Exercise and Environmental Enrichment as Enablers of Task-Specific Neuroplasticity and Stroke Recovery

Enriched environment treatment promotes neurofunctional recovery by regulating the ALK5/Smad2/3/Gadd45β signaling pathway in rats with cerebral ischemia /reperfusion injury

It has been demonstrated that an enriched environment (EE) treatment can alter neuroplasticity in neurodegenerative diseases. However, the role of EE treatment in ischemic stroke remains unclear. Previous findings have revealed that EE treatment can promote cerebral activin-receptor-like-kinase-5 (ALK5) expression after cerebral ischemia/reperfusion (I/R) injury. ALK5 has been identified as a potential mediator of neuroplasticity through its modulation of Smad2/3 and Gadd45β. Therefore, the aim of this study was to investigate whether EE treatment could promote neurofunctional recovery by regulating the ALK5/Smad2/3/Gadd45β pathway. The study utilized the rat model of middle cerebral artery occlusion/reperfusion (MCAO/R). The ALK5/Smad2/3/Gadd45β signaling pathway changes were evaluated using western blotting (WB). Brain injury was assessed by infarct volume and neurobehavioral scores. The effect of EE treatment on neurogenesis was evaluated using Doublecortin (DCX) and Nestin, axonal plasticity with biotinylated dextran amine (BDA) nerve tracing, and dendritic plasticity was assessed using Golgi-Cox staining. EE treatment has been demonstrated to modulate the Smad2/3/Gadd45β pathway by regulating the expression of ALK5. The protective effects of EE treatment on brain infarct volume, neurological function, newborn neurons, dendritic and axonal plasticity following cerebral I/R injury were counteracted by ALK5 silencing. EE treatment can enhance neurofunctional recovery after cerebral I/R injury, which is achieved by regulating the ALK5/Smad2/3/Gadd45β signaling pathway to promote neuroplasticity.

Activity-dependent transcriptional programs in memory regulate motor recovery after stroke

Stroke causes death of brain tissue leading to long-term deficits. Behavioral evidence from neurorehabilitative therapies suggest learning-induced neuroplasticity can lead to beneficial outcomes. However, molecular and cellular mechanisms that link learning and stroke recovery are unknown. We show that in a mouse model of stroke, which exhibits enhanced recovery of function due to genetic perturbations of learning and memory genes, animals display activity-dependent transcriptional programs that are normally active during formation or storage of new memories. The expression of neuronal activity-dependent genes are predictive of recovery and occupy a molecular latent space unique to motor recovery. With motor recovery, networks of activity-dependent genes are co-expressed with their transcription factor targets forming gene regulatory networks that support activity-dependent transcription, that are normally diminished after stroke. Neuronal activity-dependent changes at the circuit level are influenced by interactions with microglia. At the molecular level, we show that enrichment of activity-dependent programs in neurons lead to transcriptional changes in microglia where they differentially interact to support intercellular signaling pathways for axon guidance, growth and synaptogenesis. Together, these studies identify activity-dependent transcriptional programs as a fundamental mechanism for neural repair post-stroke.

Feasibility of a self-management intervention to improve mobility in the community after stroke (SIMS): A mixed-methods pilot study

OBJECTIVE

To evaluate the feasibility of implementing a self-management intervention to improve mobility in the community for stroke survivors.

METHODS

A two-phase sequential mixed methods design was used (a pilot randomised controlled trial and focus groups). Participants were adult stroke survivors within six months post discharge from hospital with functional and cognitive capacity for self-management. The intervention included education sessions, goal setting and action planning, group sessions, self-monitoring and follow up. The control group received usual care and both groups enrolled for 3 months in the study. Feasibility outcomes (recruitment and retention rates, randomisation and blinding, adherence to the intervention, collection of outcome measures, and the fidelity and acceptability of the intervention). Participants assessed at baseline, 3 months and 6 months for functional mobility and walking, self-efficacy, goal attainment, cognitive ability, and general health. A descriptive analysis was done for quantitative data and content analysis for the qualitative data. Findings of quantitative and qualitative data were integrated to present the final results of the study.

RESULTS

Twenty-four participants were recruited and randomised into two groups (12 each). It was feasible to recruit from hospital and community and to deliver the intervention remotely. Randomisation and blinding were successful. Participants were retained (83%) at 3 months and (79.2%) at 6 months assessments. Adherence to the intervention varied due to multiple factors. Focus groups discussed participants' motivations for joining the programme, their perspectives on the intervention (fidelity and acceptability) and methodology, perceived improvements in mobility, facilitators and challenges for self-management, and suggestions for improvement.

CONCLUSION

The self-management intervention seems feasible for implementation for stroke survivors in the community. Participants appreciated the support provided and perceived improvement in their mobility. The study was not powered enough to draw a conclusion about the efficacy of the program and a future full-scale study is warranted.

A modified rehabilitation paradigm bilaterally increased rat extensor digitorum communis muscle size but did not improve forelimb function after stroke

Malnutrition after stroke may lessen the beneficial effects of rehabilitation on motor recovery through influences on both brain and skeletal muscle. Enriched rehabilitation (ER), a combination of environmental enrichment and forelimb reaching practice, is used preclinically to study recovery of skilled reaching after stroke. However, the chronic food restriction typically used to motivate engagement in reaching practice is a barrier to using ER to investigate interactions between nutritional status and rehabilitation. Thus, our objectives were to determine if a modified ER program comprised of environmental enrichment and skilled reaching practice motivated by a short fast would enhance post-stroke forelimb motor recovery and preserve forelimb muscle size and metabolic fiber type, relative to a group exposed to stroke without ER. At one week after photothrombotic cortical stroke, male, Sprague-Dawley rats were assigned to modified ER or standard care for 2 weeks. Forelimb recovery was assessed in the Montoya staircase and cylinder task before stroke and on days 5-6, 22-23, and 33-34 after stroke. ER failed to improve forelimb function in either task (p > 0.05). Atrophy of extensor digitorum communis (EDC) and triceps brachii long head (TBL) muscles was not evident in the stroke-targeted forelimb on day 35, but the area occupied by hybrid fibers was increased in the EDC muscle (p = 0.038). ER bilaterally increased EDC (p = 0.046), but not TBL, muscle size; EDC muscle fiber type was unchanged by ER. While the modified ER did not promote forelimb motor recovery, it does appear to have utility for studying the role of skeletal muscle plasticity in post-stroke recovery.

What Can Laboratory Animal Facility Managers Do to Improve the Welfare of Laboratory Animals and Laboratory Animal Facility Staff? A German Perspective

Laboratory animal facility managers must ensure that animal experiments can be carried out under optimal scientific conditions, that all legal requirements are met, and that animal welfare is maximized. Animal experimentation is stressful not only for the animals involved but also for the people who maintain these animals or carry out the experiments. Many of those involved find themselves in a constant conflict between scientific necessity, care, and harm. Under the term Culture of Care, procedures have been developed to reduce the burden of animal experimentation on the animals and the staff involved. The focus here is on what laboratory animal facility managers can do to improve the welfare of laboratory animals and the people working with them. Exemplary measures are the improvement of the housing conditions of laboratory animals, the introduction of uniform handling measures, clear and transparent structures via a quality management system, implementation of a no-blame culture of error (e.g., via Critical Incident Reporting System in Laboratory Animal Science [CIRS-LAS]), and open and respectful communication with all parties involved in animal experimentation, including the public and representatives of the authorities (public webpage, open house policy). The 6 Rs must be considered at all times: replacement, reduction, refinement, respect, responsibility, and reproducibility. We are writing this article from the perspective of laboratory animal facility managers in Germany.

Combination of fMRI and PET reveals the beneficial effect of three-phase enriched environment on post-stroke memory deficits by enhancing plasticity of brain connectivity between hippocampus and peri-hippocampal cortex

AIM

The three-phase enriched environment (EE) intervention paradigm has been shown to improve learning and memory function after cerebral ischemia, but the neuronal mechanisms are still unclear. This study aimed to investigate the hippocampal-cortical connectivity and the metabolic interactions between neurons and astrocytes to elucidate the underlying mechanisms of EE-induced memory improvement after stroke.

METHODS

Rats were subjected to permanent middle cerebral artery occlusion (pMCAO) or sham surgery and housed in standard environment or EE for 30 days. Memory function was examined by Morris water maze (MWM) test. Magnetic resonance imaging (MRI) was conducted to detect the structural and functional changes. [18 F]-fluorodeoxyglucose (FDG) positron emission tomography (PET) was conducted to detect brain energy metabolism. PET-based brain connectivity and network analysis was performed to study the changes of hippocampal-cortical connectivity. Astrocyte-neuron metabolic coupling, including gap junction protein connexin 43 (Cx43), glucose transporters (GLUTs), and monocarboxylate transporters (MCTs), was detected by histological studies.

RESULTS

Our results showed EE promoted memory function improvement, protected structure integrity, and benefited energy metabolism after stroke. More importantly, EE intervention significantly increased functional connectivity between the hippocampus and peri-hippocampal cortical regions, and specifically regulated the level of Cx43, GLUTs and MCTs in the hippocampus and cortex.

