Early locomotor training with clonidine in spinal cats

Botulinum Toxin and Dynamic Splint Restore Grasping Function after Stroke: A Case Report

Evidence on the effectiveness of upper extremity rehabilitation post-stroke is inconclusive. We evaluated a tailored therapeutic program with dynamic splint and botulinum toxin injections for the treatment of upper extremity muscle spasticity. A case of a 43-year-old woman with chronic spastic hemiparesis after ischemic stroke with significant mobility impairment in the left upper extremity was described. A 16-week program consisted of three 50-min sessions daily and focused on grasping and releasing with and without the splint. The patient was evaluated before botulinum toxin injection and after 6, 12 and 16 weeks according to the International Classification of Functioning, Disability and Health, and included the following scales: Fugl-Meyer Upper Extremity Assessment (FMA-UE), Modified Ashworth Scale, Numerical Rating Scale (NRS), MyotonPro, Stroke Impact Scale, Box and Blocks. Photographic documentation made before and after the experiment was compared. Motor functions improved by 19.7% on FMA-UE, spasticity was reduced by one degree and pain at rest and during activity decreased by one score on NRS. A reduction in the oscillation frequency of the relaxed muscle and the stiffness of the examined muscles was observed. The patient regained grasping function. Health-related quality of life was systematically improving with a 35% increase at week 16 compared to the baseline. The combination treatment for spasticity based on botulinum toxin and SaeboFlex^® dynamic splint in a patient with chronic spastic hemiparesis reduces disability and improves quality of life. However, further research is needed to investigate the treatment results.

Personalized practice dosages may improve motor learning in older adults compared to "standard of care" practice dosages: A randomized controlled trial

Standard dosages of motor practice in clinical physical rehabilitation are insufficient to optimize motor learning, particularly for older patients who often learn at a slower rate than younger patients. Personalized practice dosing (i.e., practicing a task to or beyond one's plateau in performance) may provide a clinically feasible method for determining a dose of practice that is both standardized and individualized, and may improve motor learning. The purpose of this study was to investigate whether personalized practice dosages [practice to plateau (PtP) and overpractice (OVP)] improve retention and transfer of a motor task, compared to low dose [LD] practice that mimics standard clinical dosages. In this pilot randomized controlled trial (NCT02898701, ClinicalTrials.gov), community-dwelling older adults (n = 41, 25 female, mean age 68.9 years) with a range of balance ability performed a standing serial reaction time task in which they stepped to specific targets. Presented stimuli included random sequences and a blinded repeating sequence. Participants were randomly assigned to one of three groups: LD (n = 15, 6 practice trials equaling 144 steps), PtP (n = 14, practice until reaching an estimated personal plateau in performance), or OVP (n = 12, practice 100% more trials after reaching an estimated plateau in performance). Measures of task-specific learning (i.e., faster speed on retention tests) and transfer of learning were performed after 2-4 days of no practice. Learning of the random sequence was greater for the OVP group compared to the LD group (p = 0.020). The OVP (p = 0.004) and PtP (p = 0.010) groups learned the repeated sequence more than the LD group, although the number of practice trials across groups more strongly predicted learning (p = 0.020) than did group assignment (OVP vs. PtP, p = 0.270). No group effect was observed for transfer, although significant transfer was observed in this study as a whole (p < 0.001). Overall, high and personalized dosages of postural training were well-tolerated by older adults, suggesting that this approach is clinically feasible. Practicing well-beyond standard dosages also improved motor learning. Further research should determine the clinical benefit of this personalized approach, and if one of the personalized approaches (PtP vs. OVP) is more beneficial than the other for older patients.

A Validation of Supervised Deep Learning for Gait Analysis in the Cat

Gait analysis in cats and other animals is generally performed with custom-made or commercially developed software to track reflective markers placed on bony landmarks. This often involves costly motion tracking systems. However, deep learning, and in particular DeepLabCut^TM (DLC), allows motion tracking without requiring placing reflective markers or an expensive system. The purpose of this study was to validate the accuracy of DLC for gait analysis in the adult cat by comparing results obtained with DLC and a custom-made software (Expresso) that has been used in several cat studies. Four intact adult cats performed tied-belt (both belts at same speed) and split-belt (belts operating at different speeds) locomotion at different speeds and left-right speed differences on a split-belt treadmill. We calculated several kinematic variables, such as step/stride lengths and joint angles from the estimates made by the two software and assessed the agreement between the two measurements using intraclass correlation coefficient or Lin's concordance correlation coefficient as well as Pearson's correlation coefficients. The results showed that DLC is at least as precise as Expresso with good to excellent agreement for all variables. Indeed, all 12 variables showed an agreement above 0.75, considered good, while nine showed an agreement above 0.9, considered excellent. Therefore, deep learning, specifically DLC, is valid for measuring kinematic variables during locomotion in cats, without requiring reflective markers and using a relatively low-cost system.

Spinal Locomotion in Cats Following Spinal Cord Injury: A Prospective Study

Simple Summary

Functional neurorehabilitation promotes neural reorganization by stimulating subjects without deep pain perception, leading to a faster recovery when compared to spontaneous recovery, and achieving fewer compensatory errors, or even deviations to neuropathic or adaptive pain pathways, such as spasticity. The present study demonstrates the importance of intensive and repetition-based functional neurorehabilitation, which is essential for subjects classified as grade 0 according to the modified Frankel scale.

Abstract

This article aimed to evaluate the safety and efficacy of intensive neurorehabilitation in paraplegic cats, with no deep pain perception (grade 0 on the modified Frankel scale), with more than three months of injury. Nine cats, admitted to the Arrábida Veterinary Hospital/Arrábida Animal Rehabilitation Center (CRAA), were subjected to a 12-week intensive functional neurorehabilitation protocol, based on ground and underwater treadmill locomotor training, electrostimulation, and kinesiotherapy exercises, aiming to obtain a faster recovery to ambulation and a modulated locomotor pattern of flexion/extension. Of the nine cats that were admitted in this study, 56% (n = 5) recovered from ambulation, 44% of which (4/9) did so through functional spinal locomotion by reflexes, while one achieved this through the recovery of deep pain perception. These results suggest that intensive neurorehabilitation can play an important role in ambulation recovery, allowing for a better quality of life and well-being, which may lead to a reduction in the number of euthanasia procedures performed on paraplegic animals.

