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New treatments in neurorehabiliation founded on basic research

Nature Reviews Neuroscience volume 3, pages 228–236 (2002)Cite this article

Key Points

  • The traditional view in neuroscience was that the mature brain had little capacity to repair itself in response to injury. However, research from several laboratories has shown that the adult nervous system can reorganize after a lesion. A crucial issue is whether this capacity for repair can be helpful to a patient with neurological injury.

  • When somatic sensation is abolished from a monkey forelimb, the animal does not make use of it, even though the motor outflow remains intact. But monkeys can be induced to use the deafferented extremity by restricting movement of the intact limb for a number of days and training the deafferented limb. In this regard, the training technique known as 'shaping' (a method in which a behavioural objective is approached in small steps, such that the improvement required at any time is small) has been very successful.

  • Nonuse of the deafferented limb seems to be a learning phenomenon that involves a conditioned suppression of movement — 'learned nonuse'. Restraint and training techniques, such as Constraint-Induced (CI) Movement therapy, seem to work by overcoming learned nonuse.

  • CI therapy involves training of the affected arm and restraint of the contralateral arm for a period of two or three weeks. This leads to imperfect, but substantially increased, use of the paretic arm that persists even after the constraint is removed. One mechanism by which CI therapy might result in motor improvements is by promoting the cortical reorganization that has been shown to occur.

  • The original CI therapy has been extended to treat deficits in arm use in people with traumatic brain injury, focal hand dystonia, phantom limb pain and aphasia. CI therapy has also been used to treat lower limb impairments in people with chronic stroke, spinal cord injury and hip fractures.

  • Other new approaches to rehabilitation are beginning to emerge from progress in basic research in neuroscience; for example, an effective remedial approach in people with dyslexia. Importantly, the new approaches are not restricted solely to the motor system, but also encompass several sensory modalities, as exemplified by the earlier development of cochlear implants and, recently, of tactile substitution systems for vision.

Abstract

Recent discoveries about how the central nervous system responds to injury and how patients reacquire lost behaviours by training have yielded promising new therapies for neurorehabilitation. Until recently, this field had been largely static, but the current melding of basic behavioural science with neuroscience promises entirely new approaches to improving behavioural, perceptual and cognitive capabilities after neurological damage. Studies of phenomena such as cortical reorganization after a lesion, central nervous system repair, and the substantial enhancement of extremity use and linguistic function by behavioural therapy, support this emerging view. The ongoing changes in rehabilitation strategies might well amount to an impending paradigm shift in this field.

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Figure 1: Development and overcoming of 'learned nonuse' of an upper extremity.
Figure 2: Constraint-Induced Movement therapy.
Figure 3: Types of recovery.
Figure 4: Reorganization in the motor cortex of a monkey after rehabilitative therapy.
Figure 5: Change in motor coordination and movement pattern in musicians as a result of therapy.

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Acknowledgements

We thank the James S. McDonnell Foundation for supporting a conference on “The impending paradigm shift in neurorehabilitation and remediation: the melding of basic research in neuroscience and behavioral science to produce advances in therapeutics.” This conference, on which the article is based, was organized by E.T., W. H. R. Miltner and T.E., and was held at the University of Alabama at Birmingham in 2001.

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  1. Birmingham Veterans Affairs Medical Center and Department of Psychology, University of Alabama at Birmingham, CPM 712, 1530 3rd Avenue South, Birmingham, 35294-0018, Alabama, USA

    Edward Taub & Gitendra Uswatte

  2. Department of Psychology, University of Konstanz, P.O. Box D25, Konstanz, D-78457, Germany

    Thomas Elbert

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FURTHER INFORMATION

Broca, Pierre Paul

cortical plasticity: use-dependent remodelling

Jackson, John Hughlings

stroke

traumatic central nervous system injury

Glossary

CONDITIONED RESPONSE TECHNIQUES

Methods inspired by studies of operant conditioning in which a specified response is strengthened or increased in frequency by presenting a reward after its performance.

SHAPING

An operant training method in which a desired motor or behavioural objective is approached in small steps — by successive approximations — so that the improvement required for successful performance at any point in the training programme is small.

EFFECT SIZE

A measure of effect that is adopted when different scales are used to measure an outcome. It is usually defined as the difference in means between the experimental and control groups, divided by the standard deviation of the control or both groups. As effect size is a standardized measure, it allows us to compare and/or combine the effects found in different studies of the same phenomenon.

TRANSCRANIAL MAGNETIC STIMULATION

A technique used to induce a transient stimulation of activity in a relatively restricted area of the brain. It is based on the generation of a strong magnetic field near the area of interest, which, if changed rapidly enough, will induce an electric field that is sufficient to stimulate neurons.

MAGNETIC SOURCE IMAGING

The detection of the changing magnetic fields that are associated with brain activity, and their subsequent overlaying on magnetic resonance images to identify the precise source of the signal.

READINESS POTENTIAL

A broad negativity in the electroencephalogram that begins 300–3,000 ms before voluntary movements. One peculiarity of the readiness potential is that, whereas most event-related potential are time-locked to the arrival of an input, the readiness potential is time-locked to an output and always precedes it.

FOCAL HAND DYSTONIA

Manual incoordination in people that engage in extensive and forceful use of the digits.

APHASIA

A language impairment that is acquired as a result of stroke or other brain injury.

SPECIFIC LANGUAGE IMPAIRMENT

A term that is often assigned to developmental language disorders that do not have any other apparent social, psychological or neurological cause.

DYSLEXIA

Difficulty in learning to write, spell and read that is observed in people of otherwise normal intelligence. In some cases, a genetic cause is suspected.

STOP CONSONANT

Spoken sounds vary depending on the degree of air-stream opening. Vowels are the most open sounds, followed by liquid, nasal, fricative and stop consonants, in which the air stream is maximally obstructed. In English, the six stop consonants are p, t, k, b, d and g.

MAGNETOENCEPHALOGRAPHY

A non-invasive technique that allows the detection of the changing magnetic fields that are associated with brain activity. As the magnetic fields of the brain are very weak, extremely sensitive magnetic detectors known as superconducting quantum interference devices, which work at very low, superconducting temperatures (−269 °C), are used to pick up the signal.

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Taub, E., Uswatte, G. & Elbert, T. New treatments in neurorehabiliation founded on basic research. Nat Rev Neurosci 3, 228–236 (2002). https://doi.org/10.1038/nrn754

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