Stop Learned Non-Use to Improve Stroke Recovery

NeuroRehab Team
Wednesday, December 21st, 2022

If one asked 10 new stroke survivors the following question, what do you think they would say?


“Would you rather spend most of your time learning compensatory one-handed strategies with your unaffected side, or would you rather focus on improving strength, range of motion and function in your affected limb?” That’s a big question.


Patients often express frustration with the lack of attention paid to their affected side during the subacute stage of stroke. Therapists have spent too many hours on one-handed compensatory strategies instead of providing interventions that improve the affected limb.


“If they only worked on this early on” or “this is the first time I have ever tried this”.


Research shows the average number of reps reported in an OT subacute session is about 30.  (Kimberly et al., Lang et al.)  Not even close to what is needed for recovery (should be hundreds!). Therapists learn how to improve independence following an injury, disease or disorder.  They will modify a task so patients can be independent,as quickly as possible.


Although driving independence after an injury is great, could we be causing more harm than good when it comes to neuro recovery? For example, following an ischemic stroke, an area of the brain (i.e., core) loses blood supply and begins to die. The area immediately surrounding the infarct (penumbra) experiences cortical “shock and awe”.


Although it is affected, it is still alive. As the surrounding tissues heal over the next several months, it enters the “cerebral sweet spot” for recovery (Dromerick et al). As the brain gets more feedback from the impaired limb, the penumbra will reactivate and engage the affected side in a neuroplastic way.


Unfortunately, many stroke survivors are set up to fail thanks to the pressures of insurance payers, inpatient rehab discharge processes and faulty guidance by the therapy profession. Instead of focusing on bombarding the affected brain with the necessary stimulation at the time it needs it the most, we are spending this critical window providing compensatory one-handed strategies, ultimately leading to learned non-use and debilitating setbacks.


The portion of the brain responsible for the affected arm and hand shrinks the more we avoid using it.


Sadly, the concept of “use it or lose it” has long been replaced with gross imbecility.  It is unethical and profoundly contrary to the principles of science and neurorehabilitation to pressure clinicians to focus on ADL independence, regardless of the affected side’s involvement.


Yes, patients need to be independent with ADL’s, but it shouldn’t take a majority of their treatment time. As science has now confirmed, the clock dictates the outcome for many patients. We need to be smarter with our therapy time and intervention choices.


Let’s take a page out of Greg McKeown’s book “essentialism” where he talks about the disciplined pursuit of less and embrace the 80/20 rule: most sessions should drive neuroplastic changes to the brain. With guidance from the clinician, patients can practice many of the basic ADL tasks with their loved ones at home. They can also watch videos and read self-guided instructions on proper ADL techniques from head to toe.


Stroke recovery is hard enough. Let’s not make it harder! Learn more about stroke recover tools by visiting the


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