Motor skills training enhances lesion-induced structural plasticity in the motor cortex of adult rats

Pneumatic robotic systems for upper limb rehabilitation

The aim of rehabilitation robotic area is to research on the application of robotic devices to therapeutic procedures. The goal is to achieve the best possible motor, cognitive and functional recovery for people with impairments following various diseases. Pneumatic actuators are attractive for robotic rehabilitation applications because they are lightweight, powerful, and compliant, but their control has historically been difficult, limiting their use. This article first reviews the current state-of-art in rehabilitation robotic devices with pneumatic actuation systems reporting main features and control issues of each therapeutic device. Then, a new pneumatic rehabilitation robot for proprioceptive neuromuscular facilitation therapies and for relearning daily living skills: like taking a glass, drinking, and placing object on shelves is described as a case study and compared with the current pneumatic rehabilitation devices.

Quantitative evaluation of upper-limb motor control in robot-aided rehabilitation

This paper is focused on the multimodal analysis of patient performance, carried out by means of robotic technology and wearable sensors, and aims at providing quantitative measure of biomechanical and motion planning features of arm motor control following rehabilitation. Upper-limb robotic therapy was administered to 24 community-dwelling persons with chronic stroke. Performance indices on patient motor performance were computed from data recorded with the InMotion2 robotic machine and a magneto-inertial sensor. Motor planning issues were investigated by means of techniques of motion decomposition into submovements. A linear regression analysis was carried out to study correlation with clinical scales. Robotic outcome measures showed a significant improvement of kinematic motor performance; improvement of dynamic components was more significant in resistive motion and highly correlated with MP. The analysis of motion decomposition into submovements showed an important change with recovery of submovement number, amplitude and order, tending to patterns measured in healthy subjects. Preliminary results showed that arm biomechanical functions can be objectively measured by means of the proposed set of performance indices. Correlation with MP is high, while correlation with FM is moderate. Features related to motion planning strategies can be extracted from submovement analysis.

Sensory retraining: a cognitive behavioral therapy for altered sensation

Sensory retraining teaches the patient to ignore or blot out postinjury unpleasant orofacial sensations to optimally tune into and decipher the weakened and damaged signals from the tissues. Sensory retraining is a simple, inexpensive, noninvasive exercise program, which initiated shortly after injury, can lessen the objectionable impression of orofacial altered sensations. Sensory retraining exercises are most effective on decreasing the perceived burden associated with hypoesthetic orofacial altered sensations.

The role of exercise in facilitating basal ganglia function in Parkinson's disease

Epidemiological and clinical studies have suggested that exercise is beneficial for patients with Parkinson's disease (PD). Through research in normal (noninjured) animals, neuroscientists have begun to understand the mechanisms in the brain by which behavioral training and exercise facilitates improvement in motor behavior through modulation of neuronal function and structure, called experience-dependent neuroplasticity. Recent studies are beginning to reveal molecules and downstream signaling pathways that are regulated during exercise and motor learning in animal models of PD and that are important in driving protective and/or adaptive changes in neuronal connections of the basal ganglia and related circuitry. These molecules include the neurotransmitters dopamine and glutamate (and their respective receptors) as well as neurotrophic factors (brain-derived neurotrophic factor). In parallel, human exercise studies have been important in revealing 'proof of concept' including examining the types and parameters of exercise that are important for behavioral/functional improvements and brain changes; the feasibility of incorporating and maintaining an exercise program in individuals with motor disability; and, importantly, the translation and investigation of exercise effects observed in animal studies to exercise effects on brain and behavior in individuals with PD. In this article we highlight findings from both animal and human exercise studies that provide insight into brain changes of the basal ganglia and its related circuitry and that support potentially key parameters of exercise that may lead to long-term benefit and disease modification in PD. In addition, we discuss the current and future impact on patient care and point out gaps in our knowledge where continuing research is needed. Elucidation of exercise parameters important in driving neuroplasticity, as well as the accompanying mechanisms that underlie experience-dependent neuroplasticity may also provide insights towards new therapeutic targets, including neurorestorative and/or neuroprotective agents, for individuals with PD and related neurodegenerative disorders.

Neuroplasticity in the context of motor rehabilitation after stroke

Approximately one-third of patients with stroke exhibit persistent disability after the initial cerebrovascular episode, with motor impairments accounting for most poststroke disability. Exercise and training have long been used to restore motor function after stroke. Better training strategies and therapies to enhance the effects of these rehabilitative protocols are currently being developed for poststroke disability. The advancement of our understanding of the neuroplastic changes associated with poststroke motor impairment and the innate mechanisms of repair is crucial to this endeavor. Pharmaceutical, biological and electrophysiological treatments that augment neuroplasticity are being explored to further extend the boundaries of poststroke rehabilitation. Potential motor rehabilitation therapies, such as stem cell therapy, exogenous tissue engineering and brain-computer interface technologies, could be integral in helping patients with stroke regain motor control. As the methods for providing motor rehabilitation change, the primary goals of poststroke rehabilitation will be driven by the activity and quality of life needs of individual patients. This Review aims to provide a focused overview of neuroplasticity associated with poststroke motor impairment, and the latest experimental interventions being developed to manipulate neuroplasticity to enhance motor rehabilitation.

Structural plasticity within highly specific neuronal populations identifies a unique parcellation of motor learning in the adult brain

Cortical networks undergo adaptations during learning, including increases in dendritic complexity and spines. We hypothesized that structural elaborations during learning are restricted to discrete subsets of cells preferentially activated by, and relevant to, novel experience. Accordingly, we examined corticospinal motor neurons segregated on the basis of their distinct descending projection patterns, and their contribution to specific aspects of motor control during a forelimb skilled grasping task in adult rats. Learning-mediated structural adaptations, including extensive expansions of spine density and dendritic complexity, were restricted solely to neurons associated with control of distal forelimb musculature required for skilled grasping; neurons associated with control of proximal musculature were unchanged by the experience. We further found that distal forelimb-projecting and proximal forelimb-projecting neurons are intermingled within motor cortex, and that this distribution does not change as a function of skill acquisition. These findings indicate that representations of novel experience in the adult motor cortex are associated with selective structural expansion in networks of functionally related, active neurons that are distributed across a single cortical domain. These results identify a distinct parcellation of cortical resources in support of learning.

