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European Journal of Physiotherapy
ISSN: 2167-9169 (Print) 2167-9177 (Online) Journal homepage: http://www.tandfonline.com/loi/iejp20
Neuroplasticity in action post-stroke: Challenges
for physiotherapists
Gunilla E. Frykberg & Rajul Vasa
To cite this article: Gunilla E. Frykberg & Rajul Vasa (2015) Neuroplasticity in action post-
stroke: Challenges for physiotherapists, European Journal of Physiotherapy, 17:2, 56-65, DOI:
10.3109/21679169.2015.1039575
To link to this article: http://dx.doi.org/10.3109/21679169.2015.1039575
Published online: 28 Apr 2015.
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Correspondence: Gunilla Elmgren Frykberg, RPT, PhD, Department of Neuroscience/Rehabilitation Medicine, Uppsala University, SE-751 85 Uppsala,
Sweden. Tel: ⫹ 46 18 611 28 75. E-mail: gunilla.elmgren.frykberg@neuro.uu.se
(Received 15 December 2014 ; accepted 6 April 2015 )
and urgently needed in order to develop strategies
for therapy-induced recovery (4 – 7).
Furthermore, two fundamental questions with
respect to different motor control theories, namely
“ What is being controlled? ” and “ How are these pro-
cesses organized? ” , posed in the 1960s (8), have still
not been answered. In addition, if and how central
concepts such as self-organization of dynamic bio-
logical systems, non-linearity and movement vari-
ability from one recently developed motor control
theory, the dynamic systems theory (DST) (9,10),
might be integrated into the development of effective
physiotherapeutic interventions post-stroke is still an
open question. Altogether, the above implies that
new questions need to be asked addressing clinical
as well as research issues for physiotherapists in
the areas of recovery versus compensation, neuro-
plasticity post-stroke and the state of the art of
REVIEW ARTICLE
Neuroplasticity in action post-stroke: Challenges for physiotherapists
GUNILLA E. FRYKBERG
1
& RAJUL VASA
2
1
Department of Neuroscience/Rehabilitation Medicine, Uppsala University, Sweden, and
2
Rajul Vasa Foundation, Center for
Brain and Spinal Injury Rehab, Mumbai, India
Abstract
Knowledge regarding neuroplasticity post-stroke is increasingly expanding. In spite of this, only a few physiotherapy
interventions have been able to demonstrate effectiveness in achieving recovery of lost sensorimotor control. The aims of
this review article are to highlight and discuss challenges for physiotherapists working with patients post-stroke, to question
some current assessment methods and treatment approaches, and to pose critical questions indicating a possible new direc-
tion for physiotherapists in stroke rehabilitation. Differentiation between recovery and compensation post-stroke is increas-
ingly being emphasized. Implementation of this goal in the clinic is insuffi cient, with a lack of assessment tools with
potential to discriminate between the concepts. Large-scale reviews are performed without considering whether functional
gains are achieved through “ more effective ” compensatory strategies or through recovery. Cortical plasticity in neuroreha-
bilitation research and voluntary control in contemporary treatment methods are in focus. Challenges for physiotherapists
in stroke rehabilitation consist of rethinking, including looking upon the body under the infl uence of gravity, focusing on
implicit factors that impact movement control and developing new assessment tools. The introduction of a new assessment
and treatment concept aiming at expanding the boundaries of center of mass movements towards the paretic side is pro-
posed. In conclusion, we need to assume our responsibilities and step forward as the experts in movement science that we
have the potential to be.
Key words:
Biomechanics , motor control , neurology , rehabilitation
Introduction
In the clinic, we observe people affl icted by stroke
compensating with the non-paretic side of the body
to reach everyday goals. We, as physiotherapists,
support the patient in using the paretic side, aiming
for true recovery of mobility and selective voluntary
control in the process of rehabilitation. However,
compensatory movement strategies are often noticed
as a result.
