August 28, 2001
By SANDRA BLAKESLEE
BIRMINGHAM, Ala. — At a growing number of rehabilitation centers, stroke patients move around with their limbs tightly bandaged, mummy style. Toddlers with cerebral palsy are ensconced in partial body casts. Paraplegics are slung in harnesses and made to walk on treadmills, with automatic equipment moving their feet. Even the blind are having their brains reconfigured with a special camera that allows them "see" via a device worn on the tongue.
Rehabilitation may never look the same. Like engineers in thrall to a new idea, many of the doctors and therapists who help patients with brain injuries are using revolutionary insights about the brain to coax the nervous system into rewiring itself.
But even as new approaches show promise, much uncertainty remains about which patients, if any, are likely to benefit from specific treatments. And the amount of rehabilitation time that is covered by Medicare and private insurers is shrinking just as the patients' options are growing.
The new rehabilitation strategies stem from the realization that the brain makes new neurons in adulthood, and from indications in animals that these cells may be able to migrate to areas damaged by disease or injury. Moreover, researchers know that activity can keep neurons from atrophying.
The challenge is translating that increasingly dynamic view of the brain into useful therapies, said Dr. Susan Fitzpatrick, vice president of the James S. McDonnell Foundation in St. Louis, which promotes research on the mind, the brain and behavior.
Of the half-million people who survive strokes each year, a third recover spontaneously. A quarter are too severely injured to benefit from therapy. The rest can be helped to varying degrees by conventional therapy. It is too soon to know how many people may be helped with the new approaches.
Most physicians adopt a wait-and-see attitude after a brain injury because they are pessimistic, said Dr. Jordan Grafman, a neurologist at the National Institute of Neurological Diseases and Stroke.
"They recommend rehabilitation therapy more out of a sense that something has to be done than a real expectation that it will help the patient," Dr. Grafman said.
To assess where the new therapies are headed, the McDonnell Foundation invited 30 leading research scientists and rehabilitation therapists to Birmingham in July for a two-day meeting.
Dr. Pamela W. Duncan, director of the Center on Aging at the University of Kansas Medical Center in Kansas City, said at the meeting that the new insights should be greeted cautiously. "The insights hold great promise but we must proceed with caution," Dr. Duncan said. "It is premature to know exactly how beneficial the therapies may be for most patients."
Some patients are very sick and confused, Dr. Duncan said, and nothing much can help them, while others may benefit enormously. So far, she said, there are more questions than answers: Who decides which patients are candidates for the therapies? What is the definition of improvement or recovery? And, more important, who will pay?
A few years ago, Dr. Duncan said, stroke patients who qualified for Medicare services got three weeks of rehabilitation care. Now they get about 11 days. Medicare is cutting back because the cost of rehabilitation services rose to $30 billion in 1996 from $2.5 billion in 1986.
When patients with brain and spinal cord injuries hear about seemingly miraculous new treatments, said Dr. Anne Shumway- Cook, an associate professor and rehabilitation therapist at the University of Washington, they pressure therapists to provide them.
Frustrated that ordinary methods — like teaching a patient to get dressed using only one hand — do not do much, especially in 11 days or so, many therapists are offering the new treatments without quite knowing how they work, Dr. Shumway-Cook said. If a method fails, no one knows if it was a problem with the technique or with the way it was being delivered.
The new rehabilitation methods try to kick-start the process of self-repair in the brain or spinal cord. One way to do that appears to be to give amphetamines several weeks after a stroke; that strategy is being tested in a large multicenter trial.
The therapies that rely on restricting or encouraging movement are based on the idea that after a brain injury, a number of brain cells are killed outright, but many cells surrounding the injury are merely stunned. The therapies try to wake up the cells that have been stunned, said Dr. Edward Taub, a neuroscientist at the University of Alabama.
"Right after a stroke, a limb is paralyzed," Dr. Taub said. "Whenever the person tries to move an arm, it simply doesn't work." Even when all the cells that represent the arm in the brain are not dead, he said, the patient, expecting failure, stops trying to move it. "We call it learned non- use," Dr. Taub said.
When the patient relies on the good arm, the recovery of the use of the bad arm becomes less likely.
One approach, called constraint-induced movement-based therapy, rests on the principle that lots of practice can reorganize the brain, said Dr. Wolfgang Miltner, a neuroscientist at the Friedrich-Schiller University of Jena in Germany. But it has to be carried out in a specific manner.
"You don't just repeat movements," Dr. Miltner said. "You have to shape them, which means thinking about the elements of each movement."
In the therapy, a person's good arm is immobilized in thick bandages so the bad arm must be used. Or a good leg is put in a splint, forcing greater reliance on the bad leg. Patients practice moving the bad limb six to seven hours every day for two to three weeks. They sweep the floor, throw balls, draw, play checkers, or walk to the cafeteria.
More than 150 stroke patients have been treated with this method in Birmingham and in Germany, Dr. Taub said, and all have improved, some regaining a great deal of movement. The improvements appear to be permanent, he added.
Constraint-induced movement therapy
cannot work if it is given two hours a day for three days a week for a
couple of weeks, Dr. Taub said, which is what most medical insurance plans
allow. The therapy must be intensive and almost overwhelming, he said.
Copyright 2001 The New York Times
Copyright 2001 The New York Times Company