A Comparison Between Body Weight-Supported Treadmill Training and Conventional Over-Ground Training in Dogs With Incomplete Spinal Cord Injury

In human medicine there was no evidence registered of a significant difference in recovery between body weight-supported treadmill training (BWSTT) and conventional over-ground (COGI). There isn't any similar study in veterinary medicine. Thus, this study aimed to compare the locomotor recovery obtained in incomplete SCI (T11–L3 Hansen type I) post-surgical dogs following BWSTT or COGI protocols, describing their evolution during 7 weeks in regard to OFS classifications. At admission, dogs were blindly randomized in two groups but all were subjected to the same protocol (underwater treadmill training) for the first 2 weeks. After, they were divided in the BWSTT group (n = 10) and the COGI group (n = 10) for the next 2 weeks, where they performed different training. In both groups locomotor training was accompanied by functional electrical stimulation (FES) protocols. Results reported statistically significant differences between all OFS evaluations time-points (p < 0.001) and between the two groups (p < 0.001). In particular with focus on T1 to T3 a two-way repeated measures ANOVA was performed and similar results were obtained (p = 0.007). Functional recovery was achieved in 90% (17/19) of all dogs and 100% recovered bladder function. The BWSTT group showed 100% (10/10) recovery within a mean time of 4.6 weeks, while the COGI group had 78% (7/9) within 6.1 weeks. Therefore, BWSTT leads to a faster recovery with a better outcome in general.

Cutaneous inputs from perineal region facilitate spinal locomotor activity and modulate cutaneous reflexes from the foot in spinal cats

It is well known that mechanically stimulating the perineal region potently facilitates hindlimb locomotion and weight support in mammals with a spinal transection (spinal mammals). However, how perineal stimulation mediates this excitatory effect is poorly understood. We evaluated the effect of mechanically stimulating (vibration or pinch) the perineal region on ipsilateral (9-14 ms onset) and contralateral (14-18 ms onset) short-latency cutaneous reflex responses evoked by electrically stimulating the superficial peroneal or distal tibial nerve in seven adult spinal cats where hindlimb movement was restrained. Cutaneous reflexes were evoked before, during, and after mechanical stimulation of the perineal region. We found that vibration or pinch of the perineal region effectively triggered rhythmic activity, ipsilateral and contralateral to nerve stimulation. When electrically stimulating nerves, adding perineal stimulation modulated rhythmic activity by decreasing cycle and burst durations and by increasing the amplitude of flexors and extensors. Perineal stimulation also disrupted the timing of the ipsilateral rhythm, which had been entrained by nerve stimulation. Mechanically stimulating the perineal region decreased ipsilateral and contralateral short-latency reflex responses evoked by cutaneous inputs, a phenomenon we observed in muscles crossing different joints and located in different limbs. The results suggest that the excitatory effect of perineal stimulation on locomotion and weight support is mediated by increasing the excitability of central pattern-generating circuitry and not by increasing excitatory inputs from cutaneous afferents of the foot. Our results are consistent with a state-dependent modulation of reflexes by spinal interneuronal circuits.

Biphasic Effect of Buspirone on the H-Reflex in Acute Spinal Decerebrated Mice

Pharmacological treatment facilitating locomotor expression will also have some effects on reflex expression through the modulation of spinal circuitry. Buspirone, a partial serotonin receptor agonist (5-HT_{1 A}), was recently shown to facilitate and even trigger locomotor movements in mice after complete spinal lesion (Tx). Here, we studied its effect on the H-reflex after acute Tx in adult mice. To avoid possible impacts of anesthetics on H-reflex depression, experiments were performed after decerebration in un-anesthetized mice (N = 20). The H-reflex in plantar muscles of the hind paw was recorded after tibial nerve stimulation 2 h after Tx at the 8th thoracic vertebrae and was compared before and every 10 min after buspirone (8 mg/kg, i.p.) for 60 min (N = 8). Frequency-dependent depression (FDD) of the H-reflex was assessed before and 60 min after buspirone. Before buspirone, a stable H-reflex could be elicited in acute spinal mice and FDD of the H-reflex was observed at 5 and 10 Hz relative to 0.2 Hz, FDD was still present 60 min after buspirone. Early after buspirone, the H-reflex was significantly decreased to 69% of pre-treatment, it then increased significantly 30-60 min after treatment, reaching 170% 60 min after injection. This effect was not observed in a control group (saline, N = 5) and was blocked when a 5-HT_{1 A} antagonist (NAD-299) was administered with buspirone (N = 7). Altogether results suggest that the reported pro-locomotor effect of buspirone occurs at a time where there is a 5-HT_{1 A} receptors mediated reflex depression followed by a second phase marked by enhancement of reflex excitability.

The recovery of standing and locomotion after spinal cord injury does not require task-specific training

After complete spinal cord injury, mammals, including mice, rats and cats, recover hindlimb locomotion with treadmill training. The premise is that sensory cues consistent with locomotion reorganize spinal sensorimotor circuits. Here, we show that hindlimb standing and locomotion recover after spinal transection in cats without task-specific training. Spinal-transected cats recovered full weight bearing standing and locomotion after five weeks of rhythmic manual stimulation of triceps surae muscles (non-specific training) and without any intervention. Moreover, cats modulated locomotor speed and performed split-belt locomotion six weeks after spinal transection, functions that were not trained or tested in the weeks prior. This indicates that spinal networks controlling standing and locomotion and their interactions with sensory feedback from the limbs remain largely intact after complete spinal cord injury. We conclude that standing and locomotor recovery is due to the return of neuronal excitability within spinal sensorimotor circuits that do not require task-specific activity-dependent plasticity.

Exogenous neuromodulation of spinal neurons induces beta-band coherence during self-sustained discharge of hind limb motor unit populations

The spontaneous or self-sustained discharge of spinal motoneurons can be observed in both animals and humans. Although the origins of this self-sustained discharge are not fully known, it can be generated by activation of persistent inward currents intrinsic to the motoneuron. If self-sustained discharge is generated exclusively through this intrinsic mechanism, the discharge of individual motor units will be relatively independent of one another. Alternatively, if increased activation of premotor circuits underlies this prolonged discharge of spinal motoneurons, we would expect correlated activity among motoneurons. Our aim is to assess potential synaptic drive by quantifying coherence during self-sustained discharge of spinal motoneurons. Electromyographic activity was collected from 20 decerebrate animals using a 64-channel electrode grid placed on the isolated soleus muscle before and following intrathecal administration of methoxamine, a selective α₁-noradrenergic agonist. Sustained muscle activity was recorded and decomposed into the discharge times of ~10-30 concurrently active individual motor units. Consistent with previous reports, the self-sustained discharge of motor units occurred at low mean discharge rates with low-interspike variability. Before methoxamine administration, significant low-frequency coherence (<2 Hz) was observed, while minimal coherence was observed within higher frequency bands. Following intrathecal administration of methoxamine, increases in motor unit discharge rates and strong coherence in both the low-frequency and 15- to 30-Hz beta bands were observed. These data demonstrate beta-band coherence among motor units can be observed through noncortical mechanisms and that neuromodulation of spinal/brainstem neurons greatly influences coherent discharge within spinal motor pools.NEW & NOTEWORTHY The correlated discharge of spinal motoneurons is often used to describe the input to the motor pool. We demonstrate spinal/brainstem neurons devoid of cortical input can generate correlated motor unit discharge in the 15- to 30-Hz beta band, which is amplified through neuromodulation. Activity in the beta band is often ascribed to cortical drive in humans; however, these data demonstrate the capability of the mammalian segmental motor system to generate and modulate this coherent state of motor unit discharge.

