Exercise. Energy. Recovery.

There are good reasons for muscle strengthening after stroke, of course. But therapists know these reasons well. For instance, the muscles on the affected side, even the ones that are the most spastic and seem overwhelmingly strong, are usually no more than half as strong as the unaffected side. Because spasticity is such an issue after stroke, some clinicians believe that strengthening "tight" spastic muscles will exacerbate spasticity. Research has shown that this is untrue; exercising muscles does not increase spasticity. It is important to focus on the muscles that are the weakest, of course. For instance, most stroke survivors have no problem at all bending their elbow, but extending their elbow is often very difficult, especially at the end of the range of motion. In this case it would be wise to work the triceps because it is the weaker of the two muscle groups. 

The other form of exercise that therapists focus on is cardiovascular. Unfortunately stroke survivors get a double whammy: They are in half as good cardiovascular shape as age-matched couch potatoes, but everything they do takes twice as much energy. A good example is walking. Before stroke, walking takes very little energy. Most of the energy is expended in small bursts of muscle power, perfectly timed to use momentum forces and gravitational pull. After stroke, gait loses its subtlety and coordination. The gait that is typically left in the wake of stroke uses twice as much energy as prior to the stroke.

So cardio and muscular strengthening are important, but viewed as more of a "pre-process" than the process itself. In fact, many of the leading-edge treatment options (i.e., repetitive practice, CIT, forced use) are considered "intensive." They require that the survivor "hits the ground running" and be able to withstand the rigors of the intensity right from the get-go. In this regard there is a necessity for the survivor to be in pretty good cardiovascular and muscular shape prior to the initiation of treatment. Once the survivor has the stamina, the focus comes off the body and shifts to the brain.

Hell Yes.

Can someone get better after they "plateaued?" Hell yes.

What is the plateau? 

It's the point at which all of the neurons that were "stunned" by the stroke have come back online. Why were the neurons stunned in the first  place? The stunning of neurons is known as "cortical shock." Neurons, right after the stroke, are fighting a battle to survive. And while they're fighting this battle, they don't work. These neurons eventually come back online. They usually come back online between one week and three or four months after the stroke. This is known as the subacute phase. (Note: there is no "one size fits all" timeline for these events. Two stroke survivors can have radically different timelines.)

In any case, at some point these neurons come back online. Recovery is sometimes very rapid and relatively "easy" during this phase. This kind of recovery, stunned neurons coming back online, is known as natural recovery, or spontaneous recovery. In other words, "Not a lot of work, but a lot of recovery."
 

Eventually, all of the neurons that were stunned are back online. The survivor "plateaus" and the chronic phase of stroke begins. Once this happens there is a discernible reduction in the rate of recovery. The reduction is because there's no neurons to come back online and help the process along. But recovery can still happen.

It's just that recovery takes a different form. Now neurons from around the brain have to be recruited in order to make up for the neurons killed by the stroke. This makes recovery a much different (and effortful) process during the chronic phase, than during subacute phase.

But... you hear this all the time. I even hear this from therapists. They'll say something like, "We ended therapy with this guy, 14 months later he walks through the door and he can do stuff that he couldn't do when he was discharged!" This sort of recovery can then trigger more rehab. Remember, rehab ends when the person plateaus. (Its a managed care thing.) So if there are changes in the ability to move, therapy can be justified. So you could go through the cycle where you work your butt off to get a little bit better, which then triggers more therapy. 

It's a beautiful cycle, and it can continue for decades.

~

Your meds are probably wrong. And its probably gonna hurt.

The statistics about medications and falls are pretty clear. The more medications, the more chance of falls. This is as true in stroke survivors as anybody else. 

But stroke survivors automatically have two additional things going against them:
1. They are usually on more medications
2. They are more likely to fall in the first place

But there are other reasons to reconsider medications. In 2008 almost 2,000,000 people became ill or injured because of the use of prescription drugs. These are from "medication errors." 

So how do you go about reconsidering medications? The "Brown Bag Medication Review." And you should do it. (My favorite line: “Out of 10-15 brown bag reviews, only 2 were accurate.”) About 50% of the time the meds will, in some way, be wrong.
The idea is you throw all your medications in a brown paper bag.
 

