What should i do when there is no movement?

wait, well nothing

One of the common questions PTs ask me is “ what should i do if my patient with stroke can’t open his hand”. In simpler terms, how can I stimulate or facilitate muscle action in such cases?

The answer is of course we can. We understand that the brain possesses plasticity, enabling it to undergo changes and recover. It's true that repetitive actions lead to alterations in the brain, fostering learning (semi-permanent changes). This principle is evident in various aspects of life, from improving skills like driving a car to mastering a video game.

The movement training:

We need to remember movement emerges when the person perceives the environment and wants to complete a goal. Say, your host comes with 3 different cups of coffee and keeps on the table in front of you. (as shown below)

Imagine you are reaching for the cups. As you can sees they are all different? Each cup, despite looking similar, has unique features that your brain instantly recognizes, influencing the way you approach it. The concept of affordance comes into play here; you naturally perceive the cup's characteristics, and your movements adapt accordingly. This process feels almost magical, as your brain and body seamlessly coordinate without conscious planning.

Now how will I teach this to my patient?. Well, put your patient in an environment where they can interact with objects. Have the patient to reach and manipulate or transport the objects in accordance to the goal. The patient engages in the task, experiencing trial and error, persistent efforts, and gradual learning. Through this hands-on experience, the patient learns to adapt and perform these actions over time.

No magic required:

Nothing you can do to facilitate this activity. There is no magical place to touch the patient, no unique muscles which needs to facilitated or inhibited before the activity it is tried. As i have written earlier, there is not magical feedback - like “open your hands”, “be careful” when picking the cup, don’t spill the coffee is mostly just a verbal token.

When i say this people are not convinced. Well, i don’t know what else there is to do. Icing the muscle? Botox the extensors?, prolonged stretching the extensors you don’t want us to do that?. Of course not. We know they are like the feedback be careful, just white noise.

Rehab or keep on with bull shit?

However, when faced with patients who is completely unable to initiate movement or muscle activity, the question arises: what can be done? The reality is, not much. In early stages of hand rehabilitation, you keep on ask the patient to perform functional activity. If the patient is unable to initiate a movement you wait and keep on trying. Sometimes after some months (probably after 3- 6) patient is still unable to initiate any movement, sadly nothing can be done.

The options often suggested, such as attempting to reduce spasticity through quick icing, stroking, or bouncing on a ball, seem to amount to futile efforts. Engaging in these activities may feel like participating in unnecessary tasks, akin to engaging in pointless paperwork for accreditation bodies like NAAC or other seemingly meaningless jobs.

Why doesn't it work?

In simple terms, the lack of effectiveness can be attributed to neural damage that prevents the activation of muscles. This is often associated with damage to the white matter of the brain. No amount of coaxing is likely to create new pathways or neurons in such cases. so no we are not god or medicine is magical.

What should we do?

So, if i have a patient who is completely unable to open his hand, initiate shoulder, elbow and wrist movement to reach for a object. Again nothing. There is no sorcessory like robotics, NDT, functional activity based treatment only the master Yoda knows. So, the first advice i give my patient:

1. My initial advice to patients is candid: I'm uncertain if the desired movement will manifest, but perseverance is crucial. It's important to note that some patients may express frustration or disappointment, possibly thinking I lack skill or employing defensive methods. Emphasizing open communication about uncertainties and the collaborative nature of rehabilitation could help manage expectations and build trust.

2. I counsel patients against "doctor shopping" - (please note many may not agree with that, but we should keep in mind it is their body their choice)

3. remember to rehabilitate- that’s our job. This is what many of us forget, How is the patient going to earn a living, go to the temple, manage is toilet activities- that rehab, that’s the goal. We need to try to achieve these with modification or compensations.

4. Stop asking me. I don’t have any secret sauce. If i had i could have got the freaking Nobel prize.