Evidence-based therapy for recovery of function after spinal cord injury

Physical rehabilitation for individuals coping with neurological deficits is evolving in response to a paradigm shift in thinking about the injured nervous system and using evidence as a basis for clinical decisions. Functional recovery from paralysis was generally believed to be nearly impossible, based on traditional expert opinion, and the priority was to develop compensation strategies to achieve functional goals in the home and community. Research, which began in animal models of neurological insult and is currently being translated to the clinic, has challenged these assumptions. The nervous system, whether intact or injured, has enormous potential for adaptation and modification, which can be harnessed to facilitate recovery. In this chapter we will briefly outline the history of physical rehabilitation as it concerns the development of strategies aimed at compensation, rather than functional recovery. Then we will discuss how new activity-based therapies are being developed, based on evidence from basic science and clinical evidence. One of these activity-based therapies is locomotor training, a program which relies on the intrinsic, automatic, control of locomotion by "lower" neural centers. A brief description of the program, including the four foundational principles, will be followed by an introduction to the use of robotics in these programs. Finally, we will discuss a second activity-based therapy, functional electrical stimulation (FES), and the future of physical rehabilitation for spinal cord injury and other neurological disorders.