Post-Stroke Motor Recovery and Neuroplasticity

Stroke is one of the most common diagnoses encountered in rehabilitation. A common deficit experienced by individuals with stroke is hemiparesis and a large amount of time in therapy is spent on motor rehabilitation.^1,2

Therapy-Induced Neuroplasticity

In the mid-1990s, Nudo and colleagues³ clearly showed that motor rehabilitation was critical for facilitating improvements in motor control after stroke and that this improvement was associated with therapy-induced neuroplasticity in the motor system.

The remaining questions are – what the motor rehabilitation should look like, how much should be provided, when it should be provided, and what the schedule should be. Although limited research has looked into these questions, some studies have shed light on a flurry of intervention development and when therapy should be provided.

Most research suggests motor rehabilitation should begin early, but no intervention approach stands out clearly above the others. What is clear, instead, is that motor rehabilitation needs to conform to basic principles for facilitating neuroplasticity that have been discovered based on basic animal research. Principles of neuroplasticity include: use it or lose it, repetition, practice early, practice skilled tasks, and attend to the practice.⁴

Use It or Lose It

After stroke, individuals tend to rely on their nonparetic limb, excluding the paretic limb. When the paretic limb is not used, its neural representation shrinks and its ultimate recovery is delayed.^3,5 If the paretic limb is used at least some of the time, it appears that the reduction in recovery is not experienced.⁶ Therefore, all individuals with stroke should be encouraged to use their paretic limb, if possible.

Repetition

Promoting neuroplasticity and improving motor function takes repetitive practice. Practice that provides too few repetitions fails to promote neuroplasticity and reduces long-term motor gains.^7,8 Because current therapy is limited in the amount of time that can be spent with a client and only on motor rehabilitation, therapists should develop strategies to assist clients with practice on their own.

Practice Early

The largest gains in motor recovery are experienced when motor rehabilitation begins early after stroke.⁹Thus, as early as possible, individuals with stroke should engage in motor rehabilitation. However, it is not clear how early the therapist should introduce intensive motor practice. Some studies have found increases in lesion size and reduced motor recovery with intense repetitive practice compared to more moderate practice in early rehabilitation.^{10, 11}

Practice Skilled Tasks

Motor practice should consist of skilled task practice that is challenging. Practicing simple movements – that are already easily accomplished – does not facilitate neuroplasticity.⁸

Attend to the Practice

Lastly, individuals with stroke need to pay attention to what they are practicing, at least early in the training, as distraction results in less neuroplasticity.¹² Therapists should reduce conversation with the individual during practice and remove distractions from the therapy environment.

Thus, as current evidence cannot definitively establish the best interventions for promoting neuroplasticity and motor recovery, therapists should choose an approach consistent with the principles of neuroplasticity: the early use of the paretic limb, a lot of repetitive practice (although perhaps more moderate amounts of repetition very early), practice of skilled tasks, and minimal distractions during practice.