From the research point of view, in spite of an
increasing amount of research regarding recovery
versus compensation [e.g. (1)] and neuroplasticity
post-stroke [e.g. (2)], this new knowledge has yet not
resulted in evidence-based physiotherapy interven-
tions with proven effects on recovery of lost senso-
rimotor function (3). It is argued that an in-depth
understanding of the underlying mechanisms behind
recovery and compensation post-stroke is still lacking
European Journal of Physiotherapy, 2015; 17: 56–65
ISSN 2167-9169 print/ISSN 2167-9177 online © 2015 Informa Healthcare
DOI: 10.3109/21679169.2015.1039575
Downloaded by [Uppsala universitetsbibliotek] at 07:36 30 October 2015
Neuroplasticity in action post-stroke 57
non-paretic hand, reaching for objects with atypical
movement patterns and walking with specifi c gait
deviations. These atypical movement strategies were
described as early as the 1960s by Signe Brunnstr ö m,
a Swedish physiotherapist (16). In addition, while
walking, the person who has had a stroke is often
observed to “ give ” the control over the body ’ s center
of mass (COM) to the non-paretic leg and occasion-
ally also to the non-paretic hand with the help of a
walking stick. The whole body ’ s COM is considered
a key component in balance control and is defi ned
as an abstract point about which the mass of the
body is evenly distributed and balanced (17 – 19).
Similarly, examples from research, using a force
platform with separate left/right force sensors, dem-
onstrate compensatory movement strategies illustrated
through a signifi cantly smaller contribution from the
paretic leg to standing balance, and consequently with
greater responsibility taken by the non-paretic leg
(20). Furthermore, in the same study the association
between weight-bearing and balance contribution was
unclear in the stroke group, but shown to be one-to-
one when the control subjects consciously distributed
their weight unevenly. Results in a study of sit-to-walk
in a stroke and a control group, where all subjects
succeeded in fulfi lling the task, revealed 4.5 times
larger braking impulses beneath the buttocks and feet
prior to seat-off in the stroke group, in spite of their
displaying the same total amount of anterior – posterior
force impulses as the controls (21). Similar results
have been presented during a reaching task, where all
stroke subjects, irrespective of severity of disability,
succeeded in accomplishing the task, but with consid-
erably different movement strategies (22). Compensa-
tory strategies have also been demonstrated in studies
investigating gait initiation (23) and walking post-
stroke (24,25), even independent of walking speed
(26). Signifi cant asymmetry effects of walking aids on
ground reaction force parameters have been shown,
revealing different roles for the non-paretic and paretic
lower limb (27).
In this context of recovery and compensation,
some concepts from the DST)may be relevant to
refl ect upon. The DST tries to explain fundamental
principles of dynamic systems (10,28,29), such as
the brain and nervous system. One fundamental
principle is the capability of self-organization, i.e.
the potential to create new spatial and/or temporal
movement patterns from within as a reaction to
changing prerequisites (30), such as a brain lesion.
New movement patterns emerge owing to interac-
tion between interrelated subsystems making up
the whole system (9). It is essential in DST to sug-
gest an answer regarding the control over the
redundant degrees of freedom (DoF) existing
within the human body, with all its skeletal bones,
physiotherapy in stroke rehabilitation, irrespective of
lesion location, phase post-stroke and age of the
patients. In this article, which does not claim to com-
prehensively cover all aspects of the aforementioned
areas, we will highlight experience-based clinical
refl ections and research results, question some exist-
ing assessment methods and treatment approaches,
and ask some critical questions which address chal-
lenges that physiotherapists involved in stroke reha-
bilitation are facing today.
Recovery and compensation
In recent years it has become more and more clear
that it is critical to distinguish between the concepts
of recovery and compensation in stroke rehabilitation
(4,5,7,11 – 13).
In this article, we join the defi nition formulated
by Kitago and colleagues (1):
We defi ne motor recovery as the re-emergence
of movement kinematics similar to those of
healthy age-matched controls, resulting from a
decrease in impairments, whereas compensa-
tion involves the use of the unaffected limb or
alternative muscle groups on the affected side
to accomplish the task.
Without highlighting the quality of movement it is
not possible to distinguish between the two concepts
of recovery and compensation (11). It is also gener-
ally accepted that the different levels of the Interna-
tional Classifi cation of Functioning (14) should be
taken into account when these two concepts are
defi ned and discussed (11).
Still, there seems to be some confusion regarding
the defi nitions of these two concepts post-stroke,
which is further illustrated by the use of the concept
“ functional recovery ” , indicating improvements in
the capability to move and to use the arm/hand in
daily life post-stroke (5,15), regardless of the quality
of movement.
Likewise, in a recent review including 467
research studies regarding the effect of physiothera-
peutic interventions post-stroke, the importance of
discriminating between these two concepts was men-
tioned in the Discussion, aiming at true understand-
ing of what happens in the process after a stroke (7).
