A road map for transforming stroke recovery

As neurologists, we have always been told (by those in other fields) that we work in a speciality that has no treatments and is obsessed by clinical diagnosis and little else. The advent of biological therapeutic targets in neurological disease is of course changing all that. The popular view of neurorehabilitation on the other hand is that it is falling behind because there are no 'recovery' drugs, only physical, behavioural or adaptive therapies that are not particularly effective. As illustration, many years ago a recently appointed consultant neurologist was asked why he had an interest in neurorehabilitation when it amounted to nothing more than the provision of a walking stick or a wheelchair. That behavioural interventions are generally overlooked in neurology is curious for a speciality that deals with the brain, whose very structure and therefore function can be changed through experience. The naive reader of Broken Movement might be surprised to find that when it comes to recovery from hemiplegic stroke there are a wide range of treatments, from behavioural to pharmacological. What Krakauer and Carmichael show us is that with a little clear thinking and honest critical appraisal, we will be on the threshold of some remarkable breakthroughs in a field that has proven stubborn to crack. However, the crisis in confidence in neurorehabilitation that currently grips us is not because existing therapies have been inadequately tested in randomized controlled trials, but because these therapies are ill-conceived from a neurobiological perspective in the first place. The message is clear—develop therapeutic approaches from a mechanistic perspective.

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