Since when is “productive” fun?

When it comes to stroke recovery, no clinician, no matter how skilled, can "do it for them." Recovery from stroke is dependent on repetitive and demanding practice by the owner of the damaged nervous system—the survivor. If done correctly repetitive and demanding practice drives cortical plasticity ("brain rewiring") robustly enough to be evident in increased quality of movement. 

But this sort of repetitive practice is boring! Repetitive practice does not necessarily involve functional activity. For example, a clinician, seeing a deficit in the last 15 or 20° of dorsiflexion, may have the patient repetitively practice dorsiflexion, irrespective of ambulation. At least in that example the end goal, whether it's stated or not, is obvious; walking. In the upper extremity repetitive practice of single joint movements may or may not relate to any particular everyday activity. Instead repetitive practice may be used just to increase active range of motion in those joints. Because it does not involve anything functional, repetitive practice can be inherently boring.  And what makes it even more boring is that stroke survivors aren't even working on anything novel; there relearning movement that they used to do perfectly well. So where's the motivation? 

The motivation ends up being a conjuring. Some of this motivation may come from the minds of clinicians. OTs, PTs and speech therapists should try to make repetitive practice as interesting as possible. But some of this motivation comes from the survivor. The survivor needs the imagination enough to understand how this hard and boring work will help realize potential.

Flexible and measurable DIY plan

Everyone needs a plan. At work we have schedules and care plans and goals. During our education we have schedules and syllabi and tests. Athletes, with the aid of coaches, have a plan for every practice, and benchmarks are built into every practice.

Most stroke survivors don't have a plan. Sure, therapists set a plan with goals during therapy. But once discharged, survivors tend to drift, hoping not to lose what has been recovered.  Instead, the most recovery is achieved when the focus is on further gains.

Upon discharge from traditional therapy, survivors enter a new chapter in recovery. Their recovery plan is essential in optimizing their recovery. This is true for the short-term, and for the rest of their lives. 

There are three aspects to every successful recovery plan.
 

Measurable benchmarks. Gains made during the chronic period after stroke are hard to see because they tend to be modest. Specific goals should be stated and strived for. If the patient says, "I will walk 500 yards by September," then a 500-yard route should be mapped out. The total goal should be chunked in a way that the survivor sees incremental gains toward the entire goal (i.e., 50, then 100, then 200 yards and so on).  

Focus on what YOU can do. For recovery to continue beyond the traditional therapy period, the survivor has to drive his own therapy. This dovetails well with the concept that for the brain to rewire, neuroplastcially, the patient has to drive his own nervous system. The recovery plan should emphasize self-reliance. Not only should survivors be able to do most of the therapy themselves, but they should also understand how to progress their efforts. 

Make the plan flexible. Stroke recovery research is galloping along. What comes of this research? New treatment options. All these new treatments dictates that the survivor be flexible enough to incorporate new ideas into their plan. But there's something else that requires flexibility: the survivor changes. One thing that every researcher agrees about: Intensity rules. So if the survivor chnages and intesity rules, the foucs must change while the level of intesity increases.

Otherwise you're just spinning your wheels.