Next Frontier in Stroke Recovery

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: July 1, 2025
Expiration Date: June 30, 2026

Estimated Time of Completion: 30 minutes

Next Frontier in Stroke Recovery
Francois Bethoux, MD and Mark Bain, MD

Description
Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience
Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

ACCREDITATION

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

• American Medical Association (AMA)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  
  Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation
  A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)
  Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Credit will be reported within 30 days of claiming credit.

Podcast Series Director
Andreas Alexopoulos, MD, MPH
Epilepsy Center

Additional Planner/Reviewer
Cindy Willis, DNP

Faculty
Francois Bethoux, MD
Physical Medicine and Rehabilitation

Mark Bain, MD
Cerebrovascular Center

Host
Glen Stevens, DO, PhD
Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Next Frontier in Stroke Recovery
Francois Bethoux, MD and Mark Bain, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

Mark Bain, MD	Borvo Ownership Interest - Stock CIT Ortho Consulting Codman (Johnson & Johnson) Consulting Integra Lifesciences Corp Consulting Medtronic Consulting MicroVention Consulting Stryker Neurovascular Consulting
Francois Bethoux, MD	Bristol-Myers Squibb Co. Consulting Advisor or review panel participant GW Pharma Advisor or review panel participant (Ended: 09/23/2023) Springer International Publishing Intellectual property rights (Royalties or patent sales) Amneal Pharmaceuticals Advisor or review panel participant (Ended: 03/09/2023) MedRhythms Inc Advisor or review panel participant Research Qr8 Intellectual property rights (Royalties or patent sales)
Glen H Stevens, DO	DynaMed Consulting

All other individuals have indicated no relationship which, in the context of their involvement, could be perceived as a potential conflict of interest.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: Neuro Pathways Podcast July 1, 2025 to log into myCME and begin the activity evaluation and print your certificate If you need assistance, contact the CME office at myCME@ccf.org

Copyright © 2025 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neurorehab, and psychiatry.

Glen Stevens, DO, PhD: The World Stroke Organization estimates that globally, one in four adults over the age of 25 will experience a stroke as a result. There are currently over a hundred million people who've experienced a stroke.

Stroke recovery is a long-term dynamic process that requires a holistic and personalized approach, adjusted over time depending on the person's evolving needs. In today's episode, we're discussing the latest post-stroke recovery options, including those that have been newly adopted or in trial phase. I'm your host Glenn Stevens, neuro-oncologist in Cleveland Clinic's Neurological Institute. And joining me for today's conversation are Francois Bethoux, MD and Mark Bain.

Dr. Bethoux is a director of the Department of Physical Medicine and Rehabilitation, and Dr. Bain is a neurosurgeon in the Cerebrovascular Center, both within Cleveland Clinic's Neurological Institute. Francois, Mark, welcome to Neuro Pathways.

Francois Bethoux, MD: Thank you.

Mark Bain, MD: Thank you.

Glen Stevens, DO, PhD: Thank you. Francois, why don't you tell us a little bit about yourself, your background, why you came to Cleveland, what you do on a regular basis, and we'll have Mark do the same thing.

Francois Bethoux, MD: So, I was born in France and came to the U.S., came to the Cleveland Clinic in '97. And during my whole tenure at the Cleveland Clinic, I have really been focused on neuro-rehabilitation, but working closely with neurologists and neurosurgeons, and that's what I've found one of the most rewarding aspects of my work. I've worked with people who have MS, people who've had a stroke, brain injury, spinal cord injury, and I'm particularly focused on how to help facilitate movement after there's been damage to the nervous system.

Glen Stevens, DO, PhD: Mark?

Mark Bain, MD: Yes, I grew up a lot closer than Francois, in Buffalo, New York. Just moved down the lake and settled here in 2004 where I did my neurosurgery training. I did some interventional work here and training here at the Cleveland Clinic, and I did some skull-based open cerebrovascular training at Emory University.

Came on staff right after that and we've been focusing in cerebrovascular on treating stroke really in the acute phase when people have bleeds in the brain, when people are having ischemic strokes, we are getting up in the middle of the night and taking clots out of arteries in the brain. So this is sort of a new field for us, as surgeons and interventionalists, to be getting involved in doing procedures where we're doing surgery interventions for people that have had stroke maybe six months after, up to three years after. So it's a really new exciting field for us and we're happy to be participating.

