur and CNRS, InstitutFédératif des Neurosciences, Strasbourg, France

Background: In animals, many studies have demonstratedthat transplants rich in cholinergic neurons from the basalforebrain are able to restore significantly, though partially,the memory functions impaired by surgical damage en-croaching onto brain cholinergic systems. However, recoveryof memory requires more than reinstatement of cholinergicneurotransmission. To achieve functional recovery, grafts mustbe implanted in the normal terminal area of the lesioned projec-tion neurons, but even in this case, they do not compensate forall lesion-induced dysfunctions. Methods: In animals with



septohippocampal lesions, recovery of normal locomotion andhippocampal electrophysiology requires reconnection ofsource and target areas. Is this recovery possible by the com-bined implantation of 1) a bridging substrate between sourceand target and of 2) homotopically transplanted fetal cells? Re-sults: Such a combined implantation induced recovery of thefunctions, i .e., normal locomotion and hippocampalelectrophysiology that are not improved by ectopically placedgrafts but failed in contrast to ectopic grafts, to promote an ex-tensive reinnervation of the target (dorsal hippocampus) andrecovery of normal spatial memory. Conclusion: Progresses areto be made to promote a better reinnervation of the target. Thismay be achieved via a new “smart” alginate polymer bridge en-riched in or associated with neuroprotective factors or treat-ments antagonizing myelin-induced growth inhibition. If thereinnervation is similar to that observed following ectopic trans-plantation, one may assume that the double implantation(homotopic transplants + polymer bridge) could entail a combi-nation of the effects that are observed either after ectopic or af-ter homotopic plus bridge grafts.

S2D-2 The Role of Progesterone in the Treatmentof Traumatic Brain Injury: From the LaboratoryBench to the Bedside

Donald G. SteinEmory University School of Medicine, Georgia, USA

Background: At present, there are no clinically effectivetreatments for traumatic brain injury (TBI), and many of theclinical trials seeking safe and effective treatments for strokeand TBI have ended in disappointment. A growing contingentof investigators are now proposing that progesterone plays amuch more important role in CNS repair, organization, andfunction than has previously been realized. For more than a de-cade, our laboratory has been examining the role of progester-one and its precursors and metabolites to determine their spe-cific molecular, physiologic, and mechanisms of action in repairand protection of the damaged central nervous system. There isnow substantial experimental evidence that progesterone andits metabolite, allopregnanolone, can reduce inflammatory dis-orders of the brain and support morphologic and functional re-pair for victims of TBI and stroke. A principal effect ofpostinjury progesterone treatment is to reduce the cerebraledema and inflammation that accompany TBI. Cerebral edemaalso occurs after stroke and can be very problematic for patientsundergoing open-heart surgery. Thus, an agent like progester-one or allopregnanolone, capable of resolving edema with fewside effects, could be of major benefit in a clinical setting. Pro-gesterone and allopreganolone may differ in their actions onTBI and stroke, with the former being more appropriate for TBIand the latter more effective in treating ischemic stroke. Afterbackground experimental data have been presented, the resultsof a recently completed National Institutes of Health–sponsoredphase II(a) single-center trial for safety and efficacy of proges-terone will be discussed. This 100-patient trial has shown thatprogesterone can substantially reduce mortality in moderatelyto severely brain-injured patients. Summary Points: In labora-tory animals, females with TBI have better functional andmorphologic outcomes than males with the same extent of in-jury. Treatment with exogenous progesterone and its metabo-lite, allopregnanolone, in both adult males and females, en-hances the rate and extent of recovery from traumatic braininjury and stroke. Progesterone and its metabolites act by reduc-ing immune-inflammatory reactions, membrane lipid

peroxidation, cerebral edema, apoptosis and necrosis—eventswhich will lead to the slow but steady death of nerve cells longafter the initial injury itself. Progesterone and allopregnanolonestimulate the remyelination of damaged axons and enhance re-generation. These neurosteroids regulate gene expression andprotein synthesis involved in glial activity, apoptosis, and re-generative repair. They may differ in their effectiveness instroke versus TBI. New research is showing that progesteroneand its metabolites may also prove effective in the treatment ofspinal cord injuries and neurodegenerative disorders such asmultiple sclerosis. Objectives of the Presentation: Provide abetter understanding of the role of neurosteroids in the early,acute-stage treatment of traumatic brain injury and stroke. Con-sider data showing that sex differences in CNS functions mayplay an important role in both TBI and subsequent treatmentoutcomes. Recognize that early intervention with neurosteroidtreatments may enhance the efficacy of later rehabilitation ther-apies. Demonstrate that neurosteroids may play a moresystemic role in enhancing tissue repair than previouslythought.


S3A-1 Results of the WHO Collaborating Centrefor Neurotrauma Task Force on Mild TraumaticBrain Injury

J. Borg,1 L. J. Carrol,2 J. D. Cassidy,3 and L. Holm4

1Uppsala University, Uppsala, Sweden; 2University ofAlberta, Canada; 3University of Toronto, Canada;4Institute for Environmental Medicine, KarolinskaInstitutet, Stockholm, Sweden

This lecture will survey the key findings of a systematic re-view of the literature performed by the WHO CollaboratingCentre for Neurotrauma Task Force on Mild Traumatic Brain In-jury (MTBI) to assemble the best evidence on the epidemiology,diagnosis, intervention, cost, and prognosis of MTBI. Of 38 806citations, 671 studies were relevant to the mandate of the taskforce and another 70 studies were identified by hand-searchingreference lists. After review, 42% of the studies were acceptedon scientific merit. Thus, serious, methodological flaws werecommon in this literature, and the heterogeneity of case defini-tions was conspicuous. Studies show that 70% to 90% of alltreated traumatic brain injuries are mild and that the incidenceof hospital-treated MTBI is about 100-300/100 000 population.Strong evidence supports helmet use to prevent MTBI in motor-cyclists and bicyclist. Even though the studies on incidence andrisk factors for MTBI are very heterogeneous with different casedefinition, there is evidence that MTBI is an important publichealth problem. The estimated prevalence of intracranial CTscan abnormalities is 5% in studies of patients presenting to hos-pitals with a Glasgow Coma Scale (GCS) score of 15 and 30% orhigher in patients presenting with a score of 13. About 1% of allhospital-treated MTBI patients required neurosurgical interven-tion in these studies. There is strong evidence that clinical fac-tors can be used to predict CT scan abnormalities and the needfor intervention in adults. Skull fracture is a risk factor forintracranial lesions, but the diagnostic value of this finding ver-sus intracranial lesion is poor. Some evidence indicates thatearly educational information can reduce long-term complaintsafter MTBI and that this intervention need not be intensive. Coststudies were few, and most of them were outdated. Prognostic



studies contained evidence that children’s prognosis after MTBIis good, with resolution of MTBI-specific symptoms within 2 or3 months and little evidence of residual cognitive, behavioral,or academic deficits. For adults, cognitive deficits and symp-toms are common in the acute stage. The stronger studies thatuse appropriate control groups and consider the effects of othernon-MTBI factors generally show resolution of symptomswithin weeks or a few months. There is also evidence that someof the observed long-standing postconcussion symptoms maybe attributable to factors other than the MTBI, and the inde-pendent role of severity of MTBI in long-term disability cannotbe confirmed. The best evidence suggests that MTBI increasesthe risk of seizures during the 1st 4 years postinjury, althoughthe absolute risk is still low; but there is little or no increasedrisk of brain tumors after MTBI. No conclusions could bereached on the role of MTBI as a risk factor for dementia. Thissystematic review of the literature disclosed gaps in all areassurveyed. One area of high priority should be studies aiming atthe identification of factors associated with poor prognosis afterMTBI, which might offer useful targets for intervention trials.

S3A-2 The Long-term Impact of Minor BrainInjury on Education and Participation

Anthony B. WardNorth Staffordshire Rehabilitation Centre,United Kingdom

Background: The North Staffordshire Rehabilitation Centrehas since 1992 held a registry of every patient who has attendedthe emergency department with a traumatic brain injury. It hasalso held a weekly minor brain injury clinic, on to which furtherdata have been submitted. The registry was therefore used toidentify a cohort of children who suffered a minor brain injury,and they and their families were contacted 5 to 8 years later toidentify problems with school and with participation in society.Methods: A postal questionnaire was sent to 974 children, whichincluded a number of control subjects, who attended the emer-gency department after injury but who were not head injured. Aseparate questionnaire was sent to the parents and to teachersat the child’s school. A random sample of 97 head-injured chil-d ren and 31 cont ro l s were then in te rv iewed andneuropsychological assessment was carried out on 80 subjectsand 31 controls. Results: 525 respondents were achieved andthe questionnaire produced new data on outcomes. There waspersistent stress and burden in more than 40% of parents, andteachers were often not aware of the injury. Many children weredisruptive or regarded as slow. Implicit memory was preserved,but global difficulties remain. Conclusion: Children with mod-erate or severe brain injury are at particular risk of cognitive, ed-ucational, and behavioral problems. Few were offered rehabili-tation or therapy, and symptoms remain several yearspostinjury.

S3A-3 What Is Really Behind NeuropsychologicalDysfunction after MTBI?

Thierry EttlinBasel and Rheinfelden, Switzerland

The most frequent neuropsychologic deficits after MTBI aredisturbances of attention, concentration, and memory as well aspsychomotor retardation, fatigue, and (usually depressive) af-fective disorders. These symptoms are not proof that an organicbrain lesion has occurred. For neuropsychological examina-

tion, usually a test battery is used that consists of subtests fordifferent brain functions and clinical exploration of the neuro-psychiatric functions. Aphasias, amnesias, agnosias, andapraxias are classic cortical instrumental dysfunctions. They arespecific to an organic lesion in a circumscribed brain area butnot specific to etiology. In contrast, a constellation of distur-bance of attention, concentration, retrieval of memory, mentalf lexibi l i ty, and regulat ion of affect , combined withpsychomotor retardation and mental fatigue, as frequentlyfound after MTBI, corresponds to an unspecific, subcorticalbrain dysfunction with a broad neurologic and nonneurologicdifferential diagnosis. After MTBI, the differential diagnosis ofsubcortical neuropsychological deficits has to include the fol-lowing: pain-related processes connected to headache andneck pain; brain dysfunction due to an organic brain lesion;pharmacologic side effects of centrally acting drugs;neuropsychological interferences caused by vegetative,visuomotor, or vestibular disturbances; and, most important,psychopathological complications of affective disorders, espe-cially depression, in the context of preexisting psycho-pathology, adaptation disorders or posttraumatic stressdisorders. Several of these factors may coexist and exert amultifactorial influence.

S3B-1 Locomotor Activity in Spinal CordInjured Persons

V. DietzBalgrist University Hospital, Zurich, Switzerland

Background: After a spinal cord injury (SCI) of the cat or rat,neuronal centers below the level of lesion exhibit plasticity thancan be exploited by specific training paradigms. In persons withcomplete or incomplete SCI, human spinal locomotor centerscan be activated and modulated by locomotor training (facilitat-ing stepping movements of the legs using body weight supporton a treadmill to provide appropriate sensory cues) Methods: Inpersons with incomplete SCI, locomotor activity was analyzedduring locomotion on a treadmill. Results: Persons with incom-plete SCI benefit from locomotor training such that they im-prove their ability to walk over ground. Load-related or hipjoint–related afferent input seems to be of crucial importancefor both the generation of a locomotor pattern and the effective-ness of the training. However, it may be a critical combinationof afferent signals that is needed to generate a locomotor pat-tern after severe SCI. Conclusion: Mobility of persons after a SCIcan be improved by taking advantage of the plasticity of thecentral nervous system and can be maintained with persistentlocomotor activity. In the future, if regeneration approaches cansuccessfully be applied in human SCI, even persons with com-plete SCI may recover waking ability with locomotor training.

S3B-2 Sexual Rehabilitation after Spinal CordInjury

Joan VidalNeurorehabilitation Hospital, Institut Guttmann,Spinal Cord Unit, Barcelona, Spain

Decrease in sexual function after a spinal cord injury (SCI) isa major cause of decreased quality of life for men and women.The complex mechanism regulating normal sexual activity is se-verely altered. In men, it causes a serious alteration of the physi-cal phenomena that controls sexual activity, such as erection,ejaculation, and perception of orgasm, and changes the sexual



behavior of the patient. These alterations are often accompa-nied by a personality disorder, manifesting as decreased self-image, low self-esteem, feelings of distrust, and fear of aban-donment. Treatment of sexual dysfunction in SCI men popula-tion has focused on the restoration of erectile function. It is pos-sible to restore satisfactory erectile function with oral drugs,vacuum devices, constriction rings, intracavernous injection ofvasoactive drugs, and surgical procedures like penile prosthesisand sacral anterior root stimulation. However, sensation is im-paired, and this factor is considered to be much more difficult totreat. No technique available to reestablish or substitute penilesensibility in these patients. Therefore, management of sexualdysfunction in an SCI patient is considered an important part ofthe comprehensive rehabilitation program.

S3B-3 Spasticity in Spinal Cord Injury

A. Martinez-ArizalaMiami VA Medical Center, The Miami Project,University of Miami School of Medicine, USA

Spasticity has been defined as “a motor disorder character-ized by a velocity dependent increase in tonic stretch reflexes,which results from abnormal intraspinal processing of primaryafferent input, as one component of the upper motor neuronsyndrome.” It is a frequent symptom in spinal cord injury, andits pathophysiology includes interference of the descendingcontrol of interneuronal systems in the cord by the spinal lesion.In spinal cord injury, it is a consequence of a spinal cord lesionabove the level of the conus and follows the resolution of thephase of spinal shock. The manifestations include exaggeratedreflexes, increased tone, and autonomic hyperreflexia.Spasticity may be focal or generalized; and if severe and un-treated, it may lead to dystonic posturing, contractures, and skinbreakdown. Grading is largely subjective and includes toolssuch as the Ashworth Scale, spasms score, and reflex grading.More objective measurements like the pendulum test are usedin research studies. Spasticity does not necessarily require treat-ment, and therefore treatment should be initiated when it inter-feres with the patient’s activities (ADLs, sitting, sleeping). Treat-ment should also be offered to those who experiencediscomfort from the spasms and to prevent joint contractures.Spasticity may have positive effects as it can helps maintainmuscle tone and may be utilized by patients to assist them intheir activities such as dressing, transfers, and emptying of theirbladders. Changes in spasticity, particularly an increase, can beattributed to a variety of causes such as an acute serious illness(pulmonary embolus, perforated ulcer), skin irritation (ingrowntoenail, burns), urinary tract irritation (infections, stones), rectalirritation (impaction, fissure), skeletal (fractures, dislocations),and certain medications. Some patients can control theirspasticity through mechanical means like stretching, range ofmotion, standing, ice packs, and exercise. However, the main-stay of treatment has been largely pharmacologic, particularlydrugs such as baclofen and diazepam, which act on the GABAsystem. Tizanidine and, less frequently, clonidine are also usedbecause of their inhibitory effects in the spinal cord via their ac-tions in the alpha-2 adrenergic system. Dantrolene sodium af-fects spasticity by interfering with calcium release from thesarcoplasmic reticulum in the muscles, but it has potential hepa-totoxicity. Spasticity can also be treated by the chemical inter-ruption of the reflex arc via injections of anesthetics, alcohols,

phenol, or botulinum toxin. This can be accomplished by injec-tions in different points of the reflex arc such as the musclemotor point, peripheral nerve, nerve root, and, less frequently,in the spinal cord or the spinal subarachnoid space. Some ofthese techniques are more appropriate in the treatment of focalspasticity. Surgical alternatives for the treatment of spasticity areusually applied when oral medications fail. This includes proce-dures like tenotomies, tendon lengthening, and myotomy,which treat the orthopaedic consequences of spasticity. The im-plantation of the intrathecal baclofen pumps or dorsal columnstimulators have also been successfully used to treat general-ized spasticity. Destructive procedures such as neurectomies,rhizotomies, and Bischof longitudinal myelotomyies are nolonger used often.

S3C-1 Rehabilitation of Neuropathies

W. Grisold,1 A. Vass,2 U. Zifko3

1Kaiser Franz Josef Hospital, 2LBI forNeurooncology, 3Neurological Rehabilitation CenterPirawarth, Austria

Background: Contrary to CNS neurologic diseases as stroke,Parkinson’s disease, and multiple sclerosis, the rehabilitation ofperipheral neuropathies is often neglected. Methods: The over-view is based on the experience from the authors working in aneuromuscular clinic and a rehabilitation center. A review ofthe literature using PubMed with terms “neuropathy rehabilita-tion” and “polyneuropathy rehabilitation” revealed many spe-cific rehabilitative procedures of peripheral nerve lesions butfew reviews of general principles of the rehabilitation ofpolyneuropathies. This may be because of the heterogeneousetiology of neuropathy and heterogeneous approaches of treat-ment and also rehabilitation. Results: Polyneuropathies are aheterogeneous group of diseases of the peripheral nerves, insome cases the spinal ganglia and also the posterior columns.Etiology, clinical symptoms and signs, the clinical course, acuteand chronic treatment, and prognosis vary. For this reason, theconcept of rehabilitation must be tailored to individual diseasesand principles of rehabilitative treatment can be discussed. Theassessment of function needs to be recorded in a reproducibleway. Motor, sensory disability scales should be used; however,there is little consent in common neuropathy assessment scalesfor different types of neuropathy. Electrophysiological methodsare used to record the neuromuscular system and its objectivefunction parameters also in regard to prognosis. Fatigue hasbeen reported to occur as a sequel of acute and chronicneuropathies and impair the quality of life. Painfulneuropathies and autonomic neuropathies have a negative im-pact on the patient’s quality of life. Increasingly universally ap-plicable and acceptable tools of measuring peripheral nervefunctions need to be implemented. Neurorehabilitation of pe-ripheral nerve disorders is initiated once the disease is diag-nosed and specific treatment, if available, is initiated. The targetof rehabilitation is the recovery of function of the peripheralnervous system in regard to motor, sensory, autonomic, andcomposite function. This can be achieved by drug therapy,physiotherapy, and occupational therapy, treatment of compli-cations, orthosis, and adaptive equipment. Treatment ofcomplications as skin lesions, ulcers, and joint deformities mustbe part of the concept. In severe quadriparetic cases ofneuropathies, communication can be an issue. Conclusion: The



future vision is the complete restitution of function either byconventional therapy or by new concepts as neuroplasticity.Last but not least, social and neuropsychiatric aspects need tobe considered in the management and guidance of patients.

S3C-2 Management of Patients withNeuromuscular Diseases

Eric Altschuler and John R. BachUniversity of Medicine and Dentistry of New Jersey,New Jersey Medical School, USA

A great deal can be done at every stage of neuromusculardisease to prolong survival and maintain quality of life. Duringthe ambulatory stage, orthopedic interventions and physicaltherapy based on pathokinesiological assessment extend brace-free ambulation for patients with Duchenne muscular dystro-phy by 1.3 to 1.5 years. These can be even more beneficial forpatients with milder conditions like Becker and limb-girdlemuscular dystrophy, spinal muscular atrophy type 3, and polio-myelitis. During the wheelchair stage of pediatric conditions,severe scoliosis can be prevented surgically without resort totracheotomy, irrespective of the extent of the restrictive pulmo-nary syndrome. Thus, even patients who require continuous(noninvasive) ventilatory support can undergo surgery, havefull-term pregnancies, and not require tracheostomy, providedthat there is some residual bulbar-innervated muscle function.For patients with cardiomyopathies, the combination of beta-blockers, ACE inhibitors, digitalis, and spironolactone has acardioprotective effect. Left ventricular ejection fractions can in-crease by 30% to 40% and prolong life. Gastrostomy tube place-ment can now be done under local anesthesia by the modifiedStamm procedure. This can avoid the high risk of respiratorycomplications inherent for these patients who undergo generalanesthesia. The predominant cause of death in these patients isrespiratory failure. About 90% of the time this results from pneu-monia that occurs during intercurrent respiratory infections dueto an ineffective cough. It is preventable with the use ofnoninvasive intermittent positive pressure ventilation (IPPV)and manually and mechanically assisted coughing. The proto-col involves the use of oximetry during intercurrent respiratorytract infections to maintain oxyhemoglobin saturation (SpO2)greater than 94% by some combination of noninvasive IPPV andassisted coughing. More than 100 hospitalizations have beenavoided by using this protocol for pediatric patients. Likewise,with this approach, many patients have gradually become con-tinuously dependent on noninvasive IPPV without ever beinghospitalized. Otherwise invariably fatal by 2 years of age, pa-tients with severe and typical spinal muscular atrophy type 1(Werdnig-Hoffman’s disease) are now living beyond age 10 andare likely to live into adulthood without tracheostomy tubes.The milder spinal muscular atrophies and all myopathies aremore easily managed without resort to tracheostomy. When atracheostomy tube is present, rehabilitation includes the re-moval of the tube and closure of the ostomy provided that bul-bar-innervated muscle function suffices for assisted coughingflows to reach 160 L/m or greater. Decanulation facilitates mas-tery of glossopharyngeal breathing for ventilator-free breath-ing. It also facilitates both manually and mechanically assistedcoughing to eliminate airway secretions and preventintercurrent pneumonias. Ventilator dependent patients withneuromuscular disorders have significantly lower pneumoniaand hospitalization rates when using noninvasive rather thantracheostomy IPPV.

S3D-1 Gait Rehabilitation after Stroke

S. HesseCharité-Universitätsmedizin Berlin, Klinik Berlin,Germany

Background: In former times, tone-inhibiting and gait-pre-paratory maneuvers prevailed, resulting in very little gait prac-tice. These days a task-specific repetitive approach is mostpromising. Treadmill training with partial body weight supportwas a 1st step enabling the practice of up to 1000 steps per ses-sion. In nonambulatory stroke subjects, controlled studies,however, failed to show a superior effect. One possible expla-nation was the therapists’ effort, e.g., when setting the limbs, re-sulting in a too little gait practice. Methods: Gait machines, theelectromechanical GaitTrainer GT I or the Locomat, addressedthis problem. For the GT I, a recent study (DEGAS) included 155nonambulatory subacute stroke patients, allocated to group A(20 min + 25 min PT) and B (45 min PT). They practiced everyworkday for 4 weeks. At study end, gait ability (FAC score) andADL competence (BI), were significantly better in A. Controlledtrials in Hong Kong, Korea, and Slovenia confirmed this supe-rior result. Results: For ambulatory patients, treadmill training isan optimal tool to improve the highly relevant parametersspeed and endurance. Successful studies applied a sprint train-ing (stepwise increase of belt speed) or an aerobic fitness train-ing. By gradually increasing belt speed and inclination, patientsreach a target heart rate to elicit an aerobic training effect. Con-clusion: In conclusion, gait rehabilitation after stroke is highlydynamic and fascinating.

S3D-2 Physical Fitness in Persons withHemiparetic Stroke: Its Structure andLongitudinal Changes during an InpatientRehabilitation Program

M. Liu and T. TsujiKeio University School of Medicine, Japan

Background: In persons with hemiparetic stroke, assess-ment and promotion of fitness have so far received limited at-tention, partly because of the lack of appropriate measures ap-plicable to them. Because these mobility-impaired persons areprone to inactivity, disuse and insulin resistance are likely to oc-cur and can aggravate the already significant health and eco-nomic consequences that stroke entails. It is therefore impor-tant to assess objectively their fitness to devise effective andefficient fitness promotion programs. In this study, based on theconceptual model of fitness in healthy persons, we tested thehypothesis that the structure of fitness in patients withhemiparetic stroke can be categorized as impairment/disability,cardiopulmonary, muscular, and metabolic domains and stud-ied longitudinal changes in their fitness during an inpatient re-habilitation program. Methods: 107 consecutive inpatients withhemiparetic stroke participated in the study. To analyze the sta-tistical structure of fitness, the following parameters represent-ing the four hypothetical domains were measured and sub-jected to principal component analysis (PCA) followed by anorthogonal rotation of the initially extracted components: pare-sis/daily living (the stroke impairment assessment set [SIAS] andthe Functional Independence Measure [FIM]); muscular (gripstrength [GS], knee extensor torque, and cross-sectional areas ofthigh muscles); metabolic (body mass index [BMI] and fat accu-mulation on CT); cardiopulmonary (heart rate oxygen coeffi-



cient [HR-O2-Coeff]) obtained with a graded bridging activityand a 12-minute propulsion distance). The changes of PCAscores were analyzed during a conventional stroke rehabilita-tion program consisting of 80 minutes of physical therapy andoccupational therapy sessions 5 days a week and daily rehabili-tation nursing for a median duration of 105.5 days. Results: PCAcategorized the original 15 variables into 4 factors correspond-ing to paresis/activities of daily living, muscular, metabolic, andcardiopulmonary domains and explained 78.1% of the totalvariance at admission and 69.6% at discharge. Except the meta-bolic domain, PCA scores for the other 3 domains improved sig-nificantly at discharge (paired t test, P < 0.05). Conclusion: Thestructure of their fitness could be described by our hypotheticalfitness model of healthy persons (cardiopulmonary, muscular,and metabolic dimensions) if the paresis/activities of daily liv-ing dimension is added. Studying the changes of the above 4dimensions can help develop more effective fitness trainingprograms.

S3D-3 Stroke Rehabilitation: ElectricalStimulation or Task-Related Training?

C. W. Y. Hui-ChanThe Hong Kong Polytechnic University, Hong Kong

Background: Animal studies showed that large-diameter fi-bers could presynaptically inhibit group 1a fibers mediating thestretch reflex. Our previous study showed that transcutaneouselectrical stimulation (TENS) stimulates large-diameter fibers.So a question was raised as to whether it could reduce hyperac-tive stretch reflex and thereby spasticity. Now, if TENS—a pas-sive form of peripheral stimulation—was effective in reducingspasticity and improving voluntary movement, what about task-related training (TRT), which involves voluntary descending,commands from the brain to the targeted motor neurons and themuscles they innervate? Will combining TENS with TRT be moreeffective in improving motor function in spastic hemiplegic pa-tients than either TENS or TRT alone? During the past decade,we have launched a series of randomized, clinical controlled tri-als (RCTs) to determine which treatment strategy was more ef-fective in improving motor function in clients with both acuteand chronic stroke. Results: 1) Electrical stimulation: Our earlierstudy showed that 3 weeks of TENS applied to the peronealnerve was significantly more effective than placebo stimulationin reducing spasticity and in improving voluntary ankledorsiflexion in persons with chronic stroke. We hypothesizedthat these effects would also be obtained when 3 weeks of TENSwas applied to lower limb acupoints during acute stroke andthat the effects would outlast the treatment period. Such posi-tive findings were indeed demonstrated in our recent RCT onacute stroke patients, showing that in contrast to placebo stimu-lation, the effects were maintained even after treatment ended.2) Task-related training: We then set out to compare the effec-tiveness of TENS alone and when combined with task-relatedtraining (TRT) in patients with chronic stroke. Eighty-eightpatients were randomly assigned to 1 of 4 groups receiving 4weeks of a) TENS, b) placebo stimulation plus TRT, c) TENSplus TRT, or d) control with no active treatment. When com-pared with control and placebo plus TRT groups, the adminis-tration of TENS alone and when combined with TRT producedsignificantly earlier decrease of ankle plantarflexor spasticity—after just 2 weeks of treatment (P < 0.01). However, only the 2exercise (TENS plus TRT and placebo plus TRT) groups

achieved greater increase of both ankle dorsiflexor andplantarflexor torques after 4 weeks of treatment and at follow-up, when compared with those of the control group (P < 0.01).Of interest is that by 4 weeks after treatment ended, the com-bined TENS plus TRT group had greater gains than those of theTENS-alone group—not just in ankle dorsiflexor andplantarflexor torque production but also in gait velocity and inwalking endurance as measured by a 6-minute walk. Conclu-sion: Our results demonstrated that although TENS is effectivein reducing spasticity and improving voluntary ankledorsiflexion, combining TENS with TRT was more effective inimproving movement mobility in addition to muscle strength inpatients with chronic stroke. The author thanks the Hong KongPolytechnic University and Health Service Research Fund fortheir financial support and her 3 former PhD students, Dr M. F.Levin, Dr T. Yan, and Dr S. S. Ng for their contributions.

S4A-1 Depression in Aging:A Neurorehabilitation Perspective

M. F. MorrisonUniversity of Pennsylvania, USA

Depression is a common mental disorder that is experiencedby an estimated 5.8% of men and 9.5% of women in any year.Patients with CNS illness are at a substantially increased risk fordepression, with a prevalence of ~30% to 40%. Poststroke de-pression impedes rehabilitation and recovery, impairs qualityof life and is associated with increased mortality. A comprehen-sive review of the current understanding of major depressionand depressive syndromes in the elderly will be accompaniedby discussion of the impact of depression on disability and mor-tality. Treatment options for depression associated with neuro-logic illness will be reviewed including medication, cognitivetherapy (in person, telephone, or computer assisted), interper-sonal therapy, and transcranial magnetic stimulation. Executivedysfunction on cognitive tests has been associated with failureto respond to selective serotonin reuptake inhibitor treatment.In a sample of older patients seeing their general practitioner,~6% had suicidal ideation, which was closely linked to depres-sion. The suicide rate in the elderly has been increasing, and ef-forts to prevent suicide by treating depression more vigorouslyin the elderly are being studied. Promising questions for futureresearch will be presented. Early recognition and initiation oftreatment for depression tailored for associated executive dys-function and specific neurologic illness presents opportunitiesfor improvement in the quality of life and the maintenance ofoptimal levels of function for older people.

S4A-2 Poststroke Depressive Symptoms andAssociating Factors in Chinese Stroke Patients:A Prospective Study

W. J. Sit,1 S. W. L. Li,2 T. K. S. Wong,1 and Y. M. Fong2

1The Hong Kong Polytechnic University; 2Tung WahHospital and the University of Hong Kong,Hong Kong

Poststroke depression (PSD) is common and has become anarea of significance in the study of stroke during the past 2 de-cades, mostly in the Western population. A question arises as towhether findings about PSD from Western culture mirror those



in Chinese culture. The aims of this study were to identify com-mon depressive symptoms found in Chinese stroke patients andto examine factors associating with depression after stroke inHong Kong. This study has 2 parts: A 6-month prospective studyfollowed with a qualitative study using triangulated approach.Data were collected in 2 time points: baseline (T1), within 48hours of admission to the rehabilitation hospitals, and follow-up (T2), 6 months after the baseline. One hundred twelve sub-jects, who met the inclusion criteria, were recruited at T1. Theywere all Chinese first-time stroke patients, not having had de-pression or physical disability before the stroke and not havingcognitive decline or aphasia/dysphasia that was severe enoughto prevent reliable communication. Subjects’ sociodemographicdata, comorbidity, stroke characteristics, stroke severity, func-tional ability, social support received, and depressive symp-toms (measured by CES-D) were obtained at baseline. Ninety-five subjects completed the study at T2, where the prevalence ofdepressive symptoms was 48% (CES-D ≥16). A structured multi-phase regression analysis found 5 variables explaining 54% ofthe variance of higher CES-D score at T2. Results showedwomen, those who reported higher CES-D score at baseline,were self-care dependent, had a lack of informational support,and had reduced social companionship at T2, tended to havehigher levels of depressive symptoms at 6 months after stroke.Based on these findings, 10 depressed subjects and their familycaregivers were invited to participate in a semistructured in-depth interview so as to enrich our understanding about livedexperience with stroke and the characteristic of depressivesymptoms among Chinese stroke patients. Results echoed andelaborated perspectives of the associating factors found in theprospective study, especially on how functional disability andthe salience of friendship after stroke play the role in influenc-ing depression among stroke patients. Findings also showedthat culture might play a part in how depression was expressed.Patterns of verbal descriptors from the depressed stroke pa-tients revealed a majority (around 60%) on somatic symptoms,32% on neurocognitive/psychological symptoms, and 10% re-lated to worry or fearful feeling. Common verbal descriptors ondepressed patients from family caregivers included somaticsymptoms (46%), interpersonal problem (36%), and spiritualbehavior (18%). A majority (90%) of patients attributed their so-matic symptoms to the preexisting physical health problems re-sulting from stroke. Yet when asked directly with the screeningtool, most of them endorsed the psychological symptoms (de-pressed mood) and attributed those somatic symptoms topsychosocial causes. The lack of awareness on poststroke de-pression may partly be due to the overwhelming physical prob-lems resulting from stroke, which may mask or distract detec-tion of early signs of poststroke depression. Findings in thisstudy highlight the need for early screening for depressivesymptoms after stroke. Further study is needed to examine thediscriminative property of different depressive symptoms in thescreening of poststroke depression in Chinese population.

S4A-3 Management of Depression inParkinson’s Disease

Louis C. S. TanNational Neuroscience Institute, Singapore

Background: Depression has been estimated to occur in25% to 40% of patients with Parkinson’s disease (PD). Studies

have revealed inconsistent findings with regard to the risk fac-tors for development of depression. The diagnosis is oftenconfounded by the overlap of motor and nonmotor features ofPD with the clinical features of depression, such as social isola-tion and sleep problems. Depression in PD may be due to a re-active state or it may be intrinsic, related to changes in metabo-lism or alterations in neurochemicals such as serotonin,dopamine, and noradrenaline in specific areas of the brain.Evaluation: In patients with suspected depression, vitamin B12deficiency, hypothyroidism, and anemia should be looked forand treated. Various screening questionnaires such as the Beckdepression inventory, Montgomery and Ashberg depression rat-ing scale (MADRS), and the Hamilton depression scale may beused to screen for depression. Pharmacological treatment: Asmost studies on the use of antidepressants in PD were open-la-beled or underpowered placebo-controlled ones, most reviewshave concluded that there is insufficient evidence available toconclude on the efficacy and safety of any antidepressant ther-apy in PD. Tricyclic anti-depressants (TCA) such as nortriptylinehave been found to be useful for the treatment of depression inPD. During the past decade, physicians have started using se-lective serotonin reuptake inhibitors (SSRIs) as a first-line treat-ment of PD depression based on the favorable experience withits use in treating depression in non-PD patients and their betterside effect profiles. Caution should however be exercised in theuse of TCAs or SSRIs in patients taking monoamine oxidase(MAO) inhibitors, such as selegiline, in view of the potential oc-currence of serotonin syndrome. There is also some suggestionthat some dopamine agonist, such as pramipexole, may be ef-fective in the treatment of depression. Nonpharmacologic treat-ment: Adequate sleep, good nutrition, regular exercise, socialsupport, and participation at support groups are useful adjunctsto managing depression in PD patients. Counseling and psycho-therapy may also be useful adjuvants to treatment with an anti-depressant. In severe or resistant cases, comanagement with apsychiatrist would be useful. Electroconvulsive treatment mayalso be considered in refractory patients. Conclusion: Depres-sion is common among PD patients. Symptoms of depressionshould be sought for or screened, and treatment instituted onceit interferes with the patient’s daily function and quality of life.TCAs and SSRIs are the most commonly used medications. Man-agement of depression in PD involves a holistic approach thatalso includes non-pharmacological aspects, such as ensuringadequate sleep, nutrition, exercise, and support.

4B-1 Review of Medical Treatment ofMultiple Sclerosis

A. J. ThompsonInstitute of Neurology, University College London,London, United Kingdom

Medical treatment is but one element of the optimum man-agement of multiple sclerosis (MS). However, it is encouragingto see how it has evolved during the past 15 years such that MSis no longer considered an untreatable condition. This morepositive approach, a far cry from Charcot’s nihilistic philoso-phy, has stimulated a more positive and active approach to themanagement overall. In considering the medical managementof MS, it is helpful to view it according to the several differenttreatment goals, in order of increasing difficulty—reducing re-lapses, slowing disease progression, and encouraging recovery



and repair. Corticosteroids are the mainstay of the treatment ofrelapses, given in high doses either orally or intravenously. Theview is that they can reduce the duration of relapses, butwhether they can influence outcome or have any long-termbenefit remains uncertain. The greatest advance in the medicaltreatment of MS has been the emergence of the beta-interferonsand glatiramer acetate. These agents result in a mean reductionin relapse rate of about 30% in patients with relapsing/remittingMS, with some impact on the severity of the relapse. Issues relat-ing to the timing of treatment, choice of agent, existence ofdose-effect and impact of antibodies continue to be much dis-cussed. Another immunosuppressive agent, mitoxantrone is be-ing used in poorly responsive, aggressive relapsing/remitting,and secondary progressive MS. The most recently licensedagent, Natalizumab, a monoclonal antibody against integrin,one of the adhesion molecules, showed very promising resultsboth in reducing relapses and new lesions shown on MRI. How-ever, after licensing, it was found to cause progressivemultifocal leukoencephalopathy in a small number of patientstaking a combination of treatments. It is improbable that suchimmunomodulatory treatments alone (or in combination) willhave a sufficiently powerful effect on the disease process. Thereis little evidence to suggest that they have a significant effect onprogressive disability, and other approaches, notably the role ofneuroprotective agents, are being considered. A number ofneuroprotective agents including lamotrogine and thecannabinoids are currently being studied in phase 2 and phase 3trials, respectively. One of the greatest challenges in MS is theprospect of repair and encouraging remyelination. Althoughmany different options are under study, none has progressed toclinical trials. On a more global level, there is accumulating evi-dence from functional MRI to support the concept of brain plas-ticity in MS and to suggest that it may play a part in limiting theimpact of the neurologic deficit. There is also the exciting possi-bility that some rehabilitation strategies may stimulate function-ally useful changes in brain activity. Overall there have been im-portant advances in the medical treatment of MS, but equallythere is increasing appreciation that neuroprotection and repairare key elements of a more effective treatment strategy for thefuture.

S4B-2 Neurorehabilitation in Multiple Sclerosis

Jürg KesselringRehabilitation Centre, Valens, Switzerland

Reorganization of structures and functions in the brain arethe basis of learning. Plastic changes occur in normal as well asin diseased brains and can be enhanced by specific therapeuticinterventions (neurorehabilitation). Because of the variety ofsymptoms and functional deficits, multiple sclerosis (MS) canlead to a broad range of functional impairments and handicap.Even with newer immunomudulating therapies, the course re-mains progressive. The symptoms themselves, loss of inde-pendence, and participation in social activities are responsiblefor the progressive decline of quality of life. The main objectiveof a comprehensive rehabilitation program is to ease the burdenof disease by improving self-performance and independence.Restoration of function is not the key effect of rehabilitation inMS. As rehabilitation measures have no direct influence on theongoing disease process and progression of the disease, com-pensation of functional deficits, adaptation, and reconditioningtogether with other nonspecific effects (management of specificsymptoms and impairments, emotional coping, self-estimation)

is more important in the long term. Newer studies in MS patientsshow that despite the ongoing progression of the disease pro-cess, rehabilitation is effective by improving personal activitiesand participation in social activities leading to better quality oflife. After comprehensive inpatient rehabilitation, improvementoutlasts the treatment period for several months. Quality of lifeis correlated more with disability and handicap rather than withfunctional deficits and progression of the disease.

S4B-3 Management of Spasticity in MultipleSclerosis Patients

M. BerteanuUniv. Hosp. ELIAS, Univ. of Medicine andPharmacy ‘Carol Davila’ Bucharest, Romania

Multiple Sclerosis (MS) is a lifetime disease, so lifetime reha-bilitation management must be employed. Spasticity is verycommon in MS, and many patients have difficulties in recogniz-ing it. Typically, lower limbs are more affected than upperlimbs. Before initiating the treatment, a careful evaluationshould be performed, as spasticity can mask an important mo-tor deficit; in these cases, spasticity is useful for the patient andshould only be treated if it improves function. Management ofspasticity includes pharmacologic interventions, botulinumtoxic and nerve blocks, and physical agents. Disease-modifyingagents are important in stabilizing or diminishing the evolutionof the disease, thus influencing spasticity. Pharmacologic inter-ventions are used on a wide scale; but dosage has to be moni-tored carefully, as adequate suppression of spasticity varieswith each patient. Most patients are managed on baclofen, butcommonly used are also tizanidine and dantrolene. Fatigue,somnolence, weakness, and impaired cognition are adverseevents that can negatively influence the rehabilitation process.An implantable baclofen pump may be indicated in patientswith severe lower limb spasticity. Botulinum toxin injectionand 4% to 5% phenol or 30% to 50% alcohol nerve blocks maybe used in more localized spasticity alone or to minimize thedose of oral spasmolytics. Nerve blocks with long-acting localanesthetics, bupivacaine 0.375%, or ropivacine 0.75% have di-agnostic and/or prognostic role. Local anesthetic nerve blocks,when repeated, may also have therapeutic effect. Physicalagents: Therapeutic exercises are most important in loweringspasticity and improve voluntary motor control. Electrical stim-ulation, magnetotherapy, massage, aquatic rehabilitation(hydrotherapy), etc., are also discussed. In prescribing physicalagents, patients with heat intolerance and fatigue have to bemost carefully evaluated.

S4C-1 A Forgotten Disability: Bowel Dysfunctionin Neurologic Rehabilitation

Barbara Chandler and Raji ThomasRegional Neurological Rehabilitation Centre,Newcastle upon Tyne, United Kingdom

Introduction: Bowel dysfunction can cause distress and so-cial isolation. Bowel incontinence may be the factor that deter-mines a move into institutional care. It is a source of embarrass-ment and may be overlooked in routine consultations.Physiology of the colon: Control over bowel function requiresintegration of the central, peripheral, and autonomic nervoussystems. The bowel has a complex intrinsic nervous supply



from the myenteric and submucosal plexus. The extrinsic sys-tem includes the parasympathetic supply from the Vagus to theforegut and midgut (ending at the splenic flexure) and the sa-cral pelvic nerves (S234). Stimulation promotes peristalsis andincreases blood flow and secretions. The sympathetic supply isvia the hypogastric nerves to the internal anal sphincter, main-taining its high resting tone. The peripheral nervous systemmaintains the tone of the external anal sphincter through thepudendal nerve (S234); this is under voluntary control. Physiol-ogy of defecation: Distension of the rectum triggers theanorectal inhibitory reflex, producing relaxation of the internalsphincter and allowing rectal contents onto the mucosa of theanal canal, in turn allowing solid, liquid, and gaseous contentsto be distinguished. Continence is maintained by voluntary orinvoluntary contraction of the external sphincter. Other factorsinfluencing social as well as physiological continence are stoolconsistency, mobility, upper limb function, cognitive ability,clothing, location of toilet, and availability of assistance. Bowelfunction in diseases of the nervous system: The result of dysfunc-tion within the nervous system may be constipation, inconti-nence, or a combination of both. More than 50% of MS patientsexperience bowel dysfunction; more than 50% with Parkinson’sdisease have constipation; after stroke, one-third of patientsmay have incontinence initially and 5% at 6 months poststroke;almost one-third of spinal injury patients have incontinence andup to 80% have constipation, to give just a few examples. Man-agement: There is little consensus about management, but withincreasing understanding of the pathology, more rational ap-proaches will become possible. We have found that a nurse-ledcontinence clinic allows time for the problem to be discussedand a management plan to be developed and subsequently re-viewed. Changes to diet, lifestyle education of caregivers andalterations to care packages, as well as the use of oral laxatives,suppositories, and enemas may be necessary. The aim is toachieve an acceptable level of control in keeping with the life-style of the patient. Arriving at a suitable bowel regime is often aresult of trial and error with the guidance of a specialist nurse.New developments such as the percutaneous endoscopic colos-tomy and the availability of specialist centers where more de-tailed neurophysiological assessments can be undertaken willhelp some patients. The majority of problems will continue tobe managed in the community. Summary: Continence has a ma-jor impact on participation, ability to live in the community, andquality of life. Routine assessment of bowel function should bea standard part of rehabilitation assessment and management.

S4C-2 Bladder Management of NeurologicDisability

Clare J. FowlerInstitute of Neurology, London, United Kingdom

The neurologic control of the bladder is highly complex,and for physiological control, extensive connections betweenthe frontal lobes, brain stem, and sacral spinal cord must be in-tact. Not surprisingly, bladder dysfunction is common in pa-tients with neurologic disease. Broadly speaking, the causes ofneurogenic incontinence can be divided into those that affectbrain regions which in health persons have an inhibitory effecton the pontine micturition center and those that disrupt the con-nections between the pons and the sacral outflow to the blad-der. After a spinal lesion, a new functional controlling pathwayemerges, the afferent limb of the reflex arc being formerly silentunmyelinated bladder afferents that respond to bladder filling

and cause reflex detrusor contractions. The mainstay of man-agement is the antimuscarinics, and there are now a variety ofthese available. Although introduced on the basis that theywould block the parasympathetic innervation of the detrusorand so reduce unwanted detrusor contractions, it is nowthought that their action must be more complex and affect blad-der afferents during the filling phase. Many patients withneurogenic bladder dysfunction, particularly those with spinalcord lesions, have incomplete bladder emptying and a raisedpostvoid residual volume, due both to detrusor sphincterdyssynergia and poorly voiding contractions. Incomplete emp-tying has a significant effect on compromised bladder function,such that the point at which detrusor overactivity is reachedmuch sooner in the filling cycle. The best solution is for the pa-tient to perform intermittent catheterization. Much work hasbeen done in recent years to improve the type of catheters avail-able, and although urinary tract infections remain a risk, pa-tients who master the technique and perform catheterizationseveral times a day may obtain considerable symptomatic bene-fit. A combination of oral anticholinergics and intermittent self-catheterization if necessary can be regarded as first-line thera-pies. However, as neurologic diseases progress, these interven-tions may be insufficient to prevent urgency incontinence. Inpatients needing further treatment, various other medicationshave been tried, including intravesical vanilloids, firstcapsaicin, and then resiniferatoxin. However, large-scale clini-cal trials were not successful, and there is currently no pharma-ceutical agent based on this principle of action available. Themost promising treatment, although as yet still unlicensed, isthe injection of botulinum toxin A through a cystoscope intomultiple sites into the bladder wall. Improvement lasts for amean of 10 months, when repeat injections appear to be equallyefficacious. Although patients with traumatic spinal cord injuryand spina bifida are at risk of developing upper urinary tractdysfunction, this complication fortunately appears to be un-common in patients with progressive neurologic disease. Blad-der symptoms in most instances of neurologic disability shouldbe managed in much the same way as other symptoms of neuro-logic origin, and the advent of increasingly effectiveinterventions means that incontinence can often be effectivelyalleviated.

S4C-3 Sexual Dysfunction—The Challenging Disability

N. C. ChaterRegional Neurological Rehabilitation Centre,Newcastle upon Tyne, United Kingdom

Intr oduct ion : Address ing sexua l prob lems inneurorehabilitation is challenging for a number of reasons:knowledge and understanding of the sexual pathways withinthe brain is partial, and apart from the direct effects of neuro-logic damage centrally and peripherally on sexual function,there may be indirect effects, for example, pain, andpsychosocial and relationship factors. The incidence of sexualproblems in neurologic rehabilitation may be high; one esti-mate gives 50% to 90% in multiple sclerosis. Physiology of Sex-ual Response and Potential Sexual Dysfunction from Neuro-logic Damage: Sexual pathways outside of the brain involvesensory input via the pudendal nerve to S2, S3, and S4 spinal seg-ments. Both parasympathetic (sacral outflow S2–S4) and sympa-thetic (thoracic and upper lumbar T11–L2) are involved in gener-ating myotonia and vasocongestion. In men, relaxation of the



muscle cells in the walls of penile blood vessels and erectile tis-sue, initiated mainly by nitric oxide released from parasympa-thetic nerve endings and vascular endothelium, results invasodilation and erection. Therapeutic interventions for erectiledysfunction in the neurorehabilitation setting can include phar-macology (Phosphodiesterase type-5 inhibitors, Apomorphine,Alprostadil, Papaverine) or mechanical devices. In women,vasocongestion causes increased vaginal secretion and clitoraland labial swelling. The uterus increases in size and rises in thepelvis, pulling the cervix up. The inner two-thirds of the vaginalengthens and expands. Thus, vaginal dryness and difficultywith penetration and dyspareunia can be a consequence of neu-rologic disease. Neurologic damage in both men and womenmay cause reduced perineal sensation. Widespread muscle con-traction in the pelvic area leads to expulsion of semen and asensation of orgasm in both genders. Problems with ejaculationand orgasm may result from neurologic damage. Apart from therole of frontal and temporal cortex on behavior and cognition, akey area of the brain in sexual activity is the limbic system with arange of hormones and neurotransmitters (e.g., oxytocin,vasopressin, dopamine, serotonin). Hence, traumatic brain in-jury may have a direct impact on sexual function and expres-sion, and a change in sexual response can be a consequence ofmedications used, for example, anticonvulsants and mood sta-bilizers. A Framework to Assess Sexual Problems: Foley andWerner categorized sexual problems in multiple sclerosis as pri-mary, secondary, and tertiary. The approach encourages a thor-ough assessment of a sexual problem but does not specificallyhighlight relationship issues as recommended by others. Sum-mary: There are significant challenges in attempting to managesexual dysfunction in neurorehabilitation, but it is possible andappropriate to do so. There are challenges to knowledge, train-ing, and service design, and any service requires appropriate re-sources. An approach, which allows relationship problems andpsychosocial, emotional, and physical concerns to beconsidered, is recommended. Some examples from practicewill be given.

S4D-1 Pediatric CI Therapy:Results and Mechanisms

Edward TaubUniversity of Alabama at Birmingham, USA

Constraint-Induced Movement (CI) therapy has been foundto be a promising treatment for substantially increasing the useof extremities affected by such neurologic injuries as stroke andtraumatic brain injury in adults. It was derived from earlier workwith monkeys in which the basic components of the treatmentwere worked out. A relatively small modification of the proce-dures used with monkeys and adult humans has been appliedsuccessfully to young children with cerebral palsy. The initialwork with children was carried out in collaboration with SharonRamey, Stephanie DeLuca, and Karen Echols. The 1st study wasa randomized controlled clinical trial of pediatric CI therapy inwhich 18 children with diagnosed asymmetric upper extremitymotor deficit associated with cerebral palsy (7–96 months old)were randomly assigned to receive either pediatric CI therapyor conventional treatment. Pediatric CI therapy involved pro-moting increased use of the more affected arm and hand by in-tensive training (using shaping) of the more impaired upper ex-tremity for 6 hours/day for 21 consecutive days coupled withbivalved casting of the child’s less affected upper extremity for

that period. Children’s functional upper extremity skills wereassessed in the laboratory (blinded scoring) and at home (par-ent ratings) just before, after, and 3 weeks posttreatment.Treated children were observed for 6 months. The sample in-cluded children with hemiparesis resulting from perinatalstroke or with substantially greater deficit in one upper extrem-ity than in the other from other causes. Children receiving pedi-atric CI therapy compared with controls acquired significantlymore new classes of motoric skills (9.3 vs. 2.2), demonstratedsignificant gains in the mean amount (2.1 vs. 0.1) and quality(1.7 vs. 0.3) of more affected arm use at home, and in a labora-tory motor function test displayed substantial improvement in-cluding increases in unprompted use of the more affected up-per extremity (52.1% vs. 2.1% of items). Benefits weremaintained over 6 months, with supplemental evidence of qual-ity-of-life changes for many children. In other work, 2 childrenwith hemispherectomy showed equivalent improvement. Inadults, there is evidence that the efficacy of CI therapy is predi-cated on 2 linked but independent mechanisms: use-dependentcortical reorganization and overcoming learned nonuse. In chil-dren with cerebral palsy, the same 2 mechanisms are thought tooperate, though direct evidence for this is not yet available andwould be a high priority for future work. On an empirical level,however, the work to date has shown that pediatric CI therapycan produce major and sustained improvement in motoric up-per extremity function in young children with cerebral palsyinvolving several different etiologies.

S4D-2 Disorders of Executive Functions inChildren and Adolescents

Wendy MarloweIndependent Practice, USA

Background: Within those children with dysexecutive syn-drome, there is a subset that is unable to see relationships be-tween events or build generalizations. Methods: To ascertain theincidence of impaired generalization in children withdysexecutive disorders and normal IQ, 130 consecutive cases,ages of 5 to 19 years were studied. Fifty-seven percent haddysexecutive syndrome, with a subset of 45% demonstratingdisorders of generalization. Results: Common to those impairedin generalization was language disability. A systematicremediation approach was utilized with 16 children. Conclu-sion: Generalization emerged.


S5A-1 Sports Training as a Rehabilitation Toolfor Persons with Disabilities

J. H. RimmerUniversity of Illinois at Chicago, USA

Despite growing evidence that people who participate insports and recreational activities have higher levels of physicalfitness and a reduced risk of various secondary (e.g., fatigue,pain) and chronic conditions (e.g., type 2 diabetes, coronaryheart disease) and are more physically independent in later life,people with disabilities continue to engage in higher rates ofsedentary behavior, have significantly lower levels of physical



fitness, and have a thinner margin of health compared to thegeneral population. This increases the likelihood that, as theyage, they will have greater difficulty maintaining their ability towork, participating in recreational activities, and performingself-care activities. As a result, they are also more likely to expe-rience lowered self-esteem and to perceive themselves as hav-ing a reduced quality of life. Beyond these impacts on the pa-tient, there is an impact on society through higher health carecosts and a greater strain on the national health care budget.Sports and physical activity are essential for recovery fromneurorehabilitation and for reintegration into the community.Taking advantage of current and anticipated advancements ininformation technology, the National Center on Physical Activ-ity and Disability (NCPAD, www.ncpad.org) has developed aninternational platform for delivering an increasing number ofproducts related to sports and physical activity for people withdisabilities tailored to the needs and preferences of the individ-ual user. The Center offers interactive features, such as person-alized goal setting and recording of physical activity, to over-come many current barriers to participation in, and adherenceto, healthful exercise programs. This presentation will providean overview of the Center’s activities and will encourageneurorehabilitation professionals to use sports and physical ac-tivity as a mechanism for increasing health and quality of life intheir patient population.

S5A-2 The Health Promotion Effect of Tai Chiand Its Potential Application inNeurorehabilitation

Ching LanNational Taiwan University Hospital and NationalTaiwan University, Chinese Taipei

Tai Chi Chuan (TCC) is a Chinese conditioning exercise andis well-known for its harmonic and coordinated manner. TCC ispracticed in a semisquat posture with controlled abdominalbreathing, and integrated circular movements involving multi-ple joints were performed. Health-related fitness includes aero-bic capacity, muscular strength, flexibility, and body composi-tion. In elderly persons, declines of health-related fitness mayhinder performance of daily activities and reduce the quality oflife. In elderly persons, cross-sectional studies show that TCC isbeneficial for health-related fitness. Long-term TCC practitio-ners also exhibit reduced age-related decline of peripheral vas-cular function and microcirculation. In a 12-month TCC trainingstudy, subjects showed a significant increase in aerobic capac-ity. The peak oxygen uptake (VO2peak) increased 16.1% and21.3% in male and female TCC groups, respectively. TCC train-ing may also enhance muscular strength of the knee extensor.After 6 months of TCC training, the concentric peak torque in-creased 15.1% to 20.0% in men, whereas the peak torque in-creased 13.5% to 24.2% in women. In a 5-year follow-up study,the TCC group displayed a smaller decrease in VO2peak than thesedentary group. The annual decrease of VO2peak in TCC menand women was 0.32 and 0.22 mL•kg–1•min–1, respectively.Meanwhile, in the control group, the annual decrease of VO2peak

was 0.50 and 0.36 mL•kg–1•min–1 in men and women, respec-tively. In addition, the TCC group showed a smaller increase inbody fat ratio and a less decrease in flexibility than the controlgroup. TCC also improves balance function in novice practitio-ners. TCC program preserves the balance gains after 3-month

balance training and shows a trend of further improvement inbalance. In addition, TCC training decreases 25% to 48% of thefall risks in the elderly. TCC has been applied in selected neuro-logic patients. After TCC training in 3 severe traumatic brain-in-jured patients, all patients walk without assistance and feelmore secure while walking. One patient can lead independentdaily activities and even returned to car driving. TCC programhas been applied to 19 patients with multiple sclerosis. Aftertraining, walking speed increased 21% and hamstring flexibilityincreased 28%. The results may be attributed to the effect ofneuromuscular facilitation during TCC practice. TCC can beprescribed as an alternative exercise program for selected pa-tients with neurologic, cardiovascular, or orthopedic diseases.TCC is easily accessible, low cost, and suitable for implementa-tion in the community. Recent research suggests that TCC issuitable for health promotion in the elderly and for patients withchronic disease.

S5B-1 Virtual Reality-Based Neurorehabilitationfor the Recovery of Balance and LocomotorFunctions

J. Fung,1 C. L. Richards,2 F. Malouin,2 B. J. McFadyen,2

and A. Lamontagne1

1Jewish Rehabilitation Hospital (CRIR), McGillUniversity, Montreal, 2Rehabilitation Institute ofQuebec (CIRRIS), Laval University, Quebec, Canada

Background: The current state of knowledge in rehabilita-tion emphasizes the need for task-specific repetitions to pro-mote the reacquisition of motor skills. Motor-learning is pro-moted by factors such as changing environmental contexts,alterations in the physical demands, problem solving, randompresentation of practice tasks, sufficient practice, and patientempowerment. It is difficult to meet these criteria in currentlyconstrained rehabilitation settings or to practice outdoor bal-ance and mobility tasks in different weather and lighting condi-tions. Vision has a profound influence on the regulation of bal-ance and locomotion. Optic flow, which is a predictable patternof motion of the surrounding environment generated at themoving eye during self-motion, is important for the perceptionof heading direction and speed during walking, 2 essential gaitfeatures that are often compromised in persons who had astroke. Virtual reality (VR) technology with the capacity of sim-ulating environments offers a new and safe way to not only ma-nipulate optic flow but also to offer the varied environmentsand constraints needed to maximize learning and optimizefunctional gains. Thus, a virtual reality (VR)–based locomotortraining system has been developed for balance and gait reha-bilitation. Methods: The system consists of a self-paced tread-mill mounted onto a 6-degree-of-freedom motion platform. Vir-tual environments (VEs) that are synchronized with the speed ofthe treadmill and the motions of the platform are rear-projectedonto a screen in front of the walking subject. A feasibility studywas conducted to test the capability of 2 stroke patients and 1healthy control to be trained with the system. Three VE scenar-ios (corridor walking, street crossing, and park stroll) were wo-ven into a gait-training program that provided 3 levels of com-plexity (walking speed, slopes, collision avoidances),progression criteria (number of successful trials) and knowl-edge of results. Results: As expected, all subjects adapted wellto the self-paced treadmill and were able to complete all the



tasks required in the different levels in 3 one-hour sessions.They reacted well to the novel training environments and be-came immersed without being disturbed by the equipment. Re-sults show that with practice, patients can effectively increasetheir gait speed as demanded by the task and adapt their gaitwith respect to the change in physical terrain. However, suc-cessful completion of tasks requiring adaptation to increasingdemands related to speed and physical terrains does not neces-sarily predict the patient’s ability to anticipate and avoid colli-sion with obstacles during walking. Conclusion: It is feasible touse a VR-based self-paced treadmill system to retrain balanceand locomotion after neurologic insults such as stroke.

S5B-3 Early Rehabilitation of Higher CorticalBrain Functioning in Neurosurgery—How toHumanize Human Skills after Acute Brain Lesions

Klaus R. H. von Wild,1 in cooperation with SaschaSkudelny,2 Federico Hernández-Meyer3

1Medical Faculty University of Münster, Germany,and Neurorehabilitation and Re-engineering ofBrain and Spinal Cord Lesions, InternationalNeuroscience Institute, Hannover; 2Media ScienceUniversity of Siegen; 3Pharmaceutical and MedicalCommunications, Huétor-Vega (Granada), Spain

Background: Today, increasingly more patients with mod-erate and severe brain lesions will survive the acute stage afterthe impact to the brain, thanks to emergency and intensive caremanagement, modern diagnostic imaging, and medical treat-ment. However, the majority of patients will suffer from long-lasting impairments of higher cerebral functioning (WHO-ICF).Early neurorehabilitation (ENR) was introduced in Germany bythe German Task Force of ENR 1993, based on an interdisciplin-ary team approach. ENR interventions support the process ofspontaneous physical recuperation and quicken restoration ofimpaired sensory motor, mental cognitive, and neurobehavioralfunctioning by using brain plasticity. ENR aims at patient’s so-cial reintegration in the long run. Methods: Functional rehabili-tation is an original task of neurosurgery. Impairments refer toloss of structures and functions. Disabilities refer to limitationsor participating restrictions. Functioning is an umbrella termencompassing all body functions, activities, and participation.ENR, therefore, needs a multidisciplinary team approach. ENRshould be performed best as part of general neurosurgery in re-spect to frequent concomitant multiple organ lesions and/or nu-merous secondary complications during the acute phase afterbrain damage. Concerning TBI, one has to note that MTBI (80%of all in-hospital TBI patients) may also suffer from severeneurobehavioral disturbances and severe multiple organ le-sions that need ENR. Results: The essential aspect in ENR is theintegration of disciplines and consistent goal setting to regardindividual patients’ needs. Good structural organization of theteam, notice of basic communication rules, conflict manage-ment, and a definite decision making increase productivemultidisciplinary working. Coma Remission Scale (CRS, 24points) and Early Rehabilitation Barthel Index (ERBI) allow as-sessment of best functional performance with prognostic value.ENR cut off points CRS 24 and FRBI +40 points. Residents andspecial ists are educated and trained in neurologic-neurosurgical early rehabilitation. Our team approach duringdaily work is exemplarily demonstrated. At the end, 2 examples

are shown with final social reintegration after some years; a fe-male student after severe TBI with secondary hypoxia followedby AS/VS and a businessman following recurrent brainstemhemorrhage with long-lasting coma and swallowing disorders.Conclusion: Obviously the impairment of mental-cognitive andneurobehavioral functioning and not the loss of physical skillswill cause patients’ loss of life transactions and final outcome.Rehabilitation is possible because of the persons’ neural plastic-ity. Functional rehabilitation is a process whereby patients whosuffer from impaired higher cerebral functions after brain dam-age regain their former abilities or, if full recovery is not possi-ble, achieve their optimum physical, mental, social, and voca-tional capacity for social reintegration. To facilitate such goals,neurosurgeons, like neurologists, should be educated in ENR tostart with functional rehabilitation at the intensive care ward inclose collaboration with the neuropsychologist and all othermembers of the multidisciplinary team day by day.

S5B-2 Head Injury Prediction: Its Validation

W. S. Poon, X. L. Zhu, S. C. P. Ng, G. K. Wong,and T. F. SunPrince of Wales Hospital and the Chinese Universityof Hong Kong, Hong Kong

Predicting long-term clinical outcome for patients with trau-matic brain injury (TBI) at the beginning of rehabilitation pro-vides essential information for counseling of the family and pri-ority setting for the limited resources in intensive rehabilitation.We have recently demonstrated in 68 patients that age, GlasgowComa Scale (GCS) score, and baseline FIM (functional inde-pendent measure) are independent predictors for their 1-yearoutcome. A new set of data from 50 patients were collected forits validation.

S5C-1 Pain in Spinal Cord Injury

A. Martinez-ArizalaMiami VA Medical Center, The Miami Project,University of Miami School of Medicine, USA

Pain after spinal cord injury (SCI) is a significant problemwith a reported range of prevalence between 33% to 94% in spi-nal cord injured patients. It has also been reported to be func-tionally disabling in 5% to 45% of patients. Patients with SCI ex-perience many different types of pain, which can be locatedabove the level, at the level, or below the level of injury. Thepain can be nociceptive or neuropathic pain (NP), and manypatients experience both. Neuropathic pain results from injuryto the pain-conducting pathways of the nervous system and isoften the most difficult type of pain to treat. Various mecha-nisms have been proposed to explain NP and including both ex-citatory and disinhibitory theories, central sensitization, bio-chemical changes, and neurophysiologic changes. Themainstay of treatment of NP has been pharmacotherapy. How-ever, drug study results are difficult to interpret, for most drugstudies of NP have dealt with other forms of NP, such as periph-eral neuropathy. Surgical treatment strategies for neuropathicpain associated with SCI are limited to conditions such as pe-ripheral nerve entrapments, compressive radiculopathies, post-traumatic progressive syringomyelia, tethered cord syndromes,and dorsal root entry zone (DREZ) ablation procedures.Anticonvulsants are used because they suppress aberrant elec-



trical activity throughout the nervous system, and positive re-sults have been noted in their use for treatment of NP from dis-orders like trigeminal neuralgia and peripheral neuropathy.Numerous anticonvulsant drugs with varied mechanisms of ac-tion have been recently developed that have a beneficial effectin the treatment of NP of other etiologies such as peripheralneuropathies. The most widely used has been gabapentin, butthese medications also include lamotrigine, topiramate,oxcarbazepine, levetiracetam, tiagabine, and pregabilin. Theireffect on NP from SCI has been more limited. Antidepressantshave also been commonly used in the treatment of NP from SCI,though also with limited success. The mechanisms of their ef-fects are theorized to be from their actions on blocking thereuptake of norepinephrine and serotonin. Older medicationssuch as the tertiary amines amitriptyline and doxepin are moresedating, which may help with nighttime sleep, but they havestronger anticholinergic side effects. Newer ones such asduloxetine can be quite effective in controlling NP from dia-betic peripheral neuropathy, but their effects on NP from SCI islargely unknown. Other approaches to pharmacotherapy suchas excitatory amino acid receptor antagonists are potential fu-ture avenues, but the present repertoire of these drugs is verylimited. A number of other medications such as tizanidine,mexilitine, and clonidine may have also limited usefulness. De-spite controversies, narcotics have a role in the treatment of NPfrom SCI. Although we are presently significantly limited in thetreatment of NP associated with SCI, future avenues includeintrathecal drugs and the transplantation of genetically engi-neered cells. In summary, although pain of neuropathic originin SCI remains difficult to treat, if it is approached with patienceand diligence, combination therapy (the use of several agents)may afford reasonable pain control.

S5C-2 Botulinum Toxin in the Chronic PainClinic

Mike KocanNevill Hall Hospital, United Kingdom

Many established interventional and pharmacologic treat-ments used in chronic pain clinics have disappointing successrates. Botulinum Neurotoxin type A is finding an increasing rolein the pain clinic for an expanding range of applications, withfar more satisfying results. Many applications are explainable interms of the known actions of the toxin, and some of these willbe presented. However in some applications, such as headache,the success of toxin is difficult to reconcile with thepathogenesis of the condition. Nonetheless, evidence will bepresented showing evidence of good results, particularly in mi-graine. More recent evidence will be presented which showsother more recently discovered actions of toxin, which may ex-plain this success.

S5C-3 Pain Management in NeuromuscularDiseases

Martin GraboisBaylor College of Medicine, Houston, Texas, USA

This presentation will cover the etiology, pathophysiology,classification, clinical evaluation, and utilized treatment of painin neuromuscular diseases. Although pain in neuromusculardiseases will be discussed in general, emphasis will be placed

on multiple sclerosis, Parkinsonism and Guillain-Barre syn-drome as models for pain management. Much more informationis known about the etiology and pathophysiology of someneuromuscular disorders than about the pain syndrome associ-ated with them. If one divides the pain into nociceptive,neuropathic, and psychological, one will have a better under-standing of the evaluation and treatment of these pain syn-dromes. Al though pain syndromes associated wi thneuromuscular diseases are not predominate in the discussionof these diseases, in talking with the patient he or she will in-form you how distributing and disabling these pain signs andsymptoms are. Likewise, the patient will note the relative lack ofevaluation and treatment of these signs and symptoms. The in-cidence of neuropathic pain in the United States in multiplesclerosis case is at least 50 000. The clinical assessment includesa complete history and physical with emphasis on pain charac-teristics and their impact on function. Utilization of aneuropathic pain scale can be used to follow the course of thesigns and symptoms and treatment. In some cases,neurododiographic and electrophysiologic techniques as wellas quantitative sensory testing can be helpful if nothing morethan to rule out other neuropathic pain syndromes. The man-agement of pain signs and symptoms in neuromuscular disor-ders is mult idimensional including pharmaceutical ,psychosocial, and physical therapy approaches. Managementshould prevent the symptoms if possible, reduce the pain se-verely or frequently, improve function, reduce psychologicaldistress and overall improve the quality of life. Recently, oldand new medications have been utilized to treat neuropathicpain signs and symptoms including antidepressants,anticonvulsants, and analgesic medication. Each will be dis-cussed and evaluated as to its efficacy and safety. A stepladderapproach for medication will be presented and discussed. Atthe same time, to treat psychologic components of pain, stressmanagement training, cognitive behavioral therapy, and sup-portive psychotherapy will be presented. Emphasis will includeareas of physical therapy, treatment of muscle weakness, softtissue tightness, and assistive devices, if necessary. Appropriaterecognitive evaluation and treatment of pain syndromes inneuromuscular diseases can significantly improve the pain syn-dromes and function, leading to a better quality of life in thesepatients.

S5D-1 Psychopharmacological Managementof Challenging Neurobehavioral Issues afterAcquired Brain Injury

Nathan D. ZaslerConcussion Care Centre of Virginia and Tree of LifeServices, Glen Allen, Virginia; Chairperson,International Brain Injury Association (IBIA);Virginia Commonwealth University, Richmond,Virginia; University of Virginia, Charlottesville,Virginia, USA

This session will review current practices, research, and ad-vances in the use of psychopharmacologic agents to modulateimpairment in persons with neurobehavioral impairments afteracquired brain injury (ABI). There remains a dearth of consoli-dated information on the psychopharmacologic approachesthat are effective for neurobehavioral problems after ABI, aswell as the rationale for recommending specific agents. This



plenary session will focus on presenting current information onpsychopharmacologic assessment and management principlesand practices. General caveats regarding holistic behavioraltreatment principles will be reviewed. Drug treatment para-digms for persons with ABI will be discussed as will proposedindividualized methodologies for choosing drug interventionsincluding the role of understanding the multidimensional na-ture of assessment and presentation of neurobehavioral im-pairment in persons with ABI, use of neurodiagnostic testingas an adjutant prescription guide, and cautions regarding risksof treatment. Theoretical vs. practical issues in psychophar-macologic treatment will also be examined. Specific drugs, aswell as dosages, will be recommended during the discussion ofeach of the impairment areas. Impairment areas to be discussedwill include neurobehavioral syndromes (such as dorsolateraland medial frontal), sleep/wake cycle disorders, fatigue,libidinal alterations, depression, anxiety spectrum disorders in-cluding PTSD, mania, psychosis, obsessive-compulsive disor-ders, aggression/irritability, and impulse control disorders in-cluding disinhibition and apathy. The need for adequateelaboration regarding often-ignored agents such as caffeine,nicotine, alcohol, and marijuana will also be reviewed in thecontext of their potential impact on behavior. General conclu-sions regarding the current role of pharmacotherapy in modula-tion of chronic neurobehavioral impairment will wrap up thisplenary session.

S5D-2 The Role Cognitive and EmotionalProblems Play in Challenging Behaviour—Impacton Community Functioning

A. J. HunterHunters Moor Regional Neurological RehabilitationCentre, Newcastle upon Tyne, United Kingdom

Research has shown that on a long-term basis the most sig-nificant barriers to effective psychosocial functioning after ac-quired brain injury are created by impairments in cognition,emotions, and behavior. Changes in persons’ behavior aftertraumatic brain injury are one of the most frequent complaintsreported by relatives and constitute the most persistent prob-lems in preventing a person from maintaining old relationships,developing new ones, and retaining employment successfully.What is considered a challenging behavior is to a large extentdependent on context; what is routinely encountered in one sit-uation may be unacceptable in another. Violent or aggressivebehavior might be anticipated during the initial stages of recov-ery or in a specialist rehabilitation unit, but in the longer termrelatives most commonly report problems relating to “changesin personality,” “poor motivation,” “irritability,” and “poor an-ger control,” within the wider community the making of “inap-propriate comments” is a common concern. This talk aims tocover the ways in which cognitive and emotional problems aris-ing as a consequence of acquired brain injury can cause and in-fluence behavior; aspects of cognition covered will include rea-soning abilities, information processing speed, memory,language, executive functioning, and recent research address-ing the impact of deficits in emotional processing. Acquiredbrain injury constitutes a traumatic event not only physiologi-cally but also psychologically. The interaction between cogni-tive problems and secondary psychological difficulties whichhave developed as a reaction to the brain injury, for example,anxiety and depression, will be discussed, and the impact ofpremorbid factors and the environment considered.

S5D-3 Management of Challenging Behavior inHospital and Rehabilitation Settings

Jennie L. PonsfordMonash University and Monash-EpworthRehabilitation Research Centre, Melbourne,Australia

Dealing with difficult behavior represents one of the great-est challenges of working with brain-injured persons. It mayalso present a significant barrier to successful community rein-tegration. This paper will discuss methods of assessing andmanaging behavioral problems in a hospital or rehabilitationsetting. It is very important to obtain an accurate and objectivepicture of problem behaviors by observation and careful re-cording, in observable terms, of the behavior itself and of thecontext within which it occurs, and to make a comprehensiveassessment of potential contributing factors. These factors mayrelate to the person, including premorbid personality, psychiat-ric, cultural or developmental factors, the brain injury itself, orto the context in which the behavior is occurring. Results of thisassessment will form the basis of design of the intervention. In-volvement of staff, family, and others planning and implement-ing interventions is important. In many cases, environmentalmanipulation will address the problem. However, in somecases, operant behavioral methods may be necessary, whereverpossible, using positive reinforcement such as praise or mate-rial rewards, which need to be given in a meaningful, immedi-ate, obvious, frequent, and consistent manner. Recordings ofbehavior should continue throughout the intervention phaseand for a follow-up period. A gradual weaning process is impor-tant to ensure generalization to a broad range of settings. Use ofmedication to manage behavior problems should be mini-mized. The same principles may be applied to the managementof behavior problems in community settings, with an evengreater need for naturalistic observation and involvement offamily or others in the natural environment, as well as the in-jured person. In those with some degree of self-awareness andmotivation, cognitive behavioral interventions may be used todeal with anger management problems. Community-based in-terventions will frequently also necessitate addressing anxietyand depression and other psychiatric issues, substance useproblems, and facilitation of involvement in activities that pro-vide the injured person with a more rewarding lifestyle.

S6A-1 Creating an Environment in Brain InjuryRehabilitation to Allow People to Return to Work

Robert D. VoogtRobert Voogt & Associates, Inc., Virginia Beach,Virginia, USA

The effects of traumatic brain injury on the ability to returnto work have been well documented in the literature. There aremany factors that contribute to the typically poor vocational op-portunities that are observed in this population, includingpsychosocial, physical, cognitive, and behavioral, among oth-ers. Studies that discuss rates of return to work vary from 10% to78%. One of the difficulties has been in defining employment.This varies from volunteer, or unpaid, work to competitive em-ployment. Modifications of the environment beyond just thephysical are imperative. Addressing psychosocial concerns, be-havioral responses, cognitive demands, and executive functionsuch as motivation, attention, memory, etc., is imperative in or-



der to create an environment that enables persons to return towork. The relationship between self-awareness and employ-ability are well documented. The work setting, paid or unpaid,requires significant changes in attitude, expectations, training,and individualizing the environment. This presentation de-scribes an environment necessary for persons to return to workthat contributes to improving the quality of life for the person.Various components of rehabilitation to address handicaps afterTBI will be explored to assist in developing a framework forsuccessful return to employment.

S6A-2 Opportunities for Interagency Initiativesin Return to Work after Brain Injury

A. D. TyermanVale of Aylesbury Primary Care Trust, UnitedKingdom

Introduction: In the United Kingdom, many people withbrain injury do not receive the vocational assessment, rehabili-tation, and support to enable them to return to previous or alter-native employment. The National Health Service typically pro-vides only limited, short-term advice and support for thosereturning to work. Government-funded employment rehabilita-tion schemes have, in the past, struggled to meet the complexneeds of people with brain injury, with very little joint workingacross agencies. There has been some service development dur-ing the past 15 years, including specialist brain injury workpreparation programs funded by Jobcentre Plus, Departmentfor Work and Pensions. However, a recent survey highlights thepatchy and limited access to vocational rehabilitation for peo-ple with brain injury in the United Kingdom. Service Develop-ment: With funding from the Department of Health and the Em-ployment Service, the Community Head Injury Service inAylesbury had the opportunity to develop “Working Out,” aspecialist brain injury vocational rehabilitation program for per-sons unable to return to previous employment. The programprovides a blend of brain injury and vocational rehabilitationthrough 4 interlinked phases: vocational assessment, workpreparation, voluntary work trials, and supported work place-ments. The program will be outlined briefly along with out-comes (i.e., 67% employment or training; 19% permitted workor voluntary work). Outcomes in the original project were wellretained during 2 years. The Working Out program was devel-oped in partnership with Jobcentre Plus, working closely withDisability Employment Advisors and Occupational Psycholo-gists. Joint working has continued through a series of specialistbrain injury work preparation contracts with Jobcentre Plus.This has required close interagency working to facilitate appro-priate referrals, pooled assessments, joint program planning,monitoring, and review and joint training initiatives. This jointworking is encapsulated in recently published interagencyguidelines on vocational rehabilitation after brain injury. Inter-agency Guidelines: A UK Inter-Agency Advisory Group has de-veloped a joint framework and interagency guidelines on voca-tional assessment and rehabilitation after brain injury. This setsout specific guidelines on return to previous employment, edu-cation or training; vocational or employment assessment; voca-tional rehabilitation; WORKSTEP (supported employment); andoccupational or educational provision. Suggestions for local im-plementation of the guidelines are also provided. Conclusions:It is concluded that a combination of brain injury and vocationalrehabilitation expertise is required to assist people with braininjury in fulfilling their vocational potential. In the United King-

dom, this requires joint working across the National HealthService, Jobcentre Plus, Social Services, and independent andvoluntary providers. The specific quality requirement on Voca-tional Rehabilitation in the National Service Framework forLong-term Conditions provides a welcome opportunity toreview and develop interagency initiatives in vocationalrehabilitation for persons with brain injury.

S6A-3 Neurorehabilitation Approaches toEnhancing Community Reintegration

David W. K. ManThe Hong Kong Polytechnic University, Hong Kong

Background: Rehabilitation of persons with traumatic braininjury (TBI) has been one of the challenges of the modernhealth care team. A summary of locally accomplished projectsby the author will be summarized, and they have been targetedat investigating possible ways to enhance the community rein-tegration and lead to return to work of this population of TBI.The long-term associated problems of TBI will be highlightedand the related neurorehabilitation will be delivered in 2 inter-related streams: 1) using skill-acquisition approach throughcomputer-assisted training program and in the form of a com-munity-based, telerehabilitation for persistent cognitive prob-lems (memory and problem solving); 2) using a 4-factor em-powerment model for program planning so as to enhancepersons with TBI’s coping abilities in personal, family, andmore important, social perspective. Method: 1) In the commu-nity phase of rehabilitation, a local randomized control studyevaluated the effectiveness of an online, interactive, skill-train-ing program on the solving of daily problems using analogies.Another qausiexperimental study developed and evaluated acomputer-assisted memory rehabilitation program, based on apostulated enriched environment and errorless learning (EE &EL) model so as to improve everyday memory functions in per-sons with TBI. 2) An empowerment construct for both clientswith TBI and their family illustrated the structure (4 postulatedempowering dimensions) and effectiveness community-basedempowerment program. The perceptual difference in empow-erment between health care professionals and TBI/family werealso highlighted for improvement in service delivery. Results:The tele-based problem-solving training strategies were foundto be effective in improving problem-solving skills in daily lifeand self-efficacy. Computer-aided errorless learning was likelyto be an effective method to improve memory performance andfunction after TBI. This memory training mode may affect thewhole memory process, including encoding, storage, and re-trieval, and may produce a better carryover treatment effect.The empowerment program is also found to enhance persons’skill and knowledge in coping with TBI and the importance ofaspiration and support are highlighted. Conclusion: Personswith TBI had gained improvement in cognitive skills, especiallymemory and problem-solving abilities, which are consideredvital to their community reintegration and return to work. Sig-nificant improvement through cognitive training has proved tobe valid and effective to equip them with a better repertoire forintegration and competition in society. Psychosocial adaptationthrough focused empowerment in skill, knowledge aspiration,and support would definitely promote a better adaptability; es-pecially they are perceived and utilized within the family. Thestudy also hinted that improvement was required in some ser-vices to meet the clients’ demands, so as to enhance their physi-cal and psychological well-being. It is proposed that an empow-



erment framework, using specific cognitive skill training andtechnology can guide ways to improve the case management ofpersons with TBI and lead to better community integration.

S6B-1 Shaping of Rehabilitation Practices forPharyngeal Motility Disorders: IncorporatingLiterature into Clinical Work

Maggie-Lee HuckabeeUniversity of Canterbury, Van der Veer Institute forParkinson’s and Brain Research, New Zealand

Background: Speech pathologists historically have donevery well in developing compensatory treatment plans for pa-tients with swallowing impairment. However, only recentlyhave we shifted our attention in both clinic and research labora-tory to rehabilitation practices. Recent research has shaped ourthinking on how these maneuvers may both positively and neg-atively influence swallowing biomechanics. In response to re-search that suggests potential adverse effects of effortful swal-low on both anterior hyoid movement and pharyngeal pressuregeneration, a series of projects were completed to evaluate pha-ryngeal effects of this technique. Research data from these pro-jects will be presented and will be integrated into existing litera-ture to provide an overview of issues in pharyngealrehabilitation. Methods: For each project, 22 young, healthy re-search participants (gender equally represented) were evalu-ated using concurrent anterior suprahyoid surface electro-myography (sEMG) and pharyngeal manometry (Model CT/S3+emg, 2.5 mm in diameter, Medical Measurements Inc.); forthe final 2 projects, orolingual manometry was also employed.Each subject completed a series of repetitions of several coun-terbalanced research tasks including normal dry (saliva) swal-lows and effortful dry (saliva) swallows under various perfor-mance conditions. Manometric and sEMG data were visuallydisplayed and stored on the Kay Elemetrics Digital SwallowingWorkstation (Lincoln Park, NJ). Peak sEMG amplitudes andpeak manometric pressure recordings from all manometric sen-sors were collected off-line and subjected to statistical analyses.In addition, temporal measures between sensors were assessedfor statistical analyses. Results: Based on our research, severalkey findings were identified. Huckabee and Butler documentedincreased pressure generation in the pharynx for effortful swal-low compared to noneffortful swallow with significantly de-creased pharyngeal pressure in the upper pharynx compared tothe lower pharynx for both conditions. Submental sEMG ampli-tudes were greater in the effortful swallowing condition; how-ever, the absence of a clear correlation between measures sug-gests that suprahyoid sEMG is not a suitable proxy forpharyngeal swallowing. In a further temporal analysis of thesame data, Butler and Huckabee identified that the onset ofpharyngeal pressure for effortful swallows occurred signifi-cantly later and lasted longer than pharyngeal pressures for nor-mal swallows at all measured sensors. These temporal adapta-tions to effortful swallow were site specific with longer pressuredurations in the upper pharynx compared to the lower pharynxfor the effortful swallowing condition only. Huckabee andSteele subsequently evaluated the influence of lingual trajectoryand pressure on pharyngeal dynamics during effortful swallow.Tongue-to-palate emphasis during execution of effortful swal-lowing increased amplitudes of all sEMG and manometric mea-sures greater than a strategy of inhibiting tongue-to-palate em-phasis. These data suggest that lingual effort has a greaterinfluence on pharyngeal pressure than lingual trajectory. Con-

clusions: This seminar will provide an overview and update ofinformation related to long-term rehabilitation of disorderedswallowing physiology; in particular, focus will be on exercisestargeted toward improving pharyngeal motility. Integration ofthis information in clinical practice will allow us greaterspecificity in the design of a rehabilitation program.

S6B-2 The Management of Complex Dysphagiain the Community

Amanda McLeodSouthdowns Health NHS Trust, Brighton,United Kingdom

Brighton and Hove is a coastal area in the south of Englandwith a population of about 250 000. There is a mixed demogra-phy encompassing affluence and social deprivation, large num-bers of older people, younger people, and families. This speechand language therapy role is to assess and manage swallowingdifficulties in adults and older people who have complex medi-cal and social needs. The community dysphagia caseload ismade up of older people residing in nursing homes and otherresidential care including community hospital beds. A smallernumber of people on the caseload continue to live in their ownhomes, usually with packages of care provided by social careservices. Two clinics support the community dysphagia service:1) weekly videofluoroscopy clinic and 2) twice monthly outpa-tient dysphagia assessment and advice clinic. This talk will fo-cus on the following—the medical and social needs of olderpeople residing in the community, with particular emphasis oneating and drinking as a quality of life issue, the assessment ofswallowing in the community setting—clinical observation,clinical tools, videofluoroscopy and dysphagia outpatient clin-ics, swallow assessment as part of nutritional needs assessment,issues of “nil by mouth” and alternative feeding regimes, practi-cal management approaches, balancing risk and quality of life,and how to be imaginative and pragmatic in terms of ideas andstrategies for best management. These issues will be high-lighted throughout with case examples.

S6B-3 Treatment of Dysphagia in NeurologicDisorders via a Protocol that Includes SuperficialElectrical Stimulation of the Swallowing Muscles

J. Hernández,1 M. Jacobo,2 S. L. Guevara,2 A.E.Laguna,2 and V. Aceves1

1National Neurology, Neurosurgery Institute,2Teleton Children’s Rehabilitation Centre, Mexico

Background: The 2 main strategies for the management ofdysphagia are rehabilitation techniques that change the swal-lowing physiology and compensatory techniques, which arepalliative temporary. Both strategies demand voluntary and ac-tive participation of the patient during the swallowing processwith respect to the coordination of muscle contraction andbreathing. Electrical stimulation to treat the swallowing muscu-lature in dysphagic patients was introduced in Mexico 2 yearsago. Since then it has been adopted into the swallowing disor-ders treatment protocols of many health institutions. The maingoal of applying neuromuscular electrical stimulation to theswallowing musculature is to promote contraction of swallow-ing muscles. Electrical stimulation assists the muscle-strength-ening process; however, only through task-specific exercise



and daily activities will normal swallowing function be re-stored. Several studies have been performed to increase knowl-edge about how to use electrical stimulation in children andadults. Two studies will be presented; one conducted in chil-dren ages 3 to 15 years with cerebral palsy. The 2nd study is apilot about how to implement these techniques proven in theUnited States in neurologic patients the Mexican culture. Meth-ods: In the 1st study, 18 patients aged 3 to 15 years (7 boys and11 girls) received 14 sessions of electrical stimulation. Twelvepatients had oral dysphagia, and 6 patients had oropharyngealdysphagia. The factors evaluated before and after treatmentwere lip closure, tongue mobility, drooling control, and time toeat. The severity of dysphagia was evaluated via the SwallowingFunction Scale. Results: Before treatment, the patients wereevaluated as 1 slight, 12 severe, and 5 profound. After treat-ment, the patients were evaluated as 1 normal swallowing, 9slight, 6 moderate, and 2 severe. Before treatment, 5 patientshad lip closure; after treatment, 10 had lip closure. Before treat-ment, 4 patients had saliva control; after treatment, 16 patientshad saliva control. Before treatment, 1 patient had tongue mo-bility; after treatment, 17 had tongue mobility. The average timeto eat was 58 min before treatment and 32 min after treatment.The pilot study included 2 ALS patients, 2 MS patients, and 1stroke patient. They were evaluated with a still X ray of a modi-fied barium swallow and with a clinical evaluation. These pa-tients received 10 treatments. Four improved their swallowingand could eat at home. One of the ALS patients swallowedbetter with electrical stimulation but had no permanent im-provement. Conclusion: Above all, the therapy must focus onthe big picture of helping the patient to recover the ability toswallow through a task-specific regimen and not on manycomplicated details of prior therapy practices.

S6C-1 Neuroregeneration in the CentralNervous System

Kwok-Fai SoThe University of Hong Kong, Hong Kong

Axons in the central nervous system (CNS) in adult mam-mals do not generally regenerate after damage. It is hypothe-sized that the lack of axonal regeneration is because of both ex-trinsic and intrinsic factors. The extrinsic factors would includethe insufficient supply of trophic factor and/or neurite growthpermissive molecules and the presence of inhibitory moleculesin the axons. The intrinsic factor could be the decrease in theaxonal growth potential in adult mammals. We have used a se-ries of approaches to alter the extrinsic environment and to en-hance the growth potentials of adult axons in the optic nerveand spinal cord. The external environment of the CNS axonscould be enhanced by providing an environment suitable foraxon regeneration, e.g., through the provision of a conduit us-ing peripheral nerve graft for the damaged axons or Schwanncells or olfactory-ensheathing cell transplantation. We couldalso neutralize the inhibitory molecules using IN-1 or Nogo re-ceptor blocker or to block inhibitory signaling pathways viaRho pathway inhibitor. The prevention of scar tissue formationby Chondroitinase ABC could also promote axon regenerationin CNS. The intrinsic factors could be modified to enhance re-generation by supplementing appropriate neurotrophic factors,e.g., ciliary neurotrophic factors (CNTF), or by elevating intrin-sic regrowth capability, e.g., via the use of cAMP. Our studiessuggest that a combined experimental approach is critical in op-timizing the regeneration ability of CNS axons in adultmammals.

S6C-2 Stem Cell Therapy of Spinal Cord Injury

Wise YoungRutgers University, Piscataway, New Jersey, USA

Stem cell therapies may be useful for restoring function inspinal cord injury in several ways: neuroprotective and repara-tive, bridging the injury site, remyelinating the spinal cord, andreplacing neurons that have been lost. These will be discussed.Stem cells have been reported to be neuroprotective whentransplanted into the spinal cord shortly after injury. These in-clude bone marrow stem cells and fetal neural stem cells (radialglia). The mechanism is not well understood but may be relatedto factors that are secreted by the cells, including growth factorssuch as glial derived neurotrophic factor (GDNF). Stem cellsmay also enhance repair of the spinal cord injury site, akin tothe effect that bone marrow stem cell infusion has on myocar-dial infarctions. One of the major obstacles to regeneration isthe inhospitality of the spinal cord injury site to growing axons.Injured tissues may lack appropriate cell adhesion molecules toencourage axonal growth or may have proteins that inhibitaxonal, such as chondroitin-6-sulfate proteoglycan (CSPG).Stem cells that take up residence at the injury site may provideattractive substrate for axonal growth. Spinal cord injury dam-ages oligodendroglia that myelinate axons. Regenerated axonsare also unmyelinated and need to be myelinated. Many stemcells have been shown to producing myelinating cells. Severalstudies have now shown that embryonic stem cells, fetal neuralstem cells, and bone marrow mesenchymal stem cells will effec-tively remyelinate the spinal cord and produce functional re-covery. The holy grail of stem cell research for neurologic con-ditions has long been replacement of neurons. At present, only2 types of stem cells have been reported to replace neurons inthe spinal cord: embryonic stem cells and fetal neural stemcells. In the 1st case, embryonic stem cells need to bepredifferentiated to neuronal precursors by treatment withretinoic acid and sonic hedgehog. Note that the newly gener-ated neurons will need regenerative therapies to reconnect toother cells. In summary, stem cells have many roles in spinalcord injury and are likely to play an increasing role in restoringfunction to spinal cord injury. Much research suggest that atleast 3 obstacles need to be addressed in order for regenerationto occur in the spinal cord: growth factors to stimulate andmaintain axonal growth, provision of a hospitable terrain tobridge the injury site, and countering growth inhibitors in thespinal cord that may prevent the axons from growing all the wayto the target. Stem cells have the capability of addressing at least2 of these obstacles. It is likely that the most effective use ofstem cell therapies in spinal cord injury will need to be com-bined with other therapies to maximize functional recovery. Ifthere is time, I will also discuss the progress in China SCI Net, aclinical trial network that has been set up to test promisingtherapies for spinal cord injury, including stem cell transplants.

S6C-3 Stem Cells Therapy for Stroke

Shinn-Zong Lin,1 Woei-Cherng Shyu,1 and Hung Li21Neuro-Medical Scientific Center, Tzu-Chi BuddhistGeneral Hospital, Tzu-Chi University, Hualien;2Institutes of Biochemistry, National Yang-MingUniversity, Chinese Taipei

Patients are our teachers presenting medical staffs with theirdisease profiles. Some of them are treated easily, but most of theproblems are very challenging to medical teams, and cliniciansand scientists need to work together to fulfill quickly the pa-



tients’ requirements. For instance, stroke is a leading cause ofdeath and disability worldwide; however, no effective treat-ment currently exists. A new therapy for stroke was tested incells and then in animals. Rats receiving subcutaneousgranulocyte–colony stimulating factor (G-CSF) showed less ce-rebral infarction, as evaluated by magnetic resonance imaging(MRI), and improved motor performance after right middle ce-rebral artery (MCA) ligation than vehicle-treated control rats.Subcutaneous administration of G-CSF enhanced the availabil-ity of circulating hematopoietic stem cells (HSCs) to the brainand their capacity for neurogenesis and angiogenesis in cere-bral ischemic rats. G-CSF–induced increases in bone marrowcell mobilization and targeting to the brain reduce the volumeof cerebral infarction and improve neural plasticity andvascularization. Subsequently, we would evaluate the safetyand clinical effects of subcutaneous injection of G-CSF in pa-tients with major motor deficits after acute cerebral infarction.Patients between 35 and 75 years of age were eligible for inclu-sion in the study if they had a 1st acute cerebral infarction,which localized at middle cerebral artery (MCA) territory de-fined by the findings of magnetic resonance imaging (MRI). Adisabling neurologic deficit at the moment of inclusion was de-fined as having a total NIH stroke scale (NIHSS) between 9 and20 (9 ≤ NIHSS ≤ 20). The study protocol has been assigned torandomly recruit the patients of acute cerebral infarction within7 days through emergency room (ER). The baseline measure-ment included stroke severity determination (including NIHSS,European Stroke Scale [ESS], ESS-Motor Subscale [EMS], andBarthel index [BI]). Neuroimaging study including brain MRI,[18F]Fluorodeoxyglucose-Positron Emission Tomography(FDG-PET), and brain CT-perfusion study was required forintracranial vascular condition. After the baseline measure-ment, all eligible treated participants were given 15 µg/kg G-CSF (Filgrastim®, Kirin, Japan) for 5 consecutive days subcuta-neously. After 6 months follow-up, significant improvement inclinical stroke scoring was found in the G-CSF–treated groupcompared with the control group. At 24-week follow-up, rela-tive regional FDG brain uptake of PET study in the stroke arearevealed a significant increase in the G-CSF group comparedwith the control group. In the surrounding stroke area, higheripsilateral-to-contralateral uptake activity was observed in theG-CSF group compared with the control group. In summary, G-CSF presents a novel therapeutic target in acute stroke patientswithout adverse effect. The following multicenter, double-blinded, and placebo control study should be developed to de-lineate the definite effect in acute stroke. This new therapy forstroke patients is an example demonstrating a successful har-mony interaction in basic and clinical research. Once the samevision and purpose is established, scientists and cliniciansshould work together with unity, harmony, fellowship, andcooperation. They would have fruitful results.

S6D-1 Family Consequences of PediatricTraumatic Brain Injury: Implications forChild Recovery and Rehabilitation Needs

H. G. Taylor,1 S. Wade,2 K. O. Yeates,3 and D. Drotar1

1Case Western Reserve University and RainbowBabies & Children’s Hospital, USA; 2University ofCincinnati and Cincinnati Children’s Hospital

Medical Center, USA; 3The Ohio State Universityand Columbus Children’s Hospital, USA

Background: Appreciation of the effects of pediatric trau-matic brain injury (TBI) on families is important in determiningrehabilitation needs. In addition to the value of identifying andtreating injury-related adjustment problems in family members,better family functioning may promote children’s recovery. Thispresentation reviews the research literature on effects on pedi-atric TBI on families and on the implications of those findingsfor treatment of families after injury. Special emphasis is placedon studies by our research group of long-term family outcomesand of the effects of an ongoing family intervention. Methods:Children in the follow-up study, injured between 6 and 12 yearsof age, included 53 with severe TBI, 56 with moderate TBI, and80 with orthopedic injuries only. The children and their familieswere observed across multiple assessments for up to a mean of6 years postinjury. Family outcomes were evaluated using mea-sures of burden, parent distress, and family functioning. SES,parent coping, and family resources and stressors were exam-ined as predictors of these outcomes. Child outcomes were as-sessed using tests of cognitive ability and academic achieve-ment and parent and teacher behavior ratings. Results: Familiesof children with severe TBI reported persistently higher levelsof burden and greater family dysfunction than did families ofchildren with orthopedic injuries. Sources of family burdenwere concerns about the child and reactions of spouses and ex-tended family members. The negative effects of severe TBI wereworse for families with low resources and active coping styles,suggesting that lack of family support and failure to help fami-lies manage children may exacerbate family adversity. Familyand child outcomes were interrelated, with poorer family out-comes predicting more pronounced effects of TBI on the child.Preliminary findings from an ongoing treatment study by Wadeet al. confirm the efficacy of family interventions. Specifically,an online program to help families develop problem-solvingand communication skills reduced parental burden and distressas well as children’s antisocial behaviors. Conclusion: The find-ings from these studies document the long-term consequencesof pediatric TBI on families, help in identifying the nature ofthese consequences, and raise awareness of the families ingreatest need and how to assist them. The results also supportthe efficacy of family interventions in improving both familyand child outcomes. Further research will be required to refinethese treatments and to match them to individual family needs.

S6D-2 Educating Parents in the Care of TBIChildren

L. W. BragaSARAH Network of Rehabilitation Hospitals,Brasilia, Brazil

Objective: Evaluate whether children with traumatic braininjury (TBI) present better motor and cognitive outcomes dur-ing the period of 1 year when treated exclusively by profession-als compared with children predominantly treated by the familyunder the supervision of a team. Materials and Methods: A studywas conducted with randomized controlled trials using the evi-dence-based approach. Eighty-seven children, age 5 to 12 yearsat the study’s onset, with injuries, which had occurred 6 to 30



months earlier, were randomized and submitted to 2 differenttreatment approaches during 1 year. Group A: 38 children pre-dominantly rehabilitated by the family. The parents underwentintensive training and performed the activities at home with thechild, returning to the hospital biweekly for new orientations.Group B: 34 children who, during 1 year, attended daily rehabil-itation sessions at the hospital and were exclusively treated byprofessionals. The children were assessed by the Weschler In-telligence Scale for Children and the Sarah Scale of Motor De-velopment before and 1 year after starting treatment. Results:Two-sided chi-square and Mann-Whitney tests and logistic-re-gression assessment revealed that the children in group A ob-tained better outcomes in the motor and the cognitive develop-ment scales than did group B (P < 0.05). The parents’educational levels showed no statistically significant bearing.Conclusion: The children with TBI and CP who received devel-opment and cognitive stimulation from the family under the su-pervision of a specialized team presented better progress thanthose treated exclusively by professionals. These results pointto a new perspective in the rehabilitation of these childrenbased on family participation.


S7A-1 The Child and Adolescent after SevereTraumatic Brain Injury: Quality of Life andFunctional Outcomes

L. W. BragaSARAH Network of Rehabilitation Hospitals,Brasília, Brazil

Background: This study evaluates the outcomes of childrenand adolescents with severe and moderate TBI a mean of 4years postaccident, addressing neuroimaging findings,neuropsychological evaluation, motor performance, academicsand QoL. Methods: A group of 23 children with TBI aged 7 to 13years were matched with a control group of 23 children. MRI,medical charts, WISC, list of 12 words, Signoret recognition, se-mantic verbal fluency test, calculation battery, physical-func-tional scale, interview with parents and QoL questionnaire an-swered by each child were used for evaluation. Statistical dataanalysis: Mann-Whitney and Pearson correlation tests. Results:Statistically significant associations were found between overallIQ and visual and verbal memory tests; lesions to corpus callo-sum and automobile accidents; dyscalculia and parietal lobe le-sions; low verbal memory performance and temporal lobe le-sions; occipital lobe lesions and visual memory; posterior fossalesions and overall IQ, visual memory and verbal memory. Norelation was found between total lesion volume andneuropsychologic or physical-functional evaluation results. Allchildren returned to school after the accident; 65% needed rein-forced academic assistance. Parents primarily reported behav-ioral problems and attention disorders. Results showed a statis-tically significant relation between the TBI and the controlgroups in overall QoL scores, with academic performance beingthe most important variable. Conclusion: This study revealedseveral associations between neuroimaging findings and

neuropsychologic outcomes. Despite a Glasgow average scoreof 5, most of the children achieved independent gait and re-turned to regular schooling. Academic performance was themost significant variable in the child’s assessment of his or herown quality of life.

S7A-2 The Latest Development of Measurement inQuality of Life After Stroke

J. A. OparaUniversity of Physical Education, Katowice, Poland

Background: One of the most important aims of rehabilita-tion is to improve quality of life. The purpose of this report wasthe assessment of the quality of life in stroke patients using lastdeveloped scale SA-SIP 30. In part I, the effect of sex andpathomechanism of stroke has been assessed. In part II, the ef-fect of side of hemiparesis and time after onset on psychosocialaspects of disease has been assessed. Methods: The survey wasperformed on a group of 76 patients, approximately 19 monthsafter stroke. In the 1st research, 4 of the 8 subscales of stroke-adapted 30-item version of the Sickness Impact Profile—SA-SIP30 referring to the physical activity were used for this purpose.The next 4 subscales, referring to psychosocial aspects of dis-ease were used in the 2nd research. Results: In part I, as far asthe self-reliance is concerned, 65.9% to 84.6% of the hemor-rhagic stroke patients reported difficulties with specific activi-ties, whereas in the ischemic stroke patients it varied from 40%to 70%. About 82% to 90% of respondents spent most of theirtime at homes. The patients, who suffered most from thepoststroke problems, are the hemorrhagic stroke patients. Re-gardless of the kind of a stroke, women seem to encounter moreproblems than men. The problems usually apply to mobility inlimited visibility situations and in the darkness. As far as house-hold care is concerned, the variation of the responses was muchsmaller. Hemorrhagic stroke patients, mostly women, hadslightly fewer problems in household. Hemorrhagic stroke pa-tients also revealed the feeling of very poor fitness condition.And in here these are also the women who had bigger problemswith mobility as such. In part II, the decreasing of health-relatedquality of life has been observed in 50% of respondents. Lefthemiparetic patients and men more often reported problemswith social reintegration. The patients with right hemiparesismore often reported difficulties with oral communication. Pa-tients with left hemiparesis were more criticized to their emo-tional behavior then those with right hemiparesis. The alertnessbehavior occurred to be bigger problem in the left hemipareticpatients than in the right hemiparetic ones. Conclusions: Takingall surveys into consideration, it may be concluded that hemor-rhagic stroke patients assess their fitness condition as very poor(especially in the fields of self-reliance and mobility) and thatwomen are generally more critical when assessing their situa-tion, regardless of the kind of stroke they had. As for part II, inhalf of the study group the decrease of the global health-relatedquality of life has been observed. These are differences in feel-ing of quality of life in psychosocial aspect in particularsubscales. In left hemiparesis persons who more often feel thedecrease of social activity, emotional behavior and alertness be-havior can be observed. Right hemiparetic patients more oftenrelated problems with oral communication.



S7A-3 ICF Classification in Neurorehabilitation:Guiding the Multidisciplinary Care

M. LeonardiHead Headnet Group: Public Health Disability, ICFand Italian National Neurological Institute CarloBesta, Milan, Italy

Since its release in 2001, the ICF Classification has become areference in the fields of disability and rehabilitation:neurorehabilitation is one of the most interesting fields for ICF’sapplication. ICF’s concept is that disability is multidimensionaland the product of an interaction between attributes of a personand features of the person’s physical, social, and attitudinal en-vironment. ICF’s model of functioning and disability identifies 3levels of human functions (body functions and structures, activ-ities and participation) with parallel levels of disability (impair-ments, activity limitations, and participation restrictions). Inshort, disability is not one thing only: it is 3, in a complex inter-action. ICF brings theoretical innovations that have a great im-pact on clinical practice. The most relevant concerns the possi-bility to have a worldwide common language to describefunctioning and disability; the fact of focusing on positive as-pects of a person’s health status, which means to keep function-ing (and not disability) as the main target of rehabilitative work;the wide consideration given to the environment, which can bea facilitator and a barrier to a person’s functioning; the applica-tion of a biopsychosocial model to the comprehension of func-tioning. Applying ICF to neurorehabilitation means to place theperson at the center of interventions and meet the need to de-scribe different kinds of impairments (in neurocognitive, emo-tional, and sensory-motor functions) as well as their impact onactivities and participation in life situations. Professionals ofneurorehabilitation are in need of a way to describe the clinicalsituation and highlight the most relevant areas of intervention.Being a classification of human functioning and assuming abiopsychosocial model as cultural and scientific background,ICF makes no difference between the person’s medical, psycho-logic, and social components. Information about functional sta-tus is integral to all forms of health care because 2 persons withthe same medical diagnosis may have very different levels offunctioning and, consequently, different needs and require dif-ferent kinds of health interventions. Functional status data areessential for determining the broader clinical, rehabilitative,and social needs of persons with disability, as well as, for exam-ple, the need for assistive technology. This ICF approach re-quires and encourages the collaboration of multiple profession-als and the integration of knowledge in multidisciplinary teams.This is particularly relevant in all those clinical situations inwhich curing a person is not possible, and the dimension ofcare is the only workable way. Highlighting the areas of possi-ble intervention, ICF utilization enables people who are incharge of distributing available resources to shape them onthose areas that could be positively affected by clinical and re-habilitative interventions. Finally, ICF and ICF-related tools(ICF checklist and WHO-DAS II, Disability Assessment Sched-ule) have been constructed and validated in 65 countries byWHO, with special attention to cultural and practical compari-son, with the most important existing tools for describing healthstatus. Specifically, data on correlations between WHO-DAS II,SF-36 (Health Survey Short Form 36) and FIM (Functional Inde-

pendence Measure) point out how this new tool can be used inassociation with those more widespread, allowing health pro-fessionals to perform multiple comparison between quality oflife and functional status. The experience of the Headnet Re-search group of the Italian National Neurological Institute onapplying ICF and related instruments in neurologic patients willbe reported.

S7B-1 Rehabilitation of People withParkinson’s Disease

B. R. BloemRadboud University Nijmegen Medical Centre,the Netherlands

Parkinson’s disease is a complex disorder that requires man-agement by a well-coordinated multidisciplinary team, with sig-nificant contributions not only from general practitioners andmedical specialists (neurology, geriatrics, rehabilitation), but—in the ideal situation—also from a range of other health profes-sionals, including physiotherapists, occupational therapists,speech therapists, dieticians, neuropsychologists, and nurses(employed in both inpatient and outpatient clinics). A crucialrole can be played by the Parkinson nurse specialist who oftenhas a central coordinating function in this multidisciplinary re-habilitation team. The contributions input and feedback fromthe patients themselves, as well as their caregivers, are also vitalas the multidisciplinary team is there to provide an answer tothese needs. The urgent need for a multidisciplinary approachis underscored by the many complex and often closely inter-twined problems that face patients with Parkinson’s disease.These problems not only include the well-recognized motorsigns but also encompass nonmotor features such as cognitiveimpairment, pain, sleep disorders, sexual problems, urinaryurge or incontinence, constipation, anxiety, and depression. Itis impossible for medical specialists to manage all these prob-lems, first, because of lack of time and secondly because stan-dard medical management (drugs or neurosurgery) often lacksefficacy in many of these domains. In fact, some of these prob-lems may be caused or aggravated by drug therapy. The prob-lems of gait impairment and falls—eventually resulting in im-mobil i ty and loss of independence—also demand amultidisciplinary approach, again because conventional medi-cal management usually fails to relieve these problems ade-quately. The situation is particularly complex in elderly patientsin whom other age-related problems compound the handicapscaused by Parkinson’s disease alone. It is important to realizethat multidisciplinary rehabilitation teams are not just there forthe “complex” patient with advanced disease but also havegreat potential importance for earlier stages of the disease, forexample, to discuss possible worries about the future or to pre-vent problems before they arise. Despite growing worldwiderecogni t ion of the potent ia l benef i t s re la ted to amultidisciplinary team approach, only few such teams are oper-ative to date. In fact, its efficacy and added value remain to bescientifically proven, and fundamental questions such as cost-effectiveness and possible adverse effects need to be answered.The next decade will hopefully provide additional backgroundknowledge that should lead to a much more widespread imple-mentation of multidisciplinary rehabilitation for patients withParkinson’s disease.



S7B-2 Rhythmic Auditory Training inSensorimotor Rehabilitation of Peoplewith Parkinson’s Disease (PD)

M. H. Thaut and G. C. McIntoshColorado State University, USA

Background: Rhythmic auditory cues have been shown toenhance motor function via entrainment mechanisms that arefast acting, have stable synchronization, and can facilitate motorlearning and training. There is evidence that auditory rhythmoperates as a physiologic attractor that drives optimization ofspatiotemporal and force parameters in motor control by pro-viding a continuous time reference or temporal template to mapmovement kinematics. We have investigated a variety of clinicalpopulations with movement disorders, such as stroke, cerebralpalsy, Huntington’s disease, and traumatic brain injury. A largefocus of our investigations has been how rhythmic auditorystimulation (RAS) can be used in the rehabilitation of patientswith Parkinson’s disease. Since the basal ganglia has been asso-ciated with timing functions of movement in the human brain,the effect of temporal cuing on movement in PD allows us alsoto investigate timing mechanisms in the human brain. Methods:We have conducted 4 controlled research studies in Parkinsonrehabilitation (N = 160) in our center to assess the effect of RASon 1) immediate entrainment of gait patterns in patients on andoff dopaminergic medication, 2) gait improvements after a 3-week training program, 3) changes in EMG activation after RAS-training, and 4) long-term retention of gains after gait training.Furthermore, we have conducted a rhythmic speech cuingstudy in hypokinetic dysarthric speakers with PD (n = 20) tostudy rhythmic entrainment effects on speech oscillators. Re-sults: Consistent evidence has shown in all studies that RAS sig-nificantly improves gait parameters (velocity, stride length, ca-dence, symmetry) in entrainment as well as training protocolsand normalizes asymmetry, timing, and shape variability ofEMG in gastrocnemius and anterior tibialis muscle activation.Significant entrainment effects have been demonstrated inpatients both on and off dopaminergic medication. Outcomequestionnaires after RAS show a strong (>80%) agreement inself-perceived ability of increased functional movement. Long-term retention of training effects has been observed during 4weeks posttraining before significant decline. Rhythmic speechcuing resulted in significant improvements in the severely in-volved group (intelligibility <60%) and no significant improve-ments in moderately and mildly affected speakers. Conclusion:Our results have been confirmed by a number of recent studiesshowing that auditory rhythm can facilitate substantial gains infunctional gait of patients with PD. Auditory rhythm as an exter-nal zeitgeber can be used to entrain optimal limit cycles, result-ing in enhanced stability of temporal, spatial, and force parame-ters. We suggest that rhythmic input operates through 2mechanisms: first, rhythmic cues enhance temporal precision inmotor control that, based on optimization principles, will en-hance accuracy and stability in the control of space and forcedynamics of the entire movement pattern; second, rhythmicpatterns function as “sensory sequencers,” possibly bypassingfaulty pallidal-SMA circuitry, to reduce akinesia andbradykinesia. Research evidence shows that RAS can play animportant role in functional movement rehabilitation for PD, es-pecially in light of its ease of application in home- or commu-nity-based settings.

S7B-3 Memory Functioning of Older Peoplewith Mild Cognitive Impairment: Implicationsfor Cognitive Intervention

J. C. C. ChungThe Hong Kong Polytechnic University, Hong Kong

Background: Mild cognitive impairment (MCI) is a clinicalclassification referring to some degrees of cognitive impair-ments, especially for memory, that do not fulfill the diagnosticcriteria of dementia. Petersen has suggested that the memoryperformances MCI persons were about 1.5 SD below the norm.To date, the understanding of memory functioning MCI suffer-ers is primarily related to encoding and recall of episodic infor-mation; little is known about their other memory functions suchas everyday memory and metamemory. This study aimed to 1)examine the memory functioning of older Chinese Hong Kongpeople with MCI in the aspects of basic memory processes ofencoding and recall, working memory, everyday memory, andmetamemory, when compared with normal controls; and 2) ex-plore any possible relationship between metamemory and ob-jective memory performance. Methods: A convenience sampleof 96 community-dwelling older persons was recruited from 4community centers. Using clinical dementia rating (CDR) scale,37 subjects received a score of 0.5 and were classified as MCIand 59 had a score of 0 (normal cognitive functioning). All sub-jects were assessed by Fuld Object Memory Evaluation (FOME),a test of episodic memory; WAIS-III Digit Span (DS), a test of at-tention and working memory; Rivermead Behavioral MemoryTest (RBMT), a test of everyday memory; and MultifactorialMetamemory Questionnaire (MMQ), a test of self-appraisal ofmemory functioning. Results: The gender distribution was simi-lar in both groups, primarily consisting of females. The MCIgroup was significantly older (mean age, 78 years) and less edu-cated (mean, 2.4 years) than the normal group (73 years old and4.9 years of education). These 2 factors were used as covariatesfor group comparison in different aspects of memory function-ing. When compared with the normal group, the MCI group ob-tained significantly lower scores in FOME encoding (Z = –4.30,P < 0.0001), immediate recall (Z = –4.80, P < 0.001) and delayedrecall (Z = –3.86, P < 0.0001); DS forward sequence (Z = –2.64,P = 0.008), forward span (Z = –2.27, P = 0.023), backward se-quence (F = 7.95, P = 0.006), and backward span (F = 5.10, P =0.027); RBMT (F = 43.52, P < 0.001); and the “strategy use” as-pect of MMQ (F = 6.28, P = 0.014). No significant group differ-ences were found in the aspects of contentment and ability ofMMQ. There were no significant correlations betweenmetamemory performance and objective memory tests for theMCI group, except a moderate correlation was found betweenRBMT and strategy use of MMQ (r = 0.57, P = 0.002). Conclu-sion: Consistent with many overseas studies, the Hong KongChinese MCI subjects demonstrated less satisfactory perfor-mance in basic memory functions of encoding and recall andworking memory compared to normal controls. The MCI sub-jects were also less capable of applying memory skills to per-form daily living tasks such as recall of faces, message, androute than their normal counterparts, which support previousfindings that subtle changes were observed in everyday func-tional competence of MCI. Interestingly, the metamemory func-tioning of MCI subjects were similar with normal controls ex-cept for strategy use. MCI subjects reported using few memorystrategies, which was found associating with their everyday per-formances. Cognitive interventions for MCI patients are sug-



gested to remediate their subtle impairments in functional tasksthrough simple memory strategies.

S7C-1 Role of Oriental Medicine and AlternativeMedicine in Rehabilitation

Sae-il ChunM. D. Pochon CHA University, Seoul, Korea

The ultimate goal of eliminating diseases and maintainingnormal health is same both in Western medicine, Oriental medi-cine, and alternative medicine. At the present time, the Westernmedicine tends to take more scientific technological approachin their practice, whereas Oriental medicine still maintains amore humanistic approach. Traditional medicine, 5000 yearsold, still challenges the 21st-century scientific modern medicinein the field of clinical practices. The disease-oriented Westernmedicine classifies the human condition as diseased andnondiseased states. In the mean time, the health-oriented Ori-ental medicine classify it into healthy and unhealthy states. Forthe maintenance of normal health, 5 principles are emphasized.They are 1) eat right, 2) move right, 3) sleep right, 4) breatheright, and 5) mind right. To reverse an unhealthy condition backto the normal healthy state, the methods of 1) natural substancetherapy, 2) exercise therapy, and 3) stimulation therapies in-cluding acupuncture, moxibustion, finger pressure, and cup-ping techniques. In order to eliminate the diseases, 4 distinctapproaches, namely 1) chemical, 2) physical, 3) psychological,and 4) surgical treatments, are uzed. Recent international trendof globalization has brought an information explosion andtranscultural exchange of science, technology, arts, and medi-cine. There are so many different kinds of traditional medicine,hidden popular folk medicine, and various less recognizedtechniques and theories of healing arts. Some originate in Ori-ental culture, whereas others originate in Western culture. Ex-perts of Western medicine claim that only that information clari-fied or proven by the objective and scientific methodology canbe recognized as a part of Western (orthodox or conventional)medicine. All kinds of traditional medicines, folk medicines,and many other fragments of medical techniques and theoriesare collectively labeled as alternative medicine or complemen-tary medicine. There is clear evidence that Western medicine,Oriental medicine, and alternative medicine are complimentaryto each other and that alternative medicine and rehabilitationmedicine share much in common regarding “whole person ori-ented” and “integrative approach.” If and when all the compli-mentary components existing in various healing arts come to-gether in one medicine, a new integrated comprehensiveholistic medicine can be produced and useful in the field ofrehabilitation medicine.

S7C-2 Randomized Evidence of TraditionalChinese Medicine for Stroke Rehabilitation

M. Liu, B. Wu, S. H. Zhang, and S. TanWest China Hospital, Sichuan University,Chengdu, China

Background: Traditional Chinese patent medicine (TCPM)and acupuncture are widely used for stroke in China. This studyis to provide current randomized evidence of traditional Chi-nese medicine for stroke rehabilitation. Methods: (1) The Chi-nese National Essential Drug List of 2004 and commonly usedTCPM in current clinical practice were screened. Fifty-nineTCPM were identified for further evaluation. We searched 8

electronic databases. Seven relevant Chinese medical journalsand reference lists of eligible studies were hand-searched (lastsearched, March 2005). Randomized controlled trials (RCTs)and controlled clinical trials on any of the 59 TCPM for ischemicstroke comparing 1 TCPM with the control were eligible. (2)Acupuncture trials published before 2003 were searched in theCochrane Stroke Group Trials Register, the Chinese Stroke Tri-als Register, and the Chinese Acupuncture Trials Register. Elec-tronic searches were also performed in the Cochrane Library(2003 issue 3), MEDLINE (1966-2003), EMBASE (1980-2003), Al-ternative Medicine Database (1985-2003), CINAHL (1982-2003),and the Chinese Biological Medicine Database (1981-2003). Tri-als of acupuncture started within 30 days of stroke onset wereeligible for inclusion. Cochrane review methods were used. Re-sults: (1) 191 trials (19 338 patients) on 22 TCPM were included,of which 120 were RCTs and 71 controlled trials. The method-ological quality of included trials was generally poor. Few trialsreported methods of randomization. Two trials were doubleblind and placebo controlled. Only 1 trial on puerarin assesseddeath and dependence at 6 months and no difference between 2groups. The reported adverse events varied from 1% to 34.8%including allergic reaction, headache, nausea, diarrhea, belly-ache, blood pressure change, and subcutaneous andintracranial hemorrhage. Most of the adverse events were notsevere. Eight of the 59 drugs (Milk vetch, Mailuoning,Ligustrazine, Ginkgo biloba, Xuesetong, Danshen agents,Puerarin, and Acanthopanax) had relatively more studies andpatient numbers. (2) 14 trials (10 conducted in China) on acu-puncture for stroke involving 1208 patients were included. Acu-puncture was compared with placebo/sham acupuncture oropen control in patients with acute ischemic and/or hemor-rhagic stroke. Most of the included trials were of poor quality.When acupuncture was compared with sham acupuncture oropen control, there was a borderline significant trend towardfewer patients being dead or dependent (Odds ratio [OR], 0.66;95% confidence interval [CI], 0.43-0.99) and significantly fewerbeing dead or needing institutional care (OR, 0.58; 95% CI, 0.35-0.96) in the acupuncture group after 3 months or more. Compar-ison of acupuncture with sham acupuncture only showed a sta-tistically significant difference on death or requiring institu-tional care (OR, 0.49; 95% CI, 0.25-0.96), but not on death ordependency (OR, 0.67; 95% CI, 0.40-1.12). Severe adverseevents with acupuncture (dizziness, intolerable pain, and infec-tion of acupoints) were rare (6 of 386, 1.55%). Conclusion:There is insufficient randomized evidence for effectiveness ofTCPM and acupuncture for stroke currently. Furthermore,larger, methodologically sound truly randomized trials arerequired.

S7C-3 Use of Functional MRI to EvaluateResponse to Acupuncture

Raymond Tak-Fai CheungThe University of Hong Kong, Hong Kong

Background: Stroke is the 2nd leading cause of death inChina and the 3rd leading cause of death in Hong Kong. Strokeis also a leading source of functional disability. Many stroke pa-tients have tried acupuncture to promote functional recoverydespite an absence of evidence of effectiveness from well-de-signed clinical trials. Functional magnetic resonance imaging(fMRI) has been applied by several groups of researchers tomap the sites of brain activation during acupuncture stimulationin healthy volunteers. The overall purpose of the present studyis to use fMRI to evaluate response to acupuncture in stroke pa-



tients. Methods: Brain activations were mapped by fMRI onphysiologic tasks with or without stimulation of deficit-relatedacupoints in healthy volunteers, stroke patients with persistentneurologic deficits, and age-matched healthy control subjects.We tested several acupoints related to motor, language, visual,or sensory dysfunctions. Standard parametric mapping 99 wasused in generating the fMRI data. Results: Among healthy volun-teers and age-matched controls, our results were similar tothose obtained by other research groups. Briefly, stimulation ofcertain acupoints per se can activate specific brain regions simi-lar in pattern when compared to physiologic tasks. Amongstroke patients with persistent neurologic deficits, significantbrain activations were seen during electrical stimulation ofacupoints implicated in motor, language, or sensory but not vi-sual dysfunctions. In general, activations were seen in theperilesional and homologous sites of stroke patients. Conclu-sions: Cortical functional reorganization is an important mecha-nism in functional recovery after stroke. Benefit of acupuncturein stroke patients may be derived from its ability in modulatingthe activities of the cerebral cortex. Functional MRI may be use-ful in identifying responders to a course of acupuncture overspecific acupoints. Randomized controlled clinical trials are be-ing conducted to test this hypothesis in patients with recentstroke and in stroke patients with persistent neurologic deficits.

