Principles and Practice of Restorative Neurology

Butterworths International Medical Reviews

Robert R Young, Paul J Delwaide

• Publisher: Butterworth-Heinemann
• Year: 2013
• ISBN:
  9781483163222
• Topic: Medicine
• Subtopic: Internal Medicine & Diagnosis

Principles and Practice of Restorative Neurology is a collection of topics in clinical neurology where progress through research has brought concepts of patient management. The collection emphasizes research done clinically and in experimental laboratories and attempts to discuss restorative neurology in the larger context, encompassing biology, neurobiology, and rehabilitative engineering. The book discusses the concept that neurology should be more therapeutic instead of being just diagnostic because of advances in techniques and drugs. An epidemiology of disability and the evaluation of restorative neurology are explained. The text also presents the developments in the pharmacotherapy of major neurological disorders, such as Parkinson's disease, dementia, and stroke. The use of biomechanical or rehabilitation engineering to treat impaired or lost functions in a patient is compared; the feedback mechanisms and the kinds of treatment including microsurgery, nuerostimulation methods, surgery, and molecular genetics that are applied to specific disorders are discussed extensively. The book also reviews the approaches of gene correction for disorders in the central nervous system. Finally, the future needs of neurology in terms of diagnosis and treatments are dealt with as more research, techniques, and drugs are being discovered and proved useful. The collection is intended for neurologists, neurologists in training, and other physicians whose work lies with neurological disorders. The book can also prove useful for practitioners and academicians in the fields of neurosurgery, internal medicine, psychiatry, and rehabilitation medicine.

1

Introduction—why restorative neurology?

P.J. Delwaide and R.R. Young

Publisher Summary

This chapter discusses the importance of restorative neurology. Restorative neurology is a subspecialty of neurology, and it deals with techniques and strategies used to restore a disordered nervous system to a state of optimal function. Restorative neurology is characterized by a pathophysiological approach to nervous system disease and, as such, differs from neurosurgery, which is primarily an anatomical discipline, and from pharmacology, which relies essentially on neurochemistry. In addition to being multidisciplinary, restorative neurology is uniquely dependent upon the two endeavors. The first endeavor is quantitative evaluation of neurologic deficits, which is the cornerstone of restorative neurology. Proposed therapeutic efforts must prove their efficacy on an objective basis, and quantitative assessment is mandatory if one is to be able to compare results and outcomes. This goal is difficult to achieve because tools of assessment are in development and rarely incorporated into the routine practice of most neurology departments. The second essential endeavor is clinical neurophysiology. In addition to providing objective data to contribute to assessment, clinical neurophysiology also permits pathophysiological analyses of the consequences of nervous system lesions.

Neurologic impairments and disabilities constitute important medical and socio-economic problems. Paradoxically, treatment of chronic neurologic diseases has been considered frustrating and of little value. Neurology has been viewed as a medical specialty more concerned with diagnosis than with therapy.

This opinion should now be changed. In the last 20 years, indisputable progress has been made in the discovery of techniques which reduce patients’ disabilities and ameliorate their discomfort. However, to an extent unusual in other medical disciplines, these therapeutic modalities are not represented only by drugs but involve various procedures; surgical, psychological or rehabilitative in nature. Parkinson’s disease provides a good example of the way in which different useful techniques have evolved. In the 1960s, before the advent of dopamine precursors and agonists, patients benefited from stereotactic surgery. In the 1980s, the major problem was to define optimal strategies of pharmacologic treatment. The 1990s promise neural grafting although it will certainly not replace drug therapy and has yet to establish its proper place in overall management. New approaches have been developed for the management of patients with spinal cord injuries which aim to reduce the extent of their lesions and make their lives longer and more productive. In neurology, disability is not only the consequence of dysfunctions in cell metabolism but often results from disruptions of neuronal circuits; These disconnections trigger compensatory and adaptive mechanisms which, when understood, may be improved by drugs or by alternative strategies such as training or correction of imbalance between excitatory and inhibitory processes.

There are many new therapeutic techniques to complement well established ones but they may appear disparate and clinicians are faced with confusing choices, sometimes in competition with one another, to improve their patients’ function. Classically trained doctors may be reluctant to turn to new techniques but many clinicians are interested in the rationale, principles and achievements of these unusual or new procedures. They are anxious to identify those which are well-founded and derive directly from advances in the field of neuroscience and to discriminate them from other empirical ones which are advocated on the basis of anecdotal evidence. In addition, some clinicians are eager to learn about research techniques, such as neural grafting, which hold promise for the future.

