Why "They've Plateaued" Doesn't Always Mean They've Reached Their Potential
If you've spent time in physical therapy with your parent, you've probably heard the word before:
"They've plateaued."
It sounds final. Like a door closing. Like this is simply as good as it's going to get.
But a plateau doesn't necessarily mean someone has reached the limit of what they're capable of doing. Sometimes it simply means they've reached the limit of what their current strength allows them to do.
And that distinction matters.
Why This Word Causes So Much Confusion
When a therapist says someone has plateaued, they're describing what's happening right now: progress has slowed or stopped with the current plan of care.
Families can hear something very different. They hear:
"There is nothing more that can be done."
Those two statements are not the same. A person can stop making progress with a particular approach without having reached their full physical potential.
The more important question may be: what's actually limiting them right now? Is it pain? Fatigue? Cognition? A medical condition? Fear of falling? Or is it strength?
That last question matters most, because strength takes time to build.
Sometimes the Plateau Is Really a Strength Plateau
Progress after an illness, hospitalization, surgery, or injury can happen quickly at first. Pain may decrease. Swelling may go down. Movement may return. Someone may go from needing extensive assistance to standing or walking with a walker.
Those are meaningful improvements. But recovery often reaches a different stage after that.
The person may be able to perform the movement, but not well enough to be independent. They can stand - but only by pushing heavily with their arms. They can walk - but still need a walker. They can transfer - but still need someone nearby, or helping.
At that point, doing more of the same activity isn't always enough. The person may need something different: more strength.
Strength isn't built simply by repeating a movement. Muscles adapt when they're challenged appropriately and consistently, and that adaptation takes time - which is one reason progress can appear to slow down even when there's still real room to improve.
A plateau may be the point where recovery from the original event has slowed, and building the strength needed for the next level of function has to take over. That's a very different message than "this is as good as they can ever get."
Plateau Doesn't Mean Ceiling
Consider a few examples.
Someone who can walk with a walker but still can't safely walk without one has made real progress - but "needs a walker" describes their current ability, not a prediction of their future.
Someone who can get out of a chair, but has to push hard with both arms, has made progress - but "can stand using their arms" doesn't tell us whether stronger legs could eventually let them stand with less assistance.
Someone who can transfer from a bed to a wheelchair with help has made progress - but "needs assistance" doesn't automatically mean they always will.
In each case, the real question becomes: what's preventing the next step? If the answer is insufficient strength, strength needs to become part of the solution.
Can Someone Really Get Stronger at 80, 90, or Older?
This is one of the questions families ask most often, and it's a fair one.
The answer is yes - older adults can improve strength, including very old adults. One of the most widely cited studies on this, published in The New England Journal of Medicine in 1994, followed 100 frail nursing home residents with a mean age of 87.1 through a 10-week high-intensity resistance training program.
The results were substantial. Compared with residents who didn't exercise, participants in the training program increased muscle strength by 113%, improved gait velocity by nearly 12%, and improved stair-climbing power by more than 28%.
The point isn't that every 87-year-old will respond the same way - they won't. The point is that age alone doesn't tell us how much strength someone can build. A person's medical conditions, cognition, nutrition, activity level, starting strength, consistency, and ability to safely participate all matter. But "they're in their 80s" or "they're in their 90s" shouldn't be treated as an automatic answer to whether they can get stronger.
Strength Takes Time
One of the biggest problems families run into is expecting strength gains to happen as quickly as other parts of recovery. They often don't.
A person may feel better within days or weeks. They may become more comfortable walking. They may learn how to use a walker well. They may get better at a transfer. But building meaningful strength is different - it requires repeated exposure to an appropriate challenge over time.
That's why a program focused on strength may not produce dramatic changes after a handful of visits. It can take weeks or months before the increased strength becomes obvious in everyday activities. And once strength improves, it has to be maintained - strength isn't permanent. It has to be built, challenged, and maintained.
More Walking Isn't Always the Answer
When someone struggles to walk, the natural response is often to practice walking more. When someone struggles to stand, it's more standing practice. When someone has difficulty getting out of a chair, it's repeated sit-to-stands.
Practice has value. But practice doesn't automatically create the strength required to perform an activity independently.
If someone's legs aren't strong enough to rise from a chair without using their arms, doing more sit-to-stands may not solve the underlying problem - not if the person can't generate enough force to actually challenge and strengthen those muscles. The same is true for walking: someone may cover hundreds of feet with a walker and still not have the leg strength needed to walk safely without it. Walking helps someone practice walking. It doesn't necessarily build the strength required to walk better.
Does Medicare Require Someone to Keep Improving?
This is where the word "plateau" gets especially confusing.
