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Rehabilitation: Neuroplasticity and challenging the Recovery 'Plateau'
- Jamie Grant
- 6 days ago
- 7 min read
As a Specialist Occupational Therapist (OT) working in neurological rehabilitation, there are two words which arise frequently in conversation - with other clinicians and with the patients we support: 'Neuroplasticity' and the concept of the recovery 'plateau'...
-Neuroplasticity- As rehab therapists, we are passionately driven by this!
-Plateau- This concept - that progress can tail off completely after a period of time - is arguable, usually unhelpful and very often not due to the patient themselves.
This article will explain why we 'love and loathe' these two words respectively. It will cover:
So what is Neuroplasticity?
Common Constraints of Rehab
Why is Recovery Plateau an Unfair Disservice to Patients?
Summing Up and Final Food-for-thought...
References and Further Reading
So what is Neuroplasticity?
Neuroplasticity refers to the brain's ability to change, reorganise, or grow neural networks, in order to adapt from experiences. Neurons (nerve cells) - and their nervous system connections - alter as a consequence of new information received, such as when processing sensory inputs, practising targeted movements, or from damage or dysfunction (Britannica Academic, 2022; in Brown, 2022). The process can involve functional changes due to brain injury, or structural changes due to learning; '-plasticity' refers to the brain's malleability, or its ability to change (Cherry, 2024). Neuroplasticity is actually an on-going process in everyone's lives, as the brain is constantly shaped and rewired.
The occupations (activities) that we engage in contribute to either establishing new synaptic connections between neurons, or altering of the strength of existing synapses...
...This impacts how our physiology and body systems work, as well as the behaviours and skills we exhibit and possess. It is important to note that neuroplasticity has the potential to be both supportive and damaging to our health and well-being. Negative consequences of this process include the ingrained adoption of unhealthy eating habits and the pain and dysfunction of organs controlled by the autonomic nervous system (Brown and Weaver, 2012). However, this article discusses its key benefit.
Healthcare professionals (HCPs) in the neuro rehab world - including occupational therapists, physiotherapists and psychologists - draw on neuroplasticity, to facilitate recovery of a patient/client's body and/or brain. This could be after an ischaemic or haemorrhagic stroke, a spinal cord injury (SCI), traumatic brain injury (TBI), hypoxic brain injury (when cells are starved of oxygen), or a brain tumour.
An example of this in my personal work is supporting an individual with hemiparesis (one-sided muscle weakness). Through both conventional, hands-on rehabilitation approaches and the use of neurotechnology, I can assist the return of strength and functional range of movement of the upper limb. In doing so, that person can aim to return to engagement in everyday life and their activities of daily living (ADLs) - such as brushing their teeth, preparing a meal, using a computer or playing the piano.
Common Constraints of Rehab
Firstly, the benefit: In animal models and human trials, it has been found that high-repetition, task-specific training drives cortical reorganisation, improving motor outcomes. So science dictates that repetition and duration are fundamental.
Person-centric factors are, of course, influential in the recovery trajectory. These include:
nature and severity of the injury
speed and type of treatment received in the acute phase
past medical history
general health and fitness levels
executive functioning and wider cognitive levels post-injury - e.g. ability to sustain attention, process and retain information and plan/sequence activities
level of motivation to engage in recovery
social support structures around the individual - e.g. an encouraging partner or friends
Despite the wonders of neuroplasticity, a breadth of factors and variables mean that improving skills and abilities can be highly challenging, or sometimes not possible. This article explores the argument that this is largely due to external limitations - in time, staffing, resources and/or funding (these factors are usually interlinked).
'Studies in neuroplasticity have shown that approximately 400-600 repetitions per day of a difficult functional task are needed before the brain reorganises. This means that, if an individual is working on a functional task such as grasping, it will take 400-600 repetitions of grasping per day to help drive neuroplasticity and cause changes in the brain' (Kimberly et al, 2010; in Grant, 2022a).
To reiterate, evidence dictates that we need to give patients sufficient time and frequency for neuroplastic change to occur - but the systems and settings we work within often do not allow enough of this. For example, Page (2025) states that, in outpatient settings, it is common for stroke survivors to perform just 30 to 40 upper limb movements in an entire session. Clearly, if such individuals have just one therapy session in a day, it is highly unlikely they will reach the number of repetitions recommended above.
The limitations raised - which are largely outside of the patient's control - then directly contribute to that other frequently-used word in recovery: Plateau.
Why is Recovery Plateau an Unfair Disservice to Patients?
Plateau
noun
plural: plateaus, plateaux
a period or state of little or no growth, or decline
Psychology: a period of little or no apparent progress in an individual's learning, marked by an inability to increase speed, reduce number of errors, etc., and indicated by a horizontal stretch in a learning curve or graph.
(Dictionary.com, 2025)
I'll start here by prefacing that the organisation I work for is very research-informed and benefits from the use of neurotechnology, maximising the number of functional repetitions a patient can make in a block of treatment.
