11782 • The Journal of Neuroscience, October 31, 2007 • 27(44):11782–11792

Symposium

Spinal Cord Injury: Time to Move?

Serge Rossignol,1,2 Martin Schwab,3,4 Michal Schwartz,5 and Michael G. Fehlings6
1Department of Physiology and Groupe de Recherche sur le Système Nerveux Central, University of Montreal, Faculty of Medicine, Montreal, Quebec,
Canada H3C 3J7, 2Multidisciplinary Team on Locomotor Rehabilitation, Canadian Institutes of Health Research, Ottawa, Ontario, Canada K1A 0W9, 3Brain
Research Institute, University of Zurich, CH-8057 Zurich, Switzerland, 4Department of Biology, Swiss Federal Institute of Technology, CH-8092 Zurich,
Switzerland, 5Department of Neurobiology, The Weizmann Institute of Science, Rehovot 76100, Israel, and 6University Health Network, University of
Toronto, Toronto, Ontario, Canada M5G 2C4

This symposium aims at summarizing some of the scientific bases for current or planned clinical trials in patients with spinal cord injury
(SCI). It stems from the interactions of four researchers involved in basic and clinical research who presented their work at a dedicated
Symposium of the Society for Neuroscience in San Diego. After SCI, primary and secondary damage occurs and several endogenous
processes are triggered that may foster or hinder axonal reconnection from supralesional structures. Studies in animals show that some
of these processes can be enhanced or decreased by exogenous interventions using drugs to diminish repulsive barriers (anti-Nogo,
anti-Rho) that prevent regeneration and/or sprouting of axons. Cell grafts are also envisaged to enhance beneficial immunological
mechanisms (autologous macrophages, vaccines) or remyelinate axons (oligodendrocytes derived from stem cells). Some of these
treatments could be planned concurrently with neurosurgical approaches that are themselves beneficial to decrease secondary damage
(e.g., decompression/reconstructive spinal surgery). Finally, rehabilitative approaches based on the presence of functional networks (i.e.,
central pattern generator) below the lesion combined with the above neurobiological approaches may produce significant functional
recovery of some sensorimotor functions, such as locomotion, by ensuring an optimal function of endogenous spinal networks and
establishing new dynamic interactions with supralesional structures. More work is needed on all fronts, but already the results offer great
hope for functional recovery after SCI based on sound basic and clinical neuroscience research.
Key words: central pattern generator; locomotion; macrophage; myelin repair; neuroinflammation; regeneration; Rho GTPases; spinal
cord injury; sprouting; stem cells

Introduction is thus important to pursue research on all aspects of spinal cord

It is estimated that the worldwide annual incidence of spinal cord injury, hoping that understanding basic mechanisms involved in
injury (SCI) is 22 per million of population and that there are actu- spinal cord injury will continue to establish therapeutic strategies
ally ⬃2.5 million survivors of SCI (http://www.rickhansenregistry. designed to alleviate such sensorimotor deficits and favor a better
org/page192.htm). SCI most often occurs in people in their mid-20s social reintegration of SCI patients.
who can anticipate a quasi-normal life expectancy albeit with chal- Extensive progress has been made on repair and recovery of
lenges to maintain an acceptable quality of life. This generates im- function after spinal injury in animal models and humans, and
portant personal, societal, and economic costs. Although life expect- the time has come to move even further in the investigation of the
ancy is very good, SCI patients suffer from some important validity and applicability of some of this new knowledge to the
handicaps (depending on the level and severity of the lesion) that clinical reality. Promising translational research must be based on
seriously diminish their quality of life (e.g., paralysis, sensory loss, concepts that have been solidly established in basic sciences, and
intractable pain, pressure sores, and urinary and other infections). It it is important to translate these basic concepts into clinical prac-
tice using a similar language. This was the aim of the Society for
Received July 30, 2007; revised Aug. 10, 2007; accepted Aug. 24, 2007. Neuroscience at the annual meeting held in San Diego and of this
M. Schwab was supported by Swiss National Science Foundation Grant 31-63633.00, the National Centres for symposium.
Competence in Research “Neural Plasticity and Repair” of the Swiss National Science Foundation, and the Spinal Cord
Consortium of the Christopher Reeve Foundation (Springfield, NJ). M. Schwartz holds the Maurice and Ilse Katz The general field of spinal cord injuries offers tremendous
Professorial Chair in Neuroimmunology. M.G.F. holds the Krembil Chair in Neural Repair and Regeneration at the challenges and opportunities for basic and clinical scientists. The
Toronto Western Hospital and University of Toronto and was supported by Canadian Institutes of Health Research repair of the spinal cord requires a good knowledge of the mech-
(CIHR) through an operating grant and a New Emerging Team Grant in Regenerative Medicine and Nanotechnology.
anisms of the lesion itself, of axonal growth, of anatomical and
S.R. was supported by individual and group grants from CIHR, as well as through the Multidisciplinary Team for
Locomotor Rehabilitation after Spinal Cord Injury and Stroke (Strategic Initiative on Regenerative Medicine and functional organization of the spinal cord, as well as of other
Nanomedicine) and a Canada Research Chair on the Spinal Cord. structures of the CNS. Studies on SCI have revealed an extensive
Correspondence should be addressed to Dr. Serge Rossignol, Department of Physiology, Groupe de Recherche sur potential for endogenous neuroplasticity (anatomical, neuro-
le Système Nerveux Central, Faculty of Medicine, Université de Montréal, P.O. Box 6128, Station Centre-Ville, Mon-
tréal, Québec, Canada H3C 3J7. E-mail: serge.rossignol@umontreal.ca.
chemical, and physiological) that could be manipulated (en-
DOI:10.1523/JNEUROSCI.3444-07.2007 hanced or diminished) by appropriate exogenous interventions
Copyright © 2007 Society for Neuroscience 0270-6474/07/2711782-11$15.00/0 (pharmacological, surgical, and rehabilitative). It is known now that
Rossignol et al. • Spinal Cord Injury: Time to Move? J. Neurosci., October 31, 2007 • 27(44):11782–11792 • 11783

although supraspinal commands that nor-

mally activate or control them may be al-
tered. Here the clinical approach is to facili-
tate through rehabilitation the maintenance
of the functionality of these circuits and fa-
vor the plastic reorganization of dynamic in-
teractions with descending pathways.
In this symposium, four researchers in-
volved in both basic and clinical sciences
have addressed these various issues with the
aim of critically reviewing and connecting
basic concepts (processes) that underlie on-
going or planned clinical interventions in
humans with SCI in the fields of spinal repair
and/or functional recovery. This symposium
is based on these four lectures, and the four
sections summarize the essential contribu-
tion of each speaker.

Antibodies against Nogo-A as a

therapeutic agent to enhance
regenerative growth and functional
recovery of the spinal cord injury (M.
Figure 1. Left, Schematic representation of a spinal lesion together with some descending pathways originating from the Schwab)
telencephalon or the brainstem. Some axons are lesioned, and others are intact although they could be demyelinated. Below the For a long time, the field of spinal cord
lesion, a CGP for locomotion interacts with descending inputs and peripheral afferents originating from a lower limb. Middle, injury research was paralyzed by the (at
Endogenous processes lead to sprouting of descending fibers but little axonal growth through the glial scar. Autonomous spinal that time intuitively plausible) dogma that
functions return to a certain degree. Right, Various exogenous interventions enhance or diminish some mechanisms that may help no major growth of nerve fibers would be
regeneration or sprouting. Cellular replacement may also favor beneficial immunological processes or foster remyelination.
possible within the adult brain and spinal
Rehabilitation such as treadmill training can accelerate and stabilize locomotor performance.
cord attributable to the inability of adult
neurons to grow. The demonstration that
the CNS has to some extent the capacity to regrow axons after injury lesioned CNS neurons can regenerate axons over very long dis-
when some barriers are partially lifted, that glial scar tissue at the site tances in the environment of a peripheral nerve transplant (Ri-
of the lesion can be manipulated so as to make it more permissive for chardson et al., 1984) and the subsequent discovery of specific
axonal growth, that stem cells can participate in remyelinating fibers neurite growth inhibitory factors in the adult CNS (Schwab and
damaged but not cut by the lesions, and finally that the spinal cord, Thoenen, 1985; Caroni and Schwab, 1988) removed this dog-
below the lesion, possesses a repertoire of primarily autonomous matic barrier and allowed to approach the problem of CNS injury
sensorimotor functions that can potentially be rehabilitated. and axonal regeneration with molecular and cell biological tech-
Figure 1 schematically represents (left) a spinal lesion that usually niques. Membrane, extracellular matrix, or secretory proteins or
results in a cavitation with various degrees of local damage. Axons glycoproteins with potent neurite growth inhibitory action were
originating from the telencephalon, the brainstem, or other suprale- found in particular in CNS white matter and myelin and in lesion
sional structures can be severed (only descending pathways are rep- scars. Starting with the identification of NI-250/Nogo-A, close to
resented for the sake of simplicity) or demyelinated at the site of the 10 myelin constituents with growth cone-collapsing and neurite
lesion. Below the lesion, some spinal circuits, although deprived of growth-inhibitory activity are currently known (Schwab, 2004)
some/all descending inputs remain essentially intact with afferent (Yiu and He, 2006). They include the three myelin proteins
feedback. Here only a spinal pattern generator (CGP) is indicated. Nogo-A, myelin-associated glycoprotein (MAG), and oligoden-
The middle and right columns of Figure 1 represent different drocyte–myelin glycoprotein (OMgp), several members of the
endogenous processes that are at work after such a spinal injury and Ephrin and semaphorin families, as well as specific proteogly-
clinical interventions that are underway or planned to manipulate cans. Neurite growth-inhibitory components of lesion scars have
some of these processes. Damaged axons may regenerate through been identified mainly as chondroitin sulfate proteoglycans,
the lesion if intrinsic axonal mechanisms preventing axonal growth semaphorins, and tenascin family members (Fawcett, 2006; Yiu
are controlled and extrinsic barriers (glial scar) are made more per- and He, 2006). All these components exert strong inhibitory ef-
missive. Thus, neurochemical approaches to diminish collapse of fects on growing neurites in vitro, either as culture substrates or in
growth cones or diminish the potent effect of myelin-derived inhib- a soluble form. Many of them are membrane proteins, however,
itory molecules have been devised. Undamaged axons may also and seem to exert their effects in direct cell– cell encounters.
sprout in an attempt to create new pathways that may bypass the In vivo studies in which the significance of individual inhibi-
spinal lesion. At the site of the lesion itself, important immunological tory factors could be tested especially for axonal regeneration and
mechanisms are at play, and these might be positively boosted to functional recovery require appropriate molecular tools.
enhance the repair mechanisms. Furthermore, some axons may still Function-blocking antibodies specifically recognizing Nogo-A
remain continuous but demyelinated so that they become nonfunc- have to be available in sufficient quantities to treat rats, mice, or
tional. Therapies to favor myelination by stem cells that may evolve monkeys over days or weeks (Schwab, 2004). Conventional
as oligodendrocytes is thus a valid approach. Finally, below the spinal knock-out animals are often of limited value because of compen-
lesion exist a number of functions whose intrinsic circuitry is intact satory mechanisms (Dimou et al., 2006). Blockers of second-
11784 • J. Neurosci., October 31, 2007 • 27(44):11782–11792 Rossignol et al. • Spinal Cord Injury: Time to Move?

