Saturday, October 19, 2013

Building the Recovery Wall


Scott Gallagher posted a comment to a previous blog post. I'll paste that comment at the bottom.

What caught my eye in his comment is the conflict between repetition and quality. The conflict goes like this: If you do a ton of repetitions you may not concentrate on quality. If you concentrate on quality you may not hit enough repetitions.

I do a lot of talks about stroke recovery to clinicians. There is a small but vocal group of therapists who believe that if you don't focus on quality you may as well not practice. "Perfect practice means perfect recovery." I completely disagree. What if the survivor doesn't move perfectly? The answer by these clinicians is "I use hand over hand techniques to make sure that they do." Basically, they move the stroke survivor in the proper arc of movement. (BTW: the original quote was, "Practice does not make perfect. Only perfect practice makes perfect." - Vince Lombardi. Vince Lombardi was dealing with professional athletes. If he was coaching peewee football his quote would've been "We're not asking for perfection, we're asking you practice.")

There's several problems with stroke recovery put to this "If its not perfect, don't bother" philosophy. First of all, who's to say what "good" movement is after stroke? If somebody's trying to learn golf and they suck, nobody stands behind them and says, "You're doing it wrong." The more you practice golf, the better you'll get. Should you practice proper technique? Yes. But stroke survivors know proper technique. They've been doing these movements for all the years prior to their stroke. And even if they forgot they can model with the unaffected side.
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Second, this philosophy suggests a therapist. "Don't move unless I'm there to help you move." Alternatively this can be expressed as, "The more you move the worse you'll get." But therapists can't be with the survivor all the time, and the survivor doesn't have enough money in their pocket to pay for endless therapy. There is some good news... "The more you move the worse you'll get." Hogwash. Moving a lot on your own leads to better movement as long as you make the movements challenging (always reaching beyond you present ability).

Third, when's the last time you saw a coach with their hands all over a player? When's the last time you saw a music teacher with their hands overlapping the hands of the trumpet player? Learning movement involves mistakes corrected.

Scott Gallagher puts it this way "...any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall." And I know that is taken out of context, but as it stands as a quote I agree with it.

Scott Gallagher: If complete recovery is the goal, one problem might be in the sheer numbers involved. I have no reason to think that my stroke was anything but whatever might be considered a normal stroke, but currently in measured distance I'm at 5,112 walking miles. I'm so close to recovered, I'd say 5,000 miles is what it took for me to fully walk normally again. I tried speed walking, but the problem I was having was that any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall. My strategy, then, became one of brute force: keep it simple and push those repetition numbers up. But even if I had effectively used speed walking, how effective could it be? Even if it took 3,000 miles off my total distance, that would still leave 2,000 miles left to cover. I only made it through by switching from an exercise-based program to a mind and motivation-strengthening program. For all but a very, very few the repetitions required for full stroke recovery may make it, although possible, simply unfeasible. Come to think of it, though, your post may have been intended for a less hardened recovery program. Thanks.

Thank you Scott! 
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8 comments:

Linda said...

Part of all the Suzuki violin training with my kids involved huge amounts of repetition but I think one aspect was that movement was corrected by listening for the desired sound or bad sound which acts like a little wake up call bringing your attention back. I noticed the same thing when practicing walking on the treadmill. Walk long enough , get bored get sloppy and there would be a flop sound of my foot dragging so refocus and continue. Basically I'm trying to say repetition numbers and if not precision perhaps focus seems like a good idea to me.

Scott Gallagher said...

I just want to say that I am deeply honored by this post, coming as it does from the very person who made my recovery possible. Thank you. I have one complaint, however, and it's directed at my comment. I'm an idiot. I painted the prospects for a survivor's successful recovery as bleak based on my miles walked. Actually, the word was “unfeasible”. Let me hastily backtrack. This runs counter to the entire message I'm trying to push forward myself right now. Based on my stroke recovery experience, a typical stroke recoverer may well have to walk thousands of miles or perform “millions” of repetitions of various exercises for a complete recovery. That can't be helped. But I spread my work over four and a half years, and never really had to go over a thirty-five hour workweek. Hard? Sure, but humans naturally adapt to that sort of thing, and if you add in a good motivation program, “too much” becomes “do-able”---for anyone. It's a matter of perspective. If I'm ever going to get someone to do what it might take, I'm going to have to convince them that “thousands of miles” and “millions of repetitions” is unremarkable enough (and it is) for them to go ahead and spend a few short years to knock 'em out. At some point they will see a light at the end of their tunnel, and believe me, when they see that it all becomes worth it. Sorry.

Barb Polan said...

I once had a PT who told me not to continue with an exercise once I started doing it wrong. she then gave me an exercise she told me to do 100times per hour, I guess to creep toward the total I needed to reach neuroplastic change. I went home, and you know how much closer I got to my goal? Not a bit ... I couldn't do it even once, so instead of adding repetitions, I did the exercise exactly zero times.

Give me reps over quality anytime. remember: some stroke survivors can't do ANYTHING. the expectation of high quality is absurd. And damaging.

Barb Polan said...

I once had a PT who told me not to continue with an exercise once I started doing it wrong. she then gave me an exercise she told me to do 100times per hour, I guess to creep toward the total I needed to reach neuroplastic change. I went home, and you know how much closer I got to my goal? Not a bit ... I couldn't do it even once, so instead of adding repetitions, I did the exercise exactly zero times.

Give me reps over quality anytime. remember: some stroke survivors can't do ANYTHING. the expectation of high quality is absurd. And damaging.

Peter G Levine said...

Linda, Scott, Barb: I appreciate your thoughtfulness. These comments are so good I need to make a separate entry about them.

BrookeFuller said...

Howdy, my husband has a cerebellar injury. Not a stroke, but a rare autoimmune disorder that caused inflammation (randomly) in his cerebellum. One of his PT's told me that repetition wasn't the key with cerebellar injuries. She said injuries with the cerebellum are all about planning. How does that square up with your thinking and experience?

BrookeFuller said...

Howdy, my husband has a cerebellar injury, not a stroke. He had a rare autoimmune response from another disease that caused inflammation in his cerebellum. His PT told us that repetition wasn't the key with cerebellar injuries, but that it was all about planning. How does that square up with your thinking and experience?

Julia said...

I'm finding this discussion of quantity versus quality very interesting. I have been told by every OT I ever had that I shouldn't be doing "bad movement". I believe that this attitude has made me feel powerless since all I had was "bad movement" and as a result has slowed and curtailed the recovery of my arm and hand. I have now been without an OT for a month and my PT and my Pilates instructor have been working more with my arm at my request. With their attitude ("just do it even if it isn't pretty") I have started to make some progress. A concrete example would be my pectoralis muscle. My OT was obsessed with trying to get me to "turn it off" as he was convinced that my "overactive" pec was preventing me from moving forward. My PT and my Pilates instructor said to just strengthen everything as all my muscles, including my pec, were weak from disuse relative to my good side. Now, with a stronger pec, I can carry light objects against my chest with my bad arm. I am also starting to be able to bear more weight on my bad arm without collapsing which will allow me to do yoga and move on to exercises like push-ups and planks. This is new. Question - Is there something in OT training that makes them so unable to think outside the box as opposed to my PT or my Pilates instructor? I don't have any cognitive issues and I am both an MD and a trained ballet dancer. I have made it clear that I am interested in recovery, not compensation. I should be the ideal patient and yet I have been continually frustrated by the exercises I've been given by OTs as opposed to the ones from PTs even though they have all been for my arm . OT as it is currently practiced simply makes no sense to me, and seems to contribute to rather than ameliorate the dismal stats for upper extremity recovery.

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