Paralysis recovery in humans and model systems

The intractable problems with brain death and possible solutions

Brain death has been accepted worldwide medically and legally as the biological state of death of the organism. Nevertheless, the literature has described persistent problems with this acceptance ever since brain death was described. Many of these problems are not widely known or properly understood by much of the medical community. Here we aim to clarify these issues, based on the two intractable problems in the brain death debates. First, the metaphysical problem: there is no reason that withstands critical scrutiny to believe that BD is the state of biological death of the human organism. Second, the epistemic problem: there is no way currently to diagnose the state of BD, the irreversible loss of all brain functions, using clinical tests and ancillary tests, given potential confounders to testing. We discuss these problems and their main objections and conclude that these problems are intractable in that there has been no acceptable solution offered other than bare assertions of an 'operational definition' of death. We present possible ways to move forward that accept both the metaphysical problem - that BD is not biological death of the human organism - and the epistemic problem - that as currently diagnosed, BD is a devastating neurological state where recovery of sentience is very unlikely, but not a confirmed state of irreversible loss of all [critical] brain functions. We argue that the best solution is to abandon the dead donor rule, thus allowing vital organ donation from patients currently diagnosed as BD, assuming appropriate changes are made to the consent process and to laws about killing.

FES Cycling and Closed-Loop Feedback Control for Rehabilitative Human–Robot Interaction

For individuals with movement impairments due to neurological injuries, rehabilitative therapies such as functional electrical stimulation (FES) and rehabilitation robots hold vast potential to improve their mobility and activities of daily living. Combining FES with rehabilitation robots results in intimately coordinated human–robot interaction. An example of such interaction is FES cycling, where motorized assistance can provide high-intensity and repetitive practice of coordinated limb motion, resulting in physiological and functional benefits. In this paper, the development of multiple FES cycling testbeds and safeguards is described, along with the switched nonlinear dynamics of the cycle–rider system. Closed-loop FES cycling control designs are described for cadence and torque tracking. For each tracking objective, the authors’ past work on robust and adaptive controllers used to compute muscle stimulation and motor current inputs is presented and discussed. Experimental results involving both able-bodied individuals and participants with neurological injuries are provided for each combination of controller and tracking objective. Trade-offs for the control algorithms are discussed based on the requirements for implementation, desired rehabilitation outcomes and resulting rider performance. Lastly, future works and the applicability of the developed methods to additional technologies including teleoperated robotics are outlined.

Electrical Stimulation as a Tool to Promote Plasticity of the Injured Spinal Cord

Unlike their peripheral nervous system counterparts, the capacity of central nervous system neurons and axons for regeneration after injury is minimal. Although a myriad of therapies (and different combinations thereof) to help promote repair and recovery after spinal cord injury (SCI) have been trialed, few have progressed from bench-top to bedside. One of the few such therapies that has been successfully translated from basic science to clinical applications is electrical stimulation (ES). Although the use and study of ES in peripheral nerve growth dates back nearly a century, only recently has it started to be used in a clinical setting. Since those initial experiments and seminal publications, the application of ES to restore function and promote healing have greatly expanded. In this review, we discuss the progression and use of ES over time as it pertains to promoting axonal outgrowth and functional recovery post-SCI. In doing so, we consider four major uses for the study of ES based on the proposed or documented underlying mechanism: (1) using ES to introduce an electric field at the site of injury to promote axonal outgrowth and plasticity; (2) using spinal cord ES to activate or to increase the excitability of neuronal networks below the injury; (3) using motor cortex ES to promote corticospinal tract axonal outgrowth and plasticity; and (4) leveraging the timing of paired stimuli to produce plasticity. Finally, the use of ES in its current state in the context of human SCI studies is discussed, in addition to ongoing research and current knowledge gaps, to highlight the direction of future studies for this therapeutic modality.

Improvements in skilled walking associated with kinematic adaptations in people with spinal cord injury

Introduction

Individuals with motor-incomplete SCI (m-iSCI) remain limited community ambulators, partly because they have difficulty with the skilled walking requirements of everyday life that require adaptations in inter-joint coordination and range of motion of the lower limbs. Following locomotor training, individuals with SCI show improvements in skilled walking and walking speed, however there is limited understanding of how adaptations in lower limb kinematics following training contribute to improvements in walking.

Objective

To determine the relationship between changes in lower limb kinematics (range of motion and inter-joint coordination) and improvements in walking function (walking speed and skilled walking) following locomotor training.

Methods

Lower limb kinematics were recorded from 8 individuals with chronic m-iSCI during treadmill walking before and after a 3-month locomotor training program. Data were also collected from 5 able-bodied individuals to provide normative values. In individuals with SCI, muscle strength was used to define the stronger and weaker limb. Motion analysis was used to determine, hip, knee and ankle angles. Joint angle-angle plots (cyclograms) were used to quantify inter-joint coordination. Shape differences between pre-and post-training cyclograms were used to assess the changes in coordination and their relation to improvements in walking function. Walking function was assessed using the 10MWT for walking speed and the SCI-FAP for skilled walking. Comparing pre- and post-training cyclograms to the able-bodied pattern was used to understand the extent to which changes in coordination involved the recovery of normative motor patterns.

Results

Following training, improvements in skilled walking were significantly related to changes in hip-ankle coordination (ρ = − .833, p = 0.010) and knee range of motion (ρ = .833, p = 0.010) of the weaker limb. Inter-joint coordination tended to revert towards normative patterns, but not completely. No relationships were observed with walking speed.

Conclusion

Larger changes in hip-ankle coordination and a decrease in knee range of motion in the weaker limb during treadmill walking were related to improvements in skilled walking following locomotor training in individuals with SCI. The changes in coordination seem to reflect some restoration of normative patterns and the adoption of compensatory strategies, depending on the participant.

Use of Lower-Limb Robotics to Enhance Practice and Participation in Individuals With Neurological Conditions

PURPOSE

To review lower-limb technology currently available for people with neurological disorders, such as spinal cord injury, stroke, or other conditions. We focus on 3 emerging technologies: treadmill-based training devices, exoskeletons, and other wearable robots.

SUMMARY OF KEY POINTS

Efficacy for these devices remains unclear, although preliminary data indicate that specific patient populations may benefit from robotic training used with more traditional physical therapy. Potential benefits include improved lower-limb function and a more typical gait trajectory.

STATEMENT OF CONCLUSIONS

Use of these devices is limited by insufficient data, cost, and in some cases size of the machine. However, robotic technology is likely to become more prevalent as these machines are enhanced and able to produce targeted physical rehabilitation.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Therapists should be aware of these technologies as they continue to advance but understand the limitations and challenges posed with therapeutic/mobility robots.

Prognostic Factors for Recovery of Patients After Surgery for Thoracic Spinal Tuberculosis

BACKGROUND

Thoracic spinal tuberculosis (TST) is a dangerous disease. Besides antituberculosis chemotherapy, surgery is also necessary for treating TST. To date, no study has focused on the prognostic factors for recovery of patients after surgery for TST.

METHODS

From 2001-2016, 237 patients who underwent surgery for TST in our department were included in this study. Japanese Orthopedic Association score was used to assess recovery after surgery. Kaplan-Meier method and Cox regression analysis were employed to identify the significant prognostic factors.

RESULTS

Univariate analysis demonstrated that diabetes, paralysis, kyphosis, duration of symptoms (≥3/<3 months), and number of involved vertebrae (>2/≤2) were identified as potential prognostic factors responsible for recovery after surgery for TST. Multivariate analysis suggested that paralysis, duration of symptoms (≥3/<3 months), and number of involved vertebrae (>2/≤2) were identified as the significant prognostic factors responsible for recovery after surgery for TST.

