“Dis-” words have gotten my attention. They become a mainstay in the US and UK political discourse over the past few years as disinformation became an ongoing topic and concern. “Dis-” is a simple little prefix that turns a word on its head! A word of opposite meaning is formed just by placing “dis” in front if it.  In the field of rehabilitation, we seem to love this metamorphosis.  We could start with disease. If there wasn’t disease in the world, we wouldn’t have a profession. We begin the rehabilitation journey with patients who are lacking ease. Seems our job must be to give them ease. Particularly with diseases of or affecting the movement system, we often say that the movement is disordered. When the movement system loses its order and organization, we lose the beautiful, fluid and effortless quality of movement.  In rehabilitation, returning order to the movement system is a high priority. If we fail, then surely disability ensues. Patients with disease and disordered movement systems lose their many abilities to move. This renders them unable to perform in basic life tasks as well as in chosen tasks of interest. Our job is to make them able. If we fail, huge disadvantage overtakes even the smallest attempts for patients to live independently. The control of their movement system has lost the many options and advantages they were accustomed to. Even a few small advantages in the movement system can make an enormous difference . . . maybe the difference in standing or being confined to a wheelchair. We have to create advantages for patients. If we fail, the patient will give up and disuse will perhaps become an even bigger obstacle than the primary disease and disadvantages. Disuse is also a natural outcome of substitution based therapy. We have a “work around” for everything in the therapy world. We need more “working on” in therapy, requiring use of the limbs and movement synergies and actions that make us capable of meeting the physical demands of life. Restoring use is the focus of therapy. If we fail, our patients become discouraged. Who could blame them? They don’t know how to get their lives back! They lose hope and fade further into the wheelchair and into the background of their own lives. We must be the ones to hold the knowledge, to hold the hope, and to encourage them in their bid to regain control over their body. If we fail, the patient will disengage with the process of rehabilitation and possibly (dangerously) the process of living. They aren’t dead but they aren’t really living either. This is a very dark space for patients. They can’t see a way or don’t see a reason to be engaged. We can lead them to a better place by engaging them in therapy involving things they really care about!  If we fail, we won’t be able to tolerate our own shortcomings and we will discontinue the patient’s therapy. We never blame ourselves. It is either a “plateau”, or “low patient motivation”, or some other fault that we place at the feet of the patient. We must continue to make ourselves more capable of solutions, so the patients can continue to progress. You and I may disagree about some of my thoughts about these “dis” words. But it would be dishonest if I didn’t express how dissatisfied I am some days about the kind of disservice done to patients by well-meaning but under prepared, unenthusiastic, or disinterested therapists in neurorehabilitation.  The “dis” words of rehabilitation bother me a lot. If we could lose the “dis”, and set those words right side up again, we would be left with ease, order, ability, advantage, use, courage, engagement and continuation to work on. But only if we are interested enough to honestly provide satisfactory service to all the people who are counting on us.