Glen Stevens, DO, PhD: Well, it's a pleasure to have you both here. Being Canadian, one of my favorite neurologists of all time, of course, is C. Miller Fisher, who's from Waterloo, Ontario, and one of his famous quotes was that neurologists learn neurology stroke by stroke. He's really, in a lot of ways, the father of stroke neurology, even though he's a pathologist, a neuropathologist, and really defined all the lacunar syndromes. And of course, back in the day, and I remember when I was training, and you guys may have done it, we used to do brain cutting, where we'd go with the pathologist, someone who had a stroke, and they would cut the brain and you would say that area of the brain's affected what were their symptoms, and that's how they figured out how all these things work. So I still think that's true to today. It really has helped us understand what we can do.

And of course as a surgeon, it helps you understand, when you see a deficit, does it make sense? Does it make sense? Should we go in surgically and treat this patient or not? But we appreciate what you both do.

So Francois, I'll start with you. Tell us a little bit about your role and of course with the numbers that we see here, prevention is the key, but we're sort of past that. We're also, you do a lot of interventions where you would go in and suck a clot out or put a stent in. We're kind of, I think past those things, but someone's had a stroke. Francois, I've had a stroke, I come see you. What do you do with me?

Francois Bethoux, MD: I ensure you that I will provide you the best care I can.

Glen Stevens, DO, PhD: And I know I'll get it.

Francois Bethoux, MD: And I will optimize your quality of life as much as I can.

I would say that typically the field of rehabilitation was taking care of a patient after the acute phase where the neurologist and neurosurgeons would work together to minimize the damage to the brain. And so to maximize their residual function, and then take the patient where they are.

And know that there is an expected, what we call natural recovery due to brain plasticity and other phenomena and accompany that. Also, try to address issues that could get in the way of that recovery. For example, severe pain, or severe spasticity, or some musculoskeletal injuries, for example. In your shoulder pain that can happen, because an arm is paralyzed and so the shoulder's hanging there and then it gets damaged, for example.

And then we would say, well, at some point that's the maximum recovery that's been happening. And still rehab would be involved in saying, how can we maximize your function given the residual problems that you have using devices, using all kinds of techniques or strategies to compensate with the other side, for example, when you have deficits on one side.

And then often follow people long-term because as people are aging, then their ability to function with what the stroke has caused, is less and less evident, so it needs adaptations. So that's really the traditional model of what we were doing with clearly the fastest phase of recovery in the first three to six months and then somewhat of a plateau. That's kind of the traditional way of doing it.

But there's been strategies to favor the affected side, right? Often a stroke will result in hemiparesis, in weakness, in loss of coordination, loss of sensation, sometimes on one side of the body. So there's techniques, such as a constraint induced therapy, where you could temporarily constrain the healthy limb or healthy side to force the use of the unaffected side and promote brain plasticity.

Glen Stevens, DO, PhD: Yeah, I recall that that was after my training, but I remember they used to start to talk about doing limb restraints to force the person. How well does that work?

Francois Bethoux, MD: First, that sounds barbaric, right?

Glen Stevens, DO, PhD: Yes.

Francois Bethoux, MD: You have a healthy limb that could help a lot. Well, let me just tie it up. But the technique has evolved and first it's used during the therapy, not during people's everyday life.

Actually, there were very interesting results because in the brain, if you don't use it, you lose it. That, kind of saying works in a way. So the more you use it, you try instead of trying to circumvent and taking the easy way, then you will have more recovery. It's very important because, for example, many, many of the things we do every day require both hands, at least one hand that helps hold an object or support it, and the other one can manipulate it and do the fine thing.

And the reason why I'm insisting on that is that it basically is illustrated now in the new techniques such as the vagus nerve stimulation that we will discuss today.

Glen Stevens, DO, PhD: It's always great to watch old movies. And old isn't always that long ago, but someone will have a heart attack and they'll immediately put them in bed for three weeks and give them a cigarette. And I think we've evolved past all of that now, right? But it was always the way that you have a problem, just let them rest, right? Don't do anything. When do you start rehab?

