Chapter 14 - Neurorehabilitation approaches to facilitate motor recovery

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Abstract

Over the last decade a dramatic change has occurred in the field of neurorehabilitation in motor recovery that is marked by three transitions: first, by movement away from intuitive and ideology-based approaches to evidence-based therapy practices; second, by a change from hands-on treatment of patients to hands-off coaching approaches by motor therapists, who incorporate knowledge about motor reorganization and motor learning; and, finally, by a transition from one-on-one treatments to group-oriented treatments.

General rules (such as the need for repetition, feedback of results, shaping task difficulty) have been derived from the animal experimental and human behavioral literature and incorporated into the design of innovative treatment strategies that can be adapted to individual patients' needs.

This chapter reviews the state of the art for most of the evidence-based motor therapy concepts in the rehabilitation of patients with motor deficits after stroke, traumatic brain injury, etc., and other conditions. Treatment approaches derived from neuromodulation techniques such as stimulation or blockage of peripheral nerves, noninvasive brain stimulation, and pharmacological means are addressed. Finally, a modular concept is proposed to define optimal therapeutic approaches according to the individual level and type of impairment.

Section snippets

Paradigmatic change

Over the last decade there has been a dramatic change in the paradigms of motor rehabilitation. This can be marked by three transitions:

  • 1.

    From confession to profession, i.e., from intuitive motor rehabilitation strategies to knowledge-based selection of therapeutic regimes.

  • 2.

    From “hands on” treatment of patients to “hands off” coaching of patients. This means that the modern motor therapist in most instances is not treating the patient in a direct way but is rather working as a teacher giving the

Evidence-based medicine

In recent years the number of clinical trials addressing issues on efficacy of motor rehabilitation in neurology has increased so that the knowledge basis for decision making according to EBM has broadened. The limitations and possible shortcomings of purely EBM-based approaches in rehabilitation will be discussed later.

The recommended use of evidence-based principles to be applied in the selection of rehabilitation strategies follows two revolutionary aspects of 18th century epistemology: (1)

Advances ln knowledge about “motor learning”

Neurological motor therapies have taken advantage of the immense increase in scientific knowledge about motor learning, motor reorganization, cerebral recovery, and plasticity. Space is too limited here to give an extensive review, but it is important to shed some light on the basic elements that now contribute to a scientific basis for the advancement of motor therapeutic techniques. Knowledge of motor learning helps us understand the process of reducing kinetic mistakes and goal errors for

Training approaches for the upper extremity

This section will review evidence pointing to the applicability and usefulness of certain selected motor treatment strategies for the upper extremity.

Training approaches for the lower extremity

There are substantial differences in central motor organization between arm and leg movements. Arm movements are discrete, goal-directed, and under cortical control, whereas leg movements usually are rhythmical, not really goal-directed (except for kicking a football), and are primarily under subcortical control by spinal and supraspinal pattern generators. Nevertheless these two types of movement are similarly embedded into behavioral and environmental contexts. Therefore we can suppose that

The use of mechanical devices (robots)

Over the last decade mechanical devices have been introduced to enhance therapeutic options in neurological patients. When these machines are equipped with motors to actively move the patient's limb they may be called “robots”; however, this term may cause some misunderstanding. The term “robot” was coined after the Czech word for “hard work” in a drama by Kopek in 1922 describing man-like working machines. In this sense the term “robot” conveys the idea of replacement of human resources by

Modular therapies

It has been shown that there are multiple, evidence-based therapy options available for treating patients with motor impairments. The treatment time available for an individual patient is limited because of economic constraints. Therefore, it is usually not possible to systematically determine which particular approach will work in an individual patient. Consequently it appears useful to define therapy modules for various severities of motor problems in a particular part of the body (e.g.,

Where to go from here?

Considerable progress has been made in the scientific evaluation of neuromotor treatments, which is reflected in the increasing number of randomized controlled trials in this area. It must be kept in mind that many studies use strict inclusion/exclusion criteria which may make it difficult to generalize results to actual patients in rehabilitation settings. Study designs more applicable to “real” patients seen every day would be useful, and more multicenter studies are necessary.

Furthermore,

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