Spinal cord-transected mice learn to step in response to quipazine treatment and robotic training

Changes in motoneuron properties and synaptic inputs related to step training after spinal cord transection in rats

Although recovery from spinal cord injury is generally meager, evidence suggests that step training can improve stepping performance, particularly after neonatal spinal injury. The location and nature of the changes in neural substrates underlying the behavioral improvements are not well understood. We examined the kinematics of stepping performance and cellular and synaptic electrophysiological parameters in ankle extensor motoneurons in nontrained and treadmill-trained rats, all receiving a complete spinal transection as neonates. For comparison, electrophysiological experiments included animals injured as young adults, which are far less responsive to training. Recovery of treadmill stepping was associated with significant changes in the cellular properties of motoneurons and their synaptic input from spinal white matter [ipsilateral ventrolateral funiculus (VLF)] and muscle spindle afferents. A strong correlation was found between the effectiveness of step training and the amplitude of both the action potential afterhyperpolarization and synaptic inputs to motoneurons (from peripheral nerve and VLF). These changes were absent if step training was unsuccessful, but other spinal projections, apparently inhibitory to step training, became evident. Greater plasticity of axonal projections after neonatal than after adult injury was suggested by anatomical demonstration of denser VLF projections to hindlimb motoneurons after neonatal injury. This finding confirmed electrophysiological measurements and provides a possible mechanism underlying the greater training susceptibility of animals injured as neonates. Thus, we have demonstrated an "age-at-injury"-related difference that may influence training effectiveness, that successful treadmill step training can alter electrophysiological parameters in the transected spinal cord, and that activation of different pathways may prevent functional improvement.

Plasticity of functional connectivity in the adult spinal cord

This paper emphasizes several characteristics of the neural control of locomotion that provide opportunities for developing strategies to maximize the recovery of postural and locomotor functions after a spinal cord injury (SCI). The major points of this paper are: (i) the circuitry that controls standing and stepping is extremely malleable and reflects a continuously varying combination of neurons that are activated when executing stereotypical movements; (ii) the connectivity between neurons is more accurately perceived as a functional rather than as an anatomical phenomenon; (iii) the functional connectivity that controls standing and stepping reflects the physiological state of a given assembly of synapses, where the probability of these synaptic events is not deterministic; (iv) rather, this probability can be modulated by other factors such as pharmacological agents, epidural stimulation and/or motor training; (v) the variability observed in the kinematics of consecutive steps reflects a fundamental feature of the neural control system and (vi) machine-learning theories elucidate the need to accommodate variability in developing strategies designed to enhance motor performance by motor training using robotic devices after an SCI.

Confounders in rehabilitation trials of task-oriented training: lessons from the designs of the EXCITE and SCILT multicenter trials

Two multicenter randomized clinical trials (MRCT), the Extremity Constraint Induced Therapy Evaluation (EXCITE) to improve upper extremity function after stroke and the Spinal Cord Injury Locomotor Trial (SCILT) to enable functional walking after incomplete spinal cord injury, demonstrate that complex, task-oriented physical therapies can be studied using a scientific methodology during inpatient or outpatient rehabilitation. In the past, a new therapy's benefit may have been overestimated by comparing it to no treatment or to a conventional treatment at a low intensity of practice. Sample sizes were often too small and may have failed to detect the efficacy of a new intervention. In addition, whereas statistical significance in outcomes has been critical to understanding whether one treatment is better than another, the clinical significance of outcomes must also impact the interpretation of the results of a trial. MRCT designs will continue to improve through attention to the limitations of preclinical animal models that offer a conceptual basis for the treatment, [corrected] from enrichment strategies at every phase of trial development, [corrected] from more vigorous dose-response studies using adaptive methods, [corrected] by capturing interim measures of behavior and functional neurophysiologic adaptations during the treatment phase, [corrected] by aiming for a clinically meaningful control intervention, [corrected] and by including ratio or interval outcome measures when feasible that capture a target of the intervention in relation to gains in daily functioning and quality of life.

Implications of assist-as-needed robotic step training after a complete spinal cord injury on intrinsic strategies of motor learning

Robotic training paradigms that enforce a fixed kinematic control might be suboptimal for rehabilitative training because they abolish variability, an intrinsic property of neuromuscular control (Jezernik et al., 2003). In the present study we introduce "assist-as-needed" (AAN) robotic training paradigms for rehabilitation of spinal cord injury subjects. To test the efficacy of these robotic control strategies to teach spinal mice to step, we divided 27 adult female Swiss-Webster mice randomly into three groups. Each group was trained robotically by using one of three control strategies: a fixed training trajectory (Fixed group), an AAN training paradigm without interlimb coordination (Band group), and an AAN training paradigm with bilateral hindlimb coordination (Window group). Beginning at 14 d after a complete midthoracic spinal cord transection, the mice were trained daily (10 min/d, 5 d/week) to step on a treadmill 10 min after the administration of quipazine (0.5 mg/kg), a serotonin agonist, for a period of 6 weeks. During weekly performance evaluations, the mice trained with the AAN window paradigm generally showed the highest level of recovery as measured by the number, consistency, and periodicity of steps during the testing sessions. In all three measurements there were no significant differences between the Band and the Fixed training groups. These results indicate that the window training approach, which includes loose alternating interlimb coordination, is more effective than a fixed trajectory paradigm with rigid alternating interlimb coordination or an AAN paradigm without any interlimb constraints in promoting robust postinjury stepping behavior.

