Plasticity of primary somatosensory cortex paralleling sensorimotor skill recovery from stroke in adult monkeys

Somatotopy and movement representation sites following cortical stroke

Stroke has been associated with many changes in motor system function, but there has been limited study of changes in somatotopic organization. This was examined in a group of patients with cortical stroke affecting primary sensorimotor cortex. In 17 patients with good outcome after cortical stroke involving precentral and/or postcentral gyri, plus 14 controls, four functional MRI evaluations of brain activity were obtained: finger, shoulder, and face motor tasks plus a sensory task, passive finger motion. For each, coordinates for contralateral primary sensorimotor cortex activation site were determined, as was a measure of inter-hemispheric balance. The normal motor somatotopy measured in controls was largely preserved after stroke. The main difference found between controls and patients was that the face was lateral to finger motor activation in all controls, but face was centered medial to finger in 43% of patients. Among patients, smaller infarct volume was associated with more ventral, and larger infarct with more dorsal, contralateral primary sensorimotor cortex activation. On the other hand, better behavioral outcome was associated with a more posterior, and poorer outcome with more anterior, activation. Larger infarct and poorer behavioral outcome were each associated with a change in inter-hemispheric balance towards the non-stroke hemisphere. Shifts in contralateral movement representation site did not correlate with changes in inter-hemispheric balance. Motor somatotopy is generally preserved after injury to primary sensorimotor cortex. Greater injury and larger behavioral deficits are associated with distinct effects on movement representation sites. Changes in motor organization within and between hemispheres arise independently after stroke.

Rapid and long-term plasticity in the neonatal and adult retinotectal pathways following a retinal lesion

The uncrossed retinotectal projection restricts its terminal fields to the ventral boundary of the visual layers at the rostral tectum during early post natal development. During this critical period, temporal retinal lesions in one eye induce laminar rearrangements in the uncrossed pathway of the intact eye toward the collicular surface previously occupied, almost exclusively, by the crossed retinal axon population. We have compared, using anterograde tracing techniques, the time course and magnitude of the axonal sprouting resulting from retinal lesions in neonates and adults. Early retinal lesions (within the first two post natal weeks) induced extensive and rapid plasticity of the ipsilateral projection 48 h after the lesions. On the third post natal week, similar retinal lesions induced a small reorganization of the intact eye's uncrossed projection within a 3-week survival time. Nevertheless, giving the animals a long-term survival, resulted in an increased plastic capability, suggesting that even after the critical period, intact retinal axons can respond efficiently to injury. The results suggest two phases of axonal reorganization within this subcortical pathway: a rapid plasticity within the critical period and a slow, but continuous plasticity in adulthood.

Perceptual context-dependent remodeling of the forepaw map in the SI cortex of rats trained on tactile discrimination

We combined behavioral assessment of texture discrimination and electrophysiological mapping of concomitant reorganization in the forepaw representation within the SI cortex. Rats were housed in enriched (EE) or impoverished (IE) environments which have been shown to remodel the forepaw map and possibly alter discriminative abilities. In addition, animals were trained to discriminate homogeneous floorboards of invariant roughness from heterogeneous floorboards of gradually decreasing roughness contrasts during locomotion. As reported recently, differences in perceptual abilities were not related to housing conditions, but to a predilection for a floorboard type [Bourgeon S, Xerri C, Coq JO. Abilities in tactile discrimination of textures in adult rats exposed to enriched or impoverished environments. Behav Brain Res 2004;153:217-231]. Consistently, the present study shows that cortical map remodeling resulting from short-duration daily experience can prevail over changes induced by housing conditions. The relative area of glabrous skin representation was related to the discrimination performance and learning abilities in the rats (H) with a predilection for heterogeneous floorboards, i.e. in the animals performing discrimination in the most challenging perceptual context. By contrast, this cortical area was influenced by the duration of sensory experience in rats (h) with a predilection for homogeneous floorboards. Both EE condition and training to discrimination selectively decreased the sizes of the SI neurons' receptive fields (RFs) located on glabrous skin. Smaller RFs and larger cortical areas serving glabrous skin were correlated with better perceptual performances and learning abilities in the H rats only. The present study shows that representational reorganization related to tactile discrimination performances depends upon the perceptual context.

Évolution des concepts en rééducation du patient hémiplégique

INTRODUCTION

The author attempts to show the evolution of the ideas guiding the rehabilitation treatment of motricity disorders after a vascular or traumatic brain lesion.

METHOD

Expert opinion based on an uncomprehensive review of the literature, from the databases Reedoc and Medline and from the Institut Lionnois library in Nancy and the Charcot library in Paris.

RESULTS AND DISCUSSION

Many theories and techniques have been proposed. The modern history of this rehabilitation treatment has been marked by a period that stressed control of the abnormal motricity characterizing central motor disorders, sometimes too exclusively. The development of evidence-based medicine in the 1980s undermined certain dogmas. At the same time, the advent of cerebral imaging technology confirmed clinical observations and hypotheses concerning cerebral plasticity. Today, the rehabilitation treatment of these motor disorders uses notions of learning; the diversity and complementarity of the exercises, which must be task-oriented; relative earliness and intensity of therapy; close interactions between sensitivity and motricity; and different concepts as mental imagery, the perception of verticality, or muscle strengthening.

CONCLUSION

To its well-known preventive and palliative roles, rehabilitation treatment has now added a curative role. All the concepts applied today are not new, but the spirit of their application is new. Because we are sure that neurological recovery can be improved, no idea can be rejected at the outset; its effect must be demonstrated. Among the numerous ideas presently proposed, future studies will define the best ones, for the most suitable patient, at the best time.

Bi-hemispheric contribution to functional motor recovery of the affected forelimb following focal ischemic brain injury in rats

In many recovering hemiparetic stroke patients, movement of the affected limb elicits ipsilateral activation of sensorimotor areas within the undamaged hemisphere, which is not observed in control subjects. Following middle cerebral artery occlusion, rats received intensive enriched-rehabilitation (ER) of the impaired forelimb for 4 weeks. Weekly assessments on a skilled reaching test demonstrated significant improvement in ischemic animals over 4 weeks of ER (P < 0.05). We hypothesized that if the undamaged forelimb motor cortex contributed to improved forelimb function, then inhibition of neural activity within this region should reinstate (at least some of) the initial motor impairment. After 3 and 4 weeks of ER, animals received a microinjection of lidocaine hydrochloride into the undamaged motor cortex and were re-assessed on reaching ability. The behavioral effect of lidocaine challenge was dependent on the size of the infarct: animals with large infarcts were rendered unable to retrieve any food pellets and had great difficulty even contacting a pellet with the affected forepaw. Small-infarct animals were only moderately affected (25% reduction in success) by lidocaine, an effect similar to that observed in control animals. Qualitative assessments of recovered reaching after 4 weeks of rehabilitation revealed that impairments in forelimb lift, advance and aim were exacerbated (P < 0.05) following lidocaine-inactivation of the undamaged motor cortex of animals with large ischemic infarcts. In animals with small infarcts, lidocaine challenge only impaired limb advance. Thus, recruitment of the undamaged hemisphere may depend on the functional integrity of the remaining sensorimotor system. These data suggest that, in the rat, the undamaged (ipsilateral) motor system may contribute to compensatory recovery of the affected forelimb.

Dissociation of sensorimotor deficits after rostral versus caudal lesions in the primary motor cortex hand representation

Primary motor cortex (M1) has traditionally been considered a motor structure. Although neurophysiologic studies have demonstrated that M1 is also influenced by somatosensory inputs (cutaneous and proprioceptive), the behavioral significance of these inputs has yet to be fully defined in primates. The present study describes differential sensory-related deficits after small ischemic lesions in either the rostral or caudal subregion of the M1 hand area in a nonhuman primate. Squirrel monkeys retrieved food pellets out of different sized wells drilled into a Plexiglas board. Before the lesion, monkeys retrieved pellets by directing the hand to the well, inserting fingers directly into it, and extracting the pellet. After a lesion to the rostral portion of M1, monkeys frequently failed to direct the hand accurately to the well. Instead, fingers contacted the surface of the board outside the well before entering the well. These aiming errors are consistent with both the large amount of proximal motor outputs and the predominant proprioceptive inputs of rostral M1. Overall, these aiming errors are suggestive of dysfunctional processing of proprioceptive information or the failure to integrate proprioceptive information with motor commands. In contrast, after a lesion to the caudal portion of M1, monkeys frequently examined their palm visually for the presence of the pellet after an attempted retrieval. These errors are consistent with both the large amount of distal motor outputs and the predominant cutaneous inputs of caudal M1. Thus these errors are suggestive of a deficit in processing of cutaneous information or the failure to integrate cutaneous information with motor commands. Rostral and caudal M1 lesions result in different deficits in sensory-dependent motor control that appear to correlate with broad segregation of motor outputs and previously described sensory inputs of M1.

