Plasticity properties of CPG circuits in humans: impact on gait recovery

Neuromodulation of central pattern generators and its role in the functional recovery of central pattern generator activity

Neuromodulators play an important role in how the nervous system organizes activity that results in behavior. Disruption of the normal patterns of neuromodulatory release or production is known to be related to the onset of severe pathologies such as Parkinson's disease, Rett syndrome, Alzheimer's disease, and affective disorders. Some of these pathologies involve neuronal structures that are called central pattern generators (CPGs), which are involved in the production of rhythmic activities throughout the nervous system. Here I discuss the interplay between CPGs and neuromodulatory activity, with particular emphasis on the potential role of neuromodulators in the recovery of disrupted neuronal activity. I refer to invertebrate and vertebrate model systems and some of the lessons we have learned from research on these systems and propose a few avenues for future research. I make one suggestion that may guide future research in the field: neuromodulators restrict the parameter landscape in which CPG components operate, and the removal of neuromodulators may enable a perturbed CPG in finding a new set of parameter values that can allow it to regain normal function.

Spinal Cord Injury: How Could Acupuncture Help?

Spinal cord injury (SCI) is one of the most common causes of death and disability worldwide, and it can result in both permanent disability and serial complications in patients. Research shows that patients with SCI complications are often interested in acupuncture for symptomatic relief. Therefore, the issue of physicians advising their patients regarding the use of acupuncture to alleviate SCI complications becomes pertinent. We review and summarize two types of relevant publications: (1) literature concerning acupuncture for SCI and its complications and (2) underlying mechanisms of acupuncture therapy for SCI. Clinical trials and reviews have suggested that acupuncture effectively manages a range of post-SCI complications, including motor and sensory dysfunction, pain, neurogenic bowel and bladder, pressure ulcers, spasticity, and osteoporosis. The effect of acupuncture on post-SCI orthostatic hypotension and sexual dysfunction remains unclear. Decreased oxidative stress, inhibition of inflammation and neuronal apoptosis, regulation of the expression and activity of endogenous biological mediators, and increased regenerative stem cell production are the possible mechanisms of acupuncture therapy for SCI. Although many limitations have been reported in previous studies, given the evidence for the efficacy of acupuncture, we recommend that physicians should support the use of acupuncture therapy for SCI complications.

Movement goals encoded within the cortex and muscle synergies to reduce redundancy pre and post-stroke. The relevance for gait rehabilitation and the prescription of walking-aids. A literature review and scholarly discussion

Current knowledge of neural and neuromuscular processes controlling gait and movement as well as an understanding of how these mechanisms change following stroke is an important basis for the development of effective rehabilitation interventions. To support the translation of findings from basic research into useful treatments in clinical practice, up-to-date neuroscience should be presented in forms accessible to all members of the multidisciplinary team. In this review we discuss aspects of cortical control of gait and movement, muscle synergies as a way of translating cortical commands into specific muscle activity and as an efficient means of reducing neural and musculoskeletal redundancy. We discuss how these mechanisms change following stroke, potential consequences for gait rehabilitation, and the prescription and use of walking-aids as well as areas requiring further research.

The influence of walking-aids on the plasticity of spinal interneuronal networks, central-pattern-generators and the recovery of gait post-stroke. A literature review and scholarly discussion

BACKGROUND

Many aspects of post-stroke gait-rehabilitation are based on low-level evidence or expert opinion. Neuroscientific principles are often not considered when evaluating the impact of interventions. The use of walking-aids including canes and rollators, although widely used for long periods, has primarily been investigated to assess the immediate kinetic, kinematic or physiological effects. The long-term impact on neural structures und functions remains unclear.

METHODS

A literature review of the function of and factors affecting plasticity of spinal interneuronal-networks and central-pattern-generators (CPG) in healthy and post-stroke patients. The relevance of these mechanisms for gait recovery and the potential impact of walking-aids is discussed.

RESULTS

Afferent-input to spinal-networks influences motor-output and spinal and cortical plasticity. Disrupted input may adversely affect post-stroke plasticity and functional recovery. Joint and muscle unloading and decoupling from four-limb CPG control may be particularly relevant.

