Study reveals why brain has limited capacity for repair after stroke

I couldn't tell from reading this if this doesn't apply in my case since I am 4.5 years post-stroke but maybe it could help in the hospital stage.
Study reveals why brain has limited capacity for repair after stroke

sleep enhances motor memory post-stroke

I wish they would write this stuff in understandable English. Even a careful reading did not give me any clues as how to use this knowledge to help my recovery.
Sleep Enhances Motor Skill Learning and Memory Consolidation

I do wonder about the comment in this paper that
Sleep is important for motor learning and memory
consolidation in young neurologically intact individuals
but not for older individuals. What is the definition of an older individual?
I did like these final comments
•Clinical Implications:
• May lead to an emphasis on the need for sleep
between therapy sessions (I did that in 10 minutes)
• Address underlying sleep disorders - my sleep apnea was never found during my stay at the hospital

I did email one of the authors asking about what young meant but no reply

Theoretical basis of stroke rehab

 And we wonder why there are so many stroke forums and websites set up by survivors trying to understand stroke rehabilitation. I doubt the US is any better, no survivor has ever posted any understanding by their doctors or therapists on stroke rehab.
http://informahealthcare.com/doi/abs/10.3109/09593989409036399
As in the Swedish study, although the respondents were able to describe their treatment choices, they had difficulty explaining the underlying theoretical basis for their choice. Difficulty providing a scientific and rational explanation for intervention may have implications for the future development of physiotherapy as a clinical science.
In a survey of Swedish physiotherapists working in neurology, the treatment of individuals following stroke was found to be essentially praxis-oriented (What?)(Nilsson and Nordholm, 1992). The present study replicated the Swedish survey in order to compare the responses of Australian physiotherapists with those of their Swedish colleagues. The questionnaire, designed to establish choice of treatment, factors influencing and theoretical bases for the choice of treatment, and attitudes towards new methods, was sent to the 331 members of the Neurology Special Interest Group of the Australian Physiotherapy Association. The response rate was 72%. Respondents viewed experience working with patients as the most important factor influencing current choice of treatment. As in the Swedish study, although the respondents were able to describe their treatment choices, they had difficulty explaining the underlying theoretical basis for their choice. Difficulty providing a scientific and rational explanation for intervention may have implications for the future development of physiotherapy as a clinical science.

This study comes to the same conclusion Determinants of research use in clinical decision making among physical therapists providing services post-stroke: a cross-sectional study

We're screwed, doctors say they know nothing, therapists don't have any basis for their therapies. We are all completely on our own. I think we are all going to have to go to medical school ourselves. Wait, that won't work either, the instructors probably don't have any clue either. Ok, survivors set up their own school and training and we get medical staff to pay us for our knowledge in stroke rehab.

And I bet I have a better understanding of the theoretical basis of stroke rehab than those physiotherapists. Read my posting on What my doctor should have told me about stroke recovery

triking and dangerous stroke rehab

When I went looking for a trike, after 1 year 2 months, my choices were a cool looking recumbent or the staid upright. I really wanted the recumbent because it looked cool and fast and nothing I was doing anymore was fast.
But there was no way  I could hold my left foot on the pedal unless I wanted to get biking shoes with the builtin clips and the pedals to go with. And since I can't tie shoelaces that ruled this out.  So I got the staid one.
This is an upright trike with the huge basket in back. Talk about feeling ancient. I took it out on the bike path that runs along the West River road in front of our house. I got about 100 yards down the bike path when  I tipped the trike over. So Emma went back home for elbow pads and bandaids. It comes with a coaster brake, single speed, and a single brake lever for the front wheel on the right handlebar.  With 20+ years of  bicycle commuting I figured I knew how to ride, but I needed to unlearn the idea of turning the bike by leaning and also to relearn how to use the coaster brake. From one of the websites selling 3 wheel adult trikes comes this quote.'Enjoy cycling without the need to balance'.  I think for those of us who come to this from many years of regular biking, this is an extremely dangerous piece of equipment, at least until you retrain your old habits. Speed is definitely not something that will occur on this trike. You have to constantly be on the alert to make sure it is pointing straight ahead, there is no margin of error. There are biking trails on old railroad beds near our house, great for practicing on level paths. Year 2 of recovery I would do an 18 mile loop in 4 hours. In year 3 I got it down to 3 hours mainly because I finally got a 3 inch longer seatpost so I could have better cycling form. In year 4 the loop still takes 3 hours, I haven't done enough riding this year.  You can read about my plans to get back to a two-wheeler here.

