1
|
Guerreiro Fernandes F, Raemaekers M, Freudenburg Z, Ramsey N. Considerations for implanting speech brain computer interfaces based on functional magnetic resonance imaging. J Neural Eng 2024; 21:036005. [PMID: 38648782 DOI: 10.1088/1741-2552/ad4178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 04/22/2024] [Indexed: 04/25/2024]
Abstract
Objective.Brain-computer interfaces (BCIs) have the potential to reinstate lost communication faculties. Results from speech decoding studies indicate that a usable speech BCI based on activity in the sensorimotor cortex (SMC) can be achieved using subdurally implanted electrodes. However, the optimal characteristics for a successful speech implant are largely unknown. We address this topic in a high field blood oxygenation level dependent functional magnetic resonance imaging (fMRI) study, by assessing the decodability of spoken words as a function of hemisphere, gyrus, sulcal depth, and position along the ventral/dorsal-axis.Approach.Twelve subjects conducted a 7T fMRI experiment in which they pronounced 6 different pseudo-words over 6 runs. We divided the SMC by hemisphere, gyrus, sulcal depth, and position along the ventral/dorsal axis. Classification was performed on in these SMC areas using multiclass support vector machine (SVM).Main results.Significant classification was possible from the SMC, but no preference for the left or right hemisphere, nor for the precentral or postcentral gyrus for optimal word classification was detected. Classification while using information from the cortical surface was slightly better than when using information from deep in the central sulcus and was highest within the ventral 50% of SMC. Confusion matrices where highly similar across the entire SMC. An SVM-searchlight analysis revealed significant classification in the superior temporal gyrus and left planum temporale in addition to the SMC.Significance.The current results support a unilateral implant using surface electrodes, covering the ventral 50% of the SMC. The added value of depth electrodes is unclear. We did not observe evidence for variations in the qualitative nature of information across SMC. The current results need to be confirmed in paralyzed patients performing attempted speech.
Collapse
Affiliation(s)
- F Guerreiro Fernandes
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - M Raemaekers
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Z Freudenburg
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - N Ramsey
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
2
|
Claassen J, Kondziella D, Alkhachroum A, Diringer M, Edlow BL, Fins JJ, Gosseries O, Hannawi Y, Rohaut B, Schnakers C, Stevens RD, Thibaut A, Monti M. Cognitive Motor Dissociation: Gap Analysis and Future Directions. Neurocrit Care 2024; 40:81-98. [PMID: 37349602 DOI: 10.1007/s12028-023-01769-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/26/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Patients with disorders of consciousness who are behaviorally unresponsive may demonstrate volitional brain responses to motor imagery or motor commands detectable on functional magnetic resonance imaging or electroencephalography. This state of cognitive motor dissociation (CMD) may have prognostic significance. METHODS The Neurocritical Care Society's Curing Coma Campaign identified an international group of experts who convened in a series of monthly online meetings between September 2021 and April 2023 to examine the science of CMD and identify key knowledge gaps and unmet needs. RESULTS The group identified major knowledge gaps in CMD research: (1) lack of information about patient experiences and caregiver accounts of CMD, (2) limited epidemiological data on CMD, (3) uncertainty about underlying mechanisms of CMD, (4) methodological variability that limits testing of CMD as a biomarker for prognostication and treatment trials, (5) educational gaps for health care personnel about the incidence and potential prognostic relevance of CMD, and (6) challenges related to identification of patients with CMD who may be able to communicate using brain-computer interfaces. CONCLUSIONS To improve the management of patients with disorders of consciousness, research efforts should address these mechanistic, epidemiological, bioengineering, and educational gaps to enable large-scale implementation of CMD assessment in clinical practice.
Collapse
Affiliation(s)
- Jan Claassen
- Department of Neurology, Neurological Institute, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Michael Diringer
- Department of Neurology, Washington University, St. Louis, MO, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Joseph J Fins
- Division of Medical Ethics, Department of Medicine, Weill Cornell Medical College, NewYork Presbyterian Hospital, New York, NY, 10032, USA
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Yousef Hannawi
- Division of Cerebrovascular Diseases and Neurocritical Care, Department of Neurology, The Ohio State University, Columbus, OH, USA
| | - Benjamin Rohaut
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP) - Pitié Salpêtrière, Paris, France
| | | | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Neurology, and Radiology, School of Medicine, Secondary Appointment in Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Martin Monti
- Department of Psychology, University of California Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
3
|
Canny E, Vansteensel MJ, van der Salm SMA, Müller-Putz GR, Berezutskaya J. Boosting brain-computer interfaces with functional electrical stimulation: potential applications in people with locked-in syndrome. J Neuroeng Rehabil 2023; 20:157. [PMID: 37980536 PMCID: PMC10656959 DOI: 10.1186/s12984-023-01272-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/23/2023] [Indexed: 11/20/2023] Open
Abstract
Individuals with a locked-in state live with severe whole-body paralysis that limits their ability to communicate with family and loved ones. Recent advances in brain-computer interface (BCI) technology have presented a potential alternative for these people to communicate by detecting neural activity associated with attempted hand or speech movements and translating the decoded intended movements to a control signal for a computer. A technique that could potentially enrich the communication capacity of BCIs is functional electrical stimulation (FES) of paralyzed limbs and face to restore body and facial movements of paralyzed individuals, allowing to add body language and facial expression to communication BCI utterances. Here, we review the current state of the art of existing BCI and FES work in people with paralysis of body and face and propose that a combined BCI-FES approach, which has already proved successful in several applications in stroke and spinal cord injury, can provide a novel promising mode of communication for locked-in individuals.
Collapse
Affiliation(s)
- Evan Canny
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mariska J Vansteensel
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sandra M A van der Salm
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gernot R Müller-Putz
- Institute of Neural Engineering, Laboratory of Brain-Computer Interfaces, Graz University of Technology, Graz, Austria
| | - Julia Berezutskaya
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands.
| |
Collapse
|
4
|
Le Fort M, Demeure Dit Latte D, Perrouin-Verbe B, Ville I. Organizational ethics in urgent transfers of severely disabled people to intensive care units - a qualitative study. Disabil Rehabil 2023; 45:3852-3860. [PMID: 36369957 DOI: 10.1080/09638288.2022.2140847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/20/2022] [Accepted: 10/23/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE Urgent transfers of severely impaired patients with chronic neurological disability (PwND) from a neurological physical and rehabilitation medicine (nPRM) to an intensive care unit (ICU) or an emergency room (ER) served as the basis for this study. We hypothesized that human and structural factors interfered with but were not directly related to the acute context. METHODS We decided to use a qualitative methodology, based on in-depth interviews with 16 ICU/ER physicians. We used mixed bottom-up and top-down methods. We interpreted our data using a thematic approach based on the key principles of grounded theory, which were modified with consideration of the literature. RESULTS Three main domains emerged. The impact of the clinical setting notably implied the patient's clinical typology between the acute event and the chronic background, but also bed availability. Key elements of the telephone negotiation were confidence and perceived usefulness of the transfer. Finally, the otherness of some categories of patients, transferred with more difficulty, involved those with cognitive impairment. CONCLUSIONS The existence of healthcare pathways for many years has created an organizational culture between departments of nPRM and ICUs. But urgent transfers also imply organizational ethics, as a balance should be struck between utility and equity. IMPLICATIONS FOR REHABILITATIONStructural and human factors interfere in urgent transfers, involving the settings within health pathways, the key elements of negotiation to get confidence and a perceived utility of transfer, and certain categories of people, especially those with cognitive impairment.Transfers that imply negotiation between practitioners from physical and rehabilitation medicine and intensive care unit departments, lead to a need of organizational ethics, as a balance should be struck between the principles of utility and equity.The development of facilitating tools such as a commitment charter is of paramount importance as it can support ethical decision-making.
Collapse
Affiliation(s)
- Marc Le Fort
- Nantes Université, Centre Hospitalier Universitaire de Nantes, Service universitaire de Médecine Physique et de Réadaptation neurologique, Hôpital Saint-Jacques, Nantes, France
- Institut national de la santé et de la recherche médicale (INSERM-CERMES3), Ecole des hautes études en sciences sociales (EHESS-PHS), Paris, France
| | - Dominique Demeure Dit Latte
- Nantes Université, Centre Hospitalier Universitaire de Nantes, Service de Réanimation chirurgicale, Hôtel-Dieu, Nantes, France
| | - Brigitte Perrouin-Verbe
- Nantes Université, Centre Hospitalier Universitaire de Nantes, Service universitaire de Médecine Physique et de Réadaptation neurologique, Hôpital Saint-Jacques, Nantes, France
| | - Isabelle Ville
- Institut national de la santé et de la recherche médicale (INSERM-CERMES3), Ecole des hautes études en sciences sociales (EHESS-PHS), Paris, France
| |
Collapse
|
5
|
Abstract
Neuroprognostication following acute brain injury (ABI) is a complex process that involves integrating vast amounts of information to predict a patient's likely trajectory of neurologic recovery. In this setting, critically evaluating salient ethical questions is imperative, and the implications often inform high-stakes conversations about the continuation, limitation, or withdrawal of life-sustaining therapy. While neuroprognostication is central to these clinical "life-or-death" decisions, the ethical underpinnings of neuroprognostication itself have been underexplored for patients with ABI. In this article, we discuss the ethical challenges of individualized neuroprognostication including parsing and communicating its inherent uncertainty to surrogate decision-makers. We also explore the population-based ethical considerations that arise in the context of heterogenous prognostication practices. Finally, we examine the emergence of artificial intelligence-aided neuroprognostication, proposing an ethical framework relevant to both modern and longstanding prognostic tools.
