Conventional Stroke PT vs. Neuroplasticity

Up to about a decade ago, most stroke rehabilitation was based on the premise that any functional recovery after stroke was pretty much beyond the control of the therapist or the patient. Recovery of function like speech and walking was attributed to reduction of swelling and inflammation in the area of the stroke. At six to twelve months post-stroke, the process of spontaneous recovery was perceived to end, and the patient’s ability at that point was believed permanent. Today, we know recovery needn’t end there.


Neuroplasticity describes the ability of the brain to effectively “rewire” itself around areas lost by stroke. By guided effort, therapists can help patients “teach” areas of the brain not ordinarily used for walking and arm movement to take over. Until recently, scientists were largely unaware of this brain capability, but now, it is recognized as the most important aspect of post-stroke rehabilitation.

For a rehabilitation exercise to support neuroplasticity, it must provide three essential characteristics:

  • Intention The patient must initiate the movement, and actively participate in the exercise. If therapists perform the movement for the patient, there is no neuroplasticity benefit.
  • Intensive The exercise or activity must demand the patient work hard – put in maximum effort to accomplish the task. If patient effort is largely handled by a therapist or robotic machine, the neuroplasticity benefit is minimal.
  • Repetition. The patient must repeatedly perform the intention-initiated, intensive exercise. Repetition “bakes in” the education of brain and muscles.

Conventional gait therapy.

Many clinics today rehabilitate patients much as they did 20-30 years, before the principles of neuroplasticity were appreciated. Conventional therapy involves several PTs supporting the patient and moving the patient’s affected leg. The therapists avoid the need for the patient to apply weight to, or initiate movement, of the affected leg. Because this technique quickly exhausts therapists and places both them and it patient at risk for a fall, two forms of technology are routinely used in many clinics.

  • Body weight support treadmill therapy (BWSTT) – patients are suspended over a treadmill, and therapists seated at treadmill-track level attempt to move the patient’s affected foot in a simulation of normal gait – the PTs move the affected leg, and the patient moves the unaffected leg.
  • Robotic BWSTT. Similar to BWSS, except a robotic machine moves both the patient’s affected and unaffected leg.

Both techniques evolved from research on spinal cord injured animals and humans, whose injuries caused bilateral (both legs) loss of function. In both spinal cord injured and stroke patients, the results of BWSTT have been mixed.

The reason? – while both techniques allow considerable repetition, in both, therapists or robots initiate the effort and minimize the intensity of effort the patient must apply. The overhead suspension of BWSTT blunts the development of many balance instincts. And since both are limited to walking on treadmills, the patient develops no experience handling surfaces or stairs.