15 Synopsis and implications of neuroscience for neurological rehabilitation

Chapter contents

Introduction

Synopsis

Redundancy and plasticity

Functional localisation

Perceptuo-motor control and learning as a problem-solving activity

Attention as a gatekeeper

Network processing in sensation and perception

Communication

Executive function

Emotion

Other problems

Neuroscience and neurological rehabilitation: some reflection and challenges ahead

Introduction

The intention behind this book was to provide students from a range of health-care professions, especially allied health professions, with a foundation in neuroscience to inform their clinical practice. As we have seen, neuroscience is a complex, transdisciplinary area, comprising highly specialised lines of research. This cognate area has expanded tremendously over the last few decades, but despite the plethora of excellent textbooks and high-quality journals, this information is not always easily accessible to health professionals, while its relevance to practice is not always immediately apparent. Our key aim was to select, from the wealth of information available, a number of key topics that we felt would be useful for students in an allied health profession starting out in neurological rehabilitation. In addition, we hope that components of this text would be useful for students in related disciplines with an interest in neurological rehabilitation.

Synopsis

We started by laying the foundation of neuroscience. Following a brief synopsis of the fascinating history of neuroscience, we set out the basic structure and function of the nervous system, explored normal and abnormal changes in the nervous system across the life span, and examined the various ways in which drugs work. This was an area that could have had a whole textbook devoted to it and, indeed, there are many such books on the market. What we attempted to do was ‘cherry-pick’ the key areas that we thought would be of most interest and/or relevance.

Redundancy and plasticity

Having laid the foundation, we then moved on to explore how the brain works – or at least an exploration of our current, and still limited, understanding of how we think it works! This revealed the brain as the most complex structure in the universe; a complex, heterogeneous, integrated organ that exhibits both redundancy (i.e. spare capacity) and plasticity (i.e. the capability to change). Redundancy and plasticity are key phenomena in neuroscience and their relevance for rehabilitation cannot be underestimated. Redundancy implies that there is spare capacity that can be tapped into, and plasticity means that the brain responds to change – and thus to therapeutic input. Plasticity can go ‘haywire’, however, and the phenomenon of spasticity was used as an example of how disorganised movement may result from dysfunctional neural connections. The implications for health-care professionals are to provide timely therapeutic input of the right intensity and type, to drive neuroplastic changes that will ultimately enable long-term, functional improvement.

Interventions that involve intensive activity of a functional nature where possible, comprising an element of problem solving, currently seem to be the most likely candidates. Although there are promising lines of evidence in specific patient populations (e.g. constraint-induced movement therapy for people with some active hand movement after stroke), much more research is needed to establish a library of interventions that are effective, acceptable and meaningful to people with different levels of ability, wanting to achieve different rehabilitation goals.

Functional localisation

We saw how function is localised in the brain, which means that each specific function (e.g. colour perception), is mediated by a dedicated, complex, integrated neural network. An appreciation of the level of integration of brain function is essential; a function can only be executed successfully if the brain is able to receive the right information at the right time, process this using all necessary connections, relay the information to the areas involved in planning, sequencing and finally execution, and complete this on time. So there is much more to action than meets the eye! The role of the health professional is to unravel this complexity by carefully and systematically assessing the patient (often involving other members of the multidisciplinary team), and test various hypotheses as to the main causes of the patient’s problems.

Having explored generic principles of the structure and function of the nervous system in general and the brain in particular, we then went on to examine a range of problems that are commonly found in people with neurological conditions.

Perceptuo-motor control and learning as a problem-solving activity

We started off with normal motor control and explored the role of different levels of the nervous system in the control of reflex, as well as voluntary movement. We looked at various expressions of disordered motor control, and compared and contrasted spasticity with rigidity and hypertonia, which highlighted the importance of differentiating between neural and biomechanical contributions to soft-tissue stiffness.

Next, we looked at more complex processes involved in perceptuo-motor control and introduced various theoretical models. We focused on an information processing approach, which describes successive stages of motor control from sensory input to planning, programming, execution and, finally, feedback. According to this approach, movement is coordinated by a generalised motor programme (GMP) that stores the equivalent of a ‘blueprint’ for each class of action. This template can be fine-tuned to the specific requirements of the task within the environment in which the action takes place. Although there is no consensus (yet) regarding the most convincing theoretical model of motor control, most movement scientists would agree that purposeful movement is a problem-solving activity. In the search for a solution to this problem, motor control operates at the interface between the individual with their particular characteristics, the specific task requirements, and the environmental conditions.

The implications for therapists are that they need to consider this interface in its entirety, as focusing on perfecting movement per se (e.g. gait) without training this in the environment in which the walking is to take place, and without exploring relevant task variations (e.g. sideward stepping to avoid obstacles, or holding a shopping bag while walking) is unlikely to carry over into a walking activity that is useful for the patient following discharge.

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