S7D-1 Telerehabilitation: Clinical, Technological,and Socioeconomic Aspects

Lamberto PironI.R.C.C.S. San Camillo Venezia, Venezia, Italy

Telerehabilitation encompasses several activities in the areaof rehabilitation medicine including therapeutic interventionsat distance, remote assessment and monitoring of patients clini-cal progress, operators’ training, education, and counseling.From a clinical point of view, the development of technologicalapplications offered by the mass market, the increased perfor-mances of computing products, and the available broadbandInternet accesses lead rehabilitation service providers to exploittelerehabilitation in the attempt to treat effectively patients athome, shortening length of stays in hospital and long-term carefacilities, overcoming long distances, and reducing cost of care.Telerehabilitation has been advocated also to prevent patients’clinical complications and to reduce the hospital admissions,which means consistent money saving for the national healthservice in many countries. Despite the recent technological ad-vances and the promising advantages of telerehabilitation,there is a lack of large, controlled, randomized studies that con-firm these opportunities, and on the other hand, a general clini-cal standard is missing in the currently used applications. Themajority of experimentations are focused on teletherapy usingdiverse techniques for delivering remotely treatments to the pa-tients, but there is not robust evidence about the efficacy ofthese therapeutic protocols. Additional randomized controlledinvestigations are needed to legitimate the clinical value oftelemedicine interventions in the neurorehabilitative fieldreaching an evidence-based practice. The technology appliedto rehabilitation is changing and updating continuously; for in-stance, a lot of forms of wide bandwidth connectivity are of-fered in various countries to access the Internet (xDSL, ISDN,optic fibers, cable, satellite, etc) covering a very broad territory.Moreover, a new telecommunication technology, Universal Mo-bile Telecommunications System (UMTS), is becoming a stan-dard in Europe, allowing the use of wireless telerehabilitativeapplications that will permit the advantageous reaching of sub-

jects everywhere. The development of friendly interfaces andinexpensive systems for the telerehabilitation should be a pri-mary concern to avoid the digital divide for persons and institu-tions with fiscal, physical, or cognitive disability. The socioeco-nomic aspects involve several factors in a very complex subjectthat is diverse from country to country and often varies amongstates or regions. The telerehabilitation reimbursement de-pends on the type of provided rehabilitative service, geographicarea, health system, different involved players, etc. Eventhough the health care systems are becoming more receptive totelerehabilitation, not many institutions or insurances are reim-bursing telerehabilitation service at present. A crucial point isthe cost-effectiveness of telerehabilitation. Although somepromising perspectives have been often outlined, an exhaustivescientific report of the cost-effectiveness is not available yet. Atpresent, telemedicine in rehabilitation is not a widespread prac-tice, in spite of its potential to aid disabled persons and to assisthealth professionals; we need scientific research demonstratingthe clinical and cost-effectiveness evidences.

S7D-2 Experimental Projects of UpperLimb Telerehabilitation

M. ZampoliniDepartment of Rehabilitation, Brain Injury Unit,Umbria, Italy

During the past decade, there has been growing interest forapplications in rehabilitation. Telerehabilitation is rehabilita-tion applied at a distance through electronic technology used asinformation and communication. Access at a distance allowspersons living in remote areas to have access to health care ser-vices. Telerehabilitation has been developed to provide com-munication and access to health care over distance in areas thatare difficult to be reached by conventional care. In physiother-apy, the application of telerehabilitation has been explored incase studies. A connection to transmit information about astroke patient’s movement ability was applied, allowing 8weeks of telerehabilitation, after which the patients’ impair-ment and functional abil i ty improved. A system oftelerehabilitation based mainly on teleconference for stroke pa-tient has been demonstrated to be feasible and efficacious.Telerehabilitation has been used for the rehabilitation of the up-per limbs with a system including a Web-based library of statustests, therapy games, and progress charts. Traumatic brain in-jury has also been treated with a physiotherapy program at dis-tance with improvements in physical functioning andneuropsychological status. Telerehabilitation allows the appli-cation of virtual reality tools to be performed in a home environ-ment. Virtual reality has also been applied for traumatic braininjury through an Internet-based virtual rehabilitation centerthat provides rehabilitation, education, and support services orupper limb rehabilitation in stroke. A PC-based desktop virtualreality system for rehabilitating hand function in stroke patientshas been developed. The use of performance-based target lev-els is designed to increase patient motivation and to individual-ize exercise difficulty to a patient’s current state. A newtelerehabilitation system for home physical therapy for the up-per limbs has been developed: the Home Care Activity Desk(HCAD). The project consists of an electronic desktop installedat home, allowing a set of task-oriented exercises to be per-formed and monitored with both electronic and video recordingof the exercises. These data are sent to the clinic where physio-therapists and physiatrists control the exercises and suggest fur-ther adaptation through videoconference, as needed. The main



goal of the project is to demonstrate the feasibility of atelerehabilitation program applied for the recovery of upperlimb function due to stroke, traumatic brain injury, or multiplesclerosis. An evolution of HCAD is HelloDoc (Healthcare Ser-vice Linking Tele-rehabilitation to Disabled People and Clini-cians). The project aims to validate the market in relation withthe settlement of a home-care-based service capable to extendrehabilitation treatment in patients affected by neurologic disor-ders while at home under the control and supervision of thehospital. At least 3 paradigms are required in telerehabilitationof the upper limb: teleconference, task oriented exercises, andvirtual reality.

S7D-3 Telestroke and TelecognitiveRehabilitation: A tribute to Professor Alan Tam

C. W. Y. Hui-Chan, M. K. Y. Mak, and D. W. K. ManThe Hong Kong Polytechnic University, Hong Kong

People with stroke and head injuries are known to sufferfrom different degrees of physical and cognitive disabilities andrequire long-term rehabilitation beyond the period of their hos-pital stay. Consequently, many of them find it difficult to func-tion independently in the community. Therefore, accessibilityto tailor-made rehabilitation services at venues convenient tothe patients is highly desirable. With the development of com-puter technology, we have pioneered telestroke andtelecognitive rehabilitation programs to allow customized treat-ments to be delivered by therapists to patients at their ownhomes. Telestroke Rehabilitation: An 8-week home-basedtelephysiotherapy program aimed to improve upper limbsensorimotor and functional ability in persons with chronicstroke has been developed with low-cost performance-feed-back devices and built-in or online software. Before launching arandomized, control trial, its efficacy was tested in a pilot studyon 10 subjects with chronic stroke. All patients were assessedbefore treatment, at 2-week intervals during the 8-week treat-ment and at 4 and 8 weeks after treatment ended. Findingsshowed a significant reduction in spasticity measured by com-posite spasticity scale, as well as significant improvements inupper limb muscle strength and function assessed by hand gripstrength, motricity index, and action arm research test. Interest-ingly, these improvements were even performed to 8 weeks af-ter treatment ended. This study demonstrated the feasibility ofusing telephysiotherapy program to enhance upper limb func-tions in people with chronic stroke. Telecognitive Rehabilita-tion: In addition to physical limitations, persons with neuro-logic dysfunction also have cognitive disabilities. The presentstudy reports the efficacy of a telecognitive program in personswith acquired brain injury (ABI). Subjects (n = 103) were ran-domly assigned to 1 of 4 twenty-session analogy problem-solv-ing skill training groups receiving telerehabilitation training(through computer video conferencing with interactive soft-ware), computer-assisted training (through interactive patient-directed software), therapist-administered training (face-to-face therapist-guided training activities), or a no-treatment con-trol group. Subjects’ problem-solving skills and self-efficacywere assessed during a 4-week period. Overall, all 3 trainingmethods were found to be effective in improving problem-solv-ing skills, regardless of delivery mode, except for the no-treat-ment group. Statistically significant improvements in problem-solving skills in the telerehabilitation group suggests that thisapproach can effectively improve cognitive functions in personwith ABI and yield treatment outcomes comparable to other

modes of delivery such as face-to-face training. Conclusion:Our findings showed positive effects of telerehabilitation in im-proving physical and cognitive functions in people with strokeand brain injuries. This innovative, seamless, and interactivemode of delivery extends rehabilitation services beyond hospi-tal stay and into patients’ homes. It allows therapists to monitorand further promote patients’ progress, which will enhancetheir functional independence and reintegration into commu-nity. The conceptualization and applicability of telerehabili-tation, its implications for persons with stroke and ABI, and fu-ture studies in these research areas will be discussed.Acknowledgment: Donation by Mr. and Mrs. Lui Chi Woo. As acollective tribute to the late A. Tam, whose exceptional IT ex-pertise had made the concept of real-time interactivetelerehabilitation a reality, the paper will be presented by thewhole team.

S8A-1 Stroke Rehabilitation in China:East Meets West

T. YanSun Yat-sen University, Guangzhou, China

Stroke, as in most developing countries of the world, is oneof the most common causes for disabilities in China. There areabout 1 500 000 to 2 000 000 new cases each year, and 75% ofthem live with different disabilities that are big burdens to theirfamilies and communities. For many years, medications havebeen the main management for patients with stroke in China,and rehabilitation only focused on applying traditional Chinesemedicine (TCM), including Chinese herbs, acupuncture, mas-sage, and Chinese exercise. Majorities of these modalities, how-ever, are passive, and the effectiveness in the recovery of func-tions could only be demonstrated slowly. Few Chineseprofessionals knew the theory and techniques of modern reha-bilitation in stroke such as Bobath techniques, Brunnstrunnskills, or motor relearning program until the late of 1980s. Be-cause of the professional exchanges in rehabilitation betweenChina and Western countries, as well as some short trainingcourses in the late of 1980s and early of 1990s, modern rehabili-tation in stroke management initiated in China and developedprogressively, though slowly, in big cities such as inGuangzhou (Canton), Beijing, and Shanghai. The conceptionsof stroke rehabilitation such as early intervention, active partici-pants from patients and their families, multiple disciplines, in-tensive training, and so on, lead Chinese professionals to exam-ine the current strategies in stroke management in China. At thattime, 2 systems related to stroke rehabilitation; TCM and theWestern management were used simultaneously and separatelyin general hospitals of big cities. In the counties and communi-ties, however, TCM is still predominant, and passive strategiesare still welcomed by patients and their families. At the sametime, professionals in China have worked very hard to find evi-dence to support the use of TCM in stroke rehabilitation. Withthe achievement of “the 10-year of the brain” during the past de-cade of the 20th century, many studies in the literature reportedthe effectiveness of TCM on patients with stroke. Foundlingsfrom both animal and human researches supported the hypoth-esis that TCM, in terms of acupuncture and traditional therapeu-tic exercises, stimulate the neuroplasticity and functional reor-ganization in promoting functional recovery after stroke.Results from multiple centers and randomized clinical trials inChina in recent years also suggested that patients with strokehad better clinical recovery if they were treated with TCM com-



bined with Western modalities than those who received eitheronly TCM or only modern modalities. Therefore, TCM in theworld now is approaching the evidence-based practice ratherthan the experience-based practice as it was. To conclude, moreand more professionals in China are learning the modern reha-bilitation techniques and are using them as a combination ofTCM with Western modalities on patients with stroke. Stroke pa-tients are benefiting from this combination though furtherclinical randomized trials, and multicenter research is needed.

S8A-2 Stroke Rehabilitation in Long-term CareSettings—Development of a Checklist to Screenthe “Quasi-in-Need-of-Care State” in theCommunity

M. Liu and S. YamadaKeio University School of Medicine, Japan

Background: With the aging of the society, the number ofpersons who need to care is increasing. It is important to maxi-mize their functioning and lessen their care burden with appro-priate rehabilitative interventions from the acute to the chronicphase. Together with health insurance plans that cover acuteand recovery phase rehabilitation services, a nationwide publicinsurance program called the Public Long-Term Care Insurancewas started in 2000 in Japan to cover care and rehabilitationneeds after finishing active medical treatment. In the so-calledchronic phase, we experience 3 types of patients: 1) those whohave had sufficient rehabilitation and are in need of maintainingthe acquired functions; 2) those who were discharged to thecommunity without getting sufficient rehabilitation services; 3)those patients whose once-acquired functions have deterio-rated with immobilization, worsening of preexisting illness,and/or development of new illness. If we could efficientlyscreen persons belonging to the 2nd and 3rd categories andprovide appropriate rehabilitative interventions, it would bebeneficial for the patients, their caregivers, and society. Thestudy purpose is to develop an efficient screening system to de-tect the so-called “quasi-in-need-of-care state (QUINOCS)”, i.e.,those who are in need of care but whose functioning can be im-proved with appropriate interventions. Methods: 1) Based onour preliminary study in which we analyzed the frequency ofand factors related to the QUINOCS in the community (n = 456),we developed a simple checklist to detect QUINOCS. 2) Tostudy the face validity of the checklist, we organized a consen-sus meeting with 5 physiatrists, 5 physical therapists, 3 occupa-tional therapists, 3 visiting nurses, and 1 social worker whowere all experienced in community rehabilitation. The originalchecklist was modified according to their recommendations. 3)We pilot-tested the validity of the modified checklist in 23 com-munity-dwelling persons with disability by comparing thescreening results with the judgment by an experiencedphysiatrist regarding indication for rehabilitation. 4) We testedthe sensitivity, specificity, and positive and negative predictivevalues of the checklist in 108 elderly persons with disability inthe community. Results: Based on the preliminary study, ascreening checklist comprising 13 items was constructed. After4 consensus meetings and the pilot testing, necessary modifica-tions were made and a final checklist consisting of 3 categoriesof 1) triggers for functional decline (4 items), 2) factors leadingto decline (10 items) and 3) indications for rehabilitation (2items) was generated. The indication for rehabilitation wasjudged as positive if at least 1 item in each category was marked.

The sensitivity, specificity, and positive and negative predictivevalues of the checklist as compared with physiatrist’s judgmentwere 0.86, 0.94, 0.86, and 0.94, respectively. Conclusion: Ascreening system to detect the QUINOCS in the community wasdeveloped, and its preliminary performance seemed satisfac-tory. As a next step, we are planning to institute a model systemfor screening and intervention for the QUINOCS to study itsfeasibility and effectiveness.

S8A-3 Cross-cultural Issues in StrokeRehabilitation: Thai Scenario

Witsanu KumthornthipSiriraj Hospital, Mahidol University, Bangkok,Thailand

Stroke is a leading cause of disability among different coun-tries. From the study in 1985, the prevalence of stroke in Thai-land was 690 cases per 100 000 population. From Heart andStroke Statistical Update–2005 by American Heart Association,40% of stroke patients have moderate functional impairmentsand 15% to 30% have severe disability. Absolutely, most of themare the target group of continuing intensive rehabilitation. Ef-fective stroke rehabilitation can prevent complications, en-hance the recovery, minimize disability, maximize function andindependency, and, finally, improve quality of life. Early assess-ment and rehabilitation intervention are critical to ensure opti-mal outcome. The multidisciplinary team approach includingpatient, family members, and caregivers are essential in com-prehensive rehabilitation management. There are several mod-els of stroke rehabilitation from country to country, dependingon public health policy, medical practices and specialties, eco-nomic status, cultural background, etc. From evidence for acuteand postacute stroke care, coordinated and organized stroke re-habilitation is worthwhile to achieve optimal outcomes. In ran-domized controlled trials, stroke unit care or organized inpa-tient multidisciplinary rehabilitation improved outcomecompared with standard care. Rehabilitation services improvedshort-term survival, functional ability, and most independentdischarge location. In Thailand, there are many stroke rehabili-tation services both in public and private hospitals. In the acutephase of stroke care, some patients are admitted in the generalward attended by internists, whereas others are in the strokeunit attended by neurologists. The criteria of admission and dis-charge vary. During their stay, rehabilitation consultation isusually a routine to prevent complications, assess, and screenthe patients for intensive rehabilitation. After that, the patientsare discharged to different settings such as inpatient rehabilita-tion, free-standing rehabilitation, outpatient rehabilitation,nursing home, or home-based rehabilitation depending on thepatients’ status, their potential and living area, and providedcare. For example, my rehabilitation ward is a model ofpostacute rehabilitation unit as a part of a university hospital lo-cated in Bangkok. Criteria for intensive rehabilitation in ourprogram are stable medical and neurologic conditions, follow-ing at least 2-step commands, retaining sufficient memory forrehabilitation learning, and being a good potential. Stroke reha-bilitation programs in Thailand follow some clinical practiceguidelines of different developed countries with some modifi-cations. A combination of Western- (advanced technology, task-specific approach) and Eastern-styled (Thai traditional mas-sage, acupuncture) practice is implemented among variousprograms. More details will be addressed and discussed in asymposium.



S8A-4 Stroke Rehabilitation in Germany

K. H. MauritzKlinik Berlin & Charité Medical School Berlin,Germany

Background: Although rehabilitation medicine had alreadybeen introduced around 1900 in Germany, stroke rehabilitationon a broader basis was developed only after 1970. This develop-ment was driven by necessity due to an older population, in-creased mobility of the working population, and the disappear-ance of multigenerational families. Methods: In recent years,stroke units have been created in acute care hospitals and alsoin some rehabilitation hospitals. From these stroke units the pa-tient is transferred to rehabilitation within 2 weeks. Accordingto the severity of the stroke, patients are grouped in 3 differentgroups: In group B the patient is still unconscious, comatous, orhas severe deficits in consciousness and is unable to cooperate.In group C the patient is able to cooperate; however, he or sheneeds much help in ADLs. Patients of group D are cooperativeand in most ADLs independent; however, they still need train-ing in physiotherapy, neuropsychology, or speech therapy. Re-cently a group F has been added for patients from group B (orC) who did not improve but need some minimal therapy toavoid secondary complications. Results: The length of stay andpayments are different according to the grouping. The outpa-tient rehabilitation in Germany is still developing, and moststroke rehabilitation is done on an inpatient basis. Conclusion:Although stroke rehabilitation seems to be efficiently organizedin Germany, one weak point is the further treatment andtraining after discharge in the community.

S8A-5 Stroke Rehabilitation: An InternationalSurvey

Leonard S. W. LiTung Wah Hospital and The University of HongKong, Hong Kong

Background: Although there is good evidence showing theeffectiveness of stroke rehabilitation and guidelines on strokerehabilitation have been published in various countries, thepractice and organization of stroke rehabilitation services arevaried among different countries. Obviously, the organizationof stroke rehabilitation services will be to some extent affectedby the cultural backgrounds, socioeconomic conditions, andnational health policies. However, information about the varia-tion of practices in stroke rehabilitation would be valuable to fa-cilitate a more international approach for development ofstroke rehabilitation services. Methods: A semiquantitativequestionnaire was sent to neurorehabilitationists in differentcountries in various continents. Returned data were based ei-ther on some national data related to stroke or the data of a typi-cal stroke rehabilitation center in the country. The data werethen analyzed by simple statistics to look into the profile of av-erage length of stay (ALOS) for inpatient, range of inpatienttherapy time (RTT), and types of settings and therapies avail-able. At the same time, a survey on the use of task-specific train-ing and alternative rehabilitation was also made. Results: Inter-esting results were obtained after simple statistical analysis fromthe returned questionnaires. The ALOS had a range of less than10 days to more than 100 days. In a few countries, there were animposed maximal inpatients LOS. There was also a big variationin therapy hours per day from 1 to 2 hours to 4 to 7 hours. Week-

end inpatient therapy was available in about 50% of countries.Most countries had the day rehabilitation services, but the homerehabilitation services were provided only in 50% of countriessurveyed. A few countries were lack of support from psycholo-gists for their stroke rehabilitation programs. Career training isnot a routine practice in most stroke rehabilitation programs.The use of task-specific training such as constrained inducedmovement therapy and partial weight-supported treadmilltraining were not a routine practice in all surveyed countries.Some centers would only be used in selected cases. Among thealternative medicine used, most would not provide routine al-ternative medicine, but acupuncture would be used in selectedcases in some centers. Discussion: This explorative survey iden-tified the profile of practices in stroke rehabilitation in differentcountries. Quite a number of interesting variations existed. Be-cause the survey did not address the question of how to explainthe variations, further discussion or even research should be en-couraged to look into these variations of practice in strokerehabilitation globally.

S8B-1 Neurorehabilitation—The AustralianExperience

J. E. Marosszeky, T. Stevermuer, and J. GreenAustralasian Rehabilitation Outcomes Centre,University of Wollongong, Australia

This paper describes 3 years of neurorehabilitation in Aus-tralia using data held by the Australasian Rehabilitation Out-comes Centre (AROC). We will present an analysis of approxi-mately 12 000 episodes of stroke, 3500 episodes of braindysfunction, 2000 episodes of spinal cord dysfunction, and 5000episodes of other neurologic impairments, grouped together.Variables considered include rehabilitation length of stay, func-tional change and rate of change using the FIM instrument, andpercentage of patients returning to the community after dis-charge from hospital. The AROC was established in July 2002 asa joint initiative of the Australian rehabilitation sector, includingproviders, funders, regulators, and consumers. To date, AROChas received data on approximately 200 000 episodes of inpa-tient rehabilitation from 110 of the 130 rehabilitation facilities,both public and private sector, across Australia.

In 2005, AROC initiated a series of benchmarking workshopsin which health care professionals from a number of selectedfacilities share information about management of patients witha specific impairment. The AROC database provides baselineinformation that can be used in the evaluation of the perfor-mance of the units. We believe the activity undertaken by AROCrepresents a very important development for specialist rehabili-tation services by assisting in continuous quality managementfor the benefit of the patients and to provide performanceindicators for accreditation.

S8B-2 Rehabilitation Management—Long-termModel of TBI

Robert D. VoogtRobert Voogt & Associates, Inc., Virginia Beach,Virginia, USA

There has been limited discussion regarding long-term mod-els of rehabilitation. Investigation regarding persons’ recoveryover time seems to suggest that recovery in fact does continuebut not across all groups. Others suggest long-term intervention



may prevent regression in individual cases. Still others addressthe long-term negative impact on the family who are in the care-givers’ role. The period after the initial acute state of TBI often isfollowed by diminished intervention. Persons with TBI return tohome where, typically, very little therapeutic support is offered.Not only persons who have sustained a severe TBI but otherswith moderate and mild TBI may need to be part of a long-termmodel. This presentation examines the changes caused by neu-rologic insult outside of the traditional medical impairmentssuch as walking, talking, or eating. Those elements that meetbasic individual needs such as loving relationships, meaningfulwork, enjoying oneself, and having access to a stimulating envi-ronment are defined as the most significant losses after brain in-jury. A model of comprehensive rehabilitation with a lifelongcomponent addresses the nonmedical aspect of brain injury,which becomes the most significant impairment to persons whoseek to improve their quality of life after TBI. The componentsof this model will be described with supporting research data asto the outcomes for persons who have been exposed to thismodel and have been maintained in an environment that usesthis model.

S8B-3 Comprehensive Management of CerebralPalsy in Korea

Chang-il ParkRehabilitation Hospital, Yonsei University, Seoul,Korea

Introduction: Cerebral palsy (CP) is a disorder of movementand posture resulting from a nonprogressive injury to an imma-ture brain. According to our study, the incidence of CP is 2.7 per1000 live births and 47.1 per 1000 live births with risk factors inKorea. The management of CP must be comprehensive andplanned according to the status of each case. Diagnosis: Earlydiagnosis is very important but a definite diagnosis of CP is notalways easy, particularly before the child’s 1st birthday. Accord-ing to our study, the most significant signs for detecting a braindysfunction before 6 months of age are motor developmentaldelay, abnormal muscle tone, and abnormal postural reactions.Also neuroimaging techniques including brain MRI (conven-tional and tractography) and brain PET, can assist the diagnosis.Treatment: The management for CP should be directed towardmaximizing the quality of life by improvement in the functionand reductions of the disability and complication; themultidisciplinary team is required to address the therapeuticgoals. There are various methods to manage CP, such as physi-cal and occupational therapy, medication, orthoses, neuromus-cular blockade, orthopedic surgery, and selective posteriorrhizotomy and intrathecal baclofen therapy. In young CP chil-dren younger than 2 years, the appropriate physical therapy in-cluding neurodevelopmental technique and occupational ther-apy is the mainstay in the treatment program in Korea. Ourstudy showed the effects of early treatment program, started be-fore 6 months of age. Medication can reduce the spasticity, butthe effect is minimal. Orthoses may be prescribed to maintainthe range of motion, prevent contractures, and provide stabilitywith ankle-foot orthosis increasing the maximal ankledorsiflexion during gait. Although these therapy programs areongoing, in spastic type, the effect of physical and conservativetherapy alone has limited value. So there is also the need formore invasive forms, for example, a neuromuscular block, se-lective posterior rhizotomy, orthopedic surgery, and intrathecalbaclofen therapy. Neuromuscular blockade, by botulinum toxin

used during the past 10 years, is effective for reducing spasticityof the gastrocnemius in equinus gait and by phenol forspasticity of the hip adductor. Favorable results have been re-ported with selective posterior rhizotomy in reducing the levelof spasticity without significant complications. In our hospital,selective posterior rhizotomy has been performed since 1988;and according to our study, if candidates for surgery were cho-sen by the proper indications, a selective posterior rhizotomycombined with postsurgery rehabilitation had significant effectson both the gross motor function and ADL. Orthopedic surgeryplays a valuable role in the correction of fixed deformities andreducing muscle tone without any effect on the basic neuro-logic imbalance. The fundamental goals of surgery should re-flect a functional approach to the problems of alignment.Intrathecal baclofen therapy has become a more common treat-ment for spasticity in cerebral palsy. It has some advantages thatare reversible compared with surgery and minimal sedation.Conclusion: A treatment program for CP should be comprehen-sive and prescribed on a case-by-case basis, according to thedevelopmental stage and functional level of the child.

S8C-1 Neurorehabilitation and EthicalBackground

Holger BaumgartnerResearch Ethics Committee, Medical UniversityInnsbruck, Austria

A globalized world needs global ethical concepts for medi-cine. Some 80 years ago, “reverence for life” was proclaimed asthe key to a universal concept of ethics by Albert Schweitzer,who received the Nobel Peace Prize of 1952 for both his culturalphilosophy and his humanitarian medical efforts. For NormanBethune of Canada, international solidarity was the basis for hishumanitarian medical services rendered in Spain and China(where he died in 1939 in pursuit of his mission). Today, respectfor human dignity and the other principles of the United Na-tion’s (UN’s) Universal Declaration of Human Rights of 1945 arebecoming increasingly recognized as the foundation for solidar-ity and benefit-sharing both at the international level and at thepersonal level. Scientific support comes from unraveling the hu-man genome and the recognition that “the human genome in asymbolic sense is the heritage of humanity” (Universal Declara-tion on the Human Genome and Human Rights; UN 1998). TheHelsinki Declaration of the World Medical Association and theInternational Ethical Guidelines of the Council for InternationalOrganizations of Medical Sciences of the World Health Organi-zation (WHO) and the United Nations Educational, Scientificand Cultural Organization (UNESCO) serve as internationallyaccepted ethical guidelines for medical research. Finally, theDeclaration on Bioethics and Human Rights approved byUNESCO in 2005 is an important step of the international com-munity to provide ethical guidance for states, professionals, andpersons dealing with ethical issues in the fields of medicine, lifesciences, and associated technologies. Medical services canonly be properly delivered in an appropriate social environ-ment. This is particularly true for disadvantaged groups who de-pend on a health care system based on solidarity. Important de-velopments with a global perspective were the United Nation’sDecade of Disabled Persons (1983-1992) and the StandardRules on the Equalization of Opportunities for Persons with Dis-abilities adopted by the UN general assembly in 1993. The latterdocument addresses comprehensively the needs of the disabledincluding medical care, rehabilitation needs, support services,



accessibility, etc. The WHO’s International Classification of Dis-eases (ICD-10) providing an etiological framework togetherwith WHO’s International Classification of Functioning, Disabil-ity and Health (ICF) describing functioning and disability asso-ciated with health conditions permit both better assessment ofthe situation and the needs of patient populations and more ra-tional decision making. These new models place medical careinto the social environment and context and consider disabilitynot as an “attribute of a person, but rather a complex collectionof conditions, many of which are created by the social environ-ment” (e.g., full integration of individual persons into society).With a solid international ethical background for medicine es-tablished and international concepts for dealing with disabili-ties in place, it is up to national health care policies to enablethe medical community to provide appropriate rehabilitationservices, like neurorehabilitation, to those in need. However, itis an ethical imperative that physicians act as advocates ofpatients, who are not able to claim for their own interests andrights.

S8C-2 The Present Status of Rehabilitation Rightsof the Patient with Neurologic Disorders in theMainland of China

T. ZhangChina Rehabilitation Research Center, China

Background: Neurologic disorders, such as cerebral vascu-lar disease (CVD), degenerative disease, peripheral neuropa-thy, and others, can lead to multiple dysfunctions.Neurorehabilitation, the main method to ease the dysfunction,has been given great recognition. Also, more and more atten-tion has been paid to it in the mainland of China. The article is toreflect the neurorehabilitation status in the mainland of Chinawith respect to the varieties and costs of neurologic disordersmanaged in China Rehabilitation Research Center (CRRC) dur-ing 2002 through 2004. Methods: To collect the information ofinpatients managed in the neurorehabilitation department ofCRRC during 3 past years and analyze the varieties and costs ofneurologic disorders. Results: With the review of the inpatientinformation, it can be concluded that CVD is the most commoncause. The 2nd is traumatic brain injury. Degenerative disease,multiple sclerosis, and the others are seldom seen. As for thecosts, 7.66% is covered by medical insurance, 42.48% is fromfree medical care, 42.2% is at patients’ own expenses, the othersare 7.66%. Conclusion: Patients resulted from CVD that re-ceived the rehabilitation constituted the biggest part. The rea-sons may be concerned with incidence of varied kinds of dis-ease, the levels of cognition about rehabilitation, and thelimitation of payment.

S8C-3 Neurorehabilitation and the Epochof Globalization

Franz Gerstenbrand1 and Heinrich Binder1,2

1Ludwig Boltzmann Institute for RestaurativeNeurology and Neuromodulation, Vienna;2Neurological Center Otto Wagner Hospital,Vienna, Austria

During the past years, neuromodulatory techniques haveled to enormous improvement of choice in neurorehabilitationregarding impairment and disability. Everybody’s talking about

DBS, pumps, FES, locomat, and other techniques, which havebecome established firmly. For some time, even stem cell ther-apy is also discussed in neurorehabilitation. But we have to facethe facts that the world is practically divided in 2 parts. A not in-significant part of world population has much more burning un-resolved problems with poverty, hunger, and all kinds of infec-tious diseases like HIV, TBC, and malaria. Therefore, theyprioritize elimination of these scourges and put under compul-sion the handling of disability and handicap last. The rich part isfighting against explosion of health care system costs the soci-ety is not willing to cover to the same extent as up to the pres-ent. Their problems are not infectious diseases. Their burden is,on the one hand, diseases of affluent society and their conse-quences and, on the other hand, the age pyramid, which has be-come upside down. In addition, unemployment figures are in-creasing at the same time. In this part of society,neurorehabilitation has to ask first how to start up with all dis-abled and handicapped persons and second who is willing topay for all the necessary and demanding, in particular expen-sive, techniques. In the growing unsupervised zone of healthcare systems, economy and material constraints gains increas-ingly the upper hand, and we are endangered that capitalismguzzles amongst his children the disabled first. Therefore, not atleast an answer is requested how to reach the real goals of reha-bilitation: social and vocational integration of our disabled andhandicapped neighbors.

S8D-1 Current Treatment in Epilepsy

O. W. WitteHans Berger Clinics, Jena, Germany

Background: After stroke or trauma, but also in associationwith degenerative processes, often epileptic disorders are ob-served. These require special attention for several reasons.Methods: 1) The treatment of epilepsy may interfere with theprocess of brain plasticity; thus, the treatment may impede re-habilitation. A review of the effects of antiepileptic drugs onbrain plasticity will be given. 2) These lesions often occur inolder patients. In these patients many metabolic parameters arealtered, which has to be taken into account when choosing theappropriate treatment. Furthermore, many of these patientstake several drugs; thus, drug interactions become especiallyimportant. Results: The prevalence and incidence of epilepsy af-ter stroke and trauma, as well as in association with degenera-tive disorders, will be reviewed. Furthermore, specific mecha-nisms, which cause epilepsy after such lesions, will bedescribed. Special emphasis will be placed on the role of age inthe choice of treatment schedules. A review of the currentlyavailable drugs and their suitability for these patients will begiven. Conclusion: The newly available drugs for the treatmentof epilepsy offer better treatment possibilities in patients whohave secondary epilepsy.

S8D-2 Neuromodulation in the Treatment ofRefractory Epilepsy

Mojgan Hodaie, Clement Hamani, and Andres LozanoToronto Western Hospital Research Institute,Krembil Neuroscience Center, University of Toronto,Toronto Western Hospital, Canada

A significant number of patients with epilepsy are poorlytreated despite currently available medical and surgical treat-



ment modalities. Neuromodulation is a novel strategy in thetreatment of these patients and consists in the delivery of anelectrical stimulus to a specific target to interfere with the gene-sis or propagation of seizures. The majority of neuromodulationtechniques are based on deep brain stimulation. This techniqueand the variety of targets that are currently being investigatedwill be reviewed. A number of studies suggest that the anteriorthalamic area may have an important role in the treatment of ep-ilepsy, based on neuroanatomical and functional connectivitiesto the cortex. Prior animal and human studies, including in-creased metabolic activity in the anterior nucleus during sei-zures and the effects of lesioning or high-frequency stimulationon seizure control, have demonstrated an important role of theanterior thalamic nucleus in maintenance of and propagation ofseizures. We undertook a clinical study of bilateral chronic deepbrain stimulation of the anterior thalamic nucleus in 6 medicallyintractable epilepsy patients. Age at implantation ranged be-tween 19 and 46 years. All patients underwent insertion of bilat-eral deep brain stimulation of the anterior nucleus of thethalamus, with high-frequency stimulation starting 4 weeks af-ter electrode insertion. Postoperative MR images were recon-structed to determine electrode and active contact location. Sei-zure frequency was assessed in all patients using seizurediaries. Low-frequency stimulation was employed to determinepresence of recruiting rhythm on EEG. All patients remained onantiepileptic drugs, and no changes were made to their stimula-tion regime in the 1st year. Patients showed initial and contin-ued benefit to seizure control with deep brain stimulation, withmore than 50% reduction in seizures in 50% of patients. Twp pa-tients showed more than 75% reduction in seizures. Patient age,baseline number of seizures, and type of seizures could not becorrelated to a response group. The patients who showed thehighest response had reduction in seizures immediately aftersurgery and before onset of stimulation, reminiscent of amicrothalamotomy-like effect. These patients also had EEG re-cruiting rhythm with low-frequency stimulation, and postoper-ative MR analysis showed the electrodes to be placed in theanteroventral portion of the anterior nuclear complex or in thedorsomedian nucleus. Conversely, patients who showed mod-erate or poor response to deep brain stimulation also had mod-erate response after implantation and did not benefit from stim-ulation adjustments. Deep brain stimulation of the anteriornucleus of the thalamus appears to be effective in seizure reduc-tion, and the effect appears to be maintained up to 60 monthspostoperatively. Factors that correlate closely with good re-sponse to treatment are insertional effect of electrode on seizurebenefit, presence of recruiting rhythm on EEG with low-fre-quency stimulation, and placement of the electrodes in theanterior nucleus complex or the dorsomedian nucleus.

FREE PAPER SESSIONS–Febuary 13, 2006

F1A-1 Fractionation of Everyday ActionsPerformance and Its Implications onRehabilitation

W. L. Bickerton and M. J. RiddochUniversity of Birmingham, United Kingdom

Background: Successful planning and execution of every-day actions rely on a range of cognitive processes. These in-

clude object knowledge and schema knowledge as well as gen-eral cognitive resources and executive processes. To develop arehabilitation focus for deficits in everyday actions, we ask 1)whether difficulties in everyday actions are dissociable (study1); and 2) does increased environmental complexity (the pres-ence of objects not related to the task) affect patients with differ-ent basic deficits differently (study 2). Methods: Study 1: Theperformance of 3 neurologically damaged patients (FK, BL, EC)on everyday actions are analyzed to determine knowledge ofcomponent actions, action sequence, object use, object manip-ulation, and error awareness. Study 2: The performance of 6 pa-tients on everyday actions with and without distracters wascompared. Results: FK, BL, EC demonstrated differential diffi-culties in task sequencing, object use, and object manipulation,respectively. Patients in study 2 were differentially affected inthe presence of distracters. Two patients were not affected bydistracters, 2 patients produced significantly less steps whendistracters were present, and 2 patients misused objects signifi-cantly more in the distracter condition. Conclusion: Fine-grainassessment of everyday actions of patients with cognitive im-pairments can identify specific areas of deficit and allow moreprecise targeting of rehabilitation.

F1A-2 The Effect of Errorless Learning on theMemory Processes of Patients with Brain Injury:An Initial Study

Z. L. Dou,1 H. N. Ou,1 D. W. K. Man,2 S. F. Tam,2

and C. W. Y. Hui-Chan2

1Department of Rehabilitation Medicine, The ThirdAffiliated Hospital, Sun Yat-sen University, China;2Department of Rehabilitation Sciences, Hong KongPolytechnic University, Hong Kong

Objective: To evaluate the effect of errorless learning (EL) onmemory rehabilitation and memory processes following braininjury. Methods: 84 participants were randomly sorted into 3groups: CAMG, (n = 30), TAMG (n = 24), and CG (n = 30). A 20-session training course was developed and used in this study.The former 2 groups each underwent a 1-month training courseof similar structure and content but using different deliverymodes. The RBMT-CV and HKLLT were used to assess memoryability and processes at the start and end of the training programand in a 1-month follow-up. A repeated measures analysis ofvariance was used to compare differences across the 3 groups.Results: Comparing pretraining with posttraining and follow-up, some RBMT-CV subscores improved significantly (P < 0.01)in the CAMG and TAMG groups, but no statistically significantdifferences were found between the CAMG and TAMG groupsin terms of total RBMT-CV scores. Significant positive changeswere seen in HKLLT subscores related to memory processesfrom pretraining to follow-up in the CAMG and TAMG groups(P < 0.01). The CAMG group demonstrated a more significantpositive effectiveness (P < 0.05) than the TAMG group in encod-ing and storage. Conclusion: EL is likely to be an effectivemethod for improving memory performance in patients withTBI, and the improvement may persist for 1 month. This learn-ing mode may affect the whole memory process. Moreover, theCAMG is more effective than TAMG, especially in improving en-coding and the storage processes.



F1A-3 EEG Test Reactivity for Coma Patients inUGCA: Significance for Consciousness Recovery

A. Giustini,1 F. Logi,2 F. Tomaiuolo,2 M. Bresci,2

and R. Galli21Fondazione S. Maugeri, Italy; 2AuxiliumVitae-Volterra, Italy

Background: Patients with serious acute brain injury aretransferred from the intensive care unit to the intensive rehabili-tation unit (UGCA). Until now we have not had any reliableprognostic directory. Forty-eight coma patients (GCS ≤ 8 andLCF ≤ 2) coming to Volterra UGCA were submitted to a basicEEG. There were 24 traumatic patients (TP; mean age, 36.8years; range, 19-75 years) and 24 nontraumatic patients (NTP,mean age, 60 years; range, 33-80 years) with coma due to vascu-lar events or anoxia. Methods: EEG was recorded following theI.F.C.N guidelines (1999). We assessed 1) EEG pattern (benign/doubtful/malignant results); 2) the EEG test by acoustic and no-ciceptive stimulus. Each patient was daily stimulated and the re-covery was identified. Chi-square tests were applied to patientsin the following categories: 1) EEG benign versus malignant andconsciousness recovery or not, 2) EEG reactive versusnonreactive and recovery versus nonrecovery. Results: We di-vided the groups into benign-conscious, benign/nonconscious,malignant-conscious, and malignant/nonconscious. Chi-test re-sult was significant. One hundred percent of patients showingEEG reactivity to stimulus regained consciousness within 6months from the event. Also, 25% (3 of 12) of TP patients and38% (5 of 13) of NTP patients who showed no EEG reactivity re-covered consciousness within 6 months. Conclusion: EEG reac-tivity as a prognostic sign is very specific (100% prediction) andpredicts a total of 75% (TP 81% and NTP 69%) patients, whereasEEG pattern seems to be less useful.

F1A-4 Implicit Sequential Learning inNondemented Patients with Parkinson’s Disease

E. Kerckhofs,1 M. Coene,1 N. Deroost,2 G. Wynants,1

and E. Soetens2

1VUB—Department of Neurological Rehabilitation,Belgium; 2VUB—Department of Cognitive andBiological Psychology, Belgium

Background: We determined to what extent patients withParkinson’s disease (PD) have the ability to implicit sequentiallearning. Methods: 16 nondemented PD patients (H & Y stageIII) and 16 matched healthy controls performed a serial choicereaction time test (SRT): subjects pressed as quickly as possible1 of 4 keys corresponding to the stimulus location on the screen.In all but the last block of trials a fixed order of stimulus loca-tions was implicitly introduced. The difference in reaction time(RT) between the random block and the mean of the adjacentstructured blocks was taken as a learning index. Results: In theSRT-task PD patients were significantly slower than controlsand did not show any implicit learning effect. We subdividedthe patients in 2 subgroups based on the number of errors. Theslowest patients (n = 5) did not show any learning effect,whereas the learning pattern of the fastest patients (n = 11) wascomparable to that of the healthy controls. The slowest patientgroup scored significantly lower on the SOCPA-COG, and thelearning index for all patients was significantly correlated withthe SCOPA-COG and the MMSE. Conclusion: In the SRT-task,the ability to implicit sequential learning of PD patients in H & Ystage III is associated with their cognitive levels as measured by

the SCOPA-COG and the MMSE. Those results can have impor-tant consequences for cognitively oriented therapies of patientswith PD.

F1A-5 The Validity of the Hospital Anxiety andDepression Scale (HADS) and Beck’s DepressionInventory II (BDI-II) in Acquired Brain Injury(ABI)

Z. F. Falope,1 S. Deb,2 H. Rickards,2 and T. Powell21South Birmingham Primare Trust, UnitedKingdom; 2University of Birmingham,United Kingdom

Background: Depression is a frequent complication of ABI.Diagnosis may be difficult with the use of structured interviewsand self-report measures. There is no consensus on the cut-offscores for available measures. The HADS has been validated asa screening measure mainly in stroke. BDI has establishedpsychometric properties, but BDI-II requires further evidenceof validity for patients with brain injury. Methods: Forty-fourconsecutive patients (30 males and 14 females) with ABI (headinjury and strokes) seen in the brain injury clinic completedHADS and BDI-II followed by a clinical interview to assess theDSM-IV criteria for depression (the gold standard). The sensitiv-ity, specificity, and positive and negative predictive values (PPVand NPV) were calculated at different HADS and BDI cut-offpoints. Receiver operating characteristics curves (ROC) wereobtained. Results: Maximum discrimination was obtained with acut-off score of 8 of 9 for HADS (depression); the sensitivity was88%, and the specificity 68%. High sensitivity and NPV were ob-tained with a cut-off of 5 of 6 or lower. The area under the ROCcurve was 0.804. For the BDI-II, maximum discrimination wasobtained with a cut-off score of 18 of 19; the sensitivity was 81%,the specificity 75%. One hundred percent sensitivity and NPVwere obtained with a cut-off of 15 of 16 or lower. The area underthe ROC curve was 0.853. Conclusion: Contrary to the commonbelief that HADS is a better instrument than BDI for screeningfor depression in patients with organic brain lesions, it appearsthat both HADS and BDI-II are equally effective screening toolsfor patients with ABI.

F1A-6 The Brain Integration® RehabilitationProgram: A New Holistic NeuropsychologicalTreatment Approach for Brain Injury:A Program Evaluation

G. J. Geurtsen and J. D. MartinaRehabilitation Centre Groot Klimmendaal,the Netherlands

Background: The consequences of a brain injury can have atremendous impact on both the patient and his or her family.Many persons with BI experience serious problems at a laterstage. The problems lie in the areas of living, day spending, andsocial contacts. The Brain Integration Program® (BIP) aims to-wards reintegration in these areas. The BIP introduces a newstandard for delivery of neurorehabilitation by shifting the focusfrom a medical to a psychopedagogic holistic neuro-psychologic–oriented approach. The patient group is complexwith multiple problems such as limited awareness, drug abuse,psychiatric complaints, or behavioral problems. Methods: Todetermine the effectiveness of the BIP in the short and longterm, 24 patients are prospectively assessed at start and end of



treatment and at 1-year follow-up. Assessment is performed us-ing validated social and emotional rating scales and question-naires. Results: Analysis of data was made by paired samples ttests. Results show that there are significant improvements aftertreatment and no significant differences between the 2 assess-ments after treatment. On employability there even is a furtherimprovement because finding a suitable workplace costs timeand can’t be realized directly after treatment. Conclusion: Thesignificant improvements after treatment indicate that the BIP iseffective in resolving the needs of this complex patient group.The stability of the results over 1 year shows that effects aremaintained after treatment.

F1A-7 Memory Strategies Used for Recall Task

J. K. Y. Wu, K. P. Y. Liu, C. C. H. ChanThe Hong Kong Polytechnic University, Hong Kong

Background: The rehabilitation of people involves theirlearning and hence their ways of recalling what they havelearned. We conducted a study on the recall of words. Methods:29 healthy elderly, 20 stroke patients, and 31 young adults wererecruited. After training on 30 Chinese words, they completed acomputer-based task with these trained words together with 30distracters. Results: About half of the participants recall thephysical characteristics of the words during the task. About one-third recalled usign semantic characteristics. A small percentageof the healthy elderly and stroke subjects could not recall theuse of any strategies and they memorized by rote memory. Sig-nificant differences were found in the accuracy of recall be-tween subjects using physical characteristics for recall andthose using rote memory (P < 0.005) and between those usingsemantic characteristics and those using rote memory (P <0.001). When comparing with subjects using rote memory,those who recalled by using the physical characteristics had ahigher recall accuracy of photographic words (P < 0.05), andthose using semantic characteristics had a higher accuracy in re-call of words loaded with semantic meaning (P < 0.005). Con-clusion: This study suggests that people might memorize wordsby looking at their shapes (physical), referring to their mean-ings (semantic), or by rote memory. The use of different strate-gies affects the accuracy of recall. When we provide rehabilita-tion, we could select appropriate methods to help in theirlearning.

F1A-8 Efficacy of Metacognitive RehabilitationTraining in Patients with Multiple Sclerosis (MS)

M. Falautano, F. Martinelli Boneschi,M. F. Possa, M. Comola, and G. ComiVita-Salute Scientific Institute San RaffaeleHospital, Italy

Background: Cognitive dysfunction is a cause of disabilityin patients affected with MS with all the different diseasecourses with a prevalence estimated between 45% to 65%. Dur-ing the past 3 years, we selected 38 MS patients and enrolledthem into a metacognitive (meta) rehabilitation program with afinal improvement in memory and attentive efficiency. Methods:After our results, we performed a randomized, double-blinded,age and sex-matched trial. Forty MS patients were enrolled andassigned to 2 therapy arms: 1) experimental meta-approach, 2)control basic mnemotecnique learning. They underwent 10 in-dividual rehabilitation sessions and neuropsychologic

evaluations at the beginning, at the end, and at 6-month and 1-year follow-up. Statistical analyses will be performed by meansof nonparametric tests to compare the difference between thescores after and before the treatment across the 2 treatmentarms. Results: Preliminary (22 patients) results showed an effi-cacy by both rehabilitation training in memory and executivefunctions. This positive result seems not to be influenced by thetype of treatment, whether standard or experimental. Conclu-sion: These analyses need to be considered preliminary, as weneed to wait the inclusion of additional 18 patients to achieve asufficient statistical power of the study. Moreover, it is also pos-sible that the efficacy of the meta treatment is more pronouncedat the 6-month and 1-year follow-up. A particular acknowledg-ment to FISM for the support and financing

F1B-1 Trunk Impairment in Parkinson’s Disease

G. Verheyden, A. Nieuwboer, A. Willems, F. Chavret,and W. De WeerdtKatholieke Universiteit Leuven, Belgium

Background: It was the aim of this study to examine the mo-tor impairment of the trunk in persons with Parkinson’s disease(PD). Variables that contribute to motor impairment in PD andthe importance of trunk deficit in disease severity were ana-lyzed. Methods: 26 PD subjects and 26 age- and sex-matchedhealthy controls were included in the study. Trunk performancewas evaluated with the Trunk Impairment Scale (TIS). The TISexamines static and dynamic sitting balance and trunk coordi-nation. Results: Persons with PD scored significantly lower onthe static sitting balance (P = 0.005) and coordination (P <0.0001) subscale and total TIS (P < 0.0001) in comparison tohealthy subjects. Multivariate linear regression analysis showedthat disease severity (R = 0.54, P < 0.0001), measured as UPDRSIII score and age (added R = 0.09, P = 0.03) were significant vari-ables of trunk impairment in PD. Total TIS score explained 54%(P < 0.0001) of the variance in UPDRS III score with an added10% (P = 0.02) for Hoehn and Yahr stage of the disease. Conclu-sion: The motor performance of the trunk in persons with PD issignificantly impaired. Disease severity and age play an impor-tant role in the degree of trunk impairment. Trunk impairmentitself is an important variable in disease severity and shouldtherefore receive further attention during assessment of personswith PD. Treatment of the trunk should also be considered asrehabilitation strategy.

F1B-2 The Effects of Guideline-Based CueingTherapy on Gait-Related Mobility in Parkinson’sDisease Patients: The RESCUE project

A. Willems,1 A. Nieuwboer,1 F. Chavret,1 G. Kwakkel,2

and E. van Wegen2

1Katholieke Universiteit Leuven, Belgium; 2

Vrije Universiteit Amsterdam, the Netherlands

Background: Up till now, cueing studies focused mainly onthe immediate effects on gait in a gait laboratory. This study isthe first to address the training effects within a physiotherapycontext in a home setting. Methods: For this study, PD patientswere recruited in 3 countries (UK, NL, B) to participate in a ran-domized, single-blind, crossover trial. Patients were allocatedto either an early or a late 3-week cueing therapy. The therapywas provided by trained physiotherapists using a prototype



cueing device and was based on cueing guidelines. Patientswere evaluated at baseline, 3, 6, and 12 weeks. Results: 153 PDpatients were recruited with a mean Hoehn and Yahr score of2.7 (±0.6). Multiple linear regression analyses showed a signifi-cant therapy effect for the posture & gait score (P = 0.005), gaitspeed (P = 0.005), step length (P < 0.0001), Falls Efficacy scale(P = 0.03), balance (P = 0.003) and the Unified Parkinson’s dis-ease rating scale part III (P = 0.03). Risk of falling did not in-crease with therapy. At 12 weeks, the intervention effects de-creased but gait outcomes remained significantly better than atbaseline. Conclusion: Home-based cueing therapy improvesgait and balance in PD, confirming laboratory-based results.Despite the increase in mobility, the risk of falling remains sta-ble. The intervention effect diminishes after the intervention pe-riod and shows the need for constant support and follow-upsessions in this patient group.

F1B-3 A Randomized Controlled Trial of aHome-Based Exercise Program to Reduce FallFrequency among People with Parkinson’sDisease (PD)

A. Ashburn,1 C. Ballinger,2 L. Fazakarley,1 R. M.Pickering,1 and D. L. McLellan1

1University of Southampton, United Kingdom;2London South Bank University, United Kingdom

Background: Postural instability and falls in PD are commonbut difficult to treat. Our aim was to evaluate the effectivenessof an exercise program for repeat fallers. Methods: A random-ized controlled trial with blinded assessments was used to com-pare usual care with a personalized 6-week, home-based exer-cise program for repeat fallers with confirmed PD living in thecommunity (independently mobile with intact gross cognitivefunction). Assessments were conducted at baseline, 8 weeks,and 6 months postrandomization. The specific objectives werefrequency of falls, near-falls, and injuries. Secondary outcomeswere the Functional Reach, Berg Balance Test, Get Up & Go,Chair Stand Test, muscle strength, PD Self-Assessment Scalescores, and Euro Quol ratings. Results: Participants were ran-domly assigned to the exercise (70) and control groups (72); ageand disease severity were similar. There was a trend towardlower fa l l ra tes in the exercise group at 8 weeks(postintervention) and 6 months, lower injury rates needingmedical attention at 6 months, and significantly lower near-fallrates for the exercise group at 8 weeks (P = 0.004) and 6 months(P = 0.005). There was a positive effect at 6 months on func-tional reach (P = 0.009) and quality of life (P = 0.033) for those inthe exercise group. No significant differences were found interms of other secondary outcome measures. Conclusion: Therewas a trend toward a reduction of fall events and severe injuriescaused by falls with a positive effect of exercises on near-fallsand quality of life.

F1B-4 Physiotherapy Guidelines on the Use ofCueing in Parkinson’s Disease

A. M. Willems,1 A. M. Nieuwboer,1 F. Chavret,1 L.Rochester,2 and D. Jones2

1Katholieke Universiteit Leuven, Belgium;2Northumbria University, United Kingdom

Background: At present, no guidelines exist which helptherapists to apply cues for the treatment of gait-related prob-

lems in Parkinson’s disease. The RESCUE project aimed to de-velop evidence-based guidelines for cueing published on CD-ROM. Methods: In a preparatory phase, the effect of differentmodalities and parameters of cueing was studied in 3 gait labs(UK, NL, B). Review of the literature on cueing complementedexperimental data. Thirty-one cueing guidelines were initiallydeveloped. The therapy applied in the RESCUE randomizedcontrolled trial was based on these guidelines. Results: After re-vision, 15 guidelines were retained. These give information onthe use of auditory and visual cues, in different circumstances(complex and not-complex tasks) and in different patientgroups (with and without freezing of gait). Furthermore, theguidelines were organized into 12 therapeutic goals, so they canserve as a practical manual for therapists. Every therapeutic goalwas linked to 1) an evidence-based guideline; 2) exercise exam-ples, illustrated with video-material; 3) evaluation methods; and4) an informative handout for patients. This manual is pub-lished on a CD-ROM to enable video illustrations and automaticcueing frequency calculations. Conclusion: Evidence-basedguidelines on cueing were developed based on RESCUE resultsand current literature and directly related to therapeutic goals.Publication on a CD-ROM ensures an accessible and practicaltool for therapists.

F1B-5 The Role of Clinical Balance Tests asPredictors of Fall Risk in Patients withParkinson’s Disease

E. Kerckhofs,1 K. Vanroy,2 N. Senden,3 V. Strykova,2

and S. Truijen2

1Vrije Universiteit Brussel, NeurologicalRehabilitation, Belgium; 2Hogeschool Antwerpen,Dept. of Physical Therapy, Belgium; 3HogeschoolAntwerpen, Dept. of Occupational Therapy,Belgium

Background: Fall incidents are an important clinical prob-lem in patients with Parkinson’s disease (PD) that negatively af-fects their quality of life. To screen PD patients for their fall risk,we examined the predictive role of static and dynamic balancetests. Methods: 31 PD patients were recruited for the study (18men and 13 women; mean age, 70.0 ± 8.7 years; mean durationof PD 8.2 ± 5.0 years; Hoehn & Yahr stage: I, 3; II, 13; III, 12; IV,3; mean MMSE, 26.5 ± 1.8). An extensive set of balance tests wasperformed by the patients at home: 1) bipedal and monopedalstance tests, 2) balance perturbation by self-initiated move-ments, 3) external balance perturbation, 4) functional balancetasks. During a follow-up period of 3 months, patients had tocomplete a fall registration form in case of a fall incident. Re-sults: 10 PD patients (32.3 %) had a fall incident during the fol-low-up period of 3 months, whereas the remaining patients hadnot. Fallers scored significantly (P < 0.05) worse on the follow-ing balance tests: Berg Balance Scale, Tinetti Mobility Score,walking while carrying a tray with 3 goblets on top of it, benchand reach test, straddle with right foot forward. A logistic re-gression analysis showed that the only significant predictor forfalls was the severity of the disease (H & Y stage). No one bal-ance test seemed to have a sufficient predictive power. Conclu-sion: Our results suggest that clinical balance tests have notenough predictive power to discriminate between potentialfallers and nonfallers.



F1B-6 Polio in the Upper Extremities:Frequency and Consequences

K. S. SunnerhagenInstitute of Clinical Neuroscience-RehabilitationMedicine, Göteborg University, Göteborg, Sweden

Background: Polio was recently a common disease, leavingmany with paresis in the legs. The incidence in the upper ex-tremities is unknown. The aim was to assess polio involvementin the arms and its consequences for daily life. Methods: The po-lio clinic, Sahlgrenska University Hospital, sees more than 600persons; EMG is performed in 4 extremities and hand grip istested with Grip-It®. The force values are presented as percent-age of expected from a population sample. Consecutive follow-up patients were asked to fill in a questionnaire (ABILHAND),asking “how difficult are the following” uni- and bimanual ac-tivities, and the alternatives were easy, difficult, very difficult,impossible, or not applicable. Results: Data from 89 persons (73% women); mean age 63 years (23-86 years) are given. Poliowas EMG-verified in 55 persons and mostly in both arms (65%).The grip force was reduced to ~65% of expected and sustainedgrip more than 10 s to ~61%. Sixty-one persons acknowledgedifficulties in arm or hand activities and most difficult was “us-ing a screwdriver” (35%) and “peeling a potato with a knife”(32%). Conclusion: In this consecutive sample of polio survi-vors, more than 50% had involvement in the upper extremitiesand reduced hand grip. This has not been described before.Many had difficulties in everyday activities. More data areneeded to assess the psychometric aspects of the questionnaireas well as statistically evaluate different associations betweenvariables.

F1B-7 Feed-Forward Audiovisual Cues CouldEnhance Sit-to-Stand in Parkinsonian Patients

M. K. Y. Mak and C. W. Y. Hui-ChanRehabilitation Sciences, The Hong Kong PolytechnicUniversity, Hong Kong

Background: Our previous study demonstrated that audio-visual (AV) cues could enhance sit-to-stand (STS) in patientswith Parkinson’s disease (PD). We aimed to examine the effi-cacy of a STS training program using these feed-forward motorpreparatory signals in PD patients. Methods: PD subjects wererandomly allocated into cued (n = 19), Ex (n = 19) and control(n = 14) groups. In cued training, STS was initiated after AV cueswere given, whereas mobilizing and strengthening exerciseswere given for the Ex group. Cued and Ex groups received treat-ment for 4 weeks, whereas the control group had no treatment.Three-dimensional motion analysis was performed, and thespeed and time taken to complete STS were examined. Results:Cued training resulted in faster and greater improvement thanthat of Ex group. By the end of week 2, cued group significantlyincreased the peak horizontal velocity (by 13%, P < 0.01),whereas the Ex group made no improvement. By week 4, thecued group increased both peak horizontal and vertical veloci-ties by 18% and 48%, respectively, and reduced time taken tocomplete STS (by 40%). These improvements were significantlygreater than those of Ex group (6% and 18% increase for peakhorizontal and vertical velocity, respectively, and 14% reducedmovement time; P < 0.01). The improvement made by the cuedgroup could carry over to 2 weeks after the completion of treat-ment. Conclusion: The findings from this randomized con-

trolled trial provided solid evidence for the use of AV cues asfeed-forward signals to reeducate STS in PD patients

F1B-8 Handwriting Improvements andGeneralized Effects of a Training Therapy ofWriter’s Cramp

J. Hermsdörfer, W. Fürholzer, B. Steidle, C. Marquardt,and B. BaurClinical Neuropsychology Research Group (EKN),Hospital München-Bogenhausen, Germany

Background: Writer’s cramp is an occupational dystoniacharacterized by hyperactivity of antagonistic muscles duringhandwriting, causing irregular and encumbering script produc-tion. Although dystonia mainly affects writing, adverse general-ized effects on other fine motor skills may be present. Methods:We used the training therapy developed by Mai and colleaguesto treat patients with writer’s cramp. The training aimed at re-solving dystonic movements and establishing altered writingstrategies. In an ongoing therapy study, we evaluated writingkinematics and pen grip forces before and after 5 training ses-sions. In addition, we measured grip force during object manip-ulation to analyze the generalization of dystonia during otherfine motor tasks. Results: The training improved writing kine-matics in a majority of participating patients. The grip force ex-erted against the pen was sometimes grossly increased or de-creased during the training. In addition, an attenuation ofinitially increased grip force during object manipulation wasobvious after the training in some of the patients. Conclusion:The results confirmed the efficacy of the training therapy for re-ducing the adverse effects of writer’s cramp. Amelioration of ex-aggerated grip force during fine motor tasks indicates a general-ized effect of the training in reducing dystonia. Therapy successis dependent on various factors, the determination of whichseems highly desirable in order to increase the efficiency ofwriter’s cramp therapy.

F1C-1 Silent Period Evoked by NavigatedTranscranial Magnetic Stimulation Monitored inPatients with Acute Stroke

I. M. Tarkka,1 M. Kononen,2 S. Maatta,2 J. Karhu,4

and J. Sivenius1

1Brain Research and Rehabilitation Center Neuron,Finland; 2Department of Clinical Neurophysiology,Kuopio University Hospital, Finland; 4Nexstim Ltd.,Finland

Background: Motor recovery is difficult to predict in severestroke. For these cases, additional indicators other than motor-evoked potentials (MEPs) are needed to predict recovery. Silentperiod (SP) is a transient suppression of EMG activity after MEPwhen the target muscle is active. Using navigated transcranialmagnetic stimulation, we selectively stimulated upper andlower limbs in the acute phase of stroke. The purpose of thepresent study was to assess the prognostic value of SP in acutestroke. Methods: Navigation (Nexstim Ltd.) based on individualMRIs was utilized in eliciting MEPs and SPs in stroke patients.Stimuli for SP were delivered at 130% of the intensity of individ-ual motor threshold (MT) and EMGs were recorded bilaterallyon abductor pollicis, digiti minimi, tibialis anterior, and soleusmuscles. The MTs, MEPs, and SPs were analyzed. SP was de-fined from the MEP onset to the reappearance of uninterrupted



EMG. Five patients with acute unilateral stroke were observedtill 6 months. Results: Electric field to find MT was higher on theaffected side than on the nonaffected side where MTs were al-ways obtained. Affected side failed to respond in 1 case in thehand area and in 2 cases in the leg area. SPs were obtained inthe acute recording in 2 of 5 affected hands; after 6 months, in 3of 5 affected hands and 3 of 5 affected legs. The nonaffectedside SPs were always present. Conclusion: Interindividual vari-ability among the patients was large in SPs. They reappeared orshortened during functional recovery.

F1C-2 A Study on the Neurophysiologic Effects ofExposure to Refined Petroleum Products on AdultResidents Near a Manila Oil Depot

T. J. P. Evangelista, E. P. Capul, K. M. S. Abat,R. A. Abrencillo, and C. M. T. AganUniversity of the Philippines College of Medicine,Philippines

Background: This study determined the neurophysiologiceffects of exposure to refined petroleum products of adultsaged 18 to 64 years residing near the Pandacan, Manila Oil De-pot. Methods: This cross-sectional single population study in-volved systematic randomization with triple blinding. Threecommunities were selected and designated as area I (Barangay833), area II (Barangay 835), and area III (Barangay 848). Tensubjects from each area underwent neurologic examination,monofilament, dynamometer, and nerve conduction velocitytests, and urine lead level measurement. Results: Deep tendonreflexes were intact in the upper arms but were abnormal in thelegs. A mean of 33.33% per area had pinch weakness, 26.67%had grip weakness, 100% had ankle dorsiflexion weakness. Re-duced tactile and protective sensations were evident in the pa-tients using the monofilament test. Seventy percent of the pa-tients had median neuropathy for all the areas. Forpolyneuropathy, there was 40% in area I, 30% in area II, and20% in area III. The mean of the abnormal urine lead levels washighest for area I, followed by area II, and the least for area III.Conclusion: This study established that for the selected popula-tion, as the distance from the Pandacan Oil Depot increases, theexposure to lead and the incidence of polyneuropathy de-crease. This research revealed the health effects of the said ex-posure and directed medical attention to the affected locals ofPandacan.

F1C-3 Primary Motor Cortex Was Suppressed by aHigh-Frequency Repetitive Transcranial MagneticStimulation (rTMS) Protocol for Central PainControl

J. E. Shin, H. I. Shin, and Y. S. JeongSeoul National University Bundang Hospital,South Korea

Background: Recently intermittent high-frequency rTMSover the primary motor cortex has been reported to amelioratecentral pain. Although high-frequency rTMS on primary motorcortex applied continuously is known to have excitatory effect,the change of motor cortex excitability is not known if it is ap-plied intermittently as rTMS protocols for central pain control.Methods: 10 Hz rTMS was applied over the hand area of motorcortex to 13 healthy subjects using a protocol for central pain

control (20 trains of 5 s stimulation and 55 s rest, intensity of 80%resting motor threshold). The motor-evoked potential (MEP)amplitudes recorded at contralateral 1st dorsal interossei mus-cle were measured before, immediately after, 30, 60, 90, and 120minutes after rTMS. The intracortical inhibition and facilitationwere investigated using paired pulse technique. The excitabilityof unstimulated cortex was also evaluated using the same tech-niques. Results: The mean MEP amplitude decreased from 1.54mV to 1.07 mV immediately after rTMS and remained decreasedup to 90 min. The mean MEP amplitude obtained from unstimu-lated cortex was also decreased up to 60 min. By paired pulsetechnique, enhancement of intracortical inhibition and sup-pression of intracortical facilitation were observed bilaterally.Conclusion: Primary motor cortex was suppressed bilaterallyby the high-frequency rTMS protocol for central pain control.Motor cortex suppression is a possible component of pain reliefmechanism induced by rTMS.

F1C-4 Event-Related Potentials of VibrotactileImagery—A Potential Treatment for Patients withSensory Impairments

K. W. S. Chow,1 C. C. H. Chan,1 K. P. Y. Liu,1 L. S. W.Li,2 and C. W. Y. Hui-Chan1

1The Hong Kong Polytechnic University, HongKong; 2Tung Wah Hospital and the University ofHong Kong, Hong Kong

Background: Mental imagery might be a potential treatmentmodality for patients with sensory deficits. The neural mecha-nism associated with tactile imagery is still not under study. Thepresent study used event-related potentials to examine the neu-ral processes associated with the imagery of vibrotactile sensa-tion among older subjects. Methods: 12 normal subjects partici-pated in the study. The imagery task required the subjects todetect a brief vibrotactile priming stimulus followed by imagin-ing that particular sensation. To ensure engagement in the im-agery task, the subjects then detected another brief primingstimuli that indicated whether the stimuli came from the samepair. In the control condition, the subjects passively detectedthe brief priming stimuli but without imagining it. Results: Whencompared with the control task, imagery of vibrotactile stimuliwas found to elicit a less negative-going N400 in thefrontocentral and temporal areas. Less positive-going P600 waselicited primarily in the central and then the frontoparietal ar-eas. The latency of these 2 components in the contralateral sidewas shorter than the ipsilateral in the control but not the imag-ery condition. Conclusion: The results suggest a dual sequentialimagery process, which probably represents generatingvibrotactile images from memory followed by maintainingthose images. The image maintenance process was task andmodality specific, which involves the sensorimotor areas. Theimplications of the study results are discussed.

F1C-5 Electrophysiological Correlates ofRecovery of Anomia in an Aphasic Patient

M. Laganaro, V. Schwitter, S. Morand, and A. SchniderUniversity Hospitals Geneva, Division ofRehabilitation, Switzerland

Background: Computer-assisted therapy for anomia can beeffective in acute aphasic patients. Here we present behavioral



and electrophysiologic correlates of recovery from anomia in anaphasic patient who underwent 2 periods of intensive com-puter-assisted therapy for anomia. Methods: The patient (57years old) suffered from conduction aphasia with severeanomia 3 months after a left temporo-parieto-occipital stroke.He had daily computer-assisted treatment sessions for 2 one-week periods. Behavioral assessment and EEG recording (128channels) were performed at baseline and after each therapyweek with a delayed picture-naming task. Results: The patient’snaming ability improved during the computer-assisted therapy.Waveform analyses were performed between failed items atbaseline and the succeeded items in the posttherapy assessmentsessions. The analysis of the electrophysiologic data showed adifference between the successful and the failed items on theleft frontotemporal electrodes in the period of 200 to 350 ms.The comparison before and after treatment was associated witha topographic difference marked by a left frontal activity forfailed items and a more posterior activity for the successfulitems. Conclusion: Computer-assisted treatment was efficient inthis patient, thus confirming earlier findings. Improved namingwas associated with electrophysiologic changes in the lefthemisphere. Additional patients are currently being explored toverify this finding.

F1C-6 Does a TMS-Induced Increase in CorticalExcitability Trigger Adaptive Mechanisms?A Repeat Bout iTMS Study

D. J. Edwards,1,2 F. L. Mastaglia,2 M. L. Byrnes,2

and G. W. Thickbroom2

1Centre for Neuromuscular andNeurological Disorders, The University of WesternAustralia, Australia; 2School of Exercise,Biomedical and Health Sciences, Edith CowanUniversity, Australia

Background: We have previously shown that repetitive (0.2Hz) paired-pulse (1.5 ms) transcranial magnetic stimulation(TMS) at I-wave intervals (iTMS) can increase corticomotor ex-citability by up to 4-fold. While substantial, the increase incorticomotor excitability is relatively short-lasting (10 min),raising the possibility that mechanisms may have been activatedto contain and reverse the increase in excitability. To explorewhether such mechanisms may be long-lasting, we comparedthe effectiveness of iTMS in a group of 7 subjects (5 M; 20-50years) who underwent 2 iTMS interventions 2 weeks to 8months apart. Methods: MEP amplitude (1st dorsal interosseousm.) was measured before, during, and after each intervention.Change in MEP amplitude (%) before and after intervention andrate of increase during intervention were measured. Results:Study 1 showed a progressive increase in MEP amplitude duringthe intervention (9.2%/min; P < 0.001) and a mean 470% in-crease in amplitude postintervention (P < 0.01), whereas no sig-nificant change in MEP amplitude during or after intervention(1.68%/min, P > 0.2; 85%, P = 0.96; during and postintervention)was observed in study 2. Conclusion: iTMS is highly effective inincreasing cortical excitability in persons first exposed to the in-tervention but not thereafter. We hypothesize that some form ofcortical plasticity (e.g., homeostatic plasticity) may have beenactivated to control the increase in excitability and that thisresponse is enduring.

F1C-7 Case Studies on Vibrotactile Imageryamong Poststroke Patients

C. C. H. Chan,1 K. W. S. Chow,1 K. P. Y. Liu,1 L. S. W.Li,2 and C. W. Y. Hui-Chan1

1The Hong Kong Polytechnic University, HongKong; 2Tung Wah Hospital and the University ofHong Kong, Hong Kong

Background: Previous event-related potential (ERP) studyindicated that vibrotactile imagery was composed of at least 2processes: image generation (denoted by N400) and mainte-nance (P600) which elicited from the frontoparietal and centralareas. This study examines the ERPs associated with imaginingvibrotactile sensations among 3 poststroke patients with differ-ent brain lesions. Methods: 3 patients participated in this study.Their brain lesions were infarction of right cerebellum (1st), theright thalamus (2nd), and left MCA identified by Miring the im-agery task; the subjects imagine the vibrotactile sensationprimed by a vibrotactile stimulus applied on the right hand. Inthe control task, the subjects passively detected vibrotactilestimuli. The ERP of 12 normal subjects was used for compari-sons. Results: For patient 1, when compared with normal, theN400 was more negative-going in all except the bilateral occipi-tal sites, whereas the P600 was more positive-going in all exceptthe left temporal area. The only difference identified in patient 2was that the amplitude of the P300 was relatively more positive-going than that of the control condition at the right central andtemporal areas. Patient 3’s ERPs component was missing in bothconditions. Conclusion: The vibrotactile imagery processeswere probably modulated by lesions in the cerebellum andthalamus. More prominent modulation effects were originatedfrom lesions over the frontoparietal areas. This supported theroles of the frontoparietal areas in the vibrotactile imagery.

F1C-8 Cortical Sensorimotor Plasticity afterSpinal Cord Injury

M. C. Verrier,1 M. G. Fehlings,2 D. J. Mikulis,3 W. E.McIlroy,4 M. J. Jurkiewicz5

1Department of Rehabilitation Science UofT,Canada; 2Department of Surgery UofT, Canada;3Department of Medical Imaging UofT, Canada;4Department of Physical Therapy UofT, Canada;5Department of Physiology UofT, Canada

Background: Although the consequences of spinal cord in-jury (SCI) within the spinal cord and peripheral nervous systemare well defined, the influence of SCI on the brain during recov-ery remains largely unexplored. Methods: We investigated therelationship between recovery from SCI and the associatedchange in movement-related cortical activation using a func-tional MRI paradigm. Seven persons with acute SCI were stud-ied over the 1st year postinjury. Ten control subjects were stud-ied, 2 longitudinally. Motor tasks consisted of wrist, hand, andfoot movements. Sensory and motor recovery was assessed us-ing the ASIA Neurological Classification of SCI. Results: In theSCI subjects, initially impaired wrist movement recovered suchthat by the final study session, movement was performed with-out observable impairment. During impaired movement, littletask-related activation within primary motor cortex (M1) waspresent, whereas higher-order sensorimotor cortical activationwas extensive. During recovery, M1 activation increased and



higher-order activation decreased such that by the final studysession, the overall pattern was similar to that in controls per-forming comparable movements. The results for hand and footmovements were similar. If movement did not recover, how-ever, a progressive decrease toward no activation was observedacross all sensorimotor areas. Conclusion: Understanding corti-cal contributions to movement recovery could prove useful inimproving therapeutic interventions.

F1D-1 Feasibility of an Explosive-Jump Trainingfor Nonambulatory Hemiparetic Patients afterStroke

J. Mehrholz, K. Rutte, and M. PohlDepartment of Early Rehabilitation, Klinik BavariaKreischa, Germany

Background: In recent years, valuable sport and trainingprinciples were introduced into stroke rehabilitation. Drawingon the principle of task-oriented training, a modified form of ex-plosive-jump training could be helpful in increasing musclestrength and force production of the affected limb in patientswith hemiparesis. The aim of the present study has been, there-fore, to summarize the feasibility of an explosive-jump training,as implemented in the rehabilitation process of nonambulatorypatients. Methods: Six nonambulatory patients with hemiparesisdue to stroke received a modified form of explosive-jump train-ing performed during 6 weeks. FAC, 6-minute walk test, gait ve-locity, stride length, Rivermead visual gait index (RVGA),motricity index, modified Tardieu and Ashworth Scale and Fugl-Meyer subtest passive joint motion, and pain were measured atbaseline and after 6 weeks. Results: All patients were able towalk at the end of training, increased gait capacity (from mean97 ± 33 m to 289 ± 134 m; P < 0.05), increased gait velocity (from0.25 ± 0.10 to 1.05 ± 0.50 m/s; P < 0.05) and improved stridelength (from 0.30 ± 0.09 cm to 0.58 ± 0.23 cm; P < 0.05). Gaitquality (RVGA) improved from 38.7 ± 5.6 points to 24.8 ± 7.0points (P < 0.05) together with motricity index of the affectedleg (from 38 ± 11 points to 56 ± 15 points; P < 0.05). Spasticity re-mained unchanged over time (n.s.). Conclusion: Explosive-jump exercises are feasible for selected patients after strokewith hemiparesis and may be helpful in improving gait ability.

F1D-2 No Long-term Effects of 6 WeeksWhole-Body Vibration on Balance Recoveryand ADL in the Postacute Phase of Stroke:a Randomized Controlled Trial

A. C. H. Geurts1 and I. J. W. van Nes2

1Radboud University Medical Centre, theNetherlands; 2St Maartenskliniek, the Netherlands

Background: The long-term effects of 6 weeks whole-bodyvibration (WBV), as a novel method of somatosensory stimula-tion, on postural control and ADL were compared to those of 6weeks exercise therapy on music (ETM) of the same intensity inthe postacute phase of stroke. Methods: 53 stroke patients ad-mitted for clinical rehabilitation with moderate to severe func-tional disabilities were randomized within 6 weeks poststrokeand within 3 days after admission to either a WBV or ETMgroup. The WBV group received 4 × 45 s daily stimulation onthe Galileo 900 (30Hz frontal-plane oscillations of 3 mm ampli-tude) for 5 d/wk during 6 weeks. The ETM group received thesame amount of exercise therapy on music. All patients fol-

lowed a regular inpatient rehabilitation program. Outcomevariables included the Berg Balance Scale, Rivermead MobilityIndex, Barthel Index, Functional Ambulation Categories, and10-meter walking test at 0, 6, and 12 weeks follow-up. Results:At baseline, both groups were comparable in terms of prognos-tic factors and outcome measures. During the study, bothgroups received the same amount of rehabilitation training.Both at 6 and 12 weeks follow-up, no clinically relevant or sta-tistical differences in outcome were observed between thegroups. No side effects were reported. Conclusion: Daily ses-sions of whole-body vibration during 6 weeks are no more ef-fective in terms of recovery of balance and related ADL than thesame amount of exercise therapy on music in the postacutephase of stroke.

F1D-3 Using Video-Link Technology to ContinueRehabilitation in Spinal Cord Injury

H. Pain,1 A. Soopramanien,1 R. Prior,3 M. Menarini,2

and M. Ventura4

1Salisbury Healthcare NHS Trust, United Kingdom;3Centro di Neurologia, Italy; 2MontecatoneRehabilitation Institute, Italy; 4Centre deTraumatologie et de Readaptation, Belgium

Background: Spinal injury centers in many European statesseek to observe patients for life. Scarce resources are threaten-ing this concept, and telemedicine (TM) may salvage it. TM ismainly used in tertiary care. The THRIVE project is a random-ized controlled trial to evaluate the use of video-link sessions tosupport patients at home in Belgium, Italy, and the United King-dom. Methods: Real-time sound and video is encrypted andtransmitted via the Internet. At discharge, adults with acute spi-nal cord injury were randomized into trial or control groups;both had the usual postdischarge support, but the trial groupalso received regular TM sessions, alternating between medicaland therapy protocols weekly for 2 months and then fortnightly.Both groups kept a record of their health status. Participantswere visited at 2 and 6 months postdischarge. At entry and at 2and 6 months, measures were applied, and at 6 months, a satis-faction questionnaire was administered. Results: So far, 89 pa-tients have entered the study, which will continue until June2006. In general, the TM group has appreciated the additionalcontact with their spinal injury centers, but some felt it was notneeded as frequently. The effectiveness of TM and comparisonbetween the trial and control groups of intrasubject differencesin the quality of life measure between discharge and 6 monthswill be presented. Conclusion: Video-link surmounts geograph-ical barriers and improves access to quality care. This study pro-vides evidence of TM as a tool in rehabilitating disabling neuro-logic conditions.

F1D-4 TENS during Acute Stroke ImprovesMotor Functions of the Paretic Upper Extremity

S. S. Y. Au-Yeung and C. W. Y. Hui-ChanThe Hong Kong Polytechnic University, Hong Kong

Background: A previous study in our laboratory has shownthat TENS applied during acute stroke reduced ankle spasticityand improved dorsiflexion torque. The present study set out toexamine the effects of early TENS on stroke-inducedsensorimotor dysfunctions of the paretic upper extremity (UE)in a double-blind controlled clinical trial. Methods: Aside from19 acute stroke subjects recruited as controls, patients within 46



h after stroke onset were randomly allocated to receive eitherconventional rehabilitation alone as a control (n = 17) or withTENS (n = 28) or placebo-TENS (n = 21) applied to 6 acupunc-ture points 1 h/d, 5 d/wk for 4 weeks. Outcome measures were2-point discrimination in finger pulp, strength of power andpinch grips, and UE function measured with the Action Re-search Arm Test. Assessments were made at recruitment and atmonthly follow-ups until 5 months after treatment ended.Mixed model ANOVA was used to test for differences betweenthe groups. Results: There was no difference in 2-point discrimi-nation between groups. Grip strength and UE function werefound to be greater in the TENS than in the control group (re-spectively, P < 0.01 and P ≤ 0.01), starting respectively from 1and 3 months after TENS ended. These effects were maintainedto 5 months after treatment. Conclusion: Early intensive TENSimproved the strength of hand grips and UE function but not 2-point discrimination in the wake of acute stroke. The lack of dif-ference between the effects of TENS and placebo-TENS couldbe due to small sample size or the presence of placebo effects.

F1D-5 The Intensity of the Afferent Input is theMain Factor for the Benefit of the Rehabilitationin Acute Stroke Patients

R. M. Umarova, M. M. Tanashyan, L. A. Chernikova,and M. V. KrotenkovaInstitute of Neurology, Russia

Background: It was shown that intensive motor exerciseswere harmful for motor recovery in acute stroke. But the affer-ent input (AI) is necessary for a better recovery. The possibilityof using adequate rehabilitation methods for acute stroke pa-t i en t s needs proper eva lua t ion . Neuromuscu la relectrostimulation (NES) could be the potential AI. Methods: 25patients (67 [61; 74] years) within 48 hours after the symptomsonset of acute ischemic stroke were included in the study. Allpatients had upper extremity paresis. The treatment group con-sisted of 17 patients receiving NES of the paretic wrist and fin-gers extensors with average 26 [13; 41] hours after stroke onset.NES was made 20 min twice daily for 3 weeks. All patients re-ceived conventional therapy. They were studied with MRI in-cluding diffusion- and perfusion-weighted imaging beforetreatment and at 5 and 21 days and 3 months after stroke onset,and clinical scales were assessed at the same time. Results: NESimproved motor and functional recovery in the treatment group(assessed by European Stroke Scale, Fugl-Meyer Scale, MotorAssessment Scale) (P < 0.05). None in the treatment group hadhands’ flexor spasticity. According to dynamic MRI data, NESdid not disturb normal evolution of acute ischemic lesion. Con-clusion: We suppose that in our study NES provided the AI,which was adequate for the neurons and did not lead to any ad-ditional damage. The safety of rehabilitation in acute stroke de-pends most of all from the intensity of AI provided by themethod.

F1D-6 New Technologies in Rehabilitation ofStroke Patients

A. B. Guekht1 and I. B. Kozlovskaya2

1Russian State Medical University, Russia; 2Instituteof Medical and Biological Problems (IMBP), Russia

Background: Stroke is one of the main causes of disability.New technologies, based on the methodology of dynamic

proprioceptive correction, are being implemented in the reha-bilitation of stroke patients (SP). Methods: ”Loading suit” and“medical shoe” artificial support were evaluated. Each methodhas been investigated in an open-label randomized compara-tive study. Loading suit study included 98 SP, and medical shoe,30 SP. Informed consent was obtained in all patients. The stud-ies were single-blind, and the control groups underwent thesame procedure, but the suit or shoe was loosely put on patientsand corrective procedures were not initiated. The efficacy wastested with the use of Lindmark and Barthel scales, muscle stiff-ness analysis and transcranial magnetic stimulation (TMS).EuroQoL was assessed before and in 6 months after treatment.Results: According to the scales and TMS, improvement was sig-nificantly more pronounced in the “new technologies” groups(NTG) over controls. In the loading suit group, there was obvi-ous (P < 0.05) decrease of central conduction time values (12.38± 0.68 ms before and 10.22 ± 0.69 ms after the course) as well asthe increase of the amplitude of M response of m. abd. pol.brevis in paretic hand (1228.2 ± 56.9 mcV before; 1740.3 ± 65.4mcV after). Improvement in all domains of the EuroQoL wassignificantly superior in the NTG over controls. Conclusion:The results of the study proved the beneficial influence of thenew technologies in SP.

F1D-7 The Therapeutic Effect ofElectromechanical Gait Trainer and FunctionalElectrical Stimulation for Patients with AcuteStroke

M. F. W. Ng,1 K. Y. Tong,1 E. F. M. So,2 and L. S. W. Li31The Hong Kong Polytechnic University, HongKong; 2Department of Physiotherapy, Tung WahHospital, Hong Kong; 3Tung Wah Hospital/TheUniversity of Hong Kong, Hong Kong

Background: Both functional electrical stimulation (FES)and electromechanical gait trainer (GT) have demonstratedpositive therapeutic effects during stroke rehabilitation. The ob-jective is to evaluate the short-term and long-term effects ofcombined GT-FES in postacute stroke rehabilitation. Methods:Patients with acute stroke (onset time shorter than 6 weeks)were randomly assigned to 3 groups: control with overgroundgait training (CT), GT, and GT-FES groups. All subjects prac-ticed for 20 min/d, 5 d/wk for 4 weeks in addition to the con-ventional therapy. Outcome measures of 5-meters walkingspeed, Elderly Mobility Scale (EMS), Berg Balance Scale(BBS),Functional Ambulatory Category(FAC), and Motricity Index legsubscore(MI) were recorded before, after 4 weeks intervention,and at 6-month follow-up (6mthFU). Results: GT and GT-FESgroups showed greater improvement than the CT group after 4weeks in EMS (CT vs. GT, P = 0.008; CT vs. GT-FES = 0.008),walking speed (CT vs. GT = 0.038; CT vs. GT-FES = 0.005) andFAC (CT vs. GT = 0.001; CT vs. GT-FES = 0.006). At 6mthFU, MI(CT vs. GT-FES = 0.016) and FAC (CT vs. GT = 0.001; CT vs. GT-FES = 0.006) still showed significant difference. However, therewas no significant difference between GT and GT-FES groups at4 weeks and 6mthFU. Conclusion: The GT, with or without FES,helps the patients have faster gait, greater mobility, and ambula-tory improvement than CT in the postacute stroke rehabilita-tion. 6mthFU showed that both GT and GT-FES groups still hadthe beneficial effects persisted.



F1D-8 Body-Weight Supported Gait TrainerExercises with or without Functional ElectricalStimulation Improves Gait in Patients withChronic Stroke

S. H. Peurala,1 K. Pitkanen,2 J. Sivenius,2

and I. M. Tarkka2

1University of Jyvaskyla, The Finnish Centre forInterdisciplinary Gerontology, Finland; 2BrainResearch and Rehabilitation Center Neuron,Finland

Background: Despite being independent ambulators, moststroke patients have endurance problem due to muscle weak-ness and decreased walking velocity. The purpose of this studywas to evaluate the body-weight supported gait rehabilitationin patients over 6 months poststroke and to see whether func-tional electrical stimulation (FES) had an additional effect.Methods: Each patient practiced every workday for 20 min walk-ing either 1) in the electromechanical gait trainer with FES deliv-ered to 2 muscles on the paretic lower extremity (GTstim, n =11) or 2) in the gait trainer without FES (GT, n = 11) during 3weeks in-patient rehabilitation period. The patients’ motor abil-ity was assessed with the Modified Motor Assessment Scale(MMAS), 10-meter walking test, and 6-minute walking test.Spatiotemporal gait characteristics were assessed with an elec-trical walkway. Results: Comparison of 2 groups revealed nodifferences between groups. Motor ability by MMAS improved19% vs. 12% (GTstim vs. GT), gait velocity improved 13% vs.20% and 6-minute walking distance improved 21% vs. 14%, thedifferences did not reach statistical significance. Gait-orientedrehabilitation improved step time, step length, stride length,and swing time on the affected side. The follow-up at 6 monthsshowed no decline in gains in gait. Conclusion: The gait trainerprovided lot of steps and resulted in motor improvements.However, FES did not have additional effect. Intensive trainingimproved gait in patients with chronic stroke.

FREE PAPER SESSIONS–February 14, 2006

F2A-1 Effect of Carers’ Psychological Functioningand Coping on Rehabilitation Outcome of HeadInjured Patients

R. Kausar,1 C. F. Schaw,2 S. Hampson,2

and M. V. D. Broek2

1University of the Punjab, Lahore, Pakistan;2United Kingdom

Background: Head injury is a common cause of persistentdisability, and survivors are left with a range of physical, cogni-tive, and emotional deficits. Main responsibility of care after dis-charge from the hospital usually rests with the family and carers.Main aim of the present research was to investigate whethercarers’ psychological functioning and coping strategies they useeffect rehabilitation outcome of the head injured person. Meth-ods: Sample comprised 42 head-injured patients who had ac-quired head injury 4 to 18 months before the assessment andwas recruited through St. Goerges’ Hospital in London. GeneralHealth Questionnaire, Coping Response Inventory, and BrianInjury Community Rehabilitation Outcome scales were used as

assessment measures. Results: Analysis revealed that carerswere significantly distressed, and they employed a range ofemotion-focused and problem-focused strategies. Distress incarers varied as a function of severity of head injury, the carers’relationship to the patient, and coping strategies they em-ployed. Patients’ functioning, in particular patients’ self-organi-zation ability, interpersonal relationships, employment out-come, and emotional outcome were predicted by carers’psychological functioning. However, coping did not emerge asa strong predictor of patients’ outcome. Conclusion: Findingshighlight the importance of provision of psychological supportfor carers to deal with their distress so that they in turn couldprovide quality care to the head injured persons in thecommunity.

F2A-2 Measurement of Nutritional Outcome inSeverely Brain-Injured Adults—The IndianExperience

S. C. Damaraju and P. NarayanLakshmi Neuro Centre, India

Background: Patients with severe brain injury require pro-longed care and intensive rehabilitation. During this period,they are incapable of self-nutrition and vulnerable to infections.It is also difficult to measure outcome of nutritionalsupplementation particularly in developing countries due toscarce resources. The aims of this study are to highlight the im-portance of nutrition in brain-injured adults and explore the useof simple lab tests to measure outcome. It is hypothesized thatoptimal nutrition will nurture the patient’s immune system andreduce infection. White blood cell counts (WBC) and serumprotein values were used to measure outcome. Methods: Datawere collected prospectively from 15 (n = 15) brain-injured pa-tients who underwent rehabilitation for 4 or more weeks. Theywere all put on nutritional supplements until they were able tofeed themselves. Total white blood cell (TWBC) counts and se-rum protein levels were checked at admission and after 4 weeksof rehabilitation. Results: Infections were minimal in these pa-tients reflected by low TWBC counts pointing to better infectioncontrol. TWBC, neutrophils, and lymphocytes showed statisti-cally significant reduction in values over the 4-week period (P <0.01). Other white cell counts and serum proteins did notchange significantly. Conclusion: Nutrition can be indirectlymonitored using TWBC values indicating good immunity in awell-nourished patient.

F2A-3 Clonidine in the Management ofDysautonomia after Severe TBI

I. J. Baguley, R. E. Heriseanu, and S. Slewa-YounanBrain Injury Rehabilitation Service, WestmeadHospital, Australia

Background: Dysautonomia is a distinct clinical syndromeaffecting a small subgroup of severe traumatic brain injury (TBI)survivors who exhibit severe, paroxysmal autonomic distur-bances associated with noxious stimuli. Intensive care clini-cians often use clonidine to minimize the extent of autonomicchanges in this condition. Clonidine is an alpha2 adrenoceptorreceptor agonist that inhibits both central and peripheral sym-pathetic activity. In 1 study of 7 cases with severe TBI, clonidinereduced plasma norepinephrine and decreased HR without adecrease in cerebral blood flow. However, there is little evi-dence to support the use of clonidine in dysautonomia. Meth-



ods: Physiological variables and heart rate variability were com-pared in 5 dysautonomic and 5 nondysautonomic patients atrest a mean of 7 d after TBI. To assess the paroxysmal nature ofdysautonomia, data were collected before and after a surrogatenoxious stimulus (routine endotracheal tube suctioning). Re-sults: Dysautonomic patients on clonidine showed lower rest-ing heart rates (80 vs. 100 bpm) than patients without the condi-tion. Suctioning produced a mean 20 bpm rise in heart rate indysautonomia compared to a 1.5 bpm fa l l in thenondysautonomia group. Conclusion: Clonidine produced a re-duction in resting heart rate in dysautonomic patients but didnot overtly influence variables during dysautonomic crises.

F2A-4 The Effect of Early Intervention on BoneQuality in Rats after Spinal Cord Injury

F. Cong, S. R. Ji, H. J. Zhou, and J. J. LiChina Rehabilitation Research Center, China

Background: To explore the effect of early administration ofalendronate (ALN) and pulsed electromagnetic fields (PEMFs)on bone quality in rats after spinal cord injury (SCI). Methods: 62healthy 3-month-old female SD rats were randomly allocatedinto 5 groups: a sham group, SCI group, SCI+ALN group,SCI+PEMF group, SCI+PEMF+ALN group. Rats in the shamgroup underwent laminectomy, whereas rats in the other 4groups underwent complete spinal cord transection, and thelatter 3 groups were treated with ALN and/or PEMF 1 week afterSCI. All rats were sacrificed 8 weeks after the operations. Bonemineral density (BMD), biomechanical parameters of the fe-murs, and histomorphometric parameters of the proximal tib-ias were measured. The resulting data were analyzed using one-way ANOVA and factorial design ANOVA. Results: After earlyALN and/or PEMF treatment, the BMD of the femur was signifi-cantly increased compared to the rats in the SCI group. The elas-tic load and maximal load of the femur were also significantlyincreased compared with the rats in the SCI group, and the per-centage trabecular bone area and the trabecular bone width ofthe tibia were significantly increased compared with the SCIgroup. Conclusion: Early treatment using ALN and PEMFs canreduce the loss of bone, improve the biomechanical propertiesof the femur, and inhibit the decay of microstructure in the up-per part of the tibia. The study suggests that ALN and PEMFsmay help to prevent osteoporosis after SCI.

F2A-5 Functional Restoration of VoluntaryLocomotion in Paraplegics T 6-10 (ASIA Group A)by Nerves Graft Bypass and FES Neuroprosthesis

K. R. H. von Wild,1 G. A. Brunelli,2 and P. Rabischong3

Medical Faculty of the Westphalien Wilhelm’sUniversity, Germany; 2Foundation for Research ofSpinal Cord Lesion Brescia, Italy; 3Faculty ofMedicine of Montpellier, Centre ProparaMontpellier, France

Background: Up till now, complete cord lesions cannot behealed. Bypass nerve grafting and implantation of FES may beused to restore useful locomotion in paraplegics. Methods: Ap-proval of the ethical committees was obtained. At 1) 2000 to2002, we connected in 3 patients SCI of T 8/9 ASIA-A the intacttractus corticospinalis lateralis of both sides to the disconnecteddistal nerve stumps of Mm. gluteus maximus, medius, andquadriceps femoris with the aid of Nn. surales. At 2) 1999 to2000, implantation of neuroprosthesis (16 channel) for com-

puter added FES in 2 male patients SCI of T 7/8 ASIA-A, con-nected via implanted epineural and epimyseal electrodes to thehip muscles mentioned above. Results: After grafting in patientNo. 1, 1st movements occurred after 17 months. Now sheswims, and with the aid of crutches, she can walk and climbsome steps. Patient No. 1 uses FES 3 times a week to stand andwalk (80 m each), whereas in the 2nd patient the implant wasremoved because of infec t ion. Conclus ion: Underglutamatergic transmission, NMJ switches from cholinergic typesynapse so that bypass grafting works via the 1st motor neuron.Neuroprosthesis has the advantage of a permanently implantedFES system but the disadvantage of high costs and risk of infec-tion. Lifelong physical training is necessary in both groups.

F2A-6 Assessing Fine-tuning of Voluntary MotorOutput in Patients with Incomplete SpinalCord Injury

H. J. A. van Hedel1 and A. Curt21Balgrist University Hospital, Switzerland;2University of British Columbia, Canada

Background: A lesion of corticospinal motor pathways in in-complete spinal cord injury (iSCI) impairs voluntary motor con-trol. The latter depends on appropriate temporal and spatial re-cruitment of motor units and can be indirectly assessed by thefine-regulation of skilled motor tasks. Methods: In 17 healthyand 19 iSCI subjects (tested in supine position) the foot wasplaced in a device that measured isometric plantar and dorsalflexion torque. Maximal torques were used to calibrate targettrajectories displayed on a monitor. The subjects were in-structed to “follow” the target trajectories by applying adequatetorque. The accuracy was quantified by an accuracy index (AI).A perfect match of the trajectories resulted in AI = 100. AI wascorrelated with maximal torque and clinical tests. Results: Per-formance after repetitive trials was reduced in iSCI (AI = 48 ± 23;controls: AI = 71 ± 9; P < 0.001), but the learning rate was pre-served. In patients, higher accuracy correlated with maximaltorque (rho = 0.29) and better proprioception (rho = 0.52), butsome patients with no proprioception scored normally (AI =60). Conclusion: Task performance (dexterity) is reduced iniSCI subjects, although learning remains unchanged. As this im-pairment is not simply related to the preserved muscle strengthand proprioception, it is assumed to allow an indirect assess-ment of the corticospinal motor pathways.

F2A-7 Symptoms and Life Satisfaction 3 Yearsafter Head Injury in a 1-Year Sample of Patientsin the University Hospital of Umeå Sweden

P. Sojka, B. M. Stalnacke, and U. BjornstigDepartment of Community Medicine andRehabilitation, Rehabilitation Medicine, UmeåUniversity, Sweden

Background: There are only a few comprehensive studiescomprising long-term follow-up of patients with head injury inspecifically defined geographic areas. Methods: Patients withhead trauma during 2001 were enrolled at the Umeå UniversityHospital (serving a population of 138 000 inhabitants). The on-going injury and trauma register and ambulance and hospital re-cords were used to collect data. During 2004, a follow-up of pa-tients between 18 and 64 years of age was performed usingRivermead Post-Concussion Symptom Questionnaire (RPQ),Becks Depression Index (BDI), and Life Satisfaction Question-



naire (LiSat-11) during 2004. Results: Altogether 226 subjects(age 15-61 years during 2001) were treated in the hospital be-cause of head injury (Glasgow Coma Scale 13-15: 214 subjects;9-12: 5 subjects; 3-8: 8 subjects). It was possible to reach 213 pa-tients with questionnaires, which were completed by 171(80.3%). On follow-up, the 3 most commonly reported symp-toms were fatigue (52.9% of the responders), memory problems(51.8%), and headache (51.2%); 2.4% of the patients fulfilled cri-teria for severe and 11.8% for moderate depression. LiSat-11 dis-closed that all measures of life satisfaction were lower in com-parison to a normal population of Swedish subjects (there werestatistically significant differences for physical health, psycho-logical health and economy, P < 0.05). Conclusion: Three yearsafter a head injury, persisting symptoms are very common andthe life satisfaction levels appear to be lowered.

F2A-8 Effect of Varying FES-Induced PedalCadences on Cardiorespiratory Responses andLeg Metabolism in Persons with SCI

G. M. Davis and C. FornusekRehabilitation Research Centre, University ofSydney, Australia

Background: Functional electrical stimulation (FES) exer-cise has been used after chronic SCI to reverse muscle atrophyand improve cardiorespiratory fitness. This study investigatedthe influence of 15, 30, and 50 rev•min–1 pedaling cadences oncardiorespiratory and peripheral muscle responses evoked dur-ing FES-cycling. Methods: Nine T4-T9 SCI performed isokineticFES-evoked leg cycling exercise (iFES-LCE) over 35 min. Ateach pedal cadence, cardiovascular responses (HR & CO), oxy-gen uptake (VO2), leg muscle oxygenation and mechanical effi-ciency (MEgross) were recorded. Results: Passive cycling exer-cise at each pedal cadence did not alter physiologic responsesabove resting values. In contrast, iFES-LCE significantly (P <0.05) elevated cardiorespiratory responses over rest (iFES-LCE542 ± 31 mL•min–1, HRiFES-LCE 91 ± 4 b•min–1, COiFES-LCE7.1 ± 0.5 L•min–1). However, the different pedaling cadenceswere not associated with any variation of exercise metabolism.Over 35 min, MEgross was significantly greater at 30 and 50rev•min–1, compared to 15 rev•min–1 (ME30gross 2.6% ± 0.2%,ME50gross 2.5% ± 0.2% vs. ME15gross 2.0% ± 0.2%, P < 0.05).There was also a nonsignificant trend for a lower muscle oxy-gen saturation at 15 rev•min–1. Conclusion: Complex relation-ships between chronically paralyzed muscle fiber compositionand contraction velocity may explain these results. FES cyclingat a faster cadence did not confer any obvious advantages over30 or 15 rev•min–1 for cardiorespiratory fitness development.

F2B-1 Muscle Activation in Multiple SclerosisPatients during Antigravity Movementof Lower Limbs

R. Gatti, M. Corti, M. Comola, G. Comi, and P. RossiUniversity Vita-Salute—San Raffaele Hospital, Italy

Background: Aim of the study is to analyze muscles recruit-ment of lower limbs during motor activity in reaching theantigravitary position in patients with multiple sclerosis (MS)and compare with that in the healthy subjects. Methods: Westudied 11 healthy subjects and 11 MS patients with mild tomoderate disability (EDSS range, 2.5-4.5). All subjects were re-quested to keep their lower limbs elevated with 2 different mo-tor tasks: A) raising the limbs from the supine position and B)

reaching same position by raising up both legs and then layingdown the left one. We studied motor activity of right rectusfemoris, both recti abdominis, and left biceps femoris with sur-face EMG and kinematic analysis. Results: Both MS patients andhealthy subjects were able to perform the tasks. In task B,healthy subjects showed increased activity of recti abdominisand decreased on one of biceps femoris (P < 0.0001) when com-pared to exercise A. In MS patients, there was no significant dif-ference in muscle activation between the 2 motor tasks, but theyshowed greater muscle activation than healthy subjects. Con-clusion: MS patients showed a widespread muscle activity dur-ing tasks compared with the healthy subjects, loosing the possi-bility of choosing how to activate them. This data seems toreveal a sort of “luxury recruitment,” which tries to compensatemotor control impairment due to disease.

F2B-2 Correlations between Speed Impairmentand Strength Reduction in Ambulatory Patientswith Multiple Sclerosis

P. Thoumie, M. Faucher, M. Vinti, S. Cantalloube,and D. LamotteHopital Rothschild APHP et U731 Inserm/UPMC,France

Background: A prospective analysis of gait and strength pa-rameters was performed in 100 patients diagnosed with MS andpyramidal involvement to assess the correlation betweenstrength and gait impairments. Methods: The patients were di-vided into 2 groups based on their ability to walk in daily life(nonassisted or cane-assisted gait) and into 4 clinical sub-groups, depending on associated involvements such as sensoryloss or cerebellar ataxia. Twenty healthy subjects were studiedas a control group. Gait parameters were evaluated with aLocometer and muscle strength with an isokinetic dynamome-ter at 60-sec speed. Results: The average velocity and strength ofthe hamstring and quadriceps were strongly correlated and re-duced in the MS group in comparison with the control and in thecane-assisted group compared with the nonassisted group. Gaitvelocity tended to be more correlated to hamstring strength inthe nonassisted group with a determination coefficient (r)reaching a value of 0.44 in the sensory subgroup. Conclusion:These findings provide evidence that a correlation betweenstrength reduction and gait impairment is obvious whicheverclinical form in patients with MS but may change depending onthe disability level and the clinical form. This could be taken inaccount in the individual assessment of further rehabilitationprograms.

F2B-3 In-Phase and Antiphase movements inNondisabled Multiple Sclerosis Patients: AKinematic and Brain MRI Study to DetectSubclinical Motor Impairment

P. Rossi, M. A. Rocca, R. Gatti, G. Comi, and M. FilippiUniversity Vita-Salute—San Raffaele Hospital, Italy

Background: We compared in-phase and antiphase rhyth-mic movements of dominant hand and foot in a group of right-handed MS patients without disability and in healthy subjects.Motor performance was evaluated with kinematics analysis andwith fMRI to detect subclinical impairment and its correlationwith brain activity. Methods: 16 MS patients without disabilityand a group of 14 healthy volunteers performed in-phase and



antiphase movements of right hand and foot at a spontaneousand maximum speed and at a frequency of 1 Hz. Kinematicsanalysis analyze frequency, time to error (TE), and delay ofhand in respect of foot; fMRI analysis evaluated brain activityduring the task. Results: In-phase movements were performedat higher frequencies at all speeds than antiphase ones. Healthysubjects had better performance than MS patients at spontane-ous speed and at 1 Hz. Seven MS patients were not able to per-form the antiphase test at 1 Hz and showed a significant differ-ence in frequencies and in TE at maximum speed. Delaysanalysis showed a significant impairment in MS patients. fMRIrevealed that MS patients who are unable to perform antiphasemovements had an increased activation of frontal and parietalareas compared with those that were able to perform it. Conclu-sion: Analysis of antiphase movements could be a test able todetect a subclinical motor impairment in MS patients. Increasedactivation of frontal and parietal areas seems to contribute inlimiting the clinical consequences of tissue damage.

F2B-4 High Concurrent Presence of Disability inMultiple Sclerosis: Associations with PerceivedHealth

S. Johansson, C. Ytterberg, J. Hillert, L. WidénHolmqvist, L. von KochKarolinska Institute, Sweden

Background: Objectives: 1) To explore functioning and thepresence of disabilities—concerning cognition, manual dexter-ity, walking, energy (fatigue), mood (signs of depression), ac-tivities of daily living (ADL), and social/lifestyle activities—inpersons with multiple sclerosis (PwMS) at an outpatient special-ist clinic. 2) To describe, from the PwMS’s perspective, the per-ceived physical and psychologic impact and to explore their as-sociations with the studied disabilities. Methods: A descriptivecross-sectional study was carried out in 219 PwMS at the MSCentre, Karolinska University Hospital, Huddinge, Stockholm.Standardized instruments and recommended cutoffs were usedfor categorizations of presence of disability. Logistic regressionemploying proportional odds models was used to identify theassociations of the disabilities with the perceived impact. Re-sults: Disability regarding cognition was found in 49%; manualdexterity, 76%; walking, 43%; energy, 67%; mood, 29%; ADL,44%; and in social/lifestyle activities, 47%. Two or more disabili-ties were found in 80%. Disability in energy, mood, walking,manual dexterity, and ADL was significantly associated with in-crease in physical impact, whereas disability in energy andmood was significantly associated with increase in psychologicimpact. Conclusion: The clinical implications are to developstrategies aiming to identify disability in order to develop/sup-ply health care services that may decrease the limitations andthe perceived impact.

F2B-5 Cooling and Multiple Sclerosis:Experiences with 235 patients with MultipleSclerosis for 4 Weeks in a NeurorehabilitationCenter

P. Grieshofer, M. Scarpatetti, R. Scherer,U. Hammer, and K. PapstKlinik Judendorf Strassengel, Austria

Background: Approximately 60% to 80% of multiple sclero-sis (MS) patients are heat sensitive. The aim of this retrospective

study was to gain information on the effects of an assistive de-vice, the cooling suit, on MS patients. Methods: The cooling suitwas used by 235 patients with diagnosed MS in different stagesfrom relapsing/remitting to chronic/progressive and ananamnesis of heat sensitivity. Every patient wore an active cool-ing garment for 30 minutes at 7° C (active cooling) 1 time a dayand 5 times a week as an additional therapy to classical thera-peutical methods (physiotherapy, occupational therapy,neuropsychology, and medical exercising therapy.) Questionswere asked, before the cooling therapy and after 4 weeks oftraining, about their clinical experience. The questions on clini-cal effects included fatigue, muscle strength, walking safety,time of the clinical effects, and side effects. Every patient wasmonitored of blood pressure and tympanic temperature. Re-sults: Fatique showed improvement of 76%; muscle strength of82%, and walking safety of 54%. Clinical effects after coolingwere 2.3 hours. Ten percent of patients stopped the coolingprogram, and the reason was subjective bad feeling. Otherwise,there was no obvious clinical side effect. Conclusion: Cooling isan interesting assistive therapy during a neurorehabilitationprogram to improve the clinical effects for multiple sclerosis butwithout side effects. However, further investigations arenecessary about the long-term effects.

F2B-6 An Innovative Early Approach toNeurorehabilitation in Multiple Sclerosis inCanada

E. P. Weiss,2 N. M. Beauregard,1 J. Spring,1

and G. Vorobeychik1

1Fraser Health MS Clinic, Burnaby Hospital,Burnaby, Canada; 2Dept Medicine, St. Paul’sHospital, Vancouver, Canada

Background: Multiple sclerosis (MS) neurorehabilitation inCanada has been primarily driven by neurologists and nurseswho use therapists when needed. Outside of inpatientneurorehabilitation, there is little evidence to support serviceneeds, levels of care, and functional outcomes. Fraser HealthMS clinic was established in 2004 to provide comprehensive, in-novative, community-based MS care to a large underservicedhealth region. We describe how we established a uniqueneurorehabilitation referral process and assessment tool. Meth-ods: Our neurorehabilitation team used focus groups to identifyan early referral process to their services. They also used the In-ternational Classification of Function, Disability and Health(ICF) to develop a neurorehabilitation tool which assesses,treats, and sets goals for MS patient care. Results: All patientswith neurologic examination impairments or EDSS scoregreater than 3.0 are referred to the neurorehabilitation program.The physiatrist assesses the patient and then includes therapistsfor interventions and outcomes. The assessment tool uses bodyfunction, structures and impairments, activities and participa-tion, and environmental factors to evaluate MS patients. Teaminterventions are suggested and negotiated with the patient, set-ting clear goals to measure outcomes. Conclusion: We believeour unique early referral process and assessments facilitateachievement and maintenance of optimal function in MS pa-tients. We are currently piloting the tool in 10 patients.



F2B-7 Neurorehabilitation Is Effective in theTreatment of Daytime Fatigue in MS Patients

U. A. Zifko,1 M. Rupp1 S. Schwarz,2 and W. Grisold1

1Neurological Rehabilitation Centre, ClinicPirawarth, Austria; 2Neurologic Department KaiserFranz Josef hospital, Austria

Background: Daytime fatigue has a major impact on activi-ties of daily living, quality of life, employment, and on psycho-logic well-being. This study evaluates the efficacy of pharmaco-logic versus pharmacologic and rehabilitative treatment in themanagement of multiple sclerosis associated daytime fatigue.Methods: A total of 50 patients diagnosed with MS (mean age,40.4 ± 10.3 years, 30 females and 20 males; mean disabilitylevel, 3.8 ± 1.5 on the Kurtzke EDSS) were enrolled in a pro-spective 3-month, 2-center, open-label study and received 100to 300 mg modafinil daily. Center A is a general hospital with aneurologic department. All patients in center A were treated onan outpatient basis. Center B is a neurologic rehabilitation cen-ter. Patients in the rehabilitation center received a daily programconsisting of physiotherapy, endurance training, pulsed mag-netic field therapy, and additional procedures adapted to indi-vidual necessity. Results: Mean FSS scores improved from 30.3 ±8.5 at baseline to 25.4 ± 3.7 (P < 0.0001) after treatment withmodafinil. Mean ESS scores also improved significantly from 9.7± 3.9 at baseline to 4.9 ± 2.9 after treatment with modafinil (P <0.0001). Response to treatment was not related to patient age,type of MS, EDSS scores, duration of MS, or gender. Improve-ment of ESS was significantly greater in patients from center B(7.1 ± 5.2) compared to center A (4.5 ± 2.6; P < 0.001). Conclu-sion: Neurorehabilitation is effective in the treatment of daytimefatigue and pronounces the positive effect of modafinil.

F2B-8 Clinical Outcome of 2 Different Tasks forHand Rehabilitation in Patients with ProgressiveMultiple Sclerosis

P. Rossi, R. Gatti, M. Comola, V. Sirtori, and G. ComiUniversity Vita-Salute—San Raffaele Hospital, Italy

Background: In patients with multiple sclerosis (MS), a spe-cific task for hand rehabilitation after a relapse drives to a goodchance of recovery. Here we compare 2 different motor tasksfor hand rehabilitation in progressive MS. Methods: We random-ized 11 MS patients in 2 groups matched for age, sex, diseaseduration, and disability. Group A underwent to a cycle of reha-bilitative therapy with nonspecific motor tasks, whereas groupB made the motor training for the dominant hand through theexecution of specific exercises and biofeedback. Motor perfor-mance of both hands was measured with Jamar test, Pinch test,and 9-Hole Peg Test (9HPT) to evaluate the clinical outcome.Results: MS patients showed an improved performance in all of3 tests. The treated hand showed evidence but not statisticallysignificant improvement of the mean value of delta score beforeand after treatment in group B compared to A in Jamar, Pinch,and 9HPT. The mean absolute scores were significantly differ-ent in group B for Pinch score (P < 0.05). We differently foundthat all 11 patients did not improve their mean absolute scoresafter treatment in the untreated hand. The B group showed asignificant improvement of 9HPT score even in the untreatedhand (P < 0.02). Conclusion: These data seem to attribute amore significant role of specific rehabilitative motor task associ-ated with biofeedback in hand motor recovery that could be at-

tributed to a recruitment of supplementary central motorpathways.

F2C-1 Intrathecal Baclofen (ITB) Therapy forPoststroke Spastic Hypertonia: Recommendationsof a Consensus Panel

G. E. Francisco,1 S. A. Yablon,3 M. C. Schiess,1 S.Cavalier,4 and L. Wiggs2

1University of Texas Health Science Center, USA;2The Institute for Rehabilitation and Research, USA;3Mississippi Methodist Rehabilitation Center, USA;4NeuroMedical Center, Methodist, USA

Background: Intrathecal baclofen (ITB) successfully man-ages poststroke hypertonia in persons who fail to respond to ortolerate adverse effects of oral drugs, botulinum toxin, orneurolysis. Because ITB is a novel therapy in stroke, guidance isneeded as clinicians incorporate ITB in the armamentarium oftherapies for spastic hypertonia. Methods: A consensus panel (3physiatrists, 2 neurologists, 1 physical therapist) who care forstroke survivors with ITB and are active in research on ITB dis-cussed the evidence of ITB’s efficacy and safety, patient selec-tion, timing of ITB therapy, and optimization of therapy out-come. A literature search yielded 35 articles. Only 4 studies thatprimarily studied persons with stroke were considered (2 ran-domized controlled, crossover trials and 2 case series). Becauseof the relative lack of literature, recommendations were heavilybased on expert opinion. Results: Two distinct groups of strokesurvivors benefit from ITB: the low-level group benefits fromimproved positioning and hygiene, and the high-level group,from improving mobility and self-care. The best candidates forITB are those whose hypertonia results in functional impair-ment and discomfort and who have failed other interventions.ITB can be safely used within the 1st 6 months after a stroke, de-pending on impairment severity, and can also be safely usedmany years poststroke. Conclusion: Keys to successful use ofITB in poststroke spastic hypertonia include appropriate pa-tient selection, ITB pump management, and rehabilitationtherapies.

F2C-2 L-Stiff: A New Tool for the Assessment ofMuscle Stiffness with the Lokomat®

A. Mayr and L. SaltuariHospital Hochzirl, Austria

Background: To explore the efficacy of a new measurementtool for the evaluation of muscle stiffness with the driven gaitorthosis Lokomat® (Hocoma AG, Volketswil, Switzerland) inhealthy subjects and in patients with neurologic disorders.Ashworth Scale is the accepted standard for measurement ofspasticity in neurorehabilitation. A more precise and less sub-jective assessment method would be of great value. A newly de-veloped software module of the Lokomat®, the L-Stiff, offers anobjective alternative for evaluating stiffness in the lower limb.Methods: 15 healthy subjects and 15 patients with neurologicdisorders of different causes were tested. Two joints (hip andknee) were examined, pre- and posttraining, with 3 differentangular velocities (30°, 60°, 120°), and on 2 different days (test-retest reliability). Results: Within-group comparison showedlessening of hip spasticity of stroke patients after Lokomat®

training. Young healthy subjects (mean age, 24.6) had less mus-



cle tone in the hip joint than older healthy subjects (mean age,67.6; P = 0.043). The testing on different days and with differentangular velocities showed no differences in tone. Conclusion:This study demonstrates the clinical efficacy of this new mea-suring tool. It could provide valuable and objective documenta-tion of the rehabilitation process of spastic patients.

F2C-3 Reduced Stiffness and Reflexive Gainsaround the Wrist in Spastic Paresis after Stroke

C. G. M. Meskers,1 A. C. Schouten,2 J. H. de Groot,1

F. C. T. van der Helm,2 and J. H. Arendzen1

1Department of Rehabilitation Medicine, LeidenUniversity Medical Center, the Netherlands;2Department of Biomechanical Engineering, DelftUniversity of Technology, the Netherlands

Background: Spastic paresis is a combination of paresis andspasticity, which is a velocity-dependent increase in joint resis-tance. Quantitative data on the contribution of the paretic andspastic component during active or functional tasks are yetsparse. Methods: 10 patients with spasticity after stroke withsome active wrist flexion/extension and an Ashworth scoregreater than 1 were asked to resist linear random force perturba-tions applied around the wrist in the neutral position, holdingthe handle of a haptic robot. Resulting handle position and sur-face EMG of wrist flexors and extensors were used to estimatejoint and reflexive impedance; parameterization was performedby application of 1) a mass-spring-damper (obtaining mass, vis-cosity, and elasticity) and 2) a neuromuscular model (mass, vis-cosity, elasticity, reflexive gain, and time delay). The parame-ters were compared to those obtained from an age- and sex-matched control group. Results: During maximal resistance inthe neutral position (work space) of the wrist, joint stiffness wasfound to be significantly lower in patients compared to controls(4.73 SD 3.80 versus 9.89 SD 2.59 Nm/rad) and reflexive gainswere found not be enhanced (0.35 SD 0.34 versus 0.44 SD 0.14Nms/rad). Conclusion: From the dominance of the paresis com-ponent found in this study considering a maximal task per-formed around the wrist in its neutral position, we concludethat the application of neuromuscular blocks to enhance func-tionality in spastic paresis after stroke should be evaluatedcarefully.

F2C-4 A Comparative Randomized ControlledTrial of the Management of Early Lower LimbSpasticity following Acute Acquired Severe BrainInjury

A. B. Ward,1 D. Verplancke,1 S. Snape,1 C. F.Salisbury,1 and P. W. Jones2

1North Staffordshire Rehabilitation Centre, UnitedKingdom; 2Dept of Mathematics, University of Keele,United Kingdom

Background: To determine whether serial casting combinedwith botulinum toxin reduces the development of calfcontracture after severe head injury. Methods: A double-blindplacebo-controlled trial of 3 parallel treatments for adults aftersevere brain injury and lower limb spasticity. Patients were allo-cated to 1 of 3 groups, if they started to lose ankle dorsiflexion.Control patients received standard physical treatment (group I)

and actively treated patients were placed in a lower leg castingplus gastrocnemius and soleus muscle injections with either sa-line (group II) or with botulinum toxin (group III). Measures in-cluded the limit of ankle dorsiflexion, the Glasgow OutcomeScore (GOS), and modified Ashworth Score (MAS). Results: 253patients were screened and 35 were entered into randomizedpart of the trial. Of the latter, 88.3% developed spasticity within14 days of their injury, and the mean improvement ROM of pas-sive ankle dorsiflexion was 4.59° in controls, 11.69° in cast andsaline, and 13.59° in cast and botulinum toxin. (I vs. II, P = NS; Ivs. III, P = 0.07; and II vs. III, P = 0.11). There were significantimprovements in the MAS in actively treated groups but not incontrols. Conclusion: Casting prevents talipes equinovarus de-formities in patients losing ankle movement after severe braininjury. Casting alone in these patients is sufficient, but the roleof additional botulinum toxin needs further investigation.

F2C-5 REPAS, Resistance to Passive MovementScale: A Summated Rating Scale for Resistance toPassive Movement. Results from a Reliability andValidity Study

T. Platz,1 C. Eickhof,1 K.F. Heise,1 P. Arnold,2 and P.Vuadens2

1Klinik Berlin, Dept. of Neurological Rehabilitation,Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Germany; 2CliniqueRomande de Readaptation, Sion, Switzerland

Background: A systematic literature review of the SPASMgroup (Support Programme for Assembly of Database forSpasticity Measurement; www.spasmproject.org) identified 24clinical scales that assess spasticity and/or related phenomenaas well as 10 scales for active function and 3 scales for passivefunction with an association with spasticity. When reliabilitydata were available, the reviewed evidence signaled that a highinterrater reliability could be achieved but frequently was not,as was shown for interrater reliability of the Ashworth and Mod-ified Ashworth Scales. The purpose of the present study is toevaluate the REPAS, a new summary rating scale for resistanceto passive movement (spasticity). Methods: The REPAS was de-signed (by TP) 1) to improve reliability by describing standardsfor test performance (for individual joint motions) and by defin-ing scoring criteria more precisely (based on the AshworthScale) and 2) to develop a summated rating scale for individuallimbs and across limbs. A cross-sectional twin-center studyevaluates reliability and construct validity of the REPAS andother spasticity scales. Results: Reliability and construct validitydata of this ongoing cross-sectional study will be presented atthe meeting. Conclusion: The REPAS is a new summary ratingscale for resistance to passive movement (spasticity). Results ofa twin-center study provide information regarding its reliabilityand validity.

F2C-6 Neurophysiologic Guidance in InfiltrativeTherapy for Pudendal Neuralgia

S. Malaguti,1 M. Spinelli,2 M. Citeri,2 J. Tarantola,2

and T. Redaelli31Neurourophysiology Spinal Unit NiguardaHospital, Italy; 2Urology Spinal Unit Niguarda



Hospital, Italy; 3Spinal Unit Niguarda Hospital,Italy

Background: Pudendal neuralgia is the major cause ofchronic perineal pain due to pudendal nerve entrapment. It isgenerally treated by injection of anesthetics and corticosteroidsor surgical decompression, under CT or fluoroscopy. Our aim isto verify the feasibility of a new method to deliver infiltrativetherapy (5 mL of 1% of ropivacaina plus 1 mL of long-releaseglucocorticoids) by means of neurophysiologic guidance to thesite of entrapment (proximally or distally to the sacrospinousligament) via dorsal or perineal approach. Methods: Thepudendal nerve terminal motor latency (PNTML) is used as ref-erence trace (RT); electrical stimulation is then used to positiona needle tip adjacent to the pudendal nerve and a continuousmonitoring of PNTML is recorded and compared until the RT isobtained. Five females and 4 males (47.8 ± 13.5 yrs, 2 idiopathic,5 iatrogenic, 2 posttraumatic origin, 12-60 months duration ofsymptoms) underwent infiltrative therapy, 5 via dorsal and 4 viaperineal way. Results: After 2 infiltrations, 6 patients werecured, in 2 patients pain was unchanged, and in 1 patient therewas an improvement of 50%. No significant difference wasfound between the routes of infiltration, but it is related to theduration of symptoms. Conclusion: Neurophysiologic guidanceto infiltrative therapy in pudendal neuralgia is feasible. The pre-cision of diagnosis and accuracy of method suggest our tech-nique as a promising tool in the algorithm of chronic perinealpain treatment due to entrapment of pudendal nerve.

