Michael A. Dimyan, MD,
Bruce H. Dobkin, MD and
Leonardo G. Cohen, MD
From the Human Cortical Physiology Section (M.A.D., L.G.C.), Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; and Brain Research Institute (B.H.D.), Department of Neurology, Geffen School of Medicine, University of California, Los Angeles.
Address correspondence and reprint requests to Dr. Michael A. Dimyan, 10 Center Dr., 10/5N234 MSC1428, Bethesda, MD 20892-1428 dimyanm{at}mail.nih.gov.
If not newly emerging, the subspecialty of neurorehabilitationis definitely burgeoning, and neurology trainees may not beaware of the exciting career opportunities within the field.The contemporary neurology resident is trained in a disciplinethat has changed dramatically in the last two decades. The modernday neurologist has a slew of treatment options at hand, fromr-tPA to multiple immune-modulating medications, and practiceswith this arsenal of treatments from the emergency room to theoutpatient clinic. Despite these advances, many patients stillleave the hospital or clinic with debilitating cognitive andsensorimotor impairments and ask what we can do to help themwalk or use a hand again or regain enough function to returnto their ordinary life activities. Some want advice regardingthe prevention of further neurologic deterioration.
The discipline of neurorehabilitation is the field concernedwith these reminders of past and present neurologic illnessand the improvement of neurologic function. Yet it is not uncommonfor many neurology residents to get only a glimpse of this discipline,caught perhaps during a short spinal cord or traumatic braininjury rotation. Beyond the first 72 hours of acute stroke care,most residents will have no interaction with patients to helpthem swallow, walk, reach and grasp, or manage language andhemineglect disorders. For many residents and practicing neurologists,the team-based approach to therapy characteristic of rehabilitationmedicine, and the lack of focus on "localize the lesion" discussions,may seem foreign and fail to inspire a vision of their potentialrole as a neurorehabilitationist.
But it is precisely neurologists' background knowledge and intereststhat make them ideal leaders and partners in the neurorehabilitationteam. The neurologist's in-depth understanding of the anatomy,physiology, mechanisms of injury, and plasticity of the nervoussystem is an essential component both in offering prognosticguidance to patients and families during rehabilitation andin the development of new and more effective techniques to enhancemotor control and cognitive skills. The neurologist's appreciationof how the web of neuromedical complications and symptomaticallytargeted medications can affect the nervous system is also animportant component in managing the course of rehabilitationand helping move the patient and therapy team toward a set ofrealizable goals.1
Beyond this currently available leadership role in neurorehabilitation,the future of the discipline offers young neurologists evenmore exciting career prospects. From the molecular neurologistto the neurologic ethicist, the "plastic" nervous system isan intriguing target of study. Neurologists with an interestin research are increasingly directing the translation of stemcell neurobiology,2 fundamental mechanisms of learning, neuropharmacologicalmanipulations, cortical electromagnetic stimulation,3 robotictherapy,4 and brain-computer interfaces5 into ways to improveoutcomes. The recent introduction of large scale neuroscientificallybased therapeutic clinical trials6,7 into the field of rehabilitationis advancing the opportunities for evidence-based patient care.Another aspect of great appeal in neurorehabilitation is thatit continues to be grounded within general neurology. The principlesof neural repair and plasticity share a basic foundation acrossand beyond the various pathophysiologic etiologies of the originalneural injury, so the neurologist trained in neurorehabilitationmay contribute to the care of patients with multiple sclerosis,peripheral neuropathy, traumatic brain injury, stroke, or otherdiseases. A neurologist who can help them identify spared pathwaysand enable them to practice a skill will give patients hopeand better quality of life. As young soldiers return from battlefieldswith the scars of traumatic nervous system injury, or as theaging population suffers cerebrovascular complications in greaternumbers, the skills of the neurorehabilitationist will be ineven greater demand.
