Functional reorganization of the cerebral motor system after stroke

[Combination of TMS and MRT to understand neurological diseases]

Modern neuroimaging techniques, such as structural and functional magnetic resonance imaging (MRI) and non-invasive brain stimulation techniques, such as transcranial magnetic stimulation (TMS) are increasingly used in the neuroscientific research of neurological disorders, such as stroke, tinnitus and movement disorders. These methods offer a non-invasive approach and especially in combination, not only the opportunity to add to the pathophysiological understanding of these disorders but also to provide information about the functional recovery and the natural course of the disease in a predictive way. Based on such knowledge therapeutic approaches can be adapted in a patient-tailored fashion to achieve the best therapeutic effects. Furthermore, these methods might provide additional non-invasive information for neurosurgical interventions reducing perioperative interventional risks.In the present article these aspects will be discussed with a focus on the combination of MRI and TMS especially addressed for the topic of recovery from stroke.

Understanding the pharmacology of stroke and multiple sclerosis through imaging

Stroke and multiple sclerosis (MS) illustrate how clinical imaging can facilitate early phase drug development and most effective medicine use in the clinic. Imaging has enhanced understanding of the dynamics of evolution of disease pathophysiology, better defining treatment targets. Imaging measures can enable stratification of patients for clinical trials and for most cost-effective use in the clinic. In MS, imaging has allowed smaller Phase II clinical trials and contributed to medicine differentiation. It also has led to consideration of suppression of inflammation and neurodegeneration as meaningfully distinct pharmacodynamic concepts. Similar imaging measures can be used in preclinical and clinical studies. Testing translational pharmacological hypotheses using clinical imaging more explicitly could improve the success of the next generation of stroke therapeutics.

Cortical reorganization after hand immobilization: the beta qEEG spectral coherence evidences

There is increasing evidence that hand immobilization is associated with various changes in the brain. Indeed, beta band coherence is strongly related to motor act and sensitive stimuli. In this study we investigate the electrophysiological and cortical changes that occur when subjects are submitted to hand immobilization. We hypothesized that beta coherence oscillations act as a mechanism underlying inter- and intra-hemispheric changes. As a methodology for our study fifteen healthy individuals between the ages of 20 and 30 years were subjected to a right index finger task before and after hand immobilization while their brain activity pattern was recorded using quantitative electroencephalography. This analysis revealed that hand immobilization caused changes in frontal, central and parietal areas of the brain. The main findings showed a lower beta-2 band in frontal regions and greater cortical activity in central and parietal areas. In summary, the coherence increased in the frontal, central and parietal cortex, due to hand immobilization and it adjusted the brains functioning, which had been disrupted by the procedure. Moreover, the brain adaptation upon hand immobilization of the subjects involved inter- and intra-hemispheric changes.

Cortical reorganization after hand immobilization: the beta qEEG spectral coherence evidences

There is increasing evidence that hand immobilization is associated with various changes in the brain. Indeed, beta band coherence is strongly related to motor act and sensitive stimuli. In this study we investigate the electrophysiological and cortical changes that occur when subjects are submitted to hand immobilization. We hypothesized that beta coherence oscillations act as a mechanism underlying inter- and intra-hemispheric changes. As a methodology for our study fifteen healthy individuals between the ages of 20 and 30 years were subjected to a right index finger task before and after hand immobilization while their brain activity pattern was recorded using quantitative electroencephalography. This analysis revealed that hand immobilization caused changes in frontal, central and parietal areas of the brain. The main findings showed a lower beta-2 band in frontal regions and greater cortical activity in central and parietal areas. In summary, the coherence increased in the frontal, central and parietal cortex, due to hand immobilization and it adjusted the brains functioning, which had been disrupted by the procedure. Moreover, the brain adaptation upon hand immobilization of the subjects involved inter- and intra-hemispheric changes.

Cortical reorganization after experimental traumatic brain injury: a functional autoradiography study

Cortical sensorimotor (SM) maps are a useful readout for providing a global view of the underlying status of evoked brain function, as well as a gross overview of ongoing mechanisms of plasticity. Recent evidence in the rat controlled cortical impact (CCI) injury model shows that the ipsilesional (injured) hemisphere is temporarily permissive for axon sprouting. This would predict that size and spatial alterations in cortical maps may occur much earlier than previously tested and that they might be useful as potential markers of the postinjury plasticity period as well as indicators of outcome. We investigated the evolution of changes in brain activation evoked by affected hindlimb electrical stimulation at 4, 7, and 30 days following CCI or sham injury over the hindlimb cortical region of adult rats. [(14)C]-iodoantipyrine autoradiography was used to quantitatively examine the local cerebral blood flow changes in response to hindlimb stimulation as a marker for neuronal activity. The results show that although ipsilesional hindlimb SM activity was persistently depressed from 4 days, additional novel regions of ipsilesional activity appeared concurrently within SM barrel and S2 regions as well as posterior auditory cortex. Simultaneously with this was the appearance of evoked activity within the intact, contralesional cortex that was maximal at 4 and 7 days, compared to stimulated sham-injured rats, where activation was solely unilateral. By 30 days, however, contralesional activation had greatly subsided and existing ipsilesional activity was enhanced within the same novel cortical regions that were identified acutely. These data indicate that significant reorganization of the cortical SM maps occurs after injury that evolves with a particular postinjury time course. We discuss these data in terms of the known mechanisms of plasticity that are likely to underlie these map changes, with particular reference to the differences and similarities that exist between rodent models of stroke and traumatic brain injury.

Stroke induces long-lasting deficits in the temporal fidelity of sensory processing in the somatosensory cortex

Recovery from stroke is rarely complete as humans and experimental animals typically show lingering deficits in sensory function. One explanation for limited recovery could be that rewired cortical networks do not process sensory stimuli with the same temporal precision as they normally would. To examine how well peri-infarct and more distant cortical networks process successive vibro-tactile stimulations of the affected forepaw (a measure of temporal fidelity), we imaged cortical depolarizations with millisecond temporal resolution using voltage-sensitive dyes. In control mice, paired forepaw stimulations (ranging from 50 to 200 milliseconds apart) induced temporally distinct depolarizations in primary forelimb somatosensory (FLS1) cortex, and to a lesser extent in secondary FLS (FLS2) cortex. For mice imaged 3 months after stroke, the first forepaw stimulus reliably evoked a strong depolarization in the surviving region of FLS1 and FLS2 cortex. However, depolarizations to subsequent forepaw stimuli were significantly reduced or completely absent (for stimuli ≤100 milliseconds apart) in the FLS1 cortex, whereas FLS2 responses were relatively unaffected. Our data reveal that stroke induces long-lasting impairments in how well the rewired FLS1 cortex processes temporal aspects of sensory stimuli. Future therapies directed at enhancing the temporal fidelity of cortical circuits may be necessary for achieving full recovery of sensory functions.