F2C-7 Clinical Predictor Factors of Efficiency ofintrathecal Baclofen in Spastic Patients

D. Ben Smail, N. Roche, A. Peskine, P. Denys,and B. BusselR. Poincare Hospital, France

Background: Intrathecal baclofen (ITB) is a treatment of dif-fuse spasticity since 1984. Numerous publications described theefficiency and tolerance of chronic ITB infusion via a pump.Clinical characteristics of nonimplanted patients after trials arenot described in the literature. We evaluated the clinical predic-tor factors of ITB efficiency. Methods: Evaluation of 100 consec-utive cases of patients who underwent trials in a rehabilitationunit between 2001 and 2003. We compared characteristics of im-planted and nonimplanted populations after trials. Numerousclinical parameters were studied (pathology and its clinical ex-pression, motor disability, type of ambulation, Ashworth Scaleand Penn spasm scores, objectives of treatment before trials).The reasons of failure of ITB therapy were analysed. Results:Statistical analysis showed a significant association betweenpump and gait variables. A significant association was alsofound between pump and functional ambulation categoriesscale score, Penn spasm score variables. On the other hand, norelation was found between pump and Ashworth score, pathol-ogy and clinical expression of the pathology variables. Conclu-sion: This study showed that ITB is preferentially indicated innonwalking patients, who suffer from troublesome spasms. Theobjective was frequently an improvement of comfort and not afunctional improvement at the time of pump implantation deci-sion. The rare failures of the treatment occurred in walkingpatients.

F2C-8 Reliability of the Modified Tardieu Scaleand the Modified Ashworth Scale in AdultPatients with Severe Brain Injury: A ComparisonStudy

J. Mehrholz, K. Wagner, D. Meißner, C. Zange, M. PohlDepartment of Neurological Rehabilitation, KlinikBavaria, Kreischa, Russia

Background: The Modified Tardieu Scale (MTS) has beensuggested to be more appropriate than the Modified AshworthScale (MAS) for use in the measurement of clinical spasticity.Aim of the present study was therefore to assess and to comparetest-retest and interrater reliability of the MTS with the MAS inpatients with severe brain injury and impaired consciousness.Methods: 30 patients with impaired consciousness due to severecerebral damage of various causes were rated in a randomizedorder once daily for 2 consecutive days from 4 experiencedphysical therapists. Shoulder, elbow, wrist, hip, knee, and anklespasticity were assessed by the use of MTS and MAS during datacollection procedures. Results: The test-retest reliability of theMAS was moderate to good (k = 0.47-0.62) and of the MTSmoderate to very good (k = 0.52-0.87). Test-retest reliabilitywas significantly higher within the MTS in comparison with theMAS (Z > 1.96; P < 0.05) except for shoulder extensor and inter-nal rotator muscles (Z > 1.96; P > 0.05). Although interrater reli-ability of both scales was poor to moderate (MAS: k = 0.16-0.42;MTS: k = 0.29-0.53), significantly higher k-values were revealedwith the MTS for all tested muscle groups (Z > 1.96; P < 0.05) ex-cept for wrist extensors (Z < 1.96; P > 0.05). Conclusion: In pa-tients with severe brain injury and impaired consciousness, theMTS provides higher reliability compared with the MAS andmay therefore be a more valid spasticity scale in adults.

F2D-1 Computerized Arm Training Improvesthe Motor Control of the Severely Affected ArmAfter Stroke: A Single-Blinded Randomized Trialin 2 Centers

S. Hesse,1 C. Werner,1 M. Pohl,2 S. Rückriem,2 and J.Mehrholz2

1Charité—Universitätsmedizin Berlin, Klinik Berlin,Germany; 2Klinik Bavaria, Kreischa, Germany

Background: To compare a computerized arm trainer (AT),allowing repetitive practice of passive and active bilateral fore-arm and wrist movement cycle, and EMG-initiated electricalstimulation of the paretic wrist extensor (ES) in severely af-fected subacute stroke patients. Methods: 44 patients, 4 to 8weeks after stroke with severe arm paresis Fugl-Meyer MotorScore (FM, 0-66) were randomly assigned to either AT or ES. In-tervention: 20 min/workday for 6 weeks. AT patients performed800 repetitions and ES patients performed 60 to 80 wrist exten-sions per session. Primary outcome measure: blindly assessedFM (0-66), secondary measures: upper limb muscle power(MRC-sum, 0-45) and muscle tone (Ashworth score-sum, 0-25),assessed at the beginning and end of treatment and at 3-monthfollow-up. Results: Both groups were initially homogenous. FMand MRC-sum scores improved over time in both groups but sig-nificantly more in the robot AT group. In the robot AT group, FMscore was 15 points higher at study end and 13 points higher at3-month follow-up than the control ES group. MRC-sum score



was 15 points higher at study end and at 3-month follow-upcompared to the control ES group. Muscle tone remained un-changed, and no side effects occurred. Conclusion: The com-puterized active arm training produced a superior improvementin upper limb motor control and power compared to electricalstimulation in severely affected stroke patients. This is probablybecause of the greater number of repetitions and the bilateralapproach.

F2D-2 Enhanced Cortical Reorganization inPoststroke Patients after Constraint-InducedMovement Therapy: A Clinical and fMRI Study

G. Miscio,1 S. Baudo,1 C. Trotti,1 A. Boghi,2

and A. Mauro2

1Istituto Auxologico Italiano, IRCCS, Italy;2Department of Neurosciences,University of Turin, Italy

Background: Constraint-induced movement therapy (CIMT)improves motor performance after stroke by the restriction ofusage of the unaffected limb and induces a functional motor re-organization as shown by cerebral mapping. This study aimedto assess clinical improvement and motor cortical reorganiza-tion by functional MRI, after CIMT in poststroke patients. Meth-ods: 7 poststroke patients underwent CIMT, repeated twice perhour for 6 h/d for 15 d. Frenchay Arm Test (FAT) and Nine-HolePeg Test (NHPT) were used to evaluate manual skills. Handgripstrength was assessed by a dynamometer. fMRI was performedwhile patients attempted sequential finger tapping using a box-car protocol. Clinical and fMRI evaluations were carried out atT0, T15, and T45 days. Results: In all patients, CIMT induced amarked clinical change: a significant decrease in NHPT time ofexecution after 15 d and FAT score improvement after 30 d ofCIMT. Handgrip strength significantly increased. At baselinefMRI maps showed bilateral activations in motor and premotorcortices, supplementary motor area, basal ganglia, and cerebel-lum. After training, a strong activation in the premotor area wasfound; ipsilesional primary motor cortex was not active. Con-clusion: CIMT improved strength and motor dexterity that par-allel a cortical reorganization, after only 2 weeks of treatment.Our data seem to confirm the role of the contralesional motorand premotor cortices and the spared perilesional cortex as thesubstrate of motor recovery in poststroke patients.

F2D-3 Subacute Constraint-Induced Therapy afterStroke Results in Lasting Changes in BrainActivation Related to Motor Task Performance

G. F. Wittenberg,1 T. H. E. FICIT Group,1 T. H. E. FICITGroup,2 and T. H. E. FICIT Group3

1Wake Forest University School of Medicine, USA;2Emory University School of Medicine, USA; 3TheOhio State University, USA

Background: Constraint-induced movement therapy (CIT)has become an important method in motor rehabilitation re-search. Decreases in brain activation during motor tasks havebeen described in chronic stroke patients, after CIT. In subacutestroke patients, greater neuronal plasticity might facilitate morebrain reorganization. Methods: Subjects recruited during thesubacute period (4-12 months after stroke onset) were ran-

domly assigned to receive CIT for 2 weeks or to enter a waitingperiod. Functional MRI (fMRI) was performed after enrollment,after 2 weeks, and again at 4 months. fMRI was used to identifythe brain regions related to performance of finger flexion/extension. A custom-made splint provided standard positioningand movement amplitude. The maximum sustainable rate ofmovement was determined, and subjects were tested at 70% ofthat rate. Results: 31 subacute subjects completed the study, 16in the immediate group, 15 in delayed. In both groups, fMRI ini-tially showed large clusters of activated voxels in supplemen-tary motor area, ipsilesional superior parietal cortex, andcontralesional primary motor and premotor areas. Activation ofthese areas markedly diminished or disappeared after CIT, andthe effect lasted 4 months after intervention. No such change oc-curred in the delayed group. Conclusion: Reduction in brain ac-tivation is a common feature of CIT, regardless of when it is ap-plied, and results in a more normal pattern of brain activationrela ted to ef for t -control led submaximal motor- taskperformance. (Support: NIH R01 HD040984)

F2D-4 Acute Stroke Survivors’ Residual Deficits ofUpper Limb Function after 12 Weeks of PhysicalRehabilitation Training and FES

G. Alon and A. F. LevittUniversity of Maryland, School of Medicine, USA

Background: The functional recovery of the upper limb af-ter a stroke is notoriously poor. The purpose of this study was toquantify the residual deficits of upper limb function at the endof 3 months of an advanced training paradigm provided to acuteand subacute stroke survivors. Methods: Subjects: Ischemicstroke survivors (n = 20) began physical (PT) and occupational(OT) therapy within 15.2 ± 7.8 d of admission to an acute reha-bilitation center. Eleven patients received functional electricalstimulation (FES) program combined with standardized, task-specific PT/OT rehabilitation, whereas 9 patients (control) re-ceived standardized task-specific PT/OT rehabilitation alone.Outcome measures: Box & Blocks (B&B); Jebsen Taylor lightobject lift (J-T) were videorecorded for both upper limbs atbaseline, 4, 8, and 12 weeks. Results: B&B mean score at 12weeks was 26.1 ± 21.7 and 15.2 ± 16.2 for the FES and controlgroups, respectively (grand mean, 21.6 ± 19.8 blocks), a 61.3%residual deficit. The J-T task time was 23.4 s (FES) and 32.4 s(control), yielding a grand mean of 27.4 ± 25.0 s, a 6.2-fold re-sidual deficit. Five patients did not regain any measurable handfunction, whereas 63% were below 50% recovery. Conclusion:Upper limb functional recovery seems favorable using the ad-vanced training paradigm. Yet stroke survivors’ upper limb islikely to remain considerably dysfunctional after 3 months of re-habilitation. The data suggest that longer advanced trainingperiod is warranted.

F2D-5 Effectiveness of Constraint-InducedMovement Therapy in Subacute and ChronicStroke Patients

C. S. Weng, J. Wang, X. Y. Pan, G. Wang, and Z. Z. YuDepartment of Rehabilitation Medicine, the GeneralHospital of the PLA, Beijing, China

Background: Constraint-induced movement therapy (CIMT)is a promising approach to promoting recovery of functional



arm movement after stroke. The goal of this study was to evalu-ate and compare the treatment effect of CIMT given within 6months of subacute and 1 year after chronic stroke. Methods: 30stroke patients, who had upper limb hemiparesis and learnednonuse, were recruited. They were allocated either to a sub-acute group (n = 14) or a chronic group (n = 16) according totheir poststroke duration. The 2 groups of patients were givenCIMT, involving restriction of movement of the normal upperextremity by placing it in a sling for 90% of waking hours for 12d and training (by repetitive practice, shaping) of the affectedextremity for 6 h for 10 weekdays during the period of study.The outcome measure was the upper extremity function test(UEFT). Results: Statistical analyses showed no significant dif-ferences between the subacute group and the chronic group inmotor improvement on the UEFT (P > 0.05). However, the func-tional gain on the UEFT for the subacute group was significantlyhigher than that of the chronic group (P < 0.05). The effect sizemeasured by quality of movement (UEFT) for the subacutegroup 1.51 was larger than that for the chronic group (0.89).Conclusion: These results demonstrate that CIMT is an effectiverehabilitation technique for subacute and chronic stroke pa-tients, especially for the subacute stroke patients.

F2D-6 Contraint-Induced Movement TherapyImproves Spasticity and Dexterity after Stroke

A. Suputtitada, N. C. Suwanwela, and S. TumviteeFaculty of Medicine, Chulalongkorn Medicine,Thailand

Background: To evaluate the effectiveness of constraint-in-duced movement therapy (CIMT) in managing spasticity and re-storing dexterity after stroke. Methods: An observer-blindedrandomized control trial with 69 chronic stroke patients allo-cated them to either a group using the constraint-inducedmovement technique (n = 33) or conservative treatment (n =36). The CIMT group received 6 h of daily affected-upper-ex-tremity training and had their unaffected upper extremities re-strained 5 d/wk for 2 weeks. The control group receivedbimanual-upper-extremity training using a conservativeneurodevelopmental technique for 2 weeks without restrainingtheir unaffected upper extremities. Results: After 2 weeks oftraining, the CIMT group had significantly lower spasticityscores and higher dexterity scores for the affected upper ex-tremities than the control group (P < 0.05). Conclusion: CIMT ofthe affected upper extremities can decrease spasticity andimprove dexterity after stroke.

F2D-7 Combining Mental Imagery withFunctional Electrical Stimulation PromotesFunctional Regain after Acute Stroke

K. P. Y. Liu,1 C. C. H. Chan,1 C. W. Y. Hui-Chan,1 T.Yan,2 and L. S. W. Li31The Hong Kong Polytechnic University, HongKong; 2Sun Yat-Sen University Second AffiliatedHospital, China; 3Tung Wah Hospital and theUniversity of Hong Kong, Hong Kong

Background: Our previous studies on acute stroke patientsdemonstrated that mental imagery enhanced their daily task

performance and that functional electrical stimulation im-proved their walking abilities. This randomized controlled trialinvestigated the effects of combining mental imagery with func-tional electrical stimulation on promoting the regain of dailytask performance in acute stroke patients. Methods: 69 patientswith acute stroke were randomized to 1 of 3 groups receiving 3weeks of mental imagery and functional electrical stimulation(MI+FES), mental imagery alone (MI), or functional rehabilita-tion (FR as control) treatment. Outcome measurements in-cluded performance on daily tasks (trained and novel) beforeand after treatment each week and at 1-month follow-up. Re-sults: No significant differences were found in the baseline mea-surements. Patients who received MI in both the MI+FES and MIgroups showed better performance than the control group onthe trained tasks by the end of each week, and on the noveltasks by the end of program (P < 0.001). The MI+FES groupshowed significantly better results than the MR group in all taskperformances (P < 0.05) at the end of the program. Conclusion:Combining MI with FES produces a better outcome in patients’daily task performance.

F2D-8 Amphetamine Fails to Facilitate MotorPerformance and to Enhance Motor Recoveryamong Stroke Patients with Mild Arm Paresis

T. Platz,1 I. H. Kim,1 U. Engel,1 C. Pinkowski,1

and M. Kutzner5

1Klinik Berlin, Dept. of Neurological Rehabilitation,Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Germany;5Neurologisches Zentrum, Segeberger Kliniken,Bad Segeberg, Germany

Background: This RCT assessed the effects of d-amphet-amine on motor facilitation and recovery in stroke patients withmild arm paresis receiving the arm ability training. It was termi-nated after an interim analysis. Methods: 31 stroke patients withmild arm paresis were randomly assigned to either 1) receivingplacebo or 2) d-amphetamine twice a week 2 h before arm abil-ity training sessions for 3 weeks. Main outcome measure: timeneeded to perform TEMPA tasks, a measure of upper extremityperformance reflecting everyday life tasks. Secondary mea-sures: aimed movements, tapping, and a 10-m walkway as wellas motor performance during training sessions. Results: The in-terim efficacy analysis of 26 stroke patients who completed thestudy intervention showed overall arm motor recovery bothfrom pre- to posttest after 3 weeks of training and from pretestto follow-up 1 year later. No superior effect of d-amphetamineover placebo could be substantiated for either motor facilitationduring training or motor recovery (posttraining or long term). d-Amphetamine exerted mild effects on blood pressure. Seriousadverse events were not observed. Conclusion: d-Amphetamine failed to facilitate motor performance duringtraining sessions, to promote skill acquisition with trainingtasks, and, most important, to enhance motor recovery amongpatients with mild arm paresis after stroke.




F3A-1 Community-Based Rehabilitation afterTraumatic Brain Injury

J. PonsfordMonash University and Monash-EpworthRehabilitation Research Centre, Australia

Background: There has been a growing awareness thatmany people with brain injury have difficulty generalizing fromone situation to another. The development of a community-based rehabilitation program focusing on roles and tasks rele-vant to the injured person in real work contexts is described.This study compared 2-year outcome after this interventionwith that of a center-based outpatient program. Methods: Partic-ipants included a group of 98 persons with severe TBI who re-ceived community-based intervention and 98 TBI controls whoreceived center-based outpatient treatment, matched for age,gender, education, occupation, GCS, PTA duration, initial inde-pendence in ADL, and time in inpatient rehabilitation. Theycompleted measures of ADL, employment status, emotionalchanges, and the Craig Handicap Assessment and ReportingTechnique at 2 years postinjury. Costs and number of hours oftherapy were also documented. Results: Those treated in thecommunity showed significantly higher levels of independencein personal ADL and somewhat higher independence in domes-tic and community ADL. There were no significant group differ-ences in employment outcomes or emotional state. Thosetreated in the community had received fewer therapy sessionsso that treatment costs were lower and had lower attendant carecosts. They showed high levels of satisfaction with the program.Conclusion: Implementation of community-based programscan be successful. However, it is important to maximize contactwith trained therapists.

F3A-2 Important Reason That Affects the ComaPatients’ Regaining Consciousness—Hydrocephalus

Z. Chen, M. Wang, and G. ChenBeijing Xuanwu Hospital, China

Background: Some brain injury patients with coma re-mained unconscious due to insidious hydrocephalus. After op-eration and active rehabilitation, some of these patients couldrecover gradually. Methods: This is a retrospective review ofdata of 60 brain injury patients with coma, including 48 suffer-ing from traumatic brain injury, 6 from brain aneurysm, 4 fromcerebellar hemorrhage, and 2 from craniopharyngioma. Ac-cording to the clinical examination, assessment of rehabilita-tion, and imaging data, 22 brain injury patients were diagnosedas hav ing chronic hydrocepha lus and rece ivedventriculoperitoneal shunt (PVS). The duration which patientsgot chronic hydrocephalus was 12 ≤ 3 months, 6 ≤ 6 months,and 4 > 6 months. The neurorehabilitation treatments were usedafter PVS, and the rehabilitative principle of prevention and ac-tive training were emphasized. Results: 13 of 22 coma patientsrecovered gradually, 6 patients remained in minimally con-scious state, and 3 patients did not improve. Half to 1 month af-ter operations, ventricles on imaging became smaller. The GCS

score and Barthel Index improved greatly after rehabilitation.The duration of these 13 coma patients got chronic hydrocepha-lus were as follows: 10 ≤ 3 months and 3 ≤ 6 months. Conclu-sion: It is very important to find chronic hydrocephalus as soonas possible in the rehabilitative setting. Coma patients may re-cover after the brain pressure reduced. There is little opportu-nity to recover if the duration for the chronic hydrocephalus isover 6 months.

F3A-3 Medical, Physical and PsychosocialOutcomes of Adults at 5 and 10 Years afterTraumatic Brain Injury

J. H. Olver, J. Ponsford, and D. GoffEpworth Hospital, Australia

Background: This study examined the long-term outcomeof a group of young persons with traumatic brain injury afterdischarge from a comprehensive rehabilitation program. Meth-ods: Currently, 111 patients with TBI have been observed atboth 5 and 10 years postinjury using a validated structured inter-view to look at their self-reported medical, physical, psycho-logic, and social status after traumatic brain injury. Results: Theaverage age of the patients was 29.5 years and their averagelength of posttraumatic amnesia was 48.6 days. Neurologicsequelae of headaches and dizziness continued to be reportedby 30% of the patients at both time intervals. Only 18% of the pa-tients reported reaching their previous level physically. Cogni-tive problems including difficulties with memory and concen-tration continued in 65% of the patients. Half of the patientsnoted increased anxiety and depression in the long term. Thir-teen percent more subjects were driving at 10 years after injurythan at 5. Twenty percent fewer patients were married at 10years, and reports of social isolation increased during the 10years. Conclusion: Generally, long-term physical, cognitive,and emotional sequelae in patients with traumatic brain injurydid not change significantly between 5 and 10 years. There ap-peared to be a plateau in recovery at 5 years. Psychosocialsequelae of brain injury need to be addressed in the long term.

F3A-4 Patient Participation in Rehabilitation afterSevere Brain Injury

L. M. Maendl,1 H. L. Rayner,1 T. Dearnaly,2

and J. Ducat21Bath Head Injury Unit, Royal National Hospital forRheumatic Diseases, United Kingdom; 2Headway,Bath, United Kingdom

Background: Research suggests that patient participationenhances dignity and enriches quality of life, giving patients agreater sense of personal control, increased satisfaction andbetter compliance with treatment and improved transfer to dailylife and, consequently, better outcomes. The study aimed to dis-cover what factors affect patient participation in rehabilitationafter severe brain injury and to develop a way of measuringthese factors. Methods: 2 patients with brain injuries collabo-rated with the clinical researchers. Four focus groups were heldto establish perceptions of patient participation. Subjects werepatients, former patients, carers, and staff. Content analysis wasperformed on the focus group transcriptions. Themes were de-veloped into questions for an observational checklist. Thechecklist was applied to 30 rehabilitation sessions, covering a



range of activities. Results: Many diverse factors were found toinfluence patient participation. These include relationships be-tween patients and staff (dignity, trust, and rapport); decisionmaking (independence, engagement, and choice); patient abili-ties, motivation and insight; and staff skills, attitude, and values.Other factors appeared to be information, the environment,support and advocacy from family and friends, and aspects ofthe rehabilitation process (flexibility, individualized program,goal setting, and team work). Conclusion: A complex interac-tion of factors influence patient participation in rehabilitationafter severe brain injury.

F3A-5 A 2-Point Outcome-Analysis after SevereTraumatic Brain Injury (TBI)

M. Mertl-Rötzer, B. Schäpers, M. Heinz-Leisenheimer,E. Koenig, and F. MüllerNeurologische Klinik Bad Aibling, Germany

Background: Over 8 years, 249 patients with severe TBIwere treated for a mean length of stay of 98.7 d. We have evalu-ated the long-term outcome of this expensive intervention.Methods: In a retrospective analysis with exploration at 2 timepoints (at least 6 and 30 months after discharge), we contactedpatients with a questionnaire and explored their disabilities(Barthel-Index), quality of life (SF-36) and living conditions. Re-sults: Of 565 patients with all severities of TBI asked in 2003, 210sent back a valid questionnaire; these 210 were asked again in2005 (128 answered). As expected, patients improved duringtheir stay in hospital but also after discharge. The patientsstarted with a Barthel Score of 26.8 at admission and reached85.5 at discharge. This level remained stable at both inquiries(85.6 in 2003 vs. 80.0 in 2005). The quality of life was deter-mined by the SF-36, which registers physical, mental health,and social aspects. In all of these items, the patients improvedbetween the 2 points of examination. There was also an im-provement in patients’ living conditions: more of them couldlive at home (79.4% vs. 83.1%), 44.7% vs. 51.6% could drive acar, and 18.4% vs. 23.8% worked again in a comparable positionas before the TBI. Conclusion: These results underline the ne-cessity for neurologic rehabilitation. Although their disabilitydid not change after discharge, social integration continues toimprove over years. Consequences for further integrationprograms are discussed.

F3A-6 Effect of Early Rehabilitative Approachfor Traumatic Brain Injury Patients onEmergency Care Unit in Japan

N. Kikuchi, H. Sashika, and R. MutohYokohama City University Medical Center, Japan

Background: In Japan, there is no consistent rehabilitationsystem from acute stage to social reintegration for patients withtraumatic brain injury (TBI). Thus, it is important to start inten-sive rehabilitative training in the early stage and to guide propermanagement after discharge from acute hospital. This study re-ported the effect of an early intervention with rehabilitation forTBI starting in an emergency care unit. Methods: We analyzedretrospective data of 3 years. Participants were 106 TBI patientsadmitted to emergency care unit in our university hospitalwithin 24 hours after injury. They received acute neurotraumaand inpatient rehabilitation treatment. Main outcome measureswere the admission and discharge FIM, time to sit independ-

ently (TTSI), cognitive function, and management after dis-charge. Results: Mean admission and discharge FIM were 36.9and 60.2, respectively. Sixty-three cases sat independently afterrehabilitation, but 12 cases could not sit at discharge. Mean TTSIwas 10.4 d after rehabilitation. Main cognitive disorders at dis-charge were amnesia (n = 24), memory disorder (n = 20) and at-tention disorder (n = 13). The discharge outcome was rehabili-tation hospital (13.9%), general hospital with PT/OT(63.1%),general hospital without PT/OT (15.8%), and return home(7.2%). Conclusion: Early rehabilitative approach for TBI pa-tients was effective to improve physical function and ADL. Earlyintervention by rehabilitation was useful to evaluate cognitivedisorders and arrange intervention on discharge.

F3A-7 Neurorehabilitation after AcuteCraniocerebral Injury (CCI) with 1-Year Follow-up: German Prospective Controlled MulticenterStudy

K. R. H. von Wild, E. Rickels, and P. WenzlaffMedical Faculty University Münester, Germany

Background: To review incidence and quality managementof neurorehabilitation after craniocerebral injury (CCI). Meth-ods: It was a prospective, population-based study on the epide-miology of acute CCI. Analysis of acute medical care, functionalrehabilitation, and outcome (GOS) after 1 year was done. Catch-ments areas covered over 2.114 million population. Definitionof CCI was ICD 10 S-02, S-04, S-06, S-07, S-09 combined withdizziness or vomiting, retrograde or anterograde amnesia, im-paired consciousness, skull fracture, and/or focal neurologicimpairment. Results: 6,783 CCI patients (58% male) were admit-ted for hospital treatment, of which 63.5% completed question-naires. One-year follow-up completed in two-thirds. Incidencewas 321 per 100 000. GCS was assessed in 55% of patients:90.9% mild, 3.9% moderate, and 5.2% severe TBI. Seventy-seven percent of patients was hospitalized; 1.4% died. Follow-up of 63.5%, only 258 patients (3.8%) received rehabilitation(73% male), 68% within 1 month. Five percent were youngerthan 16 years; 25% older than 65 years. Early rehabilitation per-formed in 100 patients (39%), one-fifth within 1st week. GOS atthe end of rehab: GOS 1 = 1.2%, 2 = 1.7%, 3 = 21.8%, 4 = 36.2%,and 5 = 39.1%. One year after CCI, 240 patients (66% severe,23% moderate, 11% mild) achieved the following: 32% GOS 5,27% GOS 4, 32% GOS 3. Fifty-five percent underwent outpatientrehabilitation but only 7% psychological training. Conclusion:Fewer than 4% of 4307 patients were referred for rehabilitation.Quality of neurosurgical early rehabilitation was superior tocommon rehabilitation.

F3A-8 Mild Traumatic Brain Injury (TBI):Developing a Simple Clinical Tool for EmergencyDepartments (EDs) and Primary Care Providersto Improve Their Predictions of OutcomesCompared with Present Triage Methods

M. A. Slatyer,1 C. Skilbeck,1 M. Thomas,1 K. Holm,2

and K. Marsden1

1Neuro-Trauma Research Group, Australia;2University of Berlin, Germany

Background: Much is known about the psychopathology ofmild TBI, but clinicians have difficulty deciding which patients



require intervention or further care. There is no simple toolavailable to enable physicians, nurses, and others working inEDs to identify those patients whose recovery will be problem-atic. Methods: 400 consecutive patients with mild TBI were pro-spectively followed to 6 months to examine their outcomes. De-mographic, psychosocial (anxiety, depression, quality of life),functional (FIM, DRS), and clinical data (loss of consciousness,PTA, postconcussion symptoms) were used to investigate pre-dictors of outcome (return to work/study, symptoms at 6months posttrauma) using multiple regression. The factor struc-tures of the Rivermead Post-Concussion Symptoms (RPCS) andHospital Anxiety & Depression Scale (HADS) were included toestablish which components offered the strongest prediction.Results: Significant predictive relationships with outcome wereobtained from a number of variables, including years of educa-tion and premorbid quality of life, initial RPCS and HADS factorscores, and FIM. A very useful predictive tool for mild TBI wasdeveloped by combining these variables in multiple regressionanalyses. Conclusion: The authors have developed an effectivepredictive tool, which is easy to administer without extensivetraining, for use by nonneuropsychologists in an ED or primarycare setting. Administration requires 20 min. A future study willcross-validate our findings and reduce completion time.

F3B-1 Brain-Computer Interface—Communication by Cognition for NeurologicPatients with Severe Cerebellar and BrainstemLesions

K. Diserens,1 H. Ullrich,2 E. Girardet,3 T. Ebrahimi,2

and P. A. Despland1

1Department of Neurology, Universital hospitalLausanne, Switzerland; 2Ecole PolytechniqueFédérale de Lausanne (EPFL), Switzerland;3Fondation Suisse des Teletheses (FST), Switzerland

Background: A brain-computer interface (BCI) is a commu-nication system. This means a BCI allows a user to act on his en-vironment by using his thoughts, without using peripheralnerves and muscles. Two approaches of noninvasive BCIs canbe distinguished. One approach relies on external stimuli and isreferred to as evoked potentials. The 2nd approach requires noexternal stimuli, allowing commands to be sent by voluntarilymodifying the brain signals. Methods: This new mode of com-munication can be used by neurologic patients with communi-cation impairments. The target population consists of personsseeking treatment for severe ataxia and brainstem lesions.Given the restricted cognitive and concentration abilities in thetarget population, a BCI based on evoked potentials is pro-posed, notably a P300-based BCI. Evoked potential–based BCIsrequire only a relatively small amount of concentration andtraining. Three kinds of stimuli are evaluated: sound tones vari-ations, flashing letters, and flashing pictures. Results: 5 patientswere selected. After several training sessions, some of the pa-tients have been able to spell simple words using the P300-based BCI and to interact with their environment. Conclusion:BCI allows patients with severe brainstem lesion and impair-ment of the control of oculomotricity and muscle function to in-teract with an environment control system. Nevertheless, manyobstacles still need to be overcome to increase communicationspeed and improve ease of use by patients.

F3B-2 A New Driven Orthosis for the UpperExtremity (ARMOR): Preliminary Results

A. Mayr,1 S. Mina,2 G. Köchl,1 G. Kronreif,2 and L.Saltuari11Hospital Hochzirl, Austria; 2ARC SeibersdorfResearch, Austria

Background: Upper limb function continues to be a chal-lenging problem in neurorehabilitation of stroke survivors. Ro-bot-assisted training has been valuable in relearning gait. Toachieve similar results in the upper limb, a kinematic orthosis,which moves all joints in complex movement patterns, has beendeveloped. Methods: 10 patients after stroke of different causeswere included in a clinical AB-BA crossover study comparingARMOR training and functional electrical stimulation (FES).Functional Dexterity Test, Chedoke-McMaster Assessmentform, and Action Research Arm Test served as outcome mea-sures. Results: Grasp, grip, pinch, and gross arm movement im-proved greatly with ARMOR but not with FES. Abnormal muscletone and exaggerated tendon jerks tended to normalize inARMOR training phases but worsened in FES phases. Conclu-sion: This study demonstrates the clinical applicability of a newdriven orthosis (ARMOR) for the upper limb. This deviceproved to be valuable for recovering function of the upper ex-tremity in the rehabilitation process.

F3B-3 Conditional Visuomotor Learning:A Goal-Oriented Training

E. A. Fridman,1 R. C. Leiguarda,1 and M. Hallett,21Institute for Neurological Research-FLENI,Argentina; 2Human Motor Control Section-NINDS-NIH, USA

Background: Conditional visuomotor learning (CVML) re-fers to an arbitrary association between sensory cues and goal-directed actions. During this type of learning, the dorsalpremotor cortex (PMd) is highly implicated. Previous findingssuggested that following a stroke, PMd is involved in motor re-covery. Thus, CVML might be a useful technique to induce re-covery of motor deficits after stroke. However, it has been sug-gested that this form of learning does not involve modificationsof motor performance (motor learning itself). Methods: In thepresent work, we used a CVML paradigm, which involved an as-sociation between 6 arbitrary visual stimuli and 6 object-medi-ated tasks, in 32 healthy subjects. We tested the null hypothesisthat CVML relies on the consolidation of arbitrary associationsbut does not influence visuomotor transformation. Results: Wefound that the time required for arbitrary association did not ex-perience any modification between 3 different sessions. How-ever, timing of motor performance decreased from session 1 tosession 3. A control experiment consisting in a 1 to 6 simple re-action time of the same movement ruled out the possibility thatmotor consolidation relies on the repetition of movements andis independent of the conditioning of them. Conclusion: Thepresent findings suggest that CVML implicates a motor learningcomponent that requires training in order to consolidate (goal-oriented). This type of learning might guide future motorrehabilitation in stroke patients.



F3B-4 Robotic in Hand Rehabilitation—An Innovation in Hand Therapy

P. Grieshofer, M. Scarpatetti, and R. SchererKlinik Judendorf Strassengel, Austria

Background: The “Klinik Judendorf Strassengel” developedin cooperation with the Technical University of Graz this techni-cal device. Methods: The development of the hand robotic sys-tem after 4 years of research and 3 years of engineering has pro-duced a crucial improvement in hand rehabilitation therapy.Our robotic hand and finger movement orthosis is being usedsuccessfully in our clinic as a prototype of the institute ofneurorehabilitation and research. This hand robotic system isthe 1st driven orthosis that assists finger movements in patientswith impaired upper limb. The theoretical background is the ex-perience of the locomotion therapy. This automated process re-lieves therapists from the manual labor; therefore, the trainingsessions can be longer and more repeatable. The therapy ismore efficient and the patients achieve their goals faster. Evenin the early phases of the rehabilitation, 1 therapist can accom-plish the training. We are using this hand robotic system as aprototype about half a year and our clinic practice shows afterviewing patients that rehabilitation of the hand could be accel-erated. Results: Our 1st experience shows that rehabilitation ofthe hand could be accelerated and that spasticity is going down.Conclusion: We know we need more experience and data, butwe want to present this technology as a new opportunity forhand rehabilitation.

F3B-5 Robot-Aided Sensorimotor Arm Trainingin Patients with Chronic Stroke and BrainInjury—from Chinese Experience

S. Bi,1 L. H. Ji,2 S. R. Ji,3 G. Z. Wang,2 and Z. X. Wang2

1Chinese PLA General Hospital, China; 2TsinghuaUniversity, China; 3China Rehabilitation ResearchCenter, China

Background: Robot-aided training can provide safe, inten-sive, and task-specific intervention to persons with motor im-pairments after neurologic injury. We developed the upper ex-tremity compound movements (UECM) rehabilitation trainingrobot and designed repetitive and progressive resistance train-ing based on neurologic rehabilitation principles. Methods: 22persons with chronic stroke and brain injury were enrolled inthe research for A-B design. The Fugl-Meyer test of upper ex-tremity function, Motor Status Score (MSS) and ModifiedAshworth Scale (MAS) of elbow joints were performed before,during, and after 4-week robotic training. Subjects performedpassive or active line and exterior-oriented circle movementson the robot according to their motor abilities for 45 minutes, 5times every week over 4 weeks. Results: Fugl-Meyer assessmentand MSS of motor impairment were significantly increased aftertreatment (P < 0.001). MAS were decreased in elbow flexor (P =0.03) and not significantly reduced compared with baseline as-sessment (P = 0.061). Conclusion: Robot-aided sensorimotorarm training can reduce the upper limb impairments and maydecrease spasticity in patients with chronic stroke and brain in-jury. This suggests that robot-aided therapy can attenuatechronic neurologic deficits of upper limb. This work was sup-ported by the Hi-tech Research and Development Program ofChina Grant 2002AA420100 2.

F3B-6 Teleneurorehabilitation:A Vision Becomes Reality

N. Steinhoff,1 P. Schnider,1 A. Hochgatterer,2 S. Mina,2

and E. Auff31Dept. of Neurology/LK Hochegg, Austria; 2AustrianResearch Centers, Austria; 3Dept. of Neurology/Med.Univ. Vienna, Austria

Background: With the upheaval of the world into a societyof information and using telecommunication techniques, medi-cine has obtained a new tool for diagnostics, treatment, atten-dance, and support but also for data exchange, education, andtraining. First telecommunication facilitated successfully medi-cal support over a distance especially in remote areas raisingquality and velocity. Also in urban environment, similartelemedical success could be achieved. This presentation is spe-cifically aiming at the implementation of telemedicine inneurorehabilitation, showing the results of 7 years of appliedteleneurorehabilitation. Methods: As teleneurorehabilitationwas not performed before, on the basis of a pilot study, feasibil-ity and acceptance were 1st investigated. Then, using validatedrehabilitation scales over several periods of telemedical appli-cation in neurorehabiltation, outcome and quality of life athome (2 patients and caregivers at a time and more) were mea-sured. Results: Both the neurorehabilitation scores and the sub-jective rating of the patients and caregivers showed improve-ment of outcome and quality of life. There was increasedsecurity and quality of support at home through enhanced ser-vice and case management by telemedical means. The techni-cal and time effort remained always in a reasonable range.Conclusion: This leads to a posi t ive est imation ofteleneurorehabilitation and to the conclusion that the applica-tion of telemedicine in neurorehabilitation is successful and fea-sible under certain conditions.

F3B-7 The Lokomat as a Possibility in theRehabilitation of Patients with NeurologicDisorders: Results after 3 Years of ClinicalPractice

P. Grieshofer, G. Streit, G. Resnik, M. Scarpatetti,and R. SchererKlinik Judendorf Strassengel, Austria

Background: With new knowledge about brain plasticity,task-specific treatments like the treadmill training or the forceduse therapy of E. Taub have been developed. These are under-lying reasons for new developments. Methods: The Lokomat is adriven orthosis that assists walking movements of gait-impairedpatients on the treadmill. Hip and knee joint angles are con-trolled in real time by software to achieve a physiologicallymeaningful gait pattern. Each of the 4 axes is individually con-trolled to correspond precisely to the desired joint angle trajec-tories. The biofeedback displays the patient’s effort during ther-apy in real time on an additional screen. Results: For 3 years, wetreated patients with 2 Lokomat units in addition to classicaltherapeutic methods. Every patient received this therapy 3 to 4times per week. The mean therapeutic time was 40 min. Among365 patients treated, there were 225 patients withcerebrovascular disease, 65 with multiple sclerosis, 25 with in-complete paraplegic patients, 20 with infantile cerebral paresis,and 30 with neuromuscular diseases. Conclusion: The Lokomat



therapy reduces spasticity and improves physiologic gait pat-tern (data from the gait laboratory). Clinically, this therapy maybe able to accelerate the process of learning to walk. Patientswho participated were highly motivated to participate, and noside effects were observed. The Lokomat therapy was ceasedfor patients with severe arthritis of the hip or knee. These dataare only preliminary; therefore, we are preparing a multicenterstudy to obtain further data.

F3B-8 A Gait Rehabilitation Robot for theTraining of Subtasks in Walking

E. H. F. van Asseldonk, R. Ekkelenkamp, J. F.Veneman, F. C. T. van der Helm,and H. van der KooijInstitute for Biomedical Technology, theNetherlands

Background: In the past decade, different gait rehabilitationrobots have been developed. These robots concentrated on re-learning gait by repeatedly enforcing a walking pattern for thewhole leg or only for the foot. Such training might be less taskspecific as generally thought, because learning to walk is morecomplex than learning a position trajectory. We believe activeparticipation of the patient in training and subdivision of thetraining in several subtasks leads to more comprehensive andfunctional training. Methods: Using a newly developed actuatedexoskeleton (LOPES) in combination with a treadmill, weaimed to selectively and gently support specific subtasks ofwalking, like knee stabilization, lateral balance, and foot clear-ance. Foot clearance and knee stabilization subtask had beenimplemented with dedicated controllers and tested duringwalking with healthy subjects. Results: Foot clearance could beincreased without disrupting the subject’s own initiated walk-ing in the remainder of the gait cycle. During weight accepta-tion, the knee stabilization ensured by the exoskeleton whilethe subject relaxed his knee. The gentle control of the robot al-lowed a comfortable interaction between subject and robot.Conclusion: Selective support of subtasks seems to be a viablemethod of interaction with the patient to train his or her gait. Inthe near future, we will implement a complete set of gaitsubtasks, which makes all kinds of training interventionspossible.

F3C-1 The Effect of 3-Dimensional InstrumentedGait Analysis on Decision Making in theTreatment of Cerebral Palsy

J. M. Watt,1 A. Liggins,2 J. McIvor,1 B. Watkins,3

and J. Andersen1

1University of Alberta, Canada; 2Syncrude Centerfor Motion and Balance, Canada; 3GlenroseRehabilitation Hospital, Canada

Background: Instrumented gait analysis adds objectivity inthe assessment of ambulatory children with cerebral palsy andmay assist decision making in treatment, including the use oforhotics, casting, medications, botulinum toxin, selective dorsalrhizotomy, intrathecal baclofen, or orthopedic surgeries. Re-peat assessment after treatment can improve best practice anddetermine efficacy. DeLuca (1997), Kay (2000), and Cook(2003) all reported significant changes in orthopedic surgicaldecision making after reviewing instrumented gait analysis

data. This report is to examine the effect of instrumented gaitanalysis on decision making in the surgical and nonsurgicaltreatment of cerebral palsy. Methods: This is a prospectivestudy. From 2002 through 2004, all patients with cerebral palsyreferred to the Syncrude Center for Motion and Balance wereexamined by experienced clinicians (J.W., J.M.) before gaitanalysis, and treatment strategies were formulated. After instru-mented gait analysis, revised treatment plans were designedwithout reference to the original plans. The treatment recom-mendations were compared. Results: 157 pediatric patientswere assessed. Confirmation of initially proposed treatmentplan, 45 (29%). Surgical plan modified, 47% (no surgery, 13%;botulinum toxin, 13%; orthotics, 8%; more surgery, 10%; lesssurgery, 5%). Nonsurgical plan modified, 16% (surgery, 6%).Conclusion: Instrumented gait analysis significantly modifiesdecision making in the treatment plans of ambulatory childrenwith cerebral palsy.

F3C-2 Improving Quality of Life in Children withCerebral Palsy by Acupuncture Therapy

Z. H. LiuNanhai Affiliated Maternity Children HospitalGuangzhou University of Traditional ChineseMedicine, China

Background: A study aimed at investigating the action andvalue of acupuncture in cerebral palsy rehabilitation. Methods:100 spastic cerebral palsy patients from 2 to 7 years were ran-domly divided into 2 groups. Group A with 50 patients weretreated with rehabilitation training including physical therapyof Bobath and Vojta methods. Group B with another 50 patientswere treated with acupuncture plus rehabilitation training. Re-sults: The total effective rate of group B was higher than that ofgroup A. After treatment, the DQ value of group B was higherthan that of group A (P < 0.01). In acupuncture and rehabilita-tion training group, improvement rate of brain dysphasia, brainatrophy in skull CT, and recovery normal rate of skull ECT wereobviously higher than the group with rehabilitation training (P< 0.01). Conclusion: Acupuncture can increase cerebral bloodflow (CBF) and improve cerebral cell metabolism, promote par-tial or complete compensation of cerebral function, and pro-mote the restoration and function of plasticity of cerebral tissuein children with cerebral palsy.

F3C-3 Cerebral Palsy with Speech DisorderTreated by Acupuncture Combined with SpeechTherapy

Z. H. LiuNanhai Affiliated Maternity Children HospitalGuangzhou University of Traditional ChineseMedicine, China

Background: To study the best way to treat children with ce-rebral palsy and speech disorder. Methods: 76 children with ce-rebral palsy and speech disorder were studied by randomizedcontrolled trial since 2000. Thirty-eight children in the treatmentgroup were treated by speech therapy combined with ‘sharpen-ing mind’ and ‘inducing consciousness’ acupuncture. The con-trol group was treated only by speech therapy. One treatmentcourse lasted for 3 months. ‘Sharpening mind’ and ‘inducingconsciousness’ acupuncture were used every other day, and



one treatment course was 30 times of acupuncturing. Results:The assessment by clinical good improvement rate showed thatthe treatment group (27 of 38) was 71% and the control group(13 of 38) was 34.44% with chi square = 10.34 and P < 0.01. Thespeech DQ after treatment showed that treatment group was56.36 ± 19.77 and the control group was 46.96 ± 15.63 with t =2.524 and P < 0.05. Conclusion: The outcome by the combinedtraditional Chinese medicine with Western rehabilitation is sig-nificantly better than that by simple speech therapy in the treat-ment of cerebral palsy with speech disorder.

F3C-4 Effect of Botulinum Toxin Type A andHand Function Training Program to Childrenwith Spastic Pronated Forearm and ImpairedHand Function

S. S. L. Fong,1 K. B. Tam,2 K. Y. Chan,3 S. W. C.Cheng,1 and C. K. Y. Fung1

1Occ Dept, PMH, Hong Kong; 2Dept of O&T, PMH,Hong Kong; 3Dept of Paed & Ado Med, PMH, HongKong

Background: Botulinum toxin type A (Bt) has been used inthe treatment of hypertonicity since 1970s. The clinical effect ofpostinjection rehabilitation (PIR) was scarcely reported. Thispaper is intended to study the combined effects of Bt and PIR inchildren with spastic pronated forearm (SPF) and impairedhand function. Methods: 13 children aged 4 to 10 years were re-cruited for Bt injection and PIR. All of them were assessedjointly by orthopaedic surgeon, pediatric neurologist, and occu-pational therapist. Treatment regimens and assessment proto-col were standardized for all patients. Five of the 13 cases thatwere given Bt injection to pronator teres (PT) alone had com-pleted follow-up for more than 12 months. Their performancewere assessed and analyzed at baseline, 1, 3, 6, and 12 months.Outcome measurement included AROM, Modified AshworthScale, sensibility, grasp & release pattern, Zancoli’s grade, func-tional handgrip, strength, and speed. The PIR consisted of dailyforearm supination splint and hand function training. Results:All 5 patients improved in muscle strength, active forearmsupination and wrist extension, mean functional handgrip, anda decrease in pronator tone. The beneficial effect sustainedeven after 6 months. Children developed sensibility that per-sisted more than 12 months. Conclusion: Injection of Bt to PT inchildren with SPF followed by PIR was proved to be effective.Functional improvement were observed in all our patients withyounger age, no contracture, and complied well with our PIRprotocol.

F3C-5 Treating Children with Botulinum Toxinand Physical Therapy: An Integrated Approach

P. Narayan and S. C. DamarajuLakshmi Neuro Centre, India

Background: Using botulinum toxin A (BTX-A) as a treat-ment tool in cerebral palsy (CP) is well established in literature.The need for reinjection is between 2 weeks to 22 months. In In-dia, usage of BTX-A is driven by the cost factor. The need forreinjection deters use of the drug in CP because of chronicity ofthe condition. There is a great need to optimize the effects of

BTX-A and increase the time intervals for reinjection. We pres-ent our experience in the use of BTX-A as part of an integratedapproach in managing spastic CP. Methods: Our experience hasbeen with 24 children injected during the past 3 years. The ageof the children varied between 1 and 5 years. Of these, 8 hadmultievent or multilevel intervention. We followed a standard-ized 6 week pre- and postinjection protocol in which BTX-Awith orthotics, electric stimulation, and motor training was usedto optimize results. The modified Ashworth score, gross motorfunction measure, and videography were used to measure out-come. Results: Of the 24 children, only 5 required reinjectionsinto the same muscle group. Twenty-two children had signifi-cant functional gains. One showed therapeutic gains. There was1 drop-out. In the postinjection group, 4 had a mild flulike ill-ness phase lasting 24 to 48 hours. The mean duration of follow-up was 13 months. Conclusion: BTX-A as a part of comprehen-sive program can help correct movement dysfunction in chil-dren with CP. To date, this approach appears to prolong theeffects of BTX-A.

F3C-6 Content Reliability of the PeabodyDevelopmental Motor Scales-Second Editionfor Chinese children

S. Fang1

1Zhujiang hospital, The Southern Medical college,China

Background: The Peabody Developmental Motor Scales-Second Edition (PDMS-2) is a standard scale to assess both grossand fine motor skills on children population from 0 to 72months of age, providing examiners with both items and seriesof activities for assessment of specific problems. However, clini-cal experience with its application in Chinese children sug-gested that several items of the scale could result in falsely lowscores. The study aimed at analyzing the content reliability ofthe scale for Chinese children. Methods: With stratified ran-dom cluster sampling, 300 children aged 9 months were se-lected. Their scooting in sitting was assessed by using PDMS-2.Another 300 children aged 25-26 months were selected, andtheir snipping with scissors were assessed. Results: There wassignificant difference between Chinese and American childrenin the abilities of scooting in sitting at age of 9 months and snip-ping with scissors at the age of 25 to 26 months (P < 0.01). Con-clusion: The adaptability of PDMS-2 should be consideredwhen it is applied to Chinese children because of potentialproblems of racial, educational, and other variables. Differencein content sampling exists.

F3C-7 Spinal Muscular Atropy (SMA)—NaturalHistory and Functional Status in Hong KongChildren

B. Chung, V. Wong, P. Ip, and S. HuiThe University of Hong Kong, Hong Kong

Background: To study the natural history and functional sta-tus of patients with childhood-onset SMA in Hong Kong. Meth-ods: 81 cases ascertained through DKCH and the Hong KongFamilies of SMA were analyzed. The validated Chinese Func-tional Independence Measure for Children (WeeFIM) was ad-



ministered to 39 active cases to assess 3 functional domains(self-care, mobility, and cognition). Results: A) Survival and am-bulatory status (n = 81): There were 20 type I; 26 type II, and 35type III patients. Survival probabilities at 1, 2, 4, 10, and 20 yearsof age were 55%, 40%, 30%, 30%, 30%, respectively, in patientswith SMA I; and 100%, 100%, 100%, 92%, 88%, respectively, forthose with SMA II, respectively. Probabilities of remaining am-bulatory (defined as walking with/without assistance) at 2, 4,10, 20 years of age were 64%, 59%, 32%, 5%, respectively, fortype II; 100%, 100%, 82%, 71%, respectively, for type IIIa (<3years); and 100%, 100%, 89%, 67%, respectively, for type IIIb. B)WeeFIM (n = 39): Total scores were 30 (n = 4), 72 (n = 15), 94 (n= 9), and 97 (n = 11) of a total of 126 for types I, II, IIIa, and IIIb,respectively. In mobility domain, more than 90% of type I, II,IIIa and 63% of type IIIb required assistance. Around 55% typeIII cases could attain independence in both self-care and cogni-tion domains. Conclusion: Compared to earlier Caucasian stud-ies, the survival probability of patients with type I SMA is betterin our cohort. However, the achievement of functional inde-pendence is still limited in the majority of our SMA patients.

F3C-8 Selective Dorsal Rhizotomy in Hong Kong:A Multidimensional Assessment of Outcome

H. S. S. Chan,1 N. Chan,2 C. Poon,3 B. Yiu,3

and K. Y. Yam4

1Central Kowloon Child Assessment Centre, HongKong; 2Tuen Mun Hospital PhysiotherapyDepartment, Hong Kong; 3Tuen Mun ChildAssessment Centre, Hong Kong; 4Tuen Mun HospitalDepartment of Neurosurgery, Hong Kong

Background: Selective dorsal rhizotomy (SDR) is one treat-ment option for children with spastic cerebral palsy. This pro-spective outcome study adopts a multidimensional approach.Methods: All children were evaluated by a multidisciplinaryteam. They received physiotherapy after SDR and baseline, 6-month assessment, and 12-month assessment. Outcome mea-sures including modified Ashworth score for spasticity, GrossMotor Function Measure (GMFM) for function, Pediatric Evalua-tion of Disability Inventory (PEDI) for activity, Canadian Occu-pational Performance Measure (COPM) for participation and 3-D gait analysis, were performed. Results: Between June 2003and August 2005, 17 patients had completed 6-month assess-ment. Fourteen patients of this group completed 12-month as-sessment. At baseline, 17 patients had mean age of 92 monthswith 9 males. Sixteen patients had spastic diplegia. Twelve pa-tients had normal intelligence. Comparing baseline with 6-month assessment, there was statistically significant improve-ment in spasticity (P < 0.001), GMFM total score (P < 0.001),PEDI mobility functional skill score (P < 0.001) and COPM per-formance and satisfaction scores (P < 0.001; P < 0.001). The 12-month assessment showed similar improvement. Ten patientsof GMFCS level I or II had gait analysis. Improvement in kneekinematics at initial contact (P = 0.002), ankle power quotient(P = 0.014), and oxygen consumption (P = 0.044) was noted.Conclusion: SDR and physiotherapy can improve outcome ofchildren with spastic diplegia in impairment domain, activitylevel, and participation level, under ICF framework.

F3D-1 Review on the Effectiveness of the StrokeCarer Training Program and the SatisfactionLevel of Carers

W. C. Chan, H. F. Mak, C. W. Woo, K. Y. Luk,and K. W. ChauQueen Elizabeth Hospital, Hong Kong

Background: The demand on rehabilitation and training ofcarers are increasing worldwide. To enhance the rehabilitationand reintegration of stroke patients back to community, aStroke Carer Training Program (SCYP) has been launched sinceNovember 2002. This paper aims to review the program’s effec-tiveness and the carers’ satisfaction level on completing the pro-gram. Methods: It was a prospective qualitative questionnairestudy. Carers of stroke patients were invited to attend a 4-ses-sion training program. At the end of the program, they wereasked to fill in a questionnaire, which comprised 10 statementsand 1 open-ended question. The statements covered areas inknowledge and skills, stress relieving in caring patients, suit-ability, and depth of the program contents. Each statement wasrated through a Likert Scale, which ranged from strongly agree(score 4) to strongly disagree (score 1). Results: 193 careers at-tended the program and completed the questionnaire in the pe-riod of November 2002 to November 2004. The respondent ratewas 100%. The mean score on satisfaction level of 10 statementsranged from 3.08 (SD, 0.58) to 3.40 (SD, 0.53). Majority of carers(99%) agreed or strongly agreed on the positive effects of thetraining program. Conclusion: The review suggested that theSCTP was effective in empowerment of the stroke carers interms of knowledge and skills in patient care, in stress relieving,in enhancement of careers’ confidence, safety, and efficiency inthe caring process.

F3D-2 ICF-Based Evaluation of the Effect of BrainEfficiency Training with Mentamove in Patientswith Various Neurologic Diseases

C. G. Garner, R. Crisan, and A. G. LammertKWA-Klinik Stift Rottal, Germany

Background: The Mentamove method is used for rehabilita-tion of patients after various brain lesions. It consists of a mentalfeedback training of impaired motor skills. An action is mentallypracticed by the subject without executing the real movement.If the electric impulse measured by surface EMG over the men-tally activated muscles is exceeding a preset threshold level, anelectric stimulation of the underlying muscles will be done. Tomeasure the effectiveness of this method, we used a set of 13qualitative or quantitative tests (e.g., nine-hole peg test), eachof which was transposed by a mathematical formula to the ap-propriate ICF code by that creating a Mentamove specific ICFsubset. Methods: After formal consent, 28 patients were in-cluded in the study. Examinations were done before and afterthe rehabilitation. ICF functions included pain, strength of pa-retic upper/lower limb, muscle tone, and arbitrary and complexmovement of finger or foot. ICF structures included structuresof brain and spinal cord. Participants were measured for theability of lifting objects, using an object, walking, and mobilitywith devices. Results: Mean ICF score improved significantlyfrom 2.26 to 2.10 (t test, P < 0.05). Median values remained in-variably at 2.0. Mean duration of treatment was 22.8 d. Conclu-



sion: Transformation of a set of qualitative and quantitative teststo ICF criteria seems to be a possible method to measure the ef-ficiency of a specific rehabilitation technique. We thank pIfRGmbH Karlsfeld Germany for the support.

F3D-3 Early Supported Discharge and ContinuedRehabilitation at Home after Stroke in South WestStockholm: 5-Year Follow-up of Resource Use

A. Thorsen, L. Widen Holmqvist, and L. von KochKarolinska Institutet, Sweden

Background: Early supported discharge from hospital withcontinued rehabilitation at home (ESD), with core componentsof initial treatment in a stroke unit and the involvement of anoutreach team to deliver and coordinate rehabilitation in part-nership with the patient, has shown a beneficial effect on theextended ADL and in household activities for patients mildly tomoderately impaired 5 years after stroke. The purpose of thepresent study was to assess the effect of ESD services on utiliza-tion of health care and social service resources 5 years afterstroke. Methods: A 5-year follow-up of 54 patients in a random-ized controlled trial was conducted. Of the 83 patients enrolledin the study, 20 patients had died, 4 were no longer residents inStockholm County, and 4 declined to participate at the 5-yearfollow-up. Information on resource was collected from thecomputerized registery of the Stockholm County Council andby interviewing the patient or his or her spouse during a homevisit. Results: A difference in total length of hospital stay was ob-served in favor of the intervention group. The control groupregistered more outpatient visits to physiotherapists as well asin total outpatient rehabilitation. At 5 years after stroke, therewere no differences between the groups either in the use ofcommunity-based social service or in informal care. Conclu-sion: We conclude that 5 years after stroke, our ESD service forpatients with mild to moderate disabilities was favorable withregard to resource utilization.

F3D-4 Walking Function in Long-term StrokeSurvivors

T. S. Olsen and L. P. KammersgaardHvidovre University Hospital, Denmark

Background: We studied durability of walking skillsachieved during rehabilitation in long-term stroke survivorswith initial lower extremity (LE) paresis. Methods: LE paresisand LE function (walking) were examined in 1183 unselectedpatients with acute stroke. A follow-up examination was per-formed after 6 months and 7 years. Stroke severity was deter-mined by the Scandinavian Stroke Scale. According to this scale,LE paresis was graded in 3 ways: severe, moderate, and mild;walking function was graded in 2 ways: independent walking(with and without an aid) and dependent walking (no walkingor walking with personal assistance). Uni- and multivariate sta-tistics were applied. Results: LE paresis was seen in 765 patientson admission. Of these, 64% and 22% were alive at 6 monthsand 7 years, respectively. Mean age of survivors seen at 7-yearfollow-up was 67 years on the acute admission. In these, walk-ing prognosis was as follows: Patients with severe LE paresis onadmission: Walking was independent in 6% in the acute state,62% at 6 months, and 69% at 7 years. Patients with moderate LE

paresis on admission: Walking was independent in 33% in theacute state and in 100% at 6 months and 7 years. Patients withmild LE paresis on admission: Walking was independent in 52%in the acute state, 94% at 6 months, and 91% at 7 years. Conclu-sion: In the long term, stroke survivors’ walking skills achievedduring rehabilitation was related to initial stroke severity and re-mained stable as long as 7 years after stroke.

F3D-5 The Prognostic Value of the ElderlyMobility Scale for Stroke Rehabilitation inHong Kong

R. W. M. LoPhysiotherapy Department, Pok Oi Hospital,Hong Kong

Background: Elderly Mobility Scale (EMS) is a common as-sessment tool for the stroke rehabilitation in Hong Kong. Clini-cians are always devoted to find out a practicable assessmentscore to predict the outcome of the stroke survivors under theircare. Methods: Medical data of the stroke patients who under-went stroke rehabilitation in a district hospital were reviewedretrospectively for the period from January 2004 to December2004. Bivariate comparison between EMS score on admissionand outcomes of discharge destination and ambulation statuswere made using chi-square tests at significance level 0.05. Thevalidity values of the EMS on admission to the outcomes weredetermined. Results: Medical data of 530 community-livingstroke patients who fulfilled the inclusion criteria were re-cruited for analysis. The mean age is 69.7 years and the meanlength of stay for hospital-based rehabilitation was 19.25 days.The sensitivity, specificity, and predictive values of the EMSscore on admission at cut-off points 6, 8, 10, 12, and 14 with thedischarge destination and ambulation status was determinedand will be presented. Conclusion: The EMS score on admissioncutoff at 6 was recommended for clinicians to predict the dis-charge destination (sensitivity of 56.5%, specificity of 80%, posi-tive and negative predictive values of 87.2% and 43.1%, respec-tively) and ambulation status (sensitivity of 82.9%, specificity of81.3%, positive and negative predictive values of 75.8% and87.0%, respectively) for the stroke survivors in Hong Kong.

F3D-6 The Need of Nursing Home Care in theYears after Stroke: A Community-Based 7-YearFollow-up of the Copenhagen Stroke StudyCohort


Background: We studied the need for nursing home (NH)care in the years after a stroke and identified predictors of pa-tients needing NH care. Methods: In a community-based cohortof 1197 hospitalized patients with acute stroke, we identified allpatients who required NH care during a 7-year follow-up.Stroke severity was measured by the Scandinavian Stroke Scale(SSS, 0-58 points) at stroke onset. Type of stroke was deter-mined by CT scan, and all had a cardiovascular risk factor evalu-ation. Independent predictors of NH placement were identifiedby multiple logistic regression analysis. Results: Of the 1197 pa-tients, 899 were discharged alive, and of these, 309 (34%) hadrequired NH care during the subsequent 7 years. Independent



predictors of NH placement in the following 7 years were ad-vancing age (OR, 1.4 per 10 years; P < 0.0001), increasing strokeseverity (OR, 0.6 per 10 SSS points; P < 0.0001) and diabetes(OR, 2.0; P < 0.005). Sex, type of stroke, and other cardiovascu-lar diseases had no predictive power. Six percent of patientsyounger than 65 years at stroke onset (n = 176) required NHduring the subsequent 7 years compared to 57% of patientsolder than 85 years at stroke onset (n = 113). Of patients withinitially mild stroke (SSS greater than 50; n = 313), 19% requiredNH care compared to 64% of patients with initially severe stroke(SSS less than 20; n = 92). Conclusion: One in 3 patients withacute stroke require nursing home care during the following 7poststroke years. Age, stroke severity, and diabetes aresignificant predictors.

F3D-7 Profile of Cerebrovascular Accidentsin the Department of Rehabilitation Medicinein General Hospital

S. Zhou, H. Wang, and J. LiFirst Affiliated Hospital of Nanjing MedicalUniversity, China

Background: Rehabilitation medicine is developing rapidlyin China. However, there is no clear profile of neurologic dis-eases in the departments of rehabilitation in general hospitals.This study aimed to analyze the spectrum of neurologic patientsin a major general hospital. Methods: Retrospective study of 637inpatient files from July 2003 to July 2005 was performed in theJiangsu Province Hospital, which has 1600 inpatient beds and8000 outpatient visits per day. Results: Cerebrovascular accident(CVA) was diagnosed in 192 cases (30.1%), including 100 cere-bral hemorrhage and 92 cerebral infarction. The average agewas 51.9 ± 8.6 years in patients with cerebral hemorrhage(14 subjects with cerebral vessels malformation and aneurysm)and 62.5 ± 12.3 years in patients with cerebral infarction. Aver-age course of diseases was 3.22 month. Average length of hospi-tal stay was 45.6 ± 3.6 days. Major associated dysfunctions andmorbidity included aphasia (31.8%), dysphagia (3.8%), shoul-der subluxation (13.2%), complex regional pain syndrome(4.7%), and foot-drop (22.9%). Hypertension, diabetes mellitus,and hyperlipidaemia were seen in 90% of these patients. Modi-fied Barthel Index on discharge increased significantly than thaton admission. The score reached 65.9 ± 13.7 and 68.4 ± 14.4 inhemorrhage and infarction, respectively, at discharge. On ad-mission, 71 patients can walk independently. After treatment,the number increased to 106. Conclusion: CVA is the most com-mon disease in the department of rehabilitation in the generalhospitals in China.

F3D-8 Spasticity and Its Association withFunctioning and Health-Related Quality of Life18 Months after Stroke

A. K. Welmer, M. von Arbin, L. Widen Holmqvist,and D. K. SommerfeldKarolinska Institutet, Sweden

Background: There is no consensus concerning the pres-ence of spasticity or the relationship between spasticity andfunctioning and health-related quality of life (HRQL), respec-tively, in the stable phase after stroke. The aim of the present

study was to describe, 18 months after stroke, the frequency ofspasticity, and its association with functioning and HRQL. Meth-ods: 66 consecutive patients with first-ever stroke were assessed18 months after stroke with the Modified Ashworth Scale forspasticity, tendon reflexes, self-reported muscle stiffness,Lindmark Motor Assessment Scale, Rivermead Mobility Index,Barthel Index, and Short Form 36 health-survey (SF-36) forHRQL. Results: Of the 66 patients studied, 38 were hemiparetic,13 were spastic, 12 had increased tendon reflexes, and 7 re-ported muscle stiffness. Weak to moderate correlations wereseen between spasticity and functioning scores. Correlationsbetween spasticity and HRQL were generally weak.Hemiparetic patients without spasticity had significantly betterfunctioning scores and significantly better HRQL on 2 of the 8SF-36 health scales than patients with spasticity. Conclusion:Few patients displayed spasticity 18 months after stroke.Spasticity might contribute to movement impairments and activ-ity limitations, but seems to have a less pronounced effect onHRQL. The current exaggerated focus on reflex-mediatedspasticity in stroke care seems to overestimate its clinical impor-tance from a population-based perspective.


F4A-1 Intention Exercise Is More Effective forFunctional Recovery Than Simple Exercise on theRat Experimental Model of Hemiplegia

S. Ikeda, A. Oowatashi, K. Harada, Y. Kamikawa,and K. KawahiraDepartment of Rehabilitation and PhysicalMedicine, Graduate School of Medical and DentalSciences, Kagoshima Univ., Japan

Background: The effects of rehabilitation approach on func-tional recovery in stroke are controversial. The effects of differ-ent approach to the hemiplegic patient are not clear. So westudied the effects of different rehabilitative approaches tofunctional recovery on the rat photochecmically cerebral infarc-tion model. Methods: 24 male Wistar rats aged 8 weeks wereused. Cranial bone was exposed under deep anesthesia.Rosebengal 20 mg/kg was injected intravenously and 560 nmlight beam was irradiated transcranially for 20 min onsomatosensory area of the cerebral cortex. Animals were di-vided into 3 groups. On the simple exercise group, treadmill ex-ercise was done for 20 min every day. On the intention traininggroup, beam-walking exercise was done for 20 min daily, andthe control group was left at natural course. Hindlimb functionwas evaluated with beam-walking test. Results: Dysfunction ofcontralateral extremities was observed. On the intention train-ing group, functional recovery was observed earlier than theother groups. Although rats in the treadmill group recoverd ear-lier than those in the control group, recovery was more rapid onthe intention training group. Conclusion: Rehabilitative exer-cise facilitated the functional recovery on the rat hemiplegicmodel. Especially, intentional rehabilitative approach is moreeffective on functional recovery. These findings considered im-portant on the clinical rehabilitation for functional recovery.



F4A-2 Effect of the Transplantation of HumanEmbryonic Stem Cell-Derived Neuronal PrecursorCells to MCA Infarct Model Rats with Exercise

D. Y. Kim,1 S. H. Park,2 S. P. Park,4 D. H. Choi,3

and T. R. Han3

1Dept of PM & R, Seoul National UniversityBoramae Hospital, South Korea; 2Dept of Pathology,Seoul National University Hospital, South Korea;3Dept of PM & R, Seoul National University Hospital,South Korea; 4Maria Infertility Hospital MedicalInstitute/Maria Biotech, 104, South Korea

Background: We analyzed the therapeutic effect of humanembryonal stem cell derived neuronal precursor (hES-NP) celltransplantation and exercise on rats with middle cerebral artery(MCA) infarcts. Methods: A cortical infarct was induced in 20adult Sprague-Dawley rats by occlusion and reperfusion ofMCA. They were divided into 4 groups: hES-NP transplantationand treadmill exercise, hES-NP cell transplantation only, tread-mill exercise only, and buffer only inoculation with no exercise.hES-NP cells were transplanted by stereotactic inoculation intoipsilateral basal ganglia 7 days after infarct and the rats werethen housed in standard environment for 3 weeks. We evalu-ated their motor behavior index, the size of infarct, and the sur-vival, migration, and differentiation of the transplanted cells.Results: Transplanted hES-NP cells survived robustly in theischemic brains in the 3 weeks posttransplant. The majority ofmigrating cells in ischemic rats had a neuronal phenotype. Themotor behavior index improved from day 14 in thenontransplanted group and from day 17 in the transplantedgroup, but infarct size was significantly reduced in both the ex-ercise only group and the cell transplanted groups comparedwith the control group. However, it was robustly reduced in theexercised group compared with the nonexcercised group, re-gardless of stem cell transplantation. Conclusion: Stem celltransplantation improved behavioral recovery; however, thereduction of infarct size was greatly affected by postischemicexercise, reconfirming the importance of postinfarctrehabilitation.

F4A-3 Promotion of Motor Recovery byContinuous and Low Amplitude CorticalStimulation in Photothrombotic Stroke Model

Y. I. Shin,1 H. S. Kim,1 S. K. Moon,1 H. I. Kim,2

and M. C. Lee3

1Wonkwang University School of Medicine, SouthKorea; 2Presbyterian Medical Center, South Korea;3Chonnam University School of Medicine,South Korea

Background: Electrical stimulation is assumed to augmentthe adaptive plasticity of the brain around the region of a strokeand to enhance motor recovery. However, the optimal parame-ters and mode of electrical stimulation to improve functional re-covery should be further elucidated. Methods: This study used aphotothrombotic model of stroke to examine the behavioral ef-fect of cortical stimulation. Sprague-Dawley rats were trainedon a task of single pellet reaching (SPR) before surgery.Photothrombosis was applied on the sensorimotor cortexcontralateral to hand predominance using Rose Bengal dye andcold light. A unipolar electrode was implanted; then continuouslow-voltage stimulation was delivered for 3 weeks. Daily SPR

tasks were performed to evaluate motor recovery using a be-havior-stimulation box. Results: Electrical stimulation not onlyprompted an earlier start of motor recovery but also improvedfinal recovery. It also eliminated any “inflammatory dip” of mo-tor deficit. Anodal and cathodal stimulation showed similar re-covery patterns in the early period, but cathodal stimulationproduced better final outcomes. Low-voltage electrical stimula-tion showed no adverse effects. Conclusion: Low-voltage con-tinuous stimulation can remarkably enhance motor recoveryfrom photothrombotic stroke.

F4A-4 Changes in Functional Cortical GeneratorsCorrelated with the Clinical Improvement inStroke Patients: Plasticity Indicators

F. S. AL-ShahryKing Abdulaziz Medical City, Riyadh, Saudi Arabia

Background: To correlate the clinical recovery of functionswith the changes in the functional generators (FG) of the ner-vous system of stroke patients. Methods: Telemetry equivalentdipole (ED) localizing techniques in 30 normal subjects and 42stroke patients. SEPs were obtained in 3 successive sessions 1,6, and 20 weeks after stroke. FG of SEPs elicited by ES to mediannerve were investigated by submitting a 3-dimensional recon-structed brain model to dipole tracing. It can equate the poten-tial spatiotemporal (ST) distribution to a corresponding ED. Theearly components of the cortical potentials were recordedwidely on both hemispheres using the 32 channels in 10.20.Source generators of the early component were localized dipoleby Brain Electric Source Analysis (BESA) program. Results: EDtends to show changes in different aspects. Increase was ob-served in 17 patients (40.4%) of the 42 stroke patients and wascorrelated with excellent functional recovery. ST analysisshowed changes in ED and amplitude in 20 patients (47.6%). In5 patients (11.9%), there were no changes in dipole or in func-tion. Conclusion: The improvement in clinical function and EDamplitude and the stability of the other parameter indicate im-provement in the lesion. The correlation of improvement inclinical function with ST changes of the FG gave an indication ofreorganization of representation of function in the cortex. Thissuggests that there are dynamic plastic changes that correlatewith restoration of function. This confirms the changes in thefunctional generators.

F4A-5 The Effect of Rehabilitation Training onthe Function of Learning and Memory in Ratswith a Bilateral Hippocampal Infarction

L. Li1., H. J. Pan3

1Bingjing 304 Hospital, China; 2Shanghai EastHospital, China

Background: Those patients with cerebral ischemia willusually have the main clinical manifestations as impairment ofmotor and sensory function. The impairment of the ability tolearn and memory is not uncommon with long-term sequlae.Large amounts of experimentation and research indicate thatthe CNS of adult animals after CNS injury is plastic and recover-able, structurally and functionally, which makes it possible forrehabilitation after CNS injury. CNS plasticity is reflected atmany levels, both on synaptic and neuron levels, on pathwaylevels, and on cerebral cortex level. The rehabilitative training isequally important in the early, middle, and advanced phases ofCNS injury. Methods: 30 rats were divided into 2 groups at ran-



dom after infarction induced by photochemistry: rehabilitationand braking group. The rats of the rehabilitation group weregiven training 3e days after infarction, whereas the rats of thebraking group were braked. The behavioral tests were per-formed at different times: before infarction, 3 d after infarction,7d, 14d, and 21d after training. Results: The rats with infarctionhad reduced learning and memory function when comparedwith the assessment done before infarction (P < 0.01). The reha-bilitation group showed better score and faster recovery oflearning and memory function than the braking group at differ-ent time point after training (P < 0.05). Conclusion: Rehabilita-tion training could accelerate the recovery of learning andmemory function in rats with bilateral hippocampus infarction.

F4A-6 Peripheral Infusion of IGF-I IncreasesProliferation in the Adult SVZ and CerebralCortex

U. Johansson, D. Aberg, M. Aberg, J. Lind,and P. ErikssonInstutute of Clinical Neuroscience, GoteborgUniversity, Sweden

Background: Cell renewal in the adult cerebral cortex islikely to play an important role in normal physiology as well asCNS regeneration. Newborn cells in the cerebral cortex mayoriginate from local cell division or by migration from otherbrain sites, such as the subventricular zone (SVZ). Methods: Weinvestigated the effect of peripheral administration of recombi-nant human IGF-I (rhIGF-I) on cellular proliferation and differ-entiation in the cerebral cortex of adult hypophysectomized(hx) rats using BrdU labeling and specific cell markers. Results:After 6 d peripheral rhIGF-I administration, there were no dif-ferences in the number of BrdU-labeled cells in the cerebral cor-tex. However, after 20 d peripheral treatment with IGF-I, abun-dance of BrdU-positive cells in the cortex was increasedapproximately 3-fold. The total number of capillary-associatedBrdU-positive cells increased approximately 3-fold. GFAp-BrdU coexpression was unchanged, and no neurogenesis wasobserved. In the SVZ, the number of BRdU-positive cells wasalso increased. In this structure, the changes were observed asearly as 6 d after onset of peripheral rhIGF-I administration,thus representing a possible source of cells for the cerebral cor-tex. Conclusion: The generation of newborn cells in the SVZand cerebral cortex, as well as effects on angiogenesis, mayhave significance for the understanding of physiologic andregenerative processes in the adult brain.

F4A-7 Depression-Like Behaviors and ReducedCell Proliferation in Dorsal Raphe NucleiLesioned Mice

H. Yuan,1 H. Long,2 and X. Mu1

1Xijing Hospital, the Fourth Military MedicalUniversity, China; 2Tangdu Hospital, the FourthMilitary Medical University, China

Background: Stroke is the most common serious disorder inthe world accounting for a significant number of cases for acutehospitalization. Until recently, little attention has been paid tothe neuropsychiatric sequelae of stroke. Depression occurs in30% to 50% of patients after stroke. Evidence in favor of the per-spective that 5-HT is involved in depression comes from the

pharmacologic, postmortem, and cerebral spinal fluid (CSF)studies. But the precise role of serotonin is unclear yet. Methods:C57BL/6J mice were depleted of brain serotonin usingintracerebroventricular administration of 5,7-dihydroxytrypta-mine (5,7-DHT). Body weight was measured every 2 days. At 14days after surgery, the forced swimming test (FST) and the tailsuspension test (TST) were used to detect the depressive-likebehavior and immunohistochemical staining used to observethe 5-HT neurons in dorsal raphe nuclei (DRN). Proliferatingcells in the dentate gyrus (DG) were investigated usingbromodeoxyuridine (BrdU). Results: It showed that 5,7-DHT ef-fectively depleted the 5-HT neurons in DRN. The mice treatedwith 5,7-DHT showed obviously less increase of body weightand depressive-like behavior both in FST and TST. 5-HT deple-tion also caused a significant decrease in granular cell prolifera-tion in DG of the hippocampus. Conclusion: The present find-ings further supported the role of brain 5-HT in the etiology ofdepression. The 5-HT depletion may cause depression, whichpartly involves the suppression of production of new granularcells.

F4A-8 Effects of Cyclic-AMP on Axon Retractionand Regeneration in the Lamprey Spinal Cord

M. E. Selzer, L. Q. Jin, G. Zhang, and C. Jamison, JrUniversity of Pennsylvania School of Medicine, USA

Background: Cyclic-AMP (cAMP) signaling improvesneuronal survival and inhibits growth cone collapse by growth-inhibitory molecules in vitro. In the lamprey spinal cord (SC),regenerating axons appear to lack true growth cones. Thiswould call into question therapeutic approaches based on sup-pression of growth cone collapsing activity by raisingintracellular cAMP levels. We determined, by imaging living ax-ons, whether they regenerated without growth cones, and if so,whether cAMP enhanced their regeneration. Methods: Retrac-tion: Under Tricaine anesthesia, reticulospinal axons werefluorescently labeled by application of rhodamine ± 100 mM 8-OH cAMP to a transection site. After 2 weeks, the SCs werereexposed and the distance of labeled axon tips from thetransection was measured. Regeneration: After 2 weeks recov-ery, SCs were treated topically with 0, 50, or 100 mM db-cAMPfor 1 to 3 days and visualized daily. Growing tips were closelyobserved by dissecting and confocal and 2-photon microscopyor after fixation and neurofilament-immunostaining. Results: 8-OH-cAMP (100mM) inhibited axon retraction (2.62 ± 0.30 mmSE in controls; 1.19 ± 0.16 mm in the cAMP group). Regenera-tion rates were 34.5 ± 2.4, 85.2 ± 5.9, and 243.0 ± 66.6 µm/dayfor the control, 50-mM and 100-mM groups, respectively. Onlysimple growing tips were observed. Conclusion: 1) Mature SCaxons regenerate without growth cones. 2). Despite this, cAMPinhibits axon retraction and enhances axon regeneration.

F4B-1 Impairment-Oriented Training or BobathTherapy for Severe Arm Paresis after Stroke:A Single-Blind, MultiCenter RandomizedControlled Trial

T. Platz,1 C. Eickhof,1 S. van Kaick,1 C. Pinkowski,1

and M. Pause2

1Klinik Berlin, Dept. of Neurological Rehabilitation,Campus Benjamin Franklin, Charité—



Universitätsmedizin Berlin, Germany;2Neurologisches Rehabilitationszentrum,Magdeburg, Germany

Background: The effects of augmented exercise therapytime (AETT) were investigated for arm rehabilitation as eitherBobath therapy or the impairment-oriented training (Arm BASIStraining) in stroke patients with arm severe paresis. Methods:Single-blind, multicenter RCT. Sixty-two anterior circulationischemic stroke patients. Random assignment to either A) noAETT, or AETT as either B) Bobath therapy or C) arm BASIStraining. Main outcome measure: Fugl-Meyer arm motor score.Secondary measure: Action Research Arm test. Ancillary mea-sures: Fugl-Meyer arm sensation and joint motion/pain scoresand the Ashworth Scale (elbow flexors). Results: An overall ef-fect of AETT on Fugl-Meyer scores after 4 weeks was not corrob-orated (mean and 95% CI of change scores: no AETT (n = 20)8.8, 5.2-12.3; AETT (n = 40) 9.9, 6.8-13.9; P = 0.2657). The groupwho received the AETT as arm BASIS training (n = 20), how-ever, had higher gains than the group receiving the AETT asBobath therapy (n = 20) (mean and 95% CI of change scores:Bobath 7.2, 2.6-11.8; BASIS 12.6, 8.4-16.8; P = 0.0432). Passivejoint motion/pain deteriorated less in the group who receivedBASIS training (mean and 95% CI of change scores: Bobath –3.2,–5.2 to –1.1; BASIS 0.1, –1.8 to 2.0; P = 0.0090). Other measureswere not differentially affected. Conclusion: The AETT as armBASIS training enhanced selective motor control. Type of train-ing was more relevant for recovery of motor control than thera-peutic time spent.

F4B-2 Compliance of Acute/Subacute StrokeSurvivors with a 12-Week FES Training of theParetic Upper Limb

G. Alon, A. F. Levitt, and P. M. McCarthyUniversity of Maryland, School of Medicine, USA

Background: Evidence is mounting that the course of recov-ering upper limb function after ischemic stroke is nonlinear,much longer than previously reported and highly dependent onpatient compliance with the training program. The purpose ofthis study was to document patients’ compliance with a 3-month functional electrical stimulation program. Methods:Ischemic stroke survivors (n = 12), mean age 60.9 ± 16.2, begantraining with functional electrical stimulation (FES) programcombined with standardized, task-specific PT/OT rehabilitation14.0 ± 6.2 days postadmission to an acute rehabilitation centerand continue the stimulation at home after discharge from thecenter. Stimulation time increased gradually from 40 min to 4 hper day. Internal timer monitored the time of use. Results: Allpatients completed the 12 weeks training. Mean stimulation was197.2 ± 93.8 h, a 62% of maximal compliance. Individual com-pliance ranged from minimum 30 h (21 min/d) to 362 h (4.3 h/d). Correlations with upper limb motor control improvement (r= 0.27), age (r = 0.0), FES commencement (r = 0.21), orminimental status (r = 0.17) were nonexistent. Conclusion: Mostischemic stroke survivors in the acute/subacute rehabilitationphase are likely to comply with a self-administered FES for 2 to2.5 h daily.

F4B-3 The Vibromyography of Persons afterStroke during Isometric Voluntary Contractionat Different Levels

X. L. Hu, K. Y. Tong, and L. LiThe Hong Kong Polytechnic University, Hong Kong

Background: The purpose of the study was to investigatethe effects of the contraction intensity on the vibromyography(VMG) from the paretic muscle in subjects after stroke duringvoluntary contractions compared to the synchronizedelectromyography (EMG). Methods: VMG and EMG signalswere recorded from the biceps brachii muscles of the dominantarm of unimpaired subjects (n = 5) and the unaffected and af-fected arms of subjects after stroke (n = 8), when performing el-bow flexions at 20%, 40%, 60%, and 80% of the maximal volun-tary contraction (MVC) with repetition of 3 times at each level.Results: EMG mean frequency (MF) decreased significantly withthe increase of the contraction level in the healthy muscles ofunimpaired subjects (P < 0.05), and significant increases inVMG MF were found in the healthy and unaffected muscles (P <0.05). Group difference brought significant effects (P < 0.05) onthe VMG MFs at 20% MVC (affected > healthy; affected > unaf-fected) and at 80% MVC (healthy > unaffected; unaffected > af-fected) but not on the EMG MFs. The high-frequency compo-nents (above 15 Hz) in the power density spectrum of VMGwere found to be significantly higher in the healthy and unaf-fected groups than the affected (P < 0.05). Conclusion: VMG ismore related to the changes in muscle fiber types and the strat-egy of motor unit recruitment than EMG, which could be usedas a complementary to EMG for the analysis on muscular char-acteristics in subjects after stroke.

F4B-4 Trunk Rehabilitation after Stroke:A Pilot Randomized Controlled Trial

G. Verheyden,1 L. Vereeck,2 S. Truijen,2 A. Nieuwboer,1

and W. De Weerdt11Katholieke Universiteit Leuven, Belgium;2Hogeschool Antwerpen, Belgium

Background: This study examines the effect of additionaltrunk activity on trunk performance in subacute stroke patientsin an inpatient rehabilitation setting. Methods: In addition tousual therapy, subjects randomly allocated to an experimentalgroup (n = 14) received 4 times a week 30 min of hands-ontrunk therapy, for 5 weeks. Patients in the control group (n = 11)received no additional therapy. Main outcome measures werethe Trunk Impairment Scale (TIS) total and subscale scores(static and dynamic sitting balance and trunk coordination). Be-cause of a significant difference in age between the experimen-tal and control group, a 2-way ANCOVA analysis was used.Paired t tests evaluated the evolution in the experimental andcontrol group separately. Results: A significant effect of addi-tional trunk therapy was found for the dynamic sitting balancesubscale of the TIS (P = 0.027). When looking at the experimen-tal and control group separately, significant improvementswere found for the dynamic sitting balance subscale in the ex-perimental group (P < 0.0001), the coordination subscale in theexperimental (P = 0.022) and control group (P < 0.0001) and thetotal TIS score for the experimental (P < 0.0001) and controlgroup (P = 0.008). Conclusion: This pilot study indicates that



there is a potentially beneficial effect of additional trunk reha-bilitation for stroke patients. Clinical practice and stroke re-search would benefit from future studies with larger number ofpatients and a placebo treatment for the control group.

F4B-5 Learning a Motor Control Task Is NotImpaired in Patients with Chronic UnilateralStroke: An Approach with an EMG-ControlledComputer Game

I. M. Tarkka,1 K. Pitkanen,2 P. Tuomainen,3

and A. Remes4

1Brain Research and Rehab Center Neuron,Finland; 2Brain Research and Rehab CenterNeuron, Finland; 3Mega Electronics Ltd, Finland;4Mega Electronics Ltd, Finland

Background: Recently, rehabilitation of stroke subjects fa-vor massed practice to regain lost function via cerebral pro-cesses of motor learning. Our purpose was to assess motorlearning ability in chronic stroke subjects using an EMG-con-trolled computer game. Methods: 9 stroke (mean age, 50 years;disease duration, 3.2 years; paretic side, 5 left/4 right) and 10healthy subjects participated. Motor abilities of the arms wereassessed (Arm Research Action Test and Wolf Motor FunctionTest). Surface EMG in 4 channels (Biomonitor ME6000, MegaElectronics Ltd, Kuopio, Finland) from arm muscles (right andleft flexor carpii radialis and extensor carpii radialis) controlleda novel computer game. EMGs were calibrated with individualrange of motion and the voluntary EMGs were transmitted to theball movement in a maze. Time to reach the goal on the screenwas the indicator of motor learning, traveled distance was alsorecorded. Results: Paretic hands were severely affected: ARATscores (mean ± SE) were 23 ± 3 for left and 32 ± 6 for right pare-sis, and affected hand WMFT functionality score was 56 ± 5. Atthe 1st attempt to play an up/down game version, patients weresignificantly slower than healthy subjects (84 ± 36 s/49 ± 9 s),but they reached the level of healthy subjects in the 2nd run, in aright/left version they reached healthy subjects in the 4th run.Conclusion: Regardless of hemiparesis, unrelated to the af-fected hemisphere, chronic stroke subjects were able to learnquickly a complex EMG control task when reaching the goalwas the analyzed variable.

F4B-6 Motor Relearning Program for Patientswith Stroke: A Randomized Controlled Trial

Y. L. D. Chan,1 C. H. C. Chan,2 and K. S. D. Au1

1Kowloon Hospital, Hospital Authority, Hong Kong;2Hong Kong Polytechnic University, Hong Kong

Background: Stroke survivors were found inactive in partic-ipating household and community activities that were highlycorrelated with the balance function. This study investigated theefficacy of a 6-week sequential function-based motor relearn-ing program for improving the balance function and functionalperformance of a group of poststroke patients. Methods: This isa matched-pair randomized controlled trail study. Fifty-two out-patients with thombotic or hemorrhagic stroke received 18 two-hour sessions in 6 weeks in the motor relearning (MR) or con-ventional therapy (CT) program. The outcome measures in-

cluded the Berg’s Balance Scale (BBS), the Timed Up & Go(TUG) test, the Functional Independence Measure (FIM), themodified Lawton IADL test, and the Community IntegrationQuestionnaire (CIQ). They are done at pretreatment andposttreatment 2nd, 4th, and 6th week. Results: The patients inthe motor relearning group had significantly better perfor-mance on all but the TUG test as compared with the controlgroup [F(1,150) = 6.34 to 41.86, P < 0.015]. The interactions be-tween group and occasion were significant on all 5 outcomemeasures, indicating that different rates of change across timebetween the MR and CT groups [F(3,150)=3.60 to 33.58, P <0.015]. Conclusion: The motor relearning program was foundeffective for enhancing functional recovery of patients who hadsuffered a stroke. Both sequential and function-based conceptsare important in applying the motor relearning approach to therehabilitation of stroke patients.

F4B-7 Voluntary Trunk Rotation and Eye Patchingfor Patients with Unilateral Neglect in Stroke:A Single-Blinded Randomized Controlled Trial

K. N. K. Fong, M. K. L. Chan, P. P. K. Ng, M. H. M.Tsang, and K. K. Y. ChowKowloon Hospital, Hong Kong

Background: This study investigated the efficacy of trainingtargeting spatial representations relative to conventional occu-pational therapy training for patients with unilateral neglect(UN) after stroke. Methods: 60 hospital patients with UN, col-lected over a 2-year period, were randomly divided into 3groups: group 1 (n = 19) received voluntary trunk rotation to thehemiside; group 2 (n = 20) received voluntary trunk rotationand half-eye patching to the ipsilesional hemifield; group 3 (n =15) received conventional therapy. Repeated measurements us-ing the Chinese Behavioral Inattention Test, a Clock DrawingTest, FIM, and MMSE by 2 independent assessors for all subjectswere done at admission, after 4 weeks (at the end of training),and in a follow-up at 1 month. Results: There were significantdifferences in mobility and locomotion as measured by FIMamong all groups after training (P = 0.038 and 0.033), and intransfer, mobility, and FIM (motor measure) (P = 0.012-0.035)between groups 1 and 3 after training and at follow-up (P =0.023-0.032). No significant differences were found in neglectmeasures between groups after training except letter cancella-tion (P = 0.035). Conclusion: Training regarding trunk rotationalone was more effective than using it with eye patching, rela-tive to the conventional approach, in enhancing functional per-formance rather than reducing neglect for patients with UN. Thelong-term effect of training could be maintained partially after 1month.

F4B-8 The Effect of Cognitive Training for theElderly Based on a Virtual Reality (VR) Program

M. Kim,1 S. Chun,1 J. Choi,2 and K. Lee2

1Pochon CHA University College of Medicine, SouthKorea; 2Electronics and TelecommunicationsResearch Institute (ETRI), South Korea

Background: Dementia is a disorder of cognitive functions,and VR has been thought to have great potential for cognitivetreatment. As we get older, the cognitive functions decline. A VR



program designed for the elderly might thus be effective to pre-vent and treat dementia. Methods: We developed a VR programto train cognitive functions in the elderly. This system has spe-cial input units and a large monitor. The virtual environmentswere a house and a village. If subjects could not perform thetasks, verbal or visual cues were provided. The subjects weremedically healthy old persons, including 10 with dementia and22 without (mean age, 79.3 years). The subjects were randomlydivided into 2 equal training and control groups. The traininggroup underwent the VR program for 8 weeks, 3 times a week.Just before and after this program, a well-trained psychologistevaluated their neuropsychologic function. Results: 1) At the be-ginning, there was no difference between the 2 groups in termsof demographic data and neuropsychologic functioning. 2) Af-ter the VR program, the training group showed significantlyhigher attention scores on the Dementia Rating Scale and mem-ory scores on the Rey-Kim memory test of auditory verbal learn-ing (both immediate and delayed memory). 3) Bothnondementia and dementia persons showed improvement afterusing the VR program. Conclusion: The VR program developedin this study was effective in improving attention and immediateand delayed verbal memory functions in the elderly.

F4C-1 Comparison of Stroke RehabilitationOutcome and Services between RehabilitationUnit in Australia and Acute Medical Wards inMalaysia

L. A. Latif,1 R. B. Abdul Rahim,1 Z. Omar,1

and P. B. Disler2

1University of Malaya, Malaysia; 2University ofMelbourne, Australia

Background: The aim is to compare the outcome of rehabili-tation and services for stroke patients between a dedicated re-habilitation unit in Melbourne and acute medical wards in KualaLumpur. The outcome measures used were Functional Inde-pendence Measurement (F IM) score , dea th , andinstitutionalization after discharge. Methods: Retrospectivestudy. Centers: 1) Melbourne Extended Care and RehabilitationServices (MECRS), which specializes in rehabilitation and geri-atric care. 2) University of Malaya Medical Center (UMMC) is anacute teaching hospital for the Faculty of Medicine University ofMalaya, Kuala Lumpur. A total of 42 patients were included inMECRS and 51 patients in UMMC. Results: The mean FIM totalscore on admission for stroke patients in MECRS was 83.09 ±22.89 and 65.2 ± 28.3. The mean score for stroke patients wassignificantly higher with P = 0.0013.The mean total FIM score ondischarge was 107.14 ± 17.99 for patients in MECRS and 71.8 ±30.0 for UMMC. The difference was statistically significant withP < 0.001. Discharge destination for MECRS: 85% were dis-charged home, 9.5% transferred to other institutions, and 5.5%to nursing home. For UMMC, 96.1% went home and 3.9% tonursing home. No death documented in either group. Conclu-sion: Functional outcome of stroke survivors after rehabilitationin a dedicated rehabilitation ward in MECRS was significantlyhigher compared to that of stroke survivors from UMMC. Com-munity services in Melbourne are well developed to supportstroke survivors living independently in the community.

F4C-2 Prospective Assessment of RehabilitationOutcome after Subarachnoid Hemorrhage:What Is the Suitable Time Point for Study Design?

G. K. C. Wong,2 W. S. Poon,2 M. T. V. Chan,1

and X. L. Zhu2

1Department of Anaesthesia and Intensive Care,Chinese University of Hong Kong, Hong Kong;2Department of Surgery, Chinese University of HongKong, 86, Hong Kong

Background: Many of the currently reported trials onaneurysmal subarachnoid hemorrhage and clinical vasospasmutilized 3-month clinical outcome as primary outcome measure.However, we noticed that in clinical practice some of the poorgrade subarachnoid hemorrhage patients showed improvementbeyond 3 months after the initial hemorrhage. We aim to quan-tify the difference and explore the underlying pattern. Methods:We prospectively col lected the data of aneurysmalsubarachnoid hemorrhage patients in our institute within 1 yearand assessed the rehabilitation outcome using GOSE at 3months, 6 months, and 1 year. Secondary analysis to identify thetime pattern and case studies were done. Results: A total of 37patients were recruited for the analysis. There was no new mor-tality after 3-month outcome assessment. In comparison withthe 3-month assessment result, there was a 16% increase innumber of patients attaining GOSE 7-8 (good recovery) and22% increase in number of patients attaining GOSE 8 (excellentoutcome) at 12-month assessment. A similar trend at a lesser ex-tent was noted at 6-month outcome. Conclusion: Consideringthe time trend of rehabilitation, 1-year GOSE may be a bettertime point for assessment of clinical outcome in clinical trial in-volving patients with aneurysmal subarachnoid hemorrhage.

F4C-3 Outcomes from a Program Targeted atYoung People with Very Severe Acquired BrainInjury

J. H. Olver,1 M. Gee,2 and N. Best31Epworth Hospital, Australia; 2Southern HealthcareNetwork, Australia; 3Caulfield General MedicalCentre, Australia

Background: The study evaluated the acquired brain injury“slow to recover” program which was developed with a uniquebrokerage-funding model to deliver targeted services to peoplewith very severe ABI who were unable to access therapy andhad limited accommodation and community integration op-tions. Methods: 35 clients who had been on the program for 12months or more were assessed by a clinician using the CanadianNeurological Scale (CNS), the Disability Rating Scale (DRS) andthe Functional Independence Measure (FIM). A social re-searcher measured community integration and burden of careby administering the Community Integration Questionnaire(CIQ) and the Relatives Questionnaire (RQ). Results: At a meantime of 5 years postinjury, 75% of the clients were rated as se-vere. Before the program commencement, 80% of clients wereliving in nursing homes. At survey only 34% were in nursinghomes. On the CIQ, 60% of the clients were reliant on others forall domestic tasks but on social subscales showed a moderatelevel of social integration. Overall, clients were not productivein the community, with only 1 person studying and none em-



ployed. Measuring burden of care by relatives’ level of strain, allbut 1 relative were rated as experiencing high to extreme levelsof strain. Conclusion: The ABI-STR program is successfullymoving significantly disabled clients from acute hospitals tohome with ongoing therapy input; however, they continue torequire a high level of care leading to significant carer stresslevels.

F4C-4 Coping Style and Quality of Lifein Stroke Patients

E. Kerckhofs,1 L. Lefvre,2 and W. Duquet11Vrije Universiteit Brussel, Belgium; 2AZ St. BlasiusDendermonde, Belgium

Background: We wanted to examine 1) which coping stylesare used by stroke patients who completed a rehabilitation pro-gram and 2) whether an association exists between copingstyles and factors that determine the quality of life. Methods: 4questionnaires were completed by 42 home-living stroke pa-tients (30 men and 12 women; mean age, 63.3 ± 13.6 years; timesince stroke, 3.8 [0.5-13.7] years): 1) the Utrecht Coping List, 2)the COPE-questionnaire, 3) the EQ-5D quality of life question-naire, and 4) the adapted Uniform Assessment Outcome. Re-sults: After the EQ-5D patients have moderate problems withmobility (73%), pain/complaints (50%), self-care (42%), ADLand anger and depression (30%) or severe problems with ADL(50%) or self-care (30%). The coping style “active approach” issignificantly but weakly correlated with ADL performance (K =0.265; P = 0.039) and marginally inversely correlated with an-ger/depression (K = 0.251; P = 0.052). The patients used signifi-cantly less the coping style “active approach” and on averagemore the coping styles “palliative reaction,” “avoiding,” “seek-ing social support,” “depressive reaction,” and “reassuringthoughts,” thus less problem-solving-oriented coping styles.More than 40% declared to have moderate to serious depres-sion. Conclusion: These results suggest spending more atten-tion to 1) the education of more adequate coping styles in reha-bilitation and 2) to the prevention and treatment of depressionin stroke patients.

F4C-5 The Validity and Test-Retest Reliability ofLeeds Multiple Sclerosis Quality of Life Scale byElimination of Depression Effect

V. Sumbuloglu,1 D. I. Akbiyik,2 Z. Guney,3 K.Armutlu,4 and R. Karabudak4

1Karaelmas University, Turkey; 2Turkish Ministry ofHealth, Turkey; 3IDE Company, Turkey; 4HacettepeUniversity, Turkey

Background: Multiple sclerosis, which is a progressive ill-ness, usually with serious depressive symptoms, leaves remark-able effects on quality of life. The aim of this study is to measurethe validity and reliability of the Turkish version of 8-item LMSQuality of Life Scale to be used as an easily applicable tool, alsoconsidering depression effect. Methods: 69 patients with MS andmatching 62 healthy controls in the study answered the ques-tions in a quality of life scale previously developed in Turkish,the LMSQoL Scale, Beck Depression Scale, and a questionnaireincluding sociodemographic characteristics. For the test-retest

reliability, they were asked to answer the questions again 10days after the 1st test. Results: There was a meaningful differ-ence between the mean values of the 2 groups for LMSQoLscores. The correlation between the scores of the QoL scaleswas significant. The test-retest correlation of LMSQoL scale was0.85. The mean scores for BDS in MS and control group were12.06 and 8.39, respectively. To test the effect of depressivesymptoms, the adjusted means of LMSQoL scores for the groupsMS and controls were 14.25 and 15.86, respectively. Conclu-sion: The Turkish 8-item LMSQoL scale is a valid and reliabletool for measuring the quality of life in MS patients. It is also in-dicated that it has similar acceptable results with or without thedepression effect. The clinicians and the patients can take theadvantage of having a short and easy-to-use tool in Turkish.

F4C-6 Prediction of Functional Outcome inStroke Rehabilitation: A Pilot Study

A. Sarhan1 and F. Maclean2

1Salmaniya Medical Complex (SMC), Bahrain;2Queen Margaret University College,United Kingdom

Background: Individual and accurate predictions of strokepatients’ functional outcome can help clinicians plan realisticand cost-effective treatments. Regression models could providesuch predictions if the independent variables were appropri-ately identified. The aim of this pilot study, therefore, was toevaluate the use of admission Functional Independence Mea-sure (FIM) subscores and age to produce regression models thatpredict functional outcomes of a strictly homogeneous strokesample. Methods: Design: Exploratory (predictive) design, a pi-lot study. Sample: A retrospective data set of 20 patients diag-nosed with infarct stroke and aged 65 years or younger. All sub-jects were independent in ADL and lived alone before the strokeonset. Independent variables: age, admission FIM subscores.Dependent variables: length of hospital stay, discharge needs,and functional improvement. Results: A multivariant analysiswas undertaken that indicated that the regression models usingthe FIM subscores and age were highly accurate in predicting asubjects’ functional outcome. These regression models had100% sensitivity and specificity in predicting most of the de-pendent variables. Conclusion: Tentatively, the results offer amethod that could be used in future studies with a larger samplesize. This may provide an accurate regression model for strokepatients’ functional outcomes. It appears that using a homoge-neous sample, age, and FIM subscores in an exploratory de-signed study could improve regression models’ accuracy.

F4C-7 QOLBI: A Quality of Life Instrument forBrain Injury: Validation Studies

G. J. Geurtsen,1 H. J. Eilander,2 A. van Sluijs-Boer,2

A. M. V. Dommisse,1 and J. D. Martina1

1Rehabilitation Centre Groot Klimmendaal, theNetherlands; 2Rehabilitation Centre Leypark, theNetherlands

Background: Traumatic brain injury (TBI) can have devas-tating consequences with huge effects on the quality of life(QOL). QOL becomes increasingly important in outcome as-



sessment. In our view, quality of life is about satisfaction and,therefore, a subjective construct to be measured from the view-point of the person with TBI. The quality of life scale for braininjury (QOLBI) is such an instrument for TBI patients. Methods:In 3 studies, the reliability, validity, and the test-retest reliabilityof the QOLBI were determined. In study 1, 56 patients com-pleted the QOLBI and other questionnaires and their relativeson the relative-version of QOLBI. In study 2, the QOLBI was ad-ministered twice with 3 to 4 months interval to 29 patients. In anongoing study, the QOLBI is administered twice with 2 weeksinterval with 40 patients. Results: The internal consistency of theQOLBI was moderate to satisfactory. It was satisfactory to goodfor the relative-version. The construct validity of the QOLBI wassatisfactory. Correlations with other instruments which measureabout the same were as expected. This was also true for scalesthat measure different related constructs. Three to 4 monthstest-retest reliability was inadequate for the functional domain,moderate to good for the other domains, and good for theQOLBI total. Conclusion: The QOLBI is an acceptable, reliable,and valid instrument to assess the quality of life of people withTBI. Because it asks about satisfaction and not about function-ing, it really taps into ones’ quality of life.

F4C-8 Multidimensional FunctionalConsequences of severe Multiple Injuries withTraumatic Brain Injury 2 Years after the Accident

H. Soberg,1 E. Bautz-Holter,1 0. Roise,1 and A. Finset21Ulleval University Hospital, Norway; 2University ofOslo, Norway

Background: The assessment of outcome after multipletrauma with brain injury (TBI) is increasingly important intrauma rehabilitation research. The purpose of this study was toassess functioning and quality of life (QOL) after severe injuriesusing a prospective cohort design. Methods: A subgroup of 64patients with injuries including TBI was selected from a groupof 105 patients admitted to a level I trauma center. The patientswere included from January 2002 through June 2003. New In-jury Severity Score (NISS) was more than 15, age 18 to 67. Out-comes were assessed at 6 weeks after discharge and at 1 and 2years postinjury. Self-reported health was measured by SF-36,WHO Disability Assessment Schedule II (WHODAS II), and theCOG for cognitive functioning. Results: Mean age was 34.8 ±13.6 years, 84% were male. Mean NISS was 36.1 ± 12.3, GCS 10.7± 4.2. SF-36 and COG scores were below population scores atall times. WHODAS II disability score showed substantiallyworse functioning compared with general population data.Length of stay in hospital/rehabilitation, bodily pain, socialfunctioning, and physical functioning 1 year postinjury madeindependent contributions to WHODAS II 2 years postinjuryand explained 69% of the model. Conclusion: Long-lastingfunctional problems after multiple trauma affect most life do-mains. Knowledge about the reduced physical, mental, cogni-tive, social, and role functioning should have an impact on therehabilitation provided for severely injured patients from thehospital to community rehabilitation.

F4D-1 Susceptibility to Deterioration ofMobility in Long Term after Stroke:A Prospective Cohort Study

I. G. L. van de Port, G. Kwakkel, I. van Wijk, E.LindemanRehabilitation Center De Hoogstraat and UniversityMedical Center, Utrecht, the Netherlands

Background: The aim of the present study was to identifyclinical determinants of mobility deterioration in stroke pa-tients. Methods: Prospective cohort study of stroke patients con-secutively admitted for inpatient rehabilitation. Two hundredfive relatively young (mean age, 57 years), first-ever stroke pa-tients were assessed at 1 and 3 years poststroke. Mobility statuswas determined by the Rivermead Mobility Index (RMI), anddecline was defined as a deterioration of 2 or more points on theRMI. Univariate and multivariate logistic regression analyseswere performed to identify prognostic factors for mobility de-cline. Results: A decline in mobility status was found in 21% ofthe patients. Inactivity and the presence of cognitive problems,fatigue, and depression at 1-year poststroke were significantpredictors of mobility decline. The multivariate model showeda good fit (Hosmer-Lemeshow test P > 0.05) and discriminatingability was good (area under the ROC curve = 0.79). Conclu-sion: Mobility decline is an essential concern in chronic strokepatients, especially because it might lead to ADL dependenceand affects social reintegration. Early recognition of prognosticfactors in patients at risk may guide clinicians to apply interven-tions aimed to prevent deterioration of mobility status inchronic stroke patients.

F4D-2 Characteristics of Rehabilitationin the Home Environment after Stroke:The Therapists’ Perspective

A. Wohlin Wottrich, L. von Koch, and K. ThamKarolinska Institutet, Sweden

Background: A growing demand for rehabilitation services,e.g., rehabilitation after stroke for older people, has generatedan increased interest in the use of alternative care environmentssuch as the home. Home rehabilitation programs after strokedescribed in the literature vary in organization content, length,and frequency of visits. The scheme is however not yet fully de-scribed, and the meaning therapists’ attribute to work with reha-bilitation in a home environment needs to be further under-stood. The aim of the study was to identify what characterisesrehabilitation in the home environment after stroke from thetherapists’ perspective. Methods: A qualitative method based oninterviews was used. The members in an outreach team wereasked to tell the therapeutic story of patients with stroke whohad completed a home rehabilitation program. Results: Thequalitative analysis generated a meaning structure of what char-acterises the rehabilitation in the patients’ home presented inone main characteristic, supporting continuity and in 4subcharacteristics, transferring from hospital to home—makinga journey together, enabling bodily experiences—finding the



habit body, refraining from interventions—taking risks, endingin uncertainty, looking for a new phase, as well as representingthe strategies used by the therapists. Conclusion: The resultsmake explicit the therapists’ tacit knowledge and can serve as abasis for how to develop the rehabilitation strategies forrehabilitation at home after stroke.

F4D-3 Does Motor Recovery afterStroke Depend on Intact Attention?A 1-Year Follow-up Study

D. Hyndman, A. M. Ashburn, and R. M. PickeringThe Stroke Association Rehabilitation ResearchCentre, University of Southampton, United Kingdom

Background: Attention deficits have been linked to poor re-covery after stroke and may predict outcome. We exploredwhether attentional ability at discharge from hospital predictsoutcomes at 12 months. Methods: Hospitalized people withstroke completed measures of attention, balance, mobility,ADL, and mood at discharge and 12 months later. We used linearregression to explore the potential predictors of outcome. Re-sults: We recruited 122 men and women; mean age, 70.2. At dis-charge, 56 (51%) had deficits of divided attention; 45 (37%), ofsustained attention; 43 (36%), of auditory selective attention; 41(37%), of visual selective attention, and 27 (24%) had visual ne-glect. Attention deficits were associated with stroke severity,longer hospital stay, depression, poor mobility, balance, andADL ability (P < 0.01) but not age, gender, lesion side, or mobil-ity milestones. Attention at discharge correlated with outcome12 months later for 10 of 12 mobility, balance, and ADL vari-ables (P < 0.01); however, after controlling for the level of mo-bility at discharge, this only remained significant for 3 variables.Linear regression revealed that stroke severity (P = 0.054), num-ber of medications (P = 0.001), mobility (P = 0.000) and balanceat discharge (P = 0.004) were better predictors of outcome thanmeasures of attention (all P > 0.10). Conclusion: After control-ling for function at discharge, attention correlated only weaklywith function: other factors were better predictors of outcome12 months later.

F4D-4 Tibial Bone Changes with a 19-WeekExercise Program in People with Chronic Stroke:A Peripheral Quantitative Computed Tomography(pQCT) Study

M. Y. C. Pang,1 M. C. Ashe,1 J. J. Eng,1 H. A. McKay,1

and A. S. Dawson2

1University of British Columbia, Canada; 2GFStrong Centre, Canada

Background: After a stroke, diminished bone density and anincreased likelihood of falls substantially enhance the risk offragility fractures. Regular skeletal-loading exercise may be aneffective intervention to improve bone health in the stroke pop-ulation. Methods: We undertook a randomized controlled inter-vention trial. Sixty-three persons with chronic stroke were ran-domly allocated to either an experimental group or a controlgroup. The experimental group participated in a 19-week exer-cise program consisting of high-impact aerobic exercises andother skeleton-loading activities. The control group completeda seated upper extremity program. We used peripheral quantita-

tive computed tomography (pQCT) to measure before and afterbone geometry and volumetric mineral density at the distal 4%and midshaft 50% of the tibia. Results: At the 4% site, we found asignificant increase in trabecular bone content (P = 0.006),trabecular bone density (P = 0.009) and trabecular bone area (P= 0.016) on the paretic side in the experimental group. Thenonparetic side also had increased trabecular bone content (P =0.009) at the 4% site in the experimental group. In contrast, thecontrol group had no significant changes in any of thetrabecular bone outcomes. At the 50% site, there were no signif-icant changes in any of the cortical bone outcomes in bothgroups. Conclusion: This is the 1st study to show that intensiveskeleton-loading exercise can increase trabecular bone contentin chronic stroke patients.

F4D-5 Fecal Incontinence in Long-TermStroke Survivors


Background: Fecal incontinence (FI) and determinants of FIwas studied in long-term stroke survivors. Methods: FI was re-corded in 1050 acute stroke patients from the community-basedCopenhagen Stroke Study. The patients were observed at 6months and 7 years poststroke (at which time 69% and 27%, re-spectively, had survived). The patients were divided in conti-nent and incontinent patients according to the Barthel Index.Stroke severity was measured on admission using the Scandina-vian Stroke Scale (0-58) and graded in 3: severe (0-19), moder-ate (20-39), mild (40-58). Predictors of FI were identified usinglogistic regression statistics. Results: On admission in the acutestate 436 patients (42%) had FI: In 94% of patients with severestroke, 58% with moderate stroke, and 12% with mild stroke. At6 months, 10% of the survivors had FI: In 43% of patients withinitially severe stroke, 16% with moderate stroke, and 3% withmild strokes. At 7 years poststroke, FI occurred in 12% of thesurvivors: In 60% of patients with initially severe strokes, 21%with moderate strokes, and 9% with mild strokes. Only strokeseverity was a significant predictor of FI in the acute state, 6months and 7 years poststroke. Age was a significant predictorof FI in the acute state but not at 6 months and 7 yearspoststroke. Sex was not a predictor of FI. Conclusion: Approxi-mately 40% of patients with acute stroke and 10% of long-termsurvivors have FI. Stroke severity but not age or sex predicts FIin long-term stroke survivors.

F4D-6 Evidence for a Pathologically RealignedBody Orientation in Contraversive Pushing

C. Lafosse,1 M. Troch,1 L. Vereeck,1 E. Kerckhofs,2

and G. Verheyden3

1Rehabilitation Clinic Hofter Schelde Belgium,Belgium; 2Free University of Brussels, Belgium;3Catholic University of Leuven, Belgium

Background: We aimed to demonstrate the existence of a bi-ased postural body scheme in patients with pusher syndrome.Methods: We have systematically studied the subjective posturalvertical (SPV), the location of the center of gravity (COG) andspinal EMG analysis in 43 right brain–damaged stroke patients,classified according to the severity of their neglect and the all or



no presence of contraversive pushing (CP). Time course ofchanges in the body-centered representation of space was in-vestigated in a case with right posterior cortical atrophy. Re-sults: The perceived localization of the body saggital midplanein space is ipsilesionally displaced in patients with hemispatialneglect resulting in an ipsilesional deviation of the COG. How-ever, in the neglect patients with CP, we noticed a displacedCOG towards the contralesional side of space withipsilesionally increased EMG patterns. No additional lesionswere found in the (posterolateral) thalamic regions. Conclu-sion: The results indicated an increasing mismatch between theSPV and the direction of the gravitational force in patients withCP. This conflict is compensated by a contraversive shift of theCOG in order to realign the postural body scheme with the grav-itational vertical. In this respect, our results favor the interpreta-tion that the underlying cause of contraversive pushing is a se-vere graviceptive misperception of the body orientation inrelation to gravity.

F4D-7 Differences in Morbidity and Mortality inStroke Patients with Percutaneous EndoscopicGastrostomy or Nasogastric Tube Feeding

M. M. Y. Tse, L. S. W. Li, K. P. Leung, and M. M. T. NgTung Wah Hospital and the University of HongKong, Hong Kong

Background: Both percutaneous endoscopic gastrostomy(PEG) and nasogastric tube (NGT) feeding are popular modesof enteral feeding. No concrete study has directly comparedPEG with NGT feeding. The aim of this study was to look at mor-bidities and mortality differences. Methods: Retrospective casenote review of a cohort of stroke patients from June 1999 to June2001 who received either PEG or NGT insertion was observeduntil the patients died, were weaned off enteral feeding, or until31 August 2005. Results: A total of 62 stroke patients were re-cruited; 36 received PEG and 26 had NGT inserted. There wereno statistically significant differences between the groups interms of the patients’ ages, sex, nature, side and number ofstrokes, comorbidity, or duration on enteral feeding. NGT feed-ing was assoicated with a significantly higher pneumonia ad-mission rate. The adjusted pneumonia rate per 1000 days was9.00 compared to only 3.32 in the PEG group, a difference sig-nificant at the P = 0.008 level. There was a 63% reduction inpneumonia admission risk with PEG usage. There was no over-all difference in total admission rates or in admission due totube dysfunction. More than 80% of the patients on enteral feed-ing died during this follow-up period. The PEG group had sig-nificantly lower mortality secondary to pneumonia (P = 0.044),despite similar overall mortality. Conclusion: PEG feeding wasshown to reduce pneumonia admission and mortality second-ary to pneumonia. PEG is therefore the preferred mode of feed-ing to reduce the complication of pneumonia.

F4D-8 Functional Outcome after Stroke inCAPD Patients

T. K. Kwok and L. S. W. LiTung Wah Hospital and the University of HongKong, Hong Kong

Background: Renal failure patients experienced higher rateof stroke but dialysis does not alter this situation. Outcome afterstroke rehabilitation for patients with continuous ambulatoryperitoneal dialysis (CAPD) have not been investigated. Meth-

ods: A matched case control study compared the length of stay,discharge destination, Functional Independence Measure(FIM), and survival between stroke patients with CAPD andwith normal renal function. Twenty-five CAPD patients who de-veloped stroke from 1998 to 2002 entered the study. Fiftymatched control patients were also recruited. Results: The meanlength of stay of CAPD patients (49.2 ± 8.8 days) was longer (P <0.05) than the control group (30.5 ± 2.2 days). The initial andpredischarge FIM of CAPD patients (63.2 ± 7.0, 76.1 ± 38.7) weresignificantly lower (P < 0.05 and P < 0.01, respectively) than thatof the control group (82.7 ± 4.1, 101.5 ± 29.5). No difference ofdischarge destination between the 2 groups of patients (P =0.49) was observed. One-year survival of CAPD patients (0.6)was significantly lower than the control group (0.9) and 20%CAPD patients died of peritonitis. Conclusion: Patients withCAPD and stroke had lower functional level with a longerlength of stay for rehabilitation. Their mortality within 1 yearwas high especially because of peritonitis. Their rate of dis-charged home was as good as the control, probably because ofsufficient care provided by relatives existed before stroke. Mod-ified method to accommodate their motor weakness to carry outdialysis exchange should be developed to prevent peritonitis.

POSTER SESSIONS–February 13, 2006

P1-001 Antinociceptive Effect of Gabapentin onthe Central Neuropathic Pain in the Spinal CordContusive Rat Model by Direct Nerve Recordings

I. S. Choi,1 S. G. Lee,1 S. R. Ryu,1 J. H. Kim,2

and S. Y. Lee2

1Department of Physical Medicine & Rehabilitation,Research Institute of Medical Sciences, ChonnamNational University Medical School & Hospital,South Korea; 2Chonnam National UniversityHwasun Hospital, South Korea

Background: The central neuropathic pain (CNP) syndromeafter spinal cord injury is a very bothersome sequelae and repre-sents a major therapeutic challenge. The aim of this study is toinvestigate the antinociceptive effect of gabapentin on the CNPin the spinal cord contusive rat model by the direct nerve re-cording method. Methods: 20 Sprague-Dawley rats (male, 300 ±50 g.) that underwent spinal cord contusion from a drop-heightof 2.5 cm at the T10 cord and 10 rats that underwent sham oper-ation of laminectomy were recruited. The gabapentin-treated(GT) group (n = 10) was orally administered gabapentin (30mg/kg), and the saline-treated (ST) group (n = 10) was adminis-tered only saline. They were subjected to the neurobehavioralanalysis for the mechanical allodynia and thermal hyperalgesiafor 4 weeks after cord contusion. Direct nerve recordings intothe dorsal horn at the L1 spinal cord were performed at the 28thday after cord contusion by the microelectrode recording sys-tem, according to the stimulation at the plantar surface of hindpaw. Results: In GT group, when compared to ST group, 1)withdrawal thresholds and latencies were significantly im-proved (P < 0.05), 2) the spike counts from the dorsal horn weresignificantly decreased (P < 0.05). Conclusion: The systemic ad-ministration of gabapentin exhibits an antiallodynic andantihyperalgesic effects on the CNP in spinal cord contusive ratmodel by modulating the excitability in the dorsal horn of thespinal cord.



P1-002 Rehabilitation Outcomes afterCerebellar Strokes

K. P. Leung, T.K. Kwok, M. M.Y. Tse, Y. M. Fong,and L. S. W. LiTung Wah Hospital and the University of HongKong, Hong Kong

Background: Data on functional recovery after cerebellarstroke are lacking in Hong Kong and literatures. We sought toquantify the functional recovery of cerebellar stroke patientsand to identify variables that predicted their functional out-comes. Methods: A retrospective study of cerebellar stroke pa-tients who were admitted for inpatient rehabilitation between 1January 2002 and 31 December 2004 was performed. Demo-graphic, clinical, and functional outcome data were analyzed.Results: 78 patients (49 males and 29 females; mean age, 72.2years) were identified with 58 infarcts and 20 hemorrhages. Theaverage acute length of stay (LOS), average rehabilitation LOS,and average total inpatient LOS were 26.2, 28.3, and 45.2 days,respectively. Mean admission and discharge Barthel Index (BI)scores were 58 and 74. Mean admission and discharge Func-tional Independent Measures (FIM) were 78.5 and 92.3. Meanadmission and discharge Berg’s Balance Scores (BBS) were 27.9and 34.5. Changes in these 3 functional measures were statisti-cally significant. Sixty (76.9%) were discharged home, whereas18 (23.1%) were discharged to institutions or dead. The infarctsubgroup had statistically higher admission and discharge func-tional scores and higher home return rate. Favorable functionaloutcomes or home return also correlated positively with higheradmission BBS, FIM, and BI scores. Conclusion: Significant im-provements in mean BBS, FIM, and BI scores uniformly occurafter rehabilitation. Favorable outcomes are predictable by ad-mission functional scores and the infarct subtype.

P1-003 Urinary Retention after Stroke

T. K. Kwok, K. P. Leung, Y. L. Leung, L. S. W. Li1Tung Wah Hospital and the University of HongKong, Hong Kong

Background: Urinary problems are an obstacle for stroke re-habilitation and themselves constitute a major disability forstroke patients. Retention of urine is one of the common prob-lems after stroke, but limited studies have been conducted onthis issue. Methods: A prospective study collected data from pa-tients, who had their 1st stroke and were admitted to a hospitalrehabilitation unit from 1 May 2004 to 31 December 2004. Allpatients were assessed by the continence team. Urodynamicstudies (VUD) were performed within 1 month after theirstrokes. Results: 232 patients were admitted during the study pe-riod. Of the patients, 18.5% developed retention of urine; 84.4%of these patients were able to wean off the catheter, but 15.6% ofthe patients required long-term catheterization. The mean dura-tion for weaning off the catheter was 40.3 days (SD ±23.5). Ofthese patients, 53.1% had transient retention, 21.9% of the pa-tients had detrusor failure, 6.3% had detrusor instability, 12.5%experienced constipation-related retention, and 3.1% of the pa-tients were found to have prostatic hypertrophy. Of these pa-tients, 56.2% had urinary tract infections (UTIs). Patients whofailed to wean off the catheter had significantly higher UTI rates(P < 0.01). Conclusion: Retention of urine is common in patientswith subacute stroke. The majority had transient retention.Detrusor failure and detrusor instability were not uncommoncauses, which could be overlooked.

P1-004 Incontinence of Poststroke Patients

T. K. Kwok, K. P. Leung, Y. L. Leung, and L. S. W. LiTung Wah Hospital and the University of HongKong, Hong Kong

Background: Around 17% to 41% stroke patients have uri-nary incontinence, but not much study has been conducted tolook into the details. Better understanding of the incontinencecan help prescribing appropriate treatment and improving theoutcome for these patients. Methods: A prospective study col-lected data from patients having their 1st stroke from 1 May2004 to 31 December 2004 and admitted to a rehabilitation unit.All patients were assessed by the continence team. Urodynamicstudies (UD) were performed for those who did not respond toconventional treatment. Results: 232 patients were admittedduring the study period; 10.8% patients had incontinence;72.2% of these patients regained continence, but 27.8% re-mained incontinent on discharge from the rehabilitation pro-gram. UD was performed for 22.2% of the incontinent patientswith uncertain diagnosis; 74.9% of these patients had detrusorinstability, and 25.1% patients had prostatic hypertrophy. Theremaining 5.6% patients with normal UD were considered tohave functional incontinence. Significantly more continent pa-tients (74.3%) were discharged back home than incontinent pa-tients (34.2%) (P = 0.01). Female patients (P = 0.02) andischemic stroke patients (P = 0.03) had significantly more incon-tinence. Conclusion: The commonest cause for incontinence af-ter stroke is detrusor instability. The actual incidence may beeven higher because most of the patients in our study recoveredbefore UD. Incontinence seems to be a poor prognostic factorfor home discharge.

