Promises and challenges of neurorehabilitation technology

An increasing number of technologies are being used in rehabilitation hospitals and clinics to help therapists and physicians improve recovery of upper or lower extremity function in patients who have sustained a severe neurological injury. These technologies include robotic devices such as exoskeletons, electrical stimulation systems, wearable sensors, and virtual reality training systems. While various types of robotic devices will likely continue to be developed for therapeutic purposes at rapid speed as technology improves, there has been limited systematic collection of higher levels of evidence for everyday clinical practice. This chapter examines some of the reasons for the limited collection of evidence thus far, and offers potential reasons why technological approaches have not been more successful in the clinical application of these systems. A brief discussion on some advances in robotics and rehabilitation science research is also presented. Finally, the chapter explores ways in which some of the observed performance limitations can be circumvented, leading potentially to more effective therapies in the near future.

Technology to enhance arm and hand function

About 2% of people have weak or paralysed upper limbs (ULs) due to stroke or spinal cord injury (SCI). Physiotherapy involving exercise can improve motor function in many such cases, but the time and resources required are often unavailable. Adherence to repeated intensive exercise tends to decline, especially after participants leave the clinical environment. There is a need for technology that can restore neuromuscular control and improve motivation by making exercise therapy enjoyable, and that extends the therapy into the home with the use of remote communication (e.g. ‘tele-coaching’). Over the last 20 years many devices have been developed and tested. Neuroprostheses (NPs) that activate UL muscles with functional electrical stimulation (FES) either via surface or implanted electrodes are now commercially available or in clinical trials. The use of robotic devices to enhance exercise therapy has been an active area of research and development. Recent studies indicate that improvements in motor function depend largely on the efforts made by the participant. This chapter reviews conventional exercise therapy, FES, and robotic and passive exercise devices that improve motor function and enhance engagement in UL rehabilitation. It is suggested that important developments in the next few years will include the widespread availability of affordable FES and in-home exercise devices, and the gradual adoption of tele-coaching over the internet.

Application of orthoses and neurostimulation in neurorehabilitation

Electrical stimulation can allow the recruitment of muscles to achieve functional movements. This approach is therefore very interesting to restore motor functions in subjects who have lost them because of neurological problems. In this chapter the main approaches to restoration of grasping and of locomotor functions using electrical stimulation and also the combined use of electrical stimulation and mechanical orthoses are presented. The potentials and limits related to the use of these different non-invasive or invasive techniques are highlighted and examined. Finally, a brief description of future trends and current limitations is also provided.

Self-management strategies in neurorehabilitation

This chapter examines self-management in a way that introduces evidence, ideas, and concepts which illustrate the benefits of a personalized collaborative approach to neurorehabilitation. It reviews constructions of self-management from the chronic disease literature and the relevance to neurology and overlapping methods such as shared decision-making, health coaching, and motivational interviewing. It also reviews the benefits of integrating key self-management strategies into clinical encounters and current methods of measuring outcomes. It has been written for any healthcare professional who seeks to understand how to support and enable self-management within neurorehabilitation.

Management of lower urinary tract, bowel, and sexual dysfunction

Lower urinary tract, bowel, and sexual dysfunctions are frequent sequelae of neurotrauma and neurodegenerative diseases that require adequate management. All three pelvic organ dysfunction severely compromise quality of life and can jeopardize health. Thus, treatment is mandatory and therapy options range from simple conservative measures to major surgery. The main therapeutic principles that should be considered in regard to treatment of pelvic organ dysfunction include protection of kidney function, reduction of urinary and/or faecal incontinence, independent management of lower urinary tract and bowel function, ability to sustain a satisfactory sexual relationship, fertility support, and improvement of quality of life. To comply with such principles and to select, initiate, maintain, and eventually adapt the ‘optimal’ treatment regimen for each patient requires a specialized multidisciplinary team not only during inpatient rehabilitation but also during outpatient follow-up. This chapter provides an overview on the management of lower urinary tract, bowel, and sexual dysfunction and aims to sensitize healthcare professionals for this essential part/aspect of neurorehabilitation.