Collapse
Affiliation(s)
- India A Lissak
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Eric Rosenthal
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael J Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
6
|
Nilsen HW, Martinsen ACT, Johansen I, Kirkevold M, Sunnerhagen KS, Becker F. Demographic, Medical, and Clinical Characteristics of a Population-Based Sample of Patients With Long-lasting Locked-In Syndrome. Neurology 2023; 101:e1025-e1035. [PMID: 37442623 PMCID: PMC10491452 DOI: 10.1212/wnl.0000000000207577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 05/10/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with classic locked-in syndrome (LIS), typically caused by ventral pontine stroke, present with quadriplegia, mutism, intact consciousness, and communication skills limited to vertical gazing and/or blinking. Clinical presentations and definitions of LIS differ, especially regarding incomplete LIS. In our study, we explored the functional diversity of LIS, its outcomes, and the complexity of its course along with variations in the location of lesions and their potential significance for outcomes. METHODS A national cohort of patients with vascular LIS who remained in the LIS state for at least 6 weeks according to a functional definition of LIS was studied. Demographic, medical, and follow-up data, collected between 2012 and 2022, were obtained from the quality register of the Norwegian National Unit for Rehabilitation of Locked-In Syndrome. Outcomes in verbal communication, motor function, and dependency were evaluated according to criteria for being in or not in the LIS state. The modified Rankin scale and LIS motor recovery scale were applied. Descriptive analysis was performed. The relationship between lesion location and functional outcome was investigated. RESULTS The sample included 51 patients (median age: 55.7 years, 36 male individuals), 43 of whom had follow-up data. Ischemic stroke was the most common etiology (n = 35). Twenty-three patients had emerged from the LIS state, mostly within 2 years after onset. All but 1 patient achieved some motor improvement, whereas only 3 achieved full motor recovery, and 88% had a persistently high level of dependence. The 3-year survival rate was 87%. Five patients had an isolated pontine lesion, whereas 80% showed various lesions outside the brain stem. Patients who emerged from the LIS state had a significantly lower prevalence of lesions outside the brain stem than patients who remained in the LIS state did. DISCUSSION Investigating an unselected population-based sample of patients with vascular LIS offers important insights into the functional diversity of LIS. Although most patients remained severely disabled, even small improvements in function can substantially increase the potential for activity and participation. Additional lesions outside the brain stem seem to be common in long-lasting LIS and might be prognostic for remaining in the LIS state.
Collapse
Affiliation(s)
- Helle Walseth Nilsen
- From the Sunnaas Rehabilitation Hospital (H.W.N., A.C.T.M., F.B.), Nesoddtangen; Institute of Clinical Medicine (H.W.N., F.B.), University of Oslo; Department of Radiology (A.C.T.M.), Oslo Metropolitan University; Institute of Health and Society (I.J.), University of Oslo; Department of Nursing and Health Promotion (M.K.), Oslo Metropolitan University, Norway; Department of Clinical Neuroscience (K.S.S.), University of Gothenburg; and Neurocare (K.S.S.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anne Catrine T Martinsen
- From the Sunnaas Rehabilitation Hospital (H.W.N., A.C.T.M., F.B.), Nesoddtangen; Institute of Clinical Medicine (H.W.N., F.B.), University of Oslo; Department of Radiology (A.C.T.M.), Oslo Metropolitan University; Institute of Health and Society (I.J.), University of Oslo; Department of Nursing and Health Promotion (M.K.), Oslo Metropolitan University, Norway; Department of Clinical Neuroscience (K.S.S.), University of Gothenburg; and Neurocare (K.S.S.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Inger Johansen
- From the Sunnaas Rehabilitation Hospital (H.W.N., A.C.T.M., F.B.), Nesoddtangen; Institute of Clinical Medicine (H.W.N., F.B.), University of Oslo; Department of Radiology (A.C.T.M.), Oslo Metropolitan University; Institute of Health and Society (I.J.), University of Oslo; Department of Nursing and Health Promotion (M.K.), Oslo Metropolitan University, Norway; Department of Clinical Neuroscience (K.S.S.), University of Gothenburg; and Neurocare (K.S.S.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marit Kirkevold
- From the Sunnaas Rehabilitation Hospital (H.W.N., A.C.T.M., F.B.), Nesoddtangen; Institute of Clinical Medicine (H.W.N., F.B.), University of Oslo; Department of Radiology (A.C.T.M.), Oslo Metropolitan University; Institute of Health and Society (I.J.), University of Oslo; Department of Nursing and Health Promotion (M.K.), Oslo Metropolitan University, Norway; Department of Clinical Neuroscience (K.S.S.), University of Gothenburg; and Neurocare (K.S.S.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Katharina Stibrant Sunnerhagen
- From the Sunnaas Rehabilitation Hospital (H.W.N., A.C.T.M., F.B.), Nesoddtangen; Institute of Clinical Medicine (H.W.N., F.B.), University of Oslo; Department of Radiology (A.C.T.M.), Oslo Metropolitan University; Institute of Health and Society (I.J.), University of Oslo; Department of Nursing and Health Promotion (M.K.), Oslo Metropolitan University, Norway; Department of Clinical Neuroscience (K.S.S.), University of Gothenburg; and Neurocare (K.S.S.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Frank Becker
- From the Sunnaas Rehabilitation Hospital (H.W.N., A.C.T.M., F.B.), Nesoddtangen; Institute of Clinical Medicine (H.W.N., F.B.), University of Oslo; Department of Radiology (A.C.T.M.), Oslo Metropolitan University; Institute of Health and Society (I.J.), University of Oslo; Department of Nursing and Health Promotion (M.K.), Oslo Metropolitan University, Norway; Department of Clinical Neuroscience (K.S.S.), University of Gothenburg; and Neurocare (K.S.S.), Sahlgrenska University Hospital, Gothenburg, Sweden.
| |
Collapse
|
7
|
Gosseries O, Schnakers C, Vanhaudenhuyse A, Martial C, Aubinet C, Charland-Verville V, Thibaut A, Annen J, Ledoux D, Laureys S, Grégoire C. Needs and Quality of Life of Caregivers of Patients with Prolonged Disorders of Consciousness. Brain Sci 2023; 13. [PMID: 36831851 DOI: 10.3390/brainsci13020308] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/30/2023] [Accepted: 02/04/2023] [Indexed: 02/15/2023] Open
Abstract
Background. Many patients with severe brain damage may survive and remain in a prolonged disorder of consciousness (PDoC), impacting the quality of life (QoL) and needs of their family caregivers. However, the current literature on the factors influencing these needs is contradictory. We aim to describe the needs, QoL, and emotional distress of caregivers of patients with PDoC. Methods. Questionnaires investigating the importance and satisfaction of six categories of needs (i.e., health information, emotional, instrumental, and professional supports, community support network, and involvement in care), QoL, and emotional distress were completed by the main caregivers of PDoC patients. Results. We analyzed 177 questionnaires. Seventy-nine percent of the needs were considered as important or very important, and 44% were partially met or unmet. The needs for health information and professional support were the most important, while the needs for involvement in care and for health information were the most satisfied. Mean QoL was low and emotional distress high. Variables such as care setting and time since brain injury affected the level of QoL and distress. Conclusion. The needs for health information and professional support should receive particular attention. Given their low QoL and high distress, adequate support structures should be provided to caregivers of PDoC patients.
Collapse
|
8
|
Schnetzer L, McCoy M, Bergmann J, Kunz A, Leis S, Trinka E. Locked-in syndrome revisited. Ther Adv Neurol Disord 2023; 16:17562864231160873. [PMID: 37006459 PMCID: PMC10064471 DOI: 10.1177/17562864231160873] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/14/2023] [Indexed: 03/31/2023] Open
Abstract
The locked-in syndrome (LiS) is characterized by quadriplegia with preserved vertical eye and eyelid movements and retained cognitive abilities. Subcategorization, aetiologies and the anatomical foundation of LiS are discussed. The damage of different structures in the pons, mesencephalon and thalamus are attributed to symptoms of classical, complete and incomplete LiS and the locked-in plus syndrome, which is characterized by additional impairments of consciousness, making the clinical distinction to other chronic disorders of consciousness at times difficult. Other differential diagnoses are cognitive motor dissociation (CMD) and akinetic mutism. Treatment options are reviewed and an early, interdisciplinary and aggressive approach, including the provision of psychological support and coping strategies is favoured. The establishment of communication is a main goal of rehabilitation. Finally, the quality of life of LiS patients and ethical implications are considered. While patients with LiS report a high quality of life and well-being, medical professionals and caregivers have largely pessimistic perceptions. The negative view on life with LiS must be overthought and the autonomy and dignity of LiS patients prioritized. Knowledge has to be disseminated, diagnostics accelerated and technical support system development promoted. More well-designed research but also more awareness of the needs of LiS patients and their perception as individual persons is needed to enable a life with LiS that is worth living.
