An intracortical neuroprosthesis immediately alleviates walking deficits and improves recovery of leg control after spinal cord injury

Invasive Brain Computer Interface for Motor Restoration in Spinal Cord Injury: A Systematic Review

STUDY DESIGN

Systematic review of the literature.

OBJECTIVES

In recent years, brain-computer interface (BCI) has emerged as a potential treatment for patients with spinal cord injury (SCI). This is the first systematic review of the literature on invasive closed-loop BCI technologies for the treatment of SCI in humans.

MATERIALS AND METHODS

A comprehensive search of PubMed MEDLINE, Web of Science, and Ovid EMBASE was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Of 8316 articles collected, 19 studies met all the inclusion criteria. Data from 21 patients were extracted from these studies. All patients sustained a cervical SCI and were treated using either a BCI with intracortical microelectrode arrays (n = 18, 85.7%) or electrocorticography (n = 3, 14.3%). To decode these neural signals, machine learning and statistical models were used: support vector machine in eight patients (38.1%), linear estimator in seven patients (33.3%), Hidden Markov Model in three patients (14.3%), and other in three patients (14.3%). As the outputs, ten patients (47.6%) underwent noninvasive functional electrical stimulation (FES) with a cuff; one (4.8%) had an invasive FES with percutaneous stimulation, and ten (47.6%) used an external device (neuroprosthesis or virtual avatar). Motor function was restored in all patients for each assigned task. Clinical outcome measures were heterogeneous across all studies.

CONCLUSIONS

Invasive techniques of BCI show promise for the treatment of SCI, but there is currently no technology that can restore complete functional autonomy in patients with SCI. The current techniques and outcomes of BCI vary greatly. Because invasive BCIs are still in the early stages of development, further clinical studies should be conducted to optimize the prognosis for patients with SCI.

Characterization of Sleep, Emotional, and Cognitive Functions in a New Rat Model of Concomitant Spinal Cord and Traumatic Brain Injuries

Traumatic injuries to the spinal cord or the brain have serious medical consequences and lead to long-term disability. The epidemiology, medical complications, and prognosis of isolated spinal cord injury (SCI) and traumatic brain injury (TBI) have been well described. However, there are limited data on patients suffering from concurrent SCI and TBI, even if a large proportion of SCI patients have concomitant TBI. The complications associated with this "dual-diagnosis" such as cognitive or behavioral dysfunction are well known in the rehabilitation setting, but evidence-based and standardized approaches for diagnosis and treatment are lacking. Our goal was to develop and characterize a pre-clinical animal model of concurrent SCI and TBI to help identifying "dual-diagnosis" tools. Female rats received a unilateral contusive SCI at the thoracic level alone (SCI group) or combined with a TBI centered on the contralateral sensorimotor cortex (SCI-TBI group). We first validated that the SCI extent was comparable between SCI-TBI and SCI groups, and that hindlimb function was impaired. We characterized various neurological outcomes, including locomotion, sleep architecture, brain activity during sleep, depressive- and anxiety-like behaviors, and working memory. We report that SCI-TBI and SCI groups show similar impairments in global locomotor function. While wake/sleep amount and distribution and anxiety- and depression-like symptoms were not affected in SCI-TBI and SCI groups in comparison to the control group (laminectomy and craniotomy only), working memory was impaired only in SCI-TBI rats. This pre-clinical model of concomitant SCI and TBI, including more severe variations of it, shows a translational value for the identification of biomarkers to refine the "dual-diagnosis" of neurotrauma in humans.

The evolution of neuromodulation for chronic stroke: From neuroplasticity mechanisms to brain-computer interfaces

Stroke is one of the most common and debilitating neurological conditions worldwide. Those who survive experience motor, sensory, speech, vision, and/or cognitive deficits that severely limit remaining quality of life. While rehabilitation programs can help improve patients' symptoms, recovery is often limited, and patients frequently continue to experience impairments in functional status. In this review, invasive neuromodulation techniques to augment the effects of conventional rehabilitation methods are described, including vagus nerve stimulation (VNS), deep brain stimulation (DBS) and brain-computer interfaces (BCIs). In addition, the evidence base for each of these techniques, pivotal trials, and future directions are explored. Finally, emerging technologies such as functional near-infrared spectroscopy (fNIRS) and the shift to artificial intelligence-enabled implants and wearables are examined. While the field of implantable devices for chronic stroke recovery is still in a nascent stage, the data reviewed are suggestive of immense potential for reducing the impact and impairment from this globally prevalent disorder.