Unfortunately, in many other therapy services worldwide, the aforementioned limitations (time, staffing, resources, funding) mean that patients are unable to perform the necessary intensity and frequency of movements needed to trigger neuroplastic change. This often then leads HCPs to deduce that a person's scope for further recovery has slowed - or worse, no longer exists. In their eyes, it has plateaued.
In turn, the clinician de-prioritises the patient on their caseload, refers them to a step-down service, or discharges them completely. This is arguably an injustice to that individual's rehab potential.
'Imagine telling a marathon runner to train by jogging for 3 minutes twice a week. And then acting surprised when they don't improve.' (Page, 2025)
Demain et al (2006) argue that the concept of plateau is ambiguous. They point out that recovery has been considered to plateau within the first six months, yet studies indicate that later recovery is possible. This rings true from my personal experience as a neurological OT, currently in an outpatient setting in the UK. I see progress sometimes years after the injury has occurred.
There is nuance and obvious variation here; the nature of the progress might be motor (physical), sensory (improved sensory feedback, or reduced hypersensitivity), cognitive, mood-related (affect), or a mixture of these elements. Yes, it is likely to be slower than during the initial six months - but it can still be both functionally significant and highly meaningful to the individual.
A significant number of people engaging in rehabilitation will, at some point, ask a therapist how long they think their recovery could take. The answer can never be accurately forecast, due to the myriad of personal, social and institutional factors unique to each individual. Fundamentally though...
'The one thing the answer should not be is "That's as good as your recovery will get." Many medical providers used to say this in the past, but published research has since proven that brain injury and stroke survivors can push past a supposed "progress plateau" and improve with effective and continuous brain rehabilitation - even years after the initial event' (Constant Therapy, 2025).
Summing Up and Final Food-for-thought...
With months and potentially years following injury, many barriers can prevent a patient's further focused recovery - not least the constraints and pressures of the healthcare organisation supporting them. As a clinician, you may be limited by the time or resources you can offer those coming through your door. And, as an occupational therapist, there is a time to convey optimism and a time to be realistic with what you might achieve...
Nonetheless - as Page (2025) argues - the problem with progressing rehab in most cases is neither the patient's effort, nor the adaptability of his/her nervous system. It is decisions made by the therapist and/or the system in which the patient is being treated.
You may not have the power to change the service - but make sure you are the clinician fighting your patient's corner, every step of the way!
References and Further Reading
Alawieh, A., Zhao, J. and Feng, W. (2018) Factors affecting post-stroke motor recovery: Implications on neurotherapy after brain injury. Behavioural Brain Research. 2018, 340: 94-101. Available from: https://doi.org/10.1016/j.bbr.2016.08.029. ISSN 0166-4328.
Brown, A. (2022) Neuroplasticity. Therapy Articles on The Occupational Therapy Hub (online). Available from: https://www.theothub.com/article/neuroplasticity.
Brown, A. and Weaver, L.C. (2012) The dark side of neuroplasticity. Experimental Neurology. 2012, 235 (1): 133-141. Available from: https://doi.org/10.1016/j.expneurol.2011.11.004. ISSN 0014-4886.
Cherry, K. (2024) How Neuroplasticity Works. Verywell Mind (online). Available from: https://www.verywellmind.com/what-is-brain-plasticity-2794886.
Cleveland Clinic (2023) Hemiparesis (image). Available from: https://my.clevelandclinic.org/health/symptoms/24952-hemiparesis.
Constant Therapy (2025) Debunking the myths about the brain injury "recovery plateau" (online). Available from: https://constanttherapyhealth.com/brainwire/debunking-the-myths-about-the-brain-injury-recovery-plateau-infographic/.
Demain, S., Wiles, R., Roberts, L. and McPherson, K. (2006) Recovery plateau following stroke: fact or fiction? Disability and Rehabilitation. 2006 Jul 15-30;28 (13-14): 815-21. doi: 10.1080/09638280500534796. PMID: 16777768.
Dictionary.com (2025) Plateau (definition). Available from: https://www.dictionary.com/browse/plateau.
Grant, J. (2022) Occupational Therapy and Neurology. e-document on The Occupational Therapy Hub (online). Available from: https://www.theothub.com/product-page/occupational-therapy-and-neurology.
Grant, J. (2022a) The Power of Routine. Therapy Articles on The Occupational Therapy Hub (online). Available from: https://www.theothub.com/article/the-power-of-routine.
Page, Dr. S. (2025) Sometimes It’s The Therapist Who Plateaus; Not The Stroke Survivor. StevePRehab (online). Available from: https://www.steveprehab.com/post/plateau.
TactusTherapy (2025) The Truth about the Plateau in Stroke Recovery (image). Available from: https://tactustherapy.com/stroke-recovery-plateau-truth-myth/.
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