blocking the scar-associated semaphorin 3A or Ephrin/EphA4

pathways (Niclou et al., 2006).

The physiological roles of myelin-associated inhibitory proteins.

The physiological roles of Nogo-A and the other neurite growth-
inhibitory proteins are not understood yet. Myelin formation is a
late event in CNS development and is probably induced by signals
coming from maturing axons that have reached their targets.
Nogo-A, MAG, and OMgp appear on the plasma membrane with
oligodendrocyte differentiation and myelin formation (Huber et
al., 2002; Wang et al., 2002). In this way, they may terminate
growth and branch formation in the maturing white matter tracts
and close down these CNS regions for fiber growth. In addition,
Nogo-A, which resides in the adaxonal membrane of myelin
(Huber et al., 2002; Wang et al., 2002), may send a tonic growth-
inhibitory signal to the axon and its cell body. Such retrograde
(positive) signals are well known for neurotrophins; myelin-
associated neurite growth inhibitors may thus act as stabilizers
and growth suppressors in the adult CNS. Experimental support
for this hypothesis comes from experiments in which function-
blocking antibodies against Nogo-A were applied to the intact
CNS of adult rats. Injection of three different anti-Nogo antibod-
ies into the adult cerebellum induced the upregulation of growth-
associated genes in Purkinje cells and collateral sprouting along
their axons (Zagrebelsky et al., 1998; Buffo et al., 2000; Gianola et
al., 2003). These effects were transitory, and sprouts disappeared
Figure 2. Molecular mechanisms involved in neurite growth inhibition in CNS myelin in- 3 weeks after the antibody injection. In the spinal cord of anti
clude Nogo-A, MAG, and OMgp and their signaling partners. Methods and reagents that were Nogo-A antibody-treated rats, collateral sprouting of corticospi-
successfully used to induce regenerative fiber growth and functional recovery in rats, mice, or nal axons occurred, along with the upregulation of cytoskeletal
monkeys after spinal cord injury are shown in red. Nogo-66, 66 aa extracellular domain of Nogo;
genes as observed by a transcriptomic screen (Bareyre et al.,
NgR, Nogo-66 receptor; Cai , intracellular calcium; Y27632, selective ROCK inhibitor; Nogo-KO,
Nogo-A knock-out mouse; NgR-Fc, soluble fusion protein blocking Nogo-A; NEP1– 40, first 40
2002). An extensive genetic and proteomic analysis of intact adult
aa of the Nogo-66 region of Nogo-A, which act as an Nogo-66 receptor antagonist; Ab brain and spinal cord of Nogo-A knock-out mice also showed
␣-Nogo-A, anti-Nogo-A antibody; Ab ␣-Lingo-1, anti-Lingo-1 antibody; NgR KD, NgR knock- higher levels of key cytoskeletal and growth regulatory genes and
down (small interference RNA experiments). proteins in the Nogo-A knock-out compared with wild-type mice
(L. Montani and M. Schwab, unpublished observations). All
these results are consistent with a tonic growth-suppressive role
messenger pathways have been used but include the risk of com-
of Nogo-A in the adult CNS tissue. In such a way, Nogo-A could
plex effects on other cell types and functions (Dergham et al.,
act as a general stabilizer of the complex fiber architecture and
2002; Yiu and He, 2006). For Nogo-A, three different function-
wiring of the adult CNS.
blocking antibodies have been used in in vivo experiments over
Upregulation of the growth machinery of neurons attribut-
the past 15 years (Schwab, 2004; Liebscher et al., 2005). They all
able to neutralization of inhibitory factors, e.g., Nogo-A, as well
induced enhanced regenerative sprouting from injured fibers,
as a local improvement of the growth environment for regener-
long-distance regeneration of subpopulations of fibers, and en-
ating and sprouting fibers could be the two ways by which re-
hanced compensatory fiber growth from non-injured fibers and
agents that interfere with inhibitory factor signaling produce
tracts, along with impressive recoveries of sensorimotor func-
their effects of enhanced regeneration and compensatory fiber
tions. Many of these results obtained by antibody application into
growth in the brain and spinal cord after injury. An important
the CSF were reproduced by using a Nogo receptor-blocking
observation was that antibodies against Nogo-A infused into the
peptide (GrandPre et al., 2002) or a soluble receptor fragment (Li
lumbar CSF space by a pump linked to an intrathecal catheter for
et al., 2004). Very similar results were also obtained in Nogo
7 d reached the entire spinal cord and large parts of the brain in
knock-out mice (Kim et al., 2003; Simonen et al., 2003; Dimou et
adult rats as well as adult macaque monkeys (Weinmann et al.,
al., 2006) or by blocking the postreceptor RhoA/ROCK (Rho
2006). These antibodies were retained in the tissues by binding to
kinase) pathway (Fig. 2) (Dergham et al., 2002). Unfortunately
surface Nogo-A in white matter, on oligodendrocytes, and also
and mainly attributable do unavailability of reagents, such in vivo
on a subpopulations of neurons expressing Nogo-A throughout
experiments were not successfully conducted yet on any of the
life. Many peripheral and central neurons express Nogo-A in
other myelin-associated neurite growth-inhibitory factors, ex-
development but downregulate the protein to low or undetect-
cept for Nogo-A.
able levels after birth (Huber et al., 2002). Antibodies were found
Scar-associated inhibitory factors intracellularly, internalized together with endogenous Nogo-A in
Chondroitin sulfate proteoglycans can be partly digested with the endosomes and lysosomes (Weinmann et al., 2006). In accor-
enzyme chondroitinase ABC. Injections of chondroitinase into dance with these findings, the overall Nogo-A levels as deter-
or close to lesion sites in the brain or spinal cord have lead to mined by immunoblots and immunofluorescence were de-
increased regenerative sprouting and fiber growth and to en- creased in CNS tissues exposed to antibodies in vivo. Thus, in
hanced recovery of lost functions (Fawcett, 2006; Yiu and He, addition to masking the antigen and presumably blocking its
2006). Increased growth of injured fibers was also observed by interaction with its receptor, an effect of downregulation of the
Rossignol et al. • Spinal Cord Injury: Time to Move? J. Neurosci., October 31, 2007 • 27(44):11782–11792 • 11785