Gaussian-process-based Bayesian optimization for neurostimulation interventions in rats

Effective neural stimulation requires adequate parametrization. Gaussian-process (GP)-based Bayesian optimization (BO) offers a framework to discover optimal stimulation parameters in real time. Here, we first provide a general protocol to deploy this framework in neurostimulation interventions and follow by exemplifying its use in detail. Specifically, we describe the steps to implant rats with multi-channel electrode arrays in the hindlimb motor cortex. We then detail how to utilize the GP-BO algorithm to maximize evoked target movements, measured as electromyographic responses. For complete details on the use and execution of this protocol, please refer to Bonizzato and colleagues (2023).1.

Brain region changes following a spinal cord injury

Brain-related complications are common in clinical practice after spinal cord injury (SCI); however, the molecular mechanisms of these complications are still unclear. Here, we reviewed the changes in the brain regions caused by SCI from three perspectives: imaging, molecular analysis, and electrophysiology. Imaging studies revealed abnormal functional connectivity, gray matter volume atrophy, and metabolic abnormalities in brain regions after SCI, leading to changes in the structure and function of brain regions. At the molecular level, chemokines, inflammatory factors, and damage-associated molecular patterns produced in the injured area were retrogradely transmitted through the corticospinal tract, cerebrospinal fluid, or blood circulation to the specific brain area to cause pathologic changes. Electrophysiologic recordings also suggested abnormal changes in brain electrical activity after SCI. Transcranial magnetic stimulation, transcranial direct current stimulation, and deep brain stimulation alleviated pain and improved motor function in patients with SCI; therefore, transcranial therapy may be a new strategy for the treatment of patients with SCI.

Functional plasticity of glutamatergic neurons of medullary reticular nuclei after spinal cord injury in mice

Spinal cord injury disrupts the descending command from the brain and causes a range of motor deficits. Here, we use optogenetic tools to investigate the functional plasticity of the glutamatergic reticulospinal drive of the medullary reticular formation after a lateral thoracic hemisection in female mice. Sites evoking stronger excitatory descending drive in intact conditions are the most impaired after injury, whereas those associated with a weaker drive are potentiated. After lesion, pro- and anti-locomotor activities (that is, initiation/acceleration versus stop/deceleration) are overall preserved. Activating the descending reticulospinal drive improves stepping ability on a flat surface of chronically impaired injured mice, and its priming enhances recovery of skilled locomotion on a horizontal ladder. This study highlights the resilience and capacity for reorganization of the glutamatergic reticulospinal command after injury, along with its suitability as a therapeutical target to promote functional recovery.

Longitudinal optogenetic mapping reveals enhanced motor control by the contralesional cortex after traumatic brain injury in mice

Traumatic brain injury (TBI) is a significant cause of human disability, and understanding its spontaneous recovery pattern after injury is critical for potential treatments. However, studies on the function of the contralesional cortex after TBI have mostly focused on acute-phase changes, and long-term dynamic changes in the control of the affected limb by the contralesional cortex are less understood. To unravel long-term adaptations in the contralesional cortex, we developed a mouse model of TBI and used longitudinal optogenetic motor mapping to observe the function of contralesional corticospinal neurons (CSNs) projecting to the unilateral seventh cervical (C7) segment of the spinal cord. We injected a retrograde adeno-associated virus (AAV) expressing channelrhodopsin-2 to optogenetically stimulate and map the functional connections of the motor-sensory cortex. We validated the effectiveness of transcranial optogenetic stimulation for functional mapping and observed a general increase in the control of the affected limb by the contralesional cortex over time. Using retrograde labeling techniques, we showed that TBI does not affect the distribution of C7-CSNs but alters their function, and the labeled CSNs are concentrated in the caudal and rostral forelimb areas. Our findings provide new insights into harnessing contralesional cortical plasticity to improve treatment for affected limbs. This study sheds light on the long-term adaptations in the contralesional cortex after TBI, paving the way for potential clinical applications of optogenetic stimulation to improve motor control and rehabilitation outcomes.