lack of visibility for stroke survivors

This was a great article on the lack of visibility for stroke survivors.
Bringing stroke out of the shadows
Shame, lack of attention still surround disease despite its prevalence
http://www.baltimoresun.com/news/opinion/oped/bs-ed-stroke-20101028,0,4151798.story

My take on this is that not until survivors get into positions of power in the stroke associations and the World Stroke Organization will visibility change. The other unmentioned problem is that stroke is seen as an old persons disease and they just need to pass the time until they die.

world domination vs. stroke rehab protocols

Which is easier? I would go with world domination. Getting standard stroke rehab
protocols would be like pushing an al dente noodle up a mountain. All the stroke
associations have a vested interest in the status quo, therapists would have to
realize that their training was incomplete, Doctors would lose their mythical know
everything status.
Hippocratic dictum that ‘It is impossible to cure a severe attack of apoplexy and difficult to cure a mild one’
In 2400 years not much has occurred.
I hope we get something in the next 10-20 years.

Oh well, thats what happens when a stroke-addled brain thinks logically. And because I am so stupid I am working on the harder task of getting standard stroke rehab protocols.

woodworking and stroke rehab

I used to do a fair amount of woodworking, I have the tablesaw, several routers, mortiser, planer, jigsaw and pneumatic nailers and staple guns.I built the medicine chest and cabinet for the bathroom. also the complete upper and lower kitchen cabinets. Our compost bin was falling apart so one weekend when my wife and daughter were out of town I cut cedar 2x4s to length on the tablesaw using my sliding sled, They were butt nailed with my pneumatic nailer and the screening attached with my pneumatic stapler. I was quite proud of my accomplishments. However my wife saw it differently as a complete lack of higher reasoning. In her defense she had recently seen me sneeze at the kitchen table during supper and sweep the plate and glass from the table with my left arm, breaking them. Her reasoning being that woodshops produce dust, dust causes sneezing, and cutting off the non-functioning hand is not a good idea. I however reasoned that only doing crosscuts and doing them with a sled would keep my left arm at least two feet away from the blade at all times. The end result was that I was banned from the workshop. She did the next year give me a gift of a beginning woodturning course at the North House Folk School in Grand Marais, MN and the next Christmas got me a lathe. She thinks that because no sharp objects are spinning it is safer. When I relate this idea to woodturners I have met they invariably mention how many holes are in their walls from chunks of wood flying off the lathe. And then there was the story from the woodturning association I joined. It seemed that during a demo the month prior to me joining that there was an individual standing behind the demonstrator. The demonstrator had on the apron and full face shield, his turning gouge caught on the wood and was thrown over his shoulder. The bystanders eye was put out. I do wear safety gear when turning but I haven't related any of these horror stories to her yet.
My hope with this as rehab is first that the vibrations of the gouges on the left hand will wake them up proprioceptively and then start on the motor control.

Don't even think of doing anything as stupid as this. Remember your doctor has to ok all your rehab and check with your spouse also.

black hole of stroke rehab knowledge

A common question from survivors is, 'what should I do to have the best chance of recovery and my doctor hasn't told me anything useful?
You have hit the black hole of stroke knowledge. Nobody will tell you anything because they don't know.
If your doctors were good they would show you a 3d image of your scan mapped onto a brain and describe the penumbra damage and what functions were damaged. Then they would describe the dead brain areas and the functions those covered. You can try asking your doctors again but they will use the Sargeant Schultz reply, ' I know nuthin'. The problem is that everyone looks at the symptom of the deficits rather than the cause, which is the damage to the brain. You probably need to train your doctors in these concepts.

Standard response to stroke rehab questions

Since I post in numerous forums and there are lots of questions on what to do next I came up with this standard response. Of course this does contradict what you will hear from your medical staff; 'All strokes are different, all stroke recoveries are different.'