However, in the same review there was almost no
consideration given to whether achieved gains after
53 scrutinized interventions were mediated through
compensatory movement strategies or through truly
recovered, i.e. typical, movements.
From a clinical perspective, we observe people
who have had a stroke standing with asymmetrical
weight-bearing, rising up to walk pushing with the
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58 G. E. Frykberg & R. Vasa
joints and muscles, where external (i.e. gravita-
tional) and internal forces acting on the body also
need to be considered (28). Coordination of move-
ment is proposed to be the means to achieve mas-
tery of the multitude of DoF and muscles working
together in synergy, thus contributing towards
solving the DoF problem (28).
Altogether, these theoretical refl ections as well as
clinical observations and research results, demon-
strating compensatory movement strategies in every-
day activities post-stroke, challenge us to formulate
some new critical questions:
Does the self-organizing human brain imme- •
diately post-injury start acting without waiting
for the rehabilitation team to give instruc-
tions?
How does the brain solve the problem of •
increased DoF when the muscles are fl accid/
hypotonic on the paretic side?
How does the brain deal with gravitational •
forces to control its COM safety, when half of
the body ’ s muscles are not available for gener-
ating forces with respect to this control?
Is there a correlation between the clinical •
observations of the patient shifting the control
for the safety of COM over to the non-paretic
side and the self-organizing brain trying to
solve its problem of safety?
Why would the brain choose to group the •
muscles into fl exion and extension synergies
[as described by Brunnstr ö m (16)] instead of
restoring segmental voluntary control?
Is there a correlation between abnormal syn- •
ergic grouping and restriction of DoF for the
safety of COM?
Might it be possible to achieve normal synergy •
grouping if the COM post-stroke is controlled
through the paretic limbs and trunk?
Some assumptions regarding recovery and compen-
sation in stroke rehabilitation need to be commented
and refl ected upon.
It seems to be generally accepted that there is a
limited time window within which most of the
improvements occur after a brain lesion (31 – 35). In
a large-scale stroke study (36) it was proposed that
a probable prognosis of walking ability might be
determined as early as 3 weeks post-injury and that
one should not expect improvements after 9 weeks.
Similarly, recovery of arm function outcome at
6 months has been suggested to be predicted
at 4 weeks post-onset (37).
Critical new questions arise here:
Are these predictions based on what we observe •
as the brain ’ s spontaneous recovery?
Are these predictions based on an understand- •
ing of the underlying mechanisms behind
recovery and compensation?
How do these predictions infl uence the mind- •
set of a clinician in his or her goal-setting for
the patient?
From clinical experience-based understanding of the
mechanisms underlying sensorimotor problems post-
stroke and of how to achieve true recovery, this time-
limited perspective on recovery after stroke may not
be valid. Most important, it is suggested, is under-
standing “ what not to do ” with the body and the
brain, while these are in constant interaction with
gravity.
Another assumption within the area of recovery
and compensation is the emphasis in rehabilitation
interventions on the explicit loss, i.e. voluntary con-
trol to be achieved post-stroke. Other questions are
raised here:
What is the priority of the brain post-injury, •
especially when the muscles on one side of the
body are unable to generate forces to combat
gravity?
Would in-depth knowledge about • implicit con-
trol of different paretic body segments to con-
trol their own segmental COM as well as the
whole body ’ s global COM be of signifi cant
importance for true recovery?
A further assumption has been that compensatory
movement strategies post-stroke have primarily been
supposed to be due to dysfunction mainly in the
neural system. However, biomechanical changes in
the musculoskeletal system itself, proposed to be
separated into viscosity and elasticity of soft tissues
(38), also need to be considered (39,40), as well as
Bernstein ’ s suggestion of viewing the whole body as
a mechanical system (28).
For a long time, it has been a profound assump-
tion that we should allow compensatory movement
strategies post-stroke (12). However, this view is now
changing and the debate is ongoing as to whether we
should prevent atypical movement patterns occur-
ring or not (41,42). A critical question is whether
permitting patients early post-stroke to use compen-
satory movement strategies prevents recovery
(4,12,22). Obviously, there are many challenging
questions for physiotherapists to deal with in current
stroke rehabilitation.
