Thalamic and cortical contributions to neural plasticity after limb amputation

Pain without presence: a narrative review of the pathophysiological landscape of phantom limb pain

Phantom limb pain (PLP) is defined as the perception of pain in a limb that has been amputated. In the United States, approximately 30,000-40,000 amputations are performed annually with an estimated 2.3 million people living with amputations. The prevalence of PLP among amputees is approximately 64%. Over the years, various theories regarding the etiology of PLP have been proposed, with some gaining more prominence than others. Yet, there is a lack of consensus on PLP mechanisms as the current literature exploring the pathophysiology of PLP is multifactorial, involving complex interactions between the central and peripheral nervous systems, psychosocial factors, and genetic influences. This review seeks to enhance the understanding of PLP by exploring its multifaceted pathophysiology, including genetic predispositions. We highlight historical aspects of pain theories and PLP, examining how these theories have expanded to include psychosocial dimensions associated with chronic pain in amputees. Additionally, we present significant findings from both human and animal studies focused on neuroaxial systems and recent advances in molecular research to further elucidate the complex and multifactorial nature of PLP. Ultimately, we hope that the integration of current theoretical frameworks and findings will lay a more robust foundation for future research on PLP.

Post-Critical Period Transcriptional and Physiological Adaptations of Thalamocortical Connections after Sensory Loss

Unilateral whisker denervation activates plasticity mechanisms and circuit adaptations in adults. Single nucleus RNA sequencing and multiplex fluorescence in situ hybridization revealed differentially expressed genes related to altered glutamate receptor distributions and synaptogenesis in thalamocortical (TC) recipient layer 4 (L4) neurons of the sensory cortex, specifically those receiving input from the intact whiskers after whisker denervation. Electrophysiology detected increased spontaneous excitatory events at L4 neurons, confirming an increase in synaptic connections. Elevated expression levels of Gria2 mRNA and functional GluA2 subunit of AMPA receptors at the TC synapse indicate the presence of stabilized and potentiated TC synapses to L4 excitatory neurons along the intact pathway after unilateral whisker denervation. These adaptations likely underlie the increased cortical activity observed in rodents during intact whisker sensation after unilateral whisker denervation. Our findings provide new insights into the mechanisms by which the adult brain supports recovery after unilateral sensory loss.

Sources of Rapid and Delayed New Lower Jaw Input in the Forepaw Barrel Subfield (FBS) in Rat Primary Somatosensory Cortex (SI) Following Forelimb Deafferentation

Previously, we reported an immediate emergence of new lower jaw input to the anterior forepaw barrel subfield (FBS) in primary somatosensory cortex (SI) following forelimb deafferentation. However, a delay of 7 weeks or more post-amputation results in the presence of this new input to both anterior and posterior FBS. The immediate change suggests pre-existing latent lower jaw input in the FBS, whereas the delayed alteration implies the involvement of alternative sources. One possible source for immediate lower jaw responses is the neighboring lower jaw barrel subfield (LJBSF). We used anatomical tracers to investigate the possible projection of LJBSF to the FBS in normal and forelimb-amputated rats. Our findings are as follows: (1) anterograde tracer injection into LJBSF in normal and amputated rats labeled fibers and terminals exclusively in the anterior FBS; (2) retrograde tracer injection in the anterior FBS in normal and forelimb-amputated rats, heavily labeled cell bodies predominantly in the posterior LJBSF, with fewer in the anterior LJBSF; (3) retrograde tracer injection in the posterior FBS in normal and forelimb-amputated rats, sparsely labeled cell bodies in the posterior LJBSF; (4) retrograde tracer injection in anterior and posterior FBS in normal and forelimb-amputated rats, labeled cells exclusively in ventral posterior lateral (VPL) nucleus and posterior thalamus (PO); (5) retrograde tracer injection in LJBSF-labeled cell bodies exclusively in ventral posterior medial thalamic nucleus and PO. These findings suggest that LJBSF facilitates rapid lower jaw reorganization in the anterior FBS, whereas VPL and/or other subcortical sites provide a likely substrate for delayed reorganization observed in the posterior FBS.

Cortical Reorganization after Limb Loss: Bridging the Gap between Basic Science and Clinical Recovery

Despite the increasing incidence and prevalence of amputation across the globe, individuals with acquired limb loss continue to struggle with functional recovery and chronic pain. A more complete understanding of the motor and sensory remodeling of the peripheral and central nervous system that occurs postamputation may help advance clinical interventions to improve the quality of life for individuals with acquired limb loss. The purpose of this article is to first provide background clinical context on individuals with acquired limb loss and then to provide a comprehensive review of the known motor and sensory neural adaptations from both animal models and human clinical trials. Finally, the article bridges the gap between basic science researchers and clinicians that treat individuals with limb loss by explaining how current clinical treatments may restore function and modulate phantom limb pain using the underlying neural adaptations described above. This review should encourage the further development of novel treatments with known neurological targets to improve the recovery of individuals postamputation.Significance Statement In the United States, 1.6 million people live with limb loss; this number is expected to more than double by 2050. Improved surgical procedures enhance recovery, and new prosthetics and neural interfaces can replace missing limbs with those that communicate bidirectionally with the brain. These advances have been fairly successful, but still most patients experience persistent problems like phantom limb pain, and others discontinue prostheses instead of learning to use them daily. These problematic patient outcomes may be due in part to the lack of consensus among basic and clinical researchers regarding the plasticity mechanisms that occur in the brain after amputation injuries. Here we review results from clinical and animal model studies to bridge this clinical-basic science gap.

Lower jaw-to-forepaw rapid and delayed reorganization in the rat forepaw barrel subfield in primary somatosensory cortex

We used the forepaw barrel subfield (FBS), that normally receives input from the forepaw skin surface, in rat primary somatosensory cortex as a model system to study rapid and delayed lower jaw-to-forepaw cortical reorganization. Single and multi-unit recording from FBS neurons was used to examine the FBS for the presence of "new" lower jaw input following deafferentations that include forelimb amputation, brachial plexus nerve cut, and brachial plexus anesthesia. The major findings are as follows: (1) immediately following forelimb deafferentations, new input from the lower jaw becomes expressed in the anterior FBS; (2) 7-27 weeks after forelimb amputation, new input from the lower jaw is expressed in both anterior and posterior FBS; (3) evoked response latencies recorded in the deafferented FBS following electrical stimulation of the lower jaw skin surface are significantly longer in both rapid and delayed deafferents compared to control latencies for input from the forepaw to reach the FBS or for input from lower jaw to reach the LJBSF; (4) the longer latencies suggest that an additional relay site is imposed along the somatosensory pathway for lower jaw input to access the deafferented FBS. We conclude that different sources of input and different mechanisms underlie rapid and delayed reorganization in the FBS and suggest that these findings are relevant, as an initial step, for developing a rodent animal model to investigate phantom limb phenomena.

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.

Does Forward Head Posture Influence Somatosensory Evoked Potentials and Somatosensory Processing in Asymptomatic Young Adults?