Vicarious function within the human primary motor cortex?

While experimental studies in the monkey have shown that motor recovery after partial destruction of the hand motor cortex was based on adjacent motor reorganization, functional MRI (fMRI) studies with isolated primary motor cortical stroke have not yet been reported in humans. Based on experimental data, we designed a study to test if recovery after stroke within primary motor cortex (M1) was associated with reorganization within the surrounding motor cortex, i.e. the motor cortex was able to vicariate. Since motor recovery is time-dependent and might be inflected according to the tested task, the delay after stroke and two motor tasks were included in our design. We examined four patients with one ischaemic stroke limited to M1, and four sex- and age-matched healthy controls in a temporally balanced prospective longitudinal fMRI study over three sessions: <20 days, 4 months and 2 years after stroke. The paradigm included two motor tasks, finger tapping (FT) and finger extension (FE). Distinct patterns of motor activation were observed with time for FT and FE. At the first session, FT-related activation was lateralized in the ipsilateral hemisphere while FE-related activation was contralateral, involving bilateral cerebellar regions for both tasks. From 4 months, skilled motor recovery was associated with contralateral dorsal premotor and sensorimotor cortex and ipsilateral cerebellum motor-related activations, leading to lateralized motor patterns for both tasks. For the left recovered hand, FT and FE-related activations within M1 were more dorsal in patients than in controls. This dorsal shift progressively increased over 2 years, reflecting functional reorganization in the motor cortex adjacent to the lesion. In addition, patients showed a reverse representation of FT and FE within M1, corresponding to a greater dorsal shift for FT than for FE. This functional dissociation might reflect the structural subdivision of M1 with two distinct finger motor representations within M1. Recovery of FT, located within the lesioned depth of the rolandic sulcus in controls, might be related to the re-emergence of a new representation in the intact dorsal M1, while FE, located more dorsally, underwent minor reorganization. This is the first fMRI study of humans presenting with isolated M1 stroke comparable with experimental lesions in animals. Despite the small number of patients, our findings showing the re-emergence of a fingers motor task in the intact dorsal M1 instead of in ventral M1 are consistent with 'vicariation' models of stroke recovery.

Visual Plasticity and Its Clinical Applications

Normal visual development requires: 1) environmental factors (i.e. sensory experience) and 2) molecular programs that are genetically determined. Experience determines the development and preservation of visual cortical circuitry in accordance with Hebb's principle. The molecular and genetic mechanisms that regulate visual plasticity are less known. Visual experience induces postnatal neural activity that triggers a cascade of molecular processes including release of neurotrophic factors from target neurons and genetic expression of protein synthesis, transcription factors and neurotransmitters. The continuous sensory experience induces activity-dependent tuning of synaptic connections. The present knowledge permits some manipulation of plasticity and the induction of functional changes beneficial for vision. Three areas of intervention will be discussed: 1) enhancement of visual experience for children with ocular disorders, 2) re-organization of visual cortical maps, 3) retinal and cortical implants (prostheses) and transplants.

Functional activation within the PI–DWI mismatch region in recovery from ischemic stroke: preliminary observations

In this study, we sought to investigate if brain tissue affected by ischemia can accommodate areas of activation related to restoration of brain function following ischemic stroke. In two patients perfusion imaging (PI) and diffusion weighted imaging (DWI) obtained in the acute phase after stroke was coregistered with BOLD imaging of brain functions acquired when profound recovery had occurred. Both patients suffered from thrombembolic brain infarction due to dissection of the internal carotid artery (ICA) characterized by a severe PI-DWI mismatch in the acute stage of stroke. Following ICA recanalization and clinical recovery BOLD imaging showed task-specific activation adjacent to the infarct lesion within the former PI-DWI mismatch area. The data in these two stroke patients provide evidence that brain tissue at risk of infarction as shown by the PI-DWI mismatch can survive and, thereby, constitute the major site underlying post-ischemic recovery.

Methods for functional magnetic resonance imaging in normal and lesioned behaving monkeys

Methods for performing functional magnetic resonance imaging (fMRI) studies in behaving and lesioned monkeys using a human MR scanner are reported. Materials for head implant surgery were selected based on tests for magnetic susceptibility. A primate chair with a rigid head fixation system and a mock scanner environment for training were developed. To perform controlled visual studies, monkeys were trained to maintain fixation for several minutes using a novel training technique that utilized continuous juice rewards. A surface coil was used to acquire anatomical and functional images in four monkeys, one with a partial lesion of striate cortex. High-resolution anatomical images were used after non-uniform intensity correction to create cortical surface reconstructions of both lesioned and normal hemispheres. Our methods were confirmed in two visual experiments, in which functional activations were obtained during both free viewing and fixation conditions. In one experiment, face-selective activity was found in the fundus and banks of the superior temporal sulcus and the middle temporal gyrus in monkeys viewing pictures of faces and objects while maintaining fixation. In a second experiment, regions in occipital, parietal, and frontal cortex were activated in lesioned and normal animals viewing a cartoon movie. Importantly, in the animal with the striate lesion, fMRI signals were obtained in the immediate vicinity of the lesion. Our results extend those previously reported by providing a detailed account of the technique and by demonstrating the feasibility of fMRI in monkeys with lesions.

Progressive plastic changes in the hand representation of the primary motor cortex parallel incomplete recovery from a unilateral section of the corticospinal tract at cervical level in monkeys

After a sub-total hemisection of the cervical cord at level C7/C8 in monkeys, a paralysis of the homolateral hand is rapidly followed by an incomplete recovery of manual dexterity, reaching a plateau after about 40-50 days, whose extent appears related to the size of the lesion. During a few days after the lesion, the hand representation in the contralateral motor cortex disappeared, replaced by representations of either face or more proximal body parts. Later, however, following a time course (about 40 days) consistent with the functional recovery, progressive plastic changes in the contralateral motor cortex took place, as demonstrated by a progressive reappearance of digit movements elicited by intracortical microstimulation. These progressive plastic changes, which parallel the functional recovery, correspond to a reinstallation of a hand representation, though substantially diminished in size as compared to pre-lesion. Regarding the functional recovery, the motor cortex (including the reestablished hand area) contralateral to the unilateral cervical cord lesion played a crucial role in reestablishing control on finger movements, as assessed by reversible inactivation experiments. In contrast, the motor cortex ipsilateral to the cervical cord lesion, with largely intact projections to the spinal cord, did not contribute significantly to the recovered movements by the affected hand. These observations indicate that the CS fibers spared by the lesion are not sufficient, at least in their pre-lesion condition, to control the motoneurones innervating the digit muscles and that the pathways conveying signals from the contralateral M1 underwent reorganization.

The effects of intracortical endothelin-1 injections on skilled forelimb use: implications for modelling recovery of function after stroke

Different methods of inducing experimental brain lesions can result in distinct neuropathological sequelae. This could be of consequence in attempts to establish animal models of recovery of function following stroke, as differences in the progression of experimental lesion pathology may have an impact on the magnitude and rate of recovery of function observable with any particular lesioning method. In the present study, a novel method of producing a focal ischaemic lesion by intracortical microinjection of endothelin-1 (ET-1) was compared with excitotoxic (microinjection of quinolinic acid) and mechanical (aspiration) lesioning procedures. Lesions were unilateral and were targeted at the forelimb representation zone in sensorimotor cortex. It was found that all three types of lesion had an essentially identical effect with regard to reaching accuracy in a paw-reaching task. All lesioned animals displayed a similar, significant long-term deficit in reaching accuracy and limited degree of recovery relative to sham animals. Off-line analysis of the performance of animals during post-lesion week 9 indicated that animals in each lesion group also displayed a similar deficit. The current results suggest that the spontaneous behavioural consequences of a unilateral lesion of FL in the rat appear to be independent of the nature of lesion production. However, the increased face validity of an ET-1-induced lesion, coupled with the ease of control of lesion placement and extent offered by this technique make for a potentially important animal model for research into drug effects on recovery of function following stroke.

