Perfect not.

Should practice of movement after stroke concentrate on perfection. I guess. But what stroke survivor is going to be perfect? This was addressed in an earlier entry. To quote that entry: "There is a small but vocal group of therapists who believe that if you don't focus on quality you may as well not practice."

Why should the practice be perfect when the next step should be better. If you look way up to perfect there's too much room to say "Forget it. Too hard." And you have every excuse to forget it because it will be too hard.

Focus on the small goals ahead of you, not perfection. 

There is a great blog called Seth's Blog. He has an entry that might be helpful. In it he says,

"Growth is messy and dangerous. Life is messy and dangerous. When we insist on a guarantee, an ever-increasing standard in everything we measure and a Hollywood ending, we get none of those."

 In another entry he quotes someone as saying, "I find myself getting uninterested/unmotivated on projects that I start. The emotion of deciding to start has faded and the results are slow to keep me motivated." He answers this plateau by saying, "The real work comes after the novelty wears off." Like me, Seth is not a big fan of perfection mostly because it gets in the way of forward movement. Here are some more Seth quotes about perfection and perfect:

• Perfection is overrated, particularly if it keeps you from trying things that are interesting.
• Perfect doesn't mean flawless. Perfect means it does exactly what I need it to do.
• The object isn’t to be perfect. The goal isn’t to hold back until you’ve created something beyond reproach. I believe the opposite is true. Our birthright is to fail and to fail often, but to fail in search of something bigger than we can imagine. To do anything else is to waste it all.
• Perfect is the enemy of good. [Voltaire] No doubt about it.

And on and on... Still some readers of this blog have chimed in and what they say has value (as pulled from the comments section)...

Blogger Linda said... ...if not precision perhaps focus seems like a good idea to me. 

Pete: Agree! Head towards challenging, not perfection.

Scott Gallagher said... If I'm ever going to get someone to do what it might take, I'm going to have to convince them that “thousands of miles” and “millions of repetitions” is unremarkable enough (and it is) for them to go ahead and spend a few short years to knock 'em out.

Pete: Is there anything to be said for that "few years" beyond "I practiced." Was it interesting in any way? Was there a spiritual element? Did it test you in new ways that helped you grow or know yourself (or others) better?

Barb Polan said...Give me reps over quality anytime. remember: some stroke survivors can't do ANYTHING. the expectation of high quality is absurd. And damaging.

Pete: Forgive therapists; they've not had a stroke. The expectation of high quality is absurd, for most survivors. And for survivors who are nudging up against high quality movements, then great! But most survivors will not hedge high quality but the rules remain the same: Get better.

Therapists are not like oncologists.

Therapists are not like oncologists.

Imagine an oncologist who has no idea what the latest treatment is. Imagine now that they are trying to cover their butts. "You have cancer, but I have something that works in my patients." "Something that works in your patients?" Even in your distress something seems odd about that statement. "Does it work in all patients or just in yours?" Its one of those questions you think twice about asking an MD because it smacks of sarcasm and hints a possible incompetence. But it is exactly the most rational question.

Of course, of an oncologist you'd not have to ask this question because oncologists are required by law to use the most effective treatment. If they do not do the latest and greatest they can get sued. Into oblivion.

People die of cancer. People generally don't die of bad therapy.

Now imagine your therapists says this... "You've had a stroke but I have something that works in my patients." "Does it work in all patients or just in yours?" There are 2 possible answers:

1. I have a lot of clinical experience, and in my experience it works.

2. Actually, its not ME saying it works in MY patients, but the research says it works in patients with your sequalae (symptoms).

I feel safer with #2.

#1 could have an unspoken "...but I've never really collected data or analyzed data or compared it to a control group or blinded myself during your measurement, or done anything else that science does to make sure that my data is "clean"."

"Does it work in all patients or just in yours?" is really the question, "Is there research that says it works?"

Encourage therapists to have a look at their diploma. It'll say, clear as day "Associate's of applied SCIENCE," "Bachelors of SCIENCE," "Masters of SCIENCE," and so on. The the notion that they base treatment solely on clinical experience is dangerous. One of the biggest determinants of recovery is the therapist sitting in front of you. Do yourself a favor, and do them a favor: Call them on the evidence.

