Chronic stroke: the 6-month-plus patient and the plateau myth

1. Case. A 71-year-old woman, 14 months post-right-MCA stroke. Left hemiparesis. Comfortable gait speed 0.55 m/s with AFO and single-point cane. Previous PT episode discharged her 6 months ago at "plateau."

2. CPG section. The Locomotor CPG (Hornby 2020) was written specifically for this population: greater than 6 months post-stroke, iSCI, or TBI. Strong recommendation: moderate-to-high intensity walking training. Strong recommendation against: body weight–supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality as primary interventions for improving walking speed or distance in this population. The CPG notes these against-recommendations do not apply to non-ambulatory individuals.

3. Reasoning walkthrough. "Plateau" is a clinical descriptor, not a biological ceiling. Moore JL, Roth EJ, Killian C, Hornby TG (*Stroke*. 2010;41:129–135) demonstrated that locomotor training in chronic stroke produced gains in daily stepping and gait efficiency in patients previously labeled plateaued. The evidence-based starting point is high-intensity stepping practice, not modalities. Boyne P, Billinger SA, Reisman DS, et al. (*JAMA Neurol*. 2023;80:342–351) reported that 12 weeks of vigorous-intensity treadmill training produced a mean 6MWT gain of 71 m versus 27 m for moderate-intensity training in chronic stroke — a significant between-group difference that anchors current intensity dosing.

4. Outcome measure. 6MWT plus mini-BESTest. 6MWT MCID in stroke ≈ 34.4 m (Fulk GD, He Y. *J Neurol Phys Ther*. 2018;42:235–240). Mini-BESTest MCID in subacute stroke pooled estimate = 3.8 points (95% CI 2.9–5.0; Yamamoto Y et al., *Phys Ther*. 2024;104:pzae017).