Weaning in der neurologischen Frührehabilitation (NFR)

Weaning in neurological early rehabilitation represents an important participation goal that can be achieved in up to 90% of cases after an average of two to three weeks of weaning through a combination of intensive care and rehabilitative interventions. The weaning process should be based on a standardized weaning protocol, with which a gradual expansion of spontaneous breathing phases can be achieved. The German Society for Neurorehabilitation (DGNR) has taken the special features of prolonged weaning in NFR into account in a separate guideline.

Das Team in der Neurorehabilitation

Neurological rehabilitation is rehabilitative therapy that is concerned with neurological patients in a multi-professional team under the leadership of a physician. The members of this interdisciplinary team work together closely with an intense exchange of knowledge and competence. This primary treatment team includes specialists in neuropsychology, speech therapy, occupational therapy and physiotherapy (including physical therapy), along with social workers and co-therapeutic nursing. Other forms of therapy may also be included. A secondary team is defined by the cooperation of the neurologist with other medical fields, e.g., neurosurgery, geriatrics, psychiatry, orthopedics and neuropediatrics. A tertiary team exists in the form of organizational cooperation between the medical und economic clinic management with insurance companies and political decision makers. Every kind of rehabilitation is basically multi-professional from an organizational viewpoint, and it is performed interdisciplinarily applying the methods of all therapeutic disciplines to create synergies. This particularly applies to neurorehabilitation, as in this field – generally following a disease or an injury to the brain as the central regulation organ – several different disorders occur in combination: sensorimotor symptoms and signs like paralysis, spasticity, dysphagia and loss of coordination; cognitive or speech disorders; or finally psychological alterations like depression or anxiety. Therefore it is particularly important that the professional team members match and coordinate their therapeutic procedures to reach common rehabilitative goals. »Multi-professional« in this context means that the representatives of the different therapeutic fields work with the patient on an advanced competency level, and »interdisciplinary« means that the members of the team work together closely with thorough cross-consultation between their disciplines. Transdisciplinary cooperation represents the highest level of team competency and includes regularly adopting the tasks and therapeutic procedures from other disciplines. All kinds of cooperation are performed under the supervision of a physician who assumes full responsibility for the rehabilitative therapy, including the prescription of medication and introduction of acute interventions, e.g., surgical procedures. This paper is only concerned with the primary – therapeutic – team. The secondary and tertiary forms of team cooperation are planned to be published separately.

Rechtliche Rahmenbedingungen, Qualitätssicherungsprogramme, Zertifizierungen, DRGs, OPS, Pflege als Therapie

The establishment of structural and minimum features within the DRG system by the operations and procedure key (OPS) gave the neurological early rehabilitation phase B a definitional framework and ensured standardization. In the field of nursing, it has given rise to a new self-image and a boost to interdisciplinarity. The assignment of patients at the interface between acute inpatient treatment and rehabilitation remains problematic. The article gives an overview of the regulatory framework

Rehabilitation organisch bedingter Gedächtnisstörungen: Was, wann, für welche Betroffenen?

The aim of this paper is to provide an overview of treatment strategies and methods as well as a practical decision support, based on the current version of the guideline on memory rehabilitation [55] and the authorsʼ views. We show that the choice of a method for efficient neuropsychological treatment depends on the type and severity of the memory disorder as well as on the previous therapy experience of the affected person and the defined therapy goal: e.g., what it means to work with implicit »errorless learning« methods; which form of external memory aids can be used with which patients; that methods for improving memory performance are available for persons with moderate to mild memory disorders; and that PC therapy is also likely to help younger and more mildly affected persons. The aim is also to provide a broad overview of current studies on memory rehabilitation, some with very promising results. However, many questions remain unanswered to date, some of which have been highlighted in this paper with the aim of stimulating future research to enable those affected by memory impairment to achieve the best possible rehabilitation and the greatest possible independence

