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t m c » p u l s e | j u n e 2 0 1 6 19 attached to the vagus nerve at the neck and a bat- tery is placed in the chest beneath the skin. Using a remote to activate the battery from the outside, the system sends electrical pulses to the entire neural system to help the brain rebuild neural circuits that control upper limb functions. "In other forms of neuromodulation, the non-invasive brain stimulation focused on the motor cortex, the part of the brain that is directly responsible for movement, planning and move- ment execution," said the study's lead researcher Nuray Yozbatiran, Ph.D., assistant professor in the department of physical medicine and rehabil- itation at UTHealth. "But with the vagus nerve, we are not directly stimulating the motor cortex but stimulate parts of the brain (basal forebrain and locus coeruleus) that release neurotransmit- ters such as acetylcholine and norepinephrine that are known to facilitate reorganization of cortical networks." A critical component in the clinical trial, Yozbatiran said, is combining the technique with simple, activity-based training and exercises that reteach the portion of the brain responsible for motor function how to do certain movements, such as reaching, grabbing and turning objects of various sizes. Each time a movement is attempted, the patient receives small electrical pulses to acti- vate the vagus nerve and rebuild neural connec- tions affected by stroke. For retired Richmond, Virginia-based busi- ness consultant and investor Paul Kelly, 56, that possibility of regaining function in his left arm was enough for him to move to Houston for two months to participate in the trial. After he suffered a stroke in January 2013 while working out at his home, Kelly became paralyzed from the neck down on his left side, and he was determined to regain full function of his body. Eventually, he was able to use his left leg again, but his tenacity, cou- pled with his business savvy, drove him to exper- iment with a variety of therapies—including stem cell treatments and an upper limb exoskeleton—to see what else could be done for his left arm. At the encouragement of one of his doctors in Virginia, Kelly decided that one of the best ways to improve, while also helping others, was to participate in the vagus nerve stimulation clinical trial at TIRR Memorial Hermann. To him, the deci- sion was clear and recovering from a stroke was no different than solving complex tax situations in China. "I'd pull together a team of experts—account- ing experts, tax experts—and we would go through in detail everything we needed to do to solve that problem," Kelly said. "I told my wife many times, 'I don't know why we can't have a team like that to address stroke?' […] But when I had lunch with Drs. Francisco, Yozbatiran and their team, I told her, 'That's my dream team right there. That's it.'" Starting in August 2015, Kelly committed each week to working with Yozbatiran and her team to perform different exercises, such as moving small blocks and turning cards. The two months of hard work eventually paid off: By the end of the clinical trial, Kelly, a self-proclaimed outdoorsman, was able to cast a fishing rod. For many, this was a simple task, but for Kelly, this was a major, mean- ingful milestone. "My greatest accomplishment has been that I have not allowed [the stroke] to ruin my life," said Kelly, who recently returned from a hiking trip to Machu Picchu in Peru. "I loved the life I had before, but probably the most important lesson I've learned in the three and a half years is to not let what you cannot do keep you from enjoying the things you can do." * * * * * While the NRRC already has a cutting-edge setup, the team's hope is to further develop their program and continue providing the clinical rehabilitation version of precision medicine for their patients by using and finding new neurore- habilitation applications for the most advanced technology available. "What I want to see in the future for this center is to develop very novel and effective treatments in physical rehabilitation and neurorehabilitation to help patients," Chang said. "My hope is that we can push this to the clinical phase to help the public. That is my vision of what is next for the NRRC." In the process of the NRRC's ongoing evolution, and in keeping with the center's mission of finding novel and creative ways to rehabilitate people, the team is currently prepar- ing for the addition of three new harness support devices, including one from NASA that runs on pre-installed ceiling tracks to provide over- ground gait training to help people develop the strength to walk again. "The first time I see a patient moving around the facility, either walking, through a power chair or some assisted device, being able to take back control and feel like they're in charge of their life again, there's just nothing better than that," Josehart said. "We really don't think that good is good enough, so we're always tweaking, always looking for that next level of function. We're always trying to push the boundaries [because] it's our goal that people not just recover medically, but they recover emotionally and that they get back to life." Long-term P H Y S I C A L D I S A B I L I T I E S f rom S T R O K E include: muscle weakness, pain in hands and feet, and paralysis on both or one side of the body. We really don't think that good is good enough, so we're always tweaking, always looking for that next level of function. — CARL JOSEHART Chief Executive Officer of TIRR Memorial Hermann Physical therapist Nuray Yozbatiran, Ph.D., works with patient and stroke survivor Paul Kelly on improving function and control in his left hand as part of a clinical trial.