Next Frontier in Stroke Recovery (Podcast)

“We used to have to tell patients six months after a stroke that they had likely reached their maximum recovery and shouldn’t expect further progress,” says Francois Bethoux, MD, Chair of the Department of Physical Medicine and Rehabilitation at Cleveland Clinic. “Now we can tell people who are five or 10 years out from a stroke that they may still be able to make gains if we all work hard at it and apply some techniques — including perhaps surgical techniques — along with rehabilitation therapy.”

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Bethoux and cerebrovascular neurosurgeon Mark Bain, MD, outline the recent evolution of stroke recovery and what’s on the horizon. They address the following and more:

• Key issues involved in post-stroke recovery and the need for a personalized, holistic approach that changes over time
• New options for post-stroke recovery, including the use of active assistive devices
• Use of neuromodulation techniques like transcranial magnetic stimulation and vagus nerve stimulation to promote neuroplasticity and motor recovery
• How vagus nerve stimulation works and the evidence supporting its use in conjunction with intensive rehabilitation

Click the podcast player above to listen to the 32-minute episode now, or read on for a brief excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

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Excerpt from the podcast

Podcast host Glen Stevens, DO, PhD: Are you using transcranial magnetic stimulation for post-stroke recovery?

Francois Bethoux, MD: At Cleveland Clinic we have been using it in research but not yet in the clinic. It is being studied to promote upper extremity motor recovery after stroke, with some encouraging results. It’s part of the neuromodulation movement — the idea that if you pair rehab with modulation of the nervous system, the patient becomes more receptive to the effects of the rehab, resulting in more recovery. It’s a synergistic effect.

Dr. Stevens: Let’s talk about another type of neuromodulation, vagus nerve stimulation. How does that work?

Mark Bain, MD: We don’t know exactly how it works, but when we stimulate the vagus nerve, it produces a parasympathetic response, a global response in the brain. And that stimulates some degree of neuroplasticity, as Francois was discussing earlier. It definitely does this for motor function; it’d be interesting to know if does for speech as well.

We don’t yet understand the pathways. There are preclinical studies showing that stimulating the vagus nerve triples the connectivity in the corticospinal tracts. So there is something going on there that’s inducing this plasticity.

It’s worth noting that in the pivotal trial of vagus nerve stimulation for stroke, patients were receiving stimulation at a mean interval of three years after their stroke, and they were still getting meaningful benefit at that point. So that was groundbreaking, in light of Francois’ earlier point that we used to tell patients not to expect further improvement after six months.

Of course, that was achieved in combination with pretty significant rehabilitation therapy. If a person gets vagal nerve stimulation and just sits on a couch, nothing will happen. It really does have to be paired with an intensive rehab program.