Saturday, December 3, 2011

What Task-Specific Stroke Recovery Really Does

Find out what they want. 

"Task specificity" and "task-specific training" are buzzwords in stroke-specific neurorehabilitation research. The foundation of recovery from stroke is rewiring of the cortex "around" the area of infarct. And the best way for anyone to rewire their brain is to focus. 

As completely as possible, the focus should be on a specific task. Most therapists will tell you that they do task-specific training.

PTs and OTs have every right to claim that what they work on is task-specific. ADLs ("activities of daily living"; the focus of much of OT) transfers, walking, etc. are inherently task-specific. But working on recovery using the "task-specific" approach can be magnified if you focus on tasks that are vital to the survivor.

You might ask, "What is more vital than ADLs, standing, walking and transferring?"

The answer is, "Ask the survivor."

The more focus, the more rewiring. Let's consider someone who has not had a stroke: Jim. Let's say Jim decides to take French because he is required to take a foreign language for school. Now consider Tina. She is an American who grew up in Texas but is now living in France.

Which of the two will get the most robust brain rewiring dedicated to learning French? Tina, quite a bit; Jim, not so much. Tina will naturally bring quite a bit more focus to the task. So there will be quite a bit more rewiring.

Now let's consider relearning walking after stroke. Walking means much more than simply getting from place to place. The ability to walk can impact the ability to be independent, the ability to earn a living, friendships, self-esteem and much more.

Walking, especially in a clinical setting, may or may not be tied to what really matters to the stroke survivor. I worked with one stroke survivor who told me, "I can't continue to walk funny. It's bad for business."

He was a surveyor. When he went on construction sites the other workers didn't believe he could do the job. And they believed this because, although his speech and cognition were perfect, his movements were typically hemiparetic. In this case, the motivation is not walking, it's really the ability to make a living.

Another stroke survivor told me, "I can't cope with this constant fear of falling." The motivation here is not walking, but fear. I know stroke survivors who have lost friendships because of their stroke. "As soon as I had my stroke, the boys stopped coming around."

Another survivor told me, "The fact that I've lost the use of my hand keeps me from doing things with my friends." The motivation here is friendship. Other stroke survivors hate being dependent on their families.

Fear, friendship, career, independence. All of these are powerful motivators.
In some ways it's easier for occupational therapists. They ask, "What is it that you have to do? What is it that you love to do?"

The answers will be as varied as stroke survivors. One might say painting is the most important thing. Another might say golf. Another might say child care.

For OTs, "task specificity" can be just about anything. An OT can work on hand grasp/release. Putting grasp/release within the context of a highly valued task is relatively easy. And putting it within the context of a valued task will drive more cortical plasticity (thus more recovery) much more than stacking cones or playing with a pegboard.

Support Motivation
So how can PTs and PTAs promote the same sort of focus to walking as an OT promotes in a vital task done with the upper extremities? The first thing to do is to listen. "Patient education" time can be used as "therapist education" time. What did the stroke survivor do before his stroke? What did he do for a living? Did he ever play any sports or instruments? What were his hobbies?

Revealing the activities that patients most want to recover reveals what drives them. And what drives them drives their nervous system toward recovery.

But there is a gorilla in the room. What if their motivator is beyond their present capacity? Walking a golf course may be the ambition. But even nine holes of a par 3 is a couple of miles. So what is the first step in recovering enough robust walking to take the survivor miles?

First, the ambition must be revealed. Once walking a golf course is established as the goal, the goal is always kept in mind. An essential aspect of task-specific training is keeping the task in sight.

For instance, even if the painter can't yet paint, a paint brush and paints are kept as reminders of the task to be accomplished. But how do you keep a golf course in line of sight?

Keeping the task front and center is a matter of allowing the vista of a golf course to form within the walls of a therapy gym. The survivor may never make it to the golf course but the love of the game will have him walking further than he might have.

Research has revealed better tools than ever to help survivors along their journey. From partial weight-supported intensive treadmill training, tools to recover walking after stroke increase in numbers and in their evidence. But don't let survivors forget what most motivates them. The most powerful tools live inside the survivor.


oc1dean said...

Sorry Peter, but I'll have to disagree with you on this one.
Task-specific training is just taking the easy way out because if you can't walk properly you're not going to get better
by practicing bad walking. The surveyor wants to dorsiflex properly and also not have his lower leg swing out due to
spasticity. In order to correct these problems very specific muscles need to be worked on. Therapists should be able to

assess what needs to be corrected by using:
1. Computerized gait analysis or
2. compare to EMG profiles during normal human walking, available since 1986, or
3. motion-sensing technology, or
4. Epants can monitor your joints, or
5. the ForceShoe with identification of gait events using an instrumented sock.
Any of these should be able to identify specific muscles to work on. Spasticity may prevent success but that becomes a separate issue.
By focusing on task-specific actions everyone is taking the easy way out and not expending any brainpower on how to

recover the more complex problems.
In my case I have to consider that my pre-motor cortex is mostly gone so the planning of complex muscle movement like
walking needs to be recreated.

Peter G Levine said...

Thanks Dean and you're right. I plan to have a full and open response in a blog entry soon. This is an issue that has come up in seminars recently and I'd like to address it fully. Thanks again....

Mike said...

During my first 2 weeks at the rehab, most of my affected side was not moving, my vision was bad and there was no prorioception.My therapists could not do much.But those less severely affected were able to get more recovery.I was satisfied to gain something from the ADLs,PT.After I was discharged,I recovered more on my own since I was more confident with the transers, swallowing, and simple activities.Task specific approach is suitable when the survivor is more confident which I don't have during the first few months at the rehab.

Elizabeth, John and Jack said...

This was exactly what my theapists did, but they did break it down to the muscle groups that needed to work well for me to care for my son. He was 30lbs at the time and my left side was so weak...I wanted to be able to pick him up more than anything. Walking came fairly easily but my shoulder and arm required much more work.

Amy said...

I completely agree Dean, you need the foundation first.

Peter G Levine said...

Please note I dealt with this issue in the entry here:

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