Brain-machine interface facilitated neurorehabilitation via spinal stimulation after spinal cord injury: Recent progress and future perspectives

Combined Transcutaneous Electrical Spinal Cord Stimulation and Task-Specific Rehabilitation Improves Trunk and Sitting Functions in People with Chronic Tetraplegia

The aim of this study was to examine the effects of transcutaneous electrical spinal cord stimulation (TSCS) and conventional task-specific rehabilitation (TSR) on trunk control and sitting stability in people with chronic tetraplegia secondary to a spinal cord injury (SCI). Five individuals with complete cervical (C4-C7) cord injury participated in 24-week therapy that combined TSCS and TSR in the first 12 weeks, followed by TSR alone for another 12 weeks. The TSCS was delivered simultaneously at T11 and L1 spinal levels, at a frequency ranging from 20-30 Hz with 0.1-1.0 ms. pulse width biphasically. Although the neurological prognosis did not manifest after either treatment, the results show that there were significant increases in forward reach distance (10.3 ± 4.5 cm), right lateral reach distance (3.7 ± 1.8 cm), and left lateral reach distance (3.0 ± 0.9 cm) after the combinational treatment (TSCS+TSR). The stimulation also significantly improved the participants' trunk control and function in sitting. Additionally, the trunk range of motion and the electromyographic response of the trunk muscles were significantly elevated after TSCS+TSR. The TSCS+TSR intervention improved independent trunk control with significantly increased static and dynamic sitting balance, which were maintained throughout the TSR period and the follow-up period, indicating long-term sustainable recovery.

Non-invasive brain-spine interface: Continuous control of trans-spinal magnetic stimulation using EEG

Brain-controlled neuromodulation has emerged as a promising tool to promote functional recovery in patients with motor disorders. Brain-machine interfaces exploit this neuromodulatory strategy and could be used for restoring voluntary control of lower limbs. In this work, we propose a non-invasive brain-spine interface (BSI) that processes electroencephalographic (EEG) activity to volitionally control trans-spinal magnetic stimulation (ts-MS), as an approach for lower-limb neurorehabilitation. This novel platform allows to contingently connect motor cortical activation during leg motor imagery with the activation of leg muscles via ts-MS. We tested this closed-loop system in 10 healthy participants using different stimulation conditions. This BSI efficiently removed stimulation artifacts from EEG regardless of ts-MS intensity used, allowing continuous monitoring of cortical activity and real-time closed-loop control of ts-MS. Our BSI induced afferent and efferent evoked responses, being this activation ts-MS intensity-dependent. We demonstrated the feasibility, safety and usability of this non-invasive BSI. The presented system represents a novel non-invasive means of brain-controlled neuromodulation and opens the door towards its integration as a therapeutic tool for lower-limb rehabilitation.

Is Graphene Shortening the Path toward Spinal Cord Regeneration?

Along with the development of the next generation of biomedical platforms, the inclusion of graphene-based materials (GBMs) into therapeutics for spinal cord injury (SCI) has potential to nourish topmost neuroprotective and neuroregenerative strategies for enhancing neural structural and physiological recovery. In the context of SCI, contemplated as one of the most convoluted challenges of modern medicine, this review first provides an overview of its characteristics and pathophysiological features. Then, the most relevant ongoing clinical trials targeting SCI, including pharmaceutical, robotics/neuromodulation, and scaffolding approaches, are introduced and discussed in sequence with the most important insights brought by GBMs into each particular topic. The current role of these nanomaterials on restoring the spinal cord microenvironment after injury is critically contextualized, while proposing future concepts and desirable outputs for graphene-based technologies aiming to reach clinical significance for SCI.

Restoring Sensorimotor Function Through Neuromodulation After Spinal Cord Injury: Progress and Remaining Challenges

Spinal cord injury (SCI) is a major disability that results in motor and sensory impairment and extensive complications for the affected individuals which not only affect the quality of life of the patients but also result in a heavy burden for their families and the health care system. Although there are few clinically effective treatments for SCI, research over the past few decades has resulted in several novel treatment strategies which are related to neuromodulation. Neuromodulation-the use of neuromodulators, electrical stimulation or optogenetics to modulate neuronal activity-can substantially promote the recovery of sensorimotor function after SCI. Recent studies have shown that neuromodulation, in combination with other technologies, can allow paralyzed patients to carry out intentional, controlled movement, and promote sensory recovery. Although such treatments hold promise for completely overcoming SCI, the mechanisms by which neuromodulation has this effect have been difficult to determine. Here we review recent progress relative to electrical neuromodulation and optogenetics neuromodulation. We also examine potential mechanisms by which these methods may restore sensorimotor function. We then highlight the strengths of these approaches and remaining challenges with respect to its application.

Keratin Biomaterials Improve Functional Recovery in a Rat Spinal Cord Injury Model

STUDY DESIGN

Laboratory study using a rat T9 contusion model of spinal cord injury (SCI).

OBJECTIVE

The purpose of this study was to evaluate which method of delivery of soluble keratin biomaterials would best support functional restoration through the macrophage polarization paradigm.

