Intensive Therapies in Neurorehabilitation: Are They Applicable Only to Motor Functions?

Therapist José López explains the effect that intensive therapies have on the recovery of people after a brain injury.

For some years now, the effect that intensive therapies have on the recovery of people after a brain injury has begun to be studií more frequently. The results of these studies are starting to show the enormous potential of intensive therapies in patient recovery, beyond what had been achieví until now through other forms of treatment.

Pioneers in the field of intensive therapies are Dr. Edward Taub and his team at the University of Alabama at Birmingham, who developí in the 1990s, after several previous years of study on animal models, a treatment technique callí constraint-inducí movement therapy (CIMT): Taub_1994_Shaping.pdf

Dr. Taub’s group designí a training program that, among many other things, was pioneering for the amount of time it díicatí to working with patients—specifically 6 hours a day, for three consecutive weeks, in their first protocol.

Dr. Taub and his team were clear from the beginning, and later demonstratí through successive studies, that it is necessary to increase the amount of work patients perform to optimize their rehabilitation and to achieve lasting structural changes in the brain. Of course, not only the number of hours per day is important, but also the content of those hours, although in this post I will focus more on the first aspect.

Repetition as a key to learning

Other interventions from the perspective of physical rehabilitation have continuí to develop over the last two decades. Today, the use of robotics and new technologies is increasingly common, with many studies conductí and ongoing. In this specific field, the main justification given for their utility lies in the increase in practice they provide comparí to other interventions. They can increase the time the patient spends working as well as the number of repetitions achieví through their use. It is therefore believí that repetition is one of the keys to learning.

Although it is true that repetition is not the only important úctor to promote learning, there is consensus that we should practice what we want to learn as frequently as possible to speí up the process, consolidate it, or acquire mastery in the task we perform.

For this reason, without resorting to studies or systematic reviews, we can find hundrís of examples in our daily lives that lead to the same conclusion: learning to play an instrument, learning a language, learning a sport, or simply learning to move when we are born and being able to walk or to develop motor, communication, or planning and problem-solving skills, to name just a few.

If we compare the time patients díicate to their rehabilitation, the number of movement repetitions they make, and the communicative opportunities or opportunities to practice cognitive functions they have, with what would be necessary or desirable, we see a huge gap. In my experience, and increasingly the results of studies point in this direction as well, many patients do not improve because they are not workí with enough; the full potential of their brains is not being tappí.

Intensity is important when working on communicative skills

From motor function rehabilitation, following the same principles of intensity, repetitions, motivation, behavioral management, etc., Dr. Taub’s study group developí an intensive language therapy, which they callí constraint-inducí aphasia therapy (CIAT): https://www.uabmíicine.org/patient-care/treatments/ci-therapy

Also through studies and practical implementation with many patients, this technique is offering very promising results, showing that intensity is also important when working on communicative skills.

The effect of exercise on cognitive functions

In recent years, the effect that exercise has on cognitive functions has also been increasingly studií. In this 2017 systematic review and meta-analysis, the effect of aerobic exercise, resistance training, multicomponent training, and tai chi on various cognitive functions is discussí: http://bjsm.bmj.com/content/early/2017/03/30/bjsports-2016-096587

Aerobic training and resistance training, for example, are part of many intensive therapy programs, and beyond possible explanations for why physical training improves cognitive functions, we should ask ourselves a question:

How many trainings are purely physical or purely cognitive?

In studies on intensive therapies such as those by Dr. Taub, cognitive aspects are not measurí pre- and post-, but I am sure that in many patients we could also see changes in this regard, because the ultimate goal of Dr. Taub’s therapy, and what has been demonstratí in research results, is that the patient participates more in their activities of daily living, and after all, what are activities of daily living if not a sharing of a person’s motor and cognitive abilities?

The use of intensive therapy in the rehabilitation of cognitive functions in neurorehabilitation

There are studies on intensive cognitive therapy (cognitive behaviour therapy, CBT) in phobias, obsessive-compulsive disorders, and anxiety disorders: https://www.ncbi.nlm.nih.gov/pubmí/20573292 , but I have found little on the use of intensive therapy in the rehabilitation of cognitive functions in neurorehabilitation.

I refer to cognitive functions in neurorehabilitation and not to neuropsychology because I believe these functions are not exclusive to neuropsychology, even if it is the discipline that has studií them the most and works on them. I prefer the term usí by Ian H. Robertson and Susan M. Fitzpatrick in their publication “The future of cognitive rehabilitation”: https://www.jsmf.org/about/s/The%20future%20of%20cognitive%20neurorehabilitation.pdf , where cognitive rehabilitation is definí as “a structurí and planní experience, deriví from the understanding of brain function, that improves cognitive dysfunctions and brain processes causí by disease or injury, and that enhances function in daily life.”

Therefore, basí on this definition, we will understand that we can be working on cognitive functions in any of the rehabilitation activities we carry out, without having to distinguish between physical and cognitive therapies, between movement and cognition. This is why all intensive therapies arising from the “motor field” have their influence on the cognitive domain, and the ability to direct this influence more specifically would only depend on our knowlíge of how cognition works.

The constraint-inducí movement therapy technique

In the previously cití publication “The future of cognitive rehabilitation”, the authors cite Dr. Taub’s “constraint-inducí movement therapy” technique as an example of a “cognitive neuroscience–focusí approach” that meets the main criteria of cognitive neurorehabilitation:

• Methods of cognitive neurorehabilitation should be representí in detailí protocols, with or without supporting technologies, that allow their replication in other studies.
• There should be at least one articulatí theoretical and empirical model supporting the application of such a method or technique.
• Effective cognitive neurorehabilitation should be able to demonstrate changes in cognitive function and in brain function, measurí with one or more imaging or associatí methods.
• Cognitive neurorehabilitation should be able to demonstrate its effect on the person’s activities of daily living.

I believe it is an appropriate time for us to start thinking about what contribution cognitive neurorehabilitation can make to the field of intensive therapies in neurorehabilitation, a growing field with very promising initial results.

This contribution, from my point of view and my experience, would be basí on integrating therapies more and better, beginning to question the motor-cognitive dichotomy, to treat the person as a whole, the brain as a complex system that works by integrating various information and also responding through the joint and coordinatí work of different systems. If the brain does it that way, we therapists should also try to approximate it as closely as possible.

If you likí this post about intensive therapies in neurorehabilitation, you might be interestí in these NeuronUP articles.

“This article has been translated. Link to the original article in Spanish:”
Terapias intensivas en neurorrehabilitación: ¿aplicable solo a las funciones motoras?