CONCLUSIONS

Canes and rollators disrupt afferent-input and may negatively affect the recovery of gait.

Implicit Motor Sequence Learning in Individuals with Parkinson Disease: A Meta-Analysis

BACKGROUND

Deficits in implicit motor sequence learning (IMSL) in individuals with Parkinson disease (PD) compared to age matched healthy controls (HC) are unclear.

OBJECTIVE

The purpose of this paper is to present results of a systematic review with a meta-analysis examining the hypothesis that IMSL is impaired in individuals with PD when compared to HC.

METHODS

Fifteen articles met our final criteria and assessed 299 individuals with PD and 244 HC. Raw mean and standard deviation data for the final block of repeated and final block of random practice trials were obtained to calculate sequence-specific learning (SSL) for individuals with PD and HC. Forest plots were used to depict the comparison of the groups by assessing standardized mean difference with random effect size.

RESULTS

A significant and moderate effect size, 0.83 was found suggesting that individuals with PD demonstrated impaired SSL of motor sequences compared to HC.

CONCLUSIONS

Individuals with PD demonstrate a deficit compared with HC in their ability to implicitly learn motor tasks. Existing research lacks detail on the factors which may alter IMSL, either negatively or positively, such as the design features of current IMSL paradigms utilized and disease-specific characteristics. Successful motor rehabilitation of functional tasks in persons with PD is highly dependent on IMSL; therefore, an improved knowledge of the influence of these additional variables is critical.

Early application of tail nerve electrical stimulation-induced walking training promotes locomotor recovery in rats with spinal cord injury

Study design:

This is a randomized controlled prospective trial with two parallel groups.

Objectives:

The objective of this study was to determine whether early application of tail nerve electrical stimulation (TANES)-induced walking training can improve the locomotor function.

Setting:

This study was conducted in SCS Research Center in Colorado, USA.

Methods:

A contusion injury to spinal cord T10 was produced using the New York University impactor device with a 25 -mm height setting in female, adult Long–Evans rats. Injured rats were randomly divided into two groups (n=12 per group). One group was subjected to TANES-induced walking training 2 weeks post injury, and the other group, as control, received no TANES-induced walking training. Restorations of behavior and conduction were assessed using the Basso, Beattie and Bresnahan open-field rating scale, horizontal ladder rung walking test and electrophysiological test (Hoffmann reflex).

Results:

Early application of TANES-induced walking training significantly improved the recovery of locomotor function and benefited the restoration of Hoffmann reflex.

Conclusion:

TANES-induced walking training is a useful method to promote locomotor recovery in rats with spinal cord injury.

EMG patterns during assisted walking in the exoskeleton

Neuroprosthetic technology and robotic exoskeletons are being developed to facilitate stepping, reduce muscle efforts, and promote motor recovery. Nevertheless, the guidance forces of an exoskeleton may influence the sensory inputs, sensorimotor interactions and resulting muscle activity patterns during stepping. The aim of this study was to report the muscle activation patterns in a sample of intact and injured subjects while walking with a robotic exoskeleton and, in particular, to quantify the level of muscle activity during assisted gait. We recorded electromyographic (EMG) activity of different leg and arm muscles during overground walking in an exoskeleton in six healthy individuals and four spinal cord injury (SCI) participants. In SCI patients, EMG activity of the upper limb muscles was augmented while activation of leg muscles was typically small. Contrary to our expectations, however, in neurologically intact subjects, EMG activity of leg muscles was similar or even larger during exoskeleton-assisted walking compared to normal overground walking. In addition, significant variations in the EMG waveforms were found across different walking conditions. The most variable pattern was observed in the hamstring muscles. Overall, the results are consistent with a non-linear reorganization of the locomotor output when using the robotic stepping devices. The findings may contribute to our understanding of human-machine interactions and adaptation of locomotor activity patterns.

