Chapter 53 Rehabilitation therapies

Handbook of Clinical Neurology, Vol. 95 (3rd series) History of Neurology S. Finger, F. Boller, K.L. Tyler, Editors # 2010 Elsevier B.V. All rights reserved

Chapter 53

Rehabilitation therapies DAVID E. TUPPER* Neuropsychology Section, Hennepin County Medical Center; Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, USA

INTRODUCTION The personal and social impact of neurological disorders is immense. There are probably more individuals with neurological disabilities alive today than ever before (Wade, 1997). The cost of disorders of the brain and related neurological illnesses is only beginning to be estimated; recently, direct and indirect economic estimates in the United States topped $400 billion (7.3% of the Gross Domestic Product) in 1991 (National Foundation for Brain Research, 1992), and approached  386 billion in Europe in 2004 (Andlin-Sobocki et al., 2005). According to the World Health Organization’s current classification system (WHO, 1980, 2001), impairments of the nervous system often result in persisting disability and alteration in social roles (handicap). Compared to the history of other concepts or practices in neurology, the history of the rehabilitation of neurological disorders is relatively brief. The word “rehabilitation” is likely derived from the Medieval Latin word rehabilitare, which means to restore or make fit once again. The word rehabilitation can be used in a variety of contexts but, in neurology, rehabilitation therapies are meant to provide interventions that go beyond traditional medical treatment aimed at treating impairments, and to help those with neurological injuries and illness to re-establish themselves as productive and socially integrated citizens (Nagi, 1969; Glanville, 1982). As stated by Swan (1964, p. 938), “Rehabilitation may be described as the restoration of the human being to living in the full sense. It is the treatment of the whole man [person], and not only of his [or her] disability.” Many neurologists in the past believed that neurological deficits were static and resistant to rehabilitation. In fact, even in prominent contemporary neurology *

texts (e.g., Victor and Ropper, 2001) rehabilitation is not mentioned or discussed only in passing. At the root of some of this skepticism is the fact that some degree of spontaneous recovery is always present, and this recovery can range from full to slight improvement. In the past century, however, a more optimistic view of nervous system recovery and response to treatment has emerged (Rothi and Barrett, 2006), due in particular to the influence of several world wars leading to a marked increase in the number of young adult wounded veterans who have required services to become more productive again. Some progress in documenting the effectiveness of rehabilitation therapies has been made, and this will be touched on later in the chapter. Although other rehabilitative specialties are slightly older, it is only in the past 25 years that a defined subspecialty of neurological rehabilitation has been formed (Good and Couch, 1994; Dobkin and Thompson, 2000; Barnes, 2003; Dobkin, 2003; Noseworthy, 2003). Unlike the rest of neurology, neurological rehabilitation has also been described as a process (Delwaide and Young, 1992; Lazar, 1998). Neurological disorders have certain notable characteristics that separate them from other medical conditions. They are large in number, few are totally curable (due to degeneration or limited nervous system plasticity), they are associated with many varied symptoms, and they are a major cause of disability, particularly accounting for a high proportion of severely disabled people under the age of 65 years (Hewer, 1997; Wood and McMillan, 2001). Neurological disorders that are curable or that can lead to more full recovery include some types of infectious disorders that can be treated successfully with medication, and nerve disorders or tumors that can be cured by neurosurgical intervention. Many, if not most, neurological

Correspondence to: David E. Tupper PhD, Director, Neuropsychology Section (G8), Hennepin County Medical Center, 701 Park Ave., Minneapolis, MN 55415, USA. E-mail: [email protected], Tel: +1-612-873-2599, Fax: +1-612-904-4208.