tissue levels of Nogo-A was achieved by antibody application. ment at the hyperacute phase of SCI (Young, 2002). Beneficial
Both these molecular mechanisms may lead to the enhanced results were also reported by sporadic research in which SCI was
growth responses of injured and intact neurons that were ob- followed by experimental depletion of macrophages (Popovich et
served in many studies. al., 1999) or blocking of neutrophil infiltration (Ditor et al.,
Most of the experimental spinal cord repair studies are cur- 2006).
rently conducted as combined anatomical and functional analy- In contrast to these and other studies, and in opposition to the
ses. A surprising but consistent result in particular, in those stud- generally negative reputation ascribed to immune cells in the
ies in which anatomical regeneration and fiber growth were CNS, work from our laboratory and by other groups over the past
enhanced with either treatments interfering with Nogo-A signal- decade has brought to light the seminal finding that a well con-
ing or chondroitinase-mediated reduction of inhibitory extracel- trolled innate and adaptive immune response is pivotal for repair
lular matrix and scar components, was the often impressive im- (Rapalino et al., 1998; Moalem et al., 1999; Hammarberg et al.,
provement in sensorimotor functions in the absence of detectable 2000; Yin et al., 2003; Turrin and Rivest, 2006; Hashimoto et al.,
malfunctions (Schwab, 2004; Liebscher et al., 2005; Fawcett, 2007; Hendrix and Nitsch, 2007).
2006). Malfunctions that could be expected from the formation
of inappropriate new connections include neurogenic pain and Innate and adaptive immunity in CNS repair: the evidence and
spasticity, two phenomena that are common in paraplegic pa- the mechanism
tients, as well as epileptic attacks. Close observations of a large The healthy CNS houses the resident microglia, the innate im-
number of animals (mostly rats but also monkeys) showed a clear mune players of the CNS. Until recently, these cells were viewed
absence of such side effects, in particular for anti-Nogo-A anti- as existing in either a nonactivated or an activated state, and, in
body treatments (Liebscher et al., 2005; Freund et al., 2006). A their activated form after SCI, as destructive inflammatory cells
central, essentially unanswered question, therefore, is how indistinguishable from infiltrating macrophages. It is now clear,
(re-)growing fibers find meaningful targets and stabilize connec- however, that these cells have a wide range of functions that vary
tions that can function as new, functionally meaningful circuits. with context and with time (Schwartz et al., 2006). Our first sig-
Concepts from developmental neurobiology would suggest that nificant observation of this connection, reported in 1998, was
fiber growth and target identification would follow guidance cues that the effect of blood-borne monocytes (macrophages) on the
and target recognition signals (Dickson, 2002); some of these injured spinal cord is distinct from that of resident microglia.
molecular cues may persist in the adult CNS or reappear after This unexpected finding was disclosed first by our demonstration
injury. The fine tuning of the connections with stabilization of that exogenously applied macrophages possessing well controlled
functionally meaningful synapses and retraction of nonfunc- activities, unlike destructive microglia, could promote recovery
tional ones would then essentially be controlled by activity- of the completely transected spinal cord (Rapalino et al., 1998).
dependent mechanisms (Goodman and Shatz, 1993). Indeed, as This finding was greeted with a high degree of skepticism. Among
outlined below in the section by S. Rossignol, intense training and the questions raised were the following. Why introduce more
physiotherapy are key factors for the functional restoration in inflammatory cells if they are already present in abundance as a
paraplegic and tetraplegic patients. Animal models clearly indi- result of the injury? How can this finding be reconciled with
cate that locomotion training in rats or cats with large but incom- reports that blockage of inflammation is beneficial for CNS re-
plete spinal cord injuries leads to enhanced recovery of function. pair? Why do other laboratories have difficulty in reproducing
Adding a treatment that facilitates regenerative and compensa- the results?
tory fiber growth can, therefore, be expected to further augment To resolve the conflict by reconciling apparent discrepancies
the effect of rehabilitative training. and to further understand the role of immune cells in CNS repair,
Many years of in vivo studies with anti-Nogo antibodies, the we began by characterizing the relevant macrophages in terms of
confirmation of the concept by several laboratories using differ- their activities, optimal location, and timing of their operation. In
ent tools to block the Nogo-A signaling pathways, proof of prin- addition, we embarked on research aimed at elucidating the en-
ciple in monkeys, and extensive toxicological studies have been tire network of immune activities in CNS repair.
the bases for the initiation of a large-scale clinical trial that is We soon discovered that not only macrophages are needed
currently conducted by Novartis Pharma (Basel, Switzerland) in but that other immune cells also participate in the network of
close collaboration with the European and North American Clin- functions needed for repair, and that they do so in a manner
ical Trial Networks for spinal cord injury (Curt et al., 2004). reminiscent of immune system activities in the recovery of any
other tissue. In particular, T cells and B cells were found to par-
Harnessing immune cells and adult stem cells for spinal cord ticipate in controlling the local immune response (Moalem et al.,
repair (M. Schwartz) 1999; Hauben et al., 2001, 2000; Yoles et al., 2001; Schori et al.,
Immune activity and recovery from spinal cord injury: 2002, 2007). We also found that the relevant T cells are CD4 ⫹
an overview cells that recognize CNS-specific antigens. The disclosure that
The role of immune cells in recovery from CNS injury in general CNS-specific T cells participate in recovery from CNS axonal
and from SCI in particular has long been a subject of controversy. injury was again received with much skepticism. Here, too, we
Infiltration of immune cells after CNS injury has traditionally emphasized that the beneficial effect of these cells is critically
been regarded as pathological. This view was based on the fact dependent on their tight control (Hauben et al., 2001), in partic-
that immune– cell infiltration has been exclusively identified with ular with respect to the timing of their arrival at the site of injury
inflammation and that this is harmful. There has been little effort and the duration of their persistence there, as well as their affinity
to discern the types of cells that infiltrate the CNS, the dynamics (Shaked et al., 2004; Ziv et al., 2006a). We warned that if the T-cell
of infiltration, or the ability of the cells to acquire the potential for activity boosted by encephalitic peptides caused an overwhelm-
a wide diversity of activities. The negative view of immune-cell ing autoimmune response, this would probably override the ben-
activity in the CNS was supported by reports of beneficial effects, efit (Fisher et al., 2001; Hauben et al., 2001; Ziv et al., 2006a).
in both animal models and patients, of high-dose steroidal treat- Unfortunately, despite this warning, some authors related to this
11786 • J. Neurosci., October 31, 2007 • 27(44):11782–11792 Rossignol et al. • Spinal Cord Injury: Time to Move?

situation of overwhelming response as the default activity and

accordingly claimed, in line with the mainstream conceptions
(now considered questionable at best), that the message reflected
in the titles of our publications were the opposite of the truth
(Popovich et al., 1996). Our data, however, clearly argued against
that exceptional state as the general situation. We showed (1) that
recovery from SCI in immune-deficient mice is worse than that in
matched wild-type controls (Hauben et al., 2002; Schori et al.,
2007), and (2) that controlled boosting of T-cell activity in all
tested strains of both mice and rats is beneficial for recovery from
axonal injury (Hauben et al., 2000, 2001; Ziv et al., 2006a). The
observed nature of recovery of the rodent spinal cord after active
or passive vaccination with myelin-derived peptides suggests that
the benefit is reflected mainly in protection of spared neural tis-
sue (i.e., in cases in which injury to the spinal cord is partial),
whereas the effect of macrophage transplantation in our previous
work, demonstrated in a model of complete spinal cord transec-
tion, is on axonal growth. This difference in the nature of recov-
ery seen with two different injury models (partial vs complete
transection) and with two types of immune cells (T cells vs mac-
rophages) raised a key question: are the two phenomena related?
Studies over the past few years have taught us that the two
phenomena are not only related but are part of an immune-based
cascade that participates in CNS repair. It was found, first, that
the beneficial effect of local transplantation of activated macro-
phages is not restricted to acute complete SCI but is effective also
in a contusion (partial injury) model (Schwartz and Yoles, 2006).
Second, the site of the transplanted macrophages as well as their
numbers and the timing of their activity were found to be critical.
Macrophages should be injected into the outer margin of the site
of injury, not in the center or distally to the lesion, and the injec-
tion should be administered at the subacute phase, not in the
hyperacute phase (Schwartz and Yoles, 2006). Third, having
achieved a better understanding of the roles of both macrophages
and T cells in recovery from SCI, we were further encouraged to
seek a link between the two cell types. To that end, we created
chimeric mice in which the bone marrow cells of the naive mice
were replaced by donor bone marrow containing myeloid cells
that express green fluorescent protein (GFP) and diphtheria
toxin receptor on a CD11c promoter. On subjecting the chimeric
mice to SCI, with or without vaccination with myelin-derived
peptides, we found as before that the vaccination resulted in an
earlier response of resident microglia/blood-borne macrophages, Figure 3. Early recruitment of blood-borne monocytes at the margins of the lesion site is
needed for CNS repair. The blood-borne monocytes acquire a beneficial phenotype only when
manifested by earlier expression of growth factors, class II major
they encounter the extracellular matrix proteins that delineate the lesion site. Spontaneous
histocompatibility complex proteins MHCII and CD11c. In ad- recruitment of blood-borne monocytes is restricted. Therefore, timely injection to the margins
dition, the use of GFP-labeled myeloid cells enabled us to distin- of the lesion site of specifically activated autologous macrophages can promote recovery. TNF␣,
guish between resident microglia and infiltrating macrophages. Tumor necrosis factor ␣; MHCII, class II major histocompatibility complex proteins; IGF-I,
Most interesting was the finding that the effect of the vaccination insulin-like growth factor I.
was primarily on the recruitment of blood-borne monocytes (R.
Shechter et al., unpublished observations). In our previous stud-
ies, we could not discern between the cellular subsets of innate
immune cells in the injured CNS (i.e., the monocytes recruited
from the peripheral blood circulation and the resident microglia) How can the findings of different research groups be reconciled?
Our data suggest that SCI triggers a cascade of synchronized and
(Butovsky et al., 2001, 2006). These new findings suggest that not
only resident microglia but also blood-borne monocytes express dynamic immune response processes both in the center and at
a beneficial phenotype at the injured parenchyma. Moreover, the periphery of the lesion. Processes occurring at the periphery
depletion of blood-borne monocytes that express CD11c resulted require the timely recruitment of blood-borne monocytes that
in a significantly worse outcome than that of the nontreated con- are capable of acquiring the phenotype needed for repair (Fig. 3).
trols (R. Shechter, unpublished observations). The beneficial ef- Apparent discrepancies between some of the results obtained in
fect of blood-borne monocytes in spinal cord injury is in line with different laboratories probably reflect the phenotypic diversity of
many recent studies demonstrating the beneficial role of mono- the various immune cells, their origins, locations, amounts, and
cytes in neurodegenerative conditions (Butovsky et al., 2006, changing requirements with time, as well as differences in species,
2007; Simard and Rivest, 2006) strains, gender, and the research approach.
Rossignol et al. • Spinal Cord Injury: Time to Move? J. Neurosci., October 31, 2007 • 27(44):11782–11792 • 11787

