A Wheelchair is Not for a Stroke Patient - Reactivating the Brain

I received this personal letter from Ms Sofea, a physiotherapist working at the Kuala Lumpur  Hospital. With her permission I reproduce what she wrote to me unedited in pink:  

Your most welcome, Dr Lim. Truth be told, we as physiotherapists often face challenges in our practice due to the bad system as how you mention earlier.
Even for dietician its so difficult for patient to have an access or to be referred to dietician and learn about nutrition.

To share a little story — two years ago, my mum had a minor stroke and was left with muscle weakness. She developed a circumduction gait, couldn’t carry her right arm forward, had mild balance disturbance, and poor bladder control.

Luckily, being a physiotherapist, I knew that for neurological cases, time is gold. You have to keep practicing to stimulate neuroplasticity and prevent muscle deconditioning. I told my family not to give her a wheelchair or walking aid, and I prescribed an exercise regime along with hydrotherapy at my condo.

Praise be to Allah, she recovered and returned to

her premorbid state. Before going back to Ipoh,

she could walk and perform her daily activities independently. I always tell my mum — I’m not forcing you to exercise or take your medication for me, but for yourself — so you can live your life well and in comfort.

People will eventually pass on, that’s true, but until that time comes, let’s live beautifully and meaningfully

 

Here is my reply to Ms Sofea 

Thank you Sofea for your letter. 

Yes, I too agree all you said. Let me explain a little bit more about the healthcare professions.  

 Healthcare professionals are any trained individuals who work in the medical field to promote health, prevention of disease and illness, and care of others with injuries and illnesses. They are not just medical doctors, but include paramedics, emergency medical technicians, nurses, dentists, pharmacists, physiotherapists, dietitians, medically-trained nutritionists, medical scientists, and many other specialized workers who use their skills, knowledge, and research-based practices to diagnose and treat patients while upholding ethical standards and acting in their patients' best interests.  

It is very unfortunate the public thinks only medical doctors are health-care professionals, and doctors seldom refer cases beyond their training and expertise to other healthcare professionals like physiotherapists, chiropractors, osteopaths who are far more expert in manipulative medicine than a doctor who is more orientated towards drug-based medicine and surgery that hardly could cure any of those chronic lifestyle diseases such as cardiovascular diseases, cancers, type 2 diabetes, and chronic respiratory diseases. These conditions, also known as noncommunicable diseases (NCDs), are linked to lifestyle factors like unhealthy diets, physical inactivity, tobacco use, and harmful alcohol consumption. Diseases such as type 2 diabetes. cardiovascular, gout, obesity and all diseases related to the ways we live and eat that would best be referred and managed by a dietician using dietotherapy  than being  treated by a doctor using drugs which are actually chemicals. How do chemicals treat, remove or heal a chronic disease due to unhealthy  eating or health-damaging lifestyles is extremely difficult for me as a clinician, nutritionist and a research medical scientist to understand. But doctors seldom want to refer  cases outside their training and expertise to other healthcare professionals. They want all the patients for themselves.  Even among the doctors  they are very reluctant to refer their patients to other specialists, because a patient referred is a customer lost. This has been going on for many, many decades already.

See link here among many others I have written

1. https://scientificlogic.blogspot.com/2025/09/a-patient-cured-is-customer-lost.html

2. https://scientificlogic.blogspot.com/2025/09/the-pitfalls-of-polypharmacy-in.html

As you rightly pointed out it is just due to bad system in a hospital or in the healthcare system if not selfishness of a doctor at the expense of the patient. Even in such a major hospital like the Kuala Lumpur Hospital where you work, all the departments are separate and compartmentalized, and seldom would  a doctor from one department wishes to refer his / her patient to a specialist or doctor in another department. They just keep the same patient for themselves for “follow-up” in their own department. We all are aware of this.  In a stroke patient for example, doctors would treat the  patient by first diagnosing the stroke type (ischemic or hemorrhagic) with imaging like CT or MRI scans, then using medications to dissolve clots or perform mechanical thrombectomy to remove them for ischemic strokes. For hemorrhagic strokes, treatment involves controlling the bleeding, reducing ICP - Intracranial Pressure (fluid pressure in the brain), and sometimes surgery to repair the vessel. After this treatment very few doctors would refer their patients for rehabilitation therapies to  help patients regain abilities and adjust to any permanent changes.  

Having said all that, that is where physiotherapy comes in. In fact, physiotherapy should be the first line of treatment as soon as possible, especially for mild stroke as shown in your mother’s case. You did a good and a correct job.