The current investigation used somatosensory evoked potentials (SEPs) to assess differences in sensorimotor integration and somatosensory processing variables between asymptomatic individuals with and without forward head posture (FHP). We assessed different neural regions of the somatosensory pathway, including the amplitudes of the peripheral N9, spinal N13, brainstem P14, peak-to-peak amplitudes of parietal N20 and P27, and frontal N30 potentials. Central conduction time (N13-N20) was measured as the difference in peak latencies of N13 and N20. We measured these variables in 60 participants with FHP defined as a craniovertebral angle (CVA) < 50° and 60 control participants matched for age, gender, and body mass index (BMI) with normal FHP defined as CVA > 55°. Differences in variable measures were examined using the parametric t-test. Pearson's correlation was used to evaluate the relationship between the CVA and sensorimotor integration and SEP measurements. A generalized linear model (GLM) was used to compare the SEP measures between groups, with adjustment for educational level, marital status, BMI, and working hours per week. There were statistically significant differences between the FHP group and control group for all sensorimotor integration and SEP processing variables, including the amplitudes of spinal N13 (p < 0.005), brainstem P14 (p < 0.005), peak-to-peak amplitudes of parietal N20 and P27 (p < 0.005), frontal N30 potentials (p < 0.005), and the conduction time N13-N20 (p = 0.004). The CVA significantly correlated with all measured neurophysiological variables indicating that as FHP increased, sensorimotor integration and SEP processing became less efficient. FHP group correlations were: N9 (r = -0.44, p < 0.001); N13 (r = -0.67, p < 0.001); P14 (r = -0.58, p < 0.001); N20 (r = -0.49, p = 0.001); P27 (r = -0.58, p < 0.001); N30 potentials (r = -0.64, p < 0.001); and N13-N20 (r = -0.61, p < 0.001). GLM identified that increased working hours adversely affected the SEP measures (p < 0.005), while each 1° increase in the CVA was associated with improved SEP amplitudes and more efficient central conduction time (N13-N20; p < 0.005). Less efficient sensorimotor integration and SEP processing may be related to previous scientific reports of altered sensorimotor control and athletic skill measures in populations with FHP. Future investigations should seek to replicate our findings in different spine disorders and symptomatic populations in an effort to understand how improving forward head posture might benefit functional outcomes of patient care.

Somatosensory and motor representations following bilateral transplants of the hands: A 6-year longitudinal case report on the first pediatric bilateral hand transplant patient

A vascularized composite tissue allotransplantation (VCA) was performed at the Children's Hospital of Philadelphia (CHOP), on an 8-year-old patient in 2015, six years after bilateral hand and foot amputation. Hand VCA resulted in reafferentation of the medial, ulnar, and radial nerves serving hand somatosensation and motor function. We used magnetoencephalography (MEG) to assess somatosensory cortical plasticity following the post-transplantation recovery of the peripheral sensory nerves of the hands. Our 2-year postoperative MEG showed that somatosensory lip representations, initially observed at "hand areas", reverted to canonical, orthotopic lip locations with recovery of post-transplant hand function. Here, we continue the assessment of motor and somatosensory responses up to 6-years post-transplant. Magnetoencephalographic somatosensory responses were recorded eight times over a six-year period following hand transplantation, using a 275-channel MEG system. Somatosensory tactile stimuli were presented to the right lower lip (all 8 visits) as well as right and left index fingers (visits 3-8) and fifth digits (visits 4-8). In addition, left and right-hand motor responses were also recorded for left index finger and right thumb (visit 8 only).During the acute recovery phase (visits 3 and 4), somatosensory responses of the digits were observed to be significantly larger and more phasic (i.e., smoother) than controls. Subsequent measures showed that digit responses maintain this atypical response profile (evoked-response magnitudes typically exceed 1 picoTesla). Orthotopic somatosensory localization of the lip, D2, and D5 was preserved. Motor beta-band desynchrony was age-typical in localization and response magnitude; however, the motor gamma-band response was significantly larger than that observed in a reference population.These novel findings show that the restoration of somatosensory input of the hands resulted in persistent and atypically large cortical responses to digit stimulation, which remain atypically large at 6 years post-transplant; there is no known perceptual correlate, and no reports of phantom pain. Normal somatosensory organization of the lip, D2, and D5 representation remain stable following post-recovery reorganization of the lip's somatosensory response.

Post-amputation pain: Comparing pain presentations between adults with and without increased amputated-region sensitivity

OBJECTIVE

Among adults with persistent post-amputation pain, increased amputated-region pain sensitivity may reflect peripheral sensitization or indicate underlying central sensitization. To determine whether underlying central sensitization may contribute to increased pain sensitivity in this population, this study compared clinical signs and symptoms associated with central sensitization between adults with post-amputation pain who demonstrate or lack increased amputated-region sensitivity (as compared to reference data).

DESIGN

Cross-sectional.

SUBJECTS

Ninety-nine adults (60 with a unilateral, transtibial amputation and post-amputation pain, 39 pain-free controls with intact limbs).

METHODS

Participants underwent pain-pressure threshold testing of amputated-region and secondary (non-amputated region) sites and completed outcome measures assessing central sensitization symptoms (Patient-Reported Outcomes Measurement Information System® pain intensity and interference domains, Central Sensitization Inventory). Among the full sample, the presence and frequency of specific central sensitization symptoms were evaluated. Participants with post-amputation pain were then grouped based on whether normalized, amputated-region pain-pressure thresholds fell below (i.e., sensitive) or above (i.e., non-sensitive) the 25th percentile of sex-specific reference data. Between-group differences in normalized secondary-site sensitivity were evaluated using a multivariate analysis of variance; central sensitization symptom scores were compared using a Kruskal-Wallis test.

RESULTS

Noteworthy symptoms associated with central sensitization (e.g., fatigue, sleep disturbance, cognitive difficulty) were reported by 33%-62% of participants. Secondary-site pain sensitivity was greater among individuals with increased amputated-region sensitivity (n = 24) compared to peers without increased amputated-region sensitivity ([n = 36], mean difference > 1.33 standard deviation [SD], p < 0.001). Central sensitization symptom scores, however, were similar between groups (p > 0.187).

CONCLUSIONS

Participants with increased amputated-region sensitivity demonstrate generalized, secondary-site pain hypersensitivity, potentially indicating underlying central sensitization. Central sensitization symptom scores, however, were similar between groups, suggesting differences in physiological pain sensitivity may not manifest in subjective post-amputation pain descriptions.

Comparison of Sensorimotor Integration and Skill-Related Physical Fitness Components Between College Athletes With and Without Forward Head Posture

OBJECTIVE

To evaluate sensorimotor integration and skill-related physical fitness components for participants with forward head posture (FHP) compared with strictly matched controls with normal head alignment.

MATERIAL AND METHODS

We measured FHP, sensorimotor processing, and skill-related physical fitness variables in 50 participants with FHP and in 50 participants matched for age, gender, and body mass index with normal FHP, defined as having a craniovertebral angle >55°. Sensorimotor processing and integration variables were: (1) amplitudes of the spinal N13, (2) brainstem P14, (3) parietal N20 and P27, and (4) frontal N30 potentials. The skill-related physical fitness variables selected for the study were (1) T-test agility, (2) leg power, (3) stork static balance test, and (4) Y-balance test.

RESULTS

There was a statistically significant difference between the FHP group and control group for the sensorimotor integration variable: frontal N30 potentials (P < .05). Additionally, between-group differences were found for the sensorimotor processing variables: amplitudes of spinal N13, brainstem P14, and parietal N20, and P27 (P < .05). Statistically significant differences between groups for the skill-related physical fitness variables were also identified: T-test agility, leg power, stork static balance test, and Y-balance test (P < .05). The magnitude of the craniovertebral angle showed a correlation with all measured variables (P < .05).

CONCLUSION

College athletes with FHP exhibited altered sensorimotor processing and integration measurements and less efficient skill-related physical fitness compared with athletes with normal sagittal head posture alignment.

