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Throughout training, the potential occurrence of functional cortical plasticity was evaluated through longitudinal analyses of EEG recordings. For this, patients were instructed to imagine movements of their own legs while EEG signals from 11 scalp electrodes were recorded over the leg primary somatosensory and motor cortical areas. Independent Component Analysis (ICA,39) was employed to determine potential cortical sources, represented by individual independent components (ICs), of novel leg representations in the primary motor and somatosensory cortices and to detect functional changes of these representations over time. To evaluate brain dynamics modulation, before and after many months of training, we calculated for each IC the Event Related Spectral Perturbations (ERSPs) with respect to a baseline of 1 second prior to the event and normalized by the average power across trials at each frequency. Event Related Potentials (ERPs), sampled from two EEG electrodes located over the leg representation area, averaged over all patients, before and after training, were also calculated and used for statistical comparison.
In both animals68,69 and humans70, central pattern generators (CPGs) have been shown to generate bilateral rhythmic patterns, alternating motor activity between the flexor and extensor motoneurons in the absence of descending inputs71. Animal studies have shown that the gait pattern itself is generated in the spinal cord by CPGs, which are modulated by a peripheral sensory feedback. Conversely, once gait is re-established, proprioceptive and cutaneous afferents signals derived from receptors located in muscles, joints and skin, can once again drive intraspinal circuits that interact with motor neurons, interneurons and CPGs in order to assist movement adaptations, such as postural corrections69. The level of this CPG activity would be determined by the brainstem locomotor command systems through the reticulospinal pathways68 (Fig. 5). The existence of CPGs in humans has been suggested, but its exact location is still unclear71.
Based on our clinical findings, we propose that long-term gait training with a BWS that employs BMI-based robotic actuators, combined with rich tactile feedback, could recruit the activation of CPGs in SCI patients81. Likely, BMI-based training and tactile feedback in a virtual reality environment could also enhance CPG activity by recruiting cortical afferents to influence locomotion control. If some corticospinal or vestibulospinal axons are still intact in a fraction of SCI patients, these locomotion-related signals could reach lower alpha-motor neurons below the level of the SCI. Moreover, by making patients walk routinely upright and against load, peripheral tactile and proprioceptive feedback would be generated and transmitted back to the spinal cord, contributing to the process of spinal cord functional reorganization (Fig. 6B).
Although there was heterogeneity in the response of tumours to single agent gefitinib, there was no relationship between immunostaining for EGFR and gefitinib activity, consistent with other published studies [26]. Sirotnak et al. [9] showed that gefitinib caused growth inhibition in human tumour xenografts that was not dependent on high levels of EGFR expression. However, EGFR activation leads to activation of at least three separate second messenger cascades. While the ras/raf pathway may mediate the proliferative effects, survival signals are thought be mediated by the PI3/Akt pathway. As cells have to die in the ATP-TCA to register increased inhibition, sensitivity might be related to the degree of activation of the Akt pathway by other mechanisms. Sensitivity to gefitinib and other non-TKI EGFR inhibitors might therefore be related to pathway activation assessed by detection of pAkt, rather than the levels of EGFR expression. However, this study has not found any such relationship and, when EGFR staining was compared to pAkt staining there was no correlation between EGFR levels to pAkt activity. A similar observation was made by Campiglio et al., [27] whose data suggested that neither MAPK nor pAkt were reliable markers of gefitinib activity. It should be noted that many receptors lead to Akt activation and that constitutive activation of the PI3/Akt pathway may be the result of PTEN inactivation. 2b1af7f3a8