SUMMARY OF BACKGROUND DATA

SCI is a devastating neurologic event with complex pathophysiological mechanisms that currently has no cure. After injury, macrophages and resident microglia are key regulators of inflammation and tissue repair exhibiting phenotypic and functional plasticity. Keratin biomaterials have been demonstrated to influence macrophage polarization and promote the M2 anti-inflammatory phenotype that attenuates inflammatory responses.

METHODS

Anesthetized female Lewis rats were subjected to moderate T9 contusion SCI and randomly divided into: no therapy (control group), an intrathecally injected keratin group, and a keratin-soaked sponge group (n = 11 in all groups). Functional recovery assessments were obtained at 3- and 6-weeks post-injury (WPI) using gait analysis performed with the DigiGait Imaging System treadmill and at 1, 3, 7, 14, 21, 28, 35, and 42 days post-injury by the Basso, Beattie, Bresnahan (BBB) locomotor rating scale. Histology and immunohistochemistry of serial spinal cord sections were performed to assess injury severity and treatment efficacy.

RESULTS

Compared to control rats, applying keratin materials after injury improved functional recovery in certain gait parameters and overall trended toward significance in BBB scores; however, no significant differences were observed with tissue analysis between groups at 6 WPI.

CONCLUSION

Results suggest that keratin biomaterials support some locomotor functional recovery and may alter the acute inflammatory response by inducing macrophage polarization following SCI. This therapy warrants further investigation into treatment of SCI.Level of Evidence: N/A.

Effect of electromyographic biofeedback training on motor function of quadriceps femoris in patients with incomplete spinal cord injury: A randomized controlled trial

BACKGROUND

Electromyographic biofeedback (EMG BF) training is an effective method of promoting motor learning and control in neurorehabilitation, but its effect on quadriceps femoris muscle in individuals with spinal cord injury (SCI) is unknown.

OBJECTIVE

The aim of the study was to investigate the therapeutic effect of EMG BF training on motor function of quadriceps femoris in patients with incomplete SCI.

METHODS

Thirty-three incomplete paraplegic patients with quadriceps femoris strength ranging grade 1 to grade 3 less than 6 months post-injury were enrolled. Control group (n = 16) received conventional physical therapy to enhance quadriceps femoris strength, while intervention group (n = 17) was treated with conventional physical therapy and EMG BF training. All received treatment once a day for 30 days. Surface electromyograph (sEMG), muscle strength and thigh circumference size were assessed to evaluate motor function of quadriceps femoris. Activities of daily living (ADL) was evaluated by Modified Barthel Index (MBI). All the measures evaluated three times in total.

RESULTS

Compared to the control group, intervention group significantly improved on sEMG values and strength of quadriceps femoris (PsEMG < 0.001, Pstrength < 0.05). sEMG values of quadriceps femoris increased earlier than strength of quadriceps femoris in intervention group (Prest = 0.07, Pactive = 0.031). There were no statistical differences in thigh circumference size and ADL scores between groups (Pthigh > 0.05, PADL = 0.423).

CONCLUSIONS

EMG BF training appeared to be a useful tool to enhance motor function of quadriceps femoris in patients with incomplete SCI. sEMG could quantify the changes of single muscle myodynamia precisely before visible or touchable changes occur.

Spinal cord regeneration: A brief overview of the present scenario and a sneak peek into the future

The central nervous system (CNS) portrays appreciable complexity in developing from a neural tube to controlling major functions of the body and orchestrated co-ordination in maintaining its homeostasis. Any insult or pathology to such an organized tissue leads to a plethora of events ranging from local hypoxia, ischemia, oxidative stress to reactive gliosis and scarring. Despite unravelling the pathophysiology of spinal cord injury (SCI) and linked cellular and molecular mechanism, the over exhaustive inflammatory response at the site of injury, limited intrinsic regeneration capability of CNS, and the dual role of glial scar halts the expected accomplishment. The review discusses major current treatment approaches for traumatic SCI, addressing their limitation and scope for further development in the field under three main categories- neuroprotection, neuro-regeneration, and neuroplasticity. We further propose that a multi-disciplinary combinatorial treatment approach exploring any two or all three heads simultaneously might alleviate the inhibitory milieu and ameliorate functional recovery.

Concerns in the Blurred Divisions between Medical and Consumer Neurotechnology

Neurotechnology has traditionally been central to the diagnosis and treatment of neurological disorders. While these devices have initially been utilized in clinical and research settings, recent advancements in neurotechnology have yielded devices that are more portable, user-friendly, and less expensive. These improvements allow laypeople to monitor their brain waves and interface their brains with external devices. Such improvements have led to the rise of wearable neurotechnology that is marketed to the consumer. While many of the consumer devices are marketed for innocuous applications, such as use in video games, there is potential for them to be repurposed for medical use. How do we manage neurotechnologies that skirt the line between medical and consumer applications and what can be done to ensure consumer safety? Here, we characterize neurotechnology based on medical and consumer applications and summarize currently marketed uses of consumer-grade wearable headsets. We lay out concerns that may arise due to the similar claims associated with both medical and consumer devices, the possibility of consumer devices being repurposed for medical uses, and the potential for medical uses of neurotechnology to influence commercial markets related to employment and self-enhancement.