In the bag should be... 

• All prescription medicines (including pills and creams).
• All over-the-counter medicine they take regularly.
• All vitamins and supplements.
• All herbal medicines.

All medications are placed on the counter in the exam room. The physician or pharmacist, with your help, decides which meds to keep, which to pitch and which dosages to tweak. Also decided...

• Tips for safe and effective medication use
• Answers to your questions about medications 

Once the whole thing is  figured out you are given a card that has all the information on it. This information would be available for you to review, and for you to hand to doctors, dentists, etc. who may need to know your medications at a glance.

More info here.

Intention tremor, and a possible neuroplastic treatment

In stroke intention tremor is caused by damage to the cerebellum. 

The cerebellum is important in fine coordination. If the stroke damages the cerebellum fine motor coordination suffers. 

(Note: Intention tremor is different from essential tremor, often found in Parkinson's) 

It is called intention tremor because the tremor happens when somebody moves intentionally. So let's say the intended movement is touching your nose with a fingertip. If someone has intention tremor the trajectory toward the nose is good but when they get close to the nose (closer to the intended target) the tremor begins. As the New York Times put it:

Intention (or kinetic) tremors: These tremors occur at the end of a purposeful (intended) movement, such as writing, pressing a button, or reaching for an object. The tremor will often disappear while the affected body part is at rest.

Outside of stroke it is often seen long-term alcoholics. So here's my first suggestion: If you have intention tremors, don't drink. Other drugs can cause tremors as well. So, the "Brown Bag Medication Review" may help in reducing tremors.

How has intention tremor typically been treated? 

Intention tremor is notoriously difficult to treat. There are several drugs that are used for treatment, but they all work for some of the people some of the time. (Here's an example of an herbal "remedy.")

Other things that had been tried:

Physical therapy: In some people it works great to temporarily reduce tremors. It's not cure.
 

Meditation, yoga, deep breathing exercises, biofeedback have all been used with varying levels of success.

The neuroplastic model
So what is the neuroplastic model for overcoming intention tremor? I guess the first question is: Is there a neuroplastic model? Is there anything that can be done to rewire the brain "around" this movement disorder?

We will wait for neuroscience to catch up to that question. It could take decades, it could take centuries. On the other hand, somebody could come up with a really good way of applying the brain's inherent plasticity tomorrow. So you never know.

Having said all that, I still have some suggestions that may very well rewire the brain to help overcome this issue. Here are my suggestions:

Mirror therapy. This is the way that mirror therapy would be applied:

Just like in mirror therapy for movement recovery, you look only at the "good" side. That is, you only see the flawless movement of the unaffected side.

Bimanual training. This option involves having the "good" train the "bad." It's a simple enough concept; whatever the good hand does, the bad hand attempts to copy.

Recovery with a Beat

With the lower extremity "function" is inherently bilateral. That is, because the primary function of the lower extremities is ambulation, bilaterality is inherent. 

(By "advantage" I do not suggest that I buy into the concept that the lower extremities come back before the upper extremities post-stroke. This is common wisdom in rehab, but it may be incorrect. The only way to prove the lower extremity comes back before the upper extremity would be to measure the most distal element of both: the fingers and toes. Measuring toe extension in comparison to finger extension has, to my knowledge, never been done.)

Beyond bilaterality, ambulation is also inherently rhythmic. The rhythm after stroke is disrupted and made unequal. And rhythm is what bilateral leg training with rhythmic auditory cueing attempts to re-establish in the lower extremity.

That is, if you re-establish the rhythm of gait, you will go a long way to re-establish symmetry of both step length and step timing.

There are commercial systems that use a heel switch so that the moment of heel strike is radio-delivered to headphones. The patient hears their own heel strike through the headphones, as well as a beat that they have to match with each heel strike.

But as is true with many technologies purported to help stroke survivors relearn movement, no special system is really needed to bring the idea of rhythmicity into gait.

A simple metronome either heard through headphones or carried by the therapist next to the stroke survivor can be used to promote the re-establishment of rhythmicity of gait. Plugging the ears using standard noise-reducing plugs can boost the volume of footfall to make that obvious to the survivor. The trick is then to match the footfall to the beat.