CONCLUSIONS

This study supports the previously published evidence that nonparalysis, shorter duration of symptoms, and fewer involved vertebrae are favorable prognostic factors for recovery after surgery for TST. For a better recovery effect, the key points for treating TST were timely diagnosis and treatment. It is urgent for government to arouse attention and popularize the knowledge of spinal tuberculosis.

Canadian Association of Neuroscience Review: Axonal Regeneration in the Peripheral and Central Nervous Systems – Current Issues and Advances

Injured nerves regenerate their axons in the peripheral (PNS) but not the central nervous system (CNS). The contrasting capacities have been attributed to the growth permissive Schwann cells in the PNS and the growth inhibitory environment of the oligodendrocytes in the CNS. In the current review, we first contrast the robust regenerative response of injured PNS neurons with the weak response of the CNS neurons, and the capacity of Schwann cells and not the oligodendrocytes to support axonal regeneration. We then consider the factors that limit axonal regeneration in both the PNS and CNS. Limiting factors in the PNS include slow regeneration of axons across the injury site, progressive decline in the regenerative capacity of axotomized neurons (chronic axotomy) and progressive failure of denervated Schwann cells to support axonal regeneration (chronic denervation). In the CNS on the other hand, it is the poor regenerative response of neurons, the inhibitory proteins that are expressed by oligodendrocytes and act via a common receptor on CNS neurons, and the formation of the glial scar that prevent axonal regeneration in the CNS. Strategies to overcome these limitations in the PNS are considered in detail and contrasted with strategies in the CNS.

Neuroplasticity and Repair in Rodent Neurotoxic Models of Spinal Motoneuron Disease

Retrogradely transported toxins are widely used to set up protocols for selective lesioning of the nervous system. These methods could be collectively named "molecular neurosurgery" because they are able to destroy specific types of neurons by using targeted neurotoxins. Lectins such as ricin, volkensin, or modeccin and neuropeptide- or antibody-conjugated saporin represent the most effective toxins used for neuronal lesioning. Some of these specific neurotoxins could be used to induce selective depletion of spinal motoneurons. In this review, we extensively describe two rodent models of motoneuron degeneration induced by volkensin or cholera toxin-B saporin. In particular, we focus on the possible experimental use of these models to mimic neurodegenerative diseases, to dissect the molecular mechanisms of neuroplastic changes underlying the spontaneous functional recovery after motoneuron death, and finally to test different strategies of neural repair. The potential clinical applications of these approaches are also discussed.

Activity-based therapy for recovery of walking in individuals with chronic spinal cord injury: results from a randomized clinical trial

OBJECTIVE

To examine the effects of activity-based therapy (ABT) on neurologic function, walking ability, functional independence, metabolic health, and community participation.

DESIGN

Randomized controlled trial with delayed treatment design.

SETTING

Outpatient program in a private, nonprofit rehabilitation hospital.

PARTICIPANTS

Volunteer sample of adults (N=48; 37 men and 11 women; age, 18-66y) with chronic (≥12mo postinjury), motor-incomplete (ASIA Impairment Scale grade C or D) spinal cord injury (SCI).

INTERVENTIONS

A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression.

MAIN OUTCOME MEASURES

Neurologic function (International Standards for Neurological Classification of Spinal Cord Injury); walking speed and endurance (10-meter walk test, 6-minute walk test, and Timed Up and Go test); community participation (Spinal Cord Independence Measure, version III, and Reintegration to Normal Living Index); and metabolic function (weight, body mass index, and Quantitative Insulin Sensitivity Check).

RESULTS

Significant improvements in neurologic function were noted for experimental versus control groups (International Standards for Neurological Classification of Spinal Cord Injury total motor score [5.1±6.3 vs 0.9±5.0; P=.024] and lower extremity motor score [4.2±5.2 vs -0.6±4.2; P=.004]). Significant differences between experimental and control groups were observed for 10-meter walk test speed (0.096±0.14m/s vs 0.027±0.10m/s; P=.036) and 6-minute walk test total distance (35.97±48.2m vs 3.0±25.5m; P=.002).

CONCLUSIONS

ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, further analysis is needed to determine for whom ABT is going to lead to meaningful clinical benefits.

Tissue sparing, behavioral recovery, supraspinal axonal sparing/regeneration following sub-acute glial transplantation in a model of spinal cord contusion

Background

It has been shown that olfactory ensheathing glia (OEG) and Schwann cell (SCs) transplantation are beneficial as cellular treatments for spinal cord injury (SCI), especially acute and sub-acute time points. In this study, we transplanted DsRED transduced adult OEG and SCs sub-acutely (14 days) following a T10 moderate spinal cord contusion injury in the rat. Behaviour was measured by open field (BBB) and horizontal ladder walking tests to ascertain improvements in locomotor function. Fluorogold staining was injected into the distal spinal cord to determine the extent of supraspinal and propriospinal axonal sparing/regeneration at 4 months post injection time point. The purpose of this study was to investigate if OEG and SCs cells injected sub acutely (14 days after injury) could: (i) improve behavioral outcomes, (ii) induce sparing/regeneration of propriospinal and supraspinal projections, and (iii) reduce tissue loss.

Results

OEG and SCs transplanted rats showed significant increased locomotion when compared to control injury only in the open field tests (BBB). However, the ladder walk test did not show statistically significant differences between treatment and control groups. Fluorogold retrograde tracing showed a statistically significant increase in the number of supraspinal nuclei projecting into the distal spinal cord in both OEG and SCs transplanted rats. These included the raphe, reticular and vestibular systems. Further pairwise multiple comparison tests also showed a statistically significant increase in raphe projecting neurons in OEG transplanted rats when compared to SCs transplanted animals. Immunohistochemistry of spinal cord sections short term (2 weeks) and long term (4 months) showed differences in host glial activity, migration and proteoglycan deposits between the two cell types. Histochemical staining revealed that the volume of tissue remaining at the lesion site had increased in all OEG and SCs treated groups. Significant tissue sparing was observed at both time points following glial SCs transplantation. In addition, OEG transplants showed significantly decreased chondroitin proteoglycan synthesis in the lesion site, suggesting a more CNS tolerant graft.

Conclusions

These results show that transplantation of OEG and SCs in a sub-acute phase can improve anatomical outcomes after a contusion injury to the spinal cord, by increasing the number of spared/regenerated supraspinal fibers, reducing cavitation and enhancing tissue integrity. This provides important information on the time window of glial transplantation for the repair of the spinal cord.

One-year evolution of ulnar somatosensory potentials after trauma in 365 tetraplegic patients: early prediction of potential upper limb function

Early prediction of hand function is crucial for efficient rehabilitation of cervical spinal cord injury (cSCI). This study investigated correlations between ulnar somatosensory evoked potentials (ulnar SSEPs) and functional outcome of hand function following acute traumatic cervical cord injury. Neurological assessment of sensory scores and hand function were compared with five ulnar SSEP categories of similar persistence and quality in 365 patients throughout the first year after cSCI. Of the 365 patients, 218 (68%) exhibited ulnar SSEP potentials at any one stage during the year, and in 147 patients (40.3%) ulnar SSEPs were obtainable at every assessment stage. While ulnar SSEP latency and amplitude assessments remained largely unchanged over time in the majority of patients, hand function improved remarkably during the first year following cSCI. One year outcome of hand function was predetermined by ulnar SSEP category due to distinct differences in the ulnar SSEP parameters. Additionally, an early prognostic group allocation by ulnar SSEP criteria at the first assessment stage within 4 weeks after spinal trauma allowed reliable prediction of hand function outcome after 1 year. We conclude that early assessment of ulnar SSEP as a non-invasive and objective neurophysiological test is a valuable marker of prospective hand function and independence 1 year after cSCI. This could be most relevant for planning neurorehabilitation, and in prospective clinical SCI trials.

