Retraining the Brain With Neurosurgical Breakthrough

An emerging approach to stroke recovery involves an outpatient neurosurgical procedure that implants a device capable of stimulating a nerve found to be central to the brain’s ability to learn. Dr. Christopher Conner in UConn Health’s Brain and Spine Institute is the first neurosurgeon in Connecticut to implant this device, which can make the brain more receptive to intensive occupational therapy. Dr. Conner explains vagus nerve stimulation (VNS) and describes its early success.

(November 2024, Dr. Christopher Conner, Carolyn Pennington, Chris DeFrancesco)

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Transcript

Chris: Strokes are hard to come back from, and patients often have to learn a new normal. Today on the Pulse, we learn about a first-in-Connecticut intervention that can help restore some function.

This is the UConn Health Pulse, a podcast to help you get to know UConn Health and its people a little better, and ideally leave you with some health information you’ll find useful. With Carolyn Pennington, I’m Chris DeFrancesco. Recovering from a stroke in many cases means a long road of rehabilitation ahead.

Carolyn: And patients can restore some function with intensive rehabilitation, but often hit a plateau. Earlier this year, a patient at UConn Health became the first in Connecticut to use a device that helps stimulate the nervous system to break through that plateau. Joining us today is the neurosurgeon who implanted it, Dr. Christopher Conner from UConn Health’s Brain and Spine Institute. Thank you for joining us.

Dr. Conner: It’s a real pleasure to be here, guys. Thank you for having me.

Carolyn: Well, this sounds very exciting. Could you just explain to the listeners exactly what it is? How does it work? Just to get us started.

Dr. Conner: So the system is called the Vivistim System. It is a system which employs a technique called vagal nerve stimulation in order to boost and enhance It’s a lot of the therapy that many post-stroke patients are currently undergoing. It involves placing a small battery and wire into the chest, and the wire goes up into the neck, and it wraps around a big nerve there called the vagus nerve. It’s a nerve that comes out of the brain stem. And the vagus nerve does a lot of things in the body, including regulating heart rate, regulating some things in your gut, and helping you swallow.

But one of the cool things that we found over the last 10 or 15 years is that stimulating it can also put your brain into a high state of learning, or neuroplasticity. And that’s when the brain can actually learn and kind of regrow. And that’s really useful in patients who’ve had stroke, because when you’ve had a stroke, you need to relearn a lot of the things that you already knew how to do. And so this is a new technology that’s been out for a couple of years, and we’re really excited to bring it here to UConn to be able to offer it to the people of Connecticut.

Carolyn: Why do some people have problems with their vagus nerve than after a stroke? Why do some people heal better than others?

Dr. Conner: A lot of the recovery that you have after a stroke is due to where the stroke is at and the degree of the brain that ends up being affected by the stroke. And so there are some people who their strokes are small, there’s some people who their strokes are bigger. And the larger your stroke is, the more deficits you’re going to have afterwards, and so the more work you’re going to need to do to fully recover if that’s even possible. And so the vagus nerve itself is not affected by the stroke, but the vagus nerve is an easy way for us to put information or to modulate what the brain is doing.

And so the vagus nerve is something that’s actually accessible to us without having to do a big brain surgery itself in order for us to kind of change how the brain is functioning. And so it’s a way for us to access that and influence it, without having to drill someone’s skull open.

Chris: That’s fascinating, the vagus nerve and its capability puts you in a better state of learning, essentially, they teach your brain how to learn or relearn something, almost like more receptive to the information?

Dr. Conner: Yeah. So, Chris, I will tell you one thing. We don’t actually really know how this works precisely, which that is something that happens really frequently in modern medicine, actually. We don’t understand exactly, but that’s actually what the theory is. The theory is that the vagus nerve actually has all these connections in the brain stem, and those connections allow you to change brain activity as a whole. And that actually is what allows people to, again, get into this high state of learning or this high state of regrowth and retraining, and that’s how we access it.

The way that they’ve done this is a completely new paradigm. Vagal nerve stimulation’s been around for a long time. for treating epilepsy and depression, where it was partially effective. But the thing about those conditions is that the stimulation was on all the time. The beauty of this system is that it’s only on when we want you to be learning. And so, we implant this system, and then you go back to your occupational therapist, and they have like a clicker. And whenever you’re doing therapy with them, right when you’re trying to do something and learn something again, let’s say you’re trying to learn how to paint again, they can hit a button and the stimulation turns on. And then you start doing the activity, and then you take a break and it turns off. And so we’re literally turning on a light switch, turning on a light bulb, getting you into that high learning state. And that’s what the system’s designed to do.

Chris: So you’re actually like reprogramming the person.

Dr. Conner: Yeah, in theory, yeah.

Carolyn: Wow, very interesting. But how long after a stroke is this effective?

Dr. Conner: That is something that we are currently still investigating. I mean, there have been people who are more than a decade, two decades out from their stroke. There are reports of people who are many, many, many years out from their stroke who are getting good benefit from this.