852 D.E. TUPPER disorders cannot be cured completely, and may in fact before the time of death (see Schiller, 1979; Clower be progressive, but they may be responsive to treatand Finger, 2001). ment attempts designed to reduce the suffering and Among primitive peoples or those in earlier civilizadisability caused by their symptoms. tions, children with deformities or adults with lesions This chapter will review the history and evolution of were at times allowed to die or were separated from rehabilitative efforts by physicians and other health prothe social group (Leo´n-Carrio´n, 1997); for numerous fessionals to alleviate the symptoms and disabilities generations, supernatural causes were posited for neuassociated with neurological disorders. Because the rological or functional disorders. As noted, it was not scope of such an endeavor can be quite large, the focus until the ancient Greeks in Hippocratic times, who first of this chapter will necessarily be selective; there will be thought that the brain governed the body and housed greater description of the history and development the soul, that a new way of thinking about brain of rehabilitation for acquired cerebral disorders such damage emerged. Head trauma sustained in sporting as cerebral trauma or cerebrovascular accidents, so contests was particularly noted in Greek and Roman these etiologies will be emphasized, to the exclusion of times, given the beginnings of organized contact sport rehabilitation efforts in developmental or degenerative competitions (McCrory and Berkovic, 2001; Zillmer conditions. In addition, management strategies or rehaet al., 2006); however, development and use of a bilitation therapies for disorders affecting the peripheral helmet for protection did not begin until the Middle nervous system, primary physical, orthopedic, or motor Ages (Blackburn et al., 2000). consequences, or disorders affecting the spinal cord Some ancient peoples used physical means for treat(although often acquired) will generally not be included. ment of injury and illness. Physical agents for healing Although pain is a frequent symptom and co-occurring have included water, heat, cold, massage, light, exerfactor in disability for individuals with a variety of cise, and what would later be found to be electricity neurological illnesses, discussion of pain management (from fish). Many of the physical agents employed in strategies also will not be included here. modern physical therapy were used in ancient times, and joint manipulation and massage was used in China about 3000 BC (Braverman and Schulman, 1999). MasEARLY HISTORY OF REHABILITATION sage and hot poultice (liquefied flax seed bandages) IN NEUROLOGICAL CONDITIONS were primary treatment methods for the effects of It is likely that early in history, as humans recognized stroke in the Assyrian and Babylonian world, and mendefects attributable to nervous system problems, tion of the use of a crutch for lower extremity paralyattempts at remediation were made. As examples, probsis is suggested in a Babylonian diagnostic tablet ably because they represented obvious functional (Reynolds and Wilson, 2004). Early Greek and Roman changes, early descriptions of aphasia can be found writings refer to the beneficial effects of sun and among the oldest medical documents (Benton and Joynt, water, and both exercise and massage were used by 1960), and spinal cord injuries were also frequently the ancient Chinese, Persians, Egyptians, and Greeks noted in ancient Egypt (Eltorai, 2003). Hippocratic phy(Calvert, 2002). The use of massage in ancient Greece sicians and philosophers regarded the brain as important was an integral part of wellness, healing, and sports. for perception and thought based on observations of Written accounts of physical techniques for healing, individuals who sustained head trauma. such as hydrotherapy, can be traced back as far Nevertheless, from the earliest times in human hisas the writings of Hippocrates in 400–460 BC. Hippotory, assistance given to people with physical or brain crates also wrote important papers on the use of lesions has been varied. All cultures have not treated friction after sprains and dislocations, and about these persons in the same manner, and a number of kneading in case of constipation (Knapp, 1990). Pliny, varied “therapies” have been developed from reliAristotle, and Plutarch all knew that electric eels, rays gious, scientific, medical, or spiritual perspectives. and catfish could produce numbness, but knowledge For example, dating as far back as prehistoric times of electricity increased only slowly; it was not until (late Paleolithic and Neolithic periods), skulls have after the Middle Ages when Leyden jars and other genbeen found with openings indicative of trepanation, erators and storage devices were available that the presumably for medical reasons (Gurdjian, 1973; see exploration of other benefits of electricity could occur Ch. 1). Paul Broca, in fact, who subsequently was (Basford, 1990). known for the cerebral localization of expressive lanDuring the Renaissance in Western Europe, society guage but who also had interests in anthropology, was began to take major steps in recognizing its responsibilparticularly fascinated by a Peruvian skull found with ities to its more needy members, including the poor, a man-made hole in it, due to surgery a week or two the sick, and those with injuries. In this period, interest

REHABILITATION THERAPIES 853 in medical conditions increased. It is primarily in the and a large experience base for the development of 18th century, when more clarity in description, etiolmore effective rehabilitative approaches. Not only ogy, and detection of brain dysfunction was being were more individuals able to survive neurological developed, that a greater emphasis was placed on findinsults, as overall medical care advanced, but greater ing new treatments for these disorders. societal acceptance of individuals with persisting disElectrical machines and magnets were used to alleabilities allowed the birth of rehabilitation medicine viate neurological conditions in the 18th and 19th centuand the maturation of various rehabilitation specialties. ries, although not always with success (Harms, 1955; Rehabilitative care for persons with cerebral dysfuncHolcomb, 1967; Gersh, 1992). Benjamin Franklin, for tion was aimed at reducing disability and handicap instance, whose name is not typically associated with resulting from nervous system impairments, and it medical therapies, followed the early work of Nollet promised good returns for the monetary and societal (1746) and used his new understanding of the nature investment. of electricity in the experimental treatment of individuals suffering various palsies, particularly from MEDICAL AND PHYSICAL stroke (Finger, 2006a, b). Although Franklin never forREHABILITATION mally published his case studies and remained skeptical Some of the earliest modern therapists in rehabilitation about the beneficial effects of electricity for palsies of were physical therapists (McKenzie, 1918; Pagliarulo, long standing (Finger, 2006c), he clearly was one of the 2006). The field of physical therapy was established first electrotherapists who tried to treat neurological in Britain in the latter part of the 19th century, and disorders. shortly thereafter American orthopedic surgeons Attitudes toward the injured as different from the trained women in physical treatment methods, such rest of society began to change soon after Franklin. as muscle re-education, to deal with the 1916 epidemic Around 1800, increased knowledge regarding cerebral of poliomyelitis in the United States. Concurrently, the function was gained, as Gall’s phrenological theories American Electrotherapy Association, founded in correlated cerebral geography with mental faculties 1890, was the first American organization to utilize (Miller, 1996) and stimulated subsequent work on physical measures for therapeutic means (Gersh, 1992; brain–behavior relationships and various treatment Opitz et al., 1997). During and after World War I, approaches. And in the opening decades of the 19th additional empirical research indicated that various century, Napoleon, who otherwise did not look favorphysical methods were useful to augment the medical ably on phrenology, required his injured soldiers with care and convalescence of patients. Physicians began a good chance of survival to receive rapid medical practicing physical rehabilitation methods in “reconand appropriate rehabilitative care to assist in the construction hospitals” designed to accommodate the tinuation of their lives (Leo´n-Carrio´n, 1997). injured and disabled soldiers. By the end of the 19th century, based on further World War I transformed rehabilitation medicine by progress concerning the concept of localization of adding a steady flow of maimed and disabled indivifunction by Broca, Jackson, Ferrier, and others, duals to the United States and other countries. Gritzer researchers gave cerebral localization of function a and Arluke (1985) estimate that 123 000 disabled solmore solid scientific foundation (Rosner, 1974). With diers returned to the United States by May 1919. Folthis came the realization that one cortical territory lowing the lead of European nations, the United might not easily substitute for another, except perhaps States was forced to develop medical and rehabilitative in childhood (see Ch. 10). Spontaneous recovery from services for soldiers wounded and disabled in the war. cerebral lesions was therefore thought to be limited. Assisting physicians, World War I-era reconstruction Also, unfortunately, most penetrating brain wounds aides, forerunners of current physical and occupational were, in fact, still fatal. The fatality rate during the therapists, treated primarily patients with orthopedic American Civil War, for example, was about 70% injuries, because few patients with brain injuries sur(Gurdjian, 1973). These factors, among others, likely vived serious war wounds (see Fig. 53.1). increased the skepticism about treating neurological Beginning in the 1920s, medical organizations, such disorders. A more humanitarian approach to dealing as the AMA Congress of Physical Therapy, were with individuals with nervous system disorders paralinitiated. Throughout subsequent years, the organizaleled the advancement of medical approaches and techtions and their names were changed a number of nology in the past two centuries. times to reflect the evolving specialties of physical As will be discussed below, the large numbers of medicine, physical therapy, electrotherapeutics, radisoldiers cared for during the two World Wars in the ology, and rehabilitation. During these early years, early-20th century provided a major societal impetus