CONCLUSIONS

Our results revealed the three-phase enriched environment paradigm enhanced hippocampal-cortical connectivity plasticity and ameliorated post-stroke memory deficits. These findings might provide some new clues for the development of EE and thus facilitate the clinical transformation of EE.

Brain-Derived Neurotrophic Factor in Pediatric Acquired Brain Injury and Recovery

We review emerging preclinical and clinical evidence regarding brain-derived neurotrophic factor (BDNF) protein, genotype, and DNA methylation (DNAm) as biomarkers of outcomes in three important etiologies of pediatric acquired brain injury (ABI), traumatic brain injury, global cerebral ischemia, and stroke. We also summarize evidence suggesting that BDNF is (1) involved in the biological embedding of the psychosocial environment, (2) responsive to rehabilitative therapies, and (3) potentially modifiable. BDNF's unique potential as a biomarker of neuroplasticity and neural repair that is reflective of and responsive to both pre- and post-injury environmental influences separates it from traditional protein biomarkers of structural brain injury with exciting potential to advance pediatric ABI management by increasing the accuracy of prognostic tools and informing clinical decision making through the monitoring of therapeutic effects.

The feasibility, acceptability, and effectiveness of the multimodal, community-based LoveYourBrain Retreat program for people with traumatic brain injury and caregivers

PURPOSE

To evaluate the feasibility, acceptability, and effectiveness of the LoveYourBrain Retreat program using a pre-post, retrospective, concurrent triangulation mixed methods study.

MATERIALS AND METHODS

A 5-day, multimodal, residential Retreat intervention was designed to improve quality of life among traumatic brain injury (TBI) survivors and caregivers through mindfulness, movement, nutrition, art, and community-building. Eligibility included being a TBI survivor (>2 years post-injury) or caregiver, 18+ years old, independently mobile, able to communicate verbally, and a first-time participant. Self-reported quantitative and qualitative data were collected via electronic surveys pre- and post-retreat, analyzed separately, then combined. Paired t-tests assessed mean differences in scores on Quality of Life After Brain Injury Overall scale (QOLIBRI-OS) and NIH TBI/Neuro-QOL Resilience, Cognition, Positive Affect/Wellbeing, and Emotional/Behavioral Dysregulation scales. We assessed feasibility using sample characteristics and program frequency and retention, and acceptability using quality ratings. Content analysis explored perceived benefits and improvements.

RESULTS

68 People-53 with TBI and 15 caregivers-participated in one of three LoveYourBrain Retreats. Significant improvements were found in QOLIBRI-OS (6.91, 95%CI 1.88-11.94), Resilience (2.14, 95%CI 0.50-3.78), Cognition (2.81, 95%CI 0.79-4.83), and Emotional/Behavioral Dysregulation (2.84, 95%CI 0.14-5.54) among TBI survivors (n = 41). Mean satisfaction was 9.6/10 (SD = 0.64). Content analysis revealed community connection, reframing TBI experience, self-regulation, and self-care themes.

CONCLUSIONS

The LoveYourBrain Retreat is feasible, acceptable, and may be effective complementary rehabilitation to improve QOL among TBI survivors.

Environmental Enrichment for Stroke and Traumatic Brain Injury: Mechanisms and Translational Implications

Acquired brain injuries, such as ischemic stroke, intracerebral hemorrhage (ICH), and traumatic brain injury (TBI), can cause severe neurologic damage and even death. Unfortunately, currently, there are no effective and safe treatments to reduce the high disability and mortality rates associated with these brain injuries. However, environmental enrichment (EE) is an emerging approach to treating and rehabilitating acquired brain injuries by promoting motor, sensory, and social stimulation. Multiple preclinical studies have shown that EE benefits functional recovery, including improved motor and cognitive function and psychological benefits mediated by complex protective signaling pathways. This article provides an overview of the enriched environment protocols used in animal models of ischemic stroke, ICH, and TBI, as well as relevant clinical studies, with a particular focus on ischemic stroke. Additionally, we explored studies of animals with stroke and TBI exposed to EE alone or in combination with multiple drugs and other rehabilitation modalities. Finally, we discuss the potential clinical applications of EE in future brain rehabilitation therapy and the molecular and cellular changes caused by EE in rodents with stroke or TBI. This article aims to advance preclinical and clinical research on EE rehabilitation therapy for acquired brain injury. © 2024 American Physiological Society. Compr Physiol 14:5291-5323, 2024.

The Critical Period After Stroke Study (CPASS) Upper Extremity Treatment Protocol

Objective

To present the development of a novel upper extremity (UE) treatment and assess how it was delivered in the Critical Periods After Stroke Study (CPASS), a phase II randomized controlled trial (RCT).

Design

Secondary analysis of data from the RCT.

Setting

Inpatient and outpatient settings the first year after stroke.

Participants

Of the 72 participants enrolled in CPASS (N=72), 53 were in the study groups eligible to receive the treatment initiated at ≤30 days (acute), 2-3 months (subacute), or ≥6 months (chronic) poststroke. Individuals were 65.1±10.5 years of age, 55% were women, and had mild to moderate UE motor capacity (Action Research Arm Test=17.2±14.3) at baseline.

Intervention

The additional 20 hours of treatment began using the Activity Card Sort (ACS), a standardized assessment of activities and participation after stroke, to identify UE treatment goals selected by the participants that were meaningful to them. Treatment activities were broken down into smaller components from a standardized protocol and process that operationalized the treatments essential elements.

Main Outcome Measures

Feasibility of performing the treatment in a variety of clinical settings in an RCT and contextual factors that influenced adherence.

Results

A total of 49/53 participants fully adhered to the CPASS treatment. The duration and location of the treatment sessions and the UE activities practiced during therapy are presented for the total sample (n=49) and per study group as an assessment of feasibility and the contextual factors that influenced adherence.

Conclusions

The CPASS treatment and therapy goals were explicitly based on the meaningful activities identified by the participants using the ACS as a treatment planning tool. This approach provided flexibility to customize UE motor therapy without sacrificing standardization or quantification of the data regardless of the location and UE impairments of participants within the first year poststroke.

Environmental modifications to rehabilitate social behavior deficits after acquired brain injury: What is the evidence?

Social behavior deficits are a common, debilitating consequence of traumatic brain injury and stroke, particularly when sustained during childhood. Numerous factors influence the manifestation of social problems after acquired brain injuries, raising the question of whether environmental manipulations can minimize or prevent such deficits. Here, we examine both clinical and preclinical evidence addressing this question, with a particular focus on environmental enrichment paradigms and differing housing conditions. We aimed to understand whether environmental manipulations can ameliorate injury-induced social behavior deficits. In summary, promising data from experimental models supports a beneficial role of environmental enrichment on social behavior. However, limited studies have considered social outcomes in the chronic setting, and few studies have addressed the social context specifically as an important component of the post-injury environment. Clinically, limited high-caliber evidence supports the use of specific interventions for social deficits after acquired brain injuries. An improved understanding of how the post-injury environment interacts with the injured brain, particularly during development, is needed to validate the implementation of rehabilitative interventions that involve manipulating an individuals' environment.

Effect of the physical rehabilitation program based on self-care ability in patients with acute ischemic stroke: a quasi-experimental study

Introduction

It is the most practical goal of limb rehabilitation for stroke patients to make the upper limb, trunk, and lower limb joints link together as a whole and restore the ability to self-care. However, many previous studies focused on the single joint or single muscle group movement of stroke patients and did not integrate self-care ability training into the whole process of rehabilitation, which lacks accuracy, integrity, and systematization.

Methods

A quasi-experimental study was conducted in a tertiary hospital. Eligible patients were recruited according to the inclusion criteria and exclusion criteria and then divided into an experimental group (n = 80) and a control group (n = 80) by the medical district. The control group received the routine physical rehabilitation intervention. The experimental group adopted the physical rehabilitation program based on self-care ability led by the nurses specializing in stroke rehabilitation to carry out the multi-joint coordinated exercise based on the control group. The training time and frequency were the same in both groups (45 min per session, one session per day for three consecutive months). The primary outcome was myodynamia. Secondary outcomes were the modified Barthel Index (MBI) and Stroke Specific Quality of Life Scale (SS-QOL). The primary and secondary outcomes were assessed before the intervention and at 1 and 3 months of intervention. In this study, the TREND checklist was followed for non-randomized controlled trials.

Results

A total of 160 participants completed the study. The physical rehabilitation program based on self-care ability was better than the routine rehabilitation program. With the prolongation of intervention time, all outcomes improved gradually in the experimental group (P < 0.05), and the myodynamia of lower limbs recovered faster than that of upper limbs. In the control group, the myodynamia of the affected limb was not significantly improved (P > 0.05), with only a small increase in MBI and SS-QOL scores (P < 0.05).

Conclusion

The physical rehabilitation program based on self-care ability after stroke was beneficial for acute ischemic stroke patients and improved the patient's myodynamia, quality of life, and self-care ability within the third month.

