Toward functioning and usable brain–computer interfaces (BCIs): A literature review

Purpose: The aim of this paper is to provide an exhaustive review of the literature about brain–computer interfaces (BCIs) that could be used with these paralysed patients. The electroencephalography (EEG) is the best candidate for the continuous use in the environment of patients’ houses, due to its portability and ease of use. For this reason, the present paper will focus on this kind of BCI. Moreover, it is our aim to focus more on the patients, regarding their active role in the modulation of the brain activity. This leads to a differentiation between studies that use an active regulation and studies that use a non-active regulation. Method: Relevant articles in the BCIs field were selected using MEDLINE and PsycINFO. Results: Research through data banks produced 980 results, which were reduced to 127 after exclusion criteria selection. These references were divided in four categories, based on the use of active or non-active regulation, and on the event related potential used. Conclusions: In most of the examined works, the focus was on the development of systems and algorithms able to recognise and classify brain events. Although this kind of research is fundamental, a user-centred point of view was rarely adopted.

Implications for Rehabilitation

• Locked-in syndrome (LIS) is a condition of severe or complete motor paralysis, where the intellect is still intact.

• A brain-computer interface (BCI) is a direct connection between the brain and a machine.

• In the past 15 years, several different BCI prototypes have been developed for research purposes.

• BCIs could be used for rehabilitation to restore communication and movement in patients with severe and multiple disabilities

     

Are we there yet? Evaluating commercial grade brain–computer interface for control of computer applications by individuals with cerebral palsy

Purpose: Using a commercial electroencephalography (EEG)-based brain–computer interface (BCI), the training and testing protocol for six individuals with spastic quadriplegic cerebral palsy (GMFCS and MACS IV and V) was evaluated. Method: A customised, gamified training paradigm was employed. Over three weeks, the participants spent two sessions exploring the system, and up to six sessions playing the game which focussed on EEG feedback of left and right arm motor imagery. Results: The participants showed variable inconclusive results in the ability to produce two distinct EEG patterns. Participant performance was influenced by physical illness, motivation, fatigue and concentration. Conclusions: The results from this case study highlight the infancy of BCIs as a form of assistive technology for people with cerebral palsy. Existing commercial BCIs are not designed according to the needs of end-users.

• Implications for Rehabilitation

• Mood, fatigue, physical illness and motivation influence the usability of a brain–computer interface.

• Commercial brain–computer interfaces are not designed for practical assistive technology use for