Animal models of neurologic disorders: a nonhuman primate model of spinal cord injury

Primates are an important and unique animal resource. We have developed a nonhuman primate model of spinal cord injury (SCI) to expand our knowledge of normal primate motor function, to assess the impact of disease and injury on sensory and motor function, and to test candidate therapies before they are applied to human patients. The lesion model consists of a lateral spinal cord hemisection at the C7 spinal level with subsequent examination of behavioral, electrophysiological, and anatomical outcomes. Results to date have revealed significant neuroanatomical and functional differences between rodents and primates that impact the development of candidate therapies. Moreover, these findings suggest the importance of testing some therapeutic approaches in nonhuman primates prior to the use of invasive approaches in human clinical trials. Our primate model is intended to: 1) lend greater positive predictive value to human translatable therapies, 2) develop appropriate methods for human translation, 3) lead to basic discoveries that might not be identified in rodent models and are relevant to human translation, and 4) identify new avenues of basic research to "reverse-translate" important questions back to rodent models.

Melatonin plus exercise-based neurorehabilitative therapy for spinal cord injury

Spinal cord injury (SCI) is damage to the spinal cord caused by the trauma or disease that results in compromised or loss of body function. Subsequent to SCI in humans, many individuals have residual motor and sensory deficits that impair functional performance and quality of life. The available treatments for SCI are rehabilitation therapy, activity-based therapies, and pharmacological treatment using antioxidants and their agonists. Among pharmacological treatments, the most efficient and commonly used antioxidant for experimental SCI treatment is melatonin, an indolamine secreted by pineal gland at night. Melatonin's receptor-independent free radical scavenging action and its broad-spectrum antioxidant activity makes it an ideal antioxidant to protect tissue from oxidative stress-induced secondary damage after SCI. Owing to the limitations of an activity-based therapy and antioxidant treatment singly on the functional recovery and oxidative stress-induced secondary damages after SCI, a melatonin plus exercise treatment may be a more effective therapy for SCI. As suggested herein, supplementation with melatonin in conjunction with exercise not only would improve the functional recovery by enhancing the beneficial effects of exercise but would reduce the secondary tissue damage simultaneously. Finally, melatonin may protect against exercise-induced fatigue and impairments. In this review, based on the documented evidence regarding the beneficial effects of melatonin, activity-based therapy and the combination of both on functional recovery, as well as reduction of secondary damage caused by oxidative stress after SCI, we suggest the melatonin combined with exercise would be a novel neurorehabilitative strategy for the faster recovery after SCI.

Synergistic effect of melatonin on exercise-induced neuronal reconstruction and functional recovery in a spinal cord injury animal model

Nitric oxide (NO) may aggravate neuronal damage after spinal cord injury (SCI). We hypothesized that NO produced by inducible nitric oxide synthase (iNOS) accelerates secondary damage to spinal tissue, which may be reversed by the neuroprotectant, melatonin. This study investigated the effects of combination therapy with melatonin (10 mg/kg) and exercise (10 m/min) on recovery from SCI caused by contusion. We examined locomotor recovery, iNOS gene expression, autophagic and apoptotic signaling, including Beclin-1, LC3, p53 and IKKalpha protein expression and histological alterations in the ventral horn of the spinal cord. Melatonin in combination with exercise resulted in significantly increased hindlimb movement (P < 0.05), a reduced level of iNOS mRNA (P < 0.05) and more motor neurons in the ventral horn, versus control SCI and SCI plus exercise alone, with no effect on the other signaling molecules examined. This study shows that combined therapy with melatonin and exercise reduces the degree of secondary damage associated with SCI in rats and supports the possible use of melatonin in combination with exercise to reduce the side effects related to exercise-induced fatigue and impairment.

Activity-dependent plasticity in spinal cord injury

The adult mammalian central nervous system (CNS) is capable of considerable plasticity, both in health and disease. After spinal neurotrauma, the degrees and extent of neuroplasticity and recovery depend on multiple factors, including the level and extent of injury, postinjury medical and surgical care, and rehabilitative interventions. Rehabilitation strategies focus less on repairing lost connections and more on influencing CNS plasticity for regaining function. Current evidence indicates that strategies for rehabilitation, including passive exercise, active exercise with some voluntary control, and use of neuroprostheses, can enhance sensorimotor recovery after spinal cord injury (SCI) by promoting adaptive structural and functional plasticity while mitigating maladaptive changes at multiple levels of the neuraxis. In this review, we will discuss CNS plasticity that occurs both spontaneously after SCI and in response to rehabilitative therapies.

Animal models in spinal cord injury: a review

Multiple neuroprotective agents have shown benefit for the treatment of acute spinal cord injury (SCI) in animal studies. However, clinical trials have, thus far, been uniformly disappointing. This review explores reasons for discrepancies between promising animal studies and disappointing clinical trials and potential barriers to extrapolation of research results from animals to humans. The three major barriers disclosed are: differences in injury type between laboratory-induced SCI and clinical SCI, difficulties in interpreting functional outcome in animals, and inter-species and interstrain differences in pathophysiology of SCI. These barriers can impair the effectiveness of animal models of SCI to predict human outcomes. While some of these barriers can be overcome, others are inherent to the animal models.

Exercise and brain health--implications for multiple sclerosis: Part II--immune factors and stress hormones

Part I of this review addressed the possible modulatory role of exercise on neuronal growth factors to promote brain health in neurodegenerative diseases such as multiple sclerosis (MS), which is characterized by varied patterns of inflammation, demyelination and axonal loss. Part II presents evidence that supports the potential neuroprotective effect of exercise on the modulation of immune factors and stress hormones in MS. Many current therapies used to attenuate MS progression are mediated, at least in part, through alterations in the relative concentrations of pro- and anti-inflammatory cytokines. Exercise-induced alterations in local and systemic cytokine production may also benefit immune function in health and disease. Exercise immunomodulation appears to be mediated by a complex interaction of hormones, cytokines and neural factors that may favorably influence immune variables in MS. The promising interplay between exercise and brain health in MS deserves further investigation.

Training locomotor networks

For a complete adult spinal rat to regain some weight-bearing stepping capability, it appears that a sequence of specific proprioceptive inputs that are similar, but not identical, from step to step must be generated over repetitive step cycles. Furthermore, these cycles must include the activation of specific neural circuits that are intrinsic to the lumbosacral spinal cord segments. For these sensorimotor pathways to be effective in generating stepping, the spinal circuitry must be modulated to an appropriate excitability level. This level of modulation is sustained from supraspinal input in intact, but not spinal, rats. In a series of experiments with complete spinal rats, we have shown that an appropriate level of excitability of the spinal circuitry can be achieved using widely different means. For example, this modulation level can be acquired pharmacologically, via epidural electrical stimulation over specific lumbosacral spinal cord segments, and/or by use-dependent mechanisms such as step or stand training. Evidence as to how each of these treatments can "tune" the spinal circuitry to a "physiological state" that enables it to respond appropriately to proprioceptive input will be presented. We have found that each of these interventions can enable the proprioceptive input to actually control extensive details that define the dynamics of stepping over a range of speeds, loads, and directions. A series of experiments will be described that illustrate sensory control of stepping and standing after a spinal cord injury and the necessity for the "physiological state" of the spinal circuitry to be modulated within a critical window of excitability for this control to be manifested. The present findings have important consequences not only for our understanding of how the motor pattern for stepping is formed, but also for the design of rehabilitation intervention to restore lumbosacral circuit function in humans following a spinal cord injury.

