Thursday, February 22nd, 2018
In all stages of growth and development, repetition is key to successful long-term learning and information retention. Repetition is especially beneficial for stroke survivors who seek to regain motor function, strength, and coordination. Consistent repetition that re-establishes communication between the damaged parts of the brain and the body is crucial in stroke rehabilitation.
The brain is our most complex organ and scientists still don’t fully understand it, but we have extensive evidence of one amazing capability called “neuroplasticity.” Neuroplasticity is the brain’s ability to form new synapses, or connections between neurons, especially in response to a brain injury. The nervous system compensates for damage by reorganizing the neurons that remain intact. To form new connections, the involved neurons must be stimulated through consistent activity. Fully understanding this process—and why it works—motivates and clarifies the essential role of repetition in post-stroke rehabilitation.
For our bodies to perform even the simplest tasks, networks of nerve cells, or neurons, must act in tandem to stimulate the correct parts of our bodies. However, when a stroke causes damage to an area of the brain, damaged neurons become unable to send out signals to the corresponding regions of the body. Although a stroke survivor may appear to have suffered damage to an area of the body—for example, the right arm and leg might be paralyzed—the issue actually stems from damage in the brain.
Amazingly, the brain compensates for these losses through various regenerative strategies. A common process, neuroplasticity, is something that the brain undergoes whenever we learn a new piece of information. As our environments and daily routines change throughout life, we create new synapses, or neural connections. During a healing process, the brain is even more engaged when building these new networks. Synaptic pathways are restructured to work around damaged neurons and may even relocate to entirely different areas of the brain.
Under the right circumstances, the brain can even create new neurons in a process known as neurogenesis. Any healing process requires a healthy body, to support the regeneration of cells, and neurogenesis is no different—the regenerating areas of the brain must be healthy, with the proper blood and oxygen supply, and must be activated consistently. Stroke survivors can encourage neurogenesis through frequent therapy, as well as at-home practice. Careful, diligent practice also ensures that new synapses and neurons do not lead to additional issues or symptoms.
Research has shown that stroke survivors who use repetition to promote neuroplasticity enjoy significant progress in their recovery. In one study, patients who initially struggled with grasp-and-release exercises demonstrated increased cortical reorganization after adhering to a repetitive rehabilitation regimen.
We are only just beginning to discover the magnitude of the brain’s capabilities. Not only can the brain heal itself through proper support and repetitive exercises, but it can also respond positively to diligent and focused visualization of those same exercises. People who visualize a process can strengthen the involved synapses without performing the actual, physical motion. Visualization is a great introduction to rehabilitation for those who cannot physically complete the motions. In the early stages of regaining motor function or range-of-motion in an affected limb, it is important for stroke survivors to apply themselves to visualization with the same commitment as they would a physical exercise.
In a 1995 study, synapses strengthened in participants who imagined completing a particular piano exercise. Even though they were not performing any physical motions, their brains still registered and retained the musical information. This principle is vital for those in the early stages of stroke recovery. Visualization bridges the gap between the motivational difficulties inherent to the early stages of rehabilitation and the more physically intense practices later on in recovery.
The transition between visualization and physical performance can be challenging. Supportive tools such as the SaeboMAS provide support to the affected limb while relieving stress from the joints and muscles involved in the exercise. By guiding the arm through its first physical motions, SaeboMAS helps the brain transition from visualization to independent task completion. Tools like SaeboMAS also encourage consistency in motion, a crucial factor when attempting such intensely repetitive action.
Once you master a repetitive action, it’s important to continue challenging yourself with an exercise routine. This is against human nature because once a task feels easy, we feel that we have succeeded; however, repetitions while on autopilot are far less beneficial than when the individual is actively focused on performing each repetition. It takes self-discipline to continue increasing the difficulty of an exercise but you can derive motivation from the support of a therapist, friends or family.