Pre exposure to enriched environment alleviates brain injury after ischemia-reperfusion by inhibiting p38MAPK/STAT1 pathway

BACKGROUND

Stroke is one of the major diseases that endangers human health. It is widely reported that enriched environment (EE) can improve the neurological function in different brain injury models. Recently, relevant researches have indicated that MAPK pathway is closely related to the inflammatory response in nervous system related diseases. However, whether pre exposure to EE (EE pretreatment) has a preventive effect, and its mechanism are not clear. Therefore, this study aimed to determine the possible benefits and related mechanisms of EE in preventing brain injury after acute ischemia-reperfusion.

METHODS

Adult Sprague Dawley rats were kept in enriched or standardized environments for 21 days. Then the middle cerebral artery of rats was occluded for one hour and 30 min, and then reperfusion was performed. Then their neurological deficit score was evaluated. Cerebral edema, along with ELISA and protein quantities of p38MAPK, JNK, ERK, IL-1β, TNF-α, and co-localization of Iba1 were assessed. Changes in neuroinflammation and apoptosis were also detected in the penumbra cortex.

RESULTS

Our research showed that EE pretreatment significantly alleviated acute cerebral ischemia-reperfusion injury in rats. Including the reduction of brain edema and apoptosis, and the improvement of neurological scores. In addition, the protein level of p38MAPK was significantly down regulated in EE pretreatment group, and the downstream protein STAT1 had the same trend. In addition, immunofluorescence results showed that Iba1 in EE pretreatment group decreased, the ELISA results showed that the classical proinflammatory cytokines increased significantly, while anti-inflammatory cytokines in EE pretreatment group increased, and the same results were obtained by Western blot analysis.

CONCLUSION

On the whole, our research demonstrated that EE pretreatment can have a protective effect on the organism by inhibiting the p38 MAPK/STAT1 pathway. Thus, EE can be one of the most promising means of disease prevention. Secondly, p38MAPK/STAT1 pathway may be a latent target for the prevention of acute ischemic stroke.

Very early environmental enrichment protects against apoptosis and improves functional recovery from hypoxic-ischemic brain injury

Appropriate rehabilitation of stroke patients at a very early phase results in favorable outcomes. However, the optimal strategy for very early rehabilitation is at present unclear due to the limited knowledge on the effects of very early initiation of rehabilitation based on voluntary exercise (VE). Environmental enrichment (EE) is a therapeutic paradigm for laboratory animals that involves complex combinations of physical, cognitive, and social stimuli, as well as VE. Few studies delineated the effect of EE on apoptosis in very early stroke in an experimental model. Although a minimal benefit of early rehabilitation in stroke models has been claimed in previous studies, these were based on a forced exercise paradigm. The aim of this study is to determine whether very early exposure to EE can effectively regulate Fas/FasL-mediated apoptosis following hypoxic-ischemic (HI) brain injury and improve neurobehavioral function. C57Bl/6 mice were housed for 2 weeks in either cages with EE or standard cages (SC) 3 h or 72 h after HI brain injury. Very early exposure to EE was associated with greater improvement in motor function and cognitive ability, reduced volume of the infarcted area, decreased mitochondria-mediated apoptosis, and decreased oxidative stress. Very early exposure to EE significantly downregulated Fas/FasL-mediated apoptosis, decreased expression of Fas, Fas-associated death domain, cleaved caspase-8/caspase-8, cleaved caspase-3/caspase-3, as well as Bax and Bcl-2, in the cerebral cortex and the hippocampus. Delayed exposure to EE, on the other hand, failed to inhibit the extrinsic pathway of apoptosis. This study demonstrates that very early exposure to EE is a potentially useful therapeutic translation for stroke rehabilitation through effective inhibition of the extrinsic and intrinsic apoptotic pathways.

Rationale and methodology for examining the acute effects of aerobic exercise combined with varying degrees of virtual reality immersion on cognition in persons with TBI

Persons with Traumatic Brain Injury (TBI) commonly present with long-term cognitive deficits in executive function, processing speed, attention, and learning and memory. While specific cognitive rehabilitation techniques have shown significant success for deficits in individual domains, aerobic exercise training represents a promising approach for an efficient and general treatment modality that might improve many cognitive domains concurrently. Existing studies in TBI report equivocal results, however, and are hampered by methodological concerns, including small sample sizes, uncontrolled single-group designs, and the use of suboptimal exercise modalities for eliciting cognitive improvements in this population. One particularly promising modality involves the application of environmental enrichment via virtual reality (VR) during aerobic exercise in persons with TBI, but this has yet to be investigated. One approach for systematically developing an optimal aerobic exercise intervention for persons with TBI involves the examination of single bouts of aerobic exercise (i.e., acute aerobic exercise) on cognition. Acute exercise research is a necessary first step for informing the development of high-quality exercise training interventions that are more likely to induce meaningful beneficial effects. To date, such an acute exercise paradigm has yet to be conducted in persons with TBI. To that end, we propose an acute exercise study that will investigate the acute effects of aerobic exercise with incremental degrees of environmental enrichment (VR) relative to a control comparison condition on executive function (divided attention and working memory) and processing speed in 24 people with TBI.

Intimate partner violence: psycho-physio-pathological sequelae for defining a holistic enriched treatment

Intimate partner violence (IPV) is a health priority, which worldwide, mainly affects women. The consequences of IPV include several psychophysiological effects. These range from altered levels of hormones and neurotrophins to difficulties in emotion regulation and cognitive impairment. Mounting evidence from preclinical studies has shown that environmental enrichment, a form of sensory-motor, cognitive, and social stimulation, can induce a wide range of neuroplastic processes in the brain which consistently improve recovery from a wide variety of somatic and psychiatric diseases. To support IPV survivors, it is essential to ensure a safe housing environment, which can serve as a foundation for environmental enrichment-based interventions. However, some concerns have been raised when supportive housing interventions focus on the economic aspects of survivors’ lives instead of the emotional ones. We thus propose a holistic intervention in which supportive housing is integrated with evidenced-based psychotherapies which could constitute an enriched therapeutic approach for IPV survivors.

The effects and mechanism of environmental enrichment on MK-801 induced cognitive impairment in rodents with schizophrenia

Schizophrenia is a severe mental disorder characterized by positive, negative, and cognitive symptoms. Cognitive symptoms are a kind of symptoms with high incidence and great impact on patients. There is no effective treatment in clinical practice. N-methyl-d-aspartic acid (NMDA) receptor hypofunction may be an important cause of cognitive symptoms. MK-801 (also named Dizocilpine), a noncompetitive antagonist of NMDA receptor, is often used to construct a model of NMDA receptor dysfunction. In terms of treatment, environmental enrichment (EE) as an environmental intervention can effectively improve the symptoms of cognitive impairment in rodents. In this paper, we first briefly introduce the background of cognitive symptoms and EE in schizophrenia, and then investigate the manifestations of MK-801 induced cognitive impairment, the improvement of EE on these cognitive impairments based on the MK-801 induced schizophrenia rodent models, and the possible mechanism of EE in improving cognitive symptoms. This article reviews the literature in recent years, which provides an important reference for MK-801 to construct a cognitive symptom model of schizophrenia and the mechanism of EE in improving cognitive symptoms of schizophrenia.

Behavioral effects of environmental enrichment on male and female wistar rats with early life stress experiences

Exposure to adverse childhood experiences or early life stress experiences (ELSs) increase the risk of non-adaptive behaviors and psychopathology in adulthood. Environmental enrichment (EE) has been proposed to minimize these effects. The vast number of methodological variations in animal studies underscores the lack of systematicity in the studies and the need for a detailed understanding of how enrichment interacts with other variables. Here we evaluate the effects of environmental enrichment in male and female Wistar rats exposed to adverse early life experiences (prenatal, postnatal, and combined) on emotional (elevated plus maze), social (social interaction chamber), memory (Morris water maze) and flexibility tasks. Our results—collected from PND 51 to 64—confirmed: 1) the positive effect of environmental enrichment (PND 28–49) on anxiety-like behaviors in animals submitted to ELSs. These effects depended on type of experience and type of enrichment: foraging enrichment reduced anxiety-like behaviors in animals with prenatal and postnatal stress but increased them in animals without ELSs. This effect was sex-dependent: females showed lower anxiety compared to males. Our data also indicated that females exposed to prenatal and postnatal stress had lower anxious responses than males in the same conditions; 2) no differences were found for social interactions; 3) concerning memory, there was a significant interaction between the three factors: A significant interaction for males with prenatal stress was observed for foraging enrichment, while physical enrichment was positive for males with postnatal stress; d) regarding cognitive flexibility, a positive effect of EE was found in animals exposed to adverse ELSs: animals with combined stress and exposed to physical enrichment showed a higher index of cognitive flexibility than those not exposed to enrichment. Yet, within animals with no EE, those exposed to combined stress showed lower flexibility than those exposed to both prenatal stress and no stress. On the other hand, animals with prenatal stress and exposed to foraging-type enrichment showed lower cognitive flexibility than those with no EE. The prenatal stress-inducing conditions used here 5) did not induced fetal or maternal problems and 6) did not induced changes in the volume of the dentate gyrus of the hippocampus.

