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The dexterity of hands and fingers is related to the strength of control by cortico-motoneuronal connections which exclusively exist in primates. The cortical command is associated with a task-specific, rapid proprioceptive adaptation of forces applied by hands and fingers to an object. This neural control differs between "power grip" movements (e.g., reach and grasp of a cup) where hand and fingers act as a unity and "precision grip" movements (e.g., picking up a raspberry) where fingers move independently from the hand. In motor tasks requiring hands and fingers of both sides a "neural coupling" (reflected in bilateral reflex responses to unilateral stimulations) coordinates power grip movements (e.g., opening a bottle). In contrast, during bilateral precision movements, such as playing piano, the fingers of both hands move independently, due to a direct cortico-motoneuronal control, while the hands are coupled (e.g., to maintain the rhythm between the two sides). While most studies on prehension concern unilateral hand movements, many activities of daily life are tackled by bilateral power grips where a neural coupling serves for an automatic movement performance. In primates this mode of motor control is supplemented by a system that enables the uni- or bilateral performance of skilled individual finger movements.

Introduction: Pain is a prominent complication in spinal cord injury (SCI). It can either occur as a direct or as an indirect consequence of SCI and it often heavily influences the quality of life of affected individuals. In SCI, nociceptive and neuropathic pain can equally emerge at the same time above or below the level of injury. Thus, classification and grading of pain is frequently difficult. Effective treatment of SCI-related pain in general and of neuropathic pain in particular is challenging. Current treatment options are sparse and their evidence is considered to be limited. Considering these aspects, a clinical practice guideline was developed as basis for an optimized, comprehensive and standardized pain management in SCI-related pain. Methods: The German-Speaking Medical Society for Spinal Cord Injury (Deutschsprachige Medizinische Gesellschaft für Paraplegiologie – DMGP) developed a clinical practice guideline that received consensus from seven further German-speaking medical societies and one patient organization. The evidence base from clinical trials and meta-analyses was summarized and subjected to a structured consensus-process in accordance with the regulations of the Association of Scientific Medical Societies in Germany (AWMF) and the methodological requirements of the “German instrument for methodological guideline appraisal”. Results: This consensus-based guideline (S2k classification according to the AWMF guidance manual and rules) resulted in seven on-topic statements and 17 specific recommendations relevant to the classification, assessment and therapy of pain directly or indirectly caused by SCI. Recommended therapeutic approaches comprise pharmacological (e.g. nonsteroidal anti-inflammatory drugs or anticonvulsants) and non-pharmacological (e.g. physical activity or psychotherapeutic techniques) strategies for both nociceptive and neuropathic pain. Discussion: Assessment of SCI-related pain is standardized and respective methods in terms of examination, classification and grading of pain are already in use and validated in German language. In contrast, valid, evidence-based and efficient therapeutic options are limited and ask for further clinical studies, ideally randomized controlled trials and meta-analyses., Einleitung: Schmerzen sind eine höchst relevante Komplikation nach erlittener Querschnittlähmung. Sie können als eine direkte oder indirekte Folge auftreten und erheblichen Einfluss auf die Lebensqualität Betroffener haben. Nach einer Querschnittlähmung können nozizeptive und neuropathische Schmerzen gleichermaßen und zeitgleich sowohl oberhalb als auch unterhalb des Lähmungsniveaus auftreten. Deshalb erscheinen Klassifikation und Einordnung der Schmerzen häufig problematisch. Die Behandlung dieser Schmerzen ist generell schwierig und insbesondere für neuropathische Schmerzen herausfordernd. Dies ergibt sich nicht zuletzt aus den wenig vorhandenen und kaum evidenzbasierten Behandlungsmöglichkeiten. In Anbetracht dessen soll die Leitlinie als valide Basis für ein optimiertes, umfassendes und standardisiertes Schmerzmanagement dienen. Methoden: Sieben deutschsprachige medizinische Fachgesellschaften mit thematischem Bezug zur Leitlinie und eine Fördergemeinschaft Betroffener entwickelten unter Federführung der Deutschsprachigen Medizinischen Gesellschaft für Paraplegiologie (DMGP) diese Leitlinie mittels einer strukturierten Konsensfindung nach den Maßgaben des Regelwerks der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) sowie in Übereinstimmung mit dem deutschen Instrument zur methodischen Leitlinienbewertung. Ergebnisse: Diese Leitlinie (S2k-Klassifikation gemäß dem Regelwerk der AWMF) ergab einen einstimmigen Konsens für sieben Kernaussagen und 17 spezifische Empfehlungen mit Bezug zur Klassifikation, Untersuchung/Beurteilung und Therapie von direkt oder indirekt infolge einer Querschnittlähmung auftretender Schmerzen. Empfohlene Therapien umfassen sowohl medikamentöse (z.B. nicht-steroidale Antirheumatika und Antikonvulsiva), als auch nicht-medikamentöse (z.B. körperliche Aktivität und psychotherapeutische Maßnahmen) Ansätze und betreffen nozizeptive wie auch neuropathische Schmerzen. Diskussion: Es existieren diverse standardisierte und verlässliche Methoden zur Beurteilung und Untersuchung von Schmerzen nach Querschnittlähmung, die auch häufig in deutscher Sprache validiert sind. Demgegenüber sind evidenzbasierte und effektive schmerztherapeutische Möglichkeiten stark begrenzt und bedürfen weiterer wissenschaftlicher Auseinandersetzung, die sich im Idealfall aus randomisierten kontrollierten Studien und Metaanalysen ergibt., GMS German Medical Science; 17:Doc05