Hubs of brain functional networks are radically reorganized in comatose patients

Human brain networks have topological properties in common with many other complex systems, prompting the following question: what aspects of brain network organization are critical for distinctive functional properties of the brain, such as consciousness? To address this question, we used graph theoretical methods to explore brain network topology in resting state functional MRI data acquired from 17 patients with severely impaired consciousness and 20 healthy volunteers. We found that many global network properties were conserved in comatose patients. Specifically, there was no significant abnormality of global efficiency, clustering, small-worldness, modularity, or degree distribution in the patient group. However, in every patient, we found evidence for a radical reorganization of high degree or highly efficient "hub" nodes. Cortical regions that were hubs of healthy brain networks had typically become nonhubs of comatose brain networks and vice versa. These results indicate that global topological properties of complex brain networks may be homeostatically conserved under extremely different clinical conditions and that consciousness likely depends on the anatomical location of hub nodes in human brain networks.

Cortical activation during executed, imagined, observed, and passive wrist movements in healthy volunteers and stroke patients

Motor imagery, passive movement, and movement observation have been suggested to activate the sensorimotor system without overt movement. The present study investigated these three covert movement modes together with overt movement in a within-subject design to allow for a fine-grained comparison of their abilities in activating the sensorimotor system, i.e. premotor, primary motor, and somatosensory cortices. For this, 21 healthy volunteers underwent functional magnetic resonance imaging (fMRI). In addition we explored the abilities of the different covert movement modes in activating the sensorimotor system in a pilot study of 5 stroke patients suffering from chronic severe hemiparesis. Results demonstrated that while all covert movement modes activated sensorimotor areas, there were profound differences between modes and between healthy volunteers and patients. In healthy volunteers, the pattern of neural activation in overt execution was best resembled by passive movement, followed by motor imagery, and lastly by movement observation. In patients, attempted overt execution was best resembled by motor imagery, followed by passive movement, and lastly by movement observation. Our results indicate that for severely hemiparetic stroke patients motor imagery may be the preferred way to activate the sensorimotor system without overt behavior. In addition, the clear differences between the covert movement modes point to the need for within-subject comparisons.

Chronic in vivo imaging shows no evidence of dendritic plasticity or functional remapping in the contralesional cortex after stroke

Most stroke survivors exhibit a partial recovery from their deficits. This presumably occurs because of remapping of lost capabilities to functionally related brain areas. Functional brain imaging studies suggest that remapping in the contralateral uninjured cortex might represent a transient stage of compensatory plasticity. Some postmortem studies have also shown that cortical lesions, including stroke, can trigger dendritic plasticity in the contralateral hemisphere, but the data are controversial. We used longitudinal in vivo two-photon microscopy in the contralateral homotopic cortex to record changes in dendritic spines of layer 5 pyramidal neurons in green fluorescent protein mice. We could not detect de novo growth of dendrites or changes in the density or turnover of spines for up to 4 weeks after stroke. We also used intrinsic optical signal imaging to investigate whether the forepaw (FP) sensory representation is remapped to the spared homotopic cortex after stroke. Stimulation of the contralateral FP reliably produced strong intrinsic signals in the spared hemisphere, but we could never detect a signal with ipsilateral FP stimulation after stroke. This lack of contralateral plasticity at the level of apical dendrites of layer 5 pyramidal neurons and FP sensory maps suggests that the contralesional cortex may not contribute to functional recovery after stroke and that, at least in mice, the peri-infarct cortex plays the dominant role in postischemic plasticity.

The path to memory is guided by strategy: distinct networks are engaged in associative encoding under visual and verbal strategy and influence memory performance in healthy and impaired individuals

Given the diversity of stimuli encountered in daily life, a variety of strategies must be used for learning new information. Relating and encoding visual and verbal stimuli into memory has been probed using various tasks and stimulus types. Engagement of specific subsequent memory and cortical processing regions depends on the stimulus modality of studied material; however, it remains unclear whether different encoding strategies similarly influence regional activity when stimulus type is held constant. In this study, participants encoded object pairs using a visual or verbal associative strategy during fMRI, and subsequent memory was assessed for pairs encoded under each strategy. Each strategy elicited distinct regional processing and subsequent memory effects: middle/superior frontal, lateral parietal, and lateral occipital for visually associated pairs and inferior frontal, medial frontal, and medial occipital for verbally associated pairs. This regional selectivity mimics the effects of stimulus modality, suggesting that cortical involvement in associative encoding is driven by strategy and not simply by stimulus type. The clinical relevance of these findings, probed in a patient with a recent aphasic stroke, suggest that training with strategies utilizing unaffected cortical regions might improve memory ability in patients with brain damage.

Muscle atrophy and functional deficits of knee extensors and flexors in people with chronic stroke

BACKGROUND

Further clarification is needed with regard to the degree of atrophy in individual muscle groups and its possible relationship to joint torque deficit poststroke.

OBJECTIVE

The purpose of this study was to investigate quadriceps and hamstring muscle volume and strength deficits of the knee extensors and flexors in people with chronic hemiparesis compared with a control group.

DESIGN

This was a cross-sectional study.

METHODS

Thirteen individuals with hemiparesis due to chronic stroke (hemiparetic group) and 13 individuals who were healthy (control group) participated in this study. Motor function, quadriceps and hamstring muscle volume, and maximal concentric and eccentric contractions of the knee extensors and flexors were assessed.

RESULTS

Only the quadriceps muscle of the paretic limb showed reduced muscle volume (24%) compared with the contralateral (nonparetic) limb. There were no differences in muscle volume between the hemiparetic and control groups. The peak torque of the paretic-limb knee extensors and flexors was reduced in both contraction modes and velocities compared with the nonparetic limb (36%-67%) and with the control group (49%-75%). The nonparetic limb also showed decreased extensor and flexor peak torque compared with the control group (17%-23%). Power showed similar deficits in strength (12%-78%). There were significant correlations between motor function and strength deficits (.54-.67).

LIMITATIONS

Magnetic resonance imaging coil length did not allow measurement of the proximal region of the thigh.

CONCLUSIONS

There were different responses between quadriceps and hamstring muscle volumes in the paretic limb that had quadriceps muscle atrophy only. However, both paretic and nonparetic limbs showed knee extensor and flexor torque and power reduction.