Collapse
Affiliation(s)
| | - Mark McCoy
- Department of Neurology, Neurological Intensive Care and Neurorehabilitation, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
| | - Jürgen Bergmann
- Department of Neurology, Neurological Intensive Care and Neurorehabilitation, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
| | - Alexander Kunz
- Department of Neurology, Neurological Intensive Care and Neurorehabilitation, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute of Neurorehabilitation and Space Neurology, Salzburg, Austria
| | - Stefan Leis
- Department of Neurology, Neurological Intensive Care and Neurorehabilitation, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Neurological Intensive Care and Neurorehabilitation, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
- MRI Research Unit, Neuroscience Institute, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute of Neurorehabilitation and Space Neurology, Salzburg, Austria
| |
Collapse
|
9
|
Bonin EAC, Lejeune N, Szymkowicz E, Bonhomme V, Martial C, Gosseries O, Laureys S, Thibaut A. Assessment and management of pain/nociception in patients with disorders of consciousness or locked-in syndrome: A narrative review. Front Syst Neurosci 2023; 17:1112206. [PMID: 37021037 PMCID: PMC10067681 DOI: 10.3389/fnsys.2023.1112206] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/06/2023] [Indexed: 04/07/2023] Open
Abstract
The assessment and management of pain and nociception is very challenging in patients unable to communicate functionally such as patients with disorders of consciousness (DoC) or in locked-in syndrome (LIS). In a clinical setting, the detection of signs of pain and nociception by the medical staff is therefore essential for the wellbeing and management of these patients. However, there is still a lot unknown and a lack of clear guidelines regarding the assessment, management and treatment of pain and nociception in these populations. The purpose of this narrative review is to examine the current knowledge regarding this issue by covering different topics such as: the neurophysiology of pain and nociception (in healthy subjects and patients), the source and impact of nociception and pain in DoC and LIS and, finally, the assessment and treatment of pain and nociception in these populations. In this review we will also give possible research directions that could help to improve the management of this specific population of severely brain damaged patients.
Collapse
Affiliation(s)
- Estelle A. C. Bonin
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre Hospitalier Neurologique (CHN) William Lennox, Saint-Luc Hospital Group, Ottignies-Louvain-la-Neuve, Belgium
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
| | - Emilie Szymkowicz
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Vincent Bonhomme
- Department of Anesthesia and Intensive Care Medicine, Liège University Hospital, Liège, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, Centre Intégré Universitaire de Santé et Services Sociaux (CIUSS), University Laval, Québec City, QC, Canada
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
- *Correspondence: Aurore Thibaut,
| |
Collapse
|
10
|
Muacevic A, Adler JR, Khalayla M, Lazraq M, Miloudi Y, Bensaid A, El Harrar N. Moroccans' Views on Resuscitation According to Presumed Degree of Disability: A Cross-Sectional Study. Cureus 2023; 15:e33460. [PMID: 36628402 PMCID: PMC9822531 DOI: 10.7759/cureus.33460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION According to the World Health Organization (WHO), disability is a public health problem that can be difficult to manage medically and financially. Disability can either be innate or develop after resuscitation. Therefore, the decision regarding whether to resuscitate a patient or not raises certain ethical questions, especially in the context of a Muslim country such as Morocco. AIM The main aim of this study is to survey the public's opinions regarding their willingness to be resuscitated or have their relatives be resuscitated based on their foreseeable degree of disability. METHODS This cross-sectional study was conducted over a 10-month period and employed a self-administered questionnaire. The participants included were all adult (i.e., over 18 years of age) Moroccan nationals, and they were selected regardless of their religious identity. Moreover, the modified Rankin Scale (mRS) was used to measure the participants' foreseeable degree of handicap. The participants were divided into two groups: healthcare workers and non-healthcare workers. RESULTS In total, 1083 questionnaires were retained. The average age of the participants was 30 (± 8) years, with the male-to-female sex ratio being 0.78. Moreover, 39.6% of the participants were healthcare workers. It was found that compared to the non healthcare workers, the healthcare professionals were more willing to be resuscitated themselves and have resuscitation performed on their relatives, but only when the degree of foreseeable disability was estimated to be absent or insignificant, whereas they were less willing to be resuscitated and have resuscitation performed on their relatives when the degree of foreseeable disability was estimated to be mild or higher. CONCLUSION In conclusion, there should be a pre-established procedure, along with a legislative and multidisciplinary framework, within the hospital structures in order to help in the decision-making process regarding whether to resuscitate a patient or not.
Collapse
|
11
|
Muacevic A, Adler JR, Urayama KY. Understanding the Psychological Well-being of Patients With Locked-in Syndrome: A Scoping Review. Cureus 2023; 15:e34295. [PMID: 36860234 PMCID: PMC9970725 DOI: 10.7759/cureus.34295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2023] [Indexed: 01/30/2023] Open
Abstract
Locked-in syndrome (LiS) is a neurological disorder caused by lesions affecting the ventral pons and midbrain and is characterized by loss of physical function, but with perceived consciousness intact. Despite severely limited function, previous studies have shown the quality of life (QoL) in patients to be more positive than naturally assumed by caregivers and relatives. The present review aims to synthesize the broad scientific literature focused on the psychological well-being of LiS patients. A scoping review was performed to synthesize the available evidence on the psychological well-being of LiS patients. Eligible studies included those that target individuals with LiS as the study population, evaluated psychological well-being, and explored the factors related to it. We extracted study population details, type of QoL methods, method of communication, and primary findings from the studies. We summarized the findings categorized into health-related QoL (HRQoL), global QoL, and other tools for assessing psychological status. Across the 13 eligible studies, we observed that patients with LiS had reasonable or similar psychological well-being as the standard based on HRQoL and global QoL assessment. Caregivers and healthcare professionals seem to rate the psychological QoL of LiS patients lower than patients themselves. Studies showed evidence that the longer duration of LiS is a factor that positively affects QoL, and augmentative and alternative communication tools and recovery of speech production showed positive effects as well. Studies reported a range of 27% to 68% of patients experiencing thoughts of suicide and euthanasia. The evidence shows that LiS patients had reasonable psychological well-being. There appear to be differences between patients' assessed well-being and the negative perceptions by caregivers. Response shift and adaptation to disease by patients are considered potential reasons. A sufficient moratorium period and provision of information to support patients' QoL and appropriate decision-making seems necessary.
Collapse
|
12
|
Vansteensel MJ, Branco MP, Leinders S, Freudenburg ZF, Schippers A, Geukes SH, Gaytant MA, Gosselaar PH, Aarnoutse EJ, Ramsey NF. Methodological Recommendations for Studies on the Daily Life Implementation of Implantable Communication-Brain-Computer Interfaces for Individuals With Locked-in Syndrome. Neurorehabil Neural Repair 2022; 36:666-677. [PMID: 36124975 DOI: 10.1177/15459683221125788] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Implantable brain-computer interfaces (BCIs) promise to be a viable means to restore communication in individuals with locked-in syndrome (LIS). In 2016, we presented the world-first fully implantable BCI system that uses subdural electrocorticography electrodes to record brain signals and a subcutaneous amplifier to transmit the signals to the outside world, and that enabled an individual with LIS to communicate via a tablet computer by selecting icons in spelling software. For future clinical implementation of implantable communication-BCIs, however, much work is still needed, for example, to validate these systems in daily life settings with more participants, and to improve the speed of communication. We believe the design and execution of future studies on these and other topics may benefit from the experience we have gained. Therefore, based on relevant literature and our own experiences, we here provide an overview of procedures, as well as recommendations, for recruitment, screening, inclusion, imaging, hospital admission, implantation, training, and support of participants with LIS, for studies on daily life implementation of implantable communication-BCIs. With this article, we not only aim to inform the BCI community about important topics of concern, but also hope to contribute to improved methodological standardization of implantable BCI research.
Collapse
Affiliation(s)
- Mariska J Vansteensel
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mariana P Branco
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sacha Leinders
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Zac F Freudenburg
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anouck Schippers
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Simon H Geukes
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michael A Gaytant
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter H Gosselaar
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Erik J Aarnoutse
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nick F Ramsey
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
13
|
Goostrey K, Muehlschlegel S. Prognostication and shared decision making in neurocritical care. BMJ 2022; 377:e060154. [PMID: 35696329 DOI: 10.1136/bmj-2021-060154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Prognostication is crucial in the neurological intensive care unit (neuroICU). Patients with severe acute brain injury (SABI) are unable to make their own decisions because of the insult itself or sedation needs. Surrogate decision makers, usually family members, must make decisions on the patient's behalf. However, many are unprepared for their role as surrogates owing to the sudden and unexpected nature of SABI. Surrogates rely on clinicians in the neuroICU to provide them with an outlook (prognosis) with which to make substituted judgments and decide on treatments and goals of care on behalf of the patient. Therefore, how a prognostic estimate is derived, and then communicated, is extremely important. Prognostication in the neuroICU is highly variable between clinicians and institutions, and evidence based guidelines are lacking. Shared decision making (SDM), where surrogates and clinicians arrive together at an individualized decision based on patient values and preferences, has been proposed as an opportunity to improve clinician-family communication and ensure that patients receive treatments they would choose. This review outlines the importance and current challenges of prognostication in the neuroICU and how prognostication and SDM intersect, based on relevant research and expert opinion.
