Sometimes It’s The Therapist Who Plateaus; Not The Stroke Survivor

“This patient isn’t motivated.” "That patient has #plateaued."

Plateaus aren't always this pretty...

Clinicians often place the blame for slow #therapy response on their patients. But let’s call it what it really is: a cowardly smokescreen. In most cases, the problem is neither the #strokesurvivor's effort, nor the adaptability of his/her nervous system: It’s the therapist and/or the system in which the patient is being treated.

The Clock Starts Too Early and Ends Too Soon

As I've written elsewhere, #strokerecovery doesn’t follow a tidy arc. Functional gains occur months and even years post ictus, especially with targeted, high-repetition practice1.

Unfortunately, insurance companies don’t operate on biological timelines. And therapists (literally) have to check a box in the medical record indicating the reason that they are discharging a client, while also communicating to the client the rationale for terminating therapy.

Take the example of a gentleman treated by one of my former colleagues; a 62-year-old recovering from a left MCA #stroke. He was discharged from inpatient #rehabilitation after just 10 days. And, insurance only approved him for outpatient services (ie, my former colleague's services), occurring just two visits per week over a six week period. That’s twelve sessions in total; barely enough time to re-learn how to stand safely, let alone return to his job in an office environment.

By the time he started acclimating to therapy and his home program, it was literally time to #discharge him. What did his chart say? “Lacks motivation.” What did his therapist tell him? "You have plateaued."

We Train for Transfers, Not Transformation

The hospital where I earned my post doctoral fellowship was where Cristopher Reeve, Ben Vereen, and many others were carrying out their rehabilitation. ON more than one occasion, I shared an elevator with Dudley Moore. Another time, I walked downstairs to the outpatient gym to say "hello" to my outpatient therapy colleagues (something that, sadly, my learned colleagues in research never did) and Yogi Berra was testing out his new knee. Christopher Reeve was a critic of the content and length of stay for inpatient rehabilitation, stating that it's goal was to "treat 'em and street 'em." In other words, he believed that the goal of inpatient therapies was often to provide superficial care with a focus on volume and throughput over long-term outcomes that benefitted the patient.

The fact is that we’ve built entire rehabilitative care and assessment protocols around discharge readiness rather than human potential. Our rehabilitation system largely incentivizes quick, competency-based, patient training: can they toilet safely? Can they feed themselves? Can they transfer from bed to chair? Great. Discharge them.

The unsavory truth is that therapists often train people to function at a minimum, then blame them when they aren't pushed beyond those levels. But what if we trained them for maximum potential from day one?

Low Dose, Low Passion, Low Results

The science is clear: duration matters. In animal models and human trials, high-repetition, task-specific training drives cortical reorganization and improved motor outcomes. Yet in outpatient settings, it’s common for stroke survivors to perform just 30 to 40 upper limb movements in an entire session2.

Imagine telling a marathon runner to train by jogging for 3 minutes twice a week. And then acting surprised when they don’t improve.

Let’s take Ms. R, a retired teacher with moderate hemiparesis. She diligently attended therapy but rarely broke a sweat. The focus? Light stretching, one round of cone stacking, and sit-to-stands. When her progress plateaued, she was told, “You need to work harder at home.”

But she wasn’t lazy. She was under-dosed. That's a failure that should be owned by her treating therapist; not blamed on a "plateauing" nervous system or her motivation.

Blaming patients for low motivation:

• Justifies short stays.

• Protects productivity quotas.

• Makes us feel better when they don’t improve.

But it doesn’t serve recovery.

(The Obligatory) Call for Systemic Change

This is always the hardest part of these blogs for me to write. But, without suggesting change, I'm just a complainer. So here goes: We can’t keep expecting recovery when it's ensconced in a broken model. We, as therapists, need:

✅ Reimbursement policies that reflect scientific literature and recovery potential, not arbitrary limits.

✅ Ongoing support beyond acute care, including community reintegration programs, group exercise, virtual therapy, and peer mentoring. Ironically, "comprehensive" stroke centers are not incentivized to provide outstanding support (let alone care) in the post acute phase (something that I've also discussed previously)

✅ Education for clinicians to recognize default of “patient blame.”

✅ Metrics that matter.

Stroke survivors want to get better. Our job is to give them the structure, time, and belief system to make it possible.

Motivation Isn’t the Problem. We Are.

The next time you're tempted to a patient as unmotivated, ask instead:

• Were they given the time they needed?

• The reps they required?

• The dignity of high expectations?

• Most importantly, can I justify keeping them for a little longer to address the above shortfalls?

If the answer to any of these questions is no, maybe we’re the ones who need to try harder.

References:

1. Page, SJ, Peters H. Mental practice: Applying motor PRACTICE principles and neuroplasticity principles to increase upper extremity function. Stroke, 2014; 45(11): 3454-60.

2. Hayward KS, Brauer SG, Ruddy KL, Carson RG. Dose-response relationships in stroke rehabilitation: knowledge gaps and future directions. J Neurol Phys Ther. 2021;45(1):3–13.