Post-stroke aphasia rehabilitation using an adapted visual P300 brain-computer interface training: improvement over time, but specificity remains undetermined.

Introduction: This study aimed to evaluate the efficacy of visual P300 brain-computer interface use to support rehabilitation of chronic language production deficits commonly experienced by individuals with a left-sided stroke resulting in post-stroke aphasia. Methods: The study involved twelve participants, but five dropped out. Additionally, data points were missing for three participants in the remaining sample of seven participants. The participants underwent four assessments-a baseline, pre-assessment, post-assessment, and follow-up assessment. Between the pre-and post-assessment, the participants underwent at least 14 sessions of visual spelling using a brain-computer interface. The study aimed to investigate the impact of this intervention on attention, language production, and language comprehension and to determine whether there were any potential effects on quality of life and well-being. Results: None of the participants showed a consistent improvement in attention. All participants showed an improvement in spontaneous speech production, and three participants experienced a reduction in aphasia severity. We found an improvement in subjective quality of life and daily functioning. However, we cannot rule out the possibility of unspecific effects causing or at least contributing to these results. Conclusion: Due to challenges in assessing the patient population, resulting in a small sample size and missing data points, the results of using visual P300 brain-computer interfaces for chronic post-stroke aphasia rehabilitation are preliminary. Thus, we cannot decisively judge the potential of this approach.

Inconclusive results of slow cortical potential neurofeedback for the treatment of chronic post-stroke attention deficits.

Introduction: Individuals who have suffered a stroke may experience long-lasting cognitive impairments that can worsen if left untreated. We investigated whether voluntary control of slow cortical potentials (SCP) through neurofeedback would help alleviate chronic post-stroke symptoms of impaired attention. Methods: The study initially enrolled twenty-eight participants, but due to a high drop-out rate, only sixteen participants completed eight SCP neurofeedback training sessions within three to four weeks. During these sessions, we gave feedback to the participants on their ability to regulate SCPs on a computer screen. Results: Our findings showed a non-significant increase in SCP regulation towards cortical negativity. On the behavioral level, we found improved test values in the divided attention and attentional flexibility subtests of the test battery for attention performance. However, we cannot eliminate the possibility that nonspecific effects influenced or caused our results. We have not observed any improvement regarding the effects of attention deficits on participants' daily lives. We identified five individuals who could gain SCP control successfully and consistently towards negativity. In this group of responders, we observed an improvement in the test results related to divided attention but no other attention-related improvements. Discussion: Based on our observations, results of SCP neurofeedback training for the treatment of attention deficits after a stroke are inconclusive. More research is necessary to determine the effectiveness of SCP neurofeedback in helping stroke survivors cope with attention-related challenges in their daily lives.

Behavior Change Techniques in Wrist-Worn Wearables to Promote Physical Activity: Content Analysis.

BACKGROUND: Decreasing levels of physical activity (PA) increase the incidences of noncommunicable diseases, obesity, and mortality. To counteract these developments, interventions aiming to increase PA are urgently needed. Mobile health (mHealth) solutions such as wearable sensors (wearables) may assist with an improvement in PA. OBJECTIVE: The aim of this study is to examine which behavior change techniques (BCTs) are incorporated in currently available commercial high-end wearables that target users' PA behavior. METHODS: The BCTs incorporated in 5 different high-end wearables (Apple Watch Series 3, Garmin Vívoactive 3, Fitbit Versa, Xiaomi Amazfit Stratos 2, and Polar M600) were assessed by 2 researchers using the BCT Taxonomy version 1 (BCTTv1). Effectiveness of the incorporated BCTs in promoting PA behavior was assessed by a content analysis of the existing literature. RESULTS: The most common BCTs were goal setting (behavior), action planning, review behavior goal(s), discrepancy between current behavior and goal, feedback on behavior, self-monitoring of behavior, and biofeedback. Fitbit Versa, Garmin Vívoactive 3, Apple Watch Series 3, Polar M600, and Xiaomi Amazfit Stratos 2 incorporated 17, 16, 12, 11, and 11 BCTs, respectively, which are proven to effectively promote PA. CONCLUSIONS: Wearables employ different numbers and combinations of BCTs, which might impact their effectiveness in improving PA. To promote PA by employing wearables, we encourage researchers to develop a taxonomy specifically designed to assess BCTs incorporated in wearables. We also encourage manufacturers to customize BCTs based on the targeted populations.

