Rehab to Live or Live to Rehab?

I recently had a conversation with a patient who has been coming to our clinic for a number of months for therapy. Since her stroke several years ago she has returned to work and much of her normal household and social activities. She hasn’t put much of an emphasis on rehabilitation until she came to Aim2Walk. Since she is right-handed and her stroke resulted in limited function in her left hand, she has learned to adapt to doing many of her daily tasks one-handed. Now she is attending therapy three times a week and working towards her goal of increased movement and function in her left arm and hand. She sometimes wonders whether she should have been more focused on her affected side in the early stages after her stroke, rather than making it a priority to learn new ways of doing things and compensating for her injury. She summed it up quite well when she asked “Do I rehab to live or live to rehab?”

I have been thinking about the implications of this question ever since. Is it better to focus therapy on getting someone back to her everyday life, even if that means she will have a non-functional arm? Or would it be more beneficial to undertake a program trying to regain the normal movement of that arm- even if that required the patient to ‘live for rehab’ and have a slower return to independent living. This is not a new debate, and is reflected in two different approaches to stroke rehabilitation. The compensatory and restorative approaches are not exclusive of each other, but they do reflect differing philosophies.

The goal of the compensatory approach is not to restore or improve the movement or function of the affected side, but to teach new skills and adaptive techniques to allow the patient to achieve tasks required for daily living. For instance, the compensatory approach would encourage a patient to learn to button her shirt with one hand if that was the most efficient means to achieve independence quickly. This approach would also include adaptive equipment, such as foot splints or AFOS, and mobility aids. The benefit of a compensatory approach can be greater independence. For instance, if a person is unable to restore her original walking pattern, using a cane for compensation can help to improve her mobility so that she can walk to her mailbox and get her own mail. The concern with this approach is learned non-use. Learned non-use is the therapy term for the ‘use it or lose it’ concept. The longer a patient goes without using the affected limb, the more permanent or pronounced those deficits may become. While the compensatory approach may achieve better short-term results, it may deny the patient the opportunity for long-term restorative gains.

The goal of the restorative approach is restore the stroke patient’s lost physical functioning as close to normal as possible. Techniques such as neurodevelopmental training (NDT) and motor learning are used to encourage recovery of as normal a pattern of movement as possible. Compensatory movements that may potentially inhibit a return to normal neurological functioning are discouraged. Using the restorative approach, the patient would be encouraged to learn to button her shirt using two hands the way she would have prior to her stroke. Another technique used in this approach is forced-use or constraint induced therapy (CIT). This technique tries to combat learned non-use by actually forcing the patient to use her affected hand by preventing her from using her intact hand, usually by wearing a special mitten. The benefits of a restorative approach are decreased learned non-use and a return to more normal patterns of movement. However, the restorative approach can lead to longer recovery times and less independence in the interim.

Luckily, a therapy program doesn’t have to choose just one of these therapy approaches. Reviews of research have shown that using a mix of components from different therapy approaches is effective and that no one therapy approach is superior to another. There are also a number of personal factors that each patient must consider when deciding on how much of their therapy will be focused on compensation and how much will be restorative. Limited access to therapy, living alone, and returning to work may all be reasons that someone needs a more compensatory approach to therapy. A patient that is highly motivated and has the resources for more intensive therapy may decide on a more restorative approach. Finding a good balance between the two approaches can help find that middle ground between life and recovery.

6 responses

    • Peter, thank you for your feedback.You are correct that NDT and Bobath have poor efficacy in scientific research. Recent systematic reviews conclude that NDT/bobath are not superior to other approaches and that the effectiveness of these approaches is not proven. That being said, these reviews also report that the evidence (or lack thereof) is poor due to poor methodology of the studies, as opposed to an ineffective treatment technique. The treatment concepts of NDT/bobath can be challenging to define, which creates a problem with research. In situations where a treatment approach may not have strong support from the literature, the therapist must rely on his/her experience and critical thinking to decide whether or not the approach is the best option for a given client. This is what is referred to as the “art” of therapy. Unfortunately, if therapists always go by what the evidence says (evidence-based practice), clients would be missing out on many fantastic and effective treatment methods. It is imperative for therapists to be familiar with the research for all of their treatments and allow their knowledge and experience, in addition to the recommendations in the literature to guide their practice (evidence-guided approach). This is a topic that may need its own blog entry 🙂 I enjoy your informative and educational blog entries on thestrokerecoveryblog and thank you for your interest in neurochangers!

      • So often I hear the argument that research can’t possibly know because its flawed, so therapists need to rely on their “art.” Haven’t we had enough of that? The science should lead the art, not “I’m an artist so don’t confuse me with the facts as we know them.” You hedge on the same idea as “Evolution is just a theory.” Or, “Global warming is political, not scientific.” NDT has been around for, what…since 1970 as codified in Bobath’s book. Again and again it has been tested as ineffective. There are great papers on this. Let me know if you need references.

      • I agree that therapists can take the “art” of therapy way too far and completely ignore the science. Clearly you feel that is what happens with all therapists do that use NDT or Bobath or any other treatment approach that doesn’t have rock solid research behind it, when in fact what happens is that therapists will use aspects of these treatment approaches that that fit into the scientifically proven treatment. For instance, the research tells us that overground gait training IS effective for improving specific gait parameters, such as gait speed, balance, step length and symmetry, etc. A therapist with NDT training will do overground gait training with some hands on “facilitation” to provide feedback. This approach certainly doesn’t stray from good ‘ol scientific physiotherapy, even though it might incorporate some aspects of NDT. As someone who trains other therapists and future therapists (not in NDT, mind you), I would never encourage a therapist to ignore the science. Everything he/she does with a patient should be based on science. However, if every therapist did exactly what the research suggested for every patient, and didn’t take into account individual responses to different techniques, we would have a lot of bad therapists. I agree with you 100%, “the science should lead the art”.

  1. Speaking from my own experience in restoring normal gait pattern as part of MS, restorative therapy is the way to go. Yes, it takes longer and can be frustrating, but it keeps the pathways functioning. I had an experience with an AFO splint. After using it for several months, when I wasn’t wearing it such as barefoot at the beach, my foot barely responded and felt like a big flipper. in response to Matt’s therapy discussion, the therapists at Aim2Walk are all artists in their approach to therapy. That is what sets them apart from other therapists.

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