What are the potential targets for immune-based results indicated that injection into the CSF might be an accept-
clinical interventions? able alternative. In light of the above arguments and the good
In principle, there are several immune-based interventions. They safety profile of the therapy, although it was not able to show
include injection of autologous activated macrophages and T efficacy of the treatment in the phase II, Proneuron Biotechnol-
cell-based vaccination (active or passive) or dendritic cell-based ogies wants to continue with the clinical study using a different
vaccination. Each approach has advantages and disadvantages. protocol for cell administration. The partial results obtained for
the phase II clinical trial, together with the results of the preclin-
Autologous macrophages: ProCord
The use of autologous macrophages was the first approach devel- ical studies with CSF administration, will be submitted to the
oped for clinical trial. Because the preparation of these autolo- FDA with an application for changes in the protocol. Such
gous cells requires only minimal modification, this approach had changes might require additional safety studies in animals, fol-
the advantage of a relatively short development time. In addition, lowed by a shortened phase I/II.
it allowed the experimenter to control the number, activity, and T-cell-based vaccination for clinical studies?
site of administration of the injected cells. A Food and Drug The T-cell-based vaccination is based on our discovery that T
Administration (FDA)-approved phase I clinical trial was initi- cells recognizing self-antigens are needed to promote recovery
ated after comprehensive safety studies in laboratory animals, from SCI, coupled with observations that the major effect of the T
which were performed by external independent investigators and cells, via their evoked response (delivered at the right time and for
subjected to rigorous histopathological analyses. Because admin- the right duration, at the correct dosage, and with the required
istration of the activated macrophages in the clinical trial neces- activity) is to shape the local response by conferring on resident
sitated surgery, the FDA recommended that the macrophage ad- microglia and recruited blood-borne monocytes, an activity re-
ministration be combined with surgical cord fixation. In sembling that of the injected macrophages. Such a local immune
addition, only patients with complete SCI were enrolled at that response ensures the timely removal of degradation products,
stage to avoid any possible risk to patients with incomplete SCI. limitation of the spread of cytotoxicity, as well as the adequate
In light of our preclinical demonstration that macrophages are demarcation of the interface between the site of injury and the
needed at the subacute phase, patients were enrolled only after spared tissue, and the provision of growth factors there. Boosting
the hyperacute phase, by which time their complete paralysis of such a T-cell response, for example, by the use of specific
[American Spinal Injury Association (ASIA) A score] could be peptides derived from self-antigens, increases its efficacy. Because
verified. The purpose of the phase I trial was to determine the the use of such peptides carries the risk of overshooting by trig-
safety of autologous skin-incubated macrophages, administered gering an overwhelming response, we chose peptides that are
by a single injection into the parenchyma of the spinal cord of weak agonists of self-antigens (Hauben et al., 2003; Ziv et al.,
patients diagnosed with acute complete SCI. 2006a). Such antigens (e.g., altered peptide ligand of myelin basic
The design was a nonrandomized, open-label study (Knoller protein) were shown in rodent models of SCI to be both efficient
et al., 2005) and enrolled 16 patients. Five showed ASIA improve- in promoting functional recovery and safe with regard to the
ment: three patients became ASIA C, and two patients became ensued autoimmune response.
ASIA B. In addition, two patients showed some bladder recovery,
one full recovery and one sensation of fullness. No adverse event A synergy between T-cell-based vaccination and adult neural
directly related to the administration of the experimental therapy stem cells
was observed. The majority of adverse effects, when present, were Another interesting finding from our studies was that the im-
typical of acute SCI population. Patients whose scores were con- mune response that supports neuronal survival also supports the
verted from the ASIA A score underwent a single operation in formation of a niche for neurogenesis in the healthy and damaged
which cord fixation and macrophage administration were per- CNS (Ziv et al., 2006b). On the assumption that the molecules
formed at the same time. that attract immune cells also attract stem cells, we designed an
The promising results of phase I (Knoller et al., 2005) encour- experimental paradigm consisting of a T-cell-based vaccination
aged the investigators to embark on phase II. This study, entitled in combination with adult neural stem cell injection. The results
a multicenter, randomized controlled study to evaluate the safety showed that the adult neural stem cells, like immune cells, found
and efficacy of autologous macrophages for complete SCI, was their way to the site of injury. The combined therapy indeed
the first randomized controlled phase II study of a cell-based promoted recovery better than each treatment given alone (Ziv et
therapy for patients with acute complete SCI. al., 2006a). Surprisingly, however, the neural progenitor cells that
homed to the lesion site did not differentiate into neurons or glia,
Why was phase II stopped before completion? but rather contributed to local immune modulation. This immu-
As the investigators progressed with the phase II, however, Pro- nomodulatory activity in turn facilitated spinal cord neurogen-
neuron Biotechnologies (Los Angeles, CA) discovered major esis from endogenous stem cells.
drawbacks in the design of the clinical trial: (1) the majority of In summary, a decade of studies, challenging the crosstalk
patients were treated relatively late, on day 14 after injury; (2) the between the immune and nervous system, have suggested that
injection of the macrophages necessitated, in all cases of phase II, immune cells are pivotal for CNS maintenance, protection, re-
a second surgery because they all underwent a first surgery of the pair, and renewal. Blood-borne monocytes are major players in
spine fixation during the first days after injury; (3) it was difficult the beneficial immune response and can acquire the correct phe-
to accurately identify the location of the border of the lesion site notype only if they demarcate the margins of the lesion and ex-
when the macrophages were injected; and (4) there was consid- press phenotypes of antigen-representing cells. Recovery from
erable expense involved in recruitment of each patient. SCI can be promoted by injection of preactivated autologous
Concurrent with the phase II trials, Proneuron Biotechnolo- macrophages, by T-cell-based vaccination, or by both. Autolo-
gies conducted additional preclinical studies. The goal was to gous macrophages have demonstrated safety and efficacy in lab-
assess the possibility of administering macrophages into the CSF oratory experiments as well as in phase I clinical trials. The T-cell-
or systemically, thereby obviating the need for an operation. The based vaccination will be considered as a second generation. Stem
11788 • J. Neurosci., October 31, 2007 • 27(44):11782–11792 Rossignol et al. • Spinal Cord Injury: Time to Move?