Objective To characterize remote secondary neurodegeneration of spinal tracts and neurons below a cervical spinal cord injury (SCI) and its relation to the severity of injury, the integrity of efferent and afferent pathways, and clinical impairment. Methods A comprehensive high-resolution MRI protocol was acquired in 17 traumatic cervical SCI patients and 14 controls at 3T. At the cervical lesion, a sagittal T2-weighted scan provided information on the width of preserved midsagittal tissue bridges. In the lumbar enlargement, high-resolution T2*-weighted and diffusion-weighted scans were used to calculate tissue-specific cross-sectional areas and diffusion indices, respectively. Regression analyses determined associations between MRI readouts and the electrophysiologic and clinical measures. Results At the cervical injury level, preserved midsagittal tissue bridges were present in the majority of patients. In the lumbar enlargement, neurodegeneration—in terms of macrostructural and microstructural MRI changes—was evident in the white matter and ventral and dorsal horns. Patients with thinner midsagittal tissue bridges had smaller ventral horn area, higher radial diffusivity in the gray matter, smaller motor evoked potential amplitude from the lower extremities, and lower motor score. In addition, smaller width of midsagittal tissue bridges was also associated with smaller tibialis sensory evoked potential amplitude and lower light-touch score. Conclusions This study shows extensive tissue-specific cord pathology in infralesional spinal networks following cervical SCI, its magnitude relating to lesion severity, electrophysiologic integrity, and clinical impairment of the lower extremity. The clinical eloquence of remote neurodegenerative changes speaks to the application of neuroimaging biomarkers in diagnostic workup and planning of clinical trials.

