Neurostimulation for treatment of post-stroke impairments

Neurostimulation, the use of electrical stimulation to modulate the activity of the nervous system, is now commonly used for the treatment of chronic pain, movement disorders and epilepsy. Many neurostimulation techniques have now shown promise for the treatment of physical impairments in people with stroke. In 2021, vagus nerve stimulation was approved by the FDA as an adjunct to intensive rehabilitation therapy for the treatment of chronic upper extremity deficits after ischaemic stroke. In 2024, pharyngeal electrical stimulation was conditionally approved by the UK National Institute for Health and Care Excellence for neurogenic dysphagia in people with stroke who have a tracheostomy. Many other approaches have also been tested in pivotal device trials and a number of approaches are in early-phase study. Typically, neurostimulation techniques aim to increase neuroplasticity in response to training and rehabilitation, although the putative mechanisms of action differ and are not fully understood. Neurostimulation techniques offer a number of practical advantages for use after stroke, such as precise dosing and timing, but can be invasive and costly to implement. This Review focuses on neurostimulation techniques that are now in clinical use or that have reached the stage of pivotal trials and show considerable promise for the treatment of post-stroke impairments. Various neurostimulation techniques are being explored for the treatment of physical impairments in people with stroke. This Review summarizes our current knowledge of the techniques that are now in clinical use or have reached the stage of pivotal trials alongside emerging techniques and highlights the need for further studies. Neurostimulation techniques are ideally suited for use during stroke recovery owing to their ability to target anatomical structures or neuronal networks, alongside precise timing and dosing.Paired invasive vagus nerve stimulation has been shown to increase the number of people who achieve clinically important improvements in upper extremity impairment and performance of functional tasks following stroke. The treatment is now in clinical use in the USA.Several other neurostimulation techniques show promise for post-stroke impairments but definitive data from adequately powered trials are lacking.Pharyngeal electrical stimulation increases the odds of decannulation following tracheostomy and is under investigation as a treatment for post-stroke dysphagia.