Influence of a locomotor training approach on walking speed and distance in people with chronic spinal cord injury: a randomized clinical trial

BACKGROUND

Impaired walking limits function after spinal cord injury (SCI), but training-related improvements are possible even in people with chronic motor incomplete SCI.

OBJECTIVE

The objective of this study was to compare changes in walking speed and distance associated with 4 locomotor training approaches.

DESIGN

This study was a single-blind, randomized clinical trial.

SETTING

This study was conducted in a rehabilitation research laboratory.

PARTICIPANTS

Participants were people with minimal walking function due to chronic SCI.

INTERVENTION

Participants (n=74) trained 5 days per week for 12 weeks with the following approaches: treadmill-based training with manual assistance (TM), treadmill-based training with stimulation (TS), overground training with stimulation (OG), and treadmill-based training with robotic assistance (LR).

MEASUREMENTS

Overground walking speed and distance were the primary outcome measures.

RESULTS

In participants who completed the training (n=64), there were overall effects for speed (effect size index [d]=0.33) and distance (d=0.35). For speed, there were no significant between-group differences; however, distance gains were greatest with OG. Effect sizes for speed and distance were largest with OG (d=0.43 and d=0.40, respectively). Effect sizes for speed were the same for TM and TS (d=0.28); there was no effect for LR. The effect size for distance was greater with TS (d=0.16) than with TM or LR, for which there was no effect. Ten participants who improved with training were retested at least 6 months after training; walking speed at this time was slower than that at the conclusion of training but remained faster than before training.

LIMITATIONS

It is unknown whether the training dosage and the emphasis on training speed were optimal. Robotic training that requires active participation would likely yield different results.

CONCLUSIONS

In people with chronic motor incomplete SCI, walking speed improved with both overground training and treadmill-based training; however, walking distance improved to a greater extent with overground training.

Effects of growth hormone (GH) replacement and cognitive rehabilitation in patients with cognitive disorders after traumatic brain injury

OBJECTIVE

To assess the effects of growth hormone (GH) treatment combined with cognitive rehabilitation in patients with adult growth hormone deficiency (GHD) and cognitive disorders occurring after traumatic brain injury (TBI).

PARTICIPANTS

Nineteen adult patients with TBI: GHD was found in 11 of them.

INTERVENTION

Patients were treated with GH (GHD; sc; 1 mg/day) or vehicle (controls; sc; 1 mg/day); daily cognitive rehabilitation therapy was performed in both groups for 3 months.

MAIN OUTCOME MEASURES

The GHRH-arginine test established GHD. The neuropsychological test WAIS was performed before commencing the treatment and 3 months after commencing it.

RESULTS

Controls achieved significant improvements in digits and in manipulative intelligence quotient (IQ) (p < 0.05 vs. baseline). GHD achieved significant improvements in more cognitive parameters: understanding, digits, numbers and incomplete figures (p < 0.05 vs. baseline) and similarities, vocabulary, verbal IQ, manipulative IQ and total IQ (p < 0.01). GHD reached significantly greater improvements than controls in similarities (p < 0.01) and in vocabulary, verbal IQ and total IQ (p < 0.05).

CONCLUSION

GH administration significantly improved cognitive rehabilitation in GHD patients. Since at the end of treatment period plasma IGF-I levels were similar in both groups it is likely that exogenous GH administration is responsible for the significant differences found.

The influences of environmental enrichment, cognitive enhancement, and physical exercise on brain development: can we alter the developmental trajectory of ADHD?

Attention-deficit/Hyperactivity Disorder (ADHD) is characterized by a pervasive pattern of developmentally inappropriate inattentive, impulsive and hyperactive behaviors that typically begin during the preschool years and often persist into adulthood. The most effective and widely used treatments for ADHD are medication and behavior modification. These empirically-supported interventions are generally successful in reducing ADHD symptoms, but treatment effects are rarely maintained beyond the active intervention. Because ADHD is now generally thought of as a chronic disorder that is often present well into adolescence and early adulthood, the need for continued treatment throughout the lifetime is both costly and problematic for a number of logistical reasons. Therefore, it would be highly beneficial if treatments would have lasting effects that remain after the intervention is terminated. This review examines the burgeoning literature on the underlying neural determinants of ADHD along with research demonstrating powerful influences of environmental factors on brain development and functioning. Based upon these largely distinct scientific literatures, we propose an approach that employs directed play and physical exercise to promote brain growth which, in turn, could lead to the development of potentially more enduring treatments for the disorder.

Enhancing neuroplasticity in the basal ganglia: the role of exercise in Parkinson's disease

Epidemiological and clinical trials have suggested that exercise is beneficial for patients with Parkinson's disease (PD). However, the underlying mechanisms and potential for disease modification are currently unknown. This review presents current findings from our laboratories in patients with PD and animal models. The data indicate that alterations in both dopaminergic and glutamatergic neurotransmission, induced by activity-dependent (exercise) processes, may mitigate the cortically driven hyper-excitability in the basal ganglia normally observed in the parkinsonian state. These insights have potential to identify novel therapeutic treatments capable of reversing or delaying disease progression in PD.

Long-term motor improvement after stroke is enhanced by short-term treatment with the alpha-2 antagonist, atipamezole

Drugs that increase central noradrenergic activity have been shown to enhance the rate of recovery of motor function in pre-clinical models of brain damage. Less is known about whether noradrenergic agents can improve the extent of motor recovery and whether such improvement can be sustained over time. This study was designed to determine if increasing central noradrenergic tone using atipamezole, an alpha-2 adrenoceptor antagonist, could induce a long-term improvement in motor performance in rats subjected to ischemic brain damage caused by permanent middle cerebral artery occlusion. The importance of pairing physical "rehabilitation" with enhanced noradrenergic activity was also investigated. Atipamezole (1 mg/kg, s.c.) or vehicle (sterile saline) was administered once daily on Days 2-8 post-operatively. Half of each drug group was housed under enriched environment conditions supplemented with daily focused activity sessions while the other half received standard housing with no focused activity. Skilled motor performance in forelimb reaching and ladder rung walking was assessed for 8 weeks post-operatively. Animals receiving atipamezole plus rehabilitation exhibited significantly greater motor improvement in both behavioral tests as compared to vehicle-treated animals receiving rehabilitation. Interestingly, animals receiving atipamezole without rehabilitation exhibited a significant motor improvement in the ladder rung walk test but not the forelimb reaching test. These results suggest that a short-term increase in noradrenergic activity can lead to sustained motor improvement following stroke, especially when paired with rehabilitation.

