I get asked a version of the same question in almost every stroke assessment.
Is it still possible to improve?
Usually the person asking has already been told that it isn’t. Or, at least, that whatever was going to come back has come back.
My answer is that the brain follows a fairly well-described set of rules when it reorganises itself, and that those rules don’t include an expiry date.
They do, however, include some conditions.
Recovery isn’t automatic.
It happens when the right kind of practice is delivered in the right way.
Neuroscientists Jeffrey Kleim and Theresa Jones set out ten principles of experience-dependent plasticity in a paper that has shaped a great deal of modern neurorehabilitation. Here they are, in plain terms, and what each one actually means for you or your relative.
1. Use It or Lose It
Neural connections that aren’t used weaken over time.
This is the principle behind almost everything that goes wrong slowly after a stroke. The affected arm gets used less, so the pathways controlling it get less input, so it becomes harder to use, so it gets used even less.
I see this constantly with upper limbs in particular. Within months the arm has effectively been retired — not because it couldn’t do anything, but because nothing required it to.
In practice: the affected side needs to be given jobs, deliberately, every day.
2. Use It and Improve It
The flip side, and the encouraging one. Training a particular function drives improvement in that function.
In practice: this is why doing something is so much better than waiting to see. The brain responds to demand, and it needs demand to respond to.
3. Specificity Matters
The nature of the practice determines the nature of the change. Training one thing doesn’t automatically improve something else.
This one gets overlooked. If your goal is confident walking outdoors on uneven pavements, practising walking up and down a flat hallway isn’t the same task.
In practice: the training has to look like the thing you’re trying to get better at. That’s why I want to know what your actual goals are before I write a programme — because the programme should be built backwards from them.
4. Repetition Matters
Producing lasting change requires sufficient repetition. Not a few, and not a session’s worth.
This is where a great deal of stroke rehabilitation quietly falls short, and I’ll come back to it properly in the companion article — but the numbers from research into what actually happens in hospital therapy sessions are sobering.
In practice: the question isn’t whether you’re doing your exercises. It’s how many repetitions you’re actually accumulating in a week.
5. Intensity Matters
Sufficient intensity is required. Low-intensity practice may produce little change, whatever its duration.
In practice: gentle, comfortable movement has its place, particularly early on. But at some point the work has to become genuinely demanding, or the brain has no reason to reorganise. Safe doesn’t have to mean easy — and in my experience, under-challenging someone is a far more common error than over-challenging them.
6. Time Matters
Different forms of plasticity occur at different times during recovery. There’s a period in the early months when the brain is at its most responsive.
In practice: early, well-directed rehabilitation matters enormously, and I’d always encourage families to get input organised quickly.
But — and this is important — “time matters” is not the same as “time runs out.” The early window is the most fertile. It is not the only one. I have worked with people making meaningful gains years after their stroke, and the principles above continue to apply.
7. Salience Matters
The experience has to be meaningful to the person for plasticity to occur.
This is one of my favourite principles because it’s so often ignored. A brain doesn’t reorganise for an exercise sheet it doesn’t care about.
In practice: if your goal is getting back to the garden, then the programme should involve reaching, gripping, carrying and standing on uneven ground — not twenty repetitions of something abstract. Meaningful tasks are better rehabilitation and people actually do them.
8. Age Matters
Plasticity occurs more readily in younger brains. That’s the honest version.
But the brain remains plastic throughout life, and this principle is routinely misused to justify offering older people very little. A slower rate of change is not the same as no capacity for change, and I’ve watched people in their eighties make gains that surprised everyone including themselves.
In practice: age changes the expected pace and shapes the programme. It shouldn’t lower the goal.
9. Transference
Training one skill can enhance the acquisition of related skills.
In practice: work on sit-to-stand strength tends to help with stairs. Work on balance in standing tends to help with turning. A well-designed programme exploits this deliberately — choosing exercises that pay off in more than one place.
10. Interference
Plasticity in response to one experience can interfere with acquiring other behaviours.
This is the principle behind learned non-use. If the brain gets very good at completing tasks one-handed, that compensation becomes the established pattern — and it competes with recovering the affected side.
In practice: compensation is sometimes necessary and appropriate. But it’s a decision that should be made deliberately, not by default, because the strategies you adopt in month two can become the ceiling in year two.
What These Add Up To
Read them together and a fairly clear specification emerges for what stroke rehabilitation should look like.
It should be specific to your goals. It should be repeated enough to matter. It should be intense enough to challenge you. It should be meaningful to you personally. It should be started early but not abandoned late. And it should be careful about which compensations become permanent.
That’s a demanding list, and it’s a considerably higher bar than “here’s a sheet of exercises.”
It’s also why I don’t accept the idea that recovery simply stops. When someone stops improving, my first question is never “has the brain reached its limit?” It’s “is this programme actually meeting those conditions?”
Far more often than not, the answer is no — and that’s a fixable problem.
What I’m Not Saying
I want to be straight with you, because false hope helps nobody.
These principles don’t guarantee full recovery. Strokes vary enormously in what they damage and how much. Some function doesn’t return, and part of good rehabilitation is being honest about that while working hard on everything that can change.
What I am saying is that “you’ve plateaued” is a conclusion that should only be reached after somebody has genuinely tested it — with a programme built along the lines above. In my experience, that test frequently hasn’t been carried out.
The Medical Side Still Matters
Rehabilitation sits alongside your medical care, not instead of it. Blood pressure, cholesterol, atrial fibrillation, diabetes and medication all matter for reducing the risk of a further stroke, and those conversations belong with your GP and stroke team.
Please also mention any new symptoms — increasing spasticity, worsening fatigue, low mood, swallowing difficulties, pain in the shoulder of the affected arm, or a change in your walking — rather than assuming they’re just part of it. Several of these are treatable.
And If You See These Signs, Act Immediately
If you or somebody with you shows sudden facial drooping, arm weakness, or slurred or confused speech, call 999 straight away. Time is critical with a new stroke, and that applies just as much to someone who has already had one.
Let’s Test Whether You’ve Really Plateaued
If you’ve been told that this is as good as it gets, I’d want to know what programme that conclusion was based on before accepting it.
At Simpson Physiotherapy, my team and I are neuro-specialist physiotherapists working with stroke survivors across Glasgow. We’ll assess what’s actually limiting you, set goals that matter to you rather than to a form, and build a programme designed around the principles above — with enough specificity, repetition and challenge to give your brain something to work with.
We see people at our clinic in Bearsden, and where getting to us is difficult we provide rehabilitation at home.
We offer a free discovery visit at no cost and no obligation — a chance to talk through where you are, what you’d like to get back to, and whether we’re the right people to help.
