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.