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Toni Talks about PT Today

Recovery or Compensation?

Published August 10, 2010 9:58 AM by Toni Patt

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.


As I was reading this I thought about quality and quantity.

Recovery is quality and compensation is quantity.  This isn't going to be a perfect analogy, but...

Quality without quantity is useless.  If I have a crisp new one dollar bill - even though it looks pretty - I am severely limited in our current economic conditions.  I can't even buy a (good) cup of coffee.

Quantity without quality is functional.  If I have one thousand dollar bills that are wrinkled, torn, and taped back together, I can still do a lot with them.  They don't look pretty and they take up a lot of room in my pocket (because they won't even fit in my wallet), but they get the job done.

So, if you can only choose one, you have to choose quantity.

But if you have the option to choose quality and quantity (one thousand crisp, new dollar bills that neatly store in my mega wallet), then it would be foolish to choose only quantity.

I'm sure your patients appreciate you, Toni, especially when they visit their wrinkled, torn, and taped back together friends.

Janey Goude August 15, 2010 3:46 PM

Toni, great discussion. I've had a similar one with an OT here in the UK not long ago. Here OTs do gait training. I had a client who had a dense hemiplegia who was given a cane in the acute care setting and set out into the community. He was a young(ish) man who was bound and determined to get a life back. He fell at least daily with his cane. I had a limited amount of time to work with him so I ordered a hemi-walker knowing that the step to gait it offered was not the best gait pattern I could've hoped for. The result was a man who was independent in the community who didn't fall down anymore and who voiced happiness with the outcome. I didn't have the luxury of extened treatment in an inpatient setting, I had to settle for less than perfect function.

I agree, if recovery is possible, it should be the route attempted. Sometimes, like in my case, I had to settle for less.


Dean Metz August 10, 2010 1:07 PM

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