The above mentioned considerations have promoted the development of this book, Principles and Practice of Restorative Neurology. Each term in the title deserves comment.

The principles describe the rationale behind available therapeutic techniques as well as future ones which will derive from actual achievements in experimental neurology. They indicate, from a theoretical point of view, the promises and limitations of transposition to human pathology of advances being made in animal laboratories. This intellectual approach, however, is not sufficient for clinicians who have to make decisions for individual patients, choose the best treatment and learn to apply it. Practice is thus a complementary aspect which derives from principles or sends investigators back to the laboratory to discover new principles. Practice refers to the well established procedures that have proved useful including how and when to apply them.

Although all of us would welcome critical and quantitative analyses of techniques currently employed in the practice of restorative neurology, such data, for the most part, do not exist. Collecting such data is an important aspect of the future of restorative neurology.

Restorative neurology is a subspecialty of neurology; it deals with techniques and strategies used to restore a disordered nervous system to a state of optimal function. Restorative neurology is characterized by a pathophysiological approach to nervous system disease and, as such, differs from neurosurgery which is primarily an anatomical discipline and from pharmacology which relies essentially on neurochemistry. However, restorative neurology tries to integrate these modalities of treatment into a comprehensive approach to the patient’s disability; it combines disparate disciplines, including new techniques derived from neurobiology, in a pragmatic attempt to improve neurologic functions. It is thus not surprising that restorative neurology encompasses a range of interests; some of these include pharmacology, plasticity, retraining, motivation, substitution, rehabilitation, functional surgery, neural grafting, and genetic engineering.

To be applied effectively, these various modalities of treatment require specialists so restorative neurology relies on a team of physicians, scientists and paramedical personnel assisting them. A coordinator experienced in many of the various aspects of care must define strategies of treatment and assess overall results. At this time, a neurologist seems best suited for that role.

In addition to being multidisciplinary, restorative neurology is uniquely dependent upon the following two endeavors. First is quantitative evaluation of neurologic deficits which is the cornerstone of restorative neurology. Proposed therapeutic efforts must prove their efficacy on an objective basis; quantitative assessment is mandatory if one is to be able to compare results and outcomes. This goal is difficult to achieve because tools of assessment are in development and rarely incorporated into the routine practice of most neurology departments. A continuous effort must be maintained to obtain reliable methods of assessment and, considering the interest raised in recent years by quantification of neurologic deficits, codification and generalization of these procedures which can be accepted worldwide may be expected. The second essential endeavor is clinical neurophysiology. In addition to providing objective data to contribute to assessment, clinical neurophysiology also permits pathophysiological analyses of the consequences of nervous system lesions. These results are useful to explain not only the general mechanisms involved in common syndromes such as spasticity but also to specify the unique functional particularities of individual patients. Clinical neurophysiology provides means to help understand defective function of the nervous system, develop strategies to correct abnormalities and assess the results. Finally, clinical neurophysiology has practical advantages because its equipment and techniques are widely available and not expensive; however, they are time-consuming.

One may, however, ask whether restorative neurology is a new field in neurology or is only a new name for an old practice, namely rehabilitation. Where does restorative neurology find its place and where are its borders with established medical specialities? We believe restorative neurology has a specific place in the treatment of individuals with neurologic disorders which can best be understood by considering schematically the sequence of events occurring immediately after a nervous system lesion. Similar considerations apply to patients following initial diagnosis of a chronic progressive disorder.

The first step is to make a correct diagnosis including a lesion’s localization and extent. If possible, adequate measures are taken immediately to halt progression of the lesion and suppress its effects. This phase is that of diagnosis and acute treatment and may require an Intensive Care Unit. If acute management does not succeed completely, the patient is left with a permanent lesion and following that, biological processes such as plasticity and compensatory mechanisms enter into play to rearrange the nervous system and restore function. A pathophysiological approach to the patient combined with good knowledge of neurobiology may at that stage help one to enhance the recovery process. This is the role of restorative neurology. Many complementary techniques, and new ones appear regularly, are put in place to limit or compensate for disability.

This part of the treatment is the responsibility of a neurologist who knows nervous system semeiology and has the background to understand future developments in neurobiology. Neurologists are accustomed to interpreting results of sophisticated procedures such as brain mapping, MRI and CT scans. The role of the neurologist is not to apply all the therapeutic techniques but to act instead as a coordinator, defining the best strategy and the timing for specific specialists, such as speech therapists, to intervene.