Plasticity of the Central Nervous System Involving Peripheral Nerve Transfer

Peripheral nerve injury can lead to partial or complete loss of limb function, and nerve transfer is an effective surgical salvage for patients with these injuries. The inability of deprived cortical regions representing damaged nerves to overcome corresponding maladaptive plasticity after the reinnervation of muscle fibers and sensory receptors is thought to be correlated with lasting and unfavorable functional recovery. However, the concept of central nervous system plasticity is rarely elucidated in classical textbooks involving peripheral nerve injury, let alone peripheral nerve transfer. This article is aimed at providing a comprehensive understanding of central nervous system plasticity involving peripheral nerve injury by reviewing studies mainly in human or nonhuman primate and by highlighting the functional and structural modifications in the central nervous system after peripheral nerve transfer. Hopefully, it will help surgeons perform successful nerve transfer under the guidance of modern concepts in neuroplasticity.

Demonstration of central conduction time and neuroplastic changes after cervical lordosis rehabilitation in asymptomatic subjects: a randomized, placebo-controlled trial

A randomized controlled study was conducted to evaluate the effect of rehabilitation of the cervical sagittal configuration on sensorimotor integration and central conduction time in an asymptomatic population. Eighty (32 female) participants with radiographic cervical hypolordosis and anterior head translation posture were randomly assigned to either a control or an experimental group. The experimental group received the Denneroll cervical traction while the control group received a placebo treatment. Interventions were applied 3 × per week for 10 weeks. Outcome measures included radiographic measured anterior head translation distance, cervical lordosis (posterior bodies of C2–C7), central somatosensory conduction time (latency) (N13–N20), and amplitudes of potentials for spinal N13, brainstem P14, parietal N20 and P27, and frontal N30. Outcomes were obtained at: baseline, after 10 weeks of intervention, and at 3 months follow up. After 10 weeks and 3-months, between-group analyses revealed statistically significant differences between the groups for the following measured variables: lordosis C2–C7, anterior head translation, amplitudes of spinal N13, brainstem P14, parietal N20 and P27, frontal N30 potentials (P < 0.001), and conduction time N13–N20 (P = 0.004). Significant correlation between the sagittal alignment and measured variables were found (P < 0.005). These findings indicate restoration of cervical sagittal alignment has a direct influence on the central conduction time in an asymptomatic population.

Cortical plasticity and nerve regeneration after peripheral nerve injury

With the development of neuroscience, substantial advances have been achieved in peripheral nerve regeneration over the past decades. However, peripheral nerve injury remains a critical public health problem because of the subsequent impairment or absence of sensorimotor function. Uncomfortable complications of peripheral nerve injury, such as chronic pain, can also cause problems for families and society. A number of studies have demonstrated that the proper functioning of the nervous system depends not only on a complete connection from the central nervous system to the surrounding targets at an anatomical level, but also on the continuous bilateral communication between the two. After peripheral nerve injury, the interruption of afferent and efferent signals can cause complex pathophysiological changes, including neurochemical alterations, modifications in the adaptability of excitatory and inhibitory neurons, and the reorganization of somatosensory and motor regions. This review discusses the close relationship between the cerebral cortex and peripheral nerves. We also focus on common therapies for peripheral nerve injury and summarize their potential mechanisms in relation to cortical plasticity. It has been suggested that cortical plasticity may be important for improving functional recovery after peripheral nerve damage. Further understanding of the potential common mechanisms between cortical reorganization and nerve injury will help to elucidate the pathophysiological processes of nerve injury, and may allow for the reduction of adverse consequences during peripheral nerve injury recovery. We also review the role that regulating reorganization mechanisms plays in functional recovery, and conclude with a suggestion to target cortical plasticity along with therapeutic interventions to promote peripheral nerve injury recovery.

Reorganization of Higher-Order Somatosensory Cortex After Sensory Loss from Hand in Squirrel Monkeys

Unilateral dorsal column lesions (DCL) at the cervical spinal cord deprive the hand regions of somatosensory cortex of tactile activation. However, considerable cortical reactivation occurs over weeks to months of recovery. While most studies focused on the reactivation of primary somatosensory area 3b, here, for the first time, we address how the higher-order somatosensory cortex reactivates in the same monkeys after DCL that vary across cases in completeness, post-lesion recovery times, and types of treatments. We recorded neural responses to tactile stimulation in areas 3a, 3b, 1, secondary somatosensory cortex (S2), parietal ventral (PV), and occasionally areas 2/5. Our analysis emphasized comparisons of the responsiveness, somatotopy, and receptive field size between areas 3b, 1, and S2/PV across DCL conditions and recovery times. The results indicate that the extents of the reactivation in higher-order somatosensory areas 1 and S2/PV closely reflect the reactivation in primary somatosensory cortex. Responses in higher-order areas S2 and PV can be stronger than those in area 3b, thus suggesting converging or alternative sources of inputs. The results also provide evidence that both primary and higher-order fields are effectively activated after long recovery times as well as after behavioral and electrocutaneous stimulation interventions.

Is forward head posture relevant to autonomic nervous system function and cervical sensorimotor control? Cross sectional study

BACKGROUND

There is a growing interest concerning the understanding of the sagittal configuration of the cervical spine as a clinical outcome. However, evaluating sensorimotor control and autonomic nervous system for participants with forward head posture (FHP) compared to strictly matched control participants with normal head alignment has not been adequately addressed.

METHODS

Sensorimotor control variables include smooth pursuit neck torsion test(SPNT), Overall stability index (OSI) and left and right rotation repositioning accuracy. Autonomic nervous system function includes amplitude and latency of skin sympathetic response (SSR). We measured these variables in 80 participants with definite forward head posture (Craniovertebral angle less than 50 degrees) and 80 participants with age, gender, and BMI matched normal head alignment (Craniovertebral angle (CVA) more than 50 degrees). Differences in variable measures were examined using the parametric t-test. Pearson correlation was used to evaluate the relationship between FHP, sensorimotor control, and autonomic nervous system function.

RESULTS

The unpaired t-test analysis showed that there were statistically significant differences between the FHP group and control group for all of the sensorimotor measured variables including SPNT, OSI and left and right rotation repositioning accuracy (P < 0.001). Also, there was a significant difference in neurophysiological findings, including SSR amplitude (P = .005), but there was no significant difference for SSR Latency (P = .7). The CVA significantly correlated with all measured variables (P < 0.001).

CONCLUSIONS

Participants with FHP exhibited abnormal sensorimotor control and autonomic nervous system dysfunction compared to those with normal head alignment.

Brain and Body: A Review of Central Nervous System Contributions to Movement Impairments in Diabetes

Diabetes is associated with a loss of somatosensory and motor function, leading to impairments in gait, balance, and manual dexterity. Data-driven neuroimaging studies frequently report a negative impact of diabetes on sensorimotor regions in the brain; however, relationships with sensorimotor behavior are rarely considered. The goal of this review is to consider existing diabetes neuroimaging evidence through the lens of sensorimotor neuroscience. We review evidence for diabetes-related disruptions to three critical circuits for movement control: the cerebral cortex, the cerebellum, and the basal ganglia. In addition, we discuss how central nervous system (CNS) degeneration might interact with the loss of sensory feedback from the limbs due to peripheral neuropathy to result in motor impairments in individuals with diabetes. We argue that our understanding of movement impairments in individuals with diabetes is incomplete without the consideration of disease complications in both the central and peripheral nervous systems. Neuroimaging evidence for disrupted central sensorimotor circuitry suggests that there may be unrecognized behavioral impairments in individuals with diabetes. Applying knowledge from the existing literature on CNS contributions to motor control and motor learning in healthy individuals provides a framework for hypothesis generation for future research on this topic.