A systematic review of the efficacy of gait rehabilitation strategies for spinal cord injury

OBJECTIVE: To systematically review the evidence for the efficacy of different rehabilitation strategies on functional ambulation following spinal cord injury (SCI). METHODS: A keyword literature search of original articles was used to identify published literature evaluating the effectiveness of any treatment or therapy on functional ambulation in people with SCI. The rigor and quality of each study were scored on standardized scales by two independent reviewers. RESULTS: The search yielded 160 articles, of which 119 were excluded for not meeting our inclusion criteria. The remaining 41 articles covered various strategies for improving gait: bodyweight supported treadmill training (BWSTT) (n=12), functional electrical stimulation (FES) (n=7), braces/orthoses (n=10), or a combination of these (n=12). There is strong evidence from randomized controlled trials that functional ambulation outcomes following body-weight supported treadmill training (BWSTT) are comparable to an equivalent intensity of overground gait training in sub-acute SCI. In chronic SCI, evidence from pre-test/post-test studies shows that BWSTT may be effective in improving functional ambulation. Pre-test/post-test or post-test only studies provide evidence that FES may augment functional ambulation in sub-acute/chronic SCI while braces may afford particular benefits to people with complete SCI to stand up and ambulate with assistive devices. CONCLUSIONS: Rehabilitation strategies that facilitate repeated practice of gait offer the greatest benefits to functional ambulation in sub-acute or chronic SCI. Supportive devices may augment functional ambulation particularly in people with incomplete SCI.

Implantation of pure cultured olfactory ensheathing cells in an animal model of parkinsonism

BACKGROUND

Implantation of neural cells has been proposed as a therapeutic strategy for repairing the injured or diseased brain. In the present study we have examined the potential of olfactory ensheathing cells (OEC) to promote brain repair after surgical implantation in a rodent model of parkinsonism.

METHODS

Neonatal OECs were implanted in the striatum after a 6-hydroxydopamine lesion of the ipsilateral substantia nigra. Amphetamine-induced rotational asymmetry scores were determined 48 hours before and 4, 6 and 8 weeks after OEC implantation. The density of immunostaining for tyrosine hydroxylase and synaptophysin in the striatum and the number of tyrosine hydroxylase-positive cells remaining in the substantia nigra were also determined.

RESULTS

Rotational asymmetry scores were similar in OEC-implanted and vehicle-treated groups at all time points examined, and at each time were similar to those observed prior to implantation. Levels of striatal tyrosine-hydroxylase and synaptophysin immunoreactivity were similar in OEC- and vehicle-treated groups. The number of tyrosine-hydroxylase-positive cells in the substantia nigra was similar in both groups indicating that severity of the lesion was similar. Visualisation of GFP-labelled OECs one week after implantation in a separate group of animals revealed the cells to be located in the area immediately surrounding the needle tract.

CONCLUSION

This study demonstrates that implantation of OECs alone is not sufficient to promote tissue repair and functional recovery in a rodent model of parkinsonism. The results add to a growing number of studies that propose a caveat for the use of pure OECs as a neurosurgical strategy for the treatment of brain disease or injury.

Synaptic plasticity modulates the spontaneous recovery of locomotion after spinal cord hemisection

Several evidences have demonstrated that adult mammals could achieve a wide range of spontaneous sensory-motor recovery after spinal cord injury by means of various forms of neuroplasticity. In this study we evaluated the possibility that after low-thoracic spinal cord hemisection in the adult rat, significant hindlimb locomotor recovery could occur, and that this recovery may be driven, at least in part, by mechanisms of synaptic plasticity. In order to address these issues, we measured the expression levels of synapsin-I and brain-derived neurotrophic factor by Western blotting, at various time points after hemisection and correlated them with the motor performance on a grid walk test. Regression analysis showed that the expression of synapsin-I was strongly correlated with the spontaneous recovery of hindlimb locomotion (R=0.78). Conversely, neither the expression levels of synapsin-I nor the locomotor recovery were associated with the expression of brain-derived neurotrophic factor. Overall results indicate that after spinal cord hemisection, substantial recovery of hindlimb locomotion could occur spontaneously, and that synaptic plasticity within spinal circuitries below the level of the lesion, could be an important mechanism involved in these processes.

The impact of spinal cord injury on sexual function: concerns of the general population

STUDY DESIGN

Secure, web-based survey.

OBJECTIVES

Obtain information from the spinal cord injured (SCI) population regarding sexual dysfunctions, with the aim of developing new basic science and clinical research and eventual therapies targeting these issues.

SETTING

Worldwide web.

METHODS

Individuals 18 years or older living with SCI. Participants obtained a pass-code to enter a secure website and answered survey questions. A total of 286 subjects completed the survey.

RESULTS

The majority of participants stated that their SCI altered their sexual sense of self and that improving their sexual function would improve their quality of life (QoL). The primary reason for pursuing sexual activity was for intimacy need, not fertility. Bladder and bowel concerns during sexual activity were not strong enough to deter the majority of the population from engaging in sexual activity. However, in the subset of individuals concerned about bladder and/or bowel incontinence during sexual activity, this was a highly significant issue. In addition, the occurrence of autonomic dysreflexia (AD) during typical bladder or bowel care was a significant variable predicting the occurrence and distress of AD during sexual activity.

CONCLUSION

Sexual function and its resultant impact on QoL is a major issue to an overwhelming majority of people living with SCI. This certainly constitutes the need for expanding research in multiple aspects to develop future therapeutic interventions for sexual health and SCI.

Adaptations in the walking pattern of spinal cord injured rats

Walking ability is a measure of recovery used in many studies that test experimental strategies to treat injuries or diseases of the central nervous system (CNS) in animal models. A common measure in the rat animal model of thoracic spinal cord injury (SCI) is visual inspection and scoring of hind limb activity, which allows the documentation of movements associated with the recovery of locomotor function. In this study, we expand on previously documented visible changes in the locomotor pattern following SCI. The spontaneous recovery of locomotion in rats with thoracic SCIs of variable extent was evaluated using electromyographic (EMG) and kinematic analysis while rats walked on an elevated runway. Comparisons with pre-lesion walking sequences revealed changes in the kinematics and in the muscle activation pattern of various muscles, including enhanced fore limb extensor activity, possibly reflecting an increased contribution to propulsion, altered recruitment of back muscles inserting into the hip (possibly to support stepping movements), and elevated posture during stance, which may compensate for deficits in weight support. These changes were noted in spinal cord injured rats with varying degrees of impairment, including animals with no visually detectable deficit in open-field walking. In summary, the presented results demonstrate that spinal cord injured rats develop alternative locomotor patterns following SCI that cannot be discriminated by the use of qualitative visually based analysis, thus urging the use of quantitative outcome measures in assessing motor function after SCI.