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Fig. 53.1. An early occupational therapy unit during World War I. (From Crane, 1927, p. 80.)

physicians pioneering in physical medicine were involved with diagnostic and therapeutic radiology, diathermy, electrocoagulation, hydrotherapy, massage, therapeutic exercise, iontophoresis, and the use of various types of electrical stimulation and infrared heating, as well as the social and vocational reintegration of the disabled into society (Opitz et al., 1997). Radiologists were, in fact, among the first physicians to specialize in a physical method of medical practice (Kottke and Knapp, 1988). The decade of the 1930s brought further organization and purpose to the field of rehabilitation, and an increasing demand and specialization in radiotherapeutics split physical medicine physicians from radiological physicians. At this time, a small group of physicians who practiced physical therapy and rehabilitation worked to identify rehabilitation medicine as a distinct specialty (DeLisa et al., 1998). Frank H. Krusen, MD (Fig. 53.2), working at Temple University in Philadelphia, PA and then the Mayo Clinic in Rochester, MN, promoted physical medicine and rehabilitation as a specialty in the AMA and, in 1938, proposed the term “physiatrist” to identify a physician in physical medicine (Krusen, 1941; Folz et al., 1997). Other prominent

rehabilitation physicians at the time included John Coulter and Walter J. Zeiter (Coulter, 1947; Zeiter, 1954). In spite of this advocacy, it was not until after World War II that societies began to understand the need for more advanced treatment and rehabilitation of the disabled (Krusen, 1946, 1969; Folz et al., 1997). This was based on the more widespread use of physical therapy in the care of patients, not only from the substantial numbers of debilitating war injuries, but also due to the thousands of individuals disabled by another poliomyelitis epidemic. An Australian nurse, Sister Elizabeth Kenny, developed an effective method of treating muscle spasm and deformities from paralytic polio in the 1940s, thus adding significantly to the knowledge of neuromuscular diseases and their physical management, and also demonstrating effective clinical methods for restoration of normal mobility (Knapp, 1969). World War II also broadened the focus of physical medicine, from the more limited goal of restoration of ambulation in the physically disabled to comprehensive activities to restore an optimal level of an individual’s physical, mental, emotional, vocational,

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based on his experiences at Stoke Mandeville Hospital in England (Eltorai, 2003; Silver, 2003). Much like Howard Rusk, Guttmann pioneered active, integrated rehabilitation and demonstrated efficacy for the management of physical consequences of paraplegia, so maximal independence could be achieved (Schu¨ltke, 2001). Importantly, Guttmann also championed re-integration into physical activities for individuals with paraplegia, and he was the organizer of the first sporting event for people with disabilities (the International Stoke Mandeville Games), which has continued as the Paralympics. Thereafter, more rehabilitation centers started, because the value of medical and physical rehabilitative therapies have been demonstrated many times over during the major World Wars, and in other rehabilitative contexts worldwide. The concept and processes of rehabilitation now includes a team of professionals, including physiatrists, occupational and physical therapists, speech-language pathologists, psychologists, and other allied health professionals, working together using interdisciplinary goals for individual patients (see DeLisa, 2004).

Fig. 53.2. Frank Hammond Krusen, MD (1898–1973), considered the “father” of physical medicine and rehabilitation in the United States. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.

and social capabilities (Kessler, 1965; Kottke and Lehmann, 1990). Physician Howard Rusk, another rehabilitation medicine pioneer, initially working in the Army and in private practice, and later establishing the Institute of Rehabilitation Medicine at New York University-Bellevue, introduced the notion of active rehabilitation. He inspired people to develop more comprehensive and dynamic rehabilitation programs that addressed the multiple needs of individuals with various types of functional disabilities. Rusk (1949) advocated an aggressive approach to rehabilitation, which is practiced more widely today. After World War II, physiatry became more solidified in America when the Baruch Committee awarded funds to develop physiatry training programs at selected institutions, the Veterans Administration continued to add rehabilitation medicine departments at many hospitals throughout the United States, and the Office of Vocational Rehabilitation brought about additional expansion of rehabilitative services. On an international level, German-born physician Ludwig Guttmann advocated a comprehensive approach to the rehabilitation of spinal cord injury and paraplegia,

OCCUPATIONAL AND VOCATIONAL REHABILITATION The current clinical belief is that neurological rehabilitation efforts must focus on improving functional and adaptive behaviors. Often, an emphasis on more practical behaviors fosters a patient’s motivation to make further change. As with the early development of physical therapy, the evolution of occupational therapy has occurred primarily in the past 100 years, and primarily due to the influence of the influx of the disabled during World War I and World War II (Cohen and Reed, 1996). Occupational therapists traditionally maintain a focus on improving adaptive behaviors of individuals and foster the goal of independence in self-care during the rehabilitation process (Crepeau et al., 2003). During World War I, occupational therapy’s evolution in the United States was facilitated by the efforts of Army orthopedists, who attempted to establish rehabilitation programs based on the English reconstruction model initiated by a British colonel and orthopedic surgeon, Robert Jones. Jones was in charge of a 400-bed hospital in Liverpool, and soon received national recognition in Britain for his role in the development of rehabilitation centers designed to emphasize restoration of athletic prowess and confidence (Swan, 1964). The reconstruction programs in England were founded to help mitigate the economic strain of disabled soldiers in that country, and to recognize the moral