The whole problem here is that the medical world does not have any clue as how to approach getting stroke survivors back to full recovery. They are hoping that your spontaneous recovery in 6-12 months is enough to satisfy you. What needs to be done is identify the penumbra and those functions, these are helped by standard therapy protocols because you still have a limited ability to do those functions and repetition will help recover them. The second part is to identify the dead brain area and the functions they covered. This requires a totally different approach, mainly you need to neuroplastically move those functions to another part of your brain. Some therapies than might be able to accomplish that are; mental imagery, passive movement, mirror-box therapy, thermal therapy. I would say your crucial answer is to completely understand neuroplasticity and find therapists who understand how to do that. But what the hell do I know, I'm just a stroke-addled survivor,

car driving and stroke rehab

I got back to driving after 1.5 years. My doctor never cancelled my license, but my spouse had me take an adapted driving assessment anyway to check my reaction times and have a driving test with a car with an automatic transmission and a spinner knob on the steering wheel. I'm right handed - my good side so I would have to reach around the steering wheel to turn on the turn signals. That is the hardest thing to coordinate because you have to be going straight while doing this. I didn't have left neglect so that was not an issue. Had to buy a new vehicle with automatic transmission since the two we had were manuals.  I've been driving for over 3 years now I do have to pay a lot more attention to what I am seeing, checking the mirrors constantly since blind spots are harder to see into. Backing up is something I try very hard not to do. One constant problem is where to put my spastic left arm, if I put it on the outside of my left leg , that pushes the leg into the steering wheel. So it is possible but you may have to solve some problems on your own. You are limited in when you can change the radio/CD player, work on the defroster/heater. You basically have to wait until you are stopped to do anything else. There is no multitasking when driving, no drinking coffee, sodas, pop or eating snacks, even talking is sometimes too much.

My first woodturning class in Grand Marais was in March 2008 and driving home at dusk, a deer ran in front of my car. I managed to at least slow down a little by hitting the brakes, killed the deer, kept the car on the road. Luckily it was still driveable. Since  it was a deer accident it was fully covered by comprehensive with no deductible. Some 3500 dollars in damage.

Took a homebrewing class 2 years ago at North House Folk School in Grand Marais,MN about a 4.5 hour drive for me. Last year I looked at my turn signal and tried to figure out a way to start using the affected left arm to turn it on and off. Since I can't lift my arm when sitting I thought about putting my arm on the window edge but it just slid right down. So I bought a gel padded arm rest that slides into the window opening about 3x6 inches. My pectoral spasticity just pulled my arm right off the pad. So I thought some more and bought some velcro straps and attached them to the pad and velcroed my arm to the pad. The pectoral took over again and after 1 minute pulled the whole thing from the window. So on the drive up I thought I would just loop the velcro over the car door frame and attach it to my wrist brace, mainly to try to quiet down my pectoral by keeping it in a stretched form and keep my arm straight relaxing my bicep. I was sucessful at that for about two hours when my bicep started flexing and I had to stop because the weight wasn't distributed properly. I needed more velco in order to pull the whole arm forward and another piece to hold up my elbow. So I went to Joynes Ben Franklin in Grand Marais and got more velcro. On the way home the setup worked for an hour. I can't move my arm to reach the turn signal but my objective has now changed to stop the spasticity in my bicep and pectoral which it does seem to help. This is only possible on long trips since it takes about 20 minutes to setup.

This is not medical advice, don't try this at home.

I went on a road trip to an Elderhostel program in Santa Fe,NM, Brain Skills Training in March 2010. I had to choose between flying there and driving. Driving won hands down. Cost was the same, I hate having to lug my luggage thru airports, especially trying to carry bags and walk with a cane so I don't tip over. I'm left side affected and I wanted to get in three days of driving therapy. I would put my left hand at the 11 o'clock position and just leave it there,. This meant hours of spasticity reduction in my bicep and pectoralis. My wrist was also cocked up at 80 degrees. I don't trust driving with my left arm alone so my right hand would always be on the spinner knob at the 4 o'clock position. Luckily I coud rest my right elbow on the center console. Changing CD's or radio stations would mean coming to a stop to do it. When my left arm got tired I would put it between my legs and sit on the thumb with the fingers dangling loose, this wasn't quite as effective in reducing my spasticity but still allowed hours of enforced stillness.

In order to combat the fatigue I still experience, I would get a large coffee from the motel and one hour later stop and buy another one. Drinking it did require stopping. This had a two-fold advantage, the caffeine kept me alert and the urge to urinate made me stop at almost every rest area.

As one survivor wrote about her walking, she had to "brain" her walking. In my case I had to expend 100% of my brainpower to drive. On Friday I drove 7.5 hours to Omaha,NE from Minneapolis including 4 hours in a snowstorm through Iowa. On Saturday I drove 9 hours to Denver. On Sunday I drove 6 hours to Santa Fe. I can see why the speed limits are 75 mph in NE, CO and NM, it takes forever to get any place.

No problems encountered on the drive.

