Reinstatement of binocular depth perception by amphetamine and visual experience after visual cortex ablation

Pharmacological Stimulation of Neuronal Plasticity in Acquired Brain Injury

INTRODUCTION

Brain injuries are one of the leading causes of disability worldwide. It is estimated that nearly half of patients who develop severe sequelae will continue with a chronic severe disability despite having received an appropriate rehabilitation program. For more than 3 decades, there has been a worldwide effort to investigate the possibility of pharmacologically stimulating the neuroplasticity process for enhancing the recovery of these patients.

OBJECTIVE

The objective of this article is to make a critical and updated review of the available evidence that supports the positive effect of different drugs on the recovery from brain injury.

METHOD

To date, there have been several clinical trials that tested different drugs that act on different neurotransmitter systems: catecholaminergic, cholinergic, serotonergic, and glutamatergic. There is both basic and clinical evidence that may support some positive effect of these drugs on motor, cognitive, and language skills; however, only few of the available studies are of sufficient methodological quality (placebo controlled, randomized, blinded, multicenter, etc) to make solid conclusions about their beneficial effects.

CONCLUSIONS

Currently, the pharmacological stimulation of neuroplasticity still does not have enough scientific evidence to make a systematic therapeutic recommendation for all patients, but it certainly is a feasible and very promising field for future research.

Enhancing Recovery after Stroke with Noradrenergic Pharmacotherapy: A New Frontier?

Despite much progress in stroke prevention and acute intervention, recovery and rehabilitation have traditionally received relatively little scientific attention. There is now increasing interest in the development of stroke recovery drugs and innovative rehabilitation techniques to promote functional recovery after completed stroke. Experimental work over the past two decades indicates that pharmacologic intervention to enhance recovery may be possible in the subacute stage, days to weeks poststroke, after irreversible injury has occurred. This paper discusses the concept of “rehabilitation pharmacology” and reviews the growing literature from animal studies and pilot clinical trials on noradrenergic pharmacotherapy, a new experimental strategy in stroke rehabilitation. Amphetamine, a monoamine agonist that increases brain norepinephrine levels, is the most extensively studied drug shown to promote recovery of function in animal models of focal brain injury. Further research is needed to investigate the mechanisms and clinical efficacy of amphetamine and other novel therapeutic interventions on the recovery process.

Amphetamine and other pharmacological agents in human and animal studies of recovery from stroke

Neuromodulation with pharmacological agents, including drugs of abuse such as amphetamine, when paired with behavioral experience, has been shown to positively modify outcomes in animal models of stroke. A number of clinical studies have tested the efficacy of a variety of drugs to enhance recovery of language deficit post-stroke. The purpose of this paper is to: (1) present pertinent animal studies supporting the use of dextro-amphetamine sulfate (AMPH) to enhance recovery after experimental lesions with emphasis on the importance of learning dependent activity for lasting recovery; (2) briefly review neuropharmacological explorations in the treatment of aphasia; (3) present a pilot study in aphasia exploring a drug combination of AMPH and donepezil hydrochloride paired with behavioral treatment to facilitate recovery; and (4) conclude with comments regarding the role of adjunctive pharmacotherapy in the rehabilitation of aphasia, particularly AMPH.

The Role of Task-Specific Training in Rehabilitation Therapies

Task-oriented therapy is important. It makes intuitive sense that the best way to relearn a given task is to train specifically for that task. In animals, functional reorganization is greater for tasks that are meaningful to the animal. Repetition alone, without usefulness or meaning in terms of function, is not enough to produce increased motor cortical representations. In humans, less intense but task-specific training regimens with the more affected limb can produce cortical reorganization and associated, meaningful functional improvements.

Drug treatment of poststroke aphasia

Impairment of language function (aphasia) is one of the most common neurological symptoms after stroke. Approximately one in every three patients who have an acute stroke will suffer from aphasia. The estimated incidence and prevalence of stroke in Western Europe is 140 and 800 per 100,000 of the population. Aphasia often results in significant disability and handicap. It is a major obstacle for patients to live independently in the community. When recovery from aphasia occurs, it is usually incomplete and patients are rarely able to return to full employment and other social activities. Currently, the main treatment for aphasia is conventional speech and language therapy. However, the effectiveness of this intervention has not been conclusively demonstrated and empirical observations suggest that spontaneous biological recovery may explain most of the improvement in language function that occurs in aphasics. The generally poor prognosis of the severe forms of poststroke language impairment (Broca, Wernicke and global aphasia), coupled with the limited effectiveness of conventional speech and language therapy has stimulated the search for other treatments that may be used in conjunction with speech and language therapy, including the use of various drugs. Dopamine agonists, piracetam (Nootropil), amphetamines, and more recently donepezil (Aricept), have been used in the treatment of aphasia in both the acute and chronic phase. The justification for the use of drugs in the treatment of aphasia is based on two types of evidence. Some drugs, such as dextroamphetamine (Dexedrine), improve attention span and enhance learning and memory. Learning is an essential mechanism for the acquisition of new motor and cognitive skills, and hence, for recovery from aphasia. Second, laboratory and clinical data suggest that drug treatment may partially restore the metabolic function in the ischemic zone that surrounds the brain lesion and also has a neuroprotective effect following acute brain damage. An example of this is the nootropic agent piracetam. Extensive animal studies have demonstrated the beneficial effects of this and other drugs on neural plasticity, but data on humans are still sparse. This review provides a critical analysis of the current evidence of the effectiveness of these drugs in the treatment of acute and chronic aphasia.

Perceptual Relearning of Binocular Fusion and Stereoacuity After Brain Injury

Background. Brain lesions may disturb binocular fusion and stereopsis, leading to blurred vision, diplopia, and reduced binocular depth perception for which no evaluated treatment is currently available. Objective. The study evaluated the effects of a novel binocular vision treatment designed to improve convergent fusional amplitude and stereoacuity in patients with stroke or traumatic brain injury (TBI). Methods. Patients (20 in all: 11 with stroke, 9 with TBI) were tested in fusional convergence, stereoacuity, near/far visual acuity, accommodation, and subjective binocular reading time until diplopia emerged at 6 different time points. All participants were treated in a single subject baseline design, with 3 baseline assessments before treatment (pretherapy), an assessment immediately after a 6-week treatment period (posttherapy), and 2 follow-up tests 3 and 6 months after treatment. Patients received a novel fusion and dichoptic training using 3 different devices to slowly increase fusional and disparity angles. Results. At pretherapy, the stroke and TBI groups showed severe impairments in convergent fusional range, stereoacuity, subjective reading duration, and partially in accommodation (only TBI group). After treatment, both groups showed considerable improvements in all these variables as well as slightly increased near visual acuity. No significant changes were observed during the pretherapy and follow-up periods, ruling out spontaneous recovery and demonstrating long-term stability of binocular treatment effects. Conclusions. This proof-of-principle study indicates a substantial treatment-induced plasticity of the lesioned brain in the relearning of binocular fusion and stereovision, thus providing new, effective rehabilitation strategies to treat binocular vision deficits resulting from permanent visual cortical damage.

