Improving poststroke recovery: Neuroplasticity and task-oriented training


Opinion statement

Neurorehabilitation is a critical part of the overall process to achieve optimal outcome after stroke. Presently, the field of neurorehabilitation is in transition. New research suggesting novel approaches to optimize functional recovery after stroke is on the horizon, but clear knowledge of the underlying mechanisms of this recovery is still being unraveled. In practice, many rehabilitation centers continue to provide traditional compensatory rehabilitation training while many others are practicing newer, “task-oriented” approaches. A few centers are incorporating new technology, such as computer-based training devices or robotics, into rehabilitation care. This transition is happening because neuroscientific research has shown that neuroplastic changes in the cerebral cortex and in other parts of the central nervous system (CNS) are necessarily linked to motor skill retraining in the affected limbs. Task-oriented training that focuses on the practice of skilled motor performance is the critical link to facilitating neural reorganization and “rewiring” in the CNS. Therefore, whenever possible, task-oriented training at an intense level should be incorporated into the rehabilitation program of any patient with stroke-related motor deficits. Two such task-oriented therapies that should be available at all neurorehabilitation centers are constraint-induced movement therapy and body weight-supported treadmill training. The optimal intensity of training (frequency and duration) is still not clear but is certainly greater than that available in clinical programs. Therefore, the incorporation of automated training devices will be necessary in the future. However, the engineering necessary to make these devices effective, easy to use, affordable, and portable remains a challenge for the next decade of neurologic bioengineering research.