P1-005 Neurophysiological and ClinicalLong-term Follow-up in Sacral Neuromodulation:A Hypothesis of Neuroplasiticity

S. Malaguti1 and M. Spinelli21Neururophysiology Spinal Unit Niguarda Hospital,Italy; 2Urology Spinal Unit Niguarda Hospital, Italy

Background: Neurophysiologic evaluation (NPE) in pa-tients addressed to sacral neuromodulation (SNM) revealed anundisclosed neurogenic alteration as a possible cause of imbal-ance in afferent input to cortical area. Moreover SNM seems toact on the afferent pathway with a specific modulating effect re-lated to parameters of stimulation. An increase from 21 to 40 Hzleads to a decrease in pudendal somatosensory evoked poten-tials (PSEPs) P40 latency resulting in a sort of facilitation on af-ferent impulse transmission suggests a reset of the processingmechanism. We hypothesized that the imbalance in afferent in-put can be modified by SNM leading to a neuroplastic effect onneurocontrol. Methods: From November 2001 to September2005, 215 patients underwent NPE (T0) and 111 patients(51.62%) implanted with SNM. PSEPs were assessed after 1 (T1)and 24 months (T2). Results: In 4 patients (3.6%) implanted foridiopathic detrusor overactivity, clinical efficacy was never fullyachieved and slowly declined with time; a return to PSEPs T0P40 was found in T2. SNM acts on neurocontrol mechanism butneed to be reinforced, which perhaps correlates with the under-lining pathophysiology of symptoms. In 5 patients (4.5%) im-planted for dysfunctional voiding with SNM switched off, per-sistent efficacy with no difference in PSEPs at T1 and T2 wasseen. If a physiologic restoration is achieved, the effect onneurocontrol mechanism persists in a normal fashion. Conclu-



sion: NPE in SNM can clarify the mechanism by which centralnervous system modifies its organization.

P1-006 Central Motor Control Failure as theBasis of the Development of Early Fatigue inFibromyalgia, a recognized NeuropathicPain Condition

R. Casale,1 P. Sarzi-Puttini,2 P. Balbi,1 C. Fundarò,1

and A. Rainoldi31Department of Clinical Neurophysiology, SalvatoreMaugeri Foundation, IRCCS, Scientific Institute ofMontescano, Montescano (PV), Italy; 2Departmentof Internal Medicine, Rheumatology Unit, LuigiSacco University Hospital, Milano, Italy;3Laboratory for Neuromuscular System Engineering(LISiN), Department of Electronics, Politecnico diTorino, Torino, Italy

Background: Fibromyalgia (FMS) is characterized by gener-alized allodynia, hyperalgesia with diminished pain threshold,and abnormal perception of muscle fatigue (MF). The aim ofthis work was to noninvasively assess if the early developmentof MF in FMS patients is centrally mediated by means of surfaceEMG (sEMG). Methods: 6 female patients (FBR 52.6 ± 10.5 years,mean ± SD) and 6 female sedentary healthy volunteers (HLT,49.1 ± 6.2 years, mean ± SD) were studied. Biceps brachiimyoelectric activity (electrically elicited as well as voluntary)was recorded using a linear array of 16 electrodes. Besidesglobal signal variables (maximal voluntary contraction [MVC]),motor unit action potential conduction velocity distributions(mean ± SD and skewness) were estimated. Results: Altered mo-tor pattern recruitment was marked by lower myoelectric mani-festations of fatigue (described by CV and MNF normalized rateof changes) in FBR (–0.086%/s ± 0.052%/s and –0.31 %/s ±0.12%/s, respectively) with respect to HLT (–0.201 %/s ±0.124%/s and –0.71 %/s ± 0.36%/s, respectively) and by a con-comitant higher CV distribution mean values and skewnesses inthe FBR than in the HLT group. Results from MVCs and electri-cally elicited contractions did not differ between FBR and HTL.Conclusion: Differences between the 2 groups were found onlyin voluntary contractions, hence possibly related to a centralmotor control failure rather than to a muscle membrane alter-ation. The observed altered motor pattern recruitments in FBRcould be subordinate to the altered sensory-motor coupling.

P1-007 The Impact of Somatosensory and MentalFunctions on Mobility and Activities of DailyLiving in Stroke Patients 65 Years and Older

A. K. Welmer, L. Widen Holmqvist,and D. K. SommerfeldKarolinska Institutet, Sweden

Background: Activity scores in the acute phase after strokehave been shown to predict rehabilitation outcome. The aim ofthe present study was to examine the relative impact ofsomatosensory and mental functions on activity (mobility andactivities of daily living [ADL]), 5 and 10 days after stroke in pa-tients 65 years and older. Methods: 100 consecutive patientswere assessed 5 (day 5) and 10 (day 10) days after acute strokefor somatosensory (touch function and proprioception), per-ceptual, specific mental,; emotional, energy and drive, sleep

functions, mobility (Rivermead Mobility Index [RMI]), and ADL(Barthel Index [BI]). Patient demographics and stroke charac-teristics were also registered. Multivariate analyses were con-ducted with the RMI and BI, respectively, as dependent vari-ables. Results: The functions with the highest positive impact onthe RMI day 5 were intact proprioception and perceptual func-tion; and on the BI intact perceptual function, touch functionand no earlier stroke. The functions with the highest positiveimpact on the RMI day 10 were intact proprioception and malegender; and on the BI intact touch function, male gender and in-tact perceptual function. Conclusion: Somatosensory functionhad the highest impact on mobility, whereas ADL depended onboth somatosensory and perceptual functions. Because patientswith low mobility (RMI less than 4) and ADL (BI less than 35)scores have been shown to have relatively worse prognoses, itis important to consider the body functions that might affectthose activities.

P1-008 Working with Epilepsy

P. K. Datta, G. Gilworth, R. M. Kent,and A. M. TennantUniversity of Leeds, United Kingdom

Background: People with epilepsy experience difficulty inobtaining and retaining work, but little is known about the ex-periences of working with epilepsy. This qualitative studyaimed to gain insight into patients’ experience of working withepilepsy. Methods: 35 participants with epilepsy, currently em-ployed, were interviewed using a semistructured format. A the-oretical sampling frame was used to ensure a representativesample by gender, seizure frequency, and job type. All inter-views were tape-recorded and transcripted. Content analysiswas used to identify emerging themes. Results: A wide range ofoccupations were represented. The median age at the time ofdiagnosis was 14 years (range, 1-48 years) and the median dura-tion of epilepsy was 17 years (range, 1-51 years). Some of themain themes identified were work factors, disclosure, and is-sues related to driving. Several subthemes within work factorsalso emerged including attitudes of work colleagues and the pa-tients, career progression, and the need for job modifications.Some persons experienced few problems, whereas for othersthere were major problems, which included a change of job.The impact of epilepsy at work related mainly to effective con-trol of seizures, the type of job, attitude of the employer, and in-ability to drive. Conclusion: The impact of epilepsy at the work-place was variable for subjects. For some of those whoexperienced problems, it had forced them to modify work prac-tices or to change job or had a negative effect on their careerprogression.

P1-009 The Modified Timed Up and Go (mTUG):An Evaluation Tool Measuring Components ofBalance and Mobility in Adults

R. T. Lazaro,1 D. A. Umphred,2 and M. L. Roller3

1Samuel Merritt College, USA; 2University of thePacific, USA; 3California State UniversityNorthridge, USA

Background: The modified Timed Up and Go (mTUG) wasdirected by the need for physical therapists to develop func-tional tests that are efficient, valid, and reliable. This is a ratio-based functional tool that contains 5 split times and an overall



time. This test is done on a normal walking speed and a fast (butsafe) speed. This study aims to determine the interrater reliabil-ity and concurrent validity of the test. Methods: For interrater re-liability, 6 physical therapy students participated. For concur-rent validity, 69 participants from a retirement communityparticipated. The 6 subjects for the interrater reliability phaseperformed mTUG measurements on 10 participants. In the con-current validity phase, subjects performed the mTUG, theDuncan Functional Reach (DFR), and the Berg Balance Tests(BBT) per protocol. Results: For the interrater reliability phase,interclass correlation coefficients were obtained to determinesignificant differences between the observations among sub-jects. In the concurrent validity phase, Spearman’s correlationswere obtained to determine the relationship between mTUG,BBS, and DFR. ICC values indicate that the mTUG has highinterrater reliability. Results also indicate high correlation be-tween the mTUG splits, BBS, and DFR, except for the Turn Timenormal speed split, indicating concurrent validity. Conclusion:The mTUG is a valid and reliable tool that therapists can use toassess movement dysfunction in patients who have mobility,balance, or ambulatory deficits.

P1-010 Treating Perceptual Problems ofVerticality—Pusher Syndrome

E. Panturin1 and S. Herman2

1Tel Aviv University, Israel; 2Gold TowerHospital, Israel

Background: Karnath (2000) found that, in Pushers, the sub-jective visual vertical (SVV) is normal, while the subjective pos-tural vertical (SPV) is abnormal. According to Mittelstaedt(1998), receptors of the SPV are located in the large abdominalorgans, such as kidneys and large blood vessels. Treatment ofthe neurologic patient, and particularly with Pusher syndrome,can be approached in 2 ways: 1) by utilizing existing recep-tors—SVV; 2) by facilitating the affected receptors—SPV. Meth-ods: 5 patients with Pusher syndrome took part in the study.Two methods of evaluation were used: 1) photographing theirsitting posture before and after treatment, 2) comparing theverticality of the body displayed when asked to draw a man—before and after treatment. Treatment: lying supine with headstabilized (to circumvent the vestibular system), the lower trunkwas moved from side to side (passive, assisted active, and activemovements) for 30 minutes. Results: Improvement was ob-served in 4 of the patients—either in more vertical sitting pos-ture or improvement in the verticality of the drawing. Conclu-sion: Further studies need to be performed on larger groups ofpatients displaying perceptual problems regarding theverticality of their bodies. Different receptors in different sys-tems are responsible for the perception of verticality, and intreatment we should attempt to facilitate all of them.

P1-011 Treatment of a Patient withOromandibular (jaw Closing) Dystonia withBotulinum Toxin A: A Single Case Study

M. K. Kudhail, T. P. A. Rasheed, and D. A. H. BadwanRoyal Leamington Spa Rehabilitation Hospital,United Kingdom

Background: Oromandibular dystonia (OMD) involves themasticatory, lower facial, and tongue muscles, resulting in

spasms and jaw deviation. The case presented here had “jawclosing” dystonia after a brain injury. The dystonia preventedboth active and passive jaw opening. The use of botulinumtoxin type A (BTx-A) in the treatment of OMD is recognized, butthe scientific literature is limited. Methods: The study of this caseaimed to examine the effect of combining BTx-A treatment witha stretching regimen, because other studies have examined theeffect of BTx-A alone. The multidisciplinary aim was to achievejaw opening 2.5 cm for this patient. The stretches were carriedout using a Therabite device (Platon Medical). The treatmentwas given in 2 phases. Phase 1 involved a Therabite stretchingregimen alone. Phase 2 involved repeating these stretches afterthe injection of 80 units BTx-A (Dysport®) into both masseterand temporalis muscles bilaterally. Results: In phase 1, stretch-ing alone resulted in a gradual increase in passive jaw opening(0.8 cm in 3 weeks), reducing joint and muscle stiffness. Inphase 2, there was a further increase in jaw range of 1.2 cm inthe 1st week. A maximum range of 3.9 cm was achieved at 4weeks postinjection. Conclusion: We conclude that this com-bined treatment was more effective in increasing the range ofjaw opening than stretching alone. It enabled an assessment ofpatient swallowing and tongue movements, improved oral hy-giene, and allowed some voluntary jaw opening.

P1-012 Analysis of the Psychosocial FactorsInfluencing the Early Rehabilitation of Patientsafter Their First Stroke

L. M. OuThe Second Affiliated Hospital of Sun Yat-SenUniversity, Guangzhou, China

Background: The factors influencing the rehabilitation ofstroke patients include both the physical and psychologic fac-tors. The aim of this study is to analyze the psychosocial factorsinfluencing the early rehabilitation of patients with their 1ststroke. Methods: To evaluate the ADL change of 38 inpatientswith 1st stroke in their early stage of rehabilitation, to investi-gate the influence of a series of psychosocial factors of these pa-tients, and to find the psychosocial factors influencing the earlyrehabilitation of patients with their 1st stroke by logistic regres-sion. Results: Age and poor emotions, such as depression andanxiety, were not beneficial to early recovery of ADL afterstroke, and the patients’ cognitive score, marital status, the sup-port of their families and society, educational level, and theknowledge of stroke are positively associated with early recov-ery of ADL after stroke. Conclusion: In the early stage of reha-bilitation after stroke, the unfavorable psychosocial factorsshould be avoided, the patients’ knowledge of stroke should beimproved, and the social and family support should be opti-mized so as to get a better early result of rehabilitation afterstroke.

P1-013 Spectral Analysis of Heart Rate Variabilityin Multiple Sclerosis Patients: An ExperimentalTool to Assess the Fatigue?

A. Merico, F. Piccione, M. R. Stabile, L. Piron,and P. ToninS. Camillo Hospital, Venezia, Italy

Background: In multiple sclerosis (MS), patients have beenreported with abnormalities of the 2 main cardiovascular auto-



nomic systems (parasympathetic and sympathetic) withoutevaluating their reciprocal interactions modulating heart ratevariability (HRV). Previous studies have hypothesized that theautonomic dysfunction can contribute to MS fatigue. Our objec-tive was to provide an evaluation of the sympathovagal balanceby spectrum analysis of HRV in MS patients with moderate dis-ability who complained of fatigue and in control subjects. Meth-ods: We studied 12 MS patients and 7 healthy age-matched sub-jects. We analyzed the spectrum of HRV at rest and after passivetilt. The spectrum presented 2 rhythms: a low-frequency (LF)marker of sympathetic and a high-frequency (HF) marker ofparasympathetic modulation. They have a reciprocal relation,and LF/HF ratio is a marker of sympathovagal balance. Results:The spectral profile at rest was normal in control subjects; in 10MS patients, we have found an abnormal spectral profile at restwith a shift toward sympathetic predominance. The passive tiltproduced smaller changes of spectral profile in all MS patientsthan in the control subjects. Conclusion: Our results seem toconfirm in MS patients an abnormal sympathovagal balance atrest and suggest a reduced sympathovagal responsiveness totilt. Further validation is important because exercise training in-fluences the modulation of autonomic cardiovascular systemand can therefore be effective for preventing fatigue in MSpatients.

P1-014 To Define Factors of Stressor in Familieswith Depressive Member

Z. Ghazavi, M. Fakari, T. Mehrabi,and A. HasanzadehUniversity Of Medical Sciences, Iran

Background: Stress is the most common issue in people’sdaily life and it is a plague in this modern century. It affects thelives of millions of people and their mental and physical healthat the same time. At this century, the advancement of technol-ogy proceeds very fast, but people are depressed anddeprivated. People have conflicts that causes depression in fam-ily members. Methods: This study was a single-stage, descrip-tive, analytic case-control and performed in the mental clinic inIsfahan. The control had 170 healthy families and the case had70 families having a depressed member, who were referred tothe mental clinics and selected by convenient method. The datawere gathered in both case and control groups by question-naires including some family demographic characterictics in the1st part and a checklist of stressful events in family in the 2ndpart. Results: The findings showed 47.5% of the subjects in thecontrol group had the least number of stressful events (1 to 2),whereas in the study group, 33% of the subjects had the higheststressful events (3 to 4). On the whole, mean difference test(3.74 for study and 2.2 for control) showed a significant differ-ence. Conclusion: The findings suggested that association ex-isted between environmental stressful factors, such as death,and depression. The findings also showed among 20 factors ofstress, families with a depressed member experience higherstress than do the others.

P1-015 Disability, Relapse Occurrence andPerceived Impact in Persons with MultipleSclerosis Treated with Immune-ModulatingMono- or Combination Therapy

C. Ytterberg, S. Johansson, M. Andersson, L. WidénHolmqvist, and L. von KochKarolinska Institutet, Sweden

Background: To compare the effects of interferon beta 1atherapy and glatiramer acetate therapy combined (IFN-β+GA)with those of IFN-β or GA alone (monotherapy) for personswith multiple sclerosis (PwMS). Methods: Data were collected inthe context of a 2-year prospective observational study of 219PwMS, consecutively recruited from the MS Centre ofKarolinska University Hospital, Huddinge, Stockholm. A sub-group of 83 PwMS receiving monotherapy at baseline was stud-ied. Twenty-one switched to IFN-β+GA combination therapyfor 16 to 24 months after MS worsening, and 62 remained on thesame monotherapy for 24 months. Data were collected every 6months regarding disability in manual dexterity, walking, cog-nition, depressive mood, and regarding relapse occurrence andperceived physical and psychological impact from the PwMS’perspective. Linear mixed-effects models and generalized esti-mating equations were employed to evaluate changes in eachoutcome over time taking sex, disease severity, and diseasecourse into account. Self-reported side effects were recorded.Results: Change in odds for high perceived psychological im-pact was larger in the IFN-β+GA group of undetermined reason.No other significant differences between treatments werefound. Self-reported side effects were minor and few in bothgroups. Conclusion: The results underline the need of a largeclinical trial, preferably a double-blind, randomized study, ofIFN-β+GA therapy combined with an extended follow-up.

P1-016 Multiple Sclerosis: Disability Profile andQuality of Life in an Australian CommunityCohort

F. Khan,1 T. McPhail,1 C. Brand,1 L. Turner- Stokes,2

and T. Kilpatrick1

1University of Melbourne, Australia; 2NorthwickPark Hospital, United Kingdom

Background: Determine the experience of disability and re-ported symptoms in Multiple sclerosis (MS) in an Australiancommunity sample, comparing the perceptions of patients,carers, and treating doctors; and to examine effects on quality oflife (QoL), carer stress, and utilization of health services. Meth-ods: Prospective cross-sectional community survey. Participantswith confirmed MS from a tertiary hospital database (n = 101),living at home, quantified neurologic, mobility and cognitivedeficits; their carers and doctors. Structured interviews con-ducted at home included 1) open questionnaires for participant,carer, and general practitioner, prioritizing symptoms and prob-lems affecting daily living; 2) standardized assessments for pa-tient quality of life, and caregiver strain and perceived burden



of care. Results: The mean age was 49 years. Those more se-verely affected had significantly reduced QoL and increasedcarer burden than those with milder disability, but discordancebetween patients, carers, and doctors was noted in their percep-tion of problems and symptom experience. Rates of depression(67%) and work-related problems were high, but vocationalsupport was rarely provided and only 10% were referred tomedical rehabilitation units. Conclusion: Access and utilizationof appropriate rehabilitation and support services appears to belacking. Opportunities may exist possibly to redeploy resourcesto develop vocational support, counseling, and rehabilitation.

P1-017 Advanced Lightweight Cooling-GarmentTechnology: Functional Improvements inThermosensitive Patients with MultipleSclerosis (MS)

A. D. Meyer-Heim,1 M. Rothmaier,2 M. Weder,2

J. Kool,1 and J. Kesselring1

1Department of Neurology, Rehabilitation Centre,Switzerland; 2Swiss Federal Institute for MaterialsScience and Technology (Empa), Switzerland

Background: Thermosensitivity (Uhthoff phenomenon), re-sulting in clinical deterioration, is described in up to 80% of pa-tients with MS. Lowering the body temperature may improveclinical symptoms. Hence, there is a high interest in an effica-cious, practical, and cost-saving cooling system. Methods:Blinded, balanced crossover study (n = 20). Outcome measure-ments were MS Functional Composite, Ashworth Scale, musclestrength and body sway, and a standardized interview. Skin andtympanic temperature were logged. Operational principle ofcooling is based on a textile-based laminate of 2 waterproof, va-por-permeable polyester membranes, which coat a hydrophilicfabric. By addition of water (40 mL), evaporation leads to locallowering of temperature. Results: Mean age within the studygroup was 48.7 years (r, 27-66); mean EDSS, 5.1 (r, 1.5-6.5). Thetemperature reduction of the skin was 4.32 ± 1.21° C (r, 1.81-6.57). There was no alteration in tympanic temperature in eithergroup. The activated cooling garment significantly improvedthe total MSFC (P = 0.017), timed 25-foot walk (P = 0.035), handdexterity (P = 0.012), and strength in lower limbs (P = 0.004). Inthe standardized interview, we found a tendency in improve-ment of pain and general well-being. Conclusion: Wearing thisadvanced cooling-garment leads to significant improvement ofmotor function and subjective benefits. Functionality of the de-vice is promising because of its low weight, skinny structure,and easy handling, requiring only low quantities of tap waterfor activation.

P1-018 Verbal Learning with a Musical TemplateIncreases Neuronal Synchronization andImproves Verbal Memory in Patients withMultiple Sclerosis (MS)

G. C. McIntosh, D. A. Peterson, and M. H. ThautColorado State University, USA

Background: There is growing evidence that auditory tem-poral pattern structure in music and rhythm can be a mediating

stimulus of cognitive function. We investigated whether a musi-cal template for verbal learning influences learning andmemory and involves a different pattern of synchronization inthe brain. Methods: We used spectral EEG to measure oscillatorysynchronization in 36 patients with MS and 20 healthy personsperforming the Auditory Rey Verbal Learning Test (RAVLT).Each group was subdivided into learning with a spoken or amusical (sung) presentation of the RAVLT. Learning-related syn-chronization (LRS) was measured as the change in EEG duringencoding associated with the 1st successful recall during thememory trials. Results: All subjects exhibited a topographicallyglobal LRS increase. Scalp distribution of the LRS between mu-sic and spoken condition differed significantly in theta, alpha,and gamma bands. MS patients in the music condition showedsignificantly better word order memory and higher coherencein alpha and gamma band synchronization in frontal areas thanin the spoken condition. Conclusion: Learning-related brainplasticity involves broadband synchronization of oscillatorybrain networks. Specifically, music enhances word order mem-ory in patients with MS and involves greater frontal alpha andgamma oscillations. It is suggested that the temporal structureimplicit in musical stimuli sharpens the timing of neural dynam-ics in brain networks degraded by demyelination in MS.

P1-019 Serious Side Effects of Botulinum Toxinfor Sialorrhoea in Amyotrophic Lateral Sclerosis(ALS):A Case Report

J. W. G. Meijer,1 A. A. van Kuijk,1 A. C. H. Geurts,2

H. J. Schelhaas,3 and M. J. Zwarts4

1Rehab Centre Tolbrug/Jeroen Bosch Hospital, theNetherlands; 2Dep of Rehabilitation, RadboudUniversity Medical Centre Nijmegen, theNetherlands; 3Dep of Neurology, RadboudUniversity Medical Centre Nijmegen, theNetherlands; 4Dep of Neurophysiology, RadboudUniversity Medical Centre Nijmegen, theNetherlands

Background: In 2000, Giess presented a new treatment op-tion for sialorrhoea in Amyotrophic Lateral Sclerosis (ALS):transcutaneous botulinum toxin injection in the parotic gland.Recurrent jaw luxation as a complication of this technique wasreported by Tan (2001). Winterholler (2001) used a transductalapproach of the parotic and sublingual glands and reportedgeneralized orofacial muscle weakness. Because there are nofurther studies about this intervention, insight in side effects islacking. Methods: A 64-year-old woman, with bulbar ALS since 6months, was treated for a disabling sialorrhoea. The submandi-bular and parotic glands were transcutaneously injected usingultrasound with botulinum toxin (Dysport) 80E each on bothsides. Results: Before injection, the patient had moderatedysphagia; however, swallowing was possible. Four days afterinjection, a rapid decline occured, resulting in completeaphagia and anarthria at the 5th day. There was a paralysis ofthe palate musculature and shortness of breath because ofwhich she had to sleep in an upright position. Immediate intro-duction of a nasogastric feeding tube was necessary, and then aPEG catheter was placed. The sialorrhoea slightly decreased.



Conclusion: We presented serious complications of botulinumtoxin treatment for sialorrhoea delivered by a transcutaneousapproach in bulbar ALS, leading to acute deterioration of bulbarfunction. Safety of this procedure has to be enhanced, and com-plications should be systematically registered.

P1-020 Gait Pattern of Subjects Affected byMyotonic Dystrophy

E. Milano,1 S. Baudo,1 C. Trotti,1 A. Mauro,2

and G. Miscio1

1Istituto Auxologico Italiano, IRCCS, Italy;2Department of Neurosciences,University of Turin, Italy

Background: Myotonic Dystrophy (MD) is characterized byprogressive muscle weakness and myotonia. Most patientsshow signs of axonal polyneuropathy. MD patients show an ab-normal gait; its pattern was not well analyzed. The aim of thiswork is the quantitative characterization of the gait pattern in agroup of MD patients. Methods: 10 MD patients performed gaitanalysis by an optoelectronic system and 2 force platforms.Spatiotemporal and kinematic parameters were calculated. Re-sults: MD patients showed higher duration of the stance phase,reduced walking velocity, and a shorter stride length. All thesubjects presented an increased absolute peak of ankledorsiflexion. Eight patients showed absence of knee flexion ofgait cycle and their ankle pattern was characterized by delayedand increased peak of plantarflexion in midstance (foot-slappattern) and dorsiflexion at toe-off. The peak of ankledorsiflexion in swing was lower than normal. No correlationwas found between kinematic data and presence ofpolyneuropathy. Conclusion: The gait pattern of MD subjectswas characterized by a reduced gait speed and increased stancephase. A delayed and increased ankle dorsiflexion peak (foot-slap pattern) associated with a hyperextended knee in thestance phase seemed to be typical of such patients. Kinematicdata related to ankle joint demonstrated the weakness of tibialisanterior muscle. The gait disturbance seems to worsen with dis-tal weakness, according to the severity of the disease.

P1-021 Upright Stance Control in Hemiparetics:Are the 2 Legs Independent?

D. Pérennou, N. Genthon, P. Decavel, and P. RougierService de Rééducation Neurologique, CHU Dijon etInserm ERM 02070, France

Background: To maintain upright undisturbed stance,healthy subjects involve simultaneously and identically their 2lower limbs. Upright undisturbed stance of hemiparetics is typi-cally characterized by an asymmetry of body weight distribu-tion on the feet. The aim of this study was to analyze the tempo-ral relationship between force patterns under each foot.Methods: Hemiparetics and healthy persons were evaluatedwith a double force platform system (PF02, Equi+), throughwhich plantar center of pressure (CP) were measured. Synchro-nization between the supports was explored through a cross-correlation analysis. Results: In hemiparetics, correlation be-tween plantar CP motions was largely reduced, for both medial-lateral and anterior-posterior axes. In addition, time lags be-tween plantar CP motions were also observed for few patients,

the sound CP moving earlier than the paretic one. Conclusion:Stroke induces a missynchronization of postural movementsperformed by the 2 legs. One solution for these patients is tostand still. On the other hand, this functioning could be viewedas less efficient. Because of both spatial and temporal lags, sup-port muscular actions could be dissociated, such as the effectsof one support counteract those of the other one.

P1-022 Gait Difficulties in Patients with DifferentNeuromuscular Disorders Do Not SimplyCorrelate with Muscle Weakness

A. Praznikar, A. Klemen, J. Krajnik, I. Tomsic,and A. ZupanRehabilitation Institute, Ljubljana, Slovenia

Background: Neuromuscular disorders (NMD) are group ofdiseases of motor unit with muscle weakness as the predomi-nant clinical sign. Difficulties in gait are often the main contrib-utor to disability in patients with NMD. The gait disorders inNMD have been studied to some extent only in patients withDuchenne muscular dystrophy (DMD). A broader consensus onmanagement of gait disorders has not been reached in any ofNMD. Therefore, we asked ourselves whether we could definecharacteristic gait disturbances in patients with specific NMD,and if so, do they correlate with the pattern of muscle weakness.Methods: For that purpose, we used clinical gait analysis (kine-matics, kinetics, and dynamic EMG) and isokinetic dynamome-ter (maximal voluntary contraction [MVC]) in 4 patients withNMD with different pattern of muscle involvement (SMA III,DM1, FSHD, and Becker MD) and a healthy volunteer (HV). Re-sults: MVC in conc./conc. mode at 60/s for flexion/extensionwere (% of HV): 20/21, 16/22, 0/11, and 0/10 in hip; 3/5, 20/17,9/3, and 8/14 in knee; 14/17, 5/17, 15/30, and 24/23 in ankle inpatients with BMD, DM1, SMA, and FSHD, respectively. Gait ve-locity was 0.77 m/s in BMD; 0.65 in DM1; 0.78 in SMA; 0.82 inFSHD vs. 1.31 in HV. Power generated in plantar fl. in all pa-tients was 1.6 to 1.8 Watt/kg (3.2 in HV). Compensatory strate-gies in kinematics (cadence, step length and width, step time)and changes in muscle activation were recognized. Conclusion:We conclude that the observed gait disturbances in differentNMD could not be solely explained by disease specific patternof muscle weakness.

P1-023 “Doctor My Neck Hurts.” A Case Report

B. A. R. Rameezan1

University of Malaya, Malaysia

Background: A 45-year-old Malay man diagnosed to havecerebral palsy with spastic athetoid has been observed at the re-habilitation clinic since 2002. The athetoid spasticity affectedmainly his cervical region, his right side of body. He used hisleft upper limb for functional activities. He was independent inself-care activities and ambulates with supervision. His cogni-tion was not affected. Methods: Over the years, his spasticityhad increased, and management included the usage of oralartane, myonal, and gabapentin. He was not keen on botulinumtoxin injection for the spasticity on his cervical muscles. Be-cause of the athetoid movement of his neck, he occasionallycomplained of soreness on his neck. Repeated examinationsshowed spastic trapezius and sternocleidomastoid muscles. Se-



rial cervical X rays showed degenerative changes. In September2005, he continued to complain of neck pain. Further examina-tion showed reduction in pinprick sensation over C4, C5, andC6 regions of the right side of his body. No other neurologicfindings were noted. A cervical X ray was done and showed ex-isting degenerative changes and subluxation of C2 on C3 verte-bra. Results: A CT scan of cervical region is pending. Conclu-sion: Adult patients with cerebral palsy are at higher risk ofdeveloping neurologic complications, especially those withdystonia or athetosis. A thorough examination must be done toaddress other possible causes of the patients’ symptoms, whichmay cause long-term disablement and functional deterioration.

P1-024 The Use of Levetiracetam to Treat Tics inChildren and Adolescents with TouretteSyndrome

Y. M. AwaadOakwood Healthcare System, USA

Background: Some drugs currently used to treat tics havedrawbacks, including the risk of side effects such as tardivedyskinesia. Therapeutic options with better safety profiles areneeded. Levetiracetam is an antiepileptic drug with atypicalGABAergic effects that might be beneficial for this indication.To evaluate the effects of levetiracetam on motor and vocal tics,behavior, and school performance in children and adolescentswith tics and Tourette syndrome. Methods: 60 patients, age ≤18years, with tics and Tourette syndrome were enrolled in thisprospective, open-label study. The initial starting dose oflevetiracetam was 250 mg/d. The dosage was titrated over 3weeks to 1000 to 2000 mg/d. Clinical outcomes were assessedwith the Clinical Global Impression Scale, Yale Global Tic Se-verity Scale, and Revised Conners’ Parent Rating Scale. Behav-ior and school performance were also recorded. Results: All 60patients showed improvements based on all of the scales usedand 43 patients improved with regard to behavior and schoolperformance. Levetiracetam was generally well tolerated. Threepatients discontinued because of exaggeration of preexistingbehavioral problems. Conclusion: Levetiracetam may be usefulin treating tics in children and adolescents. Given its establishedsafety profile, levetiracetam is a candidate for additionalevaluation.

P1-025 Long-term Follow-up use of Levetiracetamto Treat Tics in Children


Background: Some drugs currently used to treat tics havedrawbacks, including the risk of side effects such as tardivedyskinesia. Therapeutic options with better safety profiles areneeded. Levetiracetam is an antiepileptic drug with atypicalGABAergic effects that has been beneficial for this indication.Methods: 70 patients, age ≤18 years, with tics and Tourette syn-drome were enrolled in this prospective, open-label study. Theinitial starting dose of levetiracetam was 250 mg/d. The dosagewas titrated over 3 weeks to 1000 to 2000 mg/d. Clinical out-comes were assessed with the Clinical Global Impression Scale,Yale Global Tic Severity Scale, and Revised Conners’ Parent Rat-ing Scale. Behavior and school performance were also re-

corded. Patients have been observed every 3 months over 4years. Results: All 70 patients showed improvements based onall of the scales used and 49 patients improved with regard tobehavior and school performance, and still using levetiracetamas the only medication for their condition. Levetiracetam wasgenerally well tolerated. Three patients discontinued becauseof exaggeration of preexisting behavioral problems. Two pa-tients dropped their follow-up because they moved out of thestate. Conclusion: Levetiracetam may be useful in treating tics inchildren and adolescents. Given its established safety profile,levetiracetam is a candidate for additional evaluation.

P1-026 Bladder Function in People with CerebralPalsy—A Prospective Study

G. Handa, M. Nallegowda, G. Sachdev, M. Bajpai,and U. SinghAll India Institute of Medical Sciences, India

Background: It is a common notion that the bladder is usu-ally controlled by upper motor neuron. The treatment of blad-der function in people with cerebral palsy (CP) is often over-looked. Therefore, this study was undertaken to evaluate theurinary problems and bladder functions of the patients with CP.Methods: This is a prospective study in which consecutive peo-ple in the age group of 5 or above were taken over a period of1.5 years. The detailed history reviews, examinations, investiga-tions, and bladder function evaluation were done. Symptomaticpatients were further evaluated with the help of urodynamicstudies. The results were analyzed using descriptive statisticalmethods. Results: The percentage of people with cerebral palsywho had urinary problems was 16%. The different variables andtheir effect were further analyzed in detail. Conclusion: Thebladder is often neglected in people with cerebral palsy. Thefinding of high incidence of bladder problems in the peoplewith CP implies that bladder needs to be given due attention soas to prevent any upper urinary tract deterioration in the future.This study was supported by a grant from Min. of Social Justiceand Empowerment, DRC Scheme.

P1-027 Kinematic Analysis of Hyoid andEpiglottic Movement during Swallow:Comparison between the Patients of HemisphericLesion and Brain Stem Lesion

T. R. Han, S. G. Chung, I. S. Kim, J. H. Kim,and B. S. KangSeoul National University College of Medicine,South Korea

Background: Although videofluoroscopic swallowing study(VFSS) is widely used to evaluate swallowing function, it is lim-ited to identify the gross findings of aspiration and residue. Thepurpose of the study is to investigate kinematically the move-ment of hyoid bone and epiglottis, known as an important pro-tective mechanism in patients of hemispheric lesion and brainstem lesion. Methods: A total of 35 subjects (20 patients of hemi-spheric lesion and 15 patients of brain stem lesion) were en-rolled in the study. After each subject underwent VFSS, the vid-eotaped images were captured and processed digitally usingvideo-based motion analysis system. Latencies for the move-ment were defined as the time consumed until the moments of



movement initiation after the head of fluid passed the mandibleangle. Durations for movement were measured from onset untilreturn of original position, and hyoid displacement distanceand epiglottic folding angle were also measured. Results: Com-pared with patients of brain stem lesion, the latencies were sig-nificantly delayed (P < 0.040) in patients of hemispheric lesion.Also the durations in patients of hemispheric lesion were longerthan those in patients of brain stem lesion (P < 0.048). However,no significant differences were found in the hyoid displacementdistance and epiglottic folding angle between groups (P > 0.05).Conclusion: This kinematic analysis suggests that the delayedinitiation and slowness of protective movements might play animportant role in the patients of hemispheric lesion.

P1-028 Improving Quality of Life in Patients withSpina Bifida—Surgical Options

C. M. WestThe Children’s Hospital at Westmead, Australia

Background: Spina Bifida continues to present many chal-lenges to health care providers in maximizing quality of life forpatients and carers. Attitudes in society, experience of healthprofessionals, and surgical and technological advances duringthe last 40 years have contributed to major improvements inquality of life for many people with spina bifida. Methods: Thispresentation is a descriptive review of some of the advances inmanagement of patients with spina bifida, which have the po-tential to improve quality of life. In particular, patient surveyshave been carried out regarding 3 elective surgical proceduresthat have been used to potentiate quality of life. These includeappendicovesicostomy, appendicocaecostomy (or caecostomybutton), and breast reduction. Results: Patients report signifi-cant improvements in quality of life with each of these proce-dures. Improvements were reported in areas of independencein personal care, access to the community, self-image, access towork, purchase of clothing, and reduced need for assistancefrom a carer. Conclusion: There are many ways to improvequality of life for patients with spina bifida. These examples aresome of the options, which are available to improve independ-ence and access to the community as well as reduce the burdenof care.

P1-029 Identifying Risk Factors for HeterotopicOssification after Traumatic Brain Injury:Description of a Hypothesis and ResearchProposal

J. D. Martina and P. van KampenRehabilitation Centre Groot Klimmendaal, theNetherlands

Background: Heterotopic Ossification (HO) is a commonskeletal complication in patients with brain injury (BI) that canlead to severe functional disability and may interfere with therehabilitation treatment. Identification of risk factors and earlydetection of HO may help prevent a more severe handicap.Methods: Animal studies suggest that denervation of muscleleads to a proliferative response by various cell types in themuscle, mainly fibroblasts. Cell differentiation may be stimu-lated by predisposing factors such as pH changes in soft tissues,edema, free oxygen radicals, and immunologic agents. To

better characterize the risk factors implicated in HO, a 3-yearprospective study at the Brain Injury Rehabilitation Unit of Re-habilitation Centre Groot Klimmendaal in Arnhem, the Nether-lands, is being conducted. Results: In our clinical practice, wehave noticed that most patients with impaired range of motion(ROM) due to HO also have sustained a systemic infection whilebeing treated at the intensive care unit. Most of them underwentmechanical ventilation. Conclusion: Although the incidence ofthis combination of factors, traumatic brain injury, systemic in-fection and mechanical ventilation, has not been reported in theliterature, we strongly suspect that a systemic infection couldpossibly trigger the onset of HO. So far we know that thisetiologic relationship has never been established in the litera-ture. Through a case study report, we will illustrate our hypoth-esis and suggest a therapeutic approach.

P1-030 Dual Task and Postural Control inChildren with Developmental CoordinationDisorder

Y. Laufer, T. Ashekinazi, and N. JosmanUniversity of Haifa, Israel

Background: Attentional demands of postural control varydepending on the task, age, and balance abilities of the individ-ual person. The purpose of this study was to examine how con-current attentional demands of a cognitive task affect posturalcontrol of children with Developmental coordination disorder(DCD) in comparison to typical children. Methods: Subjects in-cluded 26 children fitting the DSM-IV criteria of DCD (meanage, 5.1 ± 0.59; Movement-ABC scores less than 13), and 20 typi-cal children (mean age, 5.0 ± 0.57, Movement ABC scoresgreater than 21). The postural task consisted of standing quietlyeither on a firm or foam surface. The cognitive task involvednaming simple objects, which appeared in random order on acomputer screen. The study involved 5 tests presented in ran-dom order, which consisted of the cognitive and postural taskstested either separately or concurrently. Two 20-s trials were re-peated for each test. Postural sway, as determined by pathlength (PL) of the center of pressure, was measured with anAMTI force plate. Results: PL is longer in children with DCD andis positively affected by dual tasking and compliance of stancesurface. An interaction effect between group and task indicatesthat the effect of dual tasking is greater in children with DCD (P= 0.01). Conclusion: Young children with DCD demonstrategreater postural control activity than typical children duringquiet stance, which is accentuated by the attentional require-ments of a concurrent cognitive task.

P1-031 The Study of Cerebral Hemodynamic ofChildren with Cerebral Palsy

Z. H. Liu and X. G. QianNanhai Affiliated Maternity Children HospitalGuangzhou University of Traditional ChineseMedicine, China

Background: To study the regulari ty of cerebralhemodynamic of cerebral palsy. Methods: Transcranial Dopplersonography was performed on 347 patients with cerebral palsyand 30 healthy subjects as control. Results: The Vm of ACA,MCA, and LCA of patients with cerebral palsy is lower than that



of healthy subjects (P < 0.05), but RI and PI is higher (P < 0.05).The difference is significant, especially in those below 1 year ofage (P < 0.05). Conclusion: Patients with cerebral palsy havelow cerebral blood flow and high resistance. This suggests thatimprovement of brain circulation may be important in the treat-ment of cerebral palsy.

P1-032 Analysis of Brainstem Auditory EvokedPotentials in Children with Cerebral Palsy

Z. H. Liu and X. G. QianNanhai Affiliated Maternity Children Hospital ofthe Guangzhou University of Traditional ChineseMedicine, China

Background: The study was designed to study the character-istics of brainstem auditory evoked potentials (BAEPs) in chil-dren with cerebral palsy. Methods: BAEP was measured in 140patients with cerebral palsy and 28 healthy control subjects.Subgroup analysis was performed to compare the differencesbetween the control subjects and patients with cerebral palsy ofvarious causes. Results: The abnormality rate of BAEP readingsamong the asphyxic group was higher than that of the jaundicegroup and that of the premature delivery group. The degree 2and degree 3 groups had potentials higher than those of the de-gree 1 group (P < 0.05). Conclusion: Asphyxia and HIE are themain causal factors determining auditory problems in patientswith cerebral palsy. BAEP can reflect the state of the illness andguide the rehabilitation of cerebral palsy sufferers.

P1-033 Use of Intramuscular Botulinum Toxin inMalaysian Children with Cerebral Palsy

T. B. Khoo, M. Y. Yusniza, and P. M. ChernKuala Lumpur Hospital, Malaysia

Background: This study aims to determine the clinical effi-cacy of intramuscular botulinum toxin type A (BTX) in Malay-sian children with cerebral palsy. Methods: We analyzed thedata of 58 consecutive children with cerebral palsy who re-ceived BTX at our clinic. The efficacy of the treatment was de-termined by the modified Ashworth Scale, global parental per-ception scale, and video analysis. Results: 25 of them hadspastic diplegia, 16 had spastic quadriplegia, 11 had spastichemiplegia, and 6 had dyskinetic cerebral palsy. The mean ageof BTX injection was 6 years old (range, 19 months-15 years).The most frequent aim of treatment (69%) was for functional im-provement. Others include to ease in nursing care, to preventdeformity, and to reduce pain. The mean dose of BTX (Dysport)used per patient was 17.7 unit/kg for the lower limbs and 6.5unit/kg for the upper limbs. The median interval between injec-tions was 7 months. Short-term outcome was graded as excel-lent or good by 44% and satisfactory by 39% of parents. All ourpatients with dyskinetic cerebral palsy had good response. Thepoor responders were those with fixed contractures, poor com-pliance with post-BTX therapy, hip dislocation, and weak an-tagonist muscles. Adverse effects were minimal, and none wasserious. Conclusion: Intramuscular BTX treatment is safe andeffective in the majority of our patients with spastic anddyskinetic cerebral palsy. Clear objective, proper selection ofpatients, and post-BTX therapies are crucial to ensure goodtreatment outcome.

P1-034 Prediction of Mood State of StrokePatients at the Discharge from Day RehabilitationProgram

K. K. Leung,1 Y. M. Fong,2 and L. S. W. Li21Department of Clinical Psychology, Tung WahHospital, Hong Kong; 2Department of Medicine,Tung Wah Hospital/Hong Kong University,Hong Kong

Background: Poststroke depression is common amongstroke rehabilitation patients. This study aims to identify factorsthat predict the mood outcome of these patients. Methods: Fiftystroke patients, who lived with their families, were adminis-tered on Geriatric Depression Scale (short form, GDS), MMSE,FIM, and Barthel Index (BI) twice, when they first entered theDay Rehab Centre (DRC) of Tung Wah Hospital and when theywere discharged. Linear multiple regression analyses were con-ducted separately on GDS, BDI, FIM, and BI at discharge as cri-terion variables. Patient’s age, education, and gender were en-tered into the regression equations first. Then the othermeasured variables at the admission were entered stepwise intothe models. Results: GDS at discharge was significantly pre-dicted by GDS at admission [B = 0.461, t(44) = 3.546, P = 0.01]and MMSE at admission [B = –0.218, t(44) = –2.087, P < 0.05; R2 =0.277, F(5,4) = 3.366, P = 0.012]. BDI at discharge was only pre-dicted by BDI at admission [B = 0.851, t(35) = 5.378, P = 0.000,R2 = 0.472, F(4,39) = 7.818, P = 0.000]. Similarly, FIM atdischarge was only predicted by FIM at admission [B = 0.713,t(52) = 7.694, P = 0.000, R2 = 0.560, F(4,52) = 16.565, P = 0.000].Barthel at discharge was predicted by Barthel at admission [B =0.535, t(52) = 6.966, P = 0.000] and age of patients [B = 0.212,t(52) = –2.140, P = 0.037; R2 = 0.741, F(4,52) = 15.786, P = 0.000].Conclusion: Better mood outcome of the stroke day rehabilita-tion patients was associated with better mood condition andbetter cognitive functioning during the admission.

P1-035 Correlation of Functional Assessmentwith Risk Factors in Children with Cerebral Palsy

B. Chung, V. Wong, and S. HuiThe University of Hong Kong, Hong Kong

Background: To study the correlation of various risk factorswith functional status of cerebral palsy (CP) using FunctionalIndependence Measure for Children (WeeFIM). Methods: Across-sectional study of 76 CP children was conducted with thevalidated Chinese WeeFIM. It measures a child’s consistent per-formance in daily functional skills in 3 domains (self-care, mo-bility, and cognition) by interview and observation. The scoresranged from 1 to 7 for each items, and the total score was 126.Results: The mean age of our cohort was 12 years, with sex ratio(M:F) 2.3:1. The mean total WeeFIM score was 80.7 (mean totalquotient = 67.2%). The mean subscores/quotients for self-care,mobility and cognition were 35.7%/67.9%, 21.8%/62.6% and23.2%/69.% respectively. The best functional status occurred inthe hemiplegic group (n = 14), and the worst being tetraplegia(n = 12). By using multivariate analysis, only 2 factors were sig-nificantly related to functional dependency of CP: epilepsy (P =0.02) and severity status by GMFC (P < 0.001). When underlyingcause was analyzed, only prematurity was significantly associ-ated with better scores (P = 0.007). Conclusion: Significant cor-relation with dependence was found with the severity of CP and



presence of epilepsy. The ability to achieve functional inde-pendence was better when the underlying cause is prematurity.Thus, realistic counseling on the functional prognosis can begiven to families and child carers.

P1-036 Clinical Markers Useful in EnhancingDiagnostic Yield for children with GlobalDevelopmental Delay (GDD)

B. Chung and V. WongThe University of Hong Kong, Hong Kong

Background: Selective approach is recommended for diag-nostic evaluation in GDD. The objective was to identify clinicalmarkers to improve diagnostic yield at initial assessment. Meth-ods: A retrospective review of all GDD patients followed up inDKCAC was performed. GDD was defined as delay >2 SD in ≥2developmental aspects. Nine clinical items, including sex, se-verity of delay, parental consanguinity, family history, behav-ioral disturbance, head size, facial dysmorphism, nonfacial mal-formations, and neurologic deficits, were correlated with thelikelihood of finding an underlying cause. Results: A thresholdeffect was found between patients with mild and moderateGDD (OR = 2.66; 95% CI = 1.85-3.83). Other factors that im-prove diagnostic yield include 1) female sex (OR = 2.045, 95%CI = 1.43-2.92); 2) absence of behavioral trait (OR = 6.66, 95% CI= 4.5-10); 3) microcephaly (OR = 3.5, 95% CI = 2.4-5.5); 4) facialdysmorphism (OR = 4.1, 95% CI = 2.8-5.9); 5) malformation (OR= 2.9, 95% CI = 2.1-4.2); and 6) neurologic deficits (OR = 9.0,95% CI = 6.3-12.8). A dose-response relationship was found forincreasing number of facial dysmorphic features and malforma-tion. Other factors are nonsignificant. Conclusion: Most clinicalchecklists in use are disease/syndrome specific, e.g., fragile Xor subtelomeric checklist. The markers identified will be usefulfor the initial assessment of GDD, particularly when no specificdiagnosis is suspected.

P1-037 Children with DevelopmentalCoordination Disorder (DCD) have InadequateForce Control and Longer Response Time in aReach-and-Grasp Task

E. Y. W. Leung and M. K. Y. MakThe Hong Kong Polytechnic University, Hong Kong

Background: This study aimed to investigate whether chil-dren with DCD had less effective force adjustment and requiredlonger response time when performing a dynamic reach-and-grasp task. Methods: 12 healthy and 12 children with DCD, aged7 to 8 years, participated. A toy car was slid down a slope. Thespeed of the car varied according to the 4 combinations: itsweight (180 g or 340 g) and the gradient of slope (8° or 15°).When the car was slid down, the subject had to grasp the carwith the dominant arm. The force used by the subject and thecorresponding reaction time and movement time were regis-tered. Results: The result indicated that the DCD group had ahigh failure rate (25%-35%); whereas all healthy children man-aged to grasp the car. For successful trials, the DCD group usedsignificantly larger force than healthy children. Within eachgroup, there were significant differences in peak force usedamong the 4 combinations; however, the DCD group was lessable to adjust to the various combinations. For reaction time, nowithin- or between-group difference was found. For movement

time, the healthy group took a shorter time to grasp the car, butthis difference did not reach a significant level. Healthy childrentook a shorter time to grasp the car in the combinations ofheavier weight and steeper slope, but there was no within-group difference for DCD group. Conclusion: DCD childrenhad a higher failure rate to complete a dynamic reach-and-grasptask. They had difficulty adjusting force and time to completethis task.

P1-038 Early Habilitation for High-Risk Infants ofCerebral Palsy

Z. HuangPeking University, First Hospital, China

Background: Because the number of high-risk infants withcerebral palsy (CP) is increasing in China, it is crucial to monitorthe high-risk infants closely and to provide an early habilitationto those with abnormal neurologic signs. The aim of this study isto investigate the effect of early habilitation for high-risk in-fants. Methods: 195 infants ranging from 1 day to 6 months(mean age, 2.50 ± 1.45 months) underwent an early habilitationprogram. One hundred sixty of them were highly suspected ashaving CP and the other 34 infants were diagnosed CP whentheir mean age was 4.42 ± 2.17 months. The Gesell Scale andneurologic examination were used for evaluation. One hundredninety infants were examined by ultrasound, CT, or MRI; 140 ofthem had brain damage of different severity. Results: Assess-ment of progress were performed when the mean age was 9.65± 3.00 months. Among 34 infants with CP, 19 infants were clini-cally cured, 12 were at borderline, and only 3 were still abnor-mal; 154 with suspected CP developed normally, whereas 7were at borderline and none of them remained abnormal. Tenchildren were retested by Peabody Scale, Wechsler Scale, andConners Questionnaire at mean age of 5. Only one of them wasbelow the average level of Peabody Scale. She had been diag-nosed with CP and was at borderline when she was 1 year ofage. Conclusion: The sequelae of perinatal brain damagescould be reduced by early habilitation, and this cohort sug-gested that potential good therapeutic effect could be achievedby early habilitation of infants with CP.

P1-039 Robotic-Assisted Locomotor Training—Feasible Treatment Option for Children?

A. D. Meyer-Heim,1 B. Knecht,1 I. Retzl,1 F. H.Sennhauser,1 and G. Colombo2

1Rehabilitation Centre Affoltern am Albis,University Children’s Hospital Zurich, Switzerland;2Hocomo AG, Volketswil, Switzerland

Background: There is promising evidence that robotic-guided ocomotor training may enhance functional ambulationin spinal and cerebral neurorehabilitation of adults. Further-more, body weight–supported treadmill training in childrenwith cerebral palsy, acquired brain injuries, and strokes isproven to be effective. Therefore, it is assumed that intensive,task-specific training enabled by a driven gait orthosis (DGO)could improve over-ground walking in children lastingly andcost-effectively. Methods: A pediatric module for the DGOLokomat® has been developed. It allows a training of childrenstarting at an age of about 4 years. The new device has beentested in a clinical setting in children with acute brain damage



or cerebral palsy. The effects on functional benefits have beentested with outcome measures including repeated assessmentsof standing and walking sections of the Gross Motor FunctionMeasure (GMFM), Functional Ambulation Categories (FAC),motor section of the pediatric Functional Independence Mea-surement (weeFIM), walking tests (10 m/6 min), AshworthScale, and muscle strength. Results: Preliminary results of a se-ries of children trained on the 1st pediatric module of the DGOand its technical specifications will be presented. Conclusion:This 1st pediatric trial aims to determine whether locomotorperformance improves by intensive training on a robotic-as-sisted gait orthosis and its feasibility in children with central gaitproblems.

P1-040 The Effect of Superficial TactileKinesthetic Stimulation Method on Weight Gainof Low Birth Weight Infants

P. Taheri, M. Golchin, and P. RafatiIran

Background: There is a moderate or severe delay in growthand development of low birth weight infants so they need de-velopmental interventions. Methods: This is a quasi-experimen-tal type of clinical trial study, which was conducted on 54 in-fants with low birth weight and by convenient samplingmethod. They were assigned to 2 groups with 27 infants each.One of the groups received superficial tactile-kinesthetic stimu-lation. This group was compared with a control group receivingno stimulations. Criteria for inclusion in the study were birthweight less than 2500 g; age less than 18 d; breast-feeding; theIranian race; absence of congenital heart malformation, pulmo-nary diseases, neuromuscular disorders, respiratory distress,sepsis, maternal addiction, NPO or intravenous feeding only,and blood exchange. All measurements were taken before andafter the completion of the study by the same equipment and bysame observer. The control infants were not given any specificstimulation but monitored for weight as in the treatment group.Results: The groups did not differ significantly on matched vari-ables. Means of weight gain within groups, before and after thestudy, were statistically different. Also a significant differencewas found between the 2 groups. The treatment group was sig-nificantly gaining weight better than the control group. Conclu-sion: These findings show that superficial tactile-kinestheticstimulation enhances weight gain in low birth weight infants.

P1-041 The Role of the Mother CommunicationStyles in Treatment of Stuttering

F. Berberi, M. Kapisyzi, S. Bino, and R. GjeloInstitute of Public Health, Albania

Background: Stuttering is described as a disorder of fluencyand characterized by part-word, whole-word, and phrase repe-titions; interjections; pauses; and prolongations. Studies doneabout communication patterns of parent and child generally fo-cus on the negative or positive nature of the statements, such asverbal aggression, silence, and interruptions more excessivelythan the parents of nonstutters; and at the same time, parentsbecame a part of the therapy processes of stuttering. Methods:The communication patterns used between Albanian motherand her stuttering child and her normally fluent child were in-vestigated. A total of 20 mother-stuttering child pairs and 20

mother-nonstuttering child pairs participated in the presentstudy. All mother-child pairs were administered a structuredgame to facilitate spontaneous speech. Commands, questions,critical statement, no response, and interruption were studiedas negative statements. Verbal praise and verbal acknowledge-ment were accepted as positive statements. Interaction timesand total amount of words were also measured. Results: A sig-nificant difference was found between both mother and childgroups only in the total words used. No significant differenceswere found for any other communication styles. Conclusion:These findings suggest that the communicative behavior ofmothers of stuttering children is not different from that of themothers of nonstutters.

P1-042 Results of Rehabilitation Treatment inChildren with Myelomenigocele

J. Grossman and P. TargosinskiJozef Pilsudski Academy of Physical Education inWarsaw, Faculty of Rehabilitation, Poland

Background: All children studied by us were treated in theMetropolitan Rehabilitation Centre in Konstancin. Our materialcomprises the results of rehabilitation treatment of 500 childrentreated in departments XV and XVI. The experiment has beenperformed within the scope of statutory research (Ds-55) fi-nanced from the Warsaw Academy of Physical Education funds.Methods: For ensuring a possibility of comparison of the degreeof motor function disability and evaluation of rehabilitation re-sults, a standard examination scheme was introduced. Results:1) All children with paralysis in the range of motor systemshowed, before the rehabilitation, smaller or larger delay in thedevelopment of motor skills. 2) Besides paralysis, contractureof joints and malformations of limbs and spine (which were de-tected in 80% of children) were the largest obstruction in thespontaneous movement development and rehabilitation. Con-clusion: 1) Effective control of these complications was usuallypossible only with complex treatment. Conservative therapy ofcontractures did not always lead to their permanent cure and of-ten was connected with existence of other complications suchas bedsores and pathologic fractures. However, prevention ofrelapse of contractures and trophic complications was possibleonly with cooperation of the child’s family. 2) Determining fac-tor for the possibility of motor self-dependence of the child wasthe level of spinal cord injury, which usually is connected withthe location of the hernia.

P1-043 Developing of Motor Fitness inAutistic Children

J. Grossman and P. TargosinskiJozef Pilsudski Academy of Physical Education inWarsaw Faculty of Rehabilitation, Poland

Background: The basic method applied in this study was afunctional analysis of motor behavior based on etiological ob-servation. It made possible comparison of potential causal fac-tors and their consequences and estimation of existing correla-tions. The experiment has been performed within the scope ofstatutory research (Ds-55) financed from the Warsaw Academyof Physical Education funds. Methods: It was also possible to es-tablish more precisely categories of behavior enabling qualita-tive and quantitative analysis of motor activity to be done. It



seems that this part of the study was essentially important forevolving of individual rehabilitation programs for these chil-dren. Results: Our study showed that greater stress should belaid on the influence of the environment—both planned and in-tended and spontaneous, which is more difficult to predict butexerts a positive or negative effect on the child. Conclusion: Inthis study, the problem was disclosed of the “petering-out ofstrength” of parents as well as teachers and tutors of autisticchildren. The development of scientific research in pediatric re-habilitation is strongly promoted presently by modern tech-niques. Particularly evident development trends in this field in-clude combination of induction methods with intuitiveapproach in exact sciences. Successful application and utiliza-tion of the possibilities provided by this combination dependon fulfilling certain conditions.

P1-044 Spatial Orientation of CommunicationFunction in Children with Infantile CerebralPalsy

J. Grossman and P. TargosinskiJozef Pilsudski Academy of Physical Education inWarsaw Faculty of Rehabilitation, Poland

Background: The motor efficiency was assessed in childrenwith infantile cerebral palsy in the form of diplegia or quadri-plegia with spasticity. The experiment has been performedwithin the scope of statutory research (Ds-55) financed from theWarsaw Academy of Physical Education funds. Methods: About13 000 examinations were done. Forty-two functions carriedout 3 times by 111 children were analysed. Results: The resultsof this study were subjected then to standard statistical analysis,and several conclusions were drawn that could be important inclinical practice. The results obtained in this study confirmedthe validity of the accepted principle of conducting motor reha-bilitation according to the normal sequence of motor develop-ment. Conclusion: 1) In the same form of infantile cerebralpalsy, considerable differences are found in motor efficiency ofchildren due to differences in the distribution and intensity ofpathologic signs. 2) The therapeutic program should take intoaccount the motor possibilities of the child and to prepare ac-cordingly the small patient for achieving maximal self-depend-ence. It seems right to consider in children with spastic diplegiathe presence of a greater ability of mastering motor functional inhigh body positions. On the other hand, in spastic quadriplegiaimprovement of motor functions in intermediate body positionsshould be a foundation for mastering in the future of functionsin high body position.

P1-045 Comparison of the Spine FunctionalParameters in Children with ChronicNeurologic Diseases

P. Targosinski, J. Grossman, and M. LypJozef Pilsudski Academy of Physical Education inWarsaw Faculty of Rehabilitation, Poland

Background: Effects of various, and sometimes negative,factors seen in childhood are of a potential effect on functioningof people in their mature and senior ages. Examination of therange of movement of spinal joints of children with chronicneurologic diseases will facilitate a proper assessment of thebody in its growing stage. The experiment has been performed

within the scope of statutory research (Ds-80) financed from theWarsaw Academy of Physical Education funds. Methods: Rangeof spinal mobility was examined in children. Examinations cov-ered a group of 70 children. Qualified for assessment of therange of movement of spinal joints were those children with ce-rebral palsy. Said ranges of movement were determined usingSFTR method. Results: Standards concerning ranges of move-ment of spinal joints were determined for children with cerebralpalsy. Comparison of the values of said movements in childrenand adults was performed. Conclusion: 1). Those locomotiveorgan components that face the most severe functional deficien-cies, which appear with diseases, were observed. 2). Compari-son of the above-discussed parameters in children, adults, andelderly people signals important interrelations and directions ofthe growing physical degeneration of the public.

P1-046 Hydrotherapy for Children withNeurodevelopmental Conditions

S. Yee, T. Chen, and P. LauKowloon Hospital, Hong Kong

Background: A structured hydrotherapy program for pediat-ric neurodevelopmental clients was established in response toclinical demand. The objectives of the program included en-hancement of musc le s t rength and endurance ,cardiopulmonary function, water confidence, development ofswimming prerequisites, and empowering caregivers to con-tinue water exercise in the community. In this study, the effec-tiveness and acceptance of the program were examined. Meth-ods: This was a retrospective study with single group, pre- andposttest design. The clinical record of the patients was re-viewed. Trunk and limb strength, water confidence, rotationalcontrol, and swimming speed were measured. Paired t testswere used for data analysis. Results: 45 pediatric patients aged 2to 11 years were recruited. Six had been diagnosed with cere-bral palsy, whereas the rest had developmental delay. Improve-ment was observed in all items, but with statistical significanceonly for the trunk flexion and upper limb strength results (P <0.05). Caregivers reported enjoyment by the patients and betterquality of movement. Conclusion: The hydrotherapy programwas effective in physically and psychologically enhancing thefunctioning of pediatric patients with neurodevelopmental dis-orders. Further study is warranted with the aim of drawing morerobust conclusions on the cl inical ef fect iveness ofhydrotherapy.

P1-047 Rehabilitation Management of acuteSpasticity Post-TBI in Children in Acute CareSetting Hospital: University Malaya MedicalCentre Experience

B. A. R. Rameezan and S. JagdeepUniversity of Malaya, Malaysia

Background: TBI is a major cause of acquired disability inchildhood. The best approach for intervention in post-TBI isearly recognition and prevention of growing disabilities, and itmust start at the acute stage. One main challenge is the manage-ment of acute spasticity, which leads to profound functional im-pairment. Methods: This case report describes an acute manage-ment of severe spasticity in an 11-year-old girl with severe TBIadmitted to a general pediatric surgery ward in UMMC. She sus-



tained multiple brain contusions at the frontal, occipital, andbrain stem region, which were managed conservatively. Herstay was complicated by sepsis. Rehabilitation assessment wassought at day 9 postinjury for increasing severity of spasticity in-terfering with positioning and bed mobility. Results: Examina-tion revealed patient in minimally conscious state with stable vi-tal signs. Severe spasticity affected both upper and lower limbsand trunk with MAS of 3. Patient developed flexion posture ofboth upper limbs at the elbow and wrist joints. Scissoring wasevident and both ankles were in equinovarus position. Aggres-sive management to reduce spasticity was undertaken and willbe presented. At 6 months postinjury, spasticity was reduced(MAS1+) with no deformities. At 1 year postinjury, patient hadreturned to school, with no change in severity of spasticity.Conclusion: Management of spasticity must begin early andshould be multidisciplinary to achieve the best possiblefunctional recovery.

P1-048 The Relation Between Static and DynamicMeasurements of the Popliteal Angles in CerebralPalsy Children

R. Alaca,1 B. Balaban,2 E. Yasar,2 H. Mohur,1

and K. Dincer2

1GATA Rehabilitation and Care Center, Ankara,Turkey; 2GATA Dept. of Physical Medicine andRehabilitation, Ankara, Turkey

Background: We aimed to investigate whether staticpopliteal angle measurement used in physical examination wascorrelated with dynamic knee function in patients with cerebralpalsy. Methods: 32 lower extremities of 20 children with cere-bral palsy (CP) (12 diplegic and 8 hemiplegic type CP) were in-cluded in this study. Popliteal angles of the patients were mea-sured with goniometry manually (R1: Jerk, R2: Passive).Thereafter, patients were asked to walk a 10-m walking-waywith their own walking velocity. Motion analysis was per-formed with the Vicon 512 Motion Analysis System. Kneeflexion angle at heel strike and terminal swing phase, maximumknee extension angle in stance phase, and walking velocitywere obtained. The relation between static and dynamic mea-surement was investigated with Spearman correlation analysis.Results: There was statistically significant correlation betweenR1 and R2 (r = 0.762, P < 0.05). The knee flexion angle in heelstrike and terminal swing phase and maximum knee extensionangle in stance phase were not correlated with both R1 and R2.However, walking velocity was correlated with R2 (r = 0.641, P< 0.05). Conclusion: These results show that the popliteal anglemeasurements of physical examination do not reflect maximumknee flexion or extension in walking. For this reason, both staticand dynamic evaluations should be obtained to reveal exacttreatment plan.

P1-049 The Investigation of Cognitive Function inChildren with Poor Vision

S. Atasavun and T. DügerHacettepe University Physical Therapy andRehabilitation School, Turkey

Background: Little is known about the relationship betweenvision and cognitive function and how it would affect childrenwith poor vision. This study aimed at assessing the cognitive

functions in children with poor vision and determining whichaspects of cognitive functions were affected more comparedwith children of same age with normal visual function. Methods:The study included 30 children with low vision (age, 9.36 ±2.39) and 30 children with normal visual function (age, 9.42 ±2.37). All children did not participate in any rehabilitation pro-gram. Their cognitive functions were evaluated with Mini-Men-tal State Examination (MMSE), which was modified slightly forbeing used in a pediatric outpatient setting. Results: Mann-Whit-ney U Test was used to compare the results of MMSE betweengroups. The results of MMSE were found to be statistically sig-nificant in subtests orientation (z = –2.93, P = 0.003), attentionand calculation (z = –3.40, P = 0.001), language (z = –2.86, P =0.004) and total cognitive point (z = –3.38, P = 0.001). Conclu-sion: During the 1st year of life, play and exploration use allsenses to create an enlarging cross-referenced memory store.Repetition enhances recall, but lack of reinforcement rendersdifficulties in the subsequent recognition. The presence of vi-sual impairment in early life affects development of sensoryperception–motor cognitive function. MMSE is simple to useand covers a range of cognitive functions including orientation,attention and concentration, memory, language, andconstructional ability.

P1-050 The Utility of Functional Scales inEvaluating the Effect of NeurodevelopmentalTreatment on Cerebral Palsy

I. S. Choi,1 S. G. Lee,1 J. H. Kim,2 S. Y. Lee,2

and K. Y. Kim3

1Department of Physical Medicine & Rehabilitation,Research Institute of Medical Sciences, ChonnamNational University Medical School & Hospital,South Korea; 2Chonnam National UniversityHwasun Hospital, South Korea; 3Chosun UniversityMedical School, South Korea

Background: Neurodevelopmental Treatment (NDT) is awidely used treatment option for cerebral palsy (CP). However,standard evaluation tool for the effect of NDT is not yet estab-lished. The aim of this study was to investigate the utility offunctional scales in evaluating the effect of NDT in CP. Methods:32 patients (mean age, 3.84 ± 1.47 years) with CP, receivingNDT, were recruited in this study. Nineteen patients were spas-tic diplegic, 8 patients were spastic hemiplegic, 3 patients werehypotonic, and 2 patients were athetoid type. We grouped thesepatients into A (10 men, 8 women; mean age, 3.92 ± 1.39 years)who could sit independently and B (8 men, 6 women; meanage, 3.73 ± 1.62 years) who could not sit independently. All pa-tients received NDT for 30 minutes, 3 times per week, total 12weeks. Before and after NDT, Pediatric Evaluation of DisabilityInventory (PEDI), Functional Independence Measure for Chil-dren (WeeFIM), and Gross Motor Function Measure (GMFM)were assessed. Results: After NDT, 1) Functional score of PEDIsignificantly increased in both groups (P < 0.05). 2) Caregiverassistance score of PEDI significantly increased in both groups(P < 0.05). 3) WeeFIM score significantly increased in bothgroups (P < 0.05). 4) GMFM score significantly increased ingroup A (P < 0.05) but not in group B (P = 0.082). Conclusion:Both PEDI and WeeFIM were parallel-changed irrespective ofmotor function status, but GMFM was influenced by the sittingability in CP. And so, we think the proper scales for motor func-tion status may be needed in CP.



P1-051 Augmentative Communication DevicesPromote Speech Development for Children withDevelopmental Disorders

R. A. Sevcik and M. A. RomskiGeorgia State University, Atlanta, Georgia, USA

Background: The technology for augmentative communica-tion devices has advanced substantially in the past decade. It issometimes still viewed as the choice of last resort for childrenbecause it is believed that it may hinder the development ofspeech. Methods: This poster presents data about changes in theuse of speech from a series of 2 studies about the outcomes ofaugmentative communication use in children with develop-mental disorders. These longitudinal studies provided anaugmentative communication intervention (including a speechgenerating device) to 13 school-aged children (mean age, 12.8years) and 10 toddlers (mean age, 2.6 years). Speech skills wereassessed at baseline and at least 12 months later. Results: After atleast 12 months of experience with an augmentative communi-cation device, 46% of the school-aged children and 50% of thetoddlers with developmental disorders used some intelligiblewords for communication. Findings are discussed with respectto the characteristics of the children whose speech improvedversus those children who did not develop speech. Conclusion:Augmentative communication devices should not be viewed asa last resort for children with developmental disorders. In fact,these devices can and do facilitate the use of speech. For thechildren who did not develop speech, augmentative communi-cation devices provide a functional way to communicate.Augmentative communication devices should be included aspart of early intervention approaches that may aid speechdevelopment.

P1-052 The Effects of Acupuncture inParkinson’s Disease

C. H. Wong,1 Z. Omar,2 C. T. Tan,2 N. K. Chew,2

and Z. Y. Zhang2

1Ministry of Health, Malaysia; 2University Malaya,Malaysia

Background: The traditional Chinese acupuncturists havebeen using acupuncture to treat patients diagnosed with Parkin-son’s disease. Although acupuncture treatment was widely ac-claimed by the traditional Chinese acupuncturists as effective inimproving some of the symptoms of Parkinson’s disease, strongevidence to support this claim is lacking. This research projectstudies the effects of traditional Chinese acupuncture onsymptomatology of Parkinson’s disease according to the guide-lines of Western research methods. Methods: This is a clinicalobservational case study conducted from April 2001 to April2002. Twenty-five patients with Parkinson’s disease stage II andabove were subjected to 15 courses of traditional Chinese acu-puncture within 6 weeks. The main outcome measures were ob-tained by evaluating signs and symptoms of Parkinson’s diseasebefore and after treatment and scored according to Unified Par-kinson’s Disease Rating Scale. Results: The study showed im-provement of full UPDRS score although it does not reach statis-tical significance. Some sections of UPDRS, such as UPDRSactivities of daily living (ADL), showed reduction in score.However, other sections of UPDRS such as motor examination,mental, and complications of therapy did not show any reduc-

tion in scores. Conclusion: The conclusion of the study was thattraditional acupuncture treatment is not effective in improvingthe general signs and symptoms of Parkinson’s disease in ashort-term study.

P1-053 Efficacy of Sensorial Cues on GaitRehabilitation in Parkinson’s Disease

G. Sandrini, C. Tassorelli, L. Balloni, S. Buscone, C.PacchettiIRCCS C. Mondino Foundation Institute ofNeurology, Pavia, Italy

Background: We examined the efficacy of a rehabilitationprotocol based on the use of 2 different types of sensory cues(visual and acoustic stimulation) on the gait parameters of idio-pathic Parkinson’s disease (PD). Methods: 20 patients were re-cruited (3 were in Hoen and Yahr stage II, 12 in stage III, and 5in stage IV) and were randomized into 2 groups of treatment.The 1s t g roup comple ted a cyc le of in tens iveneurorehabilitation based on rhythmic auditory cues; the 2ndone, a cycle of visual stimulation with parallel transverse highcontrasting white lines spaced at 45-cm intervals. The treat-ments were performed daily for 4 consecutive weeks.Electromyographic (EMG) activity was recorded by computer-ized system (ELITE) at baseline, at end of the rehabilitation cy-cle, and at 3 months after its end. Results: The groups showed asignificant (P < 0.05) change in several gait variables. Generally,the use of visual or acoustic conditioning increased the gaitspeed, decreased step cadence, and improved step width andstride length. The double-limb support time decreased with asubstantial improvement in swing phase versus stance phase.Conclusion: This study demonstrates that the adoption of a gaitrehabilitation protocol exploiting sensory conditioning is effec-tive in PD. However, the beneficial effect tends to vanish gradu-ally over time, which suggests the opportunity to continue thisspecific type of sensory-motor rehabilitation after the dischargeof the patient.

P1-054 Group Therapy for Persons withParkinson Disease (PD) Focusing on VoiceStrengthening

A. Tautscher-Basnett,1 V. Tomantschger,1 S. Keglevic,2

and M. Freimüller1

1Gailtal-Klinik Hermagor, Austria; 2University ofSalzburg, Austria

Background: Persons with PD often suffer from voice prob-lems. This study investigates the efficacy of a therapy focusingexclusively on voice strengthening in a small group of personswith PD. This group treatment program has been designedalong the lines of the principles of the Lee Silverman VoiceTreatment (LSVT). Methods: 3 patients with PD (male; agerange, 70-87 years; H&Y stages, II-III) participate in an intensivevoice strengthening program. Sixteen therapy sessions of 50minutes are administered during a period of 4 weeks. The pro-gram consists of an exclusive focus on voice; subjects are alsorequired to practice regularly at home. Participants are assessedon var ious speech and voice parameters pre- andposttreatment, and intelligibility scales are completed. Speechsamples are analyzed using the Multi-Dimensional Voice Pro-gram (MDVP) on the Computerized Speech Lab (CSL). Results:



Analysis suggests some improvement on voice parameters (e.g.,jitter and shimmer), energy and pitch contour, as well asdiadochokinetic rate. However, intelligibility scales show onlymarginal improvement in everyday speech. Conclusion: The ef-ficacy of individual therapy focusing on voice for patients withPD is well documented (c.f., LSVT). This pilot study shows thattreatment in a small group setting also leads to improvement onvarious voice parameters. However, more treatment studies insimilar small group settings are needed in order to come to adefinite conclusion.

P1-055 Physical Rehabilitation in Parkinson’sDisease

D. Dobi, M. Rakacolli, and J. KrujaDepartment of Neurology, UHC, Albania

Background: An important part of Parkinson’s disease treat-ment is good management of motor and cognitive dysfunction,and in this context, physical rehabilitation is significant. In Al-bania, the prevalence of Parkinson’s disease (PD) is 1.9%. Thepurpose of this study was to determine if persons with PD whocompleted an 8-week, supervised Italian version of a pole-strid-ing exercise program would undergo significant improvementsin cognitive skills, activities of daily living, motor function, andquality of life. Methods: The unified Parkinson’s disease ratingscale (UPDRS) and Parkinson’s disease questionnaire (PDQ-39)were used to measure functional independence. Eighteen malevolunteers (age, 72.7 ± 3.7 years) performed the Italian versionof the pole-striding exercise 3 times per week for 37 ± 3 min-utes. Differences in pre- and posttraining scores on the UPDRSand PDQ-39 were analyzed using the Wilcoxon signed rankstest. Results: A statistically significant improvement occurred inthe UPDRS (P < 0.026) and PDQ-39 (P < 0.028) scores after themoderate intensity exercise intervention. Conclusion: The re-sults of this nonrandomized clinical trial indicate that an 8-weekindividualized Italian pole-striding exercise program increasesperceived functional independence and quality of life in per-sons with Parkinson’s disease.

P1-056 Could Directional Asymmetry duringTurning Be a Sign of Parkinson’s Disease?

E. L. StackDepartment of Neurorehabilitation, University ofSouthampton, United Kingdom

Background: People with PD find turning difficult. If turn-ing difficulties are apparent in early PD, they might be useful di-agnostically. Methods: 36 participants (12 with early PD [lessthan 5 years duration], 12 with late PD [7-15 years duration], and12 controls) completed the Standing Start 180-Degree Turn Test(SS-180). During the SS-180, participants turned twice andwalked to a target behind them, turning first in a freely chosendirection and then turning in the opposite direction. Wecounted turning steps and calculated the 95% limits of agree-ment from the mean difference between turns in each direction.Results: Median age was 73, similar in all groups. Controls tooka median 3 steps turning both freely and in an imposed direc-tion. Step count was similar in early PD (medians 3.5 and 4) butsignificantly greater in late PD (medians 5.5 and 5; P < 0.02).Comparing turns in both directions, the 95% limits of agreementran from –1 to 1 step (controls), from –6 to 7 steps (early PD),and from –7 to 9 steps (late PD). Eight controls took the samenumber of steps turning both ways, as did 4 of 8 early PD and 2

of 8 late PD: step differences greater than 1 were demonstratedby 2 of 12 early PD and 5 of 12 late PD patients. Conclusion: Astep count difference between left and right turns distinguishedcontrols from people with PD. Left-right asymmetry was un-usual in healthy adults. This sign should alert clinicians to a pos-sibility of PD, particularly if the difference exceeds 1 step. Fur-ther research is needed.

P1-057 Efficacy of Sensorial Cues on GaitRehabilitation in Parkinson Disease

G. Sandrini, C. Tassorelli, L. Balloni, S. Buscone,and C. PacchettiRCCS C. Mondino Foundation Istitute of Neurology,University of Pavia, Italy

Background: We examined the efficacy of a rehabilitationprotocol based on the use of 2 different types of sensory cues(visual and acoustic stimulation) on the gait parameters of idio-pathic Parkinson’s disease (PD). Methods: 20 patients were re-cruited (3 were in Hoen and Yahr stage II, 12 in stage III, and 5in stage IV) and were randomized into 2 groups of treatment.The 1s t g roup comple ted a cyc le of in tens iveneurorehabilitation based on rhythmic auditory cues; the 2ndone, a cycle of visual stimulation with parallel transverse high-contrasting white lines spaced at 45-cm intervals. The treat-ments were performed daily for 4 consecutive weeks.Electromyographic (EMG) activity was recorded by computer-ized system (ELITE) at baseline, at end of the rehabilitation cy-cle, and at 3 months after its end. Results: The groups showed asignificant (P < 0.05) change in several gait variables. Generally,the use of visual or acoustic conditioning increased the gaitspeed, decreased step cadence, and improved step width andstride length. The double-limb support time decreased with asubstantial improvement in swing phase versus stance phase.Conclusion: This study demonstrates that the adoption of a gaitrehabilitation protocol exploiting sensory conditioning is effec-tive in PD. However, the beneficial effect tends to vanish gradu-ally over time, which suggests the opportunity to continue thisspecific type of sensory-motor rehabilitation after the dischargeof the patient.

P1-058 Evidence-Based Clinical Practice Guidelinefor Physical Therapy in Parkinson’s Disease

M. Munneke,1 S. H. J. Keus,2 A. B. Bredero-Cohen,3

H. J. Hendriks,4 and B. R. Bloem1

1Radboud University Nijmegen Medical Centre, theNetherlands; 2Leiden University Medical Center, theNetherlands; 3Dutch Institute of Allied Health Care(NPi), the Netherlands; 4Centre of Evidence BasedPhysiotherapy (CEBP), Maastricht University, theNetherlands

Background: In Parkinson’s disease (PD), physical therapyis often prescribed next to medical treatment. To facilitate theuniformity and efficacy of physical therapy and to clarify possi-ble indications for referral to physicians we developed an evi-dence-based guideline for physical therapy in PD. Methods: Agroup of experts developed the guideline according to interna-tional standards. The guideline was based on the available evi-dence, clinical expertise, and patient values. Recommendationswere graded according to the strength of evidence. The guide-line was reviewed by an independent, international review



panel of 16 professionals with specific expertise in movementdisorders and by a patient panel. Furthermore, the guidelinewas field-tested by 70 physical therapists nationwide. Results: 6specific core areas for physical therapy were identified: trans-fers, posture, reaching and grasping, balance, gait, and physicalcapacity. Four specific treatment strategies are recommended;cognitive movement strategies to improve transfers; exercisesto improve balance; and exercises to improve physical capacity.Conclusion: The guideline was systematically developed ac-cording to accepted international criteria. It provides a firm ba-sis for current physical therapy practice in PD, as well as for fu-ture research in this field and is freely available through thein terne t in Dutch and Engl i sh (www.kngf .n l andwww.cebp.nl). The guideline is formally approved by the Asso-ciation of Physiotherapists in PD Europe (APPDE).

P1-059 The ParkNet Trial: Implementation of anEvidence-Based Guideline for Physical Therapy inParkinson s Disease

M. Munneke,1 S. H. J. Keus,2 M. J. Nijkrake,1

L. I. Lim,3 and B. R. Bloem1

1Radboud University Nijmegen Medical Centre, theNetherlands; 2Leiden University Medical Center, theNetherlands; 3VU University Medical Center, theNetherlands

Background: In the Netherlands, physical therapy referralrates for patients with Parkinson’s disease are high. Referralseems, to some extent, arbitrary. In addition, most physicaltherapists lack specific skills in treating PD patients. We expectthat optimal structured referral, combined with expert treat-ment according to evidence-based practice guidelines(www.cebp.nl), will increase the quality and efficiency of phys-ical therapy in PD. We have designed a large multicenter RCT(ParkNet trial) with cluster randomization to investigate the cor-rectness of these expectations. Methods: 16 clusters (depart-ments of neurology in general hospitals) are randomly allocatedto an experimental group (network care) or a usual care group(unchanged care). In the network care clusters, referral will beoptimized. In addition, a multifaceted implementation strategywill be applied aimed at correct use of the guideline: installationof a network of dedicated therapists; continuous education dur-ing 1 year (e.g., a basic course and Web-based learning facili-ties); application of an electronic patient record; and improvedcommunication with participating neurologists. We intend to in-clude at least 800 eligible patients. All patients will be observedfor 6 months. Results: 43 therapists are selected to participate in1 of the 8 expert networks. Education of therapists has started inOctober 2005. Enrollment of patients starts in December 2005.Conclusion: Final results will be available in 2008.

P1-060 Quality of Allied Health Care forParkinson’s Disease

M. Munneke,1 M. J. Nijkrake,1 S. H. J. Keus,2

R. A. B. Oostendorp,1 and B. R. Bloem1

1Radboud University Nijmegen Medical Centre, theNetherlands; 2Leiden University Medical Center, theNetherlands

Background: We investigated referral characteristics andutilization of physical therapy, occupational therapy, and

speech therapy in Parkinson’s disease (PD). In addition, we in-vestigated the capability of allied health professionals to treatpatients with PD. Methods: Postal questionnaires were sent to260 patients with PD, 196 physical therapists, 22 occupationaltherapists, and 91 speech therapists. Therapists were asked howmany PD patients they had treated the previous year. In addi-tion, therapists where asked to judge their capability to treat PDpatients on a 5-point Likert scale. Results: 63% of the patientshad been referred to physical therapy, 14% to speech therapy,and 9% to occupational therapy. Of all patients who reportedexperiencing problems with gait or falls, 34% had not been re-ferred to a physical therapist. Nearly 20% of patients experienc-ing problems with speech, eating, or drooling had not been re-ferred to a speech therapist. Only 2% of patients who reportedproblems in work had been referred to an occupational thera-pist. Most therapists had treated a maximum of 3 PD patients theforegoing year. Eighty-three percent of the therapists perceiveda lack of PD-specific expertise. Conclusion: A fair number of PDpatients with an indication for referral to an allied health profes-sional were not being referred. Patients who are referred aremost often treated by therapists who judge themselves as beingincapable of optimally treating these patients. Strategies are ur-gently needed to improve the quality of allied health care in PD.

P1-061 The Effect of Cueing Therapy as Measuredby Activity Monitoring in the RESCUE Trial

E. van Wegen,1 A. Nieuwboer,2 L. Rochester,3

D. Jones,3 and G. Kwakkel11Vrije Universiteit Medisch Centrum, Amsterdam,the Netherlands; 2Katholieke Universiteit Leuven,Belgium; 3Northumbria University, Newcastle uponTyne, United Kingdom

Background: The aim of the RESCUE project was to evaluatethe effects of a rhythmic cueing program on gait and gait-relatedactivities in patients’ own home situation. An objective means toquantify daily activity in the natural environment is to apply ac-tivity monitoring. Methods: A multicentered RCT was carried outin 3 European countries (B, NL, UK). Trained therapists pro-vided a cueing program at home 3 times a week for 30 min dur-ing 3 consecutive weeks. Activity monitoring was done at base-line, 3, 6, and 12 weeks in the patients’ home. The Vitaport®activity monitor (Temec Instruments B.V., Kerkrade, the Nether-lands) was used to record the postures and motions of subjectsduring each assessment day. Day of the week and time of daywere kept identical. Results: A total of 147 patients completedall 4 monitoring sessions. An overall intervention effect wasfound for percentage dynamic activity (P = 0.0013), percentagestatic activity (P < 0.0094), percentage walking (P < 0.0001), andnumber of walking periods greater than 5 sec (P < 0.0001). Con-clusion: Rhythmic cueing therapy significantly improved ambu-latory activity, consistent with improvements seen in other gait-performance measures assessed in the trial. Treatment effectswere reduced after treatment stops, pointing to the need forsupplementing therapy with permanent cueing devices and fol-low-up. As rhythmic cueing therapy at home significantly in-creases time spent walking per day, it may allow patients tomore actively participate in everyday activities and socialevents.



P1-062 Transcutaneous Electric StimulationPromotes Peripheral Nerve Recovery:Electrophysiologic and Histologic Studies

Y. L. Bai,1 Y. S. Hu,1 W. P. Lin,2 R. K. Yu,2

and Y. M. Xu1

1Huashan Hospital, Fudan University, China;2Academy of Life Science, Shanghai JiaotongUniversity, China

Background: Although there has been much developmentin microsurgery, the functional recovery of injured peripheralnerves is still a focus of rehabilitation medicine. This enquirywas conducted into the electrophysiologic and histologic ef-fects on peripheral nerve regeneration and functional recoveryby transcutaneous electric stimulation (TES). Methods: 20 maleSD rats were randomly divided into TES and control groups. Sci-atic nerve transection and anastomosis by microsurgery wasperformed. TES was applied to the experimental rats. The ef-fects of TES on the electrophysiologic parameters and the struc-ture and number of myelin sheaths of the injured nerve wereobserved by electrophysiologic and histologic methods. Thechanges were compared with the control animals. Results:There was significant shortening in latency of the injured nervein the TES group compared with the control group (P < 0.001).Although the nerve conduction velocity was faster and the am-plitude was lower in the TES group than the control rats, no sta-tistically significant difference was found between the 2 groups.There were more myelin sheaths around the injured nerves ofthe TES rats comparing with the control rats, and a statisticallysignificant difference was found between the 2 groups (P <0.001). Conclusion: TES had promoting effects on the regenera-tion, repair, and conductive function recovery of injured periph-eral nerves through enhancing the proliferation of Schwanncells and the formation of myelin nerve sheaths.

P1-063 An Experimental Study of the PromotingEffects of Transcranial Motor Cortex MagneticStimulation for Peripheral Nerve Regenerationafter Injuries

Y. L. Bai,1 Y. S. Hu,1 W. P. Lin,2 R. K. Yu,2 and Y. M.Xu1

1Huashan Hospital, Fudan University, China;2Academy of Life Science, Shanghai JiaotongUniversity, China

Background: To find an effective method to accelerate therecovery of peripheral nerve function after injuries, theelectrophysiologic changes in injured nerves after interventionwith transcranial motor cortex magnetic stimulation (TMS) werestudied. Methods: 20 male SD rats were randomly divided intoTMS and control groups. Sciatic nerve transection and anasto-mosis by microsurgery were performed. TMS was applied to theexper imenta l ra ts , and the ef fec ts of the TMS onelectrophysiologic parameters and the structure and number ofmyelin sheaths associated with the injured nerves were ob-served by electrophysiologic and histologic methods. Thechanges were compared with the control animals. Results:There was significant shortening in latency in the injured sciaticnerves of the experimental group compared with the controlgroup. Nerve conduction velocities in TMS group were alsofaster than in the control rats, but the differences were not statis-

tically significant. More myelin sheaths were observed aroundthe injured sciatic nerves of experimental rats compared withthe control group in histologic examination, and a statisticallysignificant difference was found between the 2 groups. The my-elin sheaths of the injured nerves of the experimental rats weremore intact and clearer than in the control animals. Conclusion:Transcranial motor cortex magnetic stimulation possibly pro-moted regeneration of injured peripheral nerves and therecovery of nerve conduction function.

P1-064 Rehabilitation of Peripheral Neuropathydue to Cough Mixture Abuse—A Case Report

M. M. Y. Tse and L. S. W. LiTung Wah Hospital and the University of HongKong, Hong Kong

Background: Chronic cough mixture abuse (CCMA) induc-ing peripheral neuropathy of axonal type secondary to folatedeficiency had been reported. All of the reported cases were as-sociated with severe folate and vitamin B12 deficiency. All hadexcellent recovery in 3 months with aggressive treatment. Meth-ods: A 24-year-old boy, chronic abuser of cough mixture andketamine presented clinically with acute onset of bilateralperoneal nerve palsy with preexisting peripheral neuropathy ofaxonal type confirmed on initial nerve conduction studies. Re-sults: Despite normal red cell count and normochromic picturein this case, vitamin B12 and folate level were checked becauseof clinical suspicion. Folate deficiency with normal B12,homocysteine, and methylmelanoic acid level were found. Ag-gressive folate supplementations were commenced. Fourweeks after rehabilitation, he was able to ambulate with a frameand bilateral AFOs. Minimal motor return was noted on theperoneal muscles despite good sensory recovery. A 2nd nerveconduction study performed showed no active motor unit in theperoneal innervated muscles. Poor prognosis for motor recov-ery secondary to peroneal palsy was anticipated. Two monthslater, he was able to ambulate with a stick independently butstill required bilateral AFOs. Conclusion: The prognosis for pe-ripheral neuropathy due to CCMA is excellent with treatment.However, this group of patients are also vulnerable to pressurepalsy, which may have a less favorable prognosis.

P1-065 Prism Adaptation to Optical DeviationAlleviates Complex Regional Pain Syndrome:Longitudinal Single Case Study

M. Sumitani, M. Shibata, M. Yagisawa, T. Mashimo,and S. MiyauchiDepartment of Acute Critical Medicine(Anesthesiology), Osaka University,Graduate School of Medicine, Japan

Background: Spatial perception is achieved by integratinginformation from multiple sensory modalities. Using visual sub-jective body-midline (vSM) judgment task, we previously con-firmed pain and deafferentation affect visuospatial perception,suggesting that altered somatosensory experiences can modifyvisual perception. In the present study, we determined if visualexperience changes can modify somatosensory perception.Methods: Prism adaptation (PA) was utilized to change visualexperiences. Wearing several types of prismatic goggles thatgenerated optical shift, a complex regional pain syndrome



(CRPS) patient performed a simple target-pointing task once aday for successive weeks. For each type of goggle, we evalu-ated vSM to validate the adaptive aftereffects, pain intensity,and CRPS-associated sings (color change, edema, motor impair-ment) at 3 time points: pre-, IA-, and posttest (before PA, imme-diately after PA, and 2 weeks after PA, respectively). Results:None of PA showed an analgesic effect in IA-tests. However, inposttest, 20° PA toward the unaffected side alleviated pain andthe sings, whereas 20° PA toward the affected side had an ad-verse effect. Neutral and 5° adaptations toward the unaffectedside did not show any effect. Conclusion: PA has direction-spe-cific and reproducible effects on pain (somatosensory percep-tion) and CRPS-associated signs. We consider that PA can be ap-plied as a cognitive treatment for pain disorders, in addition tohemineglect.

P1-066 To Treat Cutaneous Nerve EntrapmentSyndrome by Mechanical Vibration

Y. WangDepartment of Rehabilitation Medicine, RenjiHospital, Shanghai Second Medical University,Shanghai, China

Background: To explore the effectiveness in treatment ofcutaneous nerve entrapment syndrome (CNES) by mechanicalvibration. Methods: Patients who suffered from CNES in the up-per back and limbs were recruited for the study. A treatmentprogram with the use of a mechanical vibration was applied.The pain degree was estimated by VAS before and after treat-ment. The changes were analysed by paired t test with the SPSS11.5 software. Results: Most patients were able to achieve clini-cally significant relief from the neuropathic pain. The degree ofpain was remarkable reduced in many cases (53 of 55). Therewas difference before and after treatment (P < 0.001). Conclu-sion: This pilot explorative study suggested this method couldalleviate pain due to CNES in the upper back and limbs. It isreadily accepted by patients and should be worthwhile to havefurther randomized studies.

P1-067 Altered Bone Metabolism after SevereTraumatic Brain Injury

I. J. Baguley, S. Ng, and S. ChanBrain Injury Rehabilitation Service, WestmeadHospital, Australia

Background: Osteoporosis is a consequence of aging andspinal cord injury; however, the effect of severe traumatic braininjury (TBI) on bone density has not been reported. It could beexpected that physically dependent TBI survivors would haveworse bone turnover. Dysautonomia is a distinct clinical syn-drome affecting a small subgroup of severe TBI survivors who,in the longer term, are often highly physically dependent. Thispilot study aimed to confirm the hypothesis that severe TBI sur-vivors exhibit increased bone turnover in the early and late re-habilitation phases. Furthermore, it was expected that dys-autonomia patients would have osteopenia/porosis on DEXA.Methods: 8 severe TBI survivors were divided into 2 groupsbased on time postinjury and the presence or absence ofdysautonomia. Bone turnover markers and relevant endocrinetests were assayed. DEXA scans were performed on thedysautonomia group. Results: 4 dysautonomic (mean age 32years and 18 months postinjury) and 4 nondysautonomic pa-tients (37 years and 2 months, respectively) were recruited. All

patients showed elevated bone resorption markers. Evidencefor bone formation markers was variable (3 raised ALP, 1 raisedand 1 low osteocalcin). Three of 4 dysautonomic patients hadosteopenia/porosis on DEXA. Conclusion: This preliminarystudy found evidence for altered bone turnover in all, irrespec-tive of time postinjury or the presence or absence ofdysautonomia.

P1-068 Mentamove Rehabilitation after HeadInjury Patient with Left Thalamic Hematoma:Case Report

Z. Akgun,1 M. Akgun,2 B. Hakyemez,3 and C. Garner4

1School of High Healthy Uludag University, Turkey;2State Hospital Bursa, Turkey; 3Uludag University,Turkey; 4KWA Klinik Stift Rottal, Germany

Background: Brain Efficiency Training (Mentamove) is aneurorehabilitation method that is used to treat various brain le-sions. If motor activities are mentally practiced by the subjectwith Mentamove, the real movement leads to a reorganizationof the brain. Methods: Our patient had a clot (2.5 × 2.5 cm) in theleft thalamus after a head injury. He (27 years old, male) hadright hemiplegia with mild central type facial paralysia andaphonia. After clot resorption, the Mentamove method wasused on the right shoulder, elbow, wrist, hip, knee, andperoneal muscles 2 times daily for 2 months. The outcome wasmonitored by applying the Medical Research Council Scale(MRC) of 0 to 5, and brain activity was investigated with fMRIbefore training and after 2 months of the treatment. Results: Us-ing the MRC scale, the motor power of the shoulder in abduc-tion, of the elbow, of knee extension, and of hip flexion in-creased from 0 to 5, and wrist extension and dorsiflexionimproved from 0 to 4+. A fMRI showed blood oxygen level de-pendence (BOLD) activity on both motor cortices before treat-ment. After 2 months, fMRI showed increased BOLD activity onthe right premotor cortex with right hand movements. In-creased activity was shown on the frontal cortex bilaterally, lefthippocampus, right thalamus, and both premotor cortices withright foot dorsiflexion. The left-side basal ganglia activity waslower than the right thalamic activity. Conclusion: These fMRIresults show new reorganization of the brain after treatmentwith the Mentamove rehabilitation method.

P1-069 Urologic Dysfunctions after TraumaticBrain Injury—An Indian Study

A. VarmaPatna Medical College, India

Background: Survivors from severe traumatic brain injuryoften complain of urologic problems. It represents an importantsource of posttraumatic disability among such persons. Oftenthese complaints remain neglected. India with its large popula-tion, poverty, illiteracy, poor health consciousness, and reli-gious disbeliefs has its own limitations. These have significantroles to play in the total outcome of the rehabilitation manage-ment in TBI patients. Methods: 143 TBI patients were evaluated,who were admitted between November 2000 to January 2003 atPatna Medical College. Mean posttrauma interval being 13months in our series with mean age being 35.4 years (range, 15-74 years). Patients with associated SCI or with history of uro-logic dysfunctions were excluded. Inclusion criteria for thesepatients were GLS less than 8. They were put to complete clini-cal examinations with reference to renal functions, hematologic



analysis, and monitoring of various bladder functions in term offrequency, urgency, etc. Results: Results clearly stated that 96%of patients had urinary tract infections. Forty-five percent ofthem had developed neurgenic bladder. Twelve percent hadareflexic bladder, whereas 40% of them demonstrated detrusorhyperreflexia. Sphincteric hypertonus and large residual vol-ume urine was seen among 35% of cases. Conclusion: Largenumber of patients with TBI presented with urologicdysfunctions in the study. Neurogenic bladder happens to bethe most common cause in our series. Thus, a comprehensiverehabilitation is needed to deal with this problem.

P1-070 Combined Chinese-Western MedicalRehabilitation of 72 Cases of Patients with SevereBrain Trauma

D. WangRehabilitation Hospital of Heilongjiang Province,China

Background: Severe brain trauma may result in coma, im-paired consciousness, and deformity because of contracture.Recovery is usually prolonged, and the prognosis is variable.The effects of combined Chinese and Western treatment are un-known. Methods: A retrospective study was done in 72 patientswith severe brain damage, managed with combined traditionalChinese and Western treatment. Measurements included Glas-gow Coma Scores, MMSE, Fugl—Meyer, FIM, DRS, and GOS toevaluate patients before and after treatment in hospital. Patientswho had not regained consciousness were treated by urgingthem to wake up, and those who had regained consciousnessreceived traditional Chinese and Western rehabilitation. MMSE,Fugl-Meyer, FIM, and DRS levels were compared before and af-ter treatment. The influence of the patients’ ages, duration ofcoma, course of disease, and duration of treatment on the out-come was analyzed statistically. Results: MMSE, Fugl-Meyer,FIM, and DRS results showed significant differences betweenbefore and after treatment. The level of disabilities was reducedwith treatment. DRS was related to the level and duration ofcoma and the duration of rehabilitation. A shorter course of dis-ease, youth, and a longer duration of treatment improved func-tional outcomes with lower levels of deformity. Conclusion:Combining traditional Chinese and Western rehabilitation re-duced disabilities in patients with brain trauma. Severity ofbrain damage and the timing of treatment are important factorsinfluencing the level of disability.

P1-071 Comprehensive, Accurate Assessment—The Key to effective Rehabilitation: A Case Report

K. Walton, J. Wilcock, and S. PimmPriory Highbank Rehabilitation Centre, UnitedKingdom

Background: A 29-year-old man sustained a severe trau-matic brain injury (TBI) in 2002 at the age of 29 years. Fifteenmonths after TBI the treating neurorehabilitation team found nomeaningful responses and so recommended a discharge place-ment to meet his basic care needs. They believed him to beblind. This was not acceptable to his family, and so transfer to amore specialist unit was agreed. Methods: Systematic review ofhis physical and medical management was combined with a val-idated assessment of sensory responses. This process has con-tinued with each subsequent stage of rehabilitation. Results: Ini-tial assessment revealed useful vision with the ability to make

basic choices. Introduction of modafinil coincided with an in-crease in interactions with people and with his environment;reduction in fatiguability enabled participation in communica-tion and functional activities. In September 2005, he was able torespond to verbal interactions appropriately (including jokes)and participate in social activities, and he has regained the abil-ity to eat and drink such that his enteral feeding tube was re-moved. The next step will be a move from institutionalized careto his home. Conclusion: Skilled assessment with targeted phys-ical, sensory, and pharmacologic interventions resulting in rec-ognition of cognition has enabled this young man to participatein social contexts relevant to his family. Cognitive and physicalimprovements can continue for several years after profoundTBI in the appropriate rehabilitation setting.

P1-072 A Prospective Study of Subjects withModerate and Severe Traumatic Brain Injury

C. Røe and N. AndelicUllevål University Hospital, Norway

Background: To acquire knowledge about TBI in terms ofmortality, medical complications, long-term function, and needof health services, nursing care, and technical aid. Methods:Adults of 16 to 55 years old admitted to Ulleval University Hos-pital (UUS) within 24 h after traumatic brain injury (TBI), whichwas defined as moderate or severe by Glasgow Coma Scale(GCS 3-8 and 9-12, respectively) at the site of injury or at admit-tance to hospital, are included from May 2005 to May 2007. De-mographic data, mortality, medical complications, days in hos-pital, and validated measurements of consciousness, amnesia,and functional, psychological, and cognitive functions are mea-sured at admittance, the 1st week, after 6 weeks, and at 3months. Follow-up at 12 and 24 months also include registra-tion of quality of life and community integration as well as theneed of health services and technical aid. Results: 26 patients(median age, 25 years) with TBI were admitted to UUS by Sep-tember 2005. Seventeen were injured in traffic, 7 died within 14days. Of the 19 survivors, 15 were men; 12 had GCS less than 9;9 were influenced by alcohol. Median length of stay in UUS was3 days for moderate TBI and 13 days for severe TBI. Conclusion:Major risk factors for TBI are age, gender, traffic accidents, andalcohol. The mortality in the 1st day after the accident is high inthe group with severe TBI, and major long-term cognitive andfunctional consequences for the survivors are suggested. Six-month data will be presented at the conference.

P1-073 Identifying Acute Onset of Shoulder Painafter Stroke

B. S. Rajaratnam,1 N. Venketasubramanian,2

and V. P. Kumar3

1Nanyang Polytechnic/National University ofSingapore, Singapore; 2National NeuroscienceInstitute, Singapore; 3National University ofSingapore, Singapore

Background: Shoulder pain has been reported to signifi-cantly influence the biomechanics of the glenohumeral jointamong clients with orthopaedic conditions. The early onset ofhemiplegic shoulder pain adversely affects rehabilitation out-comes after stroke. The purpose of this study was to identifysimple and valid clinical tests to predict early onset of acuteshoulder pain after stroke. Methods: One hundred thirty-five in-patient stroke survivors were assessed for signs of hemiplegic



shoulder pain based on their expression of pain during rest andduring objective assessment of the shoulder. Upper limb func-tion, shoulder subluxation, range of shoulder motion, strengthof shoulder musculatures, and muscle tone were compared be-tween asymptomatic and symptomatic subjects. Results: Morethan one-quarter experienced shoulder pain within 2/52 afterstroke. Shoulder pain at rest was associated with pain experi-enced during objective assessment (t = 32.81, P = 0.00). Limitedactive range of motion of flexion (c = 1529.5, P = 0.007), activerange of motion of external rotation (c = 1233.5, P = 0.001),weak shoulder abductor muscle strength (c = 1433.5, P = 0.001),and subluxation (c = 1687, P = 0.026) was significantly corre-lated with shoulder pain. Conclusion: Irrespective of severity ofparesis, limited active flexion and external rotation range of mo-tion during objective assessment with the presence of muscletone were found to be simple, noninvasive, and predictiveclinical tests for those at risk of developing hemiplegic shoulderpain.

P1-074 Evaluation of Activities and Participationafter Traumatic Brain Injury

U. Sveen, M. Mongs, E. Bautz-HolterUllevaal University Hospital, Norway

Background: Traumatic brain injury (TBI) may cause func-tional and activity limitations and restriction in participation. Itis important to assess the nature and extent of these limitationsand to predict outcome to tailor an adequate rehabilitationscheme. The Patient Competency Rating Scale (PCRS) was origi-nally developed to measure self-awareness. We evaluated thePCRS as a self-report assessment of function and activities afterTBI and how the PCRS at 3 months predicts participation 1 yearafter TBI. Methods: A cohort of 138 patients with acute TBI wasobserved over 1 year. The PCRS was applied at 3 months to as-sess functions and activity. Outcomes describing participationin society at 12 months were the Community Integration Ques-tionnaire (CIQ), the Glasgow Outcome Scale Extended (GOSE),and return to work or study. The PCRS was analysed in a logisticregression model with the outcomes CIQ, GOSE, and return towork or study to test predictive validity. Results: The PCRS wasfactor analysed and yielded 4 domains: activities demandingcognition, emotional skills, interaction, and ADL, of which the1st 2 domains predicted return to work or study (P = 0.003 and0.008). Prediction concerning participation expressed by theCIQ and GOSE will also be presented. Conclusion: The PCRSdescribes functioning and activities in 4 domains and predictsreturn to work or study 1 year after TBI.

P1-075 Continuous Subcutaneous Apomorphineto Regain Consciousness after a Severe TraumaticBrain Injury

E. A. Fridman,1 M. Bonetto,1 B. Z. Krimchansky,3 R.Zafonte,2 and R. Leiguarda1

1Institute for Neurological Research–Fleni,Argentina; 3Loewenstein Rehabilitation Hospital,Israel; 2University of Pittsburgh Medical Center, USA

Background: Dopamine agonists might play an importantrole in consciousness recovery after severe TBI. Therefore, we

tested Apo, the strongest DA agonist. Pharmacokinetics of Apoallows continuous subcutaneous (sc) administration and stablebrain levels. Methods: An open-label study of Apo administeredsc continuously via a pump for 12 h/d, corresponding to thewake portion of the diurnal cycle. Patients with severe TBI thatremained in VS or MCS between 1 and 4 months were included.Three outcome measures: Coma-Near Coma Scale (CNCS), Dis-ability Rating Scale (DRS), and Glasgow Outcome Scale Ex-tended (GOS-E). Results: To date, 2 patients completed the pro-tocol. Patient 1 is a 25-year-old man who remained in MCS for3e months. Baseline CNCS, DRS, and GOS-E scores were 20, 21,and 2, respectively. Patient showed signs of response to sc Apoon day 1 of treatment. CNCS, DRS, and GOS-E scores at 4 weekswere 0, 12.5, and 3, respectively; at 84 days, scores were 0, 10,and 3, respectively; and at the end of the treatment (day 180)CNCS, DRS, and GOS-E scores were 0, 15, and 3, respectively.Patient 2, a 30-year-old woman remained in VS for 2.5 months.Baseline scores were CNC = 33, DRS = 23, GOS-E = 2. CNCS,DRS, and GOS-E scores at 4 weeks were 0, 22, and 2, respec-tively; at 84 days, scores were 8, 21, and 3, respectively; and at180 days, 0, 12, and 3, respectively. Conclusion: Preliminarydata suggest that Apo is safe and may accelerate recovery ofconsciousness. Additional patients are being recruited beforeinitiating a double-blind, placebo-controlled, multicenterstudy.

P1-076 Effectiveness of Hippotherapy

A. Buettner,1 S. Latarnik,2 H. Remer,2 S. Rode,2

and H. Bennefeld2

1Klinik Ambrock, Germany; 2Heinrich-Mann-Klinik, Germany

Background: In neurologic rehabilitation, in addition tousua l methods (phys io therapy , speech therapy ,neuropsychology), we use hippotherapy to improve balanceand reduce spasticity. Until now, only few scientific evidencefor hippotherapy exists. As we have great experiences for years,we regard studies as important for scientific proof of the ob-served effects on patients. Methods: In our study, we used aquestionnaire including depression, anxiety, subjective physi-cal fitness, and perceived self-efficiency in activities of daily liv-ing. At admission to the clinic, all neurology patients were se-lected according to their diagnosis (ICD-10). Data were for 42patients (57.1% men; 42.9% women; mean age, 63.2 y (range,37-82 y). Results: In general, the effects of the hippotherapy cor-responded to the patients’ high expectations. The assessment ofdepression, anxiety, and subjective physical fitness show signif-icant differences between the self-estimations before and afterthe therapy (P < 0.05). Depression and anxiety were signifi-cantly decreased; physical fitness increased. In opposition toour hypothesis, perceived self-efficiency after the therapy wasdecreased in a highly significant level (P < 0.001). Conclusion:The following effects could be confirmed: The study revealedthat patients with hippotherapy treatment showed reduceddepression and anxiety, improved physical fitness, and morerealistic expectations and evaluations of the effectiveness.



P1-077 Challenges in Spinal Cord InjuryRehabilitation: Osteogenesis Imperfecta andSpinal Cord Injury—A Case Report

P. M. Chern,1 M. Y. Yusniza,1 A. Ibrahim,1 K. W. Foo,2

and M. Effendi21Hospital Putrajaya, Malaysia; 2Hospital KualaLumpur, Malaysia

Background: Osteogenesis imperfecta is a rarely seen dis-ease and the habilitation of these people by itself is a great chal-lenge to the rehabilitation physician. Methods: We report a caseof a 32-year-old man with osteogenesis imperfecta who suf-fered a cervical cord injury posttrauma with the neurologic levelof ASIA B C6. We highlight the challenges that our spinal cordinjury (SCI) rehabilitation team faced during his inpatient reha-bilitation process in view of his underlying osteogenesisimperfecta and poor social support. We also want to report onthe modification and design of the aids and equipment requiredto help him enhance his functional status as a low tetraplegicpatient. Results: With the effort of our SCI rehabilitation teamthrough interdisciplinary teamwork, his functional status al-most achieved the level of C7 tetraplegia, even without any neu-rologic improvement, within the 6 months of his inpatient SCIrehabilitation program. Conclusion: With individualized SCI re-habilitation program, the functional outcome of spinal cord in-jured patient with preexisting impairments may even be betterthan expected.

P1-078 Role of Physical Therapy in ElephantRehabilitation; A Single Case Report in SpinalCord Injured Elephant

S. Kongsawasdi,1 T. Tungsibsarm,1 and P. Kulchaiwat21Faculty of Associated Medical Sciences, ChiangmaiUniversity, Thailand; 2Faculty of VeterinaryMedicine, Chiangmai University, Thailand

Background: In the world of human medicine, physicaltherapy is known as a health care profession directed at evaluat-ing, restoring, and maintaining physical function and move-ment. Nowadays, by applying unique and specialized knowl-edge, physical therapist also extends capabilities to treat otheranimal species. This single case report illustrated rehabilitationprogram for a spinal cord–injured elephant in the Thai ElephantConservation Center. Methods: A baby elephant aged 2 yearswas consulted with the main problem of unable to stand andmove with his hind limbs. He had spinal cord injury, incompletelesion. A physical therapy program was implemented after elec-trical acupuncture by a trained veterinarian. The optimal goal oftreatment was to maximize independence, especially for basicneeds of life. Results: In the early phase, to prevent further dam-age to the spine, proper positioning and mattress were advised.Physical therapy interventions included hydrotherapy, electri-cal stimulation, and passive ROM and active assisted exercisewith sensory stimulation (i.e., tapping, quick stretch). After 3months, he was trained to bear weight and stand. Modifiedwheelchair was used for ambulation. Unfortunately, because ofhis excessive weight, he had an infected pressure sore and diedfrom sepsis 6 months later. Conclusion: Although the treatmentgoal was not achieved, this case report revealed an alternaterole of physical therapy in animal rehabilitation.

P1-079 Mentamove Rehabilitation after TraumaticCauda Equina Injury (Case Report)

C. Garner,1 M. Akgun,2 and Z. Akgun3

1KWA Klinik Stift Rottal, Germany; 2State HospitalBursa, Turkey; 3School of High Healthy Uludag,Turkey

Background: Brain Efficiency Training (Mentamove) is aneurorehabilitation method used for rehabilitation after brainlesions. But the Mentamove method never has been docu-mented for use to treat cauda equina injury (CEI) deficits andparaplegia prior to this case report. Methods: The subject of thiscase (a 30-year-old man) was operated on for an L2 compres-sion fracture 3 days after sustaining the injuries in a traffic acci-dent. The spinal surgery decompressed the cauda equina. Thepatient had total paraplegia before and after surgery, and anes-thesia was below the L1 segment. Anal tonus was lost, andpriapism was noted. Five days after the surgery, the Mentamovetreatment program was implemented. Mentamove was appliedto the hip, knee, peroneal, gluteal, and the hamstring musclegroups 2 times daily bilaterally. The response was measuredwith the Medical Research Council scale (MRC) 0 to 5 for 10days. Results: Based on the MRC scale, after 30 days the patientbegan to move the right leg from 0 to 4. His left hip demon-strated 2-point muscle activity and his left foot showed 2-pointmotor activity. After 50 days of therapy, he started to stand withassistance. After 4 months of therapy, he walked with 5-pointmuscle control of the legs. He was able to control urinary incon-tinence and anal tonus. Conclusion: These data show thatMentamove can be successfully used to treat CEI deficits afterdecompressed spinal surgery with incomplete nerve injury.

P1-080 Mentamove Rehabilitation after SpinalCord Injury and Application of the Method (CaseReport)

M. Akgun,1 Z. Akgun,2 and C. Garner3

1State Hospital Bursa, Turkey; 2School of HighHealthy Uludag, Turkey; 3KWA Klinik Stift Rottal,Germany

Background: Brain Efficiency Training (Mentamove) is aneurorehabilitation method used after various CNS lesions. Ifmotor activities are mentally practiced by the subject withMentamove, the real movement triggers a reorganization of thebrain. Methods: The patient (a 30-year-old woman) sustained aspinal cord injury during anterior cervical surgery to the level ofC5-6 for a herniated cervical disc. In the postoperative period,the subject displayed symptoms of Brown-Sequard syndrome.One week later, a 2nd operation was performed, and the spinalcord decompressed. After the 2nd operation, the Mentamovemethod was implemented. Mentamove was applied to theshoulder, elbow, wrist, hip, knee, and peroneal muscles bilater-ally 2 times daily for the duration of treatment. The results weremeasured with the Medical Research Council scale (MRC) of 0 to5. Results: The sensory deficits on the subject’s right side, uri-nary incontinence, spasticity, and body balance recovered. Theleft side elbow, wrist, hip, knee, and peroneal muscles’ motorperformance improved from 0 to 4+ on the MRC scale. Shouldermotor power increased from the 3- to the 5-point on the MRCscale. After 1 year, the subject returned to her previous employ-



ment. The injured spinal cord documented with MRI showed in-complete spinal cord injury. Conclusion: These data show thatthe Mentamove method when used to treat Brown-Sequard syn-drome can be very effective if it is applied during the earlystages of the injury.

P1-081 Functional Electrical Stimulation for theEnhancement of Gait in Subjects with IncompleteSpinal Cord Injury

E. Scott,1 S. J. Mawson,2 and B. Heller3

1Sheffield Teaching Hospitals NHS FoundationTrust, now with the Muscular DystrophyCamapaign, United Kingdom; 2Sheffield HallamUniversity, United Kingdom; 3Sheffield TeachingHospitals NHS Foundation Trust, United Kingdom

Background: This study investigated changes in walkingability with surface-applied functional electrical stimulation(FES) for subjects with incomplete spinal cord injury (ISCI).Methods: 10 subjects with ISCI were recruited. A multiple single-case study methodology was used. Initial baseline assessmentsincluded observational gait analysis with both the Rancho LosAmigos (RLA) system and gait indicators developed for use withthe TELER measurement system. Individual FES systems wereprescribed, and subjects were educated in their application anduse. Final baseline assessments were performed after treatmentand evaluation sessions with the FES. Results: The RLA datashowed an improvement for the subjects as a group (t test, P <0.05). TELER data were analyzed for both the group and individ-ual subjects. Results for the group showed a statistically signifi-cant association between improvements in gait and the use ofFES while walking (chi-square, P < 0.05). Analyses for individ-ual subjects showed clinically significant improvements in gaitfor all subjects but statistical significance for only 2. Conclusion:When considered as a small group, the subjects demonstrated astatistically significant improvement in their walking abilities.The TELER system also allowed for the analysis of individualsubjects. FES can be a useful adjunct to therapy for subjects withISCI. The use of an analysis system which allows for consider-ation of the individual facilitates the use of evidence in a clinicalsetting.

P1-082 Corundum Porous Implants in Surgeryand Rehabilitation of Cervical Part of SpinalColumn

A. Ogonowski,1 M. Lyp,2 and M. Maciak3

1Medical University in Warsaw, Poland; 2Academyof Physical Education in Warsaw, Poland; 3Centreof Rehabilitation “Attis” in Warsaw, Poland

Background: Injuries and diseases affecting the cervical partof the spinal column frequently lead to spinal cord damage andrelated neurologic complications. Prompt surgical interventionand early rehabilitation make it possible for the patients to re-turn to their everyday life. Methods: The publication presentstreatment results of 107 patients who had their spinal cord dam-aged as a consequence of an injury (66%) or a disease (34%).During treatment, corundum porous implants were used to im-prove spine stability. After the operation, the patients were im-mobilized in an orthopedic collar for 2 to 3 months in case offront access (93%) and for 4 to 6 months in the back access (7%).Rehabilitation proceedings started straight after the surgery and

were continued for 4 months. Results: 85% of patients achievedgood results, which meant correct shaping of the spine togetherwith diminishing lordosis and proper bone concrescence.Twelve percent of patients scored satisfactory results, i.e., thesuppression of lordosis or its kyphosis accompanied by the cor-rect bone concrescence. Bad results were observed in 3% of pa-tients whose postinjury deformations persisted and there wasno bone concrescence. Conclusion: Porous corundum provesto be an interesting material for stabilizing the spine in case ofdiseases and injuries at the cervical part of the spinal column.Prompt introduction of rehabilitation after the surgery improveschances of satisfactory treatment results.

P1-083 Modulation of Locomotor Activity inComplete Spinal Cord Injury

L. Lunenburger, M. Bolliger,1 D. Czell,R. Muller, and V. DietzBalgrist University Hospital, Switzerland

Background: Locomotor activity may still be present in theleg muscles of human subjects after a complete spinal cord in-jury (SCI). The aim of this study was to evaluate the modulationof this activity by different walking speeds in subjects with amotor-complete SCI compared to actively and passively walk-ing healthy subjects. Methods: Stepping movements on a tread-mill were induced and assisted by a driven gait orthosis.Electromyographic (EMG) muscle activity of 1 leg (rectus andbiceps femoris, tibialis anterior, and gastrocnemius) was re-corded and analyzed at 3 stepping velocities with similar bodyweight support in both subject groups. Results: In SCI subjects,the EMG amplitude of biceps femoris, tibialis anterior, and gas-trocnemius was in general weaker or smaller than in passivelyand actively stepping healthy subjects, but that of rectus femoriswas larger. The degree of coactivation between tibialis anteriorand gastrocnemius was higher in SCI than in the healthy sub-jects. A significant velocity-dependent EMG modulation waspresent in all 4 leg muscles in both subject groups. In SCI sub-jects, this EMG modulation was similar to that in actively step-ping healthy subjects. Conclusion: It is concluded that in com-plete spastic SCI subjects spinal neuronal circuits underlyinglocomotion can adequately respond to a change in externaldrive to adapt the neuronal pattern to a new locomotion speed.The application of various speeds might enhance the effect oflocomotor training in incomplete SCI subjects.

P1-084 Rehabilitation Effects of the Upper LimbEncircling Motion and Feedback Instrument inPatients with Spinal Cord Injury

T. Wan,g1 X. Wang,1 J. Su,2 G. Wang,1 and Q. Chen1

1First Affiliated Hospital of Nanjing MedicalUniversity, China; 2Kang-Su-Tong ScienceInstitution in Nanjing, China

Background: A new instrument called an upper limbs’ encir-cling motion and feedback (ULEMF) machine was designed,which can help patients with spinal cord injury (SCI) to regainthe motor function and the ability of daily living (ADL). The aimof this study was to evaluate the effects of this instrument in SCIpatients. Methods: 20 SCI patients were randomly divided into 2groups. The treatment group (10 patients) received the ULEMFtraining for 30 min/d for 30 d plus physical therapy (PT) and oc-cupational therapy (OT). The control group only received PTand OT with same contents and intensity. Assessments included



muscle strength of extremities and trunk, Barthel index, balancefunction, and the total colligating force vector quantities(CFVQ) before and after the training. Results: The strength ofquadriceps, flexors, and extensors of trunk and hip in the treat-ment group improved significantly after the training (P < 0.05).The extensors muscle strength in the treatment group showedgreater improvement than those in the control group (P < 0.01).Balance function in both groups improved significantly (P <0.05), especially the standing balance in the treatment group (P< 0.05). The total CFVQ showed greater improvement than thatin the control group (P < 0.05). Conclusion: ULEMF machinehas independent effect on improving motor function and ADLin selected SCI patients.

P1-085 Brief Analysis of 1007 Lumber DiscSurgery and Its End Results

U. Zakir,1 T. Yoneda,1 T. Matsubara,1, A. Miki,1

and A. Idris2

1Kobe University, Japan; 2Ibn Sina Spine Center,Dhaka, Bangladesh

Background: Spinal surgery is very complicated and doneafter consideration of indicatory points to avoid further compli-cations. Its justification and rehabilitation outcome analysis isour purpose of this study. During 1999 to 2003, Ibn Sina SpineCenter has done 1007 cases of lumber disc surgery. We collectedall patients’ treatment protocol data and follow-up data to mea-sure the outcome of lumber disc surgery. Methods: These pa-tients were diagnosed clinically and by neuroradiologic imag-ing. All patients had X ray of lumbosacral spine, 798 patientshad lumber myelogram, and 240 patients had MRI of lumberspine. Thirty-one patients had both myelogram and MRI. Retro-spective data consisting of age, sex, occupation, signs andsymptoms of patients, plain X ray of lumbar spine, myelogram,MRI, types of surgery, level of disc prolapse, and types of opera-tion and results were collected and analyzed. Results: Completerelief of symptoms was in 476 cases; partial relief of symptomsin 323 cases; no change of symptoms in 116 cases; recurrent discprolapse in 22 cases; death in 2 cases; and complications due tosurgery in 68 cases. Conclusion: Although it is very difficult toperform a nice spine surgery, our results show very good out-come. About half of the patients show complete recovery. Weshould refer all patients without delay to a surgeon if we find orsuspect any indication for spine surgery and to avoid neurologiccomplications and allow better management of the patients.