Genetically modified mice for research on human diseases: A triumph for Biotechnology or a work in progress?

Genetically modified mice are engineered as models for human diseases. These mouse models include inbred strains, mutants, gene knockouts, gene knockins, and ‘humanized’ mice. Each mouse model is engineered to mimic a specific disease based on a theory of the genetic basis of that disease. For example, to test the amyloid theory of Alzheimer’s disease, mice with amyloid precursor protein genes are engineered, and to test the tau theory, mice with tau genes are engineered. This paper discusses the importance of mouse models in basic research, drug discovery, and translational research, and examines the question of how to define the “best” mouse model of a disease. The critiques of animal models and the caveats in translating the results from animal models to the treatment of human disease are discussed. Since many diseases are heritable, multigenic, age-related and experience-dependent, resulting from multiple gene-gene and gene-environment interactions, it will be essential to develop mouse models that reflect these genetic, epigenetic and environmental factors from a developmental perspective. Such models would provide further insight into disease emergence, progression and the ability to model two-hit and multi-hit theories of disease. The summary examines the biotechnology for creating genetically modified mice which reflect these factors and how they might be used to discover new treatments for complex human diseases such as cancers, neurodevelopmental and neurodegenerative diseases.

Post-stroke enriched auditory environment induces structural connectome plasticity: secondary analysis from a randomized controlled trial

Post-stroke neuroplasticity and cognitive recovery can be enhanced by multimodal stimulation via environmental enrichment. In this vein, recent studies have shown that enriched sound environment (i.e., listening to music) during the subacute post-stroke stage improves cognitive outcomes compared to standard care. The beneficial effects of post-stroke music listening are further pronounced when listening to music containing singing, which enhances language recovery coupled with structural and functional connectivity changes within the language network. However, outside the language network, virtually nothing is known about the effects of enriched sound environment on the structural connectome of the recovering post-stroke brain. Here, we report secondary outcomes from a single-blind randomized controlled trial (NCT01749709) in patients with ischaemic or haemorrhagic stroke (N = 38) who were randomly assigned to listen to vocal music, instrumental music, or audiobooks during the first 3 post-stroke months. Utilizing the longitudinal diffusion-weighted MRI data of the trial, the present study aimed to determine whether the music listening interventions induce changes on structural white matter connectome compared to the control audiobook intervention. Both vocal and instrumental music groups increased quantitative anisotropy longitudinally in multiple left dorsal and ventral tracts as well as in the corpus callosum, and also in the right hemisphere compared to the audiobook group. Audiobook group did not show increased structural connectivity changes compared to both vocal and instrumental music groups. This study shows that listening to music, either vocal or instrumental promotes wide-spread structural connectivity changes in the post-stroke brain, providing a fertile ground for functional restoration.

The effect of game-based in comparison to conventional circuit exercise on functions, motivation level, self-efficacy and quality of life among stroke survivors

INTRODUCTION

Stroke survivors are commonly at risk of functional decline, which increase their dependency in activities of daily living and eventually affects their motivation level, self-efficacy, and quality of life. Circuit exercise has been shown to be useful in enhancing functional performance and quality of life of chronic stroke survivors. There is a need to review the existing "usual circuit exercise" and develop a better approach, such as game-based circuit exercise. Training in enriched and fun environment may possibly further promote neuroplasticity. However, evidence on inducing fun element in the existing circuit exercise among stroke survivors is limited. Also, no studies are available to date which report the benefit of circuit exercise on stroke survivors' self-efficacy and motivation level. Therefore, this study aims to assess the effectiveness of game-based circuit exercise in comparison to conventional circuit exercise on functional outcome (lower limb strength, postural stability and aerobic endurance), motivation level, self-efficacy and quality of life among stroke survivors. This study also aims to assess whether the outcomes gained from the 2 interventions could be sustained at week 12 and 24 post-trial.

METHODS

This is an assessor-blinded randomized control trial comparing 2 types of intervention which are game-based circuit exercise (experimental group) and conventional circuit exercise (control group). Based on sample size calculation using GPower, a total number of 82 participants will be recruited and allocated into either the experimental or the control group. Participants in the experimental group will receive a set of structured game-based exercise therapy which has the components of resistance, dynamic balance and aerobic exercises. While participants in the control group will receive a conventional circuit exercise as usually conducted by physiotherapists consisting of 6 exercise stations; cycling, repeated sit to stand, upper limb exercise, lower limb exercise, stepping up/down and walking over obstacles. Both groups will perform the given interventions for 2 times per week for 12 weeks under the supervision of 2 physiotherapists. Outcomes of the interventions will be measured using 30-second chair rise test (for lower limb strength), Dynamic Gait Index (for postural stability), 6-minute walk test (aerobic capacity), Intrinsic Motivation Inventory questionnaire (for motivation level), stroke self-efficacy questionnaire (for self-efficacy) and Short Form-36 quality of life questionnaire (for quality of life). All data will be analyzed using descriptive and inferential statistics.

DISCUSSION

This study will provide the information regarding the effectiveness of including game elements into circuit exercise training. Findings from this study will enable physiotherapists to design more innovative exercise therapy sessions to promote neuroplasticity and enhance functionality and quality of life among stroke survivors under their care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN 12621001489886 (last updated 1/11/2021).

Associations Between Time After Stroke and Exercise Training Outcomes: A Meta-Regression Analysis

Background Knowledge gaps exist regarding the effect of time elapsed after stroke on the effectiveness of exercise training interventions, offering incomplete guidance to clinicians. Methods and Results To determine the associations between time after stroke and 6-minute walk distance, 10-meter walk time, cardiorespiratory fitness and balance (Berg Balance Scale score [BBS]) in exercise training interventions, relevant studies in post-stroke populations were identified by systematic review. Time after stroke as continuous or dichotomized (≤3 months versus >3 months, and ≤6 months versus >6 months) variables and weighted mean differences in postintervention outcomes were examined in meta-regression analyses adjusted for study baseline mean values (pre-post comparisons) or baseline mean values and baseline control-intervention differences (controlled comparisons). Secondary models were adjusted additionally for mean age, sex, and aerobic exercise intensity, dose, and modality. We included 148 studies. Earlier exercise training initiation was associated with larger pre-post differences in mobility; studies initiated ≤3 months versus >3 months after stroke were associated with larger differences (weighted mean differences [95% confidence interval]) in 6-minute walk distance (36.3 meters; 95% CI, 14.2-58.5), comfortable 10-meter walk time (0.13 m/s; 95% CI, 0.06-0.19) and fast 10-meter walk time (0.16 m/s; 95% CI, 0.03-0.3), in fully adjusted models. Initiation ≤3 months versus >3 months was not associated with cardiorespiratory fitness but was associated with a higher but not clinically important Berg Balance Scale score difference (2.9 points; 95% CI, 0.41-5.5). In exercise training versus control studies, initiation ≤3 months was associated with a greater difference in only postintervention 6-minute walk distance (baseline-adjusted 27.3 meters; 95% CI, 6.1-48.5; fully adjusted, 24.9 meters; 95% CI, 0.82-49.1; a similar association was seen for ≤6 months versus >6 months after stroke (fully adjusted, 26.6 meters; 95% CI, 2.6-50.6). Conclusions There may be a clinically meaningful benefit to mobility outcomes when exercise is initiated within 3 months and up to 6 months after stroke.

Analysis of influencing factors of rehabilitation treatment effect in patients with first-episode stroke

OBJECTIVE

To explore the influencing factors of rehabilitation treatment effect in patients with first-episode stroke and provide a theoretical basis for clinical practice.

METHODS

The clinical data of patients with first-episode stroke who received rehabilitation treatment in our hospital from January 2015 to January 2019 were collected and analyzed retrospectively. The Modified Barthel Index (MBI) and Frenchay Activity Scale (FAS) were used to evaluate the rehabilitation treatment effect. Spearman rank correlation analysis was carried out to investigate the relationship between the data characteristics and rehabilitation treatment effect, and univariate and multivariate logistic regression analyses were conducted to explore the independent factors influencing the rehabilitation treatment effect in the first-episode stroke group.

RESULTS

In this study, 786 cases of 873 patients with first-episode stroke were included, with an effective inclusion rate of 90.0%. Univariate analysis showed that MBI and FAS scores were statistically different among patients with different ages, history of hypertension, the number of residual symptoms, depression status, attitude towards rehabilitation, starting time of rehabilitation, rehabilitation treatment duration, and family environment scores (all P<0.05). According to the Spearman rank correlation analysis, age, residual symptoms, depressive status, and starting time of rehabilitation were all negatively correlated with MBI score (r = -0.584, -0.683, -0.573, -0.783) and FAS score (r = -0.438, -0.771, -0.552, -0.599), while the scores of MBI (r = 0.683, 0.572, 0.662) and FAS (r = 0.735, 0.603, 0.724) were positively correlated with the scores of rehabilitation treatment attitude, rehabilitation treatment duration and family environment (all P<0.05). Moreover, according to multivariate logistic regression analysis, age, the number of remaining symptoms, depression status, attitude towards rehabilitation treatment, starting time of rehabilitation treatment, rehabilitation treatment duration, and family environment score could independently affect MBI and FAS scores of patients with stroke (all P<0.05).

