Improving Poststroke Recovery:

Neuroplasticity and
Task-Oriented Training
Richard L. Harvey, MD
Corresponding author
Richard L. Harvey, MD
Stroke Rehabilitation Center, The Rehabilitation Institute of Chicago,
345 East Superior Street, Chicago, IL 60611, USA.
E-mail: rharvey@ric.org
Current Treatment Options in Cardiovascular Medicine 2009, 11:251259
Current Medicine Group LLC ISSN 1092-8464
Copyright 2009 by Current Medicine Group LLC

Opinion statement
Neurorehabilitation is a critical part of the overall process to achieve optimal
outcome after stroke. Presently, the eld of neurorehabilitation is in transition.
New research suggesting novel approaches to optimize functional recovery after
stroke is on the horizon, but clear knowledge of the underlying mechanisms of
this recovery is still being unraveled. In practice, many rehabilitation centers continue to provide traditional compensatory rehabilitation training while many others are practicing newer, task-oriented approaches. A few centers are incorporating new technology, such as computer-based training devices or robotics, into
rehabilitation care. This transition is happening because neuroscientic research
has shown that neuroplastic changes in the cerebral cortex and in other parts of
the central nervous system (CNS) are necessarily linked to motor skill retraining
in the affected limbs. Task-oriented training that focuses on the practice of skilled
motor performance is the critical link to facilitating neural reorganization and
rewiring in the CNS. Therefore, whenever possible, task-oriented training at an
intense level should be incorporated into the rehabilitation program of any patient
with stroke-related motor decits. Two such task-oriented therapies that should
be available at all neurorehabilitation centers are constraint-induced movement
therapy and body weightsupported treadmill training. The optimal intensity of
training (frequency and duration) is still not clear but is certainly greater than that
available in clinical programs. Therefore, the incorporation of automated training
devices will be necessary in the future. However, the engineering necessary to
make these devices effective, easy to use, affordable, and portable remains a challenge for the next decade of neurologic bioengineering research.

Introduction
With improved acute stroke care and secondary prevention,
people with stroke can expect to live longer. There now
are approximately 5.8 million people living with stroke in
the United States, and this prevalence keeps growing [1].
Although 90% of stroke survivors will walk again, with or
without a device, many are challenged because of problems
with balance, motor control, and slow walking speed [2].
Only 50% of people with hemiplegia regain functional
arm use, and fewer than 20% achieve good arm and hand
recovery [3]. Early approaches to addressing the functional

problems of stroke survivors with hemiplegia focused primarily on compensatory training. Thus, persons who had
difficulty dressing because of hemiplegia were trained to
put on clothes, button shirts, and tie shoes with one hand.
Ambulation training involved assistive devices, the use of
ankle orthotics, extensive work on trunk posture, control
of limb dystonia, and careful transition to standing and
weight bearing on the weak lower limb.
These techniques are still common and important
aspects of comprehensive physical rehabilitation post

252 Cerebrovascular Disease and Stroke

stroke. However, today there also is a growing interest in the phenomenon of neuroplasticity following
central nervous system (CNS) injury and its critical
link to task-oriented training. Neuroplasticity is the
capacity of the CNS to modulate its physiology and
anatomy at the cellular level in response to several
internal and external events. Behavioral experience
has been shown to be a potent trigger to neuroplastic change, most notably in the cerebral cortex [47].
Task-oriented training is a form of motor learning that
focuses on skill acquisition in the context of a particular functional activity. Skill is the ability to achieve

a goal with consistency, flexibility, and efficiency [8].

Following stroke, task-oriented training results in
motor relearning by enhancing skill in meaningful
functional activities and is associated with presumably
adaptive neuroplastic changes in the cerebral cortex,
brainstem, cerebellum, and spinal cord [4,5,7,9].
This article describes several novel rehabilitation
techniques that improve motor function in patients
with hemiplegia and proposes a theoretical framework
for motor recovery after stroke. It also discusses functional relearning in the upper limb and the recovery of
walking ability.