Treating impaired cognition in schizophrenia: the case for combining cognitive-enhancing drugs with cognitive remediation

Cognitive impairment is a well-documented feature of schizophrenia and represents a major impediment to the functional recovery of patients. The therapeutic strategies to improve cognition in schizophrenia have either used medications (collectively referred to as 'cognitive-enhancing drugs' in this article) or non-pharmacological training approaches ('cognitive remediation'). Cognitive-enhancing drugs have not as yet been successful and cognitive remediation has shown modest success. Therefore, we may need to explore new therapeutic paradigms to improve cognition in schizophrenia. The optimal approach may require a combination of cognitive-enhancing drugs with cognitive remediation. We review the available data from animal and human studies that provide the conceptual basis, proof-of-concept and illustrations of success of such combination strategies in experimental and clinical paradigms in other conditions. We address the major design issues relevant to the choice of the cognitive-enhancing drugs and cognitive remediation, as well as the timing and the duration of the intervention as will be relevant for schizophrenia. Finally, we address the practical realities of the development and testing of such combined approaches in the real-world clinical situation and conclude that while scientifically attractive, there are several practical difficulties to be overcome for this approach to be clinically feasible.

Is there a role for vagus nerve stimulation therapy as a treatment of traumatic brain injury?

This paper aims to review the current literature on vagus nerve stimulation (VNS) use in animal models of traumatic brain injury (TBI) and explore its potential role in treatment of human TBI. A MEDLINE search yielded four primary papers from the same group that demonstrated VNS mediated improvement following fluid percussion models of TBI in rats, seen as motor and cognitive improvements, reduction of cortical oedema and neuroprotective effects. The underlying mechanisms are elusive and authors attribute these to attenuation of post traumatic seizures, a noradrenergic mechanism and as yet undetermined mechanisms. Reviewing and elaborating on these ideas, we speculate other potential mechanisms including attenuation of peri-infarct depolarisations, attenuation of glutamate mediated excitotoxicity, stabilisation of intracranial pressure, enhancement of synaptic plasticity, upregulation of endogenous neurogenesis and anti-inflammatory effects may have a role. Although this data unequivocally shows that VNS improves outcome from TBI in animal models, it remains to be determined if these findings translate clinically. Further studies are warranted.

The effects of amphetamine on recovery of function in animal models of cerebral injury: a critical appraisal

Therapeutic strategies to promote recovery from stroke are now beginning to utilize current knowledge of neural plasticity and the neuromodulatory role of physical rehabilitation. Current interests are also focused on adjuvant therapies that may enhance plasticity associated with recovery and rehabilitation. Amphetamine was one of the earliest pharmacological interventions and continues to show promising results as an adjuvant treatment for recovery of function in pre-clinical animal studies. This drug is a potent modulator of neurological function and cortical excitation, acting primarily through norepinephrine and dopamine mechanisms to enhance arousal and attention, and thus, to facilitate learning of motor skills. Although the results from the pre-clinical studies have been primarily positive, they have not translated well to clinical trials, which have yielded mixed results. This review addresses some of the conflicting evidence from pre-clinical studies conducted between 1982 and 2008 in order to better understand how to optimize the clinical application of amphetamine as an adjuvant therapy for stroke recovery. Among many of the factors that relate to differences in outcome, it is likely that both amphetamine dose and the timing of the intervention with respect to the time of injury affected the outcome.

Therapeutic effects of complex rearing or bFGF after perinatal frontal lesions

We investigated the effects of an enriched environment and/or basic fibroblast growth factor (bFGF) on recovery from neonatal frontal injury in rats. Rats received medial frontal lesions, or sham surgery, on postnatal day (P) 2/3. In the first set of experiments (Experiments 1 and 2), rats were housed in enriched environments that consisted of a large enclosure with multiple objects (or standard housing) for 90 days beginning at weaning (P22) or in adulthood (P110). In Experiment 3, the rats either received 7 days of subcutaneous bFGF beginning on the day after surgery or bFGF plus enriched housing beginning at weaning. After the 90-day housing period, the animals were tested on a spatial navigation task and a skilled reaching task. Early lesions of the medial frontal cortex caused severe impairments in spatial learning but this deficit was markedly reduced with enriched housing, bFGF, or a combination of both, with the latter being most effective. The housing effects varied with age, however: the earlier the experience began, the better the outcome. Enriched housing increased dendritic length in cortical pyramidal neurons, an effect that was greater in the lesion than the control animals, and enriched housing reversed the lesion-induced decrease in spine density. Enriched environment increased the thickness of the cortical mantle in both lesion and controls whereas bFGF had no effect. Experience thus can affect functional and anatomical outcome after early brain injury but the effects vary with age at experience and may be facilitated by treatment with bFGF.

No improvement by amphetamine on learned non-use, attempts, success or movement in skilled reaching by the rat after motor cortex stroke

Amphetamine (AMPH) has been proposed as a treatment for post-stroke motor deficits when coupled with symptom-relevant physical rehabilitation. Whereas a number of experimental studies report improvements in endpoint measures of skilled reaching for food by rats, there has been no assessment of whether beneficial effects extend to overcoming learned non-use of the limb in the acute post-stroke period or to the qualitative deficits in movement in the chronic post-stroke period. In addition to evaluating the effects of AMPH on success, these were the objectives of the present study. In three different reaching experiments, groups of rats were pre-trained in skilled reaching for food prior to receiving a motor cortex stroke via pial removal. Postoperatively the rats received periodic AMPH treatment and daily rehabilitation. In the acute post-stroke period, AMPH failed to prevent the development of learned non-use of the limb, and in the acute and chronic period failed to improve recovery of reaching success, and also failed to improve the qualitative aspects of reaching movements. Nevertheless, AMPH did enhance adjunct non-reaching movements of locomotion, rearing and turning. The results are discussed in relation to the idea that the beneficial effects of post-stroke AMPH treatment do not extend to all movements, especially the movements of a forelimb in retrieving and consuming food.