Degenerative and spontaneous regenerative processes after spinal cord injury

Spinal cord injury results in acute as well as progressive secondary destruction of local and distant nervous tissue through a number of degenerative mechanisms. Spinal cord injury also initiates a number of endogenous neuroprotective and regenerative responses. Understanding of these mechanisms might identify potential targets for treatments after spinal cord injury in humans. Here, we first discuss recent developments in our understanding of the immediate traumatic and subsequent secondary degeneration of local tissue and long projecting pathways in animal models. These include the inflammatory and vascular responses during the acute phase, as well as cell death, demyelination and scar formation in the subacute and chronic phases. Secondly, we discuss the spontaneous axonal regeneration of injured and plasticity of uninjured systems, and other repair-related responses in animals, including the upregulation of regeneration-associated genes in some neurons, increases in neurotrophic factors in the spinal cord and remyelination by oligodendrocyte precursors and invading Schwann cells. Lastly, we comment on the still limited understanding of the neuropathology in humans, which is largely similar to that in rodents. However, there also are potentially important differences, including the reduced glial scarring, inflammation and demyelination, the increased Schwannosis and the protracted Wallerian degeneration in humans. The validity of current rodent models for human spinal cord injury is also discussed. The emphasis of this review is on the literature from 2002 to early 2005.

The Effect of a Spinal Cord Hemisection on Changes in Nitric Oxide Synthase Pools in the Site of Injury and in Regions Located Far Away from the Injured Site

1. The present study was designed to examine the nitric oxide synthase activities (constitutive and inducible) in the site of injury in response to Th10-Th11 spinal cord hemisection and, to determine whether unilateral disconnection of the spinal cord influences the NOS pools on the contra- and ipsilateral sides in segments located far away from the epicentre of injury. 2. A radioassay detection was used to determine Ca(2+)-dependent and inducible nitric oxide synthase activities. Somal, axonal and neuropil neuronal nitric oxide synthase was assessed by immunocytochemical study. A quantitative assessment of neuronal nitric oxide synthase immunoreactivity was made by an image analyser. The level of neuronal nitric oxide synthase protein was measured by the Western blot analysis. 3. Our data show the increase of inducible nitric oxide synthase activity and a decrease of Ca(2+)-dependent nitric oxide synthase activity in the injured site analysed 1 and 7 days after surgery. In segments remote from the epicentre of injury the inducible nitric oxide synthase activity was increased at both time points. Ca(2+)-dependent nitric oxide synthase activity had decreased in L5-S1 segments in a group of animals surviving for 7 days. A hemisection performed at thoracic level did not cause significant difference in the nitric oxide synthase activities and in the level of neuronal nitric oxide synthase protein between the contra- and ipsilateral sides in C6-Th1 and L5-S1 segments taken as a whole. Significant differences were observed, but only when the spinal cord was analysed segment by segment, and/or was divided into dorsal and ventral parts. The cell counts in the cervicothoracic (C7-Th1) and lumbosacral (L5-S1) enlargements revealed changes in neuronal nitric oxide synthase immunoreactivity on the ipsilateral side of the injury. The densitometric area measurements confirmed the reduction of somal, neuropil and axonal neuronal nitric oxide synthase immunoreactive staining in the ventral part of rostrally oriented segments. 4. Our findings provide evidence that the changes in nitric oxide synthase pools are limited not only to impact zone, but spread outside the original lesion. The regional distribution of nitric oxide synthase activity and neuronal nitric oxide synthase immunoreactivity, measured segment by segment shows that nitric oxide may play a significant role in the stepping cycle in the quadrupeds.

Coordination training in individuals with incomplete spinal cord injury: consideration of motor hierarchical structures

STUDY DESIGN

Clinical commentary.

OBJECTIVE

To discuss the method of coordination training to enhance motor skills in persons after spinal cord injury (SCI).

METHOD

From the literature and clinical experience, we learn that basic motor skills like walking are refined and maintained through the millions of repetitions that take place as part of normal development. These coordinated patterns function effectively as a form of training to the system because of the presence of neural pathways that mediate commands between higher and lower levels of the central nervous system (CNS). When these pathways are disrupted as a result of a lesion, the question that arises is whether retraining can be effective.

RESULTS/DISCUSSION

The question is directed at the common practice among rehabilitation professionals to prescribe and carry out tireless repetitions of coordinated motor activities in people with SCI lesions. We discuss this fundamental question from the perspective of understanding differences in maturation and function of higher motor centres and lower motor centres.

License to run: exercise impacts functional plasticity in the intact and injured central nervous system by using neurotrophins

Exercise has been found to impact molecular systems important for maintaining neural function and plasticity. A characteristic finding for the effects of exercise in the brain and spinal cord has been the up-regulation of brain-derived neurotrophic factor (BDNF). This review focuses on the ability of exercise to impact brain circuitry by promoting neuronal repair and enhance learning and memory by increasing neurotrophic support. A paragon for the role of activity-dependent neurotrophins in the CNS is the capacity of BDNF to facilitate synaptic function and neuronal excitability. The authors discuss the effects of exercise in the intact and injured brain and spinal cord injury and the implementation of exercise preinjury and postinjury. As the CNS displays a capacity for plasticity throughout one's lifespan, exercise may be a powerful lifestyle implementation that could be used to augment synaptic plasticity, promote behavioral rehabilitation, and counteract the deleterious effects of aging.

Spontaneous locomotor recovery in spinal cord injured rats is accompanied by anatomical plasticity of reticulospinal fibers

Although injured axons in mammalian spinal cords do not regenerate, some recovery of locomotor function following incomplete injury can be observed in patients and animal models. Following a lateral hemisection injury of the thoracic spinal cord, rats spontaneously recover weight-bearing stepping in the hind limb ipsilateral to the injury. The mechanisms behind this recovery are not completely understood. Plasticity in the reticulospinal tract (RtST), the tract responsible for the initiation of walking, has not been studied. In this study, rats received lateral thoracic hemisection of the spinal cord, and RtST projections were compared in two groups of rats, one early in recovery (7 days) and the other at a time point when weight-bearing stepping was fully regained (42 days). We found that this recovery occurs in parallel with increased numbers of collaterals of spared RtST fibers entering the intermediate lamina below the injury at L2. Sprouting of injured RtST fibers above the lesion was not found. In conclusion, our study suggests that sprouting of spared RtST fibers might be involved in the recovery of locomotion following incomplete spinal cord injury.

Collateral Sprouting as a Target for Improved Function after Spinal Cord Injury

Functional recovery after spinal cord injury might be improved by enhancing the extent of innervation through stimulation of collateral sprouting, which is the growth of a new axon along the shaft of a non-injured axon. This review discusses (1) the spontaneous collateral sprouting of uninjured motor and sensory systems that has been shown after spinal cord injury in animal models, (2) experimental treatment strategies that are being developed to enhance collateral sprouting in motor systems and to reduce sensory sprouting which is associated with autonomic dysreflexia and pain, and (3) cell-surface and intracellular signaling mechanisms that are known to regulate axonal branching. The conclusion is that relatively little is known about collateral sprouting in adult mammals after spinal cord injury but that it may contribute to spontaneous functional motor recovery and causes sensory dysfunction. There is some promising data in rodents that collateral sprouting can be modulated for improved function, but the applicability to primates and relevance to human spinal cord injury remains to be determined.

Neurobiology of exercise

Voluntary physical activity and exercise training can favorably influence brain plasticity by facilitating neurogenerative, neuroadaptive, and neuroprotective processes. At least some of the processes are mediated by neurotrophic factors. Motor skill training and regular exercise enhance executive functions of cognition and some types of learning, including motor learning in the spinal cord. These adaptations in the central nervous system have implications for the prevention and treatment of obesity, cancer, depression, the decline in cognition associated with aging, and neurological disorders such as Parkinson's disease, Alzheimer's dementia, ischemic stroke, and head and spinal cord injury. Chronic voluntary physical activity also attenuates neural responses to stress in brain circuits responsible for regulating peripheral sympathetic activity, suggesting constraint on sympathetic responses to stress that could plausibly contribute to reductions in clinical disorders such as hypertension, heart failure, oxidative stress, and suppression of immunity. Mechanisms explaining these adaptations are not as yet known, but metabolic and neurochemical pathways among skeletal muscle, the spinal cord, and the brain offer plausible, testable mechanisms that might help explain effects of physical activity and exercise on the central nervous system.

