Functional. Therapists love the word functional so much that, in many cases, it has replaced the word recovery. But they have different meanings. Consider stroke. Recovery means completely retrieving all the movement and sensation swiped by the stroke. Functional means that tasks can be completed-by any means necessary.
Consider "functional in dressing" for a hemiparetic stroke survivor who is nearly flaccid on the affected side. Functional dressing is the ability to don clothing using the unaffected limbs. There's nothing wrong with this; being functional is a good thing. Discharging clients at a point in which they are as functional as possible is part of our job. But "being functional" and "reaching the highest level of potential recovery" are two different things.
Therapists do promote and facilitate recovery. But when the prime directive is to get folks as functional as possible as soon as possible, opportunities toward a more ambitious recovery endpoint can be lost. Much of the reason for the lost potential is purely physiological.
Healing Bruised Muscle
After stroke there is a period in which the brain is at a vulnerable crossroads. Stroke causes a portion of the brain to die. This area is called an infarct. The neurons immediately surrounding the area of infarct are not dead, however. They are "stunned" because of the furious metabolic activity that's going on as the body comes to grips with the injury. This area of stunned neurons is called the penumbra. An analogy can be made to muscles that have been bruised. The muscles will one day be able to move like they always did but while it's bruised it remains swollen, stiff and difficult to move. Much of the swelling is caused by physiological systems that attempt to repair the damaged muscle. In the short-term the muscle is swollen and stiff but as the swelling around the muscle resolves, movement is made easier. The brain, too, attempts to repair as much as possible after stroke, but there is a downside. During this period of repair, the neurons that surround the infarct are not able to do their job of conducting impulses. Once the corrective metabolic activity recedes, swelling declines and "stunned" neurons reawaken. This is called the resolution of the penumbra.
If the stroke survivor continues to use compensatory strategies to remain functional, these awakening neurons will be allocated toward some other mission. Ironically, these neurons that are, literally, in the best position to move the affected extremity are allocated by the brain to some other task. This is why early interventions on the affected side are essential to reestablishing those neurons to the tasks that they were meant for; namely moving the affected extremity.
This leaves therapists fighting on two fronts: teaching compensatory strategies for the sake of function and training the affected side to reestablish cortical control over the affected extremities by the "original" neurons. And for good reasons the fight should be fought on both fronts. Compensatory strategies get patients home, functional and safe. But as amounts of movement are unmasked on the affected side, the emerging movement should be recognized, celebrated, encouraged and built upon.
Lamentably, there is a tendency for emerging movement to be overlooked because it is considered "non-functional" movement. The trick here is making sure that "functional" and "recovery" are not mutually exclusive. Both should be worked on, although the work will be separate in the short-term. In the long-term they will meld indistinguishably.
The Real World
You may ask, "Why work toward more movement if we can pretty accurately predict that increased movement will NOT translate to real world tasks?" Even you were spot-on in your prediction, there are actually several reasons to promote an increase in AROM in as many planes and pivots as possible. Increase in "non-functional" AROM increases strength and muscle bulk, encourages muscular activity which promotes vascular return, decreases the potential for soft-tissue shortening and damage with resultant pain and stiffness, increases osteoblastic activity on the affected (and often osteoporetic) side, etc. But the most important outcome of focusing on raw movement is that assemblage of increased AROM at various pivots leads to the potential toward other recovery options that then can lead to more active range of motion.
In our lab we have found that low-level stroke survivors who use electrical stimulation to increase AROM at the wrist and fingers can qualify for constrain-induced therapy (CIT). CIT can then lead to increased AROM which can then lead to recovery of function.
I do a lot of outcome measures in our lab. I measure the movement of arms and legs to see if they're moving better after experimental interventions. A majority of stroke survivors, when asked to move their affected limbs will say, "I can't. It's paralyzed." I ask them to do their best, and almost always (with the exception of full flaccid paralysis) they manage to get a lot of movement out of their arm and hand. Unfortunately, they believe, partly because therapists have told them so, that their movement lacks importance.
I know when I see these folks that they'll be great for our studies.and we will show gains. And if things go well, they too will see a world of potential in very small amounts of movement.
Peter G. Levine is co-director of the Neuromotor Recovery and Rehabilitation Laboratory (rehablab.org) and the author of Stronger After Stroke (Demos Health, 2008). He also conducts seminars teaching research-based, neuroplasticity-producing stroke recovery strategies. E-mail him at StrongerAfterStroke@yahoo.com.