Referred phantom sensations and cortical reorganization after spinal cord injury in humans

Increased excitability and reduced GABAergic levels in somatosensory cortex under chronic spinal cord injury

The complete or partial damage of ascending somatosensory pathways produced by a spinal cord injury triggers changes in the somatosensory cortex consisting in a functional expansion of activity from intact cortical regions towards deafferented ones, a process known as cortical reorganization. However, it is still unclear whether cortical reorganization depends on the severity of the spinal cord damage or if a spinal cord injury always leads to a similar cortical reorganization process in the somatosensory cortex. To answer these open questions in the field, we obtained longitudinal somatosensory evoked responses from bilateral hindlimb and forelimb cortex from animals with chronic full-transection or contusive spinal cord injury at thoracic level (T9-T10) to induce sensory deprivation of hindlimb cortex while preserving intact the forelimb cortex. Electrophysiological recordings from the four locations were obtained before lesion and weekly for up to 4 weeks. Our results show that cortical reorganization depends on the type of spinal cord injury, which tends to be more bilateral in full transection while is more unilateral in the model of contusive spinal cord injury. Moreover, in full transection of spinal cord, the deafferented and intact cortex exhibited similar increments of somatosensory evoked responses in both models of spinal cord injury - a feature observed in about 80% of subjects. The other 20% were unaffected by the injury indicating that cortical reorganization does not undergo in all subjects. In addition, we demonstrated an increased probability of triggered up-states in animals with spinal cord injury. This data indicates increased cortical excitability that could be proposed as a new feature of cortical reorganization. Finally, decreased levels of GABA marker GAD67 across cortical layers were only found in those animals with increased somatosensory evoked responses, but not in the unaffected population. In conclusion, cortical reorganization depends on the types of spinal cord injuries, and suggest that the phenomenon is strongly determined by cortical circuits. Moreover, changes in GABAergic transmission at the deprived cortex may be considered one of the mechanisms underlying the process of cortical reorganization and increased excitability.

Reassessing referral of touch following peripheral deafferentation: The role of contextual bias

Some amputees have been famously reported to perceive facial touch as arising from their phantom hand. These referred sensations have since been replicated across multiple neurological disorders and were classically interpreted as a perceptual correlate of cortical plasticity. Common to all these and related studies is that participants might have been influenced in their self-reports by the experimental design or related contextual biases. Here, we investigated whether referred sensations reports might be confounded by demand characteristics (e.g., compliance, expectation, suggestion). Unilateral upper-limb amputees (N = 18), congenital one-handers (N = 19), and two-handers (N = 22) were repeatedly stimulated with computer-controlled vibrations on 10 body-parts and asked to report the occurrence of any concurrent sensations on their hand(s). To further manipulate expectations, we gave participants the suggestion that some of these vibrations had a higher probability to evoke referred sensations. We also assessed similarity between (phantom) hand and face representation in primary somatosensory cortex (S1), using functional Magnetic Resonance Imaging (fMRI) multivariate representational similarity analysis. We replicated robust reports of referred sensations in amputees towards their phantom hand; however, the frequency and distribution of reported referred sensations were similar across groups. Moreover, referred sensations were evoked by stimulation of multiple body-parts and similarly reported on both the intact and phantom hand in amputees. Face-to-phantom-hand representational similarity was not different in amputees' missing hand region, compared with controls. These findings weaken the interpretation of referred sensations as a perceptual correlate of S1 plasticity and reveal the need to account for contextual biases when evaluating anomalous perceptual phenomena.

Referred pain: characteristics, possible mechanisms, and clinical management

Purpose of this review

Referred pain is a common but less understood symptom that originates from somatic tissues. A comprehensive recognition of referred pain is important for clinicians when dealing with it. The purpose of this study is to summarize the current understanding of referred pain, including its pathogenesis, characteristics, diagnosis, and treatment.

Recent findings

Referred pain arises not only from pathologies primarily involving local tissue but also from lesions in distant structures. Central sensitization of convergent neurons and peripheral reflexes of dichotomizing afferent fibers are two theories proposed to explain the pathological mechanism of referred pain. Because syndromes related to referred pain of different origins overlap each other, it is challenging to define referred pain and identify its originating lesions. Although various approaches have been used in the diagnosis and treatment of referred pain, including conservative treatment, blockade, radiofrequency, and surgery, management of referred pain remains a clinical challenge.

Summary

Unlike radicular pain and neuropathic pain, referred pain is a less studied area, despite being common in clinics. Referred pain can derive from various spinal structures, and blockage helps identify the primary pathology. Due to the heterogeneity of referred pain, treatment outcomes remain uncertain. Further studies are needed to improve our understanding of referred pain.

The effect of dorsal column lesions in the primary somatosensory cortex and medulla of adult rats

Spinal cord injury is a devastating condition that haunts human lives. Typically, patients experience referred phantom sensations on the hand when they are touched on the face. In adult monkeys, massive deafferentations such as chronic dorsal column lesions at higher cervical levels result in the large-scale expansion of face inputs into the deafferented hand cortex of area 3b. However, adult rats with thoracic dorsal column lesions do not demonstrate such large-scale reorganization. The large-scale face expansion in area 3b of monkeys is driven by the reorganization of the cuneate nucleus in the medulla. The sprouting of afferents from the trigeminal nucleus to the adjacent deafferented cuneate nucleus is facilitated by close proximity and compactness of the medulla in primates. Previously, in adult rats with thoracic lesions, the cuneate nucleus was not deafferented and its functional organization was not explored. The extent of the deafferentation and the duration of the recovery period are two major factors that determine the extent of reorganization. Hence, higher cervical (C3-C4) dorsal column lesions were performed, which cause massive deafferentations, and physiological maps were obtained after prolonged recovery periods (3 weeks -18 months). In spite of the above, the expansion of the intact face inputs was not observed in the deafferented zones of the primary somatosensory cortex (SI) and medulla of adult rats. The deafferented forelimb and hindlimb representations in SI were unresponsive to cutaneous stimulation of any part of the body. The cuneate and gracile nuclei in rats with complete dorsal column lesions remained mostly inactive except for a few sites which responded to stimulation of the spared upper arm. Hence, dorsal column lesions have different effects on the adult primate and rodent somatosensory systems. Appreciating this inter-species difference can aid in identifying the underlying neural substrates and restrict maladaptive reorganizations to cure phantom sensations.