Collapse
Affiliation(s)
- Kelsey Goostrey
- Department of neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Susanne Muehlschlegel
- Department of neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of anesthesiology/critical care, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| |
Collapse
|
14
|
|
15
|
Fry A, Chan HW, Harel N, Spielman L, Escalon M, Putrino D. Evaluating the clinical benefit of brain-computer interfaces for control of a personal computer. J Neural Eng 2022; 19. [PMID: 35325875 DOI: 10.1088/1741-2552/ac60ca] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 03/24/2022] [Indexed: 11/11/2022]
Abstract
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.
Collapse
Affiliation(s)
- Adam Fry
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, New York, New York, 10029, UNITED STATES
| | - Ho Wing Chan
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, New York, New York, 10029, UNITED STATES
| | - Noam Harel
- James J Peters VA Medical Center, 130 W Kingsbridge Rd, New York, New York, 10468, UNITED STATES
| | - Lisa Spielman
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, New York, New York, 10029, UNITED STATES
| | - Miguel Escalon
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, New York, New York, 10029, UNITED STATES
| | - David Putrino
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, New York, New York, 10029, UNITED STATES
| |
Collapse
|
16
|
Bonin EAC, Delsemme Z, Blandin V, Alnagger NL, Thibaut A, Faymonville ME, Laureys S, Vanhaudenhuyse A, Gosseries O. French Survey on Pain Perception and Management in Patients with Locked-In Syndrome. Diagnostics (Basel) 2022; 12:769. [PMID: 35328322 DOI: 10.3390/diagnostics12030769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/08/2022] [Accepted: 03/15/2022] [Indexed: 11/17/2022] Open
Abstract
Patients with locked-in syndrome (LIS) may suffer from pain, which can significantly affect their daily life and well-being. In this study, we aim to investigate the presence and the management of pain in LIS patients. Fifty-one participants completed a survey collecting socio-demographic information and detailed reports regarding pain perception and management (type and frequency of pain, daily impact of pain, treatments). Almost half of the LIS patients reported experiencing pain (49%) that affected their quality of life, sleep and cognition. The majority of these patients reported that they did not communicate their pain to clinical staff. Out of the 25 patients reporting pain, 18 (72%) received treatment (60% pharmacological, 12% non-pharmacological) and described the treatment efficacy as 'moderate'. In addition, 14 (56%) patients were willing to try other non-pharmacological treatments, such as hypnosis or meditation. This study provides a comprehensive characterization of pain perception in LIS patients and highlights the lack of guidelines for pain detection and its management. This is especially pertinent given that pain affects diagnoses, by either inducing fatigue or by using pharmacological treatments that modulate the levels of wakefulness and concentration of such patients.
Collapse
|
17
|
Kiroy V, Bakhtin O, Krivko E, Lazurenko D, Aslanyan E, Shaposhnikov D, Shcherban I. Spoken and Inner Speech-related EEG Connectivity in Different Spatial Direction. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103224] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
18
|
Abstract
Patients with severe disorders of consciousness are thought to be unaware of themselves or their environment. However, research suggests that a minority of patients diagnosed as having a disorder of consciousness remain aware. These patients, designated as having “cognitive motor dissociation” (CMD), can demonstrate awareness by imagining specific tasks, which generates brain activity detectable via functional neuroimaging. The discovery of consciousness in these patients raises difficult questions about their well-being, and it has been argued that it would be better for these patients if they were allowed to die. Conversely, I argue that CMD patients may have a much higher level of well-being than is generally acknowledged. It is far from clear that their lives are not worth living, because there are still significant gaps in our understanding of how these patients experience the world. I attempt to fill these gaps, by analyzing the neuroscientific research that has taken place with these patients to date. Having generated as comprehensive a picture as possible of the capacities of CMD patients, I examine this picture through the lens of traditional philosophical theories of well-being. I conclude that the presumption that CMD patients do not have lives worth living is not adequately supported.
Collapse
|
19
|
Tankus A, Solomon L, Aharony Y, Faust-Socher A, Strauss I. Machine learning algorithm for decoding multiple subthalamic spike trains for speech brain-machine interfaces. J Neural Eng 2021; 18. [PMID: 34695815 DOI: 10.1088/1741-2552/ac3315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 10/25/2021] [Indexed: 11/11/2022]
Abstract
Objective. The goal of this study is to decode the electrical activity of single neurons in the human subthalamic nucleus (STN) to infer the speech features that a person articulated, heard or imagined. We also aim to evaluate the amount of subthalamic neurons required for high accuracy decoding suitable for real-life speech brain-machine interfaces (BMI).Approach. We intraoperatively recorded single-neuron activity in the STN of 21 neurosurgical patients with Parkinson's disease undergoing implantation of deep brain stimulator while patients produced, perceived or imagined the five monophthongal vowel sounds. Our decoder is based on machine learning algorithms that dynamically learn specific features of the speech-related firing patterns.Main results. In an extensive comparison of algorithms, our sparse decoder ('SpaDe'), based on sparse decomposition of the high dimensional neuronal feature space, outperformed the other algorithms in all three conditions: production, perception and imagery. For speech production, our algorithm, Spade, predicted all vowels correctly (accuracy: 100%; chance level: 20%). For perception accuracy was 96%, and for imagery: 88%. The accuracy of Spade showed a linear behavior in the amount of neurons for the perception data, and even faster for production or imagery.Significance. Our study demonstrates that the information encoded by single neurons in the STN about the production, perception and imagery of speech is suitable for high-accuracy decoding. It is therefore an important step towards BMIs for restoration of speech faculties that bears an enormous potential to alleviate the suffering of completely paralyzed ('locked-in') patients and allow them to communicate again with their environment. Moreover, our research indicates how many subthalamic neurons may be necessary to achieve each level of decoding accuracy, which is of supreme importance for a neurosurgeon planning the implantation of a speech BMI.
Collapse
Affiliation(s)
- Ariel Tankus
- Functional Neurosurgery Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel.,Department of Neurology and Neurosurgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel.,Sagol School of Neuroscience, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Lior Solomon
- School of Electrical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Yotam Aharony
- School of Electrical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Achinoam Faust-Socher
- Movement Disorders Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Ido Strauss
- Functional Neurosurgery Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel.,Department of Neurology and Neurosurgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| |
Collapse
|
20
|
Siegel CL, Besbris J, Everett EA, Lavi ES, Mehta AK, Jones CA, Creutzfeldt CJ, Kramer NM. Top Ten Tips Palliative Care Clinicians Should Know About Strokes. J Palliat Med 2021; 24:1877-1883. [PMID: 34704853 DOI: 10.1089/jpm.2021.0449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Stroke is a common cause of long-term disability and death, which leaves many patients with significant and unique palliative care (PC) needs. Shared decision-making for patients with stroke poses distinct challenges due to the sudden nature of stroke, the uncertainty inherent in prognostication around recovery, and the common necessity of relying on surrogates for decision-making. Patients with stroke suffer from frequently underrecognized symptoms, which PC clinicians should feel comfortable identifying and treating. This article provides 10 tips for palliative clinicians to increase their knowledge and comfort in caring for this important population.
Collapse
Affiliation(s)
- Cara L Siegel
- Departments of Neurology and Palliative Care, University of California, Los Angeles, Los Angeles, California, USA
| | - Jessica Besbris
- Departments of Neurology and Supportive Care Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Elyse A Everett
- Departments of Medicine and Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Elana S Lavi
- Department of Speech Language Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ambereen K Mehta
- Palliative Care Program, Department of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Neha M Kramer
- Departments of Neurology and Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
21
|
Chaudhary U, Chander BS, Ohry A, Jaramillo-Gonzalez A, Lulé D, Birbaumer N. Brain Computer Interfaces for Assisted Communication in Paralysis and Quality of Life. Int J Neural Syst 2021; 31:2130003. [PMID: 34587854 DOI: 10.1142/s0129065721300035] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The rapid evolution of Brain-Computer Interface (BCI) technology and the exponential growth of BCI literature during the past 20 years is a consequence of increasing computational power and the achievements of statistical learning theory and machine learning since the 1960s. Despite this rapid scientific progress, the range of successful clinical and societal applications remained limited, with some notable exceptions in the rehabilitation of chronic stroke and first steps towards BCI-based assisted verbal communication in paralysis. In this contribution, we focus on the effects of noninvasive and invasive BCI-based verbal communication on the quality of life (QoL) of patients with amyotrophic lateral sclerosis (ALS) in the locked-in state (LIS) and the completely locked-in state (CLIS). Despite a substantial lack of replicated scientific data, this paper complements the existing methodological knowledge and focuses future investigators' attention on (1) Social determinants of QoL and (2) Brain reorganization and behavior. While it is not documented in controlled studies that the good QoL in these patients is a consequence of BCI-based neurorehabilitation, the proposed determinants of QoL might become the theoretical background needed to develop clinically more useful BCI systems and to evaluate the effects of BCI-based communication on QoL for advanced ALS patients and other forms of severe paralysis.