Recovery from ischemia in the middle-aged brain: a nonhuman primate model

Studies of recovery from stroke mainly utilize rodent models and focus primarily on young subjects despite the increased prevalence of stroke with age and the fact that recovery of function is more limited in the aged brain. In the present study, a nonhuman primate model of cortical ischemia was developed to allow the comparison of impairments in young and middle-aged monkeys. Animals were pretrained on a fine motor task of the hand and digits and then underwent a surgical procedure to map and lesion the hand-digit representation in the dominant motor cortex. Animals were retested until performance returned to preoperative levels. To assess the recovery of grasp patterns, performance was videotaped and rated using a scale adapted from human occupational therapy. Results demonstrated that the impaired hand recovers to baseline in young animals in 65-80 days and in middle-aged animals in 130-150 days. However, analysis of grasp patterns revealed that neither group recover preoperative finger thumb grasp patterns, rather they develop compensatory movements.

Lesions to primary sensory and posterior parietal cortices impair recovery from hand paresis after stroke

Background

Neuroanatomical determinants of motor skill recovery after stroke are still poorly understood. Although lesion load onto the corticospinal tract is known to affect recovery, less is known about the effect of lesions to cortical sensorimotor areas. Here, we test the hypothesis that lesions of somatosensory cortices interfere with the capacity to recover motor skills after stroke.

Methods

Standardized tests of motor skill and somatosensory functions were acquired longitudinally over nine months in 29 patients with stroke to the pre- and postcentral gyrus, including adjacent areas of the frontal, parietal and insular cortices. We derived the recovery trajectories of each patient for five motor subtest using least-squares curve fitting and objective model selection procedures for linear and exponential models. Patients were classified into subgroups based on their motor recovery models. Lesions were mapped onto diffusion weighted imaging scans and normalized into stereotaxic space using cost-function masking. To identify critical neuranatomical regions, voxel-wise subtractions were calculated between subgroup lesion maps. A probabilistic cytoarchitectonic atlas was used to quantify of lesion extent and location.

Results

Twenty-three patients with moderate to severe initial deficits showed exponential recovery trajectories for motor subtests that relied on precise distal movements. Those that retained a chronic motor deficit had lesions that extended to the center of the somatosensory cortex (area 2) and the intraparietal sulcus (areas hIP1, hIP2). Impaired recovery outcome correlated with lesion extent on this areas and somatosensory performance. The rate of recovery, however, depended on the lesion load onto the primary motor cortex (areas 4a, 4p).

Conclusions

Our findings support a critical role of uni-and multimodal somatosensory cortices in motor skill recovery. Whereas lesions to these areas influence recovery outcome, lesions to the primary motor cortex affect recovery dynamics. This points to a possible dissociation of neural substrates for different aspects of post-stroke recovery.

Disturbed cortico-subcortical interactions during motor task switching in traumatic brain injury

The ability to suppress and flexibly adapt motor behavior is a fundamental mechanism of cognitive control, which is impaired in traumatic brain injury (TBI). Here, we used a combination of functional magnetic resonance imaging and diffusion weighted imaging tractography to study changes in brain function and structure associated with motor switching performance in TBI. Twenty-three young adults with moderate-severe TBI and twenty-six healthy controls made spatially and temporally coupled bimanual circular movements. A visual cue signaled the right hand to switch or continue its circling direction. The time to initiate the switch (switch response time) was longer and more variable in the TBI group and TBI patients exhibited a higher incidence of complete contralateral (left hand) movement disruptions. Both groups activated the basal ganglia and a previously described network for task-set implementation, including the supplementary motor complex and bilateral inferior frontal cortex (IFC). Relative to controls, patients had significantly increased activation in the presupplementary motor area (preSMA) and left IFC, and showed underactivation of the subthalamic nucleus (STN) region. This altered functional engagement was related to the white matter microstructural properties of the tracts connecting preSMA, IFC, and STN. Both functional activity in preSMA, IFC, and STN, and the integrity of the connections between them were associated with behavioral performance across patients and controls. We suggest that damage to these key pathways within the motor switching network because of TBI, shifts the patients toward the lower end of the existing structure-function-behavior spectrum.

Longitudinal changes of resting-state functional connectivity during motor recovery after stroke

BACKGROUND AND PURPOSE

Functional MRI (fMRI) studies could provide crucial information on the neural mechanisms of motor recovery in patients with stroke. Resting-state fMRI is applicable to patients with stroke who are not capable of proper performance of the motor task. In this study, we explored neural correlates of motor recovery in patients with stroke by investigating longitudinal changes in resting-state functional connectivity of the ipsilesional primary motor cortex (M1).

METHODS

A longitudinal observational study using repeated fMRI experiments was conducted in 12 patients with stroke. Resting-state fMRI data were acquired 4 times over a period of 6 months. Patients participated in the first session of fMRI shortly after onset and thereafter in subsequent sessions at 1, 3, and 6 months after onset. Resting-state functional connectivity of the ipsilesional M1 was assessed and compared with that of healthy subjects.

RESULTS

Compared with healthy subjects, patients demonstrated higher functional connectivity with the ipsilesional frontal and parietal cortices, bilateral thalamus, and cerebellum. Instead, functional connectivity with the contralesional M1 and occipital cortex were decreased in patients with stroke. Functional connectivity between the ipsilesional and contralesional M1 showed the most asymmetry at 1 month after onset to the ipsilesional side. Functional connectivity of the ipsilesional M1 with the contralesional thalamus, supplementary motor area, and middle frontal gyrus at onset was positively correlated with motor recovery at 6 months after stroke.

CONCLUSIONS

Resting-state fMRI elicited distinctive but comparable results with previous task-based fMRI, presenting complementary and practical values for use in the study of patients with stroke.

Combination treatment of low-frequency rTMS and occupational therapy with levodopa administration: an intensive neurorehabilitative approach for upper limb hemiparesis after stroke

The combination treatment of low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy was applied with concomitant oral administration of levodopa in five post-stroke patients with upper limb hemiparesis (age at treatment: 56-66 years; interval between onset of stroke and treatment: 18-143 months) as a 15-day inpatient protocol. Daily levodopa administration of 100 mg was initiated 1 week before admission and continued until 4 weeks after discharge. Low-frequency rTMS of 1 Hz was applied to the contralesional hemisphere for 40 min daily (two 20-min sessions) combined with intensive occupational therapy consisting of 60-min one-on-one training and 60-min self-exercise. Motor function of the affected upper limb was serially evaluated with the Fugl-Meyer Assessment and the Wolf Motor Function Test. At the end of the treatment, all patients showed improved motor function in the affected upper limbs. In some patients, the improvement was maintained until 4 weeks after discharge. No patient showed any adverse effect from the intervention. Our proposed protocol featuring levodopa administration, low-frequency rTMS, and intensive occupational therapy could provide a safe and feasible intervention for upper limb hemiparesis after stroke.