Identification and analysis of spinal cord injury subtypes using weighted gene co-expression network analysis

Background

Spinal cord injury (SCI) has an immediate and devastating impact on the control over various movements and sensations. However, no effective therapies for SCI currently exist.

Methods

To identify and analyze SCI subtypes, we obtained the expression profile data of the 1,057 genes (889 intersection genes) in GSE45550 using weighted gene co-expression network analysis (WGCNA), and 14 co-expression gene modules were identified. Next, we filtered out the network degree top 10 (degree >80) genes, considered the final key SCI genes. A multifactor regulatory network (105 interaction pairs), consisting of messenger RNAs (mRNAs), long non-coding RNAs (lncRNAs), and transcription factors (TFs) was constructed. This network was involved in the co-expression of key genes. We selected the top 10 regulatory factors (degree >4) as core regulators in the multifactor regulatory network.

Results

The results of functional enrichment analysis of the target gene expressing the core regulatory factor [1,059] showed that these target genes were enriched in pathways for human cytomegalovirus infection, chronic myeloid leukemia, and pancreatic cancer. Further, we used the key genes in the co-expression network to categorize the SCI samples in GSE45550. The expression levels of the top 6 genes (CCNB2, CCNB1, CKS2, COL5A1, KIF20A, and RACGAP1) may act as potential marker genes for different SCI subtypes. On the basis of these different subtypes, 8 SCI core gene CDK1-associated drugs were also found to provide potential therapeutic options for SCI.

Conclusions

These results may provide a novel therapeutic strategy for the treatment of SCI.

Novel Human-Centered Robotics: Towards an Automated Process for Neurorehabilitation

The global requirement of patient rehabilitation has surged with time due to the growing number of accidents, injuries, age-related issues, and other aspects. Parallelly, the cost of treatment and patient care also increased in a manifold. Moreover, constant monitoring and support for the patients having physical disabilities have become an ongoing challenge to the medical system. Robotics-based neurorehabilitation has reduced the human error while assisting such patients, precisely interpreting the signals, and communicating to the patient. Gradual precise application and improvement of the technology with time yielded a novel direction for patient care and support. The interdisciplinary contribution of many advanced technical branches allowed us to develop robotics-based assistance with high precision for the upper limb and the lower limb impairments. The present review summarizes the generation and background of robotic implementation for patient support, progress, present status, and future requirements.

Can Prosthetic Hands Mimic a Healthy Human Hand?

Historical evidence suggests that prostheses have been used since ancient Egyptian times. Prostheses were usually utilized for function and cosmetic appearances. Nowadays, with the advancement of technology, prostheses such as artificial hands can not only improve functional, but have psychological advantages as well and, therefore, can significantly enhance an individual’s standard of living. Combined with advanced science, a prosthesis is not only a simple mechanical device, but also an aesthetic, engineering and medical marvel. Prosthetic limbs are the best tools to help amputees reintegrate into society. In this article, we discuss the background and advancement of prosthetic hands with their working principles and possible future implications. We also leave with an open question to the readers whether prosthetic hands could ever mimic and replace our biological hands.

A Roadmap Towards Standards for Neurally Controlled End Effectors

The control and manipulation of various types of end effectors such as powered exoskeletons, prostheses, and ‘neural’ cursors by brain-machine interface (BMI) systems has been the target of many research projects. A seamless “plug and play” interface between any BMI and end effector is desired, wherein similar user's intent cause similar end effectors to behave identically. This report is based on the outcomes of an IEEE Standards Association Industry Connections working group on End Effectors for Brain-Machine Interfacing that convened to identify and address gaps in the existing standards for BMI-based solutions with a focus on the end-effector component. A roadmap towards standardization of end effectors for BMI systems is discussed by identifying current device standards that are applicable for end effectors. While current standards address basic electrical and mechanical safety, and to some extent, performance requirements, several gaps exist pertaining to unified terminologies, data communication protocols, patient safety and risk mitigation.

Feasibility and Safety of Bilateral Hybrid EEG/EOG Brain/Neural-Machine Interaction

Cervical spinal cord injuries (SCIs) often lead to loss of motor function in both hands and legs, limiting autonomy and quality of life. While it was shown that unilateral hand function can be restored after SCI using a hybrid electroencephalography/electrooculography (EEG/EOG) brain/neural hand exoskeleton (B/NHE), it remained unclear whether such hybrid paradigm also could be used for operating two hand exoskeletons, e.g., in the context of bimanual tasks such as eating with fork and knife. To test whether EEG/EOG signals allow for fluent and reliable as well as safe and user-friendly bilateral B/NHE control, eight healthy participants (six females, mean age 24.1 ± 3.2 years) as well as four chronic tetraplegics (four males, mean age 51.8 ± 15.2 years) performed a complex sequence of EEG-controlled bilateral grasping and EOG-controlled releasing motions of two exoskeletons visually presented on a screen. A novel EOG command performed by prolonged horizontal eye movements (>1 s) to the left or right was introduced as a reliable switch to activate either the left or right exoskeleton. Fluent EEG control was defined as average “time to initialize” (TTI) grasping motions below 3 s. Reliable EEG control was assumed when classification accuracy exceeded 80%. Safety was defined as “time to stop” (TTS) all unintended grasping motions within 2 s. After the experiment, tetraplegics were asked to rate the user-friendliness of bilateral B/NHE control using Likert scales. Average TTI and accuracy of EEG-controlled operations ranged at 2.14 ± 0.66 s and 85.89 ± 15.81% across healthy participants and at 1.90 ± 0.97 s and 81.25 ± 16.99% across tetraplegics. Except for one tetraplegic, all participants met the safety requirements. With 88 ± 11% of the maximum achievable score, tetraplegics rated the control paradigm as user-friendly and reliable. These results suggest that hybrid EEG/EOG B/NHE control of two assistive devices is feasible and safe, paving the way to test this paradigm in larger clinical trials performing bimanual tasks in everyday life environments.