I’ve been observing a most phenomenal thing: tomato seeds sprouting into wobbly seedlings that grow into baby tomato plants that grow into recognizable garden ready plants. Typically, I go to the nursery and I begin summer gardening by buying plants that are ready for the garden soil. But this year I decided to take a leap of faith and start with just a seed. Just a seed and a belief that in a few months I would have a harvest of beautiful Cherokee Purple heirloom tomatoes. I wanted home grown heirloom tomatoes . . . there is no substitute. Even if you don’t like tomatoes, keep reading. (It’s about process.) If you start with a seed, you had best learn a few things about sprouting and seedlings or you will not make it to the good part – – the big, beautiful tomatoes! Information, process, and problem-solving are all part of successful gardening. Turns out there is a lot to know about tomatoes. I had to select seeds from over 10,000 different tomato choices! Every single seed has a history and a story – – thousands of stories if you ask other growers about their experiences with growing tomatoes. Different seeds have different germination times and become different looking plants that yield different sizes, colors, and tastes of tomatoes. Important things to know before you start. Once you have selected a seed, there is a process to follow for seed sprouting and caring for seedlings. Decisions have to be made about when to start the sprouting. This mostly depends on outdoor temperatures and the frost free date for the area where you wish to plant them. A little “backwards math” counts you back to your indoor start date. Starting the sprouting takes the right combination of temperature, water, air, and light . . . more decision points to create just the right environment. When the seeds sprout and shoot up you have something else, seedlings, and they require special care, too, regarding temperature and water. The first transplant happens at this stage so each seedling has it’s own small pot (usually peat). As the seedlings mature, the process of “hardening off” occurs which exposes the seedlings to more outdoor conditions before you actually put them in the ground. After a week or so, they are ready to move on to the in-ground transplanting.  When you place them outdoors, the location depends on sun exposure and soil preparation. The plants often grow 3-6 feet tall and need continuous water, sun, and air. Of course, you want to continue their development so fertilizer and support structures have to be provided. Outdoors, pests may become residents on your plants and that is yet another problem to be solved. If successful, after 70-90 days, your plant should be fruiting. Yes, tomatoes are a fruit!  Maybe you are wondering why a person wouldn’t just buy a tomato at the market. I  think I just like the notion of taking the smallest start and working a process to fruition. It is a sort of biological miracle that a seed knows how to make delicious food if you follow a process and pay attention. I like the food but I love the process. I grew up in a family of gardeners so I know where my love for gardening started. But I didn’t know nearly as much about how to fully engage in the process until I was a therapist. Movement recovery is a process and, thus, therapy must be process oriented. So much of good therapy is the same as good gardening. Know the “seed” (person) you are starting with. Start with an arsenal of information about your subject (the human movement system). Make good choices about growing conditions (therapy). Know when to move on (progression). Know how to deal with difficulties and the unexpected (problem-solving).  Between the start and the outcome, whether it is a seed in gardening or a new patient   in your clinic, it is all process and problem solving. There is no substitute for process and problem-solving in neurorehabilitation just like there is no substitute for a vine-ripened, homegrown tomato. But if you like to start small, work a process, learn a ton along the way, and solve as many problems as you encounter, you probably could be great at neurorehabilitation . . . and gardening.  In therapy and in gardening – a small start, an act of believing, a process of doing (and doing and doing), and an expected but unknown (sometimes spectacular) outcome – you find all the elements of a leap of faith. 

Conspiracy theories and fake news are seemingly ubiquitous in social conversations and media reports these days. Facts must be approached with caution, and checked to confirm veracity. Public opinion can easily be swayed by use of various cognitive biases. Healthcare workers and therapists are not immune to this concept. Confirmation bias suggests we favor and seek answers that affirm our pre-existing beliefs. Advertisers online take advantage of this by matching their ads to our past searches, which is called “behavioral retargeting”. This can manifest itself in patient examination when we look for our usual or preferred impairments, so that we can provide our comfortable therapy treatment routines. Just like we may repeat similar purchases, we repeat similar impairment lists. Likewise, we may give in to similarity bias, or the belief that all our patients are more similar to each other than different, allowing us to treat them all the same. Other times, we become susceptible to authority bias when we are influenced by the opinion of a clinical or medical leader, or perhaps the availability cascade takes effect when a suggestion accumulates more credibility as it spreads among our colleagues. Vulnerability is amplified by the Dunning-Kruger effect, which states that the less we know the more confident we are. We all want to be right. Until we find out we are wrong. This is reinforced by our experiences and the learning paradox that the more we learn, the less we know. Certainly, as we explore the limits of our wisdom, we concurrently become more aware of our ignorance. This is something to celebrate. We need to embrace this discovery, and use it as motivation for the expansion of knowledge. In reflecting on your own practice, this may require a return to the literature or compel us to find continuing education courses for ongoing professional growth. It likely means asking yourself more frequently why you do the things you do, why you think the things you think, or even why you may not always achieve the outcomes you desire.  It is possible that unconscious bias (also known as implicit bias) has corrupted our expertise or that we have settled for complacency. These attitudes or behaviors affect our understanding, actions, and decisions even involuntarily. Quality and safety are often unintended sacrifices. Bias is comfortable and makes things easy for us so we do not have to consciously put effort into thinking all the time. It hijacks and sabotages our ability to be open. Although expedient, patients are the victims. They need us to think. They need us to know. We need to avoid the bias trap, and overcome our own thinking.  The intervention for this is advancement of your learning, deepening your mastery of foundational sciences, examining the root cause, and testing your facts. I dare you to be different, to stray from groupthink, to be a non-conformist, and to think harder and know more than the average clinician. Our goal should always be to find the true underlying reason a patient cannot do what they want to do…and the truth shall set them free.