Berufliche Teilhabe nach erworbener Hirnschädigung

Vocational participation after acquired brain injury – an empirical study of opportunities and barriers from the perspective of affected patients and vocational expertsT. BrehmAbstractThe following article summarizes the results and scientific findings of an empirical study on vocational participation after acquired brain injury. It describes opportunities and barriers from the perspective of affected patients and vocational experts. The empirical study was conducted in the context of a degree course on clinical social work. Essential results related to acquired brain injuries are that invisible disabilities and neu-ropsychological deficits complicate opportunities so that continuous support is needed. At the same time, the acceptance of deficits and changing work related opportunities seem to be resources. Seniority, colleagues, and the relationships between them, seem to play ano-ther important role. Risk factors are a change of leadership, change of work content and problematic relationships between colleagues. A big problem seems to be the cooperation with responsible payers (social insurance). In conclusion, the possibility of rehabilitation depends on the willingness of responsible payers. Keywords: acquired brain injury, rehabilitation phase E, return-to-work, profes-sional reintegration, integration assistance, case management

Fallvignetten aus der neurologischen Rehabilitation bei Patienten mit Post-COVID-Syndrom

Case vignettes from neurological rehabilitation in patients with post-COVID syndrome – Suggested discussion for performance diagnosticsC. Dettmers, C. Weich, C. Herrmann, R. Saile, M. Preuss, S. H. Chanyalew, L. Schleicher, D. Klaasen van Husen, J. Randerath, S. Stoll, M. Tempfli, M. Vieten, M. JöbgesAbstractSecondary illness after a previous infection with SARS-CoV-2 covers a wide spectrum in terms of organ damage, symptoms, duration, course and, above all, the severity of the disease. In patients who have been ventilated for a long time in an intensive care unit, one will look very carefully for lung damage and other organ damage, including cerebral, peripheral neurogenic and myogenic damage, and clarify to what extent the remaining deficits can be attributed to this. At the other end of the spectrum are patients who were not hospitalized during the primary infection, for whom fatigue, headache, muscle, limb or other symptoms are in the foreground and whose symptoms often fluctuate in intensity over the course of the disease. For employees in the health sector, a primary infection acquired at work may be recognized as an occupational disease. Subsequent complaints are often subsumed under “post-COVID” by the patient and then also by the attending physician, without proving a causal connection to COVID-19. We present individual case studies from this specific and non-representative group. We were surprised that there were many psy-chological, psychosomatic and psychiatric comorbidities. In the second part we present our diagnostics for cognitive, emotional and motor fatigue and fati-gability. Particularly in this initially non-hospitalized patient group, a thorough somato-psychological differential diagnosis is required in order to determine the causes and the socio-psychosomatic set of conditions. An identification of the different components within the post-COVID complaint complex should enable the most efficient therapy possible in order to initiate reintegration into social life in everyday life and at work. Keywords: Post-COVID syndrome, comorbidity, psychosomatics, fatigue, fatigability, differential diagnostics

Traumatic brain injury and coping processes – improving outcomes by involving family in the rehabilitation process

Following a traumatic brain injury, many patients struggle to cope with daily activities and experiences, both at the physical and psychological level. In addition to the patient's own coping process, the family's involvement in the heal-ing process is extremely important. Acute care is usually provided by family members and has the potential to either support or hinder rehabilitation and adaptation processes. In addition to new limits of self-care and complaints caused by brain damage, patients face far-reaching psychosocial problems. Despite increasing interest in the management of brain damage and processing of the disease, there is a lack of health-promoting concepts designed to address the impairments and psychosocial relationship difficul-ties suffered by people after traumatic brain injury. In this study, rehabilitation potential was identified by analyzing the results of biographical narrative interviews with men who had suffered a traumatic brain injury in an industrial accident, and their relatives. The selection and qualitative analysis of the rehabilitation process of traumatic brain injury patients reveals the potential for intervention and the need for a holistic integration process between the patient, relatives and physicians, which can be further supported by integrating family members into the treatment process. Keywords: rehabilitation of traumatic brain injury, qualitative social research, reintegration, relatives

Alertness-Grundmessung als stärkster Prädiktor für den Erwerbsstatus bei Patienten mit MS sechs Monate nach der Rehabilitation