CONCLUSION

Age, the number of residual symptoms, depression status, attitude towards rehabilitation treatment, starting time of rehabilitation treatment, rehabilitation treatment duration, and family environment score are independent factors for rehabilitation treatment effect in patients with first-episode stroke.

Lower ΔFosB expression in the dopaminergic system after stevia consumption in rats housed under environmental enrichment conditions

Environmental enrichment (EE) has been proven to reduce drug seeking and the development of addiction-related behaviors in rodent models, but the effects of EE on natural reward acquisition in the form of sweet beverages are poorly understood. Accumulating evidence shows that the intake of sugar, the main ingredient of sweet beverages, alters the dopaminergic system, leading to addiction-related physiological and molecular changes. Sugar in sweet beverages has been replaced with natural sweeteners, such as stevia extract, which has greater sweetener potential but no energy content. Our research group found that sucralose consumption increased the expression of ΔFosB in reward-related nuclei, suggesting activation of the dopaminergic system. The present study assessed the effects of EE on stevia consumption and the expression of ΔFosB in the nucleus accumbens, caudate putamen, and prefrontal cortex. Sixteen male Wistar rats, 21 days old, were randomly assigned to an EE group (n = 8) or standard environment (SE) group (n = 8) and reared for 30 days. On postnatal day 52 (PND52), the brains of four animals in each housing condition were extracted to determine basal ΔFosB levels. Stevia consumption with intermittent access and ΔFosB immunoreactivity were measured for 21 days in the remainder of the rats. Compared with SE animals, EE animals exhibited a reduction of stevia consumption and alterations of ΔFosB immunoreactivity in the reward system. These results indicate that EE reduces stevia consumption and the stevia-induced ΔFosB expression, suggesting addiction-related changes in dopaminergic nuclei, which may be interpreted as a neuroprotective effect.

Mechanism of Action of Dengzhan Shengmai in Regulating Stroke from an Inflammatory Perspective: A Preliminary Analysis of Network Pharmacology

Stroke is a complicated disease with an increasing incidence and a very high mortality rate. A classical Chinese herbal medicine, Dengzhan Shengmai (DZSM), has shown to have therapeutic effects on stroke; however, its chemical basis and molecular mechanism are still unclear. In this study, a systems biology approach was applicable to elucidate the underlying mechanism of action of DZSM on stroke. All the compounds were obtained from databases, and pendant-related targets were obtained from various data platforms, including the TCM Systematic Pharmacology (TCMSP) database, TCM Integrated Database (TCMIP), High Throughput Experimental Reference Database (HERB), Comparative Toxicogenomics Database (CTD), SwissTargetPredicition, and SymMap, The Human Gene Database (GENECARD) and Comparative Toxicogenomics Database (CTD) were used for stroke disease target data, followed by network pharmacology analysis to predict the potential effect of DZSM on stroke. Animal experiments were intended to validate the underlying mechanisms. A total of 846 chemical components were compiled for the targets of DZSM drug, and quercetin, kaempferol, and Wuweizisu C are the highest chemical components compiled from DZSM. Overlapping with 375 disease-specific targets and 149 core targets, the core targets include TNF, IL-6, ALB, and AKT1, which are shown to regulate the disease process from an anti-inflammatory perspective. 198 enrichment messages were obtained by KEGG enrichment analysis, and we believe that the role of the AGE-RAGE signaling pathway in diabetic complications, TNF signaling pathway, and IL-17 signaling pathway is more important. Based on rat experiments, we also demonstrated that DZSM could effectively modulate the inflammation level of brain infarct tissues and effectively alleviate behavioral characteristics. Grouped together, our study suggests that the combination of network pharmacology prediction and experimental validation can provide a useful tool to describe the molecular mechanisms of DZSM in Chinese medicine (TCM).

Enriched Environment Attenuates Pyroptosis to Improve Functional Recovery After Cerebral Ischemia/Reperfusion Injury

Enriched environment (EE) is a complex containing social, cognitive, and motor stimuli. Exposure to EE can promote functional recovery after ischemia/reperfusion (I/R) injury. However, the underlying mechanisms remained unclear. Pyroptosis has recently been identified and demonstrated a significant role in ischemic stroke. The purpose of this study was to explore the effect of EE on neuronal pyroptosis after cerebral I/R injury. In the current study, middle cerebral artery occlusion/reperfusion (MCAO/R) was applied to establish the cerebral I/R injury model. Behavior tests including the modified Neurological Severity Scores (mNSS) and the Morris Water Maze (MWM) were performed. The infarct volume was evaluated by Nissl staining. To evaluate the levels of pyroptosis-related proteins, the levels of GSDMD-N and nod-like receptor protein 1/3 (NLRP1/3) inflammasome-related proteins were examined. The mRNA levels of IL-1β and IL-18 were detected by Quantitative Real-Time PCR (qPCR). The secretion levels of IL-1β and IL-18 were analyzed by ELISA. Also, the expression of p65 and p-p65 were detected. The results showed that EE treatment improved functional recovery, reduced infarct volume, attenuated neuronal pyroptosis after cerebral I/R injury. EE treatment also suppressed the activities of NLRP1/NLRP3 inflammasomes. These may be affected by inhabiting the NF-κB p65 signaling pathway. Our findings suggested that neuronal pyroptosis was probably the neuroprotective mechanism that EE treatment rescued neurological deficits after I/R injury.

Activation of Autophagy Ameliorates Age-Related Neurogenesis Decline and Neurodysfunction in Adult Mice

Adult neurogenesis is the ongoing generation of functional new neurons from neural progenitor cells (NPCs) in the mammalian brain. However, this process declines with aging, which is implicated in the recession of brain function and neurodegeneration. Understanding the mechanism of adult neurogenesis and stimulating neurogenesis will benefit the mitigation of neurodegenerative diseases. Autophagy, a highly conserved process of cellular degradation, is essential for maintaining cellular homeostasis and normal function. Whether and how autophagy affects adult neurogenesis remains poorly understood. In present study, we revealed a close connection between impaired autophagy and adult neurogenetic decline. Expression of autophagy-related genes and autophagic activity were significantly declined in the middle-adult subventricular/subgranular zone (SVZ/SGZ) homogenates and cultured NPCs, and inhibiting autophagy by siRNA interference resulted in impaired proliferation and differentiation of NPCs. Conversely, stimulating autophagy by rapamycin not only revitalized the viability of middle-adult NPCs, but also facilitated the neurogenesis in middle-adult SVZ/SGZ. More importantly, autophagic activation by rapamycin also ameliorated the olfactory sensitivity and cognitional capacities in middle-adult mice. Taken together, our results reveal that compromised autophagy is involved in the decline of adult neurogenesis, which could be reversed by autophagy activation. It also shed light on the regulation of adult neurogenesis and paves the way for developing a therapeutic strategy for aging and neurodegenerative diseases.

Implementing technology enhanced real-time action observation therapy in persons with chronic stroke: A pilot study

This pilot study examined a novel technology-enhanced real-time action observation therapy (TERTAOT) of symmetrical bilateral movements in survivors of chronic stroke regardless of their ability to move their paretic limb(s). The TERTAOT used a Kinect XBox One to project mirror images of non-paretic limbs as participants performed symmetrical bilateral motor tasks involving whole-body movements in sitting or standing. The participants received eight weeks of treatment consisting of 30-minutes of conventional physical therapy (balance training, gait training, neuromuscular reeducation, and generalized strength training) and 30-minutes of the TERTAOT protocol per session (three sessions per week for a total of 24 sessions). Ten Meter Walk Test (10MWT), Five Times Sit-to-Stand (5TSTS), Timed Up and Go (TUG), Motor Activity Log - Quality of Movement (QOM) and Amount of Use (AOU) were administered at baseline (pretest), 4 weeks (posttest 1) and 8 weeks (posttest 2) post-TERTAOT, and 3 months after TERTAOT ended (retention). A General Linear Model Repeated Measures (parametric test) or the Friedman Test (non-parametric test) was used to compare outcomes across time points, depending on the normality of data distribution. Bonferroni post-hoc corrections were applied. Seventeen participants completed >80% of TERTAOT sessions without adverse events. The effect of time was significant for 10MWT (p = .001), 5TSTS (p = .001), TUG (p = .005), QOM (p = .001), and AOU (p = .017). TERTAOT may be feasible to be implemented in an outpatient setting. Improvements in functional outcomes including gait, balance, and use of upper limbs were observed after eight weeks of conventional therapy and TERTAOT protocol in survivors of chronic stroke.

