The State of Neurorehabilitation: Past, Present, and Future
Article Outline
This is both an exciting and challenging time for neurorehabilitation. In the 1980s, when I was a medical student, the adult central nervous system (CNS) was believed to be static and incapable of meaningful reorganization after disease or trauma. I was taught that whatever recovery a person experienced after stroke or spinal cord injury occurred from resolution of edema and hemorrhage, not from reorganization of neural tissue. Despite this somewhat fatalistic perspective, physical medicine and rehabilitation (PM&R), which developed as a relatively new field of medicine 40 years before my entrance into medical school, excited me as a specialty that addressed the medical complications of neurological injury as well as one that led to improved functional skills of people with physical and cognitive impairments.
Early in my career, I believed that functional improvement predominantly occurred because we taught our patients compensatory strategies to overcome difficulties imposed by physical and cognitive impairments, such as “1-handed” activities of daily living techniques for people with hemiplegia, rather than training the brain to more effectively use the plegic limb. However, advances in functional neuroimaging that permit visualization of cerebral function inform us that the adult CNS is capable of considerable change and adaptation when challenged with new learning or after loss of function occurring from injury or disease. More important to PM&R is emerging evidence that the various treatments we provide our neurologically injured patients–whether physical, occupational, cognitive, and speech therapies, medications, or a host of other physical modalities–significantly impact how the CNS reorganizes itself and enhances changes in function. However, regardless of these exciting scientific advances that are beginning to demonstrate the anatomical and physiological basis of how neurorehabilitation improves the well-being of people with disabilities, there are threats to our ability to realize these contributions, including the relative size and breadth of PM&R that limits a critical mass to effect change; unique research challenges posed by the very nature of our patients' medical conditions; relatively few robust rehabilitation research training programs; limitations in funding that restrict meaningful rehabilitation research; and health coverage restrictions for rehabilitation services.
While PM&R was in its infancy, it was sufficient to merely demonstrate that rehabilitation interventions enabled people with CNS injury or disease to become more functional. The methods used were less important than the end result. Not surprisingly, little research effort went into establishing how specific interventions worked, the comparative effectiveness of alternative treatments, or determining which practices were most effective or appropriate given specific clinical circumstances. During the middle of the last century, Howard Rusk, MD, the first Chair of Rehabilitation Medicine at New York University School of Medicine (where I now work), merely needed to show key stakeholders how people with disabilities were able to walk and take care of themselves following the treatment he directed, without the burden of proposing how those treatments worked. It was the recognition that rehabilitation improved function for people with seemingly untreatable conditions that helped ignite the growth of rehabilitation medicine in general. Of course, this approach is no longer sufficient in our modern medical environment as we are now pressured to use evidence-based guidelines. Ironically, now that we are beginning to better understand how specific interventions induce cerebral plasticity (that accounts for improve function), there is a growing economic force that encourages shorter hospitalizations and therefore truncated treatments. Contracted periods of rehabilitation after CNS injury strongly encourage us to teach our patients quickly learned compensatory strategies that improve their function (eg, “1-handed” activities of daily living techniques) rather than those that may lessen the actual impairment (eg, improving the functional use of a plegic limb). Although compensatory strategies are useful, and will undoubtedly remain an important tool in rehabilitation, our patients desire normalized function that requires changes at a neuronal level. Therefore, a scientific understanding of cerebral plasticity is critically important for neurorehabilitation that should guide our treatment and be a core component of the Practice Curriculum being developed by the American Academy of Physical Medicine and Rehabilitation (AAPMR).
Clearly, we need to demonstrate that improving function by encouraging cerebral plasticity is the most effective and efficient means to affect favorable outcomes that ultimately benefits our patients and hopefully reduces health care expenditures. This will require research-proven protocols that demonstrate the biological effectiveness of newer rehabilitation strategies. Unfortunately, neurorehabilitation is at a distinct disadvantage in our new health care environment that stresses evidence-based medicine as the gold standard. Classically described randomized, double-blind, placebo-controlled trials are nearly impossible to carry out in rehabilitation research for a variety of reasons, including the inability to blind subjects to their treatments and the ethical concerns of withholding interventions to “control” subjects because rehabilitation treatments are widely perceived to be beneficial. This forces other research designs such as comparative studies that directly assess the clinical effectiveness of one treatment intervention versus another. However, results using methods other than randomized, double-blind, placebo-controlled trials are not viewed as representing the strongest evidence by widely used classification systems such as the American Academy of Neurology Criteria for Prognostic Articles [1] and the Cochrane Collaboration [2]. Alternative criteria, similar to those proposed by the Grades of Recommendation, Assessment, Development and Evaluation [3], which incorporates factors in addition to study design, such as effect size, dose-response gradient, possibility of bias, unexplained heterogeneity, or inconsistency of response into determining the quality of the evidence, will likely have greater utility for neurorehabilitation research and in establishing evidence-based guidelines [4, 5].
