My focus on stroke recovery has been near myopic for the last decade. I do professional talks and seminars, and write general as well as journal articles about the subject. I have both a book and blog dedicated to stroke recovery (Google "the stroke recovery blog."). I get questions from stroke survivors, caregivers and therapists. Many are heartbreaking, but all of them are thought-provoking. And I put a lot of effort into the answers. The following questions and answers go back to 2008, just after my book Stronger After Stroke was published. The names have been changed, and the questions have been paraphrased to protect copyright.

This question was from a 70-year-old MD:

Q: I read with interest your wonderful work about spasticity and stroke. I suffered a stroke with left hemiplegia and spasticity about two years ago. I can walk slowly with a cane but I'm not very stable. Most annoying, however, is the spasticity in my elbow, wrist and fingers which are constantly flexed. The flexion increases during walking. I have weak dorsiflexion and severe plantarflexion of the big toe causing a shuffling gait. I am two years post; do you think there can be any improvement in gait and spasticity?

A: Thank you for the kind words about my work. Spasticity can only be reduced by reestablishing cortical control over the spastic muscles. Cortical control is reestablished through repetitive movement of the limbs. So as much as you can move the arm, the better. Also, be careful not to let contracture set in. Because the joints of the arm are postured in the same place for a long periods of time (because of the spasticity), the cortical representation of those joints shrinks.

Meanwhile, the soft tissue can also shrink. If enough soft-tissue shrinkage has taken place, this contracture can mean that no further gains can be made without surgery. So have an occupational or physical therapist develop a safe stretching program. Follow the program daily.

Also, consider electrical stimulation (ES). ES will move the joint through its range of motion--giving a good stretch. ES will also activate weak muscles, and ES has been shown to drive neuroplastic changes in the brain. Usually, once trained, you can do this at home without a therapist. Generally, the muscles that get ES are the weaker of the muscle groups (i.e., the finger/wrist extensors on the back of the arm.)

This question was from a PT:

Q: I just read your article "Using Gait Speed as a Marker for Progress" (ADVANCE, March 8, 2010). I was wondering if it is still a valid test if assistive devices are used.

A: My understanding is that the validity is only without an assistive device. Look at it this way; let's say somebody walks at a given speed without an assistive device, and then walks faster with an assistive device. If you accept that gait speed is an overall health indicator, then the assistive device would somehow make them healthier. Probably not a valid assumption. Having said that, there may be some importance to increased gait velocity even with an assistive device. In other words, although a bit of an empirical leap, if over time somebody is walking faster with a cane, that would be seen as a good thing. In clinical research the question of testing gait speed with or without the assistive device (or orthotic for that matter) always comes up. Generally, gait speed without any orthotic or assistive device as more indicative of a true baseline.

This question was from a physiotherapist in Columbia:

Q: I need your help! I have a patient who had a stroke caused by an embolism after liposuction. She was in the ICU for three weeks and is now at home. She has been in occupational and physical therapy for three months. She has no voluntary movement and severe spasticity that is close to rigidity. She is globally aphasic; she only moans and cries. She is not responding to proprioceptive neuromuscular facilitation techniques. Please provide suggestions.

A: This patient is at the point where the window opportunity for natural recovery (spontaneous recovery) is closing. Unfortunately, the focus at this point should be discharge planning and reduction in complications. The first concern is soft-tissue shortening. In a typical day we move our joints through their full range of motion hundreds of times. The difficult question for you is, how are you going to train caregivers and family members to take her joints through their full range of motion many, many times a day? There is some research that indicates that just moving joints drive "brain rewiring" changes in some cases. So stretching not only helps retain soft-tissue length, it may "jump start" her nervous system on some level.

One of the things you need to determine is if it is "severe spasticity" or rigidity. The line between the two is often blurred when spasticity is so severe that the limb cannot be moved through its passive range of motion. Again, spasticity/rigidity/contracture issue is the most paramount in my opinion. If soft-tissue length has been lost (contracture), serial casting is often helpful. If it is indeed spasticity, some form of medical intervention including oral or intrathecal baclofen or Botox might be something to discuss with the patient's doctor.

You have a difficult task. One thing research into stroke recovery is clear about is that there is a tipping point at which there is so much cortical damage that any recovery is rare. However, retaining soft-tissue length will help provide the broadest possible template for potential recovery.

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.