856 D.E. TUPPER obligation that the nation had to its wounded soldiers see Howard and Hatfield, 1987). The Hippocratic physi(Gutman, 1995). cians (c. 400 BC) similarly implied a dim view of language It was in this context that the United States began recovery, as speech disturbances caused by apoplexy were training female physiotherapists and occupational typically discussed in the context of protracted and fatal therapists as reconstruction aides, thereby fostering the illnesses (Benton and Anderson, 1998). Concepts of aphagrowth of the profession of occupational therapy. sia prior to the 1800s were incompletely developed (Prins Following the war, occupational therapists continued to and Bastiaanse, 2006), and speech loss following work with individuals who had sustained acquired cerecerebral lesions was often ascribed to paralysis of the tonbral and orthopedic trauma, and also began working gue (Howard and Hatfield, 1987; Wollock, 1990). The with children with cerebral palsy and other developmenusual methods for treating palsies, such as stimulants tal anomalies. Initially, the military stopped train(including electricity by the 1750s), were attempted for ing occupational therapists after World War I, but some cases. campaigning and lobbying to sympathetic physicians The remediation of aphasia by language therapy is eventually led to the recognition of appropriate training described in writings in the 16th and 17th centuries arrangements and formal organizational status for the (Eldridge, 1968; LaPointe, 1983; Sarno, 1991). Pierre profession. This occurred during World War II, when Chanet (1649) provides an early account of recovery the medical profession again rediscovered the benefits and re-education of speech and reading, when he of a therapeutic focus on occupational and functional addresses the improvement in reading and speaking of gains through rehabilitation for the war injured. Physical a relative’s aphasia following a head wound sustained medicine physicians in particular were supportive of during the Siege of Hulst in the Low Countries (also cited broadening the role of occupational therapy in rehabiliin Howard and Hatfield, 1987). Benton and Joynt (1960, tation and, although boundary disputes arose, occupap. 209), in an excellent review of the early literature on tional therapists welcomed a close relationship with aphasia, describe the findings of German physician physical medicine (Gritzer and Arluke, 1985). That relaJohann Schmidt, who, in 1673 (Schmidt, 1676), noted that tionship remains strong to the present time. one of his two apoplectic patients with aphasia and alexia Work is the most evident handicap that is affected in responded to retraining more than the other patient, who patients with nervous system dysfunction. The indivishowed no improvement. dual with a disability frequently presents a unique Therapeutic attempts during the 19th century added employment problem. The development of vocational additional refinements, based on a better understandrehabilitation has occurred alongside the increasing sociing of aphasic disorders; in particular, physical interetal recognition that people with disabilities and handiventions were abandoned for methods that involved caps have the same rights to the pursuit of fulfillment attempts at re-education or application of contemporas non-disabled individuals. As stated by Obermann ary teaching methods to patients with aphasic disorders (1965), the history of vocational rehabilitation can best (Schoolfield, 1938; Benton, 1964; Marx, 1966). In 1833, be conceived as a chronicle of the gains made in public for example, Jonathan Osborne in Great Britain attitude and acceptance regarding the vocational rights described an early attempt at re-education of jargon of people with disabilities. Practically speaking, efforts aphasia, and Thomas Hun (1847), a physician at Albany to provide meaningful work situations for individuals Medical College, was also one of the first to recomwith neurological disabilities have a very recent history, mend systematic exercises in spelling, writing, and occurring only in the past 20 or 30 years, unlike reading, when he encouraged a 35-year-old, postvocational rehabilitation efforts for individuals with stroke, aphasic patient to try them to enhance recovery. other disabilities, such as cerebral palsy or blindness Paul Broca (1865/1969; trans. in Berker et al., 1986) (Obermann, 1963). Vocational rehabilitative strategies, is often cited for advocating retraining language skills including supported employment, are often emphasized in his patients. Broca began to teach an aphasic adult in the brain-injured population (Wehman and Moon, to read once again, using a “bottom-up” strategy of 1988; Wehman and Kreutzer, 1990). reading letters and syllables, and subsequently switching to a compensatory strategy of reading the words without breaking them down. Although not formaAPHASIA REHABILITATION lized, he maintained that aphasic individuals could The skepticism regarding recovery of and treatment be taught language in the same way that children attempts for language disturbances began early in learn language skills, but he also believed that chilrecorded history, when the author of the Egyptian Edwin dren had greater potential for recovery. In his 1865 Smith papyrus (c. 2650 BC) wrote that speechlessness is paper, Broca emphasized the compensatory role of an “ailment not to be treated” (Breasted, 1930, p. 286; the right hemisphere in recovery and re-education