Collapse
Affiliation(s)
- Ujwal Chaudhary
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen 72076, Germany.,ALSVOICE gGmbH, Mössingen 72116, Germany
| | - Bankim Subhash Chander
- ALSVOICE gGmbH, Mössingen 72116, Germany.,Department of Psychiatry and Psychotherapy, Center for Innovative Psychiatric and Psychotherapeutic Research, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim 68159, Germany
| | - Avi Ohry
- Sackler Faculty of Medicine, Tel Aviv University & Reuth Medical & Rehabilitation Center, Tel Aviv, Israel
| | - Andres Jaramillo-Gonzalez
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen 72076, Germany
| | | | - Niels Birbaumer
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen 72076, Germany.,ALSVOICE gGmbH, Mössingen 72116, Germany
| |
Collapse
|
22
|
Sethi A, Everett E, Mehta A, Besbris J, Burke C, Pedowitz E, Kilpatrick M, Foster L, Maiser S. The Role of Specialty Palliative Care for Amyotrophic Lateral Sclerosis. Am J Hosp Palliat Care 2021; 39:865-873. [PMID: 34583569 DOI: 10.1177/10499091211049386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Amyotrophic Lateral Sclerosis (ALS) is a progressive and incurable neurodegenerative disease resulting in the loss of motor neurons, eventually leading to death. ALS results in complex physical, emotional, and spiritual care needs. Specialty Palliative Care (SPC) is a medical specialty for patients with serious illness that provides an extra layer of support through complicated symptom management, goals of care conversations, and support to patients and families during hard times. Using MEDLINE, APA Psychinfo, and Dynamed databases, we reviewed the literature of SPC in ALS to inform and support an expert opinion perspective on this topic. This manuscript focuses on several key areas of SPC for ALS including insurance and care models, advance care planning, symptom management, quality of life, caregiver support, and end-of-life care. Recommendations to improve specialty palliative care for patients with ALS are reviewed in the discussion section.
Collapse
Affiliation(s)
- Anish Sethi
- University of Minnesota College of Biological Sciences, Minneapolis, MN, USA
| | - Elyse Everett
- John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, MO, USA
| | - Ambereen Mehta
- Department of Medicine, John Hopkins Medicine, Baltimore, MD, USA
| | - Jessica Besbris
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christa Burke
- Division of Palliative Medicine, John T. Milliken Department of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Elizabeth Pedowitz
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Molly Kilpatrick
- Palliative Care and Supportive Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Laura Foster
- Department of Neurology, University of Colorado School of Medicine, Boulder, CO, USA
| | - Sam Maiser
- University of Minnesota College of Biological Sciences, Minneapolis, MN, USA.,Department of Neurology, Hennepin Healthcare, Minneapolis, MN, USA
| |
Collapse
|
23
|
Branco MP, Pels EGM, Nijboer F, Ramsey NF, Vansteensel MJ. Brain-Computer interfaces for communication: preferences of individuals with locked-in syndrome, caregivers and researchers. Disabil Rehabil Assist Technol 2021:1-11. [PMID: 34383613 PMCID: PMC9259829 DOI: 10.1080/17483107.2021.1958932] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The development of Brain-Computer Interfaces to restore communication (cBCIs) in people with severe motor impairment ideally relies on a close collaboration between end-users and other stakeholders, such as caregivers and researchers. Awareness about potential differences in opinion between these groups is crucial for development of usable cBCIs and access technology (AT) in general. In this study, we compared the opinions of prospective cBCI users, their caregivers and cBCI researchers regarding: (1) what applications would users like to control with a cBCI; (2) what mental strategies would users prefer to use for cBCI control; and (3) at what stage of their clinical trajectory would users like to be informed about AT and cBCIs. METHODS We collected data from 28 individuals with locked-in syndrome, 29 of their caregivers and 28 cBCI researchers. The questionnaire was supported with animation videos to explain different cBCI concepts, the utility of which was also assessed. RESULTS Opinions of the three groups were aligned with respect to the most desired cBCI applications, but diverged regarding mental strategies and the timing of being informed about cBCIs. Animation videos were regarded as clear and useful tools to explain cBCIs and mental strategies to end-users and other stakeholders. CONCLUSIONS Disagreements were clear between stakeholders regarding which mental strategies users prefer to use and when they would like to be informed about cBCIs. To move forward in the development and clinical implementation of cBCIs, it will be necessary to align the research agendas with the needs of the end-users and caregivers.IMPLICATIONS FOR REHABILITATIONBrain-Computer Interfaces may offer people with severe motor impairment a brain-based and muscle-independent approach to control communication-technology. The successful development of communication BCIs (cBCIs) relies on a close collaboration between end-users and other stakeholders, such as caregivers and researchers.Our work reveals that people with locked-in syndrome (end-users), their caregivers and researchers developing cBCIs agree that direct and private forms of communication are the most desired cBCI applications, but disagree regarding the preferred mental strategies for cBCI control and when to be informed about cBCIs.Animation videos are an effective tool for providing information to individuals, independent of their level of health literacy, regarding the concept of cBCIs and mental strategies for control.The misalignment in opinions of different groups of stakeholders about cBCIs strengthens the argument for a user-centered design approach in the development of cBCIs and access technology designed for daily life usage.
Collapse
Affiliation(s)
- Mariana P Branco
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Elmar GM Pels
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Femke Nijboer
- Health, Medical and Neuropsychology Unit, Faculty of Social and Behavioral Sciences, Leiden University, Leiden, The Netherlands,Biomedical Signals and Systems Department, Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, Enschede, The Netherlands
| | - Nick F Ramsey
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands,Corresponding author: Nick F Ramsey, UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Mariska J Vansteensel
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
24
|
|
25
|
|
26
|
Branco MP, Pels EGM, Sars RH, Aarnoutse EJ, Ramsey NF, Vansteensel MJ, Nijboer F. Brain-Computer Interfaces for Communication: Preferences of Individuals With Locked-in Syndrome. Neurorehabil Neural Repair 2021; 35:267-279. [PMID: 33530868 PMCID: PMC7934157 DOI: 10.1177/1545968321989331] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Brain-computer interfaces (BCIs) have been proposed as an assistive technology (AT) allowing people with locked-in syndrome (LIS) to use neural signals to communicate. To design a communication BCI (cBCI) that is fully accepted by the users, their opinion should be taken into consideration during the research and development process. OBJECTIVE We assessed the preferences of prospective cBCI users regarding (1) the applications they would like to control with a cBCI, (2) the mental strategies they would prefer to use to control the cBCI, and (3) when during their clinical trajectory they would like to be informed about AT and cBCIs. Furthermore, we investigated if individuals diagnosed with progressive and sudden onset (SO) disorders differ in their opinion. METHODS We interviewed 28 Dutch individuals with LIS during a 3-hour home visit using multiple-choice, ranking, and open questions. During the interview, participants were informed about BCIs and the possible mental strategies. RESULTS Participants rated (in)direct forms of communication, computer use, and environmental control as the most desired cBCI applications. In addition, active cBCI control strategies were preferred over reactive strategies. Furthermore, individuals with progressive and SO disorders preferred to be informed about AT and cBCIs at the moment they would need it. CONCLUSIONS We show that individuals diagnosed with progressive and SO disorders preferred, in general, the same applications, mental strategies, and time of information. By collecting the opinion of a large sample of individuals with LIS, this study provides valuable information to stakeholders in cBCI and other AT development.
Collapse
Affiliation(s)
| | | | - Ruben H. Sars
- University Medical Center Utrecht, Netherlands
- Leiden University, Netherlands
| | | | | | | | - Femke Nijboer
- Leiden University, Netherlands
- University of Twente, Enschede, Netherlands
| |
Collapse
|
27
|
Farr E, Altonji K, Harvey RL. Locked-In Syndrome: Practical Rehabilitation Management. PM R 2021; 13:1418-1428. [PMID: 33465298 DOI: 10.1002/pmrj.12555] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 11/07/2022]
Abstract
Locked-in syndrome is a rare and devastating condition that results in tetraplegia, lower cranial nerve paralysis, and anarthria with preserved cognition, vertical gaze, and upper eyelid movements. Although acute management is much like that of any severe stroke, rehabilitation and recovery of these patients have not been previously described. Challenges relevant to this population include blood pressure management and orthostasis, timing and appropriateness of reinstating oral feeding, ventilatory support, decannulation after tracheostomy, bowel and bladder management, vestibular dysfunction, and eye care. Targeted rehabilitation of head, neck, and trunk stability to improve function, and proper fit in an appropriate wheelchair are essential to assist with mobility. Rehabilitation interventions should include a focus on distal motor control and upright tolerance training followed by balance and mobility exercises. In addition, special considerations must be given to developing early methods of communication through use of augmentative systems to call for help and express needs. These systems along with additional technology provide the basis to promote connectivity to family and friends through the use of social media and the internet. Establishment of communication, mobility, and connectivity is essential in promoting independence, autonomy, and improving quality of life. Overall, with specialized rehabilitative care and access to the proper equipment, long-term outcomes and quality of life in these patients can be favorable.
