Source-Based EEG Neurofeedback for Sustained Motor Imagery of a Single Leg.

The aim of the study was to test the feasibility of visual-neurofeedback-guided motor imagery (MI) of the dominant leg, based on source analysis with real-time sLORETA derived from 44 EEG channels. Ten able-bodied participants took part in two sessions: session 1 sustained MI without feedback and session 2 sustained MI of a single leg with neurofeedback. MI was performed in 20 s on and 20 s off intervals to mimic functional magnetic resonance imaging. Neurofeedback in the form of a cortical slice presenting the motor cortex was provided from a frequency band with the strongest activity during real movements. The sLORETA processing delay was 250 ms. Session 1 resulted in bilateral/contralateral activity in the 8-15 Hz band dominantly over the prefrontal cortex while session 2 resulted in ipsi/bilateral activity over the primary motor cortex, covering similar areas as during motor execution. Different frequency bands and spatial distributions in sessions with and without neurofeedback may reflect different motor strategies, most notably a larger proprioception in session 1 and operant conditioning in session 2. Single-leg MI might be used in the early phases of rehabilitation of stroke patients. Simpler visual feedback and motor cueing rather than sustained MI might further increase the intensity of cortical activation.

Effective Connectivity in Spinal Cord Injury-Induced Neuropathic Pain.

AIM: The aim of this study was to differentiate the effects of spinal cord injury (SCI) and central neuropathic pain (CNP) on effective connectivity during motor imagery of legs, where CNP is typically experienced. METHODS: Multichannel EEG was recorded during motor imagery of the legs in 3 groups of people: able-bodied (N = 10), SCI with existing CNP (N = 10), and SCI with no CNP (N = 20). The last group was followed up for 6 months to check for the onset of CNP. Source reconstruction was performed to obtain cortical activity in 17 areas spanning sensorimotor regions and pain matrix. Effective connectivity was calculated using the directed transfer function in 4 frequency bands and compared between groups. RESULTS: A total of 50% of the SCI group with no CNP developed CNP later. Statistically significant differences in effective connectivity were found between all groups. The differences between groups were not dependent on the frequency band. Outflows from the supplementary motor area were greater for the able-bodied group while the outflows from the secondary somatosensory cortex were greater for the SCI groups. The group with existing CNP showed the least differences from the able-bodied group, appearing to reverse the effects of SCI. The connectivities involving the pain matrix were different between able-bodied and SCI groups irrespective of CNP status, indicating their involvement in motor networks generally. SIGNIFICANCE: The study findings might help guide therapeutic interventions targeted at the brain for CNP alleviation as well as motor recovery post SCI.

The importance of self-efficacy and negative affect for neurofeedback success for central neuropathic pain after a spinal cord injury.

EEG-based neurofeedback uses mental behaviours (MB) to enable voluntary self-modulation of brain activity, and has potential to relieve central neuropathic pain (CNP) after a spinal cord injury (SCI). This study aimed to understand neurofeedback learning and the relationship between MB and neurofeedback success. Twenty-five non-CNP participants and ten CNP participants received neurofeedback training (reinforcing 9-12 Hz; suppressing 4-8 Hz and 20-30 Hz) on four visits. Participants were interviewed about the MB they used after each visit. Questionnaires examined the following factors: self-efficacy, locus of control, motivation, and workload of neurofeedback. MB were grouped into mental strategies (a goal-directed mental action) and affect (emotional experience during neurofeedback). Successful non-CNP participants significantly used more imagination-related MS and reported more negative affect compared to successful CNP participants. However, no mental strategy was clearly associated with neurofeedback success. There was some association between the lack of success and negative affect. Self-efficacy was moderately correlated with neurofeedback success (r = < 0.587, p = < 0.020), whereas locus of control, motivation, and workload had low, non-significant correlations (r < 0.300, p > 0.05). Affect may be more important than mental strategies for a successful neurofeedback performance. Self-efficacy was associated with neurofeedback success, suggesting that increasing confidence in one's neurofeedback abilities may improve neurofeedback performance.

