Mapping the future of spinal cord injury rehabilitation

The development of new technologies and research into in the nervous system has resulted in a shift in neurorehabilitation towards recovery of function. However numerous barriers like cost and value to the patient can prevent these developments reaching clinical practice. New research published in the Journal of NeuroEngineering and Rehabilitation proposes the use of the FAME framework to help translate exciting neurorehabilitation treatments and technologies into practice.

Conducting research in the area of neurorehabilitation has never been more exciting. Over the past few decades, the field has transformed from a discipline largely focused on helping those with neurological damage learn to compensate for their lost function, to one focused on neuroplasticity and recovery of function. This transformation resulted from research demonstrating that the nervous system can change and re-organize in response to a variety of triggers, such as disease and exercise.

Nowhere has this transformation from compensation to recovery been more apparent than in the rehabilitation of those with spinal cord injury (SCI). We recently completed an environmental scan of ongoing research studies focused on the recovery of movement and function after SCI.

One trial is combining stimulation of the spinal cord with robotic-assisted practice of standing and walking.

Robotics and various forms of electrical stimulation are currently the most researched rehabilitation approaches, suggesting technology will play a lead role in the future of SCI rehabilitation. These technologies are helping patients achieve a sufficiently high quantity of movement practice to drive neuroplasticity and recovery of function, which is an important contribution to the therapeutic process as the ability to deliver high-intensity rehabilitation is becoming increasingly challenging in health care environments.

Some of the most exciting research studies are combining two approaches to augment movement practice. Typically these trials are combing a form of electrical simulation with the use of a robotic device, virtual reality training or a second form of electrical stimulation. For example, one trial is combining stimulation of the spinal cord with robotic-assisted practice of standing and walking.

Another trial is applying non-invasive brain stimulation with peripheral nerve stimulation during the practice of upper limb functional tasks. It will be interesting to see how these creative combinations can intensify the effects of more traditional movement training.

Barriers to clinical practice    

Despite how beneficial these new technologies may prove to be, what is the likelihood that they can be successfully implemented into clinical practice? Often numerous barriers must be overcome as new treatments and technologies are introduced into clinical environments. For example, do the purchase and maintenance costs of the technology exceed a typical clinical budget? Does the clinical staff have the requisite knowledge and time to administer the new treatment to patients? Does the treatment or technology address an issue that is valued by the patient?

To consider the translational potential of the treatments and technologies identified in the environmental scan we used the FAME Framework, which was designed by Pearson and colleagues (2005) to assist clinicians in their decision-making around selecting treatments to incorporate into their practice.

The framework suggests considering the Feasibility of implementation as well as the Appropriateness of the treatment for the given therapeutic environment. The Meaningfulness, or whether the intended outcomes matter to the target populations, is a key factor in the translation decision. The Effectiveness and the Economic Evidence of the treatment are the final elements of the framework.

Through application of this framework to the research studies identified in the environmental scan, we identified gaps of current SCI rehabilitation research that warrant reflection.

Traditionally, the translation of research findings to clinical practice has been the responsibility of health care professionals and administrators; however, researchers can play an important role in this endeavor as well. We suggest that researchers consider the FAME elements in a staged approach as new treatments and technologies are developed and tested. With early consideration of feasibility, appropriateness and meaningfulness, researchers will facilitate, and likely accelerate, the translation of effective treatments and technologies into neurorehabilitation practice.

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