Collapse
Affiliation(s)
- Ellen Farr
- Shirley Ryan AbilityLab, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kathryn Altonji
- Shirley Ryan AbilityLab, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard L Harvey
- Shirley Ryan AbilityLab, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
28
|
Abstract
Patients with disorders of consciousness after severe brain injury need surrogate decision makers to guide treatment decisions on their behalf. Formal guidelines for surrogate decisionmaking generally instruct decision makers to first appeal to a patient’s written advance directive, followed by making a substituted judgment of what the patient would have chosen, and lastly, to make decisions according to what seems to be in the patient’s best medical interests. Substituted judgment is preferable because it is taken to preserve patient autonomy, by using a patient’s past wishes and values to reconstruct what they would have chosen for themselves. In this paper, the author argues that for a certain population of patients, the standard interpretation of substituted judgment cannot ensure the preservation of patient autonomy. Patients with “covert awareness” may continue to have values and an authentic sense of self, which may differ from their past values and wishes. Accordingly, surrogate decision makers should make decisions based on how the patient is likely to experience their condition in the present, rather than their past wishes and values.
Collapse
|
29
|
Kageyama Y, He X, Shimokawa T, Sawada J, Yanagisawa T, Shayne M, Sakura O, Kishima H, Mochizuki H, Yoshimine T, Hirata M. Nationwide survey of 780 Japanese patients with amyotrophic lateral sclerosis: their status and expectations from brain-machine interfaces. J Neurol 2020; 267:2932-2940. [PMID: 32488296 DOI: 10.1007/s00415-020-09903-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that causes eventual death through respiratory failure unless mechanical ventilation is provided. Brain-machine interfaces (BMIs) may provide brain control supports for communication and motor function. We investigated the interests and expectations of patients with ALS concerning BMIs based on a large-scale anonymous questionnaire survey supported by the Japan Amyotrophic Lateral Sclerosis Association. METHODS We surveyed 1918 patients with ALS regarding their present status, tracheostomy use, interest in BMIs, and their level of expectation for communication (conversation, emergency alarm, internet, and writing letters) and movement support (postural change, controlling the bed, controlling household appliances, robotic arms, and wheel chairs). FINDINGS Seven hundred and eighty participants responded. Fifty-eight percent of the participants underwent tracheostomy. Approximately, 80% of the patients experienced stress or trouble during communication. For all nine supports, > 60% participants expressed expectations regarding BMIs. More than 98% of participants who underwent tracheostomy expected support with conversation and emergency alarms. Participants who did not undergo tracheostomy exhibited significantly greater expectations than participants with tracheostomy did regarding all five movement supports. Seventy-seven percent of participants were interested in BMIs. Participants aged < 60 years had greater interest in both BMIs. INTERPRETATION This is the first large-scale survey to reveal the present status of patients with ALS and probe their interests and expectations regarding BMIs. Communication and emergency alarms should be supported by BMIs initially. BMIs should provide wide-ranging and high-performance support that can easily be used by severely disabled elderly patients with ALS.
Collapse
Affiliation(s)
- Yu Kageyama
- Department of Neurological Diagnosis and Restoration, Osaka University Graduate School of Medicine, CoMIT, 2-2 Yamadaoka, Suita, Osaka, 913A565-0871, Japan.,Department of Neurosurgery, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Xin He
- Department of Neurological Diagnosis and Restoration, Osaka University Graduate School of Medicine, CoMIT, 2-2 Yamadaoka, Suita, Osaka, 913A565-0871, Japan.,Department of Neurosurgery, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Toshio Shimokawa
- Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Jinichi Sawada
- Osaka Intractable Diseases Medical Information Center, 3-1-56 Mandaihigashi, Sumiyoshi, Osaka, 558-8558, Japan
| | - Takufumi Yanagisawa
- Department of Neurosurgery, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.,Institute for Advanced Co-Creation Studies, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Morris Shayne
- Department of Neurosurgery, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Osamu Sakura
- Interfaculty Initiative in Information Studies, University of Tokyo, 7-3-1 Hongou, Bunkyou,, Tokyo, 113-0033, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Toshiki Yoshimine
- Endowed Research Department of Clinical Neuroengineering, Global Center for Medical Engineering and Informatics, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Masayuki Hirata
- Department of Neurological Diagnosis and Restoration, Osaka University Graduate School of Medicine, CoMIT, 2-2 Yamadaoka, Suita, Osaka, 913A565-0871, Japan. .,Endowed Research Department of Clinical Neuroengineering, Global Center for Medical Engineering and Informatics, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan. .,Department of Neurosurgery, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| |
Collapse
|
30
|
Rogge A, Witt VD, Valdueza JM, Borzikowsky C, Buyx A. Experience in Rehabilitation Medicine Affects Prognosis and End-of-Life Decision-Making of Neurologists: A Case-Based Survey. Neurocrit Care 2019; 31:125-34. [PMID: 30607828 DOI: 10.1007/s12028-018-0661-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Outcome predictions in patients with acute severe neurologic disorders are difficult and influenced by multiple factors. Since the decision for and the extent of life-sustaining therapies are based on the estimated prognosis, it is vital to understand which factors influence such estimates. This study examined whether previous professional experience with rehabilitation medicine influences physician decision-making. Methods A case vignette presenting a typical patient with an extensive brain stem infarction was developed and distributed online to clinical neurologists. Questions focused on prognosis, interpretation of an advanced directive, whether to withdraw life-sustaining treatments and information on prior rehabilitation experience from the survey respondent. Results Of the participating neurologists, 77% opted for the withdrawal of life-sustaining therapies (n = 70; response rate: 14.8%). This decision was not affected by age, gender, or length of clinical experience. Neurologists with experience in rehabilitation medicine tended to estimate a more positive prognosis than neurologists without, but this result was not significant (p = .13). There was an association between the intervention chosen and previous experience in rehabilitation; neurologists with experience in rehabilitation medicine opted significantly more often (31.8%) for continuing life-sustaining treatments than neurologists without such experience (8.7%, p = .04). Conclusion Our results indicate that there are subjective factors influencing decisions to limit life-sustaining treatments that are based on previous professional experience. This finding emphasizes the variability and cognitive bias of such decision processes and should be integrated into future guidelines for specialist training on end-of-life decision-making.
Collapse
|
31
|
Letourneau S, Zewdie ET, Jadavji Z, Andersen J, Burkholder LM, Kirton A. Clinician awareness of brain computer interfaces: a Canadian national survey. J Neuroeng Rehabil 2020; 17:2. [PMID: 31907010 PMCID: PMC6945584 DOI: 10.1186/s12984-019-0624-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 11/13/2019] [Indexed: 12/13/2022] Open
Abstract
Background Individuals with severe neurological disabilities but preserved cognition, including children, are often precluded from connecting with their environments. Brain computer interfaces (BCI) are a potential solution where advancing technologies create new clinical opportunities. We evaluated clinician awareness as a modifiable barrier to progress and identified eligible populations. Methods We executed a national, population-based, cross-sectional survey of physician specialists caring for persons with severe disability. An evidence- and experience-based survey had three themes: clinician BCI knowledge, eligible populations, and potential impact. A BCI knowledge index was created and scored. Canadian adult and pediatric neurologists, physiatrists and a subset of developmental pediatricians were contacted. Secure, web-based software administered the survey via email with online data collection. Results Of 922 valid emails (664 neurologists, 253 physiatrists), 137 (15%) responded. One third estimated that ≥10% of their patients had severe neurological disability with cognitive capacity. BCI knowledge scores were low with > 40% identifying as less than “vaguely aware” and only 15% as “somewhat familiar” or better. Knowledge did not differ across specialties. Only 6 physicians (4%) had patients using BCI. Communication and wheelchair control rated highest for potentially improving quality of life. Most (81%) felt BCI had high potential to improve quality of life. Estimates suggested that > 13,000 Canadians (36 M population) might benefit from BCI technologies. Conclusions Despite high potential and thousands of patients who might benefit, BCI awareness among clinicians caring for disabled persons is poor. Further, functional priorities for BCI applications may differ between medical professionals and potential BCI users, perhaps reflecting that clinicians possess a less accurate understanding of the desires and needs of potential end-users. Improving knowledge and engaging both clinicians and patients could facilitate BCI program development to improve patient outcomes.