Baseline alertness as the strongest predictor of employment status in patients with MS 6 months after rehabilitationS. Marchione, C. Dettmers, A. Weimer-Jaekel, B. Godde, M. JoebgesAbstractIntroduction: Fatigue is a dominant impairment in multiple sclerosis, which often also limits the professional performance of patients with MS (PwMS). In clini-cal practice fatigue is often difficult to assess. The question of our study was whether the objective cognitive fatigability – measured as reaction time or tonic alertness – or the subjective self-assessment of the patient – recorded by the Fatigue Scale for Motor and Cognitive Functions (FSMC) – predicts employment status 6 months after discharge from rehabilitation.Methods: PwMS whose rehabilitation measures were paid for by the government pension fund, and who had doubts about maintaining their professional per-formance in terms of their workload, underwent further testing. Tonic alertness from the test battery TAP-M was used as an indicator of cognitive fatigability. Participants were tested in the morning at 8:00 a.m., after standardized exer-cise at 11:00 a.m., and in the afternoon at 2:00 p.m. In addition, fatigue was determined using a self-assessment questionnaire (FSMC). Six months after discharge from neurological rehabilitation, their employment status was classi-fied through a telephone interview and also compared with our socio-medical performance assessment. Results: A complete data set was collected from 64 patients (43 female; age 48.9 ± 8.7 years; duration of illness 14.7 ± 9.5 years; EDSS 3.8 ± 1.3; 67 % relapsing remitting, 16 % secondary progressive, 17 % primary progressive). According to the International Standard Classification of Occupations (ISCO) code, 86 % were “white collar” workers, for example, in service, office and non-manual jobs. Six months after discharge from the rehabilitation clinic, 15 (23 %) out of 64 PwMS reported working less than 3 hours per day, 35 (55 %) PwMS reported 3 to 6 hours, and the remaining 14 (22 %) PwMS were full-time employees. The mean total value of the FSMC questionnaire for cognition was 38.9 ± 7.4, which was equivalent to severe cognitive fatigue. Eleven of the 14 full-time employees had severe fatigue. The morning alert-ness measurement (alertness1) (β = -.985; p= .003) and, the decline in alert-ness from morning to noon (alertness difference21; β = -.590; p= .033) and from noon to afternoon (alertness difference32; β =-.709; p= .020) were sig-nificant predictors for employment status. A reduction in alertness (increase in reaction time) by 1 SD on the alertness scale increases the probability of not working full-time by a factor of 2.67. Likewise, the probability of not working full-time increases by a factor of 1.80 if fatigability is increased by 1 SD from morning to noon. If fatigability increases by 1 SD from noon to eve-ning, the probability of not working full-time increases by a factor of 2.03. Discussion: The FSMC has no prognostic value for employment status 6 months after discharge from rehabilitation. The morning alertness measurement has the highest predictive value. However, an above average decline in alertness over the course of the day also reduces the probability of working full-time. Keywords: fatigue, fatigability, MS, alertness, employment status, prognostic factor

Verlaufsmodifizierende Immuntherapien bei MS-Fatigue

Zusammenfassung Obgleich sich die Zahl und die Wirkansätze der verfügbaren Immuntherapien zur Behandlung der MS in den letzten zehn Jahren deutlich vergrößert haben, ist die Datenlage zur Wirkung der verschiedenen Behandlungsformen auf Fatigue nach wie vor lückenhaft und kaum durch kontrollierte Daten belegt. Aus den in dieser Arbeit referierten Studien kann vorläufig geschlossen werden, dass von Glatirameracetat und Natalizumab am ehesten positive Auswirkungen auf das Fatigueempfinden von MS Patienten zu erwarten sind. Bei Interferonen bietet die Datenlage keine einheitliche Orientierung. Die klinische Erfahrung lehrt jedoch, dass man immer damit rechnen muss, dass eine Interferontherapie bei einzelnen Patienten zu einer Zunahme der Fatigue führt. Ein Absetzen von Interferon und ein Wechsel auf Glatirameracetat oder eines der Oralpräparate (horizontal switch) kann deshalb unter dem Aspekt der Fatigue bei Krankheitsstabilität durchaus sinnvoll sein. Die modernen Antikörpertherapien scheinen hinsichtlich einer Fatigueauslösung oder -verschlechterung eher unkritisch zu sein. Kurzfristige Schwankungen der Fatigue können aber vorkommen. Vielversprechend sehen derzeit die Daten zu Ponesimod aus, wobei es hier zu beachten gilt, dass das Messinstrument für Fatigue neu entwickelt wurde und es hierzu keinerlei Vergleichsdaten mit anderen Präparaten – abgesehen vom aktiven Komparator Teriflunomid aus der Zulassungsstudie – gibt. Hier besteht demnach wissenschaftlicher Handlungsbedarf, um zu sicherzustellen, dass es sich um eine »echte Überlegenheit« von Ponesimod in puncto Fatigue gegenüber anderen Therapien handelt. Schlüsselwörter: Multiple Sklerose, Fatigue, Therapie der Fatigue, Immuntherapien, milde bis moderate Verlaufsformen der MS, aktive bis hochaktive Verlaufsformen der MS Abstract Although the number and the mode of action of the immunotherapies available for the treatment of MS have increased significantly in the last ten years, evidence for the effect of the various forms of treatment on fatigue is still incomplete and hardly supported by controlled data. From the studies reported in this paper, it can be tentavely concluded that glatiramer acetate and natalizumab are most likely to have positive effects on the perception of fatigue in MS patients. In the case of interferons, published data do not offer a uniform orientation. However, clinical experience shows that it must always be expected that interferon therapy will lead to an increase in fatigue in individual patients. Discontinuing interferon and switching to glatiramer acetate or one of the oral drugs (horizontal switch) can therefore make sense in terms of fatigue and disease stability. Modern antibody therapies seem to be rather uncritical in terms of triggering or worsening fatigue. However, short-term fluctuations in fatigue can occur. The data on ponesimod currently look promising, although it should be noted that the measuring instrument for fatigue was newly developed and that there are no comparative data with other disease modifying therapies – apart from the active comparator teriflunomide from the registration study. There is therefore a need for scientific action here to ensure that ponesimod has a »real superiority« in terms of fatigue compared to other therapies. Keywords: multiple sclerosis, fatigue, management of fatigue, immunotherapies, mild to moderate MS, active to highly active MS