Integrated technology for evaluation of brain function and neural plasticity

The study of neural plasticity has expanded rapidly in the past decades and has shown the remarkable ability of the developing, adult, and aging brain to be shaped by environmental inputs in health and after a lesion. Robust experimental evidence supports the hypothesis that neuronal aggregates adjacent to a lesion in the sensorimotor brain areas can take over progressively the function previously played by the damaged neurons. It definitely is accepted that such a reorganization modifies sensibly the interhemispheric differences in somatotopic organization of the sensorimotor cortices. This reorganization largely subtends clinical recovery of motor performances and sensorimotor integration after a stroke. Brain functional imaging studies show that recovery from hemiplegic strokes is associated with a marked reorganization of the activation patterns of specific brain structures. To regain hand motor control, the recovery process tends over time to bring the bilateral motor network activation toward a more normal intensity/extent, while overrecruiting simultaneously new areas, perhaps to sustain this process. Considerable intersubject variability exists in activation/hyperactivation pattern changes over time. Some patients display late-appearing dorsolateral prefrontal cortex activation, suggesting the development of "executive" strategies to compensate for the lost function. The AH in stroke often undergoes a significant "remodeling" of sensory and motor hand somatotopy outside the "normal" areas, or enlargement of the hand representation. The UH also undergoes reorganization, although to a lesser degree. Although absolute values of the investigated parameters fluctuate across subjects, secondary to individual anatomic variability, variation is minimal with regards to interhemispheric differences, due to the fact that individual morphometric characters are mirrored in the two hemispheres. Excessive interhemispheric asymmetry of the sensorimotor hand areas seems to be the parameter with highest sensitivity in describing brain reorganization after a monohemispheric lesion, and mapping motor and somatosensory cortical areas through focal TMS, fMRI, PET, EEG, and MEG is useful in studying hand representation and interhemispheric asymmetries in normal and pathologic conditions. TMS and MEG allow the detection of sensorimotor areas reshaping, as a result of either neuronal reorganization or recovery of the previously damaged neural network. These techniques have the advantage of high temporal resolution but also have limitations. TMS provides only bidimensional scalp maps, whereas MEG, even if giving three-dimensional mapping of generator sources, does so by means of inverse procedures that rely on the choice of a mathematical model of the head and the sources. These techniques do not test movement execution and sensorimotor integration as used in everyday life. fMRI and PET may provide the ideal means to integrate the findings obtained with the other two techniques. This multitechnology combined approach is at present the best way to test the presence and amount of plasticity phenomena underlying partial or total recovery of several functions, sensorimotor above all. Dynamic patterns of recovery are emerging progressively from the relevant literature. Enhanced recruitment of the affected cortex, be it spared perilesional tissue, as in the case of cortical stroke, or intact but deafferented cortex, as in subcortical strokes, seems to be the rule, a mechanism especially important in early postinsult stages. The transfer over time of preferential activation toward contralesional cortices, as observed in some cases, seems, however, to reflect a less efficient type of plastic reorganization, with some aspects of maladaptive plasticity. Reinforcing the use of the affected side can cause activation to increase again in the affected side with a corresponding enhancement of clinical function. Activation of the UH MI may represent recruitment of direct (uncrossed) corticospinal tracts and relate more to mirror movements, but it more likely reflects activity redistribution within preexisting bilateral, large-scale motor networks. Finally, activation of areas not normally engaged in the dysfunctional tasks, such as the dorsolateral prefrontal cortex or the superior parietal cortex in motor paralysis, might reflect the implication of compensatory cognitive strategies. An integrated approach with technologies able to investigate functional brain imaging is of considerable value in providing information on the excitability, extension, localization, and functional hierarchy of cortical brain areas. Deepening knowledge of the mechanisms regulating the long-term recovery (even if partial), observed for most neurologic sequelae after neural damage, might prompt newer and more efficacious therapeutic and rehabilitative strategies for neurologic diseases.

Post-infarct cortical plasticity and behavioral recovery using concurrent cortical stimulation and rehabilitative training: a feasibility study in primates

Stroke is often characterized by incomplete recovery and chronic motor impairments. A nonhuman primate model of cortical ischemia was used to evaluate the feasibility of using device-assisted cortical stimulation combined with rehabilitative training to enhance behavioral recovery and cortical plasticity. Following pre-infarct training on a unimanual motor task, maps of movement representations in primary motor cortex were derived. Then, an ischemic infarct was produced which destroyed the hand representation. Several weeks later, a second cortical map was derived to guide implantation of a surface electrode over peri-infarct motor cortex. After several months of spontaneous recovery, monkeys underwent subthreshold electrical stimulation combined with rehabilitative training for several weeks. Post-therapy behavioral performance was tracked for several additional months. A third cortical map was derived several weeks post-therapy to examine changes in motor representations. Monkeys showed significant improvements in motor performance (success, speed, and efficiency) following therapy, which persisted for several months. Cortical mapping revealed large-scale emergence of new hand representations in peri-infarct motor cortex, primarily in cortical tissue underlying the electrode. Results support the feasibility of using a therapy approach combining peri-infarct electrical stimulation with rehabilitative training to alleviate chronic motor deficits and promote recovery from cortical ischemic injury.

The mechanisms of recovery from cerebellar infarction: an fMRI study

Patients with cerebellar infarction frequently make an excellent functional recovery. However, the mechanisms of functional recovery from cerebellar infarction remain unclear. Thus, functional MRI was used to investigate these mechanisms in six right-handed patients with complete recovery after cerebellar infarction, and nine right-handed normal subjects. The non-infarcted side of the cerebellum and the sensorimotor cortex contralateral to the non-infarcted side of the cerebellum were significantly activated during the infarcted-side hand movement. In the infarcted side of the cerebellum, intact regions were activated. Our results indicate that recovery from cerebellar infarction depends on reorganization in the infarcted side of the cerebellum, and recruitment of the cerebellocortical loop involving the cerebrum ipsilateral to the movement and the cerebellum contralateral to the movement.

Brain plasticity in health and disease

Research during the last decades has greatly increased our understanding of brain plasticity, i.e. how neuronal circuits can be modified by experience, learning and in response to brain lesions. Currently available neuroimaging techniques that make it possible to study the function of the human brain in vivo have had an important impact. Cross-modal plasticity during development is demonstrated by cortical reorganization in blind or deaf children. Early musical training has lasting effects in shaping the brain. Albeit the plasticity is largest during childhood, the adult brain retains a capacity for functional and structural reorganization that earlier has been underestimated. Recent research on Huntington's disease has revealed the possibility of environmental interaction even with dominant genes. Scientifically based training methods are now being applied in rehabilitation of patients after stroke and trauma, and in the sensory retraining techniques currently applied in the treatment of focal hand dystonia as well as in sensory re-education after nerve repair in hand surgery. There is evidence that frequent participation in challenging and stimulating activities is associated with reduced cognitive decline during aging. The current concept of brain plasticity has wide implication for areas outside neuroscience and for all human life.

