The fallacy of the plateau by William Lo
In almost every survivors journey, they will hear the inevitable words “your recovery has plateaued off”. A therapists kind way of letting you know you may have reached your full-potential.
While well intentioned it can be very disheartening and also misleading.
As a young stroke survivor and an occupational therapy student, for me recovery will be a lifelong process. It can be for you too.
I made the choice to get better. I believe, like any skill in life, the choice to get better can only be limited by yourself. Hell, I was told I wouldn’t walk out of hospital!
Having said that, there are only two reasons why a plateau should occur, and they are either:
1) You’ve recovered to a point where you’re 100 percent satisfied with where you are, or made a full recovery.
2) The exercises you’ve been doing haven’t been updated as your recovery progressed, or they aren’t relevant to the skill you are trying to get better at.
In most cases you’ll find that your exercises are the culprit.
There are things you can do to help your brain better rewire those lost connections after stroke.
When learning a new skill, you might’ve noticed that you found you were able to learn faster, or quicker, by using strategies to remind your brain what to do in that situation. Let’s take basketball, for example, whenever you miss the basket your eyes remind your brain the way your’re “shooting” isn’t quite right, so you make the correct adjustments, until you reach that “just right” level.
Stroke recovery is no different, particularly when your brain is attempting to learn a new movement like balancing longer on your weaker leg. To learn any new skill after stroke your brain takes “hints” from the exercises you’re doing, such as how it “feels” like, and what it “looks” like (what your eyes are seeing and sending back to your brain). You might refer to this as “muscle memory” or a blueprint.
Once you’ve learnt a new movement after stroke, your brain registers this blueprint. Over time, as you continue performing the exercise in the same way the new movement you’ve learnt is likely to stay at the level where it is or plateau, unless you add some “spice” to your blueprint. This may include making the task more challenging or changing the way you do the exercise. You might’ve heard the phrase “practice makes perfect”, in this case, it’s “practice under pressure makes perfect”.
There are a couple of ways to do this, let’s take the example of attempting to balance on one leg.
You can now successfully balance on one leg, but it is very minimal, and you may find that you can only do it for two to three seconds consistently. Occasionally you’ll get five seconds.
This is a common problem, and simply put, you’ve plateaued on your ability to balance your leg for that two to three second range. This is – in part – because your brain has not been challenged to apply balancing the leg in different environments.
In order to upgrade your blueprint, or blast through the plateau, your brain requires exposure to something which will challenge your ability to balance. By doing this, you’re justifying to your brain why it needs to recruit more brain power to balance longer.
For example, one way to increase your balancing might be to go up a flight of stairs, ensuring that you are always stepping up with your weaker leg. Then, when coming down, you come down with your stronger leg. This allows your weaker leg to take on most of the weight, since its last to leave the step.
By doing this, you are actively encouraging your weak leg to exercise in different environments, or instances where it has to step up its game.
You’ll find that over a week, your balancing time might increase by one to two seconds more.
Eventually you’ll get so good you’ll start to challenge yourself further. This might be something like taking off your shoe on your strong leg while balancing on the weaker one.
So, beating the plateau is about getting creative with how you can get closer to mimicking what you used to do before your stroke, by challenging the brain in different ways, with very stimulating exercises.
A good rule of thumb for an ideal exercise involves asking yourself the following cardinal questions:
1) Is this exercise challenging and repetitive? (i.e. have I done this before?)
2) Is this exercise performed in the manner it would typically be before my stroke? OR is it related to the task I’m trying to learn?(training balance on stairs)
3) Is this exercise giving my brain some “hint” that I’m doing it right, and how will I know? ( e.g. knowing your opening your hands cause you can see yourself releasing a ball from your hand).
If you find that an exercise fulfills all this criteria, you will know that it’s a very good exercise for stroke. Should you plateau, just look over all these questions and ask yourself which exercise component has already become too easy. After this, you can try and think of more ways you can modify the exercise, by tweaking/ adding any of the components, to help your brain better retrain itself. Also, talk to your therapist. Make it clear to them you want to continue in your recovery journey.
I’m sure that isn’t too much for you to handle right? Otherwise you wouldn’t be reading this right now.
Just kidding, but seriously, mangoes.
Hope this helped, and I wish you the best with your recovery.
Response from StrokeLine
Thanks for posting such a great blog. You’ve summed up the importance of continually challenging your brain in stroke recovery, whether that be months or years down the track after a stroke.
This brings up a good conversation about stairs - as physios we usually recommend going up using the stronger leg first and coming down leading with the weaker leg first.
The reasoning behind this is to limit the risk of a fall or knee injury – if the weaker leg doesn’t have enough strength around the knee joint we worry about it giving way.
Having said this, sometimes we’ll recommend switching the order if we feel the affected leg is strong enough to cope, so that going up and down stairs becomes a strengthening exercise in itself.
As you mentioned, talk with your therapist about your recovery. We’d recommend people speak with a physio or OT to work out the best way to go up and down stairs for them, so that the affected side can be challenged but in a safe way.
I’m looking forward to reading more from you in the future, you have a wealth of knowledge to share with the community!