REHABILITATION THERAPIES 857 from aphasia of left-hemispheric origin (also Ryalls Unlike the less frequently described treatment of and Lecours, 1996). language disorders associated with stroke, as noted The English neurologist Henry C. Bastian (1898) previously, the two World Wars of the early-20th century presented a developmental perspective on aphasia therprovided a major stimulus for the development of apy at the end of the century, although he is also treatment centers addressing not only the prominent cogknown for his center-based aphasia classification. He nitive sequelae of traumatic head wounds, but partipostulated both functional restitution (spontaneous cularly the acquired language disorders associated with recovery) and functional compensation by the other such wounds. It was at this time that the first large-scale hemisphere following acquired language disorders, reports on aphasia and cognitive rehabilitation were puband proposed language re-education methods based lished, representing the work of Froeschels, Goldstein, on teaching methods for the deaf and dumb or those Luria, and Poppelreuter. with congenital speech defects. He particularly emphaDuring World War I a number of rehabilitation hospisized the need for extensive practice and repetition tals were established for the treatment of the brain (Bastian, 1869). injured, particularly in Germany, to help care for the high Additional commentary on aphasia re-education internumber of people who had suffered such trauma. ventions came from Charles Mills (1880, 1904) and Walther Poppelreuter founded such an institution in William Broadbent (1879). Mills (1904), in particular, pubCologne in 1914, and comparable facilities were devellished a review of training methods utilized to that time, oped in Frankfurt by Goldstein and in Munich by Isserlin and commented not only on the benefits of systematic (Poser et al., 1996). Goldstein, in particular, at his Institute repetition and graded practice exercises during retraining, for Research on the After-effects of Brain Injuries, but also discussed important age differences between worked on both a theoretical foundation and practical normal child language development and relearning of therapies for language disturbances. He downplayed language by an aphasic adult. His report was also notable localizationist perspectives for a holistic approach, and in that he raised concerns about differential influences of maintained that cooperation between brain regions led other non-linguistic aspects of rehabilitation, such as to higher cortical capabilities such as language. His theraemotional factors, education, and premorbid intelligence, peutic approach primarily emphasized compensatory thus presaging several of the additional important recogstrategies. nitions of the rest of the 20th century. The large number of individuals who suffered brain Howard and Hatfield (1987) classify Mills as a practiinjuries during World War II stimulated continued protioner of the German and Austrian school of speech gymliferation of treatment programs in military and civilian nastics, as Mills’ remedial recommendations were very hospitals. In the United States, the Veterans Administrasimilar to those practiced by the German phoniatrist tion Hospital programs came into being, rehabilitation Hermann Gutzmann and the Viennese physician Emil medicine emerged as a medical specialty, and speechFroeschels, in that the gradual introduction and repetition language pathology developed as an allied health profesof speech-sounds, syllables, and words was a core element sion in rehabilitation, having spun off from their educaof his speech therapy. Gutzmann subsequently developed tional roots as teachers of speech in the 1920s and 1930s a treatment center for post-traumatic combat veterans (Moore and Kester, 1953; Simon, 1954). during World War I in Berlin (Sarno, 1998). Clearly, there Additional publications by Kurt Goldstein on the was a major advancement in understanding aphasic disorrehabilitation of language and related disorders appders and their treatment, as well as the development of the eared, based on his follow-up experiences with traumatspecialty of speech-language pathology (Weisenburg and ically injured patients from both World Wars, again McBride, 1935; Moore and Kester, 1953). emphasizing the importance of facilitating compensaRemembered for attempts at nervous and mental tory means of communication (Goldstein, 1939, 1942, re-education (see below), Shepherd Ivory Franz 1948). Butfield and Zangwill (1946) in England docupublished a report in 1905, in which he re-taught a mented the beneficial effects of speech therapy in 57-year-old stroke victim lists of words and related patients with traumatic aphasia, as opposed to aphasia information, and then compared the patient’s scores due to other causes, and Joseph Wepman (1951), from for acquiring new information versus relearning old California, drew attention to the large population of material. He carefully measured the results and untreated individuals with aphasia, both veterans and described the differences as indicating gradual acquisicivilians, who might benefit from direct speech therapy. tion of a new “habit,” while previously learned material Finally, some of the most influential work resulting could be acquired with greater efficiency. A later paper from treatment of aphasic individuals in World War II expanded on his quantitative approach in retraining is that of Aleksandr Luria from the Soviet Union. patients with aphasia (Franz, 1924). Luria (1947, 1970) treated a large series of patients with

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traumatic aphasia and concluded that systematic retraining based on a careful psycholinguistic analysis and aimed at the reorganization (intra-systemic or inter-systemic) of functions provides the foundation for the successful restoration of verbal capabilities (Hatfield, 1981; Christensen, 1986; Kagan and Saling, 1992; Christensen and Caetano, 1996). Since the mid-20th century, the amount of clinical and research activity in aphasia rehabilitation has expanded considerably. There are many theoretical issues still debated with regard to aphasia and its treatment (Shewan, 1986; Byng and Jones, 2003). Currently, although many methods have been proposed (see Sarno, 1998), most approaches to aphasia therapy follow one of two models, either a direct treatment or retraining model, or a substitute skill or compensatory model. Presently, speech-language pathology is an established allied health profession, and aphasia therapy is an important component of the practice of rehabilitation medicine, especially for those individuals with aphasia due to stroke or head trauma (see also Ch. 36 and Ch. 52).

COGNITIVE OR NEUROPSYCHOLOGICAL REHABILITATION Because cognitive or neuropsychological deficits are common sequelae of many neurological conditions, the rehabilitation of cognitive deficits has developed into an expected part of a comprehensive rehabilitation program, if not a specialized field of endeavor in its own right (Boake, 1991; Parent
e and Stapleton, 1997; Boake and Diller, 2005; Prigatano, 2005). Cognitive deficits contribute dually in rehabilitation: these deficits are themselves a primary treatment focus of rehabilitation, and they also are often related to the severity of injury and extent of recovery of the primary neurological deficit. Although various attempts to improve cognitive functioning have been utilized in non-neurologically impaired individuals for many years (see Mann, 1979), neuropsychology and rehabilitation have a relatively short history (Beauvois and Derouesn
e, 1982; Benton, 1988). It is primarily in the past century that direct attempts at intervention for neurologically mediated cognitive deficits have been applied. Many of the early attempts used whatever educational methods were available at the time. Thus, early cognitive rehabilitation efforts consisted of education or “re-education” of impaired cognitive capabilities to optimize the functioning of the individual. Nevertheless, re-education of cognitive functions is not equal to the training of muscles where repetitive practice is beneficial; re-education must rely on principles of learning and development of compensatory strategies to be most beneficial (Kreutzer et al., 1989).

