Objective Chronic stroke patients with severe hand weakness, respond poorly to rehabilitation efforts. Here, we evaluated efficacy of daily brain-machine-interface training to increase the hypothesized beneficial effects of physiotherapy alone in patients with severe paresis in a double blind sham-controlled design proof of concept study. Methods 32 chronic stroke patients with severe hand weakness, were randomly assigned to two matched groups and participated in 17.8 ± 1.4 days of training rewarding desynchronization of ipsilesional oscillatory sensorimotor rhythms (SMR) with contingent online movements of hand and arm orthoses (experimental group , n=16). In the control group (sham group, n=16) movements of the orthoses occurred randomly. Both groups received identical behavioral physiotherapy immediately following BMI training or the control intervention. Upper limb motor function scores, electromyography from arm and hand muscles, placebo-expectancy effects and functional magnetic resonance imaging (MRI) blood oxygenation level dependent activity were assessed before and after intervention. Results A significant group × time interaction in upper limb Fugl-Meyer motor (cFMA) scores was found. cFMA scores improved more in the experimental than in the control group, presenting a significant improvement of cFMA scores (3.41±0.563 points difference, p=0.018) reflecting a clinically meaningful change from no activity to some in paretic muscles. cFMA improvements in the experimental group correlated with changes in functional MRI laterality index and with paretic hand electromyography activity. Placebo-expectancy scores were comparable for both groups. Interpretation The addition of BMI training to behaviorally oriented physiotherapy can be used to induce functional improvements in motor function in chronic stroke patients without residual finger movements and may open a new door in stroke neurorehabilitation.

Background and Purpose-Stroke is a leading cause of long-term motor disability among adults. Present rehabilitative interventions are largely unsuccessful in improving the most severe cases of motor impairment, particularly in relation to hand function. Here we tested the hypothesis that patients experiencing hand plegia as a result of a single, unilateral subcortical, cortical or mixed stroke occurring at least 1 year previously, could be trained to operate a mechanical hand orthosis through a brain-computer interface (BCI). Methods-Eight patients with chronic hand plegia resulting from stroke (residual finger extension function rated on the Medical Research Council scaleϭ0/5) were recruited from the Stroke Neurorehabilitation Clinic, Human Cortical Physiology Section of the National Institute for Neurological Disorders and Stroke (NINDS) (nϭ5) and the Clinic of Neurology of the University of Tübingen (nϭ3). Diagnostic MRIs revealed single, unilateral subcortical, cortical or mixed lesions in all patients. A magnetoencephalography-based BCI system was used for this study. Patients participated in between 13 to 22 training sessions geared to volitionally modulate rhythm amplitude originating in sensorimotor areas of the cortex, which in turn raised or lowered a screen cursor in the direction of a target displayed on the screen through the BCI interface. Performance feedback was provided visually in real-time. Successful trials (in which the cursor made contact with the target) resulted in opening/closing of an orthosis attached to the paralyzed hand. Results-Training resulted in successful BCI control in 6 of 8 patients. This control was associated with increased range and specificity of rhythm modulation as recorded from sensors overlying central ipsilesional (4 patients) or contralesional (2 patients) regions of the array. Clinical scales used to rate hand function showed no significant improvement after training. Conclusions-These results suggest that volitional control of neuromagnetic activity features recorded over central scalp regions can be achieved with BCI training after stroke, and used to control grasping actions through a mechanical hand orthosis. (Stroke. 2008;39:910-917.)

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