P1-086 Pulmonary Function Tests in ChronicSpinal Cord–Injured Patients

R. Alaca, A. Goktepe, B. Yilmaz, K. Yazicioglu,and S. GunduzGMMA TAF Rehab Center, Turkey

Background: Spinal cord injury is frequently complicatedwith respiratory problems. Tetraplegics are expected to havemore common and more serious problems than paraplegics.The respiratory status of the patients starts to improve after theacute phase. Methods: 82 chronic (more than 1 year postinjuryperiod) spinal cord–injured patients who applied to TurkishArmed Forces Rehabilitation Center were included in the study.The percentages of predicted normal values of vital capacity(VC), forced vital capacity (FVC), forced expiratory volume in 1s (FEV1), FEV1/FVC, and peak expiratory flow rate (PEFR) weremeasured. The patients were divided into 4 groups according to

their level of injury: cervical, high thoracic, low thoracic, andlumbosacral. Four groups were compared for the above-men-tioned parameters. Results: Pulmonary function test results of allgroups were lower than the predicted normal. It was approxi-mately 60% of the normal values in cervical group and around90% for the lumbosacral group. Conclusion: In conclusion, pul-monary functions were found to be affected in chronic spinalcord–injured patients for all injury levels.

P1-088 Rehabilitation of a Case of ActionDisorganisation Syndrome through ErrorlessLearning of a Memorized Action Script

W. L. Bickerton, G. W. Humphreys, and M. J. RiddochUniversity of Birmingham, United Kingdom

Background: We report data from a single case on the reha-bilitation of a sequencing disorder in everyday action. Our pa-tient, FK, has long-standing action disorganization syndromethat has not been ameliorated by previous rehabilitation at-tempts. He was not able to monitor and correct his errors ontasks. We used a verbalization strategy. FK was taught to memo-rize and apply a poem of tea-making steps to help organize hisactions. The 1st phase resulted in a significant improvement inthe sequencing of actions as well as introducing initial signs oferror awareness and correction after training. These improve-ments were contingent on the application of the poem. How-ever, there were relatively weak training effects across sessions.We report results from the 2nd phase, which emphasized the er-rorless element. Methods: Errorless learning was improved by 1)reducing the number of practices per session (as fatigue in-duced error, and FK had difficulty rejecting incorrect represen-tations in working memory) while increasing session fre-quency, 2) reading of poem prior to practice, and 3) therapistassisted errorless completion of task during practice. Results:Performance and error awareness abilities were markedly im-proved and maintained across sessions. Conclusion: Possiblemechanisms for effects of the verbalization strategy arediscussed.

P1-089 A Newly Developed Assessment Scale forAttentional Disturbance Based on BehavioralProblems: Behavioral Assessment of AttentionalDisturbance (BAAD)

M. Toyokura,1 Y. Nishimura,2 M. Sawatari,2

R. Kikui,2 and I. Akutsu2

1Department of Rehabilitation Medicine, TokaiUniversity Oiso Hospital, Japan; 2Division ofRehabilitation, Tokai University Oiso Hospital,Japan

Background: Attentional disturbance after brain damagehas been commonly evaluated by having the patients performneuropsychologic tasks. In rehabilitation settings, however, theprimary concern is functional real-world behaviors. The aim ofthis study was to investigate the reliability and validity of anewly developed system for rating attentional behavior (Behav-ior Assessment of Attentional Disturbance [BAAD]). Methods:The subjects included 183 patients. The BAAD consisted of 12items to be completed by each patient’s occupational therapist.Each item was rated based on the frequency with which theproblem behaviors appeared during daily sessions of occupa-tional therapy in a week. Results: A principal component analy-



sis with varimax rotation identified 3 principal factors which to-gether explained 69.2% of the total variance. These componentswere regarded as related to “arousal,” “sustained attention,” and“selective attention.” A final version of the BAAD scale with 6items was developed by excluding all items with no significantrelation to the aforementioned factors. The scale had aCronbach’s alpha coefficient of 0.81. The intraclass correlationsfor intra- and interrater reliability were 0.94 and 0.84, respec-tively. The BAAD score was significantly correlated with the pa-tients’ performance on the neuropsychologic tests. Conclusion:The results indicate that the BAAD scale has good reliability andvalidity.

P1-090 Validation of the Rivermead BehaviouralMemory Test in Patients with Acquired BrainInjury in Turkey

S. Kutlay,1 A. A. Kucukdeveci,1 A. H. Elhan,1 S.Guzelkucuk,1 and A. Tennant21University of Ankara, Turkey; 2University of Leeds,United Kingdom

Background: Memory problems occur after acquired braininjury. Rivermead Behavioural Memory Test (RBMT) is a well-known instrument for assessment of memory. Aim in this studywas to test the reliability and validity of the Turkish version ofRBMT among acquired brain injury patients in Turkey. Methods:171 acquired brain injury patients admitted for rehabilitationwere assessed by the adapted version of RBMT at admission anddischarge. Reliability was tested by internal consistency andperson separation index, internal construct validity by Raschanalysis, external construct validity by associations with physi-cal and cognitive disability (FIM), and responsiveness by effectsize. Results: Reliability was good with Cronbach’s α 0.84 and0.79 at admission and discharge, respectively. Person separa-tion index was 0.829, showing the scale is able to discriminateacross at least 3 patient groups. Internal construct validity wasgood by fit of data to the Rasch model (mean item fit, –0.219;SD, 1.320; mean person fit, –0.171; SD, 0.680). Item-trait interac-tion was nonsignificant, supporting invariance of items overtime (χ2, 30.4; P = 0.17). Items were substantially free of differ-ential item functioning. External construct validity was con-firmed by expected correlations with physical (r = 0.378) andcognitive (r = 0.670) disability. Effect size was 0.56 comparedwith 0.38 for cognitive FIM. Conclusion: Reliability and validityof the Turkish version of RBMT in acquired brain injury hasbeen demonstrated.

P1-091 What Do the Patients Really See in LineBisection Test: The Study of Patients with RightHemispheric Stroke

W. Qiang, Z. Yunxu, and M. PingpingAffiliated Hospital of Qingdao University MedicalCollege, China

Background: The mechanism of crossover effect in line bi-section test is not clear. In this study, we want to know the men-tal representation length of the long and short lines in patientswith right hemispheric stroke. Methods: 19 patients with lefthemiparesis were proved to have unilateral hemineglect by be-havioral assessment scale-Catherine Bergego Scale (CBS, scores≥ 1). Three lines with length of 10 cm were presented on the left

side, middle, and right side on a A4 paper, and 3 lines withlength of 2 cm were presented on another A4 paper in the sameway. Subjects were asked to mark the 2 ends of the each linewith a short cross. The length of line between end markers wasmeasured. Results: By 1 sample t test, the marked length of lineby patients was significantly shortened except the 2-cm line onthe left of the paper. For 10-cm line, the marked length of lineincreased gradually from the left line to the right line. But for the2-cm line, the marked length decreased gradually from left toright. Many patients had shortened left end of the line. But somepatients shortened the right end of the line, especially if thelines were on the right of the paper. Some patients enlarged leftend of the 2-cm line. Conclusion: Patients with right hemi-spheric stroke underestimated both long lines (10 cm) and shortlines (2 cm). The crossover effect of length may not be causedby overestimation of the short line.

P1-092 Dementia Pathway: A Condition-SpecificApproach

P. De Wit, D. Van Tiggelen, T. Vandendries, T. Laporta,and G. VanspringelAZ Sint Jozef Malle, Belgium

Background: The number of people with dementia is rising.This happens in all units of a general hospital. A performant ap-proach is necessary to meet the needs of patients, family, andcaregivers. We develop and implement a condition-specific in-tegrated care pathway that can be easily consulted by everyhealth care worker and focuses on interdisciplinary integrationand communication aspects. Methods: The interdisciplinaryproject group has used the integrated clinical pathway method-ology to build a condition-specific approach on dementia carein our hospital. Results: Development and implementation of anintegrated care pathway for dementia care using Internet facili-ties. This ‘guideline’ pathway can be consulted easily online bythe whole staff. The pathway includes evidence-based ele-ments, practical flow-charts, and time indications. These arenecessary for a high performance level on quality and a cost-ef-fectiveness approach. To follow up an individual patient, an-other Web-based database system was developed, which can beconsulted from anywhere. This will ensure all the known infor-mation about any patient can be consulted and used in any case.Conclusion: With this integrated care pathway, we have a uni-form and standard approach for the dementia problem in ourhospital. This pathway is easy to understand and can to be con-sulted online, even in the home situation of the patient. The useof a Web-based database system for follow-up enables thetransmural aspect of care.

P1-093 Application of Valpar Component WorkSample for Treatment of Cognitive Impairment inPatients with Brain Trauma

Y. Yu and L. ZhangTianjin Neurological Central (Huan Hu) Hospital,China

Objective: To study the effects of the Valpar ComponentWork Sample (VCWS) in the treatment of cognitive impairmentof patients with brain trauma. Methods: Patients (N = 34) withimpaired cognitive function caused by brain trauma were ran-domly divided into a VCWS group (n = 19) and a control group(n = 15). The VCWS group received treatment by using VCWS3Numerical Sorting, VCW6 Independent Problem, and VCW7



Multilevel Sorting for cognitive function training, and the con-trol group only received conventional rehabilitation therapy.The treatment effects were evaluated by comparing the pa-tients’ cognitive functions before and after treatment using theMMSE. Results: There was a significant improvement in cogni-tive function after treatment (P < 0.05) in both groups. However,a significant difference between the VCWS group and the con-trol group (P < 0.01) was also demonstrated by statistical analy-sis. Conclusion: Both the Valpar Component Work Sample andconventional rehabilitation therapy are effective for improvingcognitive function in patients with brain trauma. The effect ofthe Valpar Component Work Sample was better than that of theconventional rehabilitation therapy.

P1-094 Does Procedure Memory TrainingHave a Better Therapeutic Effect for Patientswith Brain Trauma?

H. FanThe Department of Rehabilitation Medicine, Secondaffliate Hospital of Kunming Medical college, China

Background: Cognition is one of the major functional prob-lems for patients with brain trauma. A lot of studies were doneto evaluate the relationship between cognitive disorders andthe site of brain trauma. Only a few studies reported how totrain these patients. This study was designed to examine the ef-fect of procedure memory training for patients with braintrauma during convalescence. Methods: 20 patients were ran-domly divided into 2 groups: procedure memory training group(10 cases) and control group (10 cases). The control group wasgiven traditional cognitive training only. The period of treat-ment was 6 weeks. Evaluation was done pretraining andposttraining by using Neurobehavioral Cognitive Status Exami-nation (NCSE). Two groups were matched in age, gender, andeducational grading with similar cultural background. Results:Between-groups comparison showed that scores in NCSE forthe procedure memory training group and the control groupwere not significantly different (P > 0.05). However, bothgroups showed significant difference in scores before and aftertraining (P < 0.01). Conclusion: Procedure memory training wasnot superior to traditional cognitive training for patients withbrain trauma. Both types of treatment seem to have sometherapeutic effects.

P1-095 Is Donepezil Hydrochlorid (Aricept) aDrug to Improve the Cognitive Deficits of StrokePatients?

P. GrieshoferKlinik Judendorf Strassengel, Austria

Background: Cognitive impairments are the frequent defi-cits after stroke. The rehabilitative prognosis is often clearlyconnected with these cognitive deficits. Methods: We used thediagnosticum for cerebral defects by HILLERS (DCS), a nonver-bal procedure for the examination of the memory, as well as thesimple reaction time for visual stimuli, as a test methodology.After we performed the DCS and measured the speed of infor-mation processing within the 1st week of the patients’ stay, allexamined patients got 5 mg donepezil for an average period of20 d. The final examination was made before the patients weredischarged from the hospital. Results: We tested 40 patients: 14women and 26 men, with a mean age 63.8 years. The youngestpatient was 40 and the oldest 85 years. The result of the 1st DCS

test had a mean of 4.35 points, and after 20 d of therapy withdonepezil, it was 7.63 points. There was an increase of 75.4% (P= 0.01). The result of the simple reaction time for visual stimulishowed that the 1st test was 369.36 msec and the 2nd test after20 d was 321.41 ms. That was an improvement of reaction timeof 13.62% (P = 0.01). Conclusion: In comparison with the initialparameters, donepezil hydrochlorid showed a high significantimprovement of patients’ cognitive capacity as well as of theirreaction time. This also clearly shows that further studies ofstroke patients who are given donepezil should be made toprove the overall outcome.

P1-096 Repeatable Battery for the Assessment ofNeuropsychological Status as a Screening Test inCognitive Impairment after Traumatic BrainInjury in Japan

M. Oga,1 E. Otsuka,1 and T. Yamashima2

1Chiba Rehabilitation Center, Japan; 2KanazawaUniversity of Medicine, Japan

Background: Cognitive impairment after traumatic brain in-jury is an important feature and is highly correlated with thequality of social life. However, there are few screening instru-ments that can reliably assess the types of cognitive impairmentin a brief administration. In this preliminary research, the au-thors assessed the sensitivity and convergent validity of the Re-peatable Battery for the Assessment of Neuropsychological Sta-tus (RBANS) to the cognitive impairment after traumatic braininjury in Japan. Methods: In total, 25 RBANS data were obtainedfrom 20 Japanese patients, at Chiba Rehabilitation Center, withcognitive impairment after traumatic brain injury and were cor-related with Wechsler Adult Intelligence Scale-Revised (WAIS-R) and Wechsler Memory Scale-Revised (WMS-R). Results: TheRBANS generally demonstrated high correlations, especiallywith WMS-R (in Pearson correlation coefficients, full-scoreRBANS:full-score WMS-R 0.866,* full-scale IQ of WMS-R 0.644,*immediately memory RBANS:general memory WMS-R 0.833,*visuospatial/constructional RBANS:visual memory WMS-R0.638,* language RBANS:full-scale WMS-R 0.713,* languagememory WMS-R 0.653,* verbal IQ of WAIS-R 0.426,** attentionRBANS: performance IQ of WAIS-R 0.604,* Delayed MemoryRBANS: delayed memory WMS-R 0.770*; *P < 0.01,**P < 0.05).Conclusion: The RBANS can be a useful screening instrumentand prognostic indicator in cognitive impairment aftertraumatic brain injury in Japan.

P1-097 Compilation and Research on the ChineseComputer Software of Loewenstein OccupationalTherapy Cognitive Assessment (LOTCA)

J. Z. Fan, K. Yu, S. G. Zhang, L. Xue, and J. H. ZhangNan Fang Hospital., Southen Medical University,China

Background: To develop the LOTCA original test tool to aChinese computer software test system. Methods: The projectwas aiming at 1) compiling a Chinese version of the softwareLOTCA and provision of a platform to communicate with thecomputer among people during the assessment of cognition, 2)examining the reliability and validity of the LOTCA computersoftware in Chinese and 3) building up the cognition data ofChinese patients with brain diseases to offer the technical sup-port for future clinical research. The work had been done on



compilation of the software, debugging of the software in 19 pa-tients with brain disease or injury and studying the reliabilityand validity of the software. Results: The total scoring of com-puter version and original version had high correlation (r =0.970, P < 0.01). The 2nd examination of criteria validityshowed that not only the total scoring but also the scoring of allitems had the high correlation r = 0.608 0.983, (P < 0.01).Wilcoxon signed rank test showed that there was no significantdifference among every items of scoring between the 2 versiontest (Z = 0.227–1.807, P > 0.05). Conclusion: The Chinese com-puter software of LOTCA, which had been compiled in this re-search, had satisfied retesting reliability, criteria validity, anddiscriminated validity in Chinese patients with brain injury andcerebrovascular disease.

P1-098 Low Awareness States—DiagnosticDilemmas and Resolutions

D. A. H. Badwan, C. Pavlou, and T. P. A. RasheedRoyal Leamington Spa Rehabilitation Hospital,United Kingdom

Background: Disturbance in the level of consciousness as aresult of acquired brain injury is a diagnostic dilemma for manypracticing clinicians. The implications of a clear diagnosis of thelevel of awareness cannot be overestimated. Despite the prog-ress in medical science, ethical considerations remain problem-atic, and a method of assessment that is reliable and validatedneeds to be established. Methods: A multidisciplinary approachremains the main stay in achieving such diagnosis. Sensory mo-dalities assessment programs are used as a tool in establishingsuch diagnosis. Different assessment tools including coma-awakening programs, have failed to demonstrate a clear evi-dence for the usefulness of such programs. It is argued in this ar-ticle that the research methodologies used in some studies inthis field are unlikely to reveal such evidence. Results: In ourhospital, coma-arousal programs have been in use for morethan 10 years. The program used is described, its evaluation andoutcomes noted, and tools used described. The need for univer-sally accepted tools in these assessments and for collaborativemulticenter research is emphasized. Clarification of the diag-nostic criteria of Vegetative and minimally conscious states isexpected to lead to a better clinical and ethical understanding.Conclusion: There is a need for further clarification of otherclinical states that fall within the spectrum of low-awarenessstates. A classification based on neurobehavioral observation issuggested.

P1-099 Comprehension of Idioms in Peoplewith Schizophrenia

I. Yamazaki,1 C. Yamada,2 and H. Shimizu1

1Graduate School of Health Sciences, HiroshimaUniversity, Japan; 2Hayakawa Clinic, Japan

Background: Language disturbance is one of the majorproblems in people with schizophrenia. One of the essentialfacets of language competence is to comprehend figurative lan-guages. One type of figurative expressions in everyday settingsis idioms. Failure to grasp the meanings of idioms can impingeon a person’s understanding of language in many social set-tings. Because idioms are abundant in a language, arbitrary se-lection of idioms as experimental materials is not preferable forthe study on the comprehension of idioms. In this study, we in-vestigated the comprehension of idioms in people with schizo-

phrenia by tasks containing relatively many idioms. Methods: 10male subjects with schizophrenia were tested on 2 kinds of id-iom tests; multiple-choice task (choose 1 of 5 words to make thesentence complete with idiomatic expression, 338 idioms) andcompletion task (write down a word to make the sentencemeaningful with idiomatic expression, 278 idioms). Results: Re-sults on the multiple-choice task are better than those on thecompletion task in all participants. Some (near-) significant cor-relations were observed between task results and some charac-teristics of the subjects. Conclusion: The multiple-choice taskmay require less lexicalization than the completion task. Gen-eral language ability is well correlated with idiom comprehen-sion, which may indicate the nonspecific processing of idioms.Idioms could be taught for people with schizophrenia, whichenables them to use language more fluently and to participate indaily life.

P1-100 The Assessment of Driving Ability inPatients with Stroke

S. Domoto1 and H. Shimizu2

1Health Sciences, Faculty of Medicine, Departmentof Hiroshima University School of Medicine, Japan;2Health Sciences, Faculty of Medicine, HiroshimaUniversity School of Medicine, Japan

Background: To explore the present status of automobileoperation ability of CVA patients and to identify an evaluationmethod, interviews with several organizations such as the Driv-ing License Center, and research on related studies were made.It became clear that there was no sufficient evaluation of drivingability of these patients. Then, this study investigated whethersome certain cut-off value, which could judge CVA patients’driving ability deviated from the healthy persons’ driving skill,could be created and what kind of evaluation methods could beapplicable to predict their driving abilities. Methods: We hadpersonal interviews and cognitive assessments on 17 CVA pa-tients who were discharged home and could walk. Also, drivingaptitude diagnosis of driving was performed at the AutomobileDriving Assessment Center. Results: The cut-off value was cal-culated from the 27 355 healthy persons’ data of aptitude diag-nosis scores. Using it, we classified the CVA patients into thesafety group and the nonsafety group. As a result of the cogni-tive assessments, significant differences were recognized inMMSE, Kohs IQ, TMT-A, and TMT-B between 2 groups. In addi-tion to these, there was strong correlation between those test re-sults and the accident frequency. Conclusion: The CVA patient’sdriving ability was clarified by aptitude diagnosis of drivingunited nationally. It was able to distinguish those who can drivesafely from those who are nonsafe. Also, it can be stated thatMMSE, Kohs IQ, and TMT-A and B are effective to predictdriving ability.

P1-101 Neural Activity Associated with ImpulseControl Problems after Severe Head Injury:A fMRI Study

K. S. L. Yuen,1 A. M. K. Mak,2 K. N. Hung,3 G. Li,4

and L. S. W. Li51Institute of Clinical Neuropsychology, University ofHong Kong & MacLehose Medical RehabilitationCentre, Hong Kong; 2Neuropsychology Laboratory,Department of Psychology, University of HongKong, Hong Kong; 3Department of Neurosurgery,



Queen Mary Hospital, Hong Kong; 4Jockey ClubMagnetic Resonance Imaging Centre, University ofHong Kong, Hong Kong; 5Department of Medicine,the University of Hong Kong, Hong Kong

Background: Long-term cognitive dysfunctions were ob-served in patients with severe head injuries. Recently, 2 patientsreported emerging problems in impulse control in their dailyliving. They reported a strong impulse to collect trivial objectsfrom the street. To understand the underlying neural correlatesof such impulse, we conducted the current study to address thequestion. Methods: We employed functional magnetic reso-nance imaging (fMRI) technique to investigate the brain activi-ties associated with the impulse of collecting behavior. Duringscanning, the subjects were presented with photos of a range ofdaily objects and were asked to indicate via button presswhether they will pick up the object if they saw the object on thestreet. Contrasting the neural activation between picking versusnonpicking items, the patients were compared with matchedheal thy controls. Results : Behavioral inventory andneuropsychologic data showed that the patients were signifi-cantly more impulsive than the healthy controls. On the experi-mental task, the patients’ choice of objects was similar to thosechosen by healthy controls. Comparing the patients and healthycontrols, differential pattern of neural activations in theprefrontal cortex was observed. Conclusion: As the choices be-tween the patients and the healthy controls were not signifi-cantly different, the differential pattern of neural activationsmight be related to the different level of impulsivity. The neuralnetwork associated with impulse control was further discussed.

P1-102 Neuropsychological Costs and Benefits inParkinson Patients after 6 Months and 1 Yearfrom DBS Treatment

M. F. Possa, S. Lalli, M. Cursi,G. C. Comi, M. A. VolontèUniversity Vita-Salute Scientific Institute SanRaffaele Hospital, Italy

Background: Cognitive impairment in patients with Parkin-son’s disease (PD) is reported and can vary from a mild frontalexecutive dysfunction to dementia, resulting from the progres-sive dopamine deficiency that disrupts the functional integrityof frontostriatal circuitry. Bilateral chronic deep brain stimula-tion (DBS) has emerged as an appropriate therapy for advancedPD patients, but this procedure, aimed at targets within this cir-cuitry, can further influence the cognitive function. Methods:We studied the neuropsychologic profile of 13 patients with PDthat underwent DBS treatment (mean age = 59.4 ± 8.4; mean ed-ucation= 10.5 ± 4.4) with an extensive cognitive evaluation be-fore, after 6 months, and (8 patients) 1 year from theneurosurgical intervention. The battery of test was composed toexamine general cognitive functioning, verbal memory, atten-tion, executive function and reasoning, and verbal abilities. Re-sults: Examining the overall group results, the significant out-come is the reduction at a 6-month interval of phonemic verbalfluency (P = 0.05) and a trend to significant of the worseningshowed at Stroop test. The efficiency of the remaining cognitivefunctions remains stable, except a trend to improvement (P =0.0625) in the verbal memory at the 1-year follow-up. Conclu-sion: The DBS treatment seems to be a cognitive safe procedure,although reduced phonemic verbal fluency and a trend to mildfrontal executive dysfunction may occur. Our group of patients

has to be enlarged to monitoring the meaning of the resultsobtained.

P1-103 When is Vegetative Not Really Vegetative?A Single Case Study

J. Tierney, M. Darcy, and J. MackeyPrivate Practice, Australia

Background: The vegetative state (VS) is defined as a stateof arousal without behavioral evidence of awareness of self orcapacity to interact with the environment. We would like topresent a case of a 56-year-old man who had sustained ananoxic brain injury secondary to cardiac arrest at age 43 years.He was diagnosed by multiple physicians as being in a vegeta-tive state during a 13-year period. Methods: Initial assessmentswere undertaken using the Disability Rating Scale (DRS), Wes-sex Head Injury Matrix (WHIM), and the Abbey Pain Scale. Ca-nadian Occupational Performance Measure (COPM) was ad-ministered to identify specific goals for client-centeredinterventions. His family identified comfort in all personal careas the primary goal for intervention. The Disability Rating Scale(DRS), Wessex Head Injury Matrix (WHIM), and the Abbey PainScale were readministered after a 12-month period of interven-tion. Results: Both DRS and WHIM scores improved after the in-tervention period. Pain scores significantly reduced. DRS ratingimproved from vegetative to severe disability range. Conclu-sion: When diagnosed as being in a vegetative state, and there-fore by definition not aware of pain and discomfort, responsesto pain may be misinterpreted as reflex responses in keepingwith the diagnosis of VS. By identifying the presence of painand discomfort and applying client-centered interventionsmore than 13 years postinjury, this man was enabled to interactwith his environment and family in a meaningful way.

P1-104 Diffuse Cerebral Fat Embolism CausingComa—Rehabilitation and Recovery

N. Chater, S. Khetan, R. Thomas, and L. GrahamHunters Moor, United Kingdom

Background: Recovery from unconscious states due to cere-bral pathology depends to a degree on the cause of the insult.We presented the progress of a case in which the cause was un-usual and the initial prognosis was felt to be poor. Early rehabil-itation involvement allowed proactive multidisciplinary assess-ment and treatment of subsequent clinical problems. Methods:An 18-year-old equestrian suffered bilateral femoral shaft frac-tures and remained unconscious postfixation. MRI showed mul-tiple cerebral fat emboli, and an initial poor prognosis was sug-gested on the basis of lack of visual tracking and no response topainful stimuli. Initial rehabilitation assessment revealed shecould focus on speech for a few seconds, grimace to painfulstimuli, and exhibit nonpurposeful movements of the left side.By 6 weeks, appropriate facial expressions and nonverbal inter-actions were observed. Results: Multidisciplinary assessment at12 weeks revealed a good physical recovery. However,neuropyschologic testing revealed concentration andattentional deficits, visual scanning abnormalities, executivedysfunction, memory deficits with borderline new learning andrecall, and low scores on tests of working memory, perceptualorganization, and processing speed. Rehabilitation focused onthe impact of these issues on activities of daily living, social re-in tegra t ion , and voca t iona l i s sues . Conclus ion :Multidisciplinary assessment allowed high-level cognitive



problems to be identified and addressed, allowing successfulcommunity reintegration.

P1-105 Long-term Psychological Adjustment afterAcquired Brain Impairment: A FrameworkIntegrating Biopsychosocial and NeurocognitiveFactors

A. K. Y. MakMacLehose Medical Rehabilitation Center,Hong Kong

Background: The patient’s psychologic adjustment to achronic illness is determined by various biopsychosocial fac-tors. For patients with acquired brain impairment, the presenceof cognitive deficits also plays important direct and indirectroles in the adjustment process. This study investigated theprevalence of depression in patients with acquired brain im-pairments and examined the psychologic or cognitive factorsassociated with the psychologic outcomes. Methods: Patientssustained head injury or stroke after discharged from hospital 1year or more were recruited. Beck Depression Inventory (BDI)and State-trait Anxiety Inventory (STAI) were used to examinethe patient’s psychologic outcomes. Color Trial Test (CTT), Testof Nonverbal Reasoning-III (TONI-III), and Wisconsin CardSorting Test (WCST) were administered to tap into theirneuropsychologic status. Questionnaires tapping into their cop-ing, perception of illness, social support, and number of lifestressors were used to examine the psychosocial factors. Re-sults: The prevalence of depression was compatible with previ-ous studies. Depression was associated with less active coping,poorer physical function, more executive dysfunction, the per-ception of lower treatment controls, and more life stressors butnot associated with estimated intelligence and social support.Conclusion: A framework understanding the psychologic ad-justment of patient with acquired brain impairment is proposedand discussed.

P1-106 Psychological Adjustment of Caregiver forPatient with acquired Brain Impairment: AFramework Integrating Psychosocial andNeurocognitive Factors

A. K. Y. MakMacLehose Medical Rehabilitation Center, HongKong

Background: Caring patients with permanent physical andcognitive deficits are enduringly distressing. The patient’s phys-ical and cognitive status, the caregiver’s own personal stylesand resources are interplayed in affecting the caregiver’s adjust-ment to the patient’s impairments. This paper investigated theinterrelationship of the patient’s and the caregiver’s factors inaffecting the caregiver’s adjustment process. Methods: Care-givers of patients with sustained head injury or stroke dis-charged from hospital 1 year or more were recruited. Patient’scognitive status was assessed by Color Trial Test, Test of Non-verbal Reasoning-III and Wisconsin Card Sorting Test. Beck De-pression Inventory (BDI) and State-trait Anxiety Inventory(STAI) were used to measure patient’s psychologic status. BriefSymptom Inventory (BSI) was used to assess the caregiver’spsychologic status. Questionnaires tapping into caregiver’sown coping, family relationship, social support, and number oflife stressors were administered to examine other psychosocial

aspects of the caregiver. Results: The caregiver’s psychologichealth was more associated with the patient’s cognitive and psy-chologic factors rather than their own psychosocial factors.Conclusion: A framework understanding the psychologic ad-justment of caregiver for patient with acquired brain impair-ment is proposed and discussed.


P2-001 The Influence on Chinese Reading Causedby Unilateral Visual Neglect

X. T. Wang and Y. LinThe Second Affiliated Hospital of Wenzhou MedicalCollege, China

Background: Chinese had its own characters of recognitionprocess. The contrast research of the influences on Chinesereading caused by right hemispheric (RH) lesion, especiallywith unilateral visual neglect, has not been carried out in ourcountry yet. Methods: The investigation objectives were dividedinto 4 groups: 1) RH-1 group: the lesion of RH with the unilat-eral visual neglect. 2) RH-2 group: the lesion of RH without theunilateral visual neglect. 3) LH group: the lesion of left hemi-sphere. 4) N group: the normal. Every group had 10 persons. Allobjectives were checked by neuropsychologic methods. All ob-jectives were tested with CT or MRT to determine the focal loca-tions. Results: 1) There was no significant difference incharacter-matching-character, whereas there was significantdifference in character-word reading and character-matching-picture in 4 groups. 2) There was significant difference in simi-lar form reading disabilities, similar sound reading disabilities,similar semantic reading errors, and no correlation reading er-rors. Comparison in 2 groups showed that much more similarform reading disabilities appeared in RH-1 and RH-2 group thanin other groups, whereas much more similar sound reading dis-abilities and similar semantic reading errors appeared in RH-1than the other 3 groups, which had significant difference. Con-clusion: RH lesion causes the reading disabilities at the level ofcharacter, among which the errors of similar form reading arethe majority.

P2-002 Relation between Level of Consciousnessand Dysphagic Problems in Patients with SevereBrain Injury

M. Lovstad, S. Undseth, A. K. Schanke, J. Berstad,and S. ChristensenSunnaas Rehabilitation Hospital, Norway

Background: The aim of the study was to explore the associ-ation between level of consciousness and dysphagia and to as-sess whether feeding regime is dependent on the level ofdysphagic problems only or also on the level of cognitive func-tioning. Methods: Level of consciousness of 38 patients was as-sessed with Coma Recovery Scale (CRS) and dysphagia with ascreening instrument containing questions of biting and suck-ing reflex, oral hygiene, oral hyper- or hyposensitivity, gurglyvoice and secretions, and drooling and coughing. Results: Nocorrelation was found between the patients’ age, sex, durationof illness, or diagnosis and total score on CRS or dysphagiascreening score. CRS score did not correlate with dysphagiascore. Three subscales of CRS correlated with dysphagia score



and feeding regime; the oromotor/verbal, the communicationand the arousal subscales. Mean age was 33.8 years. Two per-sons had cerebral hemorrhage, 6 subarachnoid hemorrhage, 16cerebral contusion, 11 anoxia, and 3 others. Mean duration ofillness was 18.5 months. Mean score on CRS was 14.7 (max. 25).Conclusion: The results suggest that CRS and the dysphagiascreening instrument measure different functions. Accordingly,decision on type of feeding regime should be based on evalua-tion of both cognitive function and dysphagia. The associationbetween feeding regime and the oromotor/verbal and commu-nication scales of the CRS might be expected on anatomicalgrounds. The results also imply that severely underactivated pa-tients have more severe dysphagic problems.

P2-003 Biomechanical Performance ofOrthosis-Only, Hybrid FES/Orthosis, andImplant-Assisted Gait in Paraplegia

J. W. Middleton,1 R. M. Smith,2 G. M. Davis,3 B. T.Smith,4 and T. E. Johnson5

1The Univeristy of Sydney, Australia; 2The Univeristyof Sydney, Australia; 3The Univeristy of Sydney,Australia; 4Shriners Hospital Philadelphia, USA;5Shriners Hospital Philadelphia, USA

Background: Persons with motor-complete paraplegia of-ten wish to achieve upright mobility and minimize effects of im-mobility and deconditioning from wheelchair dependence.Methods: Informed consent was obtained from males with T3-T9 (ASIA A) paraplegia. Two subjects were assessed in theMoorong Medial Linkage Orthosis with fixed-knee versus FES-activated “free knee” gait using a computer-controlledneuromuscular stimulator; 2 using a surface-FES system (stimu-lating a flexion withdrawal reflex, quadriceps and gluteal mus-cles), and 2 subjects using Praxis24 system with surgically-im-planted electrodes to 9 leg muscles. Biomechanicalperformance was assessed using 3-D video and force data re-corded as subjects ambulated in a gait laboratory with instru-mented walking aids. Results: Stride length, gait velocity, andwalking distance were increased by ~20% during FES-assistedfixed-knee orthotic gait. Restriction of knee and ankle motioninterfered with exchange mechanisms between potential andkinetic energy. Conclusion: FES-assisted fixed-knee orthoticgait yielded extra propulsive force compared to orthosis-onlywalking, primarily through activation of stance leg hip exten-sors, reducing upper body effort and overall energy expendi-ture. The hypothesis that gait efficiency will be further im-proved by restoring knee motion is currently being tested in oursurface and implanted-FES subjects.

P2-004 The Comparison of Quality of Life in LowVision with Blind and Near Blind Children

S. Atasavun,1 T. Düger,1 E. Aki,1 A. Turan,2

and H. Kayihan1

1Hacettepe University Physical Therapy andRehabilitation School, Turkey; 2Ankara NumuneEducation and Research Hospital 3rd Eye Clinic,Turkey

Background: This study was planned to compare the qualityof life in low vision, blind and near-blind children. We aimed todetermine which parameters of quality of life were affected.Methods: This study included 42 low vision and 30 totally blind

or near-blind children whose ages were between 7 and 14years. All children were going to blind and visually impairedschool. The level of vision was evaluated by an ophthalmolo-gist. All children were assessed by Low Vision Quality of LifeQuestionnaire (LVQOL). Results: Mann-Whitney U Test wasused to compare results of LVQOL. The results of test scoreswere found to be statistically significant in distance vision-mo-bility-lighting (z = –5.93, P < 0.01), reading fine work (z = –4.77,P < 0.01) and total point (z =–5.65, P < 0.01). No statistical signif-icance was found between groups in the scores of activities ofdaily living (z = –1.38, P > 0.05), and adjustment (z = –0.83, P >0.05). Conclusion: There was no statistically significant differ-ence between the groups in daily living activities subtest be-cause that subtest was evaluating abilities like reading, writing,and eating that all children must practice routinely and inde-pendently to carry on life in their school. In spite of being visu-ally impaired, they were happy in their life so that we could notfind any difference in the adjustment subtests. Low-vision chil-dren used residual vision so that their quality of life scores werebetter than blind and near-blind children. LVQOL test is an easyand useful test for low-vision children. We modified it for blindchildren.

P2-006 Activating Severely Injured Patients withPassive Leg Movements on A Tilt Table

F. Müller, M. Luther, B. Husemann, S. Heller,and E. KoenigNeurologische Klinik Bad Aibling, Germany

Background: Verticalization is a major rehabilitation mea-sure in patients with severe brain injury or complete spinal le-sion. When positioning patients in a tilt table, autonomic prob-lems, such as a drop in blood pressure, are often observed. Thecombination of a tilt table with a stepping device (tilt stepper)allows to stabilize autonomic function and begin with locomo-tor activities in early phases of rehabilitation. Methods: We useda tilt stepper to mobilize patients in vegetative or minimally re-sponsive state due to a traumatic brain injury or serious vascularaccident. Blood pressure readings, heart rate, and oxygen satu-ration were measured before start of verticalization and at de-fined angular positions. In addition, ratings of head posturingand muscular tone were performed. Results: Patients toleratedthis intervention well. Vertical position could be maintained ap-proximately 15 minutes. Blood pressure showed a tendency toincrease during the exercise; only in rare circumstances, a non-critical decrease was observed. Selected patients showed amore active state during or after the intervention. Conclusion: Atilt stepper is a promising tool for early phases of rehabilitationin severely injured patients. In spinal cord injuries, our observa-tions already indicate a need to use this tool for patients with au-tonomic dysfunction during tilt-table exercise. Patients with ce-rebral lesions probably will profit accordingly. Further studiesare needed to quantify the effects on cerebral activation andprevention of contractures.

P2-007 The Impact of Acute Traumatic BrainInjury (TBI) on Endogenous Sex Hormone Levels

I. J. Baguley,1 S. Slewa-Younan,1 R. E. Heriseanu,2 C.D. Rea,3 and I. D. Cameron1

1Department of Rehabilitation Medicine, Faculty ofMedicine, University of Sydney, 2006, Australia;2Brain Injury Rehabilitation Service, Westmead



Hospital, Wentworthville, NSW, 2145, Australia;3Prince of Wales Medical Research Institute,University of New South Wales, 2052, Australia

Background: Arising out of the current understanding ofboth stark and subtle physiologic differences that exist betweenmen and women, sex hormones, namely progesterone, are be-ing heralded as a potential key to elucidating the complicationsthat arise after TBI. Forming part of a large prospective investi-gation of recovery after acute TBI, this study aimed to providethe 1st human data on the effect of TBI on sex hormones in anacute time period (24 h and 7 d from the time of injury [TOI]).Methods: All patients admitted to 1 of 5 intensive care units inmetropolitan Sydney for treatment of nonpenetrating TBI wereassessed for the study criteria. The person responsible for thepatient was approached for consent. Up to 30 August 2005, 20females and 50 males were recruited into the study. Blood sam-ples were taken at days 1 and 7 to examine levels of progester-one, oestradiol, luteinizing hormone, and follicle-stimulatinghormone in the females and testosterone only in the males.Measures of injury severity and outcome were also recorded.Results: Analysis of blood samples revealed that at day 7 fromTOI, levels had dropped to nondetectable ranges for each sexhormone assayed. This is in sharp contrast to normal ranges ofsex hormones found when assayed within 24 hours from TOI.Conclusion: The clinical significance of our study’s finding is ofimportance, given the recent completion of the 1st human trialof progesterone as a treatment for TBI in the USA. Furtherresults will also be discussed.

P2-008 Near-Infrared Spectroscopy Measurementof Cerebral Oxygenation Changes in HealthySubjects during Walking with the Walking-AssistRobot

K. Hachisuka, S. Saeki, F. Wada, T. Okazaki,and K. MakinoUniversity of Occupational and EnvironmentalHealth, Japan

Background: Askawa Electric Corporation developed a pro-totype walking-assist robot in 2002, consisted of trunk sup-porter, power generator, and operating arms that hold patients’lower extremities and simulates walking, control unit, andtreadmill, with the support of the New Energy and IndustrialTechnology Development Organization (Japan). The walking-assist robot provides active, active-assistive, and passive modesfor gait training, but it is not clear whether the training mode hasany effect on brain activation during walking with the walking-assist robot. Therefore, we performed near-infrared spectros-copy measurement of cerebral oxygenation changes in healthysubjects during walking with the walking-assist robot. Methods:Subjects were 7 healthy men, who were asked to walk with thewalking-assist robot in active, active-assistive, and passivemodes. Cerebral oxygenation changes were measured with anear-infrared spectroscopy (ETG-100, Photo Topography,Hitachi Medico, Japan), according to the following procedure.Twenty-two sensors were placed over the frontal and temporalareas with measurement consisting of standing for 30 s, gaitwith the walking-assist robot for 60 s and standing for 30 s,which was repeated 3 times on each training mode. Results: Ac-tive-assistive gait training increased oxyhemoglobin in thepremotor area compared with passive mode. Conclusion: Gaittraining with more intentional factors may activate cerebralfunction during gait training with the walking-assist robot.

P2-009 The Essen-Reha-Score: An Instrumentto Measure Outcome and Expenditure ofNeurologic Rehabilitation

A. F. Thilmann,1 A. Nachtmann,2 and A. Scharff11Fachklinik Rhein/Ruhr, Germany; 2HKZRotenburg, Germany

Background: Scores currently used in neurologic rehabilita-tion are fast and valid, but their range is often inadequate to de-scribe the majority of patients, for example, because of a ceilingeffect. We developed a partly new measurement instrument tocombine common scores with parameters of rehabilitation ef-forts; the latter being a control instrument for medical profes-sionals and health insurances. Methods: The Essen-Reha-Score(ERS) contains 7 groups with altogether 61 items including the10 Barthel-Index items. These groups are ADL (13), mobility(8), communication and social skills (7), arm and hand function(7), orientation and cognition skills (10), strength and pain (8),and coping and miscellaneous (8). We investigated 8139 pa-tients and determined Barthel-Index and ERS. Results: Mean agewas 62.9 years, 43.5% were females. The Barthel-Index was onaverage 71.2 points (range, 0-100 points), the ERS was on aver-age 427.8 points (range, 0-600 points). The interrater reliabilityshowed a mean kappa of 0.86 (range, 0.62-0,98). Conclusion:The Essen-Reha-Score has shown to be an effective instrumentfor the evaluation of outcome and expenditure in neurologic re-habilitation. Interrater-reliability, validity and responsivity werebetter than in the Barthel-Index. Also the ceiling effect is lessthen 1% compared to 17% in the Barthel-Index. The great ad-vantage of the Essen-Score compared to others is that the pa-tient is not only assessed in its situation but also in the status ofits environment.

P2-010 Expression of the Axonal GuidanceMolecules Netrin and Semaphorins duringAxonal Regeneration after Spinal Cord Injury inLamprey

M. E. Selzer and M. I. ShifmanUniversity of Pennsylvania School of Medicine, USA

Background: Unlike mammals, lampreys recover from spi-nal transection, and axons regenerate selectively in their correctpaths. We wish to know whether this involves developmentalguidance molecules, such as netrins and semaphorins. Methods:The effect of spinal transection on expression of mRNAs forlamprey netrin and the semaphorins Sema 3 and Sema 4, was as-sessed by in situ hybridization. Results: Control lampreys con-tained netrin-expressing neurons and glial cells along thelength of the spinal cord. After spinal transection, netrin expres-sion was decreased in neurons 0 to 5 mm from the transection at2 to 4 weeks. By 4 weeks, netrin mRNA was absent in neuronsbut increased in glia greater than 1 cm caudal to the lesion.Sema 3 expression was minimal in control spinal cords in-creased in gray matter close to the lesion by 4 weeksposttransection. The pattern of Sema 4 expression was similarto that of netrin in control animals and was not significantlychanged by transection. Conclusion: Semaphorins are generallyinhibitory to axon growth. Our previous data suggested that spi-nal cord transection causes upregulation of the chemorepulsivenetrin receptor UNC-5 in poorly regenerating neurons. Thus,the net effect of netrin would be inhibitory to axon regenera-tion. The downregulation of netrin and Sema 3 near the lesionand their upregulation distal to it correlates with distances of re-



generation observed in lamprey reticulospinal axons and sug-gest a role for netrin and semaphorins in restricting axonregeneration. (NIH grant NS38537)

P2-011 Effects of Hyperbaric Oxygen onExpression of Nuclear Factor-Kappa B andIntercellular Adhesion Molecule-1 in Ratswith Cerebral Ischemia-Reperfusion

X. Jiang and X. HuangTonji Medical College, HuaZhong University ofScience and Technology, China

Background: The nuclear transcription factor-kappa B (NF-κB) and inflammatory cytokines, including intercellular adhe-sion molecule-1 (ICAM-1), play significant roles in inflamma-tory responses that exacerbate tissue injury during acuteischemic stroke. We evaluated the effect of hyperbaric oxygen(HBO) on functional and anatomical outcomes, as well as theexpression of NF-κB and ICAM-1 after transient focal cerebralischemia in rats. Methods: The middle cerebral artery occlusion-reperfusion (MCAO) model was achieved using theintraluminal filament method in rats. SD rats (n = 72) were ran-domly divided into 3 groups: cerebral ischemia group, ischemia+ HBO treatment group, and sham-operation group. HBO treat-ment (2.5 ATA) was applied at 3 h after reperfusion. The infarctvolume was measured by 2, 3, 7-triphenyltetrazolium chloridestaining. Neurologic outcome and the expression of NF-κB andICAM-1 were determined at 24 h, 48 h, 72 h, and 120 h, respec-tively, after reperfusion. Results: HBO-treated rats had betterneurologic outcomes and smaller infarct volume thannontreatment rats. Immunohistochemistry staining showed thatcerebral ischemia produced a statistically significant increase ofNF-κB and ICAM-1 expressions. Compared with the ischemiagroup, the expression of NF-κB and ICAM-1 in HBO group wassignificantly lower. Conclusion: These results confirm theneuroprotective effects of HBO in cerebral ischemia-reperfusion injury and suggest that the mechanism of this actionmay involve inhibition of expression of NF-κB and ICAM-1.

P2-012 The Electrical Acupoint Stimulation CouldAffect Brain Excitability in Human

H. Y. Jung,1 Y. H. Sohn,2 and M. Hallett11Inha University College of Medicine, South Korea;2Human Motor Control Section, NINDS, NIH, USA

Background: There are numerous reports about the effectsof electrical acupuncture in stroke rehabilitation. However,many results are still controversial and also not valid. The pur-pose of this study is to elucidate the effects of electrical acu-puncture on cortical excitability in human by transcranial mag-netic stimulation (TMS). Methods: 10 healthy volunteers wereenrolled. Acupoint and sham point stimulations were adminis-tered through adhesive surface electrodes for 60 min each.Stroke-related acupoints (right LI-4, LI-10) were located on theextensor surface of forearm and hand; and the ipsilateral 2 shampoints, on the middle and distal portion of the extensor forearm.The cortical excitability test by TMS recorded at right 1st dorsalinterossei and abductor pollicis brevis muscles was assessed be-fore and after the electrical acupoint stimulations and both werecompared to electrical sham stimulation. Results: The resultsshowed no significant difference between before and after elec-trical acupoint and sham point stimulation including the stimu-lation intensity, rMT, ICI, ICF, and silent period. However, in

140% and 160% rMT, recruitment curves recorded at the FDI andAPB muscles were significantly increased after acupoint stimu-lation but not after sham point stimulation. Conclusion: Theabove findings suggest that the electrical acupuncture could af-fect the cortical excitability via the recruitment of some neuronsnear the cortical representation area for the target handmuscles.

P2-013 Time Dependency of WalkingClassification in Stroke

B. J. Kollen,1 G. Kwakkel,2 and E. Lindeman3

1Research Bureau, Isala Clinics, Zwolle, TheNetherlands; 2Department of Rehabilitation of VrijeUniversiteit Medical Centre, Amsterdam, TheNetherlands; 3Rehabilitation Centre “DeHoogstraat”, Rudolf Magnus Institute ofNeuroscience, UMC Utrecht, The Netherlands

Background: To study the longitudinal relationship be-tween comfortable walking speed and Functional AmbulationCategories scores for physically independent gait. Methods:Prospective cohort study with 73 acute severely affected strokepatients. Measurements were taken weekly (1st 10 weeks), bi-weekly (subsequent 10 weeks), and at 26 weeks poststroke. De-pendent variable: 10 meter comfortable walking speed. Inde-pendent variable: FAC scores 3, 4, and 5. Covariable: poststroketime of measurement. Results: Responsiveness ratios based on a10 percent MCID by far exceeded the 1.96 margin. Paired stu-dent t tests revealed mostly significant pretest-posttest differ-ences in walking speeds and kappas for pretest-posttest FACscores were all significant. All linear regression coefficients forthe relationship between comfortable walking speed and FACscores were significant. Random coefficient analysis demon-strated a significant between- and within-subject coefficientand a significant negative interaction between time of measure-ment and FAC scores. Conclusion: Comfortable walking speedmeasurements are sensitive and capable of detecting poststrokechanges in independent gait in this severely affected strokepopulation. In addition, the classification of walking abilitybased on FAC scores is dependent on the time of poststrokecomfortable walking speed measurement. Moreover, there areindications that in this relationship, repeated FAC appraisalsgradually shift over time from higher to lower speeds.

P2-014 Functional Outcome of Stroke in theYoung Patients

J. A. P. Mojica and C. A. Jerez-CortezUniversity of the Philippines Manila, Philippines

Background: Because of the growing concern for stroke inthe young, this study was done to determine functional out-comes among patients seen at the outpatient clinic of the De-partment of Rehabilitation Medicine, Philippine General Hospi-tal. Methods: 22 young poststroke patients who satisfied theinclusion criteria participated in this prospective study usingpurposive sampling. The patients were evaluated using the In-stitute of Rehabilitation and Restorative Care—Long RangeEvaluation System. The scores were analyzed using paired ttest, repeated measures ANOVA, and linear regression at 95%confidence level. Results: Results showed significant changesacross time in all variables: communication, motor function ofthe affected extremity, the unaffected extremity, proficiency inself-care activities, family and social clusters, resources, out-



look in life, and work status. Family cluster, resources, and themotor function of the affected extremity significantly affectedthe functional outcome. Conclusion: The present study sug-gests that it is not the improvement in motor recovery alone butalso increased psychosocial support that determine functionaloutcome for young poststroke patients.

P2-015 Golfing with a Right Hemiplegia:A Video Analysis

A. Wilquin-Yatsimirski,1 V. Tiffreau,1 N. Fourrier,2

and A. Thevenon1

1MPR Department, University Hospital, France;2Golf Lille Metropole, France

Background: A man of 54 years decided to learn golf 7 yearsafter the onset of a right hemiplegia. He has no motor control ofthe upper limb; spasticity was very high. There was a fixedequinus, so the man had to wear orthopaedic shoes. He couldwalk with a stick. Methods: The golf pro had to adapt the pa-tient’s swing to his impairment. The golf ball was hit only by a“fouette” of the left arm, without any rotation of the shoulders.The lines of the hips and the shoulders remain parallel to the di-rection of the shot. There was no weight transfer, two-third ofthe weight remained on the left foot all along the swing. Results:The man now plays for 5 years. He can throw the ball to morethan 100 m. He drives a golf cart. He still needs human assis-tance to tee or pick up the ball, as he is not skilful enough withhis left hand to use one of the special tools on the market de-signed to avoid bending when playing golf. He never playsalone, because he is afraid of a fall, as he cannot get up from theground alone. He is a pleasant partner. Conclusion: Golf isknown as a skill game, but even somebody with a major motorcontrol impairment can enjoy playing this sport.

P2-016 Advanced Leukoaraisosis as a Predictorfor Poor Functional Outcome after Rehabilitationin Patients with Lacunar Infarction

H. Naka,1 T. Takahashi,1 Y. Mimori,1 H. Kajikawa,1

and M. Masayasu2

1Suiseikai Kajikawa Hospital, Japan; 2HiroshimaUniversity, Graduate School of Biomedical Sciences,Japan

Background: Both lacunar infarction (LI) and leukoaraiosisare closely associated with small-artery disease. The effect ofleukoaraiosis on the outcome of LI patients is controversial. Theaim of this study was to determine whether the presence of ad-vanced leukoaraisosis is associated with functional outcome atdischarge after rehabilitation in LI patients with motor impair-ment. Methods: A total of 82 consecutive acute LI patients withmotor impairment were enrolled. Functional outcome at dis-charge after rehabilitation was evaluated by modified RankinScale (mRS) and Barthel Index (BI). Leukoaraiosis was evalu-ated on T2-weighted magnetic resonance images, and ad-vanced leukoaraiosis was defined as grade 2 or 3 by the scoringsystem of Fazekas and others. Results: Patients with advancedleukoaraiosis (n = 30) exhibited lower BI scores at dischargethan did those without advanced leukoaraiosis (n = 52) (mean,58.8 vs. 88.6, P = 0.0004). Poor outcome (mRS score 3 to 6) wasmore frequent in patients with advanced leukoaraiosis (73.3%)than in those without advanced leukoaraiosis (17.3%) (P <

0.0001). Frequencies of stroke recurrence or worsening of mo-tor impairment after admission were not different in the 2groups. Multivariate analysis revealed that advancedleukoaraiosis (odds ratio, 9.616; 95% CI, 1.976-46.809) was in-dependently associated with poor outcome. Conclusion: Pres-ence of advanced leukoaraiosis appears to be a predictor forpoor functional outcome after rehabilitation in LI patients withmotor impairment.

P2-017 When Should Rehabilitation Stop?Investigating When Older People Recoverfrom Stroke

J. M. Hammerton,1 S. J. Mawson,1 and P. Enderby2

1Sheffield Hallam University, United Kingdom;2Sheffield University, United Kingdom

Background: When to discharge a stroke patient from ther-apy is a difficult decision, influenced by staff resources andpressure of referrals. Evidence suggests that the key period ofrecovery is 12 weeks after stroke onset, and this is often a guide-line to discharge. The United Kingdom 2004 stroke sentinel au-dit showed that the mean length of hospital stay after stroke hasbeen reduced, and intensive rehabilitation in primary care islimited. This has reduced access to rehabilitation. This study in-vestigated the proportion of change in stroke patients’ disabilityduring a period of 6 months to review when they gained thegreatest proportion of change. Methods: In this prospective lon-gitudinal study, subjects were divided according to their age atstroke onset (under 65 years and over 65 years) and were as-sessed at the baseline, 6 weeks, 3 months, and 6 months. Pri-mary measures of disability were Barthel Index, RivermeadADL, and Therapy Outcome Measure. Change was calculatedfrom the baseline score and analysed using t test for propor-tions. Results: 48 subjects were under 65 years (mean, 56 years;range, 41-64 years; SD, 6.7 years), 54 subjects were over 65years (mean, 75 years; range, 66-88 years; SD, 5.7 years). Signifi-cant differences for proportion of change were found, with par-ticipants under 65 gaining more at 6 weeks and those over 65having greater change after 3 months. Conclusion: Older peo-ple take more time to consolidate and utilize learning function-ally. These results suggest that we may discharge older peopletoo soon from research and rehabilitation.

P2-018 Prevalence of Depression and ItsRelationships with Handicap, Self-esteem andSocial Support in Chinese Stroke Survivors

J. P. C. Chau,1 J. Woo,2 A. M. Chang,3 D. R. Thompson,4

and T. Kwok5

1Nethersole School of Nursing, Chinese University ofHong Kong, Hong Kong; 2School of Public Health,Chinese University of Hong Kong, Hong Kong;3Queensland Centre for Evidenced-based Nursingand Midwifery, Australia; 4Nethersole School ofNursing, Chinese University of Hong Kong, HongKong; 5Department of Medicine and Therapeutics,Chinese University of Hong Kong, Hong Kong

Background: A major challenge in stroke rehabilitation is tominimize psychologic morbidity to promote the reintegration ofstroke survivors into their family and community. The preva-



lence of depression among Chinese stroke survivors has beenfound to range from 17% to 63%, and a clear understanding ofthis and the factors influencing its outcome helps health careprofessionals plan effective interventions to minimize such psy-chologic consequences. Methods: This was a longitudinal studyand data were collected from 206 stroke survivors during a pe-riod of 6 months after their discharge from 2 rehabilitation hos-pitals. Data collection took place in either the patient’s home orother discharge destination such as old age home. The majorityof patients were male, married, and with a right-side stroke. Re-sults: At 6 months after discharge, 71 (35%) of patients screenedpositive for depression and was found to be significantly relatedto handicap (r = –.50), state self-esteem (r = –.75), social sup-port (r = –.62), and functional ability (r = –.30). Those who livedin an old age home were more likely to have mild to severe de-pression. Regression analysis indicated that handicap, state self-esteem, and social support were predictors of depression andaccounted for 63% of the variance. Conclusion: The resultshighlight the importance of assessing and attending to the psy-chologic sequelae of stroke to promote successful recovery.This investigation was supported by HK Health Care andPromotion Fund.

P2-019 Early Polyneuropathy in Diabetes:Concurrent Sensory and Motor Disturbances

J. W. G. Meijer,1 F. Lange,2 T. P. Links,3

and J. H. van der Hoeven2

1Rehabilitation Centre Tolbrug/Jeroen BoschHospital, ‘s-Hertogenbosch, the Netherlands;2Department of Neurology, University MedicalCenter Groningen, the Netherlands; 3Department ofEndocrinology, University Medical CenterGroningen, the Netherlands

Background: Diabetic polyneuropathy (PNP) is supposed tobe a primary disorder of sensory nerves, because at an earlystage motor nerve conduction velocity (MNCV) and musclestrength are preserved because of compensatory mechanisms(axonal sprouting, reinnervation). We evaluated the use of inva-sive muscle fiber conduction velocity (MFCV) measurement as amethod to detect muscle fiber denervation, as the 1st sign ofmotor dysfunction in diabetes mellitus (DM). Methods: Twelveselected male patients (8 type 1, 4 type 2; mean age, 35.8 ± 10.6y; mean duration DM, 10.0 ± 6.1 y), without any sign of micro- ormacroangiopathy, were studied by systematic clinical andneurophysiologic testing including MFCV estimation. Results:Handheld dynamometry was within the normal range in all sub-jects, in proximal as well as in distal muscle groups. NeedleEMG findings were abnormal in 1 patient (increase of MUP du-ration); there were no signs of recent denervation in any of thepatients. Sensory nerve conduction velocity (SNCV) was abnor-mal in 6 subjects. MFCV showed abnormal results in 6 subjects(5 also had low SNCV). The ratio of the fastest/slowest musclefibers in MFCV was correlated to the SNCV of the sural nerve(–0.59, P < 0.05) but not to the MNCV. Conclusion: Half of theclinically asymptomatic DM patients showed sensory involve-ment together with MFCV abnormalities, despite normal con-centric needle EMG and force. This finding shows that MFCV es-timation offers a highly sensitive method in detecting earlymotor dysfunction in DM.

P2-020 Stroke Subjects’ Conceptions aboutParticipating in a Constraint-Induced MovementTherapy Group: An Interview Study

A. Kusoffsky and G. BiguetKarolinska Institute, Sweden

Background: Constraint-induced movement therapy (CIMT)has showed promising training effects regarding the spontane-ous use of the paretic arm and hand in stroke subjects. How-ever, the participants’ response to CIMT has not been studieddeeply. The aim of the study was to explore and describe howstroke subjects perceive and respond to CIMT in a group. Meth-ods: 11 stroke subjects who had participated in a 2-week CIMTintervention were interviewed from a phenomenographic pointof view. The interviews were recorded and transcribed verbatimfor continued analysis. The focus in the phenomenographicmethod is to describe different ways of understanding a phe-nomenon. Results: All the informants stated that they used theirparetic hand more in everyday life. All of them expressed thatthe exercises were hard and intense and mostly positive experi-ences. In addition, 3 qualitatively different categories of percep-tions of CIMT could be created: 1) confrontation with ambiva-lence to CIMT, 2) the possibility to accept and adjust to reality,and 3) the possibility to obtain new personal insights, leading tothe individual person taking responsibility for continued train-ing, self-efficacy in goal setting, and the ability to look forward.Most informants were found in this last category. Conclusion: Ashort and intense training period in a group could be a source ofacceptance and motivation and facilitate responsibility for con-tinued training. This could contribute to the cost- effectivenessof CIMT in the long run.

P2-021 The Effect of a Balance Test and TrainingEquipment on Balance Function of StrokePatients

P. D. Zhang, C. H. Liu, Z. K. Pi, and X. W. PengThe First People’s Hospital of Foshan, China

Background: Falls are a significant problem among olderadults, especially in stroke patients. One of the primary reasonsis balance dysfunction. The purpose of this study was to studythe effect of a balance test and training equipment on balancefunction of stroke patients. Methods: 108 stroke patients thatcan stand independently were divided into treatment group (n= 68; male, 35; female, 33) and control group (n = 40; male, 23;female, 17). All patients were treated with routine medicationand physiotherapy; the treatment group was trained with PH-Abalance test and training equipment additionally. The patientswere assessed with Berg Balance Scale (BBS) and computerizedbalance performance monitor (BPM). The parameters of BPMwere distributing zone of center of gravity, sway index, andsway tract length and area; the patients were assessed twicewith eye opened and eye closed, respectively. Results: The BBSand BPM were improved significantly at the 2nd assessment inboth groups. The treatment group was better than the controlgroup (P < 0.05 ~ P < 0.01). There was no significant differencein the distributing zone of center of gravity at seat position aftertraining, but it was improved markedly at standing (P < 0.05 ~ P <0.001). Conclusion: Balance training with the balance test andtraining equipment is effective for stroke patients.



P2-022 The Stroke Rehabilitation PotentialScreening Test as a Stroke Outcome PredictingTool

Chulalongkorn University, Thailand

Background: An accurate assessment is important in orderto predict goals and execute planning in stroke rehabilitation.An ideal screening test should be user-friendly and not time-consuming. Methods: A prospective study was conducted from1 August 2004 to 31 July 2005 at Thai Red Cross rehabilitationcenter. A stroke rehabilitation potential screening test (SRPS)and Barthel ADL index were performed within 72 h after admis-sion. Correlation between the SRPS score and the Barthel ADLindex level (mildly severe, moderately severe, severe, and de-pendent) on admission (adm) and discharge (dc) were deter-mined using chi-square. Results: 101 stroke patients partici-pated in this study. Mean age was 62.1 ± 11.5 years. Fifty-sixwere men. Mean SRPS score was 36.7 ± 14.8. They were dividedinto group 1 (SRPS 0-30) and group 2 (SRPS 35-50). Mean scoreof adm Barthel ADL index of group 1 and 2 were 5.6 ± 3.7 and13.5 ± 3.6, respectively. Mean score of dc Barthel ADL index ofgroup 1 and 2 were 9.2 ± 5.9 and 17.8 ± 2.7, respectively. BarthelADL index of group 1 were significantly lower than group 2 (P <0.01). Seventy percent of patients in group 2 and 10% in group 1were mildly severely disabiled when discharged. Fifty-four per-cent of patients in group 2 and 5% in group 1 were supervised tototal independent ADL and ambulation. Conclusion: The strokerehabilitation potentials screening test is an easy tool for pre-dicting rehabilitation outcome. It has high correlation with theBarthel ADL index on admission and discharge.

P2-023 Passive Repetitive Movement Therapy ofthe Paretic Hand in Patients after Stroke

A. F. Thilmann, H. Potthoff, and A. ScharffFachklinik Rhein/Ruhr, Germany

Background: Restitution of the upper extremity with severeparesis after stroke is one of the major goals in neurologic reha-bilitation. Prognosis for recovery is often poor. Since repetitivemovements and robot-assisted therapy have shown to be effec-tive for motor recovery of the paretic arm, we developed a ro-botic-assisted trainer for passive repetitive finger movements.Methods: 22 patients were allocated in 2 groups, one group re-ceiving standard therapy (control group), and the other groupreceiving additional passive movement therapy. Patients wereinstructed to use the apparatus at least 60 min each day. The pa-tients were tested at take up (T0), after 4 weeks (T1), and whendischarged (T2). Spasticity was determined with spasms fre-quency scale and modified Ashworth-Scale; strength and dex-terity was tested by MRC-Scale, grip strength, Nine Hole PegTest, and Frenchay Arm Test. Results: Mean time of passive ther-apy was 22 min each day. None of the patients was able to exe-cute testing for grip strength, Frenchay Arm Test, and Nine HolePeg Test. Extension and flexion of the fingers measured withMRC-Scale improved in both groups; however, no differencewas found between control and study group. Two patients inthe study group and 1 patient in the control group were testedfor grip strength at T2. Conclusion: No significant benefit of ro-bot-assisted repetitive passive movement of the fingers instroke patients was found. Any long-term effect has to befurther evaluated.

P2-024 Effect of a Single Dose of the SSRIFluoxetine on motor Activation Patterns of theupper Extremity in Chronic Stroke Survivors

M. J. IJzerman,1 H. I. van Genderen,2

and J. J. M. Nijlant21University of Twente, BMTI, Enschede, theNetherlands; 2Roessingh Research andDevelopment, the Netherlands

Background: Clinical studies indicate that the use of selec-tive serotonin reuptake inhibitors (SSRIs), amphetamine, ormethylphenidate may be beneficial to increase motor output.Using SSRIs, it is possible to modulate cortical excitability. Theobjective of the present study is to explore the effect of a singledose of the SSRI fluoxetine on muscle activation patterns, i.e.,muscle output and cocontraction. Methods: 10 chronic strokesurvivors were included in a double-blind crossover trial. Pa-tients were given 20 mg fluoxetine or placebo after baseline as-sessments on day 1 and 2, respectively. Follow-up assessmentswere performed 5 h after intake of fluoxetine. The order of drugadministration was randomized. Outcome measures used wereisometric EMG output of both wrist flexors and extensors. Clini-cal outcome measures were the motricity index and gripstrength. Results: RMS of both wrist flexors and extensors of theimpaired limb increased significantly (F = 8.052, P < 0.01). De-lay times were not different after intake of fluoxetine.Cocontraction appears to be slightly less after fluoxetine, butthe difference was not significant. Grip strength of the pareticarm was lower after fluoxetine. Conclusion: Although motoroutput increased significantly, no improvement in delay in initi-ation and termination was found. Neither did we see a signifi-cant reduction in cocontraction. The findings suggest that it ispossible to enhance motor output using a single dose offluoxetine, but that selectivity is not improved.

P2-025 Usage of a Method of DynamicPropriocorrection in Rehabilitation of Patientsafter Brain Injury

S. L. Zuev, I. V. Sidyakina, K. V. Lyadov, T. V.Baidova, and I. A. EabralidzePirogov National Medical-Surgery Center, RussiaMoscow, Russia

Background: We estimate the effectiveness of usage of dy-namic propriocorrection in the rehabilitation after brain injury.Methods: The course includes 15 procedures. Eighty-five pa-tients were under our observation after brain injury. The agewas 20 to 57 years. The illness was from 1 month to 2 years. Theduration of the observation was from 3 weeks to 15 months.Forty-six patients in the 1st group (54%) received exercises inthe reflex-oriented device in addition to the basic course of arecreation treatment. Thirty-one patients in the 2nd group(46%) recieved only the basic course. To compare the effective-ness of the treatment given, we used biomechanical method ofstabilometrics (estimation of patient’s vertical pose and bal-ance) on a complex biomechanics. Results: After treatment, thespeed of average square declined with the pressure center coor-dinates (mms) of 27.5 before treatment and of 21.3 in group 1and 23.4 in group 2 after treatment. The length of thestabilogram (mm) was 985.6 before and 759.5 in group 1 and836.4 in group 2 after treatment. The square of the stabilogram(mm2) was 724.7 before and 644.2 in group 1 and 689.4 in group



2 after treatment. It showed a significant decline in parametersin group 1. Conclusion: The use of dynamic propriocorrectioncan achieve better results of arbitrary motorics and statics. Thisshows an advantage of this technology to be applied in thebrain injury rehabilitation.

P2-026 Mentamove Rehabilitation after RightCarotid Artery Occlusion (Case Report)

M. Akgun,1 Z. Akgun,2 B. Hakyemez,3 and C. Garner4

1State Hospital Bursa, Turkey; 2School of HighHealthy Uludag University, Turkey; 3UludagUniversity, Turkey; 4KWA Klinik Stift Rottal,Germany

Background: Brain Efficiency Training (Mentamove) is aneurorehabilitation method used for rehabilitation after brainlesions. If motor activities are mentally practiced withMentamove, the real movement gives reorganization of thebrain. Methods: The patient (a 50-year-old man) had right ca-rotid artery occlusion. He had left hemiplegia with mild centraltype facial paralysis. After hospitalisation, the Mentamovemethod was used on the left shoulder, elbow, wrist, hip, andknee, and on the peroneal muscles once daily during a 7-monthperiod. The results were measured with the Medical ResearchCouncil scale (MRC) of 0 to 5, and brain activity was investi-gated with fMRI after 7 months and 13 months after the training.Results: Using the MRC Scale, the motor power in shoulder ab-duction, hip flexion, and knee extension and dorsiflexion in-creased from 0 to 5 and in elbow extension, from 0 to 4. Wristextension improved from 0 to 2. fMRI showed blood oxygenlevel dependence (BOLD) activity after 7 months and diffusecortical activity during right and left foot dorsiflexion and lefthip flexion movements. After 13 months, left foot dorsiflexionand triceps activity showed new organized areas in the rightcortex. Conclusion: These results demonstrate increased activ-ity of the whole hemisphere during training with theMentamove method and newly reorganized areas after the ther-apy. The fMRI results support the reorganization theory of thebrain after ideomotor training.

P2-027 Mentamove Rehabilitation after LeftCarotid Artery Occlusion: fMRI Findings afterTreatment (Case Report)

M. Akgun,1 B. Hakyemez,2 Z. Akgun,3 and C. Garner4

1State Hospital Bursa, Turkey; 2Uludag University,Turkey; 3School of High Healthy Uludag University,Turkey; 4KWA Klinik Stift Rottal, Germany

Background: Brain Efficiency Training (Mentamove) is aneurorehabilitation method used for rehabilitation after variousbrain lesions. If motor activities are mentally practized by thepatient, the real movement leads to a reorganization of thebrain. Methods The patient (a 53-year-old, left-handed man)had left carotid artery occlusion. He still displayed right-sidespastic hemiparesia 15 months after the stroke, with motordysphasia and cognitive recall problems. A Mentamove trainingprogram was applied only on the right arm once daily. The re-sults were measured with the Medical Research Council scale(MRC) of 0 to 5 and video documentation. The resulting brainactivity was investigated with fMRI 3 months and 8 months afterthe use of the Mentamove treatment. Results: Using the MRCscale, the motor power in right shoulder abduction increasedfrom 3 to 5 and in elbow extension, from 2 to 5. Wrist extension

improved from 0 to 4. The fMRI showed increased blood oxy-gen level dependence (BOLD) activity after 2 months ofMentamove therapy, with right hand movements on the rightpremotor cortex. After 8 months, right hand movementsshowed newly organized areas on the right cortex. Conclusion:These results show increased activity on the right hemisphereduring training with the Mentamove method, and newly reorga-nized areas after the therapy. The fMRI results support the reor-ganization theory of the brain after ideomotor training.

P2-028 A Motor Imagery Training Program forStroke Rehabilitation

S. J. C. Hamilton,1 M. Ietswaart,2 C. Dijkerman,3 M.Johnston,2 and C. L. Scott21NHS Grampian, United Kingdom; 2University ofAberdeen, United Kingdom; 3Universty of Utrecht,the Netherlands

Background: Motor imagery is characterized by the internalmanipulations of at least some properties of overt voluntary ac-tion. Motor imagery has been shown to recruit many brainmechanisms involved in overt voluntary action. Methods: Thisprogram was developed as part of an investigation evaluatingthe therapeutic benefit of motor imagery training in stroke pa-tients with a hemiparesis. Training focused on the upper limb.Simple elementary movements, goal-directed movements, andactivities of daily living were mentally rehearsed using a rangeof techniques to facilitate motor imagery. These techniques in-cluded verbal guidance, observation, and movement illusion.Patients are asked to perform imagined variations of dynamicfinger, hand, wrist, and arm postures. The training also involvedboth manipulation of imaginary objects and imaginary manipu-lations of physically present objects. Results: Movement illu-sions were achieved through the use of mirrors and using avideo display. Motor imagery was further accomplishedthrough mental rotation of hand and body orientations. Prelimi-nary data have demonstrated the potential therapeutic benefitsof motor imagery in neurologic rehabilitation and that this is anacceptable and practical technique for stroke patients. Conclu-sion: This program was informed by current understanding incognit ive neuroscience and could be of interest inneurorehabilitation settings. Motor imagery training could po-tentially be used to stimulate motor recovery in stroke patients.

P2-029 What Affects the Burden of the Close Oneafter Stroke?

A. Bjorkdahl and K. S. SunnerhagenSahlgrenska Academy at Göteborg University,Sweden

Background: A stroke not only affects the person himselfbut also the close ones. Still there are needs of understandingthe factors impacting burden as well as evidence for efficacy ofinterventions. The aim was to evaluate if an intervention withcounseling in the home setting reduces the caregiver’s burden.Methods: 58 stroke patients, median age of 53, participated in arandomized controlled study, with 3 weeks of training either inthe home setting (H) or at the day clinic (D). In H counselingabout the stroke and its consequences were included. Twenty-seven close ones completed the Caregiver Burden scale at 3weeks, 3 months, and 1 year after discharge. Results: Therewere no significant differences between the 2 groups on any ofthe assessments. However, there seemed to be a tendency to a



lower burden for H than for D directly after the intervention.The burden of H then stayed similar from 3 weeks to 1 yearwhile D got a reduced burden over time. Correlations with otherinstruments made to examine factors influencing burdenshowed significant correlations to activity level after the inter-vention only for H. Conclusion: Tendencies support a positiveeffect of information and counseling as the burden of H tendedto be lower after the intervention while D seemed to learn bytime and reduced burden to the 1-year follow-up. The findingssuggest that with a greater knowledge of stroke, the burden ofclose ones is more associated to the patient’s real ability.

P2-030 Intensive Repetition of FacilitationExercise Promotes Motor Functional Recovery ofthe Hemiplegic Upper Limb including the Fingers

K. Kawahira, M. Shimodozono, S. Etoh, S. Ikeda,and A. YoshidaKagoshima University, Japan

Background: Functional improvements induced by inten-sive repetition of facilitation (IRF) for a hemiplegic lower limbsuggests that IRF may improve motor function of a hemiplegicupper limb. We evaluated the effects of repetition of elicitedvoluntary movements on the improvement of voluntary move-ment of a hemiplegic upper limb. Methods: The subjects con-sisted of 24 patients with stroke that were divided into 2 groups:subjects preceding IRF (age: 55 ± 17 years, time after onset: 10 ±4 weeks) and subjects following IRF (age: 60 ± 11 years, time af-ter onset: 18 ± 15 weeks). For IRF, methods designed byKawahira were used to isolate individual movement from syn-ergy. Each finger movement was isolated using stretch reflexand skin-muscle reflex. Two 2-week IRF sessions (100 repeti-tions a day for each of 8 kinds of movement) were applied at 2-week intervals in hemiplegic patients who were being treatedwith continuous conventional physical and occupational ther-apy (COT). Motor function of the affected upper limb was eval-uated at 2-week intervals using Brunnstrom recovery stage ofhemiplegia. Results: Significant improvements in Br. stage of theupper limb were seen after the 1st COT session and after the 1stand 2nd IRF sessions. The improvements after IRF sessionswere significantly greater than that after the preceding COT ses-sion in both groups. Conclusion: IRF using Kawahira’s methodsimproved the voluntary movement of a hemiplegic upper limb,especially the fingers, in patients with stroke.

P2-031 The Impact of Spasticity in Stroke onQuality of Life: The Development of a Needs-Based Quality of Life Scale–Stage 1—QualitativeAnalysis

S. A. Barker,1 R. Kent,2 and A. Tennant31Leeds University, United Kingdom; 2LeedsUniversity, United Kingdom; 3Leeds University,United Kingdom

Background: Spasticity is a significant impairment afterstroke. This research aims to identify and measure its impact onquality of life. This will enable its appropriate management.Methods: Experience of unfulfilled needs after stroke were ob-tained by taped interview. The sample, n = 48, were stratified byspasticity, gender, duration, and employment status. Strategiesof grounded theory allowed an iterative approach to analysis.

Emerging themes were identified using in vivo statements, vali-dated by an independent researcher. Results: Themes includedimpact on physical and mental health: limitation of function athome and in society; the consequences of loss of income; emo-tional reactions such as depression, altered body image, andcoping strategies; and the perceived reactions of others includ-ing stigma, prejudice, and paternalism. Conclusion: Spasticitywas associated with fatigue, pain, immobility, and poor bal-ance. This led to limitations in activity and increased depend-ency. Factors that reduced its impact included age, financial sta-tus, personality, and family support. In all cases, loss ofautonomy was significant. This was a useful indicator of theimpact of spasticity on quality of life.

P2-032 Effects of Constraint-Induced MovementTherapy on Upper Limb Function in SubacuteStroke Subjects

C. S. Weng, X. Y. Pan, J. Wang, G. Wang, and Z. Z. YuDepartment of Rehabilitation Medicine, theGeneral Hospital of the PLA, Beijing, China

Background: Stroke is the leading cause of disability inChina, and upper limb paresis is a major impairment causingdisability. Constraint-induced movement therapy (CIMT) is anintervention which has been used for the treatment of upper ex-tremity motor disabilities in chronic stroke patients. The pur-pose of this study was to determine CIMT feasibility and com-pare its efficacy to traditional rehabilitation (TR) for improvingupper limb functional outcomes in subacute stroke patients.Methods: Design: A before-after, multiple baseline, controlledpilot study. Setting: Department of Rehabilitation Medicine. Pa-tients: 13 stroke patients 1 to 6 months poststroke and exhibit-ing upper limb hemiparesis and affected limb nonuse. Interven-tions: The patients were given CIMT, involving restriction ofmovement of the normal upper extremity by placing it in a slingfor 90% of waking hours for 12 d and training (by shaping) ofthe more affected extremity for 6 h on the 10 weekdays duringthe study period. Main outcome measures: Outcome measureswere an upper extremity function test (UEFT) and a simple testfor evaluating hand function (STEF). Results: The CIMT patientsexhibited greater motor changes on the UEFT and STEF (ES,1.59 and 1.03, respectively) than those who had received regu-lar therapy (ES, 0.41 and 0.13, respectively). Conclusion: CIMTmay be an efficacious method of improving function and use ofthe more affected arms of subacute stroke patients. However,larger confirmatory studies need to be performed.

P2-033 Effects of Constraint-Induced MovementTherapy on Patients with motor Deficits in anUpper Extremity after Stroke

C. S. Weng, J. Wang, X. Y. Pan, G. Wang, and Z. Z. YuDepartment of Rehabilitation Medicine, theGeneral Hospital of the PLA, Beijing, China

Background: Constraint-induced movement therapy (CIMT)has been documented to improve motor function in the upperextremity of people with mild hemiparesis. The purpose of thisstudy was to determine the efficacy of CIMT in patients withmotor deficits of an upper extremity of different severity afterstroke. Methods: 27 stroke patients who had upper limbhemiparesis and learned nonuse were recruited. Patients wereallocated either to the moderate group (n = 12) or the severe



group (n = 15) according to the severity of their initial motordeficit as measured by the upper extremity function test (UEFT).Both groups of patients were given CIMT, involving restrictionof movement of the normal upper extremity by placing it in asling for 90% of waking hours for 12 d and training (by repeti-tive practice, shaping) of the affected extremity for 6 h for 10weekdays during the period of study. The outcome measurewas the UEFT. Results: Although the UEFT showed improve-ment in both groups after CIMT, statistical analyses showed nosignificant differences in treatment gain between the moderateand the severe groups (P < 0.05). However, the effect size forthe severe group (ES = 2.2) was larger than that for the moderatepatients (ES = 1.8) in the quality of movement UEFT assessment.Conclusion: These results demonstrate that CIMT is an effectiverehabilitation technique for motor deficits of an upper extremityof various severity after stroke. It probably has a tendency forbetter results with more severely affected patients.

P2-034 Effect of Treadmill Training on theAdaptation of Step Differentiation in aHemiparetic Stroke Subject

M. NavavongsVichaiyut Hospital, Thailand

Background: Many stroke patients use treadmill training toimprove their gait. However, the benefits of this treatment mo-dality to stride differentiation have not been assessed. Objectiveof this study is to compare the differentiation between left andright stride length of a stroke subject before and after training ona treadmill. Methods: A patient with right hemiplegic gait defi-ciency was tested while walking by applying ink to the soles ofthe shoes to mark the stride length. The differentiation betweenthe left and the right foot was measured before and after walk-ing for 15 min/d daily within 6 weeks on a treadmill at 2.4 km/h.Results: After walking on the treadmill, the differentiation offoot prints between the left and right stride length was signifi-cantly reduced (60.71%, with a mean of 2.8 cm before and 1.1cm after). Conclusion: Walking on a treadmill helped to im-prove the differentiation of left and right stride length in ahemiplegic patient.

P2-035 Use of Botulinum Toxin A (BT) in theManagement of Headache in Stroke Patients withChronic Spastic Neck Muscles (SNM)

J. K. Baruah1 and G. R. Baruah2

1St. Francis Hospital, USA; 2Aurora SinaiMedical Center, USA

Background: Poststroke patients with SNM may developgeneralized headache (GH). GH patients with SNM weretreated with BT on their spastic side (sternocleidomastoid/splenius capitis/cervical paraspinal/trapezius) and the re-sponse was reported. Methods: 15 patients (62-85 years; men, 7and women, 8) developed GH 6 to 8 weeks poststroke. The GHwas of the tension type of headache (TTH) due to muscle con-traction, though the spasticity was unilateral. Patients with in-tact speech were enrolled. After neurologic evaluation, each re-ceived BT injections (200-300 U) in the SNM (as above) and wasevaluated monthly for 12 to 15 months. The BT was repeated at3- to 4-month intervals. All recorded a brief pain inventory (BPI)

each 3 months, and the results were compared with thepreinjection BPI. Results: GH improved after BT injection. Most(11 of 15) reported relief (70%-90%) in the 3 to 6 weekspostinjection. GH recurred as spasticity reappeared. Repeat BTinjections led to relief of GH. Complete relief of GH was notedin 4 patients after 3 sets of BT injections (3-month interval). Sideeffects such as local transient pain or soreness were noted.None had swallowing difficulties. The use of pain medicationwas reduced after BT. Conclusion: TTH in stroke patients withSNM responded to BT, though the benefit was temporary. Therelief was long lasting after recurrent BT injection in 4 of 15. It ispostulated that TTH was generated because of a central mecha-nism after development of a peripheral trigger (SNM) and thatBT injection modified the peripheral pain generator in the latter.

P2-036 Discharge Destinations after SubacuteStroke Rehabilitation—A Hospital-Based Study

C. Y. Tam,1 C. Chan,2 S. W. Li,3 and F. M. So1

1Physiotherapy Department, Tung Wah Hospital,Hong Kong; 2Department of Rehabilitation Science,Hong Kong Polytechnic University, Hong Kong;3Division of Rehabilitation, Department ofMedicine, Tung Wah Hospital, Hong Kong

Background: To explore the discharge pattern and predic-tors of discharge destinations in stroke patients. Methods: A ret-rospective study based on the stroke database registry of a ma-jor stroke rehabilitation program in Hong Kong. Demographicdata, clinical characteristics, functional status, and dischargedestinations of patients at admission and before discharge werescreened and collated. Different inferential statistical proce-dures were used to identify the significant predictors of dis-charge destinations. The extent to which the predictors con-tributed to the final destinations of discharge was analyzed withpath analysis. Results: Patients were discharged home (40.9%),home with day rehabilitation (38.8%), or to nursing placement(20.3%). At admission, gender, motor, and cognitive status ofpatients and availability of social support were the significantpredictors of patients discharged home with day rehabilitationservices. Age, motor status of patients at admission, and avail-ability of social support were predictors to nursing placement.At predischarge, all the factors in admission remained signifi-cant except motor function. Conclusion: The results indicatedthat discharge destinations of stroke patients were functions ofgender, age, clinical, and social factor. An effective dischargeplanning would best begin at admission and involvemultidisciplinary rehabilitation experts. Future study should ex-plore the use of predictfxion models and clinical pathway tooptimize resources of rehabilitation service.

P2-037 Changes in Functioning between Days 5and 10 after Acute Stroke in Patients 65 Years andOlder

D. K. Sommerfeld,1 L. Widen Holmqvist,2

and M. von Arbin3

1Department of Geriatric Medicine and NeurotecDepartment, Division of Physiotherapy, KarolinskaInstitutet, Sweden; 2Neurotec Department, Divisionof Physiotherapy, Karolinska Institutet, Sweden;



3Stroke Unit, Division of Internal Medicine,Karolinska Institutet, Sweden

Background: As the cost of hospital care after stroke is con-stantly rising, there is an increasing pressure to reduce the dura-tion of hospital stay. In the decision-making process concerningdischarge from the hospital, the functioning of the patient is es-sential. Much is known about the rapid recovery during the 1stweeks after stroke, but limited information is available about re-covery between days 5 and 10 after stroke. The aim of the pres-ent study was to analyze and describe changes in functioning,between days 5 and 10 after stroke, in patients 65 years andolder. Methods: 100 stroke patients were examined for con-sciousness, perceptual, language, other mental, and urinationfunctions; mobility; and activities of daily living (ADL) 5 and 10days after stroke. Results: Only consciousness and urinationfunctions, mobility, and ADL were possible to be assessed in allpatients 5 and 10 days after stroke. Statistically significant, butsmall differences, in scores were seen in 3 of 7 tests betweendays 5 and 10 after stroke. A majority of patients did not im-prove according to the tests, except for ADL whereby 57% of thepatients improved to some extent. Conclusion: The changes inselected functioning between days 5 and 10 after stroke weresmall and in contrast to the rapid recovery pattern often seenduring the 1st week. Measures at the body functional levelmight add valuable information when assessable. However,preferable outcome measures, when following recovery 5 to 10days after stroke, are at the activity level.

P2-038 Factors Affecting Dose-Dependent Effectof Impairment-Oriented Exercise Therapy inPatients with Subacute Stroke

M. Mihara, M. Hatakenaka, and I. MiyaiNeurorehabilitation Research Institute, BobathMemorial Hospital, Japan

Background: Although there is growing evidence that aug-mented rehabilitation is beneficial to patients with stroke, opti-mal timing and strategies remain unclear. We investigated fac-tors affecting the efficacy of exercise therapy based onneurodevelopmental technique. Methods: From medical re-cords of 730 patients with subacute stroke, we retrospectivelycollected data including age, gender, stroke subtype, onset-ad-mission interval (OAI), motor subscore of the Functional Inde-pendence Measure (FIM) on admission and discharge, motorimpairment (Stroke Impairment Assessment Set [SIAS]) on ad-mission, length of stay, weekly amount of exercise therapy, anddischarge disposition. Residual scores, calculated from resultsof simple regression analysis for discharge FIM scores, wereused as dependent variables in multiple regression and regres-sion tree analysis. Results: Multiple regression analysis revealedgreater weekly amount of therapy, younger age, and less motorimpairment on admission being significantly associated withgreater gains in motor function. In addition, the dose-dependent gains were affected by OAI and motor impairment.Regression tree analysis also demonstrated that OAI less than 50d and less motor impairment on admission (SIAS more than 8 of25) affected the dose-dependent gains. Conclusion: Patientswith earlier intervention and less motor impairment are likely toshow dose-dependent effect on functional gains afterimpairment-oriented exercise therapy.

P2-039 The Long-term Outcome of aGroup of Chinese Patients with PrimaryIntracerebral Hemorrhage

C. N. Lee, T. H. Tsoi, and C. M. CheungPamela Youde Nethersole Eastern Hospital,Hong Kong

Background: Primary intracerebral hemorrhage (PICH) ac-counts for around 10% to 15% of all strokes in the Western pop-ulation, and a higher percentage of PICH was observed in theChinese population. We sought to study the long-term risk of re-currence of stroke and the risk factors among Chinese patients.Methods: All PICH patients enrolled in the PYNEH stroke regis-try from 1 July 1996 to 30 June 1999 were identified, and patientswho survived the 1st 30 days were recruited. The demographicdata, clinical characteristics, and the CT finding were reviewed.Secondary causes of ICH were excluded. The electronic recordsof each of the patient at least 5 years after the index stroke wereretrieved. Results: A total of 260 cases of PICH were identified.Seventy-seven (29.6%) died within the 1st 30 days of their ad-mission. Of the remaining patients, 32 (19.3%) patients diedwithin 5 years. Predictors of mortality within 5 years were ad-vanced age, smoker, and drinker. 10 patients had recurrent ICH(recurrence rate: 1.21% per year). Thirteen patients had recur-rent ischemic stroke (recurrence rate: 1.57% per year). Youngerage is a significant predictor of recurrent ICH, whereas presenceof HT and male sex are potential predictors of recurrent ICH.Deep site of initial PICH, HT, and smoking are potential predic-tors of ischemic stroke. Conclusion: PICH has a high 30-d mor-tality rate. Patient with PICH are at risk for developing bothischemic stroke and recurrent hemorrhage. Patient with PICHinitially at the deep site is a risk factor for ischemic stroke.

P2-040 Experience of Application of MagneticTranscranial Brain Stimulation by Paired Stimuliin Stroke Patients

I. V. Sidyakina, K. V. Lyadov, S. L. Zuev, T. V. Bajdova,and T. V. IsayevaPirogov National Medical–Surgery Center, Russia

Background: To evaluate possibility of applying the tech-nique of paired stimulation of transcranial magnetic stimulation(TMS) in stroke patients for the evaluation of clinical prognosis.Methods: Device used was Bistim and EMG machine of VikingQuest. The power of the 1st (conditioning) stimulus composed70% of the threshold quantity, and the power of the 2nd (test-able) stimulus was equal to 120% to 150% of the threshold (ob-tained by MA with amplitude of about 1 mV with the measure-ment from the peak to the peak). For 7 ms, the step of intervalwas in 1 ms, and then 2 to 3 ms. For each interval obtained 8 to10 answers. Documentation of a change in the clinical picturewas tracked in the course of 10 to 12 months. Measurements in-clude change in dynamics of the manifestation of hemiparesisand muscular force. Results: In the subgroup of stroke patients,who showed decrease in the process of intracortical braking(independent of the presence of changes in the phenomenon oflightening “simplification”), had muscular force increased by1.31 marks. In the subgroup, who were noted with “retardation”of the motor function of the struck hemisphere (strengtheningintracortical braking), the completion of motor deficiency wasobserved to 0.56 marks. Conclusion: In stroke patients, TMS can



be prognostic. The presence of reduction in the intracorticalbraking suggests favorable restoration of motor functions, butthe phenomenon of strengthening intracortical braking maysuggest an unfavorable outcome.

P2-041 Effect of Standardized TertiaryRehabilitation on the Motor Function in Patientswith Cerebral Stroke Accompanied by Hemiplegia

L. M. Sun, Y. S. Hu, Y. Wu, Y. L. Zhu, and W. K. FanHuashan Hospital, Fudan University, Shanghai,People’s Republic of China

Background: As a key project of the 10th “Five Year Re-search Plan” of the National Science Committee of China[2001BA703B18(A)], this study was designed to investigate theeffect of standardized tertiary rehabilitation (STR) on the motorfunction in patients with cerebral stroke accompanied byhemiplegia. Methods: This was a prospective, randomized, andcontrol study. Those enrolled were those with stroke accompa-nied by hemiplegia, with stabilized vital signs for 1 week. Theywere randomized into 2 groups: test and control. Those in theformer group were administered STR in addition to routinemedical interventions, whereas those in the latter were onlygiven the routine treatment. All the patients were assessed withthe scale of Fugl-Meyer Assessment of Motor Functional at thetime of the enrollment, at the end of the 1st month, the 3rdmonth, and the 6th month after the stroke, respectively. Results:82 study subjects were enrolled. Forty-two patients were as-signed in the test group, whereas 40 were assigned in the con-trol. There was no significant difference between the 2 groupsat the start of the study. At each of the following poststrokecheckpoints, however, the scores of the motor function in thetest group were higher than those in the control (P < 0.05). Con-clusion: STR could significantly improve the motor function inpatients with cerebral stroke accompanied by hemiplegia.

P2-042 Standardized Tertiary Rehabilitation (STR)for Patients with Cerebral Strokes accompaniedby Hemiplegia

Y. S. HuHuashan Hospital, Fudan University, China

Background: To investigate the effect of STR on the functionof stroke patients. Methods: 1365 subjects were enrolled se-quentially from 22 medical university–affiliated hospitals andprovincial hospitals in China; they were stabilized in vital lifesigns in the past 1 week. They were randomly divided into 2groups (test and control): 688 in the former and 677 in the latter.Those in the test group were given STR in addition to routinemedical treatment, whereas those in the control group wereonly given the routine treatment. All patients were assessedwith the comprehensive functional assessment scale at the timeof the enrollment, at the end of the 1st, 3rd, and 6th month afterstroke, respectively. The group assignment was blinded to theappraiser. Results: There was no significant difference betweenthe 2 groups at the start. At each of poststroke checkpoints,however, the scores of the mobile or cognitive functions in thecerebral infarction test subgroup, cerebral hemorrhage test sub-group, and the whole test group were higher than those in thecontrol group (P < 0.01). At the end of 6th month, the scoreswent up by 38.44 ± 4.34, 44.50 ± 6.34, and 40.10 ± 4.89 in the test

groups, respectively; whereas in the control groups, they in-creased by 24.41 ± 2.53, 27.92 ± 4.27, and 25.34 ± 2.99,correspondingly. Furthermore, the trend of increase wasgreater in the test groups than in the control ones, especially atthe early stages. Conclusion: STR could significantly improvethe stroke patients’ functions with hemiplegia.

P2-043 Standardized Tertiary Rehabilitation (STR)for Stroke Patients with Hemiplegia in Promotingthe Neurologic Function

Y. S. HuHuashan hospital, Fudan University, China

Background: To investigate the effect of STR on the neuro-logic function in patients with cerebral stroke accompanied byhemiplegia. Methods: 1365 stroke subjects with stabilized vitalsigns for 1 week were enrolled sequentially from 22 hospitalsaffiliated with medical universities and provincial hospitals inChina. They were randomly divided into 2 groups with 688 inthe test group and 677 in the control group. Those in the testgroup were administered STR plus routine medical treatment,whereas those in the control group were only given the routinetreatment. All patients were assessed with the scale of clinicalneurologic function defects at the time of the enrollment, at theend of the 1st, 3rd, and 6th month after the stroke, respectively.The randomization was blinded to the appraisers. Results: Therewas no significant difference between the 2 groups at the base-line. At each of the poststroke checking points, however, thescores of the neurologic function in both subgroups of cerebralinfarction and hemorrhage showed that those in the test groupwere higher than the control group (P < 0.01). At the end of 6thmonth, the scores went up by 17.79 and 15.23 in the test groups,respectively; whereas they increased by 8.30 and 10.65 in thecontrol group, correspondingly. Furthermore, the trend of in-crease was greater in the test group than in the control group,especially at the early stages. Conclusion: STR could signifi-cantly improve the neurologic functions in the stroke patientsaccompanied by hemiplegia.

P2-044 Does Social-Demographic InformationPredict Residential Outcomes in Elderly StrokeRehabilitation Patients in Hong Kong?

S. C. C. Chang,1 R. Fielding,2 L.S. W. Li,1

and W. Y. T. Chan1

1Tung Wah Hospital, Hong Kong; 2University ofHong Kong, Hong Kong

Background: Stroke is the 3rd leading cause of death anddisability in Hong Kong, but only a few studies on residentialoutcomes have been conducted locally. This study intended toidentify predictors of the residential outcomes of elderly strokerehabilitation patients using social-demographic informationcontrolling for local functional variables. Methods: A sample of619 elderly stroke rehabilitation patients was extracted from therecords of the Tung Wah Hospital from January 2001 to Decem-ber 2003. Chi square, t tests, and logistic regression were per-formed. Results: Significant predictors were age, marital status,financial support, discharge FIM score, and discharge voca-tional status. Those younger than 80 were 47% more likely to re-turn home than those older than 80 years (OR = 0.53, CI = 0.29-0.98, P = 0.042). Welfare nonrecipients were 68% more likely to



return home than welfare recipients (OR = 0.32, CI = 0.14-0.72,P = 0.006). Those alone were 3 times more likely to enter institu-tion than those married (OR = 3.09, CI = 1.67-5.72, P = 0.000).Those unable to return to work were almost 4 times more likelyto enter an institution than those able to return to work (OR =3.68, CI = 1.00-13.46, P = 0.049). Those with greater functionalindependence as measured by FIM scores were 3% more likelyto return home than those with lower FIM scores (OR = 0.97, CI= 0.95-0.99, P = 0.000). Conclusion: The intervention and long-term care of stroke patients should focus more on psychosocialaspects.

P2-045 Effects of the Passive Movement Exerciseon the Muscle Oxygenation of the Paretic Leg inChronic Stroke Patients

J. Enkhsaihan,1 N. Kawashima,2 H. Ogata,3 K.Nakazawa,3 M. Akai,3 and F. Eto1

1Graduate School of Medicine, Tokyo University,Japan; 2Sibaura Institute of Technology, Japan;3National Rehabilitation Center for Persons withDisabilities, Japan

Background: We found recently that passive leg movementcan induce not only muscular activity but also alteration of mus-cle oxygenation in the paralyzed leg of complete paraplegicpersons. Further hypothesis is that the oxygenation of pareticmuscle of a stroke patient would also be facilitated during thepassive leg movement. To test this hypothesis, we measuredmuscle oxygenation using the near-infrared spectroscopy(NIRS) and recorded muscular activity during and after passiveleg movement in 8 chronic stroke patients. Methods: To imposeleg movement, we used a training apparatus (Easy Stand Glider6000, Altimate Medical Inc, USA). Oxygenation levels of thegastrocnemius (MG) muscle were measured by the NIRS during10 min of exercise and 10 min of following rest. EMG signalsfrom the MG were recorded. Results: Hemoglobin levelsshowed similar picture of decrease during exercise and increaseat rest with no significant difference in both legs. However tis-sue oxygen index (TOI) during the rest was lower in the pareticleg (P < 0.05). In spite of involuntary movement, more than halfof subjects showed EMG activity in paretic legs. Given the evi-dence of enhanced TOI during exercise, we suppose that theoxygen delivery was facilitated by the passive movement. Con-clusion: Passive movement causes enhancement of the tissueblood oxygenation in the hemiparetic leg, which is close to thatof the unaffected leg. This type of movement might be anefficient method for stroke rehabilitation.

P2-046 Efficacy of Shoulder Slings in ShoulderSubluxation of Stroke Patients

P. Dajpratham, P. Sura, N. Lektrakul,and G. CharnchairujiraFaculty of Medicine, Siriraj Hospital,Mahidol University, Thailand

Background: Shoulder slings are often used in acute strokepatients with shoulder subluxation to reduce the magnitude ofsubluxation, prevent further injury, and support the affectedarm while moving. There are 2 differently designed types ofslings widely used among medical school hospitals in Bangkok.The purpose of this study was to assess the efficacy of these 2types of slings in reducing shoulder subluxation in acute stroke

patients. Methods: 21 acute stroke patients with shouldersubluxation put on each shoulder sling randomly. The gap be-tween head of humerus and acromion process was comparedside to side before and after wearing each sling on plain film Xray by 2 radiologists who are blind to each other as well as to thetype of sling used. Results: The mean gap between head of hu-merus and acromion process of normal side and affected sidebefore wearing the slings were 24.3 mm and 39.3 mm, respec-tively. After wearing the slings, the mean gap was reduced 2 and1 mm on each sling, which showed no significant difference(P >0.5). Conclusion: There was no difference in efficacy of shoul-der slings in reducing shoulder subluxation in acute strokepatients.

P2-047 A Proposed Practice Schedule ofConstraint-Induced Therapy to Improve UpperLimb Function Poststroke

N. B. Ahmad Kasah, B. A. R. Rameezan, A. H.Noorieni, M. Nor Atikah, and Z. OmarUniversity of Malaya, Malaysia

Background: Stroke is a major cause of disablement. Al-though the majority of patients regain their ability to walk, alarge number of them are not able to use their paretic upperlimbs. Constraint-induced therapy (CIT) is one of the rehabilita-tion methods used to improve upper limb function after stroke.Traditional CIT is based on massed and repeated therapy regi-men. It consists of a 2-week period of 6 to 7 h of daily training ofthe affected limb in combination with daily wear of restraint onthe unaffected limb. In this study, a new practice schedule ofCIT was proposed to accommodate outpatient stroke rehabilita-tion setting in University Malaya Medical Centre. Methods: 9 pa-tients with chronic stroke participated in this study. The pro-posed schedule consisted of a 2-week training program of theaffected limb in combination with daily use of restraint on theunaffected hand. The 3-h training sessions using shaping tech-nique were done on alternate days. Pre- and postassessmentswere performed using motor activity log (MAL) and Wolf MotorFunction Test (WMFT). The duration of restraint wear and itscorrelation with the score gains were also studied. Results: Posi-tive score gains were seen for both MAL and WMFT, but onlyMAL showed statistical significance (P < 0.01).The mean dura-tion of restraint wear was 62% of subjects’ total waking hoursand was correlated with the score gains. Conclusion: The newproposed CIT practice schedule done in outpatient setting is ef-fective to improve function of hemiparetic limb.

P2-048 Usage of Dynamic Mio-Stimulation andBalance Therapy in Rehabilitation of After-StrokePatients with Disordered Motor Function

K. V. Lyadov, I. V. Sidyakina, and S. L. ZuevNational Medical and Surgery Center afterPirogov N.I., Russia

Background: The rehabilitation was performed on 34 pa-tients who suffered from a stroke in the area of middle cerebralartery. Subjects had movement disorders in the form of lowerlimb mono-pares of moderate and mild degree and muscle toneincrease up to 3 points The age of the patients was between 42and 68 years, and the duration of the illness was from 18 days to1 year. Methods: 3 groups were formed. In the 1st group, dy-namic mio-stimulation and balance therapy courses were taken.In the 2nd group, mio-stimulation in walking was applied, and



in the 3rd group, balance therapy was given. The effectivenessof the restoration treatment was estimated by usingbiomechanical methods of walk analysis and stabilometry. Inall the groups the treatment was applied daily for 15 to 21 d. Re-sults: After the course of restoration therapy, the walk and posi-tion control were improved. Positive dynamics in phase struc-ture of walking was noticed with pressure center deviation fromthe main position decreased. The best results were observed inthe 1st group with the step period increased by 14.6%, the pointof rest period decreased by 10.1%, and pressure center devia-tion decreased by 7%. Conclusion: The obseved results give anoptimistic forecast to the potential of application of dynamicmio-stimulation together with balance therapy in a complexprogram of restoration treatment for stroke patients withdisordered motor function.

P2-049 A Study of Constraint-Induced MovementTherapy in Chinese Stroke Patients in theSubacute Period

M. W. W. Myint, G. F. C. Yuen, T. K. K. Yu, C. P. L.Kng, and C. P. WongRuttonjee Hospital, Hong Kong

Background: Overseas studies have shown that constraint-induced movement therapy (CIMT) results in substantial andclinically significant recovery of the affected upper extremity(UE) in chronic stroke patients, but data in Chinese patients, es-pecially in subacute phase of stroke, are lacking. Methods: Thisi s a randomized cont ro l l ed s tudy compar ing thepreintervention, postintervention, and 12-week UE function.The inclusion criteria are 2 to 16 weeks after an ischemic orhemorrhagic stroke with minimal function of more than 20°wrist extension and more than 10° extension of all digits of theaffected UE and no cognitive impairment. The interventiongroup underwent a program of 10 d of training, with the unaf-fected limb being restrained in a shoulder sling, and the controlgroup received traditional physiotherapy and occupationaltherapy. Results: 60 patients were screened, with 25 patients be-ing recruited at a mean interval of 37.7 d from the onset ofstroke (12 in control and 13 in CIMT group). The baseline char-acteristics were comparable. Preliminary data show that signifi-cant improvements after CIMT in the amount of use scale (P <0.001) and how well scale (P = 0.005) of motor activity log andthe grasp (P = 0.005), grip (P = 0.002), and pinch (P = 0.010)components of the Action Research Arm Test. No major compli-cations were noted. Conclusion: Success and feasibility of intro-ducing this new modality of treatment to our local populationwill enable the planning and design of future strokerehabilitation programs.

P2-050 The Effect of Intravenous Bisphosphonatein Preventing Osteoporosis in the early Stages ofStroke Rats

M. E. Chung, J. I. Lee, and Y. J. KoCollege of Medicine, the Catholic University ofKorea, South Korea

Background: Oral bisphosphonates are appropriate drugsto restrict bone resorption that occurs soon after stroke, butdysphagia or drowsiness after stroke can make it difficult to eas-ily prescribe these compounds to patients. Intravenous admin-istration of bisphosphonate is an alternative method that can

overcome these limitations. The aim of this study is to evaluatethe effect of intravenous bisphosphonate in preventing osteo-porosis during acute stroke. Methods: Female Sprague-Dawleyrats (n = 100) were randomly divided into 4 separate groups:sham group (A), stroke group (B), stroke with low-dose intrave-nous bisphosphonate supplementation group (C), and strokewith high-dose intravenous bisphosphonate supplementationgroup (D). The bone mineral density (BMD) of lumbar verte-brae and femur were measured at 3 points: the day before sur-gery, 1 week postoperatively, and 3 weeks postoperatively.Carboxy-terminal telopeptide (CTX) and the maximum load offemur neck were measured 3 weeks postoperatively Results:The BMDs of the lumbar vertebrae and the femur of the groupsA, C, and D were significantly higher than those of group B 3weeks postoperatively (P < 0.05). The CTX of groups A and Dwas significantly lower than that of group B (P = 0.032). Also,the maximum load of femur neck of group B was significantlylower than that of the groups A, C, and D (P = 0.015). Conclu-sion: The results suggest that intravenous bisphosphonatessupplementation in ischemic stroke rats might prevent boneloss during the initial stages of stroke.

P2-051 Defining Optimal Duration forPoststroke Rehabilitation

M. Hatakenaka, M. Mihara, and I. MiyaiNeurorehabilitation Res Inst, Bobath MemorialHospital, Japan

Background: To determine optimal duration for poststrokerehabilitation, time course of functional recovery needs to beevaluated according to initial disability. Methods: In 1588 con-secutive patients with subacute stroke (mean age ± SD, 62 ± 12;1036 males, 552 females; 56 ± 36 d poststroke; right/lefthemiparesis = 788/800, ICH/CI/SAH = 680/867/41), probabili-ties of acquiring functional use of the paretic hand and reachingindependent and assisted gait were assessed using Kaplan-Meier estimate. Patients were divided into 3 groups based onscores of the Functional Independence Measure on admission(severe disability, 18-53; moderate, 54-107; mild, 108-126). Allreceived 40-min physical therapy, occupational therapy, andspeech therapy as needed, 5 d a week. Results: Independentgait indoors was achieved within 60 d after the onset by 80% ofmild and within 180 days by 80% of moderate patients. Al-though only 10% of severe patients reached independent gait,50% of the patients could walk assisted by their caregiverswithin 180 days. Functional use of paretic hand was achievedwithin 180 days by 60% of mild and 20% of moderate patients,whereas it was hardly achieved by severe patients. Conclusion:Probabilities of reaching real-world goals depend on initial dis-ability and goals to be achieved. Specifically, locomotor func-tion is more likely to improve than hand function after sustainedrehabilitation in severely disabled patients.

P2-052 Effects of New Functional VibratoryStimulation for Upper Limb on Its Reaching inPatients with Stroke

S. Etoh, S. Matsumoto, K. Hujime, M. Shimodozono,and K. KawahiraKagoshima University, Japan

Background: Recently, it become easy to apply small vibra-tors, which were made for cellular telephones, on the lower



limbs in patients with stroke while walking and improve walk-ing speed. The effects of a functional vibratory stimulation(FVS) to the hemiplegic upper limbs while reaching in patientswith stroke were studied. Methods: The subjects were 7 patientswith stroke (age, 27 to 80 years; time after onset, 1-132 months;Brunnstrom stage of hemiplegic upper limb, 5-6 stage). Smallvibrators, which were controlled by the new device of FVS sys-tem involving a computer and switching program to give vibra-tory stimulations to the triceps brachi muscle in extension andto the biceps brachi muscle in flexion, were stabilized on thetendons of these muscles by a bandage. Reaching speed of theaffected upper limb were evaluated 3 session without FVS, ofcontrol, 3 reaching sessions with FVS, and 1 session withoutFVS. Two minutes of resting was inserted between reaching ses-sion and following session. The speed of reaching with FVS wascompared with that without FVS. Results: FVS to the hemiplegicupper limb improved its reaching speed in 3 of 7 patients. Theseresults suggest that the new device of FVS is useful for treatmentin patients with stroke. Conclusion: FVS using small vibratorsimproved the voluntary movement of a hemiplegic upper limbin patients with stroke.

P2-053 The Effects of Gait-Specific Trainingwithin Bobath Therapy in People after AcuteStroke: A Pilot Randomized Controlled Trial

S. Lennon,1 W. Harpur,1 K. Fullerton,2 M. Power,3

I. Wiggam,2 and A. MacSherry1

1University of Ulster, United Kingdom; 2Belfast CityHospital, United Kingdom; 3The Ulster Hospital,United Kingdom

Background: This study aimed to examine whether intro-ducing a more intense gait-specific training component toBobath therapy would promote a gait outcome that was supe-rior to Bobath therapy alone in people after acute stroke. Meth-ods: All consecutive patients within 8 to 14 d poststroke were in-cluded if medically stable with a first-ever stroke, and they wereable to stand or walk with assistance. After giving informed con-sent, 18 patients were randomized using sealed envelopes intoa Bobath group or a gait-specific group for 20 physiotherapysessions during a 4-week period. All patients were assessed atbaseline, at 4 weeks, and at 3 months poststroke using the Mo-tor Assessment Scale, a 10-m walk test, the Step Test, and theModified Rivermead Mobility Index by a blinded assessor. Re-sults: Mean group differences between week 4 and week 1, andbetween 3 months and week 4 were analyzed using nonpaired ttests with an alpha level set at 0.05. Both groups improved.There were no significant differences between the groups forany outcome measure at 4 weeks or 3 months. Conclusion: Al-tering the nature of physiotherapy based on the Bobath conceptto be more task specific did not produce a significant change inoutcome in this pilot study. Gait-specific training was not moreeffective at improving walking ability than Bobath therapyalone. Further research is required to confirm how gait shouldbe reeducated in people at an early stage poststroke. Funded bythe Northern Ireland Chest, Heart and Stroke Association.

P2-054 Antispastic Effects on the Upper Limb ofHemiplegic Patients by Using FacilitationTechnique and Massage

L. Zhang,1 X. Hu,2 and Q. Li21Shanghai Rehabilitation and Vocational TrainingCenter for the Disabled, China; 2ShanghaiUniversity of Traditional Chinese Medicine, China

Background: It would be useful to have information aboutantispastic effect on the upper limb of hemiplegic patients by ei-ther facilitation technique or massage and their combination.The aim of this study was to find out the effect on combining theWestern technique and the traditional Chinese method in reha-bilitation. Methods: 28 hemiplegic patients with spasticity wererecruited. Facilitation technique and massage were provided,and the antispastic effect was evaluated after treatment by eithermethod or a combination of them. Results: When the treatmenttime was 5 min, the effect of facilitation technique was the sameas the massage (P > 0.05). When the treatment time was 20 min,the effect of facilitation techniques was better than the massage(P < 0.05). The effect of the combined methods for 10 min wasthe same as the massage for 20 min (P > 0.05). The effect of thecombined methods for 20 min was the same as the facilitationtechnique of 20 min (P > 0.05). The antispastic effect is obvi-ously related to the treatment time (P < 0.01). Conclusion: Bothfacilitation technique and massage have the antispastic effect.The combination of the 2 methods will give a better result. Thetreatment time is also important for the treatment effect.

P2-055 Effects of Transcranial Direct CurrentStimulation on Motor Performance in SubacutePoststroke Patients

D. Y. Kim, C. I. Park, S. H. Ohn, and E. J. YangDepartment and Research Institute ofRehabilitation Medicine, South Korea

Background: Transcranial direct current stimulation (tDCS)has been well known to help the performance in normalhealthy adults and chronic poststroke patients. However, thecortical excitability in subacute poststroke patients is differentfrom that in chronic patients. Therefore, this study aimed to in-vestigate the serial changes of motor performance after tDCS inthe paretic hand of subacute poststroke stroke patients throughthe blind, sham-controlled, crossover study. Methods: 8 sub-acute poststroke patients were recruited in this study. tDCS orsham stimulation was randomly delivered through 2 saline-soaked electrodes using a Phoresor1 II Auto (IOMED, USA) onthe different day with the familiarization session. Anode wasplaced on the hot spot of the 1st dorsal interossei on the affectedhemisphere, and cathode on the contralateral supraorbital area.The acceleration of index finger and Box and Block test (BBtest) were measured before, during, just after, 30 min, 60 min,and 90 min after stimulation. Results: Repeated ANOVA revealedthat the acceleration and score of BB test were significantly im-proved after tDCS compared to sham stimulation (P < 0.05).Post hoc testing with Bonferroni correction showed that tDCSsignificantly improved the acceleration for 30 min and the scoreof Box and Block test just after stimulation compared to thebaseline(P < 0.05). Conclusion: tDCS can improve the motorperformance for the limited time in subacute poststrokepatients.



P2-056 Training of Hemiplegic Upper Limb withFunctional Transcranial Magnetic Stimulation inPatients with Stroke

S. Etoh, K. Kawahira, S. Ishikawa, M. Shimodozono,and S. IkedaDepartment of Rehabilitation and PhysicalMedicine, Faculty of Medicine, KagoshimaUniversity, Japan

Background: Intensive repetition of facilitation exerciseshas been shown to be effective to help motor functional recov-ery of the hemplegic lower limb. We used this technique withhemiplegic upper limbs and used functional transcranial mag-netic stimulation (FTMS) simultaneously for inducing move-ment. Methods: 3 patients with stroke at 3 to 8 months from on-set participated to this study. Informed consent was obtainedfrom all of the subjects. The coil was positioned on the scalpover the motor cortex at the optimal site for stimulating move-ment of the hemiplegic finger or shoulder. FTMS was applied atthe beginning of the voluntary target movement. This traininghas done 300 times per day, 5 days per week. Results: Case 1 hadsuffered a thalamic hemorrhage, and his target movement wasflexion of his middle finger. A simple test for the evaluation ofhand function showed improvement from 15 to 20 after 2weeks. Case 2 had a putaminal hemorrhage, and his targetmovement was abduction of the thumb. Brunnstrom’s measureof finger flexibility was improved from 5 to 6 after 3 weeks. Case3 also had suffered putaminal hemorrhage, and his target move-ment was abduction of the shoulder. His score on Ueda’s 12-grade test was improved from 5 to 6 after 3 weeks. Conclusion:Voluntary movements of hemiplegic hands were improved afterthis training in chronic stroke patients, but the significance ofthe effect was not conclusively demonstrated in this study.FTMS can induce target voluntary movement, even if it is weak,so FTMS might be a new method for helping functional recoveryfrom hemiplegia.

P2-057 Case Report:Mirror Writing in a Stroke Patient

C. Ho, K.K. Leung, and C. LeeTung Wah Hospital, Hong Kong

Background: Mirror writing is characterized by the produc-tion of alphanumeric characters in the direction opposite to thatwhich is normal. Letters, words, and numbers are well formedbut reversed. Cases on mirror writing after cortical stroke havebeen reported. We report a 58-year-old Chinese man who dem-onstrated left-hand mirror writing after a right cerebral hemi-sphere subcortical infarct. Methods: The patient, who was previ-ously well, had a sudden onset of left-sided weakness anddysarthria. Physical examination revealed left hemiparesis withnormal visual fields. A CT scan and MRI revealed infarct of theright anterior limb of the internal capsule. Results: Left-handmirror writing was noted during hand function assessment.There was no consistent mirror writing on the right side. Theright was his dominant hand. He could also read mirror-imagewords. Behavioral observation did not reveal left-side neglect.Neuropsychologic testing did not demonstrate any major cogni-tive impairment. However, he had difficulties in inhibiting mir-ror writing of the left hand on copying, when writing on com-mand, and with dictation. Sensory-perceptual abilities wereintact. There was no sign of parietal lobe lesions, including fin-

ger and tactile agnosia, or left-right disorientation. Despitegood motor and functional recovery, the mirror writing per-sisted 4 weeks after stroke. A training program, consisting ofwriting and drawing with feedback from therapists to correctthe mirror errors, lasted for 3 months, when he had a completerecovery. Conclusion: Mirror writing after subcortical infarcthas not been reported previously. This is the 1st case reported,and it showed satisfactory improvement in inhibiting his mirrorwriting after rehabilitation.

P2-058 A Quantitative Study of Cocontractionof the Quadriceps and Hamstrings in Stroke Gait

X. P. YunChina Rehabilitation Research Center, China

Background: Spasticity is one of the most common abnor-malities during recovery after stroke, characterized by the ab-normal cocontraction patterns of the opposing muscles duringvoluntary movement. The purpose of this study was to quantifycocontraction of agonist and antagonist muscles of the knee insubjects with spastic hemiparesis during walking. Methods: Sur-face electromyography was recorded from the quadriceps andhamstrings of 20 able-bodied subjects and 18 spastichemiparetic subjects. Lower-limb spasticity was recorded (Mod-ified Ashworth Scale). Cocontraction from EMG activity both inable-bodied subjects and in subjects with spastic hemiparesis atmatched speed was described and quantified in 2 ways: using acocontraction index and a cocontraction profile. Results: Thecocontraction index was higher in subjects with spastichemiparesis compared to able-bodied subjects walking atmatched speed (pooled-variance t test, P < 0.005).Cocontraction profiles revealed the same relationships. Theyshowed simultaneously prolonged and elevated activity of thequadriceps and hamstrings during stance, which resulted inhigh cocontraction indices and cocontraction profiles. Conclu-sion: Cocontraction indices provide sensitive measures ofcocontraction in gait, and cocontraction profiles provide de-scriptive information on the sources of variation incocontraction, particularly in the assessment of cocontractionamong spastic hemiparetic subjects after stroke.

P2-059 A Comparative Study of Home-Basedversus Department-Based Functional ElectricalStimulation Program for Poststroke Patient witha Single Dropped Foot

J. K. W. So, P. M. Y. Lau, and R. M. W. ChauKowloon Hospital, Hong Kong

Background: One of the common motor impairment instroke survivor was dropped foot problem leading to decreasedgait speed and increased fall risk. Literature suggested func-tional electrical stimulation (FES) as one of the effective inter-ventions. A single-blind comparative study of home-based ver-sus department-based functional electrical stimulation adjunctprogram for poststroke patient with a single dropped foot inpromoting gait efficiency was conducted. Methods: Patientswith a single dropped foot resulting after first-ever stroke wererecruited. Randomization table was used for group allocationinto home-based or department-based program. Interventionincludes comprehensive gait rehabilitation and adjunct FES pro-gram for six weeks (12 sessions) at either home or departmentsetting. Demographic data were captured for descriptive analy-



sis while outcome measures, including walking speed (WS) andphysiologic cost index (PCI) upon admission, at week 6 andweek 12 intervals by blind assessor, were computed using SPSS(version 11.0) for within- and between-groups comparison. Re-sults: A total of 29 patients were recruited (n = 12 for H group; n= 13 for D group). There was no significant difference in base-line demographic and outcome data. Both groups demon-strated improvement in WS and PCI with significantly greaterprogress in some gait parameters for the department-basedgroup. Conclusion: Department-based FES was an effective ad-junct intervention in gait rehabilitation for stroke.

P2-060 Effects of Therapeutic Brain Circulationon Cerebral Blood Flow in Hemiplegia

Z. FengRehabilitation Section of No.1 Affiliated Hospital ofUniversity of Nanchang, China

Background: To observe the effects of therapeutic brain cir-culation on cerebral blood flow (CBF) in hemiplegia. Methods:With therapeutic brain circulation, which was made in Shang-hai, the changes of cerebral blood flow in 5 hemiplegic patientswere observed at the beginning of therapy and at the end oftherapy after 15 d. Therapy was given once each day for 15 d.Results: Before the therapy, the biggest flow speed of cerebralblood was 44.75 ± 15.55; the least flow speed of cerebral bloodwas 16.75 ± 10.71, the index of beat (PI) was 1.19 ± 0.35. Afterthe 15 d of therapy, the biggest flow speed of cerebral bloodwas 64.75 ± 16.83, the least flow speed of cerebral blood was27.25 ± 12.03, the index of beat was 1.03 ± 0.41. Conclusion:The greater therapeutic brain circulation seems to improve thecerebral blood flow of hemiplegia.

P2-061 Acute Predictors of Social Integrationafter Mild Stroke

F. M. Wise,1 P. B. Disler,2 and S. M. Davis2

1Caulfield General Medical Centre, Australia;2University of Melbourne, Australia

Background: Despite an acknowledged need to accuratelypredict stroke outcome there is little, if any, empirical evidenceregarding acute predictors of participation restriction, includingsocial integration, poststroke. Methods: In a prospective, longi-tudinal study, 47 stroke survivors (median age, 70 years; 30% fe-male) were observed at 6 months after stroke. Acute poststrokevariables included age, stroke severity, comorbidities, impair-ment, activity limitation, and psychosocial variables. Multipleregression analyses were used to evaluate the value of these fac-tors in predicting social integration at 6 months poststroke. Re-sults: A combination of age, comorbidities, stroke severity, so-cial support, and general self-efficacy accounted for 42% ofvariance in 6-month social integration. Twenty percent of vari-ance was explained by the number and type of social supportfactors in the acute stage. Post hoc analysis revealed that maritalstatus was the mediating variable through which earlypoststroke social support factors impacted on subsequent socialintegration. Results suggested that subjects with partners per-ceived higher levels of functional social support and lower lev-els of participation restriction. Conclusion: Stroke survivorswith partners may receive greater amounts of companionship,affection, encouragement, and material support from their part-

ners, which in turn may enhance self-esteem and confidence.Consequently, they are more able to participate in and maintainrelationships with others.

P2-062 Longer-term Participation Restrictionafter Mild Stroke in the Elderly

F. M. Wise,1 P. B. Disler,2 and S. M. Davis2

1Caulfield General Medical Centre, Australia;2University of Melbourne, Australia

Background: The World Health Organization has recentlyrevised original concepts of disability and handicap as restric-tions in activity and community participation. Little data exist,however, regarding these outcomes relating to patient age afterstroke. Methods: 85 consecutively admitted stroke survivors, in-cluding 56 subjects over the age of 65 years, were followed up at6 months afterg onset of mild stroke. Levels of impairment, ac-tivity restriction, and participation restriction were measured,together with psychosocial variables. Results: At 6 monthspoststroke, less than half of elderly subjects experienced anyimpairment or limitation in activity. By contrast, more than 9 inevery 10 older stroke survivors (95%) continued to experiencesome participation restriction and were significantly worsecompared with younger subjects in terms of social integration(P = 0.000) and occupation of time (P = 0.001). In the oldergroup, social integration correlated with self-efficacy beliefs (P =0.009), functional social support (P = 0.000), coping appraisals(P = 0.016), and less depression (P = 0.012). Occupation of timecorrelated with scores on the Functional Independence Mea-sure only. Conclusion: In the elderly, even mild stroke causesparticipation restriction. Social integration relates topsychosocial variables, which may provide a focus for rehabili-tation in this group. Although occupation of time relates to ac-tivity limitation, further research to identify other influencingfactors is needed.

