3 Questions to Improve Stroke Recovery

What if recovery from stroke isn’t just about reps and protocols, but the questions we ask along the way? In this episode, I unpack three simple but transformative questions that can shift how we approach stroke rehab—for clinicians, caregivers, and survivors alike. This isn’t about chasing perfection or following a rigid recovery plan. It’s about helping the brain feel safe enough to explore, adapt, and move again. From building trust in the therapeutic relationship to rethinking what counts as “success,” I dive deep into the human side of neuroplasticity. If you work in neuro rehab or are supporting someone through recovery, these questions might just change how you show up in the process.

Resources mentioned:
Episode 2: Sensory Preferences and How They Dictate Who We Are!
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Chapters

• 0:00 Improving Stroke Recovery
• 1:53 Q1: Understanding the Non-Affected Side
• 3:08 Overworked & Underpaid
• 5:52 Strategies for Addressing Spasticity
• 13:09 Q2: Why Are You Doing That Exercise
• 19:39 Q3: Integrating Visual and Vestibular Systems

Transcript

Meghann Koppele Duffy: Welcome to Three Questions where critical thinking is king, and my opinions and research are only here to support your learning and understanding. Hey, I'm your host Meghann, and I'm so honored you clicked on Three Questions today so we can discuss stroke recovery. Now this is a pretty big topic, so in 20 minutes, here are my goals for today is honestly.

I'm talking to everyone out there who's experienced a stroke or is recovering from a stroke. So I want you guys to hear this, this episode's actually for you guys, and I want you to ask these questions to your movement professional, your pt, your ot, your doctor, your Pilates teacher, your personal trainer.

Ask your caregivers. Really make sure everybody on your team is paying attention. Because listen, even the people that love you want things to be easier for you. But in, in the effort to do that, sometimes we miss things. So you are gonna have to be your own advocate. You are gonna have to push and say, no, that exercise, although that was interesting, it actually increased my spasticity.

Let's do it again. Now that's gonna be between you and I, but right now I'm gonna kind of talk to our movement professionals. So hi movement professionals. Welcome. And these are three questions I want you to ask yourself and maybe, you know, start with your client you're having the best success with, maybe not the client you're having the least success with.

And always remember, although we're talking about stroke recovery and hemiparesis in particular today, which is single sided weakness. Realize that every single person you work with has discrepancies side to side, which are normal. So these strategies are really helpful with all your clients. So enough with the intro, let's get to it.

And question one, what is going on with your non-affected side? I want everybody to think about that. Say you had a stroke and it affected the left side of your body. What is going on on the right side of your body and vice versa. Does it feel strong? Does it feel tight? Does it feel like it's doing the most?

When you look at your shoulder movement on your non-affected, or I'm doing in quotes, good side. Does it look like it did before the stroke? Does it look organized? Does it look like a lot of parts move in a chunk? Now you don't have to have a master's degree in applied physiology and biomechanics like me to know if it looks like a duck and quacks like a duck, it's a duck.

So if you're watching me on YouTube and I'm lifting my arm like this, you can see my entire shoulder girdle. I'm actually laterally flexing my spine. I'm doing a lot of weird things. I was also lifting one of my heels, which it's not bad to do that per se, but what happens is when our good side does the most.

It becomes overworked and underpaid. So has anybody been overworked and underpaid before? Let me walk you back through those steps. I remember my first job while I was getting my master's, I worked at an investment bank in their gym, and at that point I did have my master's from top university, Columbia, and a guy came in same job as me two years after, had an undergrad degree.

No judgment, but he made more than me. Now we can go along the women men thing, but I'm not gonna go there. What I wanna focus on more is how I reacted. So I realized I was doing my job fine, I was happy, and then there was a gap in my knowledge and that gap was filled. When I found out this information, it's not that guy's fault.

I didn't ask for more money. I didn't know how to negotiate. As a 20-year-old woman. But let me tell you, once that gap in knowledge was filled, I was pissed. Pissed, everything pissed me off. If my boss looked at me the wrong way, I was up, up in arms about it. Okay? That is silly. But what happened was once that gap in knowledge was filled, I couldn't unsee it.

I was so angry. And you know what? I ended up leaving that job and going in a different direction because what is, what is this saying? I always screw up sayings. I couldn't put the cat back in the bag. You're putting something back in a bag. You know what I mean? I couldn't do it. So think about this with your effect not affected side.

I'm gonna probably screw that up 10 times during the podcast, so well, hopefully I'll do it. Okay. That right side. So we're gonna talk as if everybody had a stroke that affected their left side. We know that's not the case, but just stay with me here. So my right side's doing the most. And then one day my brain goes, all right, we've used these movement patterns.