Teletherapie und Telemedizin in Deutschland

Zusammenfassung Die durch die WHO vorgenommene Einstufung des Coronavirus als Pandemie hat Kliniker herausgefordert, die Kontinuität der medizinischen Versorgung aufrechtzuerhalten. Die Teletherapie wurde so innerhalb kürzester Zeit zum wichtigsten Mittel der Leistungserbringer, die diese zuvor nie oder nur sparsam genutzt hatten. Im Bereich der ärztlichen sowie der psychotherapeutischen Versorgung wurde parallel zum ersten Lockdown seit dem 01. April 2020 die zunächst bestehende Begrenzung der telemedizinischen Behandlung von 20 % der gesamten Behandlungen einer Praxis aufgehoben. Auch im Bereich der Heilmittelerbringer wurde phasenweise eine Erlaubnis zur Durchführung von Videotherapien erteilt. Die Studienlage zu diesem Thema weist darauf hin, dass die Wirksamkeit der logopädischen Teletherapie durchaus gegeben ist, wie am Beispiel der Sprachtherapie bei neurologisch bedingten Sprachstörungen im deutschsprachigen Raum im Artikel dargestellt wird, auch wenn weiterhin Studien in diesem Bereich erforderlich sind. Die Teletherapie sollte im Heilmittelbereich ebenso dauerhaft ermöglicht werden wie die teletherapeutische Versorgung durch Psychologen oder die elemedizinische Versorgung durch Ärzte. Auf diese Weise könnte eine Quattro-win-Situation für Leistungsträger, -finanzierer, -erbringer sowie für die Leistungsempfänger entstehen. Schlüsselwörter: Telemedizin, Teletherapie, Online-Sprachtherapie, Covid-19-Pandemie Abstract The WHO's classification of the coronavirus as a pandemic challenged clinicians to maintain continuity of care. Thus, in a very short time, teletherapy became the most important tool for healthcare providers who had never used it before, or had used it only sparingly. Parallel to the first lockdown, beginning on April 01, 2020, the existing limit on telemedicine treatment in medical and psychotherapeutic care – 20% of the total number of treatments at a practice – was lifted. Also, in the area of remedy providers, permission was given in phases for the execution of video therapies. The studies on this topic indicate that logopedic teletherapy is clearly effective, as shown in the example of speech therapy for neurologically-related speech disorders in German-speaking countries in the article, even if further studies are needed. Teletherapy should be made permanently possible in the field of remedies, just as teletherapy care by psychologists, or telemedicine treatment by physicians, are possible. This would create a “quattro-win” situation for service providers, financiers, providers and recipients. Keywords: telemedicine, teletherapy, online speech therapy, covid-19 pandemic