Building the Recovery Wall

Scott Gallagher posted a comment to a previous blog post. I'll paste that comment at the bottom.

What caught my eye in his comment is the conflict between repetition and quality. The conflict goes like this: If you do a ton of repetitions you may not concentrate on quality. If you concentrate on quality you may not hit enough repetitions.

I do a lot of talks about stroke recovery to clinicians. There is a small but vocal group of therapists who believe that if you don't focus on quality you may as well not practice. "Perfect practice means perfect recovery." I completely disagree. What if the survivor doesn't move perfectly? The answer by these clinicians is "I use hand over hand techniques to make sure that they do." Basically, they move the stroke survivor in the proper arc of movement. (BTW: the original quote was, "Practice does not make perfect. Only perfect practice makes perfect." - Vince Lombardi. Vince Lombardi was dealing with professional athletes. If he was coaching peewee football his quote would've been "We're not asking for perfection, we're asking you to practice.")

There's several problems with stroke recovery put to this "If its not perfect, don't bother" philosophy. First of all, who's to say what "good" movement is after stroke? If somebody's trying to learn golf and they suck, nobody stands behind them and says, "You're doing it wrong." The more you practice golf, the better you'll get. Should you practice proper technique? Yes. But stroke survivors know proper technique. They've been doing these movements for all the years prior to their stroke. And even if they forgot they can model with the unaffected side.

 strongerafterstrokeblogpants

Second, this philosophy suggests a therapist. "Don't move unless I'm there to help you move." Alternatively this can be expressed as, "The more you move the worse you'll get." But therapists can't be with the survivor all the time, and the survivor doesn't have enough money in their pocket to pay for endless therapy. There is some good news... "The more you move the worse you'll get." Hogwash. Moving a lot on your own leads to better movement as long as you make the movements challenging (always reaching beyond you present ability).

Third, when's the last time you saw a coach with their hands all over a player? When's the last time you saw a music teacher with their hands overlapping the hands of the trumpet player? Learning movement involves mistakes corrected.

Scott Gallagher puts it this way "...any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall." And I know that is taken out of context, but as it stands as a quote I agree with it.

Scott Gallagher: If complete recovery is the goal, one problem might be in the sheer numbers involved. I have no reason to think that my stroke was anything but whatever might be considered a normal stroke, but currently in measured distance I'm at 5,112 walking miles. I'm so close to recovered, I'd say 5,000 miles is what it took for me to fully walk normally again. I tried speed walking, but the problem I was having was that any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall. My strategy, then, became one of brute force: keep it simple and push those repetition numbers up. But even if I had effectively used speed walking, how effective could it be? Even if it took 3,000 miles off my total distance, that would still leave 2,000 miles left to cover. I only made it through by switching from an exercise-based program to a mind and motivation-strengthening program. For all but a very, very few the repetitions required for full stroke recovery may make it, although possible, simply unfeasible. Come to think of it, though, your post may have been intended for a less hardened recovery program. Thanks.

Thank you Scott! 

                                                                                            ©Stronger After Stroke Blog

Walking Faster Means Walking Better

      When it comes to walking most folks (survivors and therapists) focus on one thing: Distance walked. The distance you can walk is important. For instance you might need enough stamina to be able to get out of the car walk 50 yards to the supermarket, walk another couple hundred yards through the supermarket, and walk back another 50 yards to your car. That's 300 yards of walking. So its important to be able to nail the distance that you can walk.

But there is another element of walking that's at least as equally important as distance walked: The speed of walking.

Measuring distance walked is easy enough. You can measure out a certain distance across the floor. If you can walk further you can base distance on the number of times you can go around a track (in United States its usually 400 yards). Further than that and you can measure the distance walked using Google maps.

The standardized way of measuring the speed of walking is very simple. All you need is 20 meters in a straight line, and a stopwatch.