Altered Expression of Reorganized Inputs as They Ascend From the Cuneate Nucleus to Cortical Area 3b in Monkeys With Long-Term Spinal Cord Injuries

Chronic deafferentations in adult mammals result in reorganization of the brain. Lesions of the dorsal columns of the spinal cord at cervical levels in monkeys result in expansion of the intact chin inputs into the deafferented hand representation in area 3b, second somatosensory (S2) and parietal ventral (PV) areas of the somatosensory cortex, ventroposterior lateral nucleus (VPL) of the thalamus, and cuneate nucleus of the brainstem. Here, we describe the extent and nature of reorganization of the cuneate and gracile nuclei of adult macaque monkeys with chronic unilateral lesions of the dorsal columns, and compare it with the reorganization of area 3b in the same monkeys. In both, area 3b and the cuneate nucleus chin inputs expand to reactivate the deafferented neurons. However, unlike area 3b, neurons in the cuneate nucleus also acquire receptive fields on the shoulder, neck, and occiput. A comparison with the previously published results shows that reorganization in the cuneate nucleus is similar to that in VPL. Thus, the emergent topography following deafferentations by spinal cord injuries undergoes transformation as the reorganized inputs ascend from subcortical nuclei to area 3b. The results help us understand mechanisms of the brain plasticity following spinal cord injuries.

Functional plasticity of the ipsilateral primary sensorimotor cortex in an elite long jumper with below-knee amputation

Functional plasticity of the sensorimotor cortex occurs following motor practice, as well as after limb amputation. However, the joint effect of limb amputation and intensive, long-term motor practice on cortical plasticity remains unclear. Here, we recorded brain activity during unilateral contraction of the hip, knee, and ankle joint muscles from a long jump Paralympic gold medalist with a unilateral below-knee amputation (Amputee Long Jumper, ALJ). He used the amputated leg with a prosthesis for take-off. Under similar conditions to the ALJ, we also recorded brain activity from healthy long jumpers (HLJ) and non-athletes with a below-knee amputation. During a rhythmic isometric contraction of knee extensor muscles with the take-off/prosthetic leg, the ALJ activated not only the contralateral primary sensorimotor cortex (M1/S1), but also the ipsilateral M1/S1. In addition, this ipsilateral M1/S1 activation was significantly greater than that seen in the HLJ. However, we did not find any significant differences between the ALJ and HLJ in M1/S1 activation during knee muscle contraction in the non-take-off/intact leg, nor during hip muscle contraction on either side. Region of interest analysis revealed that the ALJ exhibited a greater difference in M1/S1 activity and activated areas ipsilateral to the movement side between the take-off/prosthetic and non-take-off/intact legs during knee muscle contraction compared with the other two groups. However, difference in activity in M1/S1 contralateral to the movement side did not differ across groups. These results suggest that a combination of below-knee amputation and intensive, prolonged long jump training using a prosthesis (i.e. fine knee joint control) induced an expansion of the functional representation of the take-off/prosthetic leg in the ipsilateral M1/S1 in a muscle-specific manner. These results provide novel insights into the potential for substantial cortical plasticity with an extensive motor rehabilitation program.

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A Paralympic gold medalist with a unilateral below-knee amputation was recruited.

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Brain activity during hip, knee, and ankle movements was recorded.

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Brain activity was compared with healthy athletes and non-athletes with amputation.

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Greater ipsilateral M1/S1 activity during knee movement was observed in the medalist.

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Intensive motor practice and limb amputation would induce drastic neural plasticity.

Decreased Distance between Representation Sites of Distinct Facial Movements in Facial Synkinesis-A Task fMRI Study

This study aimed to investigate the cortical functional alterations in patients with unilateral facial synkinesis using the task-designed functional magnetic resonance imaging. Fourteen unilateral synkinesis followed by peripheral facial nerve palsy patients and eighteen healthy adults were recruited in this study. Four facial motor tasks, i.e. left/right blinking and left/right smiling, were performed by each subject during the scans. Based on the activation maps, the spatial distance between the representation sites in the contralateral pre-/post-central gyrus of left or right blinking and smiling tasks (i.e. left/right B-S-distance) were calculated. Patients with unilateral facial synkinesis showed decreased B-S-distances during blinking and smiling tasks on the affected half face (9.68 ± 3.92 mm) compared to both average distances in healthy controls (14.95 ± 5.55 mm; p = 0.002) and unaffected half face tasks in patients (16.19 ± 7.87 mm; p = 0.011). These findings demonstrated cortical reorganization in facial synkinesis and suggested a conceivable mechanism corresponding to the simultaneous facial movement. This potentially provides a new modulation target for preventive, therapeutic and rehabilitative maneuver of this disease.

Relief from intractable phantom pain by combining psilocybin and mirror visual-feedback (MVF)

AL's leg was amputated resulting in phantom-limb pain (PLP). (1) When a volunteer placed her foot on or near the phantom - touching it evoked organized sensations in corresponding locations on AL's phantom. (2) Mirror-visual-feedback (MVF) relieved PLP, as did, "phantom massage". (3) Psilocybin-MVF pairing produced synergistic effects, complete elimination of PLP, and reduction in paroxysmal episodes. (4) Touching the volunteer's leg where AL previously had external fixators, evoked sensation of nails boring through the leg. Using a "telescoping" nail, we created the illusion of a nail being removed with corresponding pain relief. (5) Artificial flames produced warmth in the phantom.

Changes in the corticospinal tract after wearing prosthesis in bilateral transtibial amputation

BACKGROUND

After amputation, the brain is known to be reorganized especially in the primary motor cortex. We report a case to show changes in the corticospinal tract in a patient with serial bilateral transtibial amputations using diffusion tensor imaging. Case Description and Methods: A 78-year-old man had a transtibial amputation on his left side in 2008 and he underwent a right transtibial amputation in 2011. An initial brain magnetic resonance imaging with a diffusion tensor imaging was performed before starting rehabilitation on his right transtibial prosthesis, and a follow-up magnetic resonance imaging with diffusion tensor imaging was performed 2 years after this. Findings and Outcomes: In the initial diffusion tensor imaging, the number of fiber lines in his right corticospinal tract was larger than that in his left corticospinal tract. At follow-up diffusion tensor imaging, there was no definite difference in the number of fiber lines between both corticospinal tracts.

CONCLUSION

We found that side-to-side corticospinal tract differences were equalized after using bilateral prostheses. Clinical relevance This case report suggests that diffusion tensor imaging tractography could be a useful method to understand corticomotor reorganization after using prosthesis in transtibial amputation.

Afferent Fiber Remodeling in the Somatosensory Thalamus of Mice as a Neural Basis of Somatotopic Reorganization in the Brain and Ectopic Mechanical Hypersensitivity after Peripheral Sensory Nerve Injury

Plastic changes in the CNS in response to peripheral sensory nerve injury are a series of complex processes, ranging from local circuit remodeling to somatotopic reorganization. However, the link between circuit remodeling and somatotopic reorganization remains unclear. We have previously reported that transection of the primary whisker sensory nerve causes the abnormal rewiring of lemniscal fibers (sensory afferents) on a neuron in the mouse whisker sensory thalamus (V2 VPM). In the present study, using transgenic mice whose lemniscal fibers originate from the whisker sensory principle trigeminal nucleus (PrV2) are specifically labeled, we identified that the transection induced retraction of PrV2-originating lemniscal fibers and invasion of those not originating from PrV2 in the V2 VPM. This anatomical remodeling with somatotopic reorganization was highly correlated with the rewiring of lemniscal fibers. Origins of the non-PrV2-origin lemniscal fibers in the V2 VPM included the mandibular subregion of trigeminal nuclei and the dorsal column nuclei (DCNs), which normally represent body parts other than whiskers. The transection also resulted in ectopic receptive fields of V2 VPM neurons and extraterritorial pain behavior on the uninjured mandibular region of the face. The anatomical remodeling, emergence of ectopic receptive fields, and extraterritorial pain behavior all concomitantly developed within a week and lasted more than three months after the transection. Our findings, thus, indicate a strong linkage between these plastic changes after peripheral sensory nerve injury, which may provide a neural circuit basis underlying large-scale reorganization of somatotopic representation and abnormal ectopic sensations.