Francois Bethoux, MD: So that's the thing right now, we start rehab as early as possible. At the Cleveland Clinic, there is a program for early mobilization of patients in the intensive care unit, which is not easy with all the tubes, and often patients are unstable body functions at the time, but yet it's very important to promote that as early as possible. So literally, could be the next day after a stroke or a few days after. And then as I said, it could continue to some degree and, in some form, four years and through the lifetime.

Glen Stevens, DO, PhD: So, we'll get to mark here in a minute, but I'm going to stay with you for a little bit here. Assistive devices for individuals, technologies that are developed to help people with strokes. I mean, we have a lot of devices now with people that are paralyzed and those types things. So I assume some of this is available today.

Francois Bethoux, MD: They are, and this is where technology really addresses the problems of people with disabilities. The traditional assistive devices are more what we would call passive. It's a cane, it's a walker. They're extremely helpful, easy to maneuver, but now we have active devices.

Maybe the most striking example of that is the exoskeleton. It's a brace that basically goes from the waist down to the feet, has motors, and then a complex software with algorithms. So it's a robotic device that can reproduce walking, and can either produce walking in somebody who couldn't walk at all or assist the walking, and allow them to make repetitions.

Here we have again, the idea of the more we stimulate the affected limb to move, even with some assistance, then the more they're likely to recover some function there. So that's one example, but there are many others of how technology now can be integrated early in the rehabilitation process.

Glen Stevens, DO, PhD: And can you see benefits in some areas? Let's say someone has a weakness in an arm. If you put them on a bicycle and they're just cycling on a bicycle, can it somehow help the brain make the arm better? Or you have to be specific to where the problem is or not necessarily?

Francois Bethoux, MD: This is a great question. The answer is a little complicated, but to keep it simple, I would say generally we try to stimulate movement in the affected area. So if you want to recover hand function, and we try to elicit hand movements. However, there is an emerging body of evidence that says that general exercise actually can stimulate recovery. We don't know if it stimulates brain plasticity. Some people have found that it stimulates the production of factors that can help regenerate nerve cells, nerve growth factors than others. And so that's very exciting. We are still dabbling into this.

But so to answer your question, yes, it could be that by doing general exercise, you could actually stimulate recovery even years after a stroke, which is the excited part. So part of our efforts at Cleveland Clinic and of course in other institutions, is to give people with strokes access to specialized exercise programs because often it's not easy for them to get to a regular gym to know how to use the machines with their limitations. They don't even know if it's safe.

So we have actually piloted at the Langston Hughes Family Health Center, and now at Mercy Hospital in Canton, a program that is accessible to people with a stroke. And they can have coaching there, they can have access to sophisticated machines, and then they can continue to do that exercise and promote that motor recovery.

Glen Stevens, DO, PhD: We always talk about motor. Sensory. Can we do anything? Patients will often ask that. Certainly I manage brain tumors. So we have people have tumors affecting the sensory areas of the brain, and they're always asking, and I can always ask Mark this when we get to his area as well, but any therapy makes sensory stuff better? Or, it would seem a very difficult thing to manipulate.

Francois Bethoux, MD: It is very difficult, and we don't have any techniques really that are proven in rehab that are proven to restore sensory function. However, we can stimulate the sensory system in a way that helps restore the perception of the sensation, because sometimes actually the circuits are more or less intact, but the brain doesn't perceive the sensation because of the stroke. And so there may be a way to generate plasticity so that other circuits cannot take over that function and restore some of the perception of the sensation.

Glen Stevens, DO, PhD: And I guess language, the same problem, right?

Francois Bethoux, MD: Language, same problem. There are techniques though with speech therapy. There are techniques with music therapy to help pre recover speech and motor function as well. It's amazing to see how the field is brimming with new initiatives, and time will tell which ones are the most effective.

Glen Stevens, DO, PhD: Well, I recall from many years ago that you would see somebody that had a stroke affecting their language, but they could swear, and they could sing. So again, it's an opportunity not to develop a new language for a patient.

But the singing is interesting and you would know much more than I, but it must be localized in different areas. But I guess, can you use that as a way of bringing their language back?

Francois Bethoux, MD: No, it is a neuromusic therapy technique that actually has been validated. It's called melodic intonation therapy, and it's been used, routinely actually, to restore language.