P2-063 Mental Imagery for Promoting StimulusGeneralization of Patients with Stroke

I. W. L. Kwan,1 C. C. H. Chan,2 K. P. Y. Liu,2 L. S. W.Li,1 and C. S. F. Yau1

1Tung Wah Hospital, Hong Kong; 2The Hong KongPolytechnic University, Hong Kong

Background: This study examined the use of mental imag-ery in promoting the stimulus generalization from training tonovel environments. It was postulated that mental imagerywould improve the generalization of learned skills across differ-ent environments and increase the generalization power of theskills learned for patients with stroke. Methods: A total of 21 pa-tients diagnosed with stroke with a mean age of 67.9 years werematched and randomly assigned to the experimental and con-trol groups. The experimental group intervention was the men-tal imagery program of relearning includes chunking, self-regulation, and mental rehearsal. The control group interven-tion includes conventional rehabilitation program. The fre-quency of training in both programs was 5 times a week for 3weeks. In the experimental group, the patients were required tolearn 15 complicated daily tasks. In both groups, the perfor-mance in Level 3 of the program was evaluated at thepostprogram, at training, and at novel environments. Results:The results indicated that experimental group showed signifi-



cantly higher task performance in the mean task competencescores (F(1,19) = 6.39, P = 0.021). Significant differences werealso found between the training and novel environments(F(1,19) = 9.44, P < 0.006). Conclusion: The findings suggest themental imagery program can enhance the stimulus generaliza-tion from training to novel environment. Future research shouldfocus on the clinical outcomes in community reintegration andimprovement in quality of life of patients.

P2-064 Development of an Assessment Protocolto Explore Postural Control and Head Activityin Stroke Using Video Analysis and Coda

D. Hyndman, A. Ashburn, J. Lawrence,and M. BurnettUniversity of Southampton, United Kingdom

Background: Early recovery of sitting balance has been re-ported to predict better functional outcome; it is frequently thefocus of early therapy. The aim of this study was to develop anassessment protocol for recording the head and trunk move-ments of people with stroke. Methods: Short-listed items for theprotocol came from a clinical assessment tool (HAT) previouslydeveloped for people with stroke. 3-D–movement analysis(CODA) of each item was included. Our participants, healthycontrols, and people with stroke (a sample of convenience)completed all items on the short list in order to identify 1) re-dundancy of items, 2) value and reliability of information, and3) assessment time for each item. Results: 5 controls (mean age,43 years) and 5 people with chronic stroke (mean age, 61 years;time since onset, 2 years) were recruited. The initial protocoltook 2 h to complete and required a CODA setup using 24 mark-ers. The final protocol takes 30 min to complete, requires 17markers and can distinguish between people with stroke andcontrols. It includes sitting posture, sideways reaching and vi-sual search using video analysis and CODA, and assessment ofcommunication, reaching forward, and eating with video. TheCODA recordings allow analysis of the extent, sequencing, andpatterns of head and trunk movements. Conclusion: The finalprotocol records the postural control and head activity of peo-ple with stroke and is currently being used with people withacute stroke (≥8 d poststroke) to explore change over time.

P2-065 Analysis of Treatment Effect of PNFMethod for Stroke Patients with Shoulder Pain

Q. YangGuangzhou Work Injury RehabilitationHospital, China

Background: Shoulder pain is a common problem for thestroke patients with hemiplegic symptom during the process ofrehabilitation treatment. According to the Western literature,the rate of shoulder pain occurred for stroke patients in theearly rehabilitation stage is around 72%. The Bobath method is acommon method used for management of these patients. Thereare scanty studies reported the application of PNF method intreating shoulder pain for the stroke patients. Methods: 32stroke patients with hemiplegic symptom were divided intotreatment group (n = 12) and control group (n = 20). Bobathmethod and etc are applied into the control group, whereas PNFmovement pattern and the special technique are applied into

the treatment group. VAS was used to evaluate the pain level be-fore treatment and 4 weeks after treatment. Shoulder pain andmovement function were assessed by Fugl-Meyer (FMA). Re-sults: The results showed that there was no significant differ-ence between treatment group and control group before receiv-ing treatment (P > 0.05). There were significant difference inboth groups before and after 4 weeks’ treatment (P < 0.01), butthe treatment effect in the treatment group is better than that inthe control group (P < 0.05). Conclusion: The PNF movementpattern and special technique have the better treatment effectsfor shoulder pain and movement function of the stroke patientswith hemiplegia.

P2-066 Eligiblity of Stroke Patients forSymptom-Oriented Functional ElectricalStimulation (FES)

G. Koechl, M. Kofler, A. Mayr, E. Quirbach,and L. SaltuariDepartment of Neurology, 6170 Hochzirl, Austria

Background: Results of functional electrical stimulation(FES) studies legitimate intensive efforts to improve its practica-bility. Combining electromyographic (EMG) feedback withEMG-triggered muscle stimulation programs is of particular in-terest in attempting to influence neurologic symptoms. Prereq-uisite for FES, however, is a certain degree of cognitive abilityand of motor control. Methods: The authors evaluated 57 con-secutive stroke patients to assess their ability to use an EMG-triggered electrical stimulation device (Stiwell-Myofeedback)and to determine indications based on the use of various modesof electrotherapy. After a protocol, therapists documented thepatients’ handling of the device, the amount of help requiredfrom the therapist, and the extent of response of the desiredmovement (active wrist extension). Results: Of all patients, 35%were able to use the device alone, 53% required therapeutic as-sistance, and 12% were unable to use it. The occupational thera-pists subjectively selected the following modes of therapy: 58%chose biofeedback programs without muscle stimulation; 38%,combined EMG-triggered FES and biofeedback programs; and4%, EMG-triggered FES alone. Conclusion: Eighty-eight percentof the stroke patients investigated were candidates for FES.EMG-triggered stimulation devices, however, do not providethe therapy of choice in all cases. Combining this form with ex-isting electrotherapy practice, with and without musclestimulation, would be desirable.

P2-067 Spectrum of Program Strategies inSymptom-Oriented Functional ElectricalStimulation (FES) in Neurorehabilitation

G. Koechl, M. Kofler, A. Mayr, E. Quirbach,and L. SaltuariDepartment of Neurology, 6170 Hochzirl, Austria

Background: Evaluation of the use of functional electricalstimulation (FES) in neurorehabilitation underscores the impor-tance of integrating existing methods of electrical stimulation,e.g., myofeedback- and electromyographic (EMG)-triggeredmuscle stimulation, into treatment programs to assist patients inthe active modulation of individual neurologic symptoms.Methods: Using surface EMG electrodes, the authors measured



muscle contraction of wrist flexors and extensors in 15 normalsubjects and 20 stroke patients, while performing passive, ac-tive, and holding movements. The resultant curves were investi-gated for similarities and correlated with clinical functional ex-amination. Results: The patient group curves deviated fromthose typical of the control group, as a result of characteristicdeficits in muscle tone, recruitment, and coordination. Conclu-sion: Graphically shown deviance of neurologically impairedmotor performance from the norm, as illustrated by EMG, couldfoster the use of electrotherapy programs with the goal of ap-proximating the normal curve in a particular function. Symp-tom-oriented electrical stimulation could thus be individualizedfor improving the use of FES.

P2-068 Effects of Treadmill Exercise on BrainDamage and Hippocampal Glutamate Level afterStroke in a Rat Model of Focal Cerebral Ischemia

X. L. Hu,1 L. Y. Leung,1 K. Y. Tong,1 S. M. Zhang,2

and X. X. Zheng2

1The Hong Kong Polytechnic University, HongKong; 2Zhejiang University, China

Background: Early rehabilitation training (24 h after stroke)reduced brain damage in rat after stroke, but some studiesshowed exacerbation of infarction, possibly due to excessiveglutamate in injured brain. This study aimed at evaluating theeffect of early intervention on hippocampal glutamate level af-ter stroke. Methods: Ischemic stroke was induced by middle ce-rebral artery occlusion (75 min) in 14 Sprague-Dawley rats.Two-week treadmill exercise (30 min/d) was prescribed 24 h af-ter stroke to exercise group (EX) (n = 8). Control group (n = 6)remained in cage for 2 weeks. Glutamate level in ipsilesionalhippocampus was monitored by in vivo microdialysis on days 1,2, 4, 7, and 14. Brain damage was quantified using 2,3,5-triphenyltetrazolium chloride–stained brain slices after sacrificeon day 14. Results: Concentration of hippocampal glutamate inEX group was increased during the 1st week, reached the peakon day 7, and then dropped to a lower level on day 14. Gluta-mate level in control group was decreased throughout the 2weeks. Control group had larger brain damage index comparedwith EX group. Although results showed no significant differ-ence, this pilot study provides insights for further investigationsof the relationship between intervention and neurochemicalchanges in brain after stroke. Conclusion: Early treadmill exer-cise may help to reduce brain damage. It may also increase theglutamate level during the 1st week after stroke, but the in-crease may not be high enough to exacerbate the ischemicinjury.

P2-069 Peripheral Neuropathy—A Novel Findingin Dyskeratosis Congenita

P. Ip,1 R. Knight,2 I. Dokal,2 A. Manzur,2

and F. Muntoni21Department of Paediatrics and AdolescentMedicine, Queen Mary Hospital, The University ofHong Kong, Hong Kong; 2Department of Paediatricsand Neonatal Medicine; Department ofHaematology, Imperial College of Science,

Technology and Medicine, Hammersmith Hospital,United Kingdom

Background: Dyskeratosis congenita (DC) is a raremultisystemic disorder characterized by a triad of abnormalskin pigmentation, nail dystrophy, and leucoplakia. DC has notbeen recognized to be associated with the problem ofmyelination of the nervous system. Involvement of the periph-eral nervous system had never been reported. Methods: Case re-port and literature review. Results: This boy was first seen at 7months of age because of repeated shaking of head duringwakefulness. At the age of 1 year, he was found to have sparsethin hair, failure to thrive, and global developmental delay. Inthe 2nd year of life, he was noted to have reduced sensitivity topain, distinct lack of sweating, with thin and malformed nailsprone to breakage but without any teeth abnormality. Motornerve conduction velocity at 2 years of age was suggestive ofdemyelinating neuropathy. At 2 years of age, he developedleukoplakia, petechiae, and easy bruising and was documentedto have thrombocytopenia. Bone marrow examination revealeda hypocellular marrow compatible with primary bone marrowfailure. These hematologic features and presence of dystrophicnails, sparse hair, leukoplakia, failure to thrive, and neurologicabnormality including ataxia related to cerebellar hypoplasialed to a clinical diagnosis of dyskeratosis congenita. Peripheralnerve conduction study repeated at the age of 3 years 9 monthsshowed persistent features of demyelinating neuropathy. Con-clusion: We report peripheral neuropathy as a novel finding indyskeratosis congenital.

P2-070 Attention Deficit–Hyperactivity Disorderand Learning Disabilities—Are They Related?What Is the Treatment?

P. IpThe University of Hong Kong, Queen Mary Hospitaland Children Habilitation Institute, Duchess ofKent Children’s Hospital, Hong Kong

Background: Attention Deficit/Hyperactivity Disorder(ADHD) is characterized by clinically impairing symptoms ofinattention, hyperactivity, and impulsivity that arise duringchildhood and are frequently persistent across development.Children with ADHD may experience significant functionalproblems, troublesome interpersonal relationship with familymembers and peers, and low self-esteem. The high prevalenceof learning disabilities and ADHD comorbidity has been welldocumented. Methods: Review of recent reports and recom-mendations. Results: Learning disabilities (LD) are recognizedas a heterogeneous entity consisting of various subtypes, and itis conceivable that different neurocognitive mechanisms under-lie different disabilities. Specific learning disability in childhoodis frequently associated with attention deficit disorder. Theuniqueness of ADHD associated with LD compared with ADHDwith no LD has been previously suggested. In October 2001,AAP Subcommittee on ADHD put forth a Clinical PracticeGuideline: Treatment of School-Aged Child with ADHD, in-tended to assist primary care physicians in treating ADHD chil-dren. The framework is based on 5 primary recommendations.In December 1999, MTA Cooperative Group evaluated treat-ment of 579 children with ADHD combined type; analysis ofdata concluded that use of medication combined with intensivebehavioral therapy was comparable across all domains to medi-



cal management alone. Conclusion: Early recognition, assess-ment, and management of these conditions can redirect educa-tional and psychosocial development of most ADHD children.

P2-071 Mercury Exposure in Children withAutistic Spectrum Disorder: A Case-Control Study

P. Ip, V. C. N. Wong, M. Ho, J. Lee, and W. WongQueen Mary Hospital, The University of Hong Kong,Hong Kong

Background: Mercury exposure has been proved to be aneurotoxicant at high concentration after the disasters of mer-cury poisoning in Minamata Bay and Iraq. There is a lack of datato evaluate any causal relationship between environmentalmercury exposure and autism. The aim of this study is to investi-gate whether there is any increased mercury exposure in chil-dren with autistic spectrum disorder (ASD). Methods: A cross-sectional cohort study was performed from April to September2000 in Hong Kong. We compared the simultaneous hair andblood mercury levels of children with ASD and a control groupwith normal development. Results: Altogether 82 autistic (meanage, 7.2 y) and 55 normal children (mean age, 7.8 y) were re-cruited. There was no difference in the mean hair or blood mer-cury level in the 2 groups. The mean hair mercury level of autis-tic group and control group was 2.26 ppm and 2.07 ppm,respectively (P = 0.79). The mean blood mercury level of autis-tic group and control group was 19.53 nmol/L and 17.68 nmol/L, respectively (P = 0.15). Conclusion: There was no significantdifference in the hair or blood mercury levels between autisticand normal children. Thus, from this pilot study of a compara-ble cohort with similar environmental mercury exposure, thereis no direct causal relationship between mercury as an environ-mental neurotoxin causing autism.

P2-072 Treatment of Intractable Singultus afterBrain Stem Infarction with Levetiracetam

T. Winter and J. WisselNeurologische Rehabilitationsklinik Beelitz-Heilstätten, Germany

Background: In patients with a stroke of the brain stem,symptomatic myoclonus of the diaphragm can occur, present-ing as persisting singultus. This can cause complications such asreflux and aspiration pneumonia. Common treatment ap-proaches are medication with substances that improve the mo-tility of the intestine, antiepileptic drugs, neuroleptics, and oth-ers such as baclofen or 5HT. Very often this treatment is notsuccessful or has to be terminated because of side effects. Meth-ods: To treat intractable myoclonus of the diaphragm, we exam-ined the efficacy and safety of levetiracetam, an antiepilepticdrug introduced in recent years. Myoclonus of the diaphragmwas interpreted as intractable after at least 2 of the medicationsdescribed above did not reduce singultus. Duration, frequencyand amplitude of diaphragm myoclonus were documented clin-ically and by electromyogram of the diaphragm in 7 patientswith infarction in the brain stem. Results: We started treatmentwith levetiracetam at a single dose of 500 mg, increasing twice aweek by 500 mg up to a maximum dose of 3000 mg/d. Medica-tion was given in equal dosages in the morning and evening. Wenoted a dose-dependent decrease of diaphragm myoclonus du-ration and amplitude but not of frequency. All patients becamefree of diaphragm myoclonus. No severe side effects were seen.Conclusion: We demonstrated that levetiracetam is safe and ef-

ficacious in the treatment of symptomatic myoclonus of thediaphragm after brain stem infarction.

P2-073 The Significance of CricopharyngealDysfunction-Related Dysphagia in MedullaryInfarction Patients

S. G. Lee,1 I. S. Choi,1 Y. M. Cho,2 J. H. Kim,2

and S. Y. Lee2

1Department of Physical Medicine & Rehabilitation,Research Institute of Medical Sciences, ChonnamNational University Medical School & Hospital,South Korea; 2Chonnam National UniversityHwasun Hospital, South Korea

Background: Dysphagia is the crucial symptom affecting theprognosis of patients with brain stem stroke. The aim of thisstudy was to examine the significance of cricopharyngeal dys-function–related dysphagia in medullary infarction patients andto evaluate the swallowing characteristics based on the lesionlocations. Methods: The study subjects were 8 dysphagic pa-tients associated with medullary infarction. Brain MRI andvideofluoroscopic swallowing studies were performed in allsubjects. Disability rating scale for swallowing impairment andscale for functional outcomes related to nutritional route wereassessed. Results: Increased pyriform sinus residue and incom-plete cricopharyngeal relaxation were revealed in all patients.Aspiration was detected in 7 of 8 patients. Brain lesions weredorsolateral medulla (5 patients) and inferior dorsolateral me-dulla (3 patients). Nasogastric tubes were removed at about 2months after onset. Initial disability rating scale for swallowingimpairment was grade 2 (1 patient), grade 3 (4 patients), andgrade 4 (3 patients). The scale for functional outcomes relatedto nutritional route improved to normal in all patients (to grade5 from grade 1, 5 patients; from grade 2, 2 patients; from grade3, 1 patient). Conclusion: Dorsolateral and inferior dorsolateralmedullary infarction patients showed a fairly reversiblecricopharyngeal relaxation abnormality. Conservativedysphagia management would be helpful in these patientsduring the acute stage of stroke.

P2-074 Effect of Hydrotherapy on the FunctionalStatus in Ischemic Stroke Patients

S. G. Lee,1 S. Y. Lee,2 H. L. Im,1 J. H. Kim,2

and I. S. Choi11Department of Physical Medicine & Rehabilitation,Research Institute of Medical Sciences, ChonnamNational University Medical School & Hospital,South Korea; 2Chonnam National UniversityHwasun Hospital, South Korea

Background: Hydrotherapy is one of the beneficial thera-peutic modalities for musculoskeletal relaxation, furthermoreneuromotor control in stroke patients. The aim of this study wasto investigate the effect of hydrotherapy in hemiplegic patientswith ischemic stroke. Methods: 24 stoke patients with MCA terri-tory infarction who revealed more than 26 points in Mini-MentalStatus Exam and Brunnstrom stage II were recruited in thisstudy and patients with cardiac risk were excluded. Fourteenexperimental patients were treated with neurodevelopmentaltreatment (NDT) and hydrotherapy. Ten control patients weretreated with only NDT. Hydrotherapy programs were com-posed of aquatic treadmill walking, range of motion exercise,



stretching exercise, aquatic balance training, and hydrostaticstimulation in subtotal body immersion state. Those programswere performed for 20 min a session, once a day, 5 times aweek, for a total of 6 weeks. The evaluation parameters wereFunctional Independence Measure (FIM), modified Barthel in-dex (MBI), MAS, and Balance score assessed before and afterthe treatments. Results: 1) In both groups, FIM, MBI, and MASscores increased after treatment. However, the difference be-tween the 2 groups was not significant. 2) Mean balance scoreincreased significantly in the experimental group comparedwith the control group. Conclusion: We think that hydrotherapymay be used as an adjuvant therapy for balance training inhemiplegic patients with ischemic stroke.

P2-075 The Clinical Characteristics of CentralPoststroke Pain on the 11-Year Medical Records

S. G. Lee,1 J. H. Kim,2 I. S. Choi,1 S. Y. Lee,2

and G. I. Jung3

1Department of Physical Medicine & Rehabilitation,Research Institute of Medical Sciences, ChonnamNational University Medical School & Hospital,South Korea; 2Chonnam National UniversityHwasun Hospital, South Korea; 3Gwangju VeteransHospital, South Korea

Background: Central poststroke pain (CPSP) is aneuropathic pain syndrome characterized by pain and sensoryabnormalities in body part correlated with lesion location afterstroke. The aim of this study was to investigate the clinical char-acteristics of CPSP from the data of 11-year medical records.Methods: We studied 274 stroke patients (146 men, 128 women;mean age, 61.5 ± 13.4 years; 128 ischemic, 72 hemorrhagic) ob-served between January 1994 and July 2004 by reviewing themedical records in the tertiary hospital-based setting. Results:Of 274 patients, 1) CPSP was found in 39 (14.2%) patients. 2)There were no relation between patient’s sex, age, or stroketype and the presence of CPSP. 3) CPSP was most commonlyfound in patients who had middle cerebral artery territory le-sion among the ischemic CPSP groups and subcortical lesionamong hemorrhagic CPSP groups. 4) Among CPSP patients, thesite of CPSP was found in upper limb, lower limb, trunk, head,and face in the order of frequency. 5) The pain nature of CPSPwere expressed as “aching,” “burning,” “pricking,” “lacerat-ing,” “shooting,” and “throbbing” in order of frequency. 6) Theaggravating factors of CPSP were cold stimulation, warm stim-ulation, emotional changes, movement, and skin touch in or-der of frequency. 7) Anticonvulsant, antidepressants, andantiarrhythmics were commonly used as the drugs for the man-agement of CPSP. Conclusion: We think that the understandingson the clinical features of CPSP will be helpful for the evaluationand management of CPSP.

P2-076 Correlation between FunctionalEvaluation Scales and Cognitive Evoked Potentialsin Patients with Chronic Stroke

I. S. Choi,1 S. G. Lee,1 S. H. Jung,1 J. H. Kim,2

and S. Y. Lee2

1Department of Physical Medicine & Rehabilitation,Research Institute of Medical Sciences, ChonnamNational University Medical School & Hospital,

South Korea; 2Chonnam National UniversityHwasun Hospital, South Korea

Background: Cognitive evoked potentials(CEP) is an evalu-ation tool for cognitive function in stroke patients. This studywas to investigate the correlation between functional evalua-tion scales and CEP in chronic stroke patients afterneurocognitive rehabilitative treatment. Methods: 10 patients(mean age, 53 ± 15 years; 5 men, 5 women; mean prevalence,210 ± 143 d) among chronic stroke patients with middle cere-bral artery territory infarction were more than 15 points in Mini-Mental Status Examination (MMSE). They performedneurodevelopmental and cognition-rehabilitative treatmentstwice a day, 5 times per week, for 4 weeks. Before and aftertreatment, the evaluation of cognitive ability was assessed byMMSE, Loewenstein occupational therapy cognitive assess-ment, and motor-free visual perception test, and functionalstate was assessed by Functional Independence Measure (FIM)and National Institute of Health Stroke Scale (NIHSS). P300 la-tencies of CEP were measured by 2-tone discrimination task;hearing stimulation type was oddball paradigm. Results: Instudy group, 1) All scales showed significant improvement (P <0.05). 2) P300 latencies significantly decreased from 420 ± 34 msto 391 ± 36 ms (P < 0.05). 3) Decrease of P300 latencies showedsignificant correlation with the improvement of FIM and NIHSS(r = –0.616, P < 0.05; r = 0.829, P < 0.05). Conclusion: We thinkthat CEP study may be a useful method for reflecting the effectof cognition-rehabilitative treatment and prospecting the func-tional recovery in chronic stroke patients.

P2-077 Effects of Transcutaneous Electrical NerveStimulation (TENS) on the Regional CerebralBlood Flow (rCBF) of Stroke Patients

Y. Guo,1 T. Yan,1 and C. W. Y. Hui-Chan,2

Second Affiliated hospital, Sun Yat-sen University,China; 2The Hong Kong Polytechnic University,China

Background: TENS has been used in stroke patients. How-ever, its effects on the brain rCBF of stroke patients, when ap-plied to acupuncture points, were little studied. This study wasto investigate whether TENS could improve the brain rCBF ofstroke patients tested by single photon emission computed to-mography (SPECT). Methods: 22 patients with 1st stroke wererecruited. They were randomly assigned to treatment group orcontrol group through stratification. Eight acupuncture pointsof the paralysis limbs were selected including LI15, LI11, LI4,SJ5 in the upper limb and ST36, ST41, GB34, BL60 in the lowerlimb. Electrodes of TENS devices were applied on the selectedpoints. The stimulation was delivered at 100 Hz with intensity topatients’ maximum endurance. Patients were examined forrCBF on 2 sessions with an interval of either receiving TENStreatment or only rest for 60 min. Results: No significant differ-ences were found between groups before treatment. At the 1stSPECT test, the affected area and its penumbral region of thebrain showed the low radioactive distribution in both groups.However, when compared with the control group, patients whoreceived TENS treatment showed significant improvement inrCBF of the affected area and its penumbral region, in the per-centage changes of the affected area, as well as the asymmetryindex (P < 0.01). Conclusion: 60 min of TENS applied on theacupuncture points of the paralysis limbs increased rCBF inboth affected and unaffected brain of 1st stroke patients.



P2-078 Improving Functional Activity of theSpastic Upper Limb in the Chronic Stage afterStroke following Botulinum Toxin

F. M. J. van Wijck,1 J. Mackenzie,2 A. D. Pandyan,3

M. P. Barnes,4 and G. R. Johnson4

1Queen Margaret University College, UnitedKingdom; 2Hunters Moor Regional NeurologicalRehabilitation Centre, United Kingdom; 3KeeleUniversity, United Kingdom; 4University ofNewcastle upon Tyne, United Kingdom

Background: Botulinum toxin-type A (BTX-A) is used in-creasingly to treat spasticity, but its effects on function are lim-ited. Function may be improved through task-specific training,but the effects of combining this with BTX-A have not yet beenresearched. This pilot RCT aimed to investigate the effects oftask-specific training together with BTX-A on upper limb func-tion and spasticity. Methods: 14 participants consented andwere randomized into the task-practice group (EG) or a controlgroup (CG), which was fitted with an inflatable arm splint. AfterBTX-A, treatment for both groups was given for 3 weeks, 1 hourper day, 5 days per week. Outcomes were assessed at baseline,week 4, 7, and 13 and included the Action Research Arm Test(ARAT), Stroke Impact Scale (SIS), and elbow flexor EMG as ameasure of spasticity. Results: 2 EG participants dropped out forextraneous reasons. There were no significant differences be-tween EG and CG at baseline. Changes in the CG were negligi-ble. Compared to the CG, the EG improved in hand function(SIS) between baseline and week 4 (Z = –2.35, P = 0.04), armfunction (ARAT) between baseline and week 7 (Z = –2.67, P =0.003) and ADL (SIS) between baseline and week 13 (Z = –2.35,P = 0.02). There were no significant differences in EMG be-tween EG and CG. Conclusion: Functional activity of the spasticupper limb in the chronic stage after stroke improved only inthe group where BTX-A had been combined with task-specifictraining. The additional activity did not excacerbate spasticity.

P2-079 The Chinese Alphabet Logical LanguageSystem (CALL)—An Innovative and EffectiveMethod for Stroke Patient to Learn InputtingChinese with a Computer

C. S. F. Yau,1 L. S. W. Li,1 D. M. Y. Kwong,2 M. M. L.Chu,3 and C. Y. Huang4

1Tung Wah Hospital, Hong Kong; 2Pamela YoudeNethersole Eastern Hospital, Hong Kong; 3QueenMary Hospital, Hong Kong; 4Sino Vista System(HK), Hong Kong

Background: Computer-related activity is a valuable modal-ity of rehabilitation for enhancing both communication andQOL. However, there is a relative paucity in available systemsfor Chinese-speaking subjects. The CALL system is a brand-newmethod of inputting Chinese with a computer; it overcomesmany of the problems of the current methods. This researchused a descriptive case study design to examine the effective-ness and perceptions of neurologic patients who learned to usethe CALL system. Methods: The sample consisted of 9 subjectswho completed 3 measures 1) a posttraining test, 2) an attitudequestionnaire. and 3) a semistructured interview. Componentsof the test included input speed and accuracy. The question-naire examined 1) the motivation and the needs of subject inlearning and using a computer and 2) the difficulties encoun-

tered during the learning process. Results: Results showed inputspeed to be the fastest by those who had higher motivation andnever learned other inputting systems (t = 6.75, P < 0.001) Accu-racy of input did not vary significantly. Overall performance didnot necessarily co-relate to the difficulties encountered by thesubjects. Conclusion: All subjects were able to use the CALL sys-tem to input Chinese and thus improved their computer literacy.This in turn will enhance their QOL by broadening the scope ofactivities. Further exploration of the usefulness and acceptanceof computer use in rehabilitation of Chinese speakers and fur-ther development of such systems are warranted.

P2-080 Combining Bilateral and Distal ArmTraining to Promote Arm and Hand Recovery inPatients with Chronic Hemiparesis: A CaseReport

S. McCombe Waller and J. WhitallUniversity of Maryland, USA

Background: The recovery of useful hand function afterstroke is a major scientific challenge for stroke treatment today,particularly for those with more severe hemiparesis. Combiningproximal and distal arm training strategies can potentially pro-vide a major improvement over isolated training approachesand will reach a wider range of patients. This case study de-scribes the outcome of combining bilateral proximal trainingwith unilateral distal-based training on functional recovery ofthe arm in a patient with chronic moderate-severity hemi-paresis. Methods: The patient received 6 weeks of bilateral armtraining with rhythmic auditory cueing followed by 6 weeks ofdistal-active whole arm training using the Saeboflex wristorthosis in a standardized motor retraining program. Measuresof impairment and function were taken at baseline and after 6and 12 weeks of training. Results: Improvements were seen inthe Fugl-Meyer (28.5%), Wolf Motor Arm Test (11%), UMAQs(daily use) (82%), grasp (17%), active shoulder flexion (11%)and abduction (20%), shoulder flexion strength (30%), and re-duced Modified Ashworth score. Conclusion: Combining bilat-eral proximal and distal arm training shows promise in promot-ing recovery of useful function of the arm in a patient withmoderate-severity chronic hemiparesis. We discuss the implica-tions of proximal training and its priming effect and the signifi-cance of active hand involvement in training after stroke inthose with more severe hemiparesis.

P2-081 Psychometric Properties of a ModifiedWolf Motor Function Test in Mildly andModerately Impaired Patients with ChronicHemiparesis

J. Whitall,1 D. Savin,1 M. Harris-Love,2 and S.McCombe Waller1

1University of Maryland, Baltimore, USA;2National Institutes of Health, USA

Background: Stroke is the leading cause of long-term dis-ability in the United States, and many research teams are work-ing on techniques to improve functional recovery of stroke sur-vivors. This effort requires good methods of assessing thefunctional limitations caused by stroke. One test that involvesfunctional tasks is the Wolf Motor Function Test. Since this testwas developed and validated on mildly impaired patients, wechose to investigate the psychometric properties of a modified



version of this test on mildly and moderately impaired patientsas well as investigate the need for videotaping the test. We mod-ified the test for our moderately impaired patients by excludingthe possibility of using the nonparetic arm to assist in accom-plishing the tasks. Methods: 66 subjects with chronic armhemiparesis were tested on 3 visits in a study that investigatedinterrater reliability, test-retest reliability, item stability, andconcurrent validity with the Fugl-Meyer Upper Extremity Test.Results: Regardless of impairment level, we found highintraclass coefficients (0.96-0.99) for videotape vs. direct obser-vation (3 raters), high test-retest reliability (0.97-0.99), stabilityafter the 2nd administration of the test and high concurrent va-lidity (0.86-0.89). Conclusion: The modified Wolf Motor Func-tion Test does not require videotaping with trained raters, and ithas good psychometric properties. We discuss the implicationsof the modification.

P2-082 Does Age Predict Outcome in StrokeRehabilitation? A Study of 878 Chinese Subjects

J. K. H. Luk,1 R. T. F. Cheung,2 S. L. Ho,2

and L. S. W. Li31Acute Geriatrics Unit, Grantham Hospital, HongKong; 2Department of Medicine, Queen MaryHospital, Hong Kong; 3Division of Rehabilitation,Tung Wah Hospital, Hong Kong

Background: The predicting value of age on stroke rehabili-tation has been controversial. There is a lack of large scale stud-ies in Chinese population to examine the effect of age on strokerehabilitation. Methods: This retrospective cohort study includesstroke patients receiving standard inpatient multidisciplinary re-habilitation program in a neurorehabilitation ward of a conva-lescence hospital in Hong Kong. Functional IndependenceMeasure (FIM) ≥90 was used to define a good outcome. Results:878 subjects with 471 (53.6%) men and 407 (46.4%) womenwere studied. There were important differences in clinical char-acteristics and complications of stroke among patients of 3 agegroups: <65 years, ≥65 years and <80 years, and ≥80 years. Thetotal FIM scores both on admission and at discharge were lowerin the older age groups. No significant difference was observedin the changes of FIM scores across these age groups (1-wayANOVA, P = 0.067). Age was not an independent predictor for agood outcome. FIM upon admission was an independent pre-dictor for good outcome in all patients and in individual agegroups. Having employment before stroke was a predictor forgood outcome in all patients. Living at home prior to stroke wasa predictor for the total population, and the ≥65 and <80 yearsgroup. The length of stay predicted a good outcome in the ≥80years group. Conclusion: As older patients show comparableimprovement during rehabilitation, intensive rehabilitationshould not be withheld in stroke patients simply because of ad-vanced age.

P2-083 The Influence of the Exercises ofQuadriceps Femoris Isometric Systole to theWalking Capability of Hemiplegia with lowMuscle Tone

H. B. LiuGuangzhou Working Injury RehabilitationHospital, China

Background: To observe the influence of exercises ofquadriceps femoris isometric systole to the walking capabilityof hemiplegia with low muscle tone. Methods: 46 patients,whose affected lower limbs were still in flaccid paralysis 3months after the event, were divided into 2 groups by random.Twenty-three patients, who were in the control group, receivedthe conventional care. The other patients were in the strength-ening group. In addition to the conventional rehabilitationtreatment, they received exercises of quadriceps femoris iso-metric systole by using GT-30 muscle testing and training de-vice twice every day, 20 to 30 min in each session with an aver-age period of treatment of 2.5 months. Both groups of patientswere assessed by testing of quadriceps femoris and assessmentof walking capability before and after the treatment. Results:Compared to their previous conditions, the control group didnot show significant change (P > 0.05), but the strengtheninggroup showed improvement (P < 0.01). The walking capabilityof both groups improved remarkably (P 0.05) and the strength-ening group was better than the control group (P < 0.01). Con-clusion: The exercises of quadriceps femoris isometric systoleimprove effectively the walking capability of the hemiplegicswith low muscle tone.

P2-084 Influence of Unilateral Spatial Neglect tothe Recovery of Limbs’ Motor Function of StrokePatients with Hemiplegia

S. W. LiuGuangzhou Work Injury RehabilitationHospital, China

Background: To study the effect on the limbs’ motor func-tion recovery after stroke with unilateral spatial neglect (USN).Methods: Right hemispheric stroke patients, who were admittedfor rehabilitation, were evaluated by neuropsychologic assess-ment. Thirteen stroke patients were identified with USN and re-cruited as an observation group. Twenty-one stroke patientswithout USN served as a control group. All patients did not man-ifest any other serious clinical cognitive dysfunctions and apha-sia. Both groups received conventional rehabilitation therapy.They were evaluated by Fugl-Meyer motor scale (FMA) beforeand after 8 weeks rehabilitation. Results: There were no signifi-cant differences between the FMA scores of patients in the ob-servation and control group before therapy (P > 0.05). After 8weeks of rehabilitation treatment, the change of FMA scores be-tween the observation and control group was significantly dif-ferent (P < 0.05). Conclusion: The presence of USN is an ad-verse prognostic factor for the rehabilitation of limbs’ motorfunction of stroke patients with hemiplegia.

P2-085 Improving Brain efficiency UsingEMG-Inititated Muscle Stimulation in ChronicStroke—A Pilot Study

N. J. Nairi1 and S. Hastak2

1Wellspring, India; 2Lilavati Hospital, Bandra West,Mumbai, India

Background: It is well known that functional recovery takesplace maximally in the 1st 6 months of stroke. Study conductedto find effectiveness of Mentamove method to bring functionalrecovery in chronic stroke patients. Methods: 10 patients with



MCA territory involvement from 6 months to 12 years of strokewith no definite improvement in the last month were selected.Mentamove brain efficiency training device made in Germanywas used to give EMG-initiated electrical stimulation to mus-cles. Patients were asked to imagine a purposeful movement,which increased the action potential in the muscle, triggering anactivity. Movement performed closed the voluntary motor con-trol loop via sensory pathways, starting the process of motorlearning. Patients were examined every month on the ICF scaleto assess tone, strength, pain, gait and fine motor skills. Results:3 months of training with Mentamove showed 50% reduction intone in both extremities and about 20% increase in the musclepower on MRC scale of 1 to 5. Pain was reduced to almost zeroon 0 to 10 VAS in all patients. Improvement in gait pattern andspeed was seen, and family members noted clarity in speechand sentence formation and a positive mood change in the pa-tients. Improvement in fine motor skills was noted in only 1 pa-tient. Conclusion: Pilot study suggests that Mentamove methodwas useful in reducing spasticity and pain in majority of patientsafter chronic stroke. This helped them to recover to a degreewhich was not observed with conventional physiotherapymethods.

P2-086 Changes in Cortical Excitability withFunctional Electrical Therapy

M. J. Grey,1 G. Barsi,1 S. D. Iftime,1 A. Roepstorff,2

and T. Sinkjaer1

1Center for Sensory-Motor Interaction, AalborgUniversity, Denmark; 2Center for FunctionallyIntegrative Neuroscience, University of Aarhus,Denmark

Background: Functional electrical therapy (FET) is an ex-perimental rehabilitative therapy for stroke that combines vol-untary activation with patterned peripheral electrical stimula-tion (ES). Although excellent clinical results have beenreported, the mechanisms by which the therapy may effectthese changes have not yet been fully investigated. Methods:Healthy subjects were instrumented with surface stimulationelectrodes on right arm finger flexor-extensor muscles. Pat-terned electrical stimuli were used to open and close the handwith (FET) or without (ES) voluntary activation (VA). Corticalexcitability was assessed during task execution with functionalmagnetic resonance imaging (fMRI; 3T GE scanner) and as a re-sult of the 3 tasks via stimulus-response curves with transcranialmagnetic stimulation (TMS). Results: fMRI showed activity withES, FET, and VA, mainly in a left lateralized network that in-cluded primary and sensory motor regions; FET and ES gener-ated bilateral inferior parietal activity when compared with VA.After 20 min of stimulation, a large increase in the TMS stimulus-response curve was observed with FET, whereas no change wasobserved with a similar course of ES or VA. Conclusion: Our re-sults support the idea that FET might lead to better rehabilita-tion of stroke compared with exercise alone. Our fMRI observa-tions suggest that FET evokes activity in regions that have beenassociated with proprioception. We can speculate thatproprioception might be important for effective rehabilitation.Funding: DNRF.

P2-087 Acoustical Analyses Contribution toDysarthria Rehabilitation

K. Z. Ortiz and L. CarrilloUniversidade Federal de São Paulo, Brazil

Background: Neurologic dysphonias are common indysarthric patients, and it is important to establish the correct di-agnosis and also the therapeutic intervention. The acousticalanalysis is necessary for the complete understanding of motorspeech disorders. The aim of this study is to describe auditoryand acoustical analyses of voice in different types of dysarthia.Methods: We evaluated 23 dysarthric patients, 12 men and 11women, ages ranged from 20 to 76 years. All patients had theirvoices recorded and analyzed. Results: We had 6 patients withflaccid dysarthria that had harsh- breathiness voice quality, withbadly defined harmonics; 6 patients with hypokinetic dysartrhiathat presented harsh-breathiness-asthenic voice and no supe-rior harmonics; 5 patients with spastic dysarthria with harsh-breathiness voice and strained-strangled quality, no superiorharmonics, subharmonics, and badly defined harmonics; 6 pa-tients with unilateral upper motor neuron dysartrhia had voiceharsh-breathiness with instability and superior harmonics badlydefined. All acoustical analyses showed noise. We also ob-served changes in length of phonation and main frequency re-lated to different types of dysarthria by auditory analyses. Con-clusion: In conclusion, the acoustical associated to auditoryanalyses give important information about laryngeal functionand about changes in voice quality, important parameters fortherapeutic approach, and rehabilitation.

P2-088 Assessment of Language and CalculationDisorders in aphasic Patients

K. Z. Ortiz and G. C. P. De LucciaUniversidade Federal de São Paulo, Brazil

Background: Acalculia is a deficit in calculation ability thatcan be found in brain-damaged patients. It was first describedby Henschen (1919), and it is frequently associated with lan-guage disorders. Studies are necessary to investigate the corre-lation between language and arithmetical cognition, with spe-cial attention to short- and long-term memory that are linked inmathematics processes. They are responsible by storing pho-netic or phonologic and visuospatial information, and there isalso an executive central system that can centralize and processinformation in other subsystems, making possible that cognitiveprocesses such as learning and reasoning can be activated.Methods: The aim of this study is to present a proposal of evalu-ation that investigates the association between calculation andlanguage disorders. For that, we elaborated a protocol com-posed by EC-301 battery and language evaluation tasks. EC-301battery is composed by mental calculation tasks, visual andamount-spatial orientation, and numerical reading and writingtasks. Language tasks are composed by written or oral emissionand comprehension evaluation, repetition, naming, copy, dicta-tion, and verbal fluency. Results: With this protocol, we intendto investigate how specific language disorders can influencecalculation processing in aphasic patients. Conclusion: We be-lieve that the comprehension of each calculation deficit associ-ated with specific language disorders is important for treatmentefficacy in this population.



P2-089 The Role of Working Memory inSpeech Apraxia

F. C. Martins, B. M. Chiari, and K. Z. OrtizUniversidade Federal de São Paulo, Brazil

Background: In 1974, Baddeley and Hitch proposed the 1stworking memory (WM) model, which involved a “unitary work-ing storage” with limited capacity. Changes were made throughthe decades, and in 2000, Baddeley established the latestmodel. It comprises 4 linked subsystems: a phonologic loop,which plays an important role in speech code material storageand its retrieval; a visuospacial sketchpad; an episodic buffer;and a central executive. The aim of this study was to verify theinfluence of working memory in speech programming. Meth-ods: For that, we evaluated the performance of 19 apraxic sub-jects who had suffered cerebral vascular accidents and corticaldamage in the left hemisphere using indirect digit and wordspan tests. Results: Regarding the word span test, 10 patients(52.6%) were able to store and retrieve only 2 words; 6 (31.5%)had obtained a 3-word span; 4- and 5-word spans were ob-tained by 1 (5.3%) subject each, and 1 patient (5.3%) was notsubmitted to this test. Regarding the indirect digit span test, 2(10.5%) patients were not able to store, inverse, and recall anydigit; 11 (57.9%) subjects were able to recall only 2 digits; 5(26.3%) were able to retrieve 3 digits, and 1 subject had ob-tained a 4 indirect digit span. Conclusion: Our findings show re-duced word and indirect digit spans in apraxic speech patients,indicating a deficit of the articulatory loop. Considering thesedata, we can suggest an influence of the articulatory loop com-ponent of the WM in speech motor programming.

P2-090 Performance of Normal Literate Subjectsin the M1 Beta-86 Test

F. C. Martins, E. C. S. Soares, and K. Z. OrtizUniversidade Federal de São Paulo, Brazil

Background: Language assessment should consider bothoral and written modalities. Tests are a good option for evalua-tion, but it is necessary to know the performance of a normalpopulation in their tasks. The aim of this study was to verify theperformance of normal adults with different levels of educationand ages on the M1 Beta-86 Test. Methods: For that, 68 volun-teers were evaluated, 34 with 1 to 8 years of schooling (10 menand 24 women) and 34 with more than 8 years of schooling (11men and 23 women). All subjects were Portuguese nativespeakers whose ages ranged from 17 to 76 years. The subjectswere subdivided into groups according to age: up 50 years, 51to 65 years and above 65 years of age. M1 Beta is a Brazilian testproposed for aphasic patients that has the following tasks: oraland writing comprehension, writing, reading, repetition, nam-ing, automatic series, verbal fluency, and praxia of speech. Re-sults: We found differences between the groups with differentyears of schooling in tasks like naming, verbal fluency, andwriting. In addition, we found differences according to age inverbal fluency and writing, because subjects above 65 years hadthe worst performance. There was no difference between sexes.Conclusion: In conclusion, we agree that educational level andage can be related to performance of normal adults in some lan-guage assessment tasks of the M1-Beta test.

P2-091 Assessing the Lexical Components ofGesture Processing: a Brazilian Proposal

F. C. Martins, J. Mantovani, and K. Z. OrtizUniversidade Federal de São Paulo, Brazil

Background: Apraxia is defined as a disorder in executionof learned movements that is not explained by abnormality inelemental motor or sensory systems, intellectual deficits, or ei-ther attention or comprehension disorders. Models of normalprocessing of gestures have been proposed that suggest the ex-istence of a lexical route that supports recognition, identifica-tion, and production of familiar gestures. So a deficit in the exe-cution of learned gestures could also be caused by damage tothese lexical components. Some studies have used tests to as-sess the lexical components of gesture execution, but none ofthem is Brazilian. Considering that sociocultural patterns play arole in execution of motor acts, the aim of this study was to pro-pose a Brazilian battery of tests to assess the lexical componentsof gesture processing. Methods: We reviewed most of the testsproposed for different populations, and a battery consideringBrazilian patterns was prepared. Results: Our battery comprises5 tests: naming and comprehension of actions and objects; de-scription and recognition of the function of objects; and com-prehension of transitive gestures. The same objects and transi-tive gestures are used across all tasks. Conclusion: We expect toobtain an efficient battery of tests for the assessment of the lexi-cal components involved in the processing of gestures, appro-priate to Brazilian population, which will provide us with infor-mation about the nature of apraxic disorders.

P2-092 The Development of Toxin NeutralizingAntibodies with Botulinum Toxin Type A (BoNTA)Treatment

S. Yablon,1 S. Daggett,2 F. Lai,1 and M. F. Brin1

1University of Mississippi School of Medicine, USA;2Allergan, Inc., USA

Background: There is a risk of neutralizing antibody forma-tion with repeated treatment with botulinum toxin type A(BoNTA; BOTOX®, Allergan, Inc., Irvine, CA). The currentBoNTA formulation was tested using the mouse protection as-say (MPA) on serum samples obtained from patients previouslynaive to BoNTA in cervical dystonia (CD), chronic headache,and poststroke spasticity trials. Methods: CD patients (1 study; n= 326) received 1 to 15 BoNTA treatments (median, 9 treat-ments; mean per treatment, 187 U; range, 20-500 U; maximumtotal per patient, 4210 U); chronic headache patients (2 studies;n = 356) received 3 BoNTA treatments (mean, 157 U; range, 75-260 U; maximum, 780 U); and poststroke spasticity patients (3studies; n = 247) received 1 to 4 BoNTA treatments (median, 2treatments; mean, 241 U; range, 100-360 U; maximum, 960 U).Samples (2 mL) were obtained at baseline, before each injec-tion, and study exit and analyzable samples were tested usingthe MPA. Results: Of 929 patients, 880 had analyzable samples,and 5 tested positive (0.6%), 4 of whom were CD patients, witha maximum exposure to BoNTA ranging from 1200 to 3100 U.The other patient was a spasticity patient who was MPA-positiveafter 1 treatment of 200 U of BoNTA. Only the spasticity patientdid not demonstrate clinical responsiveness at the time of re-



porting the positive MPA. Conclusion: The rate of antibody for-mation was 0.6% in patients who received repeated BoNTA in-jections with the current formulation.

P2-093 Cogntivie Screening in Common PatientGroups Seen in Neurorehabiliation

E. Esbjörnsson, C. Hofgren, and K. SunnerhagenClinical Neuroscienece–Rehabilitation Medicine,Göteborg University, Sweden

Background: There is a need for a clinical useful screeninginstrument of cognitive function. Barrow Neurological InsituteScreen (BNIS) was developed to identify brain damage and tomonitor rehabilitation. The aim was to compare the BNIS fromcommon patient groups seen in neurologic rehabilitation to acontrol population. Methods: Data from 88 persons, 18 to 70without known previous history of head injury, psychiatric dis-ease, or substance abuse, were gathered. Data from the follow-ing patient groups were gathered from the clinic: stroke righthemisphere, stroke left hemisphere, traumatic brain injury, Par-kinson’s disease, and post cardiac arrest, with 24 in each group.Results: There were significant differences between the healthycontrols and all the patient groups (P < 0.001) both for the totalscore and for the various subscales. The ranking order (Kruska-Wallis) of the subscales differed significantly (P < 0.001) be-tween the patient groups. Speech and language was most diffi-cult for left hemisphere stroke followed by cardiac arrest.Visuospatial and visual problem solving was most affected inthe cardiac arrest group followed by right hemisphere stroke.The cardiac arrest group had the most pronounced memoryproblem followed by traumatic brain injury. Conclusion: TheBNIS separate common patient groups from healthy controls.The various diagnosis show different results on the subscales asexpected. In this comparison, cardiac arrest seems to affect thecognition most and Parkinson the least.

P2-094 Training of Temporal-Order Perceptionin Aphasia: Preliminary Results

P. Ulbrich,1 M. Fink,1 J. Churan,1 and M. Wittmann2

1Ludwig-Maximilian University of Munich,Germany; 2University of California San Diego, USA

Background: It has been shown that training temporal-pro-cessing abilities can improve language abilities in children withdyslexia and language-learning impairments. Only 1 study hasbeen published in which patients with aphasia were trainedwith a temporal-order task. This training subsequently im-proved speech perception as measured by a phoneme-identifi-cation task on the syllable level. The present study investigateswhether training temporal-order perception also affects morecomplex language tasks. Methods: Temporal-order thresholdswere measured using 2 clicks (left, right) and 2 tones (high,low). Aphasic patients with elevated thresholds in 1 of the taskswere trained with the respective paradigm on 8 sessions lasting45 min each. Language abilities were assessed with phoneme-identification tasks on the word and sentence level. Results: Pre-liminary results in patients show that order thresholds decreaseafter training. After training with the click paradigm, individualpatients made fewer errors in the phoneme-identification taskon the word level. The sentence level did not seem to be af-fected. Conclusion: The training of temporal-order perception

in individual patients with aphasia can improve temporal pro-cessing, as well as phoneme-identification abilities. Furthertraining will show whether this effect is task dependent andwhether improvements in speech perception can also be seenin complex language tasks. This study was supported by BMBFgrant 01 GZ 0301.

P2-095 Computer-Asisted Treatment forAnomia in Acute Aphasia: How SpecificDoes It Have to Be?

M. Laganaro, M. Di Pietro, and A. SchniderGeneva University Hospitals, Division ofrehabilitation, Switzerland

Background: Treatment intensity is an important predictorof the efficacy of therapy for aphasia, which can be addressedby introducing computer-assisted treatment (CAT). In 2 previ-ous studies, we showed that CAT for anomia can be effectivealso in acute aphasic patients. Here, we explored whether CATprograms must be adjusted to the precise type of anomia orwhether a multicomponent program works for most anomicprofiles. Methods: 7 aphasic subjects in the acute stage took partin the study. Two periods of 4 CAT sessions each, added to dailyaphasia therapy, were compared to a 2-week period withoutCAT. In one period, a multicomponent CAT program was used;in the other period, the program was selected according to eachpatient’s anomic profile. Results: All patients improved theirnaming ability during the 2-week CAT period, whereas therewas no significant improvement during the period without CAT.Six patients showed similar improvement with the 2 CAT pro-grams. Conclusion: Results replicate those from our previousstudies and further demonstrate that CAT is effective and can beused to increase treatment intensity for anomia. In most cases, amulticomponent program leads to equivalent results as a pro-gram adjusted to the specific cognitive impairment.

P2-096 Effects of Middle- and Long-termCognitive Rehabilitation in Wernicke’s Aphasia

S. Atasavun and T. DügerHacettepe University Physical Therapy andRehabilitation School, Turkey

Background: Aphasia is a common problem in neurologicdiseases, especially after cerebrovascular accident. The aim ofthis study is to investigate the effects of mid- and long-term re-habilitation in patients with Wernicke’s aphasia. Methods: Thepatients were a 50-year-old man and a 44-year-old woman.Their brain CT scans showed that there were large infarcts in thearea supplied by the left MCA. Their cognitive levels were eval-uated with Mini-Mental State Examination (MMSE) and LOTCA.The middle-term rehabilitation was to apply 45 min, 2 times aweek of training for 5 months. The long-term rehabilitation wasto apply 45 min, 2 times a week of training for 2 years. The as-sessments were repeated at the conclusion of the rehabilitationperiod. Results: The cognitive assessments demonstrated a sig-nificant improvement in perception, visuomotor organizationsubtests, and total points of LOTCA. After the long-term cogni-tive rehabilitation, the parameters measured were better thanthose in the middle term. Conclusion: A clear understanding ofthe value of the cognitive rehabilitation process helps to im-prove the way of clinical practice, with the purpose of restoring



neuropsychologic deficits and increasing the patient’s inde-pendence and quality of life. LOTCA is very useful to apply inpatients with Wernicke’s aphasia who have got language andthinking problems. Long-term cognitive rehabilitation is veryimportant and effective in CVA patients.

P2-097 Pseudo-foreign Accent Syndrome—A Case Report

N. Surya, M. Sanghi, G. Hattangadi, and S. M. DaftaryBYL Nair Hospital and Topiwala Medical Collage,India

Background: Neurologic disease occasionally produces arather unusual speech disorder, characterized by articulatoryand prosodic disturbances that, combined in a particular fash-ion, confer to the patient’s native language a peculiar qualitythat is perceived by listeners as a foreign accent. Methods: A 27-year-old, bilingual, right-handed woman came to the hospitalwith a complaint of unintelligible speech. The patient was un-educated and had a limited exposure to the social milieu of acity life. The team members worked together during the processof differential diagnosis. Results: The literature review helped indiagnosing this condition as pseudoforeign accent syndrome.Conclusion: The aim of management for this client was toachieve functional communication, and this could be achievedafter 6 months of therapy.

P2-098 Early and Intensive Speech Therapy:Follow-up and Group Control Study onSevere Aphasia

L. Piron, F. Meneghello, S. De Pellegrin, A. Cremasco,and F. BevilacquaIRCCS San Camillo, Italy

Background: We developed a 2-hour daily program, with in-dividual intervention and a pragmatic-oriented group therapy,based on the accepted notion of the impact of the intensity ofaphasia therapy and the good results with group communica-tion treatment. To look for the most efficient way to deliver lan-guage training, we examined the results obtained with our ap-proach applied to patients with severe aphasia. Methods: 24patients with severe aphasia were submitted to early and inten-sive speech therapy. The inclusion criteria were: 1st stroke, sin-gle lesion, recruitment into 6 weeks, at least 4 subtests with thehighest impairment at Aachener Aphasie Test (AAT), and com-pliance with 2 h a day of speech therapy. Standardizedneurolinguistic testing with AAT was done at 1 and 6 monthsand for 13 patients also at 12 months. Ten patients not submittedto speech therapy with the same characteristics were compared.Results: Language functions improved significantly after thiskind of training, and the amelioration continued well after the6th month. All but 2 patients improved significantly in at least 1linguistic ability. Results at 6 months on Token Test, Namingand Written Language (but not on Repetition and Comprehen-sion) are valid predictors of the best results at 12 months. Con-clusion: Results confirm that early and intense language train-ing, based both on neurolinguistic principles and oncommunicative theory, can lead to a substantial and lasting im-provements well after the 6 months and also on severe linguisticdeficits.

P2-099 Use of Health Care, Patient Satisfaction,and Burden of Care in Guillain-Barré Syndrome

A. Forsberg,1 J. de Pedro-Cuesta,2

and L. Widén Holmqvist11Karolinska Institutet, Sweden; 2KarolinskaInstitutet and Carlos III Institute of Health, Madrid,Spain, Sweden

Background: Guillain-Barré syndrome may cause long-termdisability in about one-fourth of patients and need of rehabilita-tion services. The aim of this study was to investigate, in an un-selected sample of patients with Guillain-Barré syndrome inSweden, the utilization of health care resources, satisfactionwith these resources, informal help, and the burden of care onfamily caregivers during the 1st 2 years after onset. Methods: 44patients were enrolled from 8 hospitals, and 42 of them werefollowed for 2 years. Data on the utilization of hospital in- andoutpatient care, primary care and community-based serviceswere collected via computerized registry information, medicalrecords, and a specific protocol. Patient satisfaction and theburden on family caregivers were studied using questionnaires.Results: 41 patients required inpatient hospitalization for amean of 82 d. Patients with persistent dependency during activi-ties of daily living had significantly longer hospital stays andmore days of outpatient rehabilitation. The majority of patientswere satisfied with their care, but dissatisfaction was found re-garding information and finances. At 2 years after onset, 26% ofpatients still depended on informal help. The spouses ex-pressed increased concern and responsibility for householdand family. Conclusion: Patients with persistent disability dueto Guillain-Barré syndrome were found to have long-term needfor services from the health care system and informal help.

P2-100 The Improvement of Muscular Endurancethrough Callisthenic Exercises in Patients withMyasthenia Gravis: A Pilot Study

I. Keser,1 N. Korkmaz,1 A. Guclu,1 K. Armutlu,1

and R. Karabudak2

1The School of Physiotherapy and Rehabilitation,Hacettepe University, Turkey; 2Department ofNeurology, Hacettepe University, Turkey

Background: Myasthenia gravis(MG) leads to weakness ofmuscles that becomes more prominent, especially in repetitiveactivities. The aim of this study was to investigate the effects ofcallisthenic exercise in improving muscular endurance. Meth-ods: In this study 8 patients with MG were enrolled. As inclusioncriteria, patients had not relapsed for at least 1 month and therehad been no changes in their dosage or medication. To assessmuscular endurance, squash, push-up and sit-up tests wereused. A physiotherapy program was applied over 6 weeks. Testresults were recorded before and after the physiotherapy pro-gram, which consisted of callisthenic exercises for the musclesof the upper and lower limb and the trunk. Results: After physio-therapy, scores on the push-up test, which was used to assessupper limb muscle endurance, increased (z = –2.214, P < 0.05).The sit-up test to assess trunk muscle endurance also increased(z = –2.366, P < 0.05). Although scores on the squash test, whichwas used to assess lower limb muscle endurance, increased, the



increase was not statistically significant (z = –1.016, P > 0.05).Conclusion: There was an improvement in upper extremity andtrunk muscle endurance at the end of the physiotherapy pro-gram. The reason for the small increase in the muscular endur-ance of the lower limb muscles may arise from the short dura-tion of the physiotherapy program. Callisthenic exercises maybe a different therapeutic approach for improving muscular en-durance in MG patients.

P2-101 Disablity in a 4-Year Follow-up Study ofPeople with Postpolio Syndrome

C. Willén, A. Thorén-Jönsson, G. Grimby,and K. Stibrant SunnerhagenInstitute of Neurosciences–RehabilitationMedicine, Sweden

Background: For a long time, poliomyelitis was a majorhealth problem. The disease has disappeared as a major publichealth risk in Western countries, but new health problems havebeen reported. Methods: 106 patients with poliomyelitissequelae were included in the present study. They were self-re-ferred or had been referred to the postpolio clinic. After 4 years,the subjects were called for a follow-up. The following mea-surements were conducted at both the initial assessment andthe follow-up: questionnaires including NHP (NottinghamHealth Profile), muscle strength, EMG, and walking speed. Re-sults: The results in the present follow-up study showed minorchanges in disability during a 4-year period. A significant reduc-tion in muscle strength was only seen for right dorsal flexion inthe strong leg. No change could be seen in the total NHP scorefor the whole group. Conclusion: The studied cohort was clini-cally based and a different result might have been found in apopulation-based study of polio survivors. Alteration in muscleweakness has not been found in the present study, and this is anindication that we still do not know if and who is at risk for dete-rioration. It is impossible to say whether the small changes overtime shown in this study are associated with support from thepolio clinic or are an expression of the natural history of the syn-drome. Self-selected lifestyle changes may have influenced thedevelopment of symptoms and functional capacity positively.


P3-001 The Development of a Cognitive Model-Based Apraxia Screening Test

W. L. Bickerton and M. J. RiddochUniversity of Birmingham, United Kingdom

Background: A cognitive model-based brief apraxia screen-ing test was developed as part of a comprehensive cognitivescreening battery. The test was designed to identify patientswith mild to severe signs of apraxia as defined by the cognitivemodel of praxis processing. The aim was to isolate apraxia re-sulting from input processing deficits, long-term knowledgedeficits, or output processing deficits, respectively, using theminimum number of tasks. Methods: 4 praxis tasks were com-piled to enable cognitive analysis. These are multiple object usewith distracters, gesture production by verbal command, ges-ture recognition, as well as meaningless gesture imitation. We

tested 30 age-matched healthy subjects. Impairment was set at 2SD below control mean. Patients with a range of brain lesionswere tested, and results were compared with performance onconventional praxis tests, e.g., Florida Apraxia Screening Test,Movement Imitation Test. Results: There was high correlationbetween the screen tasks and their conventional counterparts.Profiles of patients’ performance indicating underlying deficitswere analyzed. Conclusion: The apraxia screening test offers aquick and valid way to detect different forms of apraxia and tosupport theoretical and clinical analysis of the deficits.

P3-002 Does Cognitive Function at Dischargeafter Stroke Associate with ADL Function andReturn to Work?

C. Hofgren, E. Esbjörnsson, A. Björkdahl,and K. Stibrandt-SunnerhagenInstitution of Clinical Neuroscience, SahlgrenskaAcademy, Göteborg University, Sweden

Background: In Sweden, the incidence of stroke is about30 000/year. Survivors often have disabling sequelae. The aimwas to assess cognitive function, ADL capacity, and vocationalsituation in a younger stroke population longitudinally. Meth-ods: Subjects: 1st-incidence-stroke patients (age, 18-64 years),Swedish speaking. Assessments: at discharge and at 1 year later.Instruments: the National Institute of Health Stroke Scale(NIHSS), the Barrow Neurological Institute Screen for higher ce-rebral functions (BNIS), the Functional Independence Measure(FIM), and the Instrumental Activity Measure (IAM). Vocationalsituation: at 1 and 3 years after discharge. Results: There were 59persons (44 men, 15 women; mean age, 52 years). The medianNIHSS at discharge was 5. Sixteen patients had aphasia and 17had neglect. Significant improvement during the 1st year oc-curred in cognitive function, basic ADL, and instrumental ADL.There was significant correlation between cognitive function atdischarge and basic ADL at 1 year. One year after discharge,cognitive dysfunction was present in 84% and 31% were ADLdependent. Only 4 persons were working; after 3 years, this hadincreased to 11 persons. Negative factors for work were apha-sia, neglect, neurologic deficits, and cognitive dysfunction.Conclusion: 1 year after 1st-incidence stroke, there was signifi-cant recovery in cognitive function and in basic and instrumen-tal ADL. Rate of work return was slow but had improved at 3years, indicating that vocational rehabilitation takes time.

P3-003 The Effect of Huperzia Serrata andRehabilitation for Cognitive Impairment inParkinson’s Disease

L. Q. YaoThe 2nd Affilicated Hospital of Medcal College,China

Background: With aging population, Parkinson’s disease(PD) has become one of the important diseases with disabilityaffecting health. It is not only the problem of dyskinesia but alsoprominent sequelae of cognitive impairment. At present, thereis a lack of systematic study for therapy and rehabilitation ofcognitive impairment of PD internationally. There are trials inusing Ache-I for treatmeat of PD, based on the treatment for Alz-heimer’s disease. Methods: 66 PD patients with cognitive im-



pairment were randomly divided into treatment group givenHuperzia serrata (Henan joyline and joysun pharmaceuticalstock) with a daily dose of 300 mcg and rehabilitation therapyand control group with rehabilitation only. Cognitive functionwas assessed by using electrophysiologic study of P300, Re-vised Wechsler Adult Intelligence Scale, and Wechsler MemoryScale in pre- and posttreatment period. Results: The experimentgroup showed difference in pre- and posttreatmeat (P < 0.05).Comparing 2 groups’ pre- and posttreatmeat scores: Intelli-gence was P > 0.05, but the other scales were all significantlydifferent (P = 0.000). The experiment group clearly improvedcognition with a score of 1.06 to 3.68 times more than the con-trol group. Conclusion: 1) Rehabilitation alone and Ache-I com-bined with rehabilitation showed effects on cognitive impair-ment of PD but the latter seems to be more effective. 2)Wechsler Memory Scale and P300 examination are sensitive as-sessment of cognitive impairment of PD.

P3-004 Life Situation 2 Years after Cardiac Arrestfor Patients and Close Ones

Lundgren Nilsson, K. S. Sunnerhagen, and C. HofgrenClinical Neuroscience, Sweden

Background: With the increasing knowledge of cardiopul-monary resuscitation in the community, more people survive af-ter cardiac arrest. The situation for these survivors and thoseclose to them is not well documented. In the rehabilitationclinic, these patients often pose a problem. Methods: From 1996to 1999 we have consecutively included in a study survivors ofout-of-hospital cardiac arrest, less than 75 years old, who wereadmitted to any of the hospitals in the city of Göteborg and sur-vived more than 3 days. Examinations focused on ADL, life situ-ation, and the burden of care for those close to them. Fifty pa-tients have been included: 9 women and 41 men. Patients wereexamined after 24 months with a life satisfaction (Li-Sat) survey,a Functional Independence Measure (FIM) and the EuropeanBrain Injury Questionnaire (EBIQ). For their carers, the EBIQand the Caregivers Burden scale were used. Results: 27 diedwithin 24 months, 7 declined follow-up. Five of 16 were de-pendent in ADL tasks. They were all satisfied with their lives asa whole and their family life. Nine had a close relationship withsomeone. The close ones estimated that the patients had moresevere social, cognitive, and emotional problems than did thepatients themselves. They also experienced more problems intheir life because of the patient’s situation than were perceivedby the survivors. Conclusion: 2 years after cardiac arrest, pa-tients have ADL, cognitive, social, and emotional problems.This also affects those close to them. Rehabilitation as well assupport is needed.

P3-005 Combined Cognitive Testing and EEGRecording before and after Working MemoryTraining in Children with Epilepsy—ARandomized Placebo-Controlled Trial

H. Westerberg, M. Dahlin, R. Persson, H. Forssberg,and T. StodbergKarolinska Institute, Sweden

Background: In children with epilepsy (EP), there are moreproblems with school performance than indicated by IQ. Thiscan be because of subclinical interictal epileptiform activity

(IEA), which may cause transient cognitive impairments. Espe-cially affected are working memory (WM) and attention,functions which underlie higher cognitive abilities as arithme-tic, reading, and problem solving. In earlier studies, we haveshown that these abilities can be improved by intense comput-erized training of WM in children with attention deficits. Meth-ods: We will measure the transient effects of IEA on cognition byapplying EEG simultaneously with computerized cognitive test-ing. The aim is to discriminate the effects that IEA may have oncognitive performance from other factors such as brain injuriesor side effects from medication. In addition, the present studyexamines the effects of WM training on cognition and EEG inchildren with EP. Twenty children with a diagnosis of EP arerandomized to 5 weeks’ training (adaptive computerized train-ing on WM) or to a placebo group (the same program but with-out adaptivity). Before and after WM training, the children areassessed with cognitive testing in combination with continuous21-channel EEG recording and video-monitoring. Computer-ized tests are applied for reaction time and WM. To measureother cognitive functions standard tests are used: Raven, Stroopand WISC. Results: The study will be finalized during 2005 andpresented at the WCNR. Conclusion: Results will be discussed.

P3-006 The Interdisciplinary NeuropsychologicRehabilitation Program to Treat MultipleSclerosis Patients

M. G. S. Vieira, J. T. Kamio, A. M. Freitas, F. C. P.Lima, and G. C. AmorosoBrazilian MS Society, Brazil

Background: In the Brazilian MS Society, ABEM, amultidisciplinary team provides assessment and treatment toclients with MS. The neuropsychologists, an occupational thera-pist, and a speech therapist created a neuropsychologic rehabil-itation program. Objective: The goal of this program is to im-prove MS patients’ quality of life, to help them and theirrelatives cope with cognitive impairments, to have more inde-pendence and autonomy in their daily activities. Sample: 12persons with MS and cognitive impairments, age between 30and 75 years, 3 male, 9 female, EDSS between 2.0 and 8.5. Meth-ods: The patients were separated into 2 groups by their cogni-tive impairments (6 moderate, 6 severe). Each group attended90 min, once a week for a 9-month period. The used resourceshad been compensatory strategies, neuropsychologic educa-tion, neurocognitive retraining, and emotional behavioral re-covery techniques. Results: All patients improved cognitive abil-ities: attention, memory, visual-spatial abilities, learning,language, executive function; emotional skill: mood, self-es-teem, depression, anxiety, social life, and coping with MS.These gains make possible better relationships with family andfriends, more independence, and autonomy in daily activities.Conclusion: This program is being advantageous as quality oflife and after the 9 months, the follow-up will be done bysemester.

P3-007 The Roles of Prefrontal Cortex inDecision Making

C. C. Y. Cheung,1 K. Wang,2 K. N. Hung,3

L. S. W. Li,2,4 and T. M. C. Lee1

1Institute of Clinical Neuropsychology, TheUniversity of Hong Kong and MacLehose Medical



Rehabilitation Center, Hong Kong;2Neuropsychology Laboratory, Anhui MedicalUniversity, China; 3Department of Neurosurgery,Queen Mary Hospital, Hong Kong; 4Department ofMedicine, the University of Hong Kong, Hong Kong

Background: Decision making demands the concerted ef-fort of multiple cognitive functions subserved by the prefrontalcortex. The aim of the study is to investigate the dissociate ef-fects of lesions in different parts of the prefrontal cortex on theprocesses contributing to decision making, namely, sensitivityand expectancy to valence, reversal learning, and mentalizing.Methods: 15 patients with lesion at the orbitofrontal,dorsolateral, and dorsomedial prefrontal cortex and 11 healthyparticipants participated in the study. The tasks aimed at exam-ining participants’ risk-taking behaviors, abilities in reversallearning, and mentalizing were administered. Results: The re-sults indicated that patients with damage to the orbitofrontaland dorsomedial prefrontal cortex were more impaired on risk-taking decisions than patients with dorsolateral prefrontal le-sions and healthy controls. Furthermore, a significant main ef-fect of group on the ability in identifying social faux pas wasnoted. Conclusion: The results suggest the contribution of theorbitofrontal and dorsomedial prefrontal cortex in decisionmaking. The impairment in decision making is a result of theunbalanced sensitivity towards reward and punishment, lead-ing to sensation-seeking and risk-taking behaviors. Besides, themain effect of lesion group on the ability in recognizing socialfaux pas reflected the specialized role of the dorsomedialprefrontal cortex on mentalizing.

P3-008 How Do Physiotherapists AssessUnilateral Neglect?

P. Plummer,1 M. E. Morris,2 R. E. Hurworth,3

and J. Dunai31University of Florida, USA; 2La Trobe University,Australia; 3University of Melbourne, Australia

Background: Although it is well known that unilateral ne-glect (ULN) is associated with poor rehabilitation outcomes,very little is known about how physiotherapists assess this com-plex neurologic disorder. The purpose of this study was to iden-tify the procedures used by physiotherapists to assess and diag-nose ULN after stroke. Methods: 33 physiotherapists from 1Australian state participated in 5 focus groups and 2 one-to-oneinterviews. The participants were asked to describe the proce-dures used to assess and measure ULN and to explain how theydifferentiated the different types of neglect. Data analysis in-volved transcription, coding, data reduction, identification ofmajor themes, and audit trail construction. QSR NVivo softwarewas used to facilitate management of the data. Results: Observa-tion was a key component of the assessment of ULN by physio-therapists. Real task situations were used frequently to evaluatethe functional impact of ULN. Bilateral simultaneous stimula-tion was a common procedure for differential diagnosis, but de-termining the type of neglect was not typical. Pen and papertests, such as line bisection, were also used to provide evidenceof neglect. Conclusion: Physiotherapists do not routinely distin-guish different types of neglect. Physiotherapists are primarilyconcerned with the functional implications of neglect but arenot always aware of the range of assessment tools available toaccurately measure the impact of neglect on everyday function.

P3-009 A Comparative Study of the Quality ofLife of Children with Epilepsy in Shanghai andHong Kong

V. Wong, C. Leung, S. Z. Zhou, and W. GohThe University of Hong Kong, Hong Kong

Background: To compare the health-related quality of life(QOL) of children with epilepsy and their mothers in Shanghaiand Hong Kong. Methods: In Hong Kong, 136 children were re-cruited from the clinics of Queen Mary Hospital and Duchess ofKent Children’s Hospital. In Shanghai, 60 children from Chil-dren Hospital of Fudan University were recruited. Identicalpsychosocial measurements were used: quality of life in epi-lepsy (QOLIE), Piers-Harris Children’s Self-Concept Scale, andParenting Stress Index. Results: The overall QOL scores were 50.This finding showed that health-related QOL profile of these 2patient groups were comparable with epilepsy patients in theUnited States. The Shanghai group scored highest in “Energy,”whereas the Hong Kong group scored highest in “Cognition.”“Social Functioning” and “Cognition” were most significant inthe Shanghai group, whereas in the Hong Kong group, “SocialFunctioning” and “Health Discouragement” were most signifi-cant. Overall, the Self-Concept Score of the Hong Kong groupwas lower. Profile was similar with the children perceivingthemselves weakest in “Intellectual and School Status” and“Physical Appearance and Attributes”. Parenting Stress Indexshowed that mothers were stressful, with those in the Shanghaigroup slightly higher. Conclusion: Evaluation of psychosocialprofile is essential to improve quality of care for epileptic chil-dren and their caregivers. In HRQOL, both countries have simi-lar aspects: 1) affected by “Social Functioning” most signifi-cantly (P < 0.001); 2) best performed in “Energy” and“Cognition,” respectively; 3) Modifying/polishing “OutwardAppearance” could improve self-concept; 4) stressful parents.

P3-010 Preservation of the Coupling betweenHand Orientation for Grasping and theDirection of the Reaching Movement inApraxic and Neglect Stroke Patients

A. Roby-Brami,1 S. Jacobs,1 and M. Combeaud2

1UMR 8119, France; 2Hopital Raymond Poincare,France

Background: Previous studies in healthy subjects haveshown that the hand orientation (azimuth) at the time of grasp-ing is strongly coupled to the direction of the reaching move-ment. The coupling is also present in hemiparetic patients. Thepresent study investigates its occurence in patients with lesionsin the associative brain areas. Methods: 6 healthy subjects, 8stroke patients with ideomotor apraxia and 5 with neglect par-ticipated. Hand movement and orientation were measured withan electromagnetic sensor. All were right-handed and used theleft hand to take a light cardboard cone. Two apraxic patientswere also able to use their right hand. Results: Hand azimuth atthe time of grasping was significantly correlated to arm move-ment direction. The correlation coefficients were 0.812 to 0.992in healthy subject, and the slope of the regression lines 0.62 ±0.03. The correlations were similar in apraxic (r2, 0.717-0.951)and neglect patients (r2, 0.571-0.971) with more variable but notsignificantly different slopes (0.72 ± 0.18 and 0.54 ± 0.09). Simi-lar results were obtained in the 2 apraxic patients using their



right hand. Conclusion: The coupling between hand orientationfor grasping and reaching movement direction is preserved inpatients with lesions of the left or right associative brain areas.Since a previous study showed that it was not linked to the in-tegrity of the pyramidal system, we suggest that this coupling isa basic synergy emerging from the lower levels (possiblypropriospinal) of motor control.

P3-011 Neglect: A Contribute to ClinicalNeurorehabilitative Practice

F. Onofrio, S. Abbondanza, C. Arcari, M. Comola,and M. Falautano1Vita-Salute Scientific Institute San RaffaeleHospital, Italy

Background: Neglect is an absence or a decrease in the de-tection of events that occur into the controlateral field to thebrain lesion side. The severe inability of coping with their dailylife has supported the research of a rehabilitation training effi-cacy: The effectiveness of the visuo-spatial rehabilitation hasbeen recommended for visuoperceptual deficits after righthemisphere stroke. We propose a neglect rehabilitation pro-gram, which is structured in 6 steps,with increased levels of dif-ficulty. Methods: We choose a single case study just to illustratethe rehabilitation steps and instruments: step 0: Extensiveneuropsychologic investigation and visuospatial battery pre-and postrehabilitation. Step 1: Improve patient’s responsive-ness of his left personal and extrapersonal side. Step 2: Use ofperceptive aids in order to increase his left side attention. Step3: Perceptive scanning. Step 4: Reorganization of the perceptiveinternal representation of the world. Step 5: Becoming con-scious of recovery strategies (metacognitive strategies). Step 6:Make the patient able to choose the most useful strategies forhis daily-life living. Results: Preliminary finding support the effi-cacy of the training. Conclusion: This rehabilitation programcould be proposed as a systematical design of intervention if re-sults will be confirmed in a larger group.

P3-012 Psychosocial Aspects of Coping withMultitrauma and Spinal Cord Injuries

A. K. Schanke, A. Johansen, and I. H. LarsenSunnaas Rehabilitation Hospital HF, Norway

Background: People with multitrauma, burn, and spinalcord injuries are exposed to traumatic events that may lead tocrisis and psychosocial problems. We wanted to identify the im-pact of both risk and resilience factors after a major physical in-jury. Methods: The study group included 108 inpatients consec-utively selected and admitted to Sunnaas RehabilitationHospital. Mean age was 40 years. They were assessed by scalessuch as the Impact of Event Scale-R (IES-R), Hospital Anxietyand Depression Scale (HAD), and Attitudes to Emotional Ex-pression Scale (AEES). Semistructured interview with questionsdisclosing vulnerability factors, social support, and previousand parallel stressors were included in the study. Results: Pre-liminary results show that 4% met diagnostic criteria for PTSD;24% scored above cutoff on HAD-anxiety subscale; 14%, on theHAD-depression subscale; 18% had intrusion above cutoff;15%, avoidance above cutoff. There was a correlation betweenIES-R intrusion and high number of vulnerability factors (r =0.354), intrusion and parallel stressors (r = 0.302), IES-R arousaland previous life stress (r = 0.296), HAD-depression and previ-ous life stress (r = 0.285), IES-R avoidance and arousal and poor

attitude to emotional expression (r = 0.213 and r = 0.241, re-spectively) and negative correlations between satisfaction withsocial support and both previous life stress (r = –304) and vul-nerability factors (r = –329). Conclusion: These data are consis-tent with findings in the literature and will be outlined anddiscussed.

P3-013 Prevalence and Correlative Factors ofUrinary Incontinence in Stroke Patients

P. Dajpratham and C. WechaputiFaculty of Medicine, Siriraj Hospital,Mahidol University, Thailand

Background: Urinary incontinence (UI) is a common prob-lem after stroke. It can interfere with patient discharge and com-plicate rehabilitation. The purpose of this study was to deter-mine the prevalence and pattern changes of UI in the 1st 3months after stroke. The correlation between UI and cognitiveimpairment, physical impairment, and functional disabilitywere explored. Methods: 100 acute stroke patients who had 1st-ever stroke and no past history of UI were recruited. The Thaimental state examination, Canadian neurologic scale, Barthelindex, and urogenital inventory short form were administered 3times: within 7 d, at 1 and 3 months after stroke. Results: Theprevalence of UI within 7 days, at 1 month, and at 3 months afterstroke were 34%, 21%, and 16%, respectively. The continencepattern improved in 18% at 1 month and in 21% at 3 months. UIwas mainly found in the incontinence group. The initially in-continent group was significantly more aphasic and dysphagic(P < 0.05). UI correlated moderately with physical impairment(rho = 0.57-0.62) and functional disability (rho = 0.70-0.73)across all time points. There was no correlation between UI andcognitive impairment. Conclusion: UI in acute stroke patientsimproved over time. UI was the major problem in the inconti-nence group. The stroke patients with UI had more physical im-pairments and disability than those with continence.

P3-014 Voiding Dysfunction amongHuman T-cell Lymphotrophic virusType-1-Associated Myelopathy Patients

K. Ninomiya, M. Shimodozono, K. Horinouchi,S. Matsumoto, and K. KawahiraKagoshima University Hospital, Japan

Background: The incidence of voiding dysfunction isknown to be high among human T-cell lymphotrophic virustype-1-associated myelopathy (HAM) patients. We report hereon an investigation of voiding dysfunction among HAM patientswe encountered at Kirishima Rehabilitation Center, KagoshimaUniversity Hospital. Methods: 19 HAM patients (6 males and 13females) were investigated for clinical symptoms and subjectedto urodynamic study and cystography. Results: 17 of the 19 pa-tients complained of lower urinary tract symptoms, and 11 ofthem had residual urine over 50 mL. Maximum cystometric ca-pacity was no greater than 300 mL in 9 patients, and the maxi-mum bladder contraction pressure was no higher than 50 cmH2O in 10 patients. Detrusor sphincter dyssynergia (DSDa) wasevident in 7 of 11 patients who underwent external analsphincter electromyography. Six of the 9 patients who under-went cystography were shown to have bladder deformity.Urodynamic study revealed that most subjects presented withboth overactivity during the storage phase and underactivityduring their voiding phase. These secondary conditions, which



had continued for at least 20 years since onset, were believed tohave been triggered by hyperextension of the bladder wallcaused by long-term bladder neck occlusion and high residualurine. Conclusion: Voiding dysfunction among HAM patientspresents quite differently depending on the patient and the pe-riod since onset. Careful and long-term monitoring of voidingfunction is therefore important.

P3-015 Association between Cystatin C and RenalFunction in Spinal Cord Injury Patients

S. F. ChiuCathy General Hospital, Hsinchu, Chinese Taipei

Background: Cystatin C is the highly sensitive marker for as-sessment of glomerular filtration rate (GFR). The applications ofthis ideal GFR marker include diabetic nephropathy monitor-ing. We plan to survey the renal function and cystatin C inchronic spinal cord injury patients. Methods: We includedchronic spinal cord injury patients in Hsinchu City, Taiwan. Thebaseline data include demographic factors, education level,past history, and medical history. The laboratory tests includeserum level of glucose, creatinine, urine analysis, and cystatinC. The subjects undergo neurologic examination and renalsonography. The postvoiding residual urine amount is recordedby sterile catheterization method, too. The estimation of renalfunction is based on the Modification of Diet in Renal Disease(MDRD) equation. Results: We initially subdivided the studypopulation according to the serum level of glucose and then be-gan to evaluate the association of creatinine, cystatin C, with es-timated GFR. All subjects were subgrouped according to thequartile of cystatin C. The statistical analysis will assess the asso-ciation between neurogenic bladder and renal function impair-ment in spinal cord injury patients. Conclusion: Cystatin C is asensitive tool in monitoring renal function. Regular, long-termcystatin C follow-up and proper urologic care are important inspinal cord injury patients.

P3-016 Lower Urinary Tract Dysfunction inNeurologic Patients

T. K. K. Yu and C. P. WongRuttonjee Hospital, Hong Kong

Background: Lower urinary tract symptoms are common inneurologic patients, but there are few local studies about thisaspect. Urodynamics are an essential tool in studyingneurogenic bladder conditions. Little is known about the differ-ences in urodynamics presentation between neurologic pa-tients and nonneurologic patients. Methods: This is a retrospec-tive review of urodynamics study performed by the GeriatricsDepartment of Ruttonjee Hospital in the recent 8 years. A totalof 613 urodynamics reports were retrieved and analyzed. Age,sex, urinary symptoms, urodynamics parameters (maximumflow rate, postvoid residual, maximum cystometric capacity,maximum detrusor pressure at voiding phase), andurodynamics diagnosis were compared between neurologicand nonneurologic patients. Results: The mean age of the 613cases were 76.64, with female predominance (67.4%). Amongthe 613 cases, 259 (42.25%) had neurologic diseases, withstroke being the most common, followed by dementia,parkinsonism, spinal cord problem, and others. Neurologic pa-tients had more retention of urine symptoms (P = 0.006), lowermaximum cystometric capacity (265 mL vs 288 mL, P = 0.042),higher maximum detrusor pressure at voiding phase (57 cm

H2O vs 50 cm H2O, P = 0.013) and more urodynamics diagnosisof overactive bladder (P = 0.005) when compared withnonneurologic patients. Conclusion: Neurologic patients arecommonly referred for urodynamics study for their urinarysymptoms and urodynamics are useful in studying their urinaryproblems.

P3-017 Effects of Chronic Pudendal NerveStimulation on Sacral Area Dysfunctions

S. Malaguti,1 M. Spinelli,2 M. Citeri,2 J. Tarantola,1

and T. Redaelli31Neurourophysiology Spinal Unit NiguardaHospital, Italy; 2Urology Spinal Unit NiguardaHospital, Italy; 3Spinal Unit Niguarda Hospital,Italy

Background: Neurogenic detrusor overactivity (NDO) dueto spinal cord lesion (SCL) causes high intravesical pressures,low bladder capacity, and incontinence. To assess feasibilityand clinical application of our original method for chronicpudendal nerve stimulation (CPNS) in NDO and other sacralarea dysfunctions (SAD), 36 patients (14 male, 22 female; meanage, 35 years; 34 upper and 2 lower motoneuron lesions) under-went the implant of a lead close to pudendal nerve underneurophysiologic guidance. Methods: Urodynamic evaluationat baseline T0, after 1 (T1) and 21 months (T2) and bowel andvoiding diaries for 7 d were performed by all. Index of ErectileFunction (IIEF5) was done by 7 male patients. Results: In T1 uri-nary incontinence episodes reduced from 7 ± 3.3 to 2.6 ± 3.3 (P< 0.02, paired t test). Twenty-nine patients with urge inconti-nence became dry, and the maximum cystometric capacity(MCC) increased from 153.3 ± 49.9 to 331.4 ± 110.7 mL (P < 0.01,paired t test), the pressure at MCC decreased from 66 ± 24.3 to36.8 ± 35.9 cm H2O (P = 0.059, paired t test). Two patients im-proved by more than 88%, 1 patient reduced by 50%, but 4 pa-tients with retention did not change. At T2, 17 dry patients usedcatheter to void and 15 patients voided without it. A normaliza-tion of bowel voiding was seen in 15 constipated patients with2.5 to 7 increase of weekly evacuations and decrease effort toempty and laxative use. One patient with fecal incontinence be-came continent. IIEF changed from 32% to 79% with decreaseduse of oral drugs in 7 patients. Conclusion: CPNS seems to behopeful therapy for NDO and SAD in SCL.

P3-018 Affectivity and Sexuality in NeurologicRehabilitation: Bringing New Resources througha Dedicated Web Site

H. B. Vuagnat,1 P. Breitenstein,2 N. Donnat,3

and J. Vecsey1

1Loëx Hospital, Department of Rehabilitation &Geriatrics, Bernex, University Hospitals of Geneva,Switzerland; 2SEHP Suisse, CP 2137, 1211 Geneve2, Switzerland; 3Nursing Directorate, UniversityHospitals of Geneva, Switzerland

Background: Affective and sexual lives are no easy matter toaddress, especially in rehabilitation settings. Because of theirimportance to humankind, these issues have to be taken into ac-count during the rehabilitation process. Furthermore, counsel-ing will have to adapt to each patient (e.g., specific lesion, age,cultural background, body, and psychologic evolution throughtime). Sexual and affective counseling should therefore be



made easily available throughout the patient’s lifespan. Meth-ods: To provide an easy tool to patients, relatives, and care-givers, the Swiss Association for Sexuality and Physical Disabil-ity (SEHP Suisse, a French-speaking nonprofit organization)implemented a dedicated Web site (www.sehp-suisse.ch). Mainfeatures include readily available basic information, personal-ized anonymous and free counseling delivered by selected ex-perts, and disability-oriented links. Results: After a limited 1-month experience, the Web site recorded more then 300 hitsand 10 questions were collected, their contents ranging frompsychologic issues to functional sexual problems. It is expectedthe sum and interest of these questions will grow in the nextmonths as the Web site’s URL is to be spread among those con-cerned by physical disability. Conclusion: Although at presentof very limited experience, it appears that such a Web site couldbe a helpful resource to those sustaining neurologic lesions aswell as to their relatives and caregivers.

P3-019 Development of a Fall PreventionIntervention for Older Adults with MultipleSclerosis: An Evidence-Based Process

E. Peterson,1 M. Finlayson,2 and E. Shevil21Karolinska Institutet, Sweden; 2University ofIllinois at Chicago, USA

Background: Many multiple sclerosis (MS) symptoms areknown risk factors of fall. Matter of Balance is an evidence-based program originally designed to reduce fall risk among ac-tive, well elderly. This presentation describes a 2-phase processused to customize Matter of Balance for use with older adultswith MS. Methods: In phase 1, telephone interviews were con-ducted with randomly selected older adults with MS. The goalwas to obtain descriptive and epidemiologic information toevaluate the relevance of Matter of Balance to older adults withMS and identify intervention priorities. Phase 2 (August 2005-January 2006) involves use of a small working group of expertsto interpret phase 1 findings and advise on curricular content.Results: A random sample of 359 older adults (mean age, 67years; 66% female, 97% Caucasian) was obtained. Phase 1 find-ings justified the need for fall prevention education amongolder adults with MS. For example, 50% of respondents re-ported history of an injurious fall. Intervention priorities identi-fied through phase 1 included need for fear of falling manage-ment strategies. Phase 2 is in progress. Key program changesresulting from phase 2 will be presented. Conclusion: To meetthe unique needs of older adults with MS, Matter of Balance isbeing modified through a process that combines findings fromcross-sectional data with the expertise of a work group. Theprocess has the potential to be replicated for other cohorts ofolder adults at increased fall risk.

P3-020 Returning to Work afterStroke in a UK City

J. Macfarlane1 and R. M. Kent21Hunters Moor Regional Rehabilitation Centre,United Kingdom; 2Neurological RehabilitationCentre, Pinderfields Hospital, United Kingdom

Background: Of all new strokes, 15% to 29.6% occur in peo-ple of working age. Return to work after stroke varies from 3%to 84%, partly explained by how work is defined as well as cul-tural factors and disability compensation. Methods: With limitedUK data, we performed a survey in our locality to examine re-

turn to work after stroke and views on existing vocational reha-bilitation services. A custom questionnaire asked about workbefore and after stroke, satisfaction, views on services needed,and a postal Barthel. Using the Leeds Stroke Database, we sent325 questionnaires (mean age, 54.5 years; 62% male; mean du-ration, 2.5 years poststroke) along with explanatory leaflet, fol-lowed up by a reminder. Results: There were 111 responders(response rate = 33%), not significantly differing fromnonresponders. Employment rate before stroke was 70.6%, andamong the 71 responders, 44 (62%) had returned to work at amean of 9.2 months since stroke. Nearly half (46%) had tochange hours or other aspects of their job with a mean reduc-tion of 13.8 h per week after stroke. More than half of 87 respon-dents described as being dissatisfied with vocational servicesreceived. The most frequent themes related to the need for aservice tailored to each person’s needs. Conclusion: The highreturn-to-work rate may be a responder bias. Although the lowresponse rate limits conclusions, the time to return to work, thedifficulty in coping, and high dissatisfaction level suggest theneed for an improved individualized vocational rehabilitationservice.

P3-021 Quality of Life of Patients with StrokeAnalyzed after the Standardized TertiaryRehabilitation (STR) Program

C. Y. Jiang, Y. S. Hu, Y. Wu, Y. L. Zhu, and L. M. SunHuashan Hospital, Fudan University, China

Objective: To explore how the quality of life of patients withstroke improved after STR treatment. Methods: 82 subjects withstroke who had been medically stable for 1 week were enrolledsequentially from Huashan hospital. They were randomizedinto 2 groups with 42 in the test and 40 in the control group.Those in the test group were given STR plus routine medicaltreatments, whereas those in the control group were given onlythe routine treatments without STR. All patients were assessedwith a quality of life scale at the time of enrollment and at theend of the 1st, 3rd, and 6th month after the stroke. The appraisalof the outcomes was blind. Results: All subjects in the 1st groupfinished the follow-up, but 2 subjects in the 2nd group died ofinfarction during the follow-up period. There was no significantdifference between the 2 groups at the baseline. At eachpoststroke checkpoint, however, the scores on the physical,psychologic, social, and environment domains and the subjec-tive items of the quality of life and physical health in the testgroup were higher than those of the controls (P < 0.05). At the6th month, the respective scores were 14.07, 14.68, 15.05, 15.83,4.36, and 3.95 in the test group, whereas the control groupscored 8.83, 9.59, 11.70, 11.15, 2.78, and 2.50. Furthermore, thetrend of improvement was faster in the test than in the controlgroup, especially in the early stages. Conclusion: STR can sig-nificantly improve the quality of life of patients with stroke.

P3-022 The Effection of Therapeutic Recreationon Quality of Stroke Patients

Y. Y. ZhuShanghai Jingan Geriatric Hospital, China

Background: To investigate the effect of therapeutic recre-ation on quality of life of stroke patients. Methods: 60 stroke pa-tients were randomly divided into 2 groups (treatment group, 30cases; control group, 30 cases). The 2 groups were treated rou-tinely with medicine, physical therapy, occupational therapy,



and physiotherapy. The treatment group had therapeutic recre-ation for 1 h, 5 times a week. The period of treatment of the 2groups was 2 months. Before and after treatment, the 2 groupswere assessed by life satisfaction index A and Barthel index.The assessment was worked by a same therapist, who then per-formed the clinic contrast study. Results: The score of life satis-faction index A in the treatment group was significantly higherthan that of control group (P < 0.05). Conclusion: Therapeuticrecreation can improve the quality of life on patients with cere-bral infarction.

P3-023 Returning to Work after Acquired BrainInjury: The Need for Vocational Rehabilitation

D. Gentleman and A. AmyesUniversity of Dundee, United Kingdom

Background: Returning to work after acquired brain injury(ABI) poses challenges that many fail to overcome. Vocationalrehabilitation (VR) can help, but may not be available. We re-port a survey to identify factors that are perceived to support orprevent a return to work. Methods: We retrospectively recruited35 former patients (mean age, 30 years) of a specialist rehabili-tation center in Scotland, each of whom had suffered an ABI.Each completed a questionnaire during a semistructured inter-view (13) or by post (22). We also gave questionnaires to theirpartner or parent, an employer or work colleague, and a healthprofessional who had supported the attempted return to work.Results: Only 12 of 35 people with brain injury had returned totheir preinjury occupation. This was more likely with good in-sight, motivation, a phased return to work, a sympathetic em-ployer, and support from a brain injury worker. It was less likelywith persistent fatigue, poor insight, lack of vocational support,and delayed acknowledgement by others of the effects of ABI.Those surveyed commended the value of counseling, access toVR, and telling employers about the effects of ABI. Conclusion:The consequences of ABI can have a profound and lasting ef-fect on people of working age. This survey shows that inform-ing and supporting the brain-injured person, the family, and theemployer make a return to work more likely. This highlights therole of VR, although research on how to optimize it in an area oflimited resources is greatly needed.

P3-024 Spinal Muscular Atrophy withRespiratory Distress Type 1 Mutation (SMARD1)in Chinese Boy

V. Wong, B. Chung, S. Li, C. W. Fung, and W. GohThe University of Hong Kong, Hong Kong; Duchessof Kent Children’s Hospital, Hong Kong

Background: SMARD1 is an uncommon variant of infantileSMA and constitutes 1% of early-onset SMA. Distinguishing fea-tures include diaphragmatic palsy; early-onset distal limb wast-ing and contractures are not found in infantile SMA. Its inheri-tance is autosomal recessive and the causative gene IGHMBP2.The protein is postulated to be involved in immunoglobulinclass switching, pre-mRNA processing, and regulation of tran-scription by DNA binding or interacting with TATA-binding pro-tein. Methods: A 4-month-old Chinese boy with severe respira-tory distress and inspiratory stridor. Examination showedsevere hypotonia, generalized limb weakness, and distal limbcontractures. Chest radiograph showed right-sided diaphrag-matic palsy. Electrophysiologic studies were compatible withaxonal polyneuropathy. Molecular analysis of SMN gene (de-

letion of exons 7 and 8) was negative. Results: PCR-based se-quencing of the exon-intron boundaries and 15 exons ofIGHMBP2 gene was performed based on conditioning regi-men by Grohmann and Maystadt. The boy was compoundheterozygote for [ c .1738G>A]/ [p .Va l580 l l e ] and[c.2354_2356delG]/[p.Arg785fs], which were paternally and ma-ternally inherited, respectively. Both parents are asymptomatic.Conclusion: The paternally inherited mutation has been re-ported before. Maternally inherited mutation is novel and con-sists of a frame-shift mutation producing a prematurely termi-nated IGHMBP2 protein that lacks the zinc-finger domain. Thiscase is the first case of genetically confirmed SMARD1 in theChinese population.

P3-025 Long-term Consequences of Severe HeadInjury. A Follow-up Study of Patients Treated in aNorwegian Neurosurgical Department

T. Skandsen, O. Fredriksli, K. Schirmer-Mikalsen,and A. VikSt. Olavs Hospital, Trondheim University Hospital,Norway

Background: There are few studies from Scandinavia de-scribing outcome after traumatic brain injury (TBI). In a retro-spective, collaborated study, we have registered all patientswith severe TBI treated in our hospital during a 5-year period,1998 to 2002. Demographic and clinical variables have been re-corded to analyze different aspects of the medical care. The aimof this part of the study is to assess short-term and long-termoutcome and to relate outcome to the patients’ clinical condi-tion 4 weeks postinjury. Methods: Direct or phone contact withpatients and/or parents. Structured interview for GOS andGOSE was used. Vocational or educational status and living sit-uation were recorded, in predefined categories. GOS 6 monthspostinjury and the presence of PTA or minimal conscious state4r weeks after the injury was estimated based on interviews andmedical records. Results: 135 patients were identified. One-yearmortality rate was 25%. Age was median 32.5, 18% female. MeanGCS was 6.2. The interviews are not completed, and only somepreliminary outcome results, based on 52 patients, are pre-sented in this abstract. GOS 6 months postinjury, 5.2 (SD 0.8);GOS-E long-term, 5.2 (SD1.7). Among the 25% of patients whowere in MCS after 4 weeks, mean GOS-E was 3.6 (SD 1.0). Therate of disability pension among persons working preinjury was64%, and the rate of engagement in competitive work was 15%.Conclusion: One conclusion is that participation in work is verylow after severe TBI in Norway.

P3-026 Use of Zonisamide in 12 Patients withIntractable Seizures Refractory to CommonAntiepileptic Regimens


Background: This nonrandomized, uncontrolled, single-center study was conducted to evaluate the effects ofzonisamide on intractable epilepsy in a primarily pediatric pop-ulation. Twelve patients ranging in age from 18 months to 23years were included in the study. All patients were diagnosedwith intractable seizures. Methods: Adjunctive therapy withzonisamide was initiated at 100 mg once a day and increased, ifneeded, by 50 to 100 mg after 1 week to reach the maximal ortherapeutic dosage depending on patient age and weight. Fol-



low-up occurred in person or by phone at 2 weeks, 1 month,and every 3 months. Results: All 12 patients responded favor-ably to adjunctive zonisamide. Five patients had subclinical sta-tus interrupted and stopped as evidenced by clinical examina-tions and EEG findings. These patients also became awake,alert, more attentive, and more interactive. An additional 6 pa-tients experienced clinical and EEG improvement in their sei-zure frequency, duration, and severity. One patient with auto-nomic seizures showed EEG improvement in seizure frequency,duration, and severity; however, seizure prodrome control wasnot obtained. Adjunctive therapy with zonisamide benefited allpatients in this study, despite the variation in symptoms andcauses. Conclusion: Zonisamide is thought to have multiplemechanisms of action, which may benefit more patient typesthan antiepileptic drugs with a single mechanism of action.Zonisamide was well tolerated by all patients.

P3-027 Work Instability Scale in Epilepsy (WISE)

P. K. Datta, M. C. Horton, R. M. Kent,and A. M. TennantUniversity of Leeds, United Kingdom

Background: Some people with epilepsy experience jobproblems putting them at risk of job loss. Work instability (WI)is a state arising from a mismatch between a person’s functionalabilities and the demands of the job, the consequences of whichcould threaten continuing employment. Currently, there is noreliable way of screening for people with epilepsy who mayhave WI. This research aimed to develop a screening question-naire to predict the risk of job loss for people with epilepsy.Methods: The development was in 5 stages. 1) Thirty-six qualita-tive interviews were the source of items of the questionnaire. 2)The questionnaire was piloted on 12 participants to assess facevalidity. 3) A revised questionnaire was mailed to 2020 partici-pants to assess preliminary construct validity. 4) The question-naire responses were validated against a vocational assessmentusing 5 levels of WI on 28 participants to establish criterion va-lidity. 5) A 2nd postal survey on 750 participants was used toconfirm test-retest reliability and Rasch model to confirmunidimensionality. Results: There were 55% females in the 1stpostal survey with age range 16 to 65 years and 431 participantsin employment. The 24 items WISE questionnaire showed ade-quate fit to the Rasch model (χ2 = 0.52), confirmingunidimensionality. The cutoff point for risk of job loss had asensitivity of 55% and specificity of 88%. Conclusion: The WISEquestionnaire is a useful screening tool alerting the physician tothe fact that the person is at risk of job loss.

P3-028 Pediatric Stroke in Southern Chinese

V. Wong and B. ChungThe University of Hong Kong, Hong Kong

Background: To calculate the incidence of stroke in Chinesechildren in Hong Kong and to examine the clinical spectrum,etiology, pattern, risk factors, and outcome of pediatric stroke.Methods: This study is a retrospective study (1998-2001) on all1st hospital admissions for children (1 month-15 years) in HongKong. Data of pediatric stroke (1 month-16 years) from a singlecenter (QMH) were prospectively collected as Children’s StrokeRegistry since 1991 and analyzed. Results: This study included4 545 300 person-years of observation; 94 children with acutestroke were identified. Estimated incidence was 2.1/100 000children-years. Fifty children were included (36 ischemic and

14 hemorrhagic in origin). Of the 36 ischemic strokes, 18 werecerebral thrombosis, and 15 were cerebral embolism. Importantcomplications related to congenital heart diseases (n = 15), vas-cular (n = 13) disorders, and hematologic (n = 14) diseases; 12%were undetermined. Ten percent had recurrent strokes. Overallmortality was 18%; 9 died. Forty-one percent of survivors devel-oped long-term neurologic deficit: 11 mental retardation, 7 epi-lepsy, 10 hemiplegia. Decreased level of consciousness,hematologic causes, and hemorrhagic transformation ofischemic stroke from neuroimaging predicted poor survival.Presence of seizure predicted long-term neurologic deficit. De-creased level of consciousness remained significant for mortal-ity. Conclusion: Stroke incidence in southern Chinese childrenwas similar to that in European or North American children. Theetiologic pattern was different though. Mortality and long-termneurologic deficit were similar.

P3-029 Role of Nurse in the Quality of Lifeof Persons with Epilepsy

M. M. C. Lakshmi and G. G. H. VirudhagirinathanInstitute of Neurology, Government GeneralHospital, Tamilnadu, India

Background: Epilepsy is one of the heavily stigmatized neu-rologic disorders and, by its nature, alters the life style of epilep-tics. Nursing care for persons with neurologic health problemsinvolve many considerations, as does the nurses’ role in provid-ing care. This study was aimed at assessing the role of nurses inthe awareness and management of disease condition, control orreduction of attack and quality of life of the epileptics and alsoto correlate these variables with one another. Methods: Longitu-dinal study design was used to collect data with the help of In-terview guide devised by the authors from 316 primary epilep-tics who attended the Epilepsy Clinic, Government GeneralHospital, Chennai-3. They were observed after 3 months. Thecollected data were analysed by using tables, tests, etc. Results:Study was supportive to the role of nurses by finding improve-ment between IA and FA as follows: awareness (53%), manage-ment (49%) of disease condition, control or reduction of attack(71%), and quality of life (QOL)(50%), and also the interrela-tionships among these variables were found significant (P <0.01). Conclusion: The study revealed that the role of nursesplays a vital factor in improving the QOL of the epileptics. Pa-tient education and client instruction is essential in helpingthem lead a life satisfactorily. Interrelationship among aware-ness, management of disease condition, control or reduction ofattack, and QOL was found significant (P < 0.01).

P3-030 Effects of Infrasound with 8Hz 90 db/130db on Apoptosis in Hippocampal Cells of the RatBrain

Z. H. LiuTangdu Hospital, Fourth Military MedicalUniversity, China

Background: To study the effect of infrasound on apoptosisof hippocampal cells. Methods: Eighty-eight male SD rats wererandomized into 11 groups: control group, infrasound exposedgroups at 90 dB/1 d, at 90 dB/7 d, at 90 dB/14 d, at 90 dB/21 d, at90 dB/28 d, at 130 dB/1 d, at 130 dB/7 d, at 130 dB/14 d, at 130dB/21 d, and at 130 dB/28 d. Infrasound exposed groups wereput to a field with 8 Hz, 90 dB or 130 dB infrasound separately,each day for 2 h. Acute cell separation and flow cytometer



(FCM) techniques were used for measurement of apoptosis ra-tio in hippocampal cells. Results: Compared with control group,no increase of apoptosis ratio was recorded in 90 dB/1 d, 130dB/1 d, and 130 dB/7 d infrasound exposure groups (P > 0.05),but there were increases in those with 90 dB/7 d (P < 0.01), 90dB/14 d (P < 0.01), 90 dB/21 d (P < 0.05), 130 dB/14 d (P < 0.01)and 130 dB/21 d (P < 0.05) infrasound exposed groups, reach-ing its peak level in the 90 dB/14 d group (P < 0.01 v. all others),restoring in 90 dB/28 d and 130 dB/28 d infrasound exposuregroups (P > 0.05). Conclusion: These changes showed that 8Hz, 90 dB/130 dB infrasound could produce increases ofapoptosis ratio in the hippocampus in certain time infrasoundexposure groups, which suggested that there were definitedamages induced by infrasound with 90 dB and 130 dB. Therewas some adaptation in hippocampal cells to 8 Hz, 90 dB/130dB infrasound exposure groups after a longer period ofexposure.

P3-031 Effect of Systematic Activity in Water onChronic Stroke Survivors

G. Verheyden, C. Kiekens, Y. Vanlandewijck, H. Feys,and D. DalyKatholieke Universiteit Leuven, Belgium

Background: To assess the outcome of systematic physicalactivity in water for stroke survivors on endurance, gait speed,mobility in water, spasticity, anxiety and quality of life. Meth-ods: 11 stroke survivors (greater than 12 months poststroke) fol-lowed a program of water activities 3 to 4 times a week during a5-week period. The activities were designed to help the partici-pants: 1) be safe and comfortable in water, 2) achieve independ-ent movement, and 3) improve their cardiorespiratory fitnesslevel through actual swimming. Results: All participants com-pleted the 5-week intervention. There were significant im-provements in 6-min endurance walking, (39.1%; P < 0.01), gaitspeed (16.7%; P = 0.02), and speed for 10-m water movement(23.5%; P = 0.02). Indications of depression were absent at theend of intervention in those with an initial level. Follow- up af-ter 7 weeks showed a significant improvement in 6-min walkingspeed compared to baseline (25.4%; P = 0.02) but no furtherchange compared to the 5th week. Gait speed slightly de-creased compared to 5 weeks but remained better than baseline(P = 0.07). Feeling of well-being did not increase after 5 weeksbut did at follow-up (8.9%; P < 0.01). No changes in spasticity orin anxiety and other parts of the EQ-5D were demonstrated dur-ing or after the intervention. Conclusion: Systematic physicalactivities in water are well tolerated by chronic stroke survivorsand tend to improve their fitness level as well as the feeling ofwell-being, without an increase in the level of spasticity.

P3-032 A New Approach with Emphasis onMotor Control in Treatment of Acute LateralAnkle Sprain (ALAS)

J. Bagheri1 and N. Ghaderi21Medical University of Isfahan, Iran; 2Al-ZahraHospital of Isfahan University, Iran

Background: ALAS is a common problem in present healthcare. Early mobilization with emphasis on motor learning is ad-vocated as a preferable treatment method. This case report is sopromising because our approach to her treatment is based onnew idea in neurorehabilitation of such cases. Her return to in-dependent ADL was unbelievable. Methods: This case is 27-

year-old with ALAS who was referred directly to Al-Zahra Phys-iotherapy Clinic. Moderate edema around the joint, severe restpain (VAS: 10), no ability to weightbearing were detected on ex-amination. At the 1st session, she was treated by short-timecryotherapy and a proper splint that was holding the joint at 10°of DF and IV. She was advised to follow cryotherapy, elevation,and wearing the splint 24 h/d for 3 d. Treatment continued atthe 4th day after injury with He-Ne Laser, conventional mobili-zation technique in the affected joint (grade 1 and 2), and activeROM. During 21 days, she received 6 therapeutic sessions. Signsand symptoms, such as pain, tenderness, ROM, and ability toweightbearing was assessed and reported. Results: After 3weeks, all clinical signs and symptoms were alleviated. At the6th therapeutic session, she was able to do plyometric exerciseswithout pain. Conclusion: Specific exercises to create reactiontime, ability to change direction, and functional strenghteningup to 6 months should be recommended. To sum up, the men-tioned protocol is more effective than conventional method andmay be considered by clinicians for a better outcome.

P3-033 Clinical Effectiveness of UnderwaterExercise Treatment Compared with TraditionalSport Treatment on Patients with Paralysis ofLower Limbs

J. Fan and L. ZhangTianjin Neurological Central(Huan Hu) Hospital,China

Objective: To compare the clinical effectiveness of underwa-ter exercise therapy on patients with paralysis of the lowerlimbs. Methods: 100 patients with paralysis of the lower limbswere randomly divided into 2 groups. Fifty-three patients(group 1) were treated with underwater exercise, whereas theother 47 patients (group 2) were treated with traditional sporttraining. Fugl-Meyer scores were used to evaluate the outcomesof both groups. Results: When comparing pre- and post-treatment, the Fugl-Meyer scores showed significant improve-ment in both groups (P < 0.05). When the changes of scores inFugl-Meyer scores were compared between the 2 groups, thechanges in group 1 were significantly higher than those ingroup 2 (P < 0.05). Conclusion: Both types of training showedimprovement in outcome. However, the underwater exercisetherapy showed a better treatment effect than the traditionalsport treatment for patients with lower limb paralysis.

P3-034 Effect on Genu Recurvatum by EnhancingSteady Training to Knee Joint of Stroke Patientsin the Early Course of Disease

Y. Wang and Q. TangThe Second Affiliated Hospital of HeilongjiangUniversity of Traditional Chinese Medicine, China

Background: To investigate the effect of enhancing steadytraining to the knee joint of patients with stroke in the earlycourse of disease. Methods: 58 patients were randomly dividedinto treatment group (30 patients) and control group (28 pa-tients), both of which were managed by routine medical treat-ment and general rehabilitation therapy. Patients of the treat-ment group also recieved additional enhancing steady trainingto the knee joint of the paretic limb in the early course of dis-ease. Results: After 3 months’ training, there were 9 patientswith genu recurvatum in the treatment group but 17 patients



with genu recurvatum in the control group. There is obviousdifference in the occurrence of genu recurvatum between the 2groups (P < 0.005). Conclusion: Enhancing steady training tothe knee joint of patients with stroke in the early course of dis-ease can reduce occurrence of genu recurvatum and effectivelyimprove their gait.

P3-035 Effect of Aerobic or Resistance Trainingon Cardiorespiratory Fitness after Chronic Stroke

G. M. Davis,1 M. J. Lee,1 S. L. Kilbreath,1

M. A. Fiatarone Singh,1 and B. Zeman2

1The University of Sydney, Australia; 2RoyalRehabilitation Centre Sydney, Australia

Backgr ound: Few stud ies have inves t iga tedcardiorespiratory versus peripheral adaptations after high-in-tensity cardiorespiratory training (AEROBIC) or progressive re-sistance training (PRT) in chronic stroke. Methods: 52 persons(age, 63 ± 9 years; time since stroke, 52 ±57 months) were ran-domized to AEROBIC training (30-min isokinetic cycling at50%-75% VO2peak, plus sham PRT), PRT (80% 1RM, plus shamAEROBIC), combined AEROBIC+PRT, or a sham exercisegroup. Peak cardiorespiratory fitness was assessed during maxi-mum effort cycling and steady-state cardiorespiratory re-sponses were quantified during submaximal cycling. Results:Maximal power output improved significantly (P < 0.05) afterAEROBIC (19 ± 30 W) and PRT (19 ± 31 W), whereas peakcardiorespiratory fitness increased only after AEROBIC(VO2peak: ∆148 ± 251 mL•min–1) compared to sham condi-tions. AEROBIC training resulted in significant improvements insubmaximal cycling power output (50% HRpeak: ∆8 ± 14 W),VO2 (50% HRpeak: ∆45 ± 200 mL•min–1), and net mechanicalefficiency (35% HRpeak: ∆6.1 ± 3.1%). In contrast, submaximalarteriovenous oxygen extraction improved significantly in bothAEROBIC (∆0.66 ± 1.55 mL•100 mL–1) and PRT (∆0.78 ± 1.52mL•100 mL–1) during cycling at 50% HRpeak. There were nochanges in heart rate, cardiac output, or stroke volume in eithergroup. Conclusion: The cardiorespiratory adaptations arebroader after AEROBIC compared to PRT in chronic stroke, al-though peripheral adaptations observed in both training modal-ities may improve maximal power output.

P3-036 Neurologic Reasons for Elbow Pain

M. Lyp,1 W. Maciak,2 P. Targosinski,1 and A.Ogonowski11Academy of Physical Education in Warsaw, Centreof Rehabilitation, Attis in Warsaw, Poland;2Medical University of Warsaw, Poland

Background: The occurrence of pain disorders in the elbowregion is often a reason for movement constraint. Enthesopathyis the most common reason for this disorder. In this paper wepresent other neurologic reasons for elbow pain. Methods: Per-sons who reported pain in the elbow region were interviewedto find out the reason. The physical examination consisted ofspecific tests with isometric flexion and extension of the wristjoint and fingers, isometric pronation and supination of thehand, and palpatoric assessment of the topography of the pain.A 4-step verbal scale of pain was used. We examined 117 pa-tients with elbow pain. Results: The physical examination andthe interview are very important for setting the right diagnosisand administering the optimal therapy. In the main group of pa-tients (87%), we found the reason for the pain to be

enthesopathy of the extensors or flexors of the radiocarpal jointand fingers. In 10% of the patients, a diagnosis of cervicalradiculopathy was made. In 2%, it was neuropathy of the ulnarnerve, and in 1%, neuropathy of a deep branch of the radialnerve with symptomatic pain in the elbow joint. Conclusion:The diagnosis of elbow pain is very complex. Clinical experi-ence is essential for making the right diagnosis. In some cases,pain in elbow region has a neurogenic reason, and a differenttherapy is necessary.

P3-037 Methadone in Treatment of RefractoryComplex Regional Pain Syndrome—A CaseReport

T. Y. ChuiHaven of Hope Hospital, Hong Kong

Background: A Chinese electrician sustained fracture of leftdistal radius in June 2002. Close reduction and K wire fixationwas performed. Implant was removed in August 2002. He de-veloped severe neuropathic pain due to complex regional painsyndrome of the left upper limb. Physical therapy could not betolerated. He demonstrated severe kinesiophobia. The painpersisted despite combination of amitriptyline, gabapentin,tramadol, and valproate. Drug-induced drowsiness affecteddaily functioning. There was only very transient response to astellate ganglion block or acupuncture. Methods: Since Novem-ber 2004, methadone was gradually introduced from 2.5 mg bdto 5 mg tds. There was transient drowsiness in the 1st weekonly. Results: At 10 months after methadone, there was 1) im-provement in pain intensity (NRS): worst pain in past 24 h: pre9/10, post 7/10; least pain in past 24 h: pre 8/10, post 5/10; 2) re-duction in impact of pain, as measured by the Brief Pain Inven-tory, on general activity, mood, walking ability, normal work,relations with other people, enjoyment of life; 3) reduction ofother medications; 4) improvement in active left shoulder ab-duction and left hand grip power; 5) improvement in SF-36; 6)improved compliance with rehabilitation regime. Conclusion:With careful patient selection, methadone could be an effectiveand well tolerated option in treating refractory neuropathic painin complex regional pain syndrome. It could enhance pain con-trol and physical rehabilitation. The effect is long lasting.

P3-038 Transient Vertebras as a Reason ofLumbosacral Neuropathy

M. Lyp, W. Maciak, P. Targosinski, and A. CabakAcademy of Physical Education in Warsaw,Poland; 2Medical University in Warsaw, Poland

Background: The transient vertebrae are the often met con-genital defects of the lumbosacral spine. They are usually de-tected by chance in radiologic examination. Generally, they donot cause any clinical symptoms. But they are accompanied bystatic-dynamic disturbances, which change the conditions ofthe spine’s joints. As years go by, these vertebrae can cause neu-ropathy and limiting mobility of the spine. Methods: The aim ofthis study was to assess transient vertebrae occurrence on thebasis of treatment for lumbosacral spine pain syndrome. Twogroups of patients at the age of 35 to 50 years with lumbosacralspinal pain were observed. The 1st group of patients consistedof people, in whom the transient vertebrae of lumbosacral spinewere found in radiologic examination. The control group werethose with pain but had no such congenital defect. The intensityof the pain was assessed according to a VAS scale. The treatment



kinesitherapy and physical therapy were used. Results: Themethods of treatment used reduced pain in both groups of pa-tients. In the group of patients, who did not have transient verte-brae, reduction of pain was more significant. Conclusion: Tran-sient vertebrae can be a secondary cause of neuropathic pain inlumbosacral spine. The results of treatment in patients withtransient vertebrae found by authors were less responsive incomparison with the results of treatment in patients without thisdefect.

P3-039 The Effect of Repetitive Arm Cycling onPoststroke spasticity and Motor Control

K. Diserens,1 D. Ruegg,2 P. Vuadens,3 J.Bogousslavsky,1 and F. Vingerhoets1

1Department of Neurology, CHUV, Lausanne,Switzerland; 2Department of Medicine, Switzerland;3SUVA Care, Sion, Switzerland

Background: The importance of repetitive hand movementshas recently been emphasized for the rehabilitation of theparetic hand after stroke. The aim of the present investigationwas to study whether the same principle applies also to the el-bow and shoulder. Methods: 9 patients with a stabilizedhemisyndrome underwent a cycling training on an armergometer for 30 min/d, during 5 d a week and during a periodof 3 weeks. They were tested 3 weeks before, at the beginning,at the end, and 3 weeks after the end of the training. During thesessions, torque and position signals on the ergometer were re-corded bilaterally, and 6 clinical tests were performed. Results:The Rivermead Motor Assessment, Motricity Index and the max-imum pedaling force were correlated significantly and assumedto be related to force, which increased significantly during thetraining period (P < 0.001). Similarly, the Ashworth Scale, therange of motion, and the minimum pedal force on the lesionside were correlated significantly and assumed to be related tospasticity, which decreased during the training period (but notsignificantly). Finally, the range of active elbow and shouldermovements increased significantly (P < 0.005). Conclusion:These results point at the efficacy of repetitive arm movementsin the rehabilitation of stroke patients.

P3-040 Driver Rehabilitation Specialty Service:Experience with Persons with CognitiveImpairment in Hong Kong

J. K. P. Au, J. L. S. Tse, P. H. W. Wong, and C. S. L. LamRehabaid Centre, Hong Kong

Background: Since 1995, Rehabaid Driver RehabilitationSpecialty Service is the only service providing comprehensiveon- and off-road assessment of cognitive-perceptual abilities,reaction time, and functional mobility for drivers with disabili-ties in Hong Kong. Methods: Clinical and demographic data onclients with brain impairment were collected prospectivelyfrom April 1999 to March 2005 for a descriptive analysis. Results:One hundred eighty-four clients with brain impairment (145with CVA, 39 with head injury) attended our service during theperiod. One hundred sixty-nine clients (92%) wished to resumedriving; 15 clients (8%) wished to learn to drive. Seventy-oneclients (38.6%) attended our service for assessment of drivingprivate vehicles; 113 clients (61.4%) attended for commercialvehicle driving assessment. Average brake reaction time forCVA clients was 0.53 s; for head injury clients, 0.56 s. Ten CVAclients (7%) were recommended not to drive because of side ne-

glect, visual impairment, hemianopia, and inability to steersafely. Of 135 clients recommended to drive, 18 (13%) neededvehicle modifications. Nine head injury clients (23%) were rec-ommended not to drive because of vertigo, seizure, or the in-ability to control gas and brake pedals safely. Of 30 clients whowere recommended to drive, 3 (10%) needed vehicle modifica-tions. Conclusion: The study showed that some clients withbrain impairment referred for assessment were unable to drivesafely. With modification offered, the disabilities due to brainimpairment could be compensated in some cases.

P3-041 The Effects of EMG Biofeedback on theTreatment of Arm Function after Stroke

L. ZhuNeuro Rehabilitation Center XuanWu Hospital,China

Background: EMG biofeedback emphasized that patientsmake an active moment. Stimulation used in muscles whichwere antagonists of the spastic muscles and modulated the ex-cessive excitation of these spastic muscles. We investigated theeffects of EMG biofeedback with electric stimulation of nerveand muscle system for stroke patients who had spasticity affect-ing movement. Methods: 18 subjects with stroke were recruitedfor this study. The ranges of motion of their paretic lower andupper limbs were limited. The wrist and finger flexor muscletone were evaluated. Ten subjects used physical therapy (PT)with EMG biofeedback during voluntary contraction ofextensor muscle. Eight subjects used PT only. The training pe-riod was up to 24 weeks. Dependent measures (Fugl-Meyer,range of motion, Brunnstrom, Asworth scale, finger test) wereassessed before and after training. Results: After 24 weeks oftraining, a significant improvement (P < 0.05) across time wasfound on all dependent measures except Asworth scale. WithFugl-Meyer assessment, those received EMG biofeedback train-ing with PT improved 45%, whereas those with PT improvedonly 25%. A significant improvement was also found on fingertest which showed improved coordination. Conclusion:Through the EMG biofeedback training for 6 months, therewere observed improvement of range of motion, spasticity, andfinger dexterity.

