Stroke Survivor Bootcamp with Dr. Phil: "How Do I Know If Therapy Is Working?"

In this episode of "Stroke Survivor Bootcamp", Dr. Philip Lamoreaux, OTD, OTR/L, CPT, discusses how to know if the therapy you are currently doing is working, as well as ways that you can get the most from your therapy appointments.

NOTE: Be sure to check out some of the helpful worksheets that can be accessed by clicking here, or by going to www.StrokeSurvivorBootcamp.com.

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Hosted by Dr. Philip Lamoreaux, OTD, OTR/L, CPT, Stroke Survivor Bootcamp is a practical, hope-forward podcast for stroke survivors and caregivers, built to help you understand what’s happening, ask the right questions, and take back control one step at a time. Each episode blends real-world hospital and rehab guidance with clear, compassionate coaching so you can turn fear into a plan and progress into momentum.

For more information on signing up for a one-on-one Stroke Survivor Bootcamp session with Dr. Phil, just go to www.StrokeSurvivorBootcamp.com

Created & Produced by Christopher Ewing
Hang On to the Dream Foundation

Written by Dr. Philip Lamoreaux, OTD, OTR/L, CPT

Listen each week to the Stroke Survivor Bootcamp podcast with Dr. Phil, the OT Professor, where he will share with you practical tools, real stories, and the mindset to keep moving forward on your road to recovery! 

If you are a stroke survivor, sign up for one of Dr. Phil's Stroke Survivor Bootcamp sessions.  These sessions are proven to help stroke survivors regain more mobility following a stroke.  Just go to www.strokesurvivorbootcamp.com for more information.

If you are a stroke survivor, sign up for one of Dr. Phil's Stroke Survivor Bootcamp sessions.  These sessions are proven to help stroke survivors regain more mobility following a stroke.  Just go to www.strokesurvivorbootcamp.com for more information.