Effect of environmental enrichment and isolation on behavioral and histological indices following focal ischemia in old rats

Stroke is a disease of aging. In stroke patients, the enriched group that received stimulating physical, eating, socializing, and group activities resulted in higher activity levels including spending more time on upper limb, communal socializing, listening and iPad activities. While environmental enrichment has been shown to improve the behavioral outcome of stroke in young animals, the effect of an enriched environment on behavioral recuperation and histological markers of cellular proliferation, neuroinflammation, and neurogenesis in old subjects is not known. We used behavioral testing and immunohistochemistry to assess the effect of environment on post-stroke recovery of young and aged rats kept either in isolation or stimulating social, motor, and sensory environment (( +)Env). We provide evidence that post-stroke animals environmental enrichment ( +)Env had a significant positive effect on recovery on the rotating pole, the inclined plane, and the labyrinth test. Old age exerted a small but significant effect on lesion size, which was independent of the environment. Further, a smaller infarct volume positively correlated with better recovery of spatial learning based on positive reinforcement, working and reference memory of young, and to a lesser extent, old animals kept in ( +)Env. Histologically, isolation/impoverishment was associated with an increased number of proliferating inflammatory cells expressing ED1 cells in the peri-infarcted area of old but not young rats. Further, ( +)Env and young age were associated with an increased number of neuroepithelial cells expressing nestin/BrdU as well as beta III tubulin cells in the damaged brain area which correlated with an increased performance on the inclined plane and rotating pole. Finally, ( +)Env and an increased number of neurons expressing doublecortin/BrdU cells exerted a significant effect on performance for working memory and performance on the rotating pole in both age groups. A stimulating social, motor and sensory environment had a limited beneficial effect on behavioral recovery (working memory and rotating pole) after stroke in old rats by reducing neuroinflammation and increasing the number of neuronal precursors expressing doublecortin. Old age however, exerted a small but significant effect on lesion size, which was independent of the environment.

Effectiveness of Rehabilitation Nursing versus Usual Therapist-Led Treatment in Patients with Acute Ischemic Stroke: A Randomized Non-Inferiority Trial

Purpose

To determine the effectiveness of rehabilitation nursing program interventions in patients with acute ischemic stroke.

Patients and Methods

An assessment-blinded randomized controlled trial was conducted at a tertiary referral hospital in China. Eligible patients were stratified according to their weighted corticospinal tract lesion load and then randomly assigned to an experimental group (n = 121) or a control group (n = 103). The experimental group received rehabilitation nursing from well-trained, qualified nurses (30 minutes per session, two sessions per day for seven consecutive days). The control group received therapist-led rehabilitation with the same timing and frequency. Comparative analysis of the primary outcomes was performed to determine non-inferiority with a predetermined non-inferiority margin. The primary outcomes were the Motor Assessment Scale, Fugl-Meyer Assessment, and the Action Research Arm Test assessed at baseline and after seven days of treatment. The secondary outcomes were the modified Barthel Index, the National Institutes of Health Stroke Scale, and the modified Rankin Scale, evaluated before and after the intervention and at 4 and 12 weeks of follow-up.

Results

Two hundred participants completed the trial. In both groups, all outcomes improved significantly after seven days and at follow-ups. The rehabilitation nursing program was non-inferior to therapist-led treatment with lower 95% confidence limits beyond the margins for primary outcomes (P < 0.001).

Conclusion

Both treatments had comparable effects; however, no definite conclusion could be drawn. Adequately powered studies are required.

Angiogenin in the Neurogenic Subventricular Zone After Stroke

Ischemic stroke is a leading cause of death and disability worldwide with effective acute thrombolytic treatments. However, brain repair mechanisms related to spontaneous or rehabilitation-induced recovery are still under investigation, and little is known about the molecules involved. The present study examines the potential role of angiogenin (ANG), a known regulator of cell function and metabolism linked to neurological disorders, focusing in the neurogenic subventricular zone (SVZ). Angiogenin expression was examined in the mouse SVZ and in SVZ-derived neural stem cells (NSCs), which were exposed to exogenous ANG treatment during neurosphere formation as well as in other neuron-like cells (SH-SY5Y). Additionally, male C57Bl/6 mice underwent a distal permanent occlusion of the middle cerebral artery to study endogenous and exercise-induced expression of SVZ-ANG and neuroblast migration. Our results show that SVZ areas are rich in ANG, primarily expressed in DCX+ neuroblasts but not in nestin+NSCs. In vitro, treatment with ANG increased the number of SVZ-derived NSCs forming neurospheres but could not modify SH-SY5Y neurite differentiation. Finally, physical exercise rapidly increased the amount of endogenous ANG in the ipsilateral SVZ niche after ischemia, where DCX-migrating cells increased as part of the post-stroke neurogenesis process. Our findings position for the first time ANG in the SVZ during post-stroke recovery, which could be linked to neurogenesis.

Feasibility of integrating survivors of stroke into cardiac rehabilitation: A mixed methods pilot study

BACKGROUND

Survivors of stroke are often deconditioned and have limited opportunities for exercise post-rehabilitation. Cardiac Rehabilitation (CR), a structured exercise program offered post-cardiac event in the United States (U.S.), may provide an opportunity for continued exercise. The purpose of this study was to examine the feasibility of integrating survivors of stroke into an existing, hospital-based CR program through an assessment of (1) recruitment, uptake and retention, (2) adherence and fidelity, (3) acceptability and (4) safety.

METHODS

A mixed methods design combined a single group, pre-post design, pilot feasibility study with an imbedded qualitative inquiry. Survivors of stroke were recruited into a standard 12-week, 36 visit CR program.

RESULTS

Fifty-three survivors were referred, 29 started and 24 completed the program. Program uptake rate was 55% and completion rate was 83%. Eleven completers and one non-completer participated in the qualitative interviews. Program completers attended an average of 25.25 (SD 5.82) sessions with an average of 38.93 (SD 5.64) exercise minutes per session while reaching targeted rate of perceived exertion levels. Qualitative themes included perceived benefits of an individualized program in a group setting, positive interactions with qualified staff, opportunities for socialization, and regular monitoring and staff attentiveness promoting feelings of safety.

CONCLUSIONS

Survivors of stroke were able to meet Medicare standard dosage (frequency and session duration) and rate of perceived intensity goals, and perceived the program as needed regardless of their mobility limitations or previous exercise experience. Primary challenges included managing referrals and uptake. Results support feasibility and benefit for survivors to integrate into U.S. CR programs.

Principles and requirements for stroke recovery science

The disappointing results in bench-to-bedside translation of neuroprotective strategies caused a certain shift in stroke research towards enhancing the endogenous recovery potential of the brain. One reason for this focus on recovery is the much wider time window for therapeutic interventions which is open for at least several months. Since recently two large clinical studies using d-amphetamine or fluoxetine, respectively, to enhance post-stroke neurological outcome failed again it is a good time for a critical reflection on principles and requirements for stroke recovery science. In principal, stroke recovery science deals with all events from the molecular up to the functional and behavioral level occurring after brain ischemia eventually ending up with any measurable improvement of various clinical parameters. A detailed knowledge of the spontaneously occurring post-ischemic regeneration processes is the indispensable prerequisite for any therapeutic approaches aiming to modify these responses to enhance post-stroke recovery. This review will briefly illuminate the molecular mechanisms of post-ischemic regeneration and the principle possibilities to foster post-stroke recovery. In this context, recent translational approaches are analyzed. Finally, the principal and specific requirements and pitfalls in stroke recovery research as well as potential explanations for translational failures will be discussed.

Enriched, Task-Specific Therapy in the Chronic Phase After Stroke: An Exploratory Study

Supplemental Digital Content is Available in the Text.

Background and Purpose:

There is a need to translate promising basic research about environmental enrichment to clinical stroke settings. The aim of this study was to assess the effectiveness of enriched, task-specific therapy in individuals with chronic stroke.

Methods:

This is an exploratory study with a within-subject, repeated-measures design. The intervention was preceded by a baseline period to determine the stability of the outcome measures. Forty-one participants were enrolled at a mean of 36 months poststroke. The 3-week intervention combined physical therapy with social and cognitive stimulation inherent to environmental enrichment. The primary outcome was motor recovery measured by Modified Motor Assessment Scale (M-MAS). Secondary outcomes included balance, walking, distance walked in 6 minutes, grip strength, dexterity, and multiple dimensions of health. Assessments were made at baseline, immediately before and after the intervention, and at 3 and 6 months.

Results:

The baseline measures were stable. The 39 participants (95%) who completed the intervention had increases of 2.3 points in the M-MAS UAS and 5 points on the Berg Balance Scale (both P < 0.001; SRM >0.90), an improvement of comfortable and fast gait speed of 0.13 and 0.23 m/s, respectively. (P < 0.001; SRM = 0.88), an increased distance walked over 6 minutes (24.2 m; P < 0.001; SRM = 0.64), and significant improvements in multiple dimensions of health. The improvements were sustained at 6 months.

Discussion and Conclusions:

Enriched, task-specific therapy may provide durable benefits across a wide spectrum of motor deficits and impairments after stroke. Although the results must be interpreted cautiously, the findings have implications for enriching strategies in stroke rehabilitation.

Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A304).

[Robotic recovery of walking function in patients in the early recovery period of stroke]

OBJECTIVE

To compare the efficacy of walking function recovery in patients in the early recovery period of ischemic stroke (IS) using an exoskeleton for the lower extremities and an active-passive pedal exercise bike.

