Neuroplasticity: how the brain relearns movement after a stroke

For a long time the accepted view was that the adult brain was fixed. Whatever was damaged was lost, and rehabilitation was about learning to manage without it. That view turned out to be wrong, and the correction is the single most important idea in modern neurological rehabilitation.

The brain changes its own structure and function in response to what it experiences and what it is asked to do. The term for this is neuroplasticity, and it continues throughout life.

Why it matters after a stroke

A stroke damages a region of brain tissue, and the messages that travelled through it no longer arrive properly. What follows is loss of movement, of sensation, of coordination or of balance, depending on which part was affected.

Neuroplasticity means the brain can reorganise. Other areas can take on some of the work, connections that were weak can strengthen, and pathways that were never used for a task can be recruited for it. This is not the damaged tissue repairing itself. It is the rest of the brain rewiring around the gap.

That capacity is what rehabilitation is working with. It is also why rehabilitation is not passive. The brain reorganises in response to demand, so what you practise is what it rebuilds.

Repetition and specificity

Two principles follow, and they explain most of what a neurological physiotherapist asks of a patient.

The first is repetition. Change in the nervous system requires the movement to be performed many times, not a handful. Research into upper limb recovery in particular suggests the number of repetitions needed is considerably higher than most people manage without a structured programme.

The second is specificity. The brain rebuilds the task you practise, not a general capacity for movement. Practising standing up from a chair improves standing up from a chair. If the goal is to get up the stairs at home, the rehabilitation eventually has to involve stairs.

Both principles push in the same direction. Rehabilitation works better when it is intensive, when it is specific to something you actually want to do, and when it continues between appointments.

What the guidance says about intensity

NICE guidance on stroke rehabilitation reflects this. It recommends that people who are able to participate, and for whom functional goals can be achieved, should be offered at least three hours a day of multidisciplinary therapy on at least five days a week, adjusted to what the person can tolerate.

That is a demanding standard, and it is considerably more than many people receive in practice. It is worth knowing about, because it gives you a benchmark to ask about rather than accepting whatever is offered as the natural ceiling.

Timing, and the thing people are told that is not quite true

Many people are told that recovery stops at six months, or at a year. The most rapid change does happen in the early months, and there is good reason to make the most of that window. But improvement beyond it is well documented, particularly where rehabilitation is resumed after a period without it.

We have treated people who were told they had plateaued and who made further progress once they returned to structured, specific practice. The realistic message is neither that everything comes back nor that a date exists after which nothing can change. It is that the brain responds to what it is given, at any stage.

The same principle, other conditions

Neuroplasticity underlies rehabilitation in multiple sclerosis, in spinal cord injury and in brain injury, and it is why exercise is so central in Parkinson's disease. Our article on exercise and Parkinson's goes into what the evidence supports there.

At Healthflex

Kathryn Lewis is our neurological physiotherapist and sees people with stroke, Parkinson's, multiple sclerosis and spinal cord injury at our Haslemere clinic. Assessment identifies where the movement potential actually is, and treatment combines hands on work, therapeutic exercise and the practice and advice that continue between sessions.

Stroke rehabilitation, neurological physiotherapy and balance, falls and brain injury all cover this work, and where travelling to the clinic is difficult, home visit physiotherapy is available across the Haslemere area.