Central pattern generators in the brainstem and spinal cord: an overview of basic principles, similarities and differences

Central pattern generators (CPGs) are generally defined as networks of neurons capable of enabling the production of central commands, specifically controlling stereotyped, rhythmic motor behaviors. Several CPGs localized in brainstem and spinal cord areas have been shown to underlie the expression of complex behaviors such as deglutition, mastication, respiration, defecation, micturition, ejaculation, and locomotion. Their pivotal roles have clearly been demonstrated although their organization and cellular properties remain incompletely characterized. In recent years, insightful findings about CPGs have been made mainly because (1) several complementary animal models were developed; (2) these models enabled a wide variety of techniques to be used and, hence, a plethora of characteristics to be discovered; and (3) organizations, functions, and cell properties across all models and species studied thus far were generally found to be well-preserved phylogenetically. This article aims at providing an overview for non-experts of the most important findings made on CPGs in in vivo animal models, in vitro preparations from invertebrate and vertebrate species as well as in primates. Data about CPG functions, adaptation, organization, and cellular properties will be summarized with a special attention paid to the network for locomotion given its advanced level of characterization compared with some of the other CPGs. Similarities and differences between these networks will also be highlighted.

Effect of feedback from a socially interactive humanoid robot on reaching kinematics in children with and without cerebral palsy: A pilot study

PURPOSE

To examine whether children with or without cerebral palsy (CP) would follow a humanoid robot's (i.e., Darwin) feedback to move their arm faster when playing virtual reality (VR) games.

METHODS

Seven children with mild CP and 10 able-bodied children participated. Real-time reaching was evaluated by playing the Super Pop VR^TM system, including 2-game baseline, 3-game acquisition, and another 2-game extinction. During acquisition, Darwin provided verbal feedback to direct the child to reach a kinematically defined target goal (i.e., 80% of average movement time in baseline). Outcome variables included the percentage of successful reaches ("% successful reaches"), movement time (MT), average speed, path, and number of movement units.

RESULTS

All games during acquisition and extinction had larger "%successful reaches," faster speeds, and faster MTs than the 2 games during baseline (p < .05).

CONCLUSION

Children with and without CP could follow the robot's feedback for changing their reaching kinematics when playing VR games.

Effectiveness of Virtual Reality in Children With Cerebral Palsy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Researchers recently investigated the effectiveness of virtual reality (VR) in helping children with cerebral palsy (CP) to improve motor function. A systematic review of randomized controlled trials (RCTs) using a meta-analytic method to examine the effectiveness of VR in children with CP was thus needed.

PURPOSE

The purpose of this study was to update the current evidence about VR by systematically examining the research literature.

DATA SOURCES

A systematic literature search of PubMed, CINAHL, Cochrane Central Register of Controlled Trials, ERIC, PsycINFO, and Web of Science up to December 2016 was conducted.

STUDY SELECTION

Studies with an RCT design, children with CP, comparisons of VR with other interventions, and movement-related outcomes were included.

DATA EXTRACTION

A template was created to systematically code the demographic, methodological, and miscellaneous variables of each RCT. The Physiotherapy Evidence Database (PEDro) scale was used to evaluate the study quality. Effect size was computed and combined using meta-analysis software. Moderator analyses were also used to explain the heterogeneity of the effect sizes in all RCTs.

DATA SYNTHESIS

. The literature search yielded 19 RCT studies with fair to good methodological quality. Overall, VR provided a large effect size (d = 0.861) when compared with other interventions. A large effect of VR on arm function (d = 0.835) and postural control (d = 1.003) and a medium effect on ambulation (d = 0.755) were also found. Only the VR type affected the overall VR effect: an engineer-built system was more effective than a commercial system.

LIMITATIONS

The RCTs included in this study were of fair to good quality, had a high level of heterogeneity and small sample sizes, and used various intervention protocols.

CONCLUSIONS

Then compared with other interventions, VR seems to be an effective intervention for improving motor function in children with CP.

Effect of hierarchically aligned fibrin hydrogel in regeneration of spinal cord injury demonstrated by tractography: A pilot study

Some studies have reported that scaffold or cell-based transplantation may improve functional recovery following SCI, but no imaging information regarding regeneration has been provided to date. This study used tractography to show the regenerating process induced by a new biomaterial-aligned fibrin hydrogel (AFG). A total of eight canines subjected to SCI procedures were assigned to the control or the AFG group. AFG was implanted into the SCI lesion immediately after injury in 5 canines. A follow-up was performed at 12 weeks to evaluate the therapeutic effect including the hindlimb functional recovery, anisotropy and continuity of fibers on tractography. Using tractography, we found new fibers running across the SCI in three canines of the AFG group. Further histological examination confirmed limited glial scarring and regenerated nerve fibers in the lesions. Moreover, Repeated Measures Analysis revealed a significantly different change in fractional anisotropy (FA) between the two groups during the follow-up interval. An increase in FA during the post injury time interval was detected in the AFG group, indicating a beneficial effect of AFG in the rehabilitation of injured axons. Using tractography, AFG was suggested to be helpful in the restoration of fibers in SCI lesions, thus leading to promoted functional recovery.

The "beneficial" effects of locomotor training after various types of spinal lesions in cats and rats

This chapter reviews a number of experiments on the recovery of locomotion after various types of spinal lesions and locomotor training mainly in cats. We first recall the major evidence on the recovery of hindlimb locomotion in completely spinalized cats at the T13 level and the role played by the spinal locomotor network, also known as the central pattern generator, as well as the beneficial effects of locomotor training on this recovery. Having established that hindlimb locomotion can recover, we raise the issue as to whether spinal plastic changes could also contribute to the recovery after partial spinal lesions such as unilateral hemisections. We found that after such hemisection at T10, cats could recover quadrupedal locomotion and that deficits could be improved by training. We further showed that, after a complete spinalization a few segments below the first hemisection (at T13, i.e., the level of previous studies on spinalization), cats could readily walk with the hindlimbs within hours of completely severing the remaining spinal tracts and not days as is usually the case with only a single complete spinalization. This suggests that neuroplastic changes occurred below the first hemisection so that the cat was already primed to walk after the spinalization subsequent to the hemispinalization 3 weeks before. Of interest is the fact that some characteristic kinematic features in trained or untrained hemispinalized cats could remain after complete spinalization, suggesting that spinal changes induced by training could also be durable. Other studies on reflexes and on the pattern of "fictive" locomotion recorded after curarization corroborate this view. More recent work deals with training cats in more demanding situations such as ladder treadmill (vs. flat treadmill) to evaluate how the locomotor training regimen can influence the spinal cord. Finally, we report our recent studies in rats using compressive lesions or surgical complete spinalization and find that some principles of locomotor recovery in cats also apply to rats when adequate locomotor training is provided.