On the way home: a BCI-FES hand therapy self-managed by sub-acute SCI participants and their caregivers: a usability study.

BACKGROUND: Regaining hand function is the top priority for people with tetraplegia, however access to specialised therapy outwith clinics is limited. Here we present a system for hand therapy based on brain-computer interface (BCI) which uses a consumer grade electroencephalography (EEG) device combined with functional electrical stimulation (FES), and evaluate its usability among occupational therapists (OTs) and people with spinal cord injury (SCI) and their family members. METHODS: Users: Eight people with sub-acute SCI (6 M, 2F, age 55.4 ± 15.6) and their caregivers (3 M, 5F, age 45.3 ± 14.3); four OTs (4F, age 42.3 ± 9.8). User Activity: Researchers trained OTs; OTs subsequently taught caregivers to set up the system for the people with SCI to perform hand therapy. Hand therapy consisted of attempted movement (AM) of one hand to lower the power of EEG sensory-motor rhythm in the 8-12 Hz band and thereby activate FES which induced wrist flexion and extension. Technology: Consumer grade wearable EEG, multichannel FES, custom made BCI application. LOCATION: Research space within hospital. Evaluation: donning times, BCI accuracy, BCI and FES parameter repeatability, questionnaires, focus groups and interviews. RESULTS: Effectiveness: The BCI accuracy was 70-90%. Efficiency: Median donning times decreased from 40.5 min for initial session to 27 min during last training session (N = 7), dropping to 14 min on the last self-managed session (N = 3). BCI and FES parameters were stable from session to session. Satisfaction: Mean satisfaction with the system among SCI users and caregivers was 3.68 ± 0.81 (max 5) as measured by QUEST questionnaire. Main facilitators for implementing BCI-FES technology were "seeing hand moving", "doing something useful for the loved ones", good level of computer literacy (people with SCI and caregivers), "active engagement in therapy" (OT), while main barriers were technical complexity of setup (all groups) and "lack of clinical evidence" (OT). CONCLUSION: BCI-FES has potential to be used as at home hand therapy by people with SCI or stroke, provided it is easy to use and support is provided. Transfer of knowledge of operating BCI is possible from researchers to therapists to users and caregivers. Trial registration Registered with NHS GG&C on December 6th 2017; clinicaltrials.gov reference number NCT03257982, url: https://clinicaltrials.gov/ct2/show/NCT03257982 .

Immediate effect of neurofeedback training on the pain matrix and cortical areas involved in processing neuropsychological functions.

OBJECTIVE: This study investigated the impact of neurofeedback training on the deeper cortical structures that comprise the "pain matrix" and are involved in processing neuropsychological functions. METHODS: Five paraplegic patients with central neuropathic pain received up to 40 sessions of neurofeedback training. They were asked to simultaneously modulate the relative power of the theta, alpha and beta bands, provided as a feedback from the sensorimotor cortex. The source localization technique was applied on EEG data recorded with 16 electrodes placed over the whole head. RESULTS: Neurofeedback training from the sensorimotor cortex induced effects on the pain matrix and in the areas involved in processing neuropsychological functions such as memory, executive functions and emotional regulations. Alpha and beta band activity was most increased in insular, cingulate and frontal cortex regions, and other areas corresponding to executive and emotional function processing. Theta band decreases were noted in the frontal, cingulate and motor cortices. In group analysis, theta and beta band activity was significantly reduced. CONCLUSION: The single channel electroencephalogram-based neurofeedback training produced effects on similar areas that are targeted in 19 channels standardized low-resolution brain electromagnetic tomography and expensive time-delayed functional magnetic resonance imaging feedback studies.

Upregulation of Supplementary Motor Area Activation with fMRI Neurofeedback during Motor Imagery.

