Saturday, November 14, 2015

How Instant Gratification Can Hurt Recovery

(Note: The following is a fleshing out of a previous blog entry)
Instant gratification can hurt stroke recovery. Here’s how…

Let’s say you want to retain soft tissue length in finger and wrist flexors. What do you do? How about a static splint?
It makes sense; you hold the soft tissue in a lengthened position and the soft tissue won’t shorten, right? There’s only one problem: The evidence suggests static hand/ wrist splinting does not improve movement, function, reduction of spasticity, nor does it retain soft tissue length. So what does splinting do? It provides instant gratification. The therapist can claim they’ve done something and the stroke survivor believes something is being done.

Here are some other options that play the same trick… 
  • Stretching to reduce spasticity
  • Handling techniques
  • Tapping a tendon to get a muscle to fire
All of the above are good and bad
  • The good: Instant gratification
  • The bad: no evidence of long term efficacy.
Then again, what’s the harm? If a therapist wants to progress the leg during gait by tapping the quads, why is that bad? It’s not bad, but it may be… unhelpful, confusing to the survivor and a waste of therapy resources. Using the same the same example, tapping the quads to progress the leg here’s how it may be unhelpful:

A survivor with footdrop is in the parallel bars (II bars to the rehab nerds). The therapist taps the quads, progressing the tibia at the knee. The tapping puts a quick stretch which the golgi tendon organ perceives as potentially damaging to the quad which, through spinal reflexes, contracts to protect itself, progressing the tibia. The survivor is able to take a step.

OK, we have the instant gratification done. Now, what about the next step? Another tap? What happens when the survivor wants to take a step on their own? They felt their own muscles contracting when the therapist tapped them, but can the survivor do the same thing to himself? That’s confusing. And what is the carryover of the tendon tapping? Is there any physiological advantage the next day, the next hour, the next step? 

Most of the rehab and neuroscience research suggests having the survivor struggle to get their leg to through swing, by hook or by crook, utilizing whatever they have. This sort of “productive struggle” is what drives neuroplasticity post-stroke. If there’s one thing we know about brain plasticity its this: it won’t happen if it’s easy. Tapping makes it easy, but there is no long term benefit. Further, it is confusing to the patient. "Wow, I did that!"- they may think. If you elicit one of your spinal reflexes, yes, it is your muscles doing the movement. But it is not voluntary movement. The only way to get that movement again is to elicit the reflex again.

The same is true with stretching to reduce contractures and/or spasticity. Does stretch have a short term effect? Sure. Might that effect have some clinical usefulness? Sure. Will the impact of a single stretching session or even long term program of stretching reduce spasticity? Again, there is neither supporting research nor long term efficacy.

And handling techniques like NDT? Instant gratification, yes because you can get a survivor who can’t move to move and move without “pathological movement patterns” because, basically, the clinician is moving the survivor. But there is a bit of skepticism among researchers. Here is the Wikipedia take on itHere's my take on NDT. 

My suggestion is for clinicians to ask, “What will be the effect after the next associated reaction (laughing, sneezing, getting up from a chair), later the same day, later in the week, 6 months later, and so on?”

And survivors should be asking the same question.


Rebecca Dutton said...

Your point is true. One treatment approach does not cure a client, but clients may hope it will. My post describes what happened when I stopped wearing my resting hand splint at night. Clients have to commit themselves to a well-rounded treatment plan.

Marlena Anderson said...

So, they try and try, but still can't get the extremity to move. Then what? As an OTA working with CVA patients, it seems at least a little beneficial when they can see and maybe feel what the movement should be (ie wrist extension, finger flexion with vibration or tapping). Sometimes after the facilitation, they are then able to activate the motion themselves to some degree. Obviously the arm is much more challenging than the leg (imo), and i always feel the pressure to just get SOMETHING to move. They look to me as if I am solely responsible for the movement or non-movement of the limb.

Peter G Levine said...

Marlena, thanks for your comment; survivors need more curious clinicians!

If they try and try and can't move they are paralyzed, right? What are the 2 kinds of paralysis? The reason I ask is that the opportunity to get each to move is separate. "... it seems at least a little beneficial"- That's a tough statement. I do clinical stuff and research stuff, and the research informs the clinical. I'd prefer to not use stuff that "seems at least a little beneficial" because there is stuff that is beneficial that shows efficacy in the science- so I'd start there. Again- I'd suggest you contact me at strongerafterstroke (at)


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