Hearing the needs of clinical users.

In the past 10 years, brain-computer interfaces (BCIs) for controlling assistive devices have seen tremendous progress with respect to reliability and learnability, and numerous exemplary applications were demonstrated to be controllable by a BCI. Yet, BCI-controlled applications are hardly used for patients with neurologic or neurodegenerative disease. Such patient groups are considered potential end-users of BCI, specifically for replacing or improving lost function. We argue that BCI research and development still faces a translational gap, i.e., the knowledge of how to bring BCIs from the laboratory to the field is insufficient. BCI-controlled applications lack usability and accessibility; both constitute two sides of one coin, which is the key to use in daily life and to prevent nonuse. To increase usability, we suggest rigorously adopting the user-centered design in applied BCI research and development. To provide accessibility, assistive technology (AT) experts, providers, and other stakeholders have to be included in the user-centered process. BCI experts have to ensure the transfer of knowledge to AT professionals, and listen to the needs of primary, secondary, and tertiary end-users of BCI technology. Addressing both, usability and accessibility, in applied BCI research and development will bridge the translational gap and ensure that the needs of clinical end-users are heard, understood, addressed, and fulfilled.

Psychological Predictors of Visual and Auditory P300 Brain-Computer Interface Performance.

Brain-Computer Interfaces (BCIs) provide communication channels independent from muscular control. In the current study we used two versions of the P300-BCI: one based on visual the other on auditory stimulation. Up to now, data on the impact of psychological variables on P300-BCI control are scarce. Hence, our goal was to identify new predictors with a comprehensive psychological test-battery. A total of N = 40 healthy BCI novices took part in a visual and an auditory BCI session. Psychological variables were measured with an electronic test-battery including clinical, personality, and performance tests. The personality factor "emotional stability" was negatively correlated (Spearman's rho = -0.416; p < 0.01) and an output variable of the non-verbal learning test (NVLT), which can be interpreted as ability to learn, correlated positively (Spearman's rho = 0.412; p < 0.01) with visual P300-BCI performance. In a linear regression analysis both independent variables explained 24% of the variance. "Emotional stability" was also negatively related to auditory P300-BCI performance (Spearman's rho = -0.377; p < 0.05), but failed significance in the regression analysis. Psychological parameters seem to play a moderate role in visual P300-BCI performance. "Emotional stability" was identified as a new predictor, indicating that BCI users who characterize themselves as calm and rational showed worse BCI performance. The positive relation of the ability to learn and BCI performance corroborates the notion that also for P300 based BCIs learning may constitute an important factor. Further studies are needed to consolidate or reject the presented predictors.

Heading for new shores! Overcoming pitfalls in BCI design.

Research in brain-computer interfaces has achieved impressive progress towards implementing assistive technologies for restoration or substitution of lost motor capabilities, as well as supporting technologies for able-bodied subjects. Notwithstanding this progress, effective translation of these interfaces from proof-of concept prototypes into reliable applications remains elusive. As a matter of fact, most of the current BCI systems cannot be used independently for long periods of time by their intended end-users. Multiple factors that impair achieving this goal have already been identified. However, it is not clear how do they affect the overall BCI performance or how they should be tackled. This is worsened by the publication bias where only positive results are disseminated, preventing the research community from learning from its errors. This paper is the result of a workshop held at the 6th International BCI meeting in Asilomar. We summarize here the discussion on concrete research avenues and guidelines that may help overcoming common pitfalls and make BCIs become a useful alternative communication device.

Wheelchair control by elderly participants in a virtual environment with a brain-computer interface (BCI) and tactile stimulation.

