Recovery or Compensation?
In the world of neuro physical therapy, and I suspect others as well, there are two general approaches to therapy. One is recovery, in which we strive to regain lost function through various processes such as facilitating brain plasticity and forced use. The other is compensation, in which we strive to increase functional mobility through whatever process is available. With recovery, I focus on how the patient moves. With compensation, I focus on making the patient move.
I'm a recovery person. I teach normal movement. I avoid movements that create bad habits. Everything must be done as close as possible to normal. I work with compensation people. They hand the patient an assist device and start walking. I put both feet on the ground. They say use the strong side. I use intensity, repetition, functional tasks and the environment because they enable motor learning to occur. They use those same strategies because they improve the skills being practiced.
Although we both want the same outcome, we don't agree on how to get there. Sometimes I feel like the world is overflowing with compensation people. I had a conversation about this earlier today. Afterward I asked myself, are we treating the symptoms or the cause? Does it matter if the goal is get someone walking again? Compensation people will say no. Treat what you have and move along. I say it matters. Normal movement is energy efficient. Anything abnormal increases the energy demand of walking. It's hard enough for a stroke patient to walk. Increased energy demand will only wear that person out sooner.
I'm not saying there isn't a place for compensation training. For some patients, the need to be self-sufficient and independent overrides everything else. A patient who is the caregiver for someone else needs to be able to get around safely. Who cares what it looks like? So does the person who lives alone and has no family support. Obviously I'm going to teach function over form. What frustrates me are those instances when the opportunity for recovery exists and is passed over to work on something else. I've spent entire treatment sessions getting a patient to safely transfer weight equally through both legs, only to see someone else encouraging transferring on the strong leg because it is easier.
Both approaches have a place in our therapy bag of tricks. The beauty of neuroplasticity is getting the brain to reestablish old connections and force other areas to take up the slack. It is not to find the easiest way of doing something and then engrave that motor pathway in stone. If something is challenging the brain will learn, so why not use normal movement patterns? Once a patient learns to use one leg for everything it's next to impossible to change it.
I guess I'm a perfectionist. I want to put things back in order. My goal is to develop a gait pattern that is functional and doesn't look hemiplegic.