Motor balance and coordination training enhances functional outcome in rat with transient middle cerebral artery occlusion

The goal of this study was to determine if relatively complex motor training on Rota-rod involving balance and coordination plays an essential role in improving motor function in ischemic rats, as compared with simple locomotor exercise on treadmill. Adult male Sprague-Dawley rats with (n=40) or without (n=40) ischemia were trained under each of three conditions: (1) motor balance and coordination training on Rota-rod; (2) simple exercise on treadmill; and (3) non-trained controls. Motor function was evaluated by a series of tests (foot fault placing, parallel bar crossing, rope and ladder climbing) before and at 14 or 28 days after training procedures in both ischemic and normal animals. Infarct volume in ischemic animals was determined with Nissl staining. Compared with both treadmill exercised and non-trained animals, Rota-rod-trained animals with or without ischemia significantly (P<0.01) improved motor performance of all tasks except for foot fault placing after 14 days of training, with normal rats having better performance. Animals trained for up to 28 days on the treadmill did not show significantly improved function. With regard to foot fault placing task, performance on foot placing was improved in ischemic rats across the three measurements at 0, 14 and 28 days regardless of training condition, while the normal group reached their best performance at the beginning of measurement. No significant differences in infarct volume were found in rats trained either with Rota-rod (47+/-4%; mean+/-S.E.), treadmill (45+/-5%) or non-exercised control (45+/-3%). In addition, no obvious difference could be detected in the location of the damage which included the dorso-lateral portion of the neostriatum and the frontoparietal cortex, the main regions supplied by the middle cerebral artery. The data suggest that complex motor training rather than simple exercise effectively improves functional outcome.

Rapid modulation of cortical proprioceptive activity induced by transient cutaneous deafferentation: neurophysiological evidence of short-term plasticity across different somatosensory modalities in humans

Single cell recording in non-human primates shows plastic changes of cortical somatic representations across different types of somatic inputs originating from the same peripheral territory. In humans, muscle afferents from first dorsal interosseus are supplied by the ulnar nerve while the cutaneous territory overlying this muscle is supplied by the radial nerve. This peculiar anatomical nervous distribution allowed us to devise an experimental model which provided a unique opportunity to assess, in humans with a non-invasive technique, the functional relationships between cutaneous and muscle afferent inputs originating from the same peripheral territory. We recorded spinal, brainstem and cortical somatosensory potentials evoked by stimulation of muscle afferents of the right first dorsal interosseus before, during and after anaesthetic block of the sensitive branch of the ipsilateral radial nerve. Amplitude of parietal N20 and P27 and frontal N30 somatosensory evoked potential components showed an increase of amplitudes with more profound anaesthesia. Amplitudes returned to pre-anaesthetic values several minutes after anaesthesia. By contrast, spinal N13 and brainstem P14 potentials did not change throughout the experiment. Results show, for the first time in humans, that a transient cutaneous deafferentation may induce rapid modulation of cortical activity evoked by stimulation of muscle afferents originating in the anaesthetic territory.

Rehabilitation of somatic sensation and related deficit of motor control in patients with pure sensory stroke11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To assess the effectiveness of a rehabilitative training program for deficits in somatic sensation and motor control of the hand in patients with pure sensory stroke.

DESIGN

Multiple baseline and before-after follow-up trial with behavioral analysis of single cases.

SETTING

Rehabilitation unit of a university hospital in Italy.

PARTICIPANTS

Four patients were studied: 2 had a unilateral lesion confined to the parietal lobe (patients 1, 2), and 2 had a unilateral lesion of the thalamus (patients 3, 4) that also lapped the posterior limb of the internal capsule. All 4 patients had chronic deficits in somatic sensation and motor control of the contralesional hand.

INTERVENTION

Behavioral training consisting of exercises aimed at improving somatic sensation and motor control of the affected, contralesional hand. Thirty treatment sessions, each lasting 50 minutes, were performed.

MAIN OUTCOME MEASURES

Somatic deficit was evaluated with 5 tests, and motor control deficit was assessed with 4 tests. One functional test estimated the influence of somatic deficit on daily activities. A visual analog scale (VAS) was also submitted to the patients' relatives to evaluate the amount of use of the affected arm in daily life activities. A baseline was obtained by recording each measure, except for the VAS, 4 times at the first evaluation session. Evaluation sessions were conducted before, after, and 6 months after the end of the experimental treatment.

RESULTS

All patients showed a stable baseline in at least 8 of the outcome measures. Patients 1 and 2 significantly improved in 9 and 7 outcome measures, respectively. Patients 3 and 4 improved in 4 and 7 outcome measures, respectively. With the exception of case 3, all patients considerably increased their use of the affected arm during daily life. The improvement was generally stable over a 6-month period, suggesting that the treatment had a long-term effect.

CONCLUSIONS

Results suggest the possible effectiveness of our training program for treating somatic and motor control deficits of the hand in patients with cortical or subcortical pure sensory stroke.

Ampakines reduce methamphetamine-driven rotation and activate neocortex in a regionally selective fashion

It has been proposed that glutamatergic and dopaminergic systems are functionally opposed in their regulation of striatal output. The present study tested the effects of drugs that enhance AMPA-receptor-mediated glutamatergic transmission (ampakines) for their effects on dopamine-related alterations in cortical activity and locomotor behavior. Rats with unilateral 6-hydroxydopamine lesions of the ascending nigro-striatal dopamine system were sensitized to methamphetamine and then tested for methamphetamine-induced circling behavior in the presence and absence of ampakines CX546 and CX614. Both ampakines produced rapid, dose-dependent reductions in circling that were evident within 15 min and sustained through 1 h of behavioral testing. In situ hybridization maps of c-fos mRNA expression showed that in the intact hemisphere, ampakine cotreatment markedly increased c-fos expression in parietal, sensori-motor neocortex above that found in rats treated with methamphetamine alone. Ampakine cotreatment did not augment c-fos expression in frontal, sensori-motor cortex or striatum. Still larger ampakine-elicited effects were obtained in parietal cortex of the dopamine-depleted hemisphere where labeling densities were increased by approximately 60% above values found in methamphetamine-alone rats. With these effects, the hemispheric asymmetry of cortical activation was less pronounced in the ampakine-cotreatment group as compared with the methamphetamine-alone group. These results indicate that positive modulation of AMPA-type glutamate receptors 1) can offset behavioral disturbances arising from sensitized dopamine receptors and 2) increases aggregate neuronal activity in a regionally selective manner that is probably dependent upon behavioral demands.

Somatosensory Representation of the Digits and Clinical Performance in Patients with Focal Hand Dystonia

OBJECTIVE

The purpose of this study was to incorporate magnetoencephalography and clinical testing to describe differences in somatosensory organization and sensorimotor function of the hand in patients with focal hand dystonia, a target-specific disorder of voluntary movement that interferes with fine motor control during the performance of rapid, repetitive, skilled movements.

DESIGN

This descriptive study included prospective, quasi-experimental comparisons between groups.

RESULTS

Patients with focal hand dystonia demonstrated deficits in physical variables, sensory processing, and motor control when compared with age- and sex-matched controls. They also had altered patterns of firing (amplitude and latency integrated over time) and abnormal somatosensory representations on magnetoencephalography.

CONCLUSIONS

These study findings suggest that there are alterations in both somatosensory representation of the digits and clinical performance in patients with focal hand dystonia. Future studies to determine if alterations in the sensorimotor feedback loop contribute to the development of focal hand dystonia are indicated. If so, intervention strategies may need to include specific types of somatosensory retraining as part of the rehabilitation program for patients with focal hand dystonia.

Tissue microenvironments within functional cortical subdivisions adjacent to focal stroke

Stroke produces a region of complete cell death and areas of partial damage, injury, and gliosis. The spatial relationship of these regions of damage to the infarct core and within spared neuronal circuits has not been identified. A model of cortical stroke was developed within functional subsets of the somatosensory cortex. Infarct size, regions of apoptosis, oxidative DNA damage, heat shock protein induction, and subtypes of reactive gliosis were precisely mapped with the somatosensory body map, quantified, and interrelated. Three tissue microenvironments were recognized: zones of partial ischemic damage, heat shock protein induction, and distributed gliosis. These three zones involved progressively more distant cortical regions, each larger than the infarct core. The zone of partial ischemic damage represents an overlap region of apoptotic cell death, oxidative DNA damage, loss of synaptic connections, and local reactive gliosis. The zone of distributed gliosis occupies distinct functional areas of the somatosensory cortex. The tissue reorganization induced by stroke is much larger than the stroke site itself. Adjacent tissue microenvironments are sites of distinct reactive cellular signaling and may serve as a link between the processes of acute cell death and delayed neuronal plasticity after focal stroke.