A broad range of training paradigms currently fall under theneurorehabilitation umbrella, from the basic science benchtoplaboratory to the outpatient clinic. The American Academy ofNeurology (AAN) section on Neural Repair and Rehabilitationhas drafted a proposed core curriculum for training (http://www.aan.com/globals/axon/assets/2736.pdf).Some of the skills that must be learned by the neurorehabilitationistare familiar to neurologists and make them ideal candidatesfor this role, including understanding the basic science ofnervous system plasticity, anticipating the long-term effectsof neuromuscular disorders, and managing the medical and socialconsequences of neurologic injury. However, the neurorehabilitationfellowship is also a chance for the neurologist to learn a newskill set including management of chronic pain, the use of researchdisability scales, or the completion of formal disability evaluations.Neurorehabilitationists also need to become fluent in the languageof occupational, physical, and vocational therapy and to learnhow therapists and patients use orthotics or assistive devices,and how these tools fit into the economics of rehabilitation.A set of recommended readings and a certification examinationoriginally established by the American Society of Neurorehabilitation(ASNR) may soon be managed by the United Council for NeurologicSubspecialties. Both the ASNR and the World Federation for Neurorehabilitationsponsor Neurorehabilitation and Neural Repair, a bimonthly journaldedicated to the translational clinical sciences of neurorehabilitation.Interested trainees can find listings of current fellowshipsthrough the ASNR (http://www.asnr.com/clientuploads/ASNRFellowshipInformationUPDATE.DOC?PHPSESSID=983c2c30d63c57a482c6725427f5390days), through the AAN, or through the American Academy of PhysicalMedicine and Rehabilitation (http://www.aapmr.org/member/felsearch.htm).
As with many smaller subspecialties, residents seeking trainingin neurorehabilitation need to identify those aspects of trainingthey are most interested in to find a compatible fellowship.While some programs concentrate on the topics covered in theAAN proposed curriculum, preparing a fellow for clinical neurorehabilitationpractice in about 1 year, others are aimed more toward academicneurorehabilitation, emphasizing a research-based curriculumin areas such as mechanisms of activity-dependent plasticity,functional neuroimaging, transcranial magnetic stimulation,or stem-cell biology, over 2 or more years. Some fellowshipsmay emphasize a disease orientation, such as stroke, brain orspinal cord injury, and multiple sclerosis. Trainees may wantto combine general clinical and focused research curricula throughone or more fellowships.
The career prospects for neurorehabilitationists are as variedas the primary interests that lead them to the field. Whilegeneral rehabilitation is dominated by physiatrists, neurorehabilitationis really a subspecialty that appeals only to a small subgroupof physiatrists. A brief survey of the nationwide job listingservice provided by HealthJobs.com, conducted at the time ofthis writing, revealed eight positions for neurologists withan interest in rehabilitation and one for physiatrists interestedin neurology. Many of these positions are academic, reflectinga trend seen in other parts of the world, where neurologistsare ushering in a new era in neurorehabilitation.8
Perhaps we can take inspiration from the neurologist who formallyintroduced rehabilitation techniques to modern medical practice,Dr. Henrich Sebastian Frenkel. Dr. Frenkel, a Swiss neurologist,astutely observed an improvement in the finger-to-nose examinationof one of his patients with tabes dorsalis. Upon further questioning,he learned that the patient, having "failed" the examinationin a previous visit, had "practiced" so that he would "pass"at his next appointment.9 Inspired by his patient, Dr. Frenkelbegan the organization of a field that would lead within a fewyears to a department of "ré-éducation functionelle"at La Salpétriére in Paris. The field flourishedamong neurologists in Europe, and has now led to 20 to 25 academicneurorehabilitation programs in the United States. Now US neurologytrainees can increasingly appreciate that a "functional re-education"of our understanding and treatment of the injured nervous systemmay benefit our patients, our careers, and our profession.
Dobkin BH. The Clinical Science of Neurologic Rehabilitation. Oxford: Oxford University Press, 2003.
Lindvall O, Kokaia Z. Stem cells for the treatment of neurological disorders. Nature 2006;441:1094–1096.[Medline]
Hummel FC, Cohen LG. Non-invasive brain stimulation: a new strategy to improve neurorehabilitation after stroke? Lancet Neurol 2006;5:708–712.[Medline]
Fasoli SE, Krebs HI, Hogan N. Robotic technology and stroke rehabilitation: Translating research into practice. Top Stroke Rehabil 2004;11:11–19.[Medline]
Dobkin BH. Brain-computer interface technology as a tool to augment plasticity and outcomes for neurological rehabilitation. J Physiol (Lond) 2007;579:637–642.[Abstract/Free Full Text]
Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: The EXCITE randomized clinical trial. JAMA 2006;296:2095–2104.[Abstract/Free Full Text]
Dobkin B, Apple D, Barbeau H, et al. Weight-supported treadmill vs overground training for walking after acute incomplete SCI. Neurology 2006;66:484–492.[Abstract/Free Full Text]
Greenwood R. The future of rehabilitation. BMJ 2001;323:1082–1083.[Free Full Text]
Zwecker M, Zeilig G, Ohry A. Professor Heinrich Sebastian Frenkel: a forgotten founder of rehabilitation medicine. Spinal Cord 2004;42:55–56.[Medline]
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WHY NEUROREHABILITATION?
TRAINING OPPORTUNITIES IN...
