Neurorehabilitation also called neurological or neurosurgical rehabilitation is the discipline devoted to rehabilitation in all fields of neurological abnormalities ranging from vascular over inflammatory to neoplastic and degenerative disorders. This field is now a subdivision of neurology or neurosurgery linking knowledge from the neurosciences with knowledge and skills from rehabilitative medicine and social sciences.
Over the last two decades this field has made a tremendous progress in parallel to the explosion of knowledge in the neurosciences. Today a point has been reached in which neurorehabilitation can be conceived as applied neuroscience made useful for the restoration of function in neurological disorders. Following this development in most European and many other countries specialized scientific societies have been founded addressing issues of neurorehabilitation. These are linked under the umbrella of the World Federation of Neurorehabilitation (WFNR) and recently also by a subdivision called European Federation of Neurorehabilitation Societies (EFNRS).
These developments were paralleled by an increasing interest of neurologists and neurosurgeons in aspects of neurorehabilitation. In most countries today patients with neurological disorders who need rehabilitation are treated by specialized neurologists.
Neurorehabilitation can be conceived as a truly scientific discipline: First it translates knowledge from the neurosciences into clinical practice of rehabilitation and secondly it has designed its own corpus of scientific activities. These span from elementary aspects of reorganization, repair and plasticity in the central and peripheral nervous system over design of clinical studies for evaluation of therapeutic approaches in the framework of evidence based medicine further to invention of new therapeutic procedures following elementary rules for of e.g. motor learning or learning in general.
In its scientific endeavors as well as in its day by day activities neurorehabilitation is as a multidisciplinary activity. Considering the fact that neurological abnormalities are multifold ranging from motor-sensory over cognitive, language and speech related problems to emotional problems such as depression after stroke or traumatic brain injury. Furthermore also the variability of conditions which are targets of neurorehabilitation span a wild field of different pathologies. Therefore the scientific strategies followed in neurorehabilitation are closely linked to the classical fields of the neurosciences as neuropathology, neurophysiology, neurochemistry and neuropharmacology but also encompass methods from behavioral and social sciences as psychology, neuropsychology and sociology. This is an extremely colorful and interesting spectrum of actives from all the many fields of neuro- and behavioral sciences to blend in knowledge, skills, concepts and ideas into neurorehabilitation
Another upcoming important field in neurorehabilitation is the problem how to organize appropriate services for the population in various countries in order to achieve optimal processes for treatment taking into account the individual habits and individual clinical service systems of various civilization and countries.
Neurorehabilitation worldwide conceives itself as a scientific discipline following a strict scientific epistemology (typical for clinical and experimental sciences and being close to the framework of e.g.physics) for the proper setup of studies and experiments and their interpretation. Therefore neurorehabilitation will add to science (knowledge) and not to believes and cannot be looked upon as heaving properties of a “religion” but will respect the religious beliefs of its followers.
Neurorehabilitation is distinctive among others specialties in two aspects:
- In contrast to mainstream neurology neurorehabilitation concentrates on the diagnostic, therapeutic and scientific issues of rehabilitation aspects. Therefore it has a major emphasis on treatment rather than diagnostics.
- Secondly it is also distinctive from rehabilitation medicine in general as its addresses specifically the neurological problems in rehabilitation and makes use of the rich methodological framework of the neurosciences intending to bridge the gap between knowledge from basic sciences on one side and its application on the other side. Therefore as an applied science it conceives itself very much related to translational aspects of science.
In contrast to acute medical disciplines, as e.g. mainstream neurology, the rehabilitation physician or the people working in neurorehabilitation are concentrating more on the level of abilities and functions in patients rather than on nosological entities i.e. the interest focuses on function rather than on disease entities. For this neurorehabilitation uses very much the framework and terminology of the international classification of functions (ICF) and is related more to functional aspects rather than to the nosological classification of diseases as mirrored by the ICD (International Classification of Diseases) System.
In neurorehabilitation the involved scientist and clinicians are typically confronted with complex cognitive and emotional disturbances of their patients. Therefore the people working in this field have to take into account different religious and cultural aspects of how patients conceive the world and conceive themselves and how they are willing to marshal their future etc. From this originates an interest in the tension field between science and religions as well as between science and philosophy. Also similar to neurology and the neuroscience in general also neuro-rehabilitation shares a growing interest in how the brain administers and generates religious beliefs and how religious feelings and emotions are generated and processed by the brain. Also the question of consciousness and free will are important in neurorehabilitation:
Neurorehabilitation is confronted with many patients in diminished states of consciousness such as low and minimally responsive wakefulness after severe brain injury. This often raises the question of brain organization of consciousness in a direct clinical sense. Also the related issue of “free will” can become important in the course of neurorehabilitative treatments e.g. when it comes to juristic decisions in how far a patient has to be responsible for an particular behavior after an injury.
Neurorehabilitation is a fairly young discipline which has mainly emerged over the last two to three decades. Nevertheless, earlier work dates back to the turn of the last century with people as Walther Poppelreuter (1886-1939) addressing the issue how people with cognitive deficits and neuropsychological deficits after brain injury could be helped. These questions started to emerge heavily after World War I. The first ideas of neurorehabilitative treatment to cure or at least help all patients with the sequelae of brain damage started at this time
Neurorehabilitation is a worldwide endeavor. The activities are coordinated by the World Federation of Neurorehabilitation (WFNR). The members of its boards at the moment are probably the most authoritative leaders in this field. The work of the WFNR is organized by so called “special interest groups” (SIGs). They address the whole variety of different issues raised in neurorehabilitation and try to find out optimal ways of scientific and clinical approaches. WFNR is organizing a World congress or neurorehabilitation WCNR) every second year (the last one has been in Melbourne in 2012 and the next is scheduled for Istanbul in April 2014).