The effects of stroke and age on finger interaction in multi-finger force production tasks

OBJECTIVE

The main purpose of this study was to investigate changes in finger interaction after stroke with strongly unilateral motor effects. Effects of age on finger interaction were also analyzed.

METHODS

Sixteen stroke subjects and 16 control subjects produced maximal voluntary contractions with different finger combinations by one hand and by two hands simultaneously. Individual finger forces were measured. In multi-finger tasks, force deficit (FD) was quantified as the difference between the peak finger forces in single-finger tasks and in multi-finger tasks, while enslaving (ENSL) was quantified as forces produced by fingers that were not required to produce force.

RESULTS

In stroke subjects, the peak forces produced by the fingers of the impaired hand (IH) were about 36% less than those produced by the unimpaired hand. Stroke resulted in higher ENSL and decreased FD in the IH, particularly when the index and middle fingers produced force together, while aging led to higher FD and no change in ENSL. Two-hand tasks were accompanied by an additional drop in the force of individual fingers, i.e. bilateral deficit (BD). No changes in BD were observed with age or after stroke.

CONCLUSIONS

We conclude that IH function in persons after stroke is accompanied not only by a general loss of finger force but also by changes in indices of multi-finger interaction. The contrast between the significantly changed indices of one-hand multi-finger interaction and unchanged BD implies that cortical neurons mediating interhemispheric inhibition are relatively spared in unilateral stroke.

SIGNIFICANCE

The study shows that stroke leads to changes not only in finger force but also in finger interaction. The conclusion on relatively spared interhemispheric projections is potentially important for therapy of hand function in stroke survivors.

Influence of the postlesion environment and chronic piracetam treatment on the organization of the somatotopic map in the rat primary somatosensory cortex after focal cortical injury

The influence of housing in an enriched or impoverished environment and anti-ischemic treatment (piracetam) on the organization of the intact regions of the somatosensory cortical maps adjacent to a focal cortical injury were investigated in adult rats. Response properties of small clusters of neurons were recorded in the area of the primary somatosensory cortex (SI) devoted to the contralateral forepaw representation. Electrophysiological maps were elaborated on the basis of the sensory "submodality" (cutaneous or noncutaneous) and the location of the receptive fields (RFs) of layer IV neurons. Recordings were made before, and 3 weeks after induction of a focal neurovascular lesion to the SI cortex. The main results were: 1) the focal ischemic injury induced a cellular loss which was less severe in the piracetam treated rats, regardless of the housing conditions; 2) the lesion resulted in a compression of the remaining forepaw map, a fragmentation of the representational zones serving the cutaneous surfaces (low-threshold inputs) and an enlargement of noncutaneous zones (high-threshold inputs) in the spared cortical sectors surrounding the lesion. These changes were found in all placebo rats, with the most detrimental effects in the animals exposed to an impoverished environment, and in the piracetam-plus-impoverished rats. In contrast, a limited compression of the forepaw map and a preservation of most representational sectors were observed in the piracetam-plus-enriched animals, 3) the size of the cutaneous RFs of the neurons within the intact cortical zones remained unchanged, regardless of environment or treatment; 4) consistent with the map changes, the skin surfaces lacking low-threshold cutaneous RFs increased after the lesion in all animal groups but the piracetam-plus-enriched rats; 5) cortical responsiveness as assessed with mechanical threshold evaluation was diminished in the placebo rats, whatever the environment, and in the piracetam-impoverished rats, but was not significantly affected in the piracetam-enriched animals. Our findings, based on the first double electrophysiological mapping in the rat SI cortex, highlight the protective effects of an environmental therapy associated with an anti-ischemic treatment on the neurophysiological properties of cortical neurons following a focal neurovascular injury to the neocortex.

Concepts of CNS Plasticity in the Context of Brain Damage and Repair

BACKGROUND

How effectively the brain can respond to injury and undergo structural repair has become one of the most exciting areas of contemporary basic and translational neuroscience research. Although there are no clinical treatments yet available to enhance repair of the damaged brain, there are a number of potential therapies being investigated. New drugs are designed to provide some degree of neuroprotection by preventing injured or vulnerable nerve cells from dying, or they are given in the hope of stimulating regenerative processes that could lead to the restoration or the formation of new connections that were lost because of the injury.

MAIN OUTCOME MEASURES

The developments in pharmacology are based primarily upon understanding the molecular mechanisms of drug actions at the level of the genome or with respect to cellular metabolism. Although there is a substantial interest in the pharmacology of brain repair, there seems to be less concern with the various theories of central nervous system plasticity, organization, and reorganization after an injury.

CONCLUSIONS

This review discusses some of the older and current ideas and theories that have been presented over the years to explain recovery of function. We then provide an overview of what is being done in the laboratory to develop new and safe drugs for the treatment of traumatic brain injuries.

Reorganization of remote cortical regions after ischemic brain injury: a potential substrate for stroke recovery

Although recent neurological research has shed light on the brain's mechanisms of self-repair after stroke, the role that intact tissue plays in recovery is still obscure. To explore these mechanisms further, we used microelectrode stimulation techniques to examine functional remodeling in cerebral cortex after an ischemic infarct in the hand representation of primary motor cortex in five adult squirrel monkeys. Hand preference and the motor skill of both hands were assessed periodically on a pellet retrieval task for 3 mo postinfarct. Initial postinfarct motor impairment of the contralateral hand was evident in each animal, followed by a gradual improvement in performance over 1-3 mo. Intracortical microstimulation mapping at 12 wk after infarct revealed substantial enlargements of the hand representation in a remote cortical area, the ventral premotor cortex. Increases ranged from 7.2 to 53.8% relative to the preinfarct ventral premotor hand area, with a mean increase of 36.0 +/- 20.8%. This enlargement was proportional to the amount of hand representation destroyed in primary motor cortex. That is, greater sparing of the M1 hand area resulted in less expansion of the ventral premotor cortex hand area. These results suggest that neurophysiologic reorganization of remote cortical areas occurs in response to cortical injury and that the greater the damage to reciprocal intracortical pathways, the greater the plasticity in intact areas. Reorganization in intact tissue may provide a neural substrate for adaptive motor behavior and play a critical role in postinjury recovery of function.

A squirrel monkey model of poststroke motor recovery

Nonhuman primate models of poststroke recovery have become increasingly rare primarily due to high purchase and maintenance costs and limited availability of nonhuman primate species. Despite this obstacle, nonhuman primate models may offer important advantages over rodent models for understanding many of the brain's mechanisms for self-repair due to greater similarity in cortical organization to humans. Since the mid-1990s, surgical, neurophysiological, and neuroanatomical methods have been developed to understand structural and functional remodeling of the cerebral cortex after an ischemic event, such as occurs in stroke. These methods require long surgical procedures and entail constant physiological monitoring. With careful attention to intraoperative and postsurgical monitoring, these procedures can be repeated multiple times in individual monkeys without untoward events. This model provides a statistically powerful approach for tracking brain plasticity in the ensuing weeks and months after a stroke-like injury, reducing the number of animals required for individual experiments. This methodology is described in detail, and many of the resulting findings that are relevant for understanding stroke recovery and the effects of rehabilitative and pharmacotherapeutic interventions are summarized.

