Rehabilitation
Technological Advances in Stroke Rehabilitation— High Tech Marries High Touch
Richard C Senelick, MD Neurologist, and Medical Director, Rehabilitation Institute of San Antonio
Abstract
Until recently, the rehabilitation of stroke patients relied heavily on treatment that focused on teaching them how to compensate for their physical deficits. However, the latest neurorehabilitation studies show that the concept of neural plasticity (the ability of the brain to repair itself) can be applied effectively to the rehabilitation regimen of such patients, leading to improved outcomes and enhanced functional abilities. Stroke patients with limited voluntary movement could now benefit from technologies such as functional electrical stimulation (FES) combined with necessary repetition of functional tasks (use-dependent plasticity) to enhance the neural repair process and improve outcomes, thus enabling them to begin to overcome their previous limitations and to improve their physical capabilities.
Keywords
NESS L300, NESS H200, mobility devices, mobility issues, rehabilitation, functional electrical stimulation, multiple sclerosis, stroke, traumatic brain injury, spinal cord injury
Disclosure: Richard C Senelick, MD, has received an honorarium from Bioness, Inc. Received: August 31, 2010 Accepted: Novemver 1, 2010 Citation: US Neurology, 2010;6(2):102–4 Correspondence: Richard C Senelick, MD, 9119 Cinnamon Hill, San Antonio, Texas 78240. E:
rsenelick@yahoo.com;
www.richardsenelick.com
Support: The publication of this article was funded by Bioness, Inc. The views and opinions expressed are those of the author and not necessarily those of Bioness, Inc.
For decades neurology was a specialty field of medicine that was expert in making diagnoses and applying names to esoteric disorders. However, 20–30 years ago a revolution began that included new and exciting imaging techniques, followed by a full armament of medications to treat problems long monitored by clinical neurologists, but rarely treated effectively. A similar revolution is now under way in neurorehabilitation, particularly of stroke patients. Rehabilitation is a relatively new specialty, with the primary origins of the practice only dating back to World War II. During its early stages, the rehabilitation of stroke patients was a ‘high touch’ experience, teaching the stroke survivor how to compensate for their deficits. For example, one-handed shoe tying was taught, long-handled ‘reachers’ and shoehorns were prescribed, and clumsy and uncomfortable splints were applied. For years, conventional wisdom was what I call ‘The Humpty Dumpty Myth’: all the king’s horses and all the king’s men simply could not repair an injured brain. It was thought that the only conceivable option was teaching a patient how to compensate for their deficits. However, the time has now come to forget about these notions and embrace the concept of neural plasticity; that is, the ability of the brain to repair itself. To comprehend the mechanisms of neural repair it is important to understand two major concepts:
•
Collateral sprouting: when nerve fibers (axons) are damaged, they sprout and regrow, similar to a pruned rose bush. The challenge is to
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direct these new sprouts so that they connect with the correct structures, ultimately leading to functional improvement.
• Neural plasticity: the property of the central nervous system (CNS) to adapt to an injury, lesions, or new environmental demands. After an injury, the CNS attempts to unmask other neural pathways and synapses that can take over from the damaged areas.
In a series of elegant experiments in primates, Randy Nudo showed that neural plasticity and repair depends on the performance of functional tasks and not simply on the use of an extremity.1,2
In his experiments,
monkeys that only performed range-of-motion exercises showed minimal improvement, whereas those that performed multiple repetitions of functional tasks made greater functional gains. Nudo also found that adjacent brain areas adopted the function of the damaged brain area in monkeys that received a full rehabilitation program.
Use-dependent Plasticity
Neural plasticity is “the mechanism by which the brain encodes experience and learns new behaviors,” and the brain relearns “lost behaviors in response to rehabilitation.”3
Rehabilitation is crucial in the
improvement and acquisition of functional abilities. Although the authors describe 10 key components, I summarize three points of importance:
© TOUCH BRIEFINGS 2010
Nudo’s findings have been termed ‘use-dependent plasticity’, with the concept and key components documented in a paper by Kleim and Jones.3
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