P3-042 Motor Imagery Practice in GaitRehabilitation of Chronic PoststrokeHemiparesis: 4 Case Studies

R. Dickstein, A. Dunsky, and C. AriavUniversity of Haifa, Israel

Background: The aim of this time series study was to exam-ine the contribution of motor imagery practice to walking per-formance of subjects with poststroke hemiparesis. Methods: 4persons with chronic hemiparesis received, in their home, 15min of imagery gait practice, 3 days a week for 6 weeks. The in-tervention addressed gait impairments of the affected lowerlimb and task-specific gait training. Preintervention, midterm,postintervention, and follow-up evaluations were performed.The main dependent variables were walking speed, temporalstep and stride parameters, and the Fugl-Meyer lower extremitytest. Results: At 6 weeks postintervention, participants increasedgait speed, stride length, cadence, and single support time onthe affected lower limb while decreasing double-support time.A substantial proportion of these gains were maintained at 3-week follow-up. However, the lower extremity Fugl-Meyer test



score remained unchanged. Conclusion: Motor imagery prac-tice appeared to have a task specific effect, improving walkingperformance but no motor output of individual joints of theaffected lower extremity.

P3-043 Effect of Functional Electrical StimulationTherapy on Rehabilitation

C. XieDepartment of Rehabilitation Medicine, NanjingGeneral Hospital of PLA, China

Background: The reports on functional electrical stimula-tion (FES) on the motor recovery of paretic lower limbs werevariable. This study was to evaluate the clinical effect of FES onmotor dysfunction of the paretic lower limb after stroke. Meth-ods: 100 cases with acute stroke were selected from the Depart-ment of Rehabilitation. They were randomly divided into 2groups with 50 patients in each. Patients in the treatment groupwere treated with FES in addition to Bobath’s motor relearningprogram (MRP) and occupational therapy. Those in the controlgroup only received the latter. Fugl-Meyer motor assessment(FMA) was performed to evaluate motor function of thehemiparetic lower limb before and after treatment. Results: Af-ter 4 weeks of treatment, the motor function score of the pareticlower limb was 20.89 ± 3.18 in treatment group, which was sig-nificantly higher than (P < 0.05) that before the treatment of 5.42± 2.12. In the control group, the score of FMA after treatmentwas 14.03 ± 3.11 and was also significantly higher than (P <0.05) that before the treatment of 6.01 ± 2.02. In addition, therewas also significant difference between the 2 groups after treat-ment. Conclusion: The study showed that FES combined withtraining of Bobath’s MRP and occupational therapy is more ef-fective in promoting the recovery of motor function of theparetic lower limb.

P3-044 Occlomotor Palsy after Right PosteriorCommunicant Aneurysm Surgery and Trainingwith Mentamove (Case Report)

Z. Akgun,1 M. Akgun,2 and C. Garner3

1School of High Healthy Uludag University, Turkey;2State Hospital Bursa, Turkey; 3KWA Klinik StiftRottal, Germany

Background: Brain efficiency training (Mentamove) is aneurorehabilitation method used for rehabilitation after variousbrain lesions. If motor activities are mentally practiced by thesubject, the real movement reorganizes the brain throughneuroplasticity. There has been no prior documented use oftreating cranial nerve lesions with Mentamove prior to this casereport. Methods: The case subject (a 42-year-old woman) wasoperated on for a right posterior communicating artery aneu-rysm. After the operation, she demonstrated right-side ptosis,occulomotor nerve palsy with diplopia, and pupil dilatation,and left-side central type facial paralysis. The Mentamove ther-apy was applied on the right m. O. oculi and m. frontalis, and tothe left facial muscles once daily. The outcome was docu-mented photographically. Results: After 2 weeks of Mentamovetreatment, the subject was able to slightly open her right eye. Af-ter 4 weeks of treatment, she was able to open the right eyecompletely, but she still could not look to the medial side. As aconcurrent therapy, we suggested that she imagine looking in

the direction of her nose (mentally) 20 times daily withoutMentamove. After 6 weeks, she recovered totally, and the pupildiameters and reactions showed total recovery. Left-side facialparalysis also recovered after 6 weeks of Mentamove therapy.Conclusion: These data support a new method (Mentamove) totreat the cranial nerve lesion deficits after incomplete injury ofthe affected nerves.

P3-045 Mentamove Rehabilitation afterBilateral Facial Paralysis and Brachial PlexusInjury (Case Report)

Z. Akgun,1 M. Akgun,2 and C. Garner3

1School of High Healthy Uludag University, Turkey;2State Hospital Bursa, Turkey; 3KWA Klinik StiftRottal, Germany

Background: Brain EFFICIENCY TRAINING (Mentamove) isa neurorehabilitation method used for rehabilitation after brainlesions. If motor activities are mentally practiced, the real move-ment leads to a reorganization of the brain. There has been noprior documented case of treating periferic nerve lesions withMentamove. Methods: Our case subject (a 27-year-old man) sus-tained bilateral perferic facial paralysis due to a head injury witha bilateral temporal bone fracture. He showed left shoulderluxation and monoplegia and left brachial plexus neuropraxia.After 13 days of hospitalization, he was discharged and exam-ined with EMG. EMG of the facial nerve showed denervation onthe mm. orbicularis oculi and mm. orbicularis oris bilaterally. Abrachial plexus EMG detected denervation on the axillar nerve.The results for left arm and the face were documented withvideo and photographs. The results were measured using theMedical Research Council Scale (MRC) of 0 to 5. TheMentamove treatment protocol was applied to the bilateralfascial mimic muscles, and the left shoulder, elbow, and wrist 1to 2 times daily. Results: The left-side facial paralysis recovered.After 20 d, the left arm motor weakness recovered from 0 to 5 onthe MRC Scale. The right side facial paralysis recovered after 70d of Mentamove therapy. Conclusion: This data support a newmethod (Mentamove) for use to treat peripheric nerve lesiondeficits after incomplete injury of the affected nerves.

P3-046 Effect of Ankle Taping on Postural Swayand Limb Load Asymmetry

S. A. Kim,1 K. I. Yang,2 and S. H. Jang3

1Department of Physical Medicine andRehabilitation Soonchunhyang University Hospital,Cheonan, South Korea; 2Department of NeurologySoonchunhyang University Hospital, Cheonan,South Korea; 3Department of Physical Medicine andRehabilitation Hanyang University Hostpital, Guri,South Korea

Background: This study is designed to evaluate the effect ofankle taping on postural sway and limb load asymmetry (LLA)in normal adults. Methods: 281 healthy subjects volunteered.These subjects performed the balance task on 2 different condi-tions, with ankle taping or not. Likewise, 239 healthy subjectsvolunteered and performed the balance task on 2 different con-ditions, with sham ankle taping or not. All subjects were dividedinto 2 groups; younger (<65 years) and older (≥65 years)



groups. Postural sway and body weight distribution were re-corded while the subjects were standing on 2 adjacent forceplatforms (Mediance; Human-Tech Inc, Korea) during 30-s trial.All subjects chose a comfortable stance with feet apart andasked to look straight ahead at a fixed point in a quiet room. Re-sults: There is no significant change in the sham ankle tapinggroup. In young age group, postural sway is decreased signifi-cantly by ankle taping (P < 0.05). In old age group, LLA is de-creased significantly by ankle taping (P < 0.05). Conclusion:The result indicates that ankle taping improves the balance indifferent pattern according to age. And proper methods of ankletaping should be needed.

P3-047 Power-Assisted Functional ElectricalStimulation Home Program to ImproveHemiparetic Upper Extremity Function

Y. Hara,1 S. Ogawa,1 and Y. Muraoka2

1Nippon Medical School, Chiba Hokusoh Hospital,Japan; 2Fujita Health University, Japan

Background: The objective of this study was to examine theeffect on spastic hemiparesis of power-assisted functional elec-trical stimulation (FES) at home. Methods: Five chronic strokesubjects with a mean age of 42.6 years and with moderate upperextremity impairment were recruited. A power-assisted FES de-vice induces greater muscle contraction by electrical stimula-tion in proportion to the integrated EMG signal picked up. It isapplicable to set up picked-up EMG signal sensitivity and elec-trical stimulation intensity range. The settings are individuallysaved in the portable FES device. Target muscles were the wrist,finger extensor and/or shoulder flexor muscles. Patientslearned the exercise methods and how to operate the FES de-vice from a physician and had an FES home program almost ev-ery day. Most patients received motor point blocking for spasticantagonist muscles. We investigated the root mean square(RMS) of the target muscles, active ROM, and clinical tests be-fore and after FES training. Results: Active ROM and RMS in-creased, and clinical test time was improved after 5 months onthe FES home program. The patients with the motor pointblocking of spastic antagonist muscles revealed good functionalimprovement. FES home program therapy could improvehemiparetic upper extrremity function effectively. Conclusion:Hybrid therapy consisting of motor point blocking and power-assisted FES was useful for improving impairment. It was easyfor patients to operate this new FES device, and the usual FEShome program was effective for improving hemiparetic upperextremity function.

P3-048 The Effects of Physiotherapy on Dyspneaand Fatigue in Myasthenia Gravis: A Pilot Study

I. Keser,1 N. Korkmaz,1 M. Bosnak,1 K. Armutlu,1

and R. Karabudak2

1The School of Physiotherapy and Rehabilitation,Hacettepe University, Turkey; 2Department ofNeurology, Hacettepe University, Turkey

Background: Myasthenia gravis (MG) leads to many impor-tant problems such as weakness of the respiratory muscles, fa-tigue, and decrease in pulmonary compliance and dyspnea. Theaim of this study was to investigate whether physiotherapy hasan effect on the perception of both dyspnea and fatigue. Meth-

ods: In this study, 8 MG patients whose classes were 2a and 2baccording to the Osserman clasification were included. As in-clusion criteria, patients had not relapsed for at least 1 month,and there had been no changes in dosage or medication. BORGdyspnea and fatigue scales were used to register status before,at the beginning, at the end, and in the recovery phase after a 6-min walking test. The physiotherapy session consisted of callis-thenic exercises and respiratory exercises over 6 weeks. Results:Beginning fatigue scores decreased significantly (z = –2.207, P <0.05), but there were no improvements in the end and recoveryscores (P > 0.05). The dyspnea scores decreased significantly atthe end and at the 3rd and 5th minute of recovery (z = –1.913,–2.032, –2.121; P < 0.05). Conclusion: Dyspnea decreasedprominently and the perception of fatigue decreased slightlywith physiotherapy. Although this was a small pilot study, theseresults may encourage appropriate physiotherapy approachesthat might have positive effects on MG symptoms such asdyspnea and fatigue. It is thought that this improvement may begreater with a longer physiotherapy program.

P3-049 Reliability of Measuring Isometric PeakTorque in the Driven Gait Orthosis “Lokomat”

M. Bolliger,1 L. Lunenburger,1 S. Bircher,2 G. Colombo,2

and V. Dietz1

1Balgrist University Hospital, Switzerland; 2HocomaAG, Volketswil, Switzerland

Background: Isometric assessment of muscular function is awidespread test method which has been used in exercise sci-ence for more than 30 years. Also in rehabilitation science, thismeasurement could be an important tool to monitor the recov-ery process in patients with gait disorders. Therefore we devel-oped a tool to assess the isometric muscle force of patients inthe driven gait orthosis (DGO) Lokomat. Methods: Subjects hadto produce maximal force against an immovable resistance, andmaximal torques for flexion and extension movement in hipand knee joint were recorded. Healthy subjects and patientswith gait disorders of different etiology were tested twice on thesame day by 2 different physical therapists in an alternating or-der to test interrater reliability and on 2 separate days by thesame therapist to test intrarater reliability. Results: All intraclasscorrelation coefficients (ICC) for the mechanical reliability werehigh (>0.999). The standard errors of measurements (SEM) wereless than 0.45 Nm. In healthy subjects, ICC for interrater reliabil-ity were greter than 0.77 (SEM, <11 Nm) and for intrarater reli-ability greater than 0.75 (SEM, <22 Nm). In patients, ICC weregreater than 0.73 (SEM, <30 Nm) for interrater and greter than0.72 (SEM, <24 Nm) for intrarater reliability. Conclusion: Thisstudy has demonstrated high reproducibility of the new assess-ment method for maximal isometric torque in the DGOLokomat. We suggest that this method is a valuable, as well aseasily administrable, tool to document and control the rehabili-tation process of patients.

P3-050 Diagnostic Approach Using a Computer-Based Method for Unilateral Visual Neglect

M. Kim,1 S. Chun,1 and S. Kim1

Pochon CHA University, South Korea

Background: Unilateral visual neglect is common in right-brain-damaged stroke patients. Various tests have been used to



assess this condition, but most of them are performed on the ta-ble, which does not always represent daily activity conditions.This study investigated the usefulness of newly developed com-puter-based test methods in evaluating visual neglect. Methods:26 young healthy normal control subjects (mean age, 28.0years) and 11 stroke patients (6 were left hemiplegic, and 5were right hemiplegic) (mean age, 58.2 years) were enrolled.Three lines of the line bisection test and the center scanning testin a vacant plane were performed in 4 different settings: on apaper, on a large monitor at 80 cm and 180 cm from the subjectusing a mouse controller, and on a monitor using a gaze-detec-tion system based on the movement of facial direction. Results:1) In the control group, the center perceived on the table wasslightly deviated to the left. 2) Left hemiplegic patients showedrightward deviated perception in all line bisection tests. Theyshowed the most profound deviation in computer-based testsusing a mouse at 180 cm from the monitor, and the perceivedcenter was deviated toward their inferior side when they usedthe gaze-detection system. Conclusion: Computer-based testingusing a large monitor and a gaze detection system was shown tobe more sensitive in diagnosing unilateral visual neglect thantests performed on a paper, as it better simulated daily livingvisual conditions.

P3-051 The Effect of Proprioceptive Dysfunctionon Activities of Daily Living (ADL) of the Stroke

Y. T. OuyangGuangzhou Industrial Rehabilitation Center, China

Background: Proprioception has a close relationship with aperson’s general athletic function. Proprioceptive dysfunctionis a usual problem of stroke. This paper has made an elementaryresearch through the analysis of proprioceptive dysfunctionand the lever of ADL on the basis of 67 stroke patients. Methods:67 stroke patients, who had been diagnosed by CT and receiv-ing rehabilitation therapy, were divided into 2 groups: A group(proprioceptive dysfunction) and B group (nonproprioceptivedysfunction). Barthel Index was used to assess ADL. Results:The rate of proprioceptive dysfunction was 48.7%. The totalADL score of A group was less than B group (P < 0.01). Conclu-sion: Proprioceptive dysfunction obviously affects the ADL ofstroke patients. Assessment and training of proprioceptionproblems should be emphasized.

P3-052 Mental Imagery for Promoting ResponseGeneralization of Patients with Stroke

R. S. M. Wong,1 C. S. F. Yau,2 K. P. Y. Liu,1 C. C. H.Chan,1 and L. S. W. Li21The Hong Kong Polytechnic University, HongKong; 2Tung Wah Hospital, Hong Kong

Background: Mental imagery has been reported as an effec-tive technique in improving the function of patients with stroke.This study, using RCT, examined the use of mental imagery forpromoting response generalization of patients with stroke.Methods: 21 patients with stroke with mean age of 67.9 yearswere randomized to the experimental (n = 10) and controlgroups (n = 11). The experimental group intervention was themental imagery program of relearning (MIP-R) consisting ofmental imagery technique training delivered through compli-cated daily tasks of various levels of difficulty as the training

media. The control group intervention was conventional occu-pational therapy program in which rote learning method wasused. All patients were evaluated with 5 untrained tasks of com-patible difficulty in a novel environment 1 week postprogram.Results: The results indicated that patients in the experimentalgroup showed a significantly higher level of task performancein the mean task competence scores (F(2,18) = 171.71, df = 1,P ≤ 0.001). Conclusion: The results suggest that MIR-P is effec-tive in enhancing response generalization of patients who suf-fered from stroke. MIR-P promotes response generalizationfrom untrained tasks performed in a training environment toother untrained tasks performed in a novel environment.

P3-053 Functional Status and Blood Level of IGF-1and IGFBP-3 in Postacute Stage Brain Diseases

D. H. Choi,1 T. R. Han,1 D. Y. Kim,2 S. W. Lee,2

and K. J. Yoon3

1Seoul National University Hospital, South Korea;2Seoul National University Boramae Hospital, SouthKorea; 3Seoul Medical Center, South Korea

Background: To evaluate the blood level of insulin-likegrowth factor-1 (IGF-1) and insulin-like growth factor bindingprotein-3 (IGFBP-3) in patients with postacute stage brain dis-eases and to investigate the relationship between IGF-1/IGFBP-3 blood level and functional status in patients with postacutestage brain diseases. Methods: Initial IGF-1/IGFBP-3 blood lev-els of 32 patients with postacute stage brain disease were ob-tained and various functional indices, including modifiedBarthel Index (MBI), functional ambulatory category (FAC), andJebsen hand function test (JHFT), were assessed initially and atdischarge. Results: The IGF-1 blood level was normal in 23 pa-tients and decreased in 9. The IGFBP-3 blood level was normalin 20 patients and increased in 13. The initial IGF-1/IGFBP-3levels were associated with the change of MBI score during ad-mission (P < 0.05, r2 = 0.214/P < 0.05, r2 = 0.213). There was acorrelation between IGF-1/IGFBP-3 levels and JHFT score onlyon the unaffected side at discharge (P < 0.05, r2 = 0.278). Therewas no relation between IGF-1/IGFBP-3 levels and the changeof JHFT score on either side during admission. Conclusion: Ini-tial IGF-1/IGFBP-3 blood level check can be a useful method toanticipate functional improvement of patients with postacutestage brain disease.

P3-054 Effects of Modified Constraint-InducedTherapy on Bimanual Coordination in Patientswith Stroke: A Kinemaitc Study

C. Y. Wu,1 I. H. Chen,1 K. C. Lin,2 and C. L. Chen3

1Department of Occupational Therapy andGraduate Institute of Clinical Behavioral Science,Chang-Gung University, Kwei-Shan Tao-Yuan,Chinese Taipei; 2School of Occupational Therapy,National Taiwan University, Taipei, Chinese Taipei;3Department of Physical Medicine andRehabilitation of Chang-Gung Memorial Hospital,Kwei-Shan, Tao-Yuan, Chinese Taipei

Background: To understand the control mechanism of thetherapeutic changes, this study used kinematic analyses to com-pare the efficacy of the modified constraint-induced therapy



(mCIT) to that of the traditional rehabilitation (TR) for strokepatients in a bimanual task (i.e., pulling the drawer to pick upthe glasses case inside the drawer). Methods: 18 stroke patientsparticipated in this study and received either mCIT or TR inter-vention for 3 weeks. The mCIT group received 2-h training forthe more affected limbs and 6-h constraint for the less affectedlimbs per day. The TR group received regular rehabilitationtraining for 2 h/d. Movement performance on the drawer-pull-ing task was kinematically measured pre- and postintervention.Results: Patients with the more affected pull-hand in the mCITgroup showed higher percent of movement where peak veloc-ity occurs (PPV) after training than those in the control group.No significant differences were found in the less affected pick-hand. The interval between the movement onset and the goalachievement of both hands in the mCIT group was longer aftertraining in comparison with that in the TR group. Conclusion:The findings suggested that different approaches improved theperformance of the stroke patients in different aspects of motorperformance. The mCIT preprogramed the movement better inthe more-affected limb than the TR, whereas the TR synchro-nized better than the mCIT.

P3-055 12 DOF Active Upper Extremity Orthosisfor Neurorehabilitation

S. Mina,1 A. Mayr,2 G. Kronreif,1 and L. Saltuari21ARC Seibersdorf research GmbH, Austria; 2HospitalHochzirl, Department of Neurology, Austria

Background: Motor relearning usually requires therapy witha regular and repetitive input. Very soon it could also be recog-nized that this kind of therapy is very time-consuming and ex-pensive because of the high personnel costs. With the introduc-tion of automated locomotor training, it was possible to providethe same therapy with reduced costs. The results achieved inautomated treadmill training and the lack of clinically usablesystems was the motivation to develop a training system for theupper extremity with a high degree of freedoms and varioustraining procedures. Methods: The system offers methods toperform repetitive movement of the upper limb with previouslyrecorded exercises and real-time motion synchronization for in-teractive therapy. Repetitive training movement therapy hasbeen published several times, and the implementation of thismethod on an automated therapy system was one of the mainobjectives during the development. Real-time motion synchro-nization was designed so that the therapist or the patient him- orherself can perform an exercise, which is mirrored to the activeorthosis on the patient’s paretic arm and hand. Results: With 1stexperiment, it could be demonstrated that the system provideda sufficient range of motion, force, and number of degrees offreedom for the intended application. Conclusion: Preliminaryresults show that the system is not only an interesting therapysystem but also an interesting platform for diagnosticapplications.

P3-056 Effects of Constraint-Induced MovementTherapy after Stroke: A Randomized ControlledTrial with Kinematic and fMRI Study

K. C. Lin,1 C. Y. Wu,2 I. H. Chen,2 and C. Y. Lee3

1National Taiwan University School ofOccupational Therapy, Chinese Taipei; 2ChangGung University Graduate Institute of ClinicalBehavioral Science, Chinese Taipei; 3Cathay

General Hospital Department of Rehabilitation,Chinese Taipei

Background: Constraint-induced movement therapy (CIMT)has been shown to improve motor function after stroke. Itreamins unclear whether CIMT improved organization of move-ment. This study investigated the efficacy of CIMT on move-ment quality using kinematic analysis and motor cortical reor-ganization using functional magnetic resonance imaging(fMRI). Methods: 71 unilateral stroke patients were assigned toeither the CIMT group or the traditional rehabilitation (TR)group. CIMT involved immobilization of the less-affected arm 6h/d combined with intensive training of the affected arm 2 h perweekday for 3 weeks. Pre- and posttests were performed tostudy reaching kinematics on a desk-bell task and motor cortexactivation associated with finger grasping at 2/3 Hz using a 1.5tesla fMRI. A laterality index (LI) was calculated from the fMRIdata to reflect the distribution of activation contralateral com-pared with ipsilateral to the moving hand. Results: The CIMTgroup exhibited greater improvement on movement quality(e.g., faster and smoother motor acts) than the TR group. Thebehavioral effects of CIMT were associated with a trend towarda reduced LI immediately after CIMT in chronic patients;whereas the subacute patients showed a more variable patternof change in LI. Conclusion: The finding supported the benefitsof CIMT for improving quality of arm movement. There is aneed to further study differential mechanisms of brain reorgani-zation after CIMT in relation to stage of recovery from stroke.

P3-057 Effects of Early Rehabilitation Training onBalance Function and Activities of Daily Living inPatients with Hemiplegia after Stroke

R. Han, C. M. Ni, J. B. Li, and Z. X. MengDepartment of Rehabilitation, The First AffiliatedHospital of Anhui Medical University, China

Background: To study the effect of early rehabilitation onbalace function and activities of daily living (ADL) in patientswith hemiplegia after stroke. Methods: 80 patients were ran-domly divided into 2 groups, rehabilitation group (40 cases)and control group (40 cases). Patients in the rehabilitationgroup were given clinical treatment and regular physical ther-apy, whereas those in the control group were given clinicaltreament and unguided self-training. Evaluations were madepretreatment and 3 months and 6 months after stroke. Balancefunction was assessed with Fugl-Meyer and ADL was assessedwith modified Barthel index (MBI). Results: The balance func-tion scores and MBI scores in each group before and after treat-ment showed significant difference (P < 0.05). The changes inscores after the treatment also showed that the rehabilitationgroup was superior to the control group (P < 0.001). The bal-ance function was positively correlated with ADL (r = 0.791).Conclusion: Early rehabilitation training on patients withhemiplegia after stroke will improve balance function and ADL.

P3-058 Effect of Intrathecal Baclofen on Sleepand Ventilatory Parameters in Spastic Patients

D. Ben Smail, S. Benyahia, P. Denys, F. Lofaso,and M. A. Quera-SalvaR. Poincare Hospital, France

Background: Spastic patients complain frequently of sleepdisorders. They very often describe an improvement of sleep af-



ter intrathecal baclofen (ITB) infusion. The objective of thisstudy was to evaluate the effect of ITB on sleep and ventilatoryparameters in spastic patients. Methods: It was a prospectivestudy including patients with severe intractable spasticity, resis-tant to oral antispastic medications, and undergoing pump im-plantation for chronic ITB infusion. Each patient had in theweek before and at least 15 days after the pump implantation aclinical examination with a polysomnography, evaluation ofspasticity, pulmonary function, and basal metabolism (oxygenconsumption and carbon dioxide production). Results: Sleep ef-ficiency was significantly improved by ITB (P = 0.01). Totalsleep time was improved with P = 0.05. A significant improve-ment of rapid eye movement sleep was observed (P = 0.04)without modifications of other sleep stages. Leg movements as-sociated with microarousals (MA) were reduced (P = 0.02) butthe total number of MA were not. Sleep-related respiratory pa-rameters, daytime ventilatory parameters, and basal O2 con-sumption were not modified by ITB. Conclusion: An improve-ment of sleep efficiency was observed after ITB infusion. It maybe probably via a spinal action of baclofen. Sleep architecture,MA during night, and sleep-related respiratory parameters werenot modified. Baclofen probably reduced the amount of legmovements secondary to MA reducing secondary insomnia.

P3-059 Spasticity of the Upper Extremity inPatients with Severe Stroke: Incidence andClinical Course

A. A. van Kuijk,1 H. T. Hendricks,2 J. W. Pasman,2

H. P. H. Kremer,2 and A. C. H. Geurts2

1Rehabilitation Centre Tolbrug, the Netherlands;2University Medical Centre Sint Radboud, theNetherlands

Background: Spasticity develops in 20% to 40% of all strokesurvivors. After the acute phase, muscle tone in the initial flac-cid limb may emerge over time into increasing spasticity. Empir-ical data on when and how spasticity manifests itself after se-vere stroke are lacking, although specifically this subgroup isprone to develop spasticity. Methods: Cohort study including 40acute stroke patients admitted to an academic department ofneurology with an initial paralysis of the upper extremity (UE).UE spasticity was assessed by the Ashworth Scale (AS), UE mo-tor functions by the UE subscore of the Fugl-Meyer Motor As-sessment, and functional abilities by the Barthel Index. Results:When clinical spasticity was defined as AS ≥2, the incidence ofspasticity ≤6 months poststroke was 63%. In 50%, spasticity de-veloped ≤ 6 weeks poststroke, and in 25%, even ≤ 2 weeks. In 1/3 of the patients with early spasticity, muscle tone normalized.In 13%, spasticity developed only after 3 months. At 6 monthspoststroke, 15% showed motor recovery. There was no differ-ence in motor or functional recovery between patients with andthose without spasticity. Conclusion: Patients with severestroke are probably responsible for a large proportion of the pa-tients with poststroke spasticity, given the relatively high inci-dence in this subgroup. Poststroke spasticity is not a static fea-ture but follows a dynamic course. Unlike the stroke populationin general, in this subgroup spasticity is not clearly associatedwith motor or functional recovery.

P3-060 Predicting Chronic Spasticity of the UpperExtremity after Severe Stroke

A. A. van Kuijk,1 H. T. Hendricks,1 J. W. Pasman,2

H. P. H. Kremer,2 and A. C. H. Geurts2

1Rehabilitation Centre Tolbrug, the Netherlands;2University Medical Centre Sint Radboud, theNetherlands

Background: In the upper extremity (UE), spasticity maycontribute to impaired basic arm and hand abilities. In the longterm, untreated spasticity can lead to contractures and pain,which may further impede function. It would be advantageousto predict patients at risk of severe long-term spasticity, becausethese patients are prone to suffer the negative consequences ofspasticity and will benefit most from early spasmolytic interven-tions. In previous research, only degree of paresis has been as-sociated with the chance of developing clinically relevantspasticity. Methods: Cohort study including 40 acute stroke pa-tients admitted to an academic department of neurology with aninitial paralysis of the UE. UE spasticity at 6 months poststrokewas assessed by the Ashworth Scale and selected as the out-come measure, whereas clinical and radiologic characteristicswere selected as prognostic factors. Results: Associations be-tween chronic spasticity and the selected prognostic factorswere generally low. Multiple logistic regression analysis yieldedno independent factor as a significant predictor of spasticity.Conclusion: In this selected study population with a high inci-dence of spasticity and, thus, an optimal chance of identifyingadditional prognostic factors, we could not establish any of theselected clinical or radiologic factors as predictors of chronicspasticity. Hence, the degree of paresis remains the only clinicalcharacteristic that can be used as a prognostic factor forspasticity.

P3-061 Fifty Percent Alcohol in WaterIntramuscular Neurolysis for Treatment of AnkleSpasticity

A. Suputtitada and T. PoonyachotiChulalongkorn University, Thailand

Background: Ankle spasticity often causes difficulty instanding or walking in ambulatory stroke patients. Local treat-ment such as botulinum toxin injection is an effective and safeprocedure, but it is rather expensive. Therefore, we evaluatedthe effectiveness and safety of using 50% alcohol in water intra-muscular neurolysis for treatment of ankle spasticity. Methods:Experimental study, before and after comparison was done.Stroke patients were selected with the following criteria: modi-fied Ashworth Scale (MAS) greater than 2 and ankle hyperflexiawith or without ankle clonus. Evaluation had done 4 times atpreinjection, 2 weeks and 3 months postinjection, and when theankles became spastic again. The evaluation included MAS,walking speed, ankle jerk, ankle clonus, passive range of mo-tion of ankle joints, and side effects after injection. Results: 20stroke patients were recruited. The mean age was 51.2 ± 14.6years. There were statistically significant difference at P < 0.05for the MAS, walking speed, ankle jerk, ankle clonus, and pas-sive range of motion between preinjection and 2 weekspostinjection, between 2 weeks and 3 months postinjection,and between preinjection and 3 months postinjection. The



mean duration of action was 135 ± 4 days. Four patients (20%)had complication of edema at the injected sites for 2 days; 16 pa-tients (80%) had no side effect. Conclusion: The treatment ofankle spasticity with 50% alcohol in water injection can de-crease spasticity and improve walking speed. Edema at the in-jected site was the only side effect found in about 20%.

P3-062 Contractures Do Not Potentiate CerebralSpasticity in Patients with Severe Brain Injury

J. Mehrholz,1 M. Pohl,1 S. Rückriem,1 G. Rockstroh,1

and R. Koch2

1Department of Neurological Rehabilitation, KlinikBavaria, Kreischa, Germany; 2Institute for MedicalInformatics and Biometrics of the TechnicalUniversity Dresden, Germany

Background: Although there is evidence that immobiliza-tion rather than hypereflexia leads to viscoelastic changes suchas contractures, the relationship between cerebral spasticityand contractures remains unknown. The aim was to evaluatethe influence of contractures on positive features of the uppermotor neuron syndrome (UMNS). Methods: 45 patients withtetraparesis after severe cerebral damage were investigated.Three patient groups were defined: group S (n = 17, spasticitywithout contractures), group S+C (n = 20, spasticity andcontractures), and group C (n = 8, contractures withoutspasticity). Muscle overactivity was assessed continuously overa 12-h period by measuring knee joint muscle torque. Using theintegral of raw muscle torque, a mathematical algorithm wasused to differentiate a muscle activity spectrum (PIh). Impulsesfrom the activity spectrum were defined from a Schmitt-trigger.Frequency (peaksh) and duration of impulses (peakt) werestudied. Results: A variance analytical model with Tukey-Kramer–adjusted post hoc comparisons revealed that group Shad higher PIh, more frequent peaksh and shorter peakt com-pared with group S+C and group C (P < 0.05). Group C hadlower PIh, less frequent peaksh, and longer peakt comparedwith group S (P < 0.05). Conclusion: The presence ofcontractures was associated with lower muscle overactivity, in-dicating that contractures may rather reduce than potentiate thepositive features of the UMNS in patients with severe braininjury.

P3-063 Bedside Scale to Monitor Hypertonic Hand

K. M. BoNothern Lincolnshire & Goole Hospitals NHS Trust,United Kingdom

Background: Hypertonic hand can be a complication of anupper motor neurone lesion. Extreme tight fist deformity is themost severe of all hypertonic hand deformities. This deformityis due to hypertonia of flexor digitorum superficialis (FDS) andflexor digitorum profundus (FDP) muscles. Progression to thatadvanced stage of deformity is unacceptable. Unfortunately,this is still happening today. There is no user-friendly bedsidescale to document progression of FDS and FDP hypertonia. Auser-friendly bedside scale is needed to document and monitorFDS and FDP hypertonia. Methods: After reviewing anatomy,function, and stages of hypertonia (spasticity, soft tissuechanges, contracture, and skeletal changes) and its manage-

ment, the following bedside scale is proposed: 1st degree: Fin-gers can only be straightened when wrist is in neutral position.Further extension of wrist will result in curling of fingers. 2nddegree: Fingers can only be straightened when wrist is bent.Further extension of wrist will result in curling of fingers. 3rddegree: Fingers can not be straightened regardless of wrist posi-tion. 4th degree: There is fist formation of hand, and it does notopen regardless of wrist position. 5th degree: Fist formationprogresses to extreme degree because of skeletal changes. Re-sults: Based on this bedside scale, the following forms are de-veloped: 1) Simple monitoring form and 2) detailed monitoringform. Experience in using the above monitoring forms will bepresented.

P3-064 The Use of Botulinum Toxin (A) Injectionas a Focal Spasticity Management within aCommunity-Orientated RehabilitationMedicine Service

K. M. Bo, I. Molloy, and A. JonesNothern Lincolnshire & Goole Hospitals NHS Trust,United Kingdom

Background: Spasticity can be a consequence of an uppermotor neurone lesion. It results from disinhibition of spinalstretch reflexes. Spasticity can reduce quality of life of patientsand increase cost of care. Although there are oral antispasticitymedications for generalized spasticity management, botulinumtoxin injection is invaluable for focal spasticity management. Itsdosage can be tailored to level of spasticity and desired func-tional gain. We have been providing botulinum toxin (A) injec-tion as a focal spasticity management since June 2002. This ser-vice is part of a comprehensive multidisciplinary managementof spastici ty. Methods: Retrospective document andmultidisciplinary case note analysis for the period 1 April 2003to 31 March 2004. All patients receiving 1 or more sessions ofbotulinum toxin (A) injection are included. Results: Data will bepresented on 1) profile of the patients treated with botulinumtoxin (A) injection, 2) goal profile of the treatment, 3) dose andmuscle groups treated and frequency of treatment, 4) outcomesof treatment, and 5) safety profile of botulinum toxin (A) injec-tion. Conclusion: Between 1 April 2003 and 31 March 2004, 28patients received botulinum toxin (A) injection for focalspasticity, 75% achieved treatment goals. Botulinum toxin (A)injection was found to be safe in all and effective for themajority.

P3-065 Efficacy of Botulinum Toxin in Spasticityof SCI Patients in Indian Scenario

V. SinhaPatna Medical College, Patna, India

Background: SCI often produces severe debilitating condi-tion due to spasticity. The long-term effect and safety of botuli-num toxin in reducing spasticity has been well documented. Itacts by inhibiting the release of acetylcholine because of its par-alytic effect at the neuromuscular junction. The present studyhas been carried out to evaluate its efficacy in SCI patients withspasticity in Indian scenario. Methods: 33 patients ( 26 men and7 women), suffering from spasticity after SCI lesions were givenbotox over different sites with dose ranging from 40 to 120 U per



muscle with maximum of 300 U per patient. Patients (8tetraplegics and 25 paraplegics) were subjected to baseline as-sessment with regard to Modified Ashworth Scale, Barthel In-dex, and Functional Independence Measures score and againafter 3 months of postinjection period. Results: The focal im-provement could not be appreciated in FIM score, but on grad-ing with Modified Ashworth Scale, the improvement was clearby at least grade 2 in 19 of the 33 patients and also in BI score.The frequency in spasm showed significant reduction in almost60% patients. Nine of 13 patients with intractable pain withspasticity experienced much relief with stastically significantimprovement. They were put to long-term rehabilitation man-agement subsequently. Conclusion: With BTX-A administra-tion, the spasticity in SCI patients is reduced. It diminishesspasm frequency and pain. BTX infiltration in spastic muscle isa safe and effective treatment for symptomatic spasticity.

P3-066 Improvement in Upper Limb Functionafter Botulinum Toxin Type A (BTX-A) Treatmentin Adult Chronic Spastic Hemiplegia

S. Carda, F. Molteni, and M. UgoliniUO Recupero e Rieducazione Funzionale-VillaBeretta-Ospedale Valduce, Italy

Background: BTX-A is largely used for upper limb (UL)spasticity treatment, and its efficacy in reducing hypertonia isdemonstrated. Whether reducing spasticity can produce an im-provement in active function of the UL is still debated. We de-cided to evaluate if BTX-A treatment can lead to UL active func-tion improvement. Methods: 19 subjects with UL spasticity dueto stroke were treated with BTX-A (Botox-Allergan). Mean agewas 47.3 years. Time from stroke was at least 12 months. WolfTest (WT) was used to assess UL function. Spasticity was evalu-ated with Modified Ashworth Scale (MAS) at the muscles in-jected. Single-blind evaluations were made before and 1 monthafter BTX-A administration. For statistical analysis, t test wasused. Results: Mean BTX-A dose for each patient was 193.5 ±26.9 UI. Patients showed a mean reduction in MAS scores of theinjected muscles of 2.3 ± 0.2 points (from 3.1 ± 0.3 to 0.7 ± 0.2, P< 10-3). A mean improvement in WT scores of 5.4 ± 1.3 pointswas observed (mean WT score before treatment, 35.4 ± 3; aftertreatment, 41.7 ± 3.8, P = 0.001). Conclusion: BTX-A is effectivein reducing spastic hypertonia and improves UL active function.Reducing spasticity at the UL may unmask active movement thatbecomes useful in improving active function. Probably the maindeterminant in UL functional improvement is patient’s residualactive function. It could be useful to verify the efficacy of thistreatment in association with other treatments aimed to improveUL active function (e.g., physiotherapy, constraint-inducedmovement therapy).

P3-067 Optimising Botulinum Toxin (BTX-A)Treatment of Upper Limb Spasticity in StrokeUsing Orthotics and Physiotherapy: ARandomized Controlled Trial

R. M. Kent,1 A. J. Robertson,2 and A. Tennant11University of Leeds, United Kingdom; 2MidYorkshire NHS Hospital Trust, United Kingdom

Background: BtX-A is an evidence-based treatment forspasticity after stroke, but evidence is poor for upper limb

splinting, either alone or with physiotherapy. Methods: In thisrandomized, single-blind, parallel trial, participants received(BtX-A 1000 U dysport). The intervention group received 12 ×20-min twice weekly physiotherapy plus a customized restingorthosis. Results: Of 64 patients mean age 65.3 years (SD 11.5),62.5% were male and 61.7 months poststroke (SD, 80.1); 53.1%had a left hemiparesis. Site-specific dosage of botulinum toxinwas equal. Results at 7 weeks (primary end point) showed a sig-nificant group effect, (P < 0.002) and improvement in wrist ex-tension and finger flexion (<0.0125). Spasticity improved simi-larly in both groups. There was a significant between-groupeffect at 12 weeks (P < 0.002). Finger flexion achieved signifi-cant difference, with positive trends in other measurements.Spasticity change was not significant. A significant group effectwas observed at 20 weeks (P < <.004), finger flexion was signifi-cant and strong trends were also observed for shoulder andwrist (P ⎥ 0.03). No significant changes were seen in the second-ary outcome measures at any stage. Conclusion: The addition ofsplinting and physiotherapy to botulinum toxin improves themagnitude of and duration of wrist extension and reduces fin-ger flexion, which is sustained beyond the pharmacologic effectof the drug. The differential effect on wrist and fingers impliesan improvement attributable to splinting.

P3-068 A Clinical Study of the Effects ofElectromyography-Free Injection of BotulinumToxin A in the Treatment of Children with SpasticCerebral Palsy

L. Ao, Q. Jinghua, W. Wenli, Z. Lin, and T. MeiThe Department of Rehabilitation Medicine ofSecond Affliated Hospital of Kunming MedicalCollege, China

Object ive: To evaluate the therapeut ic ef fect ofelectromyography-free injections of botulinum toxin A in thetreatment of children with spastic cerebral palsy. Methods: 68children with cerebral palsy, who had lower limb spasticity,were injected with botulinum toxin A at several muscular siteswithout the use of electromyography. On the next day after in-jection, stretching to the muscle injected and functional trainingwere started and continued for 3 months. At the same time, AFOor KAFO was used beginning 1 week after injection. All the datawere recorded at 3 days, 1 week, 2 weeks, 1 month, 2 months,and 3 months after injection. Results: The parents reported thatbotulinum toxin A began to have an effect at 6 to 72 hours afterinjection and peaked 1 to 2 weeks later and that the effect per-sisted for more than 3 months. There were no serious side ef-fects. The adductor angle, the hip flexor angle, the popliteal an-gle, and the angle of ankle dorsiflexion significantly improved 3days after injection and peaked at 1 month. The effect lastedmore than 3 months after injection. The changes in the spasticmuscle measured using the Modified Ashworth Scale (MAS)paralleled with the ROM results. The GMFM-66 increased signif-icantly 1 month postinjection, and this change was observed topersist. The dosage was significantly correlated with the onsetof side effects. Conclusion: The electromyography-free injec-tion technique using botulinum toxin A combined withorthotics and rehabilitation training effectively improved func-tional movement in children with spastic cerebral palsy.



P3-069 Identifying Factors that Predict Responseto Intrathecal Baclofen (ITB) Therapy inPoststroke Spastic Hypertonia

G. E. Francisco and C. BoakeUniversity of Texas Health ScienceCenter–Houston, USA

Background: This study aims to describe patient characteris-tics that may predict successful outcome of ITB therapy in se-vere poststroke hypertonia. Methods: The study was a singlegroup comparison from pre- to posttreatment. Ninety-fouradults (males, 52%; mean age, 57.2 ± 13 years) at least 6 monthspoststroke (ischemic = 52%) were enrolled. Following success-ful screening trial with a single ITB bolus dose of 50-100 mcg(decrease in mean Ashworth Scale [AS] of at least 1 point), 74patients underwent ITB pump placement. Patients underwentphysiotherapy and had ITB dose adjustments based on clinicalneed. Main outcome measure was the AS at screening trial and12 months after pump placement. Data were analyzed with mul-tiple regression to identify significant predictors of AS at 12months. Results: Mean upper and lower extremity AS signifi-cantly decreased (P < 0.05) from preimplant (3.62 ± 0.50) to 12months postimplant (2.17 ± 0.72). AS scores at 12 months wasworse in patients who had more spasticity at the screening trial(P = 0.003) and in those with ischemic stroke (P = 0.03). The im-provement in AS scores did not correlate with ITB dose (r =0.15). Age, final baclofen dosage, stroke location, chronicity ofstroke, and baseline ambulation and activities of daily living sta-tus did not significantly improve prediction of response to ITBtherapy. Conclusion: In persons with severe poststroke spastichypertonia, baseline spastic hypertonia severity and ischemicstroke type appear to predict response to ITB therapy at 12months.

P3-070 Long-term Outcome of Superficialis-to-Profundus Tendon Transfer in Patients withClenched Fist due to Spastic Hemiplegia

J. W. G. Meijer,1 I. C. M. Heijnen,1 B. J. W. Bevaart,1

R. A. E. Hermens,2 and R. J. P. Franken2

1Rehab Centre Tolbrug/Jeroen Bosch Hospital,’s-Hertogenbosch, the Netherlands; 2Department ofPlastic Surgery, Jeroen Bosch Hospital,’s-Hertogenbosch, the Netherlands

Background: Pain and hygienic problems due to clenchedfist influence quality of life after stroke. Operative treatment canimprove these problems. Literature about long-term effects islacking. Methods: Patients who underwent a superficialis-to-profundus tendon (StPt) transfer in the years 2003 through 2005were evaluated on skin condition, upper extremity joint mobil-ity, and muscle tone, and with VAS scores on satisfaction, hy-giene maintenance, and pain in the hand. Results: 6 patients(mean age, 54 years; duration after stroke, 10 years) were in-cluded. Indications to operate were hygienic problems only (1)or combined with pain (5). The mean follow-up period was 19months. After 6 weeks of postoperative splinting, no standardfollow-up was applied. Serious postoperative complicationswere not reported. Hygiene improved in all cases. In resting po-sition, flexion was seen in the MCP-joints (60°-90°). In all pa-tients, hands could passively be fully opened. Muscle tone was

raised in flexors of the wrist and fingers, and the muscleadductor pollicis (Ashworth 1-2). Mean VAS reduced signifi-cantly. Given the circumstances, all patients would agree tohave the surgery over again. Conclusion: StPt transfer inclenched fist in stroke patients improves hygiene and reducespain. After 19 months, the hand can still be fully opened. Muscletone remains unaffected by the surgery, leading to closing of thehand. To avoid recurrence of a clenched fist, follow-up and in-terventions might be useful (e.g., spasticity treatment,orthesiology).

P3-071 Dose-Effect Relationship of BotulinumToxin Type A in Spasticity—Preliminary Study

J. Li,1 G. Xu,1 X. Wang,1 and Y. Mao2

1First Affiliated Hospital of Nanjing MedicalUniversity, China; 2Army Police HangzhouHospital, China

Background: Botulinum toxin type A (BTX-A) has beenused in relief of spasticity for years in China. However, the opti-mal dosage is still uncertain. This study aimed to explore dose-effect relationship of BTX-A in patients with upper motor neu-ron syndrome. Methods: 48 patients with spasticity were dividedinto the high dose (HD) and lower dose (LD) groups. Dose ofBTX-A in triceps, elbow flexors, and finger flexors were 176.9 ±20.9, 182.5 ± 26.6 and 172.0 ± 45.4 IU in the HD group and 119.2 ±12.7, 63.6 ± 17.5 and 54.3 ± 20.5 IU in the LD group, respec-tively. BTX-A was injected with needle electrodes for injectionunder the guidance of electrical stimulation. Muscle tone wasassessed by the Modified Ashworth Scale. Functional goalswere set up as an outcome measurement. Follow-up was per-formed 3 months after injection. Results: The Ashworth Scale ofthe triceps, elbow flexors, and finger flexors before injectionwere similar between the groups (P > 0.05). The reduction ofthe Ashworth Scale at the follow-up were 1.17 ± 0.31, 1.07m ±0.32 and 0.86 ± 0.26 in the HD (P < 0.01); and 1.25 ± 0.35, 1.00 ±0.30, and 1.20 ± 0.22 in the LD (P < 0.01), respectively. Therewas no significantly difference of the Ashworth Scale reductionbetween the groups (P > 0.05). Conclusion: Dose-effect rela-tionship of BTX-A injection for spasticity relief is not demon-strated. There is potential to use lower dose of BTX-A forspasticity. Further study is worthwhile.

P3-072 Efficacy of Neurolysis with AlcoholInjection for Relief of Muscle Spasticity

G. Xu,1 Y. Mao,2 X. Yang,1 and J. Li11First Affiliated Hospital of Nanjing MedicalUniversity, China; 2Army Police HangzhouHospital, China

Background: Alcohol injection for neurolysis in patientswith spasticity has been used internationally for years. How-ever, there was no report in China. This study aimed to explorethe application and efficacy of neurolysis in patients with uppermotor neuron syndrome (UMNS) and spasticity in China. Meth-ods: 38 patients with muscles spasticity were involved in thisstudy, including 20 SCIs, 9 brain injuries, 5 cerebrovascular acci-dents, and 4 others. Needle electrodes for injection were per-formed in sciatic nerve and tibia nerve under the guidance ofelectrical stimulation. Concentration of the alcohol was 100%.The volume of each injection site was 3 to 3.5 mL. All subjects



received assessment of the Modified Ashworth Scale, musclestrength, and ADL. Follow-up duration was 3 months. Results:55 nerves in 38 patients were injected. Muscle spasticity was sig-nificantly reduced in 45 nerves after the 1st injection (P < 0.05).The muscle spasticity for the rest 10 nerves was relieved (P <0.05) by the 2nd injection which was performed 2 weeks afterthe 1st injection. The cost of neurolysis for relief of spasticitywas only 10% of the botox injection. Conclusion: Neurolysiswith 100% alcohol injection was an effective and cheap ap-proach for relief of spasticity in patients with UMNS.

P3-073 Patient’s Perceptions of Botulinum Toxinfor Spasticity

S. Stark,1 R. Thomas,1 A. Gani,2 and L. A. Graham1

1Hunters Moor Regional Rehabilitation Centre,United Kingdom; 2Newcastle General Hospital,United Kingdom

Background: Hunters Moor Regional Rehabilitation Centre,United Kingdom, has used intramuscular botulinum type Atoxin to treat focal spasticity for more than a decade. Many pa-tients attended regularly for a number of years. This study aimsto assess their impression of the benefits obtained by repeatedbotulinum injections for spasticity over a long time period.Methods: A semistructured anonymous questionnaire was de-signed and, after validation and modifications, delivered pro-spectively to patients attending the spasticity clinic over a 3-month period. Exclusions were those with severe speech andcognitive problems and those at 1st clinic attendance. For thosewith reading and writing difficulties, relatives and carers com-pleted the questionnaires. Results: Successfully completedquestionnaires were returned by 160 patients, 83 male; meanage, 45 years (range, 17-88 years). Length of time of attendanceranged from 3 months to 10 years; mean, 2.4 years. The majorityattended every 3 months, the time between appointments al-tered in 27 (17%). The pattern of injections was altered in 17(10%). Benefits for patients were reduction of spasms in 75%,pain relief in 40%, improved gait in 21%, and improved abnor-mal movements and seating in 20%. Side effects occurred in 26(16%). Overall, 76% of patients reported benefit from injec-tions—scoring benefit as greater than 6 on a visual analoguescale. Conclusion: Patients perceived ongoing benefit from re-peated botulinum injections over a long time period.

P3-074 Systemic Adverse Events after BotulinumToxin A Injections for Management of LowerLimbs Spasticity

C. Ko-KoWest Midlands Rehabilitation Centre, Birmingham,United Kingdom

Background: Botulinum toxin A (BTX-A) injections havebeen generally regarded as effective and safe. There has beenno published reports of anaphylaxis or other rare but serioussystemic adverse events after treatment with BTX-A injections.Methods: We would like to report 2 of our patients who devel-oped systemic adverse events similar to botulism followingDysport (BTX-A) injections for management of lower limbsspasticity. Results: Case 1—51-year-old woman with multiplesclerosis and spastic paraparesis developed generalized muscleweakness with some difficulty in breathing and bilateral ptosis

about 2 weeks after injections of 1000 units of Dysport into bi-lateral hip adductor muscles. Case 2—39-year-old woman withcerebral palsy and spastic diplegia had a total of 1500 units ofDysport injections into bilateral ilio-psoas and hip adductormuscles after clinical gait analysis. She developed generalizedmuscle weakness with some difficulty in breathing, bilateralptosis and diplopia about 4 days after Dysport injections. HerGP thought she had developed myasthenia gravis. In both pa-tients all the systemic adverse events resolved completely overthe period of 6 weeks. Conclusion: Botulinum toxin injectionshave been used widely for many years, but only 5 other patientswith botulism-like features, similar to our 2 patients, have beenreported in the literature so far. Although these systemic ad-verse events are rare, patients should be made aware of thesecomplications.

P3-075 Poststroke Spasticity in the Philippines:Definition, Epidemiology, and its PharmacologicTherapy: A Consensus Statement of the PSNR

L. G. Fugoso, R. L. Rosales, M. S. Delgado,G. S. Espiritu, M. G. Yusay, and G.B.SalazarPhilippine Society of NeuroRehabilitation, Inc.,Philippines

Background: The aim of this paper was to define poststrokespasticity, describe its prevalence, and recommend treatmentoptions appropriate in the Philippines. Methods: Research onpoststroke spasticity (PSS) was done, which yielded 56 papers.Only those dealing with prevalence, randomized controlled tri-als, meta-analysis, and pharmacologic therapy of PSS were se-lected. These were evaluated based on internationally accepted11-point criteria—Physiotherapy Evidence Database. Results:Poststroke spasticity typically occurs maximally within 3months after any type of stroke. The worldwide burdens ofpoststroke spasticity are economic and health issues. Studieshave shown a prevalence of 20% to a high of 73% of poststrokespasticity. Pharmacologic therapy of poststroke spasticity in-cludes oral medications, nerve blocks, and botulinum toxin A.Studies have shown that the benefits from oral antispasticitymedications are marginal at best and side effects are common.Phenol and ethanol used for nerve block techniques may in-duce muscle fiber destruction. Finally, meta-analysis and sev-eral randomized clinical trial studies have demonstrated the su-periority of botulinum toxin A chemodenervation over placeboin reducing muscle tone in spastic limbs. Conclusion: Furtherstudies should be conducted to establish the prevalence ofpoststroke spasticity in the Philippines. In the absence of suchdata, it has been shown that botulinum toxin A provides the bestoption when treatment of poststroke spasticity is desired.

P3-076 The Management of Spasticity inChildren with Cerebral Palsy: A ConsensusStatement of the PSNR

M. B. Lukban, M. S. Fojas, E. L. Avendano,F. A. DelosReyes, S. D. Ignacio, and R. L. RosalesPhilippine Society of NeuroRehabilitation, Inc.,Philippines

Background: A consensus statement produced for Filipinophysicians to recommend appropriate treatment for a spastic



child with cerebral palsy (CP). Methods: Research of online da-tabases from 1999 to 2004 was conducted. Quality of the articleswere evaluated using the 11-point PEDro criteria. A set of rec-ommendations was prepared. Results: The use of botulinumtoxin (Bt-A), selective dorsal root rhizotomy, intrathecalbaclofen, and oral antispasmodics was reviewed. Bt-A wasshown to be effective for lower limb dynamic spasticity; how-ever, it has no conclusive evidence for usefulness for upperlimb spasticity. It may be used for children with fixed equinuscontractures who cannot tolerate casting, though it may causeearlier recurrence of spasticity. Trials showed that dorsal rootrhizotomy with physical therapy (PT) are effective for spasticdiplegia. Continuous infusion of intrathecal baclofen can im-prove spasticity, clonus and spasms; however, it has no correla-tion with improvement of ambulation, function, and activitiesof daily living. Oral antispasmodics (dantrolene sodium andbaclofen) showed significant but modest results for CP. Conclu-sion: In the Philippines, Bt-A is recommended as 1st line treat-ment option for children with lower limb spasticity withoutfixed contractures. Selective dorsal root rhizotomy with PT isequally effective and recommended as an alternative option.Intrathecal baclofen and oral antispasmodics may reducespasticity, but because of limitations, it may or may not be usedfor spastic children with CP.

P3-077 Nonpharmacologic Management ofSpasticity in Stroke and Cerebral Palsy:A Consensus Statement of the Philippine Societyof Neurorehabilitation (PSNR)

M. J. O. Flordelis, M. C. Guerrero, P. G. Escano,T. J. P. Evangelista, M. Z. Mercado, R. R.Rey-Matias, G. M. Rodriguez, B. G. Tan-Sales,and R. L. RosalesPhilippine Society of NeuroRehabilitation, Inc.,Philippines

Background: To provide clinical guidelines for 1) direct andindirect (quality of life) assessment of spasticity, 2) use ofnonpharmacologic agents in managing spasticity among strokesurvivors (SS) or with cerebral palsy (CP) in a developing coun-try, 3) interventions to achieve the highest possible quality oflife for SS and CPs. Methods: We researched on the various toolsfor the assessment, nonpharmacologic agents, as well as ortho-pedic procedures in managing spasticity for SS and CP childrencovering 1987 to 2005. Data were assessed using the PEDro cri-teria. Consensus and guidelines were formulated. Results: Werecommend the following for 1) assessing spasticity/function inSS and CP: Mod Ashworth Scale, Mod Tardieu Scale, FIM score(culture specific); 2) adults: Ass Sickness Impact Profile, TimedAmbulation; 3) assessing improvement in child CP: Gross MotorCapability & Performance of Mobility. As adjunctive treatmentof spasticity in SS/CP, we recommend functional electrical stim-ulation/tc nerve stimulation and (in SS only) electrical stimula-tors. Studies are insufficient to support the use of thermalagents. To prevent deformities, we recommend bracing or theuse of orthotics for upper and lower limbs. To improve func-tion, we recommend therapeutic exercise—this increasedstrength and improved ambulation. Constrained movementtherapy or task-specific exercises are only recommended for SS.Orthopedic intervention may be recommended in CP. Conclu-sion: These measures for spasticity need more reliability andstandardization studies.

P3-078 Treatment of Pain with Opiates MayContribute to Increase in Spasticity: An UnusualCause of Spasticity and Pain in a Patient withMultiple Sclerosis

S. A. Wasti, C. Nayeri, K. Anderson, S. Foulkes,and S. AndersonCommunity Rehabilitation and Respite Unit, SouthYorkshire, United Kingdom

Background: Spasticity and pain are common in multiplesclerosis. Opiates are often used to treat pain in patients withneurologic disability. We present a case of a young patient withmultiple sclerosis whose spasticity and pain were aggravatedbecause of end dose withdrawal effect of dihydrocodiene.Methods: A 41-year-old man who has had multiple sclerosis for22 years was admitted to the Rehabilitation Unit with a 9-monthhistory of worsening symptoms. These included fatigue, diffi-culty swallowing, impaired memory, and increasing pain andstiffness of both legs. His medications included baclofen 20 and10 mg, dihydrocoedine contrim 120 mg BD. Assessmentsshowed that spasticity, spasms, and pain were worse in eve-nings. The baclofen was increased, and the dose ofdihydrocodiene was halved to tackle spastcitiy and fatigue. Thereduction in dihydrocodiene resulted in increased spasms andpain. He developed frank symptoms of opiate withdrawal. Heidentified the symptoms as similar to ones he often had in theevenings. The dihydrocodiene was then withdrawn during thenext 8 weeks. After stopping the dihydrocodiene, his spasmsand pain improved. We were able to reduced the baclofen,which resulted in improved leg strength and swallowing. After13 years, he was able to stand on his feet with some help. Re-sults: Participation improved in all domains. Conclusion: End ofdose withdrawal effects of analgesia should be considered as apossible cause of increasing pain and spasticity in patients withspaticity.

P3-079 What is the Clinical Effect andCost-effectiveness of Treating Upper LimbSpasticity due to Stroke with Botulinum Toxin?

F. M. J. van Wijck,1 C. I. M. Price,2 M. P. Barnes,3

G. A. Ford,4 and H. Rodgers4

1Queen Margaret University College, UnitedKingdom; 2Northumbria Healthcare NHS Trust,United Kingdom; 3Hunters Moor RegionalNeurorehabilitation Centre, United Kingdom;4University of Newcastle upon Tyne, UnitedKingdom

Background: After a stroke, 55% to 75% of patients still ex-perience upper limb (UL) problems 3 to 6 months later.Spasticity is common and may cause pain, reduce function, andlimit independence. Botulinum toxin (BTX) is used increasinglyto treat focal spasticity, but its impact on function and healtheconomics are poorly understood. The aim of this multicenterRCT is to compare the effectiveness and cost-effectiveness ofBTX plus a standard UL therapy program with the UL programalone in stroke patients with UL spasticity. Methods: Adults withmoderate or severe UL spasticity (Modified Ashworth Scalegreater than 2 at elbow, wrist, or shoulder) and reduced ULfunction due to stroke more than 1 month previously are eligi-



ble. The 2 groups will be compared in terms of arm function(Action Research Arm Test), dexterity (Nine Hole Peg Test), gripforce, attainment of patient-selected goals (Canadian Occupa-tional Performance Measure), disability (Barthel Index), andstroke-related quality of life (Stroke Impact Scale, Euroquol-5D), assessed at baseline and 1, 3, and 12 months after BTX.Health and social services resource use, adverse events, and theuse of other antispasticity treatments will be compared. The in-fluence of severity of UL impairment, time since stroke, andbaseline elbow flexor spasticity on outcomes will be deter-mined. The views of patients on the intervention will also be ex-plored. The study is funded by the Department of Health in theUnited Kingdom. Ipsen Ltd will provide the botulinum toxin.Results: Pending. Conclusion: To follow.

P3-080 Clinical Effects of Botulinum Toxin Aon Motor Function in Children with LowerLimb Spasticity

A. P. ZhuJiangsu Geriatric Hospital, China

Background: Botulinum toxin A (BTX-A) injection hasproven to be effective in the treatment of spasticity. The aim ofthis study was to assess the short-term effects of BTX-A on mo-tor function in children with lower limb spasticity. Methods: 20children with lower limb spasticity (14 boys and 6 girls; 16 cere-bral palsy children and 4 cerebral trauma children; mean age,61.53 ± 12.58 months) received BTX-A injections guided byelectric stimulation on spastic muscles (30 musculi tricepssurae, 14 musculi tibialis posterior, 8 musculi adductor vastus).All the children participated in the rehabilitation programs onpostural balance and ambulation trainings before and afterBTX-A injections and received lower limb muscle tone mea-surements (Modified Ashworth Scale) and motor function as-sessment (Motor Developmental Age Scales [MDAS]) 1 d beforeand 7 d after treatments. Results: The mean lower limb muscletone was decreased from 1.73 ± 0.56 at baseline to 0.93 ± 0.56 at7 d after treatments (P < 0.05), and the mean MDAS was in-creased from 21.67 ± 14.00 months at baseline to 29.61 ± 18.08months at 7 d (P < 0.01). There were still significant improve-ments in MDAS after correction by the actual physiologic age.Conclusion: BTX-A injections demonstrated rapid treatment ef-fects in decreasing muscle tone and improving motor functionin children with lower limb spasticity.

P3-081 A Pooled Analysis of the Safety of BoNTA(BOTOX®) in the Treatment of PoststrokeSpasticity

C. Turkel, B. Bowen, J. Liu, and M. BrinAllergan, Inc., USA

Background: This study assessed the safety of botulinumtoxin type A (BoNTA) in poststroke patients with upper- and/orlower-limb spasticity. Pooled safety data from 9 DB, PC studiesof 1 to 3 BoNTA treatments were analyzed. Methods: Seven hun-dred ninety-two adult patients with upper- or lower-limbspasticity were treated with BoNTA (67.4%) or placebo (32.6%),and the incidence of adverse events (AEs) was assessed. Results:With regard to AEs, 65.9% of BoNTA and 63.2% of placebo pa-tients experienced at least 1 AE. Two percent of BoNTA-treatedpatients discontinued the studies because of AEs. The most fre-quent AEs were infection, seizures, incoordination, and injec-tion site pain—occurring at similar frequency in BoNTA and

placebo groups. Only nausea occurred at a significantly higherincidence in the BoNTA group (0.02%, P = 0.011). The mostfrequent serious AEs were seizure (BoNTA, 2.2%; placebo,2.7%; P = 0.805) and CVA (BoNTA, 1.1%; placebo, 0.4%; P =0.437). BoNTA (25.5%) and placebo patients (24.4%) experi-enced treatment-related AEs. Conclusion: In conclusion,BoNTA had a strong safety profile in a large patient pool treatedfor poststroke focal spasticity.

P3-082 Cutaneous Mechanical Stimulations ofMedial and Lateral Plantar Surfaces on theExcitability of Ipsilateral and ContralateralMotorneurons

M. R. Hadian, S. Talebian, H. Bagheri, G. Oliaye,and A. BastaniTehran University of Medical Science,Rehablitation Faculty, Tehran, Iran

Background: Sensory feedback from the foot play an impor-tant role in the control of muscle tones and subsequently gov-erns the way in which humans move. Mechanoreceptors fromthe foot sole likely contribute in the reflex regulations. Stimula-tion of these receptors in the medial or lateral aspect of the footcorresponds to the medial and lateral plantar nerve divisions ofthe tibial nerve. It was hypothesized that repetitive low-thresh-old afferents stimulation would have an inhibitory effect on theH-reflexes of triceps surae. Methods: 8 intact neurologicallymen voluntarily participated, and written consent was ob-tained. The CMP (equal to 50% of leg and foot weight) was ap-plied to the ipsilateral medial and lateral plantar surfaces by adesigned instrument in prone position. H reflex as an indicatorfor excitability of motoneurones was bilaterally elicited beforeand after the application of the CMP. H max/M max ratio was es-timated. Results: The amplitude of H reflex and H/M ratioshowed significant differences before and after the IpsilateralCMP stimulation of the lateral side of the foot (P < 0.03; P <0.043, respectively, decreased). Furthermore, the latency of Hreflex was also increased (P < 0.04). In addition, CMP stimula-tion of the medial side also showed nonsignificant differences.Conclusion: The results highlight the modulatory effects of nat-ural stimulation of cutaneous afferents on excitability ofipsilateral motoneurones. This in respect may have practical ap-plication in the management of muscle tone disorders.

P3-083 Decreased Muscle Afferent Contributionto Muscle Activity during Human Spastic Walking

T. Sinkjaer,1 N. Mazzaro,1 J. F. Nielsen,2 and M. Grey1

1SMI, Aalborg University, Denmark; 2HammelNeurorehabilitation Center, Denmark

Background: The aim was to investigate the contribution ofproprioceptive feedback to the activation of the soleus muscleduring the stance phase of walking in spastic patients. Methods:12 hemiparetic spastic patients (cerebral stroke) and 12 age-matched able-bodied controls participated in the study. Theantispastic medication was interrupted 24 h before the test andthe spasticity level was evaluated with Ashworth score. All sub-jects walked on a treadmill with the left leg attached to a roboticactuator. MANOVA tests were used to compare responses be-tween the groups and regression analysis was used to test therelationship between the velocity of the ankle dorsiflexion andthe soleus EMG. Results: The slow-velocity dorsiflexion en-



hancements and reductions generated in the control subjects’increments and decrements, respectively, in the soleus EMG.However, in the spastic patients, these responses were de-creased. Moreover, there was an inverse relationship betweenAshworth Scale and the amplitude of the responses to the slowperturbations (slope of the regression lines). Conclusion: Al-though the short latency soleus stretch reflex was hyperexcitedin the patients (P = 0.02), the afferent feedback contribution tothe soleus activity during spastic walking was depressed (P <0.05). We speculate that part of the walking impairment in spas-tic patients is caused by reduced or impaired integration of theafferent feedback within CNS. The results have implication forantispastic treatment. Founded by DNRF.

P3-084 Percutaneous Endoscopic BottonGastrostomy Has Merits for NeurologicRehabilitation of Oropharyngeal Dysphagia

H. Muramatsu,1 R. D. Nathan,2 K. Koike,1

and T. Iwase3

1Kasugai Rehabilitation Hospital, Japan; 2TexasTech University Health Sciences Center, USA;3Yamanashi Kousei Hospital, Japan

Background: Neurogenic oropharyngeal dysphagia is com-mon and has serious disability in stroke or traumatic brain in-jury (TBI) patients. Percutaneous endoscopic buttongastrostomy (PEG button) in 1-step procedure has been devel-oped for external alimentation in high-risk patients. We evalu-ated merits of the PEG feeding during neurologic rehabilitationof stroke or TBI. Methods: Subjects consisted of 16 stroke and 4TBI survivors with severe oropharyngeal dysphagia and highercortical dysfunction. Each patient was initially fed via a naso-gastric tube (NGT) for mor than 3 months and subsequentlyplaced with a 1-step PEG button. Results: 1) Routine program ofswallowing exercise by speech therapists was more effectivelyperformed under the condition of PEG feeding. 2) Seven pa-tients attained complete and 6 patients attained partial peroraldiets, though 7 patients totally depended on long-term PEGfeeding. 3) An increase in the Barthel Index by rehabilitationduring the PEG feeding (+20 ± 13) was significantly (P < 0.001)higher than that during the NGT feeding (+3 ± 4). 4) Two pa-tients with tracheostomy could finally be decanulated afterplacing the PEG. 5) Patients with the PEG button could avoidpsychologic stress associated with the NGT feeding. Conclu-sion: The 1-step PEG button is valuable to oropharyngealdysphagic patients not only for long-term alimentation but alsofor transient feeding by temporary PEG during neurologic reha-bilitation in early stage of stroke or TBI to improve functionaloutcome.

P3-085 Miniature Sensors’ Position andOrientation for Optimal Identification of GaitPattern on Patients with Dropped Foot

A. H. Y. Lau and R. K. Y. TongThe Hong Kong Polytechnic University, Hong Kong

Background: Miniature sensors have been widely used inportable gait analysis system and functional electrical stimula-tion (FES). Sensors’ location and orientation definitely have aneffect on the accuracy and characteristics of detection algo-rithm, especially for individualized pathologic gait pattern. Theobjective of this study was to identify the types of sensor, their

locations, and their orientations with the highest reliability fordeveloping a detection algorithm of dropped foot gait pattern.Methods: Nine stroke patients with dropped foot problem per-formed level-ground walking in floor. Three sensor units con-taining a dual-axis accelerometer and a gyroscope were at-tached in 3 different locations of affected side, i.e., distal one-third of anterior aspect of thigh, tibial tuberosity of shank, andheel of shoe, to measure the anteroposterior (AP) acceleration(Acc), upward-downward (UD) Acc and AP angular velocity(AV). The local maximum and minimum peak values within thestance and swing phase were identified. The time differences ofthe peak value from the start of consecutive stance or swingwere calculated and a total of 36 measuring parameters wereproduced. Results: The subjects showed lowest variability inpeak detection by measuring thigh’s UD Acc and then thigh’s APAV for the stance phase. The coefficients of variation (CV) are8.7% and 12.5%, respectively. The lowest value of CV can be ob-tained from the peak detection of thigh’s AP AV (16.2%) andthen from foot’s AP AV (20.8%) for swing phase. Measurementof thigh’s AP AV has lower variability for dropped foot patients.Conclusion: Stroke patients generally had better control for hipflexion by which the disturbance of dropped foot problem dur-ing swing phase was compensated. It can be estimated from theanalysis that making use of the measuring parameters withlower variability can produce an optimal performance for thesimple peak detection algorithm. It also facilitates the selectionof measuring parameters for the specific gait pattern and the ap-plication of functional electrical stimulation for walking.

P3-086 Audit in Action—How an Audit ofNeurogenic Dysphagia Has Influenced ClinicalPractice

K. Walton,1 S. Boyes,2 and N. Brierley3

1Greater Manchester Neurosciences Centre, UnitedKingdom; 2Salford Primary Care Trust, UnitedKingdom; 3The Pennine Acute Hospitals NHS Trust,United Kingdom

Background: Greater Manchester, United Kingdom, has apopulation of approximately 3 million. 2001 saw a reorganiza-tion of acute neuroscience services and the development of aneurorehabilitation clinical network. Neurogenic dysphagiamanagement occurs in acute hospitals, in neurorehabilitationunits, and in the community. Service and clinical standards dif-fered across the city; it was recognized that to evaluate out-comes, it was essential to have common standards. A multisiteaudit project was set up to address this. Methods: Consensusstandards were agreed. These included several aspects ofdysphagia management, access to training, and service deliv-ery. The audit involved 17 services covering inpatients and thecommunity. Cycle 1 took place in 2003 and 2004. Results: Defi-ciencies were found in the competencies and skills of speechand language therapists with regard to specialist assessment ofdysphagia, with only 16% having had accredited advancedtraining. Only 56% felt confident working with patients whohave a tracheostomy but were expected to be involved inthe care of these patients—training has now been provided.Competencies and skills have been agreed for specialist thera-pists involved in tracheostomy care. Protocols are being devel-oped for videofluoroscopy. Conclusion: This audit project hasresulted in improvements to service delivery and the quality ofneurogenic dysphagia management to a large population. Clini-cians across 17 services continue to work together to achievecommon standards and to improve outcomes for patients.



P3-087 Long-term Outcomes of PercutaneousEndoscopic Gastrostomy Feeding in theManagement of Neurogenic Dysphagia

M. M. Y. Tse, L. S. W. Li, K. P. Leung, and M. M. T. NgTung Wah Hospital and The University of HongKong, Hong Kong

Background: Percutaneous endoscopic gastrostomy (PEG)is an increasingly popular form of enteral feeding. The aim ofthis study was to investigate the long-term morbidities and mor-tality associated with PEG feeding. Methods: A retrospectivecase note review of a cohort of patients from June 1999 to June2001 who received PEG insertion was observed until the pa-tients died, were weaned off PEG, or until 31 August 2005. Thedata were analyzed at 2 time points, initially on 30 September2002 then 31 August 2005. Results: A total of 48 patients were re-cruited; 18 women and 30 men with a mean age of 72.7 years.Thirty-six had suffered a stroke, 7 had neurodegenerative disor-ders, and 4 had head and neck malignancies. There was no in-sertion-related major morbidity or mortality. Stoma infection(22.9% increased to 25%) and leakage (14.6% increased to18.8%) were the most common complications in both early andlater stages. The most common tube dysfunctions encounteredwere self-inflicted dislodgement (52.1%) and clogged tubes(12.5%). Of the patients, 20.8% were weaned off PEG. The meantime to weaning was 171 days. Of the patients, 47.9% (initially35%) required a tube replacement. Mean service duration for a1st PEG setup was 417.5 d, and 325.3 d for a 2nd. Of the pa-tients, 79.2% (initially 47.9%) died by the time of the final re-view, with 63.2% having died from pneumonia. No demo-graphic data had significant predictive value for mortality.Conclusion: PEG feeding is a safe method of feeding with lowoverall complication rates over time. PEG proved to be a dura-ble option for the enteral feeding of this vulnerable group ofpatients.

P3-088 Is Videopharyngolaryngoscopy Using aFlexible Fiber Optic Endoscopy a PracticableMethod in the Diagnosis of SwallowingDisorders?

P. Grieshofer, J. Atanasiadis, R. Scherer, B. Haas,and M. ScarpatettiKlinik Judendorf Strassengel, Austria

Background: Neurogenic swallowing disorders (dysphagia)are very frequent symptomatic complex of neurologic diseases.The incidence and importance, however, is often underesti-mated. Patients with neurogenic dysphagia are more likely tobe affected by pulmonary infections and dehydration. The rateof lethality is high. Methods: Within 1.5 years we examined 185patients (3-16 weeks after acute stroke) using flexible fiber op-tic endoscopy. The examination criteria were anamnesticallyknown, presumed, or recurrent pulmonary infections. Results:65 of all examined 185 patients had normal findings (no swal-lowing disorders), 35 patients had pathologic findings (swal-lowing disorders without aspiration), and 34 patients had swal-lowing disorders with aspiration. Forty-four patients of all 150examined patients had a percutaneous endoscopic gastrostomytube (PEG tube) before the examination in the clinic. Twenty-five of these patients had a PEG tube, although they did notshow any sign of aspiration. Twenty-three patients had swal-lowing disorders with aspiration. All examinations were carriedout without complications. Eight patients refused examination.

Conclusion: The videopharyngolaryngoscopy using a flexiblefiber optic endoscopy is a safe and diagnostic method to exam-ine oropharyngeal swallowing disorders after stroke. Esopha-geal dyshagia, however, cannot be examined.

P3-089 Use of Fiber Optic Endoscopic Evaluationof Swallowing to Assess the Efficacy of Icing andThermal Stimulation on Dysphagia after AcquiredBrain Injury

A. Graham, G. Roxburgh, and J. HollowayFrenchay Brain Injury Rehabilitation Centre,United Kingdom

Background: Fiber optic endoscopic evaluation of swallow-ing (FEES) is a valid and reliable method of assessing the pha-ryngeal phase of the swallow function in the dysphagic popula-tion. Patients with an acquired brain injury (ABI) maycommonly present with oropharyngeal swallowing problemsincluding impaired swallow reflex, reduced pharyngeal sensoryawareness, and aspiration. FEES can assess, in real time, the im-pact of interventions on the safety of the swallow. Methods: A60-year-old woman presented with swallowing difficulties sec-ondary to a complex ABI. As well as clinical bedside examina-tion, FEES assessments were performed at 1 and 6 weeks afteradmission, between which she underwent a program of icingand thermal stimulation. Results: The initial FEES assessmentdemonstrated normal anatomy. However, there was impairedswallow initiation, premature spill and no functional responseto pharyngeal sensory stimulation. Following the 5-week dailyprogram, the repeat FEES demonstrated a safe prompt swallowresponse and a strong reliable cough to pharyngeal stimulation.Conclusion: After an ABI, swallowing difficulties are commonwith a clear association between poor pharyngeal sensationand the risk of aspiration. FEES is a complete assessment of thepharyngeal phase of swallowing and is used for both diagnosisand treatment. In this case, FEES was used to assess the benefitsof the techniques of icing and thermal stimulation. Improvedswallow and sensory functions were demonstrated.

P3-090 Computerized Evaluation of Dysphagia:A Pilot Study

C. Pistarini,1 C. Chessa,1 M. Dichiarante,1 S.Panzarasa,2 and B. Cattani11Fondazione Salvatore Maugeri, Italy; 2Consorziodi Bioingenieria ed Informatica Medica, Italy

Background: The aim of this study is to present a guidelinein care, evaluation, and rehabilitation management ofdysphagic people with brain injury (BI) or upper cervical spinelesion. Methods: Authors started 1 year ago a project to evaluate,manage, and improve dysphagia rehabilitation protocols basedon multidisciplinary, highly computerized, approach. The pro-ject is held at the Neurorehabilitation Department of theFondazione S. Maugeri in Pavia and at the Consorzio diBioingenieria ed Informatica Medica of the University of Paviaand received an EU grant. Speech therapists elaborated an easyevaluation protocol to screen swallowing impairments and toprevent aspiration or choking in neurologic patients. It per-forms functional and neurologic evaluation of oral apraxia andthe cranial nerves involved in swallowing (saliva or bolus) andsensitivity of the oral cavity. Authors created, on a wireless pal-mar PC, a computerized program, based on a clinical workflow,



to be performed directly in front of the patient and created a firstevaluation database. Results: The protocol is applied in 20 pa-tients with BI and 3 with upper cervical spine lesion. It is able toidentify even minimal risk of food bolus aspiration, to performthe correct diet and rehabilitation program ad hoc, and to mod-ify the single intervention. Conclusion: These results confirmthe efficacy of the protocol and of the workflow, which can beconsidered an efficacious tool both during screening andrehabilitation approach.

P3-091 Simple Clinical Tests for Predicting SevereOropharyngeal Dysphagia in Parkinson’s Disease

K. Lam,1 K. Y. Lam,2 K. K. Lau,3 Y. K. Chan,4

and E. Kan5

1Department of Medicine, PYNEH, Hong Kong;2Department of Speech Therapy, PMH, Hong Kong;3Department of Medicine and Geriatrics, PMH,Hong Kong; 4Department of Medicine andGeriatrics, CMC, Hong Kong; 5Department ofDiagnostic Radiology, PMH, Hong Kong

Background: Oropharyngeal dysphagia (OD) causes mor-bidity and mortality among patients with Parkinson’s disease(PD). We aimed to look for simple screening methods to detectsevere OD in patients with PD. Methods: 45 patients (26 fe-males) of mean age of 75 years (range, 65-94 years) who wereclassified in stages II to V on the modified Hoehn and Yahr (H&Y) scale were enrolled. OD was assessed by a symptom ques-tionnaire, a 50 mL water swallowing test and a videofluroscopicswallowing study (VFSS). Results: 6 patients had severe OD asdefined by the VFSS. In univariate analysis, severe OD corre-lated significantly with higher H&Y stages (P = 0.01), low BMI(P = 0.002), and also a positive answer to the following symp-toms: 1) “Food left in the mouth after swallowing” (P < 0.001),2) “Difficulty keeping food or drink in the mouth” (P < 0.001), 3)“Food gets stuck in the throat” (P = 0.046), 4) “Liquids comeback through the nose during swallowing” (P = 0.044).Multivariate analysis showed 3 independent predictors for se-vere OD in VFSS: higher H&Y stage, low BMI, and a positive an-swer to the question: “Do you have difficulty keeping food ordrink in the mouth?” A predictive index of severe OD in PD sub-jects based on these 3 independent predictive variables was de-rived. The sensitivity was 83.3%; specificity, 97.4%; and a posi-tive predictive value of 95.5% was demonstrated. Conclusion: Acombination of 3 clinical parameters was found to be highlypredictive of severe OD in PD patients. Further prospectivestudy with a larger sample is warranted.

P3-092 A Retrospective Analysis of thePharyngeal Swallow in Patients with LateralMedullary Infarction Compared with Patientswith MCA Infarction

S. H. L. Sung Hoon Lim, H. T. R. Han Tai Ryoon,Y. J. S. Young Joo Sim, and I. S. K. Il Soo KimSeoul National University Hospital, South Korea

Background: Although swallowing dysfunction is a majordisabling impairment in patients with lateral medullary infarc-

tion, few studies have been undertaken to identify the precisemechanism of their dysphagia. The present study was con-ducted to investigate the differences in swallow physiology be-tween patients with lateral medullary infarction and patientswith MCA infarction. Methods: Retrospective analysis ofvideofluoroscopic study was performed in 12 patients with lat-eral medullary infarction (LMI group) and 14 patients with MCAinfarction (MCA group). Time variables including oral transittime, pharyngeal delay time, and pharyngeal transit time werecompared between both groups. Pharyngeal residues invallecullar and piryform sinus after swallow, the frequency ofaspiration, and relaxation of upper esophageal sphincter (UES)were also compared. Results: The frequency of aspiration andimpaired UES relaxation were found to be significantly higherin LMI group than MCA group (P < 0.05). Pharyngeal transit timewas found to be greater in LMI group than MCA group (P =0.04), In case of pharyngeal residues, LMI group seemed toshow more residues in piryform sinus than MCA group. How-ever, no difference in vallecular residue was found betweengroups. Conclusion: These findings suggest that impaired UESrelaxation might result in slow pharyngeal transit of food andexcessive residue in piryform sinus, and these might also in-duce overflow aspiration in patients with lateral medullaryinfarction.

P3-093 Program for Chinese Children withDevelopmental Disabilities—The Hong KongModel

C. W. Fung and V. WongThe University of Hong Kong, Queen Mary Hospital,Hong Kong

Background: Developmental disabilities (DD) are commonchildhood problems with significant impact to the society. Earlyidentification is important as there is potential for improvementthrough intervention, educational, and rehabilitative measures.There are currently no data revealing this situation in China.Methods: We review the current model of identification andmanagement of Chinese children with DD in Hong Kong, asouthern city in China. Results: Our model was developed inearly 1960s and our system had been originally adopted fromthe Western culture because of political reasons, as Hong Kongwas a British colony. This has been modified over the years tosuit our own unique, mixed Eastern and Western culture. Thismodel starts off with early diagnosis of DD through variousscreening tests conducted by the Family Health Service and theStudent Health Service. Children who fail the tests will have aproper diagnosis in the Chi ld Assessment Centers.Multidisciplinary intervention of DD involves training by phys-iotherapists, occupational therapists, speech therapists, andclinical psychologists. Medical social workers will coordinatethe application of entry into various educational institutions.The program will have close collaboration with the hospital orcommunity pediatricians to allow a more comprehensive inter-vention. Conclusion: With the expanding Western influence inmainland China recently, we hope this integrated model can beimplemented in other parts of China.



P3-094 Improvement in the Rate of On-TimeDischarge from Inpatient NeurologicRehabilitation Using Clinical PracticeImprovement Methods

K. S. G. Chua, S. G. M. Yap, and W. W. L. ChanTan Tock Seng Hospital Rehabilitation Centre,Singapore

Background: We conducted the following study to improvethe rate of on-time discharge (OTD) from inpatient neurologicrehabilitation (stroke and brain injury) from 70% to 100% duringa 9-month period and to reduce median rehabilitation length ofstay (RLOS) by 30% without a reduction in functional scores orpatient satisfaction levels. Methods: Using CPIP methodologywith Plan-Do Study-Act (PDSA) cycles during a 9-month periodfrom 2004 to 2005, root cause analysis of the common causes ofdelayed discharge from inpatient rehabilitation and a detailedflow chart of discharge processes were constructed. Primaryoutcome measures included percentage of patients dischargedon-time, and secondary outcome measures included dischargefunctional scores using Functional Independence Measure(FIM) and patient satisfaction scores. Results: Common reasonsfor delayed discharge were caregiver delays and inadequatecaregiver training, accounting for 55% of all causes. PDSA strat-egies included early identification of patients’ decision maker,caregiver, and assignment of a team-based liaison person. Therate of OTD improved from 70.4% in December 2004 to 78% and100% in June and July 2005, respectively. Median RLOS reducedfrom 31.0 d in January 2005 to 24.5 d in July 2005 without reduc-tion in discharge FIM scores. Patient satisfaction level improvedfrom 50% to 90%. Conclusion: With more efficient dischargeprocesses employing PDSA methods, improvements in OTDand reduction in RLOS were achieved without additional cost ormanpower.

P3-095 Effect of Cholecystokinin-8 on In VitroCultured Rat Cortical Neurons against Apoptosisand Expression of Nerve Growth Factor

J. Zhou, Y. Liu and N. XiaoChilden’s Hospital, Chongqin University of MedicalScience, China

Background: To investigate the protective effect ofcholecystokinin-8 (CCK-8) on in vitro cultured rat cortical neu-rons against apoptosis induced by glutamate and study its effecton expression of nerve growth factor (NGF) in the neurons dur-ing apoptosis. Methods: Cortical neurons were removed fromnewborn rat and cultivated in the medium; the models of dam-age induced by glutamate were established on cultured corticalneurons and then treated with medium containing CCK-8,which concentration was 1 × 10–6 mol/L, 1 × 10–7 mol/L or 1 ×10–8 mol/L. Apoptosis of cultured cortical neurons were ob-served by fluorescence microscope, The expression of NGFprotein and mRNA were determined respectively byimmunohistochemistry and in situ hybridization, and apoptosisof cortical neurons was measured by in situ end labeling(TUNNEL). Results: Compared to the model groups (whichwere pretreated with glutamate), the neurons apoptosis weresignificantly decreased in the neurons treated with CCK-8,which concentration was 1 × 10–6 mol/L and 1 × 10–7 mol/L, andat the same time NGF protein and mRNA expression wasupregulated. The neurons apoptosis, NGF protein, and mRNAexpression in the neurons treated with 1 × 10–8 mol/L CCK-8

were not different from the model group statistically. Conclu-sion: Ectogenesis CCK-8 plays a protective role in apoptosis ofthe cortical neurons induced by glutamate; one of the protectivemechanisms of CCK-8 is associated with the enhanced expres-sion of NGF protein and mRNA.

P3-096 Development and Implementation of aPosture Management Integrated Care Pathway(PMICP) for People with Traumatic Brain Injury

S. Skalla and L. Jones-RobinsonBath Head Injury Unit, United Kingdom

Background: Many patients at the Bath Head Injury Unit(BHIU) are immobile and are likely to have long-term complexdisability. There is a need to maximize functional ability andminimize secondary complications. When functional disabilityand risk of secondary complications “arise as a result of postureimpairment, the issues must be addressed in terms of ongoing24-hour management” [Pope and others 2001]. The NationalService Framework for Long-Term Conditions recognizes “theneed for a holistic, integrated, interdisciplinary (IDT) approachto care planning, review and service delivery involving a rangeof agencies.” The BHIU has attempted to address the above withthe development of a PMICP. Methods: The PMICP was devel-oped according to the following: formulating an action plan;setting up an IDT focus group; review of literature; identifica-tion and mapping of the rehabilitation core principles of eachprofessional discipline; review of current practice and pro-cesses; establishing and mapping of best practice principles andprocesses; review of all unit documentation and incorporationinto an PMICP pack; ongoing peer review and collaborationwith Gloucestershire NHS Trust. Development of an audit tool,education package, and review of equipment funding is nearingcompletion. Results: By February 2006, the PMICP is expectedto have gone through a pilot phase and be fully implemented.Conclusion: Successful development of a PMICP requires astrong lead and full commitment and support from managementand those involved.

P3-097 From Review to Implementation:Development of a Standardized, Patient-Centered,Efficient Interdisciplinary Team (IDT) PatientReports Writing System

S. SkallaBath Head Injury Unit, United Kingdom

Background: The Bath Head Injury Unit (BHIU) unit pro-duces IDT patient reports to chart the developments from ad-mission to discharge. Issues with the existing reports were con-nected to standardization, efficiency, patient or familyparticipation, and answering the needs of the stakeholders whoreceive the reports. The aim was to produce professional, stan-dardized IDT reports that meet the specific and varied require-ments of those who receive them, using a straightforward, effi-cient system that fully supports and facilitates patient-centeredrehabilitation. Methods: Questionnaires (total 275) sent to pa-tients, family members, GPs, commissioners, social workers,and discharge placements; consultation with other head injuryunits; literature review; ongoing consultation with BHIU IDT(focus groups, questionnaires, direct feedback); review of feed-back; setting of standards; and development of new system. Re-sults: An IDT online reporting system has been implementedand supported by guidelines. Audit reports are tied to a formal



case review meeting involving the patient and family to facili-tate full participation in goal setting and rehabilitation planning.The system delineates the formal points of the rehabilitation cy-cle into which integrated care pathways can be fully incorpo-rated. Conclusion: The new reporting system appears to meetour aim in terms of ease of use, efficiency, and patient participa-tion. Audit and stakeholders’ consultation to ascertain whethertheir needs are met is currently ongoing. Informal feedback sofar has been very positive.

P3-098 Postural Management for Persons withProfound and Multiple Disability: An IntegratedMultidisciplinary Approach to ServiceDevelopment

C. M. Marrow and M. P. LarrettGloucestershire Partnership NHS Trust, UnitedKingdom

Background: The need for a holistic approach for peoplewith PMLD has long been recognized. The complications foundwith persons with PMLD, i.e., contractures, deformity, compro-mised tissue viability, and respiratory function, dysphagia, andmasked ability, if left unmanaged, are self-reinforcing and,without intervention, gradually increase and restrict function,engagement in occupations, choice, and control in everydaylife. This increases the effort, time, and resources of carers.Pope (2002) indicates that good posture maximizes perfor-mance and minimizes energy consumption without causing sys-tem damage. An integrated approach to postural managementsupports the person to maximize abilities, follow interests, andenhance quality of life. For carers, it reduces the burden ofphysical care. Methods: 1) Joint training in assessment and anal-ysis for physiotherapists and occupational therapists. 2) Devel-opment of local tools for assessment and client and carer infor-mation. 3) Audit of specialist equipment. 4) Establishment ofpeer review including BHIU. Results: 1) Mandatory training fordirect care staff. 2) Development of integrated care pathway. 3)Increased knowledge and evidence base, giving improved as-sessment, analysis, treatment and care planning. 4). Robustequipment provision. 5) Joint working with service commis-sioners. Conclusion: Postural management is a core approachfor PMLD and resource planning, and allocation has reflectedthis.

P3-099 The Cost-effectiveness Analysis of EarlyRehabilitation for Stroke Patients

C. Y. Jiang, Y. S. Hu, Q. Wang, Y. Wu, and Y. L. ZhuHuashan Hospital, Fudan University, Shanghai,China

Background: To analyze the cost-effectiveness of early stan-dardized tertiary rehabilitation (STR) for patients with stroke.Methods: Stroke patients were enrolled sequentially fromHuashan hospital. They were randomly divided into test andcontrol groups, the former accounting for 42 and the latter, 40.Those in the test group were given early rehabilitation usingSTR plus routine medical treatment, whereas those in the con-trol group were only given the routine treatment. Every pa-tient’s direct medical and nonmedical costs, indirect costs, anddetailed buildups of every cost during the 1st month of rehabili-tation were calculated. All patients were assessed with theFunctional Comprehensive Assessment Scale at the start and the1st month after stroke. Results: The motor and cognitive im-

provements of the test group were better than those of thecontrol group. In terms of total cost, there was no obvious dif-ference between the 2. For every 1 unit of functional score im-provement, the standardized rehabilitation costs, direct medicalcosts, and total costs were ¥66.34, ¥665.27, and ¥853.48, respec-tively in the test group, but in the control group they were ¥0,¥1851.83, and ¥2382.80. The cost for every 1-point score im-provement in the test group was significantly lower than that forthe control group. The cost per unit of function gained for con-trol group were 2 to 4 times that of those in the test group. Con-clusion: Early rehabilitation with STR is economical andeffective for stroke patients.

P3-100 Clinical Effect and Mechanism for theTreatment of Intracerebral Hemorrhage withScalp Acupuncture

X. T. Wang,1 G. Q. Zheng,1 Y. Wang,1 and I. Inoue2

1Centre for Neurology, the Second AffiliatedHospital of Wenzhou Medical College, China;2Institute for Enzyme Research, TokushimaUniversity, Japan

Background: Scalp acupuncture originated from the clinicalpractice of applying cranial acupuncture for the treatment ofdiseases in ancient China. Methods: An international standardnomenclature for the scalp acupuncture points was formallyadopted in a science group meeting for standard nomenclatureof scalp acupuncture points held by the WHO in 1989. There are14 scalp acupuncture point lines distributed in 4 regions in thestandard. Results: Till now, there has been no exact curativetherapy for the treatment of intracerebral hemorrhage in West-ern medicine. However, an initial 8 clinical trials (randomizedcontrolled trials included) of scalp acupuncture treatment foracute intracerebral hemorrhage showed excellent clinical cura-tive effects. Some patients could show immediate effects afterscalp acupuncture. Conclusion: The main mechanism may bethe influence on pathology and the blood brain barrier, influ-ence on regional cerebral blood flow, influence onneuroelectrophysiology, influence on immune function, and in-fluence on biochemical indicators. Therefore, it is extremely ur-gent and necessary to carry out a randomized controlled,multicenter clinical study to identify the clinical effect and tostrengthen experimental studies to clarify the functionalmechanism.

P3-101 Discussion on Patients’ Needs and ItsValue to the Rehabilitation Process

J. K. Y. Wu,1 K. P. Y. Liu,1 C. C. H. Chan,1

and F. Chan2

1The Hong Kong Polytechnic University, HongKong; 2University of Wisconsin-Madison, USA

Background: Therapists use different methods of clinicalreasoning in formulating treatment plan for their patients. Therehave been reports on the disagreement over a patient’s prob-lems between therapist and patient. The objective of this studywas to examine the effect of therapists’ methods of addressingpatients’ problems on the level of agreement over patients’ dailyliving problems between patients and therapists. Methods: Acomparative design was adopted to examine the 5 most impor-tant daily living problems identified by patients and their occu-pational therapists. Twelve occupational therapists and 5 stroke



patients of each therapist under inpatient rehabilitation were re-cruited. Thus, a total of 60 patients were recruited. Results: Con-tent analyses of the therapists’ methods of analyzing their pa-tients’ problems revealed that 8 therapists had discussed theirpatients’ needs with their patients (66.7%) and 4 relied on theassessment results (33.3%). The kappa statistics showed that ahigher agreement of daily living problems was identified for thepatients of those therapists who had held such discussions(kappa = 0.76; P < 0.001). Conclusion: The results suggestedthat therapists should take their patients’ needs into account inthe planning of interventions. If therapists could help their pa-tients carry out their future life roles, it would lead the patientsto better participate in the rehabilitation process.

P3-102 The Effect of a MultidisciplinaryRehabilitation Care on the Outcome of Brain and/or Spinal Cord Injury

C. Lafosse, K. Wille, M. Moeremans, K. Aerts, and J.BroeckxRehabilitation Clinic Hof ter Schelde, Belgium

Backgr ound: We inves t iga ted the ef fec t o f amultidisciplinary rehabilitation care on the outcome of brainand/or spinal cord injury. The multidisciplinary teams consist ofappropriate levels of nursing, medical, physiotherapy, occupa-tional therapy, psychologic interventions, and social work staffwith an active involvement in the rehabilitation process as pre-scribed by a disease-specific clinical pathway. Methods: 1) Theeffect of the organization of hospital care on the outcome ofbrain injury was measured on the functional and cognitive out-come of 112 stroke patients. A ratio scale was developed tomeasure the effect of an organized multidisciplinary rehabilita-tion unit compared to a general ward rehabilitation care. 2) Theeffect of the organization of hospital care on the outcome of spi-nal injury is described in the development of a clinical pathway.Results: The results demonstrated an increased functional out-come in patients of the organized multidisciplinary rehabilita-tion unit compared to a general ward rehabilitation care. Con-clusion: Functional outcome is significantly better whenpatients are treated in an organized hospital multidisciplinaryrehabilitation care compared to a general ward rehabilitationcare.

P3-103 Study on the Relationships of AdmissionFIM and Subscale Scores with Hospital Costs andLength of Stay in Neurorehabilitation Inpatients

J. F. QiuZhejiang Provincial People’s Hosital, China

Background: To investigate the characteristics of the hospi-tal cost in neurorehabilitation inpatients, the relationships ofthe Functional Independence Measure (FIM) and its subscalescores with hospital costs of major items and length of stay(LOS). Methods: The retrospective study was carried out in 64neurorehabilitation inpatients. The hospital costs, LOS, admis-sion FIM, FIM subscale scores were calculated for statisticalanalysis. Results: The average LOS for each patient was 98.77 ±99.15 day. The average hospital costs of rehabilitation was22579.61 ± 21702.24 yuan RMB for each patient. There were sig-nificantly statistical differences among different items of hospi-tal costs (P < 0.05). There were positive relationship betweenLOS and total hospital cost(r = 0.515, P < 0.001) and the relation-ship between FIM and fee of rehabilitation therapy was highly

correlated (r = 0.827, P < 0.001). Admission FIM total scores,self-care, sphincter control, transfer, and motor subscale scoreswere negatively correlated to length of stay (r = –0.258, –0.325,P < 0.01, 0.05). Admission FIM score was negatively correlatedto bed fee, fee of therapy, fee of Western medication and totalfee (r = –0.269, –0.353, –0.313, –0.362, respectively; P < 0.01,0.05). Conclusion: There is good positive relationship betweenhospital costs and length of stay. Admission FIM total scores,self-care, sphincter control, transfer, motor subscale scores maybe able to predict the hospital costs and length of stay inneurorehabilitation inpatients.


P4-001 Acute Autonomic DysfunctionContralateral to Acute Strokes: A ProspectiveStudy of 100 Consecutive Cases

K. Diserens,1 P. Vuadens,2 P. Michel,1 J.Bogousslavsky,1 and J. Ghika1

1Department of Neurology, CHUV, Lausanne,Switzerland; 2SUVA Care, Sion, Switzerland

Background: Complex painful reflex syndrome is some-times described in the chronic phase of stroke. Acute autonomicdysfunction (AD) in acute stroke has not been studied prospec-tively. Methods: 100 consecutive patients in the acute phase ofstroke were studied prospectively for AD. Changes in skin tem-perature, coloration, diaphoresis, pain, or edema were noted inthe 1st 3 days. Associations between AD and topography, age,gender, etiology, and symptoms were examined. Results: ADwas found in 71% of the patients and showed a significant posi-tive association with the presence of a lesion in the postcentralcortex (P = 0.037), internal capsule (P = 0.005), basal ganglia (P= 0.002), or insula (P = 0.011) and a negative association withthe presence of a lesion in the brainstem (P = 0.004).Multivariate logistic regression analysis including all studiedtopographic variables showed that only brainstem lesions weresignificantly associated with a decreased risk of developing AD(OR, 0.08; 95 %CI, 0.01-0.69; P = 0.022). AD was not associatedwith age, gender, the ischemic or hemorrhagic nature of the le-sion, the side of lesion, hyper- or hypotonic paresis, hyper- orhyporeflexia. AD was found in association with sensory deficits(P = 0.001) and contralateral hyperkinesia (P = 0.004). Conclu-sion: Acute AD is significantly more likely to occur in the pres-ence of hemispheric lesions involving sensory pathways fromthe cortex to the internal capsule and insula and is significantlyless prevalent in the presence of brainstem lesions.

P4-002 Autonomic Studies on 2 Patients withAdvanced Motor Neurone Disease andUnexplained Resting Tachycardia

K. P. Leung,1 T. K. Kwok,1 L. S. W. Li,1 and S. L. Ho2

1Tung Wah Hospital, 2Queen Mary Hospital and theUniversity of Hong Kong, Hong Kong

Background: Increasing evidence shows that motorneurone disease (MND) may be a more disseminated diseasewith autonomic involvement. We sought to clarify whether sim-ple electrophysiologic autonomic studies (EAS), i.e., heart-ratevariations to deep breathing and valsalva maneuver and sympa-thetic skin response are useful to pick up autonomic



dysfunctions in advanced MND patients. Methods: We reportedon 2 patients with advanced MND who developed unexplainedresting tachycardia while on ventilators. The 1st patient was a55-year-old man who was diagnosed to have MND 3 years ago.He was near tetraplegic with grade 1 to 2 limb power and re-quired BIPAP for ventilatory support. The 2nd patient was a 35-year-old woman with MND diagnosed 2 year ago. She was alsotetraplegic with just minimal motor control of a few of her dig-its. She was tracheostomized and required full ventilatory sup-port. Both patients developed sinus tachycardia documented byECGs. Routine laboratoy and thyroid function tests were nor-mal. Psychologic support to alleviate any stress or anxiety wasof no avail. EAS were performed. Results: Both patients showednormal heart rate variations to deep breathing and modifiedvalsalva maneuver. The sympathetic skin responses of their up-per and lower limbs were also normal, basically intact even invery advanced stage of MND, or the EAS is not helpful to detectmild autonomic involvement in MND patients.

P4-003 Urinary Disturbances after TraumaticBrain Injury: A Clinical and Urodynamic Study

K. P. S. NairSheffield Teaching Hospitals Trust, United Kingdom

Background: Traumatic brain injury (TBI) often results inloss of control of micturition. The aim of this study is to identifythe frequency and nature of urinary disturbances after TBI.Methods: Subjects were evaluated between 3 and 12 months af-ter TBI with Mini-Mental Status Examination, Asworth Scale forspasticity, Glasgow Outcome Scale, and International ProstateSymptom Score. Multichannel cystometric evaluation was per-formed according to guidelines of International Continence So-ciety. Results were analyzed with Fisher exact test and student ttest and P of <0.05 was taken as significant. Results: 19 men and1 woman of age 19 to 63 years (31.75 ± 12.85 yrs) were evalu-ated at 5.6 ± 0.4 months (3-12 months) after TBI. Urodynamicabnormalities were detected in 11. The types of abnormalitieswere detrussor overactivity with cocoordinated sphincters (7),detrussor over activity with sphincter incoordination (1) and re-duced detrussor compliance (3). Among 9 subjects with frontallobe damage, 7 had abnormal urodynamic studies. There wereno significant differences in age, gender, duration of coma, du-ration since TBI, and cognitive disturbances between those withnormal and abnormal urodynamic studies. Spasticity was morefrequent in the subjects with abnormal urodynamic studies (P =0.038). Conclusion: Urodynamic abnormalities are frequent af-ter TBI. The most common urodynamic finding was over activ-ity of detrussor. This was independent of cognitive problemsand was associated with spasticity.

P4-004 Effects of Repetitive TranscranialMagnetic Stimulation (rTMS) on IntracorticalInhibition

T. Furukawa,1 M. Toyokura,2 A. Ishida,3 M. Komada,3

and K. Hanayama3

1Tokai University Hachioji Hospital, Japan; 2TokaiUniversity Oiso Hospital, Japan; 3Department ofRehabilitaion Medicine, Tokai University School ofMedicine, Japan

Background: Cortical silent periods (CSPs) are thought toreflect intracortical inhibition and are used for the evaluation of

various diseases and therapeutic outcomes. The present studyexamined CSPs after rTMS in healthy persons to investigate howCSPs change with different stimulation conditions of rTMS, suchas site, intensity, and frequency. Methods: Subjects consisted of19 healthy persons; 10 men and 9 woman aged between 21 and42 years. Subjects were randomly divided into 3 groups as fol-lows: group A (0.2 Hz, stimulation with 1.2× stimulation thresh-old), group B (0.8 Hz, stimulation with 0.9× threshold), and acontrol group. For rTMS, concave round coils were placed onthe motor cortex (M1) and prefrontal cortex (Fz). Motor-evokedpotentials (MEPs), CSPs, and F waves were measured beforeand after stimulation. Results: No significant differences wereobserved in F-wave amplitude before and after either M1 or Fzstimulation in all 3 groups. In group A, a significant prolonga-tion of CSPs (P < 0.01) was observed in 1 subject with M1 stimu-lation and in 7 subjects with Fz stimulation. In group B, a signifi-cant prolongation of CPS was observed in 1 subject with M1stimulation, whereas no significant differences were observedwith Fz stimulation. In the control group, no significant prolon-gation was observed. Conclusion: The findings suggest that Fzlow-frequency (0.2 Hz) supraliminal stimulation applied underthe rTMS conditions in the present study facilitated intracorticalinhibition.

P4-005 Balance Performance among Elderly TaiChi Chuan Practitioners

P. M. Chern, N. Hasnan, and Z. OmarFaculty of Medicine, University of Malaya, Malaysia

Background: Falls in the elderly is a global health issue andimpaired balance contributes to falls in the elderly. It is impor-tant to identify a suitable physical activity and balance-screen-ing test. The aims of the study were to assess balance perfor-mance of elderly Tai Chi Chuan (TCC) practitioners usingclinical and laboratory methods and to correlate clinical andlaboratory balance measures and history of fall with balanceperformance. Methods: A cross-sectional study invloved 30community-dwelling elderly subjects. Clinical balance mea-sures comprised of Berg Balance Scale (BBS), 2- and 1-leggedstance time. The laboratory tests comprising modified ClinicalTest of Sensory Interaction on Balance (mCTSIB) and UnilateralStance (US). Results: TCC practitioners performed better in theclinical balance tests, but only BBS was statistically significant(P < 0.05). No difference was noted in all the laboratory tests.Strong correlation was noted between 1-legged stance time andUS for left-legged activities (P < 0.01). There was no correlationbetween history of fall and balance performance. Conclusion:TCC may improve balance performance in the elderly. BBS is avaluable tool to assess balance performance. One-leggedstance time may serve as a balance-screening test.

P4-006 Brain-Behavior Adaptations duringTask-Oriented Rehabilitation: The PredictiveValue of Repeated fMRI Measures

B. H. Dobkin,1 Y. Dong,1 R. Albistegui-Dubois,1

and C. Winstein2

1University of California Los Angeles, USA;2University of Southern California, USA

Background: Neurorehabilitation studies of therapy-in-duced plasticity using fMRI usually include only pre- andposttreatment imaging of the motor network in upper extremity



and walking studies. fMRI studies repeated at fixed intervalsover the course of therapy may reveal whether the motor net-work is being engaged and help predict whether continuedtherapy may lead to further recovery. Methods: Moderately im-paired patients with chronic hemiparetic stroke were studiedduring 2 weeks of constraint-induced movement therapy for theaffected arm (n = 8) or during 12 weeks of locomotor trainingfor walking (n = 8). Pre- and postintervention fMRI was per-formed, as well as interim studies—once in the CIMT group (fin-ger pinch activation) and 4 times in the walking group (ankledorsiflexion). A mixed model and regression analyses assessedvoxels activated in regions of interest and behavioral measures.Results: A decrease in activation in contralesional primary mo-tor cortex (M1) and representational expansion or subsequentfocusing of ipsilesional activation were associated with behav-ioral gains. The midpoint fMRI laterality index for bilateral M1predicted improvement on the Wolf Functional Motor Test.Other sequences of change within M1 on interim scans were as-sociated with progression of walking speed. Conclusion: In-sight into the optimal type and duration of rehabilitation for mo-tor skills relearning may be gained by combining interim serialfMRI activation and behavioral measures over the course oftask-oriented training.

P4-007 Pathobiological Changes inPhotothrombotic Ischemia Model: SequentialMRI, Behavior, and Histologic Analysis

S. K. Moon,1 H. I. Kim,2 Y. I. Shin,1 S. Lee,1

and M. C. Lee3

1Wonkwang University, South Korea; 2PresbyterianMedical Center, South Korea; 3Chonnam University,South Korea

Background: The changes and progress of ischemia wereasssessed in a photothrombotic ischemia model using MRI andbehavioral and histologic analysis to provide the informationregarding the timing and effect of therapeutic intervention.Methods: Photothrombotic ischemia was induced in the motorcortex of rats using Rose-bengal dye and cold light. Single-pel-let-reaching (SPR), Rotarod, and tray-reaching tasks wereadopted to measure any resulting motor deficit. MRIs includingT1, T2, and diffusion-weighted imaging (TIW, T2W, and DWI),were obtained through 8 weeks. Infarction volume and con-trast-noncontrast ratio (CNR) were measured in all images. Thebrain sections were stained. Results: The SPR task was the mostsensitive method for tracking the recovery of motor function.Infarction volume was measured and was largest on day 1 andthen decreased progressively. CNR was greatest at 12 h in DWIand decreased over time. On the contrary, T1W and T2W im-ages showed constant CNR from the beginning through 8weeks. Histologic analysis showed ischemic changes from 1 hafter lesioning. However, neuronal swelling was more markedin 24 h. Macrophage infiltration began to appear on day 2 andpersisted up to 4 weeks. Axonal sprouting was marked at theborder between 1 and 2 weeks. The infarct area was progres-sively replaced by gliotic tissues with a final necrotic cyst in thecentral area. Conclusion: Correlation of the MRI, behavioral,and pathologic findings is required to understand thepathobiological changes in photothrombotic stroke.

P4-008 Microinjection of MK801 and AP5 into aRat’s Dentate Gyrus Reduces Nociception inFormalin Tests

E. Soleimannejad, S. Semnanian, N. Naghdi,and Y. FathollahiSchool of Cognitive Sciences, Institute for Studies inTheoretical Physics and Mathematics, Iran

Background: Many physiologic, pharmacologic, and behav-ioral findings have suggested that the hippocampal formation isinvolved in nociception. The role of NMDA receptors in the ex-pression of nociceptive behaviors induced by a formalin irritantwas examined by microinjection of AP5 and MK801 into thedentate gyrus and the CA1 area of the hippocampal formation.Methods: The competitive and noncompetitive NMDA receptorantagonists AP5 and MK801 (1, 3, 6 g/0.5 L) were injectedstereotaxically into the dentate gyrus and CA1 area of behavingrats 5 min before subcutaneous injection of a formalin irritant.Results: The results showed that injection of AP5 (3.75 g/0.75 L)and MK801 (3 and 6 g/0.5 L) into the dentate gyrus, but not tothe CA1 region, significantly reduced pain behaviors in both theacute and tonic phases of the formalin test. Conclusion: Thepresent findings suggest that NMDA receptors of the dentategyrus may be involved in pain-related processing, in particularthe expression of pain-related behaviors.

P4-009 fMRI BOLD Activation Patterns in StrokeLate Rehabilitation

J. Hernandez, F. Barrios, R. Carrillo, R. Leder,and M. CarrilloInsituto Nacional de Neurologia Y NeurocirugiaM.V.S, Mexico

Background: Approximately 80% of acute stroke survivorslose arm and hand movement abilities. The goal of our studywas to provide objective clinical evidence that patients who ex-perienced a stroke for more than 1 year could improve with laterehabilitation therapy. fMRI was used to demonstrate the func-tional brain reorganization corresponding to the improved clin-ical measures. Methods: 20 subjects were selected from theInstituto Nacional de Neurologíay Neurocirugía stroke programand had a stroke more than 1 year ago. Subjects came to a totalof 12 one-hour therapy sessions, 3 times per week for 4 weeks.The therapy included a combination of almost continuous con-straint-induced therapy during waking hours and sessions ofplaying computer games. Clinical evaluations used were theModified Ashworth Scale, Motricity Index, Fugl-Meyer, Func-tional Independence Measure, and Barthel Index. Patients werestudied via fMRI BOLD immediately before therapy and aftertherapy. Results: All patients in the study experienced increasedmotion, reduced spasticity, and corresponding changes in theirfunctional images. The fMRI support 2 types of functional imag-ing interpretations: one with more spatially extensive activationand the other with spatially reduced but more focused activa-tion. Conclusion: fMRI BOLD studies confirm brain functionalreorganization. fMRI might be able to help determine the dos-age and duration of therapy in stroke rehabilitation based onbiological principles of brain plasticity.



P4-010 Multimodality Neuropsychologic, Sensory,Gait, and Nystagmography Analysis in Mild andModerate Head-Injured Malay Patients: AProspective Study

J. M. Abdullah, J. Tharakan, M. H. A. Munawir, A. W.Naseer, and A. T. AdnanDepartment of Neurosciences, University SainsMalaysia Health Campus, Kota Bharu, Kelantan,Malaysia

Background: Minor and moderate head-injured patientshave posttraumatic symptoms like headache, dizziness, doublevision, and imbalances of gait and require rehabilitation. Ourobjective was to analyze prospectively whether rehabilitationapparatus versus a simple psychologic test could determinewhether patient’s abnormal symptoms could be technicallyconfirmed. Methods: Twenty patients accordingly were ana-lyzed by 2 investigators blinded to the patients’ symptoms andGCS and subjected to electroencephalometry (EEM), sensoryanalyzer (SA), gait analysis (GA), as well as nystagmography(NYS). Their complaints were noted, and they were tested witha basic neuropsychologic test (NPT). The data was entered intothe SPSS data version 11.0 and analyzed. Results: There was nodifference in the NYS and SA in both groups. There was a signif-icant difference for NPT, GA, and EEM if the dominant lobe wasinvolved. Patients with frontal lobe injuries were more likely tohave psychologic symptomatology compared to other lobes.These abnormalities did not recover in the moderate head in-jury group compared to the mild head injury patients. <I>Con-clusion: Complaints by patients can be investigated byelectroencepalometry, gait analysis, and psychologic test. Theother tests involving sensory test and nystagmography were notre l iab le in determining or conf i rming compla ints .Neuropsychologic tests are most sensitive in direct relation toneuroimaging in determining genuine complaints for purposesof rehabilitation and insurance claims.

P4-011 Central Poststroke Pain: Role ofAcupuncture

H. L. YenTan Tock Seng Hospital, Singapore

Background: Central poststroke pain (CPSP) is not an un-common complication in stroke survivors and can impact ad-versely on functions, mood, and quality of life. It is notoriouslydifficult to treat; responses to conventional medical treatmentare often partial and unsatisfactory. The use of acupuncture inthe management of this condition is seldom reported in themedical literature. Methods: We describe 3 patients who devel-oped CPSP months to years after stroke onset. Pain was local-ized over the lower jaw, hand, and leg on the hemiplegic side,respectively. As a result of the pain, function deteriorated, de-pression set in, and carer stress increased. Acupuncture treat-ment was subsequently instituted, using traditional needlingmethods with the addition of electroacupuncture. Results: Sig-nificant improvements in pain scores were documented for all 3patients within 1 month of starting acupuncture. Their emo-tional state elevated, and they were able to function more inde-pendently. No adverse events occurred. During the presenta-tion, details of the acupuncture points used and the rationale fortheir selection will be discussed. In addition, the underlying

neurologic basis for the acupuncture effects will also be men-tioned. Conclusion: Conventional treatment alone for CPSPoften produces unsatisfactory results. A multimodal approach,involving acupuncture, will probably be more successful inbringing about symptomatic and functional improvement. Onesuch approach will be described during the presentation.

P4-012 Effectiveness of Acupuncture Treatmentin Stroke Rehabilitation

E. S. L. Chow, P. M. Y. Lau, and R. M. W. ChauKowloon Hospital, Hong Kong

Background: Acupuncture has been adopted as an adjunctphysiotherapeutic treatment in Kowloon Hospital. A prospec-tive clinical trial was conducted to examine the added benefit ofacupuncture in promoting the motor and functional recoveryfor patients who had a stroke during the course of subacute re-habilitation. Methods: Patients with principle diagnosis of cere-bral vascular accident were randomized to the 1 of the 2 groups:conventional rehabilitation program (control group) and a com-bination of acupuncture treatment and conventional rehabilita-tion program (acupuncture group). The outcome measures pa-rameters included Functional Ambulation Category (FAC),Elderly Mobility Scale (EMS), Functional Independence Mea-sure (FIM); its subcognitive and submotor score were collected.Results: 46 patients had successfully completed the acupuncturetreatment. The other 46 patients were recruited into controlgroup. On discharge, significant improvement in FAC, EMS, FIM(cognition), FIM (motor), and FIM (total) in both groups wereshown. Between-groups comparison reflected a statistical sig-nificant difference in the improvement of FAC, EMS, FIM cogni-tive subscore, and FIM total score, except for the FIM motorsubscore, favoring the acupuncture group. Conclusion: Ourfindings demonstrated that the acupuncture modality enhancedmotor and functional recovery in patients with subacute stroke.Acupuncture appears to be a safe and effective adjunct treat-ment in a comprehensive stroke rehabilitation program.

P4-013 The Clinical Study on Acute IntracerebralHemorrhage in Patients by Scalp AcupunctureCombined with Rehabilitation

Z. BaiThe Second Affiliated Hospital of HeilongjiangUniversity of Traditional Chinese Medicine, China

Background: The research is to explore the best method ofthe treatment to intracerebral hemorrhage (ICH) and to testifythat cluster needling of scalp point combined with rehabilita-tion techniques is a kind of no-medication therapeutics withconclusive clinical effect. Methods: In this reaserch, 60 ICH pa-tients were randomly divided to 3 groups: The cluster needlingof scalp point combined with rehabilitation techniques group,rehabilitation group, and control group. The cases in differentgroup were treated by therapy as allocated. Results: With thecluster needling of scalp point combined with rehabilitationtechniques, the rehabilitation group and the control group im-proved in the movement function and activities of daily living.With the cluster needling of scalp point combined with rehabili-tation techniques, the cluster needling of scalp point and thecontrol group had significant difference (P < 0.01) in the move-ment function and activities of daily living. The abnormal rate of



SEP also decreased in different groups. But the abnormal rate ofSEP of cluster needling of scalp point combined with rehabilita-tion techniques group was superior to that of the other groups,and the clinical effect was the best among the 3 groups. Conclu-sion: Cluster needling of scalp point combined with rehabilita-tion techniques is one of the best methods of the treatment forICH and a kind of no-medication therapeutics with goodclincial effect, which characterized by innocuity, no side effect,no pain, and readily accessible.

P4-014 Tai Chi and Regular Exercise ImproveEquilibrium of the Healthy Elderly Women

T. Yan, R. Xie, Y. Guo, and D. JinSecond Affiliated Hospital, Sun Yat-sen University,China

Background: Tai Chi is one of the most popular exercisesamong the elderly in China. However, the effects of Tai Chi andregular exercises on the equilibrium of the body were unclear.This study was to investigate their effects on the equilibrium inhealthy elderly women. Methods: 70 healthy elderly womenwere divided into 3 groups: Tai Chi group (TCG, n = 33), aged67.1 ± 7.6; exercise group (EG, n = 15), aged 69.7 ± 12.8 andnonexercise group (NEG, n = 22), aged 79.8 ± 7.3. TCG and EGhad either regularly Tai Chi practice or morning exercise for 30min each day, 3 times weekly for more than 3 months. BalancePerformance Monitor (England) Romberg’s and tandemRomberg’s signs, the timed “Up and Go” test (TUGT) were usedto examine the equilibrium of subjects. Results: There was sig-nificant difference in sway frequency between TCG and EG (P <0.05). Marginal significant differences were found betweenTCG and NEG in sway path, sway area, maximum sway angle,and the maximum sway velocity (P < 0.06). Although significantdifference was only found in the maximum sway angle betweenEG and NEG (P < 0.05). Better Romberg’s sign presented in TCGand EG than in NEG (P < 0.01). Tandem Romberg’s sign was sig-nificant longer in TCG than in the other 2 group (P < 0.01).TUGT was significantly faster in TCG than in EG (P < 0.05) andin NEG (P < 0.001). Conclusion: This study demonstrated thatboth Tai Chi and regular exercise improved the balance andwalking on the healthy elderly women but that Tai Chi hadgreater effects than that of the regular exercise.

P4-015 Stroke Rehabilitation Assisted by“Zokumeito,” a Traditional ChineseHerbal Formula

N. Maruno,1 T. Kaminaga,1 E. Hoshino,2

and M. Mikami11Teikyo University Hospital, Japan; 2CancerInstitute Hospital, Japan

Background: It has been suggested that Zokumeito (ZT),which is a traditional Chinese herbal formula (described in theancient medical textbook Jin Gui Yao Lue), may be effective inthe treatment of hemiplegia and speech disturbances. Wetreated stroke patients in the postacute phase with ZT concomi-tantly with the usual rehabilitation therapy (PT, OT, and/or ST),and compared the changes in the regional cerebral blood flow(rCBF) with treatment to examine the effectiveness of ZT. Meth-

ods: 4 patients with right hemiplegia in the postacute phase ofstroke were enrolled in this study. Informed consent was ob-tained from all of the patients prior to their participation in thestudy. Administration of ZT was commenced in the patients 1month after the onset of stroke. The pre- and posttreatmentrCBF values, evaluated by 99 m Tc-ECD (ethyl cysteinate dimer)brain SPECT in 12 areas of each brain hemisphere, that is, ante-rior, precentral, central, parietal, angular, temporal, occipitaland pericallosal cortices, lenticular nucleus, thalamus, hippo-campus, and cerebellum, were compared. Results: There was atendency toward an increase in the rCBF in the occipital andcerebellar regions of the normal brain hemisphere and in theangular region of the affected brain hemisphere. Conclusion:ZT might have the potential to increase the rCBF in thepostacute phase in stroke patients. However, to clarify the trueeffects of ZT, more randomized controlled trials with appropri-ate statistical analysis should be conducted on a large number ofpatients.

P4-016 Clinical Observation on the Effects ofCluster Needling of Scalp Point andRehabilitation Techniques on Motor Functionafter Acute Cerebral Infarction

Q. Tang,1 D. M. Zhu,2 and J. Li11The Second Affiliated Hospital of HeilongjiangUniversity of Traditional Chinese Medicine, China;2Heilongjiang University of Traditional ChineseMedicine, China

Background: To explore the effectiveness of cluster nee-dling of scalp point combined with rehabilitation techniques onpatients after acute cerebral infarction with disturbance of mo-tor function. Methods: Fugl-meyer, Bathel Index, Nerve functiondisturbance, and clinical effect assessment methods were usedto assess the motor function and activities of daily living of the 3groups: group with cluster needling of scalp point, rehabilita-tion group, and group with cluster needling of scalp point com-bined with rehabilitation group. Results: The motor functionand activity of daily living of patients in the group with clusterneedling of scalp point combined with rehabilitation were su-perior to those in the group with cluster needling of scalp pointand those in the rehabilitation group (P < 0.01 and P < 0.05, re-spectively). The total rate of effectiveness can reach to 97.14%.Also, the group with combined therapy showed that there wasless foot drop, strephennopodia, subluxation of shoulder joint,shoulder-hand syndrome, contracture of joints, and abnormaltone. Conclusion: The cluster needling of scalp point methodshows positive treatment effects and improves the quality of lifeof patients with acute cerebral infarction.