Cortical Reorganization in Patients Recovered from Bell's Palsy: An Orofacial and Finger Movements Task-State fMRI Study

Objective. To explore cortical reorganization of patients recovered from Bell's palsy (BP) by task-state functional magnetic resonance imaging (fMRI) during finger and orofacial movements and provide more evidence for acupuncture clinical treatment of BP. Methods. We collected 17 BP patients with complete clinical recovery (BP group) and 20 healthy volunteers (control group) accepted the task-state fMRI scans with lip pursing movements and finger movements, respectively. Results. It was found that there were significant differences of brain functional status between the two groups. Conclusions. The results showed that there was cortical reorganization in the brain of patients recovered from BP after acupuncture treatment, which also suggested the relationship between the hand motor areas and facial motor areas of BP patients.

A longitudinal study of pain, personality, and brain plasticity following peripheral nerve injury

We do not know precisely why pain develops and becomes chronic after peripheral nerve injury (PNI), but it is likely due to biological and psychological factors. Here, we tested the hypotheses that (1) high Pain Catastrophizing Scale (PCS) scores at the time of injury and repair are associated with pain and cold sensitivity after 1-year recovery and (2) insula gray matter changes reflect the course of injury and improvements over time. Ten patients with complete median and/or ulnar nerve transections and surgical repair were tested ∼3 weeks after surgical nerve repair (time 1) and ∼1 year later for 6 of the 10 patients (time 2). Patients and 10 age-/sex-matched healthy controls completed questionnaires that assessed pain (patients) and personality and underwent quantitative sensory testing and 3T MRI to assess cortical thickness. In patients, pain intensity and neuropathic pain correlated with pain catastrophizing. Time 1 pain catastrophizing trended toward predicting cold pain thresholds at time 2, and at time 1 cortical thickness of the right insula was reduced. At time 2, chronic pain was related to the time 1 pain-PCS relationship and cold sensitivity, pain catastrophizing correlated with cold pain threshold, and insula thickness reversed to control levels. This study highlights the interplay between personality, sensory function, and pain in patients following PNI and repair. The PCS-pain association suggests that a focus on affective or negative components of pain could render patients vulnerable to chronic pain. Cold sensitivity and structural insula changes may reflect altered thermosensory or sensorimotor awareness representations.

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.

Role of Central Plasticity in the Outcome of Peripheral Nerve Regeneration

The optimal refinement in nerve repair techniques has reached a plateau, making it imperative to continually explore newer avenues for improving the clinical outcome of peripheral nerve regeneration. The aim of this short review is to discuss the role and mechanism of brain plasticity in nerve regeneration, as well as to explore the possible application of this knowledge for improving the clinical outcome following nerve repair.

Congenital foot deformation alters the topographic organization in the primate somatosensory system

Limbs may fail to grow properly during fetal development, but the extent to which such growth alters the nervous system has not been extensively explored. Here we describe the organization of the somatosensory system in a 6-year-old monkey (Macaca radiata) born with a deformed left foot in comparison to the results from a normal monkey (Macaca fascicularis). Toes 1, 3, and 5 were missing, but the proximal parts of toes 2 and 4 were present. We used anatomical tracers to characterize the patterns of peripheral input to the spinal cord and brainstem, as well as between thalamus and cortex. We also determined the somatotopic organization of primary somatosensory area 3b of both hemispheres using multiunit electrophysiological recording. Tracers were subcutaneously injected into matching locations of each foot to reveal their representations within the lumbar spinal cord, and the gracile nucleus (GrN) of the brainstem. Tracers injected into the representations of the toes and plantar pads of cortical area 3b labeled neurons in the ventroposterior lateral nucleus (VPL) of the thalamus. Contrary to the orderly arrangement of the foot representation throughout the lemniscal pathway in the normal monkey, the plantar representation of the deformed foot was significantly expanded and intruded into the expected representations of toes in the spinal cord, GrN, VPL, and area 3b. We also observed abnormal representation of the intact foot in the ipsilateral spinal cord and contralateral area 3b. Thus, congenital malformation influences the somatotopic representation of the deformed as well as the intact foot.

Differences in AMPA and GABAA/B receptor subunit expression between the chronically reorganized cortex and brainstem of adult squirrel monkeys

The primate somatosensory neuraxis provides a highly translational model system with which to investigate adult neural plasticity. Here, we report immunohistochemical staining data for AMPA and GABAA/B receptor subunits of area 3b cortex and cuneate nucleus of adult squirrel monkeys one to five years after median and ulnar nerve transection. In Area 3B cortex, the expression of GluR1 AMPAR subunits in reorganized regions are significantly increased, while the expression of GluR2/3 AMPAR subunits are not. GABAA α1 subunit expression in the reorganized region is not significantly different from control regions. Presynaptic GABABR1a subunit expression was also not significantly different between reorganized and control regions, while postsynaptic GABABR1b subunit expression was significantly decreased. In the cuneate nucleus of the brainstem, the expression of GluR1 AMPAR subunits in reorganized regions was not significantly different, while GluR2/3 AMPAR subunit expression was significantly elevated. GABAA α1 subunit expression in the reorganized region was significantly decreased. Presynaptic GABABR1a subunit expression was not significantly different, while postsynaptic GABABR1b subunit expression was significantly decreased. When subunit expression is compared, brainstem and cortical patterns diverge over longer periods of recovery. Persistent patterns of change in the cortex are stable by 1-year. Alternatively, subunit expression in the cuneate nucleus one to five years after nerve injury is similar to that seen 1-month after a reorganizing injury. This suggests that cortical plasticity continues to change over many months as receptive field reorganization occurs, while brainstem plasticity obtains a level of stable persistence by one month.

Use-dependent cortical processing from fingertips in touchscreen phone users

Cortical activity allotted to the tactile receptors on fingertips conforms to skilful use of the hand. For instance, in string instrument players, the somatosensory cortical activity in response to touch on the little fingertip is larger than that in control subjects. Such plasticity of the fingertip sensory representation is not limited to extraordinary skills and occurs in monkeys trained to repetitively grasp and release a handle as well. Touchscreen phones also require repetitive finger movements, but whether and how the cortex conforms to this is unknown. By using electroencephalography (EEG), we measured the cortical potentials in response to mechanical touch on the thumb, index, and middle fingertips of touchscreen phone users and nonusers (owning only old-technology mobile phones). Although the thumb interacted predominantly with the screen, the potentials associated with the three fingertips were enhanced in touchscreen users compared to nonusers. Within the touchscreen users, the cortical potentials from the thumb and index fingertips were directly proportional to the intensity of use quantified with built-in battery logs. Remarkably, the thumb tip was sensitive to the day-to-day fluctuations in phone use: the shorter the time elapsed from an episode of intense phone use, the larger the cortical potential associated with it. Our results suggest that repetitive movements on the smooth touchscreen reshaped sensory processing from the hand and that the thumb representation was updated daily depending on its use. We propose that cortical sensory processing in the contemporary brain is continuously shaped by the use of personal digital technology.

