RESIDENT & FELLOW SECTION Emerging Subspecialties: Section Editor Neurorehabilitation Mitchell S.V. Elkind, Training neurologists to retrain the brain MD, MS Michael A. Dimyan, WHY NEUROREHABILITATION? If not newly jury, and plasticity of the nervous system is an MD emerging, the subspecialty of neurorehabilitation essential component both in offering prognostic Bruce H. Dobkin, MD is definitely burgeoning, and neurology trainees guidance to patients and families during rehabili- Leonardo G. Cohen, may not be aware of the exciting career opportu- tation and in the development of new and more MD nities within the field. The contemporary neurol- effective techniques to enhance motor control and ogy resident is trained in a discipline that has cognitive skills. The neurologist’s appreciation of changed dramatically in the last two decades. The how the web of neuromedical complications and Address correspondence and modern day neurologist has a slew of treatment symptomatically targeted medications can affect reprint requests to Dr. Michael options at hand, from r-tPA to multiple immune- the nervous system is also an important compo- A. Dimyan, 10 Center Dr., 10/5N234 MSC1428, Bethesda, modulating medications, and practices with this nent in managing the course of rehabilitation and MD 20892-1428 arsenal of treatments from the emergency room helping move the patient and therapy team to- [email protected] to the outpatient clinic. Despite these advances, ward a set of realizable goals.1 many patients still leave the hospital or clinic with Beyond this currently available leadership role debilitating cognitive and sensorimotor impair- in neurorehabilitation, the future of the discipline ments and ask what we can do to help them walk offers young neurologists even more exciting ca- or use a hand again or regain enough function to reer prospects. From the molecular neurologist to return to their ordinary life activities. Some want the neurologic ethicist, the “plastic” nervous sys- advice regarding the prevention of further neuro- tem is an intriguing target of study. Neurologists logic deterioration. with an interest in research are increasingly di- The discipline of neurorehabilitation is the recting the translation of stem cell neurobiology,2 field concerned with these reminders of past and fundamental mechanisms of learning, neurophar- present neurologic illness and the improvement of macological manipulations, cortical electromag- neurologic function. Yet it is not uncommon for netic stimulation,3 robotic therapy,4 and brain- many neurology residents to get only a glimpse of computer interfaces5 into ways to improve this discipline, caught perhaps during a short spi- outcomes. The recent introduction of large scale nal cord or traumatic brain injury rotation. Be- neuroscientifically based therapeutic clinical tri- yond the first 72 hours of acute stroke care, most als6,7 into the field of rehabilitation is advancing residents will have no interaction with patients to the opportunities for evidence-based patient care. help them swallow, walk, reach and grasp, or Another aspect of great appeal in neurorehabilita- manage language and hemineglect disorders. For tion is that it continues to be grounded within many residents and practicing neurologists, the general neurology. The principles of neural repair team-based approach to therapy characteristic of and plasticity share a basic foundation across and rehabilitation medicine, and the lack of focus on beyond the various pathophysiologic etiologies of “localize the lesion” discussions, may seem for- the original neural injury, so the neurologist eign and fail to inspire a vision of their potential trained in neurorehabilitation may contribute to role as a neurorehabilitationist. the care of patients with multiple sclerosis, pe- But it is precisely neurologists’ background ripheral neuropathy, traumatic brain injury, knowledge and interests that make them ideal stroke, or other diseases. A neurologist who can leaders and partners in the neurorehabilitation help them identify spared pathways and enable team. The neurologist’s in-depth understanding them to practice a skill will give patients hope and of the anatomy, physiology, mechanisms of in- better quality of life. As young soldiers return From the Human Cortical Physiology Section (M.A.D., L.G.C.), Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; and Brain Research Institute (B.H.D.), Department of Neurology, Geffen School of Medicine, University of California, Los Angeles. Disclosure: The authors report no conflicts of interest. e52 Copyright © 2008 by AAN Enterprises, Inc. from battlefields with the scars of traumatic ner- paring a fellow for clinical neurorehabilitation