Correcting Compensations – The Introduction

Symmetry in Nature

Nature often uses symmetry to convey health and vitality.

You are a survivor. A stroke survivor certainly, but surviving your stroke is just the latest in a long line, a very long line, of successful surviving. If fact, your unique combination of more than 3 billion genes exists today only because it has been entrusted to a long line of survivors extending back more than 3.5 billion years when life began on our planet. That is one incredible record of surviving.

Obviously, you were designed from the ground up to survive and survival is a top priority for your body’s systems. The body will brilliantly allocate scarce repair resources to bring critical systems back on-line asap after a major injury. Your distant relatives survived because they could still hang on to a rock, stick, spear, plow, or sword and crawl onto the hunting ground, agricultural field, or battlefield when much of the body was damaged and not fully recovered. This turns out to be a two-edged sword for stroke recovery. Once something is working well enough to support the needs of survival, the body’s repair systems move on to the next critical survival need. Unfortunately the repair needs for survival are rarely a complete recovery to pre-injury capabilities.

A typical definition and view of compensation expressed in the scientific literature is, “Our operational definition of recovery is normalization of movement smoothness, interjoint coordination, active range of motion (ROM), and normalized muscle activation patterns. Compensation is defined as changes in these variables away from normal levels, as measured in age-matched controls. Traditional treatment approaches encourage adoption of compensatory strategy early in the postacute period that can inhibit potential recovery. [1]

Compensations result when attempting to execute a pre-stroke function when body systems are only partially restored to pre-stroke capabilities. Current stroke recovery programs focus on accomplishing Activities of Daily Living (ADL) so the patient can be released from medical treatment as soon as they can perform minimum functions to survive. Compensations often are the direct result from getting a patient to accomplish ADLs and out of the medical system long before the body has been fully restored to pre-stroke conditions. Stroke recovery professionals really struggle with the often conflicting and mutually exclusive goals of accomplishing ADLs and minimizing compensations.

Many stroke recovery professionals typically work very hard on minimizing compensations during the government or insurance paid therapy phase. But the reality is most patients develop substantial compensations to accomplish their ADLs. Overcoming compensations becomes a primary focus of recovery efforts after government or insurance paid therapy ends. Nevertheless, the fewer compensations that are allowed to develop during early stroke recovery, the fewer compensations must be overcome later. Just like atrophy, it is a lot easier to prevent compensations than to eliminate them.

OSR will employ a broader definition of compensation in the context of full recovery; Any action accomplished using the affected side that differs from how the action is accomplished using the unaffected side. Note that the distinction is not only the accomplishment of the action itself, but in how the accomplishment of the action is performed as compared with the natural pre-stroke symmetry of the body. One of the great tools for full stroke recovery, one that is often under appreciated, is that the patient has right before them at all times a perfect working model of the actions they need to reproduce, the unaffected side.

As with almost everything with stroke the concept of affected and unaffected side is not so simple. There is such thing as a bilateral stroke (both sides affected) and there really is no such thing as an unaffected side (professionals often use the term less-affected). The way nerves cross midline, areas like the tongue that are not two separate parts, and the systemic effects of atrophy, brain swelling, depression, etc. result in both sides being affected by a stroke. Nevertheless, typically one side is far more affected than the other and for the purposes of OSR and compensation correcting strategies, we will use the term unaffected synonymously with the term less-affected.

It is important to distinguish between disability and compensation. Not being able to accomplish the action is a disability. Accomplishing the action with the affected side in a manner that doesn’t precisely match how it is accomplished with the unaffected side is a compensation. Disability is can you perform the action and compensation is how well can you perform the action. If your goal is full recovery how well you perform has to be the focus right from the start, not simply can you perform. The moment you get return (i.e., something starts to work), your body is relearning how to perform that action. It can learn to be perfectly symmetrical with the unaffected side, or it can learn the minimal necessary to perform the action. At OSB disability, even degrees of disability, are considered  strictly physiological. Compensation is a combination of disability and learning.

Like any learning, you shouldn’t accept wrong information because it is easier to learn, with the idea you will relearn the correct information later when you are smarter. You may simplify and slow down the learning of the correct information, or perhaps simply have to wait until you are smarter, but teaching the wrong information hoping it will get corrected later is usually not a good idea.

It should come as no surprise it is harder to train a returning capability to be perfectly symmetrical with the unaffected side than simply develop the ability to perform the action. Millions of years of survival instincts, an overwhelming drive (from you and your loved ones) for independence and to return to your pre-stroke life, fatigue, frustration, financial and career pressures, scarce resources, and the fundamental biases of most stroke recovery institutions and support systems are all pressuring you to accept compensations. It may seem overwhelming, but the key is to set the ground rules at the very beginning of your recovery. If you understand, believe in, and commit to a “no compensations policy” right from the beginning, it is much easier to overcome the formidable forces aligned against full recovery.

[1] Gains in Upper Extremity Function After Stroke via Recovery or … by PS Lum – ‎2009

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