Complexities and uncertainties of neuronal network function

The nervous system generates behaviours through the activity in groups of neurons assembled into networks. Understanding these networks is thus essential to our understanding of nervous system function. Understanding a network requires information on its component cells, their interactions and their functional properties. Few networks come close to providing complete information on these aspects. However, even if complete information were available it would still only provide limited insight into network function. This is because the functional and structural properties of a network are not fixed but are plastic and can change over time. The number of interacting network components, their (variable) functional properties, and various plasticity mechanisms endows networks with considerable flexibility, but these features inevitably complicate network analyses. This review will initially discuss the general approaches and problems of network analyses. It will then examine the success of these analyses in a model spinal cord locomotor network in the lamprey, to determine to what extent in this relatively simple vertebrate system it is possible to claim detailed understanding of network function and plasticity.

G. Heiner Sell memorial lecture: neuronal plasticity after spinal cord injury: significance for present and future treatments

Recent progress in the understanding of movement control allows us to define more precisely the requirements for successful rehabilitation of patients with neurologic deficits after a spinal cord injury (SCI). Load- and hip joint position-related afferent input seems to be of crucial importance for the generation and success of locomotor training. In addition, there is accumulating evidence from animal experiments that axonal regeneration can be induced after a SCI. Consequently, in the near future, new therapeutic approaches will be developed for the treatment of subjects with SCI. Functional training and regeneration represent complimentary approaches. Regenerating spinal tract fibers needs functional training to make the appropriate connections, and training effects will be enhanced by regenerating fibers. A clinical basis for monitoring the effects of novel interventional therapies is needed. Refined and combined clinical and neurophysiologic measures are needed for a precise qualitative and quantitative assessment of spinal cord function in patients with SCI at an early stage. This is a basic requirement for predicting functional outcome, as well as for recognizing any improvement in the recovery of function caused by a new treatment. To this aim, 14 European spinal cord injury centers involved in the rehabilitation of patients with acute SCI have built a close clinical collaboration using a standardized protocol for the assessment of the outcome after SCI and the extent of recovery achieved by actually applied therapies in a larger population of patients with SCI.

Coordinated modulation of locomotor muscle synergies constructs straight-ahead and curvilinear walking in humans

We describe the muscle synergies accompanying steering of walking along curved trajectories, in order to analyze the simultaneous control of progression and balance-threatening emerging forces. For this purpose, we bilaterally recorded in ten subjects the electromyograms (EMGs) of a representative sample of leg and trunk muscles (n=16) during continuous walking along one straight and two curved trajectories at natural speed. Curvilinear locomotion involved a graded, limb-dependent modulation of amplitude and timing of activity of the muscles of the legs and trunk. The turn-related modulation of the motor pattern was highly coordinated amongst muscles and body sides. For all muscles, linear relationships were detected between the spatial and temporal features of muscle EMG activity. The largest modulation of EMG was observed in gastrocnemius medialis and lateralis muscles, which showed opposite changes in timing and amplitude during curve-walking. Moreover, amplitude and timing characteristics of muscle activities were significantly correlated with the spatial and temporal gait adaptations that are associated with curvilinear locomotion. The present results reveal that fine-modulation of the muscle synergies underlying straight-ahead locomotion is enough to generate the adequate propulsive forces to steer walking and maintain balance. These findings suggest that the turn-related command operates by modulation of the phase relationships between the tightly coupled neuronal assemblies that drive motor neuron activity during walking. This would produce the invariant templates for locomotion kinematics that are at the base of human navigation in space.

Neuromechanical control of locomotion in the rat

Rodent models are being extensively used to investigate the effects of traumatic injury and develop and assess the mechanisms of repair and regeneration. We present quantitative assessment of two-dimensional (2D) kinematics of overground walking and for the first time three-dimensional (3D) joint angle kinematics of all four limbs during treadmill walking in intact adult female Long-Evans rats. Gait cycle with subphases and intralimb and interlimb cyclograms are presented. Phase relationships between joint angles on a cycle-by-cycle basis and interlimb footfalls are assessed using a simple technique. Electromyogram (EMG) data from major flexor and extensor muscles for each of the hindlimb joints and elbow extensor muscles of the forelimbs synchronized to the 3D kinematics are also obtained. Overground walking kinematics, provides information on base of support, stride length, and hindfoot rotation. Treadmill walking kinematics indicate primarily monophasic angle trajectories for the hip and shoulder joints, weak double peak patterns for the knee and elbow joints, and a prominent double peak pattern for the ankle joints. Maximum flexion of the knee during swing precedes that of the ankle, which precedes that of the hip. A mild exercise regimen over 8 weeks does not alter the kinematics. EMG activity indicates specific relationships of the neural activity to joint angle kinematics. We find that the ankle flexors as well as the hip and elbow extensors maintain constant burst duration with changing cycle duration. Data and techniques described here are likely to be useful for quantitative assessment of altered gait and neural control mechanisms after neurotrauma.

Performance of locomotion and foot grasping following a unilateral thoracic corticospinal tract lesion in monkeys (Macaca mulatta)

Six adult monkeys (Macaca mulatta) received a unilateral lesion of the lateral corticospinal tract (CST) in the thoracic spinal cord. Prior to surgery, the animals were trained to perform quadrupedal stepping on a treadmill, and item retrieval with the foot. Whole body kinematics and electromyogram (EMG) recordings were made prior to, and at regular intervals over a period of 12 weeks after the CST lesion. After 1 week of recovery, all monkeys were able to walk unaided quadrupedally on the treadmill. The animals, however, dragged the hindpaw ipsilateral to the lesion along the treadmill belt during the swing phase and showed a significant reorganization of the spatiotemporal pattern of hindlimb (HL) and forelimb (FL) displacements. The inability to appropriately trigger the swing phase resulted in an increase in the cycle duration and stride length of both HLs. The stance duration decreased in the ipsilateral HL, and increased in the contralateral HL and both FLs. Consequently, there was a dramatic disruption of interlimb and intralimb coupling that was reflected in the limb kinematic and EMG patterns. The CST lesion completely abolished the ability of the monkeys to retrieve items with the foot ipsilateral to the lesion and significantly disrupted the level of performance of the contralateral HL during the first 2 weeks post-lesion. Interestingly, selected HL muscles remained almost quiescent when the monkeys attempted to retrieve items, but were unsuccessful with the affected foot at 1 week post-lesion, whereas the capacity to activate the same muscles was preserved, although reduced, during stepping. Spatial and temporal parameters of gait, kinematics, and EMG patterns recorded during locomotion generally converged toward control values over time, but significant differences persisted up to 12 weeks post-lesion. Although some control was recovered over the distal foot musculature, fine foot grasping remained significantly impaired at the end of the testing period. These findings demonstrate that the CST pathway from the brain normally makes an important contribution to interlimb and intralimb coordination during basic locomotion, and to muscle activation to produce dexterous foot digit movements in the monkey. Furthermore, the present study indicates that the primate has the ability to rapidly accommodate locomotor performance, and to a lesser degree fine foot motor skills, to a reduction in supraspinal control. Identification of the neural substrates mediating the rapid recovery of motor function following injury to the primate spinal cord could provide insight into developing repair strategies to augment functional recovery from neuromotor impairments.