Collapse
Affiliation(s)
- Sasha Letourneau
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 2500 University Drive N.W., Calgary, AB, T2N 1N4, Canada
| | - Ephrem Takele Zewdie
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 2500 University Drive N.W., Calgary, AB, T2N 1N4, Canada
| | - Zeanna Jadavji
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 2500 University Drive N.W., Calgary, AB, T2N 1N4, Canada.,Clinical Neurosciences, Cumming School of Medicine, University of Calgary, 2500 University Drive N.W, Calgary, AB, AB T2N 1N4, Canada
| | - John Andersen
- Department of Pediatrics, University of Alberta, 116 St. and 85 Ave, Edmonton, AB T6G 2R3, Canada
| | - Lee M Burkholder
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 2500 University Drive N.W., Calgary, AB, T2N 1N4, Canada.,Clinical Neurosciences, Cumming School of Medicine, University of Calgary, 2500 University Drive N.W, Calgary, AB, AB T2N 1N4, Canada
| | - Adam Kirton
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 2500 University Drive N.W., Calgary, AB, T2N 1N4, Canada. .,Clinical Neurosciences, Cumming School of Medicine, University of Calgary, 2500 University Drive N.W, Calgary, AB, AB T2N 1N4, Canada. .,Department of Pediatrics, University of Alberta, 116 St. and 85 Ave, Edmonton, AB T6G 2R3, Canada. .,Alberta Children's Hospital Research Institute, 28 Oki Drive S.W, Calgary, AB, T3B6A8, Canada. .,Hotchkiss Brain Institute, University of Calgary, 2500 University Drive N.W, Calgary, AB, T2N 1N4, Canada.
| |
Collapse
|
32
|
Yan Y, Demertzi A, Xia Y, Wang J, Hu N, Zhang Z, Di H, Laureys S. Ethics of life-sustaining treatment in locked-in syndrome: A Chinese survey. Ann Phys Rehabil Med 2019; 63:483-487. [PMID: 31682940 DOI: 10.1016/j.rehab.2019.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 09/07/2019] [Accepted: 09/14/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Locked-in syndrome (LIS) characterizes individuals who have experienced pontine lesions, who have limited motor output but with preserved cognitive abilities. Despite their severe physical impairment, individuals with LIS self-profess a higher quality of life than generally expected. Such third-person expectations about LIS are shaped by personal and cultural factors in western countries. OBJECTIVE We sought to investigate whether such opinions are further influenced by the cultural background in East Asia. We surveyed attitudes about the ethics of life-sustaining treatment in LIS in a cohort of medical and non-medical Chinese participants. RESULTS The final study sample included 1545 respondents: medical professionals (n=597, 39%), neurologists (n=303, 20%), legal professionals (n=276, 18%) and other professionals (n=369, 24%), including 180 family members of individuals with LIS. Most of the participants (70%), especially neurologists, thought that life-sustaining treatment could not be stopped in individuals with LIS. It might be unnecessary to withdraw life-sustaining treatment, because the condition involved is not terminal and irreversible, and physical treatment can be beneficial for the patient. A significant proportion (59%) of respondents would like to be kept alive if they were in that condition; however, older people thought the opposite. Families experience the stress of caring for individuals with LIS. The mean (SD) quality of life score for relatives was 0.73 (2.889) (on a -5, +5 scale), which was significantly lower than that of non-relatives, 1.75 (1.969) (P<0.001). CONCLUSIONS Differences in opinions about end of life in LIS are affected by personal characteristics. The current survey did not identify a dissociation between personal preferences and general opinions, potentially because of a social uniformity in China where individualism is less pronounced. Future open-ended surveys could identify specific needs of caregivers so that strategic interventions to reduce ethical debasement are designed.
Collapse
Affiliation(s)
- Yifan Yan
- International Unresponsive Wakefulness and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Athena Demertzi
- GIGA Research, GIGA-Consciousness, Physiology of Cognition Research Lab, University of Liège, Liège, Belgium
| | - Yinyan Xia
- International Unresponsive Wakefulness and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Jing Wang
- International Unresponsive Wakefulness and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Nantu Hu
- International Unresponsive Wakefulness and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.
| | - Zhiliang Zhang
- International Unresponsive Wakefulness and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Haibo Di
- International Unresponsive Wakefulness and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.
| | - Steven Laureys
- GIGA Research, GIGA-Consciousness, Coma Science Group, University & University Hospital of Liège, Liège, Belgium
| |
Collapse
|
33
|
|
34
|
Vidal F. The Locked-in Syndrome: Perspectives from Ethics, History, and Phenomenology. NEUROETHICS-NETH 2020; 13:115-8. [DOI: 10.1007/s12152-019-09420-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
35
|
Moses DA, Leonard MK, Makin JG, Chang EF. Real-time decoding of question-and-answer speech dialogue using human cortical activity. Nat Commun 2019; 10:3096. [PMID: 31363096 PMCID: PMC6667454 DOI: 10.1038/s41467-019-10994-4] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 06/06/2019] [Indexed: 01/15/2023] Open
Abstract
Natural communication often occurs in dialogue, differentially engaging auditory and sensorimotor brain regions during listening and speaking. However, previous attempts to decode speech directly from the human brain typically consider listening or speaking tasks in isolation. Here, human participants listened to questions and responded aloud with answers while we used high-density electrocorticography (ECoG) recordings to detect when they heard or said an utterance and to then decode the utterance's identity. Because certain answers were only plausible responses to certain questions, we could dynamically update the prior probabilities of each answer using the decoded question likelihoods as context. We decode produced and perceived utterances with accuracy rates as high as 61% and 76%, respectively (chance is 7% and 20%). Contextual integration of decoded question likelihoods significantly improves answer decoding. These results demonstrate real-time decoding of speech in an interactive, conversational setting, which has important implications for patients who are unable to communicate.
Collapse
Affiliation(s)
- David A Moses
- Department of Neurological Surgery and the Center for Integrative Neuroscience at UC San Francisco, 675 Nelson Rising Lane, San Francisco, CA, 94158, USA
| | - Matthew K Leonard
- Department of Neurological Surgery and the Center for Integrative Neuroscience at UC San Francisco, 675 Nelson Rising Lane, San Francisco, CA, 94158, USA
| | - Joseph G Makin
- Department of Neurological Surgery and the Center for Integrative Neuroscience at UC San Francisco, 675 Nelson Rising Lane, San Francisco, CA, 94158, USA
| | - Edward F Chang
- Department of Neurological Surgery and the Center for Integrative Neuroscience at UC San Francisco, 675 Nelson Rising Lane, San Francisco, CA, 94158, USA.
| |
Collapse
|
36
|
Abstract
The goal of shared decision making in the neurocritical care setting is to form plans of care that are consistent with best medical practice and are respectful of the patient's values. Close cooperation and meaningful interaction must be achieved with family members so that the patient's "person can emerge" through discussions. This article highlights several caveats that can subvert this complex process, including the cognitive biases that affect both clinicians and surrogates. Impact, optimism, and gain-framing biases may be particularly relevant when considering patients who are receiving neurocritical care. Practitioners need to be cognizant of the distorting influences of these biases and make attempts to neutralize them. Quality of survival and the nature and degree of deficits are often the dominant concerns after patients experience acute severe brain injuries. Care should be taken to avoid conflating medical facts and value judgments when discussing prognoses.
Collapse
|
37
|
Napier S. The Minimally Conscious State, the Disability Bias, and the Moral Authority of Advance Directives. Int J Law Psychiatry 2019; 65:101333. [PMID: 29661479 DOI: 10.1016/j.ijlp.2018.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Stephen Napier
- SAC 108, Philosophy Department, 800 Lancaster Ave., Villanova, PA 19085, USA.
| |
Collapse
|
38
|
Berlucchi G. Wandering thoughts about consciousness, the brain, and the commentary system of Larry Weiskrantz. Neuropsychologia 2019; 128:266-269. [DOI: 10.1016/j.neuropsychologia.2017.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 10/06/2017] [Accepted: 10/08/2017] [Indexed: 11/15/2022]
|
39
|
Verhofstadt M, Chambaere K, Leontjevas R, Peters GJY. Towards an assessment instrument for suffering in patients with psychiatric conditions: assessing cognitive validity. BJPsych Open 2019; 5:e35. [PMID: 31530306 PMCID: PMC6469232 DOI: 10.1192/bjo.2019.25] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Unbearable suffering is a key criterion in legally granting patients' euthanasia requests in Belgium yet a generally accepted definition of unbearable suffering remains elusive. The ability to understand and assess unbearable suffering is essential, particularly in patients with psychiatric conditions, as the underlying causes of these conditions are not always apparent. To enable research into when and why suffering experiences incite patients with psychiatric conditions to request euthanasia, and to help explore preventive and curative perspectives, the development of an assessment instrument is needed. AIMS To improve the cognitive validity of a large initial item pool used to assess the nature and extent of suffering in patients with psychiatric conditions. METHOD Cognitive validity was established via two rounds of cognitive interviews with patients with psychiatric conditions with (n = 9) and without (n = 5) euthanasia requests. RESULTS During the first round of cognitive interviews, a variety of issues relating to content, form and language were reported and aspects that were missing were identified. During the second round, the items that had been amended were perceived as sufficiently easily to understand, sensitive to delicate nuances, comprehensive and easy to answer accurately. Neither research topic nor method were perceived as emotionally strenuous, but instead as positive, relevant, comforting and valuable. CONCLUSIONS This research resulted in an item pool that covers the concept of suffering more adequately and comprehensively. Further research endeavours should examine potential differences in suffering experiences over time and in patients with psychiatric conditions with and without euthanasia requests. The appreciation patients demonstrated regarding their ability to speak extensively and openly about their suffering and wish to die further supports the need to allow patients to speak freely and honestly during consultations. DECLARATION OF INTERESTS None.
