Cheryl Martin (Host): After experiencing a stroke, nearly 60% of survivors continue to suffer from persistent weakness and impairment in using their upper limbs. WakeMed offers a safe and effective breakthrough treatment to improve mobility. And here to tell us about it and stroke recovery is Dr. Robert Dallapiazza. He's a neurosurgeon at Raleigh Neurosurgical Clinic.

This is WakeMed Voices, brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. I'm Cheryl Martin. Dr. Dallapiazza, thanks for being on to discuss the latest in stroke recovery.

Robert Dallapiazza, MD, PhD: Thank you very much, Cheryl, for hosting me. I appreciate your invitation.

Host: Now. First, what are some of the long-term challenges that survivors of a stroke encounter?

Robert Dallapiazza, MD, PhD: One of the things that I've learned from my patients is that many of them were leading normal lives and suddenly had a big turn of events that they weren't anticipating that profoundly affect their ability to move, perform their regular normal activities, to perform their jobs, and perform cognitive tasks. No one really expects this to come inhabit to them. And so, many of these patients have been working very hard to reestablish their independence in their everyday activities to get back into the workforce, and to be able to move around and participate in activities as they once had.

What we're finding is that many patients are having difficulty with being able to do simple activities as getting up out of bed on their own without assistance. Some people have difficulty with walking without assistive devices. Many people are having difficulty moving their arms and positioning their hands in order to do bi-manual tasks, which we all take for granted so often. So many of our patients present with speech difficulties and language problems, which impairs them from being able to communicate effectively with their loved ones and their caretakers and their therapists.

All these things together demonstrate how much we take for granted our ability to get up from bed in the morning and put on our own clothes, to brush our own teeth. All these domains of life that we take for granted are impaired in these folks. Many of them are coming to us with hope that they can regain some of these functions.

Host: So as a neurosurgeon, how do you support stroke survivors?

Robert Dallapiazza, MD, PhD: That's a great question. One of the best ways that we can support stroke survivors is to raise awareness of what can happen and how to seek fast medical attention. And a lot of the efforts have been focused on awareness and rapid treatment in a hospital setting. For those patients that have had a stroke and are in the recovery process, our job is to make people aware that there are a strong community of supporters in the medical field from a rehabilitative standpoint and occupational therapy standpoint and physical therapy standpoint, as well as speech, language and swallowing.

From a neurosurgical perspective, much of what we do now is on the acute treatment of stroke. The program that we've started at WakeMed now is focusing a little bit more on the rehabilitative side of stroke.

Host: Let's talk about that. What does initial stroke recovery therapy consist of?

Robert Dallapiazza, MD, PhD: Great question. After folks have had a stroke, they're often left with profound weakness on one side of their body, and this typically is treated initially through an inpatient hospitalization that can last anywhere from one to two days to up to two to three weeks, depending on the patient's condition. Most of these patients are then transferred to an inpatient rehabilitation center where they begin to redevelop the movement of the affected upper and lower extremity, and the patients and the therapists work very hard to reestablish some of their initial independence in mobility.

What we're finding is that after months of both inpatient rehabilitation and outpatient rehabilitation, patients hit a plateau where despite the fact that they're doing plenty of exercises that they learned during their inpatient and outpatient rehabilitation phases, that they're really not seeing a lot of good progress on developing new skills, mobility, or strength. And that's where our program has inserted itself for those patients that have survived their stroke and are working to build their strength and their arm and their leg to be able to do more functional activities with this.

We've started a program to implant a vagus nerve simulator, which is a medical device similar to a cardiac pacemaker. But instead of stimulating the heart, we're stimulating a small nerve in the neck, which helps the brain undergo neuroplasticity during further physical and occupational therapy to help patients move past their barrier of the plateau and begin to regain more strength, mobility, range of motion and independence with the affected arm and leg from the stroke that they've had.

Host: This is exciting news. Can you go into more detail about how this works once this device has been implanted?

Robert Dallapiazza, MD, PhD: Yeah. So, this type of surgery is not anything new from a technical standpoint. We've used the vagus nerve stimulation in Neurosurgery, in Neurology for the treatment of epilepsy for more than 30 years. And this device and similar devices have been used to treat depression with mixed results.

The idea behind using the vagus nerve stimulator for stroke recovery comes from the fact that the vagus nerve contains mixed fibers of motor and sensory components, as well as components that affect the autonomic nervous system. So, it's a two-way channel from the brain to the body. The goal of the stimulation for the nerve is not to actually activate the muscle fibers of the nerve, but to use the pathway to the brain, which activates and excites some of the neuromodulatory centers of the brain and the midbrain that help the nervous system, and the cortex of the brain to undergo a process called neuroplasticity. So essentially, what we're doing is using the nerve fibers from the vagus nerve to create a condition in the brain where it's able to learn new motor tasks with better efficacy than without having the stimulation.

