I have to share with you a #OTfail story of mine. I was given the great privilege to work with an extraordinary client who experienced a stroke affecting his dominant right side. He had quite a few other retained impairments from his stroke too--including labile affect, expressive speech difficulties, and balance changes.
He was one of the most motivated clients I have encountered. He wanted his life back, and he worked everyday to achieve that goal. I gave him exercises and he did them. Religiously.
I focused-in on the remediation of his dominant, right arm because, you know, “OTs do the arms, right?”
In the beginning, he didn’t have much arm movement to work with--we started with a shoulder shrug and slowly progressed to weak elbow flexion and some sporadic gripping. Arm exercises, arm exercises, arm exercises.
One day, I used one of our sessions to perform a re-evaluation to discuss his progress, verify we were still on the same page for his goals, and to modify the intervention plan if need be. I began my re-evaluation as I typically do, by asking about his activities of daily living.
He started to cry.
Through tear-filled eyes and a weeping lip, he confessed to me that he couldn’t dress himself.
Y’all. I had been working with this client for six months. I was so completely distracted by rehabilitating his arm that I neglected the functional parts of his life that mattered to him.
Sure, I had addressed those so-important activities of daily living during my original evaluation. I even had goals for dressing, and bathing, and housework, and work-work. But when my client repeatedly told me ‘I want my arm back,” I became determined to do what I could to help him use his arm functionally again.
My quest for remediation sidetracked my client’s need for compensation.
Remediation vs compensation. What’s the difference and why do we even need to think about the terms as they relate to neuro-rehab?
Remediation is the restoration of a lost function (regaining elbow flexion after a stroke through interventions like mass repetitions of active range of motion, functional electrical stimulation, or weightbearing activities).
Compensation, on the other hand, is the learning of alternative methods of accomplishing a task (one-handed cooking techniques for hemiplegia).
The occupational therapist’s dilemma: ‘does the use of compensatory strategies prevent or at least delay the remediation of neurological and musculoskeletal functions of the body?’
The answer: Maybe.
When we spend time teaching out clients compensatory strategies like one-handed dressing or cooking techniques, we miss out on the opportunity to use that time to implement remedial interventions. This is the basic principle of opportunity cost.
Additionally, when our clients learn compensatory strategies and use them well, they have a risk of strengthening the neural connections of the stronger, non-affected arm while the weaker, affected extremity continues to lose neural connections and atrophy. In the extreme form of this phenomena, the client may experience learned non-use of the affected extremity.
On the flipside, when we focus on remediation only, we may neglect our client’s right to independence. When we focus only on remediation, the client runs the risk of requiring assistance to participate and complete meaningful occupations.
The real answer: We shouldn’t choose.
Our job as therapists should be to educate our clients on the evidence which supports outcomes for remediation and the option for learning compensatory strategies. We should teach pros and cons, risks of each, and our recommendations for intervention. Then, we should allow the client to make the decision.
The likely choice will be some of both.
In the case of my client, he chose to briefly slow our quest for remediation to learn compensatory strategies for his basic and instrumental activities of daily living to improve his independence and broaden his participation in occupations he had given up since his acute stroke.
Together, we developed an intervention plan which included some compensatory strategy training and some remedial interventions during each of our sessions. Between each session, he focused strongly on the remedial activities and exercises that were prescribed for his home program.
For him, this modified plan worked really well as he was able to conquer independence in meaningful occupations in the short-term, and continue to work toward his long term goal of full motor recovery.
As always, think: “client first.” Share your knowledge and give your recommendation, and then walk alongside your clients as they prioritize their specific needs and desires.
You, my (fellow) OT, continue to help clients to live today. Live better tomorrow. And Inspire others to do the same.