Application of a neural interface for restoration of leg movements: Intra-spinal stimulation using the brain electrical activity in spinally injured rabbits

This study aimed to design a neural interface that extracts movement commands from the brain to generate appropriate intra-spinal stimulation to restore leg movement. This study comprised four steps: (1) Recording electrocorticographic (ECoG) signals and corresponding leg movements in different trials. (2) Partial laminectomy to induce spinal cord injury (SCI) and detect motor modules in the spinal cord. (3) Delivering appropriate intra-spinal stimulation to the motor modules for restoration of the movements to those documented before SCI. (4) Development of a neural interface created by sparse linear regression (SLiR) model to detect movement commands transmitted from the brain to the modules. Correlation coefficient (CC) and normalized root mean square (NRMS) error was calculated to evaluate the neural interface effectiveness. It was found that by stimulating detected spinal cord modules, joint angle evaluated before SCI was not significantly different from that of post-SCI (P > 0.05). Based on results of SLiR model, overall CC and NRMS values were 0.63 ± 0.14 and 0.34 ± 0.16 (mean ± SD), respectively. These results indicated that ECoG data contained information about intra-spinal stimulations and the developed neural interface could produce intra-spinal stimulation based on ECoG data, for restoration of leg movements after SCI.

"I Felt the Ball"-The Future of Spine Injury Recovery

Spinal cord injury (SCI) has no cure and individuals with SCI become dependent on others for life. After injury, the signals below the lesion are disrupted, but the brain still produces motor commands. Researchers have bypassed this obstacle, which has given rise to the brain-machine interface (BMI). BMI devices are implanted in the brain or spinal cord, where they decode and send signals beyond the injured segment. Experiments were initially conducted on animals, with favorable results. BMIs are classified according to their type, function, signal generation, and so on. Because of invasiveness, their long-term use is questionable, because of infections and complications. The use of an implantable epidural array in patients with chronic SCI showed that participants were able to walk with the help of a stimulator, and after months of training, they were able to walk with the stimulator turned off. Another innovation is a robotic suit for paraplegics and tetraplegics that supports the movement of limbs. The research on stem cells has not shown favorable results. In future, one of these cutting-edge technologies will prevail over the other, but BMI seems to have the upper hand. The future of BMI with fusion of robotics and artificial intelligence is promising for patients with chronic SCI. These modern devices need to be less invasive, biocompatible, easily programmable, portable, and cost-effective. After these hurdles are overcome, the devices may become the mainstay of potential rehabilitation therapy for partial recovery. The time may come when all patients with severe SCI are told "You will walk again."

Closed-Loop Neuromodulation in Physiological and Translational Research

Neuromodulation, the focused delivery of energy to neural tissue to affect neural or physiological processes, is a common method to study the physiology of the nervous system. It is also successfully used as treatment for disorders in which the nervous system is affected or implicated. Typically, neurostimulation is delivered in open-loop mode (i.e., according to a predetermined schedule and independently of the state of the organ or physiological system whose function is sought to be modulated). However, the physiology of the nervous system or the modulated organ can be dynamic, and the same stimulus may have different effects depending on the underlying state. As a result, open-loop stimulation may fail to restore the desired function or cause side effects. In such cases, a neuromodulation intervention may be preferable to be administered in closed-loop mode. In a closed-loop neuromodulation (CLN) system, stimulation is delivered when certain physiological states or conditions are met (responsive neurostimulation); the stimulation parameters can also be adjusted dynamically to optimize the effect of stimulation in real time (adaptive neurostimulation). In this review, the reasons and the conditions for using CLN are discussed, the basic components of a CLN system are described, and examples of CLN systems used in physiological and translational research are presented.

Rehabilitative Training in Animal Models of Spinal Cord Injury

Rehabilitative motor training is currently one of the most widely used approaches to promote moderate recovery following injuries of the central nervous system. Such training is generally applied in the clinical setting, whereas it is not standard in preclinical research. This is a concern as it is becoming increasingly apparent that neuroplasticity enhancing treatments require training or some form of activity as a co-therapy to promote functional recovery. Despite the importance of training and the many open questions regarding its mechanistic consequences, its use in preclinical animal models is rather limited. Here we review approaches, findings and challenges when training is applied in animal models of spinal cord injury, and we suggest recommendations to facilitate the integration of training using an appropriate study design, into pre-clinical studies.