Transcript

SPEAKER_00 0:00

The comments expressed in this program are the personal opinions of the participants and not meant to diagnose or treat any medical condition that you may have. Please consult your doctor or healthcare professional before making any changes to your current medical routine. As a stroke survivor, it gets really comfortable and we're okay with just practicing. And in our mindset, we go, well, I'm not actually going to be in the game of life yet because I'm not ready. And the reality is you're never going to be, quote unquote, ready. Playing in the game is always going to be a risk and it's always going to be scary. It's okay to play in the game and to try things when you still might make mistakes. And in fact, if you allow yourself, give yourself the permission to play in the game, that is worth it. I'm a licensed occupational therapist and certified personal trainer who has over 10 years of experience working with stroke survivors. I have spent a majority of my career working in the inpatient neurorehab and then transitioned to academia where I've taught occupational therapists, and then I transitioned to work in the community and go into people's homes and help them actually thrive in their own community. And I love working with stroke survivors. In my opinion, stroke survivors happen to be the group that actually is kind of forgotten in the rehab world. And you know, usually what happens is we teach you, we give you ideas, we uh we help you set up uh for a home life um in a clinic, and then eventually what happens is you know insurance basically says, Hey, sorry, we're not gonna pay anymore, and you're left to be on your own. And then what happens is you, as a stroke survivor or stroke survivors themselves, are left to kind of their own survival, and then they're on their own, um, at least for a good period of time. And so that's exactly why I started this podcast. I started this podcast as a way to help stroke survivors not be the forgotten group and to be able to identify ways and strategies that they can keep moving forward, because one of the things that we do know is that a plateau isn't real. Now, what I mean by that is that the plateau itself, the concept of a plateau, of course, that's real, but not in the way that it's talked about with stroke survivors. Typically, stroke survivors are taught that a plateau is something that can happen to them and likely will happen to them about a year out from their stroke. And it basically means that they will stop improving a year into their stroke, and the the life that they have at that point is kind of the life that they're going to have. And they just need to, you know, the term people will use is get used to their new normal. And that is only semi-true. Your brain is always wanting to learn and adapt. That is what your brain is designed to do, and because of that, we know that you are capable of progressing and growing and changing and adapting every single day. So when it comes to a plateau, you as a stroke survivor can continue to improve no matter what. And that is why this podcast is so important, is because I am trying to help you see where you have control and how you can take control of your own life moving forward. Now, today's episode, we are going to be talking about, I think one of the hardest questions to ask, number one, because um you you'll see there's there's some specific um things about this question that go into personal relationships and the way people identify you know the people that they're around, but even more so because it's actually a really hard question to answer just in general. There was an article by Catherine Lang that was published in 2023 that actually brought this whole concept to light. And basically it's that as a stroke survivor, the the thing that typically happens is that you go into a clinic, and while you are in a clinic, you do all these exercises, you work with a clinician, uh, whether it's occupational or physical therapist, and you actually see that you have improvement. And the problem comes in that what at least the research has said is that very rarely is that improvement actually used in everyday life. And so it becomes this really difficult topic, and that is you know, how do you actually know if what you are doing is working? I mean, oftentimes the same things that you could you couldn't do before you went to therapy, you still can't do. And the same activities that you've avoided, guess what? You still avoid those activities. And the same gaps in your life, they're still there. Now, therapy uh typically is filling the calendar, but is life getting bigger? Like, are you participating more? And uh that's the question. That is the main question that I'm going to answer today is what is that like? Because feeling tired after therapy is not the same thing as you're getting better. And being busy doing things in therapy, it's not the same thing as you're actually changing your life and preventing a plateau from happening. And you working hard in a session, although that's valuable, it's not the same thing as actually making it so that you will use what it is that you are gaining and learning into where you're actually needing to use it outside of therapy and away from your therapist. And I am not saying today that your therapist is is a is a bad therapist. I'm not saying that you're not trying when we go through all this. I'm just saying we need to make sure that we're asking ourselves the right questions so that we can identify if the effort that we're giving actually has evidence that is supporting that we're really improving. Okay. So I want to give you a framework, a way to actually know if your therapy is helping you, and not how to not just how you feel about therapy or your therapist, and not how to just be polite about therapy, but how do you actually critically evaluate it so that you know that what you're doing is working? And we're gonna talk about what it actually means for therapy to actually help you transition from the clinic to home. And we're gonna talk about why measurement actually matters. Why do you or why should your clinician be measuring you? You know, that's a that's just a piece to the puzzle. And how can you actually ask for it without