Neocortical synaptophysin asymmetry and behavioral lateralization in chimpanzees (Pan troglodytes)

Although behavioral lateralization is known to correlate with certain aspects of brain asymmetry in primates, there are limited data concerning hemispheric biases in the microstructure of the neocortex. In the present study, we investigated whether there is asymmetry in synaptophysin-immunoreactive puncta density and protein expression levels in the region of hand representation of the primary motor cortex in chimpanzees (Pan troglodytes). Synaptophysin is a presynaptic vesicle-associated protein found in nearly all synapses of the central nervous system. We also tested whether there is a relationship between hand preference on a coordinated bimanual task and the interhemispheric distribution of synaptophysin as measured by both stereologic counts of immunoreactive puncta and by Western blotting. Our results demonstrated that synaptophysin-immunoreactive puncta density is not asymmetric at the population level, whereas synaptophysin protein expression levels are significantly higher in the right hemisphere. Handedness was correlated with interindividual variation in synaptophysin-immunoreactive puncta density. As a group, left-handed and ambidextrous chimpanzees showed a rightward bias in puncta density. In contrast, puncta densities were symmetrical in right-handed chimpanzees. These findings support the conclusion that synapse asymmetry is modulated by lateralization of skilled motor behavior in chimpanzees.

Combination of NEP 1-40 treatment and motor training enhances behavioral recovery after a focal cortical infarct in rats

BACKGROUND AND PURPOSE

Although myelin-associated neurite outgrowth disinhibitors have shown promise in restoring motor function after stroke, their interactive effects with motor training have rarely been investigated. The present study examined whether a combinatorial treatment (NEP 1-40+motor rehabilitation) is more effective than either treatment alone in promoting motor recovery after focal ischemic injury.

METHODS

Adult rats were assigned to one of 3 treatment groups (infarct/NEP 1-40+motor training, infarct/NEP 1-40 only, infarct/motor training only) and 2 control groups (infarct/no treatment, intact/no treatment). A focal ischemic infarct was induced by microinjecting endothelin-1 into the motor cortex. Therapeutic treatments were initiated 1 week postinfarct and included intraventricular infusion of the pharmacological agent NEP 1-40 and motor training (skilled reach task). Behavioral assessments on skilled reach, foot fault, and cylinder tests were conducted before the infarct and for 5 weeks postinfarct.

RESULTS

Rats demonstrated significant forelimb impairment on skilled reach and foot fault tests after the infarct. Although all infarct groups improved over time, motor training alone and NEP 1-40 alone facilitated recovery on the skilled reach task at the end of treatment Weeks 2 and 4, respectively. However, only NEP 1-40 paired with motor training facilitated recovery after 1 week of treatment in addition to treatment at Weeks 2 and 4. Finally, only the NEP 1-40+motor training group maintained a performance level equivalent to that of the intact group over the entire period of posttreatment assessment.

CONCLUSIONS

This study suggests that behavioral training interacts with the effects of the axonal growth promoter, NEP 1-40, and may accelerate behavioral recovery after focal cortical ischemia.

Promoting axonal rewiring to improve outcome after stroke

A limited amount of functional recovery commonly occurs in the weeks and months after stroke, and a number of studies show that such recovery is associated with changes in the brain's functional organization. Measures that augment this reorganization in a safe and effective way may therefore help improve outcome in stroke patients. Here we review some of the evidence for functional and anatomical reorganization under normal physiological conditions, along with strategies that augment these processes and improve outcome after brain injury in animal models. These strategies include counteracting inhibitors of axon growth associated with myelin, activating neurons' intrinsic growth state, enhancing physiological activity, and having behavioral therapy. These approaches represent a marked departure from the recent focus on neuroprotection and may provide a more effective way to improve outcome after stroke.

Predictable stress versus unpredictable stress: a comparison in a rodent model of stroke

Previous studies have associated stress with poor outcome in individuals affected by stroke. It was suggested that the effects of stress depend on the stressor's type and strength. Here we compare the effects of chronic predictable restraint stress and chronic unpredictable variable stress on motor recovery after focal lesion in the rat motor cortex. Adult male rats were pre-trained and tested in skilled reaching and skilled walking tasks. Animals were assigned to daily treatments of either restraint stress or variable stress starting 1 week prior to lesion up to 2 weeks post-lesion. One group served as lesion only control. The results revealed a distinct pattern of recovery and compensation of skilled movement. Animals exposed to predictable restraint stress had significantly lower reaching success at both pre- and post-lesion time points, and higher error rates in skilled walking when compared to lesion controls. Overall, restraint stress induced more pronounced motor impairments prior to and after injury than variable stress. Variable stress increased the number of attempts required to grasp food pellets and changed movement pattern performance. By contrast, variable stress improved limb placement accuracy when compared to lesion controls. The behavioural changes were not accompanied by differences in infarct size. These findings are in agreement with other studies reporting that both chronic predicable restraint stress and unpredictable variable stress influence the course of recovery following stroke, however, restraint stress might affect stroke recovery through a different route than variable stress.

Advantages of delaying the onset of rehabilitative reaching training in rats with incomplete spinal cord injury

We have previously reported that rehabilitative reaching training initiated 4 days following an incomplete cervical spinal cord injury (SCI) in adult rats promotes plasticity and task-specific recovery. This training, however, also resulted in impairments in an untrained task. Here we examined whether delaying the rehabilitative training following cervical SCI is still effective in promoting task-specific recovery, but circumvents impairments in an untrained task, comparable to what has been reported in stroke models. Therefore, reaching training for a period of 6 weeks was initiated at Day 12 following a cervical dorso-lateral quadrant lesion. Thereupon the rats' ability to reach and to walk on a horizontal ladder (i.e. the untrained task) was assessed, and 8 weeks post-injury cortical map changes were investigated through microstimulation. Further, we examined changes in phospho protein kinase A (pPKA) levels following an immediate and a delayed onset of reaching training in rats with cervical SCI. We found that delayed rehabilitative training was comparably effective as immediate training in promoting task-specific recovery and sprouting of injured axons. Importantly, delayed training did not impair the performance on horizontal ladder walking. Strikingly, only delayed reaching training restored cortical PKA levels that had dropped significantly over 2 weeks post-injury. Additionally, delayed training did not influence cortical map changes following injury, but decreased white matter damage. In conclusion, our results show that a short delay in the onset of training in a forelimb task significantly alters our outcome measures, which should be considered in future rehabilitative approaches.