What I want to point out is that in the past, and I'm unfortunately old enough to remember the time when we said, six months after a stroke, you've reached your maximum recovery. There's nothing else to expect. And now we're talking to people who may be five, 10 years after a stroke and say, if we all work hard at it and apply some techniques, maybe some surgical technique even, you may actually be able to make some gains. So really that's changed the landscape for people who were left with basically no hope six months after a stroke.

Glen Stevens, DO, PhD: I know in the psychiatry field they do a lot of trends.

Francois Bethoux, MD: Transcranial magnetic stimulation.

Glen Stevens, DO, PhD: Do you use that?

Francois Bethoux, MD: Researchers at Cleveland Clinic have been using that? We are not using it in the clinic yet, but magnetic stimulation, transcranial direct, current stimulation have been used to promote upper extremity motor recovery after stroke, and with some encouraging results. It's all part of the neuromodulation movement. The idea if you pay a rehab with a modulation of the nervous system, it's more receptive to the effects of the rehab, and then you will get more recovery. It's like that synergistic effect.

Glen Stevens, DO, PhD: So, I guess that'll take us over to Mark, and more neuromodulation types in conjunction, I guess, with what you're doing, Francois. But Mark, tell us a little bit about VNS, and if you can tell me why it works, that would be great.

Mark Bain, MD: Yeah, yeah, I would love to know exactly, but I think this gets back to a little bit, Francois, what you were talking about. We don't know exactly what's happening, but we stimulate the vagus nerve. This is a parasympathetic response, but I think it's a global response that you get in the brain. And I think exactly what you were talking about, it does stimulate some sort of plasticity. Definitely in motor, but I'm interesting to know if it's in speech as well.

And we don't know the pathways. There are pretty clinical studies that show that it triples the connectivity in the cortical spinal tracts after we stimulate the vagus nerve. So there's something going on there that's inducing this plasticity.

And the other thing I would add is that, and Francois, this is what you mentioned too, is that again, there was that six month cutoff. We always do tell our patients, you got the six months after that, we will see anything is good and we'll take it. At this point in this VNS rehab study, this is the study that got the vagal nerve stimulator approved for stroke, and FDA cleared. The mean time away from their stroke was three years, and these people were still getting meaningful benefit at that point. So that's amazing to us. That's groundbreaking that you can get benefit at three years after you've had this stroke.

Glen Stevens, DO, PhD: And I assume that's in conjunction with pretty significant therapy as well.

Mark Bain, MD: Exactly. If you just do the vagal nerve stimulation and you sit on a couch, nothing happens. And so it really does have to be paired with intensive rehab program. And then some people will say, well, is it just the rehab that you're getting? But in this trial, this VNS rehab trial, there's a sham group where they had the vagal nerve stimulator implanted and they got rehab, and then the people that got the stimulation with the rehab just did better, and it was significant.

Glen Stevens, DO, PhD: And I know that they're doing the vagal nerve stimulators for epilepsy here as well. Do you put it right, left? Does it matter for stroke recovery? I think there's, it does for epilepsy,

Mark Bain, MD: It doesn't. So we are putting them on the left side, mainly on left side. Mainly that has to do with the take off the recurrent laryngeal nerves. You don't get a lot of larynx and hoarseness complications and things like that. But we're putting them on the left, and that's why we think it's more of a global response. It doesn't matter what side the stroke is on.

Glen Stevens, DO, PhD: It's interesting, right, you would think. So, they always use terms like neuroplasticity, which is always, we don't really quite understand what that means, but it means everything's changing and working together.

Mark Bain, MD: Exactly, exactly. So again, we don't know exactly, but the clinical studies beforehand show there is something that's happening in the cortical spinal tracts. The synapses are increasing in these motor tracts with stimulation. So it doesn't seem like it's a localized effect that has an effect globally on the brain.

Glen Stevens, DO, PhD: I'm always sort of curious, was this a serendipity type thing? And maybe don't know, but I'm curious as to why someone decided they would go, well, we'll stimulate the vagus nerve and that'll help with the stroke, right?

Mark Bain, MD: Yeah. I think especially in neurosurgery in the interventional field, we're very used to new products, new devices coming on the market. And I think that's, you see a lot of young interventional is sort of pushing the field because we're so used to using new devices.