Plasticity of connections underlying locomotor recovery after central and/or peripheral lesions in the adult mammals

This review discusses some aspects of plasticity of connections after spinal injury in adult animal models as a basis for functional recovery of locomotion. After reviewing some pitfalls that must be avoided when claiming functional recovery and the importance of a conceptual framework for the control of locomotion, locomotor recovery after spinal lesions, mainly in cats, is summarized. It is concluded that recovery is partly due to plastic changes within the existing spinal locomotor networks. Locomotor training appears to change the excitability of simple reflex pathways as well as more complex circuitry. The spinal cord possesses an intrinsic capacity to adapt to lesions of central tracts or peripheral nerves but, as a rule, adaptation to lesions entails changes at both spinal and supraspinal levels. A brief summary of the spinal capacity of the rat, mouse and human to express spinal locomotor patterns is given, indicating that the concepts derived mainly from work in the cat extend to other adult mammals. It is hoped that some of the issues presented will help to evaluate how plasticity of existing connections may combine with and potentiate treatments designed to promote regeneration to optimize remaining motor functions.

Effect of robotic-assisted treadmill training and chronic quipazine treatment on hindlimb stepping in spinally transected rats

The purpose of this study was to determine if robotic-assisted treadmill training improved hindlimb stepping in complete spinal cord transected (ST) rats. In addition, we examined whether chronic quipazine treatment would enhance the effectiveness of robotic-assisted training. Hindlimb stepping was examined in four groups of ST rats: trained + quipazine; trained + vehicle; untrained + quipazine; and untrained + vehicle. To train the rats to step, a robotic device was used that moved the hindlimbs in a semi-fixed trajectory during treadmill stepping. The robotic device was also used to assess treadmill stepping. Quipazine or vehicle was administered to the lumbar spinal cord using an intrathecal cannula. The groups that received robotic-assisted training performed more stepping movements on the treadmill than the untrained groups 10 weeks after ST. However, no differences were found between the robotic-assisted and untrained groups 16 weeks after ST. Kinematic analyses revealed that abnormally small step cycles were performed by all of the groups of ST rats. There was no significant effect of combining robotic-assisted training and quipazine treatment on stepping recovery. These data suggest that robotic-assisted training may generate hindlimb sensory stimuli that are effective in enhancing the ability of the lumbar spinal cord to generate hindlimb stepping. However, the effectiveness of robotic-assisted training may be limited to the early stages of recovery following spinal cord transection.

Neurological aspects of spinal-cord repair: promises and challenges

During the past few years, several approaches to spinal-cord repair have been successfully established in animal models. For their use in trials of spinal-cord injury (SCI) in human beings, specific difficulties that affect the success of clinical trials have to be recognised. First, transection of the spinal cord is commonly applied in animal models, whereas contusion, which generally leads to injury in two to three segments, represents the typical injury mechanism in human beings. Second, the quadrupedal organisation of locomotion in animals and the more complex autonomic functions in human beings, challenge translation of animal behaviour into recovery from SCI in people. Third, the extensive damage of motor neurons and roots associated with spinal-cord contusion is not addressed in current translational studies. This damage has direct implications for rehabilitation strategies and functional outcome. Fourth, there is increasing evidence for a degradation of neuronal function below the level of the lesion in chronic complete SCI. The relevance of this degradation for a regeneration-inducing treatment needs to be investigated. Fifth, the prerequisites to enable appropriate reconnection of regenerating tract fibres in a postacute stage have still to be established.

Plasticity of spinal cord reflexes after a complete transection in adult rats: relationship to stepping ability

Changes in epidurally induced (S1) spinal cord reflexes were studied as a function of the level of restoration of stepping ability after spinal cord transection (ST). Three types of responses were observed. The early response (ER) had a latency of 2.5 to 3 ms and resulted from direct stimulation of motor fibers or motoneurons. The middle response (MR) had a latency of 5 to 7 ms and was monosynaptic. The late response (LR) had a latency of 9 to 11 ms and was polysynaptic. After a complete midthoracic ST, the LR was abolished, whereas the MR was facilitated and progressively increased. The LR reappeared about 3 wk after ST and increased during the following weeks. Restoration of stepping induced by epidural stimulation at 40 Hz coincided with changes in the LR. During the first 2 wk post-ST, rats were unable to step and electrophysiological assessment failed to show any LR. Three weeks post-ST, epidural stimulation resulted in a few steps and these coincided with reappearance of the LR. The ability of rats to step progressively improved from wk 3 to wk 6 post-ST. There was a continuously improved modulation of rhythmic EMG bursts that was correlated with restoration of the LR. These results suggest that restoration of polysynaptic spinal cord reflexes after complete ST coincides with restoration of stepping function when facilitated by epidural stimulation. Combined, these findings support the view that restoration of polysynaptic spinal cord reflexes induced epidurally may provide a measure of functional restoration of spinal cord locomotor networks after ST.

Rehabilitative Therapies after Spinal Cord Injury

We review some basic and highly relevant concepts in the effort to develop improved rehabilitative interventions for subjects with spinal cord injury (SCI). Interventions that are likely to contribute to improved sensorimotor function include (1) practice of the specific motor task that needs to be improved; and (2) combining the training with one or more interventions--such as pharmacological modulation of the excitability of spinal neural networks, implantation of selected cell types such as olfactory ensheathing glia (OEG), and/or modulation of the excitability of the spinal cord via epidural stimulation. Upon improvement of the neural control of the musculature following SCI, it will always be prudent to maximize the torque output from these activation patterns by assuring that muscle mass is maintained. Therefore, it seems quite feasible that considerable improvement in locomotor performance can be achieved by improved coordination of motor pools, as well as effective recovery of muscle mass, which will assist in the potential generation of normal forces among agonistic and antagonistic muscle groups.