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Restoring Neurological Function: Putting the neurosciences to work in neurorehabilitation A report from the Academy of Medical Sciences March 2004 The independent Academy of Medical Sciences promotes advances in medical science and campaigns to ensure these are translated as quickly as possible into benefits for patients. The Academy’s Fellows are the United Kingdom’s leading medical scientists from hospitals, academia, industry and the public service. The aims of the Academy are: • to give national and international leadership in the medical sciences; • to promote the application of research to the practice of medicine and to the advancement of human health and welfare; • to promote the aims and ethos of medical sciences with particular emphasis on excellence in research and training; • to enhance public understanding of the medical sciences and their impact on society; • to assess and advise on issues of medical science of public concern. The Academy of Medical Sciences was established in 1998 following the recommendations of a working group chaired by Sir Michael Atiyah, Past President of the Royal Society. There is an elected Council of 22 Fellows that includes the five Officers of the Academy: President Sir Keith Peters, FRS, PMedSci Vice-President (Clinical) Lord Turnberg, FMedSci Vice-President (Non-clinical) Sir John Skehel, FRS, FMedSci Treasurer Sir Colin Dollery, FMedSci Registrar Professor Patrick Vallance, FMedSci The Academy’s Executive Director is Mrs Mary Manning. For more information about the work of the Academy please see www.acmedsci.ac.uk The Academy of Medical Sciences is a company limited by guarantee Registered Charity No.: 1070618 Registered Company No.: 3520281 Registered in England ISBN No: 1-903401-07-0 Designed and produced by Quattro 020 7766 5225 Restoring Neurological Function: Putting the neurosciences to work in neurorehabilitation A report from the Academy of Medical Sciences March 2004 Acknowledgements The Academy of Medical Sciences is most grateful to Professor Richard Frackowiak, Professor Raymond Tallis and the members of the Working Group for conducting this inquiry. It would also like to thank the Review Group, the Academy Fellowship and all the respondents to the consultation for their instructive comments and support. This important exercise could not have been carried out without the generous support of the Medical Research Council and UHA. Disclaimer This report is published by the Academy of Medical Sciences and has been endorsed by its Officers and Council. Contributions by the Working Group and respondents to the call for evidence are made purely in an advisory capacity. The Review Group added a further ‘peer-review’ stage of quality control to the process of report production. The members of the Working Group and Review Group and the respondents participated in this report in an individual capacity and not as representatives of, or on behalf of, their individual affiliated hospitals, universities, organisations or associations (where indicated in the addenda). Their participation should not be taken as an endorsement by these bodies. Cover Photograph: The views contained in the websites listed in the Illustration of a network of nerve cells in the brain. ‘Other Sources’ sections of this report are those of Benedict Campbell individual organsations and do not necessarily reflect Wellcome Trust Medical Photographic Library those of the Academy of Medical Sciences. 4 Restoring Neurological Function Contents Page Summary 7 Preface 11 Part one - Background 13 Part two - Advances in neuroscience 17 Part three - Recommendations 21 Evidence 27 New research methodologies • A - Evaluation of clinical effectiveness: from individual patient studies to mega-trials 29 • B - Evaluation of clinical effectiveness: outcome measures 32 • C - Research synthesis 34 Understanding brain damage and neurological recovery • D - Developmental neuroscience 36 • E - Advances in cognitive neuroscience 39 • F - Neuroimaging 41 • G - Transcranial magnetic stimulation (TMS) 44 New treatment modalities • H - Deep brain stimulation (DBS) 46 • I - Neuroprotection and plasticity 48 • J - Neural transplantation 51 Advances in current therapeutic approaches • K - Maximising participation through rehabilitation 54 • L - Physical therapies to restore movement 56 • M - Rehabilitation engineering 58 Addenda • Addendum 1 - Acronyms and abbreviations 61 • Addendum 2 - Working Group and Review Group members 63 • Addendum 3 - Terms of reference and work plan 65 • Addendum 4 - Consultation 67 5 Restoring Neurological Function 6 Restoring Neurological Function Summary The disabling consequences of neurological disease A new clinical science of restorative neurology present a great challenge. Many neurological diseases