Effectiveness of the Combined Use of a Brain-Machine Interface System and Virtual Reality as a Therapeutic Approach in Patients with Spinal Cord Injury: A Systematic Review

Spinal cord injury has a major impact on both the individual and society. This damage can cause permanent loss of sensorimotor functions, leading to structural and functional changes in somatotopic regions of the spinal cord. The combined use of a brain-machine interface and virtual reality offers a therapeutic alternative to be considered in the treatment of this pathology. This systematic review aimed to evaluate the effectiveness of the combined use of virtual reality and the brain-machine interface in the treatment of spinal cord injuries. A search was performed in PubMed, Web of Science, PEDro, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and Medline, including articles published from the beginning of each database until January 2023. Articles were selected based on strict inclusion and exclusion criteria. The Cochrane Collaboration's tool was used to assess the risk of bias and the PEDro scale and SCIRE systems were used to evaluate the methodological quality of the studies. Eleven articles were selected from a total of eighty-two. Statistically significant changes were found in the upper limb, involving improvements in shoulder and upper arm mobility, and weaker muscles were strengthened. In conclusion, most of the articles analyzed used the electroencephalogram as a measurement instrument for the assessment of various parameters, and most studies have shown improvements. Nonetheless, further research is needed with a larger sample size and long-term follow-up to establish conclusive results regarding the effect size of these interventions.

Electroencephalogram based brain-computer interface: Applications, challenges, and opportunities

Brain-Computer Interfaces (BCI) is an exciting and emerging research area for researchers and scientists. It is a suitable combination of software and hardware to operate any device mentally. This review emphasizes the significant stages in the BCI domain, current problems, and state-of-the-art findings. This article also covers how current results can contribute to new knowledge about BCI, an overview of BCI from its early developments to recent advancements, BCI applications, challenges, and future directions. The authors pointed to unresolved issues and expressed how BCI is valuable for analyzing the human brain. Humans' dependence on machines has led humankind into a new future where BCI can play an essential role in improving this modern world.

A Therapeutic Approach Using the Combined Application of Virtual Reality with Robotics for the Treatment of Patients with Spinal Cord Injury: A Systematic Review

Spinal cord injury (SCI) has been associated with high mortality rates. Thanks to the multidisciplinary vision and approach of SCI, including the application of new technologies in the field of neurorehabilitation, people with SCI can survive and prosper after injury. The main aim of this systematic review was to analyze the effectiveness of the combined use of VR and robotics in the treatment of patients with SCI. The literature search was performed between May and July 2021 in the Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro), PubMed, and Web of Science. The methodological quality of each study was assessed using the SCIRE system and the PEDro scale, whereas the risk of bias was analyzed using the Cochrane Collaboration’s tool. A total of six studies, involving 63 participants, were included in this systematic review. Relevant changes were found in the upper limbs, with improvements of shoulder and upper arm mobility, as well as the strengthening of weaker muscles. Combined rehabilitation may be a valuable approach to improve motor function in SCI patients. Nonetheless, further research is necessary, with a larger patient sample and a longer duration.

Artificial Intelligence Algorithms in Visual Evoked Potential-Based Brain-Computer Interfaces for Motor Rehabilitation Applications: Systematic Review and Future Directions