Neuroplasticity
Neuroplasticity within the central nervous system
has been recognized for a long time (43), and its
importance for assumptions underlying neurological
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Neuroplasticity in action post-stroke 59
rehabilitation and for recovery post-stroke has been
highlighted during the past few decades (44). In this
article, we will subscribe to the defi nition of neuro-
plasticity suggested by Bethe (43), as “ … the ability
to adapt to changes and to meet the dangers of life.
It is the capacity of the central nervous system to
reorganize following insult and to restore adequate
function. ” Whether this reorganization that takes
place in the nervous system is adaptive, i.e. associ-
ated with improved movement capacity (45), or mal-
adaptive, with deterioration as a result (11,46), needs
to be discussed.
One of the principles behind post-injury neuro-
plasticity is that “ behavioral experience ” is a very
powerful modulator (2). When it comes to physio-
therapeutic interventions, this behavioral experience
is provided to patients post-stroke through different
kinds of sensorimotor training. Whether this motor
experience will reshape the brain in adaptive or mal-
adaptive ways is considered to depend on the quan-
tity and quality of the specifi c treatment (2,4).
Regarding quantity, the dose – response relation-
ship is essential to consider when translating results
from animal studies into stroke rehabilitation, as ani-
mals accomplish hundreds of repetitions daily (47).
Furthermore, constraint-induced movement therapy
(CIMT), a treatment approach in stroke rehabilita-
tion that is implemented worldwide, has its origin in
studies with non-human primates, and one of its
main components is high-repetition doses of training
(48). In the study by Birkenmeier et al. (47), the
stroke participants performed at least 300 repetitions
per therapy hour, without experiencing increased
pain or fatigue, and with functional improvements
being obtained. Similar results with signifi cant
improvements have been demonstrated in recent
studies with high-intensity training post-stroke
(49,50). However, the critical importance of how to
empower patients to take full responsibility for this
kind of training in order to achieve permanent
improvements in post-stroke rehabilitation remains
to be investigated (2,49).
Regarding the quality of the motor experience,
studies with rats show that in the absence of training,
i.e. due to so-called spontaneous recovery, the ani-
mals exhibited compensatory movement patterns at
5 weeks post-onset, revealed through intracortical
microstimulation (51). Furthermore, fi ndings from
monkeys (52) and rodents (53) suggest that motor
activity alone, such as pressing a bar, without acquir-
ing any motor skill does not seem suffi cient to pro-
mote neurophysiological changes in cortical areas. It
seems as if cortical plasticity is skill or learning
dependent, and that use itself, in the form of simple
repetitions or strength training (54), may not be
enough for neuroplastic changes to take place.
A second principle underlying neuroplasticity is
that there seems to be a limited time window for
recovery mechanisms to operate post-stroke. In the
fi rst hours to days, biochemical changes take place
aiming at both the limitation of damage in the pen-
umbra region close to the brain injury (55) and the
alleviation of diaschisis (4,56). Primarily spontane-
ous neurological recovery is assumed to contribute
to functional improvements within the fi rst weeks
post-stroke (32). Furthermore, in the course of the
fi rst 10 – 12 weeks post-injury it is assumed that most
of the restitution of impairments is accomplished
(57) and that after this period it is mainly compensa-
tory adaptation that takes place (4).
The importance of motivation is considered to be
a third principle critical for driving neuroplasticity
(3,58,59) and signifi cant functional improvements have
been demonstrated in spite of a huge lesion (44).
There is a primary focus on cortical plasticity in
many research studies, both in animals and in humans
(2). However, in humans, lesions in subcortical areas
occur much more frequently than in cortical areas
(60). Thus, our knowledge about plastic changes in
subcortical networks is limited. Logically, task-specifi c
training with a focus on upper-extremity function
involves voluntary control, and thereby cortical plastic
changes are of interest. To further the understanding
of mechanisms underlying recovery and compensa-
tion of upper-limb function post-stroke, a multicenter
research program has been implemented in the
Netherlands, called the EXPLICIT stroke program
[an acronym for EXplaining PLastICITy after stroke
(61)]. We propose that an IMPLICIT stroke research
program is needed (investigating, for example, how
gravity and movements of COM infl uence body move-
ments and strengthen paretic muscles from within),
aiming at understanding how these and other “ Invis-
ible ” factors have impact on Movement control with
the potential to drive neuroPLasticity post-stroke and
put the patient on the road to recovery.
Challenging questions for physiotherapists arise
with respect to neuroplasticity:
Should compensatory movement strategies be •
viewed as maladaptive plasticity?