MATERIAL AND METHODS

An open randomized study of 47 patients in the early recovery period of IS was conducted. The rehabilitation course included exercises on an ExoAtlet exoskeleton in group 1 and exercises on a pedal simulator for active-passive training (5 days a week for 2 weeks) in group 2. Several tests were used to evaluate treatment results, including the Hauser walking index, the 10-meter walking test, the Berg balance scale, stabilometry, and biomechanics of walking. The complete training course was completed by 20 patients of group 1 and 21 of group 2.

RESULTS

There was a significant increase in strength in paretic muscles, postural stability, functional level and walking speed in patients of both groups, but in patients of group 1, the dynamics of recovery was more pronounced (p<0.05). In group 1, there was a significant decrease in the level of disability and an increase in daily activity, which was higher compared to group 2. An analysis of the main indicators of the statokinesiogram showed the more pronounced positive shifts in patients of group 1, but significant differences were found only in the dynamics of the length and area of the curve in the test with eyes open. When studying the biomechanics of walking, it was found that the function of walking was changed: there was a significant decrease in the speed of movement by 2.2 times, the length of a double step by 1.6 times, and the pace of walking by 1.3 times compared to normal indicators. After the end of exercises, a significant increase in the length of the double step, speed and pace of walking as well as a decrease in the period of the locomotor cycle were found in group 1.

CONCLUSION

The study revealed a positive impact of hardware rehabilitation on locomotion, both with the use of an exoskeleton and an active-passive pedal simulator. The use of an exoskeleton, have the advantages resulting in a significantly greater recovery of strength, stability, speed and symmetry of walking over the same period of training. A significant increase in postural stability in vertical position was revealed.

Vocal music enhances memory and language recovery after stroke: pooled results from two RCTs

Objective

Previous studies suggest that daily music listening can aid stroke recovery, but little is known about the stimulus‐dependent and neural mechanisms driving this effect. Building on neuroimaging evidence that vocal music engages extensive and bilateral networks in the brain, we sought to determine if it would be more effective for enhancing cognitive and language recovery and neuroplasticity than instrumental music or speech after stroke.

Methods

Using data pooled from two single‐blind randomized controlled trials in stroke patients (N = 83), we compared the effects of daily listening to self‐selected vocal music, instrumental music, and audiobooks during the first 3 poststroke months. Outcome measures comprised neuropsychological tests of verbal memory (primary outcome), language, and attention and a mood questionnaire performed at acute, 3‐month, and 6‐month stages and structural and functional MRI at acute and 6‐month stages.

Results

Listening to vocal music enhanced verbal memory recovery more than instrumental music or audiobooks and language recovery more than audiobooks, especially in aphasic patients. Voxel‐based morphometry and resting‐state and task‐based fMRI results showed that vocal music listening selectively increased gray matter volume in left temporal areas and functional connectivity in the default mode network.

Interpretation

Vocal music listening is an effective and easily applicable tool to support cognitive recovery after stroke as well as to enhance early language recovery in aphasia. The rehabilitative effects of vocal music are driven by both structural and functional plasticity changes in temporoparietal networks crucial for emotional processing, language, and memory.

Non-Immersive Virtual Reality for Post-Stroke Upper Extremity Rehabilitation: A Small Cohort Randomized Trial

Immersive and non-immersive virtual reality (NIVR) technology can supplement and improve standard physiotherapy and neurorehabilitation in post-stroke patients. We aimed to use MIRA software to investigate the efficiency of specific NIVR therapy as a standalone intervention, versus standardized physiotherapy for upper extremity rehabilitation in patients post-stroke. Fifty-five inpatients were randomized to control groups (applying standard physiotherapy and dexterity exercises) and experimental groups (applying NIVR and dexterity exercises). The two groups were subdivided into subacute (six months to four years post-stroke survival patients). The following standardized tests were applied at baseline and after two weeks post-therapy: Fugl-Meyer Assessment for Upper Extremity (FMUE), the Modified Rankin Scale (MRS), Functional Independence Measure (FIM), Active Range of Motion (AROM), Manual Muscle Testing (MMT), Modified Ashworth Scale (MAS), and Functional Reach Test (FRT). The Kruskal-Wallis test was used to determine if there were significant differences between the groups, followed with pairwise comparisons. The Wilcoxon Signed-Rank test was used to determine the significance of pre to post-therapy changes. The Wilcoxon Signed-Rank test showed significant differences in all four groups regarding MMT, FMUE, and FIM assessments pre- and post-therapy, while for AROM, only experimental groups registered significant differences. Independent Kruskal-Wallis results showed that the subacute experimental group outcomes were statistically significant regarding the assessments, especially in comparison with the control groups. The results suggest that NIVR rehabilitation is efficient to be administered to post-stroke patients, and the study design can be used for a further trial, in the perspective that NIVR therapy can be more efficient than standard physiotherapy within the first six months post-stroke.

Individualized Running Wheel System with a Dynamically Adjustable Exercise Area and Speed for Rats Following Ischemic Stroke

Background

An innovative animal running wheel with an individualized design was implemented for the rehabilitation of rats following ischemic stroke.

Material/Methods

The design of the running wheel platform included the running wheel and a side plate for exercise area adjustments. A U-curve with a width of 2 cm was drawn on the lower half of the side plate for the dynamic adjustments of five infrared (IR) sensors based on the physical fitness of the rats. The individualized training process for this running wheel consisted of 2 days of free training to record their average and maximum speeds, 3 days of progressive training to determine their exercise areas, and 2 weeks of normal training based on their average speeds, maximum speeds, and exercise areas. Blood samples were obtained from the tail veins of all rats before the operations and on Days 14, 21, and 28 postsurgery to measure cortisol levels. The motor function tests were performed on Days 7 and 28 postsurgery. On Day 28 postsurgery, the rats were sacrificed under anesthesia, and their brains were removed for Nissl and H&E staining.

Results

On Day 28 after surgery, the motor function, lesion volume, and cell damage of the DEARW and control groups differed significantly, indicating that this device is effective for stroke rehabilitation.

Conclusions

The outcomes of the rats that were rehabilitated using the newly designed training system were better than those of their control-group counterparts, indicating the advantages of this designed system.

The role of the brain in the treatment of multiple sclerosis as a connectomopathy

Multiple sclerosis (MS) is an inflammatory disease of the central nervous system (CNS) causing a variety of symptoms. Although MS is recognized by the demyelinating process, the axonal injury can occur from the start of the disease and lead to neurodegenerative process in the disease. Although MS appears to damage the brain locally, the progressive and neurodegenerative nature of the disease indicate the general and global brain damage. Various studies have indicated this global damage at all areas of white and gray matter. Moreover, the earlier stages of mentioned disease can affect the structural and functional brain connections. Demyelinating lesions, which are local at first glance, lead to a global damage to the functional connections of the brain. Therefore, it seems that the brain network or brain connectome are broadly affected by this disease; therefore, MS can be referred as a connectomopathy. The drugs used in this disease all seek to suppress or regulate the immune system, and the human brain has always been considered as a therapeutic target. However, if the brain is generally involved in the disease, so the treatment should be general. In fact, the treatment process should target the connectomopathy. One of the methods that can be used to achieve the mentioned goal is attending to the role of the brain in its treatment.

[Multimodal stimulation in the neurorehabilitation of patients with poststroke cognitive impairment]

Loss of functional activity after a stroke is a leading cause of disability in adults worldwide. Particular attention is currently being paid to post-stroke cognitive impairment. Approaches based on multimodal exposure are increasingly being used when planning rehabilitation programs, which makes it possible to comprehensively cover the entire spectrum of existing neurological disorders in patients and enables to achieve a more effective recovery of functional activity after a stroke.

Development of a three-channel automatic climbing training system for rat rehabilitation after ischemic stroke

This paper reports the development of a three-channel automatic speed-matching climbing training system that could train three rats at the same time for rehabilitation after an ischemic stroke. An infrared (IR) remote sensor was installed at the end of each channel to monitor the real-time position of a climbing rat. This research was carried out in five stages: i) system design; ii) hardware circuit; iii) running speed control; iv) functional testing; and v) verification using an animal model of cerebral stroke. The rehabilitated group significantly outperformed the middle cerebral artery occlusion (MCAo) sedentary group in the rota-rod and inclined plate tests 21 days after a stroke. The rehabilitated group also had a cerebral infarction volume of 28.34±19.4%, far below 56.81±18.12% of the MCAo group 28 days after the stroke, validating the effectiveness of this training platform for stroke rehabilitation. The running speed of the climbing rehabilitation training platform was designed to adapt to the physical conditions of subjects, and overtraining injuries can be completely prevented accordingly.