Plasticity and modular control of locomotor patterns in neurological disorders with motor deficits

Human locomotor movements exhibit considerable variability and are highly complex in terms of both neural activation and biomechanical output. The building blocks with which the central nervous system constructs these motor patterns can be preserved in patients with various sensory-motor disorders. In particular, several studies highlighted a modular burst-like organization of the muscle activity. Here we review and discuss this issue with a particular emphasis on the various examples of adaptation of locomotor patterns in patients (with large fiber neuropathy, amputees, stroke and spinal cord injury). The results highlight plasticity and different solutions to reorganize muscle patterns in both peripheral and central nervous system lesions. The findings are discussed in a general context of compensatory gait mechanisms, spatiotemporal architecture and modularity of the locomotor program.

Effects of robotic guidance on the coordination of locomotion

BACKGROUND

Functional integration of motor activity patterns enables the production of coordinated movements, such as walking. The activation of muscles by weightened summation of activation signals has been demonstrated to represent the spatiotemporal components that determine motor behavior during walking. Exoskeleton robotic devices are now often used in the rehabilitation practice to assist physical therapy of individuals with neurological disorders. These devices are used to promote motor recovery by providing guidance force to the patients. The guidance should in principle lead to a muscle coordination similar to physiological human walking. However, the influence of robotic devices on locomotor patterns needs still to be characterized. The aim of this study was to analyze the effect of force guidance and gait speed on the modular organization of walking in a group of eight healthy subjects.

METHOD

A group of healthy subjects walked on a treadmill with and without robotic aiding at speeds of 1.5, 2.0 and 2.5 Km/h. The guidance force was varied between 20%, 40%, 70% and 100% level of assistance. EMG recordings were obtained from seven leg muscles of the dominant leg and kinematic and kinetic features of the knee and hip joints were extracted.

RESULTS

Four motor modules were sufficient to represent the variety of behavioral goals demanded during robotic guidance, with similar relationships between muscle patterns and biomechanical parameters across subjects, confirming that the low-dimensional and impulsive control of human walking is maintained using robotic force guidance. The conditions of guidance force and speed that maintained correct and incorrect (not natural) modular control were identified.

CONCLUSION

In neurologically intact subjects robotic-guided walking at various force guidance and speed levels does not alter the basic locomotor control and timing. This allows the design of robotic-aided rehabilitation strategies aimed at the modulation of motor modules, which are altered in stroke.

Principles of human locomotion: a review

In this article the principles of human locomotion are revisited and reviewed. This has been done in the framework of two European projects, where the elicitation of these mechanisms inform, on the one hand, the design of artificial bipedal walkers (H2R), and on the other hand the design of lower limb exoskeletons (BETTER) for rehabilitation of gait in post-stroke patients. Passive dynamics emerging from the morphology of the human musculoskeletal system, reflexes as stabilization mechanisms, modular control of movement as well as supra-spinal control of gait are reviewed to get insight on how these mechanisms can be used to explain human locomotion.

The recovery of walking in stroke patients: a review

We reviewed the literature on walking recovery of stroke patients as it relates to the following subjects:epidemiology of walking dysfunction, recovery course of walking, and recovery mechanism of walking (neural control of normal walking, the evaluation methods for leg motor function, and motor recovery mechanism of leg).The recovery of walking is one of the primary goals in stroke patients, along with the recovery of hand function and cognition. Walking function has greater potential for recovery than hand function because motor function of the leg is less dependent on the lateral corticospinal tract than that of hand function. This suggests that detailed knowledge of walking can be used to increase the likelihood that stroke patients recover their ability to walk. Therefore, we suggest that further research should focus on these topics, especially, on the neural control mechanism of walking and motor recovery mechanisms of the leg in stroke patients.