When the lesion has reached a stable state, rehabilitation and retraining may commence. This aspect is more concerned with protheses, occupational therapy and readaptation to society. The burden of socio-economic factors is particularly obvious at this stage and social workers assist the rehabilitation team to reintegrate the patient into society.

This sequence of medical care delivery is only a scheme; in many instances, one or two steps may be missing and multiple interactions and overlapping efforts are needed between the various phases. However, such a sequence corresponds to the evolution of a neural lesion and identifies individual responsibilities throughout the course of a neurologic disease. If not yet clearly or officially formulated, this opinion appears to be shared by an increasing number of clinicians.

This book is not intended to be a treatise on therapy for chronic neurological diseases. It aims, instead, to underline critically the convergence of distinct techniques in some selective exemplary areas of neurology. The editors are aware that it does not cover all the interesting aspects and apologize for that. For example, adult rather than pediatric neurologic disorders are emphasized and retraining of cortical functions after a stroke or a head injury is not discussed. These related aspects are well covered in other textbooks to which we recommend the reader (Ilis et al., 1982; Kaplan and Ceullo, 1985; Malony et al., 1985; Leek et al., 1986). We hope neurologists will find useful information here for understanding the rationale of standard as well as new therapeutic approaches and their application. However, our ultimate goal would be to stimulate young investigators to work on these problems to provide a firmer basis for an integrated therapy of neurological deficits.

References

Illis, LS, Sedgwick, EM, Glanville, HJRehabilitation of the Neurological Patient. Oxford: Blackwell Scientific, 1982.

Kaplan, PE, Ceullo, LSStroke Rehabilitation. Boston: Butterworths, 1985.

Leek, JC, Gershwin, ME, Fowler, WWPrinciples of Physical Medicine and Rehabilitation in Musculo-skeletal Diseases. Orlando: Straton, 1986.

Malony, FP, Burk, JS, Ringel, SPInterdisciplinary Rehabilitation of Multiple Sclerosis and Neuromuscular Disorders. Philadelphia: Lippincott, 1985.

2

Epidemiology of disability

D.L. McLellan

Publisher Summary

This chapter describes the epidemiology of disability. The relationship between disease and handicap is extremely complex. Many diseases or injuries cause impairments—that is, loss of a part or function. Some impairment lead to disability—that is, any restriction or lack, resulting from impairment, of ability to perform an activity in the manner or within the range considered normal for a human being. Most people with stroke, Parkinsonism, and multiple sclerosis have disability of some kind, whereas only one in every five people with arthritis is disabled at any point in time. There will be 30 times more people with disabilities caused by arthritis than there are with disabilities caused by multiple sclerosis because arthritis is much more common. Some indication of the propensity of different diseases to cause severe disability can be judged by comparing figures from disabled people living in private households with those living in communal establishments.

Discussion of this topic has become less complicated since the World Health Organization (WHO) formulated technical definitions for the terms ...

Table of contents

• Cover image
• Title page
• Table of Contents
• Butterworths International Medical Reviews
• Copyright
• Contributors
• Foreword
• Series Preface
• Chapter 1: Introduction—why restorative neurology?
• Chapter 2: Epidemiology of disability
• Chapter 3: Quantitative evaluation of the results of restorative neurology
• Chapter 4: Biochemical changes and secondary injury from stroke and trauma
• Chapter 5: Applications of principles of brain plasticity and training to restore function
• Chapter 6: Recent developments in the pharmacotherapy of major neurological dysfunction
• Chapter 7: Compensating for impaired or lost function—biomechanical or rehabilitation engineering
• Chapter 8: Bio-feedback and principles of motor learning in the rehabilitation of movement disorders
• Chapter 9: Applications of principles of training to neuromuscular disorders
• Chapter 10: Stroke rehabilitation: the scientific basis for a ‘model’ service
• Chapter 11: Acute and long-term care of patients with spinal cord injury or impairment
• Chapter 12: Multiple sclerosis—treatment and rehabilitation
• Chapter 13: Microsurgical DREZ-tomy for the treatment of pain and spasticity
• Chapter 14: Rehabilitation in Parkinson’s disease, day care programs for demented patients, and aids for living and home modifications for patients with neurologic physical disability
• Chapter 15: Thalamotomy in parkinsonism
• Chapter 16: Neurostimulation methods for correcting functional imbalances
• Chapter 17: Surgical treatment of epilepsy
• Chapter 18: Applications of molecular genetics to restorative neurology
• Chapter 19: An approach to the genetic correction of defects and disorders of the central nervous system
• Chapter 20: Summary and future needs
• Appendix
• Index