The past decades have seen rapid and vast developments of robots for the rehabilitation of sensorimotor deficits after damage to the central nervous system (CNS). Many of these innovations were technology-driven, limiting their clinical application and impact. Yet, rehabilitation robots should be designed on the basis of neurophysiological insights underlying normal and impaired sensorimotor functions, which requires interdisciplinary collaboration and background knowledge. Recovery of sensorimotor function after CNS damage is based on the exploitation of neuroplasticity, with a focus on the rehabilitation of movements needed for self-independence. This requires a physiological limb muscle activation that can be achieved through functional arm/hand and leg movement exercises and the activation of appropriate peripheral receptors. Such considerations have already led to the development of innovative rehabilitation robots with advanced interaction control schemes and the use of integrated sensors to continuously monitor and adapt the support to the actual state of patients, but many challenges remain. For a positive impact on outcome of function, rehabilitation approaches should be based on neurophysiological and clinical insights, keeping in mind that recovery of function is limited. Consequently, the design of rehabilitation robots requires a combination of specialized engineering and neurophysiological knowledge. When appropriately applied, robot-assisted therapy can provide a number of advantages over conventional approaches, including a standardized training environment, adaptable support and the ability to increase therapy intensity and dose, while reducing the physical burden on therapists. Rehabilitation robots are thus an ideal means to complement conventional therapy in the clinic, and bear great potential for continued therapy and assistance at home using simpler devices. This review summarizes the evolution of the field of rehabilitation robotics, as well as the current state of clinical evidence. It highlights fundamental neurophysiological factors influencing the recovery of sensorimotor function after a stroke or spinal cord injury, and discusses their implications for the development of effective rehabilitation robots. It thus provides insights on essential neurophysiological mechanisms to be considered for a successful development and clinical inclusion of robots in rehabilitation., Journal of NeuroEngineering and Rehabilitation, 15, ISSN:1743-0003

Mit Einführung der Umweltzone 2011 erfolgte eine beschleunigte Modernisierung der Fahrzeugflotte in Leipzig gegenüber anderen Regionen in Sachsen. Die Belastung durch Verbrennungspartikel aus der modernisierten Fahrzeugflotte reduzierte sich sehr deutlich. Die Reduzierung war im ersten Jahr der Umweltzone am stärksten. Nach sechs Jahren wurde eine Minderung für die Anzahl der Partikel von 30 bis 200 nm um 74 % und für Ruß-Partikel BC um 59 % nachgewiesen. Dies dokumentiert den Erfolg der Partikelfilter in modernen Dieselfahrzeugen beim realen Fahren in der Stadt. Der hochtoxische Feinstaubanteil in der Außenluft und damit das Gesundheitsrisiko der Bevölkerung wurden sehr deutlich gesenkt. Die Umweltzone war damit eine sinnvolle und wirkungsvolle Maßnahme der Stadtverwaltung. Gleichzeitig trat keine Verbesserung für die Stickstoffoxide durch die modernste Fahrzeugflotte Sachsens ein. Die Dieselfahrzeuge gelten als die Hauptverursacher. Der Misserfolg in der Minderung der Stickoxide moderner Diesel-PKW beim realen Fahren in der Stadt trotz verschärfter EURO-Abgasnormen wurde dokumentiert. Über die tatsächlichen Emissionen moderner Diesel-PKW wurden Bürger und Stadtverwaltung von Autoherstellern getäuscht.

Die Veröffentlichung beschreibt den Einfluss der Geschwindigkeit auf den Stickoxid-Ausstoß von Kraftfahrzeugen auf steilen Straßen. Basis sind Messungen an einzelnen Fahrzeugen. Ein höherer Stickoxid-Ausstoß mit zunehmender Geschwindigkeit wurde bei einem Diesel-PKW und dem LKW festgestellt. Die Veröffentlichung richtet sich an für Luftqualität und Straßenverkehr zuständige Behörden, an Wissenschaftler und auch an Kraftfahrer. Redaktionsschluss: 28.12.2017

The comprehension of basic spinal neuronal alterations after central nervous system lesions, such as spinal cord injury (SCI) or stroke, enables us to optimize rehabilitative approaches for affected subjects. Adverse changes in spinal neuronal function are best investigated by recordings of spinal reflexes (SR) and locomotor electromyography (EMG). In the first few weeks after an SCI, neither locomotor nor SR activity can be evoked. Once spinal shock has resolved, an early SR component can be re-evoked and locomotor EMG activity reappears in response to appropriate peripheral input. In a more chronic stage of SCI, however, alterations in SR components are accompanied by a decline of EMG amplitude in the leg muscles during assisted locomotion. It is assumed that not only the deprivation of supraspinal input but also of the lack of meaningful proprioceptive input to spinal neuronal networks account for such alterations in chronic immobilized individuals with SCI..A critical combination of sensory cues through appropriate training strategies seems to prevent the development of spinal neuronal dysfunction and to improve locomotor ability.

