For years, chronic stroke patients heard familiar feedback regarding their ability to regain strength and mobility after ischemic strokes caused upper-extremity deficits.

They were told the effectiveness of rehabilitation diminished as the brain’s window of plasticity closed, and their chances of regaining strength and mobility in their hands and arms would decline and then level off.

For more than two decades, WashU Medicine has been at the forefront of neurorehabilitation science, exploring how the brain can reorganize and recover function after injury. Their focus on translating foundational neuroscience into advanced clinical applications has positioned WashU Medicine among the nation’s leaders in developing and delivering innovative, evidence-based treatments that extend recovery potential for chronic stroke patients, the latest evolution of the neurotechnology portfolio being vagus nerve stimulation (VNS).

Originally developed and FDA-approved for the treatment of refractory epilepsy and depression, VNS has decades of clinical data supporting its neuromodulatory effects. This combination of VNS and extensive occupational and physical therapy is becoming more prominent in the United States, but in St. Louis, it is happening only at Barnes-Jewish Hospital with WashU Medicine physicians and physical and occupational therapists.

“What’s exciting about pairing VNS with stroke therapy is that this technique allows our patients to break through what was previously considered a plateau,” says Alexandre Carter, MD, PhD, a WashU Medicine neurologist specializing in neurorehabilitation at Barnes-Jewish Hospital. “Now we can offer them something else to pursue. This is a message of hope.”

Building on decades of translational neuroscience

For the past 20 years, WashU Medicine neurologists and neurosurgeons have investigated how the brain encodes, stores, and executes motor commands, research that has led to a continuum of therapies now used in clinical practice. This deep bench of expertise has allowed the team to develop noninvasive technology and implement implantable neurotechnology options to offer the latest in options that directly support motor recovery and functional independence in chronic stroke patients.

In 2004, WashU Medicine researchers identified that motor control signals could be encoded ipsilaterally within the motor cortex, demonstrating that same-sided limb movements were represented in cortical activity. This finding challenged the long-held model of purely contralateral motor control and opened new avenues for neurorehabilitation research.

Eric Leuthardt, MD, MBA, a WashU Medicine neurosurgeon at Barnes-Jewish Hospital, says this discovery laid the groundwork for the development of brain-controlled interface (BCI) technologies designed to restore upper-extremity function after stroke. Dr. Leuthardt developed the Neurolutions IpsiHand a noninvasive robotic orthosis that detects and translates a patient’s brain signals to assist with hand movement.

The IpsiHand is the first FDA-cleared device leveraging brain computer interface (BCI) technology to assist chronic stroke patients in rehabilitation.

“It’s about helping the brain learn to change itself,” Dr. Leuthardt says. “We have a unique series of offerings, from noninvasive to traditional, for patients that can transform the expectations for chronic stroke. One option is the brain-computer interface, and one is VNS. When I talk to patients, I talk about both and we determine which option is best based on the patient and their goals.”

By directly engaging the nervous system to enhance neuroplasticity, VNS represents the next step in advancing functional recovery for patients living with chronic stroke. When the vagus nerve is stimulated, it sends signals to the body from the brain and causes the release of a variety of neuromodulators, chemicals such as acetylcholine, norepinephrine, serotonin, and even dopamine, to help to increase the brain’s plasticity.

Dr. Leuthardt implants the VNS device in an outpatient procedure, the only surgery required until the device’s battery needs to be replaced or removed. After the procedure to implant the device and a brief healing process, the patient begins intensive outpatient therapy with WashU Medicine Physical and Occupational Therapy. For six weeks, patients attend three 90-minute therapy sessions per week. These sessions include many repetitions of hand and arm movements tailored to the patient’s goals: reaching, grasping, moving objects, and fine-finger movements designed to build dexterity.

During the therapy sessions, the patient’s therapist activates the VNS device using a remote often, especially at the beginning of a task and when certain movements are performed correctly. The stimulation of the nerve releases neuromodulators that reinforce the learning taking place. Patients generally receive more than 500 stimulations—and up to 800—per session.

“Through designing patient-specific interventions that are salient to an individual’s functional activities and desired goals, we can maximize patient participation and carryover of tasks into their home and community environments to improve performance,” says Kate Mueth, PT, DPT, a WashU Medicine physical therapist. “It’s taking physical therapy outside of the clinic to help make long-term changes in an individual's life.”

At home, patients are asked to turn on the stimulator using a magnetic device up to eight times per day for additional, individual work. In a 30-minute interval, the stimulator fires once every 10 seconds while patients perform daily tasks such as washing clothes, unloading the dishwasher, and other household chores.

Patient progress is tracked in various ways, from conversations during check-ups with doctors to measuring gains in strength and range of motion during therapy sessions.

“The process is a great example of how we collaborate across different departments and specialties at WashU Medicine and Barnes-Jewish Hospital,” Dr. Carter says. “This entire protocol requires collaboration of neurosurgeons, neurologists, rehabilitation clinicians, and physical and occupational therapy providers.”

 One grateful patient’s story

Crystal, 51, survived multiple ischemic strokes, the largest and most damaging occurring in 2005. As a result, she lived with upper extremity deficits for decades, specifically in her right arm and hand, which lost strength, mobility, and dexterity. Her walking speed and balance were impacted. Her speech became less fluid due to aphasia.

Crystal was evaluated and approved for VNS treatment at Barnes-Jewish Hospital and became one of the first patients to start the program, which is actively evaluating other potential candidates.

Crystal started her extensive occupational and physical therapy paired with VNS in June 2025. By September 2025, she experienced across-the-board improvement and felt increased independence as a result. Her daily tasks have become easier. She can lift her right arm higher than before. Her fingers have more dexterity, making her grip strength stronger. She can once again walk with a cup of water without spilling it.

She also noticed benefits beyond her hands and arms.

Optimism about the future

Crystal’s recovery is just one example of what’s possible with advanced neurorehabilitation techniques for chronic stroke patients. For Dr. Carter, Dr. Leuthardt, and the WashU Medicine neuroscience and orthopedic teams at Barnes-Jewish Hospital, it’s confirmation to keep exploring VNS. WashU Medicine is leading a number of clinical trials that explore further application of VNS.

Dr. Carter says WashU Medicine experts are evaluating additional ways this therapy might be enhanced, specifically for those patients who have suffered a ruptured vessel or aneurysm.

Indications for referral for VNS therapy include:

• Chronic ischemic stroke patients more than six months removed from most recent stroke
• Stroke-caused deficits in the hands or arms
• A high level of commitment to program, which includes VNS implantation and a physically and mentally rigorous therapy program

Call 314-286-1940 to learn more or refer a patient.