Task-oriented training
Task-oriented training in the hemiplegic upper limb
In 1949, psychologist Donald O. Hebb [10] described learning as a
neural process whereby if one cell repeatedly assists in firing another, the axon of the first cell develops synaptic knobs (or enlarges them
if they already exist) in contact with the soma of the second cell.
This concept, later described as Hebbian learning, was scientifically
proven in 1979 by Bliss and Lomo [11,12] in rat hippocampus, in
which they demonstrated that repeated stimulation of the perforant
pathway fibers that innervate the granule cells of the dentate area
results in long-term potentiation (LTP) in response to a single stimulus. LTP also occurs in the premotor and primary motor cortex (M1)
in response to an increase in neural activity and is an essential part
of motor learning and cortical remodeling [13,14]. The strengthening
of synaptic connectivity, especially between intracortical interneurons, and the expansion of movement representations in the motor
cortex occur in response to motor learning, in both the intact and the
injured brain [1416].
A prime example of neuroplasticity and its connection to motor relearning was demonstrated by Nudo and Milliken [16] in 1996 using
intracortical microstimulation to map out hand representation in the
M1 cortex of nonhuman primates (squirrel monkeys). The monkeys
were trained using their dominant upper limb in a skilled reaching and
grasping task that required digital manipulation. After inducing lesions
in the M1 cortex hand region, the researchers found that monkeys
forced to retrain in the task showed reorganization within the remaining movement representation surrounding the lesion site. Those not
trained showed a loss of hand representation. Motor relearning required
the application of a restraint to the nondominant upper limb to prevent
practice with the unimpaired hand, thus constraining the monkeys to
practice repetitively with the impaired limb.
Also, beginning in 1993, Taub et al. [17,18] ran a series of studies
evaluating the use of constraint-induced movement therapy (CIMT) to
improve motor relearning in adults with chronic stroke-related upper
limb hemiplegia. In these experiments, subjects wore a restraint on their
unimpaired upper limb for 90% of waking hours over a 2-week period.
During that time, the subjects also participated in rehabilitation therapy
6 hours a day over the 10 working days of the 2-week trial. Those who
participated in CIMT improved in functional hand use on standardized
laboratory tests and in real-world hand use, and they retained these
skills for up to 2 years post treatment.

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Harvey

253

Recently, the Extremity Constraint-Induced Therapy Evaluation (EXCITE)

trial, a large randomized controlled clinical trial with 1-year follow-up,
confirmed the efficacy of CIMT in subacute patients who were 3 to 9
months post stroke [19]. The subjects had to have at least 10 of active
wrist and finger/thumb extension. Those in the investigational group wore
a restraint mitt on the unimpaired upper limb over a 2-week period and
were given the signature CIMT therapy protocol as described previously.
The control subjects received only usual care. Again, the investigational
subjects showed significant improvement in hemiplegic upper limb use
following the 2-week treatment, whereas control subjects did not. Differences in functional use were maintained throughout the 1-year follow-up.
Variations in CIMT have been studied as well. Providing therapy for 3
hours instead of 6 also results in significantly improved functional use, but
not to the extent of that seen with the longer treatment day [20]. Providing
an equivalent dose of CIMT distributed over several weeks rather than
intensively over a 2-week period also shows promise and fits better with
the distribution of therapy typically seen in an outpatient setting [21,22].
Whether CIMT provided in the very early acute rehabilitation setting after
stroke improves motor recovery is still being investigated [23].
In patients who do not meet the criterion for CIMTthat is, those who
lack active hand movementthere is some evidence that neuromuscular
electrical stimulation (NMES) to the wrist and fingers may have some
efficacy in improving hand movement; however, this therapy seems to be
more effective in those with the least neurologic impairment [24,25]. There
presently is no clear evidence that therapy with NMES can improve functional arm use after stroke [26]. Functional hand training with the use of a
neuroprosthesis that is easily applied to the hemiplegic wrist and hand and
inducing hand opening with NMES have shown some short-term efficacy
[27], especially during the acute phase of stroke recovery [28], and may be
beneficial in patients with minimal wrist or finger movement [29].
Another new method of forced-use training of the hemiplegic upper limb is
the application of robotics and other mechanical devices. The advantage of
these devices is that intensive repetitive arm training can be provided to the
patient with very little supervision from the therapist. These devices do not
fatigue during intensive training as a therapist might, may cost less per hour
of use, and potentially measure improvement in skill very accurately [30].
The MIT-Manus (InMotion2 robot; Interactive Motion Technologies, Inc.,
Cambridge, MA) can provide shoulder and elbow training when the patients
forearm and hand are attached to the robots arm. Exercises are performed
in the horizontal plane with an interactive computer screen as the patient
reaches for targets. This device can facilitate improved arm movement and
strength [31,32]. Another robot, called the Mirror Image Movement Enabler,
can provide assisted and resisted arm movements in multiple planes and
is more effective than conventional therapy in improving free arm movement [33]. Other robotic devices include the Assisted Rehabilitation and
Measurement Guide [34] and a bimanual training robot [35]. Hemiplegic
arm training also has been tested using a computer gaming system (virtual
reality) with a device called the T-WREX (Training-Wilmington Robotic
Exoskeleton), which provides an adjustable exoskeletal arm that passively
counterbalances the weight of the arm with elastic bands. This device, now
available commercially as Armeo (Hocoma Inc., Rockland, MA), has shown
some efficacy and is quite motivating for patients to use as they practice arm
movements while a virtual hand performs tasks on the computer screen [36].
Although robotic and virtual reality systems may have efficacy for upper
limb motor relearning, their use is limited by their cost. Additionally, robotic
training of digit manipulation and precision hand function is not yet feasible.