Mit Einführung der Umweltzone 2011 erfolgte eine beschleunigte Modernisierung der Fahrzeugflotte in Leipzig gegenüber anderen Regionen in Sachsen. Die Belastung durch Verbrennungspartikel aus der modernisierten Fahrzeugflotte reduzierte sich sehr deutlich. Die Reduzierung war im ersten Jahr der Umweltzone am stärksten. Nach fünf Jahren wurde eine Minderung für die Anzahl der Partikel von 30 bis 200 nm um 62 % und für Ruß-Partikel BC um 48 % nachgewiesen. Dies dokumentiert den Erfolg der Partikelfilter in modernen Dieselfahrzeugen beim realen Fahren in der Stadt. Der hochtoxische Feinstaubanteil in der Außenluft und damit das Gesundheitsrisiko der Bevölkerung wurden sehr deutlich gesenkt. Gleichzeitig trat keine Verbessserungen für die Stickstoffoxide durch die modernste Fahrzeugflotte Sachsens ein. Die Dieselfahrzeuge gelten als die Hauptverursacher. Der Misserfolg in der Minderung der Stickoxide moderner Dieselfahrzeuge beim realen Fahren in der Stadt trotz verschärfter EURO-Abgasnormen wird dokumentiert. Hier besteht dringender Handlungsbedarf.

Die Einführung der Umweltzone in Leipzig wird durch Messungen an Luftmessstationen wissenschaftlich begleitet. Neben den gesetzlich vorgegebenen Schadstoffen werden erstmalig Ruß und ultrafeine Partikel überwacht. Der dritte Teil der Berichterstattung dokumentiert die Ergebnisse bis 2013. Die Umweltzone bewirkte eine beschleunigte Modernisierung der Fahrzeugflotte in der Stadt. In verkehrsnaher Außenluft wurden ein deutlicher Rückgang von Ruß und ultrafeinen Partikeln und eine Stagnation von Stickoxiden nachgewiesen. Erfolgreich wurden die hochtoxischen Bestandteile im Feinstaub gemindert.

The implementation of electromechanical devices for the quantification and treatment of movement impairments (abnormal muscle synergies, spasticity, and paralysis) resulting from brain injury is the main topic in this chapter. The specific requirements for the use of robotic devices to quantify these impairments as well as treat them effectively are discussed. A case is made that electromechanical devices not only allow the clinician to quantitatively control task practice and dosage, but, more importantly, allow for direct targeting of specific impairments, such as the loss of independent joint control (Dewald et al. Top Stroke Rehabil. 8(1):1–12, 2001), that are informed by a body of scientific evidence. Acceptance of these new technologies is dependent on proof of their effectiveness in the reduction of movement impairments and activity limitations, as opposed to compensation, and ultimately on carryover of benefits to activities of daily living and quality of life. Furthermore, the need of a concerted effort to simplify these new technologies, once essential treatment ingredients have been determined, is seen as being a key component for their acceptance in the clinic on a large scale. Finally, it is crucial that we demonstrate that electromechanical technologies augment existing rehabilitative care and serve to reduce treatment time and costs while maintaining, and even improving, functional outcomes. This is a requirement for future technology development especially in a healthcare environment where rehabilitation services have become less accessible.

Robot-aided gait training in stroke survivors and spinal cord injury patients has shown inconclusive effects on walking ability. It is widely acknowledged that the control and design of the robotic devices needs to be further optimized to be able to provide training that fits better into modern insights in neural plasticity, motor learning, and motor recovery and in doing so improves its effectiveness. We will go more deeply into the need and scientific background for improvements on active participation, task specificity, and the facilitation of different recovery mechanisms. Subsequently, we will discuss recent advances that have been made in the control and design of robotic devices to improve on these aspects. Hereby, we will focus on the robotic gait training device LOPES that has been developed within our group. We will discuss how its design and control approach should contribute to improvements on all of the aforementioned aspects. The feasibility of the chosen approach is demonstrated by experimental results in healthy subjects and chronic stroke survivors. Future clinical testing has to demonstrate whether the outcome of robot-aided gait training can indeed be improved by increasing its task specificity, by the active contribution of the patient, and by allowing different movement strategies.