Brain-Computer Interface (BCI) is a technology that uses electroencephalographic (EEG) signals to control external devices, such as Functional Electrical Stimulation (FES). Visual BCI paradigms based on P300 and Steady State Visually Evoked potentials (SSVEP) have shown high potential for clinical purposes. Numerous studies have been published on P300- and SSVEP-based non-invasive BCIs, but many of them present two shortcomings: (1) they are not aimed for motor rehabilitation applications, and (2) they do not report in detail the artificial intelligence (AI) methods used for classification, or their performance metrics. To address this gap, in this paper the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology was applied to prepare a systematic literature review (SLR). Papers older than 10 years, repeated or not related to a motor rehabilitation application, were excluded. Of all the studies, 51.02% referred to theoretical analysis of classification algorithms. Of the remaining, 28.48% were for spelling, 12.73% for diverse applications (control of wheelchair or home appliances), and only 7.77% were focused on motor rehabilitation. After the inclusion and exclusion criteria were applied and quality screening was performed, 34 articles were selected. Of them, 26.47% used the P300 and 55.8% the SSVEP signal. Five applications categories were established: Rehabilitation Systems (17.64%), Virtual Reality environments (23.52%), FES (17.64%), Orthosis (29.41%), and Prosthesis (11.76%). Of all the works, only four performed tests with patients. The most reported machine learning (ML) algorithms used for classification were linear discriminant analysis (LDA) (48.64%) and support vector machine (16.21%), while only one study used a deep learning algorithm: a Convolutional Neural Network (CNN). The reported accuracy ranged from 38.02 to 100%, and the Information Transfer Rate from 1.55 to 49.25 bits per minute. While LDA is still the most used AI algorithm, CNN has shown promising results, but due to their high technical implementation requirements, many researchers do not justify its implementation as worthwile. To achieve quick and accurate online BCIs for motor rehabilitation applications, future works on SSVEP-, P300-based and hybrid BCIs should focus on optimizing the visual stimulation module and the training stage of ML and DL algorithms.

Exploring the Embodiment of a Virtual Hand in a Spatially Augmented Respiratory Biofeedback Setting

Enhancing the embodiment of artificial limbs—the individuals' feeling that a virtual or robotic limb is integrated in their own body scheme—is an impactful strategy for improving prosthetic technology acceptance and human-machine interaction. Most studies so far focused on visuo-tactile strategies to empower the embodiment processes. However, novel approaches could emerge from self-regulation techniques able to change the psychophysiological conditions of an individual. Accordingly, this pilot study investigates the effects of a self-regulated breathing exercise on the processes of body ownership underlying the embodiment of a virtual right hand within a Spatially Augmented Respiratory Biofeedback (SARB) setting. This investigation also aims at evaluating the feasibility of the breathing exercise enabled by a low-cost SARB implementation designed for upcoming remote studies (a need emerged during the COVID-19 pandemic). Twenty-two subjects without impairments, and two transradial prosthesis users for a preparatory test, were asked (in each condition of a within-group design) to maintain a normal (about 14 breaths/min) or slow (about 6 breaths/min) respiratory rate to keep a static virtual right hand “visible” on a screen. Meanwhile, a computer-generated sphere moved from left to right toward the virtual hand during each trial (1 min) of 16. If the participant's breathing rate was within the target (slow or normal) range, a visuo-tactile event was triggered by the sphere passing under the virtual hand (the subjects observed it shaking while they perceived a vibratory feedback generated by a smartphone). Our results—mainly based on questionnaire scores and proprioceptive drift—highlight that the slow breathing condition induced higher embodiment than the normal one. This preliminary study reveals the feasibility and potential of a novel psychophysiological training strategy to enhance the embodiment of artificial limbs. Future studies are needed to further investigate mechanisms, efficacy and generalizability of the SARB techniques in training a bionic limb embodiment.

P300 Brain-Computer Interface-Based Drone Control in Virtual and Augmented Reality

Since the emergence of head-mounted displays (HMDs), researchers have attempted to introduce virtual and augmented reality (VR, AR) in brain–computer interface (BCI) studies. However, there is a lack of studies that incorporate both AR and VR to compare the performance in the two environments. Therefore, it is necessary to develop a BCI application that can be used in both VR and AR to allow BCI performance to be compared in the two environments. In this study, we developed an opensource-based drone control application using P300-based BCI, which can be used in both VR and AR. Twenty healthy subjects participated in the experiment with this application. They were asked to control the drone in two environments and filled out questionnaires before and after the experiment. We found no significant (p > 0.05) difference in online performance (classification accuracy and amplitude/latency of P300 component) and user experience (satisfaction about time length, program, environment, interest, difficulty, immersion, and feeling of self-control) between VR and AR. This indicates that the P300 BCI paradigm is relatively reliable and may work well in various situations.

