Monday, September 20, 2010

The upward spiral of recovery (II)

What tools are needed to allow for stroke survivors to drive their own recovery once they are discharged from therapy? It all starts with the home exercise program (HEP). Building the HEP should be initiated in the acute setting and continue to develop through subacute treatment. If the stroke survivor is unable to attend to an explanation of the arc of recovery and how the HEP fits into it, caregivers and family members may be educated instead. Once the stroke survivor is able to absorb the information, they would be the focus of education about the HEP. The amount of time recovering under the guidance of therapists is usually measured in months. The amount of time in which the patients is guiding their recovery is measured in decades. So the HEP becomes a flexible document.
The HEP should…
· Have the flexibility of progressing as the patient progresses
· Educate the patient on measuring progress
· Provide achievable milestones
· Provide benchmarks upon which the patient is directed back to therapy.
Upon discharge the HEP becomes an extension of the therapists’ and patients’ hard work. It's like teaching a kid to ride a bicycle. You hold them up, you run alongside, you guide them, and then you let go. We also tell our kids to keep pedaling because without the forward momentum, they fall. The HEP is the set of rules that will allow folks with brain injury continue their forward momentum. The hard work that patients have done with therapists is the first step on this upward spiral of recovery. But the HEP is the extension of that upward spiral. Finally, the patient fuse the HEP with their own plan of recovery that incorporates their own life. The life they lead drives recovery.
Therapists have to discharge patients once the patient has “plateaued.” However, research from many disciplines has refuted the concept of the definitive plateau. Any therapist worth their salt knows that recovery can continue, sometime spontaneously, well beyond the point of discharge. Unfortunately, the calculus made by many brain injured folks is simple: therapist=recovery. So part of the job of the therapist is to explain that recovery from brain injury is not just the plateau that precipitated discharge from subacute therapies. In fact, recovery becomes a lifelong series of plateaus.
Therapists are paid to be optimists. They know that focusing on disability is less effective than focusing on potential. Medical doctors have to low-ball any prognosis. Doctors feel uncomfortable setting expectations too high. An optimistic prognosis not realized goes against the medical ethics dictum; “first, do no harm.” If doctors set expectations too high, patient frustration (along with some pointed feedback) will be close behind. Therapists, on the other hand, have the responsibility of making clear the potential level of recovery. While doctors low-ball, therapists imagine. The act of transferring that imagination from therapist to patient is the proverbial "Apple a day."

Friday, September 3, 2010

The Upward Spiral of Recovery

There is a common suggestion among many in the "alternative medicine" industry expressed in the question: "If it means less business, why would your doctor want you to be healthy?” A strict emphasis on healthy lifestyle including diet and exercise would be like the proverbial "Apple a day" – keeping the doctor away. Doctors who do this – who keep themselves away as much as they can – are the best doctors. And therapists who "keep themselves away" are the best therapists.

Many pathologies allow for a definitive discharge point. The patient who has had a knee replacement gets therapy, and then goes home to live the rest of his life. But neurological disorders are different. Many, from Parkinson's to multiple sclerosis, are progressive. But what of non-progressive neurological disorders like stroke and traumatic brain injury? Does this "Apple a day" philosophy work? Is there a point at which these populations no longer need therapists?

Many patients with acquired brain injury believe that they will always need therapists. Most see therapists as essential to the recovery process, no matter how long (months, years, decades) it takes for them to achieve their highest level of potential recovery. But this view is incorrect.

There is a point at which therapists are no longer the fulcrum for recovery. Nor should they be for reasons that range from financial to practical. At discharge stroke survivors are, and should be, in complete control of their own recovery. During the chronic phase of recovery from stroke, the speed of recovery slows. In the chronic stage the physiological action of recovery is based on a lot of self-directed hard work.

Much of what is required is relatively simple, and revolves around the broad concept of repetitive practice. In order to take charge, stroke survivors need the tools to initiate and follow an "upward spiral of recovery.” This term is used to describe the path to the highest level of potential recovery. The "upward spiral of recovery" is driven by real-life demands for everything from coordination to cardiovascular strength.

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