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Practice, Practice

Vol. 24 •Issue 8 • Page 21
Practice, Practice

Rewiring the brain after stroke can be surprisingly straightforward

Neuroplasticity is based on a surprisingly intuitive concept: To learn how to move better, you have to practice. Babies understand this idea. So do animals. And it forms the unequivocal bedrock of modern stroke recovery therapies.

The human brain is comprised of 100 billion neurons just waiting to be activated to accomplish a given task. Most of the current techniques, modalities and exercises used in stroke recovery "work" to a certain degree, and are considered nominally effective by researchers.

These methods work because they leverage the neuroplasticity of the brain. Studies show that the human brain can be dramatically reconfigured within a short period of time. Alvaro Pascual-Leone, MD, PhD, associate professor of neurology at Harvard Medical School, has demonstrated that subjects who are blindfolded for 100 hours and taught to read Braille show that fingertip sensory representation moves and expands into the visual cortex of the brain, where visual stimulation is processed.

Robbed of visual input, these subjects effectively learn to "see" with their fingertips, which indicates that portions of the brain begin to reconfigure after just 100 hours. This capacity for rapid neuroplastic change is also attainable in the area of the brain that controls movement.

Practice Makes Perfect?

How can rehab therapists harness this power for post-stroke patients? The concept of massed practice makes up an essential component of neuroplastic change. Specific movements are practiced for many hours at a time, during a relatively short duration (usually 2-3 weeks).

However, typical rehab settings tend to treat patients on a "distributed practice" schedule—smaller bouts (15 minutes to two hours) over a longer duration (several months). Therapists believe a stroke weakens patients so much that they need time to recover between sessions. Insurance companies agree, and it has become the prominent mode of delivery.

But current research indicates massed practice promotes greater recovery after a stroke. Massed practice is the foundation of strategies such as constraint-induced therapy, in which patients repeat tasks with the affected extremity. These formulations have opened the floodgates of a new perspective on stroke therapy.

Put simply, the concept holds that more is better: more resistance, repetitions, speed, duration. Therapists set the stage for stroke survivors to drive their own nervous system toward the massive neuroplastic changes necessary to recover fully.

A hallmark of traditional neurorehabilitation has been the disallowing of synergistic movement. If a patient requires a therapist to physically discourage synergistic movement, his resources expire before he can begin a massed practice program. Therefore, it's essential to encourage stroke survivors to use available movement on their own to increase motor control.

There are obvious difficulties with scheduling massed practice in hospitals, skilled nursing facilities and outpatient settings. Available staff, clinic space and insurance coverage are at a constant premium.

But there are ways around these problems. Strategies, such as modified constraint-induced therapy (mCIT) programs that incorporate home "assignments" as well as rehab sessions with therapists, allow a patient to benefit from massed practice with fewer resources. An mCIT protocol is simply one means of vectoring massed practice in a sensible, reimbursable way. Therapists can modify other treatment plans to fit the needs of specific populations.

Three Universal Truths

As cliché as it sounds, every stroke is different. The location of the damage causes radically different sequelae from person to person. Plus, stroke survivors have various levels of motivation and resources. Each patient is in a different phase of recovery, with different therapeutic goals.

However, there are many universal truths that hold across the spectrum of stroke care. Sticking to these established principles adds value to a patient's treatment plan, no matter where he is in the recovery process.

Forget the plateau. Athletes use this term to describe how their bodies adapt to specific training techniques. They see a plateau as a necessary step toward getting better—a temporary period to re-evaluate and recalibrate an exercise program.

Clinicians have applied the termto describe a never-ending state of entropy. The word "plateau" carries the unfortunate connotation that the stroke survivor is on a downward slide. Often this phenomenon is more a result of limited treatment options and insurance dollars than the patient's real potential for recovery.

View patients as athletes. Stroke-related rehab research has concluded the same principles athletes use for sports performance can help stroke survivors recover the ability to move. For instance, repetitive, task-specific massed practice forms the foundation of many rehab strategies, such as mCIT, bodyweight-supported treadmill training and robot-assisted exercise. Muscle strengthening, cardiovascular training, mental practice and stretching works for athletes, and it can work for stroke patients.

Develop a plan. Most stroke survivors don't have a plan. Therapists chart a therapy protocol with specific goals during an inpatient stay, but that plan doesn't last forever. Once discharged, stroke survivors tend to drift. Instead of aspiring for higher gains, they focus on staying independent and hope to maintain what they've already recovered.

Treat this time as a new chapter in a patient's recovery. This helps ensure people maintain independence and continue to improve. There are proven strategies to help achieve this mindset.

First, use the power of metrics—measurable benchmarks. Gains made in the chronic period after stroke can be modest and hard to see, so strive for specific goals to demonstrate progress and motivate patients. If a patient wants to walk 500 yards in several months, map out a 500-yard route. Break down the total goal into incremental gains, such as every 50 yards. Also, teach patients to be driven and motivated. For recovery to continue beyond discharge, patients must be self-reliant and drive their own therapy. People must understand how to progress training as they move toward goals, such as increasing the duration or quality of performance of a desired activity.

Flexibility is key. The overwhelming amount of new stroke research means a patient and rehab team must adapt to incorporate new strategies into the care plan. As patients progress, their recovery picture evolves. By expanding expectations, patients can strive toward higher levels of recovery.

Peter Levine, BA, PTA, is co-director of the neuromotor recovery and rehabilitation laboratory at Drake Center, under the auspices of the department of rehabilitation sciences at the University of Cincinnati in Ohio. He can be reached at


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