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To maximize brain plasticity after stroke, a plethora of rehabilitation strategies have been explored. These include the use of intensive motor training, motor-imagery (MI), and action-observation (AO). Growing evidence of the positive impact of virtual reality (VR) techniques on recovery following stroke has been shown. However, most VR tools are...
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Brain computer interface (BCI) systems for neurorehabilitation have received increasing attention over the past decade. These systems provide an alternative approach to restore lost motor functions in stroke patients by inducing brain plasticity. To utilize BCI systems for stroke rehabilitation, user movement intentions from electroencephalogram ar...
Many studies have used motor imagery-based brain–computer interface (MI-BCI) systems for stroke rehabilitation to induce brain plasticity. However, they mainly focused on detecting motor imagery but did not consider the effect of false positive (FP) detection. The FP could be a threat to patients with stroke as it can induce wrong-directed brain pl...
Citations
... Neurofeedback (NFB) provides an alternative way for individuals to self-regulate their brain activity within specific regions by using non-invasive techniques, such as Electroencephalography (EEG). In short, NFB enhances therapeutic outcomes when severe impaired individuals practice Motor Imagery (MI) during rehabilitation [6], [9]. For instance, various studies have demonstrated that MI together with Visual Neurofeedback (VNFB), generate alterations in SMRs. ...
... MI is a promising tool for long-term motor recovery [6], [28], given that this mental action and its corresponding movement planning (or preparation) and actual movement similarly share activated brain regions [9], [31]. There is limited understanding regarding the ability of SCI individuals to accurately perform MI tasks. ...
Robotic systems, such as Lokomat® have shown promising results in people with severe motor impairments, who suffered a stroke or other neurological damage. Robotic devices have also been used by people with more challenging damages, such as Spinal Cord Injury (SCI), using feedback strategies that provide information about the brain activity in real-time. This study proposes a novel Motor Imagery (MI)-based Electroencephalogram (EEG) Visual Neurofeedback (VNFB) system for Lokomat® to teach individuals how to modulate their own μ (8-12 Hz) and β (15-20 Hz) rhythms during passive walking. Two individuals with complete SCI tested our VNFB system completing a total of 12 sessions, each on different days. For evaluation, clinical outcomes before and after the intervention and brain connectivity were analyzed. As findings, the sensitivity related to light touch and painful discrimination increased for both individuals. Furthermore, an improvement in neurogenic bladder and bowel functions was observed according to the American Spinal Injury Association Impairment Scale, Neurogenic Bladder Symptom Score, and Gastrointestinal Symptom Rating Scale. Moreover, brain connectivity between different EEG locations significantly (p <0.05) increased, mainly in the motor cortex. As other highlight, both SCI individuals enhanced their μ rhythm, suggesting motor learning. These results indicate that our gait training approach may have substantial clinical benefits in complete SCI individuals.
... Symptoms of stroke vary depending on the damaged brain area, but in more than 80% of the cases, patients have upper limb impairments [29], including weakness or paralysis, decreased range of motion, spasticity, coordination problems, sensory alteration, and impaired fine motor skills [30]. All the analyzed studies focusing on stroke survivors aimed at improving their upper-limb motor functions (n = 8) [30][31][32][33][34][35][36][37]. Moreover, stroke conditions can be classified based on the time elapsed from the lesion between the acute stage (1-7 days), subacute stage (≤ 6 months) and chronic stage (> 6 months) [38]. ...
... Moreover, stroke conditions can be classified based on the time elapsed from the lesion between the acute stage (1-7 days), subacute stage (≤ 6 months) and chronic stage (> 6 months) [38]. We found that the studies selected in this scoping review were almost equally distributed among two groups, with three focusing on subacute patients [30,31,37] and the other five focusing on chronic patients [32][33][34][35][36]. The presence of studies that used immersive VR in acute and subacute phases of stroke rehabilitation reflects the clinical priority given to interventions during these vital early stages, emphasizing the importance of acting as soon as possible [8,11]. ...