sounding like you're trying to pick a fight or challenge your therapist? And then I'm gonna introduce you to Anna. Many of you who are listening to this know who Anna is. She was the first stroke survivor that I ever worked with in a boot camp capacity, and she is one of the best examples of taking something and trying to apply it into your everyday life. She does that so much. And at the end, I'm gonna give you a scorecard, which are seven questions that you can run through after any therapy session so that you can actually evaluate and know whether what just happened is actually moving you toward the life that you actually want. So here is the line that I want you to carry throughout this entire episode. And that is if therapy is working, your world should start getting bigger. If it's not, then it's just information. It's it's not a judgment, it's not failure, but it's something that you can actually act on and do something about uh moving forward. So let's let's start by defining the word that this whole episode is is focusing on, and that is helping. Now, therapy is helping you. That particular phrase, it gets used a lot, and most people never stop to ask what it actually means. So I'm I'm gonna try to draw a clean line for you. Therapy is not helping just because you like your therapist. Now, this is a big thing because when I've ever asked survivors, um, what is it that you, you know, how do you know if your therapist is a good therapist? Oftentimes they will state the relationship that they have. Okay, well, that is a piece to the puzzle, but does that actually mean that you you're that what your therapist is doing is actually helping grow your your life? You know, if you're if you're sweating, does that mean that that it's uh that therapy is helping? No. What about if you're sore afterward? What if you're doing exercises? What if you show up every week without missing a session? What if someone tells you that you're doing better? They just say you're doing better. Those types of things, they're not helping you. And none of those things are actual evidence that the therapy you're doing is actually doing what it's supposed to do. You know, they're evidence that you're showing up, that you're participating, and that you enjoy the person that you're around, which can which is a part of the puzzle. But participation is not the actual goal. And I think that's a huge thing for us to talk about and identify. You showing up every week, every day to therapy, that is not enough to to actually get change and to prevent uh the plateau that inevitably is gonna happen if you don't if you don't uh push yourself, right? And if you don't actually apply what you learn into everyday life. So if those are not the things that you use as a measurement of whether therapy is actually helping, then w when do you know? How do you know if therapy is helping you? So a couple of different things. Therapy is helping you when you know what you are working on. So you need to understand and know and set goals as you know, this is this is what we're working on. Second is that when you know how it's being measured, that is a big deal. Measurement. Third is that you know you are improving beyond what could just be normal day-to-day, like what you do in a day. And then this is the biggest one of all. When whatever it is that you're working on is showing up in real life. So let's just say your your therapist is working on increasing and opening your hand. If it's not happening in everyday life, then is it actually helping? I'm I'm actually gonna take the stance that I don't believe that it's really helping. But if you go home and you start trying to do it and it starts to open up and you start trying to grab things, now what you've been doing is actually helping. So when you're doing something at home or in your community, uh in your life, that's uh you know, that that you weren't doing before, that's one way that you know that what you're doing is actually helping. And that is a different bar, it's a different measurement than what I believe I see and what I hear from therapists all over the country and all over the world. So good therapy should not just make you feel encouraged, which is important, like I said, but good therapy should actually have outcomes as expectations, and that change is something that you can visibly see, and not just visible to the therapist, because you know, us therapists, we're gonna look at these little tiny details and we're gonna see little changes, and that's kind of what we're trained to see. But ultimately, it doesn't matter if you don't see it, and it doesn't matter if your family doesn't see it, and it doesn't matter if it doesn't show up in your everyday life. And so a way that we can start talking about this is you know, for example, if you walk into a room and the way you you you sit down in your chair, you've been practicing how to do that. Is that now what you do in everyday life? Or do you just kind of go back to the things that you did before and you know you kind of stay right there? Um, if you can't really point to something specific, then really what you know what's happening, you know, there's you can't actually identify something specific that you're doing now in your everyday life. Again, this is not what not in clinic, because honestly, it truly doesn't matter what you show in the clinic. That doesn't matter. It doesn't matter what you show with your therapist. What matters is what happens outside of the clinic, what happens in your everyday life. And you know, the thing that you just need to keep asking is, you know, if you if you can actually see a change. Because if you can't, and you don't I you can't identify that change, then again, the question is, what are you actually doing in therapy and how is it actually helping you? So the very first step that you can do is you know, is something that I think a lot of people don't like hearing, especially therapists, because they don't want to take the time to do this in a lot of situations. And there are some that do. But if we're not measuring, if we're not measuring something both in the clinic and at home, then all we're doing is guessing. And there's a really easy way that uh what can happen is confirmation bias, but