On the way home I did get pulled over by a Nebraska trooper for weaving in the lane. This was because I had just gotten my left hand on the steering wheel coming down the on ramp and hadn't fully gotten control with my right hand. In the process of getting pulled over I had to switch lanes on the Interstate, which I did without signaling because I would have had to use my right hand over the steering wheel and I didn't want to lose control with a trooper right behind me. So I got a warning for inattentive driving, not signalling and not carrying car registration. I don't think he ever realized he was talking to a stroke survivor and I sure wasn't going to explain to him why I weaved and didn't signal.

Don't make any assumptions that if I could do this you can. Consult with your medical staff on your feasibilty. Of course I didn't but the OT that gave me the driving and reaction test said I did ok. And with 3 years of driving under my belt I feel pretty confident. This past summer I came up with another way to stretch my spastic left arm. I roll the drivers window all the way down and let my left arm dangle as much as possible outside the window. A couple of weeks ago I went to a Peter Levine seminar in Des Moines, IA which is a 4.5 hour drive. On the night drive down I did this for 1.5 hours until it got too cold. The wind blowing through the hand/fingers was great for getting additional sensory input to my brain. On the way back home I did the same thing again for 1.5 hours until it started to rain. That was very nice to feel because it felt like my hand was getting sandblasted. Great for overstimulating my sensory inputs.

Remember your medical staff has to ok all therapy, you didn't hear about this from me.

plane rides and stroke rehab

Ok this is just posted for fun.
What happened on my first plane flight?
On my 50th birthday my wife put up a series of questions about me for the guests to see how well they knew me. This was three months before my event.
The one I liked best was:
What happened on Deans' first airplane flight?
1. He got on the wrong plane and ended up in Fargo,ND
2. He got sick and threw up in his briefcase.
3. He jumped out.
And the answer is 3. He parachuted out.
I know this isn't a stroke related response and I certainly don't recommend this as a therapy.
One of the preparations for this was jumping from a picnic table to simulate the landing. At work there was some talk about our unit doing some skydiving, while I would gladly do it again there is no way I could jump off of any height and land safely.

nicotine and stroke rehab

Nicotine Holds Promise for Stronger Stroke Recovery

nicotine and stroke rehab

What you get with nicotine is the animals with stroke show better recovery and improvement. It speeds things up and you get to a higher level of rehabilitation.
It turns out that nicotine, in contrast to amphetamines, acts in a larger area of the brain and seems to act where the amphetamines don't - in the motor system. That's a real advantage, because one of the big problems in stroke is loss of motor functions.
 I have never smoked and don't plan on starting or using patches.

 Don't consider this an endorsement of nicotine being good for your recovery.
Ask your doctor for guidance on this.

Brewing and stroke rehab

I added a few lines to this and deleted the old post
I brew homemade beer. This is a multi-step process, First you boil 3 gallons of water with selected grains, malt extract and hops(wort), cool it down to 70 degrees to allow yeast to survive, add two gallons of water. The proper way to cool down the wort is to set the 5 gal. kettle in the sink with rafts of ice cubes. There is no way I can do this with a barely useable left arm/hand. So I siphon it into the fermenting bucket, filled with ice water. This of course introduces the possibility of contamination, but allows me to do this part by myself. The fermentation continues for 3-4 weeks and then is transferred to a glass carboy for final fermenting and settling of solids. Two weeks later after fermentation is done, the yeasties have eaten most of the sugar, turning it into alcohol. Siphon it to a bottling bucket, add 3/4 cup of sugar - This is to give the leftover yeasties something to chew on and carbonate the beer in the bottles. Bottles are filled and capped. I ask a friend over for this because the capper I have is a two-handed affair and it would take me forever to get it all done. The 5 gallons makes 48-50 bottles of beer. For the first 2 years I refrained from any alcohol because I thought it might slow up my recovery. Then I realized that recovery was going extremely slow anyway and I might as well enjoy a few brews during it. The current batch is raspberry and cherry stout.
This is all about compensation rather than doing tasks to help recovery.
This article

Alcohol Consumption and Functional Outcome After Stroke in Men

at http://stroke.ahajournals.org/cgi/content/full/41/1/141
Selected lines are as follows:
A meta-analysis found that consuming less than 1 drink per day was associated with a significantly reduced risk of stroke compared to nondrinkers.
Light-to-moderate alcohol consumption has been associated with reduced risk of total and ischemic stroke. However, data on the relationship between alcohol consumption and functional outcomes from stroke are sparse.
Don't consider this an endorsement of alcohol being good for your recovery.
Ask your doctor for guidance on this. Women you are on your own, sorry.