CIMT—or Constraint Induced Movement Therapy— allows for personal adjustments to the difficulty of an exercise. It’s common for those healing from motor function difficulties to avoid challenging the affected limb, overcompensating with the healthy limb to the point that the affected limb begins to deteriorate further due to non-use. Once the patient can comfortably rely on the affected limb, CIMT introduces “shaping” or “adaptive task practice”: the deconstruction of complex physical tasks into manageable steps that are added one at a time. This gradual addition of challenges deters the patient from switching to autopilot during long, repetitive sets.
A motivated and clear mindset is crucial, therefore the exercises themselves must follow a natural progression to become more challenging, while not being too frustrating. This balance comes from respecting each motion—no matter how small—as an important building block in the healing process. By remaining present in the repetitions, the brain picks up on more detailed messages from the body about what it needs. Any associated soreness or pain should be discussed with professionals to ensure that exercises are promoting healing and not inadvertently causing further damage.
As mindfulness increases, it will become clearer which exercises are right for each particular day, depending on how the body feels. By honoring your body as your guide, you will improve your motivation and the physical progression of neuroplasticity. However, sensing what is best for the body is a tricky practice. Harder tasks may challenge a wider variety of neural networks, speeding up the healing process even when the exercise itself feels less successful.
Overall, it’s better to challenge the brain by moving beyond repetition that no longer inspires further improvement. Start small by mastering simpler tasks and skills, then immediately move on to slightly harder versions of those actions. Always maintain the same level of consistency, but with added restraint or weight. Without added challenges, the progress made through rehabilitation can be lost. It may help to view this healing process as a long-term, ongoing journey with the goal of fully rebuilding and re-strengthening connections that would otherwise be lost.
Canadian psychologist Dr. Donald Hebb claimed that “neurons that fire together, wire together,” in his 1949 book, “The Organization of Behavior.” Long before today’s societal focus on mindfulness, Dr. Hebb recognized the occurrence of neurological regrowth when an activity or thought process is repeated diligently. This observation is pertinent to unlearning less helpful habits or thought patterns, as well. If someone in rehabilitation develops a bad habit, such as injuring a healthy limb through overuse, the brain can unlearn these habits through careful repetition.
The benefits of mindfulness are open to all kinds of learning. Intentional focus during practice is the only way to ensure the brain is fully present and supported for neuroplasticity and neurogenesis. During visualization, each movement should be imagined with extreme specificity as well; awareness that is too unspecific can lead to apathy and lack of concentration. Visualization can be motivating, pushing the person in rehabilitation past the plateau stage—a dispiriting time in the process in which progress stalls. Overall, the trick is to keep exercises from becoming routine. When each day is different or challenging in a new way, the brain stays engaged in ways more conducive to synaptic rehabilitation.
The most important mantra for post-stroke recovery is to keep moving. Once an intention or goal has been set, consistent movement is the key to warding off muscular atrophy. As mentioned earlier, even before physical movement is possible, exercises can be completed in the brain through visualization. Begin as soon as possible after the injury to take full advantage of early neurogenesis before entering the plateau phase. Whether visualizing or physically completing an action, repetition is the most important factor in long-term recovery.
The question remains, how many repetitions are enough to regain full health during stroke rehabilitation? The number of repetitions required to establish a neural pathway depends on multiple factors:
Consistent, dedicated repetition is the most important priority. Without this, the brain cannot complete the rebuilding of the neurons, networks, and capabilities it lost during the stroke.
Quality of repetitions is just as important as quantity. Practice is helpful only while remaining mindful and fully present. Concentration also bolsters motivation, especially when progress plateaus.
Together, mindfulness and repetition move those in rehabilitation past initial discomfort more quickly by strengthening the affected muscles and neurons. We now know that visualization and drive have a psychosomatic effect, speeding up rehabilitation while the brain is most susceptible to healing. Visit the Saebo blog for more information about healing after a stroke.
All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the Saebo website is solely at your own risk.