It’s November 1 and soon Election 2020 will be over. The American Psychological Association released a poll done in October that reported 68% of adults surveyed found the election to “be a significant source of stress”. I just read a new term today being used by some psychologists, election stress disorder. Yes, politics and polarization (not to mention the pandemic) have created a surge in the need for mental health services. This has been a very tough, zero sum game election season.  Understanding why politics is so polarizing and stressful has its roots in personality and, to some extent, in biology. I am especially interested in how personality and particularly, ambiguity tolerance or uncertainty, creates this divide, or tension, in politics.  Dannagal Young is a communications professor who has studied late night shows and political jokes to try to understand their impact on attitudes, behaviors, and knowledge. In addition to answering the question, “Why is political satire so liberal?”, she was led to study the psychological profiles between cultural liberals and conservatives. These differences likely account for different political views. My question is “how might these personality findings help us to understand our approach to therapy and recovery?”. Here is how Professor Young expresses the differences in the psychological profiles of more conservative and more liberal people. The main difference is comfort with uncertainty. The conservative is more “threat conscious” and, therefore, prefers order, predictability, and routine. The liberal is less threat oriented and more open to new ideas or experiences and more tolerant of ambiguity. In a further distillation, some of us are going to approach the world motivated by “protection, security, and predictability” while others are moved to experience the world by “openness, experimentation, and novelty”.  Clearly, both of these world views are completely fine. You may find that you operate out of both sets of behaviors and that is probably healthy and normal, too. But if we are honest, we know that one likely defines us more than another. Knowing who we are and how we are can help us drive our professional pursuits.  In medicine, it is said that professionals make decisions under conditions of uncertainty. There are many unknowns in clinical rehabilitation. If every single person is completely unique (and they are), then every single patient is completely unique and unknown to us. What if the unknown scares us and we want to retreat to safety and routine? What if the unknown intrigues us and drives us to examine options and completely (or partially) change the way we do things each new encounter? What if we needed to rely on both? The old mat exercise routines that have remained the same for years in stroke rehabilitation may make us feel safe but likely will not lead to greater participation in the life the patient wants. Salience and novelty drive neural plasticity. Routine (low thinking) may seem efficient but experimentation and iteration (high thinking) may lead to more effective interventions and outcomes. Neurorehabilitation Professionals know that we cannot be threatened by the diversity of the unknown. We can rely on our knowledge (security, predictability) which gives us the constant reassurance that we can play with form, function, and tools in new ways to open ourselves to the great unknown, the patient and their movement system. Yes, the threat of having to diagnose movement disorders is a daunting task. I’m banking on anatomy, kinesiology, and neuroscience for my security. After that, I’m open to what happens next. Whether you are a conservative or liberal is unimportant. In this election, what matters is that you vote. In therapy, what matters is that you remain open to reinforce your base (knowledge) and let it lead you to new interventions and solutions. We all need conservative and liberal elements . . .  just like we all need each other.