Corticocortical projections to representations of the teeth, tongue, and face in somatosensory area 3b of macaques

We placed injections of anatomical tracers into representations of the tongue, teeth, and face in the primary somatosensory cortex (area 3b) of macaque monkeys. Our injections revealed strong projections to representations of the tongue and teeth from other parts of the oral cavity responsive region in 3b. The 3b face also provided input to the representations of the intraoral structures. The primary representation of the face showed a pattern of intrinsic connections similar to that of the mouth. The area 3b hand representation provided little to no input to either the mouth or the face representations. The mouth and face representations of area 3b received projections from the presumptive oral cavity and face regions of other somatosensory areas in the anterior parietal cortex and the lateral sulcus, including areas 3a, 1, 2, the second somatosensory area (S2), the parietal ventral area (PV), and cortex that may include the parietal rostral (PR) and ventral somatosensory (VS) areas. Additional inputs came from primary motor (M1) and ventral premotor (PMv) areas. This areal pattern of projections is similar to the well-studied pattern revealed by tracer injections in regions of 3b representing the hand. The tongue representation appeared to be unique in area 3b in that it also received inputs from areas in the anterior upper bank of the lateral sulcus and anterior insula that may include the primary gustatory area (area G) and other cortical taste-processing areas, as well as a region of lateral prefrontal cortex (LPFC) lining the principal sulcus.

Peripheral nervous system origin of phantom limb pain

Nearly all amputees continue to feel their missing limb as if it still existed, and many experience chronic phantom limb pain (PLP). What is the origin of these sensations? There is currently a broad consensus among investigators that PLP is a top-down phenomenon, triggered by loss of sensory input and caused by maladaptive cortical plasticity. We tested the alternative hypothesis that PLP is primarily a bottom-up process, due not to the loss of input but rather to exaggerated input, generated ectopically in axotomized primary afferent neurons in the dorsal root ganglia (DRGs) that used to innervate the limb. In 31 amputees, the local anesthetic lidocaine was applied intrathecally and/or to the DRG surface (intraforaminal epidural block). This rapidly and reversibly extinguished PLP and also nonpainful phantom limb sensation (npPLS). Control injections were ineffective. For intraforaminal block, the effect was topographically appropriate. The suppression of PLP and npPLS could also be demonstrated using dilute lidocaine concentrations that are sufficient to suppress DRG ectopia but not to block the propagation of impulses generated further distally in the nerve. PLP is driven primarily by activity generated within the DRG. We recommend the DRG as a target for treatment of PLP and perhaps also other types of regional neuropathic pain.

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.

AMPA and GABA(A/B) receptor subunit expression in the cuneate nucleus of adult squirrel monkeys during peripheral nerve regeneration

The primate somatosensory neuroaxis provides an excellent model system with which to investigate adult neural plasticity. Here, we report immunohistochemical staining data for AMPA and GABAA/B receptor subunits in the cuneate nucleus of adult squirrel monkeys 1 and 5 months after median nerve compression. This method of nerve injury allowed the investigation of the way in which patterns of receptor correlates change during peripheral nerve regeneration. These results are compared to cortical data collected within the same animals. As observed in the cortex, the pattern of subunit staining in the brainstem 1 month after nerve compression suggests that the sensory deprived nucleus enters a state of reorganization. That is, the expression of GluR2/3 AMPA receptor subunits is significantly increased, while GABA α1 and GABABR1b receptor subunits are significantly decreased. Five months after nerve injury, the pattern of subunit expression is again very similar to that observed in the infragranular layers of cortex. At this later time we observe a significant increase in GluR2/3 and GABABR1a, with no change in GABAAα1, and a significant decrease in GABABR1b. Together these results suggest that during reorganization and recovery from injury the brainstem and cortex are governed by homogeneous mechanisms of plasticity.

Chondroitinase ABC promotes selective reactivation of somatosensory cortex in squirrel monkeys after a cervical dorsal column lesion

After large but incomplete lesions of ascending dorsal column afferents in the cervical spinal cord, the hand representation in the contralateral primary somatosensory cortex (area 3b) of monkeys is largely or completely unresponsive to touch on the hand. However, after weeks of spontaneous recovery, considerable reactivation of the hand territory in area 3b can occur. Because the reactivation process likely depends on the sprouting of remaining axons from the hand in the cuneate nucleus of the lower brainstem, we sought to influence cortical reactivation by treating the cuneate nucleus with an enzyme, chondroitinase ABC, that digests perineuronal nets, promoting axon sprouting. Dorsal column lesions were placed at a spinal cord level (C5/C6) that allowed a portion of ascending afferents from digit 1 to survive in squirrel monkeys. After 11-12 wk of recovery, the contralateral forelimb cortex was reactivated by stimulating digit 1 more extensively in treated monkeys than in control monkeys. The results are consistent with the proposal that the treatment enhances the sprouting of digit 1 afferents in the cuneate nucleus and that this sprouting allowed these preserved inputs to activate cortex more effectively.

Referred sensations and neuropathic pain following spinal cord injury

It has been proposed that painful and non-painful referred sensations (RSs) are associated with reorganization of sensory pathways in patients with complete spinal cord injury (SCI). In order to investigate the referred sensation (RS) phenomenon and its correlation with neuropathic pain (NP) 48 patients with complete SCI, 24 with chronic NP and 24 without pain or paraesthesias were studied using clinical examination and neurophysiological tests. Patients reporting RSs were re-examined at 2 and 10weeks after the first examination. We defined the presence of RS as sensations perceived below the injury level in response to touch and pinprick stimuli in various body points above the injury level. The examination was carried out by one researcher applying the stimuli to the patient under two visual conditions (open and closed eyes), and then asking the patient to make tactile self-stimulation. Seven patients with SCI and NP (29%) reported RS below the injury level. RS were well located and consistently evoked at repeated examinations. Touch and pinprick stimulation elicited similar RS that were non-painful in six patients and painful in one. Visual feedback did not change RS perception and characteristics. None of the patients in the SCI group without NP presented RS. In conclusion, our results indicate that RS is relatively frequent in patients with complete SCI and NP. The common occurrence of RS in patients with NP and the location of the sensations in the same area as NP suggest that pain and RS share common pathophysiological mechanisms.

Cross-modal plasticity in the human thalamus: evidence from intraoperative macrostimulations

During stereotactic functional neurosurgery, stimulation procedure to control for proper target localization provides a unique opportunity to investigate pathophysiological phenomena that cannot be addressed in experimental setups. Here we report on the distribution of response modalities to 487 intraoperative thalamic stimulations performed in 24 neurogenic pain (NP), 17 parkinsonian (PD) and 10 neuropsychiatric (Npsy) patients. Threshold responses were subdivided into somatosensory, motor and affective, and compared between medial (central lateral nucleus) and lateral (ventral anterior, ventral lateral and ventral medial) thalamic nuclei and between patients groups. Major findings were as follows: in the medial thalamus, evoked responses were for a large majority (95%) somatosensory in NP patients, 47% were motor in PD patients, and 54% affective in Npsy patients. In the lateral thalamus, a much higher proportion of somatosensory (83%) than motor responses (5%) was evoked in NP patients, while the proportion was reversed in PD patients (69% motor vs. 21% somatosensory). These results provide the first evidence for functional cross-modal changes in lateral and medial thalamic nuclei in response to intraoperative stimulations in different functional disorders. This extensive functional reorganization sheds new light on wide-range plasticity in the adult human thalamocortical system.

