Why aren’t I making more progress in therapy?

When a person has a brain injury or neurologic dysfunction, treatment needs to address the structures producing the motor dysfunction. Movement comes from the interaction of multiple systems including those related to sensation, cognition and motor planning.  Research that began in the 1930’s described two ways motor control can go awry: 1) the release of abnormal behaviors or positive symptoms or 2) the loss of normal behaviors or negative symptoms.  An example of a positive symptom is spasticity; an example of negative symptoms or loss of normal behaviors is loss of strength.  Very often rehabilitation planning emphasizes the treatment of positive symptoms such as unwanted increased muscle tone at the expense of negative symptoms such as loss of strength.  In other words, the focus of treatment is to reduce the increased muscle tone with the hope that doing so will help improve function.  What we now know is that it is inadequate recruitment of the “agonist” or the muscle that does the work that is the primary basis for disorders of motor control.  Take the biceps and triceps.  The biceps brachii is used to flex (bend) the arm at the elbow while the triceps does the opposite movement. During arm bending the biceps is the agonist and the triceps is the antagonist.  The triceps needs to “let go” to allow the biceps to do the work of bending the arm.  Very often the reason for not making much progress in therapy is because the clinician is focusing on the wrong thing.  In the example above instead of focusing on reducing muscle tone of the triceps the focus should be on building muscle strength in the biceps.  You really need to know how muscles work together to create a successful rehabilitation plan.

So, what can you do? One thing I do when seeing a new doctor or even a home repair person is ask about their experience.  The first time I did so felt very awkward…almost as if I was being rude or something.  I asked how long they had been in practice and how many procedures they had performed.  None of them were offended.  If I do come across one that takes exception to my questions, I don’t want to see them anyway.  My favorite question for anyone seen for health reasons is “Have you published your work”.  This question covers a lot of territory.  If they have published, it means they are up on the latest findings in their field. It also means (for most professional journals) that whatever they have written has been reviewed by others in the field and found worthy of publication.

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