Correlation between kinesthetic motor imagery of an amputated limb and phantom limb pain

BACKGROUND

Phantom limb pain (PLP) is a frequent painful sensation in amputees, and motor imagery (MI) is a useful approach for the treatment of this type of pain. However, it is not clear regarding the best MI modality for PLP.

OBJECTIVES

The purpose of this study was to investigate the relationship between the PLP and MI modality in upper limb amputees.

STUDY DESIGN

Observational study.

METHODS

Eleven patients who underwent unilateral upper limb amputation participated in this study. The MI modality (kinesthetic and visual) and PLP intensity were evaluated using the Kinesthetic and Visual Imagery Questionnaire (KVIQ)-20 and a visual analog scale. MI ability was also assessed during the hand mental rotation task. We examined the correlation between MI modalities, ability, and pain intensity.

RESULTS

The total KVIQ kinesthetic score was negatively correlated with pain intensity (r = -0.71, P < 0.01): the more vivid the kinesthetic imagery, the weaker the pain. In particular, the reduction in pain intensity was associated with strong kinesthetic imagery of opposing movements of the deficient thumb (r = -0.81, P < 0.01). The KVIQ visual score and MI ability were not associated with pain intensity.

CONCLUSIONS

Our data showed that the reduction of PLP could be associated with the kinesthetic modality of MI but not with visual modality or MI ability. In other words, it was suggested that the more vivid the sensation of moving muscles and joints in the defect area, the lower the PLP intensity. To reduce PLP, clinicians may prefer interventions using the kinesthetic modality.

Beyond body maps: Information content of specific body parts is distributed across the somatosensory homunculus

The homunculus in primary somatosensory cortex (S1) is famous for its body part selectivity, but this dominant feature may eclipse other representational features, e.g., information content, also relevant for S1 organization. Using multivariate fMRI analysis, we ask whether body part information content can be identified in S1 beyond its primary region. Throughout S1, we identify significant representational dissimilarities between body parts but also subparts in distant non-primary regions (e.g., between the hand and the lips in the foot region and between different face parts in the foot region). Two movements performed by one body part (e.g., the hand) could also be dissociated well beyond its primary region (e.g., in the foot and face regions), even within Brodmann area 3b. Our results demonstrate that information content is more distributed across S1 than selectivity maps suggest. This finding reveals underlying information contents in S1 that could be harnessed for rehabilitation and brain-machine interfaces.

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We replicate the high univariate selectivity profile of the somatosensory homunculus

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We use multivariate fMRI analysis to identify information content beyond selectivity

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Significant body part and action-related content are found throughout the homunculus

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Functional information is available, even in regions selective to other body parts

Rethinking the Body in the Brain after Spinal Cord Injury

Spinal cord injuries (SCI) are disruptive neurological events that severly affect the body leading to the interruption of sensorimotor and autonomic pathways. Recent research highlighted SCI-related alterations extend beyond than the expected network, involving most of the central nervous system and goes far beyond primary sensorimotor cortices. The present perspective offers an alternative, useful way to interpret conflicting findings by focusing on the deafferented and deefferented body as the central object of interest. After an introduction to the main processes involved in reorganization according to SCI, we will focus separately on the body regions of the head, upper limbs, and lower limbs in complete, incomplete, and deafferent SCI participants. On one hand, the imprinting of the body’s spatial organization is entrenched in the brain such that its representation likely lasts for the entire lifetime of patients, independent of the severity of the SCI. However, neural activity is extremely adaptable, even over short time scales, and is modulated by changing conditions or different compensative strategies. Therefore, a better understanding of both aspects is an invaluable clinical resource for rehabilitation and the successful use of modern robotic technologies.

Maladaptive reorganization following SCI: The role of body representation and multisensory integration

In this review we focus on maladaptive brain reorganization after spinal cord injury (SCI), including the development of neuropathic pain, and its relationship with impairments in body representation and multisensory integration. We will discuss the implications of altered sensorimotor interactions after SCI with and without neuropathic pain and possible deficits in multisensory integration and body representation. Within this framework we will examine published research findings focused on the use of bodily illusions to manipulate multisensory body representation to induce analgesic effects in heterogeneous chronic pain populations and in SCI-related neuropathic pain. We propose that the development and intensification of neuropathic pain after SCI is partly dependent on brain reorganization associated with dysfunctional multisensory integration processes and distorted body representation. We conclude this review by suggesting future research avenues that may lead to a better understanding of the complex mechanisms underlying the sense of the body after SCI, with a focus on cortical changes.

A Therapeutic Matrix: Virtual Reality as a Clinical Tool for Spinal Cord Injury-Induced Neuropathic Pain

Neuropathic pain (NP) is a chronic, debilitating, and resistant form of pain. The onset rate of NP following spinal cord injuries (SCI) is high and may reduce the quality of life more than the sensorimotor loss itself. The long-term ineffectiveness of current treatments in managing symptoms and counteracting maladaptive plasticity highlights the need to find alternative therapeutic approaches. Virtual reality (VR) is possibly the best way to administer the specific illusory or reality-like experience and promote behavioral responses that may be effective in mitigating the effects of long-established NP. This approach aims to promote a more systematic adoption of VR-related techniques in pain research and management procedures, highlighting the encouraging preliminary results in SCI. We suggest that the multisensory modulation of the sense of agency and ownership by residual body signals may produce positive responses in cases of brain-body disconnection. First, we focus on the transversal role embodiment and how multisensory and environmental or artificial stimuli modulate illusory sensations of bodily presence and ownership. Then, we present a brief overview of the use of VR in healthcare and pain management. Finally, we discus research experiences which used VR in patients with SCI to treating NP, including the most recent combinations of VR with further stimulation techniques.

