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Toni Talks about PT Today

Focus on Function

Published August 3, 2010 9:59 AM by Toni Patt

As my neuroanatomy course winds down, we've begun looking at motor learning. Research into motor learning has been steadily increasing. Many of our newer techniques such as constraint therapy and functional task specificity are directly drawn from animal models. The obvious conclusion is what works well on animals should work as well with humans. Except that doesn't happen. We aren't getting the same results with humans. As good as they are, we're not following the animal models.

One difference is the sterile environment with focus on one deficit. Another is the degree of task specificity possible in the lab that isn't possible in the clinic. A third is the relatively small size of the lesions in experimental animals as compared to large, multi-area lesions in humans. Those aren't the reason our outcomes are different. It's the number of repetitions research animals perform.

In research, the functional task is associated with something meaningful to the animal such as food. Over the course of a day a rat will perform hundreds of reps of that one task in order to get food. And that rat does the same thing every day for as long as the experiment lasts. I'm lucky to get 20 meaningful reps of an exercise out of some of my patients. There are many reasons for this but the end result is significantly less than a few hundred reps of anything.

There is research documenting how many reps of exercises patients perform. The numbers aren't very high. Out of curiosity I decided to count everything I did today with a patient. With the exception of gait I fell very short of 100 reps. I did 20 of sit-stand. I did 50 reaches R-L. I did a total of 30 reps of trunk ROM exercises. My patient took 312 steps using a partial-weight-bearing gait therapy device with the assist of myself and a tech. According to the animal model, I should have done a few hundred of everything. I didn't quite make it, did I?

Obviously we're not going to get hundreds of repetitions of everything we do from our patients on a daily basis. On the other hand, 10 to 20 reps don't seem worth the effort. Last night I read an article discussing ways to increase repetitions during therapy without sacrificing treatment. No one is going to spend a session performing 100 reps of this, 150 reps of that. Therapists and patients alike will be bored to tears in no time. One suggestion was using the HEP to increase the number of reps performed by a patient. It didn't suggest how to assure patient compliance with the HEP.

The more realistic suggestion was to incorporate more functional tasks into therapy. For gait that means increasing the distance, using a body-weight-supported system on a treadmill or robotics. I work my patients in standing to incorporate forced-use exercises into whatever else we're doing. I can get a couple hundred reps of weight shift if I set things up properly. We might not reach our daily hundred of anything but certainly we can do better than 10 or 20.



Excellent point.  I'm not sure I've ever thought of it in that context before.

In the acute setting, there really isn't any reason a patient with normal cognition couldn't perform a modified home program, focused on key muscle groups or movements, all throughout the day.  They could probably easily make a few hundreds of reps over the course of the day.  It isn't like they are having to fit in errands, or work, or cleaning house and doing laundry.  But trying to get them to turn off the that can be a challenge!  

The rat has nothing else better to do and the researcher has found a superb motivator:  food.  Part of our job as a therapist is to help the patients find their superb motivator and to sell them on the concept that they really don't have anything BETTER to do.

At least in part, we are the reason our subjects aren't making the grade.  We put them in an environment with multiple distractions and more pleasurable activities, and then we wonder why they don't want to do reps of exercises.  What if for every 25 reps of exercise, the TV would turn on for 15 minutes.  Wonder how many reps our unmotivated patients would perform then?

Janey Goude August 4, 2010 11:28 PM

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