Carolyn: Really?

Dr. Conner: Yeah. I mean, you can be a long ways out from it. So patients come in and they’re like, “I’m five, 10 years out from my stroke. Is it really going to benefit me?” And the evidence shows right now that that’s a yes. And we don’t know what the upper limit on that is. We don’t have a good idea.

Carolyn: Give us some example of what patients are going through, like you mentioned painting. What other kind of things are people having issues with that this can help?

Dr. Conner: You know, my favorite thing that I always come back to and talk to patients about is, in the actual brochure that the company gives you, there’s a picture of a guy cooking, and he’s cutting carrots. And his occupational therapist is there next to him, like in this little cartoon, and she’s hitting a clicker to turn it on. And I always at first when, before we’d had a patient come back, I thought, this is crazy, these people aren’t going to maybe get back to being able to use a knife in the kitchen to cut things like that, that seems like a little pie in the sky. And then my first patient came back and he was able to get back to doing that. And he had a video of it in our clinic and just seeing him get back to like cooking, being able to do all kinds of activities of daily living. That was when I was like, “Oh, wow. Like this, this is really that kind of thing that it can transform your entire life.”

People come back and they tell me they’re getting back into gardening. I have people who are getting back into musical instruments. The amount of improvement and recovery that you can have is fascinating. And we’re still really finding out where the limit on it is. So, I mean, the short answer is, almost everything.

Carolyn: Yeah, that’s fantastic.

Dr. Conner: Golf, by the way, that’s a really important one to note. Lots and lots of guys, they come in and they’re like, “Hey, my golf game, I can’t play. It’s terrible since my stroke,” not a surprise, but lots of people, lots of my patients are really interested in getting back to the driving range, and that is something that seems to be working.

Chris: So just to clarify, it is FDA approved for stroke survivors with ongoing hand and arm impairment. Is that kind of the window that we’re in?

Dr. Conner: That’s correct. Patients also ask me, you know, is my walking going to get better? Is my speech going to get better? The data hasn’t really been collected on that yet.

The FDA indication, and it is FDA approved, is for an upper extremity deficit or impairment. And so that is exactly what the indication is. But many, many people who are stroke survivors, that’s the thing that they come in and they really want to have help with.

Carolyn: Do they see results right away or how long does it typically take?

Dr. Conner: So after you have it implanted, we wait two weeks to start the occupational therapy and then you want to go six weeks of really intensive occupational therapy where you’re doing three sessions a week for six weeks, they’re hour-and-a-half-long sessions. And many of the patients start to notice improvement within a couple of weeks.

And by the end of six weeks, they’re making a lot of gains. And so, is it immediate right away? I mean, it depends on what your definition of immediate is, but for someone who’s a couple years out from their stroke, within a couple months of having the surgery, that feels pretty immediate to them.

Chris: In order for this to be effective, it starts with you implanting the device, but there is the intensive rehabilitation that follows. So there are a lot of people I would think involved in the health care and recovery process in order for this to be effective.

Dr. Conner: Absolutely.

Chris: So talk a little bit about who else is involved; so we’ve got the occupational therapist.

Dr. Conner: So we work very closely with our occupational therapy teams, because I tell all the patients this: It’s not the surgery that’s the magic. That’s not where the work happens. That’s just the surgery. It’s an outpatient surgery. You come in, we put it in, you go home the same day and that’s what it is.

The work and the magic really is in the occupational therapy. And the patients can even swipe the device and do some home therapy. They can do home-directed therapy at home, there’s a little magnet you can actually swipe over the battery to turn it on for 30 minutes. So you can do homework and you can do work with your occupational therapist.

And we do know that the more of that you do and the more committed you are to the therapy, the more effective it’s going to be. And so the patients I have who’ve had the best results, the are generally the patients who have been home swiping more. We can actually tell how much home therapy you’re doing. And the ones who are the therapists are telling us are showing up early, they’re leaving late, they’re doing a lot of work. The therapists are the ones who are really, really the ones who are getting it done. Because you’re going to spend a lot more time with your therapist than you’re going to spend with me.

And so our therapists, at Hospital for Special Care, or here at UConn, or at Hartford Hospital, they’re the ones who are really putting in the actual effort. And we have a lot of them that we work with. We can work with therapists anywhere, if you have one that’s established, but the occupational therapists and the patients are really the people who are putting in all the hard work. It’s not me.

Carolyn: What other facilities are offering this? Is UConn Health unique in offering this?

Dr. Conner: Currently, in the state of Connecticut, we’re the only place that can actually do the implantation. Now, we can work with occupational therapists anywhere. We can work with them at pretty much any location. But in the state of Connecticut, we’re the only place that’s offering this currently. There’s some places in New Jersey that are offering it, and there’s some places in Boston that are offering it. But outside of that, for patients in the area, we’re the only option at present.

Chris: How long does it take to determine whether it’s successful?