Involvement of the corticospinal tract in the control of human gait

Given the inherent mechanical complexity of human bipedal locomotion, and that complete spinal cord lesions in human leads to paralysis with no recovery of gait, it is often suggested that the corticospinal tract (CST) has a more predominant role in the control of walking in humans than in other animals. However, what do we actually know about the contribution of the CST to the control of gait? This chapter will provide an overview of this topic based on the premise that a better understanding of the role of the CST in gait will be essential for the design of evidence-based approaches to rehabilitation therapy, which will enhance gait ability and recovery in patients with lesions to the central nervous system (CNS). We review evidence for the involvement of the primary motor cortex and the CST during normal and perturbed walking and during gait adaptation. We will also discuss knowledge on the CST that has been gained from studies involving CNS lesions, with a particular focus on recent data acquired in people with spinal cord injury.

Functional reorganization of upper-body movement after spinal cord injury

Survivors of spinal cord injury need to reorganize their residual body movements for interacting with assistive devices and performing activities that used to be easy and natural. To investigate movement reorganization, we asked subjects with high-level spinal cord injury (SCI) and unimpaired subjects to control a cursor on a screen by performing upper-body motions. While this task would be normally accomplished by operating a computer mouse, here shoulder motions were mapped into the cursor position. Both the control and the SCI subjects were rapidly able to reorganize their movements and to successfully control the cursor. The majority of the subjects in both groups were successful in reducing the movements that were not effective at producing cursor motions. This is inconsistent with the hypothesis that the control system is merely concerned with the accurate acquisition of the targets and is unconcerned with motions that are not relevant to this goal. In contrast, our findings suggest that subjects can learn to reorganize coordination so as to increase the correspondence between the subspace of their upper-body motions with the plane in which the controlled cursor moves. This is effectively equivalent to constructing an inverse internal model of the map from body motions to cursor motions, established by the experiment. These results are relevant to the development of interfaces for assistive devices that optimize the use of residual voluntary control and enhance the learning process in disabled users, searching for an easily learnable map between their body motor space and control space of the device.

Preoperative and intraoperative brain mapping for the resection of eloquent-area tumors. A prospective analysis of methodology, correlation, and usefulness based on clinical outcomes

BACKGROUND

Localization of brain function is a fundamental requisite for the resection of eloquent-area brain tumors. Preoperative functional neuroimaging and diffusion tensor imaging can display cortical functional organization and subcortical anatomy of major white matter bundles. Direct cortical and subcortical stimulation is widely used in routine practice, however, because of its ability to reveal tissue function in eloquent regions. The role and integration of these techniques is still a matter of debate. The objective of this study was to assess surgical and functional neurological outputs of awake surgery and intraoperative cortical and subcortical electrical stimulation (CSES) and to use CSES to examine the reliability of preoperative functional magnetic resonance (fMRI) and diffusion tensor imaging fiber tracking (DTI-FT) for surgical planning.

PATIENTS AND METHODS

We prospectively studied 27 patients with eloquent-area tumors who were selected to undergo awake surgery and direct brain mapping. All subjects underwent preoperative sensorimotor and language fMRI and DTI tractography of major white matter bundles. Intra- and postoperative complications, stimulation effects, extent of resection, and neurological outcome were determined. We topographically correlated intraoperatively identified sites (cortical and subcortical) with areas of fMRI activation and DTI tractography.

RESULTS

Total plus subtotal resection reached 88.8%. Twenty-one patients (77.7%) suffered transient postoperative worsening, but at 6 months follow-up only three (11.1%) patients had persistent neurological impairment. Sensorimotor cortex direct mapping correlated 92.3% with fMRI activation, while direct mapping of language cortex correlated 42.8%. DTI fiber tracking underestimated the presence of functional fibers surrounding or inside the tumor.

CONCLUSION

Preoperative brain mapping is useful when planning awake surgery to estimate the relationship between the tumor and functional brain regions. However, these techniques cannot directly lead the surgeon during resection. Intraoperative brain mapping is necessary for safe and maximal resection and to guarantee a satisfying neurological outcome. This multimodal approach is more aggressive, leads to better outcomes, and should be used routinely for resection of lesions in eloquent brain regions.

The role of contralesional dorsal premotor cortex after stroke as studied with concurrent TMS-fMRI

Contralesional dorsal premotor cortex (cPMd) may support residual motor function following stroke. We performed two complementary experiments to explore how cPMd might perform this role in a group of chronic human stroke patients. First, we used paired-coil transcranial magnetic stimulation (TMS) to establish the physiological influence of cPMd on ipsilesional primary motor cortex (iM1) at rest. We found that this influence became less inhibitory/more facilitatory in patients with greater clinical impairment. Second, we applied TMS over cPMd during functional magnetic resonance imaging (fMRI) in these patients to examine the causal influence of cPMd TMS on the whole network of surviving cortical motor areas in either hemisphere and whether these influences changed during affected hand movement. We confirmed that hand grip-related activation in cPMd was greater in more impaired patients. Furthermore, the peak ipsilesional sensorimotor cortex activity shifted posteriorly in more impaired patients. Critical new findings were that concurrent TMS-fMRI results correlated with the level of both clinical impairment and neurophysiological impairment (i.e., less inhibitory/more facilitatory cPMd-iM1 measure at rest as assessed with paired-coil TMS). Specifically, greater clinical and neurophysiological impairment was associated with a stronger facilitatory influence of cPMd TMS on blood oxygenation level-dependent signal in posterior parts of ipsilesional sensorimotor cortex during hand grip, corresponding to the posteriorly shifted sensorimotor activity seen in more impaired patients. cPMd TMS was not found to influence activity in other brain regions in either hemisphere. This state-dependent influence on ipsilesional sensorimotor regions may provide a mechanism by which cPMd supports recovered function after stroke.

