Whether a brain or spinal cord injury is caused by a weapon of war, an accident, or a disease such as stroke, rehabilitation focuses on enabling people to make the most of what functions they still have. Physical, occupational, and speech therapy, counseling, and education can go only so far, however. For neurorehabilitation to offer the hope of curing the underlying brain damage, writes an expert in the field, it must look to basic science and better clinical trials to put to work the power of the brain’s plasticity.
More than 300,000 Americans every year receive a head injury severe enough to require medical attention, and about 75,000 of them end up with permanent neurological damage. Many more people suffer brain damage from stroke, multiple sclerosis, or Alzheimer’s and other diseases. The wars in Iraq and Afghanistan have focused the public’s attention on the potentially devastating nature of brain injuries because soldiers, whose bodies are protected by effective armor, are able to survive gunshot attacks and percussion injuries from IEDs (improvised explosive devices). Their hearts, lungs, and other vital organs are protected, and within minutes of an attack their vital body functions receive medical attention in the field. As a result, brain trauma represents a larger proportion of non-fatal war injuries than was seen in previous conflicts.
Men and women come home from the war with functional impairments that range from severe paralysis to problems with memory or speech to the more subtle but often devastating loss of the mental abilities that enable a person to concentrate on a problem and have the initiative to solve it. Without the ability to handle complex information, organize it into meaningful categories, set reasonable goals, and make good decisions, they cannot resume their careers or even successfully navigate daily life.
To give hope to our veterans suffering from traumatic brain injury as well as millions of people worldwide who have some kind of brain damage, we must seek to reverse this damage, not just ameliorate it. The current treatments for traumatic brain injury are inadequate. Rehabilitation medicine relies almost exclusively on techniques aimed at making the most of what neurological function is left, not changing the deficits themselves. Although in recent years, these techniques have received more careful scientific study, many in the field have sensed that progress has reached a standstill. For this to change, we must take an approach traditionally considered outside the definition of rehabilitation medicine: focusing on the underlying neurobiology and allowing ourselves the aspiration of actually curing brain damage through harnessing the brain’s power to change and heal.
The Traditional Approach
Rehabilitation medicine has been well ahead of the field of medicine in general because it emphasizes the importance of assessing patients’ functioning in practical tasks and of their quality of life. Traditionally, neurorehabilitation has The day does not hold enough hours to practice every single activity and, even if it did, improvement would be incomplete. employed physical, occupational, and speech therapies, evaluated the home and work environments, and worked hard to educate patients and families on strategies to compensate for lost functions. But as important as these strategies are, they cannot fully restore normal function, and research into improving their design and application does not appear to be leading to profound advances.
Typically, we retrain a patient to accomplish a specific task, using practice and repetition, but that one task is as far as it goes—what has been learned does not transfer to other tasks. For example, a stroke in the speech area of the left cerebral hemisphere may result in impaired language (aphasia), which includes difficulty finding the correct names for objects. A person may recognize a watch and understand its purpose but be unable to come up with the word “watch” when asked to identify one. With extensive practice, the aphasic person can eventually relearn to say “watch,” but this does not result in improved naming of other objects. In fact, after learning 100 words in this way, the person would take virtually the same amount of time to learn the next 100 words. Similarly, physical therapy, including passive stretching of tightened right arm and hand muscles and lots of practice performing tasks with that arm and hand, may improve those arm and hand functions, but only practicing walking can improve a limp that resulted from the same stroke.
These examples illustrate the limitations of traditional rehabilitation approaches. The day does not hold enough hours to practice every single activity and, even if it did, improvement would be incomplete.