Large-scale expansion of the face representation in somatosensory areas of the lateral sulcus after spinal cord injuries in monkeys

Transection of dorsal columns of the spinal cord in adult monkeys results in large-scale expansion of the face inputs into the deafferented hand region in the primary somatosensory cortex (area 3b) and the ventroposterior nucleus of thalamus. Here, we determined whether the upstream cortical areas, secondary somatosensory (S2) and parietal ventral (PV) areas, also undergo reorganization after lesions of the dorsal columns. Areas S2, PV, and 3b were mapped after long-term unilateral lesions of the dorsal columns at cervical levels in adult macaque monkeys. In areas S2 and PV, we found neurons responding to touch on the face in regions in which responses to touch on the hand and other body parts are normally seen. In the reorganized parts of S2 and PV, inputs from the chin as well as other parts of the face were observed, whereas in area 3b only the chin inputs expand into the deafferented regions. The results show that deafferentations lead to a more widespread brain reorganization than previously known. The data also show that reorganization in areas S2 and PV shares a common substrate with area 3b, but there are specific features that emerge in S2 and PV.

Nerve-Injury Induced Changes to GluR1 and GluR2/3 Sub-unit Expression in Area 3b of Adult Squirrel Monkeys: Developmental Recapitulation?

The primate somatosensory system provides an excellent model system with which to investigate adult neural plasticity. Here, we report immunohistochemical staining data for the GluR1 and GluR2/3 AMPA receptors subunits in somatosensory area 3b 1 week after median nerve compression in adult squirrel monkeys. We find transcortical increases in the staining intensity of GluR1 AMPAR subunits and transcortical decreases in GluR2/3 AMPAR subunits. This pattern of change in the staining intensity of these subunits differs from the changes one would expect if the deprived cortical neurons were undergoing homeostatic synaptic scaling, or from ones that would follow N-methyl-d-aspartate (NMDA) receptor-mediated long-term potentiation. Indeed, this pattern of change appears to recapitulate proportions that exist early in development as if the deprived cortex has reverted to an immature state. We suggest that this state represents yet another stage of peripheral nerve injury-induced reorganization in adult primate somatosensory cortex, and may well be essential for subsequent NMDA receptor-mediated plasticity.

Chapter 27: Neural plasticity after nerve injury and regeneration

Injuries to the peripheral nerves result in partial or total loss of motor, sensory, and autonomic functions in the denervated segments of the body due to the interruption of axons, degeneration of distal nerve fibers, and eventual death of axotomized neurons. Functional deficits caused by nerve injuries can be compensated by reinnervation of denervated targets by regenerating injured axons or by collateral branching of undamaged axons, and remodeling of nervous system circuitry related to the lost functions. Plasticity of central connections may compensate functionally for the lack of adequate target reinnervation; however, plasticity has limited effects on disturbed sensory localization or fine motor control after injuries, and may even result in maladaptive changes, such as neuropathic pain and hyperreflexia. After axotomy, neurons shift from a transmitter to a regenerative phenotype, activating molecular pathways that promote neuronal survival and axonal regeneration. Peripheral nerve injuries also induce a cascade of events, at the molecular, cellular, and system levels, initiated by the injury and progressing throughout plastic changes at the spinal cord, brainstem nuclei, thalamus, and brain cortex. Mechanisms involved in these changes include neurochemical changes, functional alterations of excitatory and inhibitory synaptic connections, sprouting of new connections, and reorganization of sensory and motor central maps. An important direction for research is the development of therapeutic strategies that enhance axonal regeneration, promote selective target reinnervation, and are also able to modulate central nervous system reorganization, amplifying positive adaptive changes that improve functional recovery and also reducing undesirable effects.

Painful and nonpainful phantom and stump sensations in acute traumatic amputees

BACKGROUND

The formation, prevalence, intensity, course, and predisposing factors of phantom limb pain were investigated to determine possible mechanisms of the origin of phantom limb pain in traumatic upper limb amputees.

METHODS

Ninety-six upper limb amputees participated in the study. A questionnaire assessed the following question: side, date, extension, and cause of amputation; preamputation pain; and presence or absence of phantom pain, phantom and stump sensations or stump pain or both.

RESULTS

The response rate was 84%. Sixty-five (81%) participants returned the questionnaire. In 64 (98.5%) participants a traumatic injury led to amputation; the amputation was necessary because of infection in one patient (1.5%). The median follow-up time (from amputation to evaluation) was 3.2 years (range, 0.9-3.8 years) The prevalence of phantom pain was 44.6%, phantom sensation 53.8%, stump pain 61.5%, and stump sensation 78.5%. After its first appearance, phantom pain had a decreasing course in 14 (48.2%) of 29 amputees, was stable in 11 (37.9%) amputees, and worsened in 2 (6.9%) of 29 amputees. Stump pain had a decreasing course in 19 (47.5%) of 40 amputees but was stable in 12 (30%) amputees. Phantom pain occurred immediately after amputation in 8 (28%) of 29 amputees between 1 month and 12 months in 3 (10%) amputees and after 12 or more months in 12 (41%) amputees.

CONCLUSION

Stump pain and stump sensation predominate traumatic amputees' somatosensory experience immediately after amputation; phantom pain and phantom sensations are often long-term consequences of amputation. Amputees experience phantom sensations and phantom pain within 1 month after amputation, a second peak occurs 12 months after amputation. Revised diagnostic criteria for phantom pain are proposed on the basis of these data.

Large-scale reorganization in the somatosensory cortex and thalamus after sensory loss in macaque monkeys

Adult brains undergo large-scale plastic changes after peripheral and central injuries. Although it has been shown that both the cortical and thalamic representations can reorganize, uncertainties exist regarding the extent, nature, and time course of changes at each level. We have determined how cortical representations in the somatosensory area 3b and the ventroposterior (VP) nucleus of thalamus are affected by long standing unilateral dorsal column lesions at cervical levels in macaque monkeys. In monkeys with recovery periods of 22-23 months, the intact face inputs expanded into the deafferented hand region of area 3b after complete or partial lesions of the dorsal columns. The expansion of the face region could extend all the way medially into the leg and foot representations. In the same monkeys, similar expansions of the face representation take place in the VP nucleus of the thalamus, indicating that both these processing levels undergo similar reorganizations. The receptive fields of the expanded representations were similar in somatosensory cortex and thalamus. In two monkeys, we determined the extent of the brain reorganization immediately after dorsal column lesions. In these monkeys, the deafferented regions of area 3b and the VP nucleus became unresponsive to the peripheral touch immediately after the lesion. No reorganization was seen in the cortex or the VP nucleus. A comparison of the extents of deafferentation across the monkeys shows that even if the dorsal column lesion is partial, preserving most of the hand representation, it is sufficient to induce an expansion of the face representation.

Cortical and subcortical plasticity in the brains of humans, primates, and rats after damage to sensory afferents in the dorsal columns of the spinal cord

The failure of injured axons to regenerate following spinal cord injury deprives brain neurons of their normal sources of activation. These injuries also result in the reorganization of affected areas of the central nervous system that is thought to drive both the ensuing recovery of function and the formation of maladaptive neuronal circuitry. Better understanding of the physiological consequences of novel synaptic connections produced by injury and the mechanisms that control their formation are important to the development of new successful strategies for the treatment of patients with spinal cord injuries. Here we discuss the anatomical, physiological and behavioral changes that take place in response to injury-induced plasticity after damage to the dorsal column pathway in rats and monkeys. Complete section of the dorsal columns of the spinal cord at a high cervical level in monkeys and rats interrupts the ascending axon branches of low threshold mechanoreceptor afferents subserving the forelimb and the rest of the lower body. Such lesions render the corresponding part of the somatotopic representation of primary somatosensory cortex totally unresponsive to tactile stimuli. There are also behavioral consequences of the sensory loss, including an impaired use of the hand/forelimb in manipulating small objects. In monkeys, if some of the afferents from the hand remain intact after dorsal column lesions, these remaining afferents extensively reactivate portions of somatosensory cortex formerly representing the hand. This functional reorganization develops over a postoperative period of 1 month, during which hand use rapidly improves. These recoveries appear to be mediated, at least in part, by the sprouting of preserved afferents within the cuneate nucleus of the dorsal column-trigeminal complex. In rats, such functional collateral sprouting has been promoted by the post-lesion digestion of the perineuronal net in the cuneate nucleus. Thus, this and other therapeutic strategies have the potential of enhancing sensorimotor recoveries after spinal cord injuries in humans.