Perpendicular to the 10 meter line you mark off four lines: The starting line, 5 meters in, 15 meters in, and at the end of the 20 meters. (See diagram below)

 

There is a chair at the beginning and at the end of the 20 meters. The survivor gets out of their chair and walks the first 5 meters. The person who is timing (it can easily be the stroke survivor themselves) clicks the stopwatch when they get to the 5 meter line. The survivor then walks the intermediate 10 meters, and the stopwatch is clicked again at the end of that 10 meters. The survivor then decelerates during the last five meters.

There are a few other rules...
1. The survivor usually does two passes, and the two times are averaged.
2. The survivor is asked to walk at a "comfortable speed," not, for instance, as fast as they can. Just a safe and comfortable speed. This is called "self-selected speed."
3. The 10 meter walk test is done over an arc of time to see if speeds increase over that arc. For this reason it is important to make all the tests apples to apples. The survivor should be timed at the same time of day, wearing the same clothes, wearing the same shoes and AFO, same cane, across the same floor, etc. etc.

So what does your hard work tell you? A ton. For instance, walking speed can be used to determine the effectiveness of a particular rehabilitation treatment option. That is, walking speed can be used as a surrogate for quality of gait; the faster the walking, generally speaking, the higher the quality of gait. Higher walking speed is generally associated with less falls, and less fear of falling.

• (Note: If you are over 75 -- whether you've had a stroke or not -- walking speed is eerily predictive of how long you will live.)

                                                  
©Stronger After Stroke Blog

Stretching reduces spasticity. Yeah, no.

OK class, here's your quiz:

1. Stretching decreases spasticity T/F

2. Stretching increases the length of spastic muscles T/F

3. Stretching reduces the chance of contracture (muscle stuck at a shortened length) T/F

4. Stretch helps make joints more mobile T/F

First of all, why stretching is good: 

Stretch is good for joints. Every time we move, joints are "lubricated." That is, joints require movement in order for the fluid in the joint (synovial fluid) to be properly distributed. Stroke survivors, because they are typically weak on one side, don't get the joints on the "bad" side to move enough. How much is enough? Look at it this way, on the "good" side your joints, all of them, will be moved through their entire arc of movement (called range of motion) dozens if not hundreds of times per day. How many times are your "bad" side joints moved? Because they have trouble moving, it is wise to move them either with the "good" side doing the work, or a caregiver doing the work. This is called passive ranging.

But while stretching may be good for joints, the affect of stretch on muscles and other soft tissue (ligaments, blood vessels, fat, etc.) is, so far as the science says, negligible. So the answer to your quiz is F, F, F, and F.

I know this is hard to believe. And it is counter to what some therapists think (this statement: Prolonged stretching can lengthen muscles to help decrease spasticity)

But it is confusing. There is an immediate effect of stretch on spasticity, everyone knows that. But this is one of the many reasons stroke is so devious; what is true now may not be true 5 minutes from now.

This is a frustration for many clinicians. You observe something is true (i.e. spasticity wanes with stretch) only to find that with the next big movement by the survivor, spasticity comes right back.

Further reading from this blog on spasticity here and here. 
                                                     ©Stronger After Stroke Blog

Are you frail and elderly?

(The following is a paraphrasing of writing by Janet Carr and Roberta Sheppard in their stellar book "Stroke Rehabilitation.")

"Frail elderly." This is the way most stroke survivors are treated, and it's not good. It is important for stroke survivors to engage in strengthening and cardiovascular training. It is also important to do a lot of intensive and repetitive practice. The problem with both training and a lot of practice is that they cause fatigue. And when the survivor is perceived as being fatigued they'll be asked to rest. But exercise is safe after stroke. Intensive rehabilitation improves not only muscle and heart/lung strength, it also improves movement.

To promote intensity in rehabilitation goals should be set. Goals can include increasing the speed of a task, increasing number of repetitions of the task is done, and improving the performance of the task. The stroke survivor can benefit from these parameters being graphed. Graphing of improvements in performance can provide type of feedback to the clinician, and can be motivating the survivor.
                                                                          ©Stronger After Stroke Blog

I'm not drunk, "retarded", or mentally unstable

Its a pretty simple calculus: If you don't use it you lose it. But there's a corollary: If you don't try it you can't possibly gain it. For example, if you use an AFO to walk during the early days after stroke, you'll not easily not use the thing again. 