Neuroprotective effects on somatotopic maps resulting from piracetam treatment and environmental enrichment after focal cortical injury

Acute and chronic postlesion reorganization of the cortical maps was examined in adult rats using electrophysiological mapping of the forepaw area in the primary somatosensory cortex. Recordings were made before and after (first 12 hr and 3 wk) induction of a focal thermal-ischemic lesion to a restricted part of the forepaw area. The influence of an anti-ischemic substance (piracetam) and housing in an enriched environment (EE) or impoverished environment (IE) on the organization of the spared regions of the cortical maps adjacent to the lesion was investigated. The results revealed (1) a gradual expansion of the injured zone and a cellular loss that were smaller in the piracetam-treated (PT) rats than in the placebo (PL) rats; (2) a better preservation of the somatotopic organization and the neuronal responsiveness in the maps of the PT rats during the first 12 hr after the lesion; (3) a gradual compression and fragmentation of the remaining forepaw map over the first 3 postlesion wk. These changes were found in all PL rats, with the most detrimental effects in the animals exposed to an IE. In the PT-EE animals, a contrasting substantial preservation of the map was observed. (4) Cortical responsiveness was diminished in the PL rats, whatever the environment, and in the PT-IE rats; but it was not significantly affected in the PT-EE animals. The findings demonstrate the protective function of acute piracetam treatment on electrophysiological properties of cortical neurons within the peri-infarct tissue and highlight the neuroprotective effects of an environmental therapy combined with the piracetam treatment during the weeks after ischemic damage.

Synaptic plasticity in thalamic nuclei enhanced by motor skill training in rat with transient middle cerebral artery occlusion

The goal of this study was to determine if synaptic plasticity in the thalamus of rats subjected to stroke could be altered by motor training. Transient occlusion of right middle cerebral artery in adult female Sprague-Dawley rats (n = 35) was induced with an intraluminal filament followed by three training conditions, 1. motor skill training on Rota-rod requiring balance and coordination skills, 2. simple exercise on treadmill, and 3. nontrained controls. Synaptic plasticity in brain was evaluated by synapotophysin immunocytochemistry at 14 or 28 days after training procedures. Infarct volume was determined in Nissl stained sections. Both at 14 and 28 days after Rota-rod training, intense synaptophysin immunoreactivity was present in the right but not the left mediodorsal and ventromedial nuclei of thalamus of ischemic rats. In treadmill-trained animals, however, similarly intense synaptic plasticity in these two thalamic nuclei was seen only at 28 days. Immunostaining was found also in other brain regions adjacent to or remote from infarct site. The data suggest that motor training, particularly motor skill training involving balance and coordination, facilitates a uniquely lateralized synaptogenesis in the thalamus.

Functional and structural plasticity in motor cortex: implications for stroke recovery

Several studies have now demonstrated that the motor cortical representations are dynamically maintained in both normal and brain-injured animals. Functional plasticity in the motor cortex of normal animals is accompanied by changes in synaptic morphology; these changes are skill-dependent rather than simply use-dependent. Finally, motor cortical areas undergo substantial functional alterations after focal ischemic infarcts; motor experience is a potent and adaptive modulator of injury-related plasticity. These recent neuroscientific advances set the stage for the development of new, more effective interventions in chronic stroke populations that are based on the basic mechanisms underlying neuroplasticity.

Functional magnetic resonance imaging in stroke recovery

A better understanding of brain reorganization following stroke may have value in predicting outcome defining the targets of restorative therapies, measuring the physiology of recovery, and in serving as a biologic marker in studies targeting stroke recovery. Measures of brain organization may provide insights as to which patients retain relevant substrate for therapies that target restorative events. Brain reorganization can be studied with many different methods that often have complementary value. Functional MR imaging provides insights into brain plasticity after stroke and remains a valuable tool in the study of motor recovery after stroke.

Neurobehavioral aspects of recovery: assessment of the learned nonuse phenomenon in hemiparetic adolescents

OBJECTIVE

To test the learned nonuse assumption of constraint-induced movement therapy (CIMT), through behavioral assessment, that residual movement abilities are not used to their fullest extent in persons with chronic hemiparesis.

DESIGN

Repeated-measures cohort design.

SETTING

Rehabilitation clinic in southwest Germany.

PARTICIPANTS

Twenty-one persons with upper-limb hemiparesis after brain injury and 21 age-matched healthy controls. Participants were hospitalized when tested.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Spontaneous affected hand use for the items of the Motor Activity Log and the Actual Amount of Use Test were compared with the subjects' actual ability to perform these items with the affected hand.

RESULTS

A significant difference between the residual movement capability and the spontaneous use was found in both tests. Most movements could be performed with moderate to good movement quality with the affected hand, but were still performed with the unaffected "good" hand in the spontaneous-use condition. This effect was equally strong in right- and left-side affected persons.

CONCLUSION

Hemiparetic persons do not use their residual movement capabilities to the fullest extent. According to the learned nonuse model, this behavior reflects a learned suppression of affected arm movements, which may be overcome by CIMT.

Functional improvement after motor training is correlated with synaptic plasticity in rat thalamus

The goals of this study were to determine whether functional outcome after motor training in rats was linked to synaptic plasticity in thalamus, and whether the Rota-rod apparatus, widely used to test motor function, could be used as an easy and quantitative motor skill training procedure. Adult female Sprague-Dawley rats (n = 39) were evaluated under three training conditions: 1. Movement requiring balance and coordination skills on Rota-rod; 2. simple exercise on treadmill; 3. nontrained controls. Motor function was evaluated by a series of motor tests (foot fault placing, parallel bar crossing, rope and ladder climbing) before and 14 or 28 days after training procedure. Synaptic strength in brain was assessed by synaptophysin immunocytochemistry. After 14 days of training, Rota-rod-trained animals significantly (p < 0.01) improved motor performance, compared to treadmill and nontrained animals. Animals with up to 28 days of simple exercises on the treadmill did not show a significantly improved performance on most motor tasks, except for an improvement in foot fault placing. Intensive synaptophysin immunoreactivity was present in the right but not the left mediodorsal and ventromedial nuclei of thalamus in Rota-rod-trained rats at 14 and 28 days, and in treadmill-trained rats at 28 days. The data suggested that functional outcome is effectively improved by motor skill training rather than by simple exercises, and this may be related, at least partially, to uniquely lateralized synaptogenesis in the thalamus. Both Rota-rod and treadmill could be quantitatively used in rats for motor training of different complexity.

An index of topographic normality in rat somatosensory cortex: application to a sciatic nerve crush model

Previous studies have demonstrated that peripheral denervation of the skin is reflected in the CNS as a reorganization of somatotopic representations. In cases in which peripheral nerve regeneration occurs there is a gradual reactivation of cortex by novel receptive fields that is reversed as regenerated nerves reestablish connections with the original skin surface. Functional recovery appears to depend on the pattern in which somatotopic organization in the cortex is reestablished. The relationship between functional recovery and cortical topography is not precise, however, since the descriptions of postinjury representations in the cortex have been largely descriptive and not quantitative. The purpose of this study was to derive an index to quantify deviations from normal somatotopic organization in the somatosensory cortex. Multiunit recordings of cutaneous representations in the somatosensory cortex (S1) of the rat were defined using Semmes-Weinstein monofilaments to stimulate the skin over the distal hindlimb of the rat 2 and 4 months after a sciatic nerve crush. To derive a sensitive index of topography, the sciatic nerve crush was selected as the injury model since nerve regeneration following crush injuries has been reported to reinstate preinjury cortical topography. Group comparisons were made with an intact control group. The results show that there were subtle, but significant differences in topography between rats with a regenerated sciatic nerve and normal rats. In addition, average thresholds for evoking cortical responses were higher than normal (but within normal range) 2 and 4 months after the crush. These results demonstrate that the index of topography derived for this study can reveal deviations that may not be distinguishable from normal topography when based on qualitative descriptions.

Environmental influences on functional outcome after a cortical infarct in the rat

The effect of postoperative housing conditions on functional outcome and brain-derived neurotrophic factor (BDNF) gene expression was evaluated 1 month after a distal ligation of the right middle cerebral artery (MCA) in spontaneously hypertensive rats. Two days postoperatively the rats were randomized into four groups; individually housed with no equipment (deprived group), individually housed with free access to a connected running wheel (running group), housed together in a large cage with no equipment (social group) or in the same size of cage furnished with bars, chains and various things to manipulate (enriched group). The enriched rats had significantly higher scores when crossing a rotating horizontal rod than deprived and running rats. The social group performed significantly better than the deprived group. The BDNF gene expression in the ipsi- and contralateral cortex, thalamus, hippocampus and cerebellum did not significantly differ between the groups. The weight of the adrenal glands was significantly increased in running rats suggesting that postischemic running may be stressful. We conclude that the beneficial effect of postischemic environmental enrichment is likely to be a combination of social and various physical activities, and that BDNF gene expression 1 month after a cortical infarct did not correlate with functional outcome.

