Journal of Neurologic Physical Therapy:
I write this on the flight home from an international motor control conference in Europe. Notwithstanding the excellent presentations, as is often the case with such meetings the exhilaration that accompanied the conference largely arose from the many informal, unscripted exchanges with enthusiastic research colleagues. The multidisciplinary nature of this conference brought to mind Dr. Carolee Winstein’s 2009 McMillan Lecture in which she called for us “to learn, engage in discussion, and collaborate.” During the presentations, I was struck by the great number of studies that were founded on strong collaborations among physical therapists, engineers, neurophysiologists, biomechanists, and others. The reciprocal exchange between applied and clinical science that is essential for optimal rehabilitation research is equally important for evidence-based clinical practice.
The nature of this particular meeting was such that there was a keen interest in studies that used high-tech interventions. At the same time, I was also pleased to note that despite the emphasis on high-tech approaches, fundamentals such as practice and training, and the need to select valid and sensitive outcome measures to track change, were also given their due. There was an implicit acknowledgment that the amazing plastic capacity of the human nervous system is the means by which any intervention has its effect, regardless of whether it is a high-tech or a low-tech approach. In fact, the true measure of the effectiveness of a high-tech intervention for improving function is in the extent to which it supports the capacity of the nervous system to adapt.
We are fortunate to live in a time when there has been an unqualified upheaval, relative to as little as two decades ago, in the way in which we think about the nervous system and its capacity for change. Our understanding of how the nervous system adapts in response to injury, how it recovers when exposed to training and practice, and how we can use this information to develop more targeted rehabilitation strategies has transformed the options that we can make available for the rehabilitation of individuals with neuropathology. In this issue, several of the articles and the Abstracts of Current Literature show how training and technology may assist the nervous system to make use of sensory information in a way that improves motor function. Together, they accentuate the importance of repetitive, long-term practice and of selecting the most appropriate outcome measures—highlighting the fundamental elements of neurologic physical therapist practice.
In a time when countless millions of dollars are spent on basic and clinical trials directed at developing pharmacologic and cellular transplantation/repair strategies to improve function in those with disorders of the nervous system, the fact remain that there are few interventions that have been shown to be more effective than rehabilitation. If a cellular repair or drug strategy were to result in a 30% to 50% improvement of the clinical signs and symptoms, it would be heralded as a great success. However, levels of improvement in this range are not uncommon with rehabilitation strategies.
Happily, it is likely that a day will come when the right combinations of strategies will be identified to repair the damaged nervous system—whether cellular transplantation or pharmacologic interventions—but these strategies can only be optimally effective when combined with the physical rehabilitation most conducive to promoting plasticity. Just as the developing nervous system requires activity and experience for cells to differentiate into a specific cell type, to sprout axons that grow to the correct target, and for these axons to form functional connections with those targets, newly transplanted cells will only be maximally functional if they are in the right environment—a body that is optimally healthy and exposed to the optimal experience (ie, training) for sufficient periods of time (ie, practice). Rehabilitation that makes optimal use of the body’s own reparative potential is, and will always be, the nexus of successful functional outcomes.