cells act in synergy with immune cells: both type of cells are re- tamate release. The use of riluzole as a therapy for SCI is poten-
cruited to an immunological niches formed in the injured CNS. tially feasible, because it has already received approval from the
Therefore, the goal is to develop immune cell-based vaccination Food and Drug Administration for treatment of amyotrophic
combined with systemic injection of stem cells, for acute spinal lateral sclerosis. Given these promising preclinical and clinical
cord injury. The use of autologous stem cells is preferable; non- data, the North American Clinical Trials Network is planning a
autologous stem cells, which often require immunosuppression phase I/II clinical trial to evaluate riluzole for patients with acute
to avoid their rejection, might be counterproductive to repair. SCI in late 2007/early 2008.
Given the vulnerability of oligodendrocytes to secondary ap-
New directions in the pathophysiology and treatment of acute optotic death, coupled with a deficient expression of myelin-
spinal cord injury: opportunity for translation of basic associated genes after SCI, demyelination of residual axons
research discoveries (M. Fehlings) within the spinal cord white matter is an important contributor
Despite advances in medical and surgical treatment, current ther- to the pathophysiology (Casha et al., 2001). Indeed, considerable
apies for SCI are limited. However, the past 15 years has seen work by our group and others has shown the feasibility of using
advances in biomedical research directed at minimizing the im-
neural stem cells to remyelinate the injured spinal cord in the
pact of secondary injury and promoting neural regeneration.
subacute phase of injury (Cummings et al., 2005; Keirstead et al.,
This section will briefly summarize recent advances in our under-
2005; Karimi-Abdolrezaee et al., 2006). These studies in models
standing of the pathophysiology of SCI and discuss the applica-
of SCI are complemented by work in various dysmyelinated mu-
tion of this enhanced knowledge in the context of several ongoing
or planned clinical trials of potentially key neurosurgical impact tants, including shiverer mice (Eftekharpour et al., 2007), which
including the following: the Surgical Treatment for Acute Spinal demonstrate that exogenously transplanted neural stem cells can
Cord Injury Study (STASCIS) trial, which is examining the im- remyelinate congenitally dysmyelinated axons, reconstruct
pact of early surgical decompression; a planned clinical trial that nodes of Ranvier, and partially restore axonal conduction. Late
will evaluate the neuroprotective efficacy of the sodium/gluta- preclinical studies are currently underway to translate these dis-
mate antagonist riluzole; and the Cethrin trial of a recombinant coveries into the clinical arena.
Rho inhibitor to reduce cell death and enhance neural regenera- The CNS has an inadequate regenerative potential attrib-
tion (Fehlings and Perrin, 2006; Baptiste and Fehlings, 2006, utable to an unfavorable balance of abundant inhibitory sig-
2007). In addition, late-stage preclinical studies focusing on neu- naling and inadequate intrinsic mitogenic capacity (Jacobs
ral stem-based remyelination strategies will be briefly reviewed and Fehlings, 2003). There is persuasive preclinical animal
given the strong translational potential of this approach (Karimi- data that the molecule Rho, which is downstream of the Nogo
Abdolrezaee et al., 2006; Eftekharpour et al., 2007). receptor (Fig. 2), is a key pathway that blocks axonal regener-
The majority of cases of SCI involve blunt mechanical injury ation and exacerbates posttraumatic neural cell death (McK-
to the spinal cord, which is usually associated with a fracture of erracher and Higuchi, 2006). A novel Rho inhibitor recombi-
the vertebral column or severe contusion in the setting of under- nant protein (Cethrin) formulated with a fibrin sealant
lying narrowing or stenosis of the spinal canal (Sekhon and Feh- inhibits cell death, promotes neural regeneration, and im-
lings, 2001). However, in certain regions of the world, penetrat- proves locomotor recovery in transection and contusion ani-
ing injuries attributable to stab or gunshot wounds are also an mal models of SCI. To evaluate safety and obtain preliminary
important cause of traumatic SCI. The primary mechanical in- efficacy data, we undertook a phase I/IIa non-placebo-
jury to the cord is amplified by a series of secondary injury mech- controlled dose-escalation study with Cethrin administered
anisms, which include compression and vertebral column insta- topically in patients with acute SCI. Although this study is
bility, ischemia, glutamatergic excitotoxicity, derangements in ongoing, initial analysis in 36 patients, with complete cervical
ionic homeostasis, oxidative cell stress, inflammation, and apo- and thoracic SCI, shows a high degree of safety and promising
ptosis. Of note, the spinal cord is rarely totally transected even clinical neurological improvements after 1 year of follow-up.
with severe SCI. The injury site is characterized by central cavita- Although the results of a single arm, uncontrolled study need
tion, an extensive astroglial scar, and a subpial rim of surviving to be interpreted cautiously, the results indicate significant neurological
axons of small diameter with varying degrees of demyelination.
recovery (ⱖ1 grade improvement on the American Spinal Injury Asso-
Based on the hypothesis that persisting compression is an impor-
ciation impairment scale). This level of improvement exceeds rates of
tant contributor to secondary injury, we (through the Spine Trauma
spontaneous neurological recovery that have been estimated at
Study Group) have been conducting a prospective clinical study
10–20%, and thus these findings provide impetus to proceed with a
(STASCIS) to evaluate the role and timing of early decompressive
surgery in patients with cervical SCI (Fehlings and Baptiste, 2005). prospective, randomized placebo-controlled efficacy trial with Cethrin.
Although this study is still underway, the initial evidence in ⬎100 In summary, the intensive biomedical research related to
prospectively collected cases indicates that early decompression spinal cord injury over the past 15–20 years are now beginning
(within 24 h after SCI) is safe, feasible, and may be associated with to pay dividends with the translational of neuroprotective and
improved neurological outcomes. It is anticipated that the STASCIS regenerative approaches in clinical trials. The next decade has
trial will complete enrolment in 2008. the promise of being a “golden era” for research in the SCI
Riluzole, a benzothiazole anticonvulsant Na ⫹ channel field. In particular, the most promising current and impend-
blocker, is neuroprotective and promotes functional neurologi- ing clinical trials from a neurosurgical and spine surgical per-
cal recovery after SCI in rodents (Schwartz and Fehlings, 2001, spective include the evaluation of the role and timing of sur-
2002; Ates et al., 2007). Riluzole exerts neuroprotective proper- gical decompression (STASCIS), the validation of novel acute
ties in the injured cord after systemic administration by sparing phase neuroprotective therapies such as sodium/glutamate
gray and white matter in rostrocaudal regions surrounding the antagonist riluzole, and the use of a locally delivered Rho
injury epicenter. In addition to its ability to antagonize Na ⫹ inhibitor (Cethrin) to enhance plasticity and reduce apoptotic
channels, riluzole also inhibits presynaptic Ca 2⫹-dependent glu- cell death.
Rossignol et al. • Spinal Cord Injury: Time to Move? J. Neurosci., October 31, 2007 • 27(44):11782–11792 • 11789

Plasticity of locomotor control mechanisms in animal models (Brustein and Rossignol, 1998). Obviously, with both types of
and clinical perspectives for functional recovery in humans lesions, the recovery of voluntary quadrupedal locomotion im-
with SCI (S. Rossignol) plies that spared descending pathways must in part substitute for
After a SCI, several sensory and motor functions are impaired to the damaged pathways. How is that achieved? Two interpreta-
various degrees depending on the amount of damage to the spinal tions are possible and both have different implications. One is
cord (Barbeau and Rossignol, 1994). However, in most species that the undamaged descending pathways, through regeneration
(Delcomyn, 1980), including humans, some of these functions and collateral sprouting, take over the previous roles of damaged
recover to various degrees. The nature and importance of such descending pathways. Although this must be true to explain the
functional recovery probably depends on various cooperative voluntary aspect of locomotor recovery, does this also imply that
mechanisms that can be regrouped under the general heading of these plastic changes in the undamaged pathways take over the
neuroplasticity (Nudo, 2006; Rossignol, 2006). Indeed, there is function of the spinal cord to produce locomotion? An alterna-
strong evidence that, when a structure of the CNS is damaged, tive explanation is that, after partial cord injury, sublesional plas-
other structures will be modified to optimize remnant functions. ticity of the spinal cord takes place to ensure the optimization of
As seen in previous sections of this review (e.g., the section by the CGP expression and that plastic changes in descending sys-
Schwab), such neuroplasticity may occur via regeneration of tems ensure that these systems can exert a new dynamical control
damaged fibers or sprouting of undamaged fibers (Raineteau and on the spinal CGP.
Schwab, 2001; Fouad et al., 2001; Raineteau et al., 2002; Bareyre et To address this question, we devised a dual-lesion paradigm in
al., 2004; Ballermann and Fouad, 2006). Neuroplastic changes which a first unilateral partial spinal lesion was produced at T10 –
can also be manifest in the spinal cord itself below the lesion T11, treadmill training provided to facilitate locomotor recovery,
(Grillner, 1981; Rossignol, 1996, 2006; Côté et al., 2003; Côté and and then a complete spinal section was made at T13, thus approx-
Gossard, 2004; Frigon and Rossignol, 2006; Rossignol et al., imately two segments below the first lesion (Barrière et al., 2007).
2006). The basic idea was that changes within the spinal cord itself ac-
Studies of SCI in animal models offer interesting perspectives companying the locomotor recovery after the partial lesion could
on this very general neurobiological problem of functional recov- be retained and demonstrated after the complete spinalization.
ery after CNS lesion, especially in the context of locomotion. The This paradigm was applied in five cats: three that were inten-
general accepted model of locomotor control is tripartite. The sively treadmill-trained after the unilateral partial spinal lesion
first level is a spinal circuit generating a detailed locomotor on the left side and two that were not trained but occasionally
rhythm of the limbs in which flexor and extensor muscles of one evaluated on the treadmill. When a symmetrical gait had recov-
hindlimb are activated in opposite phases and in alternation with ered in the hindlimbs, all cats were completely spinalized at T13
the other limb. The pioneering work of Grillner (1981) firmly and were thereafter trained on a treadmill several times a week to
established this concept of CGP, showing that it was innate (Grill- document their locomotor capabilities using electromyographic
ner, 1973). It was also shown to operate autonomously using and videographic recordings.
pharmacological stimulation (L-3,4-dihydroxyphenylalanine) The first major finding was that, within 24 h (i.e., the first
after all descending command signals and afferent inputs had testing session) after complete spinalization, treadmill-trained
been severed or inactivated (Grillner and Zangger, 1979). Tread- cats that had received a first, but partial, lesion walked astonish-
mill locomotion could also be expressed immediately after spi- ingly well on the treadmill with full hindquarter weight support,
nalization with an injection of a noradrenergic agonist such as plantar foot placement, and the ability to walk at speeds of up to
clonidine (Forssberg and Grillner, 1973). It was subsequently 1.0 m/s for tens of consecutive steps. Such an early recovery of
shown that adult chronic spinal cats could regain spontaneous hindlimb locomotion has never been observed in cats after a
hindlimb locomotion on a treadmill after weeks of locomotor complete spinal lesion without pharmacological stimulation.
training (Barbeau and Rossignol, 1987; Lovely et al., 1990) and Conversely, untrained cats showed marked asymmetry in their
that this recovery could be accelerated by intensive training with recovery of hindlimb locomotion: the left limb (on the side of the
daily injections of clonidine (Chau et al., 1998). The second con- previous partial lesion) walked within the first days of the com-
trol element of the model is the sensory afferents generating pha- plete spinalization, whereas the right limb started stepping 10 –12
sic signals to the CGP, allowing it to adapt to real environments d later, a normal delay for spinal locomotion (Barbeau and Ros-
made of uneven terrains and obstacles (Rossignol, 2006; Rossig- signol, 1987).
nol et al., 2006). Finally (third control element), for goal-oriented Some conclusions pertinent to the topic of this symposium
locomotion, interlimb coordination, and postural control, de- can be drawn from these experiments. First, after partial spinal
scending pathways from the telencephalon and the brainstem are injuries, the expression of the hindlimb locomotor pattern could
essential in providing start/stop signals, steering, coordination, primarily be attributable to the intrinsic reorganization and re-
posture, and also neurochemical drive to the cord (Rossignol, expression of the spinal locomotor CGP below the lesion. Indeed,
1996). spinal locomotion can be demonstrated within hours after a
Bearing this model in mind, it is of interest that large lesions of complete spinal section in these cats, implying that, during the
descending pathways do not prevent functional recovery of vol- period of recovery after the partial lesion, the CGP evolved to
untary quadrupedal locomotion even if some deficits persist over function essentially independently using sensory inputs as its
time. Thus, after large bilateral dorsolateral lesions of the cord, main control mechanisms. Second, the amount of locomotor
cats can regain voluntary quadrupedal locomotion albeit with training is a major factor in the recovery process because cats that
some deficits in the control of step length, foot drag, and a signif- were intensively trained after the partial lesion expressed a very
icant decrease in the ability to overcome obstacles placed on the high locomotor performance bilaterally within hours of the com-
treadmill (Jiang and Drew, 1996). Similarly, after large bilateral plete spinal section, whereas a unilateral locomotion was only
ventrolateral lesions leaving some dorsolateral fiber tracts intact, observed in the limb ipsilateral to the partial lesion in untrained
cats can also regain voluntary quadrupedal locomotion with, animals. Thus, although both supraspinal and spinal mecha-
however, deficits in interlimb coordination and postural control nisms are involved in the recovery of voluntary goal-oriented
11790 • J. Neurosci., October 31, 2007 • 27(44):11782–11792 Rossignol et al. • Spinal Cord Injury: Time to Move?