254 Cerebrovascular Disease and Stroke

These novel interventions for task-oriented motor relearning demonstrate that with intensive repetitive skill training, patients with acute and
chronic upper limb hemiplegia can regain and maintain some potentially
functional movement of the hemiplegic arm. Future research will explore
the most practical ways to facilitate this type of training using combinations of CIMT techniques, NMES, robotic devices, and virtual reality.

Task-oriented gait training and the recovery of walking after stroke

Following stroke, there are neurologic changes in the hemiplegic lower limb
that disrupt gait function. In addition to weakness, the essential problem in
hemiplegic gait is the abnormal timing of muscle contraction and relaxation
throughout the gait cycle [37]. Most simply, the quadriceps muscles remain
active through most of the gait cycle, including the swing phase, when the
limb is advanced toward the next step. In addition, the gastrocnemiussoleus complex and ankle inverters turn on during the swing phase but often
fail to provide stability during the stance phase of gait. If the patient does
not have a severe problem with dynamic standing balance, these muscle
timing problems typically do not prevent walking, but they do cause a slow,
stiff-kneed, asymmetric gait that does not accommodate well to perturbations or uneven walking surfaces [38]. The best rehabilitation technique
for walking after stroke is to walk, but the practice of walking over ground
often is hampered by the patients unwillingness to bear much weight on
the hemiplegic lower limb, his or her own fear of falling, and the real safety
concern of having a patient walk at a faster pace.
In the past decade, there has been increasing interest in the use of several
treadmill systems to safely improve walking in patients with hemiplegia.
The most common gait restoration system available in physical therapy
clinics is body weightsupported treadmill training (BWSTT). The practice of gait training on a treadmill with a body weight support system
was first described by Finch and Barbeau [39] in 1985 and first tested
as a gait restoration therapy for stroke by Hesse et al. [40] in 1994.
The concept of restoring walking ability using BWSTT originated from
studies examining preserved locomotor function in spinalized cats [4].
Paraplegic cats with spinal cord lesions maintain stepping ability when
placed on a treadmill. This locomotor ability is supported by presumed
spinal circuitry called the spinal central pattern generator, described by
Grillner and Wallen [41] and verified in lower vertebrate models [7].
BWSTT uses a standard treadmill and an overhead counterweighted
cable system with a rock climbingstyle harness (Fig. 1). Patients with
stroke-related hemiplegia can be placed in the harness with overhead
support while standing on the treadmill. The counterweighting system
can unload up to 40% of the patients weight. With the treadmill in
motion, the patient can then practice a reciprocal walking pattern. To
avoid dragging the hemiplegic leg, the therapist may need to assist in
advancing the weak limb through the gait cycle. As training proceeds,
the therapist can withdraw assistance to the hemiplegic leg, progressively
reduce body support down to 0%, and increase the treadmill speed.
Gait retraining using BWSTT has shown efficacy. It clearly is superior
to traditional rehabilitation therapies for stroke, such as neurodevelopmental techniques in which patients practice balance and weight bearing before stepping and walking [42]. Patients who train with BWSTT
also achieve better gait speed, improve balance, and have better motor
recovery than patients trained with over-ground walking, resistive leg
cycling, or treadmill walking without body weight support [43,44].

Improving Poststroke Recovery: Neuroplasticity and Task-Oriented Training

Harvey

255

Figure 1. Body weightsupported treadmill

training. The patient has up to 40% of load
off his body weight with a counterweight
system and harness. The treadmill speed can
be adjusted over time. The therapist often
must assist in advancing the hemiplegic leg
with every step.

