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."

Why a little means a lot

10°. 

10° is all you need to qualify for constraint induced therapy. Just a tiny bit of movement. Just a little bit of movement in the fingers and a little bit of movement in the wrist. This would be movement that many clinicians would call "nonfunctional" movement. That is, many clinicians make the unfortunate mistake of thinking that a small amount of movement is not helpful. The thinking is, small amounts of movement won't help you live your life, so who cares?

But every bit of neuroscience is very clear about this: a little bit movement can lead to more movement through repetitive and demanding practice. Move as much as you can. It may be ugly, it may be "incorrect," it may be "nonfunctional," and it may be "useless." But this is probably more true: Small amounts of movement may turn into something beautiful, something correct, something functional, and something useful. If someone is telling you that your movement is unimportant, or harmful, or irrelevant, politely don't listen.

~

Repetitive Practice Stroke

What is the key to recovery? Everybody now: Repetition! I've written about this before here, here and here (journal article; co-author).

Everybody knows that repetitive practice (also known as repetitive task practice) is the way to reestablish executive (brain) control over the body. To regain control of an arm and hand repetitive practice can be used to reestablish that control. To regain control over a leg during walking, repetitive practice (walking) can be used to reestablish control over walking.

It's not rocket science. And it's not brain science, until it is.

The thing that they don't tell you is how many repetitions you have to do. The first person to talk about the power of repetitive practice was Randolph J. Nudo. You pretty much can't read any journal article on stroke rehab research that doesn't involve a reference to this guy. His suggestion was that 2500 repetitions would begin to change the brain enough to make that movement better. In constraint induced therapy there is approximately 200 repetitions per therapy session. In typical rehab there's about 32 repetitions or therapy session. It looks as if the number may be approximately a total of 1200 reps. That would require about three hours per day.

As you can imagine, these numbers are rather variable. The amount of focus brought to each repetition would be one variable. The complexity of the movement that you're trying to relearn would be another variable. The number of joints that the movement required would be a variable. The number of directions that that limb would have to move in order to carry out the task would be a variable.

But I think we can all agree that most stroke survivors don't attempt these numbers of repetitions. 

Here is the other question: How do you do all the repetitions you need to do without driving yourself crazy? 

Here is the only possible answer: Tie it to something that you care about.

Get cracking.

Since when is “productive” fun?

When it comes to stroke recovery, no clinician, no matter how skilled, can "do it for them." Recovery from stroke is dependent on repetitive and demanding practice by the owner of the damaged nervous system—the survivor. If done correctly repetitive and demanding practice drives cortical plasticity ("brain rewiring") robustly enough to be evident in increased quality of movement. 

But this sort of repetitive practice is boring! Repetitive practice does not necessarily involve functional activity. For example, a clinician, seeing a deficit in the last 15 or 20° of dorsiflexion, may have the patient repetitively practice dorsiflexion, irrespective of ambulation. At least in that example the end goal, whether it's stated or not, is obvious; walking. In the upper extremity repetitive practice of single joint movements may or may not relate to any particular everyday activity. Instead repetitive practice may be used just to increase active range of motion in those joints. Because it does not involve anything functional, repetitive practice can be inherently boring.  And what makes it even more boring is that stroke survivors aren't even working on anything novel; there relearning movement that they used to do perfectly well. So where's the motivation? 

The motivation ends up being a conjuring. Some of this motivation may come from the minds of clinicians. OTs, PTs and speech therapists should try to make repetitive practice as interesting as possible. But some of this motivation comes from the survivor. The survivor needs the imagination enough to understand how this hard and boring work will help realize potential.