Two coupled motor recovery protocols are better than one: electromyogram-triggered neuromuscular stimulation and bilateral movements

BACKGROUND AND PURPOSE

Overcoming chronic hemiparesis from a cerebrovascular accident (CVA) can be challenging for many patients, especially after the first 12 months after the CVA. With the use of established motor control theories, the present study investigated electromyogram (EMG)-triggered neuromuscular stimulation and bilateral coordination training.

METHODS

Twenty-five CVA subjects volunteered to participate in this motor recovery protocol study. Subjects were randomly assigned to 1 of 3 groups: (1) coupled protocol of EMG-triggered stimulation and bilateral movement (n=10); (2) EMG-triggered stimulation and unilateral movement (n=10); or (3) control (n=5). All participants completed 6 hours of rehabilitation during a 2-week period according to group assignments. Motor capabilities of the wrist and fingers were evaluated on the basis of 3 categories of motor tasks in a pretest-posttest control group design.

RESULTS

Significant findings for the (1) number of blocks moved in a functional task, (2) chronometric reaction times to initiate movements, and (3) sustained muscle contraction capability all favored the coupled bilateral movement training and EMG-triggered neuromuscular stimulation protocol group. In addition, the unilateral movement/stimulation group exceeded the control group in the number of blocks moved and rapid onset of muscle contractions.

CONCLUSIONS

This new evidence is convincing in that subjects in the coupled protocol group were able to demonstrate enhanced voluntary motor control across 3 categories of tasks. Chronic hemiparesis decreased considerably in the wrist and fingers as CVA patients expanded their motor repertoire.

Motor disinhibition in affected and unaffected hemisphere in the early period of recovery after stroke

OBJECTIVES

To investigate motor disinhibition in affected and unaffected motor areas in the acute stage after stroke and during the early period of recovery.

METHODS

Fifteen patients with moderate to severe hemiparesis after acute unilateral stroke were compared with 10 healthy age-matched controls. We used paired transcranial magnetic stimulation to study intracortical inhibition and facilitation from the thenar eminence muscles on both sides. F-wave from the median nerve on both sides were recorded. The recordings were performed 5-7 days (T1) and 30 days after stroke.

RESULTS

In 10 patients who showed the presence of reliable motor evoked potentials on the affected side, intracortical inhibition was significantly reduced. On the unaffected side intracortical inhibition (ICI) was significantly reduced in all patients. Patients who presented significant motor recovery after 30 days showed persistence of abnormal disinhibition in the affected hemisphere but a return to normal ICI in the unaffected hemisphere. Patients with poor motor recovery showed persistence of abnormal disinhibition on both sides. No significant changes were observed in F-wave amplitude.

CONCLUSIONS

Motor disinhibition occurs on both sides after stroke in all acute stage patients. Changes in motor disinhibition on unaffected side also are related to motor recovery.

Receptive fields and response properties of neurons in the star-nosed mole's somatosensory fovea

Star-nosed moles have an extraordinary mechanosensory system consisting of 22 densely innervated nasal appendages covered with thousands of sensitive touch domes. A single appendage acts as the fovea and the star is constantly shifted to touch this foveal appendage to objects of interest. Here we investigated the receptive fields on the star and the response properties of 144 neurons in the mole's primary somatosensory cortex (S1). Excitatory receptive fields were defined by recording multiunit activity from the S1 representations of the nasal appendages that form the star, while stimulating the touch domes on the skin surface with a small probe. Receptive fields were among the smallest reported for mammalian glabrous skin, averaging <1 mm(2). The smallest receptive fields were found for the fovea representation, corresponding to its greater cortical magnification. Single units were then isolated, primarily from the representation of the somatosensory fovea, and the skin surface was stimulated with a small probe attached to a piezoelectric wafer controlled by a computer interface. The response properties of neurons and the locations of inhibitory surrounds were evaluated with two complementary approaches. In the first set of experiments, single microelectrodes were used to isolate unit activity in S1, and data were collected for stimulation to different areas of the sensory star. In the second set of experiments, a multi-electrode array (4 electrodes spaced at 200 microm in a linear sequence) was used to simultaneously record from isolated units in different cortical areas representing different parts of the sensory periphery. These experiments revealed a short-latency excitatory discharge to stimulation of the fovea followed by a long-lasting suppression of spontaneous activity. Sixty-one percent of neurons responded with an excitatory OFF response at the end of the stimulus; the remaining 39% of cells did not respond or were inhibited at stimulus offset. Stimulation of areas surrounding the central receptive field often revealed inhibitory surrounds. Forty percent of the neurons that responded to mechanosensory stimulation of the receptive field center were inhibited by stimulation of surrounding areas of skin on the same appendage. In contrast to neurons in rodent barrels, few neurons within a stripe representing an appendage responded to stimulation of neighboring (nonprimary) appendages on the snout. The small receptive fields, short latencies, and inhibitory surrounds are consistent with the star's role in rapidly determining the locations and identities of objects in a complex tactile environment.

Long term reshaping of language, sensory, and motor maps after glioma resection: a new parameter to integrate in the surgical strategy

OBJECTIVES

To describe cortical reorganisation and the effects of glioma infiltration on local brain function in three patients who underwent two operations 12-24 months apart.

METHODS

Three patients who had no neurological deficit underwent two operations for low grade glioma, located in functionally important brain regions. During each operation, local brain function was characterised by electrical mapping and awake craniotomy.

RESULTS

Language or sensorimotor areas had been invaded by the tumour at the time of the first operation, leading to incomplete glioma removal in all cases. Because of a tumour recurrence, the patients were reoperated on between 12 and 24 months later. Functional reorganisation of the language, sensory, and motor maps was detected by electrical stimulation of the brain, and this allowed total glioma removal without neurological sequelae.

CONCLUSIONS

These findings show that surgical resection of a glioma can lead to functional reorganisation in the peritumorous and infiltrated brain. It may be that this reorganisation is directly or indirectly caused by the surgical procedure. If this hypothesis is confirmed by other studies, the use of such brain plasticity potential could be used when planning surgical options in some patients with low grade glioma. Such a strategy could extend the limits of tumour resection in gliomas involving eloquent brain areas without causing permanent morbidity.

Remodeling of somotasensory hand representations following cerebral lesions in humans

There is evidence of reorganization of somatotopic maps following cortical lesions in mammals such as monkeys, raccoons and rats. However, there has been a striking lack of research on somatosensory plasticity following cerebral damage in adult humans. We describe two individuals with left hemisphere damage who misperceive the locations of tactile stimuli whose presence or absence they can readily detect. We find that the mislocalizations preserve the relative topography of pre-lesion experiences, resulting in shifted and compressed representations of the hand surfaces. These results not only provide evidence for systematic remodeling of somatotopic maps in humans, they also reveal that the systematic changes in cortical topography that have been documented using electrophysiological methods may give rise to similarly systematic changes in somatosensory perception itself.

Reorganization of somatic sensory function in the human thalamus after stroke

A patient with thalamic stroke underwent microelectrode-guided stereotactic thalamic exploration during surgery for control of tremor. The results of somatic sensory mapping in this patient were compared with explorations carried out during stereotactic surgery for the control of essential tremor (70 patients). There was evidence both of somatotopic reorganization and of anatomic reorganization of the representation of deep structures in the principal somatic sensory nucleus of the thalamus and the nuclei located anterior to it. This case demonstrates that thalamic reorganization can occur after a thalamic stroke and may play a role in recovery from such a stroke.

Is robot-aided sensorimotor training in stroke rehabilitation a realistic option?