Progress in Brain Computer Interface: Challenges and Opportunities

Brain computer interfaces (BCI) provide a direct communication link between the brain and a computer or other external devices. They offer an extended degree of freedom either by strengthening or by substituting human peripheral working capacity and have potential applications in various fields such as rehabilitation, affective computing, robotics, gaming, and neuroscience. Significant research efforts on a global scale have delivered common platforms for technology standardization and help tackle highly complex and non-linear brain dynamics and related feature extraction and classification challenges. Time-variant psycho-neurophysiological fluctuations and their impact on brain signals impose another challenge for BCI researchers to transform the technology from laboratory experiments to plug-and-play daily life. This review summarizes state-of-the-art progress in the BCI field over the last decades and highlights critical challenges.

Combining brain-computer interface and virtual reality for rehabilitation in neurological diseases: A narrative review

BACKGROUND

The traditional rehabilitation for neurological diseases lacks the active participation of patients, its process is monotonous and tedious, and the effects need to be improved. Therefore, a new type of rehabilitation technology with more active participation combining brain-computer interface (BCI) with virtual reality (VR) has developed rapidly in recent years and has been used in rehabilitation in neurological diseases.

OBJECTIVES

This narrative review analyzed and characterized the development and application of the new training system (BCI-VR) in rehabilitation of neurological diseases from the perspective of the BCI paradigm, to provide a pathway for future research in this field.

METHODS

The review involved a search of the Web of Science-Science Citation Index/Social Sciences Citation Index and the China National Knowledge Infrastructure databases; 39 papers were selected. Advantages and challenges of BCI-VR - based neurological rehabilitation were analyzed in detail.

RESULTS

Most BCI-VR studies included could be classified by 3 major BCI paradigms: motor imagery, P300, and steady-state visual-evoked potential. Integrating VR scenes into BCI systems could effectively promote the recovery process from nervous system injuries as compared with traditional methods.

CONCLUSION

As compared with rehabilitation based on traditional BCI, rehabilitation based on BCI-VR can provide better feedback information for patients and promote the recovery of brain function. By solving the challenges and continual development, the BCI-VR system can be broadly applied to the clinical treatment of various neurological diseases.

An online SSVEP-BCI system in an optical see-through augmented reality environment

OBJECTIVE

This study aimed to design and evaluate a high-speed online steady-state visually evoked potential (SSVEP)-based brain-computer interface (BCI) in an optical see-through (OST) augmented reality (AR) environment.

APPROACH

An eight-class BCI was designed in an OST-AR headset which is wearable and allows users to see the user interface of the BCI and the device to be controlled in the same view field via the OST head-mounted display. The accuracies, information transfer rates (ITRs), and SSVEP signal characteristics of the AR-BCI were evaluated and compared with a computer screen-based BCI implemented with a laptop in offline and online cue-guided tasks. Then, the performance of the AR-BCI was evaluated in an online robotic arm control task.

MAIN RESULTS

The offline results obtained during the cue-guided task performed with the AR-BCI showed maximum averaged ITRs of 65.50  ±  9.86 bits min^-1 according to the extended canonical correlation analysis-based target identification method. The online cue-guided task achieved averaged ITRs of 65.03  ±  11.40 bits min^-1. The online robotic arm control task achieved averaged ITRs of 45.57  ±  7.40 bits min^-1. Compared with the screen-based BCI, some limitations of the AR environment impaired BCI performance and the quality of SSVEP signals.

SIGNIFICANCE

The results showed the potential for providing a high-performance brain-control interaction method by combining AR and BCI. This study could provide methodological guidelines for developing more wearable BCIs in OST-AR environments and will also encourage more interesting applications involving BCIs and AR techniques.

Brain-computer interfaces and virtual reality for neurorehabilitation

Brain-computer interfaces (BCIs) and virtual reality (VR) are two technologic advances that are changing our way of interacting with the world. BCIs can be used to influence and can serve as a control mechanism in navigation tasks, communication, or other assistive functions. VR can create ad hoc interactive scenarios that involve all our senses, stimulate the brain in a multisensory fashion, and increase the motivation and fun with game-like environments. VR and motion tracking enable natural human-computer interaction at cognitive and physical levels. This includes both brain and body in the design of meaningful VR experiences; these cases in which participants feel naturally present could help augment the benefits of BCIs for assistive and neurorehabilitation applications for the relearning of motor and cognitive skills. VR technology is now available at the consumer level thanks to the proliferation of affordable head-mounted displays (HMDs). Merging both technologies into simplified, practical devices may help democratize these technologies.

