More MS news articles for Nov 2001

The future of rehabilitation

Lies in retraining, replacement, and regrowth

BMJ 2001;323:1082-1083 ( 10 November )

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.1 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. 2 3 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 basenamely, 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.4 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.7 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.8 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. 9 10

Cajal's dictat that the adult central nervous system is hard wired and the consequences of damage immutable11 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.12 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 13 and treadmill retraining of gait,14 and 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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