basically because I want to see it, like I intentionally am looking for it and I want to see it, I somehow create it in my mind. And that is something that happens, and I see that happening all the time, but we're just not we're not actually seeing any difference. So when we think about this, you know, stroke recovery is full of lots of different variables that are gonna move on their own. So, you know, things like fatigue that you know is gonna change the way you feel from day to day, you know, sleep, how well you're doing with that, what stress you're feeling, what your confidence level is, what pain you're experiencing, the environment, how that changes, even the weather can change things. And without measurement, all of these variables are gonna they have the chance uh to fool you uh or in in in good or bad. So a good day may feel like progress, but a bad day feels like a decline. And that's gonna be that that's that makes it hard because if you as a as a uh stroke survivor are trying to go every day when every day feels like a grind, it feels like a battle, and if you are just going off of what you feel, then you're going to have days where you feel like you aren't successful, and you feel like you're going backwards, and then that may limit your willingness to actually keep trying and keep pushing. So measurement and actual standardized measurement that you can get with your clinician is a really important piece that you can have in you know, that you can have in in your back pocket. And it's um it's not gonna be just a number, it's not gonna be your data, but it's because the data can actually help give you something that you can actually trust. So when we talk about tests, when we talk about measurement, there are two real foundations to measurement that you need to understand and that you need to make sure you you have and that you know. Okay, this is your responsibility as the survivor to make sure that you understand and know these two things. The first is what is your baseline? Now, baseline is your starting point. Now, this is this is the measurement that somebody is gonna take uh before you actually start an intervention. So it doesn't really matter though if you start it now and you've already been doing therapy for a while, or if you if you're just about to start a new place, um, obviously I suggest that you get measurement right off the bat so that you can then check and see where you've come from and how far you've progressed, at least within your capacity. Um but if you haven't if you haven't actually been measured, you know, in certain ways, then just do it this next time. Go into your clinic and say, hey, I would like, I'd like to get a baseline. Where am I at? Let's get some some tests. Um and and that's that is a thing that we'll go over in just a minute. Um, I will say this though, if your therapist can't tell you things like what your walking speed was on day one, or they can't tell you a score of what your balance level is, if they can't tell you a score of um how much assistance you're actually needing, they they can't actually give you a score um with confidence, um then what's happening is just guessing. And guessing is not going to lead to the best outcomes. So you want to get a baseline. Second, that I the second thing is this is gonna sound really complex, so so stick with me, but it's called minimal detectable change. Now this is a huge piece that you want to be understanding and uh making sure that your therapist can tell you this and that is minimal detectable change. Now, minimal detectable change is the smallest amount of change that we need as a clinician or as a as a uh a surv survivor, but we need to see this small amount of change in order to be confident that what we are doing is actually providing change. So if we don't see that minimal detectable change, um uh for the most part in every situation, then what we are doing isn't enough. And that is that's really important because you can you can more or less rely on that as a way to measure whether or not what you are doing and the effort you're giving and the types of interventions that you're getting, that they actually are providing real change in your life. So, in other words, um there's gonna be there's you know, when you take a test, depending on the time of day, there's you're gonna get slightly different numbers. Okay, and and so it may be like let's say you know you take a test, and the score you get at the beginning of the day is 23. And you know, 23 out of 35. At the end of the day, you take the test and you get a 19. Right? There's gonna be a version that, you know, we're not performing the same in the morning, at the end of the day. It's there's there's a range that we all have uh when it comes to our performance levels. Minimal detectable change is that number that if it goes outside of that, you know that something clinically or significant actually happened. It's it's it starts to be less of a um starts to be less of a, oh, something, you know, like it's a it's a miracle or you know, or like that it's this um random change versus you know what I've actually been doing is officially making real change. So minimal detectable change or MDC is the smallest amount of change you need to see if you want to know if you are improving in your ability. Okay, another word for that is your capacity. So you may get a small improvement, like I just did a test with somebody, and on one of the tests, um the improvement went from a 10 to a 12, and the minimal detectable change was a four. So, what does that tell me? It tells me that what I did um wasn't actually making change, or there was something significant that happened, which actually is the case. The person had a hurt knee, which impacted their ability. So it helps you understand at least how to interpret real change. Because if you're the one that's putting in the work, you want to know if the work that you're putting in actually is making a difference. Now, there are so many different tests, there are tons of standardized assessments. And my job in this in this episode is not to like make you a researcher, not to make it so that you know this, like the back of your hand, but it's more so that you can actually you can be informed, right? You