... In the selected studies, motor tasks involved using the affected limb to reach and grasp objects freely moving in the virtual environment [31,42], interacting with a virtual kitchen [37,41], manipulating objects [37], or other arm movements (e.g., wrist or fingers extension) [32][33][34]43]. Another adopted approach was motor imagery [36]. Motor imagery involves mental rehearsal or imagination of specific movements without physically executing them. ...
Background
Neurological disorders, such as stroke and chronic pain syndromes, profoundly impact independence and quality of life, especially when affecting upper extremity (UE) function. While conventional physical therapy has shown effectiveness in providing some neural recovery in affected individuals, there remains a need for improved interventions. Virtual reality (VR) has emerged as a promising technology-based approach for neurorehabilitation to make the patient’s experience more enjoyable. Among VR-based rehabilitation paradigms, those based on fully immersive systems with headsets have gained significant attention due to their potential to enhance patient’s engagement.
Methods
This scoping review aims to investigate the current state of research on the use of immersive VR for UE rehabilitation in individuals with neurological diseases, highlighting benefits and limitations. We identified thirteen relevant studies through comprehensive searches in Scopus, PubMed, and IEEE Xplore databases. Eligible studies incorporated immersive VR for UE rehabilitation in patients with neurological disorders and evaluated participants’ neurological and motor functions before and after the intervention using clinical assessments.
Results
Most of the included studies reported improvements in the participants rehabilitation outcomes, suggesting that immersive VR represents a valuable tool for UE rehabilitation in individuals with neurological disorders. In addition, immersive VR-based interventions hold the potential for personalized and intensive training within a telerehabilitation framework. However, further studies with better design are needed for true comparison with traditional therapy. Also, the potential side effects associated with VR head-mounted displays, such as dizziness and nausea, warrant careful consideration in the development and implementation of VR-based rehabilitation programs.
Conclusion
This review provides valuable insights into the application of immersive VR in UE rehabilitation, offering the foundation for future research and clinical practice. By leveraging immersive VR’s potential, researchers and rehabilitation specialists can design more tailored and patient-centric rehabilitation strategies, ultimately improving the functional outcome and enhancing the quality of life of individuals with neurological diseases.
... Yet, it is also known that increasing the energy of EEG signals increases the classification accuracy of these signals and, in this way, facilitates the identification of their pattern. To increase the energy of EEG signals, it is recommended to use Virtual Reality (VR) applications that allow the patient to participate more in rehabilitation exercises (Saposnik et al. 2016;Aida et al. 2018;Vourvopoulos et al. 2019a;Elor and Kurniawan 2020). The literature reviews by Camargo-Vargas et al. (2021) and Choy et al. (2023) show that the use of non-immersive VR technology experienced via 2D computer screens and fully-immersive VR technology experienced via headsets are the most common practices in post-stroke hand rehabilitation. ...
... They also suggested that electrophysiological indicators can be used to assess the user profile of psychophysiological responses and that this information may help to predict the success of MI-BCI training. Vourvopoulos et al. (2019a) tested the effect of fully interactive MI for upper limb motor rehabilitation in a stroke patient. After a three-week VR-based rehabilitation period, significant improvements were observed in the patient's upper extremity scores measured by the Fugl-Meyer assessment. ...
This study investigates the influence of immersive virtual reality environments and gamification on the classification of imaginary motor (MI) signals and the associated increase in energy in the motor cortex region for neurorehabilitation purposes. Two immersive virtual environments, indoor and outdoor, were selected, each with gamified and non-gamified scenarios. Event-Related Desynchronization (ERD) data underwent analyses to determine if there were significant differences in ERD levels between distinct age groups and whether Fully Immersive Virtual Reality (FIVR) environments induced notable energy increases.