I first heard about this. There was one program doing this, and I heard about it. I said, this is an amazing thing. We should be involved in this.

As a surgeon, you always feel bad because you operate acutely on patients, stop the cause of the stroke or deal with the ramifications of the stroke. And then a couple of weeks after, see you later, I'll see you in a follow-up and I have nothing else off you. And that's when Francois comes in and helps out.

But there was always this sort of feeling that we could be doing more and is there some way we can help rehab and get better patient outcomes. So when I heard of this trial, this device, I thought this is our first introduction into post-stroke recovery as a surgeon.

Glen Stevens, DO, PhD: And how is the VNS different from if you're treating someone with epilepsy? Does the time it's on different or do you know?

Mark Bain, MD: Yeah, this is only turned on when the patients... It's typically off most of the time, and it's turned on when the patients are actually doing rehab sessions. So it'll be turned on when they're at rehab doing the rehab session. They also have a little wand they can wave by the stimulator to turn it on when they're doing their home sessions as well. So it's not constantly on.

Glen Stevens, DO, PhD: And if I had one in, I turned on, would I feel anything?

Mark Bain, MD: No. So we do threshold testing, it's a great point, to make sure that we know where we put the setting. So the first, after the stimulator's implanted, we let the patient rest for two weeks just so they have everything heal up.

A lot of the patients actually will say that that's the worst time because they're not getting rehab and they get stiff and they get more spasticity. So they want to get going. They want to see the improvement. So that two week waiting time's tough for them.

But the first rehab session, they test thresholds. So they will turn up the stimulator as high as they can and to see where they get maybe some hoarseness, maybe they'll feel some nerve pulling in the neck. And then we turn it down just below that so that we get the proper threshold.

Glen Stevens, DO, PhD: And how do you decide who would get it? Is this done in conjunction with Francois? I mean, do you guys do a certain volume of infarct, a location of infarct or...

Mark Bain, MD: Yeah. No. So this is really probably the Francois's area, but there's certain criteria. A lot of it is what was sort studied in that initial, sort of pivotal trial.

But the way to think about this is that they have to have some upper extremity function if there's no function there. This is thought of sort of an amplifier what's there. But really Francois has been kind enough to do a lot of the hard work, which is seeing all the patients beforehand and screening those patients and making sure they're good candidates, they're motivated to do the rehab that it takes after the stimulator's implanted. So we're a little bit of the technicians here. We put this in and then hand it back over to Francois at the end.

Glen Stevens, DO, PhD: And thoughts about lacunar strokes versus a large cortical infarct? Would it be different?

Mark Bain, MD: Yeah, it could be, but it doesn't really matter the type of infarct. I have a patient that had a large stroke that had a huge decompressive hemicraniectomy, where we remove the bone, let it swell. I've had patients that had a small lacunar infarct.

Really, right now what we know based on the studies is it's been studied for upper extremity function. Now that being said, the patients that have been implanted for upper extremity function have noticed maybe their lower extremity is feeling better. And that's not to mention, you talked about speech before and cognitive and depression. What happens with all these things that we haven't looked at yet? So as our experience grows with the stimulation, it'll be really interesting to see what are the other effects and other positive effects that happen from this.

Glen Stevens, DO, PhD: And are people doing this under an IRB at this point, or insurance will cover it?

Mark Bain, MD: No, this is an FDA approved device, and insurance has been pretty good about covering it. It's new so that we do occasionally get a rejection or something like that, but there's a big appeal process that we can use.

Glen Stevens, DO, PhD: Are you having patients come and ask for it?

Mark Bain, MD: Absolutely. I was absolutely amazed when we started our program within the first, I don't know, I would say week, there were about 20 referrals of people that have been listening, waiting, talking to the company, seeing when our program is going to open. So I've been pretty amazed at how motivated these patients are and the families are.

Glen Stevens, DO, PhD: How late out from a stroke would you implant one?

Mark Bain, MD: I don't know.

Glen Stevens, DO, PhD: I'm sure that bar will change over time.

Mark Bain, MD: I think so, yeah. I don't know if there's an upper limit. Again, in that trial, the mean time is three years, so for me that's like an eternity after a stroke. But I don't think there's an upper limit on that, no.