Preclinical evidence supporting the clinical development of central pattern generator-modulating therapies for chronic spinal cord-injured patients

Ambulation or walking is one of the main gaits of locomotion. In terrestrial animals, it may be defined as a series of rhythmic and bilaterally coordinated movement of the limbs which creates a forward movement of the body. This applies regardless of the number of limbs-from arthropods with six or more limbs to bipedal primates. These fundamental similarities among species may explain why comparable neural systems and cellular properties have been found, thus far, to control in similar ways locomotor rhythm generation in most animal models. The aim of this article is to provide a comprehensive review of the known structural and functional features associated with central nervous system (CNS) networks that are involved in the control of ambulation and other stereotyped motor patterns-specifically Central Pattern Generators (CPGs) that produce basic rhythmic patterned outputs for locomotion, micturition, ejaculation, and defecation. Although there is compelling evidence of their existence in humans, CPGs have been most studied in reduced models including in vitro isolated preparations, genetically-engineered mice and spinal cord-transected animals. Compared with other structures of the CNS, the spinal cord is generally considered as being well-preserved phylogenetically. As such, most animal models of spinal cord-injured (SCI) should be considered as valuable tools for the development of novel pharmacological strategies aimed at modulating spinal activity and restoring corresponding functions in chronic SCI patients.

Experimental traumatic spinal cord injury

Animal models are important to develop therapies for individuals suffering from spinal cord injuries. For this purpose, rats are commonly preferred. In sharp injury models, spinal cord is completely or incompletely cut to assess axonal regeneration. On the other hand, spinal cord is compressed or contused to mimic the human injury in blunt injury models for understanding as well as managing the secondary pathophysiologic processes following injury. Especially, contusions are thought to be biomechanically similar to vertebral fractures and/or dislocations and thus provide the most realistic experimental setting in which to test potential neuroprotective and regenerative strategies.

A dual spinal cord lesion paradigm to study spinal locomotor plasticity in the cat

After a complete spinal cord injury (SCI) at the lowest thoracic level (T13), adult cats trained to walk on a treadmill can recover hindlimb locomotion within 2-3 weeks, resulting from the activity of a spinal circuitry termed the central pattern generator (CPG). The role of this spinal circuitry in the recovery of locomotion after partial SCIs, when part of descending pathways can still access the CPG, is not yet fully understood. Using a dual spinal lesion paradigm (first hemisection at T10 followed three weeks after by a complete spinalization at T13), we showed that major changes occurred in this locomotor spinal circuitry. These plastic changes at the spinal cord level could participate in the recovery of locomotion after partial SCI. This short review describes the main findings of this paradigm in adult cats.

Central pattern generator for locomotion: anatomical, physiological, and pathophysiological considerations

This article provides a perspective on major innovations over the past century in research on the spinal cord and, specifically, on specialized spinal circuits involved in the control of rhythmic locomotor pattern generation and modulation. Pioneers such as Charles Sherrington and Thomas Graham Brown have conducted experiments in the early twentieth century that changed our views of the neural control of locomotion. Their seminal work supported subsequently by several decades of evidence has led to the conclusion that walking, flying, and swimming are largely controlled by a network of spinal neurons generally referred to as the central pattern generator (CPG) for locomotion. It has been subsequently demonstrated across all vertebrate species examined, from lampreys to humans, that this CPG is capable, under some conditions, to self-produce, even in absence of descending or peripheral inputs, basic rhythmic, and coordinated locomotor movements. Recent evidence suggests, in turn, that plasticity changes of some CPG elements may contribute to the development of specific pathophysiological conditions associated with impaired locomotion or spontaneous locomotor-like movements. This article constitutes a comprehensive review summarizing key findings on the CPG as well as on its potential role in Restless Leg Syndrome, Periodic Leg Movement, and Alternating Leg Muscle Activation. Special attention will be paid to the role of the CPG in a recently identified, and uniquely different neurological disorder, called the Uner Tan Syndrome.

Effect of locomotor training in completely spinalized cats previously submitted to a spinal hemisection

After a spinal hemisection in cats, locomotor plasticity occurring at the spinal level can be revealed by performing, several weeks later, a complete spinalization below the first hemisection. Using this paradigm, we recently demonstrated that the hemisection induces durable changes in the symmetry of locomotor kinematics that persist after spinalization. Can this asymmetry be changed again in the spinal state by interventions such as treadmill locomotor training started within a few days after the spinalization? We performed, in 9 adult cats, a spinal hemisection at thoracic level 10 and then a complete spinalization at T13, 3 weeks later. Cats were not treadmill trained during the hemispinal period. After spinalization, 5 of 9 cats were not trained and served as control while 4 of 9 cats were trained on the treadmill for 20 min, 5 d a week for 3 weeks. Using detailed kinematic analyses, we showed that, without training, the asymmetrical state of locomotion induced by the hemisection was retained durably after the subsequent spinalization. By contrast, training cats after spinalization induced a reversal of the left/right asymmetries, suggesting that new plastic changes occurred within the spinal cord through locomotor training. Moreover, training was shown to improve the kinematic parameters and the performance of the hindlimb on the previously hemisected side. These results indicate that spinal locomotor circuits, previously modified by past experience such as required for adaptation to the hemisection, can remarkably respond to subsequent locomotor training and improve bilateral locomotor kinematics, clearly showing the benefits of locomotor training in the spinal state.

How physically active are people with stroke in physiotherapy sessions aimed at improving motor function? A systematic review

Background. Targeted physical activity drives functional recovery after stroke. This review aimed to determine the amount of time stroke survivors spend physically active during physiotherapy sessions. Summary of Review. A systematic search was conducted to identify published studies that investigated the use of time by people with stroke during physiotherapy sessions. Seven studies were included; six observational and one randomised controlled trial. People with stroke were found to be physically active for an average of 60 percent of their physiotherapy session duration. The most common activities practiced in a physiotherapy session were walking, sitting, and standing with a mean (SD) practice time of 8.7 (4.3), 4.5 (4.0), and 8.3 (2.6) minutes, respectively. Conclusion. People with stroke were found to spend less than two-thirds of their physiotherapy sessions duration engaged in physical activity. In light of dosage studies, practice time may be insufficient to drive optimal motor recovery.