The initial analysis found no significant energy changes between age groups under constant environmental conditions. In the second analysis, FIVR environments did not lead to a statistically significant increase in cortical energy for the 21–24 age group (Group I). However, a notable difference in cortical energy increase was identified between gamified and non-gamified environments within the 32–43 age group (Group II).
The study also explored the impact of environmental factors on MI signal classification using four deep learning algorithms. The Recurrent Neural Network (RNN) classifier exhibited the highest performance, with an average accuracy of 86.83%. Signals recorded indoors showed higher average classification performance, with a significant difference observed among age groups. Group I participants performed better in non-gamified environments (88.8%), while Group II achieved high performance indoors, especially in the gamified scenario (93.6%). Overall, the research underscores the potential of immersive virtual environments and gamification in enhancing MI signal classification and cortical energy increase, with age and environmental factors influencing the outcomes.
... State-of-the-art systematic review for MI-based smart BCI training environments is highlighted in literature [18]. Accordingly, smart BCI applications have been developed based on various types of STE criteria within training environments [19][20][21][22][23][24][25]. Ten STE criteria have recently received great attention and should be considered in BCI application development. ...
Benchmarking brain–computer interface (BCI) applications, considering all available smart training environment (STE) criteria, is a challenging task due to the following issues: inconsistent weights, static ranks and ranking stability measurements. Therefore, this study aims to develop a dynamic decision-making framework for benchmarking BCI applications based on STE criteria through three integrated phases. In the first phase, the adaptivity of the decision matrix is identified concerning two dimensions: 27 BCI applications as alternatives and 10 STE criteria. In the second phase, the consistency of weights is evaluated and constructed to each STE criterion via the fuzzy-weighted zero-inconsistency (FWZIC) method and the VIekriterijumsko KOmpromisno Rangiranje (VIKOR) method for benchmarking the BCI applications. In the third phase, four sensitive scenarios are developed for measuring the consistency of the STE criteria’s weights and the ranking performance of the BCI applications. The experimental result shows that the ‘ease of use’ STE criterion obtains a high-affected weight with a value of 0.13, while other criteria, augmented reality, hybrid and desktop use (stationary), obtain less weight with a 0.075 value. Additionally, BCI applications A5 and A6 are robust and stable among the others based on the consistency of weights concerning the four scenarios, and they are further candidates to be deployed in real-life applications. The overall ranking results are stable and less affected when applied to the four sensitive scenarios due to the robustness of the integrated FWZIC-VIKOR method of the proposed dynamic framework. The outcome of this framework is objectively validated in terms of five groups, and the ranking results are reliable and the closest to the decision-makers' viewpoints. The proposed framework considers a good solution for choosing a dependable application to support the user and community of BCI systems with a stable STE environment.
... The training was carried out in 12 sessions (3 days a week, for 4 weeks) of 30 min each, divided into 3 series of 7 min (26). ...
... Secondly, there was a difference in the dura tion of the rTMS and NFB neuromodulation protocols (10 sessions in 2 weeks and 12 sessions in 4 weeks, respectively). This discrepancy, which is due to the design of the study based on previous neuromodulation studies (21,26), could have affected the results. The assessments were carried out immediately after the whole intervention finished. ...
Objective:
To examine the clinical effects of combining motor imagery-based neurofeedback training with bilateral repetitive transcranial magnetic stimulation for upper limb motor function in subacute and chronic stroke.
Design:
Clinical trial following an AB/BA crossover design with counterbalanced assignment.
Subjects:
Twenty individuals with subacute (n = 4) or chronic stroke (n = 16).
Methods:
Ten consecutive sessions of bilateral repetitive transcranial magnetic stimulation alone (therapy A) were compared vs a combination of10 consecutive sessions of bilateral repetitive transcranial magnetic stimulation with 12 non-consecutive sessions of motor imagery-based neurofeedback training (therapy B). Patients received both therapies (1-month washout period), in sequence AB or BA. Participants were assessed before and after each therapy and at 15-days follow-up, using the Fugl-Meyer Assessment-upper limb, hand-grip strength, and the Nottingham Sensory Assessment as primary outcome measures.