Glen Stevens, DO, PhD: And what would be the negative of just leaving it on?

Mark Bain, MD: As far as the stimulation goes? There can be side effects. As our experience grows, you know when we talk to the patients, we'll know a little more about that. But yeah, I don't know as far as how this is working, is it better to do... Is pairing it the issue? And I think that is when you pair the rehab with the stimulation, that's what shows that it works. But I don't know if that's been studied yet where we just leave it on and let someone live their life and do their life rehab.

Glen Stevens, DO, PhD: How long do these things last? Do you have change a battery or...?

Mark Bain, MD: Yeah, there's a battery that's implanted just below the clavicle, just above the chest muscle. Just looks like a normal pacemaker battery. About five years, the battery lasts. So a pretty same amount of time.

Glen Stevens, DO, PhD: Yeah. Well, fascinating. DBS. Deep brain stimulation.

Mark Bain, MD: Yeah, it's amazing that I'm sitting here talking about DBS as a cerebrovascular neurosurgeon.

Glen Stevens, DO, PhD: I was going to say I was going to check your credentials.

Mark Bain, MD: Yeah, I need Dr. Machado or Dr. Nagle or Rahm or somebody here. But no, I think this is where the field is going. And I keep telling our trainees in the next probably 10 years, a lot of the cerebrovascular neurosurgeons out there, instead of treating aneurysms and hemorrhages, I think they're going to be looking at stimulation of the brain. Dr. Machado is stimulating areas of the cerebellum to help people with stroke.

I think some of the new advances that are coming out of, we're probably not going to be sticking things into the brain anymore, but we're going to be using veins and arteries. There's already stimulators that are going in the sagittal sinus in patients with ALS. Just by using their thoughts, they're able to move cursors and open up text messaging.

So I think we're heading into that realm of stimulation and stimulating different areas of the brain, whether it's interventionally or surgically. I think this is going to be an amazingly fascinating field moving forward.

Glen Stevens, DO, PhD: Yeah, I mean it really speaks to how little, unfortunately, we're understanding that someone would go, hey, you've had a stroke, you can't move your arm. I'm going to stimulate your cerebellum. And people would go, well, I took anatomy. I'm not sure that makes sense to me.

Mark Bain, MD: Yeah, it's the targets. Where in the brain are we going to target? But then also the approaches, if you think about it's almost barbaric to drill hole and put a stimulator in there. We got to think of some other better way to go up through the veins. I was even thinking about the vagal nerve stimulator. We're putting this around the vagus nerve. There's a vein right there, big jugular vein. We can't stimulate through that. So I think we're going to see a lot of these new technologies advance and minimally invasive ways to do this for our stroke patients.

Glen Stevens, DO, PhD: Are there any good pre-clinical models for these things?

Mark Bain, MD: Yeah, I mean, I think there's, basic science, pre-clinical models and things like that, but as far as there's stimulators where we can actually look at how catheters go up and then how we can implant these devices and things like that. Cadaver work as well. So yeah, there's a lot of models that we can use.

Glen Stevens, DO, PhD: Francois, talk about your experience with seeing patients that have either the vagus nerve stimulator or the deep brain stimulator. How's your experience with that?

Francois Bethoux, MD: The program at the clinic is very new, so I actually have seen screened patients for the vagal nerve stimulation, haven't seen any after surgery. What I think I want to emphasize is the amazing work that our occupational therapists do within the world of rehabilitation.

Occupational therapists may not be well known to the public at large. They tend to focus on the upper extremity rehabilitation among other things they do. And basically, after Mark implants, the vagal nerve stimulator, there will be many sessions with an occupational therapist performing movements, literally hundreds of times.

So, under the guidance of the occupational therapist and the therapist will trigger the stimulation paired with the movement. So it's very precise, a lot of work. And of course, that needs to be adjusted to the patient's own capabilities at the time, and hopefully as they progress to adjust it. And so it's a lot of groundwork basically, because we want to obviously maximize the outcome of that surgery.

And that's the message we're trying to carry to all of our patients, is that we don't have yet the device that can be implanted and then all of a sudden by itself restores function. As Mark was saying before, you can't just sit on the couch and wait for it to come. It really is a lot of work. However, it is work that in many cases is rewarded.