High impact running improves learning

Regular physical exercise improves cognitive functions and lowers the risk for age-related cognitive decline. Since little is known about the nature and the timing of the underlying mechanisms, we probed whether exercise also has immediate beneficial effects on cognition. Learning performance was assessed directly after high impact anaerobic sprints, low impact aerobic running, or a period of rest in 27 healthy subjects in a randomized cross-over design. Dependent variables comprised learning speed as well as immediate (1 week) and long-term (>8 months) overall success in acquiring a novel vocabulary. Peripheral levels of brain-derived neurotrophic factor (BDNF) and catecholamines (dopamine, epinephrine, norepinephrine) were assessed prior to and after the interventions as well as after learning. We found that vocabulary learning was 20 percent faster after intense physical exercise as compared to the other two conditions. This condition also elicited the strongest increases in BDNF and catecholamine levels. More sustained BDNF levels during learning after intense exercise were related to better short-term learning success, whereas absolute dopamine and epinephrine levels were related to better intermediate (dopamine) and long-term (epinephrine) retentions of the novel vocabulary. Thus, BDNF and two of the catecholamines seem to be mediators by which physical exercise improves learning.

Neurotransmitters and motor activity: effects on functional recovery after brain injury

There are complex relationships among behavioral experience, brain morphology, and functional recovery of an animal before and after brain injury. A large series of experimental studies have shown that exogenous manipulation of central neurotransmitter levels can directly affect plastic changes in the brain and can modulate the effects of experience and training. These complex relationships provide a formidable challenge for studies aimed at understanding neurotransmitter effects on the recovery process. Experiments delineating norepinephrine-modulated locomotor recovery after injury to the cerebral cortex illustrate the close relationships among neurotransmitter levels, brain plasticity, and behavioral recovery. Understanding the neurobiological processes underlying recovery, and how they might be manipulated, may lead to novel strategies for improving recovery from stroke-related gait impairment in humans.

A shift of paradigm: from noradrenergic to dopaminergic modulation of learning?

d-Amphetamine coupled with behavioral training has been effective for improving functional recovery after stroke. d-amphetamine acts on multiple brain transmitter systems, but the recovery enhancing effect has been attributed to its noradrenergic actions. Another potent modulator of learning is dopamine, which may also enhance stroke recovery in humans. Based on data from previous studies of our group, we compared the learning enhancing effects of d-amphetamine with a more selective dopaminergic substance (levodopa) in identical protocols. Using a prospective, randomized, double-blind, placebo-controlled design, we had taught 60 male healthy subjects a miniature lexicon of 50 concrete nouns over the course of five consecutive training days using an associative learning principle. Subjects had received either d-amphetamine (0.25 mg/kg), levodopa/carbidopa (fixed dose of 100/25 mg), or placebo 90 min prior to training on each of the 5 days. Novel word learning was significantly enhanced in both the d-amphetamine and levodopa groups as compared to the placebo group. The learning superiority was maintained at the two re-assessments (1 week and 1 month post training). Both d-amphetamine and levodopa are thus potent drugs in enhancing learning in humans. We here discuss why the efficiency of both d-amphetamine and levodopa may be related to dopaminergic rather than noradrenergic actions.

Pharmakologische Zusatzbehandlung in der Aphasietherapie

Aphasia is one of the most frequent and disabling consequences of stroke. Poor spontaneous recovery and the limited success of conventional speech therapy bring up the question of how current treatment approaches can be improved. Besides increasing training frequency-with daily sessions lasting several hours and high repetition rates of language materials ("massed training")-adjuvant drug therapy may help to increase therapy efficacy. In this article, we illuminate the potential of monoaminergic (bromocriptine, levodopa, d-amphetamine) and cholinergic (donepezil) substances for treating aphasia. For a final evaluation of combined massed training and adjuvant pharmacotherapy, randomized, placebo-controlled (multicenter) clinical trials with sufficient numbers of patients are needed. Furthermore, results of experimental animal studies of functional recovery in brain damage raise hopes that neurotrophic factors or stem cells might find a place in recovery from aphasia in the intermediate future.

Electrical stimulation of the vagus nerve enhances cognitive and motor recovery following moderate fluid percussion injury in the rat

Intermittent, chronically delivered electrical stimulation of the vagus nerve (VNS) is an FDA-approved procedure for the treatment of refractory complex/partial epilepsy in humans. Stimulation of the vagus has also been shown to enhance memory storage processes in laboratory rats and human subjects. Recent evidence suggests that some of these effects of VNS may be due to the activation of neurons in the nucleus locus coeruleus resulting in the release of norepinephrine (NE) throughout the neuraxis. Because antagonism of NE systems has been shown to delay recovery of function following brain damage, it is possible that enhanced release of NE in the CNS may facilitate recovery of function. To evaluate this hypothesis the lateral fluid percussion injury (LFP) model of traumatic brain injury was used and a variety of motor and cognitive behavioral tests were employed to assess recovery in pre-trained stimulated, control, and sham-injured laboratory rats. Two hours following moderate LFP, vagus nerve stimulation (30.0-sec trains of 0.5 mA, 20.0 Hz, biphasic pulses) was initiated. Stimulation continued in each animal's home cage at 30-min intervals for a period of 14 days, with the exception of brief periods when the animals were disconnected for behavioral assessments. Motor behaviors were evaluated every other day following LFP and tests included beam walk, locomotor placing, and skilled forelimb reaching. In each measure an enhanced rate of recovery and /or level of final performance was observed in the VNS-LFP animals compared to nonstimulated LFP controls. Behavior in the Morris water maze was assessed on days 11-14 following injury. Stimulated LFP animals showed significantly shorter latencies to find the hidden platform than did controls. Despite these behavioral effects, neurohistological examination did not reveal significant differences in lesion extent, density of fluorojade positive neurons, reactive astrocytes or numbers of spared neurons in the CA3 subarea of the hippocampus, at least at the one time point studied 15 days post-injury. These results support the idea that vagus nerve stimulation enhances the neural plasticity that underlies recovery of function following brain damage and provides indirect support for the hypothesis that enhanced NE release may mediate the effect. Importantly, since VNS facilitated both the rate of recovery and the extent of motor and cognitive recovery, these findings suggest that electrical stimulation of the vagus nerve may prove to be an effective non-pharmacological treatment for traumatic brain injury.

Pharmacological Enhancement of Aural Habilitation in Adult Cochlear Implant Users

OBJECTIVE

The purpose of this report was to examine the preliminary data collected under a larger on-going feasibility study conducted with cochlear implant patients exploring the potential benefit of pharmacologically-enhanced aural rehabilitation therapy as a means of increasing speech tracking skills.

DESIGN

Eight adult cochlear implant participants participated in a randomized, double-blind study and received either 10 mg d-amphetamine (Treatment group, N = 4) or a placebo (Placebo group, N = 4) 60 minutes prior to a 1.5 hour intensive aural rehabilitation session occurring twice a week for two months. Treatment consisted of a multi-step rehabilitation program individualized for each participant to develop auditory-only speech tracking skills. Prior to and at the conclusion of the therapy sessions, SPECT rCBF imaging and speech tracking assessments were conducted.