The global economy and business industry are presently experiencing unprecedented circumstances. Hopes for aggressive growth over short timelines have been dashed for many. The markets seem so volatile. Business schools and commerce majors look to evolve and market themselves for the future with a concentration on risk analysis and risk management. The objective is to design strategic plans more impervious to the effects of flattened revenues and recession. The debate ensues between between risk and security. Indeed, the healthcare industry must engage in this very same discussion. Patients place similar demands on their therapists. They present with the goal of rapid recovery and a return to normal function. Taking chances can lead to setbacks; however, being overly protective and careful can result in only modest improvement, reaching a plateau, and even depression. This leaves health professionals with the same dilemma between challenge and safety.  One might argue that hospitals and even insurers would happily settle for stabilized health conditions with minimal potential for deterioration. Certainly, they would accept better patient outcomes, but not likely if it meant increased cost due to incidents in the therapy department. This defensive approach may temporarily maintain health and support associated industry partners that develop aids and devices, but will not attack the impairments, diagnoses and activity limitations that ultimately restrict patient participation in their previous quality of life. The winner: industry. The loser: patients. Therefore, it would appear, therapists must decide to be risk takers or risk avoiders. All while being immersed in a culture that seems to value risk aversion, and with very little risk tolerance. The literature and research, though, would submit that best practice requires pushing patients in therapy to the point of “just right challenge”. The idea that if we are not requiring the body and system to find new solutions and improve, then we remain the same or even regress. If we only try things we can already do, then we are not changing. To get better we must try things we cannot do, things that are difficult, and work with more intensity so we rise to the challenge. In the face of failure can be found the reward of success. Accepting this all to be true, how then do we make wise choices in our therapy sessions? We may begin with assessing our own risk tolerance and proclivities. We might need a mechanism for calculating and evaluating risk, and ultimately for managing risk. Instead of the financier role, this may be the most valuable contribution of insurance companies to healthcare. Actuarial sciences might have something to teach us in this regard. Or it may be as simple as the most basic of risk formulas, that risk = probability x loss. While we have a requirement to reduce loss for our payers, surely our greatest responsibility is in maximizing the possibilities for our patients. Are you willing to take the risk to do the right thing? To explore this topic further, and its practical application in therapy, be sure to register for a course like The NeuroPro Certification Standards or The NeuroPro Skills for Rehabilitation.

On a 400 meter oval track, actually only the Lane 1 runner starts and finishes at the exact same point. The other starting points are staggered in Lanes 2-8 so no one sprinter has any advantage (or disadvantage) compared to the other runners. Each runner has his own lane and has to run his own race. Each individual knows why he is running his race — what his trophy is — maybe a personal best, maybe a school record, maybe a gold medal. Each runner starts with nothing but an ambition. Each runner runs for a prize. Knowing what you work and train for is indispensable when race day arrives. Generally, nothing in the medical paradigm prepares any person for a stroke event. Modern medicine is riddled with tests and medications and surgeries to fix things for patients. Patients are passive participants in most medical processes. Neurorehabilitation specialists must be prepared to coach and train stroke patients in an active process around the rehabilitation oval. It is genius to begin with the prize, the salient task, so the patient knows what he/she is working for, training for, competing for. It is the way a race always starts…each individual knowing the prize, record, or goal they have chosen. The stroke rehabilitation oval is not really just 400 meters nor is it a sprint. It is more like a distance event with hurdles, regularly placed hurdles and some thrown in along the way. The stroke event is usually a grueling race and it has to mean something and be for something specific — from the beginning — or it won’t be worth the hard work involved to get to the finish line. The patient and the therapist have to partner to get around the oval, over the hurdles, and into the finish. Therapists working in neurorehabilitation have become accustomed to adhering to the pacing of the payers, the regimentation of training by “evidence”, and the risk aversion of institutions. Go fast (code for: get the patients out of the hospital), don’t do anything that doesn’t have evidence and, at all cost, do NOT take any chances! How have these become the guiding principles around the oval of stroke rehabilitation? NeuroPros know that smart goal setting and effective coaching are dependent on different principles. The goal is made by the patient who has to run the race. The therapist/coach agrees to help with the patient’s hopes and dreams, not the payer’s financial goal. The start of training identifies the patient’s lane, their unique path, to run for their unique prize. It will require ingenuity on the part of the therapist and trying things that have never even been thought of, much less researched with mountains of evidence. Patient safety has been emphasized to a fault. If we just push the patients around the oval in their wheelchairs, they will never learn to walk or run. NeuroPros welcome the challenges around the oval of rehabilitation and know how to make risk/reward assessments. By our actions and confidence, we teach the patients how to be courageous and keep running toward their prize. Stroke rehabilitation is a marathon sometimes. Therapists, we have to go the distance…from the start…until we arrive back at that line where the prize is claimed.