locomotion after partial SCI, we have extracted for the first time compression) to diminish secondary damages. Finally, rehabili-
a major functional contribution from the spinal cord itself that tative approaches based on the presence of functional networks
may operate even in the presence of only limited descending below the lesion combined with such neurobiological approaches
inputs. may produce significant recovery of some functions such as lo-
This further highlights the importance of fostering such spinal comotion by allowing an optimal new dynamical configuration
cord potential of neuroplasticity in rehabilitation strategies in between new or regenerated circuits with endogenous spinal
humans with SCI. Following the pioneering work of Barbeau mechanisms. More work is needed on all fronts, but already the
⬎20 years ago using body weight supported treadmill training results offer great hope for some functional recovery after SCI-
(Wainberg and Barbeau, 1985; Barbeau and Rossignol, 1994; based therapies emerging from clinical neuroscience research
Pepin et al., 2003a,b), several studies (Dietz and Harkema, 2004; emerging from studies in animal experiments.
Wirz et al., 2005) have indicated that locomotor activity (whether
with or without body weight support) (Dobkin and Barbeau,
2007) could significantly improve locomotor recovery. What are References
Ates O, Cayli SR, Gurses I, Turkoz Y, Tarim O, Cakir CO, Kocak A (2007)
the mechanisms of such improvements? Using motor evoked Comparative neuroprotective effect of sodium channel blockers after ex-
potentials induced by transcranial magnetic stimulation as an perimental spinal cord injury. J Clin Neurosci 14:658 – 665.
indicator of excitability changes of the corticospinal pathway, it Ballermann M, Fouad K (2006) Spontaneous locomotor recovery in spinal
was found that, after a period of treadmill locomotor training, cord injured rats is accompanied by anatomical plasticity of reticulospinal
corticospinal responses (Thomas and Gorassini, 2005) are in- fibers. Eur J Neurosci 23:1988 –1996.
creased and cortical-dependent muscle unit coherence is in- Baptiste DC, Fehlings MG (2006) Pharmacological approaches to repair the
injured spinal cord. J Neurotrauma 23:318 –334.
creased, suggesting a major role of the cortex in human rehabil- Baptiste DC, Fehlings MG (2007) Update on the treatment of spinal cord
itation. Although such supraspinal participation is certainly sine injury. Prog Brain Res 161:217–233.
qua none to regain voluntary locomotor control (Yang and Barbeau H, Rossignol S (1987) Recovery of locomotion after chronic spinal-
Gorassini, 2006), intrinsic spinal mechanisms are probably also ization in the adult cat. Brain Res 412:84 –95.
of crucial importance in the proper expression of locomotion in Barbeau H, Rossignol S (1994) Enhancement of locomotor recovery follow-
humans as was shown in the cat (Barrière et al., 2007). Indeed, ing spinal cord injury. Curr Opin Neurol 7:517–524.
there are clinical observations suggesting that the spinal cord of Bareyre FM, Haudenschild B, Schwab ME (2002) Long-lasting sprouting
and gene expression changes induced by the monoclonal antibody IN-1 in
humans also possesses some degree of autonomous intrinsic the adult spinal cord. J Neurosci 22:7097–7110.
rhythmogenic potential. Indeed, after partial spinal cord lesions, Bareyre FM, Kerschensteiner M, Raineteau O, Mettenleiter TC, Weinmann
some patients may develop involuntary rhythmic activities of the O, Schwab ME (2004) The injured spinal cord spontaneously forms a
lower limb that are also modulated by sensory inputs (Bussel et new intraspinal circuit in adult rats. Nat Neurosci 7:269 –277.
al., 1988, 1992; Calancie et al., 1994; Calancie, 2006). We recently Barrière G, Leblond H, Provencher J, Rossignol S (2007) Very early locomo-
observed a patient with bouts of involuntary rhythmic activities tor abilities after complete spinal cord injury in a dual lesion paradigm in
the cat. Soc Neurosci Abstr 33:77.12.
(1–1.5 Hz) in muscles of the lower trunk and muscles of all lower
Brustein E, Rossignol S (1998) Recovery of locomotion after ventral and
limb joints that developed several years after an anatomically ventrolateral spinal lesions in the cat. I. Deficits and adaptive mecha-
complete section of the cord at T4 –T5 (Rossignol et al., 2007). nisms. J Neurophysiol 80:1245–1267.
Although in the conditions of observations the burst of dis- Buffo A, Zagrebelsky M, Huber AB, Skerra A, Schwab ME, Strata P, Rossi F
charges could be synchronous in homonymous muscles on both (2000) Application of neutralizing antibodies against NI-35/250 myelin-
sides, there were clear episodes of alternate discharges between associated neurite growth inhibitory proteins to the adult rat cerebellum
hip flexors and knee extensors reminiscent of a rhythmic loco- induces sprouting of uninjured Purkinje cell axons. J Neurosci
20:2275–2286.
motor pattern. This pattern could also be changed by sensory Bussel BC, Roby-Brami A, Yakovleff A, Bennis N (1988) Evidences for the
inputs. The implications here are obviously that such purely spi- presence of a spinal stepping generator in patients with a spinal cord
nal mechanisms are probably also active after spinal cord injuries section. In: Posture and gait: development, adaptation and modulation
in humans and could, if properly entrained, be responsible for (Amblard B, Berthoz A, Clarac F, eds), pp 273–278. Amsterdam: North
part of the functional locomotor recovery. Therefore, it seems Holland Elsevier.
likely that, after a partial spinal lesion, neuroplastic changes occur Bussel B, Roby-Brami A, Azouvi P (1992) Organization of reflexes elicited
by flexor reflex afferents in paraplegic man: evidence for a stepping gen-
at both the supraspinal and spinal levels and that rehabilitation
erator. In: Muscle afferents and spinal control of movement (Jami L,
approaches should aim at fostering locomotor training using Pierrot-Deseilligny E, Zytnicki D, eds), pp 427– 432. Oxford: Pergamon.
techniques to reinforce both voluntary aspects of locomotion as Butovsky O, Hauben E, Schwartz M (2001) Morphological aspects of spinal
well as to reinforce endogenous spinal mechanisms. cord autoimmune neuroprotection: colocalization of T cells with B7–2
(CD86) and prevention of cyst formation. FASEB J 15:1065–1067.
Conclusions Butovsky O, Koronyo-Hamaoui M, Kunis G, Ophir E, Landa G, Cohen H,
This symposium has summarized some scientific bases for the Schwartz M (2006) Glatiramer acetate fights against Alzheimer’s disease
by inducing dendritic-like microglia expressing insulin-like growth factor
current clinical trials aimed at improving functions after SCI.
1. Proc Natl Acad Sci USA 103:11784 –11789.
After the primary and secondary damage to the cord, several Butovsky O, Kunis G, Koronyo-Hamaoui M, Schwartz M (2007) Selective
endogenous processes may foster or hinder axonal reconnection, ablation of bone marrow-derived dendritic cells increases amyloid
and animal studies show that some of these processes can be plaques in a mouse Alzheimer’s disease model. Eur J Neurosci
enhanced or decreased by external applications of drugs to di- 26:413– 416.
minish repulsive barriers (anti-Nogo, anti-Rho) and to increase Calancie B (2006) Spinal myoclonus after spinal cord injury. J Spinal Cord
regeneration and/or sprouting of axons. Cellular replacement is Med 29:413– 424.
Calancie B, Needham-Shropshire B, Jacobs P, Willer K, Zych G, Green BA
also envisaged to enhance beneficial immunological mechanisms (1994) Involuntary stepping after chronic spinal cord injury. Evidence
(autologous macrophages) or remyelinate axons (stem cells). for a central rhythm generator for locomotion in man. Brain
Some of these treatments can be envisaged to be applied concur- 117:1143–1159.
rently with neurosurgical approaches themselves needed (de- Caroni P, Schwab ME (1988) Antibody against myelin-associated inhibitor
Rossignol et al. • Spinal Cord Injury: Time to Move? J. Neurosci., October 31, 2007 • 27(44):11782–11792 • 11791