Neurorehabilitation is following similar ethical principles as defined by the Hippocratic Oath stressing equal rights for the access to medical help for everyone as well as the avoidance to do harm to patients.
Neurorehabilitation specialists worldwide are also involved in improving the level of treatment services around the world and in the discussion of how to deal with disabilities and handicap worldwide to improve integration and inclusion of disabled people. This is also apparent in the work of neurorehabilitation experts as reflected by recent changes recent changes in the UN human rights convention and the recent WHO report on disability and handicap published in 2011.
The canon of values in neurorehabilitation is guided by the attempt to reduce handicaps and restore participation of patients with disabilities around the world. This does not only include medical and therapeutic attempts but it stretches far out into political areas in order to ascertain that human beings with impairments and disability have equal rights as members of the society and to achieve an equal opportunity to participate in all other areas of central human social and economic activities. It is not a trivial problem considering the fact that in many countries around the world disability is still conceived as a god given faith or sometimes even as a sort of not appropriate behavior. A major value in this respect for people working in the neurorehabilitation is to achieve optimal chances of participation in the sense of integration of the handicap and also a step further to ascertain that handicapped people are definitely included into society. This is different from organization in the sense that it appeals of the society to adapt to the handicap rather than the handicapped person adapt to the society.
Nature is conceived as the world around us which we have to maintain as intact as possible.
Human beings are considered to be on the ones hand a piece of nature with a nervous system following the elementary laws of nature described by physics chemistry, biology and other sciences. On the other hand the particular quality of the human being is that their process in nervous system which has emerging properties such as free will and the ability to interact with the environment in the most complex and creative form. Creativity is considered one of the key elements in the emergent properties of the human mind possibly allowing a final separation line between animals and men. Nevertheless neurorehabilitation scientists may follow monistic or dualistic ideas when it comes to the question of mind-brain interaction.
The precondition of life is presence of physical functions in an organism stretching all the way from viruses to mean. A major distinctive element of life compared to the nonliving part of reality is the ability of self-reproduction to reproduce itself.
Brain death in particular is defined as a measurable complete absence of brain function without any chance of recovery.
Reality is conceived to be the total ensemble of the physical world around us as far as we can act by our senses. Nevertheless it can be conceived that there is a reality also out of the reach of our senses which definitely does exist also in the absence of being sense by living organism.
Knowledge is conceived to be the total bulk of information we have about how the world is organized and how things had happened in this world. In this sense knowledge is sort of a complete memory of mankind rather than a precise mirror of reality.
Every neuroscientist more and more realizes that the brain is in some sense is “a lying organ”. Therefore term “truth” has to be handled with a lot of care. Ideally truth means that a particular fact or statement is essentially correct. This correctness of course is in primary focus when it comes to the definition to scientific statements. Also in neurorehabilitation there is broad agreement not to loosen the definition of truth in scientific conduct and discourse but conceive it as at approximate way to approach reality.
Perception is a key feature of living organisms in dealing with the environment: It means the perception signals from the real environment are transformed into the sort of an internal map of representation of the external world. In advanced organisms of course this done by the such a nervous systems especially the brain being a intentional organ to conceive the world.
In neurorehabilitation the definition of time is as complex as it is in all scientific disciplines. Albert Einstein`s statement that time is what you can read and the watch is properly the most appropriate definition still.
The major issue in the discourse between the neurosciences, philosophy and religion is the conception framework of consciousness. For clinicians consciousness usually means in how far a patient is able to attend actively to environmental stimuli e.g. if the patient is awake or in a somewhat diminished state of consciousness for instance in coma or in states between fully awake states and coma such as states of un- responsive or minimally responsive wakefulness.
Consciousness is determined in behavioral terms observing how a patient reacts to stimuli from the environment. Clinical observation can be augmented by more refined neurobiological techniques as electrophysiology or functional neuroimaging. These techniques have given new insights into a better understanding of the border zone between complete wakefulness and more diminished states of consciousness.
Philosophically there is however another definition of consciousness. We often claim that consciousness is an intimately human entity which is probably not true considering that also at least more advanced animals can build up complex representations of the environments within their nervous system. Many misunderstandings about definitions of consciousness usually can be avoided if consciousness is defined as what we can recollect from the declarative memory. Taking this as a probe one will find that usually only speaks about conscious experience when someone is able to describe what has happened before recorded in his or her episodic memory. We have to consider that the bulk of activity in our brains in this sense is unconscious.
In neurological conditions the amount of rationality a patient can use can be highly variable.
Neurorehabilitation as part of medicine has to take into account that medicine always has a magic component to it:
Treating patients is a complex process which is not always based only on rational concepts but always contains an element of mystery.
Furthermore “mystery” of course is an ongoing challenge to learn more about how the world is truly organized and mystery for scientist therefore is a permanent challenge.
An ongoing critical issue especially in neurorehabilitation is the conception of free will or the integrity or autonomy of a person. Considering the fact that we never precisely can know what our patients really have in mind when we intend to treat them or what the treating clinicians have in mind stresses the need for optimal communication between patient and scientist. This can only be reached when the two parties agree on a simple mutually understandable discourse.
- World Federation of Neurorehabilitation (www.wfnr.co.uk)
- German Society of Neuro-Rehabilitation (www.dgnr.de)
- American Society for Neurorehabilitation (www.asnr.org)
Michael Selzer , Stephanie Clarke , Leonardo Cohen, Pamela Duncan , Fred Gage (Editors)
Textbook of Neural Repair and Rehabilitation: Volume 1 and 2
Cambridge University press (2006), new edition in preparation (2012)