A proof of concept study for the integration of robot therapy with physiotherapy in the treatment of stroke patients

OBJECTIVE

To carry out a proof of concept study for integrating robot therapy with physiotherapy in the treatment of stroke patients.

DESIGN

A simple and 'gentle' paradigm of robot-patient interaction was designed in order to foster the re-emergence of smooth, active control patterns in coordinated shoulder/elbow reaching movements. A haptic robot was programmed according to a strategy of minimal, progressively reduced assistance, with a double representation of targets: (i) visual (circles on a screen) and (ii) haptic (robot-generated force fields). The protocol included trials with and without vision, in order to emphasize the role of proprioceptive feedback. The training paradigm included 10 sessions and more than 5000 movements.

SUBJECTS

Ten chronic, hemiparetic subjects; four controls provided reference values for the performance measurements.

OUTCOME MEASURES

Four performance indicators (derived from the analysis of the reaching trajectories); clinical/functional measures (Fugl-Meyer and Ashworth scales).

RESULTS

After robot therapy reaching movements became faster and smoother. The performance in the no-vision trials was at least as good as in the vision trials. The Fugl-Meyer arm scores also increased significantly and remained approximately constant at follow-up; the Ashworth scores did not change.

CONCLUSION

In spite of its simplicity, a limited number of ;gentle' robot therapy sessions appear to be beneficial, even for severely impaired patients, although no firm conclusion can be drawn at this point. However, the study provides support material for the careful design of controlled clinical trials and for a better integration with physiotherapy.

Axospinous synaptic subtype-specific differences in structure, size, ionotropic receptor expression, and connectivity in apical dendritic regions of rat hippocampal CA1 pyramidal neurons

The morphology of axospinous synapses and their parent spines varies widely. Additionally, many of these synapses are contacted by multiple synapse boutons (MSBs) and show substantial variability in receptor expression. The two major axospinous synaptic subtypes are perforated and nonperforated, but there are several subcategories within these two classes. The present study used serial section electron microscopy to determine whether perforated and nonperforated synaptic subtypes differed with regard to their distribution, size, receptor expression, and connectivity to MSBs in three apical dendritic regions of rat hippocampal area CA1: the proximal and distal thirds of stratum radiatum, and the stratum lacunosum-moleculare. All synaptic subtypes were present throughout the apical dendritic regions, but there were several subclass-specific differences. First, segmented, completely partitioned synapses changed in number, proportion, and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA) receptor expression with distance from the soma beyond that found within other perforated synaptic subtypes. Second, atypically large, nonperforated synapses showed N-methyl-D-aspartate (NMDA) receptor immunoreactivity identical to that of perforated synapses, levels of AMPA receptor expression intermediate to that of nonperforated and perforated synapses, and perforated synapse-like changes in structure with distance from the soma. Finally, MSB connectivity was highest in the proximal stratum radiatum, but only for those MSBs composed of nonperforated synapses. The immunogold data suggest that most MSBs would not generate simultaneous depolarizations in multiple neurons or spines, however, because the vast majority of MSBs are comprised of two synapses with abnormally low levels of receptor expression, or involve one synapse with a high level of receptor expression and another with only a low level.

Combined effects of acrobatic exercise and magnetic stimulation on the functional recovery after spinal cord lesions

The objective of the study was to determine whether physical exercise combined with epidural spinal cord magnetic stimulation could improve recovery after injury of the spinal cord. Spinal cord lesioning in mice resulted in reduced locomotor function and negatively affected the muscle strength tested in vitro. Acrobatic exercise attenuated the behavioral effects of spinal cord injury. The exposure to magnetic fields facilitated further this improvement. The progress in behavioral recovery was correlated with reduced muscle degeneration and enhanced muscle contraction. The acrobatic exercise combined with stimulation with magnetic fields significantly facilitates behavioral recovery and muscle physiology in mice following spinal cord injury.

Development and testing of the Gait Assessment and Intervention Tool (G.A.I.T.): a measure of coordinated gait components

Recent neuroscience methods have provided the basis upon which to develop effective gait training methods for recovery of the coordinated components of gait after neural injury. We determined that there was not an existing observational measure that was, at once, adequately comprehensive, scored in an objectively-based manner, and capable of assessing incremental improvements in the coordinated components of gait. Therefore, the purpose of this work was to use content valid procedures in order to develop a relatively inexpensive, more comprehensive measure, scored with an objectively-based system, capable of incrementally scoring improvements in given items, and that was both reliable and capable of discriminating treatment response for those who had a stroke. Eight neurorehabilitation specialists developed criteria for the gait measure, item content, and scoring method. In subjects following stroke (>12 months), the new measure was tested for intra- and inter-rater reliability using the Intraclass Correlation Coefficient; capability to detect treatment response using Wilcoxon Signed Ranks Test; and discrimination between treatment groups, using the Plum Ordinal Regression. The Gait Assessment and Intervention Tool (G.A.I.T.) is a 31-item measure of the coordinated movement components of gait and associated gait deficits. It exhibited the following advantages: comprehensive, objective-based scoring method, incremental measurement of improvement within given items. The G.A.I.T. had good intra- and inter-rater reliability (ICC=.98, p=.0001, 95% CI=.95, .99; ICC=.83, p=.007, 95% CI=.32, .96, respectively. The inexperienced clinician who had training, had an inter-rater reliability with an experienced rater of ICC=.99 (p=.0001, CI=.97, .999). The G.A.I.T. detected improvement in response to gait training for two types of interventions: comprehensive gait training (z=-2.93, p=.003); and comprehensive gait training plus functional electrical stimulation (FES; z=-3.3, p=.001). The G.A.I.T. was capable of discriminating between two gait training interventions, showing an additive advantage of FES to otherwise comparable comprehensive gait training (parameter estimate=1.72, p=.021; CI, .25, 3.1).