Shepherd Ivory Franz’s work with aphasic patients has been described previously. As a psychologist, Franz is also well known for his experimental work with animals, and especially his use of learned behavior as a baseline for the study of cerebral ablations. Based on techniques developed in animal experiments, including studies of motor recovery and responses to treatment after hemiplegia (Franz et al., 1915; Ogden and Franz, 1917), Franz became a leading advocate for rehabilitation in the early-20th century (Cotola and Bach-yRita, 2002). Franz continued to use his habit-based, functional approach during cognitive rehabilitation efforts (Franz, 1917, 1919) and emphasized quantitative measurements of recovery in his lesion research. In what is perhaps his major treatise, Franz commented on his approach: . . . the principle of re-education is that of habit formation. It is either a replacement of old, inadequate, or harmful methods of reacting with new habits more like those of the other individuals in the environment, or it is the formation of new habits to take the place of those that have been lost. In other words, re-education is to the abnormal what education is to the normal – it is a matter of the acquisition of habits that will enable the individual to take his place in the working, playing, social world. (Franz, 1923, p. 17) As was seen with aphasia rehabilitation, a number of major developments in cognitive rehabilitation took place because of the two World Wars. During World War I, along with Franz’s work in the United States, a number of rehabilitation centers were created in Germany and Austria, including centers that emphasized rehabilitation or restoration of cognitive functions. Kurt Goldstein’s work in Frankfurt with disorders of speech, reading and writing, as well as Walther Poppelreuter’s work in Cologne with visuo-perceptual disturbances, are both notable examples of early neuropsychological rehabilitation efforts (Boake, 1989, 1991). Goldstein developed therapeutic techniques that emphasized the use of preserved skills to substitute for lost skills, and he stressed the need for accurate clinical assessments and direct observation of a patient’s functioning in vocational workshops. Poppelreuter similarly used a pragmatic approach when caring for more than 700 cases of brain wounds in a large neurorehabilitation hospital and in workshops (see Fig. 53.3). He considered treatment of soldiers with cortical damage to be his social responsibility, and he utilized systematic study to differentiate between recovery and treatment effects, especially after occipital cortex lesions (Poppelreuter, 1917/1990). Other notable work was undertaken by

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Fig. 53.3. Visual search testing in a patient with a left occipital gunshot wound. Dr. Walther Poppelreuter, on the right, is carrying out the examination. [Figure 43 (p. 106) from Disturbances of Lower and Higher Visual Capacities Caused by Occipital Damage by W. Poppelreuter (1990, Oxford University Press, translated from the German by J. Zihl); German original, Die Psychischen Scha¨digungen durch Kopfschuss im Kriege 1914/ 16. Band 1: Die Sto¨rungen der Niederen und Ho¨heren Sehleistungen durch Verletzungen des Okzipitalhirns (Leipzig: Leopold Voss, 1917). By permission of Oxford University Press.]

Fig. 53.4. Aleksandr R. Luria and Lev S. Zasetsky (on the left), a soldier who suffered a severe left temporo-parietal penetrating wound in World War II. Zasetsky was studied and treated by Luria for many years (described eloquently in Luria, 1972). (From Soviet Life, September 1980, No. 9, p. 28.)

Isserlin in Munich and Hartmann and Froeschels in Austria (Boake, 1996, 2003). The advent of World War II likewise stimulated clinician-researchers in various countries to advance cognitive rehabilitation of injured soldiers. Two units for the rehabilitation of head-injured patients were established in Scotland and emphasized a team approach to rehabilitation, as well as the active participation of the patient in his or her own rehabilitation. An early brain injury unit in Bangour Hospital near Edinburgh, staffed by, among others, psychologist Oliver Zangwill and neurologist W. Ritchie Russell, focused particularly on the assessment of memory and the retraining of impaired cognitive capabilities (Zangwill, 1945; Pentland et al., 1989). Zangwill (1947) should be credited for specifying principles of re-education and direct training, and for considering the roles of compensation and substitution during the rehabilitation process. A second Scottish brain injury unit was set up in Killearn near Glasgow, and served both servicemen and civilian cases.

As noted, one of the most prominent neuropsychologists to advance brain injury rehabilitation was Aleksandr R. Luria (more accurately transliterated as Luriia), who was dually trained as a neurologist and psychologist. As director of a neurorehabilitation hospital in the Urals during World War II, Luria was involved in the treatment and rehabilitative care of over 800 patients with penetrating head trauma (see Fig. 53.4). His experiences there formed the basis for his rehabilitative approach that relied on his influential theory of functional systems of the brain (Luria et al., 1969). Luria’s general approach to rehabilitation centered on the idea that diagnosis and treatment of cognitive dysfunction are intrinsically related, and that both patient strengths and weaknesses need to be taken into account in planning intervention strategies (Luria, 1948, 1963). Luria’s theoretical principles for restoration of function included de-inhibition (de-blocking), transfer of function to the opposite hemisphere, and reorganization of functional systems (intra- or