can you can have enough information that you can know what it is that you're looking at. So I'm gonna tell you a couple of different things that if you are working on, you can then ask for this type of test because it actually is designed to measure what it is you're working on. So if you're trying to work on walking faster, then using a test called the 10-meter walk test is going to tell you how fast you're walking and it's very reliable and credible. So if in my sessions I'm trying to increase my speed, but I'm not using a test like the 10-meter walk test, then I'm going to suggest to my therapist, hey, can we do the 10-meter walk test to make sure that I get a baseline of where I'm at now and to see and make sure that I am improving in my speed and that it's being done through an actual test that can help me really measure if the effort I'm giving is really making a difference. Now, here's another one that a lot of people, you know, a lot of people are stroke survivors, therapists that they're working on, and that is walking endurance. So wanting to increase my endurance. Well, one of the best tests for that is called the six-minute walk test, and it's going to tell you how far you can walk in six minutes because endurance is really how long can you keep up a particular speed or effort and timing that. So, how long can you actually keep up that pace? You know, and you know, so for example, you know, how this actually can start coming out in your day is that you know, walking through a store, right? If you need to sit down, you know, after you get halfway through a store, partially and most likely the issue is that you know your endurance needs to improve. Um, getting across a parking lot, making it through a family event without you know needing to sit down. You know, endurance is that piece. Well, you can ask, if that's what you're focusing on, you can ask your therapist to use the six-minute walk test. Now, if you're trying to work on balance, okay, now balance has a couple of different tests. Um, the test that I am going to share with you is a very common test that so many therapists know, and that is called the Berg Balance Scale, B-E-R-G, Berg. And it looks like it looks like or looks at how you are able to stay upright during standing, reaching, turning, uh, stepping, going from one position to another, um, but really in a confined space. And so balance, balance is one of those pieces that so many stroke survivors are working on, and that really um and that really is an easy test that your therapist can do. So if you're working on balance, you should be look you should be asking about the Berg balance scale. And then you should be asking, okay, well, let's do this every week to see if I'm actually improving based on what it is that we're doing. Now, when we're talking about movement while walking and balance while walking, the test that I'm going to suggest that you do is called the functional gait assessment. Now, the functional gait assessment it is one where it starts to challenge you while you're moving in a direction. Otherwise, in other words, it's it's challenging how you're moving while you're walking. So you can ask about the functional gait assessment. And it is a really good evaluation to help you see whether or not you should have any confidence in your ability to walk. Now, many of you are doing you know sit-to-stands. I mean, that's a very, very common intervention that I've seen. Um, not my favorite, but it's something that I've seen. And you can sit there and say, hey, I want to measure how well I'm doing. And you can use the five-time sit-to-stand test. Basically, it is going to evaluate how efficiently and quickly you can stand up and sit down five times in a row. Okay. Very simple, easy to do, can be done very quickly, and that's a good one that you can use as a way to measure whether you're improving in that actual area. Now, you don't need to memorize specific numbers for each of these, um, but you do need to make sure that you're pushing your therapist and challenging your therapist to actually use them. Because then it's no longer just your therapist or your perspective that is your measurement, it's actually what is happening, and it's an objective way to measure, and that can give you a lot of confidence. And the thing that I want you to get is that by looking at these things and knowing these things, you can actually have some understanding or knowledge of what real change should look like. Because I think that's the other piece, right? The other piece is that we're told, and I've said this myself, that change is slow, and we're told that you know it's just a matter of time, and you know, and and although that is true, it's also not true. And I think that it's really important that you as a survivor um can actually identify like and and know what real change should look like. So if you're not getting, so for example, on the Berg balance scale, if you're not getting a change of nine, like a change of nine per week, then whatever you're doing is not enough, and whatever you're doing is not making an impact on your balance. If you're getting a change of two, you don't you don't really know. And in fact, likely it's just that you're showing up differently that day than you did the time before. So knowing those those numbers is really valuable, and your therapist should know. So you can ask your therapist and and in a way challenge your therapist to help you understand and know you know what types of change you should be experiencing based on the objective data. Okay, so that is part one of how you know if what you are doing is working. So now let's transition to the most important section of this entire episode. And that is, you know, even though measurement matters and numbers matter, tests matter, I'm a huge fan of those. The only thing that really matters the most is if change is happening outside of your therapy. Okay, stroke recovery is not just one inside a therapy room, it's actually one in your home, in your kitchen, in your bathroom, on your porch, in your yard, in your community, in the places where life is actually happening. So if you are not seeing change there, there's an issue. So oftentimes the way that it's looked like looked at is that the