Introduction—why restorative neurology?

Neurologic impairments and disabilities constitute important medical and socio-economic problems. Paradoxically, treatment of chronic neurologic diseases has been considered frustrating and of little value. Neurology has been viewed as a medical specialty more concerned with diagnosis than with therapy.

This opinion should now be changed. In the last 20 years, indisputable progress has been made in the discovery of techniques which reduce patients’ disabilities and ameliorate their discomfort. However, to an extent unusual in other medical disciplines, these therapeutic modalities are not represented only by drugs but involve various procedures; surgical, psychological or rehabilitative in nature. Parkinson’s disease provides a good example of the way in which different useful techniques have evolved. In the 1960s, before the advent of dopamine precursors and agonists, patients benefited from stereotactic surgery. In the 1980s, the major problem was to define optimal strategies of pharmacologic treatment. The 1990s promise neural grafting although it will certainly not replace drug therapy and has yet to establish its proper place in overall management. New approaches have been developed for the management of patients with spinal cord injuries which aim to reduce the extent of their lesions and make their lives longer and more productive. In neurology, disability is not only the consequence of dysfunctions in cell metabolism but often results from disruptions of neuronal circuits; These disconnections trigger compensatory and adaptive mechanisms which, when understood, may be improved by drugs or by alternative strategies such as training or correction of imbalance between excitatory and inhibitory processes.

There are many new therapeutic techniques to complement well established ones but they may appear disparate and clinicians are faced with confusing choices, sometimes in competition with one another, to improve their patients’ function. Classically trained doctors may be reluctant to turn to new techniques but many clinicians are interested in the rationale, principles and achievements of these unusual or new procedures. They are anxious to identify those which are well-founded and derive directly from advances in the field of neuroscience and to discriminate them from other empirical ones which are advocated on the basis of anecdotal evidence. In addition, some clinicians are eager to learn about research techniques, such as neural grafting, which hold promise for the future.

The above mentioned considerations have promoted the development of this book, Principles and Practice of Restorative Neurology. Each term in the title deserves comment.

The principles describe the rationale behind available therapeutic techniques as well as future ones which will derive from actual achievements in experimental neurology. They indicate, from a theoretical point of view, the promises and limitations of transposition to human pathology of advances being made in animal laboratories. This intellectual approach, however, is not sufficient for clinicians who have to make decisions for individual patients, choose the best treatment and learn to apply it. Practice is thus a complementary aspect which derives from principles or sends investigators back to the laboratory to discover new principles. Practice refers to the well established procedures that have proved useful including how and when to apply them.

Although all of us would welcome critical and quantitative analyses of techniques currently employed in the practice of restorative neurology, such data, for the most part, do not exist. Collecting such data is an important aspect of the future of restorative neurology.

Restorative neurology is a subspecialty of neurology; it deals with techniques and strategies used to restore a disordered nervous system to a state of optimal function. Restorative neurology is characterized by a pathophysiological approach to nervous system disease and, as such, differs from neurosurgery which is primarily an anatomical discipline and from pharmacology which relies essentially on neurochemistry. However, restorative neurology tries to integrate these modalities of treatment into a comprehensive approach to the patient’s disability; it combines disparate disciplines, including new techniques derived from neurobiology, in a pragmatic attempt to improve neurologic functions. It is thus not surprising that restorative neurology encompasses a range of interests; some of these include pharmacology, plasticity, retraining, motivation, substitution, rehabilitation, functional surgery, neural grafting, and genetic engineering.

To be applied effectively, these various modalities of treatment require specialists so restorative neurology relies on a team of physicians, scientists and paramedical personnel assisting them. A coordinator experienced in many of the various aspects of care must define strategies of treatment and assess overall results. At this time, a neurologist seems best suited for that role.

In addition to being multidisciplinary, restorative neurology is uniquely dependent upon the following two endeavors. First is quantitative evaluation of neurologic deficits which is the cornerstone of restorative neurology. Proposed therapeutic efforts must prove their efficacy on an objective basis; quantitative assessment is mandatory if one is to be able to compare results and outcomes. This goal is difficult to achieve because tools of assessment are in development and rarely incorporated into the routine practice of most neurology departments. A continuous effort must be maintained to obtain reliable methods of assessment and, considering the interest raised in recent years by quantification of neurologic deficits, codification and generalization of these procedures which can be accepted worldwide may be expected. The second essential endeavor is clinical neurophysiology. In addition to providing objective data to contribute to assessment, clinical neurophysiology also permits pathophysiological analyses of the consequences of nervous system lesions. These results are useful to explain not only the general mechanisms involved in common syndromes such as spasticity but also to specify the unique functional particularities of individual patients. Clinical neurophysiology provides means to help understand defective function of the nervous system, develop strategies to correct abnormalities and assess the results. Finally, clinical neurophysiology has practical advantages because its equipment and techniques are widely available and not expensive; however, they are time-consuming.

One may, however, ask whether restorative neurology is a new field in neurology or is only a new name for an old practice, namely rehabilitation. Where does restorative neurology find its place and where are its borders with established medical specialities? We believe restorative neurology has a specific place in the treatment of individuals with neurologic disorders which can best be understood by considering schematically the sequence of events occurring immediately after a nervous system lesion. Similar considerations apply to patients following initial diagnosis of a chronic progressive disorder.

The first step is to make a correct diagnosis including a lesion’s localization and extent. If possible, adequate measures are taken immediately to halt progression of the lesion and suppress its effects. This phase is that of diagnosis and acute treatment and may require an Intensive Care Unit. If acute management does not succeed completely, the patient is left with a permanent lesion and following that, biological processes such as plasticity and compensatory mechanisms enter into play to rearrange the nervous system and restore function. A pathophysiological approach to the patient combined with good knowledge of neurobiology may at that stage help one to enhance the recovery process. This is the role of restorative neurology. Many complementary techniques, and new ones appear regularly, are put in place to limit or compensate for disability.

This part of the treatment is the responsibility of a neurologist who knows nervous...