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inter-systemic) (Luria et al., 1969; see also Tzvetkova, 1972, 1985). Following his rehabilitation work, Luria went on to become well known internationally for his theoretical conceptualizations of brain function, his patient-sensitive neuropsychological investigations, and his research into various aspects of language disturbances and frontal lobe functioning. In the post-war era, although many head injury rehabilitation centers started because of the war were now closed, cognitive and neuropsychological rehabilitation continued to evolve. A number of acute head trauma care and rehabilitation centers were added to major hospitals in various countries, such as the Loewenstein Rehabilitation Hospital near Tel Aviv and the Rancho Los Amigos Hospital near Los Angeles (Boake, 1989). Acute neurosurgical care improved due to technological advances in medicine during the 1960s and 1970s, and resulted in increased survival from accidental head trauma, such as that from motor vehicle crashes. Unfortunately, many vehicle-related injuries proved severe (Roberts, 1979), which necessitated the secondary development of more comprehensive brain injury rehabilitation programs. Also historically noteworthy is the Israeli response to the increased number of head-injured soldiers from the 1973 Yom Kippur war. The Ministry of Defense supported development of a day treatment program for head-injured soldiers at Loewenstein Hospital in 1975, jointly run by the Israeli Department of Rehabilitation and New York University (Vakil, 1994). The neuropsychologists Yehuda Ben-Yishay and Leonard Diller initially collaborated on the program, which emphasized a rehabilitative focus on the patient’s cognitive and behavioral disabilities. Later they implemented similar programs in several centers in the United States. Based on these experiences, Ben-Yishay, in particular, became an advocate for a milieu-oriented approach to cognitive rehabilitation of individuals with acquired brain dysfunction (Ben-Yishay, 1996). Similar programs have been established by George Prigatano and his associates in Arizona, using a combined psychotherapeutic and neuropsychological treatment model (Prigatano et al., 1986; Prigatano, 1999). Given the relatively brief history of cognitive rehabilitation, it is perhaps unsurprising that relatively few models of the mechanisms underlying cognitive change in the brain injured have been described (Barat and Mazaux, 1986; Ben-Yishay and Prigatano, 1990; Gianutsos, 1991). In addition, clear practical theories that would underlie the development of specific treatment techniques in cognitive rehabilitation are still lacking, although there have been some recent endeavors in this area. Moehle and colleagues (1987) reviewed the theories or models utilized in the development and application

of cognitive rehabilitation. These authors described five primary models that include: (1) the functional system approach suggested by Luria and his colleagues (Luria and Tzvetkova, 1968; Tzvetkova, 1985); (2) developmental models (e.g., Craine, 1982); (3) learning theory models, or the application of behavioral psychology techniques in cognitive rehabilitation (see Wilson, 1997); (4) process training models (Sohlberg and Mateer, 2001); and (5) pragmatic or functionally applied models, which are not necessarily theory-based. (The reader is referred to the original sources for details.) Several major concepts also underlie the clinical understanding of cognitive dysfunction in brain injury rehabilitation and restitution and substitution of function (see Rothi and Horner, 1983). Oliver Zangwill (1947) considered the practice of re-education to include compensation, substitution, and direct training. More recently, physiologic mechanisms of neurobehavioral recovery have included the notion of restitution of function from any variety of neuronal processes, such as axonal regeneration, collateral sprouting, and denervation supersensitivity, to name just a few (Finger and Stein, 1982). Stimulation or direct retraining methods have been suggested as the main mode of cognitive rehabilitation in such instances. Nevertheless, it is largely assumed that much of the “recovery” witnessed after acute lesions is likely to occur by substitution of function, such as circumvention of deranged links within and across functional systems. Rehabilitation models based on reorganization of function (similar to Luria’s recommendations; see Almli and Finger, 1992) are thought to operate via substitution or compensation of function (see also Wilson, 1997, 2000; Dixon and Ba¨ckman, 1999). Assessment of the efficacy of cognitive rehabilitation efforts is a major contemporary issue in both research and practice. Controlled research is difficult at best (Eslinger and Oliveri, 2002; Johnston et al., 2006). Difficulties in identifying and using appropriate control groups in cognitive rehabilitation are especially notable, and some authors also emphasize that studies in rehabilitation need to yield valid data at reasonable cost (i.e., be tractable) and lead to practical outcomes (Hart and Hayden, 1986). Among efficacious research designs, a controlled study by Ruff et al. (1989) is an example of a randomized parallel design, with a neuropsychological treatment group demonstrating significant improvement over 8 weeks of training, compared to a nonspecific treatment group who receive support and professional attention to an equivalent level. Although utilising different controls, two treatment studies by Prigatano and associates (Prigatano et al., 1984, 1986) also showed beneficial effects of neuropsychological rehabilitation in