Treatment-induced plasticity in cerebral palsy: a diffusion tensor imaging study

Diffusion tensor imaging is used as a measure of white-matter organization to probe mechanisms underlying clinical responses. Diffusion tensor imaging and clinical assessment in 8 patients with spastic quadriparesis (mean age, 6.13 years) was performed before and 6 months after therapy (botulinum injection, followed by physiotherapy). All patients were graded on the basis of gross motor function. Serial diffusion tensor imaging was also performed on 10 age/sex-matched controls at baseline and after 6 months. Regions of interests were placed on corticospinal tracts at different levels (i.e., corona radiata, posterior limb of internal capsule, midbrain, pons, and upper medulla) and on other major white-matter tracts, in both patients and controls. A significant increase in fractional anisotropy was evident in corticospinal tracts at the level of the posterior limb of the internal capsule and periventricular white matter of the temporal lobe, relative to baseline values in the patient group. Gross motor function classification system grades improved in all patients during follow-up relative to baseline values. The increase in fractional anisotropy in corticospinal tracts, along with improved clinical motor scores, suggests plasticity of the central motor pathway after combined therapy.

Brain-computer interfaces in neurological rehabilitation

Recent advances in analysis of brain signals, training patients to control these signals, and improved computing capabilities have enabled people with severe motor disabilities to use their brain signals for communication and control of objects in their environment, thereby bypassing their impaired neuromuscular system. Non-invasive, electroencephalogram (EEG)-based brain-computer interface (BCI) technologies can be used to control a computer cursor or a limb orthosis, for word processing and accessing the internet, and for other functions such as environmental control or entertainment. By re-establishing some independence, BCI technologies can substantially improve the lives of people with devastating neurological disorders such as advanced amyotrophic lateral sclerosis. BCI technology might also restore more effective motor control to people after stroke or other traumatic brain disorders by helping to guide activity-dependent brain plasticity by use of EEG brain signals to indicate to the patient the current state of brain activity and to enable the user to subsequently lower abnormal activity. Alternatively, by use of brain signals to supplement impaired muscle control, BCIs might increase the efficacy of a rehabilitation protocol and thus improve muscle control for the patient.

Food restriction induces long-lasting recovery of spatial memory deficits following global ischemia in delayed matching and non-matching-to-sample radial arm maze tasks

Food restriction has been shown to be beneficial for a number of brain processes. In the current study, we characterized the impact of food restriction on hippocampal damage 70 days following ischemia. We assessed memory and cognitive flexibility of ad libitum fed (AL) and food-restricted (FR) animals using complex delayed non-matching- and matching-to-sample tasks in the radial arm maze. Our findings demonstrate that food restriction led to significant improvement of ischemia-induced memory impairments. FR ischemic animals rapidly reached comparable performance as both AL and FR sham animals in delayed-non-matching (win-shift) and matching (win-stay) radial arm maze tasks. They also made considerably fewer microchoices in the retention trials than AL ischemic animals. In contrast, AL ischemic rats showed persistent spatial memory impairments in the same paradigms. Assessment of basal and stress-induced corticosterone (CORT) secretion revealed no significant differences in baseline levels in AL and FR rats prior to or following global ischemia. However, FR animals showed a more pronounced attenuation of CORT secretion 45 min following restraint. Both FR and AL ischemic rats had comparable cell loss within CA1 and CA3 subfields of Ammon's horn (CA1 and CA3) at 70 days following reperfusion, although a trend toward increased CA3 cell survival was observed in FR ischemic rats. The functional sparing in the FR ischemic animals in the face of equivalent hippocampal cell loss suggests that food restriction somehow enhanced the efficacy of remaining hippocampal or extrahippocampal neurons following ischemia. In the current study, this phenomenon was not associated with diet- and or ischemia-related alterations of vesicular glutamate transporter 1 expression in various hippocampal regions although lower vesicular GABA transporter immunostaining was present in the CA1 stratum oriens and the CA3 stratum radiatum in FR sham and ischemic rats.

Motor cortical stimulation promotes synaptic plasticity and behavioral improvements following sensorimotor cortex lesions

Cortical stimulation (CS) as a means to modulate regional activity and excitability in cortex is emerging as a promising approach for facilitating rehabilitative interventions after brain damage, including stroke. In this study, we investigated whether CS-induced functional improvements are linked with synaptic plasticity in peri-infarct cortex and vary with the severity of impairments. Adult rats that were proficient in skilled reaching received subtotal unilateral ischemic sensorimotor cortex (SMC) lesions and implantation of chronic epidural electrodes over remaining motor cortex. Based on the initial magnitude of reaching deficits, rats were divided into severely and moderately impaired subgroups. Beginning two weeks post-surgery, rats received 100 Hz cathodal CS at 50% of movement thresholds or no-stimulation control procedures (NoCS) during 18 days of rehabilitative training on a reaching task. Stereological electron microscopy methods were used to quantify axodendritic synapse subtypes in motor cortical layer V underlying the electrode. In moderately, but not severely impaired rats, CS significantly enhanced recovery of reaching success. Sensitive movement analyses revealed that CS partially normalized reaching movements in both impairment subgroups compared to NoCS. Additionally, both CS subgroups had significantly greater density of axodendritic synapses and moderately impaired CS rats had increases in presumed efficacious synapse subtypes (perforated and multiple synapses) in stimulated cortex compared to NoCS. Synaptic density was positively correlated with post-rehabilitation reaching success. In addition to providing further support that CS can promote functional recovery, these findings suggest that CS-induced functional improvements may be mediated by synaptic structural plasticity in stimulated cortex.

Repeated seizures lead to altered skilled behaviour and are associated with more highly efficacious excitatory synapses

People with epilepsy have a high incidence of interictal behavioural problems that appear to be related to the location of their seizure focus. This study investigated a novel test of the hypotheses that repeated seizures result in behavioural deficits and altered performance during the interictal state, and that those behaviours are related to the presence of more highly efficacious excitatory synapses. We tested these hypotheses by first repeatedly eliciting seizures with electric current through indwelling electrodes in the corpus callosum at the level of the caudal forelimb area of sensorimotor neocortex in the rat. We then assessed learned skilled behaviours that primarily utilize the forelimbs on tasks that are sensitive to the functional integrity of that structure. We observed both behavioural deficits and altered kinematic performance in rats that experienced repeated neocortical seizures relative to an electrode-implanted control group. From a separate set of rats, tissue was prepared for quantification of thickness and excitatory synaptic subtypes from neocortical layer V. We observed significantly increased numbers of perforated synapses that make their connections directly onto the dendritic shaft at 3 weeks following the last seizure. Altered reaching behaviours are likely due to neural reorganization in the neocortex including more efficacious synapses.