Is it possible to reverse spasticity and abnor- •
mal synergic grouping by exploiting inter-limb
coordination (e.g. generating forces beneath
the paretic foot aiming at infl uencing improve-
ments of the paretic arm) coupled with the
brain ’ s priority suggested to be “ safety of
COM ” forced from the paretic side?
Could such treatment contribute to the much- •
needed quality of motor experience in order
to promote adaptive neuroplastic changes
post-stroke?
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60 G. E. Frykberg & R. Vasa
Could physiotherapeutic interventions based •
on the understanding of underlying mecha-
nisms promote true recovery instead of com-
pensation and extend the sensitive period for
adaptive improvements post-stroke?
Physiotherapy in stroke rehabilitation:
state of the art
The following paragraph addresses critical questions
for physiotherapists in current stroke rehabilitation
concerning “ Where do we stand? ” and “ Where are
we heading? ”
Worldwide, an interdisciplinary team approach in
stroke rehabilitation is considered optimal in sup-
porting the patient to as full a recovery as possible
(5). In this context, physiotherapists are important
team members, often with in-depth knowledge of
movement analysis, which is necessary in order to
observe and analyze how people who have had a
stroke use their bodies to reach functional goals in
everyday life. In our opinion, this expert knowledge
in observatory-based movement analysis (OMA) has
the potential to discriminate between typical (i.e.
recovered) and atypical (i.e. compensatory) move-
ment patterns, but it does not seem to be optimally
utilized in stroke rehabilitation at present.
In assessment, clinical tools currently in use by
physiotherapists in stroke rehabilitation, irrespective
of addressing arm/hand function, balance or mobil-
ity, often report only whether the patient can accom-
plish the task or not [categorical data, e.g. Stops
Walking When Talking, SWWT (62)], or can perform
the task better or worse [ordinal data, e.g. Berg
Balance Scale, BBS (63)], or just give a single sum-
mary value [e.g. the Nine Hole Peg test (64); Timed
Up and Go (65); walking speed (66)], without giving
any information about the quality with which the
task was performed. Furthermore, the focus is most
often mainly on the explicit task accomplishment
without considering more implicit contributing fac-
tors, from the initiation of movement to the end
result. Unfortunately, it seems as if physiotherapists
today only to a very limited extent use and report
structured OMA, with the potential to assess quality
of movement over time, even though these tools exist,
e.g. Rancho Los Amigos Gait Analysis Form (67). In
addition to OMA, there is a need to objectively quan-
tify and describe three-dimensional (3D) kinematics
in order to be able to differentiate between recovery
and compensation post-stroke (12,68). This can be
achieved with portable movement-analysis systems,
which is an area currently undergoing rapid develop-
ment thanks to the miniaturization of accelerometers,
gyroscopes and magnetometers [e.g. (69,70)]. In
order to explain the dynamics of neural recovery, it
has been suggested that serial kinematic measure-
ments should be undertaken early after stroke, where
the quality of motor performance is systematically
registered (4), which is also implemented in the
Dutch EXPLICIT stroke program (61,71).
Challenging questions regarding assessment post-
stroke arise here:
Shall we physiotherapists, for clinical decision- •
making, continue to be satisfi ed with
insuffi cient information in evaluating our
interventions?
What benefi t do we derive from categorical •
data, ordinal data or a single value for facilita-
tion of how we should design interventions?
In treatment, the focus in physiotherapeutic inter-
ventions in stroke rehabilitation has largely been on
muscles, although approaches have changed over the
years. During a period from the 1950s to the 1970s,
the elusive phenomenon of spasticity was central,
and treatment methods, e.g. neurofacilitation
approaches, aimed at inhibiting increased muscle
tone [e.g. (72)] and promoting muscular improve-
ments on the paretic side (16,73,74).
The muscular focus in stroke rehabilitation has
continued, with muscle weakness entering as a main
target in stroke rehabilitation, and progressive resis-
tance training has been developed and reported to
be successful in maintaining muscle strength (75 –
77), also at long-term follow-up after 4 years (78).
However, the benefi t and transfer of maintained
muscle strength to other measures of functional
activity, such as gait performance, are equivocal
(76,78 – 80).
Questions regarding this muscle focus remain to
be answered:
Are we ready to think beyond muscle inhibi- •
tion and muscle strengthening?
How can the limited transfer effects of muscle- •
strength training to everyday functional activ-
ities be explained?
