My husband's occupational therapist wants him to learn new ways of dressing and cooking instead of working directly on his arm and hand to make them more functional. She says he needs to learn to "compensate" for his right arm that doesn't move very well. It's been nine months since his brain injury and he gets really frustrated when the therapist asks him to try and use his affected arm. Is this the direction we should be going or are we giving up on improving the use of his arm?
This is a difficult question, and it brings up several important rehabilitation issues. The first is the concept of "recovery" (directly treating the arm and hand through positioning, stretching, and strengthening) versus "compensation" (using another method or using specially adapted tools or techniques). The second is about you and your husband's desire for him to be as independent as possible. And the third is about your role on the rehab team.
Recovery vs. compensation — finding a balance
The majority of healing or recovery will take place during the first six-to-12 months after a TBI, but improvement is also possible — albeit at a slower pace — for years. The overall goal of rehabilitation is to improve a person's ability to function at home and in his community. Because we cannot predict how much recovery will occur, rehabilitation therapists will often balance an approach of recovery and compensation to make daily tasks easier and safer so that a person can achieve as much independence as possible. This balance should take into account many factors such as time since the injury, the extent of a person's difficulties, the pace of recovery thus far, and, in your husband's case, his frustration level with his affected hand and arm, among other things.
It can be hard to accept the decision to try compensatory strategies but learning to do things differently is often part of life after a TBI. And because the end result increases a person's independence, it can be enormously helpful to a person's self-esteem.
Research ... and your role on the rehab team
There is no definitive research showing that learning compensatory techniques will harm your husband's eventual ability to use his affected arm. However, it's important to communicate your concerns to your husband's rehab therapist because you are a valuable member of your husband's "team" and your support is important to his recovery. Consider talking with the team about a treatment program that incorporates both exercises for your husband's hand as well as practice doing activities using compensatory techniques. Sometimes, if direct treatment of an affected hand or arm does not yield much improvement, the therapist may recommend a home exercise program and spend her treatment time working on compensatory strategies. In these days of managed care, patients and therapists are under a great deal of pressure to demonstrate measurable improvement at a steady pace or risk having insurance coverage denied.
There are exciting developments in the rehabilitation field related to motor learning and recovery of a person's hand or arm (see Dr. Campbell's Ask the Expert: What Is Neuroplasticity?) even long after an injury. Ask your therapist about his familiarity with this information and whether your husband would be a good candidate for these approaches.
Elaine Sherard practiced as a speech-language pathologist and had various roles in the neurorehabilitation field for 25 years, including management and serving as President of the Board of Directors of the Brain Injury Association of South Carolina. She continues as a consultant in the brain injury rehabilitation field as well as advocacy endeavors.