Motor Learning Chronic Stroke Arch Phys Treadmill Training Body Weight Support 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Rosamond W, Flegal K, Furie K, et al.: Heart disease and stroke statistics-2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008, 117:e25–e146.PubMedCrossRefGoogle Scholar
  2. 2.
    Reding MJ, Potes E: Rehabilitation outcome following initial unilateral hemispheric stroke. Stroke 1988, 19:1354–1358.PubMedGoogle Scholar
  3. 3.
    Kwakkel G, Kollen BJ, van der Grond J, Prevo AJH: Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke 2003, 34:2181–2186.PubMedCrossRefGoogle Scholar
  4. 4.
    Edgerton VR, Tillakaratne NJK, Bigbee AJ, et al.: Plasticity of the spinal neural circuitry after injury. Ann Rev Neurosci 2004, 27:145–167.PubMedCrossRefGoogle Scholar
  5. 5.
    Nudo RJ, Milliken GW, Jenkins GW, Merzenich MM: Use-dependent alterations of movement representations in primary motor cortex of adult squirrel monkeys. J Neurosci 1996, 16:785–807.PubMedGoogle Scholar
  6. 6.
    Rosenkranz K, Kakar A, Rothwell JC: Differential modulation of motor cortical plasticity and excitability in early and late phases of human motor learning. J Neurosci 2007, 27:12058–12066.PubMedCrossRefGoogle Scholar
  7. 7.
    Wolpaw JR, Tennissen AM: Activity-dependent spinal cord plasticity in health and disease. Ann Rev Neurosci 2001, 24:807–843.PubMedCrossRefGoogle Scholar
  8. 8.
    Winstein CJ, Wolf SL: Task-oriented training to promote upper extremity recovery. In Stroke Recovery and Rehabilitation. Edited by Stein J, Harvey RL, Macko RF, et al. New York: Demos Medical; 2008:267–290.Google Scholar
  9. 9.
    Nudo RJ: Postinfarct cortical plasticity and behavioral recovery. Stroke 2007, 38:840–845.PubMedCrossRefGoogle Scholar
  10. 10.
    Hebb DO: The Organization of Behavior. New York: Wiley; 1949.Google Scholar
  11. 11.
    Bliss TVP, Collingridge GL: A synaptic model of memory: long-term potentiation in the hippocampus. Nature 1993, 361:31–39.PubMedCrossRefGoogle Scholar
  12. 12.
    Bliss TVP, Lomo T: Long-lasting potentiation of synaptic transmission in the dentate area of the anaesthetized rabbit following stimulation of the perforant path. J Physiol 1973, 232:331–356.PubMedGoogle Scholar
  13. 13.
    Hess G: Synaptic plasticity of local connections in rat motor cortex. Acta Neurobiol Exp (Wars) 2003, 63:271–276.Google Scholar
  14. 14.
    Monofils MH, VandenBerg PM, Kleim JA, Teskey GC: Long term potentiation induces expanded movement representations and dendritic hypertrophy in layer V of rat sensorimotor neocortex. Cerebral Cortex 2004, 14:586–593.CrossRefGoogle Scholar
  15. 15.
    Kleim JA, Barbay S, Cooper NR, et al.: Motor learning-dependent synaptogenesis is localized to functionally reorganized motor cortex. Neurobiol Learning Mem 2002, 77:63–77.CrossRefGoogle Scholar
  16. 16.
    Nudo RJ, Milliken GW: Reorganization of movement representations in primary motor cortex following focal ischemic infarcts in adult squirrel monkeys. J Neurophysiol 1996, 75:2144–2149.PubMedGoogle Scholar
  17. 17.
    Taub E, Miller NE, Novack TA, et al.: Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 1993, 74:347–354.PubMedGoogle Scholar
  18. 18.
    Taub E, Uswatte G, King DK, et al.: A placebo-controlled trial of constraint-induced movement therapy for upper extremity after stroke. Stroke 2006, 37:1045–1049.PubMedCrossRefGoogle Scholar
  19. 19.
    Wolf SL, Winstein CJ, Miller JP, et al.: Effect of constraint-induced movement therapy on upper extremity function 3–9 months after stroke: The EXCITE randomized clinical trial. JAMA 2006, 296:2095–2104.PubMedCrossRefGoogle Scholar
  20. 20.
    Sterr A, Elbert T, Berthold I, et al.: Longer versus shorter daily constraint-induced movement therapy of chronic hemiparesis: an exploratory study. Arch Phys Med Rehabil 2002, 83:1374–1377.PubMedCrossRefGoogle Scholar
  21. 21.
    Dettmers C, Teske U, Hamzei F, et al.: Distributed form of constraint-induced movement therapy improves functional outcome and quality of life after stroke. Arch Phys Med Rehabil 2005, 86:204–209.PubMedCrossRefGoogle Scholar
  22. 22.
    Page SJ, Sisto S, Levine P, McGrath RE: Efficacy of modified constraint-induced movement therapy in chronic stroke: a single blinded randomized control trial. Arch Phys Med Rehabil 2004, 85:14–18.PubMedCrossRefGoogle Scholar
  23. 23.
    Dromerick AW, Edwards DF, Hahn EM: Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke? Stroke 2000, 31:2984–2988.PubMedGoogle Scholar
  24. 24.
    Cauraugh JH, Light K, Kim S, et al.: Chronic motor dysfunction after stroke: recovering wrist and finger extension by electromyography-triggered neuromuscular stimulation. Stroke 2000, 31:1360–1364.PubMedGoogle Scholar
  25. 25.
    Kimberely TJ, Lewis SM, Auerbach EJ, et al.: Electrical stimulation driving functional improvements and cortical changes in subjects with stroke. Exp Brain Res 2004, 154:450–460.CrossRefGoogle Scholar
  26. 26.
    de Kroon JR, van der Lee JH, Ijzerman MJ, Lankhorst GJ: Therapeutic electrical stimulation to improve motor control and functional abilities of the upper extremity after stroke: a systematic review. Clin Rehabil 2002, 16:350–360.PubMedCrossRefGoogle Scholar
  27. 27.
    Alon G, Ring H: Gait and hand function enhancement following training with a multisegment hybrid orthosis stimulation system in stroke patients. J Stroke Cerebrovasc Dis 2003, 12:209–216.PubMedCrossRefGoogle Scholar
  28. 28.
    Popovic DB, Popovic MB, Sinkjaer A, Schwirtlich L: Therapy of paretic arm in hemiplegic subjects augmented with a neural prosthesis: a cross-over study. Can J Phys Pharm 2004, 82:749–756.CrossRefGoogle Scholar