Treatment approaches post-stroke have gradually
changed as a result of advances in neuroscience
and our extended knowledge of mechanisms for
motor control (81). During the 1980s, principles of
motor learning, including active cognitive involve-
ment of the patient, were highlighted, and pre-
dominantly hands-off training was implemented
post-stroke (82).
A further step was taken when the “ task-oriented
approach ” in stroke rehabilitation was developed,
which includes considering not only the individual
with his or her perceptual, cognitive and neuromus-
culoskeletal abilities, but also the characteristics of
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Neuroplasticity in action post-stroke 61
the task and the environment in which the task is to
be performed (10). In this treatment model, everyday
tasks are repetitively practiced, e.g. reaching out for
a glass, grasping it, bringing it to the mouth and
drinking, i.e. the focus is on voluntary action.
When the effect of repetitive task training on
global, upper and lower limb function post-stroke
was evaluated in a Cochrane review, the results dem-
onstrated modest positive changes regarding lower-
limb function, some impact on activities of daily
living, but no effect on upper-limb motor activities
(83). Furthermore, no evidence could be found for
lasting improvements after 6 and 12 months. Out-
come measures for lower-limb function were, among
others, walking distance, walking speed and time to
complete sit-to-stand, i.e. single values representing
end results, without considering whether the improve-
ments were achieved owing to “ more effective ”
compensatory strategies or to true recovered move-
ment patterns.
CIMT, mentioned above, is a treatment model in
stroke rehabilitation which has been in use since the
early 1990s (84). Its focus is predominantly on
removal of the learned non-use of the paretic arm and
hand, with the principles of preventing the use of the
non-paretic upper limb in daily activities by use of a
sling and glove and massed practice of everyday tasks
with the paretic hand/arm (85). There has been exten-
sive evaluation of CIMT. Results from the Extremity
Constraint Induced Therapy Evaluation (EXCITE)
study, a randomized controlled study with 222 par-
ticipants, demonstrated signifi cant improvements in
daily use of the paretic hand/arm both at 1 year (86)
and at 2 year (87) follow-ups. However, the chosen
outcome measures did not have the potential to dif-
ferentiate between recovery and atypical movement
patterns, and in a later proof-of-concept study using
kinematic measures besides clinical scales it was sug-
gested that the functional improvements achieved
through CIMT were mediated through compensa-
tory movement strategies (1,68). The CIMT method
has also been scrutinized in a Cochrane review, where
moderately positive effects were demonstrated on dis-
ability and on arm motor function as well as on arm
motor impairments (88). However, many of the 19
studies included had small sample sizes and incom-
plete information about withdrawals. No evidence of
remaining positive effects was found at follow-up
after 6 months. Thus, contradictory results exist
regarding the effi cacy of CIMT.
Here, questions arise with respect to focus on
the task:
Why do we continue to focus on the end result, •
the accomplishment of the task, when there
are so many preparatory steps in the process
before the end result?
Why not consider exploiting gravity to drive •
true recovery instead of compensation when it
remains invariant and cannot be avoided?
Why not exploit different segments of the •
body, including the trunk, as a mechanical
system aiming at generating forces in
specially designed postures, wherein the
entire body is in action, with the paretic limbs
controlling segmental COMs as well as the
whole body ’ s COM?
Might the temporary and impermanent func- •
tional effects as demonstrated in the use of the
task-oriented approach be explained partly by
the focus being mainly on the end result and
partly by a lack of understanding of the under-
lying mechanisms that contribute to recovery
post-stroke?
Efforts have also been put into evaluating the effect
of different physiotherapy approaches on functional
independence (89,90). The conclusions were that no
single treatment approach post-stroke is more effec-
tive than any other in achieving “ recovery of function ”
and “ mobility ” post-stroke. It should be noted that
no discrimination between recovery and compensa-
tion was discussed in these reviews. To our knowl-
edge, the selected assessment tools and outcome
measures (independence in activities of daily living,
motor function, balance, gait velocity and length of
stay) do not have the potential to relate improvements
to either true recovery or compensation.
In recent years, many “ new ” therapies have been
introduced and are under evaluation in stroke reha-
bilitation, such as virtual reality, robot-assisted arm
and gait training, locomotor treadmill training, motor
imagery and mirror therapy. The focus regarding the
state of the art in physiotherapy in the current article
is on commonly used treatment approaches, so the
debate is limited to those.