Collapse
Affiliation(s)
- Monica Verhofstadt
- Junior Researcher, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium
| | - Kenneth Chambaere
- Senior Researcher and Assistant Professor, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium
| | - Roeslan Leontjevas
- Senior Researcher and Professor, Department of Methodology and Statistics, Faculty of Psychology and Education Science, Open University; and Department of Primary and Community Care, Radboud University, Medical Centre Nijmegen, the Netherlands
| | - Gjalt-Jorn Ygram Peters
- Senior Researcher and Assistant Professor, Department of Methodology and Statistics, Faculty of Psychology and Education Science, Open University; and Department of Work and Social Psychology, Faculty of Psychology and Neuroscience, Maastricht University, the Netherlands
| |
Collapse
|
40
|
Abstract
BACKGROUND Withdrawal of life-sustaining treatment (WOLST) is the leading proximate cause of death in patients with perceived devastating brain injury (PDBI). There are reasons to believe that a potentially significant proportion of WOLST decisions, in this setting, are premature and guided by a number of assumptions that falsely confer a sense of certainty. METHOD This manuscript proposes that these assumptions face serious challenges, and that we should replace unwarranted certainty with an appreciation for the great degree of multi-dimensional uncertainty involved. The article proceeds by offering a taxonomy of uncertainty in PDBI and explores the key role that uncertainty as a cognitive state, may play into how WOLST decisions are reached. CONCLUSION In order to properly share decision-making with families and surrogates of patients with PDBI, we will have to acknowledge, understand, and be able to communicate the great degree of uncertainty involved.
Collapse
|
41
|
Walter U, Fernández-Torre JL, Kirschstein T, Laureys S. When is “brainstem death” brain death? The case for ancillary testing in primary infratentorial brain lesion. Clin Neurophysiol 2018; 129:2451-2465. [DOI: 10.1016/j.clinph.2018.08.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/20/2018] [Accepted: 08/25/2018] [Indexed: 12/19/2022]
|
42
|
|
43
|
Abstract
Cancer survivors can carry germline mutations that will be transmitted to their progeny. Today, many of these mutations have been identified and can be tracked. With the recent development of genome-editing technologies and CRISPR (clustered regularly interspaced short palindromic repeats), the possibility of genetically modifying the human germline-gametes and embryos-has never been closer. This perspective has sparked a controversy within the scientific community with reactions ranging from calls for a ban on germline modification to cautious approval of further research. This Editorial analyzes the possible adoption of CRISPR-based germline engineering to prevent the spread of cancer predispositions in the human population. We discuss whether the genomic edition of human sperm and eggs would contribute to rectifying or altering the heritable genome. We anticipate the emergence of a new form of liberal eugenics fueled by a logic of offer and demand from stakeholders such as cancer survivors and their relatives and offspring, but also from fertility clinics, biotech firms, insurers, and clinicians. From a regulatory perspective, validating the clinical safety and utility of CRISPR-based germline engineering is an essential step. However, with time, gradually perfecting the technology and assessing the economic benefits for stakeholders could soften society's resistance and align opinions in support of genomic decontamination of human germlines. This progressive shift would be justified in the name of cancer prevention as well as a moral obligation to facilitate the conception of cancer-free children at a cost that is acceptable to individuals and health systems.
Collapse
Affiliation(s)
- Gregory Katz
- 1 Chaired Professor of Innovation Management & Healthcare Performance, School of Medicine, Paris-Descartes University, Paris, France
| | - Peter J Pitts
- 2 President of the Center for Medicine in the Public Interest, Former Associate Commissioner, United States Food and Drug Administration, New York, NY, USA
| |
Collapse
|
44
|
Magelssen M, Holmøy T, Horn MA, Fondenæs OA, Dybwik K, Førde R. Ethical challenges in tracheostomy-assisted ventilation in amyotrophic lateral sclerosis. J Neurol 2018; 265:2730-6. [DOI: 10.1007/s00415-018-9054-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/07/2018] [Accepted: 09/07/2018] [Indexed: 12/11/2022]
|
45
|
Klein E, Peters B, Higger M. Ethical Considerations in Ending Exploratory Brain-Computer Interface Research Studies in Locked-in Syndrome. Camb Q Healthc Ethics 2018; 27:660-74. [PMID: 30198467 DOI: 10.1017/S0963180118000154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Brain-computer interface (BCI) is a promising technology for restoring communication in individuals with locked-in syndrome (LIS). BCI technology offers a potential tool for individuals with impaired or absent means of effective communication to use brain activity to control an output device such as a computer keyboard. Exploratory studies of BCI devices for communication in people with LIS are underway. Research with individuals with LIS presents not only technological challenges, but ethical challenges as well. Whereas recent attention has been focused on ethical issues that arise at the initiation of studies, such as how to obtain valid consent, relatively little attention has been given to issues at the conclusion of studies. BCI research in LIS highlights one such challenge: How to decide when an exploratory BCI research study should end. In this article, we present the case of an individual with presumed LIS enrolled in an exploratory BCI study. We consider whether two common ethical frameworks for stopping randomized clinical trials-equipoise and nonexploitation-can be usefully applied to elucidating researcher obligations to end exploratory BCI research. We argue that neither framework is a good fit for exploratory BCI research. Instead, we apply recent work on clinician-researcher fiduciary obligations and in turn offer some preliminary recommendations for BCI researchers on how to end exploratory BCI studies.
Collapse
|
46
|
Nizzi MC, Blandin V, Demertzi A. Attitudes towards Personhood in the Locked-in Syndrome: from Third- to First- Person Perspective and to Interpersonal Significance. NEUROETHICS-NETH 2018. [DOI: 10.1007/s12152-018-9375-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
47
|
Abstract
OBJECTIVE In this paper, we report the performance of 9-11-year-old children using a steady-state visual evoked potential (SSVEP)-based brain-computer interface (BCI) and provide control data collected from adults for comparison. Children in our study achieved a much higher performance (79% accuracy; average age 9.64 years old) than the only previous investigation of children using an SSVEP-based BCI (∼50% accuracy; average age 9.86 years old). APPROACH Experiments were conducted in two phases, a short calibration phase and a longer experimental phase. An offline analysis of the data collected during the calibration phase was used to set two parameters for a classifier and to screen participants who did not achieve a minimum accuracy of 85%. MAIN RESULTS Eleven of the 14 children and all 11 of the adults who completed the calibration phase met the minimum accuracy requirement. During the experimental phase, children selected targets with a similar accuracy (79% for children versus 78% for adults), latency (2.1 s for children versus 1.9 s for adults), and bitrate (0.50 bits s-1 for children and 0.56 bits s-1 for adults) as adults. SIGNIFICANCE This study shows that children can use an SSVEP-based BCI with higher performance than previously believed and is the first to report the performance of children using an SSVEP-based BCI in terms of latency and bitrate. The results of this study imply that children with severe motor disabilities (such as locked-in syndrome) may use an SSVEP-based BCI to restore/replace the ability to communicate.
Collapse
Affiliation(s)
- James J S Norton
- National Center for Adaptive Neurotechnologies, Wadsworth Center, New York State Department of Health, PO Box 22002, Albany, NY 12201, United States of America. Department of Neurology, Stratton VA Medical Center, 113 Holland Ave, Albany, NY 12208, United States of America. Department of Electrical and Computer Engineering, University of Illinois, 306 N Wright St, Urbana, IL 61801, United States of America
| | | | | | | |
Collapse
|
48
|
Graham M. Domains of Well-Being in Minimally Conscious Patients: Illuminating a Persistent Problem. AJOB Neurosci 2018; 9:128-130. [PMID: 29928557 PMCID: PMC5989155 DOI: 10.1080/21507740.2018.1460415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/09/2018] [Accepted: 03/26/2018] [Indexed: 12/14/2022]
|
49
|
Abstract
OBJECTIVE Recent research has characterized the anatomical and functional basis of speech perception in the human auditory cortex. These advances have made it possible to decode speech information from activity in brain regions like the superior temporal gyrus, but no published work has demonstrated this ability in real-time, which is necessary for neuroprosthetic brain-computer interfaces. APPROACH Here, we introduce a real-time neural speech recognition (rtNSR) software package, which was used to classify spoken input from high-resolution electrocorticography signals in real-time. We tested the system with two human subjects implanted with electrode arrays over the lateral brain surface. Subjects listened to multiple repetitions of ten sentences, and rtNSR classified what was heard in real-time from neural activity patterns using direct sentence-level and HMM-based phoneme-level classification schemes. MAIN RESULTS We observed single-trial sentence classification accuracies of [Formula: see text] or higher for each subject with less than 7 minutes of training data, demonstrating the ability of rtNSR to use cortical recordings to perform accurate real-time speech decoding in a limited vocabulary setting. SIGNIFICANCE Further development and testing of the package with different speech paradigms could influence the design of future speech neuroprosthetic applications.
Collapse
Affiliation(s)
- David A Moses
- Department of Neurological Surgery, UC San Francisco, CA, United States of America
- Center for Integrative Neuroscience, UC San Francisco, CA, United States of America
- Graduate Program in Bioengineering, UC Berkeley-UC San Francisco, CA, United States of America
| | - Matthew K Leonard
- Department of Neurological Surgery, UC San Francisco, CA, United States of America
- Center for Integrative Neuroscience, UC San Francisco, CA, United States of America
| | - Edward F Chang
- Department of Neurological Surgery, UC San Francisco, CA, United States of America
- Center for Integrative Neuroscience, UC San Francisco, CA, United States of America
- Graduate Program in Bioengineering, UC Berkeley-UC San Francisco, CA, United States of America
| |
Collapse
|
50
|
Affiliation(s)
- Melanie Boly
- Department of Neurology, University of Wisconsin, Madison, USA
- Department of Psychiatry, University of Wisconsin, Madison, USA
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University and University Hospital of Liege, Belgium
| |
Collapse
|