Rehabilitation drives functional reorganization of intact corticospinal-supraspinal projections following partial spinal cord injury

Spinal cord injury (SCI) disrupts corticospinal tract (CST) connectivity and impairs skilled voluntary movement. However, most human SCIs are anatomically incomplete, allowing spared CST pathways to engage in rehabilitation-mediated plasticity to promote functional recovery. How voluntary rehabilitation engages and reorganizes the supraspinal targets of the intact CST remains incompletely understood. Here, we combined unilateral pyramidotomy (uPyX) in male and female mice with continuous voluntary complex-wheel running to test whether fine motor-dependent rehabilitation drives supraspinal CST plasticity. uPyX mice rapidly resumed wheel running after a transient deficit. In contrast to lesion-only controls, rehabilitation significantly improved skilled forelimb performance on the horizontal ladder rung task. Immunohistochemical c-Fos labeling confirmed that complex-wheel running robustly activated the intact forelimb CST in motor cortex. Whole-brain CST projection mapping using intersectional viral vector tracing revealed targeted supraspinal reorganization localized to medullary motor nuclei. Three nuclei - the lateral paragigantocellular reticular nucleus (LPGi), gigantocellular reticular nucleus, alpha part (GiA), and ventral medullary reticular nucleus (MdV) - exhibited significant lesion- and/or rehabilitation-induced increases in CST innervation. Rehabilitation-driven CST sprouting correlated with regional c-Fos activation, indicating activity-dependent remodeling. Notably, CST projection density in the MdV, critical for skilled forelimb control, correlated with functional recovery. These findings identify a set of spinally-projecting medullary nuclei as key sites of rehabilitation-induced CST plasticity and highlight the MdV as a potential mediator of restored motor function. This work defines how voluntary rehabilitation reorganizes spared corticospinal pathways and provides targets for optimizing activity-based interventions after SCI. Significance StatementEffective rehabilitation after spinal cord injury (SCI) must harness the plasticity of spared motor pathways, yet the supraspinal circuits that support rehabilitation-mediated recovery remain unknown. Using a model that preserves voluntary motor engagement, we show that continuous fine motor-dependent rehabilitation activates intact corticospinal neurons and drives highly specific remodeling of their supraspinal terminals. Rehabilitation selectively strengthens CST inputs to motor regions of the medulla, particularly the ventral medullary reticular nucleus (MdV), and CST plasticity within this region predicts enhanced behavioral recovery. These findings highlight the MdV as a central locus by which rehabilitation re-establishes descending control of the impaired limb, providing mechanistic insight to guide targeted, circuit-based rehabilitation therapies for incomplete SCI.