Clinical Effects of Immersive Multimodal BCI-VR Training after Bilateral Neuromodulation with rTMS on Upper Limb Motor Recovery after Stroke. A Study Protocol for a Randomized Controlled Trial

Abstract

Background and Objectives: The motor sequelae after a stroke are frequently persistent and cause a high degree of disability. Cortical ischemic or hemorrhagic strokes affecting the cortico-spinal pathways are known to cause a reduction of cortical excitability in the lesioned area not only for the local connectivity impairment but also due to a contralateral hemisphere inhibitory action. Non-invasive brain stimulation using high frequency repetitive magnetic transcranial stimulation (rTMS) over the lesioned hemisphere and contralateral cortical inhibition using low-frequency rTMS have been shown to increase the excitability of the lesioned hemisphere. Mental representation techniques, neurofeedback, and virtual reality have also been shown to increase cortical excitability and complement conventional rehabilitation. Materials and Methods: We aim to carry out a single-blind, randomized, controlled trial aiming to study the efficacy of immersive multimodal Brain–Computer Interfacing-Virtual Reality (BCI-VR) training after bilateral neuromodulation with rTMS on upper limb motor recovery after subacute stroke (>3 months) compared to neuromodulation combined with conventional motor imagery tasks. This study will include 42 subjects in a randomized controlled trial design. The main expected outcomes are changes in the Motricity Index of the Arm (MI), dynamometry of the upper limb, score according to Fugl-Meyer for upper limb (FMA-UE), and changes in the Stroke Impact Scale (SIS). The evaluation will be carried out before the intervention, after each intervention and 15 days after the last session. Conclusions: This trial will show the additive value of VR immersive motor imagery as an adjuvant therapy combined with a known effective neuromodulation approach opening new perspectives for clinical rehabilitation protocols.

Impact of age, VR, immersion, and spatial resolution on classifier performance for a MI-based BCI

“…Moreover, other methodological strategies such as targeting broader brain area activation from different MI approaches can improve BCI performance. Neuromodulation is a promising coadjuvant in neurorehabilitation and has encouraging pilot results using rTMS [46]. In [47] a correlation between BCI performance and sense of agency was found and that the act of imagining making a fist was more effective than raising arms in imagination.…”

Effects of motor imagery based brain-computer interface on upper limb function and attention in stroke patients with hemiplegia: A randomized controlled trial

“…KVIQ is commonly used to evaluate the motor imagination ability in stroke patients [24]. Patients with KVIQ-20 score ≥ 55points were selected for training [21]. Any subject with 20% absence of training session or follow-up test was defined as the withdrawn subject.…”

Effects of motor imagery based brain-computer interface on upper limb function and attention in stroke patients with hemiplegia: a randomized controlled trial

“…KVIQ is commonly used to evaluate the motor imagery ability in stroke patients [25]. Patients with KVIQ-20 score ≥ 55points were selected for training [22]. The CR group added 20 min of functional electrical stimulation training to conventional routine rehabilitation training.…”