Results:
Both therapies resulted in improved functionality and sensory function. Therapy B consistently exhibited superior effects compared with therapy A, according to Fugl-Meyer Assessment and tactile and kinaesthetic sensory function across multiple time-points, irrespective of treatment sequence. No statistically significant differences between therapies were found for hand-grip strength.
Conclusion:
Following subacute and chronic stroke, integrating bilateral repetitive transcranial magnetic stimulation and motor imagery-based neurofeedback training has the potential to enhance functional performance compared with using bilateral repetitive transcranial magnetic stimulation alone in upper limb recovery.
... Patients can improve their motor performance by repeatedly imagining and simulating the specified actions (Wang et al., 2019). These studies observed that motor imagery, as a complementary technique, improved upper limbs motor function (Nam et al., 2019;Vourvopoulos et al., 2019;Barclay et al., 2020;Gaughan and Boe, 2021;Hilt et al., 2023). However, there is no consensus regarding the intervention protocol for the application of motor imagery. ...
Background
Motor imagery therapy (MIT) showed positive effects on upper limbs motor function. However, the mechanism by which MIT improves upper limb motor function is not fully understood. Therefore, our purpose was to investigate the changes in functional connectivity (FC) within and outside the sensorimotor network (SMN) induced by MIT associated with improvement in upper limb motor function in stroke patients.
Methods
A total of 26 hemiplegic stroke patients were randomly divided into MIT (n = 13) and control (n = 13) groups. Fugl-Meyer Assessment Upper Extremity Scale (FMA-UL), Modified Barthel Index (MBI) and resting-state functional magnetic resonance imaging (rs-fMRI) were evaluated in the two groups before treatment and 4 weeks after treatment. The efficacy of MIT on motor function improvement in stroke patients with hemiplegia was evaluated by comparing the FMA-UL and MBI scores before and after treatment in the two groups. Furthermore, the FC within the SMN and between the SMN and the whole brain was measured and compared before and after different treatment methods in stroke patients. The correlation analysis between the improvement of upper limbs motor function and changes in FC within the SMN and between the SMN and the whole brain was examined.
Results
The FCs between ipsilesional primary motor cortex (M1.I) and contralateral supplementary motor area (SMA.C), M1.I and ipsilesional SMA (SMA.I), and SMA.C and contralateral dorsolateral premotor cortex (DLPM.C) significantly increased in the control group but decreased in the MIT group; while the FC between SMA.C and contralateral primary somatosensory cortex (S1.C) significantly increased in the control group but showed no significant difference in the MIT group. The FCs between M1.I and the ipsilesional hippocampal gyrus and ipsilesional middle frontal gyrus significantly decreased in the control group but increased in the MIT group; while the FC in the contralateral anterior cingulate cortex significantly increased in the MIT group but there was no significant difference in the control group. The results of the correlation analysis showed that the differences in abnormal intra-FCs within the SMN negatively correlated with the differences in FMA and MBI, and the difference in abnormal inter-FCs of the SMN positively correlated with the differences in FMA and MBI.
Conclusions
MIT can improve upper limb motor function and daily activities of stroke patients, and the improvement effect of conventional rehabilitation therapy (CRT) combined with MIT is significantly higher than that of CRT alone. CRT may improve the upper limb motor function of stroke patients with hemiplegia mainly through the functional reorganization between SMN, while MIT may mainly increase the interaction between SMN and other brain networks.
... For example, in Sebastián-Romagosa et al. (2020) study of 51 stoke patients, they found the combination of BCI, VR and FES in a rehab treatment "was effective in promoting long lasting functional improvements in the upper extremity" (Sebastián-Romagosa et al., 2020). In Vourvopoulos et al. (2019) closely examined a clinical case of a 60-year-old stroke patient to see how the integration of VR, EEG, and BCI intervention impacted their CMP. The use of the integrated intervention resulted in measurable improvements to upper extremity mobility scores as well as in brain activation. ...