Importance of brain alterations in spinal cord injury

Spinal cord injury (SCI) destroys the sensorimotor pathway and blocks the information flow between the peripheral nerve and the brain, resulting in autonomic function loss. Numerous studies have explored the effects of obstructed information flow on brain structure and function and proved the extensive plasticity of the brain after SCI. Great progress has also been achieved in therapeutic strategies for SCI to restore the "re-innervation" of the cerebral cortex to the limbs to some extent. Although no thorough research has been conducted, the changes of brain structure and function caused by "re-domination" have been reported. This article is a review of the recent research progress on local structure, functional changes, and circuit reorganization of the cerebral cortex after SCI. Alterations of structure and electrical activity characteristics of brain neurons, features of brain functional reorganization, and regulation of brain functions by reconfigured information flow were also explored. The integration of brain function is the basis for the human body to exercise complex/fine movements and is intricately and widely regulated by information flow. Hence, its changes after SCI and treatments should be considered.

Cortical Modulation of Nociception

Nociception is the neuronal process of encoding noxious stimuli and could be modulated at peripheral, spinal, brainstem, and cortical levels. At cortical levels, several areas including the anterior cingulate cortex (ACC), prefrontal cortex (PFC), ventrolateral orbital cortex (VLO), insular cortex (IC), motor cortex (MC), and somatosensory cortices are involved in nociception modulation through two main mechanisms: (i) a descending modulatory effect at spinal level by direct corticospinal projections or mostly by activation of brainstem structures (i.e. periaqueductal grey matter (PAG), locus coeruleus (LC), the nucleus of raphe (RM) and rostroventral medulla (RVM)); and by (ii) cortico-cortical or cortico-subcortical interactions. This review summarizes evidence related to the participation of the aforementioned cortical areas in nociception modulation and different neurotransmitters or neuromodulators that have been studied in each area. Besides, we point out the importance of considering intracortical neuronal populations and receptors expression, as well as, nociception-induced cortical changes, both functional and connectional, to better understand this modulatory effect. Finally, we discuss the possible mechanisms that could potentiate the use of cortical stimulation as a promising procedure in pain alleviation.

Neuropathic Pain: From Mechanisms to Treatment

Neuropathic pain caused by a lesion or disease of the somatosensory nervous system is a common chronic pain condition with major impact on quality of life. Examples include trigeminal neuralgia, painful polyneuropathy, postherpetic neuralgia, and central poststroke pain. Most patients complain of an ongoing or intermittent spontaneous pain of, for example, burning, pricking, squeezing quality, which may be accompanied by evoked pain, particular to light touch and cold. Ectopic activity in, for example, nerve-end neuroma, compressed nerves or nerve roots, dorsal root ganglia, and the thalamus may in different conditions underlie the spontaneous pain. Evoked pain may spread to neighboring areas, and the underlying pathophysiology involves peripheral and central sensitization. Maladaptive structural changes and a number of cell-cell interactions and molecular signaling underlie the sensitization of nociceptive pathways. These include alteration in ion channels, activation of immune cells, glial-derived mediators, and epigenetic regulation. The major classes of therapeutics include drugs acting on α₂δ subunits of calcium channels, sodium channels, and descending modulatory inhibitory pathways.

Disconnected Body Representation: Neuroplasticity Following Spinal Cord Injury

Neuroplastic changes in somatotopic organization within the motor and somatosensory systems have long been observed. The interruption of afferent and efferent brain–body pathways promotes extensive cortical reorganization. Changes are majorly related to the typical homuncular organization of sensorimotor areas and specific “somatotopic interferences”. Recent findings revealed a relevant peripheral contribution to the plasticity of body representation in addition to the role of sensorimotor cortices. Here, we review the ways in which structures and brain mechanisms react to missing or critically altered sensory and motor peripheral signals. We suggest that these plastic events are: (i) variably affected across multiple timescales, (ii) age-dependent, (iii) strongly related to altered perceptual sensations during and after remapping of the deafferented peripheral area, and (iv) may contribute to the appearance of secondary pathological conditions, such as allodynia, hyperalgesia, and neuropathic pain. Understanding the considerable complexity of plastic reorganization processes will be a fundamental step in the formulation of theoretical and clinical models useful for maximizing rehabilitation programs and resulting recovery.

Differences in neuroplasticity after spinal cord injury in varying animal models and humans

Rats have been the primary model to study the process and underlying mechanisms of recovery after spinal cord injury. Two weeks after a severe spinal cord contusion, rats can regain weight-bearing abilities without therapeutic interventions, as assessed by the Basso, Beattie and Bresnahan locomotor scale. However, many human patients suffer from permanent loss of motor function following spinal cord injury. While rats are the most understood animal model, major differences in sensorimotor pathways between quadrupeds and bipeds need to be considered. Understanding the major differences between the sensorimotor pathways of rats, non-human primates, and humans is a start to improving targets for treatments of human spinal cord injury. This review will discuss the neuroplasticity of the brain and spinal cord after spinal cord injury in rats, non-human primates, and humans. A brief overview of emerging interventions to induce plasticity in humans with spinal cord injury will also be discussed.

Head Transplantation: The Immune System, Phantom Sensations, and the Integrated Mind

The principal focus of this paper is to consider the implications of head and neck transplantation surgery on the issue of personal identity. To this end, it is noted that the immune system has not only been established to impose a level of self-identity on bodily cells, it has also been implicated in mental development and the regulation of mental state. In this it serves as a paradigm for the mind as the product of cephalic and extracephalic systems. The importance of bodily systems in identity is then discussed in relation to phantom tissue syndrome. The data strongly indicate that, even if surgically successful, head and neck transplantation will result in the loss of the continuity of personal identity.

Phantom Sensations Following Brachial Plexus Nerve Block: A Case Report

Following the administration of brachial plexus anesthesia for right thumb carpometacarpal arthroplasty with ligament reconstruction, a 54-year-old woman with all limbs intact developed phantom limb sensations, including the misperception of the placement of her right arm and frozen limb sensations in her fingers. Immobility of her fingers in a stacked position was experienced for ~3.5 days after surgery, and she described her phantom sensations as the hand experiencing "tingling" and feeling "heavy." While the onset of these phantom sensations occurred almost immediately after administration of brachial plexus anesthesia, they lasted for ~69 h after anesthesia wear off, suggesting that cortical effects from denervation resolves much more slowly than initial remapping, giving insight into the mechanisms behind phantom limb sensations that are often experienced by amputees.