Although there is solid physiological evidence and outcome support for some of the treatments that are prescribed by neurorehabilitationists (such as decreased morbidity and mortality and improved quality of life related to spinal cord injury–related neurogenic bladder), many of the treatments we prescribe are either borrowed from similar but distinctly different conditions than those that impact our patients, or from research that is often retrospective, poorly controlled, or severely underpowered. For example, in the management of brain injury–related behavioral problems, such as agitation, we are often forced to rely on data from the psychiatric literature or on a host of studies that are inadequately powered to develop widely accepted guidelines. Consequently, individual practices are widely variable, erratic, and not strongly evidence based. The relative lack of evidence-based approaches in neurorehabilitation also leaves our patients vulnerable to receiving inadequate treatments. Many insurers either deny or severely limit neurorehabilitation coverage, which often appears arbitrary or based on economic factors; but we lack sufficient counterarguments because of the paucity of strong scientific evidence that supports the type, intensity, and duration of specific interventions.
The expansion of rehabilitation research cannot be accomplished without the resources needed for success; yet, rehabilitation research is severely challenged by an inadequate number of PM&R departments that have highly productive research divisions and insufficient and poorly distributed federal funding for disability research [6]. Although the science of brain and spinal cord injury medicine has advanced over the past several decades, which in part was accomplished through the Traumatic Brain Injury and Spinal Cord Injury Model Systems of Care funded by the National Institute on Disability and Rehabilitation Research (NIDRR), relatively few PM&R departments have added to this body of knowledge [6]. However, the National Institute on Disability and Rehabilitation Research, which has historically been a main funding agency for rehabilitation research, is woefully underfunded and cannot support the vast amount of research needed to accomplish the goal of achieving evidence-based practices. Although the National Institutes of Health have funded rehabilitation research at approximately $300 million annually, less than $30 million of this is awarded to PM&R departments [6]. Clearly, agencies other than NIDRR must take responsibility to fund multicentered rehabilitation trials if we are to provide the evidence demanded by modern medicine (physicians, patients, and insurers). Other funding opportunities are available, such as through the Veterans Administration Rehabilitation Research and Development program and, recently, the Department of Defense, although many have called for the National Institutes of Health to take a lead in funding rehabilitation research.
Another growing challenge faced by neurorehabilitation is an internal one, specifically a trend toward greater involvement in other physiatric subspecialties, most notably outpatient musculoskeletal and pain medicine. My own observation of residents graduating from my affiliated training programs over the past 2 decades indicates a strong movement away from traditional hospital-based neurorehabilitation careers toward those involved primarily in musculoskeletal, pain, and interventional-based practices. An unscientific review of fellowship programs listed by the AAPMR included 81 programs for advanced training in musculoskeletal, sports, spine, or interventional medicine, whereas only 31 were listed for brain injury, spinal cord injury, or other neurorehabilitation fields–only 2 of which were primarily for research training. Although there are undoubtedly a plethora of reasons accounting for this trend, I suspect that the current reimbursement potential for outpatient pain procedures constitutes part of the pull toward interventional-based practices. However, because reimbursement for outpatient pain procedures will likely be reduced over the next decade, a greater proportion of physiatrists may choose to practice traditional hospital-based neurorehabilitation. Another factor likely accounting for waning physiatric participation in neurorehabilitation is that most medical school curricula provide inadequate exposure to the scope and impact it has on the lives of people with disabilities. Other specialties, particularly neurology, are filling the void left by physiatrists who enter into other subspecialties, representing a threat to our ability to shape and direct the field in a manner that best addresses the functional needs of people with neurologically related disabilities.
Although there is a strong move toward ambulatory-based practices as health care reform moves forward, neurologically related disabilities will undoubtedly remain prevalent, which will dictate the need for the ongoing presence of acute inpatient rehabilitation programs that have the capacity to address the complex medical, cognitive, and behavioral problems of people with CNS injury. Physiatrists remain the best qualified physicians to manage these people and should actively work to ensure that we continue to lead the way during health care reform for people with disabilities.
There are many challenges for neurorehabilitation going forward. But neurological disability is certain to remain prevalent, and there is no medical specialty better able to address the multifaceted problems associated with CNS injury and disease than PM&R. At the end of the day, if we focus on developing and delivering evidence-based rehabilitation interventions, neurorehabilitation will flourish as new advances in medicine continue to decrease mortality from disease and trauma, leaving us the job of improving the function and quality of the lives of neurologically injured persons. The keys to our success will be producing quality research, providing effective treatments for specific conditions that are based on evidence, and attracting the most talented young trainees to our field. I am encouraged that PM&R training programs have been successfully incorporated into the core curriculum at several medical schools, although the numbers remain too low and early exposure should be a main focus of all programs.
Expansion of research capacity is critically needed and should be included in the strategic plan of all academic PM&R departments with strong neurorehabilitation clinical programs. The excitement generated by the scientific advances in neurosciences is a tremendous opportunity to recruit outstanding clinicians and researchers to neurorehabilitation, where translation of basic sciences into clinical practice that improves the lives of those with neurological disabilities is so clearly possible.
As physiatrists and neurorehabilitation specialists, we are and need to remain the most qualified physicians to treat the complex array of physical, cognitive, behavioral, and social problems of people with neurological disabilities.
References
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- ⁎ Disclosure: 2A, NDI Medical; 8B, NIDRR(co-PI TBI Model System of Care)
Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org
PII: S1934-1482(10)00327-8
doi:10.1016/j.pmrj.2010.04.007
© 2010 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