And if I choose not to play violin- an instrument I've never played- I'll not get better at violin. So, both learning for anyone and relearning after stroke involves taking your brain (where learning happens) out of your brain's comfort zone.

Which leads me to spouses. I've met a ton of 'em. The wife is aphasic, the husband loves her, knows what she's trying to say and finishes the sentence for her. (When its men I always get the feeling they're saying to themselves, "Finally, I get to do the talking!") The spouse can become the exact thing they don't need. 

I always liked talking to folks who are aphasic. I usually get trampled by conversations because I'm slow in the think department. Aphasic folks give me a chance to ruminate a bit. Try it. Slow the conversation.

But "I've gotta get on with my life. How is it good to have my wife talk slowly when we're trying to check out (or ask directions, or talk to the gas station attendant)?"

Here's how its good. Do you know anyone who doesn't stumble and bumble their way through conversations? OK, a few people are so verbally dexterous that they don't really have this problem, ever. But nobody likes those people.

Why shouldn't someone who has a language deficit struggle as much as we do? They should struggle. Once they don't struggle, you know whats that's called?

A plateau. 
Beside, aphasia can be fetching. 

Repetitive Practice Stroke

What is the key to recovery? Everybody now: Repetition! I've written about this before here and here.

Everybody knows that repetitive practice (also known as repetitive task practice) is the way to reestablish executive (brain) control over the body. To regain control of an arm and hand repetitive practice can be used to reestablish that control. To regain control over a leg during walking, repetitive practice (walking) can be used to reestablish control over walking.

It's not rocket science. And it's not brain science, until it is.

The thing that they don't tell you is how many repetitions you have to do. The first person to talk about the power of repetitive practice was Randolph J. Nudo. You pretty much can't read any journal article on stroke rehab research that doesn't involve a reference to this guy. His suggestion was that 2500 repetitions would begin to change the brain enough to make that movement better. In constraint induced therapy there is approximately 200 repetitions per therapy session. In typical rehab there's about 32 repetitions per therapy session. It looks as if the number may be approximately a total of 1200 reps. That would require about three hours per day.

As you can imagine, these numbers are rather variable. The amount of focus brought to each repetition would be one variable. The complexity of the movement that you're trying to relearn would be another variable. The number of joints that the movement required would be a variable. The number of directions that that limb would have to move in order to carry out the task would be a variable.

But I think we can all agree that most stroke survivors don't attempt these numbers of repetitions. 

Here is the other question: How do you do all the repetitions you need to do without driving yourself crazy? 

Here is the only possible answer: Tie it to something that you care about.

Get cracking.

List of Post-Stroke Sequelae. Stroke symptoms.

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Sequelae: Plural of Sequela. 

A pathological condition resulting from a disease. An aftereffect of disease.

Body Including Limbs 
Sensory impairment including tactile,  pressure, Proprioception
Hemiplegia
Hemiparesis
Subluxation
Shoulder hand syndrome/RSD/CRPS
Flaccidity 
Hypotonicity
Balance problems
Apraxia
Hemineglect 
Altered walking gait
Vertigo
Neurogenic bladder
Eyes
Hemianopsia
Eating
Dysphagia is difficulty in swallowing.
Aphagia – Inability or refusal to swallow.
Risk of aspiration
Seizures
Spasticity
Soft tissue shortening/contracture
Genu recurvatum
Speaking
Dysphasia: Impairment of speech, and understanding language. 
Aphasia: Loss of the power of expression by speech, writing, or signs. 
(Dysphasia and aphasia are sometimes used interchangeably;  language disorder with impairment of speech and comprehension of speech.)
Psychosocial
Depression
Decrease sexuality
Indifference, inappropriateness, depression, mania 
"Other"
Recurrent stroke

Use what you've got to get what you need.

If you've had a stroke, your spinal cord still works fine. The spinal cord takes over some aspects of movement. The first step in this process of the spinal cord taking over is spasticity. The brain can't move you, so spasticity, generated in the spinal cord, takes over. And as much as we hate spasticity, things could be worse. Spasticity is better than nothing. "Nothing" in this case would be a completely flaccid affected ("bad") side. And being flaccid is worse than being spastic. Trust me on this.

