The Emerging Potential of Neurorehabilitation A century of pessimism about the potential for neurorehabilitation began with Cajal’s description, made over 100 years ago, of the synapse in the central nervous system (CNS). His view that there was little potential for changes (plasticity) to synaptic connections after puberty effectively became dictum for much of the 20th ... Features
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Features  |   December 01, 2004
The Emerging Potential of Neurorehabilitation
Author Notes
  • Leslie Gonzalez-Rothi, currently serves as program director of the VA RR&D Brain Rehabilitation Research Center at the Gainesville VA Medical Center; as professor of Neurology in the University of Florida (UF) College of Medicine, faculty of the UF Brain Institute; and professor of Communication Sciences and Disorders in the UF College of Liberal Arts and Sciences. Contact her at gonzalj@neurology.ufl.edu.
    Leslie Gonzalez-Rothi, currently serves as program director of the VA RR&D Brain Rehabilitation Research Center at the Gainesville VA Medical Center; as professor of Neurology in the University of Florida (UF) College of Medicine, faculty of the UF Brain Institute; and professor of Communication Sciences and Disorders in the UF College of Liberal Arts and Sciences. Contact her at gonzalj@neurology.ufl.edu.×
Article Information
Speech, Voice & Prosodic Disorders / Special Populations / Healthcare Settings / Language Disorders / Aphasia / Attention, Memory & Executive Functions / Features
Features   |   December 01, 2004
The Emerging Potential of Neurorehabilitation
The ASHA Leader, December 2004, Vol. 9, 29-30. doi:10.1044/leader.FTR4.09222004.29
The ASHA Leader, December 2004, Vol. 9, 29-30. doi:10.1044/leader.FTR4.09222004.29
A century of pessimism about the potential for neurorehabilitation began with Cajal’s description, made over 100 years ago, of the synapse in the central nervous system (CNS). His view that there was little potential for changes (plasticity) to synaptic connections after puberty effectively became dictum for much of the 20th century with few challenges from neuroscientists, and acceptance by clinicians that, following CNS injury in adulthood, recovery was limited to what nature could provide.
Rehabilitation efforts have historically been focused primarily upon helping survivors compensate for their disabilities. To the extent that neurorehabilitation efforts strove to reconstitute function, the strategies employed were based upon pragmatic or theoretical considerations that bore little if any relationship to neural processes. These restitutive efforts have been viewed with significant skepticism by those outside the field of speech-language pathology. However, the last 25 years have seen several parallel lines of physiologic investigation that recently have come together in gradual confluence and are now poised to have a profound impact on the clinical practice of neurorehabilitation.
As a result of these recently emerging discoveries, neurorehabilitation is undergoing a dramatic paradigm shift that weds the rapidly expanding basic science of neural plasticity to applied approaches including behavioral and pharmacological restitutive/substitutive treatments.
A New Optimism
While the wedding of basic science to clinical application in neurorehabilitation is a significant paradigm shift for all of us in rehabilitation (speech-language pathologists, audiologists, physical therapists, occupational therapists, etc.), neuroscience now provides plausibility and even optimism to the possibility of reconstituting damaged neural functions, and it generates hypotheses that motivate specific clinical therapeutic experiments.
We now know that rehabilitation after brain injury depends upon two processes: (1) the endogenous responses of neural tissues (reactive plasticity), which include reactive neurogenesis, neural migration, axonal sprouting and extension to target structures, and synaptogenesis; and (2) the replacement of knowledge lost due to injury through experience-based, behavioral interventions. The study of these processes at the confluence of basic and applied sciences in neurorehabilitation has provided the motive for “experience-dependent learning methods” such as constraint-induced movement therapy (CIMT) for paresis following stroke (Taub et al., 1999). Although there has certainly been controversy about the specifics of CIMT-in particular whether this particular form of therapy warrants wide application at this point (Siegert et al., 2004)-the principles have found wider applicability such as that found in “body weight supported treadmill therapy” for gait impairment following spinal cord injury (Behrman & Harkema, 2000), for one example.
The focus of these approaches is on the “replacement of knowledge” through the act of doing the desired behavior. Additionally, the idea is to do it intensively and avoid behaviors that serve to compensate for or are in lieu of the desired behavior. A promising avenue for extending these principles of “experience (or use or activity) dependent learning” beyond exclusively applying them to motor dysfunctions has been described by Pulvermuller and colleagues (2001) in their study of a method of rehabilitation for chronic forms of aphasia. These investigators reported that individuals with chronic, stable aphasia benefited (statistically as well as clinically) from language treatment designed to include attributes of CIMT (forced-use delivered in high doses over a relatively short period of time).