Stretchable surface electromyography electrode array patch for tendon location and muscle injury prevention

Surface electromyography (sEMG) can provide multiplexed information about muscle performance. If current sEMG electrodes are stretchable, arrayed, and able to be used multiple times, they would offer adequate high-quality data for continuous monitoring. The lack of these properties delays the widespread use of sEMG in clinics and in everyday life. Here, we address these constraints by design of an adhesive dry electrode using tannic acid, polyvinyl alcohol, and PEDOT:PSS (TPP). The TPP electrode offers superior stretchability (~200%) and adhesiveness (0.58 N/cm) compared to current electrodes, ensuring stable and long-term contact with the skin for recording (>20 dB; >5 days). In addition, we developed a metal-polymer electrode array patch (MEAP) comprising liquid metal (LM) circuits and TPP electrodes. The MEAP demonstrated better conformability than commercial arrays, resulting in higher signal-to-noise ratio and more stable recordings during muscle movements. Manufactured using scalable screen-printing, these MEAPs feature a completely stretchable material and array architecture, enabling real-time monitoring of muscle stress, fatigue, and tendon displacement. Their potential to reduce muscle and tendon injuries and enhance performance in daily exercise and professional sports holds great promise.

A bi-cortical neuroprosthesis to modulate locomotion after incomplete spinal cord injury

Neuroprosthetic strategies seek to immediately alleviate deficits and reinstate voluntary control of movement. To facilitate recovery, it is crucial to gain a comprehensive understanding of the mechanisms involved in the return of intentional movement. Nevertheless, the precise relationship between the resurgence of cortical commands and the recovery of locomotion remains somewhat elusive. In the study conducted by Duguay, Bonizzato, Delivet-Mongrain, Fortier-Lebel and Martinez, we introduced a neuroprosthesis designed to deliver precise bi-cortical stimulation in a clinically relevant contusive spinal cord injury model. We conducted experiments in both healthy and spinal cord injured cats, where we fine-tuned the timing, duration, amplitude, and site of stimulation to modulate hindlimb locomotor output. In healthy cats, we observed a wide range of motor programs. However, after spinal cord injury, the induced hindlimb movements became highly stereotyped but were effective in modulating gait and reducing bilateral foot dragging. These results suggest that the neural basis for motor recovery traded off selectivity for effectiveness. Through a series of longitudinal assessments, we found that the restoration of locomotion following spinal cord injury was closely linked to the recovery of the descending neural drive. This underscores the importance of directing rehabilitation interventions toward the cortical target. The study results are discussed in terms of their impact and limitations.

Uncovering and leveraging the return of voluntary motor programs after paralysis using a bi-cortical neuroprosthesis

Rehabilitative and neuroprosthetic approaches after spinal cord injury (SCI) aim to reestablish voluntary control of movement. Promoting recovery requires a mechanistic understanding of the return of volition over action, but the relationship between re-emerging cortical commands and the return of locomotion is not well established. We introduced a neuroprosthesis delivering targeted bi-cortical stimulation in a clinically relevant contusive SCI model. In healthy and SCI cats, we controlled hindlimb locomotor output by tuning stimulation timing, duration, amplitude, and site. In intact cats, we unveiled a large repertoire of motor programs. After SCI, the evoked hindlimb lifts were highly stereotyped, yet effective in modulating gait and alleviating bilateral foot drag. Results suggest that the neural substrate underpinning motor recovery had traded-off selectivity for efficacy. Longitudinal tests revealed that the return of locomotion after SCI was correlated with recovery of the descending drive, which advocates for rehabilitation interventions directed at the cortical target.

Neural ensemble dynamics in trunk and hindlimb sensorimotor cortex encode for the control of postural stability

The cortex has a disputed role in monitoring postural equilibrium and intervening in cases of major postural disturbances. Here, we investigate the patterns of neural activity in the cortex that underlie neural dynamics during unexpected perturbations. In both the primary sensory (S1) and motor (M1) cortices of the rat, unique neuronal classes differentially covary their responses to distinguish different characteristics of applied postural perturbations; however, there is substantial information gain in M1, demonstrating a role for higher-order computations in motor control. A dynamical systems model of M1 activity and forces generated by the limbs reveals that these neuronal classes contribute to a low-dimensional manifold comprised of separate subspaces enabled by congruent and incongruent neural firing patterns that define different computations depending on the postural responses. These results inform how the cortex engages in postural control, directing work aiming to understand postural instability after neurological disease.

Autonomous optimization of neuroprosthetic stimulation parameters that drive the motor cortex and spinal cord outputs in rats and monkeys

Neural stimulation can alleviate paralysis and sensory deficits. Novel high-density neural interfaces can enable refined and multipronged neurostimulation interventions. To achieve this, it is essential to develop algorithmic frameworks capable of handling optimization in large parameter spaces. Here, we leveraged an algorithmic class, Gaussian-process (GP)-based Bayesian optimization (BO), to solve this problem. We show that GP-BO efficiently explores the neurostimulation space, outperforming other search strategies after testing only a fraction of the possible combinations. Through a series of real-time multi-dimensional neurostimulation experiments, we demonstrate optimization across diverse biological targets (brain, spinal cord), animal models (rats, non-human primates), in healthy subjects, and in neuroprosthetic intervention after injury, for both immediate and continual learning over multiple sessions. GP-BO can embed and improve "prior" expert/clinical knowledge to dramatically enhance its performance. These results advocate for broader establishment of learning agents as structural elements of neuroprosthetic design, enabling personalization and maximization of therapeutic effectiveness.