Exercise restores levels of neurotrophins and synaptic plasticity following spinal cord injury

We have conducted studies to determine the potential of exercise to benefit the injured spinal cord using neurotrophins. Adult rats were randomly assigned to one of three groups: (1) intact control (Con); (2) sedentary, hemisected at a mid-thoracic level (Sed-Hx), or (3) exercised, hemisected (Ex-Hx). One week after surgery, the Ex-Hx rats were exposed to voluntary running wheels for 3, 7, or 28 days. BDNF mRNA levels on the lesioned side of the spinal cord lumbar region of Sed-Hx rats were approximately 80% of Con values at all time points and BDNF protein levels were approximately 40% of Con at 28 days. Exercise compensated for the reductions in BDNF after hemisection, such that BDNF mRNA levels in the Ex-Hx rats were similar to Con after 3 days and higher than Con after 7 (17%) and 28 (27%) days of exercise. After 28 days of exercise, BDNF protein levels were 33% higher in Ex-Hx than Con rats and were highly correlated (r=0.86) to running distance. The levels of the downstream effectors for the action of BDNF on synaptic plasticity synapsin I and CREB were lower in Sed-Hx than Con rats at all time points. Synapsin I mRNA and protein levels were higher in Ex-Hx rats than Sed-Hx rats and similar to Con rats at 28 days. CREB mRNA values were higher in Ex-Hx than Sed-Hx rats at all time points. Hemisection had no significant effects on the levels of NT-3 mRNA or protein; however, voluntary exercise resulted in an increase in NT-3 mRNA levels after 28 days (145%). These results are consistent with the concept that synaptic pathways under the regulatory role of BDNF induced by exercise can play a role in facilitating recovery of locomotion following spinal cord injury.

Behavioral characterization in a comprehensive mouse test battery reveals motor and sensory impairments in growth-associated protein-43 null mutant mice

The growth-associated protein (GAP)-43 is a major neuronal protein associated with axonal growth, neuronal plasticity and learning. The observation that only 5-10% of mice with a full GAP-43 gene deletion survive weaning suggests that basic neural functions are disturbed. Here we used a comprehensive test battery to characterise and quantify the motor and sensory function of surviving adult homozygous GAP-43 (-/-) mice as compared with GAP-43 (+/-) and wild-type animals. The test battery was comprised of motor, sensory, and reflex tests producing 25 measures of locomotion, as well as epicritic, auditory, olfactory and visual function. The analysis revealed significant impairments in muscle strength, limb coordination and balance in GAP-43 (-/-) mice. Furthermore, GAP-43 (-/-) animals were hyperactive and showed reduced anxiety as measured by open field and light dark tests. In sensory tests, GAP-43 (-/-) mice were tested for impaired tactile and labyrinthine function. Abnormal reflexes were found in the contact and vibrissa placing responses, and in the crossed extensor reflex. GAP-43 (+/-) animals showed only moderate abnormalities as compared with wild-type animals. We conclude that GAP-43 is necessary for the development and function of a variety of neuronal systems. The results also show that the comprehensive test battery used in the present study represents a sensitive approach to assess the functional integrity of ascending and descending pathways in genetically manipulated mice.

Neurologische und funktionelle Erholung nach Querschnittl�hmung

Today, there is accumulating evidence from animal experiments that axonal regeneration and an enhanced level of functional repair can be induced after a spinal cord injury (SCI). Consequently, in the near future, new therapeutic approaches will be developed for the treatment of patients with SCI. The aim of the project presented here is to provide the required clinical basis for the implementation of novel interventional therapies. Refined and combined clinical and neurophysiological measures are needed for a precise qualitative and quantitative assessment of spinal cord function in patients with SCI at an early stage. This represents a basic requirement for recognizing any improvement in the recovery of function and to monitor any significant effect of a new treatment. The paper presents objective and refined tools as a basis for monitoring the effects of new treatment strategies.

Kinematic and EMG determinants in quadrupedal locomotion of a non-human primate (Rhesus)

We hypothesized that the activation patterns of flexor and extensor muscles and the resulting kinematics of the forelimbs and hindlimbs during locomotion in the Rhesus would have unique characteristics relative to other quadrupedal mammals. Adaptations of limb movements and in motor pool recruitment patterns in accommodating a range of treadmill speeds similar to other terrestrial animals in both the hindlimb and forelimb were observed. Flexor and extensor motor neurons from motor pools in the lumbar segments, however, were more highly coordinated than in the cervical segments. Unlike the lateral sequence characterizing subprimate quadrupedal locomotion, non-human primates use diagonal coordination between the hindlimbs and forelimbs, similar to that observed in humans between the legs and arms. Although there was a high level of coordination between hind- and forelimb locomotion kinematics, limb-specific neural control strategies were evident in the intersegmental coordination patterns and limb endpoint trajectories. Based on limb kinematics and muscle recruitment patterns, it appears that the hindlimbs, and notably the distal extremities, contribute more to body propulsion than the forelimbs. Furthermore, we found adaptive changes in the recruitment patterns of distal muscles in the hind- and forelimb with increased treadmill speed that likely correlate with the anatomical and functional evolution of hand and foot digits in monkeys. Changes in the properties of both the spinal and supraspinal circuitry related to stepping, probably account for the peculiarities in the kinematic and EMG properties during non-human primate locomotion. We suggest that such adaptive changes may have facilitated evolution toward bipedal locomotion.

Neurobiology of rehabilitation

Rehabilitation aims to lessen the physical and cognitive impairments and disabilities of patients with stroke, multiple sclerosis, spinal cord or brain injury, and other neurologic diseases. Conventional approaches beyond compensatory adjustments to disability may be augmented by applying some of the myriad experimental results about mechanisms of intrinsic biological changes after injury and the effects of extrinsic manipulations on spared neuronal assemblies. The organization and inherent adaptability of the anatomical nodes within distributed pathways of the central nervous system offer a flexible substrate for treatment strategies that drive activity-dependent plasticity. Opportunities for a new generation of approaches are manifested by rodent and non-human primate studies that reveal morphologic and physiologic adaptations induced by injury, by learning-associated practice, by the effects of pharmacologic neuromodulators, by the behavioral and molecular bases for enhancing activity-dependent synaptic plasticity, and by cell replacement, gene therapy, and regenerative biologic strategies. Techniques such as functional magnetic resonance imaging and transcranial magnetic stimulation will help determine the most optimal physiologic effects of interventions in patients as the cortical representations for skilled movements and cognitive processes are modified by the combination of conventional and biologic therapies. As clinicians digest the finer details of the neurobiology of rehabilitation, they will translate laboratory data into controlled clinical trials. By determining how much they can influence neural reorganization, clinicians will extend the opportunities for neurorestoration.