Tactile event-related potential (ERP) are rarely used as input signal to control brain-computer-interfaces (BCI) due to their low accuracy and speed (information transfer rate, ITR). Age-related loss of tactile sensibility might further decrease their viability for the target population of BCI. In this study we investigated whether training improves tactile ERP-BCI performance within a virtual wheelchair navigation task. Elderly subjects participated in 5 sessions and tactors were placed at legs, abdomen and back. Mean accuracy and ITR increased from 88.43%/4.5bitsmin-1 in the 1st to 92.56%/4.98bitsmin-1 in the last session. The mean P300 amplitude increased from 5.46µV to 9.22µV. In an optional task participants achieved an accuracy of 95,56% and a mean ITR of 20,73bitsmin-1 which is the highest ever achieved with tactile stimulation. Our sample of elderly people further contributed to the external validity of our results.

Toward a P300 Based Brain-Computer Interface for Aphasia Rehabilitation after Stroke: Presentation of Theoretical Considerations and a Pilot Feasibility Study.

People with post-stroke motor aphasia know what they would like to say but cannot express it through motor pathways due to disruption of cortical circuits. We present a theoretical background for our hypothesized connection between attention and aphasia rehabilitation and suggest why in this context, Brain-Computer Interface (BCI) use might be beneficial for patients diagnosed with aphasia. Not only could BCI technology provide a communication tool, it might support neuronal plasticity by activating language circuits and thereby boost aphasia recovery. However, stroke may lead to heterogeneous symptoms that might hinder BCI use, which is why the feasibility of this approach needs to be investigated first. In this pilot study, we included five participants diagnosed with post-stroke aphasia. Four participants were initially unable to use the visual P300 speller paradigm. By adjusting the paradigm to their needs, participants could successfully learn to use the speller for communication with accuracies up to 100%. We describe necessary adjustments to the paradigm and present future steps to investigate further this approach.

The WIN-speller: a new intuitive auditory brain-computer interface spelling application.

The objective of this study was to test the usability of a new auditory Brain-Computer Interface (BCI) application for communication. We introduce a word based, intuitive auditory spelling paradigm the WIN-speller. In the WIN-speller letters are grouped by words, such as the word KLANG representing the letters A, G, K, L, and N. Thereby, the decoding step between perceiving a code and translating it to the stimuli it represents becomes superfluous. We tested 11 healthy volunteers and four end-users with motor impairment in the copy spelling mode. Spelling was successful with an average accuracy of 84% in the healthy sample. Three of the end-users communicated with average accuracies of 80% or higher while one user was not able to communicate reliably. Even though further evaluation is required, the WIN-speller represents a potential alternative for BCI based communication in end-users.

Proof of principle of a brain-computer interface approach to support poststroke arm rehabilitation in hospitalized patients: design, acceptability, and usability.

OBJECTIVE: To evaluate the feasibility of brain-computer interface (BCI)-assisted motor imagery training to support hand/arm motor rehabilitation after stroke during hospitalization. DESIGN: Proof-of-principle study. SETTING: Neurorehabilitation hospital. PARTICIPANTS: Convenience sample of patients (N=8) with new-onset arm plegia or paresis caused by unilateral stroke. INTERVENTIONS: The BCI-based intervention was administered as an "add-on" to usual care and lasted 4 weeks. Under the supervision of a therapist, patients were asked to practice motor imagery of their affected hand and received as a discrete feedback the movements of a "virtual" hand superimposed on their own. Such a BCI-based device was installed in a rehabilitation hospital ward. MAIN OUTCOME MEASURES: Following a user-centered design, we assessed system usability in terms of motivation, satisfaction (by means of visual analog scales), and workload (National Aeronautics and Space Administration-Task Load Index). The usability of the BCI-based system was also evaluated by 15 therapists who participated in a focus group. RESULTS: All patients successfully accomplished the BCI training. Significant positive correlations were found between satisfaction and motivation (P=.001, r=.393). BCI performance correlated with interest (P=.027, r=.257) and motivation (P=.012, r=.289). During the focus group, professionals positively acknowledged the opportunity offered by BCI-assisted training to measure patients' adherence to rehabilitation. CONCLUSIONS: An ecological BCI-based device to assist motor imagery practice was found to be feasible as an add-on intervention and tolerable by patients who were exposed to the system in the rehabilitation environment.

The user-centered design as novel perspective for evaluating the usability of BCI-controlled applications.

