As neurologists, we have been trained to focus on the diagnosis and treatment of a wide array of diseases of the central and peripheral nervous systems. Regular readers of CONTINUUM hone these skills and demonstrate their desire to maintain and improve their diagnostic and treatment expertise. But patients care far less about the names of their conditions and of the prescribed medications than they do about function, a territory staked out by physiatrists and other members of the rehabilitation team, including physical and occupational therapists and speech-language pathologists. While some neurologists may develop expertise in neurorehabilitation and work in this area, all of us should develop a better understanding of the field and complement the efforts of the neurorehabilitation professionals to help patients achieve their maximal level of function.
In this issue of CONTINUUM, Dr Mary Dombovy and a cadre of experts in the field bring us up to date on the current state of the art and science of neurorehabilitation. Many of us are accustomed to referring patients after the hyperacute phase of an illness, as well as many individuals with chronic neurologic disease, to "PT/OT/Speech." Yet I suspect that you may have little understanding of what happens after that. I think that you, like I, not only will be astonished at the variety of strategies and techniques available to improve the quality of life for our patients but also will be fascinated by some of the approaches on the horizon.
In her introduction, Dr Dombovy delineates the excitement about advances in understanding the plasticity of the nervous system and its possibility for regeneration and repair but also laments some of the difficulties in successfully accomplishing research in the field of neurorehabilitation. Highlighting the theme of function, Dr David Gelber next discusses the neurologic examination from the unique perspective of the neurorehabilitationist.
Cognitive and behavioral disorders are not only common sequelae of neurologic illness or trauma but also frequently have a negative effect on the rehabilitative process. Drs William Schneider and Tony Wong address this problem as well as possible ways to improve the situation. This is followed by a discussion of the frequently encountered impairments of language, motor speech, and swallowing by speech-language pathologists Maria Anderson, Jessie Anzalone, Lauren Holland, and Elvira Tracey. The authors describe not only traditional methods of dealing with these problems but also more recently developed techniques. In the subsequent article, Dr Cecilia Lim Ransom tutors us on the amazing array of orthoses and adaptive equipment that has been developed to aid patients with a variety of impairments. The sophistication of these devices and the need to tailor them specifically to each individual is fascinating.
Patients under the care of a neurorehabilitation team are often still quite sick after an acute neurologic event. In addition, those with chronic nervous system disease are often elderly or debilitated. Thus they are subject to a wide variety of medical complications, which the physiatrist must be adept at recognizing and managing. So, too, must the neurologist, who often continues to be involved in the care of these patients. Drs Carolin Dohle and Michael Reding make sure that you are up to the task.
Dr Dombovy returns to provide an exciting article titled "Emerging Therapies in Neurorehabilitation." While neurologists are accustomed to prescribing medications in the treatment of their patients, you might be surprised at the variety of pharmacologic agents now being used by physiatrists in the management of patients during neurorehabilitation. Dr Dombovy describes these fascinating advances, including constraint-induced movement and language therapy, novel neurostimulatory methods, robot-assisted therapy, and body weight-supported treadmill training.
The last four review articles move us from what has been generally a symptom approach to focus on specific neurologic disorders. Drs David Good, Kerstin Bettermann, and Raymond Reichwein address stroke rehabilitation, and Dr Mark LiVecchi focuses our attention on spinal cord injury. Subsequently Dr Dombovy brings us up to date on the specific neurorehabilitation issues facing patients with traumatic brain injury and other neurologic diseases, including multiple sclerosis, Parkinson disease, and ALS.
The practice section of this issue contains several valuable contributions. First, Ms Susan Vogl addresses the management of acute neurorehabilitation programs. While few of us are likely to enter the business of operating neurorehabilitation facilities, this is, nonetheless, a very important article because it helps us to understand the various types of programs and the qualifications a patient must have for admission to each. Revisiting the notion of function and returning us to the medical model, Dr Peter Gorman educates us about how the review of systems, sometimes relegated by physicians to an afterthought, informs the management of patients with spinal cord injury. Finally, Drs Anna Barrett and Laura Powers provide a helpful coding table for your use with patients in need of neurorehabilitation.
The need for neurorehabilitation is not unique to adults; it is commonly important in children as well. But what happens when parents refuse medical treatment, whether in the sphere of rehabilitative efforts or other advice? In this issue's section on Ethical Perspectives, Dr Geoffrey Miller considers this predicament in his article, "The Limits of Parental Authority to Accept or Refuse Medical Treatment."
I am confident that you will learn much new information in this issue of CONTINUUM. You can gain yet more knowledge, while simultaneously testing yourself and earning CME, by working through the Patient Management Problem developed by Dr Dombovy and the multiple-choice questions provided for this issue by Drs Ronnie Bergen and Joanne Lynn.
Finally, this issue of CONTINUUM is enhanced by an accompanying CD compiled by Dr Dombovy that illustrates many aspects of neurorehabilitation addressed in the issue. References to specific video segments included on the CD appear throughout the issue and will lead you to a deeper understanding of the material.
I am most appreciative of the efforts of Dr Dombovy and her colleagues, who have provided insight into an important area of neurologic care in which my knowledge was inadequate. I believe you will share my view. Dive in!
-Aaron E. Miller, MD