  29. 29.
    Dunning K, Berberich A, Albers B, et al.: A four-week, task-specific neuroprosthesis program for a person with no active wrist or finger movement because of chronic stroke. Phys Ther 2008, 88:397–405.PubMedGoogle Scholar
  30. 30.
    Stein J, Hughes R, Fasoli SE, et al.: Technological aids for motor recovery. In Stroke Recovery and Rehabilitation. Edited by Stein J, Harvey RL, Macko RF, et al. New York: Demos Medical; 2008.Google Scholar
  31. 31.
    Fasoli SE, Krebs HI, Stein J: Effects of robotic therapy on motor impairment and recovery in chronic stroke. Arch Phys Med Rehabil 2003, 84:477–482.PubMedCrossRefGoogle Scholar
  32. 32.
    Volpe BT, Krebs HI, Hogan N, et al.: A novel approach to stroke rehabilitation: robot-aided sensorimotor stimulation. Neurology 2000, 54:1938–1944.PubMedGoogle Scholar
  33. 33.
    Lum PS, Burgar CG, Shor PC, et al.: Robot-assisted movement training compared with conventional therapy techniques for the rehabilitation of upper-limb motor function after stroke. Arch Phys Med Rehabil 2002, 83:952–959.PubMedCrossRefGoogle Scholar
  34. 34.
    Kahn LE, Lum PS, Rymer WZ, Reinkensmeyer DJ: Robot assisted movement training for the stroke-impaired arm: does it matter what the robot does? J Rehab Res Dev 2006, 43:619–630.CrossRefGoogle Scholar
  35. 35.
    Hesse S, Werner C, Pohl M, et al.: Computerized arm training improves the motor control of the severely affected arm after stroke: a single blinded randomized trial in two centers. Stroke 2005, 36:1960–1966.PubMedCrossRefGoogle Scholar
  36. 36.
    Sanchez RJ, Liu J, Rao S, et al.: Automating arm movement training following severe stroke: functional exercises with quantitative feedback in a gravity-reduced environment. IEEE Trans Neural Syst Rehabil Eng 2006, 14:378–389.PubMedCrossRefGoogle Scholar
  37. 37.
    Kautz SA, Brown DA: Relationships between timing of muscle excitation and impaired motor performance during cyclical lower extremity movement in post-stroke hemiplegia. Brain 1998, 121:515–526.PubMedCrossRefGoogle Scholar
  38. 38.
    Knutsson E, Richards C: Different types of disturbed motor control in gait of hemiparetic patients. Brain 1979, 102:405–430.PubMedCrossRefGoogle Scholar
  39. 39.
    Finch L, Barbeau H: Hemiplegic gait: new treatment strategies. Physiother Can 1985, 38:36–41.Google Scholar
  40. 40.
    Hesse S, Bertelt C, Schaffrin A, et al.: Restoration of gait in nonambulatory hemiparetic patients by treadmill training with partial body-weight support. Arch Phys Med Rehabil 1994, 75:1087–1093.PubMedCrossRefGoogle Scholar
  41. 41.
    Grillner S, Wallen P: Central pattern generators for locomotion, with special reference to vertebrates. Ann Rev Neurosci 1985, 8:233–261.PubMedCrossRefGoogle Scholar
  42. 42.
    Hesse S, Bertelt C, Jahnke MT, et al.: Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients. Stroke 1995, 26:976–981.PubMedGoogle Scholar
  43. 43.
    Sullivan KJ, Brown DA, Klassen T, et al.: Effects of taskspecific locomotor and strength training in adults who were ambulatory after stroke: results of the STEPS randomized clinical trial. Phys Ther 2007, 87:1580–1602.PubMedGoogle Scholar
  44. 44.
    Visintin M, Barbeau H, Korner-Bitensky N, Mayo NE: A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. Stroke 1998, 29:1122–1128.PubMedGoogle Scholar
  45. 45.
    Lindquist ARR, Prado CL, Barros RML, et al.: Gait training combining partial body weight support, a treadmill, and functional electrical stimulation: effects on poststroke gait. Phys Ther 2007, 87:1144–1154.PubMedGoogle Scholar
  46. 46.
    Husemann B, Muller F, Krewer C, et al.: Effects of locomotion training with assistance of a robot-driven gait orthosis in hemiparetic patients after stroke: a randomized controlled pilot study. Stroke 2007, 38:349–354.PubMedCrossRefGoogle Scholar
  47. 47.
    Hornby TG, Campbell DD, Kahn JH, et al.: Enhanced gait-related improvements after therapist-versus roboticassisted locomotor training in subjects with chronic stroke: a randomized controlled study. Stroke 2008, 39:1786–1792.PubMedCrossRefGoogle Scholar
  48. 48.
    Luft AR, Macko RF, Forrester LW, et al.: Treadmill exercise activates subcortical neural networks and improves walking after stroke: a randomized controlled trial. Stroke 2008, 39:3341–3350.PubMedCrossRefGoogle Scholar
  49. 49.
    Pohl M, Mehrholz J, Ritschel C, Ruckriem S: Speed-dependent treadmill training in ambulatory hemiparetic stroke patients: a randomized controlled trial. Stroke 2005, 33:553–558.CrossRefGoogle Scholar
  50. 50.
    Harvey RL: Motor recovery after stroke: new directions in scientific inquiry. Phys Med Rehabil Clin N Am 2003, 14:S1–S5.PubMedGoogle Scholar
  51. 51.
    Taub E, Uswatte G, Morris DM: Improved motor recovery after stroke and massive cortical reorganization following constraint-induced movement therapy. Phys Med Rehabil Clin N Am 2003, 14:S77–S91.PubMedGoogle Scholar
  52. 52.
    Winstein CJ, Pohl PS, Lewthwaite R: Effects of physical guidance and knowledge of results on motor learning: support for the guidance hypothesis. Res Q Exerc Sport 1994, 65:316–323.PubMedGoogle Scholar
  53. 53.
    Cirstea MC, Levin MF: Improvement of arm movement patterns and endpoint control depends on type of feedback during practice in stroke survivors. Neurorehabil Neural Repair 2007, 21:398–411.PubMedCrossRefGoogle Scholar

Copyright information

© Current Medicine Group, LLC 2009

Authors and Affiliations

  1. 1.Stroke Rehabilitation CenterThe Rehabilitation Institute of ChicagoChicagoUSA

Personalised recommendations