RESULTS

Speech tracking scores of the placebo and treatment groups were similar before the aural habilitation intervention. In the placebo group, speech tracking performance increased 13.5% for visual plus auditory and auditory only presentations as a function of aural habilitation alone. The 10 mg d-amphetamine-facilitated program resulted in minimal increases in visual plus auditory tracking scores (2%) but led to a 43% increase for auditory-only speech tracking. Regional cerebral blood flow measures indicated no substantial improvement of brain activation in the placebo group while both the extent and magnitude of primary and associative auditory cortex activations increased significantly with the pharmacologically enhanced treatment program.

CONCLUSIONS

These data support previous studies indicating an accelerated acquisition of speech and language abilities in stroke patients receiving traditional speech therapy in combination with d-amphetamine. Data, however, are preliminary and further study is warranted.

D-amphetamine enhances skilled reaching after ischemic cortical lesions in rats

Unilateral sensorimotor cortical (SMC) lesions in rats impair reaching and grasping movements of the contralateral forelimb. These impairments can be improved using motor rehabilitative training on a skilled reaching task, but the training may be far from sufficient to return animals to pre-lesion levels of performance. Because D-amphetamine (AMPH) has been found to promote neuroplastic responses to injury and to be very beneficial when combined with some (but not all) types of rehabilitative training, we asked in this experiment whether it could improve the efficacy of rehabilitative training in skilled reaching. Ten to 14 days after unilateral ischemic (endothelin-1 induced) lesions of the SMC, adult rats were given a 3-week regimen of AMPH (1mg/kg) coupled with daily rehabilitative training on a skilled reaching task, the single pellet retrieval task. AMPH treatment not only dramatically improved reaching performance compared with saline-injected controls, the AMPH treated rats surpassed pre-lesion levels of performance by the end of the rehabilitative training period. The greater performance in AMPH compared to saline-treated rats was still evident at 1 month, but not at 2 and 3 months, after the end of rehabilitative training. Thus, AMPH treatment can greatly enhance the efficacy of rehabilitative training on a skilled reaching task after unilateral SMC lesions, but alternate injection and training regimes may be needed to produce permanent improvements.

D-amphetamine boosts language learning independent of its cardiovascular and motor arousing effects

D-Amphetamine (AMPH) was effective in a number of studies on motor and language recovery after stroke, but given safety concerns, its general use after stroke is still debated. Most stroke patients are excluded from treatment because of a significant risk of cardiovascular dysregulation. AMPH acts on multiple transmitter systems, and mainly the noradrenergic actions are related to the cardiovascular effects. If AMPH's cardiovascular and arousal effects were correlated with its plasticity-enhancing effects in humans, this would imply that desired and undesired effects are inevitably tied. If not, improved cerebral reorganization may not be mediated by AMPH's arousing effects and could be achieved with substances lacking the undesired cardiovascular effects. As a model for language recovery after stroke, we used a prospective, randomized, double-blind, placebo-controlled design and taught 40 healthy male subjects an artificial vocabulary of 50 concrete nouns over the course of five consecutive training days (high-frequency training). The associative learning principle involved higher co-occurrences of 'correct' picture-pseudoword pairings as compared to 'incorrect' pairings. Subjects received either AMPH (0.25 mg/kg) or placebo 90 min prior to training on each day. Novel word learning was significantly faster and better in the AMPH as compared to the placebo group. Increased learning success was maintained 1 month post-training. No correlation was found between training success and drug-induced increases in blood pressure, heart rate, or a facilitation of simple motor reaction time. Our data show that AMPH's plasticity-enhancing effect in humans is not related to its cardiovascular arousal. This suggests that the beneficial effects in stroke patients could also be obtained by less cardiovascular active drugs.

Drugs for Stroke Recovery

Clinical trials of pharmacological agents in stroke have mainly focused on events that need to be modified in the very acute stage, such as restoration of blood flow with thrombolytic therapy or reducing the effects of ischaemia with neuroprotective therapy. Thrombolytic therapy is, however, only effective within the first few hours of stroke onset and so far, no neuroprotective therapy has proven to be efficacious in humans. Thus, there is a great need for new pharmacological strategies to improve outcome after stroke. Accumulating evidence supports the assumption that the brain is plastic and improvements can be expected after permanent injuries. Acute and chronic alterations in neurotransmitter regulation after injury affects plasticity and may thus provide a basis for new pharmacological targets for stroke recovery. The search for pharmacological therapies that affect the recovery process after a permanent injury has been intensified during the last decade. Amphetamines, in combination with training, are currently one of the most promising pharmacological strategies studied for recovery after stroke. Several non-mutually exclusive hypotheses, more or less supported by experimental studies, have tried to explain the mechanisms underlying the facilitation of recovery of function with amphetamine treatment. Amphetamines are believed to hasten the processes in the brain, such as plasticity mechanisms and resolution of diaschisis. The combination of amphetamine and task-specific training seems to be of importance to the outcome. Results from animal studies are consistent between different models and species, and mainly show an increased rate of recovery but there are a few exceptions, with some studies reporting no effect or even a decreased recovery rate. In humans the number of randomised controlled studies of amphetamines is growing rapidly. Results from a Cochrane systematic review indicate a faster motor and language recovery rate with treatment, but the number of studies is too few and studies are too small to draw definite conclusions about the effect on recovery of stroke. Data in the systematic review also indicate that the mortality rate is higher in amphetamine-treated patients compared with placebo-treated patients. However, this is most likely because of baseline imbalances between the treatment groups with patients with more severe strokes being allocated to amphetamine treatment. Further clinical trials are justified, but at present amphetamines should not be used in clinical practice.

Dexamphetamine treatment in stroke

Reducing disability and dependency after a stroke is an important clinical objective. We examine what is known about the use of dexamphetamine in patients recovering from an acute stroke, and consider whether further clinical studies should be undertaken. Dexamphetamine has repeatedly been shown to enhance recovery after experimental brain injury in animals, the best effects being seen when dexamphetamine is combined with lesion-specific motor training or sensory stimulation. Postulated mechanisms for these beneficial effects in animals are in keeping with contemporary theories of neurophysiological rehabilitation in man. There have been few clinical studies of dexamphetamine during rehabilitation after an acute stroke. Four controlled trials demonstrated a tendency to an improved outcome when dexamphetamine was paired with therapy and administered 3-30 days after an ischaemic stroke. However, clinical studies to date have been small, included only highly selected patients, and have not addressed possible confounding effects of the drug on mood and untreated depression. Dexamphetamine has previously been used under supervision in medically ill patients and appears to be safe and well-tolerated. There is a need for well-designed studies to assess further the safety and efficacy of dexamphetamine in rehabilitation after stroke.

Neuropharmacology of TBI-induced plasticity

PRIMARY OBJECTIVE

The purpose of this report is to review both fundamental studies in laboratory animals and preliminary clinical data suggesting that certain drugs may affect behavioural recovery after brain injury.