P4-017 User Involvement in the Developmentof a Prototype Exoskeleton for the RemoteRehabilitation of Spinal Cord Injury (SCI)Patients

P. Enderby,2 S. J. Mawson,1 H. Buri,2 S. Brownsell,3

and D. Bradley4

1Sheffield Hallam University, United Kingdom;2University of Sheffield, United Kingdom; 3Barnsley



District General Hospital, NHS Trust, UnitedKingdom; 4University of Abertay,United Kingdom

Background: The incidence of SCI in the United Kingdom is10 to15 cases per million of the population, with approximately600 to 900 new cases per annum. During the rehabilitation pro-cess, the physiotherapist moves the lower limb through com-plex movement cycles. This has led to an increasing interest inthe provision of automated robotic aids to support the manipu-lative process. The development of any new technology shouldbe informed by users so that their views can influence design atan early stage. An intelligent exoskeleton is under developmentby a multidisciplinary team of clinicians, engineers, rehabilita-tion specialists, and medical physics. This paper describes themethod of eliciting and incorporating user views in the designprocess. Methods: A qualitative approach was used in which 8focus groups were conducted, 4 were with physiotherapists (n= 32) and 4 with users (n = 12). A thematic schedule steered thefocus group discussion; data were analyzed thematically withchecks for validity. Results: User requirements emerging fromthe physiotherapists: usefulness, compliance, control, locationof treatment, face-to-face contact with users, and features of therobot. User requirements emerging from the patients: progressmonitoring and feedback, contact with the physiotherapist.Conclusion: The excitement and challenge of developinghighly sophisticated equipment can blinker those unfamiliarwith clinical environments. User involvement at an early stagein development ensures that innovations have a clinical utility.

P4-018 The Effect of a New Air Cell GelatinousElastomers Cushion on Reducing Pressureand Temperature

M. J. Kao,1 Y. H. Tsuang,1 and M. W. Tsai21Taipei City Hospital, Chinese Taipei; 2NationalYang Ming University, Chinese Taipei

Background: New material and structure are developed forseat cushion not only on relieving pressure but also on reducingthermal accumulation. The aim of this study was to analyze theeffectiveness of the Elastone cushion (gelatinous elastomers), anewly developed material and structure, on reducing pressureand temperature. Methods: A volunteer was repeatedly mea-sured to compare the pressure and thermal responses on theElastone cushion with 3 other available cushions (foam, gel-filled, and air-filled villous) and 4 regular wooden or spongychair seats. The skin temperature at buttock was continuouslymeasured for 8 h of prolonged sitting. Results: The Elastonecushion reduced the peak pressure (39.7 mm Hg) comparedwith foam (60.0 mm Hg); gel-filled, (60.3 mm Hg); and air-filledcushions, (69.3 mm Hg); and with the wooden and spongy chairseats (84.7-200 mm Hg). During the 8-h period, temperaturegradually increased and reached its maximal plateau within 3hours. The peak temperature of the Elastone cushion was 29° C.Higher temperatures were found on gel-filled (33.8° C), air-filled (35° C) and foam (35.9° C) cushions, and on the woodenand spongy chair seats (34.5°-35.9° C). Conclusion: Our find-ings showed that the Elastone cushion was more advantageousin relieving pressure and minimizing temperature. It is recom-mended to wheelchair users.

P4-019 Vigilance Deficits in Cases of Patients withNeurologic Disorders

A. Buettner,1 S. Latarnik,2 S. Rode,2 L. Seiffert,2

and H. Bennefeld2


Background: Apart from a multitude of physical complaints,neurologic disorders can also lead to various kinds of cognitivechanges. In such cases, attention and vigilance may be affected,as well as the actual cognitive processes themselves. Importantfactors in this can be the severity of the disorder and the dura-tion of prior therapy. Methods: The study was performed with 2groups of randomly selected persons, neurology patients andhealthy persons. All subjects were selected according to theirclinical diagnosis (ICD-10). So far, data have been gathered for51 healthy persons (42 male, 9 female) and 148 neurology pa-tients (101 male, 47 female, with various neurologic clinical pic-tures) using the vigilance test Carda. Results: Testing of vigi-lance achievements revealed a highly significant differencebetween healthy persons and neurology patients (P < 0.001).Analysis of the degree of severity for neurology patientsshowed a significant difference between mild and severe (P =0.020) (concerning vigilance achievements). Conclusion: Thestudy revealed that patients with neurologic diseases(cerebrovascular diseases, brain traumas, brain tumors, etc.)show problems and deficits concerning their vigilance achieve-ments. In contrast, the degree of severity of the disorders (neu-rology patients) is not relevant.

P4-020 The Psychosocial Impact of AssistiveTechnology in People with NeurologicDisorders—A Pan-European Survey of Users

E. K. Stokes,1 G. R. Johnson,2 E. Laudanna,3

S. van Kaick,4 and L. von Koch5

1Trinity College Dublin, Ireland; 2University ofNewcsatle, United Kingdom; 3Fondazione DonCarlo Gnocchi, Italy; 4Charite–UniversitatsmedizinBerlin, Germany; 5Karolinska Institutet, Sweden

Background: Many people with limitations of activities dueto their neurologic disorder utilize assistive technology (AT).Evaluating the impact of AT devices for individual users andgroups of users is increasingly important to appraise servicesand justify costs. This study investigates the psychosocial im-pact of assistive technology (AT) devices, in a group of peoplewith neurologic disorders, in 4 European countries. Methods:103 current users of power wheelchairs (PWC), environmentalcontrol units (ECU), or personal computers (PC) were studied ina descriptive, cross-sectional study. The Psychosocial Impact ofAssistive Devices Survey (PIADS) was employed as a measureof the impact of AT devices on competence, adaptability, andself-esteem. Results: Results suggest that, overall, AT deviceshave a positive impact of competence, adaptability, and self-es-teem. No difference in this impact was noted between men andwomen, across differing age (18-85 years), and the diagnosticgroup stroke, cerebral palsy, multiple sclerosis, and quadriple-gia after spinal cord injury. Neither was a difference noted be-tween the AT devices. Between the 4 European country sam-



ples, a small but significant difference was noted in self-esteem.Conclusion: The 1st results of the PIADS are reported for a Euro-pean sample. The findings suggest that the impact of PWC,ECU, and PC is positive in users of all ages and gender and neu-rologic disorders. A positive impact on self-esteem,competence, and adaptability is reported.

P4-021 The Advantages of High IntensityResistance and Body Weight Support TreadmillTraining over Conventional Neurorehabilitation:2 Case Reports

J. R. Joergensen, P. Zeeman, J. Sørensen,and D. T. Pedersen1

1Center for Rehabilitation of Brain Injury,Denmark

Background: Conventional neurorehabilitation (CN) aims atoptimizing patient independence and quality of life. However,regardless of chronicity and severity, hemiplegic patients, whohave received CN, have a potential for substantial improvementof gait, speed, walking distance, and safe independent ambula-tion. Methods: Subjects: 2 patients with spastic hemiparesis (1left- and 1 right-hemisphere stroke; chronicity, greater than 1year), who previously had received CN. Intervention: As part ofa postacute, holistic outpatient rehabilitation program with pro-gressive resistance training (PRT) 7 h/week, 12 weeks for from12 to 4 RM with visual feedback of ROM and force. Endurancetraining (ET) includes body weight support treadmill andstair master training (BWST), progressing to running with em-phasis on velocity, cadence, and distance. ET also comprisesforced use, e.g., unipedal cycling. Pre- and posttests: joint mo-tion, 3-D graphics, videos, biopsies of both quadricepses, EMG-recorded dynamic/isometric muscle function, VO2max, Har-vard Step Test, 6-min walk test (6MWT), 10-m walk test wereused. Results: 5 previous biopsies showed major bilateralchanges in fiber size and distribution. Changes were reversible,especially for the affected side. Mean improvement in 6MWT for8 patients was 66%. Conclusion: Gait variables, muscle functionand fibers, and functional outcome in adults were improved.Chronic hemiplegia can all be significantly influenced by acombination of high intensity (PRT) and high speed (BWST)training.

P4-022 Gait Analysis of Hemiplegic Patients witha Newly Developed 3-D Electrogoniometer(Domotion)

J. S. Yoon,1 S. J. Kim,1 S. B. Koh,2 H. J. Baek,1

and G. S. Kim1

1Department of Physical Medicine andRehabilitation, Korea University Guro Hospital,South Korea; 2Department of Neurology , KoreaUniversity Guro Hospital, South Korea

Background: The purpose of this study was to evaluate thedifference between hemiplegic patients and controls with anewly developed 3-D electrogoniometer gait analysis program.Methods: Kinematic data at the hip, knee, and ankle joints in thesagittal plane and temporospatial gait parameters were ob-tained from 25 hemiplegic patients and 25 healthy adults withthe 3-D Domotion electrogoniometer. Results: Significant differ-ences were observed between the patients and controls in terms

of the kinematic parameters. Mean maximal hip flexion of thehealthy adults and the hemiplegic limbs of the patients aver-aged 32.89° and 18.24°, respectively. Maximal knee flexion was50.32° and 34.98°, respectively. Maximal ankle dorsiflexion was5.34° and 1.22°, respectively. Maximal ankle plantar flexion was15.63° and 8.46°, respectively (P < 0.05). Mean maximal hipflexion of the healthy adults and the unaffected limbs of thehemiplegic patients averaged 32.89° and 28.36°, respectively,and maximal ankle plantar flexion 15.63° and 8.62°, respec-tively (P < 0.05). Conclusion: The gait parameters of hemiplegicpatients showed significant differences as compared with nor-mal ga i t parameters when measured us ing theelectrogoniometer.

P4-023 ERP-Based Brain Computer Interface forCommunication and Control in CompletelyParalyzed Patients

F. Piccione,1 K. Priftis,1 P. Tonin,1 A. Merico,1

and F. Beverina2

1IRCCS S.Camillo Hospital, Alberoni, Venezia, Italy;2STMicroelectronics—AST Group,Agrate Brianza, Italy

Background: The aim of the present study was to proposethe use of event-related potentials (ERPs) as control signals in abrain-computer interface (BCI) for completely paralyzed pa-tients. We developed a device, which using ERPs controls themotion of a cursor on a computer’s graphical interface. Meth-ods: The experimental device detects P300 waves to control themovement of a cursor on a computer screen. Visual stimuli,consisting of 4 arrows (up, right, down, left), were randomlypresented in peripheral positions on the screen. Seven healthyand 5 completely motor-impaired subjects were instructed torecognize only the stimulus related to the preferred cursor’smovement. Online P300 epochs, synchronized with the targetstimulus, were recognized using independent component anal-ysis with subsequent features extraction and classification by aneural network. Results: The system needed a training period of300 to 350 trials to allow task completion. The P300-based BCI’smean performance was 68.6% for patients and 76.2% for healthycontrols. The performance of “locked in” patients was signifi-cantly worse than that of healthy controls. Conclusion: In thisstudy, effective user-system interaction took place in real timeand no time-consuming training is needed. The proposed sys-tem is effective for use in real time with healthy participants andwith less-impaired patients. Additional research is needed toimprove its overall effectiveness with “locked in” patients.

P4-024 Modified Automatic Teller MachineInterface for Older Adults

C. C. H. Chan,1 A. W. K. Wong,1 T. M. C. Lee,2

and I. Chi31Department of Rehabilitation Science, the HongKong Polytechnic University, Hong Kong; 2Instituteof Clinical Neuropsychology, the University of HongKong and MacLehose Medical RehabilitationCentre, Hong Kong; 3School of Social Work,University of Southern California, USA

Background: Technological development is meant to en-hance the quality of life of older adults. Nevertheless, the design



of these technological developments, e.g., automatic teller ma-chine (ATM), often adopts a universal design. As a result, olderadults find these developments less user-friendly. This studywas aimed to investigate the usefulness of a modified ATM pro-totype with an attempt to incorporate individual differences inthe design of technological device for older adults. Methods:187 older adults participated in operating 2 functions of ATM:cash withdrawal and account transfer. The participants wererandomly assigned to the existing and modified ATM groups.The modified ATM protocol was designed with respect to lessdemand on participants’ attention, working memory, and lan-guage function. The participants’ performance in the ATM taskswas evaluated according to standardized scoring method. Re-sults: There were statistically higher proportions of participantsin the modified than existing ATM group who succeeded in op-erating the ATM functions. Enhancement effects were obviousamong those who had low neurocognitive functions, low edu-cation, and no prior ATM experience. Conclusion: ModifiedATM prototype was useful for accommodating the declinedneurocognitive characteristics of older adults. These findingsdemonstrate the drawbacks of adopting universal design totechnological development which could equally apply topatients with neurologic deficits.

P4-025 Neuropsychologic Functions PredictingPeople with Mental Retardation in Using theComputer Technology

A. W. K. Wong,1 C. C. H. Chan,1 C. W. P. Li-Tsang,1

and C. S. Lam2

1Department of Rehabilitation Science, the HongKong Polytechnic University, Hong Kong; 2Instituteof Psychology, Illinois Institute of Technology, USA

Background: Ongoing spread of computer innovationsleads to a wider and more heterogeneous computer-based pop-ulation. Previous studies indicated that existing technologieswere too complex for persons with cognitive disabilities, suchas those with mental retardation, because the task demands ofcomputer interfaces were not matched with the special charac-teristics of this population. This study was aimed to investigatethe relationship between the neuropsychologic functions andcomputer competence by people with mental retardation.Methods: A total of 68 participants with mild to high-moderatemental retardation were administered a set of standardizedneuropsychologic testing. Computer task competence was alsoassessed with the Internet Explorer (IE) Performance Test com-posed of 16 tasks and further divided into 161 subtasks to mea-sure Web-browser-related operating skills. Results: NonverbalIQ performance and almost all neuropsychologic test scoreswere significantly related with the IE task competence. Amongall functions, attention and visual scanning, psychomotor func-tion, and language processing were significant predictors ofparticipants’ performance on operating the IE. Conclusion: Thisneuropsychologic profile was used as a basis for designing theenhanced computer programs for people with mental retarda-tion. These findings can be equally applied to those with braininjuries. The implications on using universal design or design toaccommodate individual differences are discussed.

P4-026 Locomotor Training in Childrenwith Differents Neurologic Diseases with aRobotic-Assisted Walking

N. Murillo, M. Corrons, C. Martin, M. Salvador,and J. MedinaInstitut Guttmann, Spain

Background: Existing several treatment lines in the field ofthe neurorehabilitation are to stimulate the activation of thecentral locomotor patterns generation. The robotic-assisted sys-tem developed by G. Colombo has reported good results in in-complete paraplegic patients. The objective of this study is toassess the efficacy of robotic-assisted walking as a tool for gaittraining in children with different neurologic diseases. Methods:The study was designed as a prospective single-case study. Weutilized the robotic orthosis with body weight support system in5 children with different neurologic disorders. Subjects receivedlocomotor training on this system 5 d per week for 8 weeks.Support started at 40% of body weight and a velocity of 1.5kmph and progressed by reducing support and training time upto 30 min. Main outcome measures were assessed at the begin-ning and in the end: Functional Ambulatory Categories (FAC),10-m walk test to record cadence, stride length, and velocity.They were also videorecorded for analysis of the gait pattern.Results: The 5 children increased the level of the FAC and the ca-dence, velocity, and stride length as well as trunk stability, andgait pattern improved. Conclusion: The robotic-assisted walk-ing system seems to be an adequate tool to enhance the poten-tial for walking in children with different neurologic diseases;however, we need to have more number of children in eachpathology for subgroup analysis.

P4-027 Virtual Reality as a Training Device forMovement Rehabilitation in the Upper Limb afterChronic Stroke: 2 Case Studies

J. H. Crosbie,1 S. M. McDonough,1 S. Lennon,1

and M. D. J. McNeill21Health and Rehabilitation Sciences ResearchInstitute, University of Ulster, United Kingdom;2School of Computing and InformationEngineering, University of Ulster, United Kingdom

Background: Lack of recovery of upper limb function is amajor problem for many people after stroke. Recovery is de-pendent on regular and intense training. The use of virtual real-ity (VR) may hold some solutions for this problem. VR generatesan interface for users to receive sensory information that is simi-lar to the real world and may provide a motivating practice ex-perience. The aim of this study was to investigate whether train-ing in a virtual environment would improve motor activity andfunction in the hemiparetic arm of 2 people after stroke. Meth-ods: Each person underwent a 3-week training program using aVR rehabilitation system that consisted of three 30-min sessionsper week. Each was medically stable after a 1st stroke, scored atleast 26 on the MI, and had no significant speech deficits. Pa-tient A was male, 76 years of age; patient B was female, 60 yearsof age; both were left hemiplegics with time since stroke of 3and 4 years, respectively, and both were independently mobile.Measures were the Motricity Index (MI) and the Action ResearchArm Test (ARAT). An independent assessor rated the partici-



pants at three points: pre- and posttraining and follow-up. Re-sults: Improvements were found in the MI and ARAT scores. Atthe 3 time points, patient A scored 77, 77, 81 on the MI and 3, 6,11 on the ARAT. Patient B scored 62, 73, 77 on the MI and 4, 11,19 on the ARAT. Conclusion: Training with virtual reality im-proved motor activity and function in the upper limb in 2 casestudies with patients after stroke.

P4-028 Virtual Reality (VR) inNeurorehabilitation: Preliminary Experience

A. Mayr,2 O. Irschitz,1 and L. Saltuari11Irschitz GmbH, Austria; 2Hospital Hochzirl, 13,Austria

Background: To investigate the application of VR (i-frame)in improving upper limb function and gait patterns in stroke pa-tients. Poor function in the upper limb exerts a negative influ-ence on the walking pattern of stroke patients. To improve up-per limb function, patients trained on a VR system. Gait analysiswas performed before and after the training. Methods: 8 patientsafter stroke of different origins were included in a clinical ABstudy. Data acquisition and data analysis were conducted usinga 3-D gait analysis system (Vicon 460 System, Oxford Metrix,England). Functional Dexterity Test, hand dynamometry, andsensibility measurement served as outcome measures for theupper limb. Results: After training with the VR system, the pa-tients walked more symmetrically, at higher speeds, and withless circumduction. Graphs of motion of the hip and to some ex-tent the knee joints during swing phase demonstrated peakssimilar to those of normal subjects. Motion of the ankle duringstance phase remained unaffected. Functional improvement inthe upper limb could be seen in all patients. Conclusion: Thestudy shows that the use of VR in rehabilitation of stroke pa-tients has 2 effects: improvement in function of the upper ex-tremity and in gait. This system provides an effective method oftherapy for the upper limb, which is often neglected inneurorehabilitation.

P4-029 The Treatment of Flexed KneeContractures with Botulinum Toxin A

Z. Bakran,1 I. Dubroja,1 M. Bakran,2 S. Soldo-Butkovic3

1Special Hospital for Medical RehabilitationKrapinske Toplice, Croatia; 2General HospitalZabok, Croatia; 3Teaching Hospital Osijek, Croatia

Background: We used Botox to treat flexed kneecontractures in patients with spastic tetraparesis or hemiparesisafter traumatic brain injury. Methods: Botox was applied inhamstrings muscles, in triceps surae, and in adductor muscles ofthe legs. Spastisity was measured by Modified Ashworth Scaleand range of movement (ROM, popliteal angle) withgoniometer and Tardieu test. After Botox was applied, patientshad specific kinesitherapy treatment, splints 3 to 4 h daily, andelectrostimulation of antagonist muscles. Results: Seventeen pa-tients with flexed knee contractures were treated; 13 were male(76.4%), and 4 were female (23.6%). They were on average 27.1years of age (range, 16-50 y). Modified Ashworth when Botoxwas applied was IV in 5 patients, III in 9 patients, and II in 3 pa-tients. Ninety days after Botox application, Modified Ashworthscore was III in 4 patients, II in 11 patients, and I in 2 patients.Eight patients (47%) had flexed knee contractures on bothknees. The ROM (passive) before the treatment was on average

59.4° and after 90 days of treatment was 101.8°. The averagedose of Botox was 59 mU during the 1st application and 52 mUduring the 2nd application. All the patients before the 1st appli-cation were motionless. Ninety days later and subsequent to thespecific rehabilitation program, 1 patient (5.9%) could walk in-dependently, 7 of them (41.2%) walked with a physiotherapist,5 of them (29.4%) could walk with a physiotherapist and someorthotics, and 4 of them (23.5%) could not walk. Conclusion:Botox in combination with a specific rehabilitation program isvery successful therapy in the treatment of spastic kneecontractures.

P4-030 Measurement of Viscoelastic Properties ofSoft Tissue in Spastic Syndrome

P. Sifta,1 S. Otahal,1 and J. Sussova2

1Faculty of Physical Education and Sport, CharlesUniversity in Prague, Czech Republic; 21st MedicalFaculty, Charles University in Prague, CzechRepublic

Background: The purpose of the research is to answer howto measure the viscoelastic (rheologic) properties of spasticmuscle. Methods: The main objective is to discover a methodthat allows identification of the biomechanics properties of softtissue and resembles muscle examination using palpation, as itis known in clinical use. For this purpose, an instrument withthe working name “myotonometer” has been used. The resultsof these examinations are 344 series of data from which a graphcan be drawn showing the correlation of changes in the lengthof muscle fibers with applied force. A total of 23 patients wereexamined. If the patient met the given criteria, patient wasgiven a palpation examination to find the area with the greatestmuscle resistance. Results: Measurements of each muscle usingthe myotonometer are shown in graph illustrating the relationbetween the sizes of the deflection of instrument tips under ap-plication of force. Changes in the observed parameters duringthe course of the treatment were then analyzed. Conclusion:One can state that the hypothesis proposed in the introductionregarding the possibility of measuring and detecting theviscoelastic properties of soft tissue with the aid of amyotonometer and subsequent determination of the spasticityhas been confirmed. This work is supported by 2 grants of GrantAgency of the Czech Republic, number 106/030958 and 106/0304464.

P4-031 The Dynamics of Gait Initiation inHumans

A. W. SmithThe University of Auckland, New Zealand

Background: The ability to safely initiate walking, thoughtaken for granted in healthy subjects, can pose significant prob-lems for subjects with neurlogic conditions such as Parkinson’sdisease. The aim of this study was to investigate the dynamics ofhuman gait initiation. Methods: 7 subjects were conveniencesampled for the study. Kinematic data were obtained using aVICON 370 Motion Analysis System. AMTI (2) and Kistler (1)force platforms were used to obtain force data. Two strides onthe right side (R1, R2) and one left stride (L1) were analysed.The study used a 33-marker full-body model. Subjects steppedonto the AMTI force platforms, waited at least 3 s, and steppedforward beginning with R1, and walked for several steps. Dataanalyzed included joint kinematics, moments of force, and



powers. Multiple trials within-subjects were averaged, with themeans used to calculate between-subject average patterns. Re-sults: R1: Joint kinematics demonstrated recognizable patternsmostly in the swing phase. Hip moments showed an abductorpattern initially as weight shifted to the left leg in anticipation oftoe-off. Data revealed a hip pull-off rather than ankle push-off.L1: The patterns of joint kinematics and kinetics were very simi-lar to steady-state walking, particularly from midstance throughto swing. R2: Joint dynamics were virtually indistinguishablefrom those found in normal steady-state gait, indicating howquickly normal gait emerged. Variability of kinetic variableswas substantially smaller as compared to R1. Conclusion: Thisstudy demonstrated the transition from quiet standing to steady-state walking. In addition, both joint kinematics and kineticsdemonstrated normal steady-state gait patterns on the 2ndstride of the leading leg.

P4-032 Lower Extremity Joint Stiffness inBalance Control

A. W. Smith,1 M. E. Trew,2 and A. Holden3

1The University of Auckland, New Zealand;2University of Brighton, United Kingdom;3University of Limerick, Ireland

Background: Hypotheses related to the role of joint stiffnessin balance control have created some controversy in recentyears. The proposed mechanism has challenged long-held be-liefs of how human control standing balance. The purpose ofthis study was to examine the role of joint stiffness in a balancetask under 2 visual and 2 support conditions. Methods: 7 sub-jects were convenience sampled for this study. Data were ob-tained using a Vicon 612 system and a Kistler force platform.Stiffness data were calculated from a linear regression of swaymoments of force on sway angles, with R calculated to deter-mine goodness of fit to a linear spring model. Subjects stood for30 s under combinations of 2 visual conditions (eyes open, eyesclosed) and 2 support conditions (1-legged, 2-legged). Multiplewithin-subjects trials were averaged with the means used to cal-culate between-subject average patterns. Results: Joint stiffnesswas significantly greater for AP sway as compared to ML sway,as well for 2-legged versus 1-legged stance. There was no signif-icant effect of vision. There were also significant interactionsbetween support and plane, and vision and plane, both due toML data. R data had significant main effects for plane (AP > ML),support (2-legged > 1-legged) and vision (open > closed). Also,there was a significant interaction of plane and support (due toML). Conclusion: The stiffness data from this study fell into arange similar to previously published data and indicated thathigher stiffness is seen in AP sway. Modeling the hip ab/adduc-tors (ML) and ankle dorsi/plantarflexors (AP) as linear springsseems reasonable, although the ankle muscles fit this modelbetter than the hip muscles.

P4-034 Estimation of Musculotendon Lengthand Moment Arm on Elbow Flexor Muscles byGeometric Modeling

L. Li and K. Y. TongThe Hong Kong Polytechnic University, Hong Kong

Background: Biomechanical modeling can provide bothqualitative and quantitative insights into the neuro-

musculoskeletal system and estimate the musculotendon pa-rameters that describe a skeletal muscle’s force-generatingproperties. Methods: A generic interactive graphics-basedmodel of the elbow joint and attached elbow flexors was devel-oped. A healthy volunteer joined this study. The subject wasseated in the chair, with the dominant arm placed in a horizon-tal plane at the same height of the shoulder and the shoulderwas in 90° abduction and 0° flexion. A B-mode ultrasonographyscanner was used to find the muscle origin and insertion posi-tion, and a mechanical 3-D digitizer combined on the ultra-sound probe was used to obtain the coordinates of the musclesattachments points. Musculotendon length (lmt) was deter-mined by computing the sum of the lengths of the line segmentsfrom the origin to the insertion of the muscle, and moment arm(MA) was computed as the partial derivative of lmt. Results: Thecurve of lmt and MA with different elbow joint angles for 1 ofthe elbow flexors, brachialis muscle, was plotted. The resultswere similar with the literature reports on normal subjects. Con-clusion: Geometric model of elbow joint and attached musclescould provide dynamic information of musculotendon complexwith joint angle. Estimation of the musculotendon parameterscould be used to further understand the musculoskeletal inju-ries of pathologic subjects and customization of rehabilitationprogram.

P4-035 Difference between Static and DynamicMeasures of the Efficacy of the Paretic Leg inBalance Maintenance

E. H. F. van Asseldonk,1 J. H. Buurke,2 B. R. Bloem,3

F. C. T. van der Helm,1 and H. van der Kooij11Institute for Biomedical Technology, theNetherlands; 2Roessingh Research andDevelopment, the Netherlands; 3University MedicalCentre St. Radboud, the Netherlands

Background: Regulatory activity in the paretic andnonparetic leg of stroke patients is typically determined withcenter of pressure (CoP) movements obtained from force platesduring quiet stance. In this approach, the regulatory activity isnot evaluated with respect to its efficacy in maintaining bal-ance. This study assessed the necessity of relating the generatedactivity to balance performance for a precise estimation of thecontribution to balance maintenance. Methods: 9 chronic strokepatients participated in the study. The static balance contribu-tion (SBC) of the paretic leg during quiet stance was determinedby dividing the root mean square of the CoP velocity(RMSVCoP) by the sum of the RMSVCoP of the paretic and non-paretic leg. The dynamic balance contribution (DBC) of the pa-retic leg was determined by using a system-identification tech-nique to relate its generated ankle torque to the swaymovements obtained during quasirandom platform perturba-tions. The SBC and DBC were both expressed as fractions. Re-sults: For all patients the static as well as the dynamic balancecontribution was significantly smaller (P < 0.001) in the pareticas in the nonparetic leg. Furthermore, the SBC was significantly(P < 0.10) larger as the DBC. Conclusion: Although easily appli-cable in a clinical setting, use of the SBC leads to an overestima-tion of the contribution of the paretic leg. For a more precise es-timate, the generated activity has to be related to the balanceperformance.



P4-036 Contribution of the Paretic andNonparetic Leg to Balance Maintenance in StrokePatients

E. H. F. van Asseldonk,1 J. H. Buurke,2 B. R. Bloem,3

F. C. T. van der Helm,1 and H. van der Kooij11Institute for Biomedical Technology, theNetherlands; 2Roessingh Research andDevelopment, the Netherlands; 3University MedicalCentre St. Radboud, the Netherlands

Background: Restoration of the efficacy of the paretic legand compensation in the nonparetic leg can both contribute toimproved balance maintenance during stroke recovery. Thisstudy presents a new approach to differentiate between both byquantifying the contribution of the paretic and nonparetic leg tobalance control. Methods: 8 chronic stroke patients participatedin the study. Balance responses were elicited by continuousplatform movements (forward-backward) that consisted of amultisine signal. Body sway as well as the ground reactionforces of each foot was measured. Based on the system-identifi-cation technique, the relative contribution per leg to the totalamount of generated corrective torque to correct body swayand maintain balance was calculated. Results: All patientsshowed a relatively smaller balance contribution of the pareticleg (P < 0.05). This asymmetry did not correspond to the asym-metry in weightbearing. The balance contribution of the pareticleg was consistently smaller than its contribution toweightbearing but showed no correlation. Conclusion: The pre-sented approach objectively quantifies the contribution of eachleg to overall balance maintenance. Application of this methodin longitudinal surveys of balance rehabilitation in stroke pa-tients makes it possible to differentiate between restoration ofthe affected leg and compensation in the unaffected leg. Suchinsights will be critical for the development and evaluation ofrehabilitation strategies.

P4-037 Physical Therapists’ Perceptions andUtilization of Medical Imaging Informationin Practice

R. T. Lazaro1 and T. L. Little2

1Samuel Merritt College, USA; 2University of thePacific, USA

Background: To gather information about physical thera-pists’ perceptions and utilization of medical imaging informa-tion in clinical practice. Methods: 300 physical therapists wererandomly selected. A survey questionnaire was developed andsent to these physical therapists. Of the 300, 120 completed andreturned the surveys. The questionnaire contained demo-graphic information questions and items regarding their per-ceptions and utilization of medical imaging in practice. Datawere then transcribed to spreadsheets for analysis. Results: De-scriptive statistics were generated for both demographic infor-mation and items pertaining to perception and utilization ofmedical imaging in practice. Survey results indicate that physi-cal therapists recognize the value of medical imaging informa-tion. However, availability of the information (both reports andimages) is limited all across practice areas. Therapists also al-lude to a lack of knowledge regarding the interpretation ofmedical imaging information for use in practice. Conclusion:

The results indicate that although therapists perceive that thistype of information is important, they have limited knowledgeabout how to interpret this information and utilize it to improvepatient care. Furthermore, access to medical imaging informa-tion is limited, and overall utilization of information from medi-cal imaging studies among physical therapists is low.

P4-039 Roles of Opioid Receptors in HyperalgesicEffect of Low Doses of Morphine

N. Askari,1 A. Haeri Roohani,2 and A. Ahmadiani21Shahid Beheshti University of Medical Sciences,Iran; 2Faculty of Science, Tehran University, Iran

Background: A growing body of evidence suggests that ex-tremely low doses of morphine enhance sensitivity to pain(hyperalgesia). Three opioid receptor classes are generally rec-ognized. In this study, we tried to determine which opioid re-ceptor(s) is involved in hyperalgesic effect of morphine. Meth-ods: Agonists specific for mu, kappa, and delta opioid receptors(Damgo, U50, and Dadle) were injected intraplantar 10 min be-fore formalin injection, and the resultant nociceptive behaviorwas assayed in the formalin test for 50 min (50 mcl formalin2.5% i.pl). Results: Intraplantar low dose of morphine (0.01mcg/paw), damgo (1 mcg/paw), dadle (0.01 mcg/paw), andU50 (1 mcg/PAW) before formalin injection (10 min) had no sig-nificant effect on the nociceptive behavior in phase 1 of the for-malin test. During the phase 2, morphine and other opioidagonists produced hyperalgesic effect (P < 0.01 and P < 0.05, re-spectively). Conclusion: The results demonstrate the ability ofmu, kappa, and delta opioid receptor agonists to mediatehyperalgesia during the 2nd phase of the formalin test.

P4-040 Treatment with Low-FrequencyElectromagnetic Field: Possibility of SymptomsImprovement in MS Patients (Pilot Study)

S. R. DracaClinic for Rehabilitation, Serbia and Montenegro

Background: The existence of the brain’s magnetic field,and the difference between the magnetic profile of the normalv. pathologic brain has been known from the classic work ofCohen from 1972. A low-frequency electromagnetic field (EMF)might have a broad spectrum of experimental and clinical po-tentials, including alteration of lymphocyte activities, inductionof stress genes, enhancement of nerve regeneration, and im-provement of some clinical symptoms. Methods: A total of 7 pa-tients with clinically definite multiple sclerosis (MS) weretreated with pulsed low-frequency (4-8 Hz) EMF in the 0.5 mTrange, for 20 min/d. Each patient received 20 applications. Amagnetic pulsing device was placed over the spinal column atthe low cervical level. A set of tests (EDSS, FIM, quality-of-lifequestionnaire) was used to evaluate MS disease before and afterthe treatment. Results: After 20 applications, the patients experi-enced the alleviation of some symptoms, including a prolongedreduction of hand tremor and chronic fatigue level, and im-provement of mood, with important effect to activities of dailyliving. A therapy had no effect on spasticity, bladder control,diplopia, and weakness of the legs. Conclusion: This pilotstudy, albeit small in number of patients, supports our furtherclinical investigation on potentially beneficial effects of low-fre-quency EMF in MS patients. The controversy derives from the



lack of knowledge of the mechanism of action; thus, furtherinvestigations are necessary.

P4-041 Seeing and Feeling My Hand Movement:Visuokinesthetic Perceptual Functions in theHuman Left Cerebellum

N. Hagura,1 Y. Oouchida,1 Y. Aramaki,2 N. Sadato,2

and E. Naito1

1Graduate School of Human and EnvironmentalStudies, Kyoto University, Japan; 2Department ofCerebral Research, Psychophysiology Section,National Institute for Physiological Sciences, Japan

Background: How do humans combine kinesthesia and vi-sion to perceive limb movements? We addressed this questionby conducting behavioral and neuroimaging experiments.Methods: Right-handed normal volunteers experienced illusoryhand flexion movements elicited by tendon vibration whilethey viewed their videorecorded hand flexion (CONGRUENT)or extension (INCONGRUENT) motions. Results: Illusory expe-riences were behaviorally modulated by the visual velocities ofhand motions only in the CONGRUENT tests. The 1st fMRI studyrevealed that only in the CONGRUENT condition, the left cere-bellum, which is never activated when ‘blindfolded’ subjectsexperience illusions, was recruited in a lateralized manner, andits activity showed enhanced coupling with activity in the rightparietal cortex. Another fMRI study showed that the left cerebel-lar activity reflects visuokinesthetic perception of hand move-ment. Conclusion: The left cerebellum participates in the high-order multisensory integration of kinesthesia and vision to per-ceive limb movements. The left cerebellum, in concert with theright cerebral cortex, may compute neuronal representations ofhuman dynamic body images.

P4-042 Analysis of Twist and 0.05-ms Intensitiesof I/t Curves in Predicting Prognosis of FacialParalysis

X. L. Wang, T. Y. Jiang, Y. M. Gao, and Guo YanmeiPLA General Hospital, China

Background: The 0.05-ms intensities and twists of I/t curveswere analysed statistically in an attempt to generate a prognosisfor facial paralysis. Methods: 181 cases (171 Bell’s palsy and 10Hunt’s syndrome) aged 15 to 79 years were included in ourstudy. The I/t curves of frontal muscles and the upperorbicularis were examined. The recovery time of the frontalmuscle and orbicularis were evaluated by raising the eyebrow.This and the House-Brackmann Scale were used to assess pa-tients’ course of recovery from the disease. Results: The differ-ences in recovery time of the frontal muscle and orbicularis be-tween the twist and nontwist I/t curves and between the sexeswere not significant. When the 0.05-ms intensities of the I/tcurves were classified into slight, moderate, and severe sub-groups, the differences in recovery time of the frontal muscleand orbicularis between the groups were not significant. Nei-ther were the differences between the twist and nontwist I/tcurves. Twist rate in the I/t curves was highest in moderatefacial paralysis and 2nd highest in the orbicularis in cases ofslight paralysis. The 0.05-ms intensities of the I/t curves had avery significant relationship with the recovery times of the fron-

tal muscle and orbicualris. Conclusion: The 0.05-ms intensitiesof I/t curves can play a very important role in indicating nerveinjury degree and predicting facial paralysis.

P4-044 The Hemiparetic Shoulder: AnElectromyographical Study of Motor Controlduring Active Abduction and Flexion

B. S. Rajaratnam,1 C. H. J. Goh,2 P. V. Kumar,2

and N. Venketasubramanian3

1Nanyang Polytechnic, Singapore; 2NationalUniversity of Singapore, Singapore; 3NationalNeuroscience Institute, Singapore

Background: After stroke, scapulohumeral rhythm may becompromised. This biomechanical experimental study aims toquantify motor recruitment patterns adopted by subjects withhemiparesis when they perform everyday upper limb activities.Methods: Fifteen 1st-time adult stroke survivors who could per-form active shoulder abduction and flexion were recruited. Sur-face and fine-wire electrodes were placed on 7 muscles overtheir afflicted and contralateral shoulders as they performedthese actions in a sitting position. Electromyography and kine-matic data during the range of motion were collected and com-pared with 9 aged-matched asymptomatic subjects. Resultswere correlated with WOSI, Neers, Hawkin, and apprehensiontests values. Results: There was a significant difference in meanonset of ipsilateral upper trapezius and its peak action duringperformance of both actions between the 2 groups. Delayed on-set of ST muscles and early peak action of GH muscles were ob-served among the experimental group. Correlations existed be-tween posterior deltoids and ipsilateral upper trapezius,serratus anterior, and infraspinatus, and biceps andsupraspinatus were present. Linear relationship was identifiedbetween altered motor patterning and joint dysfunction at theglenohumeral joint after stroke. Conclusion: Inappropriate mo-tor patterning may place the hemiplegic shoulder at risk of com-mon shoulder instability symptoms including subacromialimpingement and rotator cuff tears if not properly identifiedand rehabilitated early.

P4-045 TC-ECD Brain Perfusion SPECT of aPatient Developing a Pusher Syndrome afterPosterior Cortical Atrophy

C. Lafosse,1 M. Troch,1 L. Vereeck,1 and P. Santens2

1Rehabilitation Clinic Hof ter Schelde, Belgium;2University Hospital Ghent, Belgium

Background: In this study, a follow-up examination of a 55-year-old woman with bilaterally asymmetric posterior corticalatrophy (R > L). Since February 2001 she developed a pushersyndrome. A 99M-TC-ECD brain perfusion SPECT was per-formed in March 2001, and at that moment, contraversive push-ing was clearly present, and it was compared with a SPECT ofSeptember 1999. Methods: Age-matched semiquantificationanalysis was performed on the brain perfusion SPECT. Results:Age-matched semiquantification analysis confirmed the asym-metrical biparietal hypoperfusion with the right hemispheremore affected. At the onset of her pusher syndrome, the SPECTof March 2001 revealed a significantly increased hypoperfusionin the right parietal cortex, the cingulated gyrus and in the left



temporal lobe in comparison with the SPECT of September1999. Conclusion: This is the 1st functional brain image of a pa-tient with a pusher syndrome. Our results correspond with re-search indicating that damage to the right parietal cortex candisrupt the higher order neural construction of an egocentricbody-centered coordinate system for locating the origin of thespatial axis to the body seen in patients with a pushersyndrome.

P4-046 The Relationship of Cerebral Lesion Sizeand Site Outside Lateral Ventricle with MotorRecovery Level after Rehabilitation

X. L. Wang, H. Y. Xiao, T. Y. Jiang, and H. M. JiPLA General Hospital, China

Background: The relationship of cerebral lesion size andsite outside lateral ventricle with motor functional recovery af-ter rehabilitation was explored in our study. Methods: 17 casesincluding 16 cases with cerebral infarction and 1 case with trau-matic brain softening, 11 men and 6 women at the age of 26 to69 years, were chosen from 126 stroke cases in our study by thestandard criterion. Results: The good recovery of motor toBrunnstrom VI level in 4 months postonset was found in pa-tients with the lesion of 28.5 ± 61.4 cm3 posterior edge 0.8 cmfrom the frontal line outside lateral ventricle. In patients withmiddle part lesion of 4.1 ± 1.5 cm3 posterior edge 0.8 to 1.0 cmfrom frontal line, the motor got to Brunnstrom VI level from 9months to 1 year and 4 months. Two patients with the lesion of1.9 ± 1.3 cm3 posterior edge 1.3 to 1.6 cm from frontal line re-covered to Brunnstrom VI, respectively, by 9 months and 3years. Two sequelae patients with the lesion of 7.9 ± 0.4 cm3

posterior edge 0.4 to 2.0 cm from frontal line have BrunnstromV in hand by 1 year and 7 months, and Brunnstrom V in handand lower extremities by 1 year and 8 months. The patients withthe lesion of 21.3 ± 12.3 cm3 posterior edge 1.8 to 3.3 cm fromfrontal line have marked hemiplegic gaits. Conclusion: The pa-tients with the anterior part lesion outside lateral ventricle havea good motor recovery and with the posterior part lesion havedifferent motor recovery levels dependent on the lesion sizes.

P4-047 Effect of Contact and Slip Action on NerveCuff Signals

L. Li,1 K. Y. Tong,1 and J. Cao2

1The Hong Kong Polytechnic University, HongKong; 2The Fourth Military Medical University,China

Background: The implantable neuroprosthesis aims to con-trol through functional electrical stimulation (FES) and to pro-duce functional movement in the weak or paralyzed muscles.The objectives of this study are to develop a system with cuffelectrodes implanted on the tibial nerve of the cat’s hindlimb torecord nerve signals and stimulate ankle extensor muscles togenerate the extension force in the ankle joint. The relationshipbetween stimulation characteristics and the generated force onthe slip action was also studied. Methods: Three cats with samesex and similar weight were used as the animal models for thisexperiment. Cuff electrode was implanted on the tibial nerve ofthe cat’s hindlimb to record electroneurogram (ENG) signal. Bi-polar intramuscular stimulation electrodes were implanted intomedical gastrocnemius, lateral gastrocnemius, and soleus to ap-ply FES and get ankle extension. Force transducer was fixed un-der the pad of the cat to record the contact force. Results: With

the increase of the simulation level, the contact force was in-creased and the effects on the slip signals with differentcontacted force could also be found after filtering the artifacts ofEMG signal and stimulation. From the synchronized ENG, forceand position signal, it could be observed that the nerve signalchanged with contacted force and slip force accordingly. Con-clusion: The nerve signal obtained in the experiment could beused to further understand the FES effects on the nerve signalsunder the grasp and hold action on the limb.

P4-048 Age-Related Differences in ResponseRegulation as Revealed by Functional MRI

K. S. L. Yuen,1 J. X. X. Zhang,1 C. C. H. Chan,2 J. H.Gao,3 and T. M. C. Lee1

1Neuropsychology Laboratory, Department ofPsychology, University of Hong Kong, Hong Kong;2Laboratory of Applied Cognitive Neuroscience,Hong Kong Polytechnic University, Hong Kong;3Research Imaging Center, University of TexasHealth Science Center, San Antonio, Texas, USA

Background: Response regulation involves freeing oneselffrom habitual reactions to produce goal-relevant behaviors.Age-related changes in neural activation, in terms of volumeand/or pattern of activation during response regulation, remainunclear. The current study addressed the question with func-tional Magnetic Resonance Imaging (fMRI) technique. Methods:21 male subjects belonging to 2 groups, the younger and oldergroup (mean ages, 29.86 and 65.19 years, respectively) per-formed a Stroop-like task during fMRI scanning. They were firstasked to read the direction of arrowheads in the Go condition,followed by the Reverse condition, in which they were requiredto identify the direction of the arrowhead and then give the op-posite answer so that an “up” arrow should elicit a “down” re-sponse, and vice versa. Results: Behavioral data showed that theyounger group performed faster and more accurate than theolder group. Differential right frontal, right cingulate, and leftparietal activations were observed when we contrast the oldergroup with the younger group. Conclusion: Our work suggeststhat there seems to be age-related differences associated withresponse regulation in terms of behavior and brain activation.The underlying model of cognitive aging was further discussed.

P4-049 Relationship between the MotorActivation and the Power Generated duringBicycling—A Near-InfraredSpectroscopy (NIRS) Study

S. Ando,1 Y. Oouchida,2 I. Nambu,3 R. Osu,3

and E. Naito2

1Graduate School of Sports Science, OsakaUniversity of Health and Sports Sciences, Japan;2Graduate School of Human and EnvironmentalStudies, Kyoto University, Japan; 3ATRComputational Neuroscience Labs, Japan

Background: Recent NIRS allows us to measure brain activ-ity, even when humans perform whole-body movements. Herewe investigated the brain activity in the sensory-motor corticeswhile normal volunteers were bicycling. It was shown that theregional cerebral blood flow (rCBF) and blood oxygenation-level dependent (BOLD) signals in the sensory-motor areas in-crease in relation to the levels of forces generated by fingers.



Thus, we examined if the relative changes in the local hemoglo-bin oxygenation (Oxy-Hb) around foot/leg regions in the sen-sory-motor cortices also reflect the 4 levels of powers generatedby legs. Methods: We measured brain activity with NIRS aroundthe foot/leg regions in the sensory-motor cortices while 4 nor-mal volunteers were cycling the bicycling pedals with 4 levelsof workloads (40, 110, 180, 250 W). We adopted a 12-s on-offtype of block design. We evaluated the brain activity by averag-ing the Oxy-Hb 20 times for each workload condition. Results:The Oxy-Hb drastically increased during initial period of cy-cling in all conditions. The amplitudes of the initial increaseseemed to correspond to the load levels, and the amplitude wassignificantly higher in the 250-W condition than in the otherconditions. Conclusion: The Oxy-Hb measured by NIRS seemsto reflect the levels of powers generated by the legs. The NIRScan be a useful technique to examine the brain activity duringwhole-body movements.

P4-050 Navigated Brain Stimulation (NBS)in Neurorehabilitation

J. J. T. Karhu,1 M. Kononen,1 S. Maatta,1 K. Sandell,2

and P. Jakala2

1NBS Laboratory, Kuopio University Hospital,Kuopio, Finland; 2Dept. of Neurology, KuopioUniversity Hospital, Finland

Background: Transcranial Magnetic Stimulation (TMS) of-fers great potential to probe inhibition-excitation balance andconnectivity of human neural networks. Yet, despite 20 years ofexistence and thousands of research reports, only a fraction ofthis potential is in routine use. The situation is changing withthe recent technical advances in imaging capacity of themethod, as well as with the novel insights provided by TMS-in-duced neuronal responses. Methods: We have studied strokewith navigated brain stimulation (NBS), which combines TMSstimulation with accurate guidance by individual structural MRimages. Reactivity and connectivity of neuronal networks wereevaluated with EEG and EMG responses. Results: The prelimi-nary results in acute stroke suggest that repeated stimulation ofexactly the same cortical locations allows reliable follow-up oflocal changes during acute rehabilitation and recovery phase.Recovery-related changes in, for example, shortening silent pe-riods (SP) and in diminishing motor thresholds (MT) are readilydetectable. Conclusion: Recent advances in NBS are takingbrain stimulation to the verge of routine clinical use. For the 1sttime, it is possible to combine magnetic stimulation reliablywith other brain imaging modalities and reproduce scientificresults in clinical practice.

P4-051 Quality of Life in Case of NeurologicDisorders

A. Büttner,1,2 S. Latarnik,2 S. Rode,2 L. Seiffert,2

and H. Bennefeld2

1Klinik Ambrock, Klinik für Pneumologie,Allergologie und Schlafmedizin, Universität Witten/Herdecke, Germany; 2Heinrich-Mann-Klinik,Germany

Background: Apart from a multitude of physical complaints,neurologic disorders can also lead to forms of mental illness,and the latter to a reduction in quality of life (QoL) and in theability to subjectively perceive it. In such cases, different parts

of QoL may be affected. Important factors in this can be the se-verity of the disorder and the duration of prior therapy.Methods: The study was performed with 2 groups of randomlyselected persons, neurology patients and healthy persons. Allsubjects were selected according to their clinical diagnosis(ICD-10). So far, data have been gathered for 40 healthy persons(25 males, 15 females) and 132 neurology patients (76 males, 56females, with various neurologic clinical pictures), using a sam-ple of questionnaires, consisting of 4 questionnaires (amongwhich a patient questionnaire and a questionnaire concerningspecif ic domains of their quali ty of l i fe, MünchnerLebensqualitäts-Dimensionen-Liste). Results: Testing of QoL re-vealed a highly significant difference between healthy personsand neurology patients (P < 0.001). After 3 weeks of neurologicrehabilitation, the neurologic patients’ QoL improved to a sig-nificant degree (P < 0.001). Conclusion: The study revealed thatneurology patients showed problems and deficits concerningtheir quality of life. The degree of severity of the disorders(neurology patients) is relevant.

P4-053 Effects of High-Voltage GalvanicStimulation on Sleep and Health-Related Qualityof Life for Hemodialysis Patients

M. J. Kao,1 M. W. Tsai,2 C. C. Huang,3 Y. W. Cheng,3

and M. D. Chung3

1Taipei City Hospital, Chinese Taipei; 2NationalYang Ming University, Chinese Taipei; 3ChinaMedical University Hospital, Chinese Taipei

Background: Sleep and health-related quality (HRQoL) dis-turbances are common in hemodialysis patients. The aims ofthis study are to investigate the effects of FT-9000 high-voltagegalvanic stimulation (HVGS) on sleep and HRQoL forhemodialysis patients. Methods: We collected subjects from ahemodialysis center. All of them received a total of 12 weeks’HVGS therapy for 20 min each time and 3 times per week. Theassessments including basic blood cell count and biochemistry,SF-36 health survey, and the Pittsburgh Sleep Quality Index(PSQI) were done 3 times at 1) pretreatment, 2) post-12 weekstreatment and 3) follow-up at 12 weeks after stopping treat-ment. Results: 12 of 19 patients (63.15%) had completed study aslong as 24 weeks. The mean age of these 8 men and 4 womenwas 54.83 ± 12.21 years. No statistical difference was found inblood cell count and biochemistry studies. The PSQI scoreswere different at pretreatment and posttreatment groups (17.17± 0.84 vs. 14.50 ± 1.62) (F = 3.52, P < 0.01). PSQI score improvedafter 12 weeks HVGS therapy. However, PSQI score of follow-up group (17.21 ± 1.14) returned to the level of the pretreatmentgroup (F = 22.2, P < 0.01). The SF-36 health survey showed sig-nificant differences posttreatment in physical function, bodilypain, general health, vitality, and role limitation-emotional (P <0.05). Conclusion: HVGS may be a modality to reduce the dis-comfort of hemodialysis and to raise the quality of life and sleepof these patients.

P4-054 Reliability of Balance Scales inMultiple Sclerosis

D. Cattaneo, F. Panzuti, and D. CaputoDon Gnocchi Foundation, Italy

Background: Multiple sclerosis (MS) is the most commonprogressive neurologic disease in young adults. Abnormalitiesin balance control are common findings in subjects with multi-



ple sclerosis. A reliable assessment of different aspects of bal-ance control system is necessary for the development of a reha-bilitation program for fall prevention. Methods: 18 patients withMS were assessed. The patients had to be able to stand in up-right position and to walk for 6 m. The following scales weretested: 1) Berg Balance Scale (BBS): The scale rates standingbalance. 2) Dynamic Gait Index (DGI): The scale measures dy-namic balance. 3) Dizziness Handicap Inventory (DHI): It quan-tifies the level of disability and handicap. 4) Activities-specificbalance confidence (ABC): The scale rates the patient’s per-ceived level of balance performance. To assess the test-retest re-liability, 2 consecutive assessments were collected by the samerater. To assess the interrater reliability of the BBS and DGIscales, patients were concurrently assessed by 2 raters. Results:Test-retest reliability: The intraclass correlation coefficients(ICCs) were 0.95 (BBS); 0.85 (DGI); 0.84 (DHI); 0.86 (ABC).Interrater reliability: The (ICCs) were 0.98. (BBS); 0.97 (DGI).Conclusion: The interrater reliability of the instruments provedto be satisfactory. Lower but acceptable results were obtainedfor the test-retest paradigm. The data obtained suggest thatthese scales are reliable tools for patients with MS.

P4-055 Restriction in Participation in ChronicNeurological Diseases

S. D’Alisa, S. Baudo, A. Mauro, and G. MiscioIstituto Auxologico Italiano, IRCCS, Italy

Background: The consequence of a chronic disease wasclassified by ICF in terms of human functioning and its restric-tions. The concept of participation replaced the term of handi-cap. London Handicap Scale (LHS) closely measures participa-tion. We investigated restricted participation in patients withmultiple sclerosis (MS), Parkinson’s disease (PD), and stroke(STK) to verify if the restriction is disease specific and which arethe determinant factors. Methods: Restriction in participationwas assessed by the LHS in 244 patients (MS = 95; PD = 58; STK =91). LHS explores domains of mobility, physical indepen-dence, occupation, orientation, social functioning, and eco-nomic self-sufficiency. Functional disability was scored by theFunctional Independence Measure; mood impairment was as-sessed by the Hospital Anxiety and Depression Scale. Results:Restriction in participation showed similar profile in the 3groups, for each domain of LHS, although physical independ-ence was significantly more limited in the STK group. Emo-tional distress was the most important explanatory variable forrestriction in participation in every domain of LHS, for eachgroup. Conclusion: Depression state is a crucial element forparticipation, affecting patients in getting around, social setting,or leisure activities. Restriction in participation seems to be in-dependent from the underlying neurologic process. Functionaldisability and mood disorders may independently contribute torestriction in participation in SM, PD, and STK patients.

P4-056 Three-Stage Rehabilitation Program onAcute Stroke Patients and Relevant Cost-Effectiveness Analysis

W. H. ChenShanghai First People’s Hospital, Shanghai JiaotongUniversity, China

Background: Stroke is the most common cause of disabili-ties that prove to be a huge burden to the individual person as

well as to society. This study, funded by National 10th FiveYears’ Project, is designed to investigate effects of 3-stage reha-bilitation program on acute stroke patients and analyze thecost-effectiveness. Methods: 70 cases of stroke patients were di-vided into rehabilitation training group (RT); 35 cases and con-trolled group (CT) and 35 cases in randomized block design.Both groups were given general internal medicine. Patients inRT group underwent 3-stage rehabilitation (Hospital-RehabCenter-Community/Family) at 12.2 ± 9.2th day; all patients wereevaluated by the same doctor with FMA, MBI, FCA, and NDSscale at admission (V0), 1 month (V1), 3 month (V2), and 6month (V3) after stroke. The detailed expense reports wereconcluded with the method of cost-effectiveness analysis. Re-sults: There was no significant difference between RT groupand CT group about the baseline and functional assessment atadmission. In FMA, FCA, and NDS assessment at V3, differencewas significant. By one score that FMA, MBI ,FCA and NDS im-proved, the direct medical cost was 322.12¥, 288.51¥, 399.39¥,1166.88¥ in RT group separately, whereas each item cost637.49¥,453.35¥,715.14¥,1911.22¥ in CT group, which was farmore than that spent in RT group. Conclusion: Three-stage re-habilitation program has favorable economic effects on strokepatients.

P4-057 Validation of the Perception of ControlScale (PCS)

I. Sinnakaruppan, P. G. Mattison, and A. McCaffertyDouglas Grant Rehabilitation Centre,United Kingdom

Background: Chronic illness such as MS is a significantsource of stress for many patients and carers. Treatment is lim-ited and ineffective; therefore, coping is an important part inmanaging the disease process. Clinical experience suggests thatsome good copers are effective in disease management,whereas some average or poor copers may get worse. Patientswith neurologic disorders can enter rehabilitation with varyingdegrees of disability and handicap and with differing levels ofcontrol and perceptions. Assessment of perception of controlcan enable therapists to tailor the course and style of therapy.Literature search showed no appropriate tool to assess this con-cept. A new measure was developed, and the reliability was es-tablished but it failed to correlate against measures of psycho-logic symptoms. The present study used a larger sample size tovalidate the scale. Methods: 115 MS patients attending for reha-bilitation for the 1st time were invited to complete 3 measures ofpersonality characteristics along with the PCS. Results: Signifi-cant correlations were found. Negative perception of controlcorrelated significantly with decreased dispositional optimism,decreased perceptions of self-efficacy, and increased hopeless-ness. Conclusion: The Perception of Control Scale is a reliableand a valid scale for use in rehabilitation of neurologicproblems.

P4-058 Establishing Reference Values for Readingand Desk Exploration Tasks

M. Freimüller, V. Tomantschger, A. Rupitz, B.Beyweiss, and K. FheodoroffGailtal-Klinik, Austria

Background: Right hemisphere damage often leads to uni-lateral neglect. The patient will fail to pay attention to the left



side of space. Visual exploration may be affected in varioustasks such as reading and desk exploration. Up to now, for read-ing and desk exploration, there are no reference values pub-lished. Therefore, we introduced appropriate tasks for readingand desk exploration to establish reference values for clinicaluse. Methods: 85 healthy subjects (39 male, 46 female) followedstandardized procedures for a desk exploration task (4-quad-rant scan) and 2 reading tasks. Time to perform the tasks wasmeasured and was related to 2 groups of male and female adults(younger than 60 years, older than 60 years). Results: In all 4groups, both reading tasks were performed in times shorterthan 2 min with almost no neglect-associated reading mistakes.Total time for desk exploration in the group younger than 60years was within 33 sec, and in the group older than 60, within54 sec. There was no difference in scanning time for the 4 quad-rants. Conclusion: In combination with other standardized ne-glect tests, specifically developed reference values for readingand desk exploration tasks may be helpful in detecting and dif-ferentiating neglect-associated reading mistakes and desk ex-ploration deficits and may be useful for setting up treatmentgoals as well as monitoring therapy effects.

P4-059 Assessing Unilateral Neglect with VirtualReality and Haptics: A Feasibility Study

J. Broeren,1 H. Samuelsson,2 K. StibrantSunnerhagen,1 C. Blomstrand,1 and M. Rydmark3

1Institute of Clinical Neuroscience—TheSahlgrenska Academy at Göteborg University,Sweden; 2Dept of Psychology at Göteborg University,Sweden; 3Institute of Anatomy and Cell Biology—The Sahlgrenska Academy at Göteborg University,Sweden

Background: We employ contemporary information andcommunication technology, i.e., VR, haptics and telemedicine,in our research to develop precise quantitative assessment toolsand training devices for neurologic impairments. The VR envi-ronment consists of a haptic semi-immersive workbench, inwhich we combine a visual display and haptic feedback tech-nology into a form in which the user looks and reaches into avirtual space. This gives the user the ability to interact with ob-jects by touching and moving their upper limbs. The aim of thisclinical trial is to evaluate whether the results of a neglect as-sessment with VR and haptics (the VR task) are equivalent to 2standard neglect tests: Star Cancellation and Baking Tray. Meth-ods: 8 patients and 8 controls were included in this study. Re-sults: The VR task had no disadvantages but some interestingadvantages as compared to the Star Cancellation test and Bak-ing Tray task. The VR task was able to record 1) search patternor strategy, 2) time and trajectory (length), 3) repeated targetpressure, 4) exact recording of the hand movements during thesearch. These measures are usually not recorded with standardinstruments. Conclusion: The results indicate that the VR taskwas as sensitive as the other 2 tasks. The quantitative measuresof movements may imply that this VR task represents a sensitivemeasure of more subtle impairments of the explorativeperformance in stroke patients.

P4-060 Determining Normative Cut Points for theRivermead Behavioural Memory Test in a NormalPopulation in Turkey

A. A. Kucukdeveci,1 S. Kutlay,1 S. Guzelkucuk,1

A. H. Elhan,1 and A. Tennant21Ankara University, Turkey; 2Leeds University,United Kingdom

Background: Rivermead Behavioural Memory Test (RBMT)was developed to assess memory function. It includes 12subtests, each assessing a different memory task such as re-membering name or face. For each subtest, a standardized pro-file (SP) score is produced based on subject’s performance onthe tasks of that subtest, then a screening score of 0 (fail) or 1(pass) is given according to pass rate from SP score. Aim in thisstudy was to adapt RBMT for use in Turkey by identifying andvalidating the scoring system for the Turkish adult population.Methods: After the translation procedure, 266 normal subjectswere assessed by the Turkish version of RBMT. Rasch analysiswas used to test internal construct validity. Initially, appropriatepass rates for SP scores were determined through ANOVA posthoc tests according to age, gender, and education. Then datawere analyzed to test the cut points for pass rates through differ-ential item functioning (DIF) analysis by the Rasch model. Re-sults: Post hoc tests identified homogeneous subgroups, show-ing the influence of age and education but not sex. Then passrates were adjusted to reflect significant differences observed inage and education. Data with determined pass scores were ana-lyzed. All subtests were found to fit the model (mean item fit,–0.260; SD, 1.213; person fit, –0.236; SD, 0.693). DIF was foundto be largely absent. Conclusion: Final pass rates of SP Scores ofRBMT are determined. Scoring system of RBMT for Turkishadult population has been validated.

P4-061 The Validity and Reliability of the TurkishTranslation of a Fatigue Severity Scale forMultiple Sclerosis Patients

I. Keser,1 K. Armutlu,1 N. Korkmaz,1 V. Sumbuloglu,2

and R. Karabudak3

1The School of Physiotherapy and Rehabilitation,Hacettepe University, Turkey; 2Department ofBiostatistics, Karaelmas University, Turkey;3Department of Neurology, Hacettepe University,Turkey

Background: The Fatigue Severity Scale (FSS) is the bestunidimentional scale for quantifying fatigue. The purpose ofthis study was to examine the validity and reproducibility of theTurkish translation of the FSS, to determine the internal consis-tency of the FSS and what variables affect FSS scores. Methods:Before applying the FSS, MS patients’ disability levels were de-termined using the Expanded Disability Severity Scale (EDSS)and their depression status was established with the Beck De-pression Inventory (BDI). The 1st and the 2nd FSS and BDI wereapplied with a 1-week interval. Seventy-two MS patients and 76healthy controls were included to this study. Results: Therewere statistically significant differences between MS patients’and healthy controls’ FSS1 and FSS2 scores (P < 0.001). Aftercontrolling for depression, FSS scores were lowered but still



there was a significant difference between MS patients andhealthy subjects (P < 0.001). There was no statistically signifi-cant difference between the 1st and 2nd interviews for FSS (P =0.719). Internal consistency for the FSS was ICC = 0.89 (P <0.001). Crombach alpha for the FSS1 was 0.89, wheras for FSS2,it was 0.94. EDSS scores (P < 0.05) and BDI scores (P < 0.001)had significant effects. Conclusion: This study reports the re-sults of an evaluation of healthy adults’ and MS patients’ subjec-tive fatigue registered by a Turkish translation of the FSS. TheTurkish translation of the FSS was shown to be reliable andvalid.

P4-062 The Written Narrative Discourse inAlzheimer’s Disease: Informative Content Focus

K. Z. Ortiz, C. S. Miranda, G. C. P. De Luccia,and P. H. F. BertolucciUniversidade Federal de Sao Paulo, Brazil

Background: The discourse in patients with Alzheimer’s dis-ease (AD) shows lexicosemantic impairment and reduction ininformation content. Recent studies have found written mea-sures could be more sensitive indicators of the language dys-function in AD. The aim of our study was to examine informa-tive content of written narrative in mild and moderate AD.Methods: 3 groups, consisting of a total of 40 subjects, partici-pated in the study: 20 patients with a diagnosis of probable AD(10 mild and 10 moderate) and 20 healthy elderly persons, allwith 8 or more years of education. The written narratives wereassessed using the Boston Cookie Theft picture descriptiontask, and the informative content was quantified using informa-tion units (IU). Results: We found that the disease was associ-ated with a decrease in the IU, comparing patients and controls,and that the increasing disease severity was associated with adecrease in the IU with a parallel reduction in microstructure,selection process impairment, difficulty with coherency, andwritten narrative facts organization compared with healthy el-derly control. Conclusion: This study demonstrates the impair-ment of written discourse in early AD. The AD patients show im-paired lexical access associated with a decrease in the IU and arelative increase in incorrect and/or irrelevant propositions. Inaddition, the IU reduction increased as the disease progressed.

P4-063 Development and Validation of a NewScale to Measure Self-efficacy in NeurologicRehabilitation

C. A. Young,1 G. Dixon,1 and E. W. Thornton2

1Walton Centre for Neurology & Neurosurgery,United Kingdom; 2University of Liverpool, UnitedKingdom

Background: Patients are expected to be proactive in theirrehabilitation, working with the team and practicing skills indaily life. Motivation is often thought to explain differing partic-ipation and outcomes. Self-efficacy is the belief in one’s abilitiesto perform given actions that can affect one’s life. It strongly in-fluences behavior and may help determine how motivated andproactive patients are in rehabilitation. Methods: Themes from24 semistructured interviews were used to construct draft scaleitems. After piloting and expert review, 91 patients (49 women)age 19 to 71 years diagnosed with stroke (38), traumatic braininjury (13), or other monophasic neurologic impairment (40)completed the new scale and the following validated measures:

Hospital Anxiety and Depression Scale, General Self-EfficacyScale, Dispositional Resilience Index, Multidimensional HealthLocus of Control Scale, Barthel Index. Results: A new 24-item,patient-derived scale was constructed, which has high internalconsistency (Cronbach alpha = 0.92) and content validity. Con-current and construct validity were confirmed by Spearmanrank correlations with general self-efficacy (0.63), depression(–0.63), hardiness (0.42), and internal locus of control (0.56).Principal components analysis revealed 3 factors. Conclusion:The new self-efficacy scale demonstrated good reliability andvalidity in young neurologically disabled patients. Such a mea-sure could be used to objectively evaluate the role of self-effi-cacy in rehabilitation and to improve services offered.

P4-064 Translation and Validation of theActivities-Specific Balance Confidence (ABC) Scalefor Use with Chinese Older Adults in Hong Kong

F. Law, C. Cheung, I. Wong, A. Lau, and M. MakThe Hong Kong Polytechnic University, Hong Kong

Background: Falls are among the most common and serioushealth problems in older persons. The Activities-Specific Bal-ance Confidence (ABC) Scale is a 16-item measure developed inCanada to assess the level of balance confidence in ambulatory,community-living older people. The aim of this study was totranslate the ABC Scale into Chinese and examine its utility withHong Kong older adults. Methods: Phase I was to translate thecontents of the ABC Scale into Cantonese. An expert panel re-viewed it for conceptual and cultural relevance and made modi-fications. Then forward and backward translation was done.Phase II was to test the psychometric properties of the ABC Chi-nese Scale, which included internal reliability (internal consis-tency, test-retest reliability, and interrater reliability) and inter-nal validity. Besides, the ABC Chinese Scale was used todetermine the level of self-perceived balance confidence ofcommunity dwelling older adult living in Hong Kong. Results:The scale had showed good conceptual and cultural relevancy,as well as high internal consistency, test-retest reliability, andinterrater reliability (Cronbach alpha coefficient = 0.97; ICC =0.99 and 0.85, respectively). A 1-dimension construct of self-perceived balance confidence was identified in the scale. Themean total score was 71.6 of 100, with mean item scores rangingfrom 48.4 to 89.9. Conclusion: The ABC Chinese Scale was dem-onstrated to be a reliable and valid measure in assessing bal-ance confidence of Chinese older adults in Hong Kong.

P4-065 Using the Mini Sun IDEEA ActivityMonitor to Detect and Analyze ActivitiesCommonly Performed in the Acute StagesPoststroke

D. Hyndman, A. M. Atzori, and A. M. AshburnThe Stroke Association Rehabilitation ResearchCentre, University of Southampton, United Kingdom

Background: The Mini Sun IDEEA activity monitor hasproved useful in the continuous measurement of physical activ-ity but has not been evaluated for use poststroke. We assessedits ability to identify activities that are commonly performedearly after stroke and suggest strategies for identification ofthese movements from the raw data. Methods: 11 healthy menand women (age, 28 to 56 years) performed a standardized setof activities twice, generating 22 data sets. We report the per-



centage of time Mini Sun correctly identified limb movements,postures, transitions, and gait. Results: Mini Sun correctly recog-nized limb movements, postures, and gait 98% of the time. Tran-sitions were less well recognized. From sitting, transition to ly-ing was recognized 86% of the time; to standing, 27% of thetime; and to sitting, not at all. Despite these limitations, wecould define each transition from the raw data giving the posi-tion and movement of the chest, legs, and feet. For example, wecan identify sitting transfers from an increasingly positive move-ment of the chest marker from a position in which all markersare in neutral. Conclusion: The Mini Sun accurately identifiedlimb movements, postures, and gait, but not transitions. Transi-tions may be identified through analysis of the raw data usingdescriptions of marker position and movement.

P4-066 The Applicability of Gait Analysis Systemas a Quantitative Outcome Evaluation for StrokeRehabilitation Patients

S. Y. Leung, Y. L. Ho, and F. M. SoTung Wah Hospital, Hong Kong

Background: Gait reeducation is vital in stroke rehabilita-tion. The aim of this study was to evaluate the change of gait pa-rameters of stroke patients during rehabilitation by using a newgait analysis system: the Computer Dyno Graphy (CDG). Meth-ods: 46 stroke patients, who were admitted for rehabilitation(May to July 2002) with Modified Functional Ambulation Cate-gory ≥5 who were able to follow command, were included.They received conventional physiotherapy training, 90 min/session, 5 to 6 d/week.Initial and predischarge assessments byCDG were used for analysis and evaluation. Results: Steptime:There were significant improvement in gait velocity (from 0.37± 0.23 to 0.51 ± 0.27 m/s, P < 0.05), gait frequency (from 74.0 ±25.45 to 82.80 ± 21.96 step/min, P < 0.05) and stride length(from 0.29 ± 0.11 to 0.36 ± 0.12 m, P < 0.05). Gaitline: The lengthof the affected side was improved from shorter than the norm towithin the norm. Of the patients, 39.1% were improved fromasymmetrical gaitlines to symmetrical ones. Cyclogram: Most ofthe patients improved with their single support of the affectedside ended at forefoot rather than at midsole initially. Thirty-seven percent of patients showed unstable gait within 1 step,but 41.2% of them showed progression afterwards; 47.8% of pa-tients showed more symmetrical cyclogram subsequent to train-ing. Conclusion: Using CDG for evaluation, objective, andquantitative gait parameters could be obtained. It is potentiallya good quantitative outcome measure for clinical service andresearch studies of stroke patients.

P4-067 Normative Data for Clinical Testing ofHandwriting Speed: Haid-Bonatti 1-20 Test

T. Haid, E. Bonatti, M. Kofler, A. Mayr, and L. SaltuariHospital Hochzirl, Departement of Neurology,Austria

Background: After consolidation, handwriting can be inter-preted as a sequence of automatized (“open loop”) movements.Various neurologic diseases may compromise this type ofmovement. A simple clinical test could be of diagnostic valueboth for neurologicl assessment and for monitoring therapeuticinterventions and outcome. Methods: We developed a test forevaluation of the speed of handwriting in the clinical setting,the Haid-Bonatti 1-20 Test (HABO 1-20). We asked 534 neuro-

logically healthy subjects, ranging in age from 20 to 85 years(50% over 60 years), to write numbers from 1 to 20 as quickly aspossible, before and after writing a short sentence. The speed ofwriting was measured with a stopwatch. Results: Median timeneeded in the 1st trial, HABO 1-20/1, was 14 s, and 13 s in the2nd trial, HABO 1-20/2. The 2 trials showed highly significantcorrelation (r = 0.929, P < 0.001). For the entire group of sub-jects, there was a significant correlation with age (r = 0.616 forHABO 1-20/1; r = 0.578 for HABO 1-20/2; P < 0.001 each).Therefore, we provide normative data for different age groups.Conclusion: The HABO 1-20 represents a simple and standard-ized test for the quantification of finely coordinated, automa-tized movements of the dominant writing hand in adults.

P4-068 Client-Professional Partnership withinan Outpatient Brain Injury Rehabilitation Unit:A Pilot Study

S. E. Chatterton, A. Graham, and J. HollowayFrenchay Head Injury Therapy Unit, UnitedKingdom

Background: During the past few years, there has been anincreasing emphasis on promoting the partnership betweenhealth care practitioners and service users, as a means of im-proving health care services within the National Health Service,UK. The interdisciplinary community team, at the Head InjuryTherapy Unit, Frenchay Hospital, Bristol, have embraced thisapproach, in their working practices, since 2002. Methods: Cli-ents at HITU have been involved not only in their rehabilitationremit but also in other working areas of professional-client part-nership, such as development of their own rehabilitation plansand focus groups, organizing social events both for the unit andpostdischarge, writing and producing informative newsletters,and generating a video about brain injury. A qualitative assess-ment of their involvement was made. Results: Using visual ana-log scales and qualitative feedback, clients reported improvedinvolvement in the rehabilitation process, greater understand-ing of brain injury and demonstrated more confidence in over-coming difficulties in meaningful real-life situations. Conclu-sion: By embracing a closer client-professional partnership,HITU have attempted to place the client more at the center ofthe rehabilitation process by using innovative working prac-tices. In this way, we have demonstrated increased client satis-faction and motivation as well as a greater involvement in theirrehabilitation process. This approach would appear to beworthy of further study.

P4-069 Quality of Life and Physical Activity inPatients with Chronic Neurologic Diseases

P. Targosinski, J. Grossman, and M. LypJozep Pilsudski Academy of Physical Education inWarsaw, Faculty of Rehabilitation, Poland

Background: Chronic disease is seen as negative effect bymost of the society. It impairs biological functions of the bodyand leads to permanent mental changes. Health becomes themost valuable worth and at the same time is recognized as themost important component of the quality of life. Integrating roleof motional activity is often not fully appreciated and under-stood. The experiment has been performed within the scope ofstatutory research (DS 80), financed from the Warsaw Academyof Physical Education funds. Methods: For determination of the



effect of disease on quality of life of people with chronic neuro-logic diseases and assessment of the importance of physical ac-tivity in their lives, 120 people with SM and Parkinson’s diseasewere examined. The study was conducted using P&P survey,quality of life, and physical activity of handicapped people. Re-sults: 94% of Parkinson’s disease and 100% of SM affects qualityof life negatively. Negative changes experienced in professionallife in 20% of Parkinson’s disease and 30% of SM. “Physical ac-tivity in my life is very important” was 83% in Parkinson’s dis-ease and 72% in SM. Most of the interviewees opined that phys-iotherapy and physical activity would have a positive influenceon improving health and quality of life (Parkinson’s disease,97%, SM, 84%). Conclusion: People function and feel betterwhen they live active physical life. Everyday physical activityshould be recognized as the basis of healthy living, especiallyamong persons with chronic diseases.

P4-070 A Study of Reliability and Validity ofSpinal Posture Measurement in Low Back PainPatients

N. H. Wang, B. Xie, C. Luo, R. L. Wang, and M. LiFirst Hospital, Peking University, China

Background: To explore the reliability and validity of spinalposture measurement in subjects with low back pain. Methods:55 healthy subjects and 42 patients with low back pain were in-volved in the studies of reliability and validity, respectively.Pneu-map was used to measure and record the data twice withboth the healthy subjects and the low back patients. Five param-eters, cervical curve, upper and lower thoracic curve, lumbarcurve, and spinal lean, were collected for correlation analysis inthe reliability study for patients with low back pain. These pa-rameters were also compared between the 2 populations. Re-sults: The intrareliability of spinal posture measurement in lowback patients was demonstrated to be high. The ICC valuesranged from 0.523 to 0.801. P values were less than 0.01. A sig-nificant difference was found in the spine posture measure-ments between the healthy subjects and the patients with lowback pain. Conclusion: Chronic back pain is not uncommon instroke patients. The study showed that spine posture measuredusing Pneu-map demonstrated reliability and validity in pa-tients with low back pain, and it may be useful as well for its ap-plication in the assessment of stroke patients with low backpain.

P4-072 The Relationship between Reaction Time,Mental Processing Speed and Motor Speed inPersons with Mild to Moderate TraumaticBrain Injury

K. N. K. Fong, M. K. L. Chan, and P. P. K. NgKowloon Hospital, Hong Kong

Background: This study explored the relationship betweenmental processing speed, movement speed, and reaction timein patients with mild to moderate brain injury and comparedtheir performance with that of healthy adults. Methods: 20 hos-pital outpatients with brain injury were recruited into group 1.Twenty healthy subjects with closely matched ages and educa-tional levels were recruited into group 2. All subjects were eval-uated by 3 measures for each domain: 1) reaction time(Lafayatte timer, Bruininks-Oseretsky response test, stimulusfield of Captain’s Log); 2) movement speed (Lafayatte timer, fin-ger tapping, Minnesota Dexterity Test); 3) mental processing

speed (trial-making, stimulus inhibition of Captain’s Log, Valparwork sample 7 [V7]). Results: Significant differences were notedbetween the groups in terms of the measures concerning rate ofwork, but not accuracy (P = 0.000 to 0.025). Rate of work in V7was moderately correlated in all domains in both groups. Errorsin V7 were negatively correlated to fast responses in reactionand movement times in group 2. Finger tapping was negativelyrelated with reaction time in group 2 only. Conclusion: Rate ofwork was significantly reduced for patients with brain injury,but not accuracy in information processing. The results indi-cated that a complex task such as V7 required abilities from alldomains. Fast responses would lead to errors in patients withbrain injury, and their thought needs to be strengthened in dailywork so that they might sacrifice speed to obtain correct results.

P4-073 Grip Force Analyzes in the Evaluation ofHand Function Deficits and InterventionOutcome

J. Hermsdörfer,1 B. Baur,1 and D. A. Nowak2

1Clinical Neuropsychology Research Group (EKN),Hospital München-Bogenhausen, Germany;2Department of Psychiatry III, University of Ulm,Germany

Background: Objective and sensitive measures are re-quested to precisely quantify hand function deficits and to fol-low progression of rehabilitation during interventions. Assess-ment scales typically base on subjective scoring or timemeasures, reflecting global performance but frequently obscur-ing causes for impairment. Methods: We developed methods toevaluate fine motor control by analyzing dynamic force produc-tion. Grip forces were recorded during manipulation of an ob-ject equipped with force and acceleration sensors. To measurepen grip force during natural handwriting, a pen was equippedwith a flexible 64-channel sensor matrix. Results: Analyses ofgrip forces indicated 2 dissociable aspects of force control, onerelated to background grip force level, the other to dynamicforce modulation according to changing physical loads. Bothaspects contribute to disability and may be differently affectedin different diseases of the CNS such as stroke, Parkinson’s dis-ease, peripheral deafferentation, or writer’s cramp. In the laterpatient group, pen grip force is a major determinant of the dis-ease. Successful intervention is reflected by modification of gripforces. Conclusion: Grip force measurements during object ma-nipulation and writing reveal objective, reliable, and sensitiveperformance data. Because typical tasks are highly overlearned,practice and measurement are fast. Analyses may reveal distinctcauses of impairments such as deficits in speed, strength,sensorimotor integration, or load anticipation.

P4-074 Selective Ankle Control in IncompleteSpinal Cord Injury

B. Wirth,1 H. van Hedel,1 and A. Curt21Balgrist University Hospital, Switzerland;2University of British Columbia, Canada

Background: Clinical assessment after incomplete spinalcord injury (iSCI) should distinguish between neurologic andfunctional recovery. This study examined the ability of iSCI pa-tients to perform alternating dorsi- and plantarflexion in a su-pine position aiming at differentiating between paresis and finecontrol of preserved muscle strength. Methods: Computer-gen-erated tones were presented to 15 iSCI subjects and 15 controls



in blocks of different frequencies (0.8-3.6 Hz at intervals of 0.4Hz). The subjects were instructed to follow the tones with thefoot as accurately as possible and with the largest range of mo-tion (ROM) possible. For each frequency, ROM (measured by agoniometer), accuracy, peak velocity, and a quotient of the timespent in the maximum 10% of dorsi- and plantarflexion weredetermined. Results: Performance of the controls differed at 2.0,3.2, and 3.6 Hz from the target frequency, that of the patientsfrom 2.0 Hz onward. ROM and peak velocities differed signifi-cantly at all frequencies between the groups. The time quotientshowed a clear tendency toward longer time spent inplantarflexion of the patients (significant at 1.6 and 3.2 Hz).Conclusion: By means of repetitive ankle movements, paresisand fine control of the foot can be differentiated. ROM and peakvelocity relate to muscle strength. Fine control focuses on thecontrolled switch between reciprocal muscle activation and in-hibition, which is a well-known problem in lesions of thecentral nervous system.

P4-075 Quality of Life in Adult People withNeurodevelopmental Disabilities: ShelteredWorkshop and Life Satisfaction

I. Yamazaki,1 C. Yamada,2 and H. Shimizu1

1Graduate School of Health Sciences, HiroshimaUniversity, Japan; 2Hayakawa Clinic, Japan

Background: Adult people with neurodevelopmental dis-abilities who live in community make use of various social re-sources, one of which is a sheltered workshop. One major needof these people is to work in society, which can lead to betterlife satisfaction and enhancement of quality of life. Rehabilita-tion for these people need long-term follow-up with main fo-cus on life satisfaction rather than partial improvement of mo-tor and/or intellectual functions. In this study, we investigatedthe sta te of l i fe sa t i s fac t ion in adul t people wi thneurodevelopmental disabilities who engage in work at a shel-tered workshop in Japan. Methods: 26 adult people withneurodevelopmental disabilities (cerebral palsy, progressivemuscular dystrophy, etc.) were interviewed based on the ques-tion items from the WHO Quality of Life Measure-Abbreviatedversion and an additional item on job satisfaction. Results: Sub-jects were relatively well satisfied with their life circumstances.Sheltered workshop was very important for their life as a mainresource of life and job satisfaction. Conclusion: Rehabilitationfor adult people with neurodevelopmental disabilities must fos-ter their life satisfaction by enabling them to engage in social ac-tivities. Job activities are one of those activities, and workingwith friends in the community-based sheltered workshop canenhance the qua l i ty of l i f e in adul t people wi thneurodevelopmental disabilities in the long run. More supportfrom social welfare system is also important for theirsocioneurorehabilitation.

P4-076 Environmental Factors Analysis Using ICFAffected in Function for Persons with DisabilitiesLiving in Community

W. Kim, K. Eunsoo, L. Jeongeun, L. Hyunjeong,and L. MijeongNational Rehabilitation Center, South Korea

Background: Recently, the WHO has suggested new classifi-cation family, ICF, with extended concept of disability. We wish

to search the clinical usefulness of ICF through correlation withICF and existing functional evaluating tools. And we examinedenvironmental factors related to performance and capacity.Methods: This study compared the healthy and disability condi-tions using the FIM, Barthel Index, and ICF in 108 persons whowere selected randomly among PWDs in Seoul. We coded envi-ronmental factors that affected function. The codes were usedup to the 2nd level of 74 items of ICF. Results: 1) The averagescore of FIM and Barthel Index of PWDs were 112.76 and 92.97,respectively, and the capacity and performance score of ICFwere 3.23 and 5.74, respectively. 2) There was a statistical corre-lation with FIM, Barthel Index, and ICF scores. Among them,most significant relation with FIM total score was performancescore of ICF (Pearson correlation coefficient, 0.843; P < 0.01). 3)The facilitators among ICF’s environmental factors were sup-port and relationships (51.9%), attitudes (45.8%). And most fa-cilitated domains among the 68 items were immediate family(66.77%) and health professionals (52.8%). 4) The most barriercomponents in ICF was product and technology (19.5%) andenvironment changes (15.5%). And most barrier items weree150 (design, construction, and technology of buildings forpublic use, 37%) and assets e165 (37.0%). Conclusion: We knowbarrier-free environmental construction and financial supportmight be the priorities of rehabilitation policy.

P4-077 Sensory Profile of the Poststroke Patientsbefore and after Intensive Rehabilitation

K. W. S. Chow,1 C. C. H. Chan,1 K. P. Y. Liu,1 L. S. W.Li,2 and C. W. Y. Hui-Chan1

1The Hong Kong Polytechnic University, HongKong; 2Tung Wah Hospital/The University of HongKong, Hong Kong

Background: Although sensory deficits caused by strokehave been reported occasionally, the sensory recovery in theirsubacute stage has seldom been studied. This study aims to ex-plore the frequency and modality of the impaired basic anddiscriminative sensation before and after conventional rehabili-tation. Methods: 58 inpatients in the rehabilitation wards wererecruited. The mean days between the stroke onset and the 1stand 2nd assessments were 13.1 and 31.6, respectively, duringwhich they underwent conventional physical therapy. The con-trol group was composed of 20 age- and gender-matchedadults. The assessment protocol included tests on basic (pin-prick, temperature, touch, and vibration) and discriminativesensat ions ( texture discr iminat ion, posi t ion sense,stereognosis, point localization, 2-point discrimination). Re-sults: In the 1st assessment, 93.1% of patients had a deficit in atleast 1 of the discriminative sensation. For the basic sensation,only 57.4% manifested deficit in at least one modality. Thirty-five patients participated in the 2nd assessment, in which 62.9%showed improvement in discriminative sensation. For the basicsensation, 52.2% of them showed improvement, and all had nodeficit in vibrotactile sensation. Conclusion: Our study showsthat the discriminative sensation was damaged considerably inpoststroke patients before and after the rehabilitation therapy.The preserved basic sensation in the patients with stroke indi-cates that treatment should be performed to facilitate thesensory recovery.



P4-078 Patient Partnership in Practice at theFrenchay Head Injury Therapy Unit: A Case Study

S. E. Chatterton, A. Graham, and J. E. HollowayFrenchay Head Injury Therapy Unit, UnitedKingdom

Background: Developing a partnership approach with pa-tients, within the rehabilitation process, is advocated in the cur-rent delivery of services to people with acquired neurologicconditions to improve motivation and rehabilitation outcomes.Methods: A 47-year-old woman was referred to the FrenchayHead Injury Therapy Unit, 1 year after a subarachnoid hemor-rhage. She presented with memory problems, high-level cogni-tive-communication difficulties, fatigue, and low self-esteemand confidence. A close collaborative patient-partnership ap-proach was used not only to identify areas causing limitations toa more meaningful life but also, for her, to take a significant rolein organizing her own rehabilitation goals. Results: Limitationsto a more meaningful life were mostly centered around the lossof identity and low confidence rather than her cognitive prob-lems. The agreed rehabilitation program included a strong em-phasis on activities selected to enhance her confidence and forher to be able to assume more responsibility. She achieved all ofher goals during an 18-month period (on average, patients atHITU achieve 75%), and furthermore, she has since set up andruns a social group for people with an acquired brain injury.Conclusion: Because she was very much in control of her goalsand was able to complete them, entirely, this helped herachieve an identity she can now value. It is suggested that, atleast in this case, a successful rehabilitation outcome wasachieved by allowing her to drive the process.

P4-079 Morphological Study of Cyclic AMPResponse Element Binding Protein PositiveNeurons of Hypothalamus after Ovariectomy inFemale Rats

M. S. ZhangGuangdong Provincial People’s Hospital, China

Background: To study morphologic changes of cyclicAMP response element binding protein (CREB) positive neu-rons in the preoptic area (PA) of hypothalamus followingovariectomy in female rats, and the relationship betweenCREB and GnRH in hypothalamic secretion. Methods: By usingimmunocytochemistric method, we observed the distributionsand cellular forms of CREB positive neurons in medical preopticarea (MPA) and lateral preoptic area (LPA) of hypothalamus andcounted their numbers. The quantitative analyses of theimmunoreactive production in the CREB positive neurons inMPA and LPA by an imaging analyzing system were undertaken.Results: 1) A plenty of CREB positive neurons were founded inMPA and LPA of hypothalamus in intact female rats. The profileof cell bodies of CREB positive neurons was clear and the stain-ing of the nucleuses of CREB positive cell was weak. 2) Thedensities of positive CREB neurons and the average optical den-sities (AOD) of positive CREB neurons exhibited more signifi-cantly increases both in the ovariectomy (OVX) 3 months groupand the OVX 6 months group than the intact group (P < 0.01). ()There were significant differences between the AOD or the den-sities of positive CREB neurons in the OVX 3 months group thanin the OVX 6 months group and in LPA than in MPA (P < 0.05-0.01). Conclusion: The quantity of CREB positive neurons in the

preoptic area of hypothalamus after ovariectomy are more thanthat of the control group in a long time.

P4-081 Acupuncture Effects on Acute Brain Injuryand Neuronal Plasticity in Adult Rats

D. Wang, S. Sun, and Z. SunHeilongjiang University of Chinese Medicine, China

Background: To study the effect of acupuncture in acutebrain injury and to investigate the feasibility of its application inthe early stages of such injury and its effects on postinjury nerveregeneration and neuronal plasticity. Methods: Moderate sever-ity of brain injury was established in rats by the fluid percussionmethod. The behavioral obstacles of the rats are dynamicallyobserved using walking and balance tests. Observations aremade on the extent of hematoma on the cerebral surface and HEstain. The putrescence rates of the injured side of the cortex andthe hippocampus are measured. The changes of brain watercontent were measured by the wet- and dry-weight methods.Immunohistochemistry ABC method and in situ hybridizationwere used to determine the immunoreactivity and mRNA ex-pression of SS and GAP-43. Results: Acupuncture increased thespeed of resumption of the movement functions. Furthermore,the effects were better when it was applied within 1 h ratherthan 3 d postinjury. It reduced secondary neuronal putrescenceand increased the immunity reaction of bFGF protein in thebrain. The therapy induced GAP-43 mRNA gene expression ad-justments upward and affected abnormal expression of SSmRNA postinjury. However, there was no significant effect onbrain hematoma, brain edema, and death rate. Conclusion:Acupuncture can relieve postinjury pathogenic conditions, im-prove regenerative conditions for the injured neural areas, andimprove the reconstruction mechanism of the of the brainfunction.

P4-082 Expression of Glial Cell Line-DerivedNeurotrophic Factor in Rats’ Spinal Cord after aComplete Transection

Y. M. Li, T. H. Wang, and L. J. AoThe Second Affiliated Hospital of Kunming MedicalCollege, China

Background: The application of glial cell line derivedneurotrophic factor (GDNF) in spinal cord injury (SCI) has beenextensively studied, but there is a lack of information about theexpression of endogenous GDNF after SCI. Methods: 50 SD ratswere randomly divided into 5 groups: normal control, SCI 3 d, 7d, 14 d, and 21 d group. Basso, Beattie, Bresnahan (BBB) score,somatosensory evoked potential (SEP) techniques wereadopted. Immunohistochemical staining and Western blottinganalysis with anti-GDNF antibody was also explored. GDNFimmunoreactivities in spinal cord were observed under micro-scope. Densitometric analysis was performed using bio-gelimagining and analysis system. Data were analyzed by 1-wayANOVA and LSD-q test. Results: BBB score was 0 postoperationand SEP was not recorded. Till 21 dpo, they did not change.GDNF-like immunoproduct was observed in motor neurons ofventral horn, neurons of intermediate zone, sensory neurons ofdorsal horn, and neural glial cells. It was distributed in the nu-clei and cytoplasm of neurons. Western blotting analysisshowed that the level of GDNF in rostral part slightly increasedat 3 dpo and then declined distinctly at 7 dpo. Till 14 dpo, it in-



creased again and reached a peak at 21 dpo. In caudal part, thelevel of GDNF protein decreased to the lowest extends at 7 dpoand increased at 14 dpo. Conclusion: After SCI, the expressionof GDNF in the rostral segments experienced transient up-regu-lation at 1st stage. In caudal segments, the expression of GDNFwas down-regulated in the 1st stage.

P4-083 Cortical Reorganization for ResponseRegulation in a Chinese Women with UnilateralThalamic Stroke Detected by Functional MRI

K. S. L. Yuen,1 T. M. C. Lee,1 H. L. Liu,2 L. S. W. Li,3

and C. C. H. Chan4

1Neuropsychology Laboratory, Department ofPsychology, the University of Hong Kong, HongKong; 2Department of Medical Technology, ChangGung University, Chinese Taipei; 3Tung WahHospital/The University of Hong Kong, Hong Kong;4Department of Rehabilitation Sciences, the HongKong Polytechnic University, Hong Kong

Background: Recovery after stroke can be prolonged wellpast the period of the evolution of acute structural changes.How the human brain reorganizes itself to compensate func-tional loss is uncertain. To address this question, we recruited afemale stroke survivor, DN, who presented a relatively well re-covery after a massive left thalamic stroke 6 years ago and ex-amined her brain activity during response regulation. Methods:We employed functional magnetic resonance imaging (fMRI)technique to assess brain activity during response regulation.Response regulation was assessed by the arrow task, in whichsubjects were asked to first identify the correct directions of ar-rowheads and then give the opposite answers. DN’s pattern ofneural activation was compared with healthy controls. Results:Although a consistent network of prefrontal-cingulate activa-tions was observed in both healthy control groups, significantand extensive activations in the left inferior frontal gyrus (BA45)and right medial frontal gyrus (BA9) were observed in DN. Nocingulate activity was observed. Conclusion: The differentialpatterns of neural activations possibly reflect brain reorganiza-tion of the neural circuitry responsible for response regulationafter DN recovers from the stroke. Although no cingulate activ-ity was observed, DN was able to perform the task in slow butaccurate manner. The mapping between DN’s behavioral per-formance and neural activity is further discussed.

P4-084 Glutamate Uptake in Hippocampal,Cortical, and Cerebellar Slices from Rats Treatedwith Atorvastatin, a HMG-CoA ReductaseInhibitor

C. L. Carqueja, R. V. Silva, E. Stroeh, and C. I. TascaUniversidade Federal de Santa Catarina, Brazil

Background: Glutamate is the major excitatory neurotrans-mitter in the mammalian central nervous system and partici-pates in many physiologic processes and cerebral functions. Ex-cessive release of glutamate leads to a process calledexcitotoxicity, which is involved with neuronal damage that oc-curs in traumatic or ischemic brain injuries. Glutamate uptakeby excitatory amino acid transporters terminates glutamate ac-tion in synaptic cleft. 3-Hydroxi-3-Methylglutaryl-Coa (HMG-CoA) reductase inhibitors (statins) are potent cholesterol-lowering drugs. Recent studies indicate that statins reduce the

incidence of stroke and protect cultured neurons fromexcitotoxic damage. We studied the effect of statin treatment onglutamate transport in rat hippocampal, cortical, and cerebellarslices. Methods: Male Wistar rats (60-90 d) treated withAtorvastatin 1 mg/Kg/d for 1 week were sacrificed by decapita-tion, and cortical, hippocampal, and cerebellar slices of 0.4 mmwere prepared. Slices were incubated with 100 µM L-[3H]-gluta-mate for 7 min to assess glutamate uptake. Results: Atorvastatintreatment enhances Na+-dependent glutamate uptake intohippocampal slices. In cerebellar slices we observed an en-hancement of Na+-independent glutamate uptake. Atorvastatintreatment did not affect glutamate transport into cortical slices.Conclusion: Atorvastatin treatment modulates glutamate up-take in rat hippocampal and cerebellar slices. This effect maycontribute to the neuroprotective properties of statins.

P4-085 The Influence of Hypoxia/Reoxygenationon Expression of AQP4 in Cultured Astrocytes

L. Gao,1 J. Feng,2 W. Han,2 and D. Fang2

1Rehabilitition Department of Beijing Hospital,China; 2Neurology Depatment of 1st hospital of JilinUniversity, China

Background: Membrane water transport is critically in-volved in brain volume homeostasis and the handicap of watertransport is the key of the pathogenesis of brain edema. Discov-ery of aquaporin-1 answered the long-standing biophysicalquestion of how water crosses plasma membranes. In humanaquaporin family, AQP4 is most abundantly distributed in theastrocytes that are specialized for water transport. It is likely toindicate a potential mechanism of the brain edema to investi-gate the relationship between brain edema and AQP4. Methods:The primary culture of astrocytes from cerebral cortices of new-born Wistar rats was the 1st step of our study. The next step wasto get the stable cells before the homogeneity of the cell popula-tions is confirmed by immunocytochemical examinations. Themodel of hypoxia and reoxygenation was replicated to observethe changes of AQP4 by immunocytochemiscal examinationsand Western blot. Results: The expression of AQP4 was de-creased by hypoxia in a time-dependent manner. Reoxyenationincreased the level of AQP4 as the control after 3 h and reacheda higher level at 6 and 9 h. Conclusion: Hypoxia alone did notdo serious harm to the cultured cells; at the same time, AQP4protein was found to have protective impact on astrosytes.When the damage became serious in reoxygenation, AQP4manifested harmful effect on astrocytes.

P4-086 Telerehabilitation—A New Model forCommunity-Based Stroke Rehabilitation

E. Hui,1 J. C. K. Lai,2 and J. Woo1

1The Chinese University of Hong Kong, Hong Kong;2The Evangelical Lutheran Church of Hong Kong,Hong Kong

Background: Stroke is a leading cause of death and disabil-ity. Studies have found community-based stroke rehabilitationto be cost-effective and improve function and mobility in strokesurvivors. However, such services are scarce in Hong Kong. Westudied the feasibility of using videoconferencing for commu-nity-based stroke rehabilitation. Methods: This was a prepostquasiexperimental design. Twenty-one poststroke patients (6-8per class) living at home participated in an 8-week program (1.5h, once a week) at a community center for seniors. The inter-



vention, including educational talk, exercise (lower limbstrength and balance), and psychosocial support, was con-ducted by a physiotherapist via teleconferencing. The Berg Bal-ance Scale (BBS), State Self-Esteem Scale (SSES), Medical Out-comes Study 36-Item Short Form (SF-36), and a knowledge testwere evaluated at baseline and after completing the program.Results: 19 subjects completed the program and significant im-provements were achieved in BBS (P < 0.001), SSES (P < 0.001),knowledge test (P < 0.001) and all subscales of SF-36. All sub-jects accepted the use of videoconferencing for delivering theintervention. Conclusion: The pilot study demonstrated the fea-sibility, efficacy, and acceptability of telerehabilitation for com-munity dwelling poststroke clients. Moreover, this collaborativemodel between hospital and community service sectors wasable to fill the important service gap.

P4-087 EMG-Triggered Movement Therapy (EMT)in Neurology Rehabilitation

A. Buettner,1 S. Latarnik,2 H. Remer,2 S. Rode,2

and H. Bennefeld2


Background: Lesions of the central nervous system lead toplegia and spasticity, both of which are targeted in neurologicrehabilitation. EMG-controlled myostimulation is a treatmentapproach to improve treatment effects achieved by conven-tional therapies. It induces electrical activity patterns via en-hancement of action potentials of a defined minimum intensity.The contraction of the respective muscles is induced by meansof electrical impulses. Methods: In our placebo-controlledstudy, we used all 2 methods of EMT (Automove AM 800, PeR-Y-Rehabilitator) in different patient groups in neurologic reha-bilitation. During admission to the clinic, all patients were se-lected according to their clinical diagnosis (ICD-10). So far, datahave been gathered for 23 Automove AM 800—triggered pa-tients (16 males, 7 females), 20 PeR-Y-Rehabilitator–triggeredpatients (16 males, 4 females) and 18 non-EMT-triggered pa-tients (11 males, 7 females). Results: The comparison of musclemobility revealed in a direction of significant difference be-tween the PeR-Y-Rehabilitator and non-EMT controls (P =0.054). The comparison of degree of power revealed in a direc-tion of significant difference between Automove AM 800 andnon-EMT controls (P = 0.082). Conclusion: So far, we found thefollowing effects: The study revealed that patients with EMT-triggered treatment show better relearning of muscle mobilityand degree of power. Automove AM 800 increased the degree ofpower and PeR-Y-Rehabilitator increased the muscle mobility.

P4-088 Instrumental Kinesiology Approach inNeurorehabilitation Follow-up

C. Pistarini,1 G. Maggioni,1 S. Quaglini,2 M.Marchioni,1 and A. Giustini31Fondazione Salvatore Maugeri Pavia, Italy;2Department of Computer Science and SystemsUniversity of Pavia, Italy; 3Fondazione SalvatoreMaugeri Montescano, Italy

Background: According to the severity of stroke sequelaeand to the presence of comorbidities (diabetes, hypertension,etc.), poststroke patients are admitted to an intensive or exten-sive rehabilitation treatment. Intensive rehabilitation means a

treatment of about 3 h/d, whereas extensive rehabilitation im-plies a longer (in time) but weaker treatment (about 90 min/d),with a hospital stay of about 2 months. After the hospital stay,there is a periodical treatment under an outpatient ambulatoryregimen. Methods: With the aim of fostering the home rehabili-tation, we propose the use of a kinesthetic garment (with piezo-resistive sensors) able to detect the upper limb posture andmovements. The garment, wireless connected with a personalcomputer (PC), is the basis of a system that will detect anymovements, providing alerts to both patients and physicians.Results: The instrument could be used during the final period ofthe hospital stay (in order to assess the exercises and PC datamanagement). After the training period, patient may continueprotocol at home. Conclusion: The advantage for the profes-sional is to maintain a link with his patients after discharge andto perform an effective follow-up (also for scientific purposes).The advantage for the health care establishment is an earlier dis-charge (savings costs and increasing turnover while maintain-ing quality). The patient’s most important benefit is the possibil-ity of continuing rehabilitation at home, improving quality oflife and compliance.

P4-089 A Wireless Brain Stimulator for StrokeRecovery Using ZigBee Protocol

Y. S. Yang, K. H. Kim, S. M. Lee, and N. G. KimChonbuk National University, South Korea

Background: Stroke is the 2nd most significant disease lead-ing to death in Korea. Electric stimulation therapy is supposedto help neural plasticity of the nerve tissues around diseased ar-eas in the brain. It may have high potential for stroke treatment,but there has not been so much research into electrical stimula-tion for stroke recovery as for Parkinson’s disease or epilepsy.This study developed a wireless variable pulse generator usinga widespread radio-frequency (RF) protocol known as ZigBeefor wireless control of the rehabilitation processes. Methods:The level of recovery is affected by the characteristics of thestimulating pulse, such as its polarity, amplitude, period, andpulse width. To find a suitable pulse shape, an electric nervestimulator was developed with a notebook PC and voltage-out-put hardware. A mono- or biphasic pulse can be selected, withvariations in the shape parameters. For wireless control of thestimulation, ZigBee was integrated into the electric stimulator.Results: The feasibility of the technique was validated by experi-ments with rats. A prototype implantable brain nerve stimulatorwas developed. Conclusion: The electric stimulator and thewide connectivity of ZigBee are supposed to enable the tele-rehabilitation of stroke patients by remote control of an im-planted stimulator via a wireless network.

P4-090 The Effect of Lower Trapezius Exercise onthe Motor Recruitment Pattern of UpperTrapezius and Cervical Erector Spinae duringComputer Work

W. C. Chan1 and P. Y. G. Szeto2

1Physiotherapy Department, Queen ElizabethHospital, Hong Kong; 2Department of RehabilitationSciences, Hong Kong Polytechnic University,Hong Kong

Background: This study aimed at investigating the effect oflower trapezius (LT) exercise on the motor recruitment patternof upper trapezius (UT) and cervical erector spinae (CES) dur-



ing typing task. Methods: It was a pre- and posttest experimentaldesign. Ten female professional computer workers (more than4 h computer usage daily) were recruited into the study. Theywere requi red to type for 15 min whi le sur faceelectromyography (EMG) was taken at 5-min intervals on themajor stabilizers (UT, LT, and CES, respectively) of shoulder-neck region. A standardized exercise protocol involving 10 rep-etitions of LT contractions was followed. Each contraction in-volved 10-s holding at 30% maximal voluntary contraction(MVC) and followed with 10-s rest. The contraction force wasmonitored and adjusted under visual biofeedback. After theprotocol, another 15-min typing was repeated with EMG re-corded in the same way, during which subjects were required tomaintain LT contraction at 30% MVC. Results: All subjectsshowed significant increase in LT EMG activities (P = 0.012) andsignificant decrease in CES EMG activities (P = 0.008), but nosignificant decrease in UT EMG activities (P = 0.313) in thepostexercise typing task. Conclusion: The LT exercise protocolcould significantly increase the LT muscle activity and decreasethe CES muscle activity during typing task. This result suggestedthat the LT exercise is a potentially useful strategy in the preven-tion and rehabilitation of people suffering from work-relatedneck and upper limb disorder.

P4-092 The Value of Clinical Symptoms and Signsin Predicting a Positive ElectrophysiologicDiagnosis for Carpal Tunnel Syndrome

K. J. Goh and C. T. TanUniversity of Malaya, Kuala Lumpur, Malaysia

Background: The value of the clinical diagnosis of carpaltunnel syndrome has been variable. The relationship betweenclinical features and a positive electrodiagnostic test differs indifferent study populations. We sought to determine the rela-tionship between clinical findings and electrophysiology in Ma-laysian patients and evaluate a model derived in the diagnosisof carpal tunnel syndrome. Methods: 160 patients with 250symptomatic hands not predefined clinically or electro-physiologically to have carpal tunnel syndrome were prospec-tively included in the study. Clinical features were evaluatedwith a standardized questionnaire and correlated with our labo-ratory’s electrophysiologic protocol for carpal tunnel syn-drome. Results: Using multivariate logistic regression, age, handnumbness, morning symptoms, relief with shaking, symptomdistribution involving all the fingers or the middle finger only,and pos i t i ve Pha len tes t cor re la ted wi th pos i t i veelectrodiagnosis for CTS. We developed a regression model us-ing the above variables, duration, and gender. The model, usinga cutoff score of 0.5, gave a sensitivity of 93.9% but a muchlower specificity of 48.1%. Conclusion: Using a statistical modelbased on clinical features had high sensitivity but only moder-ate specificity in predicting a correct diagnosis for carpal tunnelsyndrome. Electrophysiologic studies therefore remain impor-tant, especially in patients with atypical symptoms.

P4-093 The Evaluative Effect of InfraredThermography in Cervicicardiac Syndrome

J. Xiong, W. Yang, W. Liao, and S. ZhuZhongnan Hospital of Wuhan University, China

Background: To observe the evaluative effect of infraredthermography in cervicicardiac syndrome, a type of pain syn-drome. Methods: 66 patients with cervicicardiac syndrome were

recruited and randomly divided into an observed group of 36patients and a control group of 30 patients. Stellate ganglionblock was performed in the observed group in addition to thetraditional treatments, which included local injection and phys-iotherapy, whereas only traditional treatments were given to thecontrol group. Before and after treatment, both groups weremeasured by infrared thermography to observe variations oftemperature at the thermometric points: the neck point, shoul-der point, back point, the upper arm point, forearm point, andthe palm of the hand point. Results: After 2 courses of treatment,30 patients in the treatment group showed clinical improve-ment, as did 17 patients in the control group (P < 0.05). Regard-ing the thermometric points, 6 points were observed on bothupper limbs. In both groups, the differences in temperature ofthe 6 points were reduced after treatment with P < 0.01 in theobserved group and P < 0.05 in the control group. There werealso significant differences between the 2 groups (P < 0.01), ex-cept at the neck point (P > 0.05). Conclusion: Infraredthermography could be a useful supplementary method forevaluating curative effects in cervicicardiac syndrome. Thismethod would be of high practical value clinically.

P4-094 Rehabilitation Management of ProgressiveMultifocal Leukoencephalopathy Associated withhuman Immunodeficiency Virus Infection

M. R. BowmanSt Vincents Hospital, Australia

Background: Progressive multifocal leukoencephalopathy(PML) is a demyelinating disease of the central nervous systemcaused by the JC virus (JCV). It is often associated with humanimmunodeficiency virus (HIV) infection. The prognosis for sur-vival has improved with the introduction of highly activeantiretroviral therapy (HAART), and many patients now stabi-lize and survive for years. However, more than 50% of survivorswill have some residual neurologic deficit. The extent of dis-ability and the role of rehabilitation in the management of thiscondition are not well documented. Methods: A retrospectivereview of case records of 5 patients referred to the rehabilitationservice at an inner-city teaching hospital. Results: 5 male pa-tients were referred to the rehabilitation department, with amean age of 42.2 years. The mean time from diagnosis with HIVto presentation with PML was 11.4 years. The mean CD4 countwas 176. In each case, PML was diagnosed by clinical features,magnetic resonance imaging (MRI), and cerebrospinal fluid(CSF) JCV serology. Of the 5 patients, 2 made functional gainswith rehabilitation. The other 3 patients showed clinical deteri-oration and subsequently died. Conclusion: This descriptivestudy identifies rehabilitation issues associated with PML in HIVinfection. Our experience suggests that rehabilitation in thiscondition can improve physical function and quality of life.Careful patient selection is important to identify those with poorprognoses.

P4-095 Driving Experience of Disabled Drivers

R. S. Prasad, J. Hunter, and J. HanleyScottish Driving Assessment Service, Edinburgh,United Kingdom

Background: Although the recommendation and use of caradaptations by disabled drivers is becoming common, it is un-clear how patients fare in learning to use them. The aim was tostudy the influence of nonstandard car controls on return to



driving including accidents and problems experienced. Meth-ods: Postal questionnaires sent within 2 years of assessment to972 disabled drivers seen over a 3-year period at the ScottishDriving Assessment Center. Results: Returns from 589 people(61%) were analyzed, 583 (99%) of whom had stopped drivingafter a disability and were thus returning to driving. The major-ity (72.8%) were men (mean age, 55 years), and 70.4% had beendisabled for up to 2years. Overall 79% respondents returned todriving (highest success rates of 86% in standard manual car andlowest using left foot to accelerate or brake (68%) [χ2 = 16.6, P =0.005]). Of the 30 (6.5%) admitting to accidents and 25 (5.4%) toproblems retraining a higher proportion were usingnonstandard techniques, especially handcontrols. Seventy-eight (40.2%) of the 194 patients recommended to have formallessons did not have them. Conclusion: A greater proportion ofthose who needed to use nonstandard techniques to return todriving after the onset of disability were either unsuccessful orreported difficulties or accidents compared to those who couldcontinue to use standard techniques. If confirmed in larger stud-ies, this may have implications for policy makers, patients, andpractioners alike.

P4-096 Effect of Comprehensive RehabilitationTherapy on Hemiplegia in Rats

Y. QinDepartment of physiothreapy, The 304 hospital ofPLA, Beijing, China

Background: Motor function of patients with hemiplegiacan not be significantly restored with only drug therapy clini-cally. Methods: Model of cerebral infarction and hemiplegia wasset up by blocking cerebral middle arteries with nylon silk tocause cerebral ischemia in 20 rats, which were randomly di-vided into 2 groups: comprehensive rehabilitation treatmentgroup and control group. Rats in the comprehensive rehabilita-tion treatment group (n = 10) were treated with a combinationof movement therapy and drug treatment, whereas rats in thecontrol group (n = 10) were treated with only drug treatment.The course of treatment was 20 d on average. Limb motor func-tion of rats in each group was evaluated with 5-grade approachintroduced by Longa and Bedersonon before and after treat-ment. The infarct lesions were pictured and scanned to com-pare the discrepancy of necrosis area with Photoshop software.Results: Before treatment, there was no obvious statistical differ-ence between the comprehensive rehabilitation treatmentgroup and the control group. However, after being treated for20 d, rat motor functions in rehabilitation group were both sig-nificantly increased compared with those in rats before treat-ment and the control group (P < 0.01). In comparison with thecontrol group, there have no obvious changes in cerebral infarctvolume in rats of the comprehensive rehabilitation treatmentgroup (P > 0.05). Conclusion: The study suggested that the im-provement in motor functions might be owed to the remodelingof brain functions instead of the amelioration of infarct area.

P4-097 Prevention of Movement Constraint in theElderly from Chronic Neurologic Diseases

P. Targosinski, J. Grossmam, and M. LypJozef Pilsudski Academy of Physical Education inWarsaw Faculty of Rehabilitation, Poland

Background: One of the factors showing that human organ-ism functions properly is characteristic range of joints mobility.

This study was to determine the following aspects in peoplewith chronic neurologic diseases: the ranges of motion of somejoints. It gives a possibility to evaluate the influence of in-creased motor activity on the aging process. The experimenthas been performed within the scope of statutory research (Ds-80) financed from the Warsaw Academy of Physical Educationfunds. Methods: The method of our studies was basedon goniometry commonly used in physiotherapy. Results:Ranges of movements were examined after 9 months of exer-cises with the following findings: 1) spine joints—all examinedmovements exceeded standard values; 2) hip joints—5 of 6 ex-amined movements exceeded standard values and 1 had stan-dard value (abduction). Conclusion: After 9 months of system-atic exercises the following statements can be concluded: 1)increased motor activity of the elderly influences movement or-gans, resulting in improvement of joints movements ranges; 2)Among 10 of examined movements, 9 of them exceeded stan-dard values and 1 of them was equal to standard; 3) it seems thatdecreased efficiency of movement organs in the 3rd period ofhuman life is connected not only with physiological process ofaging but also with decreasing movement activity.

P4-098 Aspects of Rehabilitation in Huntington’sDisease (HD)

C. Corradini and S. LanzingerDepartment of Rehabilitation of the Hospital ofBrunico, Italy

Background: HD, characterized by progressive deficit inmotor control, cognitive decline, and behavioral problems, isthe most frequent hereditary neurodegenerative pathology inadults. Nevertheless, Huntington patients are rarely given reha-bilitative care. In one study, only 8% had received physiother-apy; 24%, occupational therapy; and none, speech therapy. Re-served attitudes and/or resignation about HD are probablybecause of the disease’s progression contradicting the sup-posed principles of rehabilitation, which are thought to favorthe greatest possible autonomy and resocialization. Methods:Through reporting an analysis of functional limits during thecourse of HD and defining competence and intervention areasfor the rehabilitation team, the authors support the develop-ment of a project for individual rehabilitation to increase thequality of life in HD. Results: The importance of rehabilitation inHD has been pointed out in a few studies demonstrating that de-crease in motor function is the major predictor forinstitutionalization in Huntington patients. Conclusion: Thereare a few reports examining the efficacy of physio- and speechtherapy in HD based on single case reports or observations. Arecent methodologically correct study on the outcome of reha-bilitation in HD confirms the scientific basis. There are encour-aging observations in clinical practice, underlining the positiveimpressions of patients and familiy members about the benefitsof rehabilitation for patients with this disease.

P4-099 High-Voltage Static Electricity:Modern Clinical Application to Primary Insomnia

A. P. ZhuJiangsu Geriatric Hospital, China

Background: High-voltage static electricity is an equipment-producing electric field which may increase the metabolism ofvarious kinds of demic cells. The aim of this study was to assessthe effect of high-voltage static electricity to treat patients with



primary insomnia. Methods: 20 patients with primary insomnia(10 men and 10 women; mean age, 57.5 ± 19.5 years; durationsof disease, from 2 months to 10 years; mean, 4.62 years) en-rolled into a 20-d study to evaluate treatment with high-voltagestatic electricity (half an hour a day). The Athens Insomnia Scale(AIS) and the Pittaburqh Sleep Quality Index (PSQI) were mea-sured before and after treatments, and compliance and side ef-fects were monitored. Results: The mean sleep rate (actualhours of sleep/hours lying in bed) increased from 60.91% ±17.94% at baseline to 76.17% ± 8.49% at 20 d (P < 0.01), whereasthe mean AIS score decreased from 12.40 ± 3.69 at baseline to5.25 ± 3.67 at 20 d (P < 0.01), and so was the mean PSQI score(9.10 ± 3.71 at 20 d vs. 14.40 ± 2.96 at baseline, P < 0.01). The du-rations of the disease were not significantly associated with thechanges of the sleep rate, AIS scores, and PSQI scores. A highrate of compliance with treatment was seen, despite minor sideeffects, including one with nonspecific deadlimb (5%) and onewith slight headache (5%). Conclusion: High-voltage staticelectricity was safe and well tolerated by patients with primaryinsomnia and was associated with an improvement in sleepquality.

P4-100 An Indian Prospective of B12Myeloneuropathy (Subacute CombinedDegeneration)

N. SuryaSurya Neuro Centre, India

Background: Vitamine B12 deficiency is a systemic diseasethat often affects the nervous system, and one of the most preva-lent manifestation is subacute combined degeneration (SCD).Strict vegetarians have long been known to be at risk ofcobalamine deficiency, and India has a large vegetarian popula-tion making them more susceptible to this disease. Methods:Cl in ica l , e lec t rophys io log ic (e lec t roneurography,somatosensory, and motor-evoked potentials), biochemical(B12 level in serum), and MRI evaluation were performed be-fore the treatment. Results: All 5 patients were vegetarian. Fourof 4 were less then 27 years of age, with most prominent clinicaland electrophysiologic finding of posterolateral column dys-function along with peripheral nerve involvement. All the pa-tients had very low B12 level in serum. The gait disturbance onpresentation was very striking, which improved after the treat-ment. The clinical progress documented on video is to be pre-sented. Conclusion: B12 deficiency is a treatable cause of spinalcord dysfunction and should be considered with high index invegetarian population as seen in India, as the early treatmentcan make complete recovery from the symptoms.

P4-101 60-Year-Old Bed-Bound Woman withPrevious History of Polyuria, Polydipsia, andHeadache: A Neurorehabilitation Challenge

A. H. JafarRoyal Gwent Hospital, United Kingdom

Background: The dramatic effect of a central nervous sys-tem tumor on the patient’s quality of life is a well-recognizedfact. In spite of the huge development in the field of neurosur-gery, the effect of the brain tumor on the physical activity, ADL,social and emotional well-being of the patient remains signifi-cant. I am presenting herewith a case of a 60-year-old womanwith previous history of polyuria, polydipsia, and headache.She was a challenge to our neurorehabilitation team. Methods:

A 60-year-old woman was referred by her general practitionerto the medical team in Royal Gwent Hospital because ofpolydipsia. Diabetes was ruled out with normal plasma glucose.Her water deprivation test was consistent with cranial diabetesinsipidus (DI).Results: MRI brain showed a large mass in thesella which was consistent with a pituitary macroadenoma, withsuprasellar extension and elevation of the optic chiasma. Shewas diagnosed with pituitary macroadenoma with stalk com-pression. She was treated medically and surgically as granu-loma hypophysitis. Conclusion: The rehabilitation team wasconcentrating on the profound weakness on left side in upperlimbs and bilateral weakness in both her lower limbs. She hadgeneralized increased tone on the left side of the body. Theproblem with anxiety, which have complicated her rehabilita-tion, was significant. The team had managed to improve slidingboard transfers, increase standing tolerance, and give her a de-gree of independency in her ADL.

P4-102 DYT1 Mutation: From AsymptomaticCarrier to Stiff Man Syndrome

C. W. Fung,1 C. W. Lam,2 and V. Wong1

1The University of Hong Kong, Queen MaryHospital/Duchess of Kent Children HabilitationInstitute, Hong Kong; 2The Chinese University ofHong Kong, Prince of Wales Hospital, Hong Kong

Background: To identify the phenotypic variation of DYT1mutation in pediatric patients with movement disorders. Meth-ods: 3 pediatric patients who were heterozygous for904_906delGAG of DYT1 gene were selected. The clinical phe-notypes were described. DNA testing for DYT1 gene was per-formed in Prince of Wales Hospital. Results: The 1st 2 patientsbelonged to the same family. The elder sister developed writer’scramp involving the left hand since she was 9 years old. At theage of 11, the right hand was involved as well. The rest of thebody was not involved. The younger sister had symptoms onsetat 7 years old. She had dystonia starting from the left lower limbthat involved the other limbs in 3 years’ time. Our 3rd patient, amale, started to have stiffness of the left lower limb at the age of4 with intermittent painful spasm. This gradually progressed toinvolve the right lower limb, the back, and both the upper limbsin 5 years’ time with intermittent stimulus-sensitive myoclonusand muscle spasms. Electromyography showed continuous mo-tor unit activity. Clinically, the diagnosis of stiff man syndromewas made. Genetic testing was positive for DYT1 mutation. Allpatients have normal intelligence. Conclusion: Our 1st 2 pa-tients demonstrated an intrafamilial phenotypic variation fromwriter’s cramp to generalized torsion dystonia. The last patienthad a clinical diagnosis of stiff man syndrome with the sameDYT1 mutation. This study further extends the wide phenotypicspectrum of DYT1 mutation.

P4-103 A New Cause of Mental Retardationin a Young Chinese Girl: Congenital Disorderof Glycosylation

C. W. Fung, K. Y. Wong, M. S. Wong, W. Goh,and V. WongThe University of Hong Kong, Queen Mary Hospital,Hong Kong

Background: To report the clinical features of a patient withcongenital disorder of glycosylation (CDG). Methods: The medi-



cal notes of this patient are reviewed. Isoelectrofocusing of se-rum sialotransferrins was performed in the Centre for MetabolicDisease, University Hospital Leuven, Belgium. Results: This wasthe 2nd child of a nonconsanguineous Chinese couple. She wasborn at 35 weeks, with a birth weight of 4 pounds 10 ounces.Antenatally, intrauterine growth retardation was detected since20 weeks. She presented with neonatal hepatitis syndrome.This girl was subsequently noted to have global developmentaldelay. Physical examination revealed failure to thrive withmicrocephaly. There were multiple contractures over all thedigits with wasting of the small muscles of the feet and thehands. The lower limb jerks were depressed, with distal muscle

weakness but normal sensation. There was generalizedhypotonia. Extensive metabolic investigations were initiallynegative. Magnetic resonance imaging of the brain showed de-layed myelination. Serum sialotransferrins revealed a type 2pattern. The diagnosis of CDG was made. Further glycan struc-ture analysis is proceeding for subclassification. Conclusion:CDG is a recently recognized cause of mental retardation withpossible multisystem involvement. Recognition depends onhigh index of suspicion. Isoelectrofocusing of the serumsialotransferrins remain the initial screening method of mostcases.



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