Proprioceptive and cutaneous sensations in humans elicited by intracortical microstimulation

Pioneering work with nonhuman primates and recent human studies established intracortical microstimulation (ICMS) in primary somatosensory cortex (S1) as a method of inducing discriminable artificial sensation. However, these artificial sensations do not yet provide the breadth of cutaneous and proprioceptive percepts available through natural stimulation. In a tetraplegic human with two microelectrode arrays implanted in S1, we report replicable elicitations of sensations in both the cutaneous and proprioceptive modalities localized to the contralateral arm, dependent on both amplitude and frequency of stimulation. Furthermore, we found a subset of electrodes that exhibited multimodal properties, and that proprioceptive percepts on these electrodes were associated with higher amplitudes, irrespective of the frequency. These novel results demonstrate the ability to provide naturalistic percepts through ICMS that can more closely mimic the body’s natural physiological capabilities. Furthermore, delivering both cutaneous and proprioceptive sensations through artificial somatosensory feedback could improve performance and embodiment in brain-machine interfaces.

Nerves throughout the body send information about touch, temperature, body position and pain through the spinal cord to the brain. A part of the brain called the somatosensory cortex processes this information. Spinal cord injuries disrupt these messages. Even though the somatosensory cortex has not been damaged, sensation is lost for the affected body areas. No treatment exists to repair the spinal cord so the loss of sensation is permanent.

Applying electricity to the somatosensory cortex can produce artificial sensations. Scientists are testing this approach to restore a sense of touch for people with spinal cord injury. Early experiments show that using different patterns of electrical stimulation generates unnatural sensations in different body parts. People receiving the stimulation describe it as tingling or shocks. Scientists wonder if they can improve the technique to mimic feelings like touch or body position to make it easier for people with a spinal injury to move or use prostheses.

Now, Armenta Salas et al. generated more natural sensations in a person with a spinal cord injury. Instead of taking the usual approach of delivering large currents to the surface of cortex, they inserted small electrodes into the inside of the cortex to stimulate it with small currents. In the experiments, electrodes were implanted in the somatosensory cortex of a volunteer who had lost the use of his limbs and torso because of a spinal injury. Armenta Salas et al. applied different patterns of electrical stimuli and the volunteer reported what they felt like. The patient described sensations like a pinch or squeeze in the forearm or upper arm with certain patterns. In some cases, the patient reported the sensation of the arm moving with stronger electrical currents.

The experiments show that electrical stimulation of the brain can recreate some natural sensations. These sensations could help patients using robotic or prosthetic arms become more dexterous. It might also help patients view artificial limbs as part of their bodies, which could improve their sense of wellbeing.

Pain and somatic sensation are transiently normalized by illusory body ownership in a patient with spinal cord injury

PURPOSE

Spinal cord injury (SCI), a profound impairment of sensorimotor functions, is often associated with pain related phenomena, including mechanical allodynia, a condition in which non-painful tactile sensation is perceived as pain. Pain and somatic sensation are undeniable markers of normal bodily awareness. However, the mechanism by which they are integrated into a coherent sense of the bodily self remains largely unclear. In this study, we investigated the effect of high-level multisensory manipulation on subjective experiences of pain, touch, and body-ownership.

METHODS

We administered visuo-tactile stimulation based on the rubber hand illusion. In a longitudinal study, we compared the strength of the illusion in a male with SCI, who initially had lost somatosensation in all his fingers, but a few months later reported signs of tactile allodynia restricted to the left C6-dermatome.

RESULTS

After the restoration of some somatosensation, even if it were painful, synchronous but not asynchronous visuo-tactile stimulation induced body illusion. Previously painful stimuli were temporarily perceived as less painful, and the patient further regained tactile sensations in adjacent numb areas.

CONCLUSIONS

The sensations of touch and pain are mutually influenced and inextricably linked to a coherent representation of one's own body. Multisensory manipulations affecting the perception and representation of the body might thus offer a powerful opportunity to mitigate nociceptive and somatic abnormalities.

Factors Affecting Volume Changes of the Somatosensory Cortex in Patients with Spinal Cord Injury: To Be Considered for Future Neuroprosthetic Design

Spinal cord injury (SCI) leads to severe chronic disability, but also to secondary adaptive changes upstream to the injury in the brain which are most likely induced due to the lack of afferent information. These neuroplastic changes are a potential target for innovative therapies such as neuroprostheses, e.g., by stimulation in order to evoke sensation or in order to suppress phantom limb pain. Diverging results on gray matter atrophy have been reported in patients with SCI. Detectability of atrophy seems to depend on the selection of the regions of interest, while whole-brain approaches are not sensitive enough. In this study, we discussed previous research approaches and analyzed differential atrophic changes in incomplete SCI using manual segmentation of the somatosensory cortex. Patients with incomplete SCI (ASIA C-D), with cervical (N = 5) and thoracic (N = 6) injury were included. Time since injury was ≤12 months in 7 patients, and 144, 152, 216, and 312 months in the other patients. Age at the injury was ≤26 years in 4 patients and ≥50 years in 7 patients. A sample of 12 healthy controls was included in the study. In contrast to all previous studies that used voxel-based morphometry, we performed manual segmentation of the somatosensory cortex in the postcentral gyrus from structural magnetic resonance images and normalized the calculated volumes against the sum of volumes of an automated whole-head segmentation. Volumes were smaller in patients than in controls (p = 0.011), and as a tendency, female patients had smaller volumes than male patients (p = 0.017, uncorrected). No effects of duration (subacute vs. chronic), level of lesion (cervical vs. thoracic), region (left vs. right S1), and age at onset (≤26 vs. ≥50 years) was found. Our results demonstrate volume loss of S1 in incomplete SCI and encourage further research with larger sample sizes on volumetric changes in the acute and chronic stage of SCI, in order to document the moderating effect of type and location of injury on neuroplastic changes. A better understanding of neuroplastic changes in the sensorimotor cortex after SCI and its interaction with sex is needed in order to develop efficient rehabilitative interventions and neuroprosthetic technologies.