Dr. Conner: Right. We are getting improvement that is vastly in excess of what the literature shows. And again, I just think that’s because of the quality of occupational therapy. We’re also being really selective in patients right now. And so we’re getting people who are really motivated, and I think that helps quite a bit. And again, we see results, I have patients come back for their six- and eight-week follow up, we’re already starting to see patients making gains. And then I have them come back at three months and we’re seeing even more.

One of the things that we do run into that is a little bit of a challenge is, once I’ve determined I’ve seen someone, I see them in my clinic, they go to the occupational therapist to make sure that they have one established for any post-op therapy. Once we’ve done those things, it’s a battle with insurance. And that’s actually the thing that we’re running into right now, which is the biggest hurdle, is just getting insurance companies to improve this. So we have to do a lot of appeals processes. I’ve had to actually go to legal hearings to argue these cases before judges. So that actually is really the thing that’s the most difficult.

So, I do tell patients when they come in, because there’s a lot of excitement. You’re taking people who have not had hope that they’re going to recover in years, and that’s really what we are providing them, and you have to kind of temper that with, “This might take a minute.”

I’ve had patients who it’s taken nine months for it to get approved.

Carolyn: Oh, boy.

Dr. Conner: So, it can take a while. We work really hard at it, but it can take a while.

Chris: That should get better as the technology becomes more and more accepted and there’s more literature on its effectiveness, right?

Dr. Conner: I do think that it is slowly getting better. Some of the companies that are providing insurance for people in the state have started loosening things up as patients are demanding this, as they’re seeing patients get really interested in it, and as word is getting out that it’s really effective.

From an insurance company standpoint, if your patient gets a lot of return of function, they’re going to be healthier. And so, yes, the procedure, the therapy, in my mind, and I don’t have any data on this, I haven’t proven it yet, but if someone’s healthier, they’re going to need less from their insurance company. I think at some point someone’s going to do that research and is going to publish that, and I think that’s really what’s going to motivate them. But I do think that the companies are starting to get better about this. We’re starting to finally see a little bit of movement.

Chris: So if you’re the only one doing this right now in the state, people need to be able to find their way to you. Can they just do a self-consultation or they need a referral? How do they get in to talk to you about whether this is an option?

Dr. Conner: They can call my office right now and they can just say, “Hey, I’d like to come talk to I’m Dr. Conner. about vagal nerve stimulation for stroke recovery.” And they will end up on my schedule. We can help find a new occupational therapist if you need one. We can set pretty much everything up. And so, if people want to come in, I love talking to people about VNS for stroke recovery. So, if people find us on the web, if people find us however they find us, they can book an appointment with me, don’t need a referral.

Chris: OK, and we have that information in the show notes for people to get in touch with you, Dr. Conner. In the couple minutes we have left, let’s switch over to one other cool thing that you’re doing: treating Parkinson’s and movement disorders.

Dr. Conner: Yes. So, the thing that I got recruited to the University of Connecticut to do is start a program in deep brain stimulation. And deep brain stimulation is like a pacemaker, but not for the heart. It’s a pacemaker for the brain. And so this is a technology, which has been around for decades now, where we implant a couple of wires deep in the brain and they also connect up to a battery. Most of what I do ends up involving a battery at some point in time. That’s just what it is.

And then we run electricity through that. And we use it to treat a number of conditions. Most commonly, we use it to treat essential tremor. We also use it to treat things like Parkinson’s disease. And what we’ve noticed is that in patients, this can be really effective at treating many of the symptoms of Parkinson’s disease, particularly tremor, but also the slowness and rigidity that come with Parkinson’s. And so it’s highly effective at treating those things.

Carolyn: So it actually stops their tremors?

Dr. Conner: It can. Yeah, I mean, people just gotta go onto YouTube and literally just search for “Parkinson’s patient deep brain stimulation” and there are tons of videos out there of people turning it on and turning it off, and it’s really dramatic.

Chris: Vagus nerve stimulation and then deep brain stimulation, there are two pretty significant interventions that you’ve delivered in your short time here at UConn Health. Do we have anything else on the horizon at the Brain and Spine Institute?

Dr. Conner: There’s a lot of things that we’re working on right now. Some of these things it’s a little bit too early to talk about. We’re very excited about some collaborations that we have with Connecticut Children’s and trying to expand a lot of the really great offerings that they have over there. And that’s kind of what we’re working on right now, that and a lot of research things.

Carolyn: We look forward to hearing more in the future then.

Chris: Dr. Christopher Conner, neurosurgeon from UConn Health’s Brain and Spine Institute. Thank you for joining us.

Dr. Conner: Thank you.

Chris: The method is called vagus nerve stimulation or VNS. The new device that delivers it is called the Vivistim Paired VNS System. It is FDA approved for stroke survivors with ongoing hand and arm impairment, and Dr. Conner was the first in Connecticut to use it.

That is our time for today. For Dr. Conner and Carolyn Pennington, I’m Chris DeFrancesco. Thank you for listening to the UConn Health Pulse. Be sure to subscribe so you can catch us next time, and please share with a friend.