Enhancing independent community access and participation: services, technologies, and policies

This chapter examines three aspects of the community access issue: access to services, the value of both existing and emerging technologies, and social and economic policy-making. In addition to an efficient rehabilitation process focusing on physical and mental capabilities, enhancing community access and social participation will require the optimization of access to services. Key concepts in this regard include the notion of support both for individuals and their families. Technologies that enhance mobility, communication, and home adaptation also play an increasingly important role. While they are essential to compensate for various forms of disabilities, the current rapid evolution of technologies does not allow adequate efficacy testing, limiting the establishment of best practices or recommendations regarding these products and often overestimating their benefits. Finally, better community access and participation should not be based on a culture of disability but a culture of ‘ability’ that impacts all citizens.

Treatment of arm and hand dysfunction after CNS damage

Residual upper limb dysfunction after injury to the central nervous system is a major clinical, socioeconomic and societal problem. Upper limb dysfunction can occur in many disorders of the central nervous system including cervical spinal cord injury and multiple sclerosis, but therapeutic approaches for upper limb dysfunction after stroke are the most thoroughly investigated. General approaches to treatment require:�(i)�avoidance of complications such as spasticity, pain, and loss of range; (ii) early high-dose engaging functional motor training; (iii) consideration of how neuroplastic processes might be engaged to enhance the effects of training. The evidence to deliver optimal personalized treatment strategies for all patients is lacking, but there is evidence that higher doses and intensity of upper limb therapy will be beneficial to most patients. Recent work has focused on how technological innovation might be used to promote recovery of upper limb function.

Animal models of damage, repair, and plasticity in the brain

Recovery after a stroke is a multidimensional process depending on the individual deficit. Within each functional domain, spontaneous recovery occurs to a variable degree and can be improved by specific neurorehabilitative interventions. The knowledge about the neurophysiology of the processes that lead to recovery and render neurorehabilitative interventions effective is scarce. Such knowledge, however, would be necessary to find new treatments that can fully exploit the brain’s capacity for recovery. Animal models can be an experimental platform to investigate these mechanisms. But it has to be realized that they oversimplify the human condition. The complexity of motor, cognitive, social, emotional, and other factors contributing to recovery in humans cannot be modelled in animals. The opportunities and caveats of animal models are discussed.

Predicting activities after stroke

Knowledge about the functional prognosis of stroke patients admitted to a stroke unit has increased substantially over the past years. Prospective cohort studies suggest that a return of some finger extension and voluntary activity in the shoulder abductors within days post-stroke onset predicts a favourable recovery of the upper extremity function at 6 months. The Barthel Index and the ability to sit unsupported are the main predictors for recovery of gait and ADL independency. Almost all developed prediction models identify patients with a favourable prognosis but are less suitable to accurately predict individuals who will not regain dexterity, mobility, and ADL independence following stroke. In individuals with an unfavourable prognosis, this entails measuring clinical determinants frequently and longitudinally during the post-stroke course. Moreover, future research should focus on cross-validating prediction models, which should also incorporate presently excluded stroke subtypes, such as brain stem strokes, intraparenchymal and subarachnoid haemorrhages.

Promises and challenges of neurorehabilitation technology

There has been a substantial increase in the number of different technologies that are being used in rehabilitation hospitals and clinics to help therapists and physicians improve recovery of upper or lower extremity function in patients who have sustained a severe neurological injury. These technologies include robotic devices, electrical stimulation systems, wearable sensors, and virtual reality training systems. Although initial enthusiasm for the role of these technologies was high, some of this enthusiasm has now abated, because the therapeutic benefits of these systems has been less dramatic than initially anticipated. This chapter examines some of the reasons for this reduction in enthusiasm, and potential reasons why technological approaches have not been more successful in the clinical application of these robotic systems. Finally, the chapter explores ways in which some of the observed performance limitations can be circumvented, leading potentially to more effective therapies in the near future.

Recognition and management of functional (non-organic) symptoms after CNS damage

Patients witha recognized neurological disease or a structural damage to the central nervous system (CNS), may present with or later develop symptoms unexplained by that disease or damage (functional overlay). This chapter considers the relevance of functional overlay to management of patients with CNS damage.There are only few studies focusing on functional symptoms occurring specifically in the setting of CNS damage,nevertheless, there is an extensive literature on those patients who have an inexplicably catastrophic outcome after minor traumatic brain injury (mTBI). This evidence is reviewed as well as evidence for the diagnosis, pathophysiology, and treatment of functional symptoms.The wide phenomenology of possible symptoms is discussed as well as clinical tools for arriving at a positive diagnosis. We discuss the importance of giving and explaining the diagnosis in a suitable way to patients and their caregivers as well as management and treatment options.

Management of bladder, bowel, and sexual dysfunction

This chapter provides an overview of the pathophysiological basis of bladder, bowel, and sexual dysfunction, relevant therapy principles, and treatment options. These dysfunctions are frequent sequelae of neurotrauma and neurodegenerative diseases that require adequate management and treatment. Knowledge of basic neurophysiological and pathophysiological processes involved is important for understanding and interpretation of clinical symptoms and findings and for understanding current treatment concepts. Treatment is mandatory and therapy options range from simple conservative measures to major surgery. The main therapeutic principles include protection of kidney function, reduction of urinary and/or faecal incontinence, independent management of bladder and bowel function, ability to sustain a satisfactory sexual relationship, fertility support, and improvement of quality of life. To comply with such principles and to select, initiate, maintain, and eventually adapt the ‘optimal’ treatment regimen for each patient requires a specialized multidisciplinary team.

Neuropsychological rehabilitation of higher cortical functions after brain damage

Neuropsychological interventions for impairments of higher cognitive functions can be divided into four approaches:�restoration of function, compensation, physiological stimulations, and metacognitive strategies. Training that aims to restore an impaired function or to increase processing speed or capacity is repetitive and highly stereotyped. For some cognitive domains (such as memory), restoration of function is mostly impossible; consequently, training mainly relies on compensatory strategies. A�third type of approach is applied in neglect rehabilitation and uses physiological stimulations to bias attention and sensory representations or decrease interhemispheric inhibition. Finally, the fourth approach is to structure behaviour and to enhance metacognitive abilities, and is applied in the rehabilitation of complex problem-solving skills and impaired emotional regulation. Although it is difficult to control experimental biases in intervention studies targeting cognitive and behavioural disturbances, an increasing number of controlled clinical trials provide evidence for the efficacy of each of the four therapeutic approaches.