Enriched environment downregulates macrophage migration inhibitory factor and increases parvalbumin in the brain following experimental stroke

Housing rodents in an enriched environment (EE) following experimental stroke enhances neurological recovery. Understanding the underlying neural cues may provide the basis for improving stroke rehabilitation. We studied the contribution of brain macrophage migration inhibitory factor (MIF) to functional recovery after permanent middle cerebral artery occlusion (pMCAo) in rats. In the cerebral cortex, MIF is predominantly found in neurons, particularly in parvalbumin interneurons. Following pMCAo, MIF increases around the infarct core, where it is located to neurons and astrocytes. Housing rats in an EE after pMCAo resulted in a decrease of MIF protein levels in peri-infarct areas, which was accompanied by an increase in parvalbumin immunoreactive interneurons. Our data suggest that MIF is part of a signaling network involved in brain plasticity, and elevated neuronal and/or astrocytic MIF levels repress the recovery of sensory-motor function after stroke. Downregulating MIF could constitute a new therapeutic approach to promote recovery after stroke.

Development of treatment concepts for the use of botulinum toxin a in children with cerebral palsy

The treatment of children with cerebral palsy with Botulinum toxin A injections is well established, safe and effective. However, a standardized injection strategy is still missing and the used dosage has escalated over the years. In the recent past, the recommended dosages in Europe were, however, reduced due to a better understanding of the relationship between dosage, severe side effects and the kind of anesthesia used. To combine safety and efficacy, the trend tends to a lower dosage, but combined with a more specific selection of injected muscles. The treatment of these key-muscles takes into account the best support for motor development to attain each individual motor milestone.

[Botulinum toxin A in children with infantile cerebral palsy: indications and treatment concepts]

Botulinum toxin A treatment in children with cerebral palsy is now well established as a safe and effective therapy option. However, a standardised injection strategy is still lacking. There is no doubt concerning the necessity for long-term therapy to cover the duration of motor development as well as for adequate prevention of fixed contractures. The appropriate dose and treatment concept to be used, however, is still controversial. The modern BoNT-A treatment concept must combine safety and efficacy with the availability of this treatment option throughout the duration of growth in these children. Consequently, in order to provide the best possible support for motor development at each individual motor milestone and using moderate dose recommendations, the "Key-Muscle Concept" has been developed.

Selective long-term reorganization of the corticospinal projection from the supplementary motor cortex following recovery from lateral motor cortex injury

Brain injury affecting the frontal motor cortex or its descending axons often causes contralateral upper extremity paresis. Although recovery is variable, the underlying mechanisms supporting favorable motor recovery remain unclear. Because the medial wall of the cerebral hemisphere is often spared following brain injury and recent functional neuroimaging studies in patients indicate a potential role for this brain region in the recovery process, we investigated the long-term effects of isolated lateral frontal motor cortical injury on the corticospinal projection (CSP) from intact, ipsilesional supplementary motor cortex (M2). After injury to the arm region of the primary motor (M1) and lateral premotor (LPMC) cortices, upper extremity recovery is accompanied by terminal axon plasticity in the contralateral CSP but not the ipsilateral CSP from M2. Furthermore, significant contralateral plasticity occurs only in lamina VII and dorsally within lamina IX. Thus, selective intraspinal sprouting transpires in regions containing interneurons, flexor-related motor neurons, and motor neurons supplying intrinsic hand muscles, which all play important roles in mediating reaching and digit movements. After recovery, subsequent injury of M2 leads to reemergence of hand motor deficits. Considering the importance of the CSP in humans and the common occurrence of lateral frontal cortex injury, these findings suggest that spared supplementary motor cortex may serve as an important therapeutic target that should be considered when designing acute and long-term postinjury patient intervention strategies aimed to enhance the motor recovery process following lateral cortical trauma.

Human neural stem cell grafts modify microglial response and enhance axonal sprouting in neonatal hypoxic-ischemic brain injury

BACKGROUND AND PURPOSE

Hypoxic-ischemic (HI) brain injury in newborn infants represents a major cause of cerebral palsy, development delay, and epilepsy. Stem cell-based therapy has the potential to rescue and replace the ischemic tissue caused by HI and to restore function. However, the mechanisms by which stem cell transplants induce functional recovery are yet to be elucidated. In the present study, we sought to investigate the efficacy of human neural stem cells derived from human embryonic stem cells in a rat model of neonatal HI and the mechanisms enhancing brain repair.

METHODS

The human neural stem cells were genetically engineered for in vivo molecular imaging and for postmortem histological tracking. Twenty-four hours after the induction of HI, animals were grafted with human neural stem cells into the forebrain. Motor behavioral tests were performed the fourth week after transplantation. We used immunocytochemistry and neuroanatomical tracing to analyze neural differentiation, axonal sprouting, and microglia response. Treatment-induced changes in gene expression were investigated by microarray and quantitative polymerase chain reaction.

RESULTS

Bioluminescence imaging permitted real time longitudinal tracking of grafted human neural stem cells. HI transplanted animals significantly improved in their use of the contralateral impeded forelimb and in the Rotorod test. The grafts showed good survival, dispersion, and differentiation. We observed an increase of uniformly distributed microglia cells in the grafted side. Anterograde neuroanatomical tracing demonstrated significant contralesional sprouting. Microarray analysis revealed upregulation of genes involved in neurogenesis, gliogenesis, and neurotrophic support.

CONCLUSIONS

These results suggest that human neural stem cell transplants enhance endogenous brain repair through multiple modalities in response to HI.

Comparing unilateral and bilateral upper limb training: the ULTRA-stroke program design

Background

About 80% of all stroke survivors have an upper limb paresis immediately after stroke, only about a third of whom (30 to 40%) regain some dexterity within six months following conventional treatment programs. Of late, however, two recently developed interventions - constraint-induced movement therapy (CIMT) and bilateral arm training with rhythmic auditory cueing (BATRAC) - have shown promising results in the treatment of upper limb paresis in chronic stroke patients. The ULTRA-stroke (acronym for Upper Limb TRaining After stroke) program was conceived to assess the effectiveness of these interventions in subacute stroke patients and to examine how the observed changes in sensori-motor functioning relate to changes in stroke recovery mechanisms associated with peripheral stiffness, interlimb interactions, and cortical inter- and intrahemispheric networks. The present paper describes the design of this single-blinded randomized clinical trial (RCT), which has recently started and will take several years to complete.

Methods/Design

Sixty patients with a first ever stroke will be recruited. Patients will be stratified in terms of their remaining motor ability at the distal part of the arm (i.e., wrist and finger movements) and randomized over three intervention groups receiving modified CIMT, modified BATRAC, or an equally intensive (i.e., dose-matched) conventional treatment program for 6 weeks. Primary outcome variable is the score on the Action Research Arm test (ARAT), which will be assessed before, directly after, and 6 weeks after the intervention. During those test sessions all patients will also undergo measurements aimed at investigating the associated recovery mechanisms using haptic robots and magneto-encephalography (MEG).