... Another common deficiency that is plain to be seen across most of the research into the CMP for MWU is the lack of longitudinal studies. Most researchers that examine means of improving CMP for MWU only follow up after a short period of time (Achanccaray et al., 2018;Remsik et al., 2018;Carino-Escobar et al., 2019;Vourvopoulos et al., 2019;Sebastián-Romagosa et al., 2020). This is a significant gap in the research as any gains made through rehabilitation techniques are meant to be long-term, but there is a staggeringly low amount of research into what extent this occurs. ...
According to the World Health Organization, hundreds of individuals commence wheelchair use daily, often due to an injury such as spinal cord injury or through a condition such as a stroke. However, manual wheelchair users typically experience reductions in individual community mobility and participation. In this review, articles from 2017 to 2023 were reviewed to identify means of measuring community mobility and participation of manual wheelchair users, factors that can impact these aspects, and current rehabilitation techniques for improving them. The selected articles document current best practices utilizing self-surveys, in-clinic assessments, and remote tracking through GPS and accelerometer data, which rehabilitation specialists can apply to track their patients’ community mobility and participation accurately. Furthermore, rehabilitation methods such as wheelchair training programs, brain-computer interface triggered functional electric stimulation therapy, and community-based rehabilitation programs show potential to improve the community mobility and participation of manual wheelchair users. Recommendations were made to highlight potential avenues for future research.
... This study utilized a novel BCI system, i.e., the L-B300 EEG Acquisition and Rehabilitation Training System from Zhejiang Mailian Medical Technology Co., Ltd. (Hangzhou, China), and this system offers the following advantages: 1) It provides both visual and motor feedback [25], whereas most other BCI rehabilitation systems adopt single feedback modality, such as systems based on vision [26], kinesthetic sense [27], or perception [28], and 2) It provides a hightime efficiency, with real-time feedback taking only 110 ms, which is smaller than that of other systems (200 ms [29] and 300 ms [30]). In rehabilitation, having more and faster feedback could potentially improve patient outcomes [13]. ...
Background Modern stroke rehabilitation integrates exercise therapy, occupational therapy, and other technological interventions. This study investigated the short-term intervention effect of brain-computer interface (BCI) training based on visual and motor feedback on cognition, psychology, limb movement, and brain function in convalescent stroke patients with hemiplegia.
Methods: Convalescent stroke patients with hemiplegia (n=98) were randomly assigned to one of three groups: conventional exercise rehabilitation (Control), conventional exercise + conventional motor imagery (MI), and conventional exercise + BCI-based MI (BCI) groups, while MI and BCI patients imagined the upper limb swimming and lower limb cycling during the rehabilitation, and treated for six times a week for two weeks. The training effects were evaluated by the mini-mental state examination (MMSE), Hamilton Depression Scale (HAM-D), Fugl-Meyer Assessment (FMA), six min walking distance (6MWD), modified Barthel index (MBI),and transcranial magnetic stimulator before and after the intervention.
Results: (1) After intervention: All indicators of the three groups were significantly improved compared with those before intervention(P<0.05) except for the MEP amplitude in Control group and MI group. (2) Differences before and after intervention: All items in BCI group were the largest in the three groups, in which MMSE, HAMD, and FMA items in BCI group were significantly different from those in the other two groups(P<0.05), and the MEP latency in BCI group was significantly different from that in MI group(P<0.05).
Conclusion: This randomized controlled trial demonstrated that all three types of interventions could significantly improve convalescent stroke patients with hemiplegia, while BCI-based MI training with both visual and motor feedback was a better choice for clinical rehabilitation of patients to recover cognition, psychology,and limb movement. Mechanistically, BCI-based MI training also improved the excitability of the non-lesional cerebral hemisphere and the conductivity of the descending neural pathway.
