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The Future Of Rehabilitation
Lies In Retraining, Replacement, And Regrowth
Healthcare delivery continues to focus on acute
illness and the threat of death, but contact with
healthcare systems is dominated by people with chronic
conditions. In the United States they account for
nearly 50% of those in contact with healthcare but
nearly 80% of healthcare costs. Neurological damage
accounts for about 40% of those people most severely
disabled, who require daily help, and the majority
of people with complex disabilities resulting from
a combination of physical, cognitive, and behavioural
impairments. In the United Kingdom until recently
the involvement of neurologists in these patients'
rehabilitation, was not obviously encouraged. However,
there are positive signs of change, and combined
therapies and restorative neurology are likely to
attract more neurologists to the challenges of rehabilitation.
In the past senior representatives of rehabilitation
medicine apparently considered it possible for doctors
with little or no previous neurological exposure
to manage such patients after 12 months' training
in neurological rehabilitation. Dual accreditation
in rehabilitation medicine and neurology was effectively
discouraged, as it took eight and a half years compared
with four in rehabilitation medicine and five in
neurology. The appointment of candidates accredited
in neurology, rather than rehabilitation medicine,
to consultant posts responsible for the rehabilitation
of patients with neurological damage was actively
discouraged.
Rehabilitation medicine thus slowly amputated an
essential part of its knowledge base, namely, inquiry
into and promotion of neurological recovery, one
of rehabilitation's treatment goals. It left itself
with no disease or impairment to study, only a process
to propagate and, occasionally, measure. Small wonder
that suitable candidates for specialist registrar
training and consultant appointments in rehabilitation
are hard to find.
At the same time neurologists failed to grasp the
opportunity for involvement in the rehabilitation
of their patients allowed by the introduction of
magnetic resonance imaging and other technologies.
They remained unable to adopt important lessons
from the rehabilitation process, particularly an
appreciation of the various levels at which a disease
or intervention has an effect; the way in which
this informs both goal setting both at a personal
level for the individual and the medical treatment
of the disease; and the effectiveness of organised
multidisciplinary input, so well demonstrated after
stroke. Neurology failed to grasp the nettle of
the patient as a person rather than as a vehicle
for disease.
Change may, however, be occurring. The reduction
to six and a half years training recommended for
dual accreditation in neurology and rehabilitation
medicine,5 and the compulsory period of four months'
exposure to rehabilitation required during training
in neurology are examples. Several developments
will give further impetus to these changes. These
include the demonstration that rehabilitation
therapy is effective, the development of new drug
treatments for chronic neurological disease and
in the context of complex disability, and the emerging
field of restorative neurology.
Randomised controlled trials and meta-analyses
of stroke therapy have led the way in showing that
organised packages of rehabilitation work better,
at little extra cost, than unorganised care and
treatment.4 Other studies document benefit in multiple
sclerosis6 and similar studies after head injury
are clearly opportune. Future studies should focus
not only on outcomes at the level of activity, participation,
and health status but also on economic evaluations,
and the ways in which teams generate adaptive coping,
strategic actions, and changes in style in both
the person with chronic disease but also in team
members. Multidisciplinary clinical teams in these
areas will attract other biological and clinical
neuroscientists, as well as the pharmaceutical industry.
This process is already exemplified by the use of
acetylcholinesterase inhibitors for Alzheimer's
disease, immunomodulators for multiple sclerosis,
and botulinum toxin for spastic hypertonus.
Of course, if drug treatment and therapy techniques,
separately or in combination, are to achieve clinical
usefulness then benefit needs to be shown at levels
other than pathology and impairment. This requires
involvement of the social sciences in continuing
research into the consequences and impact of disease
at individual and societal level, and the rigorous
development of patient centred measures of social
outcome and health related quality of life.
Cajal's dictat that the adult central nervous system
is hard wired and the consequences of damage immutable
has at last been replaced by an explosion of research
into the three "R"s of restorative neurology: how
retraining reorganises neural circuits and networks;
the replacement of cells and chemical messengers;
and regrowth of axons, dendrites, and synaptic connections.
We now know from work in both animals and humans
with brain lesions that remodelling of the cortex
and other parts of the brain and spinal cord is
use dependent and task specific. This remodelling
probably underpins functionally useful retraining
techniques after brain injury, such as constraint
induced movement therapy and treadmill retraining
of gait,1and knowing this should hasten the incorporation
of such treatments into clinical practice. The use
of functional imaging as a surrogate outcome should
also facilitate the exploration of effective
drug treatments, as well as replacement and regrowth
strategies that have yet to have clinical impact.
Fifteen years ago a neurologist's interest in rehabilitation
provoked questions about how many ways there were
to use a walking stick. Today, such questions are
not asked, and explorations of treatment induced
plasticity in the nervous system are beginning to
attract major research efforts. These developments
must be reflected in clinical appointments.
Richard Greenwood, consultant neurologist.
National Hospital for Neurology and Neurosurgery,
London WC1N 3BG
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