Host: So once this has been installed, a patient comes in, let's say, for physical therapy, occupational therapy? Is there a certain routine that has to be established initially?

Robert Dallapiazza, MD, PhD: Exactly. After the device is installed, it's not turned on automatically. We enroll the patients in six weeks of intensive occupational therapy that's supervised with a qualified occupational therapist. The device is only turned on while they're doing certain activities. We do an initial phase of intensive therapy with three 90-minute sessions for a total of six weeks. So, patients are spending an abundant amount of time with the occupational therapists. The device is turned on and activated, and the patients are practicing range of motion and flexion-extension exercises of the affected upper extremity.

After six weeks, the patients are instructed on how to use the device and activate it at home. They're able to activate it up to eight times a day. And the activation lasts for 30 minutes. So for example, once the patients have completed their outpatient occupational therapy for six weeks, we ask them to turn the device on at home with a swipe of a magnet while they're doing everyday activities like using their affected upper extremity to brush their teeth or do their daily routine, like put on clothes, unload, or load dishwashers and other activities throughout the day.

Host: What kind of results have you seen?

Robert Dallapiazza, MD, PhD: We've seen some truly inspiring results thus far. We've heard from all of our patients that they're thankful for the progress that that they've made and their ability to use their arm more than they were previously. For each patient that comes to our office, we ask them some questions about their goals for therapy and their goals can range from things as complicated as wanting to have full use of their arm and hand back to simply being able to have confidence in their arm strength so that they can hold a grandchild or hug someone or simply play a musical instrument that they were not able to play but played previously, be able to bend over to tie their shoes.

We've seen within the first six weeks of intensive therapy that people are improving their upper extremity strength, mobility, and range of motion by up to 40%. And we think that with continued use of the device, that they'll be able to gradually improve their strength up to three years after the device has been implanted.

Host: That is wonderful. Absolutely wonderful. So, how does a stroke patient know if this device is right?

Robert Dallapiazza, MD, PhD: So, there are some qualifying evaluations that we have to do prior to instituting the program. The first step really is the patients that we're selecting have to have had an ischemic stroke, meaning a blood clot that forms, and not other types of stroke like subarachnoid hemorrhage or intracerebral hemorrhage.

Those indications may change over time, but for the time being, we're focusing on patients that have had ischemic strokes. And ideally, the patients are at least six months out from the time of their stroke. The reason that we chose that timeframe is that many people, if they've had small strokes, can recover their function quite well over the first six months and may not need this therapy. The timing of the therapy is not really limited by how long the stroke has been from a distance standpoint. That said, we've treated people successfully that have had strokes more than 10 years ago.

Secondly, the patients will undergo a Fugl-Meyer evaluation by an occupational therapist. And once that evaluation is complete, we will see them in the surgical clinic to make sure that there are no surgical contradictions to having the devices installed for them.

Host: Anything else you want to add just about Stroke VNS Rehab?

Robert Dallapiazza, MD, PhD: There are a couple of things. One, I'm really humbled by the patients themselves. They are so motivated to recover their strength and to do well by themselves. These are oftentimes reasonably healthy, normal people that have had strokes and are now taking every effort that they can to better their circumstances and improve their functional abilities. What we do from a surgical standpoint is nothing heroic. It's a relatively straightforward operation. What is really, truly heroic is the effort that the patients and the therapists put into the gradual recovery of their symptoms.

Secondly, what's really inspiring for me is that we see patients that have been stuck in a rut from standpoint of recovering their strength and function after a stroke. And with a simple surgical procedure and the paired occupational therapy we're seeing great results in terms of range of motion, strength, mobility, and activity levels from these patients. It's truly one of the most exciting things that I've done in Neurosurgery is to watch how much these patients are able to restore their ability.

Host: Well, Dr. Robert Dallapiazza, I want to thank you for bringing us up to date on stroke recovery and just sharing these inspiring stories. And like you said, so many times we take these functions for granted. But then when we unexpectedly experience a stroke, we sometimes wonder if we'll get back to where we were and we are thankful that this program is available and it's obvious that you are committed to the patients and it's exciting for you as well. So, thank you.

Robert Dallapiazza, MD, PhD: Thank you very much for having us on board, Cheryl.

Host: To learn more about Stroke VNS Rehab, just visit wakemed.org. And if you found this podcast helpful, please share it on your social channels. You can check out our entire podcast library for other topics of interest to you. Thanks for listening to WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina.