Brain-Computer interfaces for communication: preferences of individuals with locked-in syndrome, caregivers and researchers

Stakeholder's perspective on brain-computer interfaces for children and young adults with cerebral palsy

Communication Brain-Computer Interfaces (cBCIs) are a promising tool for people with motor and speech impairment, in particular for children and young adults with communication impairments, for example due to cerebral palsy (CP). Here we aimed to create a solid basis for the user-centered design of cBCIs for children and young adults with severe CP by investigating the perspectives of their parents/caregivers and health care professionals on communication and cBCIs. We conducted an online survey on 1) current communication problems and usability of used aids, 2) interest in cBCIs, and 3) preference for specific types of cBCIs. A total of 19 parents/caregivers and 36 health care professionals who interacted directly with children and young adults (8-25 years old) with severe CP, corresponding to Gross Motor Function Classification System level IV or V, participated. Both groups of respondents indicated that motor impairment occurred the most frequently and had the greatest impact on communication. The currently used communication aids included mainly no/low-tech aids and high-tech aids. The majority of health care professionals and parents/caregivers reported an interest in cBCIs, with a slight preference for implanted electrodes over non-implanted ones, and no preference for either of the two proposed mental BCI control strategies. Results indicate that cBCIs should be considered for a subpopulation of children and young adults with severe CP, and that in the development of cBCIs for this group both visual stimuli and sensorimotor rhythms, as well as the use of implanted electrodes, should be considered.

Impact of communication modalities on autonomy and social participation of persons with locked-in syndrome

Introduction Locked-in syndrome (LIS) is a complex neurological condition characterised by paralysis of all four limbs and anarthria. Persons with LIS may communicate via eye blinks/low technology Augmentative and Alternative Communication devices (low tech AAC devices) or may use high technology Augmentative and Alternative Communication devices (high tech AAC devices). Our three objectives were: (1) to describe the distribution of communication modalities used by persons with LIS, (2) to describe the satisfaction of persons with LIS with their communication modality and social participation, and (3) to compare the characteristics and social participation among high tech AAC devices users versus low tech AAC devices or eye blinking users. Methods The questionnaires were sent by e-mail to persons with LIS. Data collected were communication modality, examination of communication ability, satisfaction with the communication modality and contribution of the communication modality to social participation. Results Of the 53 participants, their mean age was 52years, 43% used low tech AAC devices, 43% used high tech AAC devices and 13% communicated via eye blinking. Communication ability was examined in only half the participants. Participants' satisfaction with their communication modality in terms of ergonomics, rapidity, adaptability and functionality were 80, 67, 36 and 47% respectively. Participants who used high tech AAC devices had significantly better e-mail and social network access, could more often initiate conversations and had longer communication durations. Conclusion The communication abilities of persons with LIS should be examined as quickly as possible and repeated regularly. High tech AAC devices should be rapidly and systematically proposed.

Designing an online BCI forum: insights from researchers and end-users

Objective.Brain-computer interfaces (BCIs) can support non-muscular communication and device control for severely paralyzed people. However, efforts that directly involve potential or actual end-users and address their individual needs are scarce, demonstrating a translational gap. An online BCI forum supported by the BCI Society could initiate and sustainably strengthen interactions between BCI researchers and end-users to bridge this gap.Approach.We interviewed six severely paralyzed individuals and surveyed 121 BCI researchers to capture their opinions and wishes concerning an online BCI forum. Data were analyzed with a mixed-method quantitative and qualitative content analysis.Main results.All end-users and most researchers (83%) reported an interest in participating in an online BCI forum. Rating questions and open comments to identify design aspects included what should be featured most prominently, how people would get engaged in the online BCI forum, and which pitfalls should be considered.Significance.Responses support establishing an online BCI forum to serve as a meaningful resource for the entire BCI community.

Considering preferences, speed and the animation of multiple symbols in developing P300 brain-computer interface for children

PURPOSE

Prior research has begun establishing the efficacy of animation in brain-computer interfaces access to augmentative and alternative communication (BCI-AAC). However, the use of animation in P300-BCI-AAC for children is in the early stages and largely limited to single item highlighting of extended durations. In pursuit of practical application, the present study aims to evaluate children's event-related potential (ERP) characteristics and user experience during a task involving an animated P300-BCI-AAC system.

MATERIALS AND METHODS

The system utilizes multi-item zoom animations to access a 28-pictorial symbols. Participants completed a fast (100 ms) and slow (200 ms) zoom animation highlighting conditions wherein four pictorial symbols were highlighted concurrently.

RESULTS

The proposed display appears feasible, eliciting all targeted ERPs. However, ERP amplitudes may be reduced in comparison to single-item animation highlighting, possibly due to distraction. Ratings of mental effort were significantly higher for the 100 ms condition, though differences in the frontal P200/P300 ERP did not achieve significance. Most participants identified a preference for the 100 ms condition, though age may impact preference.

CONCLUSIONS

Overall, findings support the preliminary feasibility of a proposed 28-item interface that utilises group zoom animation highlighting of pictorial symbols. Further research is needed evaluating ERP characteristics and outcomes from online (real-time) use of animation-based P300-BCI-AAC for children with severe speech and physical impairments across multiple training sessions.

The ethical significance of user-control in AI-driven speech-BCIs: a narrative review

AI-driven brain-computed interfaces aimed at restoring speech for individuals living with locked-in-syndrome are paired with ethical implications for user's autonomy, privacy and responsibility. Embedding options for sufficient levels of user-control in speech-BCI design has been proposed to mitigate these ethical challenges. However, how user-control in speech-BCIs is conceptualized and how it relates to these ethical challenges is underdetermined. In this narrative literature review, we aim to clarify and explicate the notion of user-control in speech-BCIs, to better understand in what way user-control could operationalize user's autonomy, privacy and responsibility and explore how such suggestions for increasing user-control can be translated to recommendations for the design or use of speech-BCIs. First, we identified types of user control, including executory control that can protect voluntariness of speech, and guidance control that can contribute to semantic accuracy. Second, we identified potential causes for a loss of user-control, including contributions of predictive language models, a lack of ability for neural control, or signal interference and external control. Such a loss of user control may have implications for semantic accuracy and mental privacy. Third we explored ways to design for user-control. While embedding initiation signals for users may increase executory control, they may conflict with other aims such as speed and continuity of speech. Design mechanisms for guidance control remain largely conceptual, similar trade-offs in design may be expected. We argue that preceding these trade-offs, the overarching aim of speech-BCIs needs to be defined, requiring input from current and potential users. Additionally, conceptual clarification of user-control and other (ethical) concepts in this debate has practical relevance for BCI researchers. For instance, different concepts of inner speech may have distinct ethical implications. Increased clarity of such concepts can improve anticipation of ethical implications of speech-BCIs and may help to steer design decisions.

Ethical issues raised by incorporating personalized language models into brain-computer interface communication technologies: a qualitative study of individuals with neurological disease

PURPOSE

To examine the views of individuals with neurodegenerative diseases about ethical issues related to incorporating personalized language models into brain-computer interface (BCI) communication technologies.

METHODS

Fifteen semi-structured interviews and 51 online free response surveys were completed with individuals diagnosed with neurodegenerative disease that could lead to loss of speech and motor skills. Each participant responded to questions after six hypothetical ethics vignettes were presented that address the possibility of building language models with personal words and phrases in BCI communication technologies. Data were analyzed with consensus coding, using modified grounded theory.

RESULTS

Four themes were identified. (1) The experience of a neurodegenerative disease shapes preferences for personalized language models. (2) An individual's identity will be affected by the ability to personalize the language model. (3) The motivation for personalization is tied to how relationships can be helped or harmed. (4) Privacy is important to people who may need BCI communication technologies. Responses suggest that the inclusion of personal lexica raises ethical issues. Stakeholders want their values to be considered during development of BCI communication technologies.

CONCLUSIONS

With the rapid development of BCI communication technologies, it is critical to incorporate feedback from individuals regarding their ethical concerns about the storage and use of personalized language models. Stakeholder values and preferences about disability, privacy, identity and relationships should drive design, innovation and implementation.IMPLICATIONS FOR REHABILITATIONIndividuals with neurodegenerative diseases are important stakeholders to consider in development of natural language processing within brain-computer interface (BCI) communication technologies.The incorporation of personalized language models raises issues related to disability, identity, relationships, and privacy.People who may one day rely on BCI communication technologies care not just about usability of communication technology but about technology that supports their values and priorities.Qualitative ethics-focused research is a valuable tool for exploring stakeholder perspectives on new capabilities of BCI communication technologies, such as the storage and use of personalized language models.

Ethical considerations for integrating multimodal computer perception and neurotechnology

Background

Artificial intelligence (AI)-based computer perception technologies (e.g., digital phenotyping and affective computing) promise to transform clinical approaches to personalized care in psychiatry and beyond by offering more objective measures of emotional states and behavior, enabling precision treatment, diagnosis, and symptom monitoring. At the same time, passive and continuous nature by which they often collect data from patients in non-clinical settings raises ethical issues related to privacy and self-determination. Little is known about how such concerns may be exacerbated by the integration of neural data, as parallel advances in computer perception, AI, and neurotechnology enable new insights into subjective states. Here, we present findings from a multi-site NCATS-funded study of ethical considerations for translating computer perception into clinical care and contextualize them within the neuroethics and neurorights literatures.

Methods

We conducted qualitative interviews with patients (n = 20), caregivers (n = 20), clinicians (n = 12), developers (n = 12), and clinician developers (n = 2) regarding their perspective toward using PC in clinical care. Transcripts were analyzed in MAXQDA using Thematic Content Analysis.

Results

Stakeholder groups voiced concerns related to (1) perceived invasiveness of passive and continuous data collection in private settings; (2) data protection and security and the potential for negative downstream/future impacts on patients of unintended disclosure; and (3) ethical issues related to patients' limited versus hyper awareness of passive and continuous data collection and monitoring. Clinicians and developers highlighted that these concerns may be exacerbated by the integration of neural data with other computer perception data.

Discussion

Our findings suggest that the integration of neurotechnologies with existing computer perception technologies raises novel concerns around dignity-related and other harms (e.g., stigma, discrimination) that stem from data security threats and the growing potential for reidentification of sensitive data. Further, our findings suggest that patients' awareness and preoccupation with feeling monitored via computer sensors ranges from hypo- to hyper-awareness, with either extreme accompanied by ethical concerns (consent vs. anxiety and preoccupation). These results highlight the need for systematic research into how best to implement these technologies into clinical care in ways that reduce disruption, maximize patient benefits, and mitigate long-term risks associated with the passive collection of sensitive emotional, behavioral and neural data.

Challenges of brain-computer interface facilitated cognitive assessment for children with cerebral palsy

Brain-computer interfaces (BCIs) have been successfully used by adults, but little information is available on BCI use by children, especially children with severe multiple impairments who may need technology to facilitate communication. Here we discuss the challenges of using non-invasive BCI with children, especially children who do not have another established method of communication with unfamiliar partners. Strategies to manage these challenges require consideration of multiple factors related to accessibility, cognition, and participation. These factors include decisions regarding where (home, clinic, or lab) participation will take place, the number of sessions involved, and the degree of participation necessary for success. A strategic approach to addressing the unique challenges inherent in BCI use by children with disabilities will increase the potential for successful BCI calibration and adoption of BCI as a valuable access method for children with the most significant impairments in movement and communication.

A systematic review of research on augmentative and alternative communication brain-computer interface systems for individuals with disabilities

Augmentative and alternative communication brain-computer interface (AAC-BCI) systems are intended to offer communication access to people with severe speech and physical impairment (SSPI) without requiring volitional movement. As the field moves toward clinical implementation of AAC-BCI systems, research involving participants with SSPI is essential. Research has demonstrated variability in AAC-BCI system performance across users, and mixed results for comparisons of performance for users with and without disabilities. The aims of this systematic review were to (1) describe study, system, and participant characteristics reported in BCI research, (2) summarize the communication task performance of participants with disabilities using AAC-BCI systems, and (3) explore any differences in performance for participants with and without disabilities. Electronic databases were searched in May, 2018, and March, 2021, identifying 6065 records, of which 73 met inclusion criteria. Non-experimental study designs were common and sample sizes were typically small, with approximately half of studies involving five or fewer participants with disabilities. There was considerable variability in participant characteristics, and in how those characteristics were reported. Over 60% of studies reported an average selection accuracy ≤70% for participants with disabilities in at least one tested condition. However, some studies excluded participants who did not reach a specific system performance criterion, and others did not state whether any participants were excluded based on performance. Twenty-nine studies included participants both with and without disabilities, but few reported statistical analyses comparing performance between the two groups. Results suggest that AAC-BCI systems show promise for supporting communication for people with SSPI, but they remain ineffective for some individuals. The lack of standards in reporting outcome measures makes it difficult to synthesize data across studies. Further research is needed to demonstrate efficacy of AAC-BCI systems for people who experience SSPI of varying etiologies and severity levels, and these individuals should be included in system design and testing. Consensus in terminology and consistent participant, protocol, and performance description will facilitate the exploration of user and system characteristics that positively or negatively affect AAC-BCI use, and support innovations that will make this technology more useful to a broader group of people.

Clinical trial registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018095345, PROSPERO: CRD42018095345.

Evaluating the clinical benefit of brain-computer interfaces for control of a personal computer

Brain-computer interfaces (BCIs) enabling the control of a personal computer could provide myriad benefits to individuals with disabilities including paralysis. However, to realize this potential, these BCIs must gain regulatory approval and be made clinically available beyond research participation. Therefore, a transition from engineering-oriented to clinically oriented outcome measures will be required in the evaluation of BCIs. This review examined how to assess the clinical benefit of BCIs for the control of a personal computer. We report that: 1) a variety of different patient-reported outcome measures can be used to evaluate improvements in how a patient feels, and we offer some considerations that should guide instrument selection. 2) Activities of daily living can be assessed to demonstrate improvements in how a patient functions, however, new instruments that are sensitive to increases in functional independence via the ability to perform digital tasks may be needed. 3) Benefits to how a patient survives has not previously been evaluated, but establishing patient-initiated communication channels using BCIs might facilitate quantifiable improvements in health outcomes.