MAIN OUTCOMES AND RESULTS

Laboratory studies show that systemically-administered drugs that affect specific central neurotransmitters including norepinephrine and GABA influence affect recovery in a predictable manner. Although some drugs such as d-amphetamine have the potential to enhance recovery, others such as neuroleptics and other central dopamine receptor antagonists, benzodiazepines and the anti-convulsants phenytoin and phenobarbital may be detrimental. In one study, 72% of patients with traumatic brain injury received one or a combination of the drugs that may impair recovery based on both animal experiments and studies in recovering stroke patients.

CONCLUSIONS

Until the true impact of these classes of drugs are better understood, care should be exercised in the use of medications that may interfere with the recovery process in patients with traumatic brain injury. Additional research needs to be completed before the clinical efficacy of drugs that may enhance recovery can be established.

Influence of enriched environment on spatial learning following cerebral insult

The fact that our brain is continuously shaped by the environment and experience presents many challenges. It was noted several decades ago that exposure of a laboratory rat to a complex environment alters its brain and improves problem solving in complex tasks. Rats that are housed in an enriched environment can better compensate for brain lesion-induced deficits and resist neurodegeneration. In this article, the role of an enriched environment on brain plasticity following experimentally-induced lesions is discussed.

Amphetamines and related drugs in motor recovery after stroke

Studies in laboratory animals indicate that the rate and extent of functional recovery after focal brain injury can be modulated by drugs affecting specific central neurotransmitters. Preliminary clinical studies suggest that similar drug effects may occur in humans recovering from stroke. Combined with principles derived from the laboratory, these clinical studies provide important insights to guide the rational design of trials aimed at determining the clinical use of this approach to improving poststroke recovery.

Selegiline treatment facilitates recovery after stroke

OBJECTIVE

Selegiline (L-deprenyl) is a selective monoamine oxidase B (MAO-B) inhibitor used in the treatment of Parkinson's disease. In addition, it is thought to rescue neurons with a loss of target-derived trophic support. Several mechanisms have been proposed to explain these phenomena, such as the production of neurotrophic actions through astrocyte activation, reduction of free radical production, or the presence of antiapoptotic properties. The aim of this study was to investigate whether the systemic administration of selegiline facilitates recovery after a cerebral infarction in humans.

METHODS

This phase II study was randomized, double-blind, and placebo controlled. Selegiline, 5 mg, or matched placebo was given twice a day for 3 months. The drug therapy was started within 48 h after a hemispheric infarction in the territory of middle cerebral artery. There were 24 patients recruited. Twenty patients were followed up to 3 months or until their death, and they represent the efficacy analysis group. The primary efficacy parameters were Scandinavian Stroke Scale (SSS), Barthel Index (BI), and Fugl-Meyer Scale (FMS). Secondary parameters were Zung Self-Rating Depression Scale (ZDS) and 15-Dimensional Measure of Health Related Quality of Life test (15-D).

RESULTS

SSS improved statistically significantly from the baseline when compared with placebo (p = 0.019). The results were parallel among the other two primary efficacy variables (BI and FMS), showing a positive trend for selegiline, although they did not reach statistical significance. Similarly, in the analysis of the secondary efficacy variables, both the 15-D test and ZDS supported this positive trend in favor of selegiline, although no statistically significant differences between groups were found (p = 0.06 in 15-D test).

CONCLUSIONS

Selegiline seems to be beneficial after a cerebral infarction. This benefit may be due to the enhancement of the recovery process.

Plasticity of the visual cortex after injury: what's different about the young brain?

The repercussions of localized injury of the cerebral cortex in young brains differ from the repercussions triggered by equivalent damage of the mature brain. In the young brain, some distant neurons are more vulnerable to the lesion, whereas others survive and expand their projections to bypass damaged and degenerated structures. The net result is sparing of neural processing and behaviors. This article summarizes both the modifications in visual pathways resulting from visual cortex lesions sustained early in life and the neural and behavioral processes that are spared or permanently impaired. Experiments using reversible deactivation show that at least two highly localizable functions of normal cerebral cortex are remapped across the cortical surface as a result of an early lesion of the primary visual cortex. Moreover, the redistributions have spread the essential neural operations underlying orienting behavior from the visual parietal cortex to a normally functionally distinct type of cortex in the visual temporal system, and in the opposite direction for complex-pattern recognition. Similar functional reorganizations may underlie sparing of neural processes and behavior following early lesions in other cerebral systems, and these other systems may respond well to emerging therapeutic strategies designed to enhance the sparing of functions.

A critical maturational period of reduced brain vulnerability to injury. A study of cerebral glucose metabolism in cats

We have developed a feline cerebral hemispherectomy model as an analog to the surgical procedure used in pediatric intractable epilepsy. Previous work with this model has shown a remarkable plasticity associated with an early period of brain development, which we have defined using morphological, cerebral metabolic and behavioral methods. However, the important functional-metabolic bracketing of this period has not yet been performed. We have conducted the present study to answer questions raised by our previous findings using [14C] 2-deoxy-D-glucose autoradiography but only including animals lesioned at day 10 postnatally (P10) or in adulthood. The questions were; (a) is there any age better than P10 for an optimal metabolic outcome?, and (b) can we determine a cutoff point for the beneficial effects of the young age-at-lesion? Twenty-one adult cats were studied. Seven cats served as intact controls, five received a left hemineodecortication at P30, three at P60, three at P90 and three at P120, respectively. Histological analysis indicated that the extent of the lesion was similar between the age groups. Local glucose metabolic rates (LCMR(glc)) were measured in 50 structures bilaterally and used to calculate overall LCMR(glc) for seven grouped sites within the cerebral cortex, thalamus, basal ganglia, mesencephalic tegmentum (and tectum), limbic system and cerebellum. Results indicated a widespread bilateral depression of LCMR(glc) in all age-at-lesion groups. The depression in overall LCMR(glc) across all structures measured in each hemisphere was significant (P<0.05) for the P120 group relative to intacts for both ipsilateral (left) and contralateral (right) sides of the brain. The ipsilateral thalamus was the region most effected by the injury, with significant losses for all age-at-lesion groups. In addition, while there were widespread depressions for all lesion groups, these losses were significant for the P120 group in five groups of structures ipsilaterally (thalamus, basal ganglia, tectum, limbic system, cerebellum) and in three contralaterally (thalamus, tectum, cerebellum). In contrast, significant depressions for the earlier age-at-lesion groups (P30, P60, P90) were found only in the ipsilateral thalamus and bilaterally in the tectum. These results, together with our previous results for the P10 group, indicate a relative sparing of LCMR(glc) after hemineodecortication during the first 60 days of life, with gradually decreasing plasticity thereafter, such that there is some residual sparing at 90 days of age, and afterwards an almost complete loss of metabolic plasticity, with lesions at P120 producing a dismal outcome. These results complement earlier morphological and behavioral studies and support the concept of a 'Critical Maturational Period' of reduced vulnerability to developmental injury.