The myelin protein Nogo-A is a potent inhibitor of neurite outgrowth in the central nervous system, thus contributing to the incapacity of fiber tracts in the adult spinal cord to regenerate after injury. In this review we report on a joint approach of different research groups to develop a therapy applying anti-Nogo-A antibodies to the injured spinal cord. While basic researchers took the initiative to provide means of neutralizing the inhibitory effect of Nogo-A and demonstrated enhanced fiber growth, regeneration and functional recovery both in rodent and primate models, clinical groups and rehabilitation engineers have sought to translate this novel strategy into a clinical setting.

Background One problem in the mobilization of patients with neurological diseases, such as spinal cord injury, is the circulatory collapse that occurs while changing from supine to vertical position because of the missing venous pump due to paralyzed leg muscles. Therefore, a tilt table with integrated stepping device (tilt stepper) was developed, which allows passive stepping movements for performing locomotion training in an early state of rehabilitation. The aim of this pilot study was to investigate if passive stepping and cycling movements of the legs during tilt table training could stabilize blood circulation and prevent neurally-mediated syncope in healthy young adults. Methods In the first experiment, healthy subjects were tested on a traditional tilt table. Subjects who had a syncope or near-syncope in this condition underwent a second trial on the tilt stepper. In the second experiment, a group of healthy subjects was investigated on a traditional tilt table, the second group on the tilt ergometer, a device that allows cycling movements during tilt table training. We used the chi-square test to compare the occurrence of near-syncope/syncope in both groups (tilt table/tilt stepper and tilt table/tilt ergometer) and ANOVA to compare the blood pressure and heart rate between the groups at the four time intervals (supine, at 2 minutes, at 6 minutes and end of head-up tilt). Results Separate chi-square tests performed for each experiment showed significant differences in the occurrence of near syncope or syncope based on the device used. Comparison of the two groups (tilt stepper/ tilt table) in experiment one (ANOVA) showed that blood pressure was significantly higher at the end of head-up tilt on the tilt stepper and on the tilt table there was a greater increase in heart rate (2 minutes after head-up tilt). Comparison of the two groups (tilt ergometer/tilt table) in experiment 2 (ANOVA) showed that blood pressure was significantly higher on the tilt ergometer at the end of head-up tilt and on the tilt table the increase in heart rate was significantly larger (at 6 min and end of head-up tilt). Conclusions Stabilization of blood circulation and prevention of benign syncope can be achieved by passive leg movement during a tilt table test in healthy adults.

What determines the effectiveness of neurorehabilitation approaches on the outcome of function in stroke or spinal cord injured subjects? Many studies claim that an improvement of function is based on the intensity of training, while some actual studies indicate no additional gain in function by a more intensive training after a stroke. Inherent factors seem to determine outcome, such as damage of specific tracts in stroke and level of lesion in spinal cord injured subjects, while the improvement of function achieved by an intensive training is small in relation to the spontaneous recovery. It is argued that an individual capacity of recovery exists depending on such factors. This capacity can be exploited by a repetitive execution of functional movements (supported as far as required), irrespective of the intensity and technology applied. Elderly subjects have difficulties to translate the recovery of motor deficit into function. Alternative, non-training approaches to restore motor function, such as epidural or deep brain stimulation as well as CNS repair are still in an early clinical or in a translational stage., Inherent factors determine outcome of function after a CNS lesion, i.e. damage of specific tracts in stroke and level of lesion in SCI subjects. There exists an individual capacity of recovery. This capacity can be exploited by a repetitive execution of functional movements irrespective of the intensity or technology applied., Graphical Abstract Graphical Abstract

Music-induced brain plasticity is a powerful means to improve neurologic function in rehabilitation following brain injury or degenerative disease. In motor dysfunctions following stroke, keyboard playing may improve fine motor functions along with neurophysiological changes in audiomotor networks. Rhythmic cueing has a positive effect in gait disorders, improving stride length, speed, and overall mobility. Melodic intonation therapy can improve recovery from non-fluent aphasia via activation of right-hemispheric networks. Music supported therapy can at least temporarily improve cognition in dementia and may have impact on rehabilitation of disorders of consciousness. Effects of music-induced brain plasticity together with music’s ability to tap into the emotion and reward system in the brain can thus be used to facilitate neurorehabilitation.