of neurite growth neutralizes nonpermissive substrate properties of CNS GrandPre T, Li S, Strittmatter SM (2002) Nogo-66 receptor antagonist pep-
white matter. Neuron 1:85–96. tide promotes axonal regeneration. Nature 417:547–551.
Casha S, Yu WR, Fehlings MG (2001) Oligodendroglial apoptosis occurs Grillner S (1973) Locomotion in the spinal cat. In: Control of posture and
along degenerating axons and is associated with FAS and p75 expression locomotion. In: Advances in behavioral biology 7 (Stein RB, Pearson KG,
following spinal cord injury in the rat. Neuroscience 103:203–218. Smith RS, Redford JB, eds), pp 515–535. New York: Plenum.
Chau C, Barbeau H, Rossignol S (1998) Early locomotor training with Grillner S (1981) Control of locomotion in bipeds, tetrapods, and fish. In:
clonidine in spinal cats. J Neurophysiol 79:392– 409. Handbook of physiology. The nervous system II (Brookhart JM, Mount-
Côté M-P, Gossard J-P (2004) Step-training dependent plasticity in spinal castle VB, eds), pp 1179 –1236. Bethesda, MD: American Physiological
cutaneous pathways. J Neurosci 24:11317–11327. Society.
Côté M-P, Menard A, Gossard J-P (2003) Spinal cats on the treadmill: Grillner S, Zangger P (1979) On the central generation of locomotion in the
changes in load pathways. J Neurosci 23:2789 –2796. low spinal cat. Exp Brain Res 34:241–261.
Cummings BJ, Uchida N, Tamaki SJ, Salazar DL, Hooshmand M, Summers Hammarberg H, Lidman O, Lundberg C, Eltayeb SY, Gielen AW, Muhallab S,
R, Gage FH, Anderson AJ (2005) Human neural stem cells differentiate Svenningsson A, Linda H, van Der Meide PH, Cullheim S, Olsson T, Piehl
and promote locomotor recovery in spinal cord-injured mice. Proc Natl F (2000) Neuroprotection by encephalomyelitis: rescue of mechanically
Acad Sci USA 102:14069 –14074. injured neurons and neurotrophin production by CNS-infiltrating T and
Curt A, Schwab ME, Dietz V (2004) Providing the clinical basis for new natural killer cells. J Neurosci 20:5283–5291.
interventional therapies: refined diagnosis and assessment of recovery Hashimoto M, Sun D, Rittling SR, Denhardt DT, Young W (2007)
after spinal cord injury. Spinal Cord 42:1– 6. Osteopontin-deficient mice exhibit less inflammation, greater tissue
Delcomyn F (1980) Neural basis of rhythmic behavior in animals. Science damage, and impaired locomotor recovery from spinal cord injury com-
210:492– 498. pared with wild-type controls. J Neurosci 27:3603–3611.
Dergham P, Ellezam B, Essagian C, Avedissian H, Lubell WD, McKerracher L Hauben E, Butovsky O, Nevo U, Yoles E, Moalem G, Agranov E, Mor F,
(2002) Rho signaling pathway targeted to promote spinal cord repair. Leibowitz-Amit R, Pevsner E, Akselrod S, Neeman M, Cohen IR,
J Neurosci 22:6570 – 6577. Schwartz M (2000) Passive or active immunization with myelin basic
Dickson BJ (2002) Molecular mechanisms of axon guidance. Science protein promotes recovery from spinal cord contusion. J Neurosci
298:1959 –1964. 20:6421– 6430.
Dietz V, Harkema SJ (2004) Locomotor activity in spinal cord-injured per- Hauben E, Agranov E, Gothilf A, Nevo U, Cohen A, Smirnov I, Steinman L,
sons. J Appl Physiol 96:1954 –1960. Schwartz M (2001) Posttraumatic therapeutic vaccination with modi-
Dimou L, Schnell L, Montani L, Duncan C, Simonen M, Schneider R, Lieb- fied myelin self-antigen prevents complete paralysis while avoiding auto-
scher T, Gullo M, Schwab ME (2006) Nogo-A-deficient mice reveal immune disease. J Clin Invest 108:591–599.
strain-dependent differences in axonal regeneration. J Neurosci Hauben E, Mizrahi T, Agranov E, Schwartz M (2002) Sexual dimorphism in
26:5591–5603. the spontaneous recovery from spinal cord injury: a gender gap in bene-
Ditor DS, Bao F, Chen Y, Dekaban GA, Weaver LC (2006) A therapeutic ficial autoimmunity? Eur J Neurosci 16:1731–1740.
time window for anti-CD 11d monoclonal antibody treatment yielding Hauben E, Gothilf A, Cohen A, Butovsky O, Nevo U, Smirnov I, Yoles E,
reduced secondary tissue damage and enhanced behavioral recovery fol- Akselrod S, Schwartz M (2003) Vaccination with dendritic cells pulsed
lowing severe spinal cord injury. J Neurosurg Spine 5:343–352. with peptides of myelin basic protein promotes functional recovery from
Dobkin B, Barbeau H (2007) The evolution of walking-related outcomes spinal cord injury. J Neurosci 23:8808 – 8819.
over the first 12 weeks of rehabilitation for incomplete traumatic spinal Hendrix S, Nitsch R (2007) The role of T helper cells in neuroprotection and
cord injury: the multicenter randomized spinal cord injury locomotor regeneration. J Neuroimmunol 184:100 –112.
trial. Neurorehabil Neural Repair 21:25–35. Huber AB, Weinmann O, Brösamle C, Oertle T, Schwab ME (2002) Pat-
Eftekharpour E, Karimi-Abdolrezaee S, Wang J, El Beheiry H, Morshead C, terns of Nogo mRNA and protein expression in the developing and adult
Fehlings MG (2007) Myelination of congenitally dysmyelinated spinal rat and after CNS lesions. J Neurosci 22:3553–3567.
cord axons by adult neural precursor cells results in formation of nodes of Jacobs WB, Fehlings MG (2003) The molecular basis of neural regeneration.
Ranvier and improved axonal conduction. J Neurosci 27:3416 –3428. Neurosurgery 53:943–948.
Fawcett JW (2006) Overcoming inhibition in the damaged spinal cord. Jiang W, Drew T (1996) Effects of bilateral lesions of the dorsolateral funic-
J Neurotrauma 23:371–383. uli and dorsal columns at the level of the low thoracic spinal cord on the
Fehlings MG, Baptiste DC (2005) Current status of clinical trials for acute control of locomotion in the adult cat. I. Treadmill walking. J Neuro-
spinal cord injury. Injury 36 [Suppl 2]:113–122. physiol 76:849 – 866.
Fehlings MG, Perrin RG (2006) The timing of surgical intervention in the Karimi-Abdolrezaee S, Eftekharpour E, Wang J, Morshead CM, Fehlings MG
treatment of spinal cord injury: a systematic review of recent clinical (2006) Delayed transplantation of adult neural precursor cells promotes
evidence. Spine 31:28 –35. remyelination and functional neurological recovery after spinal cord in-
Fisher J, Levkovitch-Verbin H, Schori H, Yoles E, Butovsky O, Kaye JF, Ben- jury. J Neurosci 26:3377–3389.
Nun A, Schwartz M (2001) Vaccination for neuroprotection in the Keirstead HS, Nistor G, Bernal G, Totoiu M, Cloutier F, Sharp K, Steward O
mouse optic nerve: implications for optic neuropathies. J Neurosci (2005) Human embryonic stem cell-derived oligodendrocyte progenitor
21:136 –142. cell transplants remyelinate and restore locomotion after spinal cord in-
Forssberg H, Grillner S (1973) The locomotion of the acute spinal cat in- jury. J Neurosci 25:4694 – 4705.
jected with clonidine i.v. Brain Res 50:184 –186. Kim JE, Li S, GrandPre T, Qiu D, Strittmatter SM (2003) Axon regeneration
Fouad K, Pedersen V, Schwab ME, Brosamle C (2001) Cervical sprouting of in young adult mice lacking Nogo-A/B. Neuron 38:187–199.
corticospinal fibers after thoracic spinal cord injury accompanies shifts in Knoller N, Auerbach G, Fulga V, Zelig G, Attias J, Bakimer R, Marder JB,
evoked motor responses. Curr Biol 11:1766 –1770. Yoles E, Belkin M, Schwartz M, Hadani M (2005) Clinical experience
Freund P, Schmidlin E, Wannier T, Bloch J, Mir A, Schwab ME, Rouiller EM using incubated autologous macrophages as a treatment for complete
(2006) Nogo-A-specific antibody treatment enhances sprouting and spinal cord injury: phase I study results. J Neurosurg Spine 3:173–181.
functional recovery after cervical lesion in adult primates. Nat Med Li S, Liu BP, Budel S, Li M, Ji B, Walus L, Li W, Jirik A, Rabacchi S, Choi E,
12:790 –792. Worley D, Sah DW, Pepinsky B, Lee D, Relton J, Strittmatter SM (2004)
Frigon A, Rossignol S (2006) Functional plasticity following spinal cord le- Blockade of Nogo-66, myelin-associated glycoprotein, and oligodendro-
sions. Prog Brain Res 157:231–260. cyte myelin glycoprotein by soluble Nogo-66 receptor promotes axonal
Gianola S, Savio T, Schwab ME, Rossi F (2003) Cell-autonomous mecha- sprouting and recovery after spinal injury. J Neurosci 24:10511–10520.
nisms and myelin-associated factors contribute to the development of Liebscher T, Schnell L, Schnell D, Scholl J, Schneider R, Gullo M, Fouad K,
Purkinje axon intracortical plexus in the rat cerebellum. J Neurosci Mir A, Rausch M, Kindler D, Hamers FP, Schwab ME (2005) Nogo-A
23:4613– 4624. antibody improves regeneration and locomotion of spinal cord-injured
Goodman CS, Shatz CJ (1993) Developmental mechanisms that generate rats. Ann Neurol 58:706 –719.
precise patterns of neuronal connectivity. Cell [Suppl] 72:77–98. Lovely RG, Gregor RJ, Roy RR, Edgerton VR (1990) Weight-bearing hind-
11792 • J. Neurosci., October 31, 2007 • 27(44):11782–11792 Rossignol et al. • Spinal Cord Injury: Time to Move?