A double-blind, placebo-controlled study of the use of amphetamine in the treatment of aphasia

BACKGROUND AND PURPOSE

A number of studies suggest that drugs which increase the release of norepinephrine promote recovery when administered late (days to weeks) after brain injury in animals. A small number of clinical studies have investigated the effects of the noradrenergic agonist dextroamphetamine in patients recovering from motor deficits following stroke. To determine whether these findings extend to communication deficits subsequent to stroke, we administered dextroamphetamine, paired with speech/language therapy, to patients with aphasia.

METHODS

In a prospective, double-blind study, 21 aphasic patients with an acute nonhemorrhagic infarction were randomly assigned to receive either 10 mg dextroamphetamine or a placebo. Patients were entered between days 16 and 45 after onset and were treated on a 3-day/4-day schedule for 10 sessions. Thirty minutes after drug/placebo administration, subjects received a 1-hour session of speech/language therapy. The Porch Index of Communicative Ability was used at baseline, at 1 week off the drug, and at 6 months after onset as the dependent language measure.

RESULTS

Although there were no differences between the drug and placebo groups before treatment (P=0.807), by 1 week after the 10 drug treatments ended there was a significant difference in gain scores between the groups (P=0.0153), with the greater gain in the dextroamphetamine group. The difference was still significant when corrected for initial aphasia severity and age. At the 6-month follow-up, the difference in gain scores between the groups had increased; however, the difference was not significant (P=0.0482) after correction for multiple comparisons.

CONCLUSIONS

Administration of dextroamphetamine paired with 10 1-hour sessions of speech/language therapy facilitated recovery from aphasia in a small group of patients in the subacute period after stroke. Neuromodulation with dextroamphetamine, and perhaps other drugs that increase central nervous system noradrenaline levels, may facilitate recovery when paired with focused behavioral treatment.

Role of adaptive plasticity in recovery of function after damage to motor cortex

Based upon neurophysiologic, neuroanatomic, and neuroimaging studies conducted over the past two decades, the cerebral cortex can now be viewed as functionally and structurally dynamic. More specifically, the functional topography of the motor cortex (commonly called the motor homunculus or motor map), can be modified by a variety of experimental manipulations, including peripheral or central injury, electrical stimulation, pharmacologic treatment, and behavioral experience. The specific types of behavioral experiences that induce long-term plasticity in motor maps appear to be limited to those that entail the development of new motor skills. Moreover, recent evidence demonstrates that functional alterations in motor cortex organization are accompanied by changes in dendritic and synaptic structure, as well as alterations in the regulation of cortical neurotransmitter systems. These findings have strong clinical relevance as it has recently been shown that after injury to the motor cortex, as might occur in stroke, post-injury behavioral experience may play an adaptive role in modifying the functional organization of the remaining, intact cortical tissue.

An alpha(2)-adrenergic antagonist, atipamezole, facilitates behavioral recovery after focal cerebral ischemia in rats

Previous studies suggest that enhanced noradrenergic neurotransmission promotes functional recovery following cerebral lesions. The present study investigated whether systemic administration of an alpha(2)-adrenergic antagonist, atipamezole, facilitates recovery following transient focal cerebral ischemia in rats. The effect of atipamezole therapy on recovery from ischemia was compared with the effect of enriched-environment housing in rats. Ischemia was induced by occlusion of the right middle cerebral artery (MCA) for 120 min using the intraluminal filament model. Daily atipamezole treatment (1 mg/kg, subcutaneously) was started on day 2 after ischemia induction and drug administration stopped after 10 days. Another group of rats was housed in an enriched environment from day 2 following ischemia induction until the end of the experiment. Several different behavioral tests were used to measure functional recovery during the 26 days following the induction of focal cerebral ischemia. There was improved performance in the limb-placing test from the beginning of atipamezole treatment to day 8, and in wheel-running in the foot-slip test on days 2 and 4. Enriched-environment housing facilitated recovery in the foot-slip test in a later phase of the test period (days 8 to 10). Discovery of a hidden platform in a water-maze task was also facilitated in rats housed in the enriched environment, but this was probably due to the increased swimming speed of these rats. The present data suggest that the alpha(2)-adrenergic antagonist, atipamezole, facilitates sensorimotor recovery after focal ischemia, but has no effect on subsequent water-maze tests assessing spatial learning and memory, when assessed 11 days after the cessation of drug administration.

Selegiline combined with enriched-environment housing attenuates spatial learning deficits following focal cerebral ischemia in rats

Selegiline (l-deprenyl) is an irreversible monoamine oxidase B (MAO-B) inhibitor that is suggested to have neuroprotective and neuronal rescuing properties. The present study investigated whether systemic administration of selegiline facilitates behavioral recovery after transient focal cerebral ischemia in rats using a combination of different behavioral tests (limb placing, foot slip, water maze, and Montoya's staircase test) to measure the outcome of recovery. Selegiline (0.5 mg/kg, SC) or 0.9% NaCl was administered once a day, beginning on the second day after induction of ischemia and continuing for 30 days. Selegiline administration combined with enriched-environment housing attenuated ischemia-induced spatial learning deficits in a water-maze task and enhanced performance of both the contralateral affected and ipsilateral nonaffected forelimbs in a staircase test. Selegiline administration alone was not beneficial in any of the tests. Subsequent histologic examination revealed that the infarct volumes were not different between the experimental ischemic groups. Thus, these results suggest that selegiline combined with enriched-environment housing reduces behavioral and cognitive deficits without affecting infarct size.

Spatial hemineglect in humans

The paper reviews the main findings of studies of hemispatial neglect after acquired brain lesions in people. The behavioral consequences of experimentally induced lesions in animals and electrophysiological studies, which shed light on the nature of the disorder, are briefly considered. Neglect is behaviorally defined as a deficit in processing or responding to sensory stimuli in the contralateral hemispace, a part of the own body, the part of an imagined scene, or may include the failure to act with the contralesional limbs despite intact motor functions. Neglect in humans is frequently encountered after right parieto-temporal lesions and leads to a multicomponent syndrome of sensory, motor and representational deficits. Relevant findings relating to neglect, extinction and unawareness are reviewed and include the following topics: etiological and anatomical basis, recovery; allocentric, egocentric, object-centered and representational neglect; motor neglect and directional hypokinesia; elementary sensorimotor and associated disorders; subdivisions of space and frames of reference; extinction versus neglect; covert processing of information; unawareness of deficits; human and animal models; effects of sensory stimulation and rehabilitation techniques.