Does reorganization in the cuneate nucleus following neonatal forelimb amputation influence development of anomalous circuits within the somatosensory cortex?

Neonatal forelimb amputation in rats produces sprouting of sciatic nerve afferent fibers into the cuneate nucleus (CN) and results in 40% of individual CN neurons expressing both forelimb-stump and hindlimb receptive fields. The forelimb-stump region of primary somatosensory cortex (S-I) of these rats contains neurons in layer IV that express both stump and hindlimb receptive fields. However, the source of the aberrant input is the S-I hindlimb region conveyed to the S-I forelimb-stump region via intracortical projections. Although the reorganization in S-I reflects changes in cortical circuitry, it is possible that these in turn are dependent on the CN reorganization. The present study was designed to directly test whether the sprouting of sciatic afferents into the CN is required for expression of the hindlimb inputs in the S-I forelimb-stump field. To inhibit sprouting, neurotrophin-3 (NT-3) was applied to the cut nerves following amputation. At P60 or older, NT-3-treated rats showed minimal sciatic nerve fibers in the CN. Multiunit electrophysiological recordings in the CN of NT-3-treated, amputated rats revealed 6.3% of sites were both stump/hindlimb responsive, compared with 30.5% in saline-treated amputated animals. Evaluation of the S-I following GABA receptor blockade, revealed that the percentage of hindlimb responsive sites in the stump representation of the NT-3-treated rats (34.2%) was not significantly different from that in saline-treated rats (31.5%). These results indicate that brain stem reorganization in the form of sprouting of sciatic afferents into the CN is not necessary for development of anomalous hindlimb receptive fields within the S-I forelimb/stump region.

Neural plasticity after peripheral nerve injury and regeneration

Injuries to the peripheral nerves result in partial or total loss of motor, sensory and autonomic functions conveyed by the lesioned nerves to the denervated segments of the body, due to the interruption of axons continuity, degeneration of nerve fibers distal to the lesion and eventual death of axotomized neurons. Injuries to the peripheral nervous system may thus result in considerable disability. After axotomy, neuronal phenotype switches from a transmitter to a regenerative state, inducing the down- and up-regulation of numerous cellular components as well as the synthesis de novo of some molecules normally not expressed in adult neurons. These changes in gene expression activate and regulate the pathways responsible for neuronal survival and axonal regeneration. Functional deficits caused by nerve injuries can be compensated by three neural mechanisms: the reinnervation of denervated targets by regeneration of injured axons, the reinnervation by collateral branching of undamaged axons, and the remodeling of nervous system circuitry related to the lost functions. Plasticity of central connections may compensate functionally for the lack of specificity in target reinnervation; plasticity in human has, however, limited effects on disturbed sensory localization or fine motor control after injuries, and may even result in maladaptive changes, such as neuropathic pain, hyperreflexia and dystonia. Recent research has uncovered that peripheral nerve injuries induce a concurrent cascade of events, at the systemic, cellular and molecular levels, initiated by the nerve injury and progressing throughout plastic changes at the spinal cord, brainstem relay nuclei, thalamus and brain cortex. Mechanisms for these changes are ubiquitous in central substrates and include neurochemical changes, functional alterations of excitatory and inhibitory connections, atrophy and degeneration of normal substrates, sprouting of new connections, and reorganization of somatosensory and motor maps. An important direction for ongoing research is the development of therapeutic strategies that enhance axonal regeneration, promote selective target reinnervation, but are also able to modulate central nervous system reorganization, amplifying those positive adaptive changes that help to improve functional recovery but also diminishing undesirable consequences.

Brain imaging of clinical pain states: a critical review and strategies for future studies

Research into brain imaging of pain is largely dominated by experimental acute-pain studies. Applied study paradigms have evolved a lot over past years and the ensuing results have furthered enormously our understanding of acute-pain processing. In sharp contrast, published work on brain-imaging in chronic pain remains scant. Furthermore, the results of these studies are highly incongruent, which could be explained by the fact that patient populations studied varied largely in terms of pain history, pain distribution, cause of pain, and psychological set-up. To circumvent these problems, several investigators have used surrogate models of neuropathic pain, but the validity of these models is highly questionable. In this Review we critically discuss the problems and shortcomings of most published reports on chronic pain and we propose some strategies for future studies. We argue that the post-operative pain model is highly appealing since it opens perspectives for prospective longitudinal studies with repeated assessments and it enables control for many confounding factors, which hamper the interpretation of most current studies. We also plead for a multimodal imaging approach in which classic brain-activation studies are supplemented with genetic, neurochemistry, brain morphometry, and transcranial magnetic stimulation studies.

Receptor autoradiographic correlates of deafferentation-induced reorganization in adult primate somatosensory cortex

The primate somatosensory system provides an excellent model system with which to investigate adult neural plasticity. We have previously shown that transection of the median and ulnar nerves is followed by an expansion in the representation of radial nerve skin, and that this plasticity proceeds in stages. Immediately following nerve injury, new receptive fields are "unmasked" in a fraction of the affected cortex. The remaining deprived cortex regains responsiveness to tactile stimulation over the following days to weeks. Given these progressive changes, it has been suggested that different mechanisms might account for the earlier and later phases of reorganization. In the present experiments, we quantified receptor autoradiographic binding data for GABAA and GABAB, AMPA, and NMDA receptors in the primary somatosensory cortices of adult squirrel monkeys at four postnerve injury survival durations: immediately (1-3 hours), 3 days, 1 month, and 2 months. We found dramatic reductions in GABAA binding in layer IV within hours following nerve injury, and this reduction was maintained across all survival durations. This finding is consistent with the idea that the earliest reorganizational changes are due to a relaxation in tonic inhibitory mechanisms permitting the expression of formerly subthreshold receptive fields. GABAB receptor binding is decreased in layer IV by 1 month after nerve injury, while binding for AMPA receptors is increased in layer IV by this time. These findings are consistent with our previous suggestion that the second stage of reorganization proceeds via mechanisms comparable to those revealed to account for NMDA-dependent long-term potentiation in the hippocampus.

Reorganization of visual processing in macular degeneration

Macular degeneration (MD), the leading cause of visual impairment in the developed world, damages the central retina, often obliterating foveal vision and severely disrupting everyday tasks such as reading, driving, and face recognition. In such cases, the macular damage eliminates the normal retinal input to a large region of visual cortex, comprising tens of square centimeters of surface area in each hemisphere, which is normally responsive only to foveal stimuli. Using functional magnetic resonance imaging, we asked whether this deprived cortex simply becomes inactive in subjects with MD, or whether it takes on new functional properties. In two adult MD subjects with extensive bilateral central retinal lesions, we found that parts of visual cortex (including primary visual cortex) that normally respond only to central visual stimuli are strongly activated by peripheral stimuli. Such activation was not observed (1) with visual stimuli presented to the position of the former fovea and (2) in control subjects with visual stimuli presented to corresponding parts of peripheral retina. These results demonstrate large-scale reorganization of visual processing in MD and will likely prove important in any effort to develop new strategies for rehabilitation of MD subjects.