DESIGN OF CONTROL SYSTEM FOR MOTOR IMAGERY BASED NEURO-AID APPLICATION

The application of Brain Computer Interface (BCI) for rehabilitation purpose has gained wide popularity in recent times. BCI for rehabilitation involves detection of brain signals, when the subject performs some sort of Motor Imagery (MI) task, for example, imagination of movement of limbs. Imagination of such movement causes desynchronization of neurons of one part of the brain gets within other parts synchronized. Band power features are best suited for quantification of the synchronization phenomenon. In the present work, extreme learning machine (ELM) and support vector machine (SVM) based classifiers are used to classify the test data. The classifier output is further used to generate control signals for driving a stepper motor, which may be used to drive some neuro-aid application device. In order to achieve a workable model for pragmatic applications, it is necessary to design a robust in nature stepper motor. Open loop analysis, closed loop analysis and performance analysis of motor with possible disturbances are carried out to evaluate the effectiveness of the proposed work. The maximum accuracy using ELM and SVM classifiers are achieved as 90% and 87.78% with a training time of 0.2496[Formula: see text]s and 3.964[Formula: see text]s, respectively. In the open loop and closed loop analysis, the desired angular movement (task imagined for rehabilitation) is achieved with an accuracy of 54.14% and 93.4%, respectively. These results suggest that a BCI system can be designed with higher efficiency with the help of MI data.

Transspinal stimulation increases motoneuron output of multiple segments in human spinal cord injury

Targeted neuromodulation strategies that strengthen neuronal activity are in great need for restoring sensorimotor function after chronic spinal cord injury (SCI). In this study, we established changes in the motoneuron output of individuals with and without SCI after repeated noninvasive transspinal stimulation at rest over the thoracolumbar enlargement, the spinal location of leg motor circuits. Cases of motor incomplete and complete SCI were included to delineate potential differences when corticospinal motor drive is minimal. All 10 SCI and 10 healthy control subjects received daily monophasic transspinal stimuli of 1-ms duration at 0.2 Hz at right soleus transspinal evoked potential (TEP) subthreshold and suprathreshold intensities at rest. Before and two days after cessation of transspinal stimulation, we determined changes in TEP recruitment input-output curves, TEP amplitude at stimulation frequencies of 0.1, 0.125, 0.2, 0.33 and 1.0 Hz, and TEP postactivation depression upon transspinal paired stimuli at interstimulus intervals of 60, 100, 300, and 500 ms. TEPs were recorded at rest from bilateral ankle and knee flexor/extensor muscles. Repeated transspinal stimulation increased the motoneuron output over multiple segments. In control and complete SCI subjects, motoneuron output increased for knee muscles, while in motor incomplete SCI subjects motoneuron output increased for both ankle and knee muscles. In control subjects, TEPs homosynaptic and postactivation depression were present at baseline, and were potentiated for the distal ankle or knee flexor muscles. TEPs homosynaptic and postactivation depression at baseline depended on the completeness of the SCI, with minimal changes observed after transspinal stimulation. These results indicate that repeated transspinal stimulation increases spinal motoneuron responsiveness of ankle and knee muscles in the injured human spinal cord, and thus can promote motor recovery. This noninvasive neuromodulation method is a promising modality for promoting functional neuroplasticity after SCI.

HD-EEG Based Classification of Motor-Imagery Related Activity in Patients With Spinal Cord Injury

Brain computer interfaces (BCIs) are thought to revolutionize rehabilitation after SCI, e.g., by controlling neuroprostheses, exoskeletons, functional electrical stimulation, or a combination of these components. However, most BCI research was performed in healthy volunteers and it is unknown whether these results can be translated to patients with spinal cord injury because of neuroplasticity. We sought to examine whether high-density EEG (HD-EEG) could improve the performance of motor-imagery classification in patients with SCI. We recorded HD-EEG with 256 channels in 22 healthy controls and 7 patients with 14 recordings (4 patients had more than one recording) in an event related design. Participants were instructed acoustically to either imagine, execute, or observe foot and hand movements, or to rest. We calculated Fast Fourier Transform (FFT) and full frequency directed transfer function (ffDTF) for each condition and classified conditions pairwise with support vector machines when using only 2 channels over the sensorimotor area, full 10-20 montage, high-density montage of the sensorimotor cortex, and full HD-montage. Classification accuracies were comparable between patients and controls, with an advantage for controls for classifications that involved the foot movement condition. Full montages led to better results for both groups (p < 0.001), and classification accuracies were higher for FFT than for ffDTF (p < 0.001), for which the feature vector might be too long. However, full-montage 10–20 montage was comparable to high-density configurations. Motor-imagery driven control of neuroprostheses or BCI systems may perform as well in patients as in healthy volunteers with adequate technical configuration. We suggest the use of a whole-head montage and analysis of a broad frequency range.