Large-Scale Network Analysis of Whole-Brain Resting-State Functional Connectivity in Spinal Cord Injury: A Comparative Study

Network analysis based on graph theory depicts the brain as a complex network that allows inspection of overall brain connectivity pattern and calculation of quantifiable network metrics. To date, large-scale network analysis has not been applied to resting-state functional networks in complete spinal cord injury (SCI) patients. To characterize modular reorganization of whole brain into constituent nodes and compare network metrics between SCI and control subjects, fifteen subjects with chronic complete cervical SCI and 15 neurologically intact controls were scanned. The data were preprocessed followed by parcellation of the brain into 116 regions of interest (ROI). Correlation analysis was performed between every ROI pair to construct connectivity matrices and ROIs were categorized into distinct modules. Subsequently, local efficiency (LE) and global efficiency (GE) network metrics were calculated at incremental cost thresholds. The application of a modularity algorithm organized the whole-brain resting-state functional network of the SCI and the control subjects into nine and seven modules, respectively. The individual modules differed across groups in terms of the number and the composition of constituent nodes. LE demonstrated statistically significant decrease at multiple cost levels in SCI subjects. GE did not differ significantly between the two groups. The demonstration of modular architecture in both groups highlights the applicability of large-scale network analysis in studying complex brain networks. Comparing modules across groups revealed differences in number and membership of constituent nodes, indicating modular reorganization due to neural plasticity.

A Wireless 32-Channel Implantable Bidirectional Brain Machine Interface

All neural information systems (NIS) rely on sensing neural activity to supply commands and control signals for computers, machines and a variety of prosthetic devices. Invasive systems achieve a high signal-to-noise ratio (SNR) by eliminating the volume conduction problems caused by tissue and bone. An implantable brain machine interface (BMI) using intracortical electrodes provides excellent detection of a broad range of frequency oscillatory activities through the placement of a sensor in direct contact with cortex. This paper introduces a compact-sized implantable wireless 32-channel bidirectional brain machine interface (BBMI) to be used with freely-moving primates. The system is designed to monitor brain sensorimotor rhythms and present current stimuli with a configurable duration, frequency and amplitude in real time to the brain based on the brain activity report. The battery is charged via a novel ultrasonic wireless power delivery module developed for efficient delivery of power into a deeply-implanted system. The system was successfully tested through bench tests and in vivo tests on a behaving primate to record the local field potential (LFP) oscillation and stimulate the target area at the same time.

Plasticity and Recovery After Dorsal Column Spinal Cord Injury in Nonhuman Primates

Here, we review recent work on plasticity and recovery after dorsal column spinal cord injury in nonhuman primates. Plasticity in the adult central nervous system has been established and studied for the past several decades; however, capacities and limits of plasticity are still under investigation. Studies of plasticity include assessing multiple measures before and after injury in animal models. Such studies are particularly important for improving recovery after injury in patients. In summarizing work by our research team and others, we suggest how the findings from plasticity studies in nonhuman primate models may affect therapeutic interventions for conditions involving sensory loss due to spinal cord injury.

Spatiotemporal trajectories of reactivation of somatosensory cortex by direct and secondary pathways after dorsal column lesions in squirrel monkeys

After lesions of the somatosensory dorsal column (DC) pathway, the cortical hand representation can become unresponsive to tactile stimuli, but considerable responsiveness returns over weeks of post-lesion recovery. The reactivation suggests that preserved subthreshold sensory inputs become potentiated and axon sprouting occurs over time to mediate recovery. Here, we studied the recovery process in 3 squirrel monkeys, using high-resolution cerebral blood volume-based functional magnetic resonance imaging (CBV-fMRI) mapping of contralateral somatosensory cortex responsiveness to stimulation of distal finger pads with low and high level electrocutaneous stimulation (ES) before and 2, 4, and 6weeks after a mid-cervical level contralateral DC lesion. Both low and high intensity ES of digits revealed the expected somatotopy of the area 3b hand representation in pre-lesion monkeys, while in areas 1 and 3a, high intensity stimulation was more effective in activating somatotopic patterns. Six weeks post-lesion, and irrespective of the severity of loss of direct DC inputs (98%, 79%, 40%), somatosensory cortical area 3b of all three animals showed near complete recovery in terms of somatotopy and responsiveness to low and high intensity ES. However there was significant variability in the patterns and amplitudes of reactivation of individual digit territories within and between animals, reflecting differences in the degree of permanent and/or transient silencing of primary DC and secondary inputs 2weeks post-lesion, and their spatio-temporal trajectories of recovery between 2 and 6weeks. Similar variations in the silencing and recovery of somatotopy and responsiveness to high intensity ES in areas 3a and 1 are consistent with individual differences in damage to and recovery of DC and spinocuneate pathways, and possibly the potentiation of spinothalamic pathways. Thus, cortical deactivation and subsequent reactivation depends not only on the degree of DC lesion, but also on the severity and duration of loss of secondary as well as primary inputs revealed by low and high intensity ES.

Discontinuity of cortical gradients reflects sensory impairment

Topographic maps and their continuity constitute a fundamental principle of brain organization. In the somatosensory system, whole-body sensory impairment may be reflected either in cortical signal reduction or disorganization of the somatotopic map, such as disturbed continuity. Here we investigated the role of continuity in pathological states. We studied whole-body cortical representations in response to continuous sensory stimulation under functional MRI (fMRI) in two unique patient populations-patients with cervical sensory Brown-Séquard syndrome (injury to one side of the spinal cord) and patients before and after surgical repair of cervical disk protrusion-enabling us to compare whole-body representations in the same study subjects. We quantified the spatial gradient of cortical activation and evaluated the divergence from a continuous pattern. Gradient continuity was found to be disturbed at the primary somatosensory cortex (S1) and the supplementary motor area (SMA), in both patient populations: contralateral to the disturbed body side in the Brown-Séquard group and before repair in the surgical group, which was further improved after intervention. Results corresponding to the nondisturbed body side and after surgical repair were comparable with control subjects. No difference was found in the fMRI signal power between the different conditions in the two groups, as well as with respect to control subjects. These results suggest that decreased sensation in our patients is related to gradient discontinuity rather than signal reduction. Gradient continuity may be crucial for somatotopic and other topographical organization, and its disruption may characterize pathological processing.