But if we go a step beyond spasticity towards recovery there is an intermediate step. This intermediate step is known as synergy. The spinal cord basically allows for basic movements. The brain is not working, the spinal cord takes over, and the spinal cord allows very basic movements.

The synergies, although often disparaged by clinicians, are brilliant. In the upper extremity, synergy allows for the most important movement you can imagine: 

 

Feeding. It looks like this...

 

In the lower extremity the flexor synergy looks very much like a stepping pattern.

Clinicians have, for 40 or 50 years or so, said that synergies are bad. I disagree. Synergies can be used in a way that replicates good coordinated movement. Synergies give you the ability to at least attempt to replicate a normal movement. Enough attempts and the brain rewires and the synergies are discarded.

Watch this video. This stroke survivor (Brian Redd) is on the right track... use what you have to get more. 

(At 2:35 he provides a stellar description of the flexor and extensor synergies of the leg).

Predicting hand recovery by infarct size -- not.

Interesting work here by my colleague Stephen J. Page.

It seems like in "no-brainer." The more brain destroyed by the stroke, the greater the disability. Right? Except that when it comes to arm and hand movement, that may not be true.

"Historically, lesion size been thought to influence recovery, but we didn't find that to be the case when looking at regaining arm and hand movement," Steve put it.

There is no way to stare at your brain scan and A.) know what the deficit is gonna be B.) know how profound any deficit will be C.) predict recovery. 


(Find the published article here)

One other note: I've always disliked the term "massive stroke." Most doctors, and therefore survivors, claim that any stroke is a massive stroke. I've heard the claim that the word massive means "likely fatal." But if that is true then it has nothing to do with the mass (size) of the infarct. Thus, the word massive is meaningless. It is a superlative to add when the word "stroke" is somehow not enough.

Neuroaid: Scam

So. It turns out that in the largest clinical trial ever of the drug, neuroaid was  "statistically no better than placebo in improving outcomes." Who'da thunk? Oh yeah, we did!

So how do you think neuroaide spun it? Not real well. "Researchers found NeuroAiD, a stroke treatment based on Traditional Chinese Medicine, increases the odds of achieving a better functional outcome." "We are totally full of crap," they did not add.

Use what you love to recover what you love

I've said this before, but it bears repeating:

Recover so you can do what you love and use what you love to recover.

This is the hidden secret of recovery. It’s hidden because it has nothing to do with rehab or rehab science or physiatry or even neurology. It has to do with neuroscience; the neuroscience of the human brain

Here's the rule: Your brain will rewire (not just for stroke but for anything you learn) if you care about what you are rewiring for. Rewiring= learning. In neuroscience learning = "Changing the structure and/or function of neurons"= "brain rewiring."

But unless you care about what you learning you won't learn it.

Take math. How many adults have used an algebraic equation in the last year? Probably about 2%. And 95% of that 2% used algebra because they had to take an algebra course to graduate. Don't get me wrong, math is important. But the math most of us see as important can be done on a dollar stroke calculator. But algebra? You never really learned it because it has no importance to your everyday life. Now consider something like texting or using a new cell phone. We learn it in a matter of days because it’s important.

The same is true for stroke recovery. Many of the "ADLs"  (activities of daily living) that are used to rehab people after stroke are dry and boring. Things like dressing, grooming, bathing etc. are all necessary, but they're not very interesting to the brain.

Here's my suggestion: as much as possible, focus on things that you really care about. If it's important to you it will be important to your brain. The more pertinent is to you, the more brain rewiring can flower.

The following video is a good example of this. It's unusual example because the guy uses what he loves to "stay in the game," not rehab in the traditional sense. Have a look at the video. His right arm is still not working. But his love of music is.

The telling shot is approximately 50 seconds in. That, my friends, is "dense hemiparesis."

 Click the photo for the full story⇩⇩⇩⇩

This entry is dedicated to Mike Chambers 

Thanks for Todd Jasko for the idea!

Two Roads Diverged...