A systematic review of the effects of pharmacological agents on walking function in people with spinal cord injury

Studies of spinalized animals indicate that some pharmacological agents may act on receptors in the spinal cord, helping to produce coordinated locomotor movement. Other drugs may help to ameliorate the neuropathological changes resulting from spinal cord injury (SCI), such as spasticity or demyelination, to improve walking. The purpose of this study was to systematically review the effects of pharmacological agents on gait in people with SCI. A keyword literature search of articles that evaluated the effects of drugs on walking after SCI was performed using the databases MEDLINE/PubMed, CINAHL, EMBASE, PsycINFO, and hand searching. Two reviewers independently evaluated each study, using the Physiotherapy Evidence Database (PEDro) tool for randomized clinical trials (RCTs), and the modified Downs & Black scale for all other studies. Results were tabulated and levels of evidence were assigned. Eleven studies met the inclusion criteria. One RCT provided Level 1 evidence that GM-1 ganglioside in combination with physical therapy improved motor scores, walking velocity, and distance better than placebo and physical therapy in persons with incomplete SCI. Multiple studies (levels of evidence 1-5) showed that clonidine and cyproheptadine may improve locomotor function and walking speed in severely impaired individuals with incomplete SCI. Gains in walking speed associated with GM-1, cyproheptadine, and clonidine are low compared to those seen with locomotor training. There was also Level 1 evidence that 4-aminopyridine and L-dopa were no better than placebo in helping to improve gait. Two Level 5 studies showed that baclofen had little to no effect on improving walking in persons with incomplete SCI. There is limited evidence that pharmacological agents tested so far would facilitate the recovery of walking after SCI. More studies are needed to better understand the effects of drugs combined with gait training on walking outcomes in people with SCI.

Differential modulation of crossed and uncrossed reflex pathways by clonidine in adult cats following complete spinal cord injury

Clonidine, an α-noradrenergic agonist, facilitates hindlimb locomotor recovery after complete spinal transection (i.e. spinalization) in adult cats. However, the mechanisms involved in clonidine-induced functional recovery are poorly understood. Sensory feedback from the legs is critical for hindlimb locomotor recovery in spinalized mammals and clonidine could alter how spinal neurons respond to peripheral inputs in adult spinalized cats. To test this hypothesis we evaluated the effect of clonidine on the responses of hindlimb muscles, primarily in the left hindlimb, evoked by stretching the left triceps surae muscles and by stimulating the right tibial and superficial peroneal nerves in eight adult decerebrate cats that were spinalized 1 month before the terminal experiment. Cats were not trained following spinalization. Clonidine had no consistent effect on responses of ipsilateral muscles evoked by triceps surae muscle stretch. However, clonidine consistently potentiated the amplitude and duration of crossed extensor responses. Moreover, following clonidine injection, stretch and tibial nerve stimulation triggered episodes of locomotor-like activity in approximately one-third of trials. Differential effects of clonidine on crossed reflexes and on ipsilateral responses to muscle stretch indicate an action at a pre-motoneuronal site. We conclude that clonidine facilitates hindlimb locomotor recovery following spinalization in untrained cats by enhancing the excitability of central pattern generating spinal neurons that also participate in crossed extensor reflex transmission.

Evidence-based therapy for recovery of function after spinal cord injury

Physical rehabilitation for individuals coping with neurological deficits is evolving in response to a paradigm shift in thinking about the injured nervous system and using evidence as a basis for clinical decisions. Functional recovery from paralysis was generally believed to be nearly impossible, based on traditional expert opinion, and the priority was to develop compensation strategies to achieve functional goals in the home and community. Research, which began in animal models of neurological insult and is currently being translated to the clinic, has challenged these assumptions. The nervous system, whether intact or injured, has enormous potential for adaptation and modification, which can be harnessed to facilitate recovery. In this chapter we will briefly outline the history of physical rehabilitation as it concerns the development of strategies aimed at compensation, rather than functional recovery. Then we will discuss how new activity-based therapies are being developed, based on evidence from basic science and clinical evidence. One of these activity-based therapies is locomotor training, a program which relies on the intrinsic, automatic, control of locomotion by "lower" neural centers. A brief description of the program, including the four foundational principles, will be followed by an introduction to the use of robotics in these programs. Finally, we will discuss a second activity-based therapy, functional electrical stimulation (FES), and the future of physical rehabilitation for spinal cord injury and other neurological disorders.

Controlling specific locomotor behaviors through multidimensional monoaminergic modulation of spinal circuitries

Descending monoaminergic inputs markedly influence spinal locomotor circuits, but the functional relationships between specific receptors and the control of walking behavior remain poorly understood. To identify these interactions, we manipulated serotonergic, dopaminergic, and noradrenergic neural pathways pharmacologically during locomotion enabled by electrical spinal cord stimulation in adult spinal rats in vivo. Using advanced neurobiomechanical recordings and multidimensional statistical procedures, we reveal that each monoaminergic receptor modulates a broad but distinct spectrum of kinematic, kinetic, and EMG characteristics, which we expressed into receptor-specific functional maps. We then exploited this catalog of monoaminergic tuning functions to devise optimal pharmacological combinations to encourage locomotion in paralyzed rats. We found that, in most cases, receptor-specific modulatory influences summed near algebraically when stimulating multiple pathways concurrently. Capitalizing on these predictive interactions, we elaborated a multidimensional monoaminergic intervention that restored coordinated hindlimb locomotion with normal levels of weight bearing and partial equilibrium maintenance in spinal rats. These findings provide new perspectives on the functions of and interactions between spinal monoaminergic receptor systems in producing stepping, and define a framework to tailor pharmacotherapies for improving neurological functions after CNS disorders.

Enhancing recovery from peripheral nerve injury using treadmill training

Full functional recovery after traumatic peripheral nerve injury is rare. We postulate three reasons for the poor functional outcome measures observed. Axon regeneration is slow and not all axons participate. Significant misdirection of regenerating axons to reinnervate inappropriate targets occurs. Seemingly permanent changes in neural circuitry in the central nervous system are found to accompany axotomy of peripheral axons. Exercise in the form of modest daily treadmill training impacts all three of these areas. Compared to untrained controls, regenerating axons elongate considerably farther in treadmill trained animals and do so via an autocrine/paracrine neurotrophin signaling pathway. This enhancement of axon regeneration takes place without an increase in the amount of misdirection of regenerating axons found without training. The enhancement also occurs in a sex-dependent manner. Slow continuous training is effective only in males, while more intense interval training is effective only in females. In treadmill trained, but not untrained mice the extent of coverage of axotomized motoneurons is maintained, thus preserving important elements of the spinal circuitry.

Strategies for spinal cord repair after injury: a review of the literature and information

INTRODUCTION

Thanks to the Internet, we can now have access to more information about spinal cord repair. Spinal cord injured (SCI) patients request more information and hospitals offer specific spinal cord repair medical consultations.

OBJECTIVE

Provide practical and relevant elements to physicians and other healthcare professionals involved in the care of SCI patients in order to provide adequate answers to their questions.