We're at risk of injury. I don't like it anymore. I'm shutting the shit down. Boom. What happens? You get excessive pain. Or you might start getting spasticity or problems in your non-affected side, and you're like, what's going on here? Now, my non-affected side is my bad side and my stroke affected side is my good side.

How did this happen? Well, it's very common, and I want you guys to hear this with the non-affected side. More is not better. It's just more. So if you're doing exercises that are require requiring your good side to do more. Yeah, you're getting movement, you're getting blood flow, you're getting nerve conduction.

So I'm not mad at that. I never want you guys to stop moving 'cause you're afraid. I just did that in quotes that you're doing it wrong, but we're screwing up our brain map. So let's keep this super simple. Say you're trying to do a squat. You're trying to get deeper in your squat. You're trying to increase your hip range of motion.

Your heels are finally staying down. You're really pumped, but every time you do that squat, your right shoulder lifts or you get an increase of spasticity in that right arm and flexor tone. What happens is the brain starts mapping those together, so your brain, every time you try to do hip flexion, might also do shoulder elevation as well.

Because every time you do hip flexion, you elevate your shoulder. Now, I don't wanna get into too much detail here because we're gonna miss the plot, but when we elevate our shoulder, everything's connected, guys. So our lat and our fascial connections to our opposite hip is gonna change the tension in the glute.

So here you are thinking you're getting deeper in your squat, you're strengthening your hips. But you're not. It's really actually the pull of that shoulder up creating more range of motion in the hip. And this ain't bad, so I don't want you to be mad at it, but you're not neurologically strengthening those muscles and that can increase spasticity.

Okay. Now anything can increase spasticity. Tight clothes can increase spasticity, weather can increase spasticity because it's a neurological response. Okay. It's a protective mechanism. So we're not gonna be mad at it. We just need to make sure we're addressing it. So when you are working with your stroke clients, there is clear research, clear significant research that says if you use bilateral movement, you can use the stronger side to teach the weaker side.

I learned it in school. I used it for a lot of years, and you're right. I did get some range of motion back in the non-affected side, and then I didn't hit a glass ceiling with clients. I hit a brick ceiling. You know why? Because in order to get the affected side moving, I had to do weird shit on the affected side with my clients, thus affecting the brain map.

And what my biggest concern is when the body moves in chunks, when it's supposed to move in smaller parts. That is going to affect the side's ability to stabilize. So people who are recovering from a stroke, I'm gonna keep this simple. You might have heard this. We need stability in order to mobilize.

Well, it's not entirely true. We can work around because our brain is amazing compensating. Okay? So we do need stability and I call it reflexive. So I need your shoulder to respond. Say I'm just doing standing marching, I'm gonna lift my left leg up. Well, I need reflexive stability in my right shoulder, right hip, and left shoulder to really effectively isolate that hip.

Okay? Now, if I'm adding a weight shift, there's gonna be mobility in other joints, so this can get pretty complicated. Quick, just think about this way. I want your body to respond no matter what position you're in. And you know what I'm talking about. You ever try to do like a leg lift or a march and your body has to like candy cane, or your head goes in the opposite direction, or you have to really squeeze your hand or clench your fist or make a face.

That's a gripping pattern, which can offer a temporary solution to a big problem. So we'll talk about reflex of stability in another um, episode, but I wanna finish up question one. What is your effect non affected side doing? Okay, I made the mistake twice. This should be a drinking game. I want you to think, is my good side doing too much?

Is it in pain? How can I better map out that side so that it's stabilizes better so that when I'm doing the stuff on my affected side, we actually get neuroplasticity to occur Now. I'm gonna teach you a really quick neuro solution to this. Say you're squatting and you lift your shoulder and your PT and or Pilates teacher, you got Meghann in your saying, stop lifting your shoulder.

Stop lifting your shoulder. Stop lifting your shoulder. Oh my God, teacher, stop doing that. They're not deaf. They hear you. They just can't map it. So if you find your movement professionals repeating things, I want you to go, Hmm. My brain doesn't know the difference between doing this movement with and without that shoulder.

So here's what I want you to do. Tell your professional to shh for a minute, and I want you to do the squat again and lift your shoulder. You heard me do exactly what they told you not to do. So you're gonna squat and lift your shoulder. Do it again, actively three times. That's it. And then say to your brain, that was squatting and lifting my shoulder.

Now squat again without lifting your shoulder. And what you'll realize is, holy shit, that was a lot easier. And this one stop bitching at me to stop lifting my shoulder. Now here's a good parental or sports training hack. If you're a coach, you're a parent, whatever you yell at your kids at, more than once, they're having trouble mapping a different way.