clinic is like the practice field, and home is the game. Okay, so the clinic is like the practice field. So when you go into therapy, it's like the practice field. But as soon as you leave, you're in the game. The clinic is where you practice, home is where it actually counts. And if your performance only ever shows up in the practice field, then you're not actually playing the game. You're training for a game that you never actually enter. You decide you're gonna sit on the bench. To use a sports metaphor. Now, what I want to you know be careful of is I'm not saying that you know the practice doesn't matter because it does, and practice is essential, repetition is essential, specific drills, specific movements, specific things are are important. But and and you and you can't actually perform if you haven't trained for something, and that's a key right there, is that if you're not training for implementing it into everyday life, then really what happens is the clinic may be increasing some capacity, some capability, but the home that capability isn't being used. So here is what should happen. You go into the clinic, the clinic should push you, your therapist should push you, and should push you to a point where you have had to practice a ton and practice in a way that when you get out, you're not really nervous or scared about trying it when you when you leave, when you no longer are around the therapist. Because that is something that's going to allow for you to actually try it in the game, which really the game that everybody is playing and that you're playing is the game of life, and I think that oftentimes what happens is that as a so stroke survivor, it gets really comfortable, and we're okay with just practicing. And in our mindset, we go, well, I'm not actually going to be in the game of life yet because I'm not ready. And the reality is you're never going to be quote unquote ready. Playing in the game is always going to be a risk and it's always going to be scary. And really that perspective change that you need to start having is that it's okay to play in the game and to try things when you still might make mistakes. And in fact, if you allow yourself, give yourself the permission to play in the game, that is where change is actually going to happen. That's where change is going to actually uh become a part of your life, and that's where plateaus don't exist. A plateau ends up happening very quickly within that first year, typically, because you're unwilling to play the game in life. Hey, this is Dr. Phil. If you're a stroke survivor and you want to regain motor function, improve mobility, and build real confidence in your recovery, then I want you to check out one of my Stroke Survivor Bootcamp training sessions. These are intensive, hands-on experiences designed to push performance, improve function, and help you get back to doing more of what matters in your life. Go to www.stroke survivorboot camp.com and let's get you back on track one step at a time. So I'm gonna I'm gonna talk about something um that I uh it's very it's very critical and it's very specific to occupational therapy. Um but it's something that is really important, especially when we're thinking about this game of life analogy. Um here's the thing. When does something ever feel like it like it becomes normal? I want you to think about that for a second. When does something ever feel like it's become normal? Okay now, I want you to think about what things feel normal. And then what I want you to do is to think about the things that you had to do in order for that to actually happen. Because the reality is, when all is said and done, things will only feel normal after we've gone through the suckiness of trying it again and again and again, away from our therapist and away from safety. Now, that doesn't mean that you don't have somebody with you, that doesn't mean that you don't actually create a safer environment when you're trying it, but anytime you're away from your therapist, it always feels more risky. In a way, you're putting yourself in the game of life. And as we as we allow ourselves this opportunity to get out there and to do something and to be in the game of life, what happens is change. It's like it's a a universal rule that if you actually allow yourself to play in the game of life, change is going to actually happen. But if you don't, then change becomes this elusive thing that you're constantly chasing that you never actually find. And so you have to get into this mindset of being okay with some version of risk, some version of you're going to do this something, whatever it is, whether it's walking more, um, letting go of your cane, going from a hemi walker to a four-point cane, like maybe your therapist just told you that you can, but you feel more comfortable with the other one. Well, again, you're the one that has to make that decision of are you going to play in the game, or are you going to stay being safe in just practice? And so that's that's that's one of those pieces that I want you to I want you to be thinking about and identifying as we go through the remainder of this episode and as you move forward is what areas or what things are you sitting here going, okay, I just want to stay in practice, but I don't want to actually play in the game. So it could be, here's an example, could be that your therapist has been working on transferring from one surface to another. So from the bed to the wheelchair, wheelchair to the bed. And your therapist has said, oh my gosh, you are capable, you've got this. You can do it. And you can do it, but then you get home and everything is set up, it's there, and you decide that you are gonna play the game, and so what you do is you actually try it. And you try it without anybody helping. Now, first time you try it at home, always make sure that you have somebody there so that you can make sure that you're safe. But overall, you try it without them touching you, without them helping you. And as you do that, what will happen is you'll likely fail. I'm gonna repeat that. You didn't hear me wrong. As you actually get in the game after you've been successful in practice, and you try what you've been working on, what will likely happen is you will likely fail.

