Sunday, July 28, 2013

Two Roads Diverged...

There are two ways to go after stroke: 
1. Compensation (technically: The compensatory approach)
2. Recovery (technically: The restorative approach)

Compensation involves getting on with your life by any means necessary. If your right hand doesn't work, you do everything with your left hand. If you can't walk because your foot drops, you put on an AFO. If you have trouble speaking, there's an app  for that.

Recovery involves using the intact part of the brain to take over for the "stroked" part of the brain.

It would be nice to say that the focus of clinical rehabilitation is on recovery. But for the most part, managed care only pays for compensation. Insurance companies want to get the survivor safe, functional, and out the door. Why do they want the survivor safe? Because an unsafe survivor will cost them more money down the road (think falls). Why do they want the survivor out the door? Because every day in any clinical setting costs a ton of money. But while survivors also want to be safe, and out the door, is it in their best interest to be "functional"?

On the face of it, sure, survivors want to be able to function. "Function" is a catchall word that means "getting on with your life." And it's seductive. Everyone wants to be functional. Everyone wants to be independent, and able to

But there is a problem with function. And it's not just a generalized idea that if you "focus on function" you'll ignore recovery. It's a very specific concept based in neuroscience.

It would make sense that if you focus on learning compensation, you would spend less time on recovery. And this would mean that you would become better at compensation, but less recovered. But it's more than just a time issue. It's a brain issue.

It turns out that something special happens to the brain after stroke. The brain is in an almost "infantile state" after stroke (in fact, after any brain injury). And "infantile state" is a good thing. The brain, through a release of special proteins is "primed" for learning
— like an infant's brain. But what will it learn?

Well, it could learn to compensate. If you are right-handed and you have limited use of your right hand after stroke, the brain could learn to compensate. Your left hand would be doing a whole bunch of things never did before. The left hand is now handwriting, attempting to tie shoes, brushing the hair and teeth, and dressing. And it's doing it all alone
no right hand to help. So during this period in which the brain is "primed" for learning, the left hand does all the learning.

But if the focus is not compensation, but recovery, there will be more recovery. The brain is "primed" for learning, and it learns to recover.

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