Effects of intense exercise in chronic spinal cord injury

BACKGROUND

Exercise has beneficial effects on muscle and motor function after spinal cord injury (SCI). Little is known regarding effects of prolonged intense exercise (IE) in humans with chronic SCI.

DESIGN

Prospective, non-randomized, controlled observational study. The intervention was either a multimodal IE program (n=21) or a control (CTL) intervention consisting of self-regulated exercise (n=8).

OBJECTIVE

Measure sensorimotor function over 6 months in relation to an IE program.

SETTING

Single outpatient center.

SUBJECTS

Subjects with chronic SCI (n=29 total), mainly ASIA Impairment Scale A and B, injury levels C4-T11.

RESULTS

Baseline neurological assessments (for example, ASIA motor score, 39+/-3 vs 42+/-5, IE vs CTL, P>0.5, mean+/-s.e.m.) did not differ between the two groups. During the 6 months, IE subjects averaged 7.3+/-0.7 h per week exercise, not significantly different from CTL subjects (5.2+/-1.3 h per week, P>0.1). However, after 6 months, IE subjects showed significantly greater motor gains than CTL subjects in the main outcome measure, ASIA motor score (change of 4.8+/-1.0 vs -0.1+/-0.5 points, P=0.0001). The main outcome measure was calculated by ASIA motor score. These IE subject ASIA motor gains correlated with number of exercise hours per week (r=0.53, P<0.02), and with type of specific IE components, particularly load bearing.

CONCLUSIONS

Multimodal IE can significantly improve motor function in subjects with chronic SCI. An organized program may provide greater motor benefits than a self-regulated program; load bearing might be of particular value. IE might have therapeutic value in chronic SCI, and as an adjunct to other restorative therapies.

Repairing the human brain after stroke: I. Mechanisms of spontaneous recovery

Stroke remains a leading cause of adult disability. Some degree of spontaneous behavioral recovery is usually seen in the weeks after stroke onset. Variability in recovery is substantial across human patients. Some principles have emerged; for example, recovery occurs slowest in those destined to have less successful outcomes. Animal studies have extended these observations, providing insight into a broad range of underlying molecular and physiological events. Brain mapping studies in human patients have provided observations at the systems level that often parallel findings in animals. In general, the best outcomes are associated with the greatest return toward the normal state of brain functional organization. Reorganization of surviving central nervous system elements supports behavioral recovery, for example, through changes in interhemispheric lateralization, activity of association cortices linked to injured zones, and organization of cortical representational maps. A number of factors influence events supporting stroke recovery, such as demographics, behavioral experience, and perhaps genetics. Such measures gain importance when viewed as covariates in therapeutic trials of restorative agents that target stroke recovery.

Impact of exercise on neuroplasticity-related proteins in spinal cord injured humans

The present study investigated the effects of exercise on the serum concentrations of brain-derived neurotrophic factor (BDNF), insulin-like growth factor 1 (IGF-1), prolactin (PRL) and cortisol (COR) in 11 chronically spinal cord-injured athletes. In these subjects BDNF concentration at rest was sixfold higher compared with the concentrations reported earlier in able-bodied persons, while IGF-1, PRL and COR were within normal range. Ten minutes of moderate intensity handbiking (54% of the maximal heart rate) during a warm-up period (W) induced an increase (P<0.05) of BDNF of approximately 1.5-fold from basal level at rest, while a decrease to basal level was found after an immediately succeeding handbiking time trial (89% of the maximal heart rate) over the marathon distance of 42 km (M). An increase (P<0.01) of serum IGF-1 was found after W and this levels remained elevated (P<0.01) until the end of M. W had no significant effects on the serum PRL and COR, however, M induced an increase (P<0.01) of both hormones. This is the first study showing elevated BDNF concentrations at rest in spinal cord-injured athletes. Furthermore, short moderate intensity handbiking but not immediately following long lasting high intensity handbiking further increases serum BDNF concentrations. IGF-1 response to exercise differs to BDNF response as this neuroplasticity-related protein remains elevated during the long lasting physical demand with high intensity. The augmented PRL concentration suggests that a possible mechanism by which exercise promotes neuroplasticity might be the activation of neural serotonergic pathways as 5-HT is the main PRL releasing factor. Elevated COR concentrations after M are unlikely to be deleterious to neuroplasticity as COR concentrations remain within the physiological range. The present study suggests that exercise might be beneficial to enhance neuroprotection and neuroplasticity, thereby improving recovery after spinal cord injury.

Maladaptive effects of learning with the less-affected forelimb after focal cortical infarcts in rats

It is common following stroke to focus early rehabilitation efforts on developing compensatory use of the less-affected body side. Here we used a rat model of focal cortical infarct to examine how motor skill acquisition with the less-affected ("intact") forelimb influences sensorimotor function of the infarct-impaired forelimb and neural activity in peri-infarct cortex. Rats proficient in skilled reaching with one forelimb were given focal ischemic lesions in the contralateral sensorimotor cortex (SMC). Recovery in this forelimb was tested following a period of reach training focused on the intact forelimb or control procedures. Quantitative measures of the cumulatively expressed transcription factor, FosB/DeltaFosB, were used to assay intact forelimb training effects on neuronal activity in remaining SMC of the infarcted hemisphere. Intact forelimb training worsened behavioral recovery in the impaired forelimb following unilateral focal ischemia. Furthermore, it decreased neuronal FosB/DeltaFosB expression in layer II/III of peri-infarct SMC. These effects were not found in sham-operated rats trained sequentially with both forelimbs or in animals receiving bilateral forelimb training after unilateral infarcts. Thus, focused use of the intact forelimb has detrimental effects on recovery of impaired forelimb function following a focal ischemic injury and this is linked to reduced neuronal activation in remaining cortex. These results suggest that peri-infarct cortex becomes vulnerable to early post-stroke experience with the less-affected forelimb and that this experience may drive neural plasticity here in a direction that is maladaptive for functional outcome.