A number of diseases of the brain and spinal cord are associated with substantial neural cell death and/or disruption of correct and functional neural networks. In the past, a variety of therapeutic strategies to rescue these systems have been proposed along with agents to induce functional plasticity within the remaining central nervous system (CNS) structures. In the case of injury or neurodegenerative disease these approaches have only met with limited success, indicating the need for novel approaches to treat diseases of the adult CNS. Recently, the idea of recruiting endogenous or transplanting stem cells to replace lost structures within the adult brain or spinal cord has gained significant attention, along with in situ reprogramming, and opened up novel therapeutic avenues in the context of regenerative medicine. Here we review recent advances in our understanding of how endogenous stem cells may be a part of pathological processes in certain neuropsychiatric diseases and summarize recent clinical and preclinical data suggesting that stem cell-based therapies hold great promise as a future treatment option in a number of diseases disrupting the proper function of the adult CNS.

Cooperative hand movements (e.g., opening a bottle) require a close coordination of the hands. This is reflected in a neural coupling between the two sides. The aim of this study was to investigate in how far neural coupling is present not only during bilateral hand but also during bilateral finger movements. For this purpose unilateral mechanical and electrical nerve stimuli were delivered during bilateral sequentially and synchronously performed finger movements on a keyboard and, for comparison, during bilateral hand flexion movements. Electromyographic (EMG) activity and reflex responses in forearm flexor and extensor muscles of both sides were recorded and analyzed. Confounding EMG activity related to hand movements during the finger task was limited by wrist fixating braces. During the hand flexion task, complex reflex responses appeared in the forearm muscles of both sides to unilateral stimulation of the ulnar nerve (mean latency 57 ms), reflecting neural coupling between the two hands. In contrast, during the bilateral finger movement task, unilateral electrical nerve or mechanical stimulation of the right index finger was followed by dominant ipsilateral reflex responses (latency 45 and 58 ms, respectively). The results indicate that in contrast to the coupled hand movements, finger movements may not be coupled but can move independently on each side. Functionally this makes sense because during most activities of daily living, a close cooperation of the hands but not of individual fingers is needed. This independence of individual finger movements may rely on strong, specific, contralateral cortico‐motoneuronal control., The coordination of bilateral hand movements is reflected by a neural coupling. In contrast bilateral finger movements can move independently on each side. This independence of finger movements may rely on strong, specific, contralateral cortico‐motoneuronal control.

Erworben im Rahmen der Schweizer Nationallizenzen (http://www.nationallizenzen.ch), The neural control of "cooperative" hand movements reflecting "opening a bottle" was explored in human subjects by electromyographic (EMG) and functional magnetic resonance imaging (fMRI) recordings. EMG responses to unilateral nonnoxious ulnar nerve stimulation were analyzed in the forearm muscles of both sides during dynamic movements against a torque applied by the right hand to a device which was compensated for by the left hand. For control, stimuli were applied while task was performed in a static/isometric mode and during bilateral synchronous pro-/supination movements. During the dynamic cooperative task, EMG responses to stimulations appeared in the right extensor and left flexor muscles, regardless of which side was stimulated. Under the control conditions, responses appeared only on the stimulated side. fMRI recordings showed a bilateral extra-activation and functional coupling of the secondary somatosensory cortex (S2) during the dynamic cooperative, but not during the control, tasks. This activation might reflect processing of shared cutaneous input during the cooperative task. Correspondingly, it is assumed that stimulation-induced unilateral volleys are processed in S2, leading to a release of EMG responses to both forearms. This indicates a task-specific neural coupling during cooperative hand movements, which has consequences for the rehabilitation of hand function in poststroke patients.