... The search strategy identified 1918 records; 191 passed beyond the title and abstract evaluation, of which 18 full texts met all inclusion criteria [41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58]. One article was added after bibliography consultation of the included studies [59]. ...
... Among the studies that reported the specific type of HMD, almost all used either the Oculus Rift [42,44,46,47,[54][55][56][57][58] or the HTC Vive [43,45,[51][52][53][54]59]. Often, the hardware component comprised hand controllers [43,47,49,52,54,56,59] and/or other devices such as the Leap Motion Controller [42,[44][45][46]53,54] or haptic tools [50,57]. ...
... Among the studies that reported the specific type of HMD, almost all used either the Oculus Rift [42,44,46,47,[54][55][56][57][58] or the HTC Vive [43,45,[51][52][53][54]59]. Often, the hardware component comprised hand controllers [43,47,49,52,54,56,59] and/or other devices such as the Leap Motion Controller [42,[44][45][46]53,54] or haptic tools [50,57]. From the software side, several authors used commercial VR platforms (i.e., Steam [43,51] and VIVE platforms [43], Tion; Human IT Solution [47], and Rehago software [49]) while some of them proposed virtual tasks through ad hoc-developed tools [41,42,44,45,48,50,[52][53][54][55][56][57][58]. ...
Upper extremity (UE) paresis is one of the most frequent and disabling clinical consequences after stroke. Head-Mounted Displays (HMDs) are wearable virtual reality devices that seem effective in promoting the recovery of functional abilities by increasing adherence levels in this population. This scoping review is aimed at collecting available evidence on the use of HMD-based immersive virtual reality systems for UE rehabilitation treatment in stroke survivors. Four electronic bibliographic databases were consulted from inception until January 18th, 2023. A total of 19 clinical trials in which HMDs were used as a clinical tool for increasing UE functioning, as a single intervention or in adjunct to other rehab treatments, were included; no restrictions were applied for UE paresis severity or stroke onset. The large majority of the clinical trials involved chronic stroke patients (15 out of 19), with a wide range of UE impairments. Overall, HMD use seemed to be well-tolerated and promising for increasing UE motor function in adult chronic stroke survivors, with benefits in subjects' arm use and independence. The possibility of executing highly realistic and task-oriented movements appears to be promising in enhancing gesture relevance, thus promoting new motor strategies in a "virtual ecological way". Across studies, we found a high hetero-geneity in protocol design and a lack of reporting that prevents us drawing conclusions regarding potential subgroups of patients that could benefit more from HMD-based interventions or suggested treatment modalities.
... Health-related intervention tools such as virtual reality (VR), serious games (SG), and brain-computer interfaces (BCI) have become increasingly important in the field of healthcare since these tools have the potential to improve the quality of life for individuals with special needs and have been shown to be effective in rehabilitation and therapy [3][4] [5]. By targeting specific therapy goals and tailoring them to the individual needs of each patient, the serious games are able to improve the therapy quality and turn a very monotonous therapy or rehabilitation experience into an engaging one for their patients to participate in, thus improving motivation and engagement in the therapy process [4]. ...
Health-related intervention tools such as virtual reality, serious games, and brain-computer interfaces have become increasingly important in the field of healthcare. These tools have the potential to improve the quality of life for individuals with special needs and have been shown to be effective in rehabilitation and therapy. However, the distribution, maintenance and remote data collection of these tools have presented a challenge for healthcare providers, researchers, and developers. In this article, we propose Reh@Store, an open-source solution designed to assist professionals and patients in using, deploying and maintaining health-related intervention tools. The solution is designed to allow easy installation, updating, and removal of software on users' devices, as well as the automatic backup of generated data to an SFTP server. A usability test, stress test and a real-world case study were conducted. The solution was also validated and is ready to be deployed and used in production environments.