So. Say, you know what? Do it that way. Keep doing it that way. And maybe their brain will figure out an alternative strategy and maybe their brain won't. But then you can step in and show them and let them decide. Humans are weird. You might see how I live my day to day and be like, oh my God, or how I organize my podcast or social media.

You might be like, that is so inefficient. Why is she doing it that way? She should just do it this way because your way doesn't work for my brain. This way works for me. Okay? Now, I'm not a parent, so obviously I'm a parental expert. And if you're watching YouTube, I rolled my eyes. I know. I know nothing about parenting.

It's so easy to preach. It's hard to practice, right? But remember, you're doing a good job. Your kids aren't trying to jam you up. There's just a gap in knowledge and maybe together you can figure it out. So before I move on to question two, get, oh, I don't know what word I wanna use there. Get focused on the non-affected side.

Fix up brain mapping issues. Improve the form, get each joint to move and differentiate from other parts of the body and move together as a whole because we are one unit. When you're moving the arm, notice what happens on the foot in both feet. See what's going on. Take a step back. Look at the whole elephant.

Don't just look at the non-affected side. I'm telling you, this will change your recovery or your patience. Now, question two, I'm just gonna stretch here. Why are you doing that? Getting hot. I gotta take off my sweatshirt. Yeah. Why are you doing that? I call it disability porn. Stay with me for a sec. I will explain.

I see this a lot on Instagram where it's trying to be motivational and you're doing these cool, creative or exercises to try, try to get a person to move better. So anybody who is doing work to help people move better, I applaud you. Keep doing what you're doing. But I want you to ask, why are you doing that?

What is your goal? Are you trying to get followers on Instagram? Uh, I, I can't, honestly, I can't judge you on that. We're all trying to get more followers on Instagram to run our businesses, but when you're forcing a client to get up, what's happening? What is their head doing? What are their eyes doing? Are they getting an increase of spasticity?

Because just getting a client up once is great because it builds confidence. But I'm all about my clients being able to do it again and again and to do it without me. So if I'm doing a floor transfer and they get an increase of spasticity, or they're fighting me and I feel like I'm dragging them across the floor, what are you doing?

These are people. Did you know when you do floor transfers, you're often pulling the client in the opposite direction. Their body wants to move. I have a rule with floor transfers. The client initiates it. I follow. 'cause it can be hard. Okay. Also, I don't do all these bracing techniques and I get people even with spinal cord injuries up using different sensory approaches, which we'll talk about in question three.

But I just really want you to think about what is the goal of the exercise. And if you are in a stroke recovery program, man, please, every exercise you do ask, could you let me know what the goal of this exercise is? Because when you know the goal, you will have a better chance of getting there. So if I say to you, I need you to get up off the ground, but every time you get up off the ground, your head and eyes go down.

So your visual vestibular system is telling you down and proprioceptive you're trying to pull up, so you're actually creating a sensory mismatch. How can we get the three systems to integrate so you don't get an increase of spasticity so your body doesn't fight itself? Okay, now the client's more like, all right, let's play here now I'll do your weird ass eye exercise or head exercises because I know.

Integrating those three systems is gonna make me better balanced. Why? Those are the three systems that determine balance. So if you're doing balance exercise with one leg up and trying to balance all over the place, that's not a balance exercise that's teaching you how to stabilize in that position. I want you to ask your practitioners, what should my eyes be doing?

What should my head be doing? What should my body be doing? Is it okay to shift at my ankles? Is it okay to shift at my shoulders? And I want my movement professionals to not get pissy. When clients ask you questions, they're not trying to jam you up. They wanna understand, and that's a moment for us to go, you know what?

I don't know. Hold on, do it. Let me see what you do. So my clients will sum to be like, Meg, is it okay? I weight shift. I go, I don't know. Hold on. Let me see. Do it. When they think they're weight shifting, they're not. They're just leaning their head and I say, yeah, it's okay to weight shift, but hold on. Do that exercise again by just moving your head.

And then I want you to do it. Do that exercise again and move your crotch and head together to actually get them to weight shift. Now, lemme tell you, when I ask them to just move their head, they're gonna be like, I can't do that now. I know they just did it. I just saw them do it. So practitioners questions aren't to jam you up, it's to fill gaps of knowledge and it's gonna challenge you to go, what do I actually want out of this exercise?

What can they do? What is available to their brain? And can we change it from there? So I might say to my client, you know what? I don't want you to weight shift here. Now I do want you to weight shift. Because my goal is I want their brain body to respond to no matter what movement they do, because walking and moving through the world is very complex, right?