The embodiment of assistive devices-from wheelchair to exoskeleton

Spinal cord injuries (SCIs) place a heavy burden on the healthcare system and have a high personal impact and marked socio-economic consequences. Clinically, no absolute cure for these conditions exists. However, in recent years, there has been an increased focus on new robotic technologies that can change the frame we think about the prognosis for recovery and for treating some functions of the body affected after SCIs. This review has two goals. The first is to assess the possibility of the embodiment of functional assistive tools after traumatic disruption of the neural pathways between the brain and the body. To this end, we will examine how altered sensorimotor information modulates the sense of the body in SCI. The second goal is to map the phenomenological experience of using external tools that typically extend the potential of the body physically impaired by SCI. More specifically, we will focus on the difference between the perception of one's physically augmented and non-augmented affected body based on observable and measurable behaviors. We discuss potential clinical benefits of enhanced embodiment of the external objects by way of multisensory interventions. This review argues that the future evolution of human robotic technologies will require adopting an embodied approach, taking advantage of brain plasticity to allow bionic limbs to be mapped within the neural circuits of physically impaired individuals.

Left Hip Pain Caused by Right Hip Osteoarthritis in a Patient With an Incomplete Cervical Spinal Cord Injury: A Case Report

A 70-year-old woman with a right hemisensory deficit caused by an incomplete cervical spinal cord injury presented with left hip pain. The clinical assessment suggested that her left-sided hip pain was attributable to severe right hip osteoarthritis. Her left hip pain resolved completely after she underwent a right total hip arthroplasty. This case is presented, along with a review of the literature on spinal and supraspinal neuronal reorganization after spinal cord injury. This case report suggests the occurrence of central sensory reorganization after an incomplete cervical spinal cord injury, which resulted in a patient perceiving right hip pathology in her left hip.

Re-establishing the disrupted sensorimotor loop in deafferented and deefferented people: The case of spinal cord injuries

Acting efficiently in the world depends on the activity of motor and somatosensory systems, the integration of which is necessary for the proper functioning of the sensorimotor loop (SL). Profound alterations of SL functioning follow spinal cord injury (SCI), a condition that brings about a disconnection of the body from the brain. Such disconnection creates a substantial deprivation of somatosensorial inputs and motor outputs. Consequent somatic deficits and motor paralysis affect the body below the lesion level. A complete restoration of normal functions of the SL cannot be expected until basic neuroscience has found a way to re-establish the interrupted neural connectivity. Meanwhile, studies should focus on the development of technical solutions for dealing with the disruption of the sensorimotor loop. This review discusses the structural and functional adaptive reorganization of the brain after SCI, and the maladaptive mechanisms that impact on the processing of body related information, which alter motor imagery strategies and EEG signals. Studies that show how residual functions (e.g. face tactile sensitivity) may help people to restore a normal body image are also reviewed. Finally, data on how brain and residual body signals may be used to improve brain computer interface systems is discussed in relation to the issue of how such systems may help SCI people to re-enter the world and interact with objects and other individuals.

Increased cortical responses to forepaw stimuli immediately after peripheral deafferentation of hindpaw inputs

Both central and peripheral injuries of the nervous system induce dramatic reorganization of the primary somatosensory cortex. We recently showed that spinal cord injuries at thoracic level in anesthetized rats can immediately increase the responses evoked in the forepaw cortex by forepaw stimuli (above the level of the lesion), suggesting that the immediate cortical reorganization after deafferentation can extend across cortical representations of different paws. Here we show that a complete deafferentation of inputs from the hindpaw induced by injury or pharmacological block of the peripheral nerves in anesthetized rats also increases the responses evoked in the forepaw cortex by forepaw stimuli. This increase of cortical responses after peripheral deafferentation is not associated with gross alterations in the state of cortical spontaneous activity. The results of the present study, together with our previous works on spinal cord injury, suggest that the forepaw somatosensory cortex is critically involved in the reorganization that starts immediately after central or peripheral deafferentation of hindpaw inputs.

Cortical reorganization after spinal cord injury: always for good?

Plasticity constitutes the basis of behavioral changes as a result of experience. It refers to neural network shaping and re-shaping at the global level and to synaptic contacts remodeling at the local level, either during learning or memory encoding, or as a result of acute or chronic pathological conditions. 'Plastic' brain reorganization after central nervous system lesions has a pivotal role in the recovery and rehabilitation of sensory and motor dysfunction, but can also be "maladaptive". Moreover, it is clear that brain reorganization is not a "static" phenomenon but rather a very dynamic process. Spinal cord injury immediately initiates a change in brain state and starts cortical reorganization. In the long term, the impact of injury - with or without accompanying therapy - on the brain is a complex balance between supraspinal reorganization and spinal recovery. The degree of cortical reorganization after spinal cord injury is highly variable, and can range from no reorganization (i.e. "silencing") to massive cortical remapping. This variability critically depends on the species, the age of the animal when the injury occurs, the time after the injury has occurred, and the behavioral activity and possible therapy regimes after the injury. We will briefly discuss these dependencies, trying to highlight their translational value. Overall, it is not only necessary to better understand how the brain can reorganize after injury with or without therapy, it is also necessary to clarify when and why brain reorganization can be either "good" or "bad" in terms of its clinical consequences. This information is critical in order to develop and optimize cost-effective therapies to maximize functional recovery while minimizing maladaptive states after spinal cord injury.

Rubber hand illusion induced by touching the face ipsilaterally to a deprived hand: evidence for plastic "somatotopic" remapping in tetraplegics

BACKGROUND

Studies in animals and humans indicate that the interruption of body-brain connections following spinal cord injury (SCI) leads to plastic cerebral reorganization.

OBJECTIVE

To explore whether inducing the Rubber Hand Illusion (RHI) via synchronous multisensory visuo-tactile bodily stimulation may reveal any perceptual correlates of plastic remapping in SCI.

METHODS

In 16 paraplegic, 16 tetraplegic and 16 healthy participants we explored whether RHI may be induced by tactile stimuli involving not only the left hand but also the left hemi-face. Touching the participants actual hand or face was either synchronous or asynchronous with tactile stimuli seen on a rubber hand. We assessed two components of the illusion, namely perceived changes in the real hand in space (indexed by proprioceptive drift) and ownership of the rubber hand (indexed by subjective responses to an ad-hoc questionnaire).

RESULTS

Proprioceptive drift and ownership were found in the healthy group only in the condition where the left real and fake hand were touched simultaneously. In contrast, no drift was found in the SCI patients who, however, showed ownership after both synchronous and asynchronous hand stroking. Importantly, only tetraplegics showed the effect also after synchronous face stroking.