REHABILITATION THERAPIES 861 treated groups, compared to groups delayed in receiving and rehabilitation was not the usual treatment method the intervention for extraneous reasons. for the survivors. The evolution of rehabilitation medA new focus on evidence-based medicine has pericine in Britain, the United States, Germany, Israel, vaded cognitive and neuropsychological rehabilitation, and other countries in the mid-20th century occurred leading to supporting evidence that rehabilitation of primarily due to the influx of many war-related TBIs. cognitive dysfunction is not only cost-effective (Diller Many comprehensive rehabilitation programs for TBI and Ben-Yishay, 2003; Wilson and Evans, 2003), but were developed in the United States and other counthat a number of specific cognitive treatment strategies tries during this timeframe. are, in fact, beneficial (Carney et al., 1999; Katz et al., The most common problems in individuals with TBI 2006). For instance, critical reviews by Cicerone and include impairments of attention, speed of information colleagues (2000, 2005) conclude that substantial processing, learning and memory, self-regulation, and evidence exists for the benefit of cognitive-linguistic psychoemotional functioning, including self-awareness. therapies for people with language deficits and apraxia Clearly, a comprehensive approach to the assessment after left hemisphere stroke, as well as for visuospatial and treatment of this array of deficits is necessary to rehabilitation for deficits associated with visual neglect optimize the outcome of the rehabilitation process for after right hemisphere stroke. Strategy training for the individual with TBI. It is beyond the scope of this mild memory impairment and post-acute attentional chapter to consider in detail the main ingredients curdeficits, and interventions for functional communicarently recognized as important in brain injury rehabilitation deficits, have been demonstrated to be effective tion of the individual with TBI, but early intervention in the cognitive rehabilitation of individuals who with a combined medical, neuropsychological, and have suffered traumatic brain injuries (Cicerone social-vocational model is often promoted as optimal et al., 2005). (Prigatano and Ben-Yishay, 1999; Gordon et al., 2006); many of these components of rehabilitation were identified 100 or more years ago. As a consequence, there has COMPREHENSIVE BRAIN INJURY been a trend toward the development of communityREHABILITATION based models of rehabilitation for individuals with head Traumatic brain injury (TBI) and stroke have been, and trauma (Katz et al., 2006). remain, by far the most prominent neurological etioloCerebrovascular disease leading to stroke is one of gies treated in comprehensive brain injury programs the leading causes of death and chronic disability that (Licht, 1975; Giles, 1994). Both etiologies represent has been described throughout history (Fields and acquired insults to the brain, usually in adult life, and Lemak, 1989; Benton, 1991). Rehabilitation of stroketypically show spontaneous recovery, although the related impairments should recognize the fact that extent and pattern of recovery differs dramatically greater specificity in symptoms is more often seen in between them. Individuals who have suffered a closed a stroke survivor than in TBI or other neurological head injury, particularly from accidental, non-wartime impairments. Frequent neurobehavioral sequelae of causes, often demonstrate a diffuse or non-focal patstroke include speech and language disturbances (aphatern of neurological and cognitive dysfunction and sia, alexia, etc.), visuoperceptual difficulties such as recovery. In contrast, individuals who have suffered unilateral neglect, memory and learning deficits, emoan open, penetrating, missile wound to the brain (often tional disorders, and resultant adaptive functioning during war), or a localized stroke, often demonstrate a deficits in daily life. A truly comprehensive intervenmore focal pattern of neurological deficit, especially tion approach to the management of stroke-related difweeks after the initial event, leading to a combination ficulties deals with the neurologic, behavioral, and of specific deficits. Thus, the histories of rehabilitation social aspects to varying degrees, depending on the efforts for TBI and stroke have differed. cerebral lesion location and the individual’s particular The incidence of TBI has varied throughout the life circumstances (Kaplan and Cerullo, 1986; Tupper, ages (Gurdjian, 1973; Torner and Schootman, 1996), 1991). and the history of TBI rehabilitation has been strongly The efficacy of stroke rehabilitation has only relatied to war-related trauma (Walker and Jablon, 1961; tively recently been investigated in terms of outcome Walker and Erculei, 1969). Bakay (1971) documents or the quality of the intervention process as a whole. the early history of head injury treatment during the Wade (2003) provides comprehensive evidence, which Thirty Years’ War (1618–1648), which occurred just as shows overwhelmingly that treatment by a specialized the modern age was dawning. Although central nerstroke service results in reduced mortality, lower incivous system function was suspected to be associated dence of stroke recurrence, faster recovery, shorter with brain trauma, surgical intervention was primary hospital stay, and lower levels of emotional distress

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in patient and caregiver than unspecialized, uncoordinated services. Similarly, Wade notes that involvement of the patient and family in the rehabilitation process is important. Studies of therapeutic approaches have so far shown mixed results, suggesting that severity of impairment may affect response to therapy. Early implementation of comprehensive stroke rehabilitation programs results in better outcomes, especially with moderately disabled survivors (Johnston and Keith, 1983). Along with some of the therapeutic interventions discussed above, the development of new methods, such as constraint-induced movement therapy (Taub et al., 1999; Uswatte and Taub, 1999; Taub and Uswatte, 2000, 2006; Taub et al., 2002; Wolf et al., 2006) or constraint-induced language therapy (Maher et al., 2006), indicates that individuals who have suffered a stroke can benefit from direct rehabilitative efforts, even after the expected period of spontaneous recovery has ended (Sunderland and Tuke, 2005).

GENERAL COMMENTS Unlike neurology’s early history, which emphasized understanding of nervous system disorders leading to a diagnosis, an increasing number of neurologists have joined professionals from other specialties to promote the rehabilitation of already-identified disorders of the nervous system (Selzer, 1992). The early skepticism of neurologists regarding cerebral recovery and response to treatment has subsided, and a somewhat more optimistic perspective on the benefits of the rehabilitation process for the individual with a neurological disability has arrived (Moore, 1980). Nevertheless, there is a great deal to be learned in order to understand better the effectiveness of neurological rehabilitation, and to help develop effective, empirically based rehabilitative strategies and therapies for individuals with neurological disability. For instance, from a neurological perspective, the basis of nervous system plasticity is yet to be fully understood (Selzer, 1994; Boller and Grafman, 2003; Boller, 2004), and use of a disability-based perspective (e.g., WHO, 2001) may challenge neurologists to consider both the medical and the social sides of rehabilitation practice. Development and application of a cognitive neuroscience perspective will likely dominate brain injury rehabilitation in the future (Feinberg and Farah, 2006). In today’s society, cost-effectiveness of rehabilitative care is an issue (Rosenthal, 1989), and evidence-based medicine approaches will help refine and determine the therapies and/or technology most utilized to treat various disorders. Principles and standards of care in neurological rehabilitation will soon be determined (Moore, 1973; European Federation of Neurological

Societies Task Force, 1997), but during this future evolution, it is hoped that both the art and the science of neurological rehabilitation can be maintained (Siegert et al., 2005; Tate, 2006). In present-day society, it is taken for granted that there is a treatment for every disability. Historically, however, that has not always been the case, and it is only in the recent past that rehabilitation has helped address the real-life consequences of neurological disorders. The personal and societal benefits of rehabilitation are probably incalculable, but rehabilitation of various neurological disorders has been a positive evolving art and science for the past century or longer. As stated almost philosophically by German-American neurologist, Walther Riese, almost 50 years ago: With the victorious rise of the reshaped human figure, medical assistance was extended from the cure of the sick to the care for the infirm. Here ends the history of neurology to merge into the history of human charity and medical ethics. (Riese, 1959, p. 180)

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