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Hebbian Rehabilitation for SCI
Lumping rare diseases into integrated clinical trials
'Hebbian' Rehabilitation for Spinal Cord Injury
Hebbian rehabilitation for spinal cord injury
Noam Y. Harel; originally posted 8/21/2008; updated 3/31/2013
Most spinal cord injuries (SCI), even if they cause complete paralysis and sensory loss below the lesion, tend to
a variable amount of nerve fibers passing through the lesion (Kakulas, 1987).
circuits comprise the majority of spared fibers (Nathan, 1996). However, people with SCI may have difficulty consciously controlling these subcortical circuits.
The locomotor central pattern generator (CPG), located within the thoraco-lumbar junction of the spinal cord, mediates reflexive walking with only minimal conscious control. The CPG is located below the level of injury in roughly 85% of human SCI patients.
Currently, gait training rehabilitation for SCI patients often focuses on stimulating the CPG through weight-supported treadmill training. Rehabilitation exercises are not as focused on re-establishing
voluntary control of the CPG (van den Brand et al., 2012).
Neural learning is strengthened by simultaneous multisensory input/activation - "Fire Together, Wire Together" (Hebb's Principle).
Could motor learning (eg SCI rehab) benefit from a similar simultaneous sensorimotor approach? Especially if the approach is aimed higher,
rather than below spinal lesions?
To strengthen cortical connections to the brainstem circuits that more likely retain spared fibers across spinal injuries.
This could be achieved using combinations of physical exercises that stimulate brainstem pathways (eg balance exercises-->vestibulospinal, reticulospinal circuits) and cortical pathways (eg skilled hand exercises-->corticospinal tract).
This should result in formation of detour pathways that re-establish volitional control over subcortical and spinal circuits.
Strengthened detour pathways should result in improved motor function and electrical transmission across and below spinal injuries.
We have tested this approach in mice with incomplete injuries (Harel et al., 2010; Harel et al., in preparation).
We are now testing this approach in humans with incomplete thoracic SCI (see clinicaltrials.gov NCT01740128).
In mice, we see improved behavioral outcomes with multimodal 'Hebbian' training. We do not see a corresponding increase in anatomical growth of the corticospinal or raphespinal tracts.
In humans, we are following both functional outcomes and electrophysiological outcomes (using transcranial magnetic stimulation and electromyography).
We hope to test a similar strategy of combining brainstem-activating balance exercises with cortical-activating direct current stimulation (DCS).
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