Acquired disorders of language and their treatment

This chapter covers the classification of acquired aphasic syndromes. It illustrates some of the speech errors aphasic stroke patients make with videos of a patient describing a picture and attempting to repeat words. The main part of the chapter assesses the evidence base for speech and language therapy (SALT) and answers the following questions: Does SALT work? What is the correct dose and intensity? And is it ever too late for SALT intervention? We then discuss two main adjuvants to SALT: one old—drug therapy; one new—non-invasive brain stimulation. Finally, we examine the role for e-rehabilitation and augmentative aids before asking what the future might hold for aphasia therapy, and wondering if it might already be here.

Enhancement of neuroplasticity by drug therapy

This chapter reviews effects of central nervous system (CNS) active drugs specifically on activity-dependent plasticity and learning. The rationale for choosing this focus is the existing evidence that CNS active drugs have an impact on rehabilitation success after stroke to a relevant extent only if coupled with task-specific practice. This chapter reviews pharmacological modulation of stimulation-induced long-term potentiation (LTP) in animal and human studies because synaptic plasticity in the form of LTP is a basic mechanism of learning and memory processes. Next, the chapter reviews the evidence of CNS active drugs on learning in animal and human studies. In the third part, the impact of CNS active drugs on neurorehabilitation of stroke patients is surveyed and the translational cascade from basic research to clinical studies is described. Finally, limitations of the current studies, open questions, and future directions are discussed. This chapter demonstrates significant impact of neuropharmacology on activity-dependent plasticity and learning.

Stem cell application in neurorehabilitation

A number of diseases of the brain and spinal cord are associated with substantial neural cell death and/or disruption of correct and functional neural networks. In the past, a variety of therapeutic strategies to rescue these systems have been proposed along with agents to induce functional plasticity within the remaining central nervous system (CNS) structures. In the case of injury or neurodegenerative disease these approaches have only met with limited success, indicating the need for novel approaches to treat diseases of the adult CNS. Recently, the idea of recruiting endogenous or transplanting stem cells to replace lost structures within the adult brain or spinal cord has gained significant attention, along with in situ reprogramming, and opened up novel therapeutic avenues in the context of regenerative medicine. Here we review recent advances in our understanding of how endogenous stem cells may be a part of pathological processes in certain neuropsychiatric diseases and summarize recent clinical and preclinical data suggesting that stem cell-based therapies hold great promise as a future treatment option in a number of diseases disrupting the proper function of the adult CNS.

Animal models of damage, repair, and plasticity in the spinal cord

Sensorimotor function can improve for years, even after a spinal cord injury (SCI). We also know that an effective intervention that can improve motor function is re-engagement of the spinal neural networks through supraspinal control and that this regularity in re-engagement is fundamental to learning within the activated sensorimotor circuits. Several interventions, ranging from monoclonal antibodies against neurit outgrowth inhibitors to epidural electrical stimulation, have been developed allowing individuals with a SCI to re-engage sensorimotor circuits. These interventions enable spinal neural circuits to neuromodulate the level of excitability closer to a near motor threshold state. This is because of the built-in level of automaticity within the spinal circuits that then is translated into motor commands specified by the sensory input. Another increasingly apparent feature of the spinal circuitry is the highly integrated nature of multiple physiological systems linked to load bearing sensory input. Thus, it is clear that multiple physiological systems are highly responsive to activity-dependent interventions after a severe SCI and that this responsiveness can persist for years post-injury and be therapeutically modulated.

Designing a clinical trial for neurorehabilitation

The design, implementation, and analysis of clinical trials for the types of complex therapies needed to lessen impairments and disabilities that result from neurological diseases are reviewed. A multistep progression from feasibility testing in small groups of selected participants to the demonstration of efficacy in large-scale, multicentre randomized clinical trials is presented. Designs other than the ‘gold standard’ parallel-group trial can be used to optimize the contents of a new therapeutic strategy. Emphasis is placed on defining clinical characteristics and establishing a stable functional baseline for study participants. How the choices of outcome measure and comparison intervention affect the statistical and clinical significance of trial results are highlighted. Discussion of methodological concerns about randomization and blinded outcome assessment is followed by a review of common statistical confounders in neurorehabilitation trials. The use of consensus standards about trial reporting provides a valuable checklist for basic decisions in trial design.