For years, there was widespread misunderstanding about whether Medicare required a patient to keep improving for skilled therapy to stay covered. The Jimmo v. Sebelius settlement - approved by the U.S. District Court for the District of Vermont in January 2013 - clarified that Medicare coverage for skilled therapy doesn't depend simply on whether someone is expected to improve. When all other coverage requirements are met, Medicare can cover skilled therapy when a qualified therapist's specialized knowledge and skills are necessary to maintain a person's current condition, or to prevent or slow further decline.
That doesn't mean everyone who's plateaued automatically qualifies for continued Medicare therapy. Skilled care still has to be medically necessary, and the services still have to require a qualified therapist's skill. If a program can be safely and effectively carried out by the patient or an unskilled caregiver, Medicare doesn't cover it as skilled therapy.
So a plateau doesn't automatically mean "Medicare must stop paying." But it also doesn't mean "Medicare will keep paying indefinitely." The real question is whether skilled therapy is still medically necessary, and whether a therapist's specialized skills are still required - we go deeper into exactly how that distinction works in our companion piece, What Is Medicare Maintenance Therapy?
What Happens When Medicare Therapy Ends?
This is a separate, important question.
Medicare therapy ending doesn't necessarily mean someone has reached their physical potential. It means they no longer meet the requirements for that particular Medicare-covered service. There may still be a real need for ongoing strength training, balance work, and physical activity - which is where families need to understand the difference between therapy coverage and physical need.
A person can still be weak after Medicare therapy ends. They can still have difficulty getting out of a chair. They can still need a walker. They can still be at risk of falling. They can still have more strength to build.
Coverage can end before the need for strength does.
What Should You Ask When Someone Says "They've Plateaued"?
If your parent has been told they've plateaued, don't be afraid to ask questions.
Ask what specifically has plateaued - their walking distance? Their balance? Their transfers? Their strength? Then ask what's actually limiting them right now. And perhaps most importantly: is strength the limiting factor? If it is, ask what it would take to make their legs stronger.
These questions don't assume more therapy will always work. They just make sure "plateau" isn't being interpreted as something it doesn't necessarily mean. Sometimes a plateau really does represent someone's realistic ceiling - a medical condition, a neurological impairment, or another factor can genuinely limit what's achievable. But sometimes a person has simply reached the limit of what their current level of strength allows. Those are very different situations, and only a conversation with their therapist can tell you which one you're in.
The Missing Piece May Be Strength
This is where Tandem Strength & Balance is different.
Our focus isn't simply on helping someone practice walking, standing, or transferring. We focus on the strength behind those movements - because leg strength is the foundation of independence. Getting up from a chair requires it. Standing safely requires it. Walking requires it. Recovering from a loss of balance requires it. And maintaining independence requires enough of it to keep doing these things day after day.
That's why our approach places such a strong emphasis on progressive strength training - particularly the muscles that directly support standing, walking, and functional movement. The goal isn't simply to help someone complete an activity during a therapy session. It's to build the physical capacity that lets them do more of that activity in everyday life.
A Plateau Can Be a Question, Not a Conclusion
If your parent has been told they've plateaued, take the word seriously. But don't necessarily take it as the end of the conversation.
Instead, ask: what would it take to get further? Maybe the answer is that they've reached a realistic limit. Maybe their medical condition has changed. Maybe they need a different approach. Or maybe they need more time and appropriately challenging strength training. You won't know unless you ask.
At Tandem Strength & Balance, we work with older adults who've made progress but still have more work to do - including people who've completed Medicare therapy but remain weak, unsteady, or dependent on assistance. Our private-pay, one-on-one, in-home physical therapy is built around a simple idea: build strength, maintain strength, protect independence.
Because where someone is today isn't always where they have to stay.
Get Strong. Stay Strong.
References
- Fiatarone, M.A., O'Neill, E.F., Ryan, N.D., et al. "Exercise Training and Nutritional Supplementation for Physical Frailty in Very Elderly People." The New England Journal of Medicine, 330: 1769-1775, 1994 - 100 frail nursing home residents, mean age 87.1, 10-week high-intensity resistance training program; muscle strength increased 113%, gait velocity increased 11.8%, and stair-climbing power increased 28.4% versus non-exercising residents.
- Jimmo v. Sebelius, settlement approved by the U.S. District Court for the District of Vermont, January 24, 2013 - clarifying that Medicare coverage for skilled therapy does not require a beneficiary to be expected to improve.
- Centers for Medicare & Medicaid Services, Frequently Asked Questions Regarding the Jimmo Settlement Agreement - confirms that a beneficiary's lack of restoration potential cannot, by itself, be the basis for denying coverage, and that services that can be safely and effectively performed by the patient or an unskilled caregiver are not covered as skilled therapy.