Neuromodulation in the restoration of function after spinal cord injury

Neuromodulation, the use of electrical interfaces to alter neuronal activity, has been successful as a treatment approach in several neurological disorders, including deep brain stimulation for Parkinson's disease and epidural spinal stimulation for chronic pain. Neuromodulation can also be beneficial for spinal cord injury, from assisting basic functions such as respiratory pacing and bladder control, through to restoring volitional movements and skilled hand function. Approaches range from electrical stimulation of peripheral muscles, either directly or via brain-controlled bypass devices, to stimulation of the spinal cord and brain. Limitations to widespread clinical application include durability of neuromodulation devices, affordability and accessibility of some approaches, and poor understanding of the underlying mechanisms. Efforts to overcome these challenges through advances in technology, together with pragmatic knowledge gained from clinical trials and basic research, could lead to personalised neuromodulatory interventions to meet the specific needs of individuals with spinal cord injury.

Influence of trans-spinal magnetic stimulation in electrophysiological recordings for closed-loop rehabilitative systems

Recent studies have shown the feasibility of spinal cord stimulation (SCS) for motor rehabilitation. Currently, there is an increasing interest in developing closed-loop systems employing SCS for lower-limb recovery. These closed-loop systems are based on the use of neurophysiological signals to modulate the stimulation. It is known that electromagnetic stimulation can introduce undesirable noise to the electrophysiological recordings. However, there is little evidence about how electroencephalographic (EEG) or electromyographic (EMG) activities are corrupted when a trans-spinal magnetic stimulation is applied. This paper studies the effects of magnetic SCS in EEG and EMG activity. Furthermore, a median filter is proposed to ameliorate the effects of the artifacts, and to preserve the neural activity. Our results show that SCS can affect both EEG and EMG, and that, while the median filter works well to clean the EEG activity, it did not improve the contaminations of the EMG activity. The obtained results underline the need of cleaning EMG and EEG signals contaminated by SCS, which is essential for optimal closed-loop rehabilitation.

Neuropathic Pain After Spinal Cord Injury: Challenges and Research Perspectives

Neuropathic pain is a debilitating consequence of spinal cord injury (SCI) that remains difficult to treat because underlying mechanisms are not yet fully understood. In part, this is due to limitations of evaluating neuropathic pain in animal models in general, and SCI rodents in particular. Though pain in patients is primarily spontaneous, with relatively few patients experiencing evoked pains, animal models of SCI pain have primarily relied upon evoked withdrawals. Greater use of operant tasks for evaluation of the affective dimension of pain in rodents is needed, but these tests have their own limitations such that additional studies of the relationship between evoked withdrawals and operant outcomes are recommended. In preclinical SCI models, enhanced reflex withdrawal or pain responses can arise from pathological changes that occur at any point along the sensory neuraxis. Use of quantitative sensory testing for identification of optimal treatment approach may yield improved identification of treatment options and clinical trial design. Additionally, a better understanding of the differences between mechanisms contributing to at- versus below-level neuropathic pain and neuropathic pain versus spasticity may shed insights into novel treatment options. Finally, the role of patient characteristics such as age and sex in pathogenesis of neuropathic SCI pain remains to be addressed.

Measurement of neurovascular coupling in human motor cortex using simultaneous transcranial Doppler and electroencephalography

OBJECTIVE

Event-related desynchronization (ERD) is a relative power decrease of electroencephalogram (EEG) signals in a specific frequency band during physical motor execution, while transcranial Doppler (TCD) measures cerebral blood flow velocity. The objective of this study was to investigate the neurovascular coupling in the motor cortex by using an integrated EEG and TCD system, and to find any difference in hemodynamic responses in healthy young male and female adults.

APPROACH

Thirty healthy volunteers, aged 20-30 years, were recruited for this study. The subjects were asked to perform a motor task for the duration of a provided visual cue. Simultaneous EEG and TCD recording was carried out using a new integrated system to detect the ERD arising from the EEG signals, and to measure the mean blood flow velocity of the left and right middle cerebral arteries from bilateral TCD signals.

MAIN RESULTS

The results showed a significant decrease in EEG power in the mu band (7.5-12.5 Hz) during the motor task compared to the resting phase. It showed significant increase in desynchronization on the contralateral side of the motor task compared to the ipsilateral side. Mean blood flow velocity during the task phase was significantly higher in comparison with the resting phase at the contralateral side. The results also showed a significantly higher increase in the percentage of mean blood flow velocity in the contralateral side of motor task compared to the ipsilateral side. However, no significant difference in desynchronization or change of mean blood flow velocity was found between males and females.

SIGNIFICANCE

A combined TCD-EEG system successfully detects ERD and blood flow velocity in cerebral arteries, and can be used as a useful tool to study neurovascular coupling in the brain. There is no significant difference in the hemodynamic responses in healthy young males and females.

Volition-adaptive control for gait training using wearable exoskeleton: preliminary tests with incomplete spinal cord injury individuals

BACKGROUND

Gait training for individuals with neurological disorders is challenging in providing the suitable assistance and more adaptive behaviour towards user needs. The user specific adaptation can be defined based on the user interaction with the orthosis and by monitoring the user intentions. In this paper, an adaptive control model, commanded by the user intention, is evaluated using a lower limb exoskeleton with incomplete spinal cord injury individuals (SCI).