Composite Fibrin and Carbon Microfibre Implant to Modulate Postraumatic Inflammation after Spinal Cord Injury

Poor functional recovery after spinal cord injury (SCI) drives the development of novel strategies to manage this devastating condition. We recently showed promising immunomodulatory and pro-regenerative actions of bio-functionalized carbon microfibres (MFs) implanted in a rodent model of SCI. In order to maximize tissue repair while easing MF implantation, we produced a composite implant based on the embedding of several MFs within a fibrin hydrogel. We used intravital imaging of fluorescent reporter mice at the early stages and spinal sections of the same animals 3 months later to characterize the neuroinflammatory response to the implant and its impact on axonal regeneration. Whereas fibrin alone was inert in the first week, its enzymatic degradation drove the chronic activation of microglial cells and axonal degeneration within 3 months. However, the presence of MFs inside the fibrin hydrogel slowed down fibrin degradation and boosted the early recruitment of immune cells. Noteworthy, there was an enhanced contribution of monocyte-derived dendritic cells (moDCs), preceding a faster transition toward an anti-inflammatory environment with increased axonal regeneration over 3 months. The inclusion of MF here ensured the long-term biocompatibility of fibrin hydrogels, which would otherwise preclude successful spinal cord regeneration.

Functional contribution of mesencephalic locomotor region nuclei to locomotor recovery after spinal cord injury

Spinal cord injury (SCI) results in a disruption of information between the brain and the spinal circuit. Electrical stimulation of the mesencephalic locomotor region (MLR) can promote locomotor recovery in acute and chronic SCI rodent models. Although clinical trials are currently under way, there is still debate about the organization of this supraspinal center and which anatomic correlate of the MLR should be targeted to promote recovery. Combining kinematics, electromyographic recordings, anatomic analysis, and mouse genetics, our study reveals that glutamatergic neurons of the cuneiform nucleus contribute to locomotor recovery by enhancing motor efficacy in hindlimb muscles, and by increasing locomotor rhythm and speed on a treadmill, over ground, and during swimming in chronic SCI mice. In contrast, glutamatergic neurons of the pedunculopontine nucleus slow down locomotion. Therefore, our study identifies the cuneiform nucleus and its glutamatergic neurons as a therapeutical target to improve locomotor recovery in patients living with SCI.

Stretchable Surface Electrode Arrays Using an Alginate/PEDOT:PSS-Based Conductive Hydrogel for Conformal Brain Interfacing

An electrocorticogram (ECoG) is the electrical activity obtainable from the cerebral cortex and an informative source with considerable potential for future advanced applications in various brain-interfacing technologies. Considerable effort has been devoted to developing biocompatible, conformal, soft, and conductive interfacial materials for bridging devices and brain tissue; however, the implementation of brain-adaptive materials with optimized electrical and mechanical characteristics remains challenging. Herein, we present surface electrode arrays using the soft tough ionic conductive hydrogel (STICH). The newly proposed STICH features brain-adaptive softness with Young's modulus of ~9.46 kPa, which is sufficient to form a conformal interface with the cortex. Additionally, the STICH has high toughness of ~36.85 kJ/mm³, highlighting its robustness for maintaining the solid structure during interfacing with wet brain tissue. The stretchable metal electrodes with a wavy pattern printed on the elastomer were coated with the STICH as an interfacial layer, resulting in an improvement of the impedance from 60 kΩ to 10 kΩ at 1 kHz after coating. Acute in vivo experiments for ECoG monitoring were performed in anesthetized rodents, thereby successfully realizing conformal interfacing to the animal's cortex and the sensitive recording of electrical activity using the STICH-coated electrodes, which exhibited a higher visual-evoked potential (VEP) amplitude than that of the control device.