Functional magnetic resonance imaging (fMRI) neurofeedback (NF) is a promising tool to study the relationship between behavior and brain activity. It enables people to self-regulate their brain signal. Here, we applied fMRI NF to train healthy participants to increase activity in their supplementary motor area (SMA) during a motor imagery (MI) task of complex body movements while they received a continuous visual feedback signal. This signal represented the activity of participants' localized SMA regions in the NF group and a prerecorded signal in the control group (sham feedback). In the NF group only, results showed a gradual increase in SMA-related activity across runs. This upregulation was largely restricted to the SMA, while other regions of the motor network showed no, or only marginal NF effects. In addition, we found behavioral changes, i.e., shorter reaction times in a Go/No-go task after the NF training only. These results suggest that NF can assist participants to develop greater control over a specifically targeted motor region involved in motor skill learning. The results contribute to a better understanding of the underlying mechanisms of SMA NF based on MI with a direct implication for rehabilitation of motor dysfunctions.

Is Implicit Motor Imagery a Reliable Strategy for a Brain-Computer Interface?

Explicit motor imagery (eMI) is a widely used brain-computer interface (BCI) paradigm, but not everybody can accomplish this task. Here, we propose a BCI based on implicit motor imagery (iMI). We compared classification accuracy between eMI and iMI of hands. Fifteen able-bodied people were asked to judge the laterality of hand images presented on a computer screen in a lateral or medial orientation. This judgment task is known to require mental rotation of a person's own hands, which in turn is thought to involve iMI. The subjects were also asked to perform eMI of the hands. Their electroencephalography was recorded. Linear classifiers were designed based on common spatial patterns. For discrimination between left hand and right hand, the classifier achieved maximum of 81 ± 8% accuracy for eMI and 83 ± 3% for iMI. These results show that iMI can be used to achieve similar classification accuracy as eMI. Additional classification was performed between iMI in medial and lateral orientations of a single hand; the classifier achieved 81 ± 7% for the left hand and 78 ± 7% for the right hand, which indicate distinctive spatial patterns of cortical activity for iMI of a single hand in different directions. These results suggest that a special BCI based on iMI may be constructed, for people who cannot perform explicit imagination, for rehabilitation of movement, or for treatment of bodily spatial neglect.

Reversed cortical over-activity during movement imagination following neurofeedback treatment for central neuropathic pain.

OBJECTIVE: One of the brain signatures of the central neuropathic pain (CNP) is the theta band over-activity of wider cortical structures, during imagination of movement. The objective of the study was to investigate whether this over-activity is reversible following the neurofeedback treatment of CNP. METHODS: Five paraplegic patients with pain in their legs underwent from twenty to forty neurofeedback sessions that significantly reduced their pain. In order to assess their dynamic cortical activity they were asked to imagine movements of all limbs a week before the first and a week after the last neurofeedback session. Using time-frequency analysis we compared EEG activity during imagination of movement before and after the therapy and further compared it with EEG signals of ten paraplegic patients with no pain and a control group of ten able-bodied people. RESULTS: Neurofeedback treatment resulted in reduced CNP and a wide spread reduction of cortical activity during imagination of movement. The reduction was significant in the alpha and beta band but was largest in the theta band. As a result cortical activity became similar to the activity of other two groups with no pain. CONCLUSIONS: Reduction of CNP is accompanied by reduced cortical over-activity during movement imagination. SIGNIFICANCE: Understanding causes and consequences mechanism through which CNP affects cortical activity.

The mechanism of neurofeedback training for treatment of central neuropathic pain in paraplegia: a pilot study.

BACKGROUND: Central neuropathic pain has a prevalence of 40% in patients with spinal cord injury. Electroencephalography (EEG) studies showed that this type of pain has identifiable signatures, that could potentially be targeted by a neuromodulation therapy. The aim of the study was to investigate the putative mechanism of neurofeedback training on central neuropathic pain and its underlying brain signatures in patients with chronic paraplegia. METHODS: Patients' EEG activity was modulated from the sensory-motor cortex, electrode location C3/Cz/C4/P4 in up to 40 training sessions Results. Six out of seven patients reported immediate reduction of pain during neurofeedback training. Best results were achieved with suppressing Ɵ and higher ß (20-30 Hz) power and reinforcing α power at C4. Four patients reported clinically significant long-term reduction of pain (>30%) which lasted at least a month beyond the therapy. EEG during neurofeedback revealed a wide spread modulation of power in all three frequency bands accompanied with changes in the coherence most notable in the beta band. The standardized low resolution electromagnetic tomography analysis of EEG before and after neurofeedback therapy showed the statistically significant reduction of power in beta frequency band in all tested patients. Areas with reduced power included the Dorsolateral Prefrontal Cortex, the Anterior Cingulate Cortex and the Insular Cortex. CONCLUSIONS: Neurofeedback training produces both immediate and longer term reduction of central neuropathic pain that is accompanied with a measurable short and long term modulation of cortical activity. Controlled trials are required to confirm the efficacy of this neurofeedback protocol on treatment of pain. The study is a registered UKCRN clinical trial Nr 9824.