Experience of enriched rehabilitation in the chronic phase of stroke

Purpose: In this study, we explored the experiences of patients who participated in an enriched task-specific therapy (ETT) program in the chronic phase after stroke.Method: Focus group interviews were conducted with twenty participants with a mean time since stroke of 30 months and mean age 61 years, who completed the ETT program including task-specific training and environmental enrichment. ETT was delivered 3.5-6 h per day, 5½ days per week for 3 weeks in a climate suitable for both indoor and outdoor activities. The training consisted of repetitive mass practice of gradually increasing difficulty. Directly after the intervention, qualitative interviews were conducted in six focus groups. The interviews were analysed with qualitative content analysis.Results: Three main categories describing the informants' experiences of the ETT program were identified. These categories were; 1. The program-different and hard - highlighting the participants view of the ETT as strenuous and different in nature; 2. My body and mind learn to know better - describing positive changes in participants' body function and functional ability as well as behavioural changes experienced throughout the ETT; and 3. The need and trust from others - emphasizing the perceived importance of trust in rehabilitation clinicians and the support of family and other participants. From these categories, a main theme emerged: It's hard but possible-but not alone!Conclusion: A therapy program including task-specific training and environmental enrichment may provide late-phase stroke survivors with perceived improvements in functional ability, knowledge insights, perceptions of rehabilitation needs and enriching emotional impacts.Implications for rehabilitationETT is feasible and may lead to perceived improvements in function and a change of mindset, even in the chronic phase after stroke.Trust in the competence of the rehabilitation staff is an important factor in compliance with the high-intensity training in the ETT program.Given the lack of stimulation and socialization among many individuals with chronic stroke, the social and physical environment are important components of the ETT program.

Potential benefits of music playing in stroke upper limb motor rehabilitation

Music-based interventions have emerged as a promising tool in stroke motor rehabilitation as they integrate most of the principles of motor training and multimodal stimulation. This paper aims to review the use of music in the rehabilitation of upper extremity motor function after stroke. First, we review the evidence supporting current music-based interventions including Music-supported Therapy, Music glove, group music therapy, Rhythm- and music-based intervention, and Musical sonification. Next, we describe the mechanisms that may be responsible for the effectiveness of these interventions, focusing on motor learning aspects, how multimodal stimulation may boost motor performance, and emotional and motivational aspects related to music. Then, we discuss methodological concerns in music therapy research related to modifications of therapy protocols, evaluation of patients and study designs. Finally, we highlight clinical considerations for the implementation of music-based interventions in clinical settings.

Differential Effects of Short-term Environmental Enrichment in Juvenile and Adult Mice

Environmental enrichment has been shown to increase cognitive abilities and accelerate recovery from a number of disease states. Typically, enrichment protocols last from four to eight weeks, however, it has previously been shown that two weeks of environmental enrichment is sufficient to increase cognitive abilities and the proliferation of the astroglial stem cell pool in juvenile mice. The current study examines whether a short-term enrichment protocol can induce similar effects in adults as compared to juveniles. Using juvenile and adult wild-type mice, we examined the effects of short-term environmental enrichment (including a running wheel) on cognitive abilities, anxiety-like behaviour, and the stem cell potential of sub-ventricular neural stem cells (NSC's) in vitro using neurosphere assays. We found that short-term environmental enrichment decreased anxiety behaviour and increased overall memory abilities similarly in juveniles and adults. However, the rate of acquisition on the Morris water maze, hippocampal Sox2 and Ki67 expression, and neurosphere potential increased in response to enrichment only in juveniles, suggesting that the effects of enrichment on these measures are age dependant. Together, these data suggest that the potential beneficial effects of environmental manipulations decrease with age.

MRI Evaluation of Axonal Remodeling After Combination Treatment With Xiaoshuan Enteric-Coated Capsule and Enriched Environment in Rats After Ischemic Stroke

Xiaoshuan enteric-coated capsule (XSEC) is a compound Chinese medicine widely used for the treatment of ischemic stroke. Enriched environment (EE) is a rehabilitative intervention designed to facilitate physical, cognitive, and social activity after brain injury. This study aimed to assess whether the XSEC and EE combination could provide synergistic efficacy in axonal remodeling compared to that with a single treatment after ischemic stroke using magnetic resonance imaging (MRI) followed by histological analysis. Rats were subjected to permanent middle cerebral artery occlusion and treated with XSEC and EE alone or in combination for 30 days. T2-weighted imaging and diffusion tensor imaging (DTI) were performed to examine the infarct volume and axonal remodeling, respectively. The co-localization of Ki67 with NG2 or CNPase was examined by immunofluorescence staining to assess oligodendrogenesis. The expressions of growth associated protein-43 (GAP-43) and growth inhibitors NogoA/Nogo receptor (NgR)/RhoA/Rho-associated kinase2 (ROCK2) were measured using western blot and qRT-PCR. The Morris water maze (MWM) was performed to evaluate the cognitive function. MRI and histological measurements indicated XSEC and EE individually benefited axonal reorganization after stroke. Notably, XSEC + EE decreased infarct volume compared with XSEC or EE monotherapy and increased ipsilateral residual volume compared with vehicle group. DTI showed XSEC + EE robustly increased fractional anisotropy while decreased axial diffusivity and radial diffusivity in the injured cortex, striatum, and external capsule. Meanwhile, diffusion tensor tractography revealed XSEC + EE elevated fiber density in the cortex and external capsule and increased fiber length in the striatum and external capsule compared with the monotherapies. These MRI measurements, confirmed by histology, showed that XSEC + EE promoted axonal restoration. Additionally, XSEC + EE amplified oligodendrogenesis, decreased the expressions of NogoA/NgR/RhoA/ROCK2, and increased the expression of GAP-43 in the peri-infarct tissues. In parallel to these findings, rats treated with XSEC + EE exhibited higher cognitive recovery than those treated with XSEC or EE monotherapy, as evidenced by MWM test. Taken together, our data implicated that XSEC + EE exerted synergistic effects on alleviating atrophy and encouraging axonal reorganization partially by promoting oligodendrogenesis and overcoming intrinsic growth-inhibitory signaling, thereby facilitating higher cognitive recovery.

Principles of Neurorehabilitation After Stroke Based on Motor Learning and Brain Plasticity Mechanisms

What are the principles underlying effective neurorehabilitation? The aim of neurorehabilitation is to exploit interventions based on human and animal studies about learning and adaptation, as well as to show that the activation of experience-dependent neuronal plasticity augments functional recovery after stroke. Instead of teaching compensatory strategies that do not reduce impairment but allow the patient to return home as soon as possible, functional recovery might be more sustainable as it ensures a long-term reduction in impairment and an improvement in quality of life. At the same time, neurorehabilitation permits the scientific community to collect valuable data, which allows inferring about the principles of brain organization. Hence neuroscience sheds light on the mechanisms of learning new functions or relearning lost ones. However, current rehabilitation methods lack the exact operationalization of evidence gained from skill learning literature, leading to an urgent need to bridge motor learning theory and present clinical work in order to identify a set of ingredients and practical applications that could guide future interventions. This work aims to unify the neuroscientific literature relevant to the recovery process and rehabilitation practice in order to provide a synthesis of the principles that constitute an effective neurorehabilitation approach. Previous attempts to achieve this goal either focused on a subset of principles or did not link clinical application to the principles of motor learning and recovery. We identified 15 principles of motor learning based on existing literature: massed practice, spaced practice, dosage, task-specific practice, goal-oriented practice, variable practice, increasing difficulty, multisensory stimulation, rhythmic cueing, explicit feedback/knowledge of results, implicit feedback/knowledge of performance, modulate effector selection, action observation/embodied practice, motor imagery, and social interaction. We comment on trials that successfully implemented these principles and report evidence from experiments with healthy individuals as well as clinical work.

Remarkable cell recovery from cerebral ischemia in rats using an adaptive escalator-based rehabilitation mechanism

Currently, many ischemic stroke patients worldwide suffer from physical and mental impairments, and thus have a low quality of life. However, although rehabilitation is acknowledged as an effective way to recover patients’ health, there does not exist yet an adaptive training platform for animal tests so far. For this sake, this paper aims to develop an adaptive escalator (AE) for rehabilitation of rats with cerebral ischemia. Rats were observed to climb upward spontaneously, and a motor-driven escalator, equipped with a position detection feature and an acceleration/deceleration mechanism, was constructed accordingly as an adaptive training platform. The rehabilitation performance was subsequently rated using an incline test, a rotarod test, the infarction volume, the lesion volume, the number of MAP2 positive cells and the level of cortisol. This paper is presented in 3 parts as follows. Part 1 refers to the escalator mechanism design, part 2 describes the adaptive ladder-climbing rehabilitation mechanism, and part 3 discusses the validation of an ischemic stroke model. As it turned out, a rehabilitated group using this training platform, designated as the AE group, significantly outperformed a control counterpart in terms of a rotarod test. After the sacrifice of the rats, the AE group gave an average infarction volume of (34.36 ± 3.8)%, while the control group gave (66.41 ± 3.1)%, validating the outperformance of the escalator-based rehabilitation platform in a sense. An obvious difference between the presented training platform and conventional counterparts is the platform mechanism, and for the first time in the literature rats can be well and voluntarily rehabilitated at full capacity using an adaptive escalator. Taking into account the physical diversity among rats, the training strength provided was made adaptive as a reliable way to eliminate workout or secondary injury. Accordingly, more convincing arguments can be made using this mental stress-free training platform.