A physical model of sensorimotor interactions during locomotion

In this paper, we describe the development of a bipedal robot that models the neuromuscular architecture of human walking. The body is based on principles derived from human muscular architecture, using muscles on straps to mimic agonist/antagonist muscle action as well as bifunctional muscles. Load sensors in the straps model Golgi tendon organs. The neural architecture is a central pattern generator (CPG) composed of a half-center oscillator combined with phase-modulated reflexes that is simulated using a spiking neural network. We show that the interaction between the reflex system, body dynamics and CPG results in a walking cycle that is entrained to the dynamics of the system. We also show that the CPG helped stabilize the gait against perturbations relative to a purely reflexive system, and compared the joint trajectories to human walking data. This robot represents a complete physical, or 'neurorobotic', model of the system, demonstrating the usefulness of this type of robotics research for investigating the neurophysiological processes underlying walking in humans and animals.

Safety and tolerance of the ReWalk™ exoskeleton suit for ambulation by people with complete spinal cord injury: a pilot study

OBJECTIVES

The objective of the study was to evaluate the safety and tolerance of use of the ReWalk™ exoskeleton ambulation system in people with spinal cord injury. Measures of functional ambulation were also assessed and correlated to neurological spinal cord level, age, and duration since injury.

STUDY DESIGN

Case series observational study.

SETTING

A national spinal cord injury centre.

METHODS

Six volunteer participants were recruited from the follow-up outpatient clinic. Safety was assessed with regard to falls, status of the skin, status of the spine and joints, blood pressure, pulse, and electrocardiography (ECG). Pain and fatigue were graded by the participants using a visual analogue scale pre- and post-training. Participants completed a 10-statement questionnaire regarding safety, comfort, and secondary medical effects. After being able to walk 100 m, timed up and go, distance walked in 6 minutes and 10-m timed walk were measured.

RESULTS

There were no adverse safety events. Use of the system was generally well tolerated, with no increase in pain and a moderate level of fatigue after use. Individuals with lower level of spinal cord injury performed walking more efficiently.

CONCLUSION

Volunteer participants were able to ambulate with the ReWalk™ for a distance of 100 m, with no adverse effects during the course of an average of 13-14 training sessions. The participants were generally positive regarding the use of the system.

Rehabilitation of gait after stroke: a review towards a top-down approach

This document provides a review of the techniques and therapies used in gait rehabilitation after stroke. It also examines the possible benefits of including assistive robotic devices and brain-computer interfaces in this field, according to a top-down approach, in which rehabilitation is driven by neural plasticity.The methods reviewed comprise classical gait rehabilitation techniques (neurophysiological and motor learning approaches), functional electrical stimulation (FES), robotic devices, and brain-computer interfaces (BCI).From the analysis of these approaches, we can draw the following conclusions. Regarding classical rehabilitation techniques, there is insufficient evidence to state that a particular approach is more effective in promoting gait recovery than other. Combination of different rehabilitation strategies seems to be more effective than over-ground gait training alone. Robotic devices need further research to show their suitability for walking training and their effects on over-ground gait. The use of FES combined with different walking retraining strategies has shown to result in improvements in hemiplegic gait. Reports on non-invasive BCIs for stroke recovery are limited to the rehabilitation of upper limbs; however, some works suggest that there might be a common mechanism which influences upper and lower limb recovery simultaneously, independently of the limb chosen for the rehabilitation therapy. Functional near infrared spectroscopy (fNIRS) enables researchers to detect signals from specific regions of the cortex during performance of motor activities for the development of future BCIs. Future research would make possible to analyze the impact of rehabilitation on brain plasticity, in order to adapt treatment resources to meet the needs of each patient and to optimize the recovery process.

Periodic limb movements during sleep and restless legs syndrome in patients with ASIA A spinal cord injury

OBJECTIVE

To establish the occurrence of Periodic Leg Movements (PLM) and Restless Legs Syndrome (RLS) in Spinal Cord Injury (SCI) subjects.

METHODS

In this study, twenty four patients were submitted to a full night polysomnography and were assessed with Epworth Sleepiness Scale and an adapted form of International Restless Legs Syndrome Scale Rating Scale (IRLS Rating Scale). Control Group (CG) was composed of 16 subjects, 50% of each sex, age: 24.38±4 years old. Spinal Cord Injury Group (SCIG) was composed of 8 subjects (29±5 years old) with a complete SCI (ASIA A) of about three and a half years of duration, 100% males.