Hybrid brain-computer interface and functional electrical stimulation for sensorimotor training in participants with tetraplegia: a proof-of-concept study.

BACKGROUND AND PURPOSE: Impaired hand function decreases quality of life in persons with tetraplegia. We tested functional electrical stimulation (FES) controlled by a hybrid brain-computer interface (BCI) for improving hand function in participants with tetraplegia. METHODS: Two participants with subacute tetraplegia (participant 1: C5 Brown-Sequard syndrome, participant 2: complete C5 lesion) took part in this proof-of-concept study. The goal was to determine whether the BCI system could drive the FES device by accurately classifying participants' intent (open or close the hand). Participants 1 and 2 received 10 sessions and 4 sessions of BCI-FES, respectively. A novel time-switch BCI strategy based on motor imagery was used to activate the FES. In one session, we tested a hybrid BCI-FES based on 2 spontaneously generated brain rhythms: a sensory-motor rhythm during motor imagery to activate a stimulator and occipital alpha rhythms to deactivate the stimulator. Participants received BCI-FES therapy 2 to 3 times a week in addition to conventional therapy. Imagery ability and muscle strength were measured before and after treatment. RESULTS: Visual feedback was associated with a 4-fold increase of brain response during motor imagery in both participants. For participant 1, classification accuracy (open/closed) for motor imagery-based BCI was 83.5% (left hand) and 83.8% (right hand); participant 2 had a classification accuracy of 83.8% for the right hand. Participant 1 had moderate improvement in muscle strength, while there was no change for participant 2. DISCUSSION AND CONCLUSION: We demonstrated feasibility of BCI-FES, using 2 naturally generated brain rhythms. Studies on a larger number of participants are needed to separate the effects of BCI training from effects of conventional therapy.Video Abstract available. (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A84) for more insights from the authors.

Similarities between explicit and implicit motor imagery in mental rotation of hands: an EEG study.

Chronometric and imaging studies have shown that motor imagery is used implicitly during mental rotation tasks in which subjects for example judge the laterality of human hand pictures at various orientations. Since explicit motor imagery is known to activate the sensorimotor areas of the cortex, mental rotation is expected to do similar if it involves a form of motor imagery. So far, functional magnetic resonance imaging and positron emission tomography have been used to study mental rotation and less attention has been paid to electroencephalogram (EEG) which offers a high time-frequency resolution. The time-frequency analysis is an established method for studying explicit motor imagery. Although hand mental rotation is claimed to involve motor imagery, the time-frequency characteristics of mental rotation have never been compared with those of explicit motor imagery. In this study, time-frequency responses of EEG recorded during explicit motor imagery and during a mental rotation task, inducing implicit motor imagery, were compared. Fifteen right-handed healthy volunteers performed motor imagery of hands in one condition and hand laterality judgement tasks in another while EEG of the whole head was recorded. The hand laterality judgement was the mental rotation task used to induce implicit motor imagery. The time-frequency analysis and sLORETA localisation of the EEG showed that the activities in the sensorimotor areas had similar spatial and time-frequency characteristics in explicit motor imagery and implicit motor imagery conditions. Furthermore this sensorimotor activity was different for the left and for the right hand in both explicit and implicit motor imagery. This result supports that motor imagery is used during mental rotation and that it can be detected and studied with EEG technology. This result should encourage the use of mental rotation of body parts in rehabilitation programmes in a similar manner as motor imagery.