Brunnstrom vs. Bobath(NDT) stroke rehab

I was involved in a stroke research trial and therapy students were running the experiment. I asked one of them, Which model of therapy are you taught? Bobath or Brunnstrom? He said he didn't know. My PT at the time was assisting the professor in teaching the class and I asked her about it. She said they were taught the difference but they were mainly ortho PTs rather than neuro PTs. I laughingly told her that she had better prepare them for patients like me that know more than they do. For those of you interested in this you can read this: Diversity in Neurological Physiotherapy: A
Content Analysis of the Brunnstrom/ Bobath
Controversy
http://en.scientificcommons.org/26409679
Well this article used to be here free in PDF form and I was able to read it - http://www.informaworld.com/smpp/content~db=all~content=a713795658

And another comparison study of Motor Relearning Program vs. Bobath:
http://cre.sagepub.com/content/14/4/361.short

Objective: To examine whether two different physiotherapy regimes caused any differences in outcome in rehabilitation after acute stroke.

Design: A double-blind study of patients with acute first-ever stroke. Sixty-one patients were consecutively included, block randomized into two groups, and stratified according to gender and hemiplegic site. Group 1 (33 patients) and group 2 (28 patients) had physiotherapy according to Motor Relearning Programme (MRP) and Bobath, respectively. The supplemental treatment did not differ in the two groups.

Main outcome measures: The Motor Assessment Scale (MAS), the Sødring Motor Evaluation Scale (SMES), the Barthel ADL Index and the Nottingham Health Profile (NHP) were used. The following parameters were also registered: length of stay in the hospital, use of assistive devices for mobility, and the patient's accommodation after discharge from the hospital.

Results: Patients treated according to MRP stayed fewer days in hospital than those treated according to Bobath (mean 21 days versus 34 days, p = 0.008). Both groups improved in MAS and SMES, but the improvement in motor function was significantly better in the MRP group. The two groups improved in Barthel ADL Index without significant differences between the groups. However, women treated by MRP improved more in ADL than women treated by Bobath. There were no differences between the groups in the life quality test (NHP), use of assistive devices or accommodation after discharge from the hospital.

Conclusion: The present study indicates that physiotherapy treatment using the MRP is preferable to that using the Bobath programme in the acute rehabilitation of stroke patients.

This was my response to a PT blogging about using clinical experience vs. evidence. NDT has wonderful clincal experience but is not supported by the evidence.
From Tonis' blog
http://community.advanceweb.com/blogs/pt_2/archive/2010/09/14/too-much-evidence.aspx
I'll give you my take on NDT(neuro Development treatment - the Bobath approach). My OT was trained in it and if you look at what I acheived with it you would say that it worked. I however think that any clinical experience with it hasn't split out the spontaneous recovery of the penumbra from what can be acheived with the therapy. Now that I have done lots more reading I prefer the Brunnstrom theory vs Bobath. The reason behind that is that NDT requires a therapist standing next to you telling you NO all the time. Brunnstrom allows you to use any movement possible. As a patient it is much more satisfying to be congratulated on some movement rather than constantly being told that what I am doing is wrong. And since I am now on the do-it-yourself model I am not going to be telling myself, No you are using muscles you are not supposed to. If it doesn't look good I will change it later whenever I neuroplastically get the dead brain functions moved.

And here is Peter Levines take on NDT:
http://recoverfromstroke.blogspot.com/2009/05/sonotthecase.html

depression and stroke rehab

If it occurs to you seek medical help, it is not easily overcome on your own and untreated really slows down your recovery.
Depression was not really present during the 5-week hospital stay, mainly because I was not told anything about how severe my stroke was or what the likelihood of recovery was. I was thinking that I would be back to normal in 9 months. The psychiatrist I saw in the hospital tried to get me to admit that I was mad at my body for failing me, I refused  to believe it because I was still under the impression I would recover fully and soon. After release from the hospital and research started on the internet did it finally dawn on me that I was totally screwed considering the physical deficits I had that barely seemed to get better. Anyway depression did set in around 6 months, I saw a social worker a couple of times. Persistence and never giving up are key to keeping going, I figure I have 40 more years of living to do yet and if I work hard on recovery they will be much more enjoyable that moaning about my sad lot in life.
Currently am seeing a therapist and taking Zoloft. It has provided a better attitude, but a lot of that is because I have figured out what needs to occur to recover, not easy but possible.
And anti-depressant drugs have been shown to help motor recovery. Although I'm not sure that I'm within the necessary timeframe.  Probably by increasing the level of serotonin in the central nervous system.
Prozac May Speed Physical Rehabilitation After Stroke