METHODS

A user intention based adaptive control model has been developed and evaluated with 4 incomplete SCI individuals across 3 sessions of training per individual. The adaptive control model modifies the joint impedance properties of the exoskeleton as a function of the human-orthosis interaction torques and the joint trajectory evolution along the gait sequence, in real time. The volitional input of the user is identified by monitoring the neural signals, pertaining to the user's motor activity. These volitional inputs are used as a trigger to initiate the gait movement, allowing the user to control the initialization of the exoskeleton movement, independently. A Finite-state machine based control model is used in this set-up which helps in combining the volitional orders with the gait adaptation.

RESULTS

The exoskeleton demonstrated an adaptive assistance depending on the patients' performance without guiding them to follow an imposed trajectory. The exoskeleton initiated the trajectory based on the user intention command received from the brain machine interface, demonstrating it as a reliable trigger. The exoskeleton maintained the equilibrium by providing suitable assistance throughout the experiments. A progressive change in the maximum flexion of the knee joint was observed at the end of each session which shows improvement in the patient performance. Results of the adaptive impedance were evaluated by comparing with the application of a constant impedance value. Participants reported that the movement of the exoskeleton was flexible and the walking patterns were similar to their own distinct patterns.

CONCLUSIONS

This study demonstrates that user specific adaptive control can be applied on a wearable robot based on the human-orthosis interaction torques and modifying the joints' impedance properties. The patients perceived no external or impulsive force and felt comfortable with the assistance provided by the exoskeleton. The main goal of such a user dependent control is to assist the patients' needs and adapt to their characteristics, thus maximizing their engagement in the therapy and avoiding slacking. In addition, the initiation directly controlled by the brain allows synchronizing the user's intention with the afferent stimulus provided by the movement of the exoskeleton, which maximizes the potentiality of the system in neuro-rehabilitative therapies.

Ethical aspects of brain computer interfaces: a scoping review

BACKGROUND

Brain-Computer Interface (BCI) is a set of technologies that are of increasing interest to researchers. BCI has been proposed as assistive technology for individuals who are non-communicative or paralyzed, such as those with amyotrophic lateral sclerosis or spinal cord injury. The technology has also been suggested for enhancement and entertainment uses, and there are companies currently marketing BCI devices for those purposes (e.g., gaming) as well as health-related purposes (e.g., communication). The unprecedented direct connection created by BCI between human brains and computer hardware raises various ethical, social, and legal challenges that merit further examination and discussion.

METHODS

To identify and characterize the key issues associated with BCI use, we performed a scoping review of biomedical ethics literature, analyzing the ethics concerns cited across multiple disciplines, including philosophy and medicine.

RESULTS

Based on this investigation, we report that BCI research and its potential translation to therapeutic intervention generate significant ethical, legal, and social concerns, notably with regards to personhood, stigma, autonomy, privacy, research ethics, safety, responsibility, and justice. Our review of the literature determined, furthermore, that while these issues have been enumerated extensively, few concrete recommendations have been expressed.

CONCLUSIONS

We conclude that future research should focus on remedying a lack of practical solutions to the ethical challenges of BCI, alongside the collection of empirical data on the perspectives of the public, BCI users, and BCI researchers.

A Systematic Review of Investigations into Functional Brain Connectivity Following Spinal Cord Injury

Background: Complete or incomplete spinal cord injury (SCI) results in varying degree of motor, sensory and autonomic impairment. Long-lasting, often irreversible disability results from disconnection of efferent and afferent pathways. How does this disconnection affect brain function is not so clear. Changes in brain organization and structure have been associated with SCI and have been extensively studied and reviewed. Yet, our knowledge regarding brain connectivity changes following SCI is overall lacking.

Methods: In this study we conduct a systematic review of articles regarding investigations of functional brain networks following SCI, searching on PubMed, Scopus and ScienceDirect according to PRISMA-P 2015 statement standards.

Results: Changes in brain connectivity have been shown even during the early stages of the chronic condition and correlate with the degree of neurological impairment. Connectivity changes appear as dynamic post-injury procedures. Sensorimotor networks of patients and healthy individuals share similar patterns but new functional interactions have been identified as unique to SCI networks.

Conclusions: Large-scale, multi-modal, longitudinal studies on SCI patients are needed to understand how brain network reorganization is established and progresses through the course of the condition. The expected insight holds clinical relevance in preventing maladaptive plasticity after SCI through individualized neurorehabilitation, as well as the design of connectivity-based brain-computer interfaces and assistive technologies for SCI patients.

Preventing Neurodegenerative Memory Loss in Hopfield Neuronal Networks Using Cerebral Organoids or External Microelectronics

Developing technologies have made significant progress towards linking the brain with brain-machine interfaces (BMIs) which have the potential to aid damaged brains to perform their original motor and cognitive functions. We consider the viability of such devices for mitigating the deleterious effects of memory loss that is induced by neurodegenerative diseases and/or traumatic brain injury (TBI). Our computational study considers the widely used Hopfield network, an autoassociative memory model in which neurons converge to a stable state pattern after receiving an input resembling the given memory. In this study, we connect an auxiliary network of neurons, which models the BMI device, to the original Hopfield network and train it to converge to its own auxiliary memory patterns. Injuries to the original Hopfield memory network, induced through neurodegeneration, for instance, can then be analyzed with the goal of evaluating the ability of the BMI to aid in memory retrieval tasks. Dense connectivity between the auxiliary and Hopfield networks is shown to promote robustness of memory retrieval tasks for both optimal and nonoptimal memory sets. Our computations estimate damage levels and parameter ranges for which full or partial memory recovery is achievable, providing a starting point for novel therapeutic strategies.

