Try: to attempt to do or accomplish

Here is clarification of a paragraph in the previous post:

Of course, there's a fine line between the exercise and movement needed to relearn movement. But the emphasis on trying to build muscle is as mistaken as changing the oil in a car with no gas: Its a good thing, but hardly the main issue.

This difference between exercise and repetitive practice (movement needed to relearn movement) may seem like a distinction without a difference. In fact, both build muscle and both drive plastic changes in the brain. The distinction is in the focus. Repetitive practice paradigms focus on driving changes in the motor and sensory cortices of the brain, not specifically in changes in muscle strength. Sure, muscles will build. But focusing on strengthening is like climbing a ladder to the top only to find the ladder is leaning against the wrong building. Stroke is brain damage. And, unlike most other forms of acquired brain injury, stroke involves just one part of the brain. So if a survivor is, say, 2 years post-stroke and they can’t open their hand and then, later they can, that is not a reflection of muscular strength. It is a clear indication of a change in the brain. The muscles have been there all along. Muscle strengthening is the easy part. 

Clinicians often sweat the fact that survivors have limited energy for therapy. But does it need to be very strenuous to be beneficial? No! The ability to open the hand (or lift the foot or straighten the elbow or move the mouth) can be done while sitting in a comfy chair. Each attempt should be focused and deliberate. The very ends of the movement should be the point of focus. Each attest is measured as a success if it is just beyond the previous attempt.

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.

Building the Recovery Wall

Scott Gallagher posted a comment to a previous blog post. I'll paste that comment at the bottom.

What caught my eye in his comment is the conflict between repetition and quality. The conflict goes like this: If you do a ton of repetitions you may not concentrate on quality. If you concentrate on quality you may not hit enough repetitions.

I do a lot of talks about stroke recovery to clinicians. There is a small but vocal group of therapists who believe that if you don't focus on quality you may as well not practice. "Perfect practice means perfect recovery." I completely disagree. What if the survivor doesn't move perfectly? The answer by these clinicians is "I use hand over hand techniques to make sure that they do." Basically, they move the stroke survivor in the proper arc of movement. (BTW: the original quote was, "Practice does not make perfect. Only perfect practice makes perfect." - Vince Lombardi. Vince Lombardi was dealing with professional athletes. If he was coaching peewee football his quote would've been "We're not asking for perfection, we're asking you practice.")

There's several problems with stroke recovery put to this "If its not perfect, don't bother" philosophy. First of all, who's to say what "good" movement is after stroke? If somebody's trying to learn golf and they suck, nobody stands behind them and says, "You're doing it wrong." The more you practice golf, the better you'll get. Should you practice proper technique? Yes. But stroke survivors know proper technique. They've been doing these movements for all the years prior to their stroke. And even if they forgot they can model with the unaffected side.

 strongerafterstrokeblogpants

Second, this philosophy suggests a therapist. "Don't move unless I'm there to help you move." Alternatively this can be expressed as, "The more you move the worse you'll get." But therapists can't be with the survivor all the time, and the survivor doesn't have enough money in their pocket to pay for endless therapy. There is some good news... "The more you move the worse you'll get." Hogwash. Moving a lot on your own leads to better movement as long as you make the movements challenging (always reaching beyond you present ability).

Third, when's the last time you saw a coach with their hands all over a player? When's the last time you saw a music teacher with their hands overlapping the hands of the trumpet player? Learning movement involves mistakes corrected.

Scott Gallagher puts it this way "...any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall." And I know that is taken out of context, but as it stands as a quote I agree with it.

Scott Gallagher: If complete recovery is the goal, one problem might be in the sheer numbers involved. I have no reason to think that my stroke was anything but whatever might be considered a normal stroke, but currently in measured distance I'm at 5,112 walking miles. I'm so close to recovered, I'd say 5,000 miles is what it took for me to fully walk normally again. I tried speed walking, but the problem I was having was that any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall. My strategy, then, became one of brute force: keep it simple and push those repetition numbers up. But even if I had effectively used speed walking, how effective could it be? Even if it took 3,000 miles off my total distance, that would still leave 2,000 miles left to cover. I only made it through by switching from an exercise-based program to a mind and motivation-strengthening program. For all but a very, very few the repetitions required for full stroke recovery may make it, although possible, simply unfeasible. Come to think of it, though, your post may have been intended for a less hardened recovery program. Thanks.

Thank you Scott! 

                                                                                            ©Stronger After Stroke Blog

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.