Repetitive Recovery and Rehabilitation

Modern clinical rehab research has confirmed what many rehabilitation clinicians have assumed to be true: Post-stroke motor recovery requires repetitive practice (RP). Many clinicians use RP as a tool to restore movement. But as is true with many core concepts in stroke recovery is also true with regard to RP. Namely, what rehab research reveals and what rehab clinicians use are two very different things. Bottom line: The fly in the ointment is the amount. Clinicians in rehab don't encourage enough repetitions.

The absolute minimum number of repetitions needed to drive cortical changes (brain rewiring) for a single joint movement is approximately 2,000. If it's a multiplanar, multi-joint movement, the numbers are in the tens of thousands if not hundreds of thousands of repetitions. Researchers in neuroscience talk about more than that; often the number of repetitions needed for quality movement is in the millions.

How many repetitions do clinicians in rehabilitation typically ask stroke survivors to perform per session? Studies in which clinicians are observed as they work with stroke survivors show that patients typically attempt approximately 50 repetitions in the average therapy session. A stroke survivor would need 40 sessions to get enough RP for a single joint.

I strongly advocate offloading much of the work to the person who owns the nervous system in question-the survivor. That is, to get enough RP to provide robust enough brain rewiring to promote quality movement, much of the work must be done when the survivor is not with the clinician. And this is a problem because many clinicians believe that if stroke survivors are encouraged to move without proper guidance, they'll use the stereotypical patterns available (called synergistic movement). If used enough, so the thinking goes, these movement patterns will be ingrained and the "incorrect" movement will never be unlearned. This perspective, reduced, sounds weird: "The more you move, the worse you'll get." It sounds weird because it erodes a foundational belief of the therapies: Exercise helps the brain and body heal.

It is true that repetitive practice of wrong movement will lead to more wrong movement. In athletes the idea of "bad practice leads to bad performance" is well known. This is why athletes strive to practice with perfect form. Stroke survivors are no different. Unless there is a precise evaluation of movement deficits, there's no way to tell what should be practiced. When it comes to movement, quality matters. And quality matters for many reasons, because bad movement:

• Takes more energy than good movement;

• Takes more time than good movement;

• Can lead to injuries;

• Can lead to a lack of enjoyment of a wide range of activities;

• Looks bad, which has social implications.

So how does a stroke survivor reverse "bad practice leads to that movement?" That is, how do you do "good practice" that leads to "good movement?"

My lab work has focused on stroke-specific outcome measures testing post-stroke movement. I used a laundry list of these outcome measures. 

They are often complicated and require special equipment. We also use movement analysis laboratories that collect thousands of bits of data to determine whether movement is increasing or decreasing in quality. Finally, we use technologies like functional magnetic resonance imaging and transcranial magnetic stimulation to determine whether the part of the brain dedicated to movement is expanding.

But what of my earlier suggestion of offloading much of the work onto the survivor? Because it takes so many repetitions to drive robust change, they are to do much of the work. So stroke survivors must evaluate their own movement. And once they evaluate the movement, they must adjust according to the evaluation. For the stroke survivor trying to improve quality of movement, some of the simplest "data collection" works quite well.

• Using mirrors to provide real-time feedback can be helpful. Using a mirror at the end of a treadmill can provide insight into the quality of gait. 
• In the upper extremity, it is helpful to use the "good" side to remind yourself what "normal" looks like.
• Videotaping specific movements throughout the arc of recovery can be helpful as well. Video provides a chronological log of where you were and where you are now, and can suggest what to work on next.

It comes down to a lot of the right kind of practice. As Vince Lombardi put it, "Practice does not make perfect. Only perfect practice makes perfect."