Towards Rehabilitation Robotics: Off-the-Shelf BCI Control of Anthropomorphic Robotic Arms

Advances in neural interfaces have demonstrated remarkable results in the direction of replacing and restoring lost sensorimotor function in human patients. Noninvasive brain-computer interfaces (BCIs) are popular due to considerable advantages including simplicity, safety, and low cost, while recent advances aim at improving past technological and neurophysiological limitations. Taking into account the neurophysiological alterations of disabled individuals, investigating brain connectivity features for implementation of BCI control holds special importance. Off-the-shelf BCI systems are based on fast, reproducible detection of mental activity and can be implemented in neurorobotic applications. Moreover, social Human-Robot Interaction (HRI) is increasingly important in rehabilitation robotics development. In this paper, we present our progress and goals towards developing off-the-shelf BCI-controlled anthropomorphic robotic arms for assistive technologies and rehabilitation applications. We account for robotics development, BCI implementation, and qualitative assessment of HRI characteristics of the system. Furthermore, we present two illustrative experimental applications of the BCI-controlled arms, a study of motor imagery modalities on healthy individuals' BCI performance, and a pilot investigation on spinal cord injured patients' BCI control and brain connectivity. We discuss strengths and limitations of our design and propose further steps on development and neurophysiological study, including implementation of connectivity features as BCI modality.

Human Thalamic Somatosensory Nucleus (Ventral Caudal, Vc) as a Locus for Stimulation by INPUTS from Tactile, Noxious and Thermal Sensors on an Active Prosthesis

The forebrain somatic sensory locus for input from sensors on the surface of an active prosthesis is an important component of the Brain Machine Interface. We now review the neuronal responses to controlled cutaneous stimuli and the sensations produced by Threshold Stimulation at Microampere current levels (TMIS) in such a locus, the human thalamic Ventral Caudal nucleus (Vc). The responses of these neurons to tactile stimuli mirror those for the corresponding class of tactile mechanoreceptor fiber in the peripheral nerve, and TMIS can evoke sensations like those produced by the stimuli that optimally activate each class. These neuronal responses show a somatotopic arrangement from lateral to medial in the sequence: leg, arm, face and intraoral structures. TMIS evoked sensations show a much more detailed organization into anterior posteriorly oriented rods, approximately 300 microns diameter, that represent smaller parts of the body, such as parts of individual digits. Neurons responding to painful and thermal stimuli are most dense around the posterior inferior border of Vc, and TMIS evoked pain sensations occur in one of two patterns: (i) pain evoked regardless of the frequency or number of spikes in a burst of TMIS; and (ii) the description and intensity of the sensation changes with increasing frequencies and numbers. In patients with major injuries leading to loss of somatic sensory input, TMIS often evokes sensations in the representation of parts of the body with loss of sensory input, e.g., the phantom after amputation. Some patients with these injuries have ongoing pain and pain evoked by TMIS of the representation in those parts of the body. Therefore, thalamic TMIS may produce useful patterned somatotopic feedback to the CNS from sensors on an active prosthesis that is sometimes complicated by TMIS evoked pain in the representation of those parts of the body.

Electrical neuromodulation of the cervical spinal cord facilitates forelimb skilled function recovery in spinal cord injured rats

Enabling motor control by epidural electrical stimulation of the spinal cord is a promising therapeutic technique for the recovery of motor function after a spinal cord injury (SCI). Although epidural electrical stimulation has resulted in improvement in hindlimb motor function, it is unknown whether it has any therapeutic benefit for improving forelimb fine motor function after a cervical SCI. We tested whether trains of pulses delivered at spinal cord segments C6 and C8 would facilitate the recovery of forelimb fine motor control after a cervical SCI in rats. Rats were trained to reach and grasp sugar pellets. Immediately after a dorsal funiculus crush at C4, the rats showed significant deficits in forelimb fine motor control. The rats were tested to reach and grasp with and without cervical epidural stimulation for 10weeks post-injury. To determine the best stimulation parameters to activate the cervical spinal networks involved in forelimb motor function, monopolar and bipolar currents were delivered at varying frequencies (20, 40, and 60Hz) concomitant with the reaching and grasping task. We found that cervical epidural stimulation increased reaching and grasping success rates compared to the no stimulation condition. Bipolar stimulation (C6- C8+ and C6+ C8-) produced the largest spinal motor-evoked potentials (sMEPs) and resulted in higher reaching and grasping success rates compared with monopolar stimulation (C6- Ref+ and C8- Ref+). Forelimb performance was similar when tested at stimulation frequencies of 20, 40, and 60Hz. We also found that the EMG activity in most forelimb muscles as well as the co-activation between flexor and extensor muscles increased post-injury. With epidural stimulation, however, this trend was reversed indicating that cervical epidural spinal cord stimulation has therapeutic potential for rehabilitation after a cervical SCI.