Neuroplasticity: 10 Clinical Principles for Rehab Professionals

Neuroplasticity is the ability of the nervous system to reorganize itself by forming new neural connections. It is the fundamental biological mechanism underlying all rehabilitation. Whether you are treating stroke, TBI, or SCI, you are essentially "brain training." This guide breaks down the 10 Principles of Experience-Dependent Plasticity (Kleim & Jones, 2008) and how to apply them clinically.

1. Adaptive vs. Maladaptive Plasticity

Plasticity is not always "good." The brain rewires based on whatever input it gets.

• Adaptive Plasticity: Learning new skills or relearning old ones (e.g., walking after stroke).
• Maladaptive Plasticity: Negative rewiring due to bad habits or injury (e.g., Learned Non-Use, Phantom Limb Pain, Focal Dystonia).

The Golden Rule: "Neurons that fire together, wire together. Neurons that fire apart, wire apart." (Hebb's Law)

2. The 10 Principles (Kleim & Jones)

These principles explain how we induce brain change through therapy.

#	Principle	Clinical Translation
1	Use It or Lose It	If a patient stops using a paretic arm, the brain map for that arm will shrink and disappear. (Prevention of non-use).
2	Use It and Improve It	Training a specific brain function can enhance that function. (Skill training).
3	Specificity	The nature of the training dictates the nature of the plasticity. If you want to walk better, you must practice walking, not just cycling.
4	Repetition Matters	Induction of plasticity requires sufficient repetition. 10 reps is not enough; hundreds are needed to rewire synapses.
5	Intensity Matters	Plasticity requires sufficient training intensity. The patient must work hard (raise Heart Rate/RPE).
6	Time Matters	Different forms of plasticity occur at different times. Early rehab is crucial to prevent bad habits, but plasticity happens in the chronic phase too.
7	Salience Matters	The training must be meaningful (salient) to the patient. Reaching for a cup of coffee (goal) is better than reaching into thin air.
8	Age Matters	Plasticity occurs more readily in younger brains, but is still possible in older adults (just requires more effort).
9	Transference	Plasticity in one skill can enhance the acquisition of similar behaviors (e.g., balance training helps gait).
10	Interference	Plasticity in response to one experience can interfere with the acquisition of others (e.g., learning a compensatory "bad" gait pattern makes it harder to learn the "correct" one later).

[Image of neuroplasticity synaptic connections diagram]

3. Practical Application in the Clinic

Application A: High-Repetition Task Practice

Applying Principles 4 (Repetition) & 5 (Intensity). Instead of doing 3 sets of 10, aim for time-based blocks (e.g., 15 minutes of continuous sit-to-stand).

Application B: Task-Specific Training

Applying Principle 3 (Specificity). Do not rely solely on "bed exercises" to improve walking. Get the patient upright and stepping as soon as possible.

Application C: Enriched Environments

Applying Principle 7 (Salience). Use real objects, music, or games (VR/Wii) to engage the patient's attention and motivation circuits (Dopamine release aids plasticity).

4. When Plasticity Goes Wrong

Therapists must guard against Interference (Principle 10).

• Compensatory Movements: If a patient learns to hike their hip to clear the foot (circumduction), the brain "wires" this pattern. Unlearning it later is harder than learning it right the first time.
• Phantom Limb Pain: Cortical maps of the missing limb are invaded by neighboring areas (e.g., face), causing pain sensations. Mirror therapy reverses this.

5. Revision Notes for Students

Definition: The nervous system's capacity to change.
Key Paper: Kleim & Jones (2008).
Primary Driver: BEHAVIOR (what the patient does).
Core Trio: Specificity + Repetition + Intensity.
Salience: If the patient doesn't care about the task, the brain won't wire it.
Interference: "Bad habits are hard to break" is a neuroplastic reality.

6. FAQs

Q1. Does neuroplasticity stop after a certain age?

No. While it is more robust in children ("Critical Periods"), adult brains retain plasticity throughout life (neurogenesis in the hippocampus continues into old age).

Q2. How many repetitions are needed?

Animal studies suggest 400-600 reps per session for hand function. Current therapy averages 30-40. We are likely "under-dosing" our patients significantly.

Q3. Can medication help?

SSRIs (Fluoxetine) have shown some promise in extending the window of plasticity post-stroke (FLAME trial), but exercise remains the most potent driver.

7. 10 Practice MCQs

Q1. "Use It or Lose It" refers to:

Answer: B) The brain prunes connections that are not actively used.

Q2. Which principle states that "Practice of a novel skill induces plasticity, but simple repetition of an already learned skill does not"?

Answer: B) The task must be challenging/skilled to drive cortical map expansion.

Q3. Training a patient to walk by having them ride a stationary bike violates which principle?

Answer: A) Cycling does not train the specific balance/coordination required for walking.

Q4. "Salience" means the training task must be:

Answer: C) Emotional relevance engages the acetylcholine system to mark synapses for change.

Q5. Learning a "bad" compensatory movement pattern early in recovery can prevent learning the "good" pattern later. This is:

Answer: B) Maladaptive plasticity interferes with adaptive plasticity.

Q6. Which statement about age and plasticity is true?

Answer: B) It requires more intensity/repetition, but remains possible.

Q7. "Transference" refers to:

Answer: B) e.g., Strengthening the quadriceps improves sit-to-stand ability.

Q8. Phantom Limb Pain is an example of:

Answer: B) It results from cortical reorganization where sensory areas invade the "missing" limb's area.

Q9. To induce plasticity, the intensity of training must be:

Answer: A) Passive or low-effort movement does not drive cortical change.

Q10. "Learned Non-Use" happens when:

Answer: C) A classic example of maladaptive plasticity treated by CIMT.

References

• Kleim, J. A., & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res.
• Nudo, R. J. (2013). Recovery after brain injury: mechanisms and therapies. Nature Reviews Neuroscience.
• Boyd, L. A., et al. (2010). Biomarkers of stroke recovery: we need them, but where will we find them?. Stroke.