And it can be sometimes baby steps, but even small gains in function can be very meaningful for someone, even if you can, as I said, hold an object with the weaker hand while the other one manipulates. All of a sudden that can open a whole field of activities that now you can do that you couldn't do before.

And so, we always have to put things into a perspective. But it's very, very exciting. And all the patients who come to us are very motivated. They want this recovery. So they all work hard. They have already worked hard in rehab. So, we're here to offer them options and then support them in what they decide to do. And it's been a very, very rewarding story so far.

Glen Stevens, DO, PhD: So, if somebody wants to refer a patient in, what do they do?

Mark Bain, MD: So, we've been putting a lot of work into this to see sort of the different pathways, but sometimes I get referrals, sometimes Francois gets referrals. There's outside patients that have already seen rehab specialists that are getting referred in. But really the best way is to probably go through Dr. Bethoux's team. So, they can do, because they need to do all the initial assessments and the OT assessments, and there's certain criteria we need to look for in the upper extremity. And then typically those patients that are deemed candidates for the surgery that they send to us.

Glen Stevens, DO, PhD: And I know this is a stroke talk, but head injury, that type of thing, trauma, would these things be applicable there as well? Or maybe we just don't know at this point?

Mark Bain, MD: Yeah, I don't know if we know at this point. Yeah, I think anytime you can induce any type of plasticity or do neuromodulation to help, I think we're going to see that. Yeah. But I think it's really limited and we're sort of in the infancy of what we know here, so it's really exciting stuff.

Glen Stevens, DO, PhD: Well, it's hard to believe that our time has run out. So final thoughts, anything that I haven't covered you think is important or things that you think need to be re-emphasized?

Mark Bain, MD: Yeah, one of the things I just wanted to mention too is a little bit about the surgery that people hear of surgery, especially patients that have been through a lot with stroke and everything, they get a little bit of fearful of the surgery, but it's a pretty well-tolerated surgery. It's a little small incision just in the neck and a little small incision above the clavicle. Outpatient procedure.

My first patient I saw right after surgery felt great. Went home a couple of hours afterwards, and it was feeling really good by about two or three days after the surgery. So anybody, I think that's fearful of the operation, doesn't really need to be, it's a very low-risk operation as well. And there's potentially a lot of benefit that they can get.

Glen Stevens, DO, PhD: Well, Mark, what they say, the only minor surgery is surgery that happens to someone else.

Mark Bain, MD: Yeah. Yeah, exactly.

Glen Stevens, DO, PhD: Francois, any closing thoughts?

Francois Bethoux, MD: What I would say is that I think it's a very exciting time, because there are so many options that are being explored. I can see some of my patients getting frustrated to say, well, when is this going to be available to me? And vagal nerve stimulation is now available.

And then, of course not everyone benefits. So I want to emphasize the concept of personalized medicine. Now it's kind of commonplace to talk about personalized medicine, but this is an exact illustration of that.

If somebody is interested in exploring options, then we can see where they're at and there's often more than one option. And so evaluate for these and then again, accompany them as they choose one or two options, and then try to get the best outcomes out of it.

It is really a global view on the person. It depends on where they live, who they live with. There's so many factors involved, but thankfully we can really help with that and try to add information that is salient to them to say, well, this is maybe what has more chance to work for you in your particular situation. It is not a cookie-cutter, standardized approach that will work for everyone, but luckily it is, for example, vagal nerve stimulation can be applied to a lot of people. So it's good to know that we don't have things that are restricted to just a very few patients.

Glen Stevens, DO, PhD: Well, something that affects one in four patients, 25% of people needs better options. So collectively, you guys are doing a great job. I love the cohesiveness of it, and this is really what it should be, right? Done together. And it sounds like that's what you guys are doing. Looking forward to seeing where this goes. And after you've treated maybe your first X number of patients, we'll have you come back and you'll let us know what you've learned.

Mark Bain, MD: Sounds great.

Glen Stevens, DO, PhD: As it goes, but I appreciate all you do for our patients. Best to you as you continue in your career. Thanks guys.

Mark Bain, MD: Thank you.

Francois Bethoux, MD: Thank you.

Closing: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's @CleClinicMD, all one word. And thank you for listening.