Albeit research on brain-computer interfaces (BCI) for controlling applications has expanded tremendously, we still face a translational gap when bringing BCI to end-users. To bridge this gap, we adapted the user-centered design (UCD) to BCI research and development which implies a shift from focusing on single aspects, such as accuracy and information transfer rate (ITR), to a more holistic user experience. The UCD implements an iterative process between end-users and developers based on a valid evaluation procedure. Within the UCD framework usability of a device can be defined with regard to its effectiveness, efficiency, and satisfaction. We operationalized these aspects to evaluate BCI-controlled applications. Effectiveness was regarded equivalent to accuracy of selections and efficiency to the amount of information transferred per time unit and the effort invested (workload). Satisfaction was assessed with questionnaires and visual-analogue scales. These metrics have been successfully applied to several BCI-controlled applications for communication and entertainment, which were evaluated by end-users with severe motor impairment. Results of four studies, involving a total of N = 19 end-users revealed: effectiveness was moderate to high; efficiency in terms of ITR was low to high and workload low to medium; depending on the match between user and technology, and type of application satisfaction was moderate to high. The here suggested evaluation metrics within the framework of the UCD proved to be an applicable and informative approach to evaluate BCI controlled applications, and end-users with severe impairment and in the locked-in state were able to participate in this process.

Visuo-motor coordination ability predicts performance with brain-computer interfaces controlled by modulation of sensorimotor rhythms (SMR).

Modulation of sensorimotor rhythms (SMR) was suggested as a control signal for brain-computer interfaces (BCI). Yet, there is a population of users estimated between 10 to 50% not able to achieve reliable control and only about 20% of users achieve high (80-100%) performance. Predicting performance prior to BCI use would facilitate selection of the most feasible system for an individual, thus constitute a practical benefit for the user, and increase our knowledge about the correlates of BCI control. In a recent study, we predicted SMR-BCI performance from psychological variables that were assessed prior to the BCI sessions and BCI control was supported with machine-learning techniques. We described two significant psychological predictors, namely the visuo-motor coordination ability and the ability to concentrate on the task. The purpose of the current study was to replicate these results thereby validating these predictors within a neurofeedback based SMR-BCI that involved no machine learning.Thirty-three healthy BCI novices participated in a calibration session and three further neurofeedback training sessions. Two variables were related with mean SMR-BCI performance: (1) a measure for the accuracy of fine motor skills, i.e., a trade for a person's visuo-motor control ability; and (2) subject's "attentional impulsivity". In a linear regression they accounted for almost 20% in variance of SMR-BCI performance, but predictor (1) failed significance. Nevertheless, on the basis of our prior regression model for sensorimotor control ability we could predict current SMR-BCI performance with an average prediction error of M = 12.07%. In more than 50% of the participants, the prediction error was smaller than 10%. Hence, psychological variables played a moderate role in predicting SMR-BCI performance in a neurofeedback approach that involved no machine learning. Future studies are needed to further consolidate (or reject) the present predictors.

Empathy, motivation, and P300 BCI performance.

Motivation moderately influences brain-computer interface (BCI) performance in healthy subjects when monetary reward is used to manipulate extrinsic motivation. However, the motivation of severely paralyzed patients, who are potentially in need for BCI, could mainly be internal and thus, an intrinsic motivator may be more powerful. Also healthy subjects who participate in BCI studies could be internally motivated as they may wish to contribute to research and thus extrinsic motivation by monetary reward would be less important than the content of the study. In this respect, motivation could be defined as "motivation-to-help." The aim of this study was to investigate, whether subjects with high motivation for helping and who are highly empathic would perform better with a BCI controlled by event-related potentials (P300-BCI). We included N = 20 healthy young participants naïve to BCI and grouped them according to their motivation for participating in a BCI study in a low and highly motivated group. Motivation was further manipulated with interesting or boring presentations about BCI and the possibility to help patients. Motivation for helping did neither influence BCI performance nor the P300 amplitude. Post hoc, subjects were re-grouped according to their ability for perspective taking. We found significantly higher P300 amplitudes on parietal electrodes in participants with a low ability for perspective taking and therefore, lower empathy, as compared to participants with higher empathy. The lack of an effect of motivation on BCI performance contradicts previous findings and thus, requires further investigation. We speculate that subjects with higher empathy who are good perspective takers with regards to patients in potential need of BCI, may be more emotionally involved and therefore, less able to allocate attention on the BCI task at hand.