fingerprinting and stroke rehab

I work for a financial services firm. After I came back from my 6 month medical leave of absense there was a requirement that all employees needed to be fingerprinted. This was an expansion since before this Information Technology employees did not need to comply. I went and this was the non ink version, glass plate technlogy. The right hand went fine, both individual fingers and palm print. The left hand was extremely recalcitrant. On the glass plate if you press too hard it won't register because the ridges smoosh together.  I never was able to get the right pressure on individual fingers due to spasticity, even though I was holding them with my right hand. The operator excused herself and went to make a call to see if the left hand was necessary. She came back and said it wasn't. My speculation was that there was a realization that if I was going to commit a crime it would be with my right hand.
 I don't plan on working this into my stroke rehab goals but it was rather funny. This would be a good idea for a crime show. 'We have a complete set of left hand prints but they don't match to anyone'

How to stay informed of stroke rehab

Add 'stroke rehabilitation' to Google alerts,  You will get a daily email containing 4-10 links that cover stroke rehab. 1-2 of them each day are worth reading.
Add 'stroke rehabilitation' to Yahoo alerts. This one gets you 1 link every week or so. not really worth doing since the Google one is better.
There are lots of neurological magazines you could put an alert in but google seems to pick those up anyway.
The google alerts picked up one of my blog postings
dean's stroke musings: Is the stroke rehab research emperor naked which was interesting because it didn't pick up brewing and stroke rehab.
Anyway I will have to put stroke rehab in all my blog posts to see if that works.

It worked!! Todays google alert had this entry in it.
dean's stroke musings: How to stay informed of stroke rehab
By oc1dean
Add 'stroke rehabilitation' to Google alerts, You will get a daily email containing 4-10 links that cover stroke rehab. 1-2 of them each day are worth reading. Add 'stroke rehabilitation' to Yahoo alerts. This one gets you 1 link every week or so.

So from now on all my titles will have stroke rehab in them. And after you read those web articles leave a comment for the authors taking them to task for the lack of detail they are providing.

You should be a bad patient in your stroke rehab

I have been reading a new book, Deep Survival : Who Lives, Who Dies and Why by Laurence Gonzales.This paragraph on page 82 I think should be applied to us stroke survivors.

Psychologists who study survival say that people who are rule followers don't do as well as those who are of independent mind and spirit. When a patient is told he has 6 months to live, he has two choices: accept the news and die, or rebel and live. People who survive cancer in the face of such a diagnosis are notorious. The medical staff observes that they are 'bad patients',unruly, troublesome. They don't follow directions. They question everything. They're annoying. They're survivors.
Make yourself into a 'bad patient'.

Remember, make sure you ask your medical staff for permission to be a 'bad patient'.

If you don't make your medical staff uncomfortable in their not answering your questions then you need to try harder. Make them feel guilty and maybe they will go back to their associations and ask for details on what to do for stroke patients. Nothing else seems to be working.

Is the stroke rehab research emperor running around naked?

Is the emperor wearing any clothes? I loved this parable. From all the research I have been reading I really can't tell if any of it is valid.
My concerns are;
1. There is no standardized definition of stroke damage. If you can't even define your starting point there is no way that research can be replicated.
2. No one seems to be separating the spontaneous recovery from the recovery due to therapy.
3. There aren't enough projects using scans to prove changes.
Maybe I am too stupid to comment on stroke research since million dollar words are used to keep us peons in the dark.

My Tai Chi exercises for stroke rehab

I took a tai chi class last year. A lot of the movements were too complicated for my abilities, all of the free swinging arm movements above my head were only possible in a compensatory way by using my right hand to grab my left and mimic the movement.
I was able to take some of the simpler moves and keep doing them after the class.
Elephant swing - hold both arms loosely at your side, rotate your body right and left letting your arms swing in front of and behind you. Due to the spastic left arm this looks rather stupid.
The wave - hold both arms at your sides, swing them forward and backward. I still can't do this, my brainpower is not enough to control two sets of muscles at once.
The bass drum - trace the outline of the rim of a bass drum clockwise and counter-clockwise in front of you. I clasp both hands together to do this.
The platter -trace the outline of the rim of a platter clockwise and counter-clockwise in front of you. I clasp both hands together to do this.
Natural stepping - stand on one leg and step forward and backward with the other one. I sometimes have to use my cane to stay balanced.
This is my personal exercise regime. Do not attempt any of these without checking with your medical providers.