Stroke research suggests the following treatments are promising for individuals who are at least six months post-stroke:

1. Mental Practice with Motor Imagery
2. Constraint Induced Movement Therapy (CIMT)
3. Virtual Reality (VR)
4. Preventing Learned Non-Use

Yes! There is Hope for Chronic Stroke!

What is a chronic stroke?
The term chronic stroke typically refers to a time frame of at least six months
after the initial stroke incident occurred. As a person enters this stage and
moves onward to years of stroke survival, he may start to encounter all new
frustrations related to recovery, especially regarding motor recovery and use of
the affected arm.

In the medical world, “most significant” recovery of movement is generally
considered to happen within the first six months, with spontaneous recovery
slowing after that time. There is a push for high-intensity and high-frequency
of therapy while the stroke is still fairly fresh, in order to capitalize on the
“critical window” of the highest responsiveness to treatment.

That doesn’t mean we should stop addressing motor recovery after six months.
What if we still focus on intensive therapy early on in stroke rehab, but also
find ways to promote motor recovery six or more months later? What if we don’t
stop searching for new strategies to improve, or at the very least, not lose
function of the weaker arm?



Can I still improve function if I am in the chronic stage of stroke?
Our understanding of the brain and its capabilities is constantly evolving. We
used to think that adult brains couldn’t change at all after a certain age!
Emerging research evidence suggests there are ways to challenge and improve the
chronic stroke brain months and even years down the road. One large-scale study
involving outcomes from 219 stroke survivors suggested the critical window for
motor recovery may be as long as 18 months! Another recent case study
highlighted motor recovery in a stroke survivor who was 23 years post-stroke!

What types of rehabilitation are effective for people with chronic stroke?
Stroke research suggests the following treatments are promising for individuals
who are at least six months post-stroke:

 1. Mental Practice with Motor Imagery
 2. Constraint Induced Movement Therapy (CIMT)
 3. Virtual Reality (VR)
 4. Preventing Learned Non-Use

Mental Practice with Motor Imagery
This is a type of treatment where a specific movement is rehearsed mentally.
Done best with a pre-recorded audio set, the person listens carefully as a task
is described in detail. The details usually include every aspect of that task,
including how the five senses may be experienced while performing it, as well as
the exact movements that would be needed to complete the task. For example, if
the task were “drinking a cup of water,” the recording would describe how to
reach out with the arm, extend the fingers, feel the weight of the cup,
experience the temperature and the liquid as it touches the mouth, and the
exactness of the motion to set it back down gently.

Studies have shown that with this type of repetitive visualization and practice,
actual movement and functional use of the arm can improve, such that an arm that
was once fairly “useless” can now actually pick up a water cup and bring it to
the mouth. The best part is, research also shows that this can be an effective
treatment 12 months and beyond since when the stroke actually happened!



Constraint Induced Movement Therapy (CIMT)
This is a type of treatment that involves blocking the stronger arm (usually
with a cast or mitt) to promote engagement of the hemiplegic
[https://www.neofect.com/us/blog/hemiplegia-vs-hemiparesis], or weaker arm. The
more a person uses the weaker arm, the less they are at risk of “learned
non-use.” By “forcing” the weaker arm to participate more, and even to be the
primary or only source of function, it has a lot more chance to stay the same or
get better, even years after the stroke happened. In fact, patients in
Constraint Induced studies reported and showed increased use of their arms
during normal activities, even if their strokes happened years before!

Virtual Reality (VR)
Virtual reality is another name for video games! This type of treatment may be
immersive (using a headset) or non-immersive, with a participant engaging in a
game on a screen. VR technology focusing on strengthening and improving limb
function is becoming more prevalent in clinics and in homes. These programs are
able to quantify arm or leg movement to control gameplay and provide immediate
performance feedback.

Research supports the use of VR therapy to enhance motor recovery for adults
with acute and chronic stroke. Virtual reality technology can also improve
motivation in addition to movement outcomes, helping users stick with their
self-training programs and continue using their affected side. Research shows
that chronic stroke patients often find self-training programs that use video
games to be user friendly and enjoyable.



Avoiding “learned non-use.”
We now know more about this phenomenon that affects many stroke survivors -
especially those who are years out from a stroke. The stronger arm starts to
take over to just get things accomplished, probably because there is a lot of
positive feedback for using the stronger arm (It’s faster! It’s easier! I can
just get it done!) and a lot of negative feedback for using the stroke-affected
arm (It’s so frustrating! It takes me forever using it!). Research is showing
that if people can still find motivation and dedication to actually trying to
use the weaker arm, it is possible to still regain function - even years later.

The bottom line: don't give up!
There IS hope. We can’t predict the exact amount of movement or strength that
could come back, or what exactly you will be able to do with your affected arm
or hand. But we are producing more research that is pointing us in the direction
of believing recovery is still possible after that six month critical window.
Don’t give up!

References:

Ballester, BR, et al. (2019). A critical time window for recovery extends beyond
one-year post-stroke. Journal of Neurophysiology, 122: 350-357. doi:
10.1152/jn.00762.2018
Soros, P, et al. (2017). Motor recovery beginning 23 years after ischemic
stroke. Journal of Neurophysiology, 118(2): 778-781. doi: 10.1152/jn.00868.2016
Page, S, Levine, P, and Leonard, A. (2007). Mental practice in chronic stroke:
results of a randomized, placebo-controlled trial. Stroke, 38(4): 1293-1297.
doi: 10.1161/01.STR.0000260205.67348.2b
Kunkel, A, et al. (1999). Constraint-induced movement therapy for motor recovery
in chronic stroke patients. Archives of Physical Medicine and Rehabilitation,
80, 624-628. doi:10.1016/s0003-9993(99)90163-6
5. Taub, E, et al. (1993). Technique to improve chronic motor deficit after
stroke. Archives of Physical Medicine and Rehabilitation, 74, 347-354.
Subramanian, SK, et al. (2013). Arm motor recovery using a virtual reality
intervention in chronic stroke: Randomized control trial. Neurorehabilitation
and Neural Repair, 27(1), 13-23. doi: 10.1177/1545968312449695.