Brain Painting: usability testing according to the user-centered design in end users with severe motor paralysis.

BACKGROUND: For many years the reestablishment of communication for people with severe motor paralysis has been in the focus of brain-computer interface (BCI) research. Recently applications for entertainment have also been developed. Brain Painting allows the user creative expression through painting pictures. OBJECTIVE: The second, revised prototype of the BCI Brain Painting application was evaluated in its target function - free painting - and compared to the P300 spelling application by four end users with severe disabilities. METHODS: According to the International Organization for Standardization (ISO), usability was evaluated in terms of effectiveness (accuracy), efficiency (information transfer rate (ITR)), utility metric, subjective workload (National Aeronautics and Space Administration Task Load Index (NASA TLX)) and user satisfaction (Quebec User Evaluation of Satisfaction with assistive Technology (QUEST) 2.0 and Assistive Technology Device Predisposition Assessment (ATD PA), Device Form). RESULTS: The results revealed high performance levels (M≥80% accuracy) in the free painting and the copy painting conditions, ITRs (4.47-6.65bits/min) comparable to other P300 applications and only low to moderate workload levels (5-49 of 100), thereby proving that the complex task of free painting did neither impair performance nor impose insurmountable workload. Users were satisfied with the BCI Brain Painting application. Main obstacles for use in daily life were the system operability and the EEG cap, particularly the need of extensive support for adjustment. CONCLUSION: The P300 Brain Painting application can be operated with high effectiveness and efficiency. End users with severe motor paralysis would like to use the application in daily life. User-friendliness, specifically ease of use, is a mandatory necessity when bringing BCI to end users. Early and active involvement of users and iterative user-centered evaluation enable developers to work toward this goal.

Prediction of auditory and visual p300 brain-computer interface aptitude.

OBJECTIVE: Brain-computer interfaces (BCIs) provide a non-muscular communication channel for patients with late-stage motoneuron disease (e.g., amyotrophic lateral sclerosis (ALS)) or otherwise motor impaired people and are also used for motor rehabilitation in chronic stroke. Differences in the ability to use a BCI vary from person to person and from session to session. A reliable predictor of aptitude would allow for the selection of suitable BCI paradigms. For this reason, we investigated whether P300 BCI aptitude could be predicted from a short experiment with a standard auditory oddball. METHODS: Forty healthy participants performed an electroencephalography (EEG) based visual and auditory P300-BCI spelling task in a single session. In addition, prior to each session an auditory oddball was presented. Features extracted from the auditory oddball were analyzed with respect to predictive power for BCI aptitude. RESULTS: Correlation between auditory oddball response and P300 BCI accuracy revealed a strong relationship between accuracy and N2 amplitude and the amplitude of a late ERP component between 400 and 600 ms. Interestingly, the P3 amplitude of the auditory oddball response was not correlated with accuracy. CONCLUSIONS: Event-related potentials recorded during a standard auditory oddball session moderately predict aptitude in an audiory and highly in a visual P300 BCI. The predictor will allow for faster paradigm selection. SIGNIFICANCE: Our method will reduce strain on patients because unsuccessful training may be avoided, provided the results can be generalized to the patient population.

Probing command following in patients with disorders of consciousness using a brain-computer interface.

OBJECTIVE: To determine if brain-computer interfaces (BCIs) could serve as supportive tools for detecting consciousness in patients with disorders of consciousness by detecting response to command and communication. METHODS: We tested a 4-choice auditory oddball EEG-BCI paradigm on 16 healthy subjects and 18 patients in a vegetative state/unresponsive wakefulness syndrome, in a minimally conscious state (MCS), and in locked-in syndrome (LIS). Subjects were exposed to 4 training trials and 10 -12 questions. RESULTS: Thirteen healthy subjects and one LIS patient were able to communicate using the BCI. Four of those did not present with a P3. One MCS patient showed command following with the BCI while no behavioral response could be detected at bedside. All other patients did not show any response to command and could not communicate with the BCI. CONCLUSION: The present study provides evidence that EEG based BCI can detect command following in patients with altered states of consciousness and functional communication in patients with locked-in syndrome. However, BCI approaches have to be simplified to increase sensitivity. SIGNIFICANCE: For some patients without any clinical sign of consciousness, a BCI might bear the potential to employ a "yes-no" spelling device offering the hope of functional interactive communication.