Every step is different. Nobody takes a perfect step. I want that cerebellum to kick in. If they put their foot down in a weird way, I want it to respond to that era in quotes and create a different motor map. If their brain doesn't realize when they're making mistakes, it's the cerebellum's never gonna kick in.

You can do all the cerebellum exercises you want. Every exercise should be a cerebellum exercise. Okay, and I'm going off topic trying to talk about the cerebellum, and if you're not sure what the cerebellum is, it's a part of our brain. Then initially it was known for the ABCs, accuracy balancing coordination, but with new and emerging research, we're seeing that the cerebellum is kind of involved in everything.

And a cool fun fact about the cerebellum is it's got about like 10 to maybe 20% of the brain volume, but 50 to 80% of the neurons. So it's kind of small, but as 50 to 80% of the neurons sounds pretty important. Everybody's looking at the frontal lobe, all the other lobes. I'm looking at the cerebellum. Okay, back on topic.

Why are you doing that? Question two, just start questioning yourself. Your clients, your patients, whatever you wanna call them, and really figure out what the heck are we actually doing here? And are we achieving a goal? Or are we just doing exercises for the sake of exercise? Hey, now not every day has to be a gold medal session.

Sometimes it's just good. The client's tired. Maybe just get them moving, get some blood flowing through the body. Always a win. So I want nobody to punish themselves for not doing what I say. Who cares what I say? Do what your patients need. Cool. Which leads us to our last question. Are the visual and vestibular system fighting the proprioceptive changes happening in your sessions?

Let's break this down. Simply proprioception is your brain's ability to know where you are in space. It's based off stretches, pressure, tension, any sensation from your skin, your tendons, your muscles, your fascia, that's all gonna tell your brain where you are in space. Maybe if you're hypermobile, proprioception is a bit affected.

It's an unreliable narrator if you have spasticity. It's also an unreliable narrator, but a little accurate because that's what's actually happening in your body. So when you have spasticity, you are gonna feel that tension a lot quicker because it's a protective mechanism. So in traditional stroke rehab, we're really focused on proprioceptive changes and then you go to visual and vestibular therapist separate, nah, nah, nah.

It should all be the same now. I am very much in support of maybe going to a vestibular specialist or a visual, but what I want you to ask them is, okay, my PT exercise or my Pilates exercise homework is this. Can you give me a visual strategy to do during this to help my sensory integration? And if that visual therapist says it doesn't matter, go find another one.

It does matter if they're just testing your eyes or your vestibular system Sit seated or in one brightly lit room, we need more. Okay. So what I want you to think right now is when I'm doing a movement is my, are my eyes and head fighting it? And you hear something really tricky. Ugh. Say our body is like.

Hooked to the left. So maybe we had a stroke that's affected Our left side, there's this thing called pusher syndrome where you tend to lean towards your affected side. So think about it. It kind of makes sense if you don't really feel your left side very well. Well, your body might lean more to the left side to try to feel it.

Think about it. Say you are leaning against somebody, but they're not leaning back up against you. You might lean more. To force them to lean more so you don't fall. Okay? So sometimes we need more sensory input to trigger response in our body or somebody else's, right? So what happens if we're leaning to the left?

There's this cool thing that our eyes do. Our eyes always wanna see things straight. So I want everybody to do this right now. Candy cane your body to the left, like lift your right shoulder. Really go there. And if you stay there habitually over time, and it might take two seconds, it might take two minutes, it might take two years.

Your head is gonna write itself. So if you are watching me on YouTube, eventually my head's gonna go like this. So that way my eyes see things straight. So, ugh. My visual system is saying we're straight. My vestibular system is saying we're straight. The three semi-circular canals, fluid, not moving. We're straight, but proprioceptions like, um, excuse me, excuse me.

Visual and vestibular. Uh, we're not straight and they say shut the hell up. Proprioception two against one. We win and we are higher systems. Okay, vestibular. I speak directly to the cerebellum visual systems. Like do you know how many parts of the brain are allotted to me? Okay, so they win. So your proprioception goes, okay.

Now guess what happens when you come into sessions? Your Pilates teacher, your pt straightens your body out and oh my God, if you're a movement professional, have you ever straightened someone and they say, oh my God, thank you. That feels so much better. No, they're always like, what are you doing? That's crooked.

I used to, back in the day, I remember one client, she had a cerebellar stroke. I used to take a picture of her. Because she's like, this isn't right. And she actually made me, 'cause I took two pictures and she's like, yeah, but I think you mixed up the pictures. So I literally had to clear my pictures and be like, okay, stand normal.