Discussion

ULTRA-stroke is a 3-year translational research program which aims (1) to assess the relative effectiveness of the three interventions, on a group level but also as a function of patient characteristics, and (2) to delineate the functional and neurophysiological changes that are induced by those interventions.

The outcome on the ARAT together with information about changes in the associated mechanisms will provide a better understanding of how specific therapies influence neurobiological changes, and which post-stroke conditions lend themselves to specific treatments.

Trial Registration

The ULTRA-stroke program is registered at the Netherlands Trial Register (NTR, http://www.trialregister.nl, number NTR1665).

The corticospinal system and transcranial magnetic stimulation in stroke

During the last decades, transcranial magnetic stimulation (TMS) has been used as a noninvasive method to investigate motor cortical reorganization and neuroplasticity in humans after stroke. An increasing number of studies in the field of motor control have used TMS to gain an understanding of the different aspects of stroke cortical physiology and motor recovery. This review addresses the effects of corticospinal tract (CST) lesions in humans and nonhuman primates on the functional organization of the motor system. We review information on the physiological mechanisms by which the CST contributes to normal motor control and to central nervous system reorganization following stroke when the CST is injured as measured using TMS. Insight into these physiological mechanisms has led to the development of scientifically sound interventional proposals in the field of neurorehabilitation.

In vivo voltage-sensitive dye imaging in adult mice reveals that somatosensory maps lost to stroke are replaced over weeks by new structural and functional circuits with prolonged modes of activation within both the peri-infarct zone and distant sites

After brain damage such as stroke, topographically organized sensory and motor cortical representations remap onto adjacent surviving tissues. It is conceivable that cortical remapping is accomplished by changes in the temporal precision of sensory processing and regional connectivity in the cortex. To understand how the adult cortex remaps and processes sensory signals during stroke recovery, we performed in vivo imaging of sensory-evoked changes in membrane potential, as well as multiphoton imaging of dendrite structure and tract tracing. In control mice, forelimb stimulation evoked a brief depolarization in forelimb cortex that quickly propagated to, and dissipated within, adjacent motor/hindlimb areas (<100 ms). One week after forelimb cortex stroke, the cortex was virtually unresponsive to tactile forelimb stimulation. After 8 weeks recovery, forelimb-evoked depolarizations reemerged with a characteristic pattern in which responses began within surviving portions of forelimb cortex (<20 ms after stimulation) and then spread horizontally into neighboring peri-infarct motor/hindlimb areas in which depolarization persisted 300-400% longer than controls. These uncharacteristically prolonged responses were not limited to the remapped peri-infarct zone and included distant posteromedial retrosplenial cortex, millimeters from the stroke. Structurally, the remapped peri-infarct area selectively exhibited high levels of dendritic spine turnover, shared more connections with retrosplenial cortex and striatum, and lost inputs from lateral somatosensory cortical regions. Our findings demonstrate that sensory remapping during stroke recovery is accompanied by the development of prolonged sensory responses and new structural circuits in both the peri-infarct zone as well as more distant sites.

Compensatory cerebral adaptations before and evolving changes after surgical decompression in cervical spondylotic myelopathy

OBJECT

The goal of this study was to compare cortical sensorimotor adaptations associated with neurological deterioration and then recovery following surgical decompression for cervical spondylotic myelopathy (CSM).

METHODS

Eight patients with CSM underwent functional MR (fMR) imaging during wrist extension and the 3-finger pinch task, along with behavioral assessments before and 3 and 6 months after surgery. Six healthy control volunteers were scanned twice.

RESULTS

Cervical spine MR imaging demonstrated successful cord decompression. The patients improved after surgery on the modified Japanese Orthopaedic Association score for the upper extremity, which correlated with the changes in task-associated activation in specific sensorimotor regions of interest. Pinch-related activation in sensorimotor cortex contralateral to the movement paradigm was reduced before surgery then increased toward the extent of healthy controls after surgery. Before surgery, patients showed broader activation in ipsilateral sensorimotor cortex during wrist extension than during pinch, but activations became similar to those of healthy controls after surgery. Pinch-related activation volume in the ipsilateral sensorimotor cortex and the magnitude of activation in the contralateral dorsal premotor cortex evolved linearly across time after surgery, along with wrist extension-related activation magnitude in the contralateral supplementary motor area.

CONCLUSIONS

Serial fMR imaging studies in CSM can capture the adaptations in specific sensorimotor cortices that accompany clinical deterioration and postsurgical improvement in sensorimotor function associated with damage and partial recovery of conduction in corticospinal pathways. These adaptive regions can be monitored by serial fMR imaging to detect a critical loss of supraspinal reserve in compensatory plasticity, which might augment clinical information about the need for surgical decompression.

Functional cortical changes of the sensorimotor network are associated with clinical recovery in multiple sclerosis

OBJECTIVE

To assess the early cortical changes following an acute motor relapse secondary to a pseudotumoral lesion in MS patients, the longitudinal cortical functional correlates of clinical recovery, and the evolution over time of cortical reorganization.

METHODS

FMRI during the performance of a simple motor task were obtained from 12 MS patients (after a clinical attack involving the motor system secondary to a pseudotumoral lesion) and 15 matched controls. In six patients and five controls, a longitudinal fMRI study was also performed.

RESULTS

In patients, at baseline, the primary sensorimotor cortex (SMC) of the ipsilateral (contralesional) hemisphere was significantly more active during task performance with the impaired than the unimpaired hand. During task performance with the unimpaired hand, the ipsilateral cerebellum and several motor areas in the contralateral hemisphere were significantly more active. Pseudotumoral lesion volume was correlated with activation of the primary SMC bilaterally (r = -0.86 and -0.85) and the nine-hole peg test score with activation of the primary SMC of the affected hemisphere (r = 0.88). A recovery of function of the primary SMC of the affected hemisphere was found in the four patients with clinical improvement. In the two patients without clinical recovery, there was a persistent recruitment of the primary SMC of the unaffected hemisphere.

CONCLUSIONS

Pseudotumoral MS lesions affecting the motor system can determine short-term cortical changes characterized by the recruitment of pathways in the unaffected hemisphere. The regain of function of motor areas of the affected hemisphere seems to be a critical factor for a favorable recovery.