To conclude:
Where are we physiotherapists heading in •
stroke rehabilitation?
Who could be better equipped to understand •
the underlying mechanisms behind movement
problems post-stroke and to fi nd solutions
beyond neural control than physiotherapists
with expertise in movement science?
Summary
Neuroplasticity in action post-stroke, with respect to
both the self-organized brain and physiotherapy
interventions post-stroke, with reports in many
research studies (20 – 27), seems to have implied the
development of compensatory movement strategies.
Thus, there is a need to think beyond the traditional
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62 G. E. Frykberg & R. Vasa
way with its focus on the lesion, on cortical plasticity
and on voluntary control for task accomplishments.
The demand to differentiate between recovered
and compensated movement strategies in stroke reha-
bilitation is increasingly being highlighted. However,
this critical issue is not yet being put into practice
neither in the clinic, where, for example, measure-
ment tools yielding this information are lacking, or
in research, where large-scale reviews concerning
physiotherapy interventions post-stroke are scruti-
nized. Furthermore, the knowledge base regarding
cortical neuroplasticity is increasingly comprehensive,
although information about subcortical, cerebellar
and spinal plastic changes post-stroke is lacking.
Physiotherapists worldwide now face the chal-
lenge of having to take a stand on whether we should
consider the emergence of compensatory movement
patterns in subjects who have had stroke as necessary
or not, also taking into account the increasing
number of reports suggesting that compensation post-
stroke may prevent true recovery. Furthermore, large-
scale reviews continue to emphasize the urgent need
to understand principles driving recovery post-stroke.
So, how can the challenges facing physiotherapists in
stroke rehabilitation today be summarized?
First, we need to rethink. There is a need to comple-
ment the focus on the neural system in stroke reha-
bilitation with looking upon the human body as a
mechanical system, with the possibility of exploiting
gravitational forces. Gravity is suggested to be the
most important and critical invariant factor that
evokes compensation and also has the potential to
drive true sensorimotor recovery post-stroke. It is
necessary to understand “ what not to do ” and “ what
to do ” with the brain and the body, which are in
constant interaction with gravity. We need to shift the
focus from voluntary control to the “ invisible ” fac-
tors infl uencing movement control, exemplifi ed by
promoting proprioceptive afferent infl ow to trigger
automatic motor outfl ow for prioritizing the safety of
the COM. This is hypothesized to be a potent mod-
ulator to drive and force the brain into adaptive neu-
roplastic changes on many levels of the nervous
system. Furthermore, the consequences of the lesion
on the body and on the brain, and not the lesion per
se , are suggested to be in focus in future physiother-
apy clinical practice and in research.
Second, the quality of movements needs to be
assessed and documented, and we should not be sat-
isfi ed with single values as outcome measures. Thus,
we need to further develop our expert skill with
respect to 3D OMA, so that we can discriminate
between true recovery and compensatory movement
patterns post-stroke. In addition, close cooperation
with bioengineers may be fruitful in order to objec-
tively capture and quantify 3D movements using
recently developed portable movement-analysis sys-
tems. Furthermore, we need to develop new assess-
ment tools which can capture not only the explicit
voluntary control, but also, more importantly, the
ability of the patient to control segmental as well as
global COM through the paretic side of the body,
which is proposed to contribute to the implicit con-
trol of movement.
Third, we need to empower and educate the
patient and his or her friends and family, as “ therapy ”
needs to be constantly ongoing to have a chance to
promote permanent sensorimotor recovery. Empow-
ering the patient will help him or her to feel respon-
sible for the treatment. Patient values as one
important component in evidence-based practice
need to be highlighted and put into practice.
Fourth, there is a need to introduce a new assess-
ment and treatment concept aiming at expanding the
boundaries of COM movements towards the paretic
side by using the paretic limbs coupled with the
paretic trunk to control the safety of the COM. With
this in focus, the ultimate goal would be to put the
patient on the road to recovery. This new concept
needs to be thoroughly scientifi cally investigated,
before it can be decided whether it can lead to true
recovery or not.
We predict that physiotherapists worldwide
taking responsibility for their contribution in stroke
rehabilitation as experts in movement science will
have the potential to direct the patients in how to
infl uence adaptive neuroplasticity in action, turning
it into recovery instead of compensation. We also
predict the evolution of physiotherapy into a clinical
science within the neurorehabilitation sciences.
Declaration of interest: The authors have no
confl icts of interest to declare.
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