In the rehabilitation of a patient suffering a spinal cord injury (SCI), the exploitation of neuroplasticity is well established. It can be facilitated through the training of functional movements with technical assistance as needed and can improve outcome after an SCI. The success of such training in individuals with incomplete SCI critically depends on the presence of physiological proprioceptive input to the spinal cord leading to meaningful muscle activations during movement performances. Some actual preclinical approaches to restore function by compensating for the loss of descending input to spinal networks following complete/incomplete SCI are critically discussed in this report. Electrical and pharmacological stimulation of spinal neural networks is still in the experimental stage, and despite promising repair studies in animal models, translations to humans up to now have not been convincing. It is possible that a combination of techniques targeting the promotion of axonal regeneration is necessary to advance the restoration of function. In the future, refinement of animal models according to clinical conditions and requirements may contribute to greater translational success.

Recent research indicates that a task-specific, interhemispheric neural coupling is involved in the control of cooperative hand movements required for activities of daily living. This neural coupling is manifested in bilateral electromyographic reflex responses in the arm muscles to unilateral arm nerve stimulation. In addition, fMRI recordings show a bilateral task-specific activation and functional coupling of the secondary somatosensory cortical areas (S2) during the cooperative, but not during bimanual control tasks. This activation is suggested to reflect processing of shared cutaneous input during the cooperative task in both cortical areas. In chronic poststroke patients, arm nerve stimulation of the unaffected arm also leads to bilateral electromyographic responses, similar to those seen in healthy subjects in the cooperative task. However, stimulation of the affected side is frequently followed only by ipsilateral responses. The presence/absence of contralateral electromyographic responses correlates with the clinical motor impairment measured by the Fugl-Meyer score. The observations suggest impaired processing of afferent input from the affected side leading to defective neural coupling during cooperative hand movements after stroke. In moderately affected patients, movement execution seems to rely on the involvement of the ipsilateral corticospinal tract arising in the non-damaged hemisphere. According to these results, hand rehabilitation of stroke patients, currently focused on reach and grasp movements of the affected side, should be supplemented with the training of cooperative hand movements required during activities of daily living.

The application of rehabilitation technologies in children with neurological impairments appears promising as these systems can induce repetitive goal-directed movements to complement conventional treatments. Characteristics of robotic-supported and computer-assisted training are in line with principles of motor learning and include high numbers of repetitions, prolonged training durations, and online feedback about the patient’s active participation. When experienced therapists apply these technologies, they can be considered a rather safe and in combination with virtual realities a motivating supplementary approach. Therapists might have to take into account that there might be some factors that are different when applying such technologies to children with congenital versus acquired neurological lesions. Currently, clinical guidelines on how to apply such technologies are missing, and clinical evidence considering the effectiveness of such technologies has just started to commence in pediatric neurorehabilitation. Experienced therapists formulated recommendations that might be useful to those with less experience on how to apply some of these systems to train the lower and upper extremity intensively and playfully. Finally, suggestions are made on how these technologies could be integrated into the clinical path.

Robots for neurorehabilitation have been designed principally to automate repetitive labor-intensive training and to support therapists and patients during different stages of rehabilitation. Devices designed for body weight-supported treadmill training are promising task-oriented tools intended to assist in the restoration of gait. In early rehabilitation, robots provide a safe environment through the use of a suspension harness and assistance in achieving a more physiological gait pattern while promoting a high number of repetitions. In the later stages of rehabilitation, more sophisticated control strategies, virtual environment scenarios, or the possibility to address specific gait deficits by modulating different parameters extends their application. Scientific and clinical evidence for the effectiveness, safety, and tolerability of these devices exists; however documentation of their comparative advantages to conventional therapies is limited.