Stroke is the leading cause of disability, despite continued advances in prevention and treatment techniques based on novel delivery of new fibrinolytic drugs. Improved medical treatment of the complications caused by acute stroke has contributed to decreased mortality, but 90% of the survivors have significant neurological deficits. Reducing the degree of permanent disability remains the goal of poststroke neuro-rehabilitation programs, and new approaches to impairment reduction through managing sensorimotor experience may contribute further to altering disability. Recent reports from a number of laboratories using enhanced sensorimotor training protocols, particularly those with robotic devices, have indicated modest success in reducing impairment and increasing motor power in the exercised limb of patients with stroke when compared with control individuals. Whether arming the therapist with new tools, especially robotic devices, to treat impairment is a realistic approach to modern interdisciplinary rehabilitation raises questions regarding the added value of impairment reduction, and under what conditions should scientific and clinical development of robotic studies continue.

Factors contributing to motor impairment and recovery after stroke

The goal of the present study was to examine factors affecting motor impairment and recovery in a primate model of cortical infarction. Microelectrode stimulation techniques were used to delineate the hand representation in the primary motor cortex (M1). Microinfarcts affecting approximately 30% of the hand representation were made by electrocoagulation of surface vessels. Electrophysiologic procedures were repeated at 1 month after the infarct to examine changes in motor map topography. Before the infarct, and at approximately 1 week (early period) and 1 month (late period) after the infarct, manual performance was assessed on a reach-and-retrieval task that required skilled use of the digits. Contrary to the expected outcome, early impairment was inversely related to the amount of digit representation destroyed by the infarct. That is, animals with less involvement of the M1 digit area demonstrated the greatest motor deficit in the early postinfarct period. In addition, improvement in motor performance between early and late postinfarct periods was directly related to a decrease in the extent of the digit + wrist/forearm area in the final postinfarct map. These results suggest that specific aspects of motor-map remodeling are expressions of adaptive mechanisms that underlie functional recovery after stroke. Further, they suggest that the adaptive mechanisms underlying postinjury recovery differ in detail from those that operate in normal motor learning. The potential role of compensatory mechanisms in these phenomena is discussed.

Palliative treatment for stroke

Despite continued advances in prevention and treatment, stroke remains the leading cause of neurologic disability. This article reviews the broad spectrum of palliative efforts underway to treat the impairment and disability that results from stroke. Emphasis is placed on the importance of symptom control, increasing compensation, and enhancing residual and recovering function in patients with stroke. New approaches to impairment reduction have produced encouraging results, but disability reduction remains the cornerstone of care.

The role of neural cell adhesion molecules in plasticity and repair

Repair and functional recovery after brain injury critically depends on structural and functional plasticity of preserved neuronal networks. A striking feature of brain structures where tissue reorganization and plasticity occur is a strong expression of the polysialylated neural cell adhesion molecule (PSA-NCAM). An important role of this molecule in various aspects of neuronal and synaptic plasticity has been revealed by many studies. Recently, a new mechanism has been elucidated whereby PSA-NCAM may contribute to signalling mediated by the neurotrophic factor BDNF, thereby sensitizing neurons to this growth factor. This mechanism was shown to be important for activity-induced synaptic plasticity and for the survival and differentiation of cortical neurons. A cross-talk between these molecules may, thus, reveal a key factor for properties of structural plasticity and in particular could mediate the activity-dependent aspects of synaptic network remodeling. Animal models have been developed to assess the role of these molecules in functional recovery after lesions.

The neural basis of perceptual learning

Perceptual learning is a lifelong process. We begin by encoding information about the basic structure of the natural world and continue to assimilate information about specific patterns with which we become familiar. The specificity of the learning suggests that all areas of the cerebral cortex are plastic and can represent various aspects of learned information. The neural substrate of perceptual learning relates to the nature of the neural code itself, including changes in cortical maps, in the temporal characteristics of neuronal responses, and in modulation of contextual influences. Top-down control of these representations suggests that learning involves an interaction between multiple cortical areas.

Role of adaptive plasticity in recovery of function after damage to motor cortex

Based upon neurophysiologic, neuroanatomic, and neuroimaging studies conducted over the past two decades, the cerebral cortex can now be viewed as functionally and structurally dynamic. More specifically, the functional topography of the motor cortex (commonly called the motor homunculus or motor map), can be modified by a variety of experimental manipulations, including peripheral or central injury, electrical stimulation, pharmacologic treatment, and behavioral experience. The specific types of behavioral experiences that induce long-term plasticity in motor maps appear to be limited to those that entail the development of new motor skills. Moreover, recent evidence demonstrates that functional alterations in motor cortex organization are accompanied by changes in dendritic and synaptic structure, as well as alterations in the regulation of cortical neurotransmitter systems. These findings have strong clinical relevance as it has recently been shown that after injury to the motor cortex, as might occur in stroke, post-injury behavioral experience may play an adaptive role in modifying the functional organization of the remaining, intact cortical tissue.

Arm Training Induced Brain Plasticity in Stroke Studied with Serial Positron Emission Tomography

We used serial positron emission tomography (PET) to study training-induced brain plasticity after severe hemiparetic stroke. Ten patients were randomized to either task-oriented arm training or to a control group and scanned before and after 22.6 +/- 1.6 days of treatment using passive movements as an activation paradigm. Increases of regional cerebral blood flow (rCBF) were assessed using statistical parametric mapping (SPM99). Before treatment, all stroke patients revealed bilateral activation of the inferior parietal cortex (IPC). After task-oriented arm training, activation was found bilaterally in IPC and premotor cortex, but also in the contralateral sensorimotor cortex (SMC). The control group only showed weak activation of the ipsilateral IPC. After treatment, the training group revealed relatively more activation bilaterally in IPC, premotor areas, and in the contralateral SMC. Five normal subjects showed no statistical significant differences between two separate PET studies. In this group of patients, task-oriented arm training induced functional brain reorganization in bilateral sensory and motor systems.

Neuronal correlates of motor performance and motor learning in the primary motor cortex of monkeys adapting to an external force field

The primary motor cortex (M1) is known to control motor performance. Recent findings have also implicated M1 in motor learning, as neurons in this area show learning-related plasticity. In the present study, we analyzed the neuronal activity recorded in M1 in a force field adaptation task. Our goal was to investigate the neuronal reorganization across behavioral epochs (before, during, and after adaptation). Here we report two main findings. First, memory cells were present in two classes. With respect to the changes of preferred direction (Pd), these two classes complemented each other after readaptation. Second, for the entire neuronal population, the shift of Pd matched the shift observed for muscles. These results provide a framework whereby the activity of distinct neuronal subpopulations combines to subserve both functions of motor performance and motor learning.

Functional MRI detects posterior shifts in primary sensorimotor cortex activation after stroke: evidence of local adaptive reorganization?

BACKGROUND AND PURPOSE

Further recovery from stroke can occur late, long after the end of the apparent evolution of pathological changes. This observation and evidence obtained from functional imaging for altered patterns of activation after brain injury suggest that cortical reorganization may contribute to recovery. Here, we have tested for potentially adaptive reorganization in the primary sensorimotor cortex.

METHODS

We used functional MRI to study brain activation with dominant hand movement in right-handed healthy control subjects (n=20) and in patients after subcortical ischemic infarcts causing mild to moderate right hemiparesis (n=8). The numbers of pixels activated above threshold and the geometric centers of activation clusters were determined.

RESULTS

Although random-effects analysis identified some differences in activation maxima, similar regions of the brain were activated with sequential finger tapping in the patient and control groups. However, consistent with the heterogeneity in the locations, sizes, and times after the infarcts, patterns and magnitudes of activation showed some heterogeneity between patients. Nonetheless, for the group as a whole, there was a decreased motor cortex lateralization index (-0.1+/-0.7 in patients and 0.7+/-0.3 in control subjects, P=0.05). The geometric center of activation of the primary sensorimotor cortex activation cluster contralateral to the affected hand in patients was also shifted posteriorly (mean 12 mm, P<0.04) relative to that of the control subjects. To confirm the latter observation, the activation response with a simple hand-tapping task was examined in some of the subjects. With this task, there was also a trend (mean 10 mm, P=0.07) toward a more posterior activation in patients.

CONCLUSIONS

These results confirm altered patterns of activation in the contralateral and ipsilateral primary sensorimotor cortices after recovery from strokes causing hemiparesis. These (and other changes) suggest that modulation of widely distributed parts of the cortical network for motor control may contribute to adaptations leading to functional recovery after stroke.