I imagine we can all agree on this one thing. We are living in uncertain times.  The global pandemic created by Covid-19 has been disruptive in many ways: to families, to routine, to livelihood, to education, to government, to business, to friendships, to socialization. It has disrupted sameness. And we don’t like it. It is no secret that we human beings do not like change, yet this virus has imposed change in nearly every conceivable way. It is inconvenient and it is uncomfortable for us. But for the nearly 100,000 people in the US who have died from the virus,  it has been a disaster. We all want to know when this will be over and we can go back to normal. Far apart from the world of Covid-19, yet similar, neurorehabilitation specialists attend to disaster every time we meet a person who has had a stroke. They wake up the day after their stroke to a changed world where restrictions are imposed by their own bodies. Their world is disrupted. The medical team stabilizes their organ systems; we are called to the disaster to attend to their movement system. Our work determines how long their restrictions will last. They want to know when it (the effects of the stroke) will be over and when they can get back to normal. Stroke patients ask many of the same questions after their stroke that we (Isolated at Home) find ourselves asking about the ongoing pandemic. The parallel is striking. Stroke Patient (SP): How long will it be before I can walk? Isolated at Home(IAH): How long will it take to flatten the curve? SP: Will I be able to return to work? IAH: When can I reopen my business and get back to work? SP: Am I going to have another stroke? IAH: Am I really likely to get the virus? SP: I’m stuck at home because I can’t walk and I can’t drive. How can I go anywhere? IAH: Why can’t things open up so I can get out of the house and go somewhere? SP: When will I be able to do the things that are important to me that I care about? IAH: Why are we being ordered to stay at home and kept from doing what we want to do? SP: How can my family survive financially if I don’t go back to work? IAH: When can we go back to work so the bills can be paid? SP: Some people say I’m not going to get better and others say I will. How do I know who to believe about what is going to happen to me? IAH: I hear varying reports about the medicines and vaccines. Who should I believe? We seem to have questions in our Covid-19 world similar to that of our patients. The pandemic has created uncertainty and inconvenience and, for some, disaster. But fortunately for us, our uncertainty due to Covid-19 is a temporary inconvenience. For our patients, their event was a personal disaster of much greater magnitude and consequence, not a mere inconvenience. But we and our patients all want the same thing. We want the uncertainty to go away so we can get back to normal . . . the way we were the day before the virus … or the stroke. In the US, someone has a stroke every 40 seconds. That is 2160 new cases every day. That is 2160 personal disasters a day. Heart disease has been the number one killer of Americans for the past 80 years. No epidemic or pandemic has ever lasted that long, not SARS, not MERS, not Zika, not Ebola and I don’t imagine Covid-19 will either.  I am not trying to downgrade the importance of what is going on right now with this very contagious, fast-moving virus. But I am wondering if this pandemic and all the uncertainty it brings, could remind us and sensitize us to the 2160 world changing events that happen every day in our country. Let us make sure that we have an excellent response plan and focus on getting our patients back out into the world. Let us understand the difference in inconvenience and disaster. Let us keep the hope and see the possibilities for them. Let us use our knowledge and skill and not let them be swallowed up by uncertainty. All of us could use some certainty right now.