METHOD

Our literature review was based on English and French publications indexed in PubMed and the main Internet websites dedicated to spinal cord repair.

RESULTS

A wide array of research possibilities including notions of anatomy, physiology, biology, anatomopathology and spinal cord imaging is available for the global care of the SCI patient. Prevention and repair strategies (regeneration, transplant, stem cells, gene therapy, biomaterials, using sublesional uninjured spinal tissue, electrical stimulation, brain/computer interface, etc.) for the injured spinal cord are under development. It is necessary to detail the studies conducted and define the limits of these new strategies and benchmark them to the realistic medical and rehabilitation care available to these patients.

CONCLUSION

Research is quickly progressing and clinical trials will be developed in the near future. They will have to answer to strict methodological and ethical guidelines. They will first be designed for a small number of patients. The results will probably be fragmented and progress will be made through different successive steps.

Chapter 13--on walking, chewing, and breathing--a tribute to Serge, Jim, and Jack

This Fest-schrift honors three outstanding scientists, Serge Rossignol, James Lund, and Jack Feldman, who have pioneered research on three complex motor systems underlying locomotion, mastication, and respiration. In this brief chapter, I highlight some of their main findings, while I also include some reminiscences of my interaction with them over more than 30 years.

Changes in CNS structures after spinal cord lesions implications for BMI

It is well established that a spinal circuitry can generate locomotor movements of the hindlimbs in absence of descending supraspinal inputs. This is based, among others, on the observation that after a complete spinalization, cats can walk with the hindlimbs on a treadmill. Does this spinal pattern generator (CPG) also participate in the recovery of locomotion after a partial spinal cord lesion (SCI)? After such SCI, functional reorganization can occur spontaneously along the whole neuraxis, namely the spinal cord circuitry below the lesion (CPG) and in supraspinal structures still partially connected to the spinal cord. This review focuses mainly on the capacity of the spinal and supraspinal structures to reorganize spontaneously after incomplete SCI in animals (rats and cats). BMI approaches to foster recovery of functions after various types of SCI should take into account these changes at the various levels of the CNS.

Chapter 16--spinal plasticity in the recovery of locomotion

Locomotion is a very robust motor pattern which can be optimized after different types of lesions to the central and/or peripheral nervous system. This implies that several plastic mechanisms are at play to re-express locomotion after such lesions. Here, we review some of the key observations that helped identify some of these plastic mechanisms. At the core of this plasticity is the existence of a spinal central pattern generator (CPG) which is responsible for hindlimb locomotion as observed after a complete spinal cord section. However, normally, the CPG pattern is adapted by sensory inputs to take the environment into account and by supraspinal inputs in the context of goal-directed locomotion. We therefore also review some of the sensory and supraspinal mechanisms involved in the recovery of locomotion after partial spinal injury. We particularly stress a recent development using a dual spinal lesion paradigm in which a first partial spinal lesion is made which is then followed, some weeks later, by a complete spinalization. The results show that the spinal cord below the spinalization has been changed by the initial partial lesion suggesting that, in the recovery of locomotion after partial spinal lesion, plastic mechanisms within the spinal cord itself are very important.

Noradrenergic modulation of intrinsic and synaptic properties of lumbar motoneurons in the neonatal rat spinal cord

Although it is known that noradrenaline (NA) powerfully controls spinal motor networks, few data are available regarding the noradrenergic (NAergic) modulation of intrinsic and synaptic properties of neurons in motor networks. Our work explores the cellular basis of NAergic modulation in the rat motor spinal cord. We first show that lumbar motoneurons express the three classes of adrenergic receptors at birth. Using patch-clamp recordings in the newborn rat spinal cord preparation, we characterized the effects of NA and of specific agonists of the three classes of adrenoreceptors on motoneuron membrane properties. NA increases the motoneuron excitability partly via the inhibition of a K(IR) like current. Methoxamine (alpha(1)), clonidine (alpha(2)) and isoproterenol (beta) differentially modulate the motoneuron membrane potential but also increase motoneuron excitability, these effects being respectively inhibited by the antagonists prazosin (alpha(1)), yohimbine (alpha(2)) and propranolol (beta). We show that the glutamatergic synaptic drive arising from the T13-L2 network is enhanced in motoneurons by NA, methoxamine and isoproterenol. On the other hand, NA, isoproterenol and clonidine inhibit both the frequency and amplitude of miniature glutamatergic EPSCs while methoxamine increases their frequency. The T13-L2 synaptic drive is thereby differentially modulated from the other glutamatergic synapses converging onto motoneurons and enhanced by presynaptic alpha(1) and beta receptor activation. Our data thus show that the NAergic system exerts a powerful and complex neuromodulation of lumbar motor networks in the neonatal rat spinal cord.

Spontaneous Motor Rhythms of the Back and Legs in a Patient With a Complete Spinal Cord Transection

Background. Spontaneous activity originating from the spinal cord has been sporadically reported in humans. Objectives. Investigation of such rhythmic activity of the trunk and legs in a 49-year-old male patient who had a complete severance of the spinal cord at the fifth thoracic vertebra. Methods. A multichannel electromyography (EMG) study was performed together with kinematics measurements obtained from an Optotrak system. Results. Episodes of rhythmic trunk and lower limb movements started 6 to 7 years after the spinal lesion, recurred at 2 to 3 month intervals, and continued uninterrupted for 2 to 3 days despite continuous delivery of intrathecal baclofen. Several muscles discharged more or less synchronously on both sides but others clearly alternated, for instance, between hip flexors and knee or ankle extensors. Sensory stimuli (hip repositioning or skin pinch) altered significantly the baseline rhythm of about 1 Hz. The patient had both hips injected with corticosteroids and was free of these episodic rhythmic crises for more than 6 months. Conclusion. The rhythmic activity observed in the patient appeared related to the activation of a spinal pattern generator akin to what has been described in most animal species after complete spinal lesions.

Sensorimotor training promotes functional recovery and somatosensory cortical map reactivation following cervical spinal cord injury

Sensorimotor activity has been shown to play a key role in functional recovery after partial spinal cord injury (SCI). Most studies in rodents have focused on the rehabilitation of hindlimb locomotor functions after thoracic or lumbar SCI, whereas forelimb motor and somatosensory abilities after cervical SCI remain largely uninvestigated, despite the high incidence of such injuries in humans. Moreover, little is known about the neurophysiological substrates of training-induced recovery in supraspinal structures. This study was aimed at evaluating the effects of a training procedure combining both motor and sensory stimulation on behavioral performance and somatosensory cortical map remodeling after cervical (C4-C5) spinal hemisection in rats. This SCI severely impaired both sensory and motor capacities in the ipsilateral limbs. Without training, post-lesion motor capacities gradually improved, whereas forepaw tactile abilities remained impaired. Consistently, no stimulus-evoked responses were recorded within the forepaw representational zone in the primary somatosensory (S1) cortex at 2 months after the SCI. However, our data reveal that with training started from the 7th day post-lesion, a nearly complete recovery (characterized by an early and rapid improvement of motor functions) was associated with a gradual compensation of tactile deficits. Furthermore, the recovery of tactile abilities was correlated with the areal extent of reactivation of S1 cortex forepaw representations. Rehabilitative training promoted post-lesion adaptive plasticity, probably by enhancing endogenous activity within spared spinal and supraspinal circuits and pathways sustaining sensory and motor functions. This study highlights the beneficial effect of sensorimotor training in motor improvement and its critical influence on tactile recovery after SCI.