CONCLUSIONS

RHI may reveal plastic phenomena in SCI. In hand representation-deprived tetraplegics, stimuli on the face (represented contiguously in the somatic and motor systems), drive the sense of hand ownership. This hand-face remapping phenomenon may be useful for restoring a sense of self in massively deprived individuals.

The reactivation of somatosensory cortex and behavioral recovery after sensory loss in mature primates

In our experiments, we removed a major source of activation of somatosensory cortex in mature monkeys by unilaterally sectioning the sensory afferents in the dorsal columns of the spinal cord at a high cervical level. At this level, the ascending branches of tactile afferents from the hand are cut, while other branches of these afferents remain intact to terminate on neurons in the dorsal horn of the spinal cord. Immediately after such a lesion, the monkeys seem relatively unimpaired in locomotion and often use the forelimb, but further inspection reveals that they prefer to use the unaffected hand in reaching for food. In addition, systematic testing indicates that they make more errors in retrieving pieces of food, and start using visual inspection of the rotated hand to confirm the success of the grasping of the food. Such difficulties are not surprising as a complete dorsal column lesion totally deactivates the contralateral hand representation in primary somatosensory cortex (area 3b). However, hand use rapidly improves over the first post-lesion weeks, and much of the hand representational territory in contralateral area 3b is reactivated by inputs from the hand in roughly a normal somatotopic pattern. Quantitative measures of single neuron response properties reveal that reactivated neurons respond to tactile stimulation on the hand with high firing rates and only slightly longer latencies. We conclude that preserved dorsal column afferents after nearly complete lesions contribute to the reactivation of cortex and the recovery of the behavior, but second-order sensory pathways in the spinal cord may also play an important role. Our microelectrode recordings indicate that these preserved first-order, and second-order pathways are initially weak and largely ineffective in activating cortex, but they are potentiated during the recovery process. Therapies that would promote this potentiation could usefully enhance recovery after spinal cord injury.

Cortical neuron response properties are related to lesion extent and behavioral recovery after sensory loss from spinal cord injury in monkeys

Lesions of the dorsal columns at a mid-cervical level render the hand representation of the contralateral primary somatosensory cortex (area 3b) unresponsive. Over weeks of recovery, most of this cortex becomes responsive to touch on the hand. Determining functional properties of neurons within the hand representation is critical to understanding the neural basis of this adaptive plasticity. Here, we recorded neural activity across the hand representation of area 3b with a 100-electrode array and compared results from owl monkeys and squirrel monkeys 5-10 weeks after lesions with controls. Even after extensive lesions, performance on reach-to-grasp tasks returned to prelesion levels, and hand touches activated territories mainly within expected cortical locations. However, some digit representations were abnormal, such that receptive fields of presumably reactivated neurons were larger and more often involved discontinuous parts of the hand compared with controls. Hand stimulation evoked similar neuronal firing rates in lesion and control monkeys. By assessing the same monkeys with multiple measures, we determined that properties of neurons in area 3b were highly correlated with both the lesion severity and the impairment of hand use. We propose that the reactivation of neurons with near-normal response properties and the recovery of near-normal somatotopy likely supported the recovery of hand use. Given the near-completeness of the more extensive dorsal column lesions we studied, we suggest that alternate spinal afferents, in addition to the few spared primary axon afferents in the dorsal columns, likely have a major role in the reactivation pattern and return of function.

Reorganization of the intact somatosensory cortex immediately after spinal cord injury

Sensory deafferentation produces extensive reorganization of the corresponding deafferented cortex. Little is known, however, about the role of the adjacent intact cortex in this reorganization. Here we show that a complete thoracic transection of the spinal cord immediately increases the responses of the intact forepaw cortex to forepaw stimuli (above the level of the lesion) in anesthetized rats. These increased forepaw responses were independent of the global changes in cortical state induced by the spinal cord transection described in our previous work (Aguilar et al., J Neurosci 2010), as the responses increased both when the cortex was in a silent state (down-state) or in an active state (up-state). The increased responses in the intact forepaw cortex correlated with increased responses in the deafferented hindpaw cortex, suggesting that they could represent different points of view of the same immediate state-independent functional reorganization of the primary somatosensory cortex after spinal cord injury. Collectively, the results of the present study and of our previous study suggest that both state-dependent and state-independent mechanisms can jointly contribute to cortical reorganization immediately after spinal cord injury.

Large-scale reorganization of the somatosensory cortex of adult macaque monkeys revealed by fMRI

Somatosensory cortex of adult primates undergoes topographic reorganization following spinal cord or peripheral nerve injuries. Electrophysiological studies in monkeys show that after chronic lesions of dorsal columns of the spinal cord at cervical levels, there is an expansion of face representation into the deafferented hand region of area 3b of cortex. However, these techniques can sample only a limited portion of the brain. In order to help understand mechanisms of brain reorganization use of noninvasive tools in non-human primate experimental model is important. Use of blood oxygen level dependent-functional magnetic resonance imaging (BOLD-fMRI) to study brain reorganization in non-human primates has been extremely limited. Here, we show that in monkeys with long-term unilateral lesions of the dorsal columns at cervical levels, tactile stimulation of the chin showed BOLD activation in the deafferented hand region of contralesional area 3b in the post-central gyrus. In a monkey with a partial lesion of the dorsal columns, stimulations of both hand and chin activated the partially deafferented hand region. We also show that the somatotopic organization in the non-deafferented ipsilesional somatosensory cortex remained normal.

Passive exercise of the hind limbs after complete thoracic transection of the spinal cord promotes cortical reorganization

Physical exercise promotes neural plasticity in the brain of healthy subjects and modulates pathophysiological neural plasticity after sensorimotor loss, but the mechanisms of this action are not fully understood. After spinal cord injury, cortical reorganization can be maximized by exercising the non-affected body or the residual functions of the affected body. However, exercise per se also produces systemic changes – such as increased cardiovascular fitness, improved circulation and neuroendocrine changes – that have a great impact on brain function and plasticity. It is therefore possible that passive exercise therapies typically applied below the level of the lesion in patients with spinal cord injury could put the brain in a more plastic state and promote cortical reorganization. To directly test this hypothesis, we applied passive hindlimb bike exercise after complete thoracic transection of the spinal cord in adult rats. Using western blot analysis, we found that the level of proteins associated with plasticity – specifically ADCY1 and BDNF – increased in the somatosensory cortex of transected animals that received passive bike exercise compared to transected animals that received sham exercise. Using electrophysiological techniques, we then verified that neurons in the deafferented hindlimb cortex increased their responsiveness to tactile stimuli delivered to the forelimb in transected animals that received passive bike exercise compared to transected animals that received sham exercise. Passive exercise below the level of the lesion, therefore, promotes cortical reorganization after spinal cord injury, uncovering a brain-body interaction that does not rely on intact sensorimotor pathways connecting the exercised body parts and the brain.