P300 brain computer interface: current challenges and emerging trends.

A brain-computer interface (BCI) enables communication without movement based on brain signals measured with electroencephalography (EEG). BCIs usually rely on one of three types of signals: the P300 and other components of the event-related potential (ERP), steady state visual evoked potential (SSVEP), or event related desynchronization (ERD). Although P300 BCIs were introduced over twenty years ago, the past few years have seen a strong increase in P300 BCI research. This closed-loop BCI approach relies on the P300 and other components of the ERP, based on an oddball paradigm presented to the subject. In this paper, we overview the current status of P300 BCI technology, and then discuss new directions: paradigms for eliciting P300s; signal processing methods; applications; and hybrid BCIs. We conclude that P300 BCIs are quite promising, as several emerging directions have not yet been fully explored and could lead to improvements in bit rate, reliability, usability, and flexibility.

Online use of error-related potentials in healthy users and people with severe motor impairment increases performance of a P300-BCI.

OBJECTIVE: To investigate whether error-related potentials can be used to increase information transfer rate of a P3 brain-computer interface (BCI) in healthy and motor-impaired individuals. METHODS: Extraction and classification of the error-related potential was performed offline on data recorded from six amyotrophic lateral sclerosis (ALS) patients. An online study with 17 healthy and six motor impaired participants followed, using a modified P3 speller to provide explicit feedback of spelled letters. On recognition of error-related potentials, the interface informed users that the incorrect letter was automatically deleted. RESULTS: The offline cross-validation estimate of P3 speller data of six ALS patients increased bit rate by 0.44 bit/trial. During online copy spelling, the participants increased their bit rate by 0.52 bit/trial with the error correction system (ECS). Some participants performed free spelling and were able to increase their bit rate. Finally, we demonstrated that healthy participants could increase their bit rate by using a classifier pre-trained on other users' data. CONCLUSIONS: Error-related potentials as a secondary source of information can be used to increase overall bit rate in a P3 BCI. SIGNIFICANCE: The method should be made available to any patient using the P3 BCI for communication.

Psychological predictors of SMR-BCI performance.

BACKGROUND: After about 30 years of research on Brain-Computer Interfaces (BCIs) there is little knowledge about the phenomenon, that some people - healthy as well as individuals with disease - are not able to learn BCI-control. To elucidate this "BCI-inefficiency" phenomenon, the current study investigated whether psychological parameters, such as attention span, personality or motivation, could predict performance in a single session with a BCI controlled by modulation of sensorimotor rhythms (SMR) with motor imagery. METHODS: A total of N=83 healthy BCI novices took part in the session. Psychological parameters were measured with an electronic test-battery including clinical, personality and performance tests. Predictors were determined by binary logistic regression analyses. RESULTS: The output variable of the Two-Hand Coordination Test (2HAND) "overall mean error duration" which is a measure for the accuracy of fine motor skills accounted for 11% of the variance in BCI-inefficiency. The Attitudes Towards Work (AHA) test variable "performance level" which can be interpreted as a degree of concentration and a neurophysiological SMR predictor were also identified as significant predictors of SMR BCI performance. CONCLUSION: Psychological parameters as measured in this study play a moderate role for one-session performance in a BCI controlled by modulation of SMR.

Out of the frying pan into the fire--the P300-based BCI faces real-world challenges.

Brain-computer interfaces (BCIs) have been investigated for more than 20 years. Many BCIs use noninvasive electroencephalography as a measurement technique and the P300 event-related potential as an input signal (P300 BCI). Since the first experiment with a P300 BCI system in 1988 by Farwell and Donchin, not only data processing has improved but also stimuli presentation has been varied and a plethora of applications was developed and refined. Nowadays, these applications are facing the challenge of being transferred from the research laboratory into real-life situations to serve motor-impaired people in their homes as assistive technology.