In patients suffering from a movement disorder after a damage of the central nervous system, improvement in walking or hand function can be achieved by providing functional training. After a stroke or a spinal cord injury (SCI), neuronal centers at and below the level of lesion exhibit plasticity that can be exploited by functional training paradigms that include assisting stepping or hand/arm movements of the affected side. Training of locomotor function, the focus of this chapter, requires body-weight support (BWS), while the subjects stand on a moving treadmill. In these individuals, human spinal locomotor centers become activated if an appropriate afferent input is provided. The stroke/SCI subjects benefit from such locomotor training that enables them to walk over ground. Load- and hip joint-related afferent input seems to be of crucial importance for the generation of a locomotor pattern and, consequently, the effectiveness of the locomotor training. In severely affected stroke/SCI subjects, rehabilitation robots enable longer, i.e., more intensive training. In addition, they also offer the ability to standardize training approaches and to obtain objective feedback within training sessions allowing to monitor functional improvements over time. This chapter provides an overview of the clinical aspects for the successful application of robotic devices in the neurorehabilitation of stroke/SCI subjects. First, background information is given for the neural mechanisms of gait recovery after stroke/SCI. Second, the afferent input required for an effective training is discussed and, third, findings from clinical studies are presented covering the feasibility and efficacy of robot-assisted locomotor training.

After a spinal cord injury (SCI) of the cat or rat, neuronal centers below the level of lesion exhibit plasticity than can be exploited by specific training paradigms. In individuals with complete or incomplete SCI, human spinal locomotor centers can be activated and modulated by locomotor training (facilitating stepping movements of the legs using body weight support on a treadmill to provide appropriate sensory cues) (for review see [2], [3]). Individuals with incomplete SCI benefit from locomotor training such that they improve their ability to walk over ground. Load- or hip joint-related afferent input seems to be of crucial importance for both the generation of a locomotor pattern and the effectiveness of the training [2]. However, it may be a critical combination of afferent signals that is needed to generate a locomotor pattern after severe SCI.

In recent decades, several novel approaches of spinal cord repair have revealed promising findings in animal models. However, for a successful translation of these into a clinical trial in humans the specific conditions pertaining to human spinal cord injuries (SCI) have to be appreciated. Firstly, transection of the spinal cord is commonly applied in animal models, whereas spinal cord contusion is the predominant type of injury in humans, and generally leads to more extensive injury in two to three spinal cord segments. Secondly, the quadrupedal organization of locomotion in animals and the more complex autonomic functions in humans challenge the translation of animal behavior into recovery from human SCI. Thirdly, so far, no adequate animal model has been developed to resemble spastic movement disorder in human SCI. Fourthly, the extensive damage to spinal motor neurons and nerve roots in human cervical and thoracolumbar in spine trauma is but little addressed in current translational studies. This damage has direct implications for rehabilitation and repair strategies. Fifthly, there is increasing evidence for a neuronal dysfunction below the level of the lesion in chronic complete SCI. The relevance of this dysfunction for a regeneration-inducing treatment needs to be investigated. Lastly, an approach to facilitate an appropriate reconnection of regenerating tract fibers by functional training in the postacute stage has yet to be confirmed.

In patients suffering from a movement disorder after a stroke or spinal cord injury (SCI), improvement in walking function can be achieved by providing intensive locomotor training. After a stroke or an SCI, neuronal centers below the level of lesion exhibit plasticity that can be exploited by specific training paradigms. In these individuals, human spinal locomotor centers can be activated by an appropriate afferent input. This includes assisting stepping movements of the affected legs and providing body-weight support (BWS), while the subjects stand on a moving treadmill. The stroke and SCI subjects benefit from such locomotor training that enables them to walk over ground.

Neuroplasticity refers to the ability of the central nervous system (CNS) to undergo persistent or lasting modifications to the function or structure of its elements. Neuroplasticity is a CNS mechanism that enables successful learning. Likely, it is also the mechanism by which recovery after CNS lesioning is possible. The chapter gives an overview of the phenomena that constitute plasticity and the cellular events leading to them. Evidence for neural plasticity in different regions of the brain and in the spinal cord is summarized in the contexts of learning, recovery, and rehabilitation therapy.