unknown 41:22

Okay.

SPEAKER_00 41:24

That is normal. So don't get discouraged by that. But the fact that you keep trying it and you keep doing it in the game, and then you say, help me just a little, help me just a little, help me just a little, and you keep trying to figure it out when your therapist is not there, that is power, and that is what's going to actually make it so that you stay away from that scary word of a plateau. Now, in order to identify if therapy is actually helping you, that is one of those pieces. Is therapy helping you have the confidence that you can actually try and play the game? Because if it's not, and it's constantly having you feel scared and that you're not a part, that you can't try this outside of therapy, and that you need your therapist, I'm here to tell you you need to find a different therapist because it's not actually helping you. You should always feel confident, or at least have some inkling of I can try this outside or away from your therapist, whatever it is that you're working on, if that is if therapy is actually truly helping you. So that is another major point that I wanted to make. You have that first, you know, first is like measurement, make sure that it's actually changing. Um, and then the other is how much is it changing and understanding what minimal detectable change is. And then third is do you have confidence that you can actually try what you've been practicing in therapy in your daily life? And if you don't, then I would suggest you need something needs to change. Um, because that is one of the signs of a really good therapist. It's that if you as an individual feel confident that you can practice and try something away from the therapist, then you know that therapist has been doing a good job. Okay, so whether that's changing to a cane from a hemi walker to transfers to taking more steps, you know, those types Of things, all of those, all of those can fall into that into that category. Okay, so those are kind of the three main pieces that I wanted to talk about. Make sure that your therapist is measuring you with actual objective tests. Second, make sure that you understand what is the minimal detectable change with those tests that they're using. So, what is the actual change that you need to be seeing in order to confirm that what you've been doing is actually making a difference? And then third, is do you have confidence of trying something outside of your therapy? I'm thinking about an individual that I that I know and I've gotten to know through TikTok. And um, you know, this individual, you know, I'm watching some of the videos, and I go, man, that person really could be doing more. And then what happened was one day that individual said, I am, I, you know, Dr. Phil, I'm so excited because I actually went up my own stairs. Up and down my own stairs for the first time. I had my I had my friend there, he was he was helping me, but I went up and down. See now that that is when you go, okay, something is happening in the therapy that's actually making a difference. Because now it's happening and performing in everyday life. So that is a huge, huge piece. Okay? So those are the three. Now let's kind of make a transition. I want to talk about Anna. So many of you found me because of Anna. Now, Anna is a hemorrhagic stroke survivor. She um was on TikTok about a year and a half ago from this episode, and she she was on a treadmill and she was walking at one mile per hour, and I just remember sitting there going, man, if I could work with her for two days, I could change her life. That was my thought. So I said, you know what? I'm just gonna reach out, see what happens. So that's what I did. I reached out. And through a bunch of conversations, and I have to give this to Anna because she ultimately said, Okay, I will pay for you to come down. So she got me down to to where she lives, and then went through uh version one of my boot camps. And we did so many crazy things. Stepping up onto really high surfaces, having you know, wearing 20, 30 pound weighted vests, you know, 30 pounds on her hemiproadic leg, and we just pushed. Like we went crazy. And it was awesome. And she it was kind of funny, you know, because what happened was at the end, you know, I had so at the beginning I'd done the I'd done the the tests, like what I was saying. I'd done the measurements. After doing the measurements, we did the interventions, so we practiced, we did stuff, and at the end we did the same measurements. And I asked her, I said, do you feel different? She said no. And yet she had shaved off somewhere around like 10 seconds on her walking speed. She had increased in her balance by the minimal detectable change. There were so many pieces that were showing that she had improved. It was crazy. And and so, you know, I I left. I was again, I was only there for a few days. And I left, and then a few days later, after she got rid of the soreness, she ended up um she ended up getting on the treadmill again and starting at her one mile per hour. And then what happened was she goes, This feels slow. So she kept increasing the speed, increasing it, increasing it until it got to just uh around two to two point one miles per hour. Doubled the speed. And she was shocked. See, that is an example of what I'm talking about. In order for you to un know if your therapist or therapy that you're getting is actually good therapy, you need to have moments like that. That's like, okay, I just I've been working with this individual and I've been doing these things. And then in real life, when nobody else is around, when the stakes are high, do you actually try it? And do you see improvement? If you do, then what you're doing is valuable. It's worth it. Keep going. You found yourself a good one. If it's not, then it's time to question. And you can go back to previous episodes, you know, to find out some of those those same things, the you know, some of those things of where you can start, how you can start getting your therapists to, you know, to push your intensity, because intensity is really valuable. You can share with them the podcast, you know, so they can go through and find out, you know, how to actually prevent a plateau from happening. They can come and train with me. And that is something that you you know that that can happen. But if you're if you don't actually see that change, like what Anna did, then you can with confidence say what I'm doing and what I did, it it actually isn't it hasn't been valuable. And it's not actually worth the amount of effort and time that I'm putting in, and I need I need a change. Whether it's you change therapist or your therapist changes strategy and they they change what they do. Now we all have there's certain things that get in the way, right? I talked about earlier that you know somebody I was working with hurt her knee. Like uh, you know, like a runner, uh runner's knee type thing. It happens. That is definitely going to impact, right? That is definitely definitely going to be something that changes, you know, everything about how the individual um about how they're gonna perform. So if if if something like that happens, it's not like I wouldn't blame your therapist. That's that's the body that it just is having a hard time with cooperating. So if the body is doing okay and it's not injured, then yeah, that's that's where you would apply all this. So let's kind of let's I I want to introduce what I call the survivor's therapy scorecard. So after every therapy session, you should be able to ask yourself these seven questions. So here you go. Question one: what are we working on? So if you can't name the target, you can't you can't actually judge the plan, you can't judge whether it was valuable, and likely it wasn't valuable, but there's no way for you to actually measure. So you yourself need to be able to say out loud in your own words what you are trying to improve. Like what is the effort that you're doing, what is it actually working towards? Question two, why does this matter to my life? So every activity, every session, everything that you do should connect back to something meaningful in