That’s where I like to explain further here where you left out under this title:

Reawakening the Brain: Harnessing Neuroplasticity to Restore Function After a Stroke 

A Wheelchair is not for a Stroke Patient

Summary

After a stroke, many patients are discouraged from active rehabilitation and instead confined to a wheelchair. Yet, neuroscience reveals that the human brain possesses a remarkable capacity for self-repair and reorganization,  a property known as neuroplasticity. Far from being static, the brain continuously adapts, forms new neural connections, and even reorganizes entire functional networks in response to training, therapy, and experience. Stimulating this natural adaptability is the cornerstone of stroke recovery with the rewiring of the brain to be done as soon as possible. 

Understanding Neuroplasticity

Neuroplasticity is the brain’s lifelong ability to modify its structure and function by creating new neural connections or strengthening existing ones. It operates through two fundamental processes:

Synaptic potentiation: 

strengthening frequently used neural pathways, enhancing signal transmission efficiency. 

Synaptic pruning: eliminating unused or inefficient connections to improve the brain’s overall network performance.

These processes enable the brain to adapt to new experiences, acquire skills, and recover from injuries. Neuroplasticity occurs on both microscopic 

(cellular) and macroscopic (network) levels, influencing everything from individual synapses to entire cortical regions.

Why Stimulating Neuroplasticity is Crucial After a Stroke

When a stroke damages part of the brain, the lost neurons cannot regenerate; however, surrounding healthy tissue can reorganize and take over the lost functions. This adaptive process, if properly guided, can restore speech, movement, and cognition. The main advantages include:

Compensating for permanent damage: Healthy neural circuits can assume the roles of destroyed ones, restoring lost motor or sensory functions.

Enhancing rehabilitation outcomes: The brain enters a “critical window” of heightened plasticity in the weeks to months following a stroke,  a period during which intensive therapy yields maximal gains.

Encouraging relearning and skill reacquisition:

Repetitive, goal-oriented tasks strengthen new pathways and reinforce desired behaviors. This principle forms the basis of constraint-induced movement therapy, gait retraining, and speech therapy. 

Preventing maladaptive plasticity: Without guidance, the brain may develop compensatory but inefficient patterns (e.g., learned non-use of a limb). Directed rehabilitation corrects these maladaptation and reinstates functional movement.

Boosting overall brain health: Stimulating neuroplasticity increases neurotrophic factors such as Brain-Derived Neurotrophic Factor (BDNF), which nourish neurons, support synaptic growth, and protect against further degeneration. 

Mechanisms of Neuroplasticity After Stroke

1. Structural Mechanisms

These involve physical changes in the brain’s architecture

Axonal sprouting: Surviving neurons grow new axonal branches that form alternative pathways around the damaged tissue.

Dendritic remodeling: Dendrites, the “receiving arms” of neurons, grow and reorient, increasing synaptic connections and communication potential.

Synaptogenesis: 

Formation of new synapses enables the establishment of fresh circuits necessary for relearning lost skills.

Neurogenesis: Although limited in adults, new neurons may arise in the hippocampus and migrate toward injured areas, aiding cognitive and memory recovery.

Angiogenesis: 

Formation of new blood vessels enhances oxygen and nutrient delivery, supporting neural repair and regeneration.

2. Functional Mechanisms

These describe changes in how the brain’s networks operate:

Cortical reorganization (remapping): Brain regions near the damaged area or in the opposite hemisphere take over lost functions. For example, motor tasks may shift to adjacent undamaged cortical zones.

Interhemispheric rebalancing: Stroke often disrupts the balance between hemispheres. Targeted therapies, such as mirror therapy or transcranial magnetic stimulation (TMS), can normalize this activity.

Reversal of diaschisis: Areas connected to the lesion but not directly injured may temporarily lose function; as communication is re-established, these regions regain activity.

Experience-dependent plasticity: The brain rewires in direct response to experience and practice. Meaningful, repetitive, and challenging tasks are the strongest stimuli for long-term adaptive change.

Clinical Implications: From Wheelchair to Rehabilitation

Encouraging stroke survivors to engage in active rehabilitation rather than permanent wheelchair dependence taps directly into the brain’s healing potential. Physiotherapy, occupational therapy, speech-language rehabilitation, and cognitive retraining all work by stimulating adaptive neuroplasticity.

Evidence shows that early, intensive, and task-specific therapy leads to better outcomes. Even years after a stroke, neuroplasticity can still be reactivated through new learning, physical activity, and environmental enrichment.