Our research program here at the Veterans Administration Rehabilitation Research and Development (VA RR&D) Brain Rehabilitation Research Center emphasizes the application of experience-dependent learning principles compatible with neural processes of recovery to chronic motor or cognitive dysfunctions resulting from neurologic disease or injury, including several studies specific to aphasia. These include a pilot study led by Lynn Maher (Houston VAMC & Baylor College of Medicine) and funded by the VA RR&D Service in which we attempt to expand and formalize a method referred to as Constraint Induced Language Therapy, begin to control for confounding variables, and study varying treatment intensities.
Additional studies are ongoing at our center that study further aspects of “experience-dependent” learning principles as applied to language, including one led by Diane Kendall (Gainesville VAMC and University of Florida) that focuses on phonological processes in which she uses an adapted version of the LIPS program (Lindamood et al., 1997). Another, led by Maher, is studying errorless learning applications in a treatment targeted at the sentence level, and two by Anastasia Raymer (Old Dominion University) and Bruce Crosson (Gainesville VAMC and University of Florida) focus on treatment targeted at deficits at the lexical level. All the studies look at aspects of experience-dependent learning principles as applied to language rehabilitation. We are expanding our focus to other aspects of communication including a project led by Jay Rosenbek and Ken Heilman (University of Florida and Gainesville VAMC) focused on refinements of a treatment for aspects of aprosodia.
All of these studies focused on motor systems will serve collectively to tell us the story on the value of experience in informing a recovering nervous system.
Neurorehabilitation References
Behrman, A. L., Harkema, S. J. (2000). Locomotor training after human spinal cord injury: A series of case studies. Physical Therapy, 80, 688–700. [PubMed]
Behrman, A. L., Harkema, S. J. (2000). Locomotor training after human spinal cord injury: A series of case studies. Physical Therapy, 80, 688–700. [PubMed]×
Lindamood, P., Bell, N., Lindamood, P. (1997). Sensory-cognitive factors in the controversy over reading instruction. Journal of Developmental and Learning Disorders, 1, 143–182.
Lindamood, P., Bell, N., Lindamood, P. (1997). Sensory-cognitive factors in the controversy over reading instruction. Journal of Developmental and Learning Disorders, 1, 143–182.×
Maher, L. M., Kendall, D., Swearengin, J. A., Pingel, K., Holland, A., & Rothi, L. J. G. (2003). Constraint induced language therapy for chronic aphasia: Preliminary findings. Journal of the International Neuropsychological Society, 9, 192.
Maher, L. M., Kendall, D., Swearengin, J. A., Pingel, K., Holland, A., & Rothi, L. J. G. (2003). Constraint induced language therapy for chronic aphasia: Preliminary findings. Journal of the International Neuropsychological Society, 9, 192.×
Meinzer, M., Elbert, T., Wienbruch, C., Djundja, D., Barthel, G., & Rockstroh, B. (2004). Intensive language training enhances brain plasticity in chronic aphasia. BMC Biology, 2, 20. [Article] [PubMed]
Meinzer, M., Elbert, T., Wienbruch, C., Djundja, D., Barthel, G., & Rockstroh, B. (2004). Intensive language training enhances brain plasticity in chronic aphasia. BMC Biology, 2, 20. [Article] [PubMed]×
Pulmermuller, F., Neininger, B., Elbert, T. R., Mohr, B., Rockstroh, B., Koebbel, P., & Taub, E. (2001). Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32, 1621–1626. [Article] [PubMed]
Pulmermuller, F., Neininger, B., Elbert, T. R., Mohr, B., Rockstroh, B., Koebbel, P., & Taub, E. (2001). Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32, 1621–1626. [Article] [PubMed]×
Siegert, R. J., Lord, S., & Porter, K. (2004). Constraint-induced movement therapy: Time for a little restraint? Clinical Rehabilitation, 18,110–114. [Article] [PubMed]
Siegert, R. J., Lord, S., & Porter, K. (2004). Constraint-induced movement therapy: Time for a little restraint? Clinical Rehabilitation, 18,110–114. [Article] [PubMed]×
Taub, E., Uswatte, G., & Pidikiti, R. (1999). Constraint-induced movement therapy: A new family of techniques with broad application to physical rehabilitation—a clinical review. Journal of Rehabilitation Research and Development, 36, 237–251. [PubMed]
Taub, E., Uswatte, G., & Pidikiti, R. (1999). Constraint-induced movement therapy: A new family of techniques with broad application to physical rehabilitation—a clinical review. Journal of Rehabilitation Research and Development, 36, 237–251. [PubMed]×
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December 2004
Volume 9, Issue 22