A Pilot Study of the Effect of L-Threodops on Rehabilitation Outcome of Stroke Patients

We investigated whether L-threodops (L-DOPS), a norepinephrine precursor, improves rehabilitation outcome in patients with initial hemiparetic supratentorial ischemic stroke (2 months post stroke). Five patients who agreed to be treated with L-DOPS received 45-minute physical therapy (PT) and occupational therapy (OT) for 2 months, 3 days a week, with an oral dose of 200 mg L-DOPS 2 hours before each session, followed by PT and OT without L-DOPS for 2 months (DOPS group). Eight patients who disagreed received PT and OT for 4 months (control). Each group demonstrated comparable age, sex, complications, Mini-Mental State Examination, and the baseline Functional Independence Measure (FIM, DOPS/control = 36/42), Fugl-Meyer (F-M) motor scale (30/27), and ambulation endurance (10/9 meters). DOPS group had significantly greater gain than control (p < 0.05, Mann-Whitney U test) in FIM score at 4 (51/45) and 6 months (57/49), ambulation at 4 (66/16) and 6 months (82/24), and F-M score at 4 months (40/29). There were no side effects that required discontinuation of the drug. These results suggest that L-DOPS treatment paired with PT and OT may be effective in improving functional outcome in stroke.

Effects of amphetamines and small related molecules on recovery after stroke in animals and man

Drugs modulating the levels of specific central neurotransmitters may influence both the rate and amount of functional recovery after focal brain injuries such as stroke. Because such drugs may be effective long after brain injury, the "therapeutic window" may be widened beyond the first few hour after stroke and an entirely new avenue for pharmacological intervention may be possible. The impact of drugs affecting norepinephrine and gamma-aminobutyric acid have been among the most extensively studied in the laboratory, and preliminary clinical data suggest similar effects in humans.

Chronic methylphenidate treatment enhances water maze performance following traumatic brain injury in rats

Methylphenidate (MPH), a central nervous system stimulant with dopaminergic activity, facilitates neurobehavioral outcome following cortical suction ablation injury, but its potential efficacy following experimental traumatic brain injury (TBI) is unknown. Thus, beginning 24 h after controlled cortical impact injury or sham surgery, male Sprague-Dawley rats were injected (i.p.) once daily for 18 days with either MPH (5 mg/kg) or saline vehicle (VEH) and motor function assessed on post-operative days 1-4, followed by Morris water maze training to find a hidden platform on days 14-18. The MPH treatment regimen was ineffective in accelerating beam-balance or beam-walk recovery, but did significantly decrease swim latencies when compared to VEH-treated controls. The results are consistent with published studies showing improved outcome with MPH therapy. Furthermore, this positive finding with delayed treatment suggests that strategies that enhance catecholamine neurotransmission during the chronic post injury phase may be a useful adjunct in ameliorating some of the neurobehavioral sequelae following TBI in humans.

L-DOPS-Accelerated recovery of locomotor function in rats subjected to sensorimotor cortex ablation injury: pharmacobehavioral studies

Central norepinephrine (NE) has been shown to play a beneficial role in amphetamine-facilitated recovery of behavior. To give insight into understanding the mechanism, the present studies were conducted to examine (a) the effects of L-threo-3,4-dihydroxyphenylserine (L-DOPS) combined with benserazide (BSZ; a peripheral aromatic amino acid decarboxylase inhibitor) and L-3,4-dihydroxyphenylalanine (L-DOPA), precursors of NE and dopamine (DA), respectively, on the recovery from beam-walking performance deficits in rats subjected to unilateral sensorimotor cortex ablation injury, and (b) the relationships between the behavioral recovery and the frequency of postoperative training and the size of ablation injury. It was found that the combined treatments with L-DOPS and BSZ promoted the recovery of locomotor function as early as 24 hours after injury. L-DOPA alone, however, did not facilitate behavioral recovery. The results of assay for the tissue levels of NE and its major metabolite (3-methoxy-4-hydoxyphenylethylene glycol; MHPG) in the brain using high-pressure liquid chromotography showed MHPG, but not NE, significantly increased in the cerebellum and the hippocampus. The behavioral recovery was also significantly correlated with the frequency of training subsequent to injury, but inversely with the size of cortex ablation. These results suggest that NE is likely to modulate functional recovery in this rodent model.

Enhanced neocortical neural sprouting, synaptogenesis, and behavioral recovery with D-amphetamine therapy after neocortical infarction in rats

BACKGROUND AND PURPOSE

D-Amphetamine administration increases behavioral recovery after various cortical lesions including cortical ablations, contusions, and focal ischemia in animals and after stroke in humans. The purpose of the present study was to test the enhanced behavioral recovery and increased expression of proteins involved in neurite growth and synaptogenesis in D-amphetamine-treated rats compared with vehicle-treated controls after a focal neocortical infarct.

METHODS

Unilateral neocortical ischemia was induced in male spontaneously hypertensive Wistar rats (n=8 per time point per group) by permanently occluding the distal middle cerebral artery and ipsilateral common carotid artery in 2 groups of rats: D-amphetamine treated (2 mg/kg IP injections) and vehicle treated (saline IP injections). To determine the spatial and temporal distribution of neurite growth and/or synaptogenesis, growth-associated protein (GAP-43), a protein expressed on axonal growth cones, and synaptophysin, a calcium-binding protein found on synaptic vesicles, were examined by immunohistochemical techniques, and both density and distribution of reaction product were measured. Since the resulting infarction included a portion of the forelimb neocortex, behavioral assessments of forelimb function using the foot-fault test of Hernandez and Schallert were performed on the same rats used for immunohistochemical studies during the period of drug action and 24 hours later. A Morris water maze and other indices of behavioral assays were also measured similarly. Recovery times were 3, 7, 14, 30, and 60 days postoperatively.

RESULTS

Both GAP-43 and synaptophysin proteins demonstrated statistically significant increases in density and distribution of immunoreaction product as determined by optical density measurements in the neocortex of the infarcted group treated with D-amphetamines compared with vehicle-treated infarcted controls. The GAP-43 was elevated to statistically significant levels in forelimb, hindlimb, and parietal neocortical regions ipsilateral to the infarction only at days 3, 7, and 14. By contrast, the synaptophysin demonstrated no statistically significant changes in expression at 3 or 7 days but demonstrated statistically significant increases at 14, 30, and 60 days in the forelimb, hindlimb, and parietal neocortical regions ipsilateral to the infarction as well as increased distribution in the contralateral parietal neocortex. Behavioral assessment of forelimb function indicated that improved recovery of forelimb placement on the side contralateral to the infarction was statistically significant in the D-amphetamine-treated group compared with the vehicle-treated group (P<0.025). Spatial memory, as measured with the Morris water maze, worsened in the vehicle-treated group compared with the D-amphetamine-treated group at 60 days (P<0.025).

