Neuroplasticity after stroke: Adaptive and maladaptive mechanisms in evidence-based rehabilitation

BACKGROUND AND PURPOSE: Ischemic stroke remains a leading cause of long-term disability and persistent motor deficits. While neuroplasticity drives post-stroke recovery, clinical rehabilitation does not always effectively utilize this mechanism. Importantly, adaptive plasticity promotes restitution through the reorganization of affected neural networks, thereby restoring original motor patterns. In contrast, maladaptive plasticity may reinforce compensatory strategies and limit recovery of normal motor control. This review examines physiotherapy strategies that stimulate neuroplasticity after stroke, focusing on how adaptive and maladaptive mechanisms influence clinical outcomes. Rapid advances in biomarker-guided therapy and multimodal technologies (2024-2026) underscore the timeliness of this review. OBSERVATIONS: Recent advances in neuroscience and technology demonstrate how different methods can selectively enhance adaptive plasticity. Evidence from randomized controlled trials and systematic reviews (2024-2026) shows that physiotherapy is most effective when it is intensive, repetitive, and task-specific. Interventions such as task-specific training, constraint-induced movement therapy, mirror therapy, aerobic exercise, robotic-assisted training, virtual reality, and non-invasive brain stimulation consistently improve motor function and activities of daily living. Multimodal rehabilitation strategies that integrate sensory feedback and neuromodulation are particularly effective, as they increase cortical activation, strengthen adaptive reorganization, and reduce reliance on the unaffected hemisphere. CONCLUSIONS: Current evidence confirms that neuroplasticity is the foundation of post-stroke rehabilitation. Early, intensive, and task-specific interventions promote restitution and limit maladaptive changes. These findings underscore the importance of actively engaging affected motor networks rather than relying on compensatory strategies. Although most evidence derives from short- to medium-term studies, the integration of multimodal technologies is a major strength of contemporary research. Future studies should focus on long-term outcomes and further refine biomarker-guided rehabilitation strategies to optimize neuroplastic recovery.