Or for her, took the pictures, showed her. She's like, holy crap. But what I didn't realize is me telling her to be straight was a waste of time because proprioception was happy, but I didn't do anything to change her visual vestibular so senses would match. Hmm. So to this client, Wendy, I love you. I'm so sorry that I tried to straighten you for, Hmm.

Oh my God, this is embarrassing. Probably six months, maybe longer, but when we know better, we do better. Now what I do when she's crooked, I put her head in line with her body. Then we do some exercises, proprioceptive, visual, vestibular. And then guess what? She's straight within the moment. Well now it's like two seconds, but sometimes it used to take longer.

So I want you asking yourself or your PTs and OTs, Hey, is my head in line with my body? What should my head and eyes be doing here? And I'll talk about scoliosis in, um, I think maybe in two episodes, three episodes. Whenever, um, you know, it pleases me, but scoliosis is another one. The visual and vestibular system are a huge problem and everybody's working on proprioception of the spine, but guess what?

They go right back because visual and vestibular always win. Okay? If your client's looking all over the place, they're trying to get sensory information, stop telling them not to do that. You need to address that so the eyes can gaze, stabilize. If their head is moving a lot, they're trying to get vestibular information.

Maybe you have a child who can't sit still. Maybe you have a child who is on the spectrum. Maybe you have a child who has been diagnosed with autism. A lot of times kids will move their heads around a lot because Proprioceptively, they're not getting any good intel. So they really need to know where there are in space and help their brain focus by moving their head around a lot.

Right? At the end of the day, we all wanna feel something. We all wanna feel something in a good way, but please don't think what feels good to you, feels good to others. It's kind of interesting, I was talking to one of my friends who's a massage therapist once she loves touch and the sense of touch, she's someone who kind of touches people, not in a creepy way.

But I don't like that. I don't like to be touched. I don't really enjoy massages because I have sensory issues with my skin. I'm very particular about my clothes. We talked about this in previous episodes. If you did not listen to episode two about sensory, please go back and listen to it.

I stopped getting massages. They don't help me. They actually aggravate my nervous system. And make me more agitated and I try so hard to relax, but I can't because all that movement in my skin is too much for my nervous system. So what feels amazing to some people, some people like deep pressure. I don't ow, I like deep pressure, but same pressure throughout the entire body.

I use the example of underwear or a bathing suit or yoga pants where the seam pushes in more than the pants. Can't do it. Everything has to be pressing in evenly. So there is research about people who like deeper pressure, but that doesn't mean pinpoint pressure. It's very specific to that person. So I know this episode went a little longer.

I, as you can tell, I'm very passionate about stroke recovery. I really do believe that people are recovering from a stroke. You deserve more, you deserve better, and full recovery is possible. But it is not easy and takes focus both on you and your team. We have to work together at a team. There's no magic bullet.

And learning a new movement patterns like learning a new language, it takes time and repetition and it's hard. So please don't, I don't want you to think I'm saying it's easy. It's probably the hardest thing anybody will do in the world is recovering from a stroke, especially when you've lost all full movement.

So do all those people recovering from a stroke? Um, if this episode restored, hope it, I hope it does. I hate when people say the same word twice in a sentence, but I just did. If you need help, reach out. I have a team of teachers. I teach workshops on this for the Neuros Studio with people all over the world using these methods.

We have our level three teachers who do this on Zoom, and yes, I do stroke recovery on Zoom and it works, but it's going to take a lot of time and energy. I. But you can do it if you want to, and it's totally fine if you are okay with where you are in your recovery. Don't let anybody judge you or call you lazy.

Let them walk a day in your shoes and see how well they do. But at the end of the day, I want you to think, what is your non-affected side doing? Is it overworked or underpaid? Give it a fricking raise. Give it a vacation. Why are you doing that? Do weird things with your body. Ask yourself, Hey, can I do this without doing that, can I move my leg without moving my head?

Can I move my leg and move my head? And practitioners, I want you to ask yourself, what do you want to see them out of that exercise? Is that right or wrong? I don't know. The body's designed to do crazy shit. Let's give our clients the availability and joints. Let the brain know it's available and let their brain make the choices.

Keep them safe and help them get stronger. And last but not least, is your visual or is your vestibular system fighting the proprioceptive changes you're doing in your recovery sessions? Or could those be the key to unlocking better proprioceptive strategies? So thank you guys for this 30 minute episode.

I know I promised I'd always keep them under 30. And if you have any questions or want any further episodes talking about different parts of stroke recovery, let me know. I don't wanna yammer on about things nobody's interested in, but this is super important to me and millions of people around the world.

So thank you and I'll see you in our next episode.