RESULTS

100% of SCIG had RLS compared to 17% in CG (p<0.0001). SCIG had 18.11±20.07 of PLM index while CG had 5.96±11.93 (p=0.01). Arousals related to PLM were recorded in CG and SCIG. There was a positive moderate correlation between RLS and age (r=0.5; p=0.01), RLS and PLM (r=0.49; p=0.01), adapted IRLS Rating Scale and PLM index (r=0.64; p=0.03) and also a negative moderate correlation between Epworth Sleepiness Scale and PLM index (r=-0.4; p=0.04) in both groups.

CONCLUSION

RLS and PLM are common findings in SCI patients with a complete injury.

Tonic Central and Sensory Stimuli Facilitate Involuntary Air-Stepping in Humans

Air-stepping can be used as a model for investigating rhythmogenesis and its interaction with sensory input. Here we show that it is possible to entrain involuntary rhythmic movement patterns in healthy humans by using different kinds of stimulation techniques. The subjects lay on their sides with one or both legs suspended, allowing low-friction horizontal rotation of the limb joints. To evoke involuntary stepping of the suspended leg, either we used continuous muscle vibration, electrical stimulation of the superficial peroneal or sural nerves, the Jendrassik maneuver, or we exploited the postcontraction state of neuronal networks (Kohnstamm phenomenon). The common feature across all stimulations was that they were tonic. Air-stepping could be elicited by most techniques in about 50% of subjects and involved prominent movements at the hip and the knee joint (∼40–70°). Typically, however, the ankle joint was not involved. Minimal loading forces (4–25 N) applied constantly to the sole (using a long elastic cord) induced noticeable (∼5–20°) ankle-joint-angle movements. The aftereffect of a voluntary long-lasting (30-s) contraction in the leg muscles featured alternating rhythmic leg movements that lasted for about 20–40 s, corresponding roughly to a typical duration of the postcontraction activity in static conditions. The Jendrassik maneuver per se did not evoke air-stepping. Nevertheless, it significantly prolonged rhythmic leg movements initiated manually by an experimenter or by a short (5-s) period of muscle vibration. Air-stepping of one leg could be evoked in both forward and backward directions with frequent spontaneous transitions, whereas involuntary alternating two-legged movements were more stable (no transitions). The hypothetical role of tonic influences, contact forces, and bilateral coordination in rhythmogenesis is discussed. The results overall demonstrated that nonspecific tonic drive may cause air-stepping and the characteristics and stability of the evoked pattern depended on the sensory input.

Distributed neural networks for controlling human locomotion: lessons from normal and SCI subjects

The control of human locomotion engages various brain structures and numerous muscles. Even though the hypothetical central pattern generator (CPG) and sensory feedback can sustain the basic locomotor rhythm, the resultant motor output is highly adaptable and context-dependent. Indeed, while the temporal architecture of the locomotor output (basic EMG components) is relatively conserved across subjects and conditions, the spatial architecture (muscle activations) shows considerable non-linear changes with walking speed, level of body unloading or the direction of progression. Even so, leg kinematics are remarkably similar in all cases. Spinal cord injured (SCI) patients may learn new motor patterns with training rather than re-activate normal motor patterns, and such locomotor improvements may not transfer to untrained tasks. Redundancy in the neuromuscular system or malfunctioning of injured 'elements' may often result in motor equivalent compensatory solutions. Injured pathways can partially recover while uninjured pathways can augment or modify their activity. As a result, the reconstructed spatiotemporal maps of motor neuron activity in SCI patients might be quite different from those of healthy subjects but they nevertheless achieve nearly normal foot kinematics. Kinematics training may thus provide a more successful rehabilitation than training based on reconstructing normal muscle activation patterns. Taken together, recent data support the idea of plasticity and distributed networks for controlling human locomotion. A new generation of robotic devices takes advantage of this by providing the opportunity for patients to generate and correct limb movements rather than just adapting muscle activation to the fixed kinematic template imposed by a gait orthosis.