limb stepping in treadmill-exercised adult spinal cat. Brain Res cord trauma: a novel therapeutic approach for the management of sec-
514:206 –218. ondary pathophysiology with the sodium channel blocker riluzole. Prog
McKerracher L, Higuchi H (2006) Targeting Rho to stimulate repair after Brain Res 137:177–190.
spinal cord injury. J Neurotrauma 23:309 –317. Schwartz M, Yoles E (2006) Immune-based therapy for spinal cord repair:
Moalem G, Leibowitz-Amit R, Yoles E, Mor F, Cohen IR, Schwartz M (1999) autologous macrophages and beyond. J Neurotrauma 23:360 –370.
Autoimmune T cells protect neurons from secondary degeneration after Schwartz M, Butovsky O, Bruck W, Hanisch UK (2006) Microglial pheno-
central nervous system axotomy. Nat Med 5:49 –55. type: is the commitment reversible? Trends Neurosci 29:68 –74.
Niclou SP, Ehlert EM, Verhaagen J (2006) Chemorepellent axon guidance Sekhon LH, Fehlings MG (2001) Epidemiology, demographics, and patho-
molecules in spinal cord injury. J Neurotrauma 23:409 – 421. physiology of acute spinal cord injury. Spine 26:2–12.
Nudo RJ (2006) Plasticity. NeuroRx 3:420 – 427. Shaked I, Porat Z, Gersner R, Kipnis J, Schwartz M (2004) Early activation
Pepin A, Norman KE, Barbeau H (2003a) Treadmill walking in incomplete of microglia as antigen-presenting cells correlates with T cell-mediated
spinal-cord-injured subjects. 1. Adaptation to changes in speed. Spinal protection and repair of the injured central nervous system. J Neuroim-
Cord 41:257–270. munol 146:84 –93.
Pepin A, Ladouceur M, Barbeau H (2003b) Treadmill walking in incom- Simard AR, Rivest 0053 (2006) Bone marrow stem cells to the rescue of
plete spinal-cord-injured subjects. 2. Factors limiting the maximal speed. Alzheimer’s disease (in French). Med Sci (Paris) 22:822– 824.
Spinal Cord 41:271–279. Simonen M, Pedersen V, Weinmann O, Schnell L, Buss A, Ledermann B,
Popovich PG, Stokes BT, Whitacre CC (1996) Concept of autoimmunity Christ F, Sansig G, van der PH, Schwab ME (2003) Systemic deletion of
following spinal cord injury: possible roles for T lymphocytes in the trau- the myelin-associated outgrowth inhibitor Nogo-A improves regenera-
matized central nervous system. J Neurosci Res 45:349 –363. tive and plastic responses after spinal cord injury. Neuron 38:201–211.
Popovich PG, Guan Z, Wei P, Huitinga I, van RN, Stokes BT (1999) Deple- Thomas SL, Gorassini MA (2005) Increases in corticospinal tract function
tion of hematogenous macrophages promotes partial hindlimb recovery by treadmill training after incomplete spinal cord injury. J Neurophysiol
and neuroanatomical repair after experimental spinal cord injury. Exp 94:2844 –2855.
Neurol 158:351–365. Turrin NP, Rivest S (2006) Molecular and cellular immune mediators of
Raineteau O, Schwab ME (2001) Plasticity of motor systems after incom- neuroprotection. Mol Neurobiol 34:221–242.
plete spinal cord injury. Nat Rev Neurosci 2:263–273. Wainberg M, Barbeau H (1985) Applicability of progressive weight bearing
Raineteau O, Fouad K, Bareyre FM, Schwab ME (2002) Reorganization of in rehabilitation of neurologically impaired gait. Can J Neurol Sci 12:183.
descending motor tracts in the rat spinal cord. Eur J Neurosci
Wang X, Chun SJ, Treloar H, Vartanian T, Greer CA, Strittmatter SM (2002)
16:1761–1771.
Localization of Nogo-A and Nogo-66 receptor proteins at sites of axon-
Rapalino O, Lazarov-Spiegler O, Agranov E, Velan GJ, Yoles E, Fraidakis M,
myelin and synaptic contact. J Neurosci 22:5505–5515.
Solomon A, Gepstein R, Katz A, Belkin M, Hadani M, Schwartz M (1998)
Weinmann O, Schnell L, Ghosh A, Montani L, Wiessner C, Wannier T,
Implantation of stimulated homologous macrophages results in partial
Rouiller E, Mir A, Schwab ME (2006) Intrathecally infused antibodies
recovery of paraplegic rats. Nat Med 4:814 – 821.
against Nogo-A penetrate the CNS and downregulate the endogenous
Richardson PM, Issa VM, Aguayo AJ (1984) Regeneration of long spinal
neurite growth inhibitor Nogo-A. Mol Cell Neurosci 32:161–173.
axons in the rat. J Neurocytol 13:165–182.
Wirz M, Zemon DH, Rupp R, Scheel A, Colombo G, Dietz V, Hornby TG
Rossignol S (1996) Neural control of stereotypic limb movements. In:
(2005) Effectiveness of automated locomotor training in patients with
Handbook of physiology, Sec 12, Exercise: regulation and integration of
multiple systems (Rowell LB, Sheperd JT, eds), pp 173–216. New York: chronic incomplete spinal cord injury: a multicenter trial. Arch Phys Med
Oxford UP. Rehabil 86:672– 680.
Rossignol S (2006) Plasticity of connections underlying locomotor recovery Yang JF, Gorassini M (2006) Spinal and brain control of human walking:
after central and/ or peripheral lesions in the adult mammals. Philos implications for retraining of walking. The Neuroscientist 12:379 –389.
Trans R Soc B Biol Sci 361:1647–1671. Yin Y, Cui Q, Li Y, Irwin N, Fischer D, Harvey AR, Benowitz LI (2003)
Rossignol S, Dubuc R, Gossard JP (2006) Dynamic sensorimotor interac- Macrophage-derived factors stimulate optic nerve regeneration. J Neuro-
tions in locomotion. Physiol Rev 86:89 –154. sci 23:2284 –2293.
Rossignol S, Jacquemin G, Nadeau S, Fournier C, Raymond D, Piotte F, Yiu G, He Z (2006) Glial inhibition of CNS axon regeneration. Nat Rev
Lamarre Y (2007) Rhythmic activity of the trunk and lower limb mus- Neurosci 7:617– 627.
cles in a patient with a complete thoracic spinal section. Soc Neurosci Yoles E, Hauben E, Palgi O, Agranov E, Gothilf A, Cohen A, Kuchroo V,
Abstr 33:769.1. Cohen IR, Weiner H, Schwartz M (2001) Protective autoimmunity is a
Schori H, Lantner F, Shachar I, Schwartz M (2002) Severe immunodefi- physiological response to CNS trauma. J Neurosci 21:3740 –3748.
ciency has opposite effects on neuronal survival in glutamate-susceptible Young W (2002) Methylprednisolone and spinal cord injury. J Neurosurg
and -resistant mice: adverse effect of B cells. J Immunol 169:2861–2865. 96:141–142.
Schori H, Shechter R, Shachar I, Schwartz M (2007) Genetic manipulation Zagrebelsky M, Buffo A, Skerra A, Schwab ME, Strata P, Rossi F (1998)
of CD74 in mouse strains of different backgrounds can result in opposite Retrograde regulation of growth-associated gene expression in adult rat
responses to central nervous system injury. J Immunol 178:163–171. Purkinje cells by myelin-associated neurite growth inhibitory proteins.
Schwab ME (2004) Nogo and axon regeneration. Curr Opin Neurobiol J Neurosci 18:7912–7929.
14:118 –124. Ziv Y, Avidan H, Pluchino S, Martino G, Schwartz M (2006a) Synergy be-
Schwab ME, Thoenen H (1985) Dissociated neurons regenerate into sciatic tween immune cells and adult neural stem/progenitor cells promotes
but not optic nerve explants in culture irrespective of neurotrophic fac- functional recovery from spinal cord injury. Proc Natl Acad Sci USA
tors. J Neurosci 5:2415–2423. 103:13174 –13179.
Schwartz G, Fehlings MG (2001) Evaluation of the neuroprotective effects Ziv Y, Ron N, Butovsky O, Landa G, Sudai E, Greenberg N, Cohen H, Kipnis
of sodium channel blockers after spinal cord injury: improved behavioral J, Schwartz M (2006b) Immune cells contribute to the maintenance of
and neuroanatomical recovery with riluzole. J Neurosurg 94:245–256. neurogenesis and spatial learning abilities in adulthood. Nat Neurosci
Schwartz G, Fehlings MG (2002) Secondary injury mechanisms of spinal 9:268 –275.