Translating principles of neural plasticity into research on speech motor control recovery and rehabilitation

PURPOSE

To review the principles of neural plasticity and make recommendations for research on the neural bases for rehabilitation of neurogenic speech disorders.

METHOD

A working group in speech motor control and disorders developed this report, which examines the potential relevance of basic research on the brain mechanisms involved in neural plasticity and discusses possible similarities and differences for application to speech motor control disorders. The possible involvement of neural plasticity in changes in speech production in normalcy, development, aging, and neurological diseases and disorders was considered. This report focuses on the appropriate use of functional and structural neuroimaging and the design of feasibility studies aimed at understanding how brain mechanisms are altered by environmental manipulations such as training and stimulation and how these changes might enhance the future development of rehabilitative methods for persons with speech motor control disorders.

CONCLUSIONS

Increased collaboration with neuroscientists working in clinical research centers addressing human communication disorders might foster research in this area. It is hoped that this article will encourage future research on speech motor control disorders to address the principles of neural plasticity and their application for rehabilitation.

Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage

PURPOSE

This paper reviews 10 principles of experience-dependent neural plasticity and considerations in applying them to the damaged brain.

METHOD

Neuroscience research using a variety of models of learning, neurological disease, and trauma are reviewed from the perspective of basic neuroscientists but in a manner intended to be useful for the development of more effective clinical rehabilitation interventions.

RESULTS

Neural plasticity is believed to be the basis for both learning in the intact brain and relearning in the damaged brain that occurs through physical rehabilitation. Neuroscience research has made significant advances in understanding experience-dependent neural plasticity, and these findings are beginning to be integrated with research on the degenerative and regenerative effects of brain damage. The qualities and constraints of experience-dependent neural plasticity are likely to be of major relevance to rehabilitation efforts in humans with brain damage. However, some research topics need much more attention in order to enhance the translation of this area of neuroscience to clinical research and practice.

CONCLUSION

The growing understanding of the nature of brain plasticity raises optimism that this knowledge can be capitalized upon to improve rehabilitation efforts and to optimize functional outcome.

Delayed recovery and exaggerated infarct size by post-lesion stress in a rat model of focal cerebral stroke

Stress might be one of the most salient intrinsic factors influencing the risk of stroke and its outcome. Previous studies have linked stress to increased infarct size and exaggerated cognitive deficits in rodent models of stroke. This study compares the effects of chronic restraint stress, representing a psychological stressor, prior to or after motor cortex devascularization lesion on motor recovery in rats. Daily testing in a skilled reaching task revealed initially exaggerated deficits in limb use caused by pre-lesion stress in the absence of increased infarct size. Both pre- and post-lesion stresses affected movement by delaying recovery and limiting compensation of lesion-induced deficits. Nevertheless, only rats that experienced post-lesion stress showed enlarged infarct size. This was accompanied by enlarged edema formation in the lesion hemisphere of post-stress animals on day 2 post-lesion. There were no significant differences in infarct size between post-lesion day 2 and day 15. The data demonstrate that both pre- and post-lesion chronic restraint stresses affect motor recovery after ischemic lesion. Lesion volume, however, is influenced by the timing of a stressful experience relative to the lesion. These findings suggest that stress represents a critical variable determining the outcome after stroke.

The problem of relating plasticity and skilled reaching after motor cortex stroke in the rat

The plasticity of the nervous system is illustrated in the many new neuronal connections that are formed during the acquisition of behavioral skills, loss of function after brain injury, and subsequent recovery of function. The present review describes the acquisition of skilled reaching, the act of reaching for food with a forelimb, and the changes that take place in skilled reaching following motor cortex stroke. The review then discusses the difficulty in associating plastic changes with specific aspects of behavioral change. Skilled reaching behavior is complex and consists of a number of oppositions (stimulus response relationships), between the rat and the food target, a number of forelimb gestures (non-weight supporting movements), which are performed to obtain food, and a complex series of segmental movements (of the limb, head, and trunk), all of which influence the success of the act. Measures of these four aspects of skilled reaching behavior following motor cortex stroke reveal that there are a number of learned changes that take place at different times, including learned nonuse, learned bad-use, and forgetting. The widespread dendritic proliferation, axonal growth, and synaptic formation that take place both before and after stroke are difficult to precisely relate to these behavioral changes. Whereas plasticity is usually proposed to be associated with improved performance it is suggested that future work should attempt to better relate plastic changes to the details of behavioral changes.

Norepinephrine depletion facilitates recovery of function after focal ischemia in the rat

Previous studies have suggested that increased norepinephrine plays an important role in recovery of function after brain injury; however, the majority of these studies used drugs that are known to also affect other monoamines to increase or decrease norepinephrine. The purpose of the present study was to determine if norepinephrine is required to promote recovery after ischemia. A form of enriched rehabilitation was used to rehabilitate animals after ischemia and the neurotoxin N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine was used to selectively destroy norepinephrine projections from the locus coeruleus. Three sensorimotor tests were used to evaluate the recovery of the animals. Depletion of norepinephrine improved sensorimotor recovery in standard-housed animals and did not impede recovery in the rehabilitation groups. Dopamine beta hydroxylase staining was used to confirm N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine-depleted terminal norepinephrine levels. The amount of norepinephrine terminal staining negatively correlated with recovery of function in the staircase test after ischemia. In addition, enriched rehabilitation increased, but depletion of norepinephrine had no effect on, brain-derived neurotrophic factor protein levels, which have also been linked to improved recovery of function. Together the above findings question the previously postulated role of norepinephrine in recovery of function after stroke.