vous system injury, or as the aging population practice in about 1 year, others are aimed more suffers cerebrovascular complications in greater toward academic neurorehabilitation, emphasiz- numbers, the skills of the neurorehabilitationist ing a research-based curriculum in areas such as will be in even greater demand. mechanisms of activity-dependent plasticity, functional neuroimaging, transcranial magnetic stimulation, or stem-cell biology, over 2 or more TRAINING OPPORTUNITIES IN NEUROREHA- years. Some fellowships may emphasize a disease BILITATION A broad range of training paradigms orientation, such as stroke, brain or spinal cord currently fall under the neurorehabilitation um- injury, and multiple sclerosis. Trainees may want brella, from the basic science benchtop laboratory to combine general clinical and focused research to the outpatient clinic. The American Academy curricula through one or more fellowships. of Neurology (AAN) section on Neural Repair and Rehabilitation has drafted a proposed core curriculum for training (http://www.aan.com/ CAREER PROSPECTS IN NEUROREHABILITA- globals/axon/assets/2736.pdf). Some of the skills TION The career prospects for neurorehabilita- that must be learned by the neurorehabilitationist tionists are as varied as the primary interests that are familiar to neurologists and make them ideal lead them to the field. While general rehabilita- candidates for this role, including understanding tion is dominated by physiatrists, neurorehabili- the basic science of nervous system plasticity, an- tation is really a subspecialty that appeals only to ticipating the long-term effects of neuromuscular a small subgroup of physiatrists. A brief survey of disorders, and managing the medical and social the nationwide job listing service provided by consequences of neurologic injury. However, the HealthJobs.com, conducted at the time of this neurorehabilitation fellowship is also a chance for writing, revealed eight positions for neurologists the neurologist to learn a new skill set including with an interest in rehabilitation and one for management of chronic pain, the use of research physiatrists interested in neurology. Many of disability scales, or the completion of formal dis- these positions are academic, reflecting a trend seen ability evaluations. Neurorehabilitationists also in other parts of the world, where neurologists are need to become fluent in the language of occupa- ushering in a new era in neurorehabilitation.8 tional, physical, and vocational therapy and to learn how therapists and patients use orthotics or DISCUSSION Perhaps we can take inspiration assistive devices, and how these tools fit into the from the neurologist who formally introduced re- economics of rehabilitation. A set of recom- habilitation techniques to modern medical prac- mended readings and a certification examination tice, Dr. Henrich Sebastian Frenkel. Dr. Frenkel, originally established by the American Society of a Swiss neurologist, astutely observed an im- Neurorehabilitation (ASNR) may soon be man- provement in the finger-to-nose examination of aged by the United Council for Neurologic Sub- one of his patients with tabes dorsalis. Upon fur- specialties. Both the ASNR and the World ther questioning, he learned that the patient, hav- Federation for Neurorehabilitation sponsor Neu- ing “failed” the examination in a previous visit, rorehabilitation and Neural Repair, a bimonthly had “practiced” so that he would “pass” at his 9 journal dedicated to the translational clinical sci- next appointment. Inspired by his patient, Dr. ences of neurorehabilitation. Interested trainees Frenkel began the organization of a field that can find listings of current fellowships through would lead within a few years to a department of the ASNR (http://www.asnr.com/clientuploads/ “re´-e´ducation functionelle” at La Salpe´trie´re in ASNRFellowshipInformationUPDATE.DOC?- Paris. The field flourished among neurologists in PHPSESSID ϭ 983c2c30d63c57a482c6725427f- Europe, and has now led to 20 to 25 academic 5390 days), through the AAN, or through the neurorehabilitation programs in the United American Academy of Physical Medicine and Re- States. Now US neurology trainees can increas- habilitation (http://www.aapmr.org/member/ ingly appreciate that a “functional re-education” felsearch.htm). of our understanding and treatment of the injured As with many smaller subspecialties, residents nervous system may benefit our patients, our ca- seeking training in neurorehabilitation need to reers, and our profession. identify those aspects of training they are most interested in to find a compatible fellowship. ACKNOWLEDGMENT While some programs concentrate on the topics The authors thank