To optimize results, therapy should be as soon as possible for:

Repetitive and purposeful (e.g., practicing meaningful movements rather than passive exercise);

Progressively challenging to continually drive new learning

Emotionally engaging, since motivation and positive reinforcement enhance plastic changes.

Multisensory, combining movement, vision, sound, and touch to activate broader neural networks

Not just physiotherapy, but even acupuncture has been shown to greatly enhance neuroplasticity and brain activity and has speed up the recovery of stroke patients. By stimulating nerve pathways, acupuncture is thought to help the brain to reorganize its neuroplasticity.

Acupuncture has been shown to activate specific brain regions. Functional MRI studies have shown that needling acupuncture points can activate corresponding zones in the brain. By targeting specific areas with scalp or body acupuncture, practitioners can stimulate and "reprogram" damaged neural connections.

Acupuncture also repairs neural circuits.  Electroacupuncture (acupuncture with a low-level electrical current) has been shown in animal studies to promote the regeneration of damaged axons in the corticospinal tract, the main pathway for motor function.

Acupuncture stimulates the brain and spinal cord, which prompts the release of neurotransmitters and hormones. These chemicals can reduce pain, boost the immune system, and regulate various bodily functions. It  improves cerebral circulation by dilating blood vessels, which improves blood flow and oxygen supply to the damaged brain tissue, a critical factor in stroke recovery.

Studies suggest acupuncture may promote the dynamic repair of the neurovascular unit, the intricate network of blood vessels and nerve cells in the brain, which is essential for restoring neurological function after a stroke.  Acupuncture has been shown to promote the growth and formation of new neurons (neurogenesis) and stimulate the proliferation of neural stem cells, which are crucial for the repair and regeneration of damaged nerve tissue.

 The process of forming new blood vessels (angiogenesis) is supported by acupuncture, further enhancing blood flow and nutrient delivery to the brain.

Acupuncture may help protect vulnerable neurons and reduce the generation of damaging free radicals, a common issue after a stroke. 

Acupuncture can influence how cells communicate with each other within the brain, contributing to overall neurorestoration and functional recovery. 

It improves swallowing function: For post-stroke dysphagia (swallowing difficulty), acupuncture may work by enhancing sensory and motor nerve conduction to the swallowing motor cortex in the brain.

Acupuncture has been shown to work very effectively  in many other disorders. 

There was a very close friend of mine whom we know each other since our college days who later became a Professor and Head of the Department of Psychological Medicine at the University Hospital of the University of Malaya. Later he became a Consultant Psychiatrist to WHO on mental health. He told me for years he had a chronic pain. He consulted numerous rheumatologists including his own colleagues at the University Hospital, and was treated with all sorts of anti-inflammatory drugs, steroids, analgesics for years - all in vain. His chronic pain persisted. He was never treated holistically except being prescribed all kinds of drugs by rheumatologists. 

Finally he went to Tung Shin Hospital in Kuala Lumpur to consult a Traditional Chinese Physician who after only a few sessions of acupuncture, his years of chronic pain just went away permanently. He told me it was so cheap too, at only RM 35 per session. He told me he was very disappointed and disgruntled at his own western-trained medicine being a psychiatrist and a doctor himself. 

 He was a very close friend of mine who would confide in me all his personal problems.

Acupuncture has been shown to work even for cerebrovascular accident  (CVA - stroke)  

In short: 

The human brain is not a static organ, it is a dynamic, living system capable of profound reorganization. CVA recovery is not merely about surviving; it is about retraining the brain to live again. Encouraging patients to use their limbs, relearn speech, and engage in meaningful activity gives the brain the stimulation it needs to rebuild itself. Wheelchair confinement should be a last resort, not the default.

Neuroplasticity reminds us that rehabilitation is not just physical, it is the science of hope translated into motion.

Selected References

1. Cramer SC, Sur M, Dobkin BH, et al. (2011). Harnessing neuroplasticity for clinical applications. Brain, 134(6), 1591–1609.

2.  Krakauer JW, Carmichael ST, Corbett D, Wittenberg GF. (2012). Getting neurorehabilitation right: What can be learned from animal models? Neurorehabilitation and Neural Repair, 26(8), 923–931.

3. Nudo RJ. (2013). Recovery after brain injury: Mechanisms and principles. Frontiers in Human Neuroscience, 7:887.

4. Kleim JA, Jones TA. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research, 51(1), S225–S239.

5. Winstein CJ, Stein J, Arena R, et al. (2016). Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke, 47:e98–e169.

6. Johansson BB. (2011). Current trends in stroke rehabilitation: A review with focus on brain plasticity. Acta Neurologica Scandinavica, 123(3), 147–159.