Intrinsic muscle strength and voluntary activation of both lower limbs and functional performance after stroke

The objective of this study was to assess the nature of muscle weakness in both legs after stroke compared with able-bodied control individuals and to examine whether there is a relationship between the degree of muscle weakness and coactivation of knee extensors and flexors as well as voluntary activation capacity of knee extensors of both paretic and non-paretic legs and indices of functional performance. Maximal voluntary isometric torques of knee extensors (MVCe) and flexors (MVCf) were determined in 14 patients (bilaterally) and 12 able-bodied controls. Simultaneous measurements were made of torque and surface EMG from agonist and antagonist muscles. Coactivation was calculated. Supramaximal triplets were evoked with electrical stimulation to estimate maximal torque capacity and degree of voluntary activation of knee extensors. MVCs, activation and coactivation parameters were correlated to scores of seven functional performance tests. MVCe, MVCf and voluntary activation were lower in paretic lower limb (PL) compared with both non-paretic lower limb (NL) and control. Besides, all these parameters of NL were also lower than control. Electrically evoked torque capacity of knee extensors of PL was about 60% of both NL and control, which were not significantly different from each other. Strong significant correlations between strength, as well as voluntary activation, and functional performance were found. Coactivation did not correlate well with functional performance. Thus, whereas for NL activation failure can explain weakness, for PL both activation failure and reduced intrinsic torque capacity are responsible for the severe weakness. Activation capacity and muscle strength correlated strongly to functional performance, while coactivation did not.

Functional imaging of stroke recovery: an ecological review from a neural network perspective with an emphasis on motor systems

Functional imaging is beginning to outline the brain's functional architecture and mechanisms of recovery from injury. I will review primarily the motor-function literature from normal populations, learning trials, stroke recovery, and rehabilitation with a neural network approach that may prove fruitful in further advancing our understanding of brain plasticity in response to focal lesions. A key consideration in this review will be how the development of distributed motor networks might constrain recovery as a function of the altered connectivity between damaged and nondamaged areas. It will be argued that this connectivity is central to both recovery from injury and response to treatment.

Neuroadaptation of presbyopia-correcting intraocular lenses

PURPOSE OF REVIEW

Advances in the design of intraocular lenses give options to patients for some return to the optical accommodation needed to focus on objects at different distances. Technology is only improving these options for presbyopic-correcting intraocular lenses. Surgeons must consider the possible neuroadaptation abilities in patients that may help in the success of using these lenses.

RECENT FINDINGS

The hierarchy of the visual system allows two disparate retinal images to combine to form a single picture with depth. Attempts to correct presbyopia with intraocular lenses add complexity to the pathway with the possible introduction of monovision or intraocular rivalry. The neuroadaptation involved in successful use of these lenses has not been study but has been well established in other neurologic processing.

SUMMARY

Understanding what patient selection factors are important for neuroadaptation may contribute to outcome success.

Ipsilesional and contralesional sensorimotor function after hemispherectomy: differences between distal and proximal function

Previous studies have reported mainly on contralesional somatosensory and motor function after hemispherectomy. So far, ipsilesional impairments have received little attention even though these have been reported in patients with less extensive lesions. In the current study we assessed ipsilesional and contralesional sensorimotor function in a group of 12 patients with hemispherectomy. In addition, we focused on differences between distal and proximal function and investigated several factors that may have contributed to individual differences between patients. The tests included tapping, force production, tactile double simultaneous stimulation, pressure sensitivity, passive joint movement sense and sensitivity to hot and cold. Ipsilesional impairments were found on all tests, except passive joint movement sense. Unexpectedly, no significant ipsilateral distal-proximal gradient was found for any of the measures. Both the removal of the diseased cerebral hemisphere and possible changes to the remaining brain structures may have affected ipsilesional sensorimotor function. Contralesional performance was impaired on all tests except for passive joint movement in the shoulder. The contralesional impairments were characterized by a distal-proximal gradient measured on all tests, except that of sensitivity to hot and cold. Distal function was always most impaired. The difference between distal and proximal motor function is in agreement with the established concepts of the motor pathways, with the motoneurons innervating proximal muscles receiving bilateral cortical and subcortical input. Age at onset of original brain damage correlated significantly with passive joint movement sense. Patients with known abnormalities to the remaining brain structures performed inferior on the tapping test only. No effect was found of the hemispheric side of removal.

Livin' on the edge: imaging dendritic spine turnover in the peri-infarct zone during ischemic stroke and recovery

The spontaneous recovery of sensory, motor, and cognitive functions after stroke is thought to be mediated primarily through the reorganization and rewiring of surviving brain circuits. Given that dendritic spine turnover underlies rewiring during normal development and plasticity, this process is likely to play a key role in mediating functional changes that occur during and after stroke. Recently, a new approach has been taken using two-photon microscopy to monitor, in real time, the temporal and spatial progression of dendritic plasticity in the living animal, both while it is experiencing the initial ischemic episode as well as during long-term recovery from stroke damage. Here, we highlight recent evidence showing that stroke can trigger extensive changes in the relatively hardwired adult brain. For example, when dendrites are challenged by acute ischemia, they can disintegrate within minutes of ischemia and rapidly reassemble during reperfusion. Over longer time scales, dendrites in the surviving peri-infarct zone show heightened levels of spine turnover for many weeks after stroke, thereby raising the possibility that future stroke therapies may be able to facilitate or optimize dendritic rewiring to improve functional recovery.

Neuromodulation by functional electrical stimulation (FES) of limb paralysis after stroke

Functional Electrical Stimulation (FES) in stroke patients has been demonstrated to provide clinical benefits such as improvement in movement, skills, function and decrease of spasticity. Imaging and neurophysiological studies have shown cortical excitability and reorganization. After injury, the parameters of timing, intensity, frequency, and duration of FES are still to be determined. Additional issues that should be determined are whether the changes induced by FES are long-lasting, and which clinical and electrophysiological parameters are important and to what extent.

Interhemispheric asymmetry of primary hand representation and recovery after stroke: A MEG study

In patients affected by monohemispheric stroke in the middle cerebral artery territory, who do not regain a normal neurological function, a positive contribution to the clinical recovery seems to be made by the involvement of primary hand representation areas in the affected hemisphere (AH), excessively asymmetric to its homologous in the unaffected hemisphere (UH). We investigated primary sensory hand areas in 41 chronic patients who had improved their clinical status without reaching complete recovery. The location and strength of the first cerebral sources activated by a contralateral galvanic median nerve stimulation (M20 and M30) were evaluated in both hemispheres, together with their interhemispheric differences. The source displacement in the AH with respect to the UH was positively correlated with clinical recovery (Spearman's rho=0.584, p=0.003). The excessive interhemispheric asymmetry - as defined on the basis of reference ranges in the healthy population - could be interpreted as the involvement of neuronal pools in the AH outside the hand 'omega zone' of the Rolandic sulcus, revealing the presence of plasticity phenomena. The present data provide support to a positive role of cerebral plasticity phenomena, partially contributing to post-stroke recovery in patients unable to achieve normal neurological function.

