Therapists usually want to know which exercises are the best for helping stroke survivors recover. If there are no exercises available (i.e., if the survivor has little volitional movement), therapists demand handling techniques. Unfortunately for therapists who are hooked on the progressive resistance exercise (PRE)-neurofacilitation continuum, research provides little support for either.

Making the Effort

Consider the only stroke-recovery option that has passed muster in Phase III trials: constraint-induced therapy (CIT). There are no specific exercises. The movements required during CIT very little resemble traditional muscle strengthening PREs, because their focus is on repetitive practice, not muscle strengthening. And there are no handling techniques. In fact, CIT is decidedly and pointedly hands-off.

It is cause of some curiosity among researchers why this hands-off philosophy is so difficult for therapists to accept. The only way of driving cortical change toward recovery is through volitional efforts by the stroke survivor. These efforts are actively encouraged no matter how ugly, synergistic or uncoordinated they are.

Edward Taub, the person who developed CIT, is a psychologist. As he was developing CIT in animal models, handling techniques and therapeutic exercise may have been the furthest thing from his mind. The closest, certainly, was operant conditioning. Stroke is a brain injury, not a problem specific to muscle weakness. The term "muscle reeducation" is telling. It suggests muscles have a will. But they don't. The will is held within the brain. Stroke recovery involves brain reeducation. Different focus, different organ, different paradigm, different rules, different outcome measures.

This difference between PRE and repetitive practice of a movement may seem like a distinction without a difference. In fact, both build muscle and both drive plastic changes in the brain. The distinction is in the focus. Repetitive practice paradigms like CIT focus on driving changes in the motor and sensory cortices of the brain, not specifically in changes in muscle strength. Sure, muscles will build. But focusing on strengthening is like climbing a ladder to the top only to find the ladder is leaning against the wrong building. Stroke is brain damage. And unlike most other forms of acquired brain injury, stroke is focal. So if a survivor is, say, two years post-stroke and can't open his hand, and then later he can, that is not a reflection of muscular strength. It is a clear indication of a change in the brain. The muscles have been there all along. Muscle strengthening is the easy part.

Real Effect of Exercise

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.

Peter G. Levine is co-director of the Neuromotor Recovery and Rehabilitation Laboratory (rehablab.org) and the author of Stronger After Stroke (Demos Health, 2008). He also conducts seminars teaching research-based, neuroplasticity-producing stroke recovery strategies. E-mail him at StrongerAfterStroke@yahoo.com.