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Neuromodulation for Post-Stroke Motor Recovery: a Narrative Review of Invasive and Non‑Invasive Tools

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Abstract

Purpose of Review

Stroke remains a leading disabling condition, and many survivors have permanent disability despite acute stroke treatment and subsequent standard-of-care rehabilitation therapies. Adjunctive neuromodulation is an emerging frontier in the field of stroke recovery. In this narrative review, we aim to highlight and summarize various neuromodulation techniques currently being investigated to enhance recovery and reduce impairment in patients with stroke.

Recent Findings

For motor recovery, repetitive transcranial magnetic simulation (rTMS) and direct current stimulation (tDCS) have shown promising results in many smaller-scale trials. Still, their efficacy has yet to be proven in large-scale pivotal trials. A promising large-scale study investigating higher dose tDCS combined with constraint movement therapy to enhance motor recovery is currently underway. MRI-guided tDCS studies in subacute and chronic post-stroke aphasia showed promising benefits for picture-naming recovery. rTMS, particularly inhibitory stimulation over the contralesional homolog, could represent a pathway forward in post-stroke motor recovery in the setting of a well-designed and adequately powered clinical trial. Recently evidenced-based guideline actually supported Level A (definite efficacy) for the use of low-frequency rTMS of the primary motor cortex for hand motor recovery in the post-acute stage of stroke based on the meta-analysis result. Adjunctive vagal nerve stimulation has recently received FDA approval to enhance upper limb motor recovery in chronic ischemic stroke with moderate impairment, and progress has been made to implement it in real-world practice. Despite a few small and large-scale studies in epidural stimulation (EDS), further research on the utilization of EDS in post-stroke recovery is needed. Deep brain stimulation or stent-based neuromodulation has yet to be further tested regarding safety and efficacy.

Summary

Adjunctive neuromodulation to rehabilitation therapy is a promising avenue for promoting post-stroke recovery and decreasing the overall burden of disability. The pipeline for neuromodulation technology remains strong as they span from the preclinical stage to the post-market stage. We are optimistic to see that more neuromodulation tools will be available to stroke survivors in the not-to-distant future.

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Data Availability

The principal investigator, Dr. Wuwei Feng, takes full responsibility for the data, analyses and interpretations, and the conduct of the research. Dr. Feng has full access to all of the data and has the right to publish any and all data separate and apart from any sponsor.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Author notes

  1. Zafer Keser and Salman Ikramuddin contribute equally as co-first authors.

Authors and Affiliations

  1. Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA

    Zafer Keser

  2. Department of Neurology, University of Minnesota, Minneapolis, MN, 55455, USA

    Salman Ikramuddin

  3. Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA

    Shashank Shekhar & Wuwei Feng

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  2. Salman Ikramuddin
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  4. Wuwei Feng
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Contributions

ZK conducted the review and wrote the manuscript text. SI prepared the figures, tables, and edited the main text of the manuscript. SS reviewed and edited the main text of the manuscript. WF designed the study and edited the main text of the manuscript.

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Correspondence to Wuwei Feng.

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Keser, Z., Ikramuddin, S., Shekhar, S. et al. Neuromodulation for Post-Stroke Motor Recovery: a Narrative Review of Invasive and Non‑Invasive Tools. Curr Neurol Neurosci Rep 23, 893–906 (2023). https://doi.org/10.1007/s11910-023-01319-6

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