Movement-dependent stroke recovery: a systematic review and meta-analysis of TMS and fMRI evidence

Evidence indicates that experience-dependent cortical plasticity underlies post-stroke motor recovery of the impaired upper extremity. Motor skill learning in neurologically intact individuals is thought to involve the primary motor cortex, and the majority of studies in the animal literature have studied changes in the primary sensorimotor cortex with motor rehabilitation. Whether changes in engagement in the sensorimotor cortex occur in humans after stroke currently is an area of much interest. The present study conducted a meta-analysis on stroke studies examining changes in neural representations following therapy specifically targeting the upper extremity to determine if rehabilitation-related motor recovery is associated with neural plasticity in the sensorimotor cortex of the lesioned hemisphere. Twenty-eight studies investigating upper extremity neural representations (e.g., TMS, fMRI, PET, or SPECT) were identified, and 13 met inclusion criteria as upper extremity intervention training studies. Common outcome variables representing changes in the primary motor and sensorimotor cortices were used in calculating standardized effect sizes for each study. The primary fixed effects model meta-analysis revealed a large overall effect size (ES=0.84, S.D.=0.15, 95% CI=0.76-0.93). Moreover, a fail-safe analysis indicated that 42 null effect studies would be necessary to lower the overall effect size to an insignificant level. These results indicate that neural changes in the sensorimotor cortex of the lesioned hemisphere accompany functional paretic upper extremity motor gains achieved with targeted rehabilitation interventions.

Circuit Class Therapy Versus Individual Physiotherapy Sessions During Inpatient Stroke Rehabilitation: A Controlled Trial

OBJECTIVE

To compare the effectiveness of circuit class therapy and individual physiotherapy (PT) sessions in improving walking ability and functional balance for people recovering from stroke.

DESIGN

Nonrandomized, single-blind controlled trial.

SETTING

Medical rehabilitation ward of a rehabilitation hospital.

PARTICIPANTS

Sixty-eight persons receiving inpatient rehabilitation after a stroke.

INTERVENTIONS

Subjects received group circuit class therapy or individual treatment sessions as the sole method of PT service delivery for the duration of their inpatient stay.

MAIN OUTCOME MEASURES

Five-meter walk test (5MWT), two-minute walk test (2MWT), and the Berg Balance Scale (BBS) measured 4 weeks after admission. Secondary outcome measures included the Iowa Level of Assistance Scale, Motor Assessment Scale upper-limb items, and patient satisfaction. Measures were taken on admission and 4 weeks later.

RESULTS

Subjects in both groups showed significant improvements between admission and week 4 in all primary outcome measures. There were no significant between group differences in the primary outcome measures at week 4 (5MWT mean difference, .07m/s; 2MWT mean difference, 1.8m; BBS mean difference, 3.9 points). A significantly higher proportion of subjects in the circuit class therapy group were able to walk independently at discharge (P=.01) and were satisfied with the amount of therapy received (P=.007).

CONCLUSIONS

Circuit class therapy appeared as effective as individual PT sessions for this sample of subjects receiving inpatient rehabilitation poststroke. Favorable results for circuit classes in terms of increased walking independence and patient satisfaction suggest this model of service delivery warrants further investigation.

Endurance exercise facilitates relearning of forelimb motor skill after focal ischemia

Endurance exercise (i.e. running), by up-regulating brain-derived neurotrophic factor (BDNF) and other modulators of synaptic plasticity, improves attention and learning, both critical components of stroke rehabilitation. We hypothesized that, following middle cerebral artery occlusion in male Sprague-Dawley rats, endurance exercise would act synergistically with a challenging skilled forelimb task to facilitate motor recovery. Animals were randomly assigned to one of four rehabilitation conditions: no rehabilitation, running only, reach training only, and reach training preceded by running (run/reach training) for 5 weeks beginning 5 days after stroke. The behavioral outcome, morphological change and mRNA expression of proteins implicated in neuroplasticity (BDNF, synapsin I and microtubule-associated protein 2) were compared. Endurance exercise on a motorized running wheel, prior to reach training, enhanced recovery of skilled reaching ability but did not transfer to gross motor skills such as postural support (forelimb asymmetry test) and gait (ladder rung walking test). Microtubule-associated protein 2 staining density in the run/reach group was slightly enhanced in the contralateral motor cortex compared with the contralateral sensory and ipsilateral cingulate cortices, suggesting that running preceding reach training may have resulted in more dendritic branching within the motor cortex in this group. No significant differences in mRNA levels were detected among the training paradigms; however, there was a trend toward greater BDNF and synapsin I mRNA in the reaching groups. These findings suggest that exercise facilitates learning of subsequent challenging reaching tasks after stroke, which has the potential to optimize outcomes in patients with stroke.

Effect of human embryonic stem cell-derived neuronal precursor cell transplantation into the cerebral infarct model of rat with exercise

We analyzed the therapeutic effect of the transplantation of the human embryonic stem cell (NIH Code: MB01)-derived neuronal precursor (hES-NP) cell and post-ischemic exercise in rats with the middle cerebral artery (MCA) infarct model. A cortical infarct was induced in 20 adult Sprague-Dawley rats by occlusion and reperfusion of the MCA. The rats were divided into four groups: hES-NP cell transplantation and exercise, transplantation only, exercise only, and Sham-operated with no exercise. In the cell-transplanted group, hES-NP cells were transplanted by stereotactic inoculation into the ipsilateral basal ganglia 7 days after infarct. We evaluated the clinical recovery of deficit, the size of infarct and the survival, migration, and differentiation of the transplanted cells. The transplanted hES-NP cells survived robustly in the ischemic brains 3 weeks post transplant. The majority of migrating cells in the ischemic rats had a neuronal phenotype. The clinical scores of all of the experimental groups were better than those of the Sham-operated group. Whereas the exercise-only group showed continuous clinical improvement, the cell-transplanted groups manifested less improvement than the exercise-only group. Moreover, the cell-transplanted groups did not differ in clinical improvement according to postinfarct-exercise or not. The infarct size was significantly reduced in both the cell-transplanted groups and the post-ischemic exercise group, compared with the Sham-operated group; however, the reduction of infarct size was most prominent in the exercise-only group. In our study, the inoculated site of the basal ganglia showed some damage induced by inoculation, such as loss of neuroglial cells, reactive gliosis and microcalcification, which was found in the Sham-operated group as well, and yet no inoculation-site injury has ever been reported. Our study revealed that stem cell transplantation can have a positive effect on behavioral recovery and reduction of infarct size, but the effect shown was no better than the effect of the exercise, which finding reconfirmed the importance of post-infarct rehabilitation. In addition, it was found that cell inoculation should be replaced by a noninvasive procedure.