Shift of motor activation areas during recovery from hemiparesis after cerebral infarction: a longitudinal study with near-infrared spectroscopy

Motor functional recovery after stroke may be attributable to cerebral reorganization. We used near-infrared spectroscopy, which measures non-invasively the changes in oxy- and deoxy-hemoglobin concentrations in response to neural activation, for monitoring cerebral activation in stroke patients, and investigated the longitudinal changes in functional laterality of activations in the primary sensorimotor cortex during unilateral audio-paced (1 Hz) hand movement. We examined five ischemic stroke patients (4 females and 1 male, 52-67 years old) with mild to moderate hemiparesis at acute stages and chronic stages at least 1 month later. Normal subjects (3 females and 2 males, 47-63 years old) were also included. Unilateral hand movement activated predominantly the contralateral primary sensorimotor cortex in the normal subjects and the stroke patients when they moved unaffected hand. Affected hand movements activated bilateral sensorimotor cortices early after stroke (< 25 days of stroke onset), whereas the activation pattern returned toward normal at later periods (> 35 days). The contralaterality index (0.34 +/- 0.12 in normal control) was reduced at early periods (0.00 +/- 0.03, p < 0.01) after stroke, and returned to normal (0.35 +/- 0.24) as motor function recovered. These findings suggest that a transient increase in motor activation in the ipsilateral intact hemisphere within 1 month may play an important role in the recovery from motor dysfunction after stroke.

CNS-active drugs in aging population at high risk of cerebrovascular events: evidence from preclinical and clinical studies

The recovery process following cerebral insults such as stroke is affected by aging and pharmacotherapy. The use of medication including CNS-active drugs has increased in the elderly during recent years. However, surprisingly little is known about how safe they are with respect to severity of sensorimotor and cognitive impairments or recovery of function following possible cerebrovascular accidents. This review examines the experimental and clinical literature, primarily from 1995 onwards, concerning medication in relation to cerebrovascular events and functional recovery. Special attention is directed to polypharmacy and to new CNS-active drugs, which the elderly are already taking or are prescribed to treat emerging, stroke-induced psychiatric symptoms. The neurobiological mechanisms affected by these drugs are discussed.

Functional anatomy of motor urgency

This PET H(2)(15)O study uses a reaching task to determine the neural basis of the unconscious motor speed up observed in the context of urgency in healthy subjects. Three conditions were considered: self-initiated (produce the fastest possible movement toward a large plate, when ready), externally-cued (same as self-initiated but in response to an acoustic cue) and temporally-pressing (same as externally-cued with the plate controlling an electromagnet that prevented a rolling ball from falling at the bottom of a tilted ramp). Results show that: (1) Urgent responses (Temporally-pressing versus Externally-cued) engage the left parasagittal and lateral cerebellar hemisphere and the sensorimotor cortex (SMC) bilaterally; (2) Externally-driven responses (Externally-cued versus Self-initiated) recruit executive areas within the contralateral SMC; (3) Volitional responses (Self-initiated versus Externally-cued) involve prefrontal cortical areas. These observations are discussed with respect to the idea that neuromuscular energy is set to a submaximal threshold in self-determined situations. In more challenging tasks, this threshold is raised and the first answer of the nervous system is to optimize the response of the lateral (i.e. crossed) corticospinal tract (contralateral SMC) and ipsilateral cerebellum. In a second step, the anterior (i.e. uncrossed) corticospinal tract (ipsilateral SMC) and the contralateral cerebellum are recruited. This recruitment is akin to the strategy observed during recovery in patients with brain lesions.

Assessing and inducing neuroplasticity with transcranial magnetic stimulation and robotics for motor function

OBJECTIVES

To describe 2 new ways of assessing and inducing neuroplasticity in the human brain--transcranial magnetic stimulation (TMS) and robotics--and to investigate and promote the recovery of motor function after brain damage.

DATA SOURCES

We identified recent articles and books directly bearing on TMS and robotics. Articles using these tools for purposes other than rehabilitation were excluded. From these studies, we emphasize the methodologic and technical details of these tools as applicable for assessing and inducing plasticity.

STUDY SELECTION

Because both tools have only recently been used for rehabilitation, the majority of the articles selected for this review have been published only within the last 10 years.

DATA EXTRACTION

We used the PubMed and Compendex databases to find relevant peer-reviewed studies for this review. The studies were required to be relevant to rehabilitation and to use TMS or robotics methodologies. Guidelines were applied via independent extraction by multiple observers.

DATA SYNTHESIS

Despite the limited amount of research using these procedures for assessing and inducing neuroplasticity, there is growing evidence that both TMS and robotics can be very effective, inexpensive, and convenient ways for assessing and inducing rehabilitation. Although TMS has primarily been used as an assessment tool for motor function, an increasing number of studies are using TMS as a tool to directly induce plasticity and improve motor function. Similarly, robotic devices have been used for rehabilitation because of their suitability for delivery of highly repeatable training. New directions in robotics-assisted rehabilitation are taking advantage of novel measurements that can be acquired via the devices, enabling unique methods of assessment of motor recovery.

CONCLUSIONS

As refinements in technology and advances in our knowledge continue, TMS and robotics should play an increasing role in assessing and promoting the recovery of function. Ongoing and future studies combining TMS and robotics within the same populations may prove fruitful for a more detailed and comprehensive assessment of the central and peripheral changes in the nervous system during precisely induced recovery.

Speed of motor re-learning after experimental stroke depends on prior skill

Many motor rehabilitation therapies are based on principles of motor learning. Motor learning depends on preliminary knowledge of the trained and other (similar) skills. This study sought to investigate the influence of prior skill knowledge on re-learning of a precision reaching skill after a cortical lesion in rat. One group of animals recovered a previously known skill (skill training, followed by stroke and re-learning training, TST, n = 8). A second group learned the skill for the first time after stroke (ST, n = 6). A control group received prolonged training without stroke (n = 6). Unilateral partial motor cortex lesions were induced photothrombotically after identifying the forelimb representation using epidural stimulation mapping. In TST animals, re-learning after stroke was slower than learning before stroke (post hoc repeated measures ANOVA P = 0.039) and learning in the control group (P = 0.033). De novo learning after stroke (ST group) was not different from healthy learning. These findings show that skill learning can be performed if the motor cortex is partially lesioned; re-learning of a skill after stroke is slowed by prior knowledge of the skill. It remains to be tested in humans whether task novelty positively influences rehabilitation therapy.