A recent study indicates that the addition of timed electrical stimulation of the hemiplegic lower limb muscles during BWSTT may further
facilitate recovery of over-ground walking [45].
Unfortunately, the amount of time a patient can use BWSTT is limited by
the amount of physical effort the therapist can tolerate in a session during
which he or she provides assistance in advancing the weak leg. In practice,
therapists fatigue after 15 to 20 minutes. To resolve this problem, there have
been efforts to design robotic systems to replace the need for physical assistance from the clinician. One such system, called the Lokomat (Hocoma
Inc., Rockland, MA), is a treadmill with a counterbalanced harness system

256 Cerebrovascular Disease and Stroke

Table 1. Six principles of task-oriented motor training necessary to

achieve improved motor skill and perhaps function
Specicity of training
Constrained use of the impaired limbs
Mass practice (repetition)
Shaping of skill
Saliency of task
Knowledge of performance and results

plus a motor-driven leg orthosis that produces a reciprocal walking pattern

timed with the motion of the treadmill belt. Thus, it can produce a near-normal walking pattern, even in nonambulatory patients and without human
assistance. The Lokomat has been tested in patients with stroke, demonstrating efficacy equivalent to that of the neurodevelopmental technique
described earlier [46], but it is inferior to therapist-assisted BWSTT without
the robot [47]. The likely reason that Lokomat fails in comparison with
BWSTT is that the robot does not challenge the patient to put any effort
into walking during training, whereas in BWSTT, the therapist plays a key
role in progressively removing supportive assistance.
Most stroke patients will practice walking over ground once they can
do so safely. However, there is still a role for treadmill walking without
body weight support in patients who are functional ambulators. Treadmill exercise enhances gait speed and aerobic capacity in patients with
stroke and can facilitate gait-related neuroplastic changes based on functional MRI [48]. Structured episodic speed training on the treadmill
also may improve over-ground walking speed significantly [49].

The principles of task-oriented training after stroke

The preceding examples of task-oriented motor training highlight certain principles that likely apply to any intervention that may be expected
to improve motor control and function after stroke [50]. These principles are listed in Table 1. First, task-oriented training must focus on
the task being learned. Thus, there is specificity in motor learning. For
example, walking skill is best achieved by treadmill training, then by leg
cycling or merely strengthening the lower limbs [43].
Second, as highlighted by CIMT, the patient must be constrained to
perform the functional task during training with the impaired limbs.
In addition, the patient should not be able to perform compensatory
techniques to achieve the therapeutic goal. For example, in CIMT, the
patients unimpaired hand is restrained so that it does not inadvertently
assist the impaired hand while performing training tasks. In BWSTT, the
patient is in a supported harness with feet on the treadmill while the belt
is running, which constrains the patient to walk. The therapist assists
only to assure proper advancement of the impaired leg.
Third is the principle of mass practice, described by Taub et al. [51] in
the context of CIMT. Repetition of training facilitates learning. The
intensity of multiple repetitions of a task solidifies neuroplastic changes
in the CNS and improves performance.
The fourth principle, shaping, a term from behavioral psychology, is
the process of progressively increasing the complexity of a functional
task by successive approximations over time. Patients with stroke, when
attempting a novel task, will be frustrated easily if it is too difficult. By

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Harvey

257

breaking the task down into parts and starting with the simplest motor
tasks first, the therapist can increase the complexity over time until the
patient can complete the functional skill, always challenging the patient
within tolerable limits.
Fifth, the tasks being learned should be salient to the patient. The relative importance of a functional task to the patient stimulates motivation
to learn and practice. Walking is a vital task for most stroke patients,
and motivation for training is always high. For upper limb training,
making a meal may be important to one patient but not to another.
Playing cards may be essential to a patient whose social life is structured
around playing bridge with friends. The tasks used to train a patient
should be selected based on the patients goals and personal needs.
Finally, knowledge of performance and results is well known to be
important in motor learning [52]. For example, it would be difficult to
learn how to serve a tennis ball if one never saw where the ball landed
following an attempted serve. Good coaching and feedback on the
serving technique may be vital to achieving a high-quality serve. Feedback also is critical in motor learning after stroke. In most cases, this
is provided directly by the therapist, but there is growing interest in
enhancing sensory feedback during motor training to improve learning
and outcome [53]. The best means for providing enhanced sensorimotor
feedback remains under investigation.

Disclosure
No potential conflict of interest relevant to this article was reported.

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