Referred sensations elicited by video-mediated mirroring of hands

Humans readily perceive ownership of a limb even when it is artificially induced as in the case of using a mirror reflection. However, mirror reflections are very constrained perceptions which do not allow transformations and varied contexts as often occurs in real life. The extent to which perceived limb ownership occurs with video-mediated manipulations is not known, particularly given the perception would no longer be a precise copy (reflection) of a person’s own limb. The present study directly compared referred sensations of the limbs with the use of a mirror reflection to those obtained with a new video-mediated setup to assess perceived ownership. Manipulations that could not be performed with a standard mirror reflection, such as reversal of the spatial positions of the limbs, were also investigated to examine how far the perceived ownership effects could be pushed. Across a series of experiments, data on the quality, intensity and location of referred sensations were collected and analyzed together with measures of hand ownership and participants’ experience of the two setups. Results reveal that participants felt referred sensations in both the optical and the video-mediated setup, and that video-mediated manipulations of hand-position reversals produced equal to stronger effects of ownership compared with the mirror reflection. These findings open up new possibilities for scientific experimentation and therapy that are discussed in the paper.

Spatio-temporal mapping cortical neuroplasticity in carpal tunnel syndrome

Neuroimaging data demonstrate that carpal tunnel syndrome, a peripheral neuropathy, is accompanied by maladaptive central neuroplasticity. To further investigate this phenomenon, we collected magnetoencephalography data from 12 patients with carpal tunnel syndrome and 12 healthy control subjects undergoing somatosensory stimulation of the median nerve-innervated Digits 2 and 3, as well as Digit 5, which is innervated by the ulnar nerve. Nerve conduction velocity and psychophysical data were acquired to determine whether standard clinical measures correlated with brain response. In subjects with carpal tunnel syndrome, but not healthy controls, sensory nerve conduction velocity for Digits 2 and 3 was slower than Digit 5. However, somatosensory M20 latencies for Digits 2 and 3 were significantly longer than those of Digit 5. The extent of the M20 delay for median nerve-innervated Digit 2 was positively correlated with decreasing nerve conduction velocity and increasing pain severity. Thus, slower peripheral nerve conduction in carpal tunnel syndrome corresponds to greater delays in the first somatosensory cortical response. Furthermore, spectral analysis demonstrated weaker post-stimulus beta event-related desynchronization and earlier and shorter event-related synchronization in subjects with carpal tunnel syndrome. The extent of the decreased event-related desynchronization for median nerve-innervated digits was positively correlated with paraesthesia severity. We propose that ongoing paraesthesias in median nerve-innervated digits render their corresponding sensorimotor cortical areas 'busy', thus reducing their capacity to process external stimulation. Finally, subjects with carpal tunnel syndrome demonstrated a smaller cortical source separation for Digits 2 and 3 compared with healthy controls. This supports our hypothesis that ongoing paraesthesias promote blurring of median nerve-innervated digit representations through Hebbian plasticity mechanisms. In summary, this study reveals significant correlation between the clinical severity of carpal tunnel syndrome and the latency of the early M20, as well as the strength of long latency beta oscillations. These temporal magnetoencephalography measures are novel markers of neuroplasticity in carpal tunnel syndrome and could be used to study central changes that may occur following clinical intervention.

Central nervous system reorganization in a variety of chronic pain states: a review

Chronic pain can develop from numerous conditions and is one of the most widespread and disabling health problems today. Unfortunately, the pathophysiology of chronic pain in most of these conditions, along with consistently effective treatments, remain elusive. However, recent advances in neuroimaging and neurophysiology are rapidly expanding our understanding of these pain syndromes. It is now clear that substantial functional and structural changes, or plasticity, in the central nervous system (CNS) are associated with many chronic pain syndromes. A group of cortical and subcortical brain regions, often referred to as the "pain matrix," often show abnormalities on functional imaging studies in persons with chronic pain, even with different pain locations and etiologies. Changes in the motor and sensory homunculus also are seen. Some of these CNS changes return to a normal state with resolution of the pain. It is hoped that this knowledge will lead to more effective treatments or even new preventative measures. The purpose of this article is to review recent advances in the understanding of the CNS changes associated with chronic pain in a number of clinical entities encountered in the field of physical medicine and rehabilitation. These clinical entities include nonspecific low back pain, fibromyalgia, complex regional pain syndrome, postamputation phantom pain, and chronic pain after spinal cord injury.

Phantom pain reduction by low-frequency and low-intensity electromagnetic fields

Although various treatments have been presented for phantom pain, there is little proof supporting the benefits of pharmacological treatments, surgery or interventional techniques, electroconvulsive therapy, electrical nerve stimulation, far infrared ray therapy, psychological therapies, etc. Here, we report the preliminary results for phantom pain reduction by low-frequency and intensity electromagnetic fields under clinical circumstances. Our method is called as Electromagnetic-Own-Signal-Treatment (EMOST). Fifteen people with phantom limb pain participated. The patients were treated using a pre-programmed, six sessions. Pain intensity was quantified upon admission using a 0-10 verbal numerical rating scale. Most of the patients (n = 10) reported a marked reduction in the intensity of phantom limb pain. Several patients also reported about improvement in their sleep and mood quality, or a reduction in the frequency of phantom pain after the treatments. No improvements in the reduction of phantom limb pain or sleep and mood improvement were reported in the control group (n = 5). Our nonlinear electromagnetic EMOST method may be a possible therapeutic application in the reduction of phantom limb pain. Here, we also suggest that some of the possible effects of the EMOST may be achieved via the redox balance of the body and redox-related neural plasticity.