your real life. If you cannot make that connection, then either you need to change and do something different, or you need to ask your therapist to help make that connection for you, or you need to ask somebody else to help you with that. But that is a huge piece. Number three, what are we measuring? That you need to be able to answer. Am I measuring speed, endurance, balance, transfers, arm use, stares, fatigue, opening of my hand, straining my elbow, my confidence? Am I participating? Am I doing something outside of the clinic? Whatever it is, you need to know what it is you are measuring and measure it. Question four. What was my baseline? Where did I actually start? What was the number on day one? And if you don't know it, ask your therapist. If your therapist doesn't know it, figure out what it is today. Because that is critical. Question five. How much have I changed? So what is different now compared to where you started? Not how do you feel, not what you think, but what can you actually show for the effort and work that you've put in? If you are still the same, then what you are doing is not working. Now question six, is the change bigger than normal measurement error? So did that you actually improve enough that it it's actually real based on what you've been doing? Or is it just that you're looking at a good day? That's called minimal detectable change. And then question seven, and this is the biggest question of all that you should be able to answer. What am I doing at home now because of what I'm doing here in therapy? So let me repeat that. What am I doing at home now because of what I'm doing in therapy? If you cannot answer that one, there's a disconnect, and the therapy is likely not actually benefiting you and helping you in the long run. It needs to be something that has improved and is happening in everyday life. Okay. So after your next session, try this. Run those seven questions. Make sure that you're honest. If most of them have clear answers, then you're you you likely have a good therapist and you have a good plan. But if most of them are blank, then it's time for you to have a s uh conversation with your therapist. Okay. Now, what if your therapist gets defensive when you ask about different measurements? Well, first and foremost, um you need to find a different therapist. If they're getting defensive over you asking questions about measurements, that's not a therapist that you want. Find a different one. And that's okay. It's not personal, it's that this one is not actually there to help you. Uh what if there's no numbers that are being tracked at all? You should ask for some. You should ask. You can say something like, Can we can we get a baseline or something so that we know whether the plan that we're on is working? And most therapists are willing to do this, they just feel like they have some they have so little time and they choose something else. But if you, as the person who is the consumer, ask for it, ah, that's gonna get changed. Um now, what if you're making progress in therapy but nothing is different at home? Okay, this is the biggest one that most people experience. And that is that there is a difference in how you are training, and that you're not actually training to do it at home. You're not training to play at home, you're not training to play in the game, you're training just to improve. So you need to ask your therapist to start having you actually train like it's happening in real life instead of just increasing a capacity. So actually doing something in the way at home, you know, and something that you can do when you're trying to perform. And then the last question I want to go over is am I being a difficult patient if you ask these types of questions? And that can be interpreted as yes. I'm gonna interpret it as no. Well, I'm gonna interpret it as you are engaged and that you care and are taking charge of your future. And if somebody doesn't see that, time to find a different person. And again, that is okay because even if you like the individual, if you they are not doing these things, then likely they're not they're not a good therapist for you. So, the tough truth of the week that I'm going to share with you is that if you are not measuring, you don't know the numbers, you are not seeing change at home. Even if you love your therapist, it's time to get a new one. That's the tough truth of the week. Or, other than getting a new one, it's time to demand that that therapist pushes you in a different way. And if they're having a hard time coming up with ideas, send them my way. I'm more than happy to help. So before you go, I want to give you something to do this week. So after your next therapy session, ask one question. That is, what is one thing I can safely trial at home this week because of what we practice today? One thing safely and at home. And it needs to be connected to what just happened in your session. Then I want you to do it. Make sure you have the right support if it's something like walking and you're not confident in walking, and you still have a little bit of balance stuff. But make sure you make sure you have somebody right there. But make sure you do it. So here's some examples. I'm gonna stand at the counter while making my own coffee. I'm gonna walk one lap around the house after lunch, and then every 20 minutes thereafter. I'll practice standing for my actual recliner five times. I'll use my affected hand, my hemiproadic hand, to stabilize my plate at dinner. Even if I don't have full movement, I'm gonna make sure that it's there and that it's visual visual and it's a part of what I'm doing. I'm gonna walk to the mailbox and get my own dang mail. I'm gonna make sure somebody's with me, but I'm gonna go and do that. I'll practice one stare at a time, alternating steps. I'm gonna make sure somebody is right there and that they've been trained. I'll stand in the sink while brushing my teeth. Easy one, guys. Easy easy. I'll step outside onto uneven ground with supervision. Those are just some good or with supervision. Those are some good examples that you can do. Pick one, just one, and do it. Do it multiple times this week until your next session. That is critical. Not I'm gonna do a home exercise program, I'm gonna do my stretches, I'm gonna do my exercises. Let go of that, get rid of that. That just that is not valuable. What is valuable is picking something that you've worked on and doing it throughout your week. Now that is kind of the loop that most people find themselves in. I go to the clinic, I go home, I adjust by playing in the game, and then I come back to the clinic and I practice more with what I've found as I try to play in the game. And for you clinicians that have been listening, take one patient this week and end the session with a clear home experiment. Not an exercise program, but an experiment. A specific, named trial that they can do safely this week. Because of what you actually practiced and focused on during your session. Actually have them show you how they will do it at home. And just make sure that they understand what they need to be looking out for. Tell them what to what you're gonna ask when they come back and what they need to report. Implementing that can greatly enhance your outcomes of your clients. And guys, you survivors deserve more than just vague encouragement. You deserve a specific plan, you deserve measurement, you deserve therapy that transfers into the life you're fighting to actually reclaim. And if therapy is working, your world should start getting bigger. Don't not just ask, am I getting better in therapy? Ask what am I doing in life now because of therapy? That is the question that changes everything. That is the work, and the work is worth it if you actually see change. Now guys, I'm Dr. Phil. I love getting to show up every week and talking to you and with you here on this podcast. I have some awesome things that are in the works that I am excited to share. And just remember, all that it really takes is one step at a time. I'm Dr. Phil, and this is Stroke Survivor Bootcamp. Breathe in.

SPEAKER_04 1:02:13

Count it out. Every scar is around.