Anna M. Barrett, MD President, ASNR

 Welcome!
 

It is an amazing time to be part of the ASNR, and to help develop the neuroscience of recovery. In the 1980s, constraint-induced therapy to improve hemiparesis and limb activation therapy for spatial neglect overturned the tradition of compensatory rehabilitation. Now, in the “aughts,” we are looking to electrophysiological interventions and biomarkers to advance and personalize pharmacologal and behavioral rehabilitation. Our field proves itself to be broad, fast-moving, and dynamic.

The greatest progress might be made by those who are ready to take translation as their mandate, using it as an imaginative reframing tool. My colleague Leslie Gonzalez Rothi, wrote eloquently on this issue, emphasizing the need for rehabilitation scientists to use “Phase II” research techniques in order to complete useful, valid intervention studies (Barrett and Rothi, 2002; Rothi, 2006; Rothi and Barrett, 2006; Barrett and Rothi, 2006; Barrett et al., 2007; Whyte et al., 2009). By the Rothi model, moving from proof of principle (improvement in controlled “N of 1” studies or case series) directly to a randomized controlled trial is viewed as excessively risky and unwise. Because feasibility, optimal parameters (intensity, dosage), neurophysiologic or behavioral predictors and correlates of response, and existence of subgroups with different response profiles have not been delineated, it is unclear how “randomized” groups should actually be matched or their improvement quantified. Groups matched by “obvious” variables (for example, matching patients in a stroke trial by radiological stroke severity in infracted tissue volume) may leave an RCT vulnerable to Type II error – a false negative result. In the example I gave, thalamic stroke patients with severe deficits might end up matched against patients with small-volume subcortical white matter lesions, making it much harder to demonstrate recovery in the thalamic stroke group. Extra time devoted to Phase II—in this case, to validating the assumption that subcortical and cortical strokes should be stratified together based on volume of infarction—could make a critical difference in carrying out a valid Phase II treatment trial.

Translation is not only in the laboratory of the researcher who develops a new medication compound, and trials it in a multi-site, multi-million dollar study. Translation is also not limited to clinician-researchers who have both animal and human laboratories, and test both groups of subjects with similar experimental procedures. Instead (Pober, 2001), translation “translation must be understood as a new form of research,” bidirectional between the laboratory and the clinic, because “laboratory discoveries are not typically made in a form ready for adoption.” An antiviral medication (amantadine) may in clinical use and research become a prototype dopaminergic treatment, and then may become a prototype NMDA-receptor blocker and neuroprotective treatment.

Clinicians in rehabilitation, called upon daily to implement treatments for disorders without the help of specific data on their patient’s population or disorder, are particularly well positioned to innovate, translating information that comes from the bench into new methods of treatment, and then bringing these methods back to the laboratory to be tested. We in the ASNR are neuroscientists, clinician-researchers, clinical trialists, and clinicians. Our organization can partner the next set of changes in neurorehabilitation, and I look forward to applauding you, our members, in this process.

References:

Barrett AM, Levy CE and Rothi LJG. Treatment Innovation in Rehabilitation of Cognitive and Motor Deficits after Stroke and Brain Injury: Physiological Adjunctive Treatments. American J of
Physical Medicine and Rehabilitation, 2007: 86(6): 423-425.

Barrett AM, Rothi LJG. Theoretical bases for neuropsychological interventions. In: Eslinger PJ, editor. Neuropsychological interventions: Clinical research and practice. New York (NY): Guilford Press; 2002. p. 16-37.

Barrett AM, Rothi LJG. Treatment innovation in behavioral rehabilitation of stroke: removing limits on recovery. J Rehabil Res Dev. 2006;43:vii–ix.

Rothi LJG. Cognitive rehabilitation: The role of theoretical rationales and respect for the maturational process needed for our evidence. J Head Trauma Rehabil. 2006;21(2): 194-97. [PMID: 16569992]

Rothi LJG, Barrett AM. The changing view of neurorehabilitation: a new era of optimism. J Int Neuropsychol Soc. 2006;12:812–5.

Whyte J, Gordon W, Rothi LGG. A phased developmental approach to neurorehabilitation research: the science of knowledge building. Arch Phys Med Rehabil. 2009 Nov;90(11 Suppl):S3-10.