The syndrome of spastic paresis occurs following a lesion involving the central motor pathways that process the execution of voluntary motor command (1, 2). The main cause is stroke, with approximately 70% of stroke survivors experiencing an initial motor deficit, with walking recovery possible in most cases (3). In contrast, only 10%–20% of stroke patients recover “normal” upper limb function, i.e., the ability to use the paretic hand in daily activities during chronic stages (>6 months) (3–9). This represents a major challenge for the rehabilitation community. Thus, there is an important need for rehabilitative approaches capable of enhancing upper limb motor recovery for stroke patients (10).

Conventional rehabilitation after stroke has included sensorimotor training, strengthening, or task-oriented exercises (11). Other techniques such as constraint-induced movement therapy (CIMT) or mirror therapy have been promoted (12, 13). More recently, technological advances have allowed upper limb exoskeletons, robot-assisted therapies, and virtual reality to also emerge (14, 15). Although research in these areas has produced preliminary results, the high cost of these devices limits their accessibility globally.

Meanwhile, today, there is a better appreciation of the various determinants of neuronal plasticity. For patients with spastic paresis, it is now understood that the dose of any rehabilitation intervention may be a more powerful stimulus to improving motor function than the exact rehabilitation technique (16).

However, in chronic stages, our current healthcare systems are unable to provide sufficient time for physical therapy through prescriptions (17). After discharge from rehabilitation units, the amount of delivered therapy typically decreases over time. Under these conditions, recovery of motor function is classically limited at the chronic phase, often improperly interpreted as having reached a form of ineluctable “plateau,” as if no further progress were then possible (6). Yet, this interpretation reflects confusion between two types of plasticity, lesion-induced plasticity, which indeed is short-lived, lasting a few months only (18), and behavior-induced plasticity, which remains available all life long (19). Therefore, recent recommendations for stroke rehabilitation advocate for intensive, long-lasting, challenging, repetitive, and motivating training (20, 21), with high doses needed to maximize neural recovery (16).

The strategy of guided self-rehabilitation contract [GSC, (22)] aims to meet the criteria of intensity through two principles, namely, psychological and technical. GSC is a diary-based rehabilitation system targeting antagonistic muscles (22). It relies on a moral contract between patient and therapist. The GSC therapist (e.g., doctor or physical or occupational therapist) prescribes and teaches a daily program of self-stretching postures and maximal alternating movement exercises targeted to the muscles found to be the most disabling at the five-step assessment (FSA) (see below) and provides the patient with the GSC manual (22). During each follow-up encounter, the GSC clinician corrects and adjusts the program according to progression.

The technical principle of GSC requires, from the clinician, a clear understanding of the pathophysiological processes involved to identify the muscle and command disorders that need treatment in chronic spastic paresis in particular. Pathophysiological understanding of the syndrome of spastic paresis revolves around the characterization of two disorders: spastic myopathy (1, 2, 23, 24), which appears early in the acute phase (loss of extensibility of muscles immobilized in a short position) and then only worsens, and the motor command disorder, due to later emerging plastic neural mechanisms causing motor neuronal overactivity that mostly involves the shortened antagonists (1, 2, 25, 26). One notable form of motor neuronal overactivity is spastic co-contraction, a misdirection of the supraspinal descending drive that fires motor neurons that are antagonists to the desired movement (1, 2, 25–27).

In chronic stages, spastic overactivity is then superimposed on muscle changes, with reciprocal potentiation between the two (1, 2, 22–26). These muscular and neural phenomena coalesce to produce agonist–antagonist imbalance around joints, with spastic co-contraction, in particular, directly impeding and sometimes reversing the desired voluntary movements (25–27). In subacute and chronic stages after a stroke, active movement becomes primarily hindered by these antagonist resistances, rather than by agonist paresis (1, 2, 25–27). In the upper limb, typical antagonists to daily functional movements are shoulder extensors, shoulder internal rotators, elbow flexors, pronators, wrist flexors, finger flexors, and interosseous muscles (28). There is a need to estimate spastic myopathy and muscle overactivity (spastic co-contraction) in such antagonist muscles, which can be achieved through the five-step assessment [see below, (23, 29, 30)].

From a therapeutic point of view, to tackle muscle shortening and excessive co-contractions, there are two key physical techniques. Daily high-load self-stretch postures (for muscles specifically selected by the prescribing clinician) stimulate muscle plasticity, and alternating with repeated maximal amplitude movement exercises against these antagonists stimulates neural plasticity (22, 31–33). The stretching program involves prolonged static self-stretching postures, >15 min/day/muscle at high load—just below pain threshold—for selected specific antagonists. The training program consists of a series of alternating efforts of maximum amplitude against each targeted antagonist, for short periods of time (10–30 s/series, adapted to fatigability) to decrease antagonist co-contractions over time (33, 34).

The psychological principle of GSC uses a strategy to enhance and maintain the motivation level of the patient over the long term, exploiting a tool of quantitative self-monitoring, the quantified diary (35–37). The patient performs the prescribed program on a daily basis and keeps a log quantifying the work actually accomplished every day, specifying the duration of self-stretching postures and the number of efforts or movements performed with each series of rapid alternating movements (when no work is actually done on a given day, the patient must write zero in the relevant boxes). The diary may be better in paper form (notebook, binder, etc.) or may be computerized. It must be turned to the GSC therapist at each encounter and enables the therapist to assess the work actually performed and the compliance with the program. The GSC therapist then provides frequent enough quantified assessments (i.e., from once a week to once a month, depending on the patient’s understanding of the program and compliance) to the patient to demonstrate clinical progress, correct the exercises performed by the patient, and adjust the program over time according to clinical evolution. Once such careful, frequent enough, quantitative estimations (23, 29, 30) are regularly generated, we observe that the GSC ends up motivating patients to apply intensive daily practice at home, increasing the amount of physical work compared to conventional systems (17). In a recent controlled trial, a 1-year GSC program targeting plantar flexors in patients with chronic hemiparesis did produce structural changes in these muscles and improved walking speed as compared with conventional rehabilitation. In this study, the patient devoted at least twice as much time to home rehabilitation than with conventional community-based physical therapy (17).

Here, from massive hemiparesis after a large ischemic stroke, we describe near-perfect upper limb motor recovery in chronic stages through a 4-year GSC (22).

In this case report, a daily customized program applied for 4 years through GSC, which targeted the most hindering antagonist muscles using high-load self-stretched postures and a series of alternating maximal efforts, resulted in exceptional functional improvement. The shortened and overactive antagonist muscles gradually increased their extensibility and reduced their spastic co-contractions, which led to gains in passive and active amplitudes in the upper limb slowly recovering physiologic values, as did the functional assessment measured using the MFS scale. The patient regained normal use of the upper limb “as if I’d never had a stroke” (see testimonial below) and resumed her full professional activity.

The GSC system makes it possible to combine daily intensity and long-term duration of rehabilitation work. This specific method is affordable at a global level for the greatest number of stroke patients. Referred to a GSC-trained therapist and provided with a specific manual and a customized prescription to be adjusted by the therapist, the patient can start a program right from the initial prescription. This case report offers promising prospects for the rehabilitation of chronic hemiparesis. If large-scale multicenter-controlled trials confirm the findings of this exceptional case, even partly, GSC may help reshape the way rehabilitation is conceived in chronic neurological disorders.