Brain Computer Interfaces in Rehabilitation Medicine

One innovation currently influencing physical medicine and rehabilitation is brain-computer interface (BCI) technology. BCI systems used for motor control record neural activity associated with thoughts, perceptions, and motor intent; decode brain signals into commands for output devices; and perform the user's intended action through an output device. BCI systems used for sensory augmentation transduce environmental stimuli into neural signals interpretable by the central nervous system. Both types of systems have potential for reducing disability by facilitating a user's interaction with the environment. Investigational BCI systems are being used in the rehabilitation setting both as neuroprostheses to replace lost function and as potential plasticity-enhancing therapy tools aimed at accelerating neurorecovery. Populations benefitting from motor and somatosensory BCI systems include those with spinal cord injury, motor neuron disease, limb amputation, and stroke. This article discusses the basic components of BCI for rehabilitation, including recording systems and locations, signal processing and translation algorithms, and external devices controlled through BCI commands. An overview of applications in motor and sensory restoration is provided, along with ethical questions and user perspectives regarding BCI technology.

HD-EEG Based Classification of Motor-Imagery Related Activity in Patients With Spinal Cord Injury

Brain computer interfaces (BCIs) are thought to revolutionize rehabilitation after SCI, e.g., by controlling neuroprostheses, exoskeletons, functional electrical stimulation, or a combination of these components. However, most BCI research was performed in healthy volunteers and it is unknown whether these results can be translated to patients with spinal cord injury because of neuroplasticity. We sought to examine whether high-density EEG (HD-EEG) could improve the performance of motor-imagery classification in patients with SCI. We recorded HD-EEG with 256 channels in 22 healthy controls and 7 patients with 14 recordings (4 patients had more than one recording) in an event related design. Participants were instructed acoustically to either imagine, execute, or observe foot and hand movements, or to rest. We calculated Fast Fourier Transform (FFT) and full frequency directed transfer function (ffDTF) for each condition and classified conditions pairwise with support vector machines when using only 2 channels over the sensorimotor area, full 10-20 montage, high-density montage of the sensorimotor cortex, and full HD-montage. Classification accuracies were comparable between patients and controls, with an advantage for controls for classifications that involved the foot movement condition. Full montages led to better results for both groups (p < 0.001), and classification accuracies were higher for FFT than for ffDTF (p < 0.001), for which the feature vector might be too long. However, full-montage 10–20 montage was comparable to high-density configurations. Motor-imagery driven control of neuroprostheses or BCI systems may perform as well in patients as in healthy volunteers with adequate technical configuration. We suggest the use of a whole-head montage and analysis of a broad frequency range.

A Human-Humanoid Interaction Through the Use of BCI for Locked-In ALS Patients Using Neuro-Biological Feedback Fusion

This paper illustrates a new architecture for a human-humanoid interaction based on EEG-brain computer interface (EEG-BCI) for patients affected by locked-in syndrome caused by Amyotrophic Lateral Sclerosis (ALS). The proposed architecture is able to recognise users' mental state accordingly to the biofeedback factor , based on users' attention, intention, and focus, that is used to elicit a robot to perform customised behaviours. Experiments have been conducted with a population of eight subjects: four ALS patients in a near locked-in status with normal ocular movement and four healthy control subjects enrolled for age, education, and computer expertise. The results showed as three ALS patients have completed the task with 96.67% success; the healthy controls with 100% success; the fourth ALS has been excluded from the results for his low general attention during the task; the analysis of factor highlights as ALS subjects have shown stronger (81.20%) than healthy controls (76.77%). Finally, a post-hoc analysis is provided to show how robotic feedback helps in maintaining focus on expected task. These preliminary data suggest that ALS patients could successfully control a humanoid robot through a BCI architecture, potentially enabling them to conduct some everyday tasks and extend their presence in the environment.