Abstract
What are the principles underlying effective neurorehabilitation? The aim of neurorehabilitation is to exploit interventions based on human and animal studies about learning and adaptation, as well as to show that the activation of experience-dependent neuronal plasticity augments functional recovery after stroke. Instead of teaching compensatory strategies that do not reduce impairment but allow the patient to return home as soon as possible, functional recovery might be more sustainable as it ensures a long-term reduction in impairment and an improvement in quality of life. At the same time, neurorehabilitation permits the scientific community to collect valuable data, which allows inferring about the principles of brain organization. Hence neuroscience sheds light on the mechanisms of learning new functions or relearning lost ones. However, current rehabilitation methods lack the exact operationalization of evidence gained from skill learning literature, leading to an urgent need to bridge motor learning theory and present clinical work in order to identify a set of ingredients and practical applications that could guide future interventions. This work aims to unify the neuroscientific literature relevant to the recovery process and rehabilitation practice in order to provide a synthesis of the principles that constitute an effective neurorehabilitation approach. Previous attempts to achieve this goal either focused on a subset of principles or did not link clinical application to the principles of motor learning and recovery. We identified 15 principles of motor learning based on existing literature: massed practice, spaced practice, dosage, task-specific practice, goal-oriented practice, variable practice, increasing difficulty, multisensory stimulation, rhythmic cueing, explicit feedback/knowledge of results, implicit feedback/knowledge of performance, modulate effector selection, action observation/embodied practice, motor imagery, and social interaction. We comment on trials that successfully implemented these principles and report evidence from experiments with healthy individuals as well as clinical work.
Highlights
There is no clear understanding of the principles underlying effective neurorehabilitation approaches
One study evaluating enriched environments that included social interaction found positive results in terms of activity (Janssen et al, 2014). This synthesis aimed at identifying a set of principles that should guide the design of effective neurorehabilitation protocols for post-stroke recovery
We identified 15 principles based on existing work on motor learning and recovery: massed practice/repetitive practice, spaced practice, dosage/duration, task-specific practice, task-oriented practice, variable practice, increasing difficulty, multisensory information, rhythmic cueing, explicit feedback/knowledge of results, implicit feedback/knowledge of performance, modulate effector selection, action observation/embodied practice, mental practice, and social interaction
Summary
There is no clear understanding of the principles underlying effective neurorehabilitation approaches. Like CIMT, clearly define their active ingredients (Carter et al, 2010; Proffitt and Lange, 2015) that should lead to effective recovery (Kwakkel et al, 2015), most others do not. Neurorehabilitation research aims to find interventions that promote recovery and to establish whether the presence or absence of improvement can be explained by any neuronal changes that occur in the post-stroke brain (Dobkin, 2005). Neuroscience can help us to create interventions that lead to changes in the brain; with no clear understanding of what an intervention does, attributing causality remains difficult. One way to formalize an intervention is by breaking it into parts, studying the behavioral and neural effects of these parts, and deriving principles from them–in the case of stroke neurorehabilitation, these would be principles that optimize acquisition, retention, and generalization of skills
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