Observation of amounts of movement practice provided during stroke rehabilitation

Lang CE, MacDonald JR, Reisman DS, Boyd L, Jacobson Kimberley T, Schindler-Ivens SM, Hornby TG, Ross SA, Scheets PL. Observation of amounts of movement practice provided during stroke rehabilitation.

OBJECTIVE

To investigate how much movement practice occurred during stroke rehabilitation, and what factors might influence doses of practice provided.

DESIGN

Observational survey of stroke therapy sessions.

SETTING

Seven inpatient and outpatient rehabilitation sites.

PARTICIPANTS

We observed a convenience sample of 312 physical and occupational therapy sessions for people with stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We recorded numbers of repetitions in specific movement categories and data on potential modifying factors (patient age, side affected, time since stroke, FIM item scores, years of therapist experience). Descriptive statistics were used to characterize amounts of practice. Correlation and regression analyses were used to determine whether potential factors were related to the amount of practice in the 2 important categories of upper extremity functional movements and gait steps.

RESULTS

Practice of task-specific, functional upper extremity movements occurred in 51% of the sessions that addressed upper limb rehabilitation, and the average number of repetitions/session was 32 (95% confidence interval [CI]=20-44). Practice of gait occurred in 84% of sessions that addressed lower limb rehabilitation and the average number of gait steps/session was 357 (95% CI=296-418). None of the potential factors listed accounted for significant variance in the amount of practice in either of these 2 categories.

CONCLUSIONS

The amount of practice provided during poststroke rehabilitation is small compared with animal models. It is possible that current doses of task-specific practice during rehabilitation are not adequate to drive the neural reorganization needed to promote function poststroke optimally.

Transformation of nonfunctional spinal circuits into functional states after the loss of brain input

After complete spinal cord transections that removed all supraspinal inputs in adult rats, combinations of serotonergic agonists and epidural electrical stimulation were able to acutely transform spinal networks from nonfunctional to highly functional and adaptive states as early as 1 week after injury. Using kinematics, physiological and anatomical analyses, we found that these interventions could recruit specific populations of spinal circuits, refine their control via sensory input and functionally remodel these locomotor pathways when combined with training. The emergence of these new functional states enabled full weight-bearing treadmill locomotion in paralyzed rats that was almost indistinguishable from voluntary stepping. We propose that, in the absence of supraspinal input, spinal locomotion can emerge from a combination of central pattern-generating capability and the ability of these spinal circuits to use sensory afferent input to control stepping. These findings provide a strategy by which individuals with spinal cord injuries could regain substantial levels of motor control.

Current status of acute spinal cord injury pathophysiology and emerging therapies: promise on the horizon

This review summarizes the current understanding of spinal cord injury pathophysiology and discusses important emerging regenerative approaches that have been translated into clinical trials or have a strong potential to do so. The pathophysiology of spinal cord injury involves a primary mechanical injury that directly disrupts axons, blood vessels, and cell membranes. This primary mechanical injury is followed by a secondary injury phase involving vascular dysfunction, edema, ischemia, excitotoxicity, electrolyte shifts, free radical production, inflammation, and delayed apoptotic cell death. Following injury, the mammalian central nervous system fails to adequately regenerate due to intrinsic inhibitory factors expressed on central myelin and the extracellular matrix of the posttraumatic gliotic scar. Regenerative approaches to block inhibitory signals including Nogo and the Rho-Rho-associated kinase pathways have shown promise and are in early stages of clinical evaluation. Cell-based strategies including using neural stem cells to remyelinate spared axons are an attractive emerging approach.

Recovery of control of posture and locomotion after a spinal cord injury: solutions staring us in the face

Over the past 20 years, tremendous advances have been made in the field of spinal cord injury research. Yet, consumed with individual pieces of the puzzle, we have failed as a community to grasp the magnitude of the sum of our findings. Our current knowledge should allow us to improve the lives of patients suffering from spinal cord injury. Advances in multiple areas have provided tools for pursuing effective combination of strategies for recovering stepping and standing after a severe spinal cord injury. Muscle physiology research has provided insight into how to maintain functional muscle properties after a spinal cord injury. Understanding the role of the spinal networks in processing sensory information that is important for the generation of motor functions has focused research on developing treatments that sharpen the sensitivity of the locomotor circuitry and that carefully manage the presentation of proprioceptive and cutaneous stimuli to favor recovery. Pharmacological facilitation or inhibition of neurotransmitter systems, spinal cord stimulation, and rehabilitative motor training, which all function by modulating the physiological state of the spinal circuitry, have emerged as promising approaches. Early technological developments, such as robotic training systems and high-density electrode arrays for stimulating the spinal cord, can significantly enhance the precision and minimize the invasiveness of treatment after an injury. Strategies that seek out the complementary effects of combination treatments and that efficiently integrate relevant technical advances in bioengineering represent an untapped potential and are likely to have an immediate impact. Herein, we review key findings in each of these areas of research and present a unified vision for moving forward. Much work remains, but we already have the capability, and more importantly, the responsibility, to help spinal cord injury patients now.

Partial denervation of ankle extensors prior to spinalization in cats impacts the expression of locomotion and the phasic modulation of reflexes

Following peripheral nerve sections some locomotor deficits appear which are gradually compensated for by spinal and supraspinal mechanisms. The present work is aimed at identifying contributions of both types of mechanisms. We performed a denervation of the left lateral gastrocnemius-soleus (LGS) muscles in three cats which was followed by a spinalization at the 13th thoracic segment. Three other cats were not denervated prior to spinalization (i.e. intact) and served as controls. Over the years, in our laboratory, there have been no instances in which cats did not express spinal locomotion with treadmill training and/or clonidine administration. After spinalization, cats were trained on a treadmill to express spinal locomotion. Reflexes, evoked by stimulating the left tibial nerve at the ankle, the electromyography of several hindlimb muscles, and kinematics were recorded during locomotion before and after denervation, during recovery, and following complete spinalization. Denervating the left LGS before spinalization induced considerable variability in the expression of spinal locomotion from one cat to another, which was not observed in the three controls. Variability ranged from a greater ankle yield in the denervated limb in one cat to inability to recover locomotion after spinalization in another. In the two denervated cats that recovered locomotion after spinalization, some reflex changes differed from "normal" spinal cats (i.e. intact at the time of spinalization), suggesting that reorganization of spinal circuits after spinalization is dissimilar to what normally takes place if denervation is performed before spinalization. First, we conclude that the transient locomotor deficits initially incurred following the LGS denervation in cats with an intact spinal cord reappear after complete spinalization indicating that supraspinal mechanisms were involved in maintaining the adapted locomotion. Second, the reappearance of locomotor deficits and/or impairment in expressing spinal locomotion suggests that spinal mechanisms were profoundly altered to compensate for the initial denervation partly because the reflex modulation is abnormal. If the same denervation is performed after spinalization only transient deficits are observed and spinal locomotion is not compromised.

