Preface

We live in a time that is ripe with possibilities. Advances in technology, pharmacology, and biomedical sciences have positioned us on the brink of unparalleled discoveries that are sure to transform the lives of individuals with disability. Then again, we are not quite there. In the past 15 years, in the field of spinal cord injury research alone, there have been countless millions of dollars spent on basic and clinical trials of pharmacological and cellular transplantation approaches aimed at restoration of neural function. Studies of stem cells, fetal tissue transplants, activated macrophages, and olfactory ensheathing glial cells, just to name a few. Despite amazing progress, there are still critical pieces to the puzzles of neurologic restoration that remain mysterious.

And yet, there is one form of intervention for which research across disciplines and across animal species has concluded, time and time again, promotes recovery of function—that intervention is rehabilitation: practice, training, and motor experience. To date, there have been no reproducible pharmacological or cellular transplantation studies showing restoration of function in individuals with SCI that equal the functional improvements that have been shown by studies of rehabilitation interventions.

When spinal cord injury affects a high profile actor or athlete, it captures the attention of the public. The inability to move without a wheelchair informs the world that the individual can no longer move his arms and legs. However, save for the individual, family, and caregivers, few people understand the full impact of damage to the spinal cord—how it affects functions that so many of us take for granted: breathing, sexuality, bowel and bladder function, and many others. Even small improvements in functional status can make tremendous differences in quality of life, such as the ability to use a fork without an assistive device, to stand and walk into bathroom that is not accessible to a wheelchair, to step up a short flight of stairs—these things make a tremendous difference to quality of life. In many cases, such functions can be regained to some extent even many years after SCI. Individuals with SCI merit access to rehabilitation professionals who can assist them in reaching their fullest potential.

One day scientists will find the right combination of strategies to improve function—be it stem cells, transplantations of activated macrophages, or a drug that promotes remyelination—but these strategies will never realize their maximum potential unless they are combined with rehabilitation. The individual with a cellular transplant is not going to jump up from the operating table and run down the hallway. These strategies will only be effective when combined with rehabilitation. Just as the developing nervous system requires activity and experience for cells to differentiate into the right cell type, to find their target end organ, and to form the necessary connections with their targets, newly transplanted cells will only be maximally functional if they are in an optimal environment—a body that is healthy and provided with opportunities for practice, training, and motor experience.

This book is intended for my colleagues and future colleagues in rehabilitation who work in partnership with individuals with spinal cord injury either in the clinical setting to maximize function in an individual or in the research setting to gather evidence that will influence clinical practice to improve function in all individuals with SCI. My goal is that the chapters will be sufficiently comprehensive to meet the needs of the rehabilitation professional, the nonclinician researcher desiring to learn about how spinal cord injury affects human beings, and the individual with SCI who wants a broader understanding of their injury. Across chapters, the material is presented at different levels—basic, intermediate, and advanced—depending on the content area. While some chapters answer basic questions related to rehabilitation management, other chapters are unapologetically scientific, delving into complex topics for which many answers are not yet known. In all chapters, the emphasis has been on summarizing the evidence that is available in the literature, identifying areas of controversy where they exist, and providing information to the reader who wishes to explore the topic further.