CONCLUSIONS

These data support the occurrence of neurite growth followed by synaptogenesis in the neocortex in a pattern that corresponds both spatially and temporally with behavioral recovery that is accelerated by D-amphetamine treatment. While the specific mechanisms responsible for D-amphetamine-promoted expression of proteins involved in neurite growth and synaptogenesis and of enhanced behavioral recovery are not known, it is suggested that protein upregulation occurs as a result of functional activation of pathways able to remodel in response to active behavioral performance.

Amphetamine and task-specific practice augment recovery of vibrissae-evoked forelimb placing after unilateral sensorimotor cortical injury in the rat

This study investigated the relative contribution of amphetamine administration and task-specific practice during the period of drug action to recovery of forelimb-placing ability after unilateral electrolytic lesions of the sensorimotor cortex (SMC) in rats. Subjects were divided into groups receiving amphetamine plus postinjection forelimb-placing practice, amphetamine only, saline plus postinjection forelimb-placing practice, or saline only. The results revealed that groups of subjects receiving either amphetamine, postinjection practice, or a combination of these treatments exhibited the greatest enhancement of rates of vibrissae-evoked forelimb-placing recovery. These data suggest that these treatments can have an enduring beneficial effect on vibrissae-evoked forelimb-placing recovery without any immediate restorative effect on forelimb-placing ability. The recovery patterns and experimental evidence (see Feeney and Sutton, 1988; Chaouloff, 1989) suggest that the beneficial effect of the two therapies may be mediated by catecholamine release.

Studies on the influence of enriched-environment housing combined with systemic administration of an alpha2-adrenergic antagonist on spatial learning and hyperactivity after global ischemia in rats

BACKGROUND AND PURPOSE

The purpose of this study was to determine whether an enriched housing environment and/or systemic administration of the alpha2-adrenergic receptor antagonist atipamezole facilitate the rate of spatial learning after global ischemia in rats.

METHODS

Carotid arteries were closed for 20 minutes after permanent cauterization of vertebral arteries on the previous day. Enriched-environment housing and drug/saline treatment were begun 3 days after ischemia. For rehabilitation, housing in an enriched environment was combined with exploration in a labyrinth. Behavioral tests (the open-arena test and water-maze learning set task) were performed after 1-week periods of drug/saline treatment three times. In addition, the open-arena test was performed to evaluate the baseline level of animals 2 days after the induction of ischemia and at the end of the experiment, when the water-maze task was assessed in another room.

RESULTS

Rats housed in an enriched environment after ischemia showed better acquisition of the water-maze learning set task after 1 week of housing. The influence of atipamezole treatment on this parameter did not reach statistical significance. In the open-arena test, ischemic animals were slightly hyperactive; however, this symptom was eliminated by housing in an enriched environment.

CONCLUSIONS

The present data suggest that housing in an enriched environment facilitates the rate of spatial learning in rats with global ischemia. Rehabilitation also alleviated the hyperactivity observed in ischemic animals.

The effects of amphetamine on recovery of function after cortical damage in the rat depend on the behavioral requirements of the task

The effects of amphetamine on the recovery of function following unilateral lesions of the rat somatic sensorimotor cortex (SMC) were examined. Rats with large SMC were tested on two measures of locomotor placing: the beam-walking test and the foot-fault test. Amphetamine produced an immediate and enduring facilitation of recovery on the beam-walking test. In contrast, the drug had no effect on the rats' ability to accurately place the forelimbs on the rungs of the elevated grid during locomotion on the foot-fault test. These data suggest that amphetamine may facilitate recovery when the requirements of the task produce a deficit in the initiation of locomotion but not when the animal is required to use somatosensory and proprioceptive cues to guide performance on the task. A second group of rats with smaller SMC lesions was evaluated with tactile-placing tests and the bilateral-tactile stimulation task. The forelimb placing reaction is elicited by unilateral tactile stimulation of the vibrissae or forelimb, whereas the ipsilateral asymmetry observed on the bilateral-tactile stimulation test has been interpreted as an impairment in processing stimuli presented on both sides of the body. On two measures of forelimb placing amphetamine produced a facilitation of recovery, but restoration of function was not observed during the period of drug intoxication. In contrast, amphetamine had no effect on recovery of function on the bilateral-tactile stimulation test. Taken together, these data suggest that the behavioral requirements of the task are an important factor in determining the facilitatory effects of amphetamine on recovery of function.

Improved arousal and initiation following tricyclic antidepressant use in severe brain injury

Three patients with severe traumatic brain injury demonstrated significant improvement in arousal and initiation after administration of tricyclic antidepressants. The first patient showed improved motor and speech initiation in response to amitriptyline following several months of functional plateau. The second patient was minimally responsive 2 months after injury and demonstrated improved arousal following the use of desipramine. Both patients deteriorated when the medications were discontinued and improved again when they were restarted. These two cases provide strong evidence for a medication effect. The third patient began to verbalize following desipramine administration, despite being mute for more than a year after injury. Previous case reports describe cognitive-enhancing effects, such as improved arousal, attention, memory, and initiation, of dopaminergic agents, and in the case of tricyclic antidepressants, effects on agitation. The role of norepinephrine in promoting neurological recovery after brain lesions has been demonstrated in animals. The cases presented here provide some of the first data to show similar efficacy in humans and underscore the need for controlled trials to better determine which patients will benefit.

Amphetamine paired with physical therapy accelerates motor recovery after stroke. Further evidence

BACKGROUND AND PURPOSE

In animal models of brain injury, administration of numerous pharmaceuticals is reported to facilitate functional recovery. However, only drugs that increase the release of norepinephrine have been shown to promote recovery when administered late (days to weeks) after injury. To determine whether these findings were applicable to humans, we administered the norepinephrine stimulant dextroamphetamine, paired with physical therapy, to hemiplegic stroke patients.

METHODS

Ten hemiplegic patients who suffered an acute ischemic infarction were entered between days 16 and 30 after onset and randomly assigned to receive either 10 mg of dextroamphetamine or a placebo orally every fourth day for 10 sessions paired with physical therapy. The Fugl-Meyer Motor Scale was used at baseline, within each session, and for 12 months after onset as the dependent measure. Confounding medications such as alpha-adrenergic antagonists or agonists were excluded in all subjects.

RESULTS

Although there were no differences between the groups at baseline (P = .599), there was a significant (P = .047) difference between the groups when the drug had been discontinued for 1 week and at the 12-month follow-up visit (P = .047).

CONCLUSIONS

Administration of dextroamphetamine paired with physical therapy increased the rate and extent of motor recovery in a small group of hemiplegic stroke patients. These data support and extend previous findings of the facilitatory aspects of certain types of drugs on recovery from brain injury. The use of neuromodulation may allow the nervous system to adapt previously unused or alternative pathways to relevant external input.