Effects of Localized Intraspinal Injections of a Noradrenergic Blocker on Locomotion of High Decerebrate Cats

Previous studies demonstrated that neuronal networks located in midlumbar segments (L3–L4) are critical for the expression of locomotion in cats following complete spinalization. In the present study the importance of several thoracolumbar segments (T8–L7) for the generation of spontaneous hindlimb locomotion in decerebrate cats was evaluated. Experiments were performed in high decerebrate cats ( n = 18) walking spontaneously. Yohimbine, an alpha2-noradrenergic antagonist, was microinjected intraspinally in various thoracolumbar segments. Locomotor performance was evaluated with kinematics and electromyographic (EMG) recordings before and after each injection. When and if spontaneous locomotion (SL) was abolished, skin or perineal stimuli (exteroceptive stimuli) were used to trigger locomotion (exteroceptive-induced locomotion [EL]). Yohimbine injections at L3 or L4 completely inhibited SL and EL. In contrast, injections at T8 did not interfere with SL or EL. Injections at T10, T11, T12, L5, L6, and L7 inhibited SL but EL could still be evoked. Injections at T13, L1, and L2 had similar effects except that the quality of locomotion evoked by exteroceptive stimulation declined. Combined injections at T13, L1, and L2 abolished SL and EL, in contrast to injections restricted to the same individual segments. Simultaneous injections at L5, L6, and L7 also abolished SL but EL could still be induced. These results suggest that noradrenergic mechanisms in L3–L4 segments are involved in the expression of locomotion in decerebrate cats, whereas antagonizing noradrenergic inputs in individual rostral or caudal segments may alter the expression and overall quality of the locomotor pattern without abolishing locomotion.

Spinal cord injury: time to move?

This symposium aims at summarizing some of the scientific bases for current or planned clinical trials in patients with spinal cord injury (SCI). It stems from the interactions of four researchers involved in basic and clinical research who presented their work at a dedicated Symposium of the Society for Neuroscience in San Diego. After SCI, primary and secondary damage occurs and several endogenous processes are triggered that may foster or hinder axonal reconnection from supralesional structures. Studies in animals show that some of these processes can be enhanced or decreased by exogenous interventions using drugs to diminish repulsive barriers (anti-Nogo, anti-Rho) that prevent regeneration and/or sprouting of axons. Cell grafts are also envisaged to enhance beneficial immunological mechanisms (autologous macrophages, vaccines) or remyelinate axons (oligodendrocytes derived from stem cells). Some of these treatments could be planned concurrently with neurosurgical approaches that are themselves beneficial to decrease secondary damage (e.g., decompression/reconstructive spinal surgery). Finally, rehabilitative approaches based on the presence of functional networks (i.e., central pattern generator) below the lesion combined with the above neurobiological approaches may produce significant functional recovery of some sensorimotor functions, such as locomotion, by ensuring an optimal function of endogenous spinal networks and establishing new dynamic interactions with supralesional structures. More work is needed on all fronts, but already the results offer great hope for functional recovery after SCI based on sound basic and clinical neuroscience research.

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.

Counting Repetitions: An Observational Study of Outpatient Therapy for People with Hemiparesis Post-Stroke

Given the contemporary clinical belief that more practice is better, it is important to determine how much practice currently occurs during physical therapy (PT) and occupational therapy (OT). The purpose of this study was to examine the number of repetitions of various activities during PT and OT outpatient treatment sessions for people with hemiparesis post-stroke. We observed 36 treatment sessions and recorded the types of activities and the number of repetitions of each activity that were done. Observations were categorized and descriptive statistics were generated for each category and subcategory. Our results showed that treatment time averaged 36 minutes per session. In sessions addressing the upper extremity, the average number of repetitions per session were 39 for active-exercise movements, 34 for passive-exercise movements, and 12 for purposeful movements. In sessions addressing the lower extremity, the average number of repetitions per session were 33 for active-exercise movements, six for passive-exercise movements, and eight for purposeful movements. In sessions addressing gait, the average number of steps taken was 292. In sessions addressing transfers, the average number of repetitions per session was 11. For most categories, there was considerable variability in the number of repetitions observed. We conclude that the numbers of repetitions observed during PT and OT for people with hemiparesis post-stroke are relatively small, except for gait steps. The fact that the number of repetitions of upper extremity purposeful movements was smaller than the number of repetitions of upper extremity active- and passive-exercise movements was surprising. This finding is inconsistent with current teaching that practice of purposeful movements is an integral part of improving functional status.

Characteristics and mechanisms of locomotion induced by intraspinal microstimulation and dorsal root stimulation in spinal cats

Intraspinal microstimulation (ISMS) through a single microelectrode can induce locomotion in cats spinalized at T(13) 1 wk before (untrained) or after 3-5 wk of treadmill training. Here we study the optimal parameters of ISMS and the characteristics of locomotion evoked. ISMS was applied in the dorsal region of segments L(3)-S(1) at different lateralities (midline to 2.5 mm) and after an intravenous injection of clonidine (noradrenergic agonist). Kinematics and electromyographic recordings were used to characterize locomotion. ISMS could induce a bilateral locomotor pattern similar to that obtained with perineal stimulation, and the characteristics of locomotion varied according to the spinal segment stimulated. Mechanisms by which ISMS could evoke locomotion were then investigated by stimulating, inactivating, or lesioning different spinal structures. Dorsal root stimulation (DRS), just like ISMS, could evoke a variety of ipsi- and bilateral nonlocomotor movements as well as locomotor responses. This suggests that sensory afferent pathways are involved in the production of locomotion by ISMS. Microinjections of yohimbine (noradrenergic antagonist) in L(3) and L(4) segments or a complete second spinal lesion at L(3)-L(4) abolished all locomotor activity evoked by ISMS applied at more caudal segments. Progressive dorsoventral spinal lesions at L(3) or L(4) and restricted ventral lesions at L(4) further suggest that the integrity of the ventral or ventrolateral funiculi as well as the L(3)-L(4) segments are critical for the induction of locomotion by ISMS at L(5) to S(1) or by DRS at these caudal segments.