therefore lies within our grasp. It depends on closer are age-related and populations in the developed world integration of the basic and clinical agendas. Currently, are ageing. While some progress has been made in neuroscientists and clinician scientists are often unaware preventing conditions such as stroke and in attenuating of each other’s work. The Academy has identified this symptoms in progressive conditions such as Parkinson’s as a serious obstacle to translating advances in disease (PD), it has been slow and so the major focus neuroscience into more effective neurorehabilitation has been on neurorehabilitation. treatments. Neurorehabilitation seeks to lessen the disabling impact Recommendations of neurological disease when there is limited potential for reversing the underlying pathological process. There The Academy’s recommendations seek to translate is evidence of its effectiveness in many conditions advances in basic and clinical neuroscience into but the degree of disability carried by many patients neurorehabilitation treatments that benefit patients. remains high. Though a simplification, it is useful to divide neurorehabilitation into measures primarily aimed at assisting adaptation to impairment and those Recommendation one: The NHS and academic primarily aimed at reducing impairments. The latter community should collaborate to create a number of address underlying neurological deficits more directly Regional Neurorehabilitation Research Centres but are relatively poorly developed. (RNRCs) each closely associated with one or more universities. In the last two decades there has been remarkable progress in neuroscience, transforming our understanding of the extent to which functional recovery is • By co-locating service delivery and research the possible following neural damage and how it may be proposed RNRCs will become the intellectual promoted. There have been advances on several fronts, foci for clinicians and scientists interested in which are set out in the ‘Evidence’ to this Report. They neurorehabilitation, foster sustained collaboration, include: encourage dissemination of a research culture • new methodologies in clinical trial design, through the clinical community and facilitate patient measurement of outcome, and research synthesis; recruitment for clinical trials. They may also act as • appreciation of the role of activity and environmental nodes for wider web-based ‘Virtual RNRCs’. input in driving neuroplasticity in healthy and injured brains; • Universities reviewing their research portfolios and • new investigations such as neuroimaging, electro- and departmental research plans should take note of magneto- encephalography (EEG/MEG), and opportunities arising from an integrated modern transcranial magnetic stimulation (TMS), singly or in scientific approach to neurorehabilitation research. combination, to investigate brain pathophysiology and to monitor treatment; • Close collaboration between RNRCs, district general • better understanding of brain-behaviour relationships hospitals (DGHs) and community services should be through cognitive neuroscience and the role of factors fostered and planned in the design of clinical trials in such as attention, motivation, mood and goal setting neurorehabilitation. The RNRCs should be at the in neurorehabilitation; centre of a ‘Hub-and-Spokes’ Model supporting the • new treatment modalities such as transcranial integration of clinical research activity. The Academy magnetic stimulation TMS, deep brain stimulation envisions that RNRCs will initiate major programmes (DBS), neural transplantation, neuroprotective agents of research, DGHs will initiate smaller projects and gene therapy that are in different stages of and participate in the major programmes, and development. community-based and other services will contribute 7 Restoring Neurological Function by helping determine research priorities and enrolling • For nurses and professions allied to medicine the patients. Academy recommends a clear commitment to the support of high-quality research by appropriate The proposed research structure closely reflects • contractual arrangements for trainees and established the recommendations of the Academy’s ‘Strengthening staff. Clinical Research’ report(1), which calls for disease specific translational research networks covering the For clinical neuropsychologists the Academy seven major causes of mortality and morbidity in the • recommends that the DH should establish clinical UK. Given the potential benefit to patients offered by academic research posts in neurorehabilitation. research into neurorehabilitation there is clearly Fellowships should be established for non-clinical potential for neurorehabilitation to be the focus of one psychologists,
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