Terapias intensivas en neurorrehabilitación: ¿aplicable solo a las funciones motoras?

Intensive therapies in neurorehabilitation: Only applicable to motor functions?


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The effect of intensive therapies on the recovery of people from brain injury has been studied with increasing frequency in recent years. The results of these studies are starting to show the enormous potential of intensive therapies in the recovery of patients, beyond what had been accomplished to date through other types of treatment.

Dr. Edward Taub and his team at the University of Alabama-Birminghamare pioneers in the field of intensive therapies; in the 1990s, after several years of researchusing animal models, they developed a treatment technique called constraint-induced movement therapy (CIMT): https://www.uab.edu/citherapy/images/CIT_training/Taub_1994_Shaping.pdf

Dr. Taub’s research group designeda training program that, among many other things, was pioneering because of the working time devoted to working with patients, specifically 6 hours a day, for three weeks in a row, in his first protocol.

From the beginning, and later demonstrated by successive studies, Dr. Taub and his colleagues were sure about the necessity to increase the work carried out by patients to optimize their rehabilitation and achieve long-lasting changes in brain structure. Of course, not only the number of hours spent per day is important, but also the content of those hours, although I will focus more on the first aspect in this post.

Repetition as a key to learning

Other physical rehabilitation interventions have continued to develop over the past two decades. Nowadays, the use of robotics and new technologies is becoming more frequent,supported by a multitude of studies that have been carried out or are in development. In this particular field, the main reason for its usefulness lies in the increase in practice that it entailsincomparison with other interventions. There can be an increase of the patient’s time spent working as well asof the number of repetitions achieved through its use. Repetition is therefore believed to be one of the keys to learning.

While it is true that repetition is not the only important factor in boosting learning, there is a consensus on the necessity of practicing what we are willing to learn as often as possible, in order to speed up the process, strengthen it or achieve mastery of the task we perform.

Therefore, without needingtoresort to systematic studies or reviews, we can find hundreds of examples in our daily lives that lead us to the same conclusion: learning to play an instrument, learning a language, learning a sport, learning to move when we are born and being able to walk or develop motor skills, communication skills or adequate planning and problem-solving skills, just to name a few.

We can see an enormous gapby comparing the amount of time patients devote to their rehabilitation to the number ofrepetitions they make, the opportunities to communicate and implement their existing cognitive functions with those that would be necessary or convenient. In my experience—and with the results of studies increasingly pointing in this direction—many patients do not improve because therapists do not work with them enough, they do not extract the full potential of their brains.

 

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Intensity is important when working on communication skills

Based on the rehabilitation of motor functions, and by following the same principles of intensity, repetition, motivation, behavioral management, etc., Dr. Taub and co-workers developed an intensive language therapy called constraint-induced aphasia therapy (CIAT): https://www.uabmedicine.org/patient-care/treatments/ci-therapy

By means of studies and implementation with many patients, this technique is yielding very promising results, showing that intensity is also important when working with communication skills.

The effect of exercise on cognitive function

In recent years, the effect of physical exercise on cognitive function has also increasingly been studied. This systematic review with meta-analysis from 2017 discusses the effect that aerobic exercise, resistance training, multicomponent training and tai chi have on different cognitive functions:http://bjsm.bmj.com/content/early/2017/03/30/bjsports-2016-096587

Aerobic exercise and resistance training, for example, are part of many programs of intensive therapy; regardless of the possible explanations about why physical activity improves cognitive function, we should ask ourselves the following question:

How many trainings are purely physical or purely cognitive?

Studies on intensive therapies such as those by Dr. Taubdo not measure cognitive aspects pre- and post-intervention, but I am sure that we could also see changes in many of the patients in this sense, because the ultimate goal of Dr. Taub’s therapy—and what the results of research studies have demonstrated—is that patients participate more in their activities of daily living; after all, activities of daily living are the association of motor and cognitive skills.

The use of intensive therapy for the rehabilitation of cognitive functions in neurorehabilitation

There are studies on intensive cognitive therapy (cognitive behavioral therapy, CBT) for phobias, obsessive-compulsive disorders, and anxiety disorders: https://www.ncbi.nlm.nih.gov/pubmed/20573292 , but I have found little on the use of intensive therapy for the rehabilitation of cognitive functions in neurorehabilitation.

I am talking about cognitive functions in neurorehabilitation and not neuropsychology, because I believe that these functions are not exclusive to neuropsychology, even though it is the discipline that has studied them the most and that trains them. I prefer the definition used by Ian H. Robertson and Susan M. Fitzpatrick in their publication The future of cognitive rehabilitation: https://www.jsmf.org/about/s/The%20future%20of%20cognitive%20neurorehabilitation.pdf, where cognitive neurorehabilitation is defined as “structured, planned experience derived from an understanding of brain function, which ameliorates dysfunctional cognitive and brain processes, caused by disease or injury and improves everyday life function.”

Based on this definition, we therefore understand that we can traincognitive functionswith any of the rehabilitation activities that we perform, without having to distinguish between physical and cognitive therapies, between movement and cognition. Thus, all intensive therapies originating from the “motor field” influence cognition, and so being able to direct this influence in a more specific way would only depend on our knowledge of how cognition works.

 

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Constraint-induced movement therapy

In The future of cognitive rehabilitation, the authors cite Dr. Taub’s constraint-induced movement therapy as an example of a “cognitive neuroscience approach” that meets the main criteria of cognitive neurorehabilitation:

  • Cognitive neurorehabilitation methods should be instantiated in detailed protocols, with or without assistive technologies, which allow for replication of evaluation studies.
  • There should be at least some theoretically articulated and empirically supported model underlying the intervention.
  • Effective cognitive neurorehabilitation should be able to demonstrate changes both in cognitive function and in brain function as measured by one or more imaging or associated methods.
  • Cognitive neurorehabilitation should be able to demonstrate effects in the everyday of the individual.

I think it’s the right time for us to start thinking about the contribution that cognitive neurorehabilitation can make to the field of intensive therapies in neurorehabilitation, a booming field that is yielding very promising first results.

This contribution, from my point of view and experience, should be based on integrating therapies more and better—by starting to question the motor-cognitive dichotomy—to treat the person as a whole, the brain as a complex system that works by integrating diverse pieces of information and also by responding by means of the coordinated work of different systems. If the brain does this, we therapists should also approximate this as close as possible.

Jose Lopez
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