Wednesday, January 18, 2012

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."


Linda said...

I have lots of smaller movements to still work on but I thought I would comment about this weeks progress.

I am working on learning guitar and it is not easy. My left hand still has a few weird issues going on.

I have been working on getting my 3,4 and 5 fingers working independently. I have been pretty much stuck (literally locking tight onto the guitar neck, as well as figuratively) for over 2 months and I just keep practicing and pushing forward most days. 70 plus days of practice with God knows how many repetitions of those offending movements! Things are just starting to kick in and my Guitar teacher looked downright hopeful yesterday. The improvement in my typing with the increased independent finger movement is huge lately too.

As far as real time feedback--- ahh that guitar sound is a big giveaway that makes me want to self correct. My PT commented that I was correcting on the treadmill, because I could hear a step-drag-step kind of sound. It was like an alarm telling me to try to pick up my foot.

oc1dean said...

Your amounts are thought provoking, my OT who was the only person who had any clue on my rehab thought it was 1000. I would do 1000 and then start on the next 1000. My only beef with RP is which recovery are we talking about? Easy neuroplasticity, aka penumbra or bleed drainage damage, or dead brain recovery, aka hard neuroplasticity. Sorry Peter, most of the research I'm seeing is the easy stuff. We don't need easy neuroplasticity to be proven over and over again. The researchers are smart enough they should be able to plan and execute the more challenging recoveries, Maybe an XPrize is needed.

CFaith23 said...

I would like to congratulate in your recovery. I would like to take this opportunity to share my friend's inspiring story as a stroke survivor, hoping it can also inspire and moved you.

The Ingrid Clarfield Story

Mike said...

But we know there are other things that affect neuroplasticity.Intensity, age are otherfactors.The pre-stroke activities and interests seem to be a factor. I know a ballet dancer who recovered quickly with not so many reps but he did intense rehab.Even at 59, his recovery was fast.He did not do a thousand reps.A few intense work out was enough for him.A few intense work out is working for me right now though I'm 2 years post stroke.

Peter G Levine said...
This comment has been removed by the author.
Peter G Levine said...

Linda: keep up the good work. Using passions to drive recovery is key.

Dean: we're talking about neuroplasticity are in the chronic.. Your right, if there is emerging neurology than the number of repetitions would be radically reduced. We're talking about is the number of repetitions needed for somebody who is relearning a movement during the chronic period.

CFaith23: use social networking judiciously. I haven't had a stroke so your comment makes no sense. I understand you have a book out, great. Good luck.

Mike: your comment nails why it is important that we do research. You're right, everything is a factor. I suggest thousands if not tens of thousands if not hundreds of thousands if not millions of repetitions. You say you know somebody who got better without a bunch of repetitions. So here's the question: did you have a look at the brain scan? Because the number one issues can be the amount of damage. For instance, often in hemorrhagic strokes, there's a bunch of problems initially but they dissipate quickly. This is because once the pressure on the brain is reduced the brain comes into full bloom. Often, of course not always, hemorrhagic strokes have much better outcomes because once the pressure is reduced the brain itself remains relatively intact. So the number of repetitions is an estimate based on an "average" stroke survivor. Whatever that is. Thanks for your comment.

Mike said...

I am hemorrhagic but because I bled at the basal ganglia, the part of the brain associated with dystonia,I was left with spasticity all over the affected side that made my recovery horribly slow.No one at the rehab is familiar with a basal ganglia stroke and how to rehab it.Mass practice worked for me lately and not at rehab because I got spastic easily after 10 reps.I'm figuring things out on my own now.Before my stroke I was training to become a runner. I can tolerate the boredom of rehabilitating on my own.

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