Using a motor imagery questionnaire to estimate the performance of a Brain-Computer Interface based on object oriented motor imagery.

OBJECTIVES: The primary objective was to test whether motor imagery (MI) questionnaires can be used to detect BCI 'illiterate'. The second objective was to test how different MI paradigms, with and without the physical presence of the goal of an action, influence a BCI classifier. METHODS: Kinaesthetic (KI) and visual (VI) motor imagery questionnaires were administered to 30 healthy volunteers. Their EEG was recorded during a cue-based, simple imagery (SI) and goal oriented imagery (GOI). RESULTS: The strongest correlation (Pearson r(2)=0.53, p=1.6e-5) was found between KI and SI, followed by a moderate correlation between KI and GOI (r(2)=0.33, p=0.001) and a weak correlation between VI and SI (r(2)=0.21, p=0.022) and VI and GOI (r(2)=0.17, p=0.05). Classification accuracy was similar for SI (71.1 ± 7.8%) and GOI (70.5 ± 5.9%) though corresponding classification features differed in 70% participants. Compared to SI, GOI improved the classification accuracy in 'poor' imagers while reducing the classification accuracy in 'very good' imagers. CONCLUSION: The KI score could potentially be a useful tool to predict the performance of a MI based BCI. The physical presence of the object of an action facilitates motor imagination in 'poor' able-bodied imagers. SIGNIFICANCE: Although this study shows results on able-bodied people, its general conclusions should be transferable to BCI based on MI for assisted rehabilitation of the upper extremities in patients.

Different pulse shapes to obtain small fiber selective activation by anodal blocking--a simulation study.

The aim of this study was to investigate whether it is possible to reduce a charge per pulse, which is needed for selective nerve stimulation. Simulation is performed using a two-part simulation model: a volume conductor model to calculate the electrical potential distribution inside a tripolar cuff electrode and a human fiber model to simulate the fiber response to simulation. Selective stimulation is obtained by anodal block. To obtain anodal block of large fibers, long square pulses (> 350 micros) with a relatively high currents (1-2.5 mA) are usually required. These pulses might not be safe for a long-term application because of a high charge per pulse. In this study, several pulse shapes are proposed that have less charge per pulse compared with the conventional square pulse and would therefore be safer in a chronic application. Compared with the conventional square pulse, it was possible to reduce the charge with all proposed pulse shapes, but the best results are obtained with a combination of a square depolarizing pulse and a blocking pulse. The charge per pulse was up to 32% less with that pulse shape than with a square pulse. Using a hyperpolarizing anodal prepulse preceding a square pulse, it was not possible to block nerve fibers in a whole nerve bundle and to obtain reduction of a charge per phase. Reduction of the charge could be achieved only with spatially selective blocking. The charge per phase was larger for the combination of a hyperpolarizing anodal prepulse and a two-step pulse than for the two-step pulse alone.

Electrostimulation: a future treatment option for patients with neurogenic urodynamic disorders?

This paper provides an overview of electrical stimulation of the nervous system as a treatment option for urodynamic dysfunction and of some of the recent results in this field. The set-up used in our studies for improved bladder filling in spinal cord injured patients by conditional stimulation of the dorsal penile/clitoral nerve is a highly efficient way to limit neurogenic detrusor overactivity and increase bladder capacity. Ongoing studies suggest that recording of bladder nerve activity is stable over time and may be a technique for chronic monitoring of bladder activity. Bladder emptying exploiting an anodal blocking technique permits bladder emptying without simultaneous urethral-perineal contraction, thus enabling a physiological voiding pattern in one continuous sequence. In patients with supraspinal lesions, deep brain electrical stimulation is established only as treatment for a subgroup of patients suffering from Parkinson's disease. Yet, with improved electrode designs and increased clinical experience and experimental results, probably other groups of patients may be candidates for deep brain stimulation. In our study in pigs there was a trend towards increased bladder capacity and compliance in response to stimulation, which is encouraging as several neurological diseases are accompanied by overactive bladder with reduced capacity.