Ankle dorsiflexion as an fMRI paradigm to assay motor control for walking during rehabilitation

The ability to walk independently with the velocity and endurance that permit home and community activities is a highly regarded goal for neurological rehabilitation after stroke. This pilot study explored a functional magnetic resonance imaging (fMRI) activation paradigm for its ability to reflect phases of motor learning over the course of locomotor rehabilitation-mediated functional gains. Ankle dorsiflexion is an important kinematic aspect of the swing and initial stance phase of the gait cycle. The motor control of dorsiflexion depends in part on descending input from primary motor cortex. Thus, an fMRI activation paradigm using voluntary ankle dorsiflexion has face validity for the serial study of walking-related interventions. Healthy control subjects consistently engaged contralateral primary sensorimotor cortex (S1M1), supplementary motor area (SMA), premotor (PM) and cingulate motor (CMA) cortices, and ipsilateral cerebellum. Four adults with chronic hemiparetic stroke evolved practice-induced representational plasticity associated with gains in speed, endurance, motor control, and kinematics for walking. For example, an initial increase in activation within the thoracolumbar muscle representation of S1M1 in these subjects was followed by more focused activity toward the foot representation with additional pulses of training. Contralateral CMA and the secondary sensory area also reflected change with practice and gains. We demonstrate that the supraspinal sensorimotor network for the neural control of walking can be assessed indirectly by ankle dorsiflexion. The ankle paradigm may serve as an ongoing physiological assay of the optimal type, duration, and intensity of rehabilitative gait training.

Plasticity of the spinal neural circuitry after injury

Motor function is severely disrupted following spinal cord injury (SCI). The spinal circuitry, however, exhibits a great degree of automaticity and plasticity after an injury. Automaticity implies that the spinal circuits have some capacity to perform complex motor tasks following the disruption of supraspinal input, and evidence for plasticity suggests that biochemical changes at the cellular level in the spinal cord can be induced in an activity-dependent manner that correlates with sensorimotor recovery. These characteristics should be strongly considered as advantageous in developing therapeutic strategies to assist in the recovery of locomotor function following SCI. Rehabilitative efforts combining locomotor training pharmacological means and/or spinal cord electrical stimulation paradigms will most likely result in more effective methods of recovery than using only one intervention.

Strategies for stroke rehabilitation

Rehabilitation after hemiplegic stroke has typically relied on the training of patients in compensatory strategies. The translation of neuroscientific research into care has led to new approaches and renewed promise for better outcomes. Improved motor control can progress with task-specific training incorporating increased use of proximal and distal movements during intensive practice of real-world activities. Functional gains are incorrectly said to plateau by 3-6 months. Many patients retain latent sensorimotor function that can be realised any time after stroke with a pulse of goal-directed therapy. The amount of practice probably best determines gains for a given level of residual movement ability. Clinicians should encourage patients to build greater strength, speed, endurance, and precision of multijoint movements on tasks that increase independence and enrich daily activity. Imaging tools may help clinicians determine the capacity of residual networks to respond to a therapeutic approach and help establish optimal dose-response curves for training. Promising adjunct approaches include practice with robotic devices or in a virtual environment, electrical stimulation to increase cortical excitability during training, and drugs to optimise molecular mechanisms for learning. Biological strategies for neural repair may augment rehabilitation in the next decade.

Effects of limb exercise after spinal cord injury on motor neuron dendrite structure

An integration center subserving locomotor leg movements resides in the upper lumbar spinal cord. If this neuronal network is preserved after a spinal cord injury, it is possible to stimulate this circuitry to initiate and promote walking. The several effective approaches (electrical stimulation, pharmacologic agents, physical therapy training programs) may all share a common modus operandi of altering synaptic activity within segmental spinal cord. To understand the neural substrate for the use-dependent behavioral improvement, we studied the dendritic architecture of spinal motor neurons. In the first experiment, we compared three groups of animals: animals with an intact spinal cord, animals that had a complete spinal cord transection (SCT) and animals with SCT who engaged in a daily exercise program of actively moving paralyzed hindlimbs through the motions of walking. When compared with animals with an intact spinal cord, the motor neurons from animals with SCT displayed marked atrophy, with loss of dendritic membrane and elimination of branching throughout the visible tree within transverse tissue slices. None of these regressive changes were found in the motor neurons from SCT animals that underwent exercise. In a second experiment, we inquired whether exercise of animals with an intact spinal cord influenced dendrite structure. Increased exercise had very modest effects on dendrite morphology, indicating an upper limit of use-dependent dendrite growth. Our findings suggest that the dendritic tree of motor neurons deprived of descending influences is rapidly pruned, and this finding is not observed in motor neurons after SCT if hindlimbs are exercised. The functional benefits of exercise after SCT injury may be subserved, in part, by stabilizing or remodeling the dendritic tree of motor neurons below the injury site.

Body-weight-support treadmill training improves blood glucose regulation in persons with incomplete spinal cord injury

The impact of a 6-mo body-weight-supported treadmill training program on glucose homeostasis and muscle metabolic characteristics was investigated. Nine individuals (31 ± 3 yr, 8.1 ± 2.5 yr postinjury; means ± SE) with incomplete spinal cord injury trained three times weekly for a total of 6 mo. Training session duration and intensity (velocity) increased by 54 ± 10% ( P < 0.01) and 135 ± 20%, respectively. Muscle biopsies and a modified glucose tolerance test (100 g glucose with [U-13C]glucose) were performed before (Pre) and after training (Post). Training resulted in a reduction in area under the curve of glucose × time (−15 ± 4%) and insulin × time (−33 ± 8%; both P < 0.05). Oxidation of exogenous (ingested) glucose increased as a result of training (Pre = 4.4 ± 0.7 g/h, Post = 7.4 ± 0.6 g/h; P < 0.05), as did oxidation of endogenous (liver) glucose (Pre = 3.8 ± 0.3 g/h, Post = 5.2 ± 0.3 g/h; P < 0.05). Training resulted in increased muscle glycogen (80 ± 23%; P < 0.05) and GLUT-4 content and hexokinase II enzyme activity (126 ± 34 and 49 ± 4%, respectively, both P < 0.01). Resting muscle phosphocreatine content also increased after training (Pre = 62.1 ± 4.3, Post = 78.7 ± 3.8, both mmol/kg dry wt and P < 0.05). Six months of thrice-weekly body-weight-supported treadmill training in persons with an incomplete spinal cord injury improved blood glucose regulation by increasing oxidation and storage of an oral glucose load. Increases in the capacity for transport and phosphorylation glucose in skeletal muscle likely play a role in these adaptations.

Tuning of a Basic Coordination Pattern Constructs Straight-Ahead and Curved Walking in Humans

We tested the hypothesis that common principles govern the production of the locomotor patterns for both straight-ahead and curved walking. Whole body movement recordings showed that continuous curved walking implies substantial, limb-specific changes in numerous gait descriptors. Principal component analysis (PCA) was used to uncover the spatiotemporal structure of coordination among lower limb segments. PCA revealed that the same kinematic law accounted for the coordination among lower limb segments during both straight-ahead and curved walking, in both the frontal and sagittal planes: turn-related changes in the complex behavior of the inner and outer limbs were captured in limb-specific adaptive tuning of coordination patterns. PCA was also performed on a data set including all elevation angles of limb segments and trunk, thus encompassing 13 degrees of freedom. The results showed that both straight-ahead and curved walking were low dimensional, given that 3 principal components accounted for more than 90% of data variance. Furthermore, the time course of the principal components was unchanged by curved walking, thereby indicating invariant coordination patterns among all body segments during straight-ahead and curved walking. Nevertheless, limb- and turn-dependent tuning of the coordination patterns encoded the adaptations of the limb kinematics to the actual direction of the walking body. Absence of vision had no significant effect on the intersegmental coordination during either straight-ahead or curved walking. Our findings indicate that kinematic laws, probably emerging from the interaction of spinal neural networks and mechanical oscillators, subserve the production of both straight-ahead and curved walking. During locomotion, the descending command tunes basic spinal networks so as to produce the changes in amplitude and phase relationships of the spinal output, sufficient to achieve the body turn.