Natural and targeted circuit reorganization after spinal cord injury

A spinal cord injury disrupts communication between the brain and the circuits in the spinal cord that regulate neurological functions. The consequences are permanent paralysis, loss of sensation and debilitating dysautonomia. However, the majority of circuits located above and below the injury remain anatomically intact, and these circuits can reorganize naturally to improve function. In addition, various neuromodulation therapies have tapped into these processes to further augment recovery. Emerging research is illuminating the requirements to reconstitute damaged circuits. Here, we summarize these natural and targeted reorganizations of circuits after a spinal cord injury. We also advocate for new concepts of reorganizing circuits informed by multi-omic single-cell atlases of recovery from injury. These atlases will uncover the molecular logic that governs the selection of 'recovery-organizing' neuronal subpopulations, and are poised to herald a new era in spinal cord medicine.

New Therapy for Spinal Cord Injury: Autologous Genetically-Enriched Leucoconcentrate Integrated with Epidural Electrical Stimulation

The contemporary strategy for spinal cord injury (SCI) therapy aims to combine multiple approaches to control pathogenic mechanisms of neurodegeneration and stimulate neuroregeneration. In this study, a novel regenerative approach using an autologous leucoconcentrate enriched with transgenes encoding vascular endothelial growth factor (VEGF), glial cell line-derived neurotrophic factor (GDNF), and neural cell adhesion molecule (NCAM) combined with supra- and sub-lesional epidural electrical stimulation (EES) was tested on mini-pigs similar in morpho-physiological scale to humans. The complex analysis of the spinal cord recovery after a moderate contusion injury in treated mini-pigs compared to control animals revealed: better performance in behavioural and joint kinematics, restoration of electromyography characteristics, and improvement in selected immunohistology features related to cell survivability, synaptic protein expression, and glial reorganization above and below the injury. These results for the first time demonstrate the positive effect of intravenous infusion of autologous genetically-enriched leucoconcentrate producing recombinant molecules stimulating neuroregeneration combined with neuromodulation by translesional multisite EES on the restoration of the post-traumatic spinal cord in mini-pigs and suggest the high translational potential of this novel regenerative therapy for SCI patients.

Respiratory Training and Plasticity After Cervical Spinal Cord Injury

While spinal cord injuries (SCIs) result in a vast array of functional deficits, many of which are life threatening, the majority of SCIs are anatomically incomplete. Spared neural pathways contribute to functional and anatomical neuroplasticity that can occur spontaneously, or can be harnessed using rehabilitative, electrophysiological, or pharmacological strategies. With a focus on respiratory networks that are affected by cervical level SCI, the present review summarizes how non-invasive respiratory treatments can be used to harness this neuroplastic potential and enhance long-term recovery. Specific attention is given to "respiratory training" strategies currently used clinically (e.g., strength training) and those being developed through pre-clinical and early clinical testing [e.g., intermittent chemical stimulation via altering inhaled oxygen (hypoxia) or carbon dioxide stimulation]. Consideration is also given to the effect of training on non-respiratory (e.g., locomotor) networks. This review highlights advances in this area of pre-clinical and translational research, with insight into future directions for enhancing plasticity and improving functional outcomes after SCI.

Chronic inactivation of the contralesional hindlimb motor cortex after thoracic spinal cord hemisection impedes locomotor recovery in the rat

After incomplete spinal cord injury (SCI), cortical plasticity is involved in hindlimb locomotor recovery. Nevertheless, whether cortical activity is required for motor map plasticity and recovery remains unresolved. Here, we combined a unilateral thoracic spinal cord injury (SCI) with a cortical inactivation protocol that uncovered a functional role of contralesional cortical activity in hindlimb recovery and ipsilesional map plasticity. In adult rats, left hindlimb paralysis was induced by sectioning half of the spinal cord at the thoracic level (hemisection) and we used a continuous infusion of muscimol (GABA_A agonist, 10 mM, 0.11 µl/h) delivered via implanted osmotic pump (n = 9) to chronically inactivate the contralesional hindlimb motor cortex. Hemisected rats with saline infusion served as a SCI control group (n = 8), and intact rats with muscimol infusion served as an inactivation control group (n = 6). Locomotion was assessed in an open field, on a horizontal ladder, and on a treadmill prior to and for three weeks after hemisection. Cortical inactivation after hemisection significantly impeded hindlimb locomotor recovery in all tasks and specifically disrupted the ability of rats to generate proper flexion of the affected hindlimb during stepping compared to SCI controls, with no significant effect of inactivation in intact rats. Chronic and acute (n = 4) cortical inactivation after hemisection also significantly reduced the representation of the affected hindlimb in the ipsilesional motor cortex derived with intracortical microsimulation (ICMS). Our results provide evidence that residual activity in the contralesional hindlimb motor cortex after thoracic hemisection contributes to spontaneous locomotor recovery and map plasticity.