There are two ways to go after stroke: 
1. Compensation (technically: The compensatory approach)
2. Recovery (technically: The restorative approach)

Compensation involves getting on with your life by any means necessary. If your right hand doesn't work, you do everything with your left hand. If you can't walk because your foot drops, you put on an AFO. If you have trouble speaking, there's an app  for that.

Recovery involves using the intact part of the brain to take over for the "stroked" part of the brain.

It would be nice to say that the focus of clinical rehabilitation is on recovery. But for the most part, managed care only pays for compensation. Insurance companies want to get the survivor safe, functional, and out the door. Why do they want the survivor safe? Because an unsafe survivor will cost them more money down the road (think falls). Why do they want the survivor out the door? Because every day in any clinical setting costs a ton of money. But while survivors also want to be safe, and out the door, is it in their best interest to be "functional"?

On the face of it, sure, survivors want to be able to function. "Function" is a catchall word that means "getting on with your life." And it's seductive. Everyone wants to be functional. Everyone wants to be independent, and able to function.

But there is a problem with function. And it's not just a generalized idea that if you "focus on function" you'll ignore recovery. It's a very specific concept based in neuroscience.

It would make sense that if you focus on learning compensation, you would spend less time on recovery. And this would mean that you would become better at compensation, but less recovered. But it's more than just a time issue. It's a brain issue.

It turns out that something special happens to the brain after stroke. The brain is in an almost "infantile state" after stroke (in fact, after any brain injury). And "infantile state" is a good thing. The brain, through a release of special proteins is "primed" for learning— like an infant's brain. But what will it learn?

Well, it could learn to compensate. If you are right-handed and you have limited use of your right hand after stroke, the brain could learn to compensate. Your left hand would be doing a whole bunch of things never did before. The left hand is now handwriting, attempting to tie shoes, brushing the hair and teeth, and dressing. And it's doing it all alone — no right hand to help. So during this period in which the brain is "primed" for learning, the left hand does all the learning.

But if the focus is not compensation, but recovery, there will be more recovery. The brain is "primed" for learning, and it learns to recover.

NSAIDs Increase Risk of Stroke

Do over the counter pain relievers cause stroke? Some do, some don't. Might some pain relievers also cause heart problems and other cardiovascular problems? Same deal: Some do, some don't.

Note: As a group these meds are called Nonsteroidal anti-inflammatory drugs or "NSAIDs" (pronounced: NAY-sads). (List of all NSAIDs here)

In 2011 rather large study of this issue was completed. This study was a meta-analysis. A meta-analysis is a study of all the available studies. Although this is not news (it did come out in 2011) it is important for folks with chronic pain. If for instance you have frequent headaches and you take certain painkillers for that headache pain it could increase your risk of stroke and heart problems. Ibuprofen, for instance, tripled the incidence of stroke. 

Keep in mind, this study was not done with people who have had stroke. The statistics may be different if you've already had a stroke.

And "dying from heart trouble was four times greater" when using some NSAIDs.  As Consumer Reports puts it: "...all (NSAIDs) except naproxen were associated with similar increased risks..."

Here's my suggestion: Ask your medical doctor about this research.

PT/OT invented rehab - not.

A scene from 
Walking with Cavemen.

Rehab is not new. It goes back -- not hundreds of years but back to the earliest humans. We’ve been "rehabbing" for hundreds of thousands of years. And what we did to recover, all those thousands of years ago, may have been more effective than most of what's been developed since. 

Consider the stroke-rehab ideas coming from recent neuroscience (and to a lesser degree, OT, PT and Speech therapy). This recent work has more in common with "rehab" tens of thousands of years ago, than it does with the decades between 1920 and 2000. What has this recent research and our deep ancestral rehabbing have in common? Researchers now call it "intensity." But back then they called it something else: Survival 

There's a lot of folks, therapists mostly, who think that rehab started in 1918 or so. They'll tell you that PT was developed in response to polio and WW I. They'll tell you that, in the US anyway, its champion was Mary McMillian, the first PT, credited with starting the first legitimate PT training school in the US. Some of them may even know that Pehr Henrik Ling developed and codified the concept that exercise=health in the 1800s. Ling went further, developing a standardized way of promoting rehabilitation and recovery. 
 

But what of “Rehab=Survival=The Latest Research"?

Imagine a survivor trying to rehab 150,000 years ago. Let's call our stroke survivor “Magch” and his mate-pair “Youngh.” It seems as if we probably had language even then. This is the way the conversation probably went…

Youngh: “How many times do I have to tell you to stop leaning to your good side?”

Magch: (leaning towards his "bad" side): “Yes honey.”

Is that rehab? Yes! If Magch did that movement tens of thousands of times until it felt natural, today's neuroscientists would call him a genius.

Our ancestors knew a thing or two about rehab. Read about it here.

How to walk when you can't (and walk better when you can).

Challenge. Challenge causes change in the body. For instance, challenge changes muscle. Once they are challenged (i.e. resistance training) muscles "micro tear." This tearing (after some days of aching muscles)  increases the thickness of muscles, which makes them stronger.

Challenge also changes the brain. 

Challenge is the way that you learn; you go to school, you're asked to do things that are hard to do, and your brain changes. Challenge is the stuff that learning is made of. Without going outside of the brain's "comfort zone" the brain will not change. You've probably heard the saying, "use it or lose it" when it comes to the brain. If you don't use a skill your ability to do that skill will get worse. And why does it get worse? Because the part of the brain that controls doing that skill gets smaller. So, maybe the saying should be "If you don't use it you'll lose it." The flipside would be: "Challenge it and gain it." The brain will only rewire the it is challenged enough to necessitate rewiring.

Challenge and walking.

Challenging walking after stroke only has one downfall: a potential downfall. (Info on reducing the risk of falls, here.) Falling strikes terror in survivors and clinicians alike. A fall by a survivor in their care can be a black mark on the clinician's career. If someone falls while under their care,  a cascade of emotional pain follows. There is a ton of paperwork and a formal review of what caused the fall. People have been known to lose their job. Not only that, a lawsuit can sometimes follow. 

For their part, managed care (insurance) hates falls because falls cost tons of $$$. The cost of fall related injuries was $23.6 billion in 2005 (Update: $50 billion in the USA in 2015. And that's only in people over 65).

Survivors are afraid of falls because hitting the ground is never fun. But when you're in a weakened state after stroke falls can be especially dangerous. Stroke survivors tend to fall towards the weak side. The weak side in stroke survivors is often more osteoporotic (weak bones) strong side. So survivor is more likely to fall towards the side of his weaker muscles, and on bones that are weaker.

So here's the question: How can you challenge walking after stroke, when walking is inherently dangerous?

For a long time the hope was partial weight supported walking (PWSW).

With PWSW the survivor is harnessed from above while they walk. So if they fell, they wouldn't fall (if you follow). The problem with PWSW is that it's laborious to set up (it often takes more than one therapist to administer) and the equipment is expensive. Plus, the research into PWSW was not very flattering. Or, as the NIH put it: "In the largest stroke rehabilitation study ever conducted in the United States, stroke patients who had PT at home improved (paraphrased) just as much as the people who got PWSW." It should be noted that some therapists believe that there was a flaw in the research into PWSW. Specifically, the amount of time on used in research is seen by clinicians as too much. In research PWSW was typically used for 20 to 30 minutes. In the clinic, therapists will often use it for as little as five minutes.

PWSW does have some advantages. Therapists will often use PWSW (where available) when patients are "pre-ambulatory." Pre-ambulatory is a fancy way of saying that these patients are right on the cusp of being able to walk. They just need a little bit of help. Therapists will often use it for people that are bariatric (obese) because these patients can be difficult to manage, especially if they are about to fall! 

Another option is aquatic treadmills. This allows the survivor to simulate land-based walking but with a reduction in bodyweight. Again, not very available, and very expensive.  

There are much less expensive options that fall into the PWSW category. Here is one example that allows for challenge, and eliminates the fear of falling (another form of PWSW).

There are also other things that can help "unweight" and  reduce fear of falling:
  
What if you're walking, but want to walk better?
If you are able to ambulate without these devices, the best way to add challenge is to add speed. There is a particular technique to get you there, and you can find my blog entry on this technique here.