The Clinical Practice of Restorative Neurology
A nervous system injury is often a devastating life-altering event. While great strides in our ability to extend life expectancy and “cope” with the new deficits have been realized, comparatively little has been accomplished to enhance the quality of life of these individuals.
When a healthy central nervous system sustains an injury, plasticity ensues and a new system emerges. That is, the input, processing and output of the system are altered so that different “rules” now apply. Restorative Neurology is the specialty concerned with investigating and defining this new system and optimizing its output based on what is found. The goal of the Restorative Neurologist is to provide the most adaptive output for the given constraints of this new system.
Defining this new system involves gathering observations which are based on detailed physical examination, neuroimaging techniques and neurophysiology. While the first two categories are indispensible, we believe that recent advancements in neurophysiology hold the key to unlocking the residual capacity of this altered nervous system and directing restorative strategies.
Understanding the injured nervous system involves understanding the degree of residual subclinical descending control, regions of preserved “normal” motor control, contribution of lower motor neuron injury to the motor impairment, and the presence or absense of systems below the injury zone, such as basic segmental reflexes or more sophisticated pattern generators. Good neurophysiological methods exist to answer each of these questions (e.g. BMCA, LSEP, SESCE, strength-duration assessments, etc.) and the effective implementation of these methods can allow for a detailed profiling of the new system.
An array of diverse interventions have emerged in recent years many of which have demonstrated promise for functional recovery in at least a subset of patients. These interventions have ranged from the more traditional tendon transfers to recent advances in nerve transfers, from constraint-induced therapy to robotic movement training, from single function functional electrical stimulation (FES) systems to electrical pattern generator activation via epidural stimulation, from pharmacological descending control optimization to stem-cell therapies, and new strategies continue to emerge.
Any intervention must be tailored to the personal goals of the patient, taking into account cooperation, motivation, age and psychosocial factors. Once functional priorities have been established, a restorative/reconstructive plan is constructed with the patient understanding that their motivation and long-term participation in this process is crucial. We believe that effective utilization of the tools available today will not only shed light on which strategies will benefit a particular patient but can help assess the real impact of a particular intervention.
This is an exciting time in the field of restorative neurology as we learn to assimilate available methods and apply them in an effective manner. Our patients stand to benefit substantially from the organized implementation of available methods. A number of clinical centers belong to our network and while none can provide all that exists to improve motor control, each holds specific expertise which represent the cutting edge of contemporary restorative neurology.
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