New Zealand Rehabilitation Association, Inc.

Levine, M., Kleim, J. A., & Wolf, S. L. (2009). What do motor 'recovery' and 'compensation' mean in patients following stroke? Neurorehabilitation and Neural Repair, 23(4), 313-319.

The basis of this paper is an observation made by Levin and colleagues that the terms ‘recovery' and ‘compensation' have been used to refer to different concepts by different researchers.  Too little attention, they argue, has been paid in the past to the distinction between gains in rehabilitation resulting from restoration of ‘normal' function at the level of physiology/kinesiology and gains resulting from physiological adaption or the development of compensatory movement strategies. Levine et al. point out that studies which evaluate the effects of various interventions by measuring functional outcomes (such as the Box and Block Test or the Frenchay Arm Test for people with arm weakness following stroke for instance) provide little information about how any improvements in function are achieved. In other words, improvements on the Box and Block test might result from the restitution of pre-stroke motor pathways or, equally, could result from the person in question developing new movement patterns (such as greater trunk movement) to compensate for impairments.

This is an important point. For rehabilitation to progress as a science, clinical researchers need to invest some energy in theory development (i.e. investigating ‘how' interventions or rehabilitation models work) as well as testing hypotheses about which interventions work best. As has been suggested in the past, rehabilitation research has tended to largely ignore the former and been dominated by the latter. In the area of rehabilitation of motor skills following stroke (the subject of this paper by Levin et al.), making a conceptual distinction between the mechanisms by which improvements are achieved is an important first step in the refinement of research questions, development of methods, and communication of results.

To this end, Levin et al. suggest that a distinction needs to be made between the terms ‘recovery' and ‘compensation' at three levels of the International Classification of Health, Function and Disability (ICF): ‘health condition', ‘body structure and function', and ‘activity'.  (They exclude the concept of measurement of 'participation' from their discussion stating that distinguishing between recovery and compensation at this level is too complex.)  Their use and interpretation of the ICF framework in this regard would be the subject of another discussion, but in general, the idea of using the ICF to make such a distinction seems sound.

Where I deviate from Levin et al. however, is in terms of the importance that should be attributed to recovery of ‘normal' movement patterns as opposed to making functional gains by ‘compensating' for impairments. Levin et al. write:

"If we are to make progress in changing how physical rehabilitation is viewed and reimbursed by third-party payers, we have to demonstrate that functional motor outcomes are superior when therapeutic intervention is aimed at the reacquisition of motor elements underlying functional task accomplishment (ie, muscle activation patterns and kinematics)." (p.315)

While I certainly do not discredit the significance of therapy aimed at motor recovery for individual with physical impairments or the value in researching such interventions, it is a massive assumption that such interventions are ‘superior' to those directed towards compensatory strategies. In fact, one of the points of developing the ICF as a interactive model (where the relationship between the multidimensional components are not linear but interrelated) was due to an increasing realisation that not all activity limitations or participation restrictions are solely the result of impairments and that not all improvements in body structure and function have a direct correlation with improvements at the level of activity and social participation. Third-party payers are correct to be uninterested in changes in body function and structure that do not result in improvements in activity limitations or participation restrictions or do not prevent the development of secondary pathology. Furthermore, if research is unable to establish such a link then it is the rehabilitation providers who should change their practice, not the health funders.

Levin et al. imply that the focus in rehabilitation on maximisation of functional abilities rather than on the ‘quality' of movement is a result of limitations that are placed on the duration of rehabilitation by health funders. I would argue that such a focus represents a contemporary, person-centred approach to rehabilitation and that a focus on maximisation of functional abilities does not preclude interventions for the minimisation of pathology and impairments where research evidence has demonstrated that it can occur in a meaningful way.

A final little point here, it is valuable in any discussion of terms such as ‘recovery' and ‘compensation' to explore and present the perspectives of people with disabilities themselves. Indeed, the ICF nomenclature was developed in consultation with the disability community. However, given that the journal Neurorehabilitation and Neural Repair does not appear to publish qualitative research, it is unlikely such views would be presented alongside the expert opinion of Levin et al. I would however hazard a guess that there is a large number of people with stroke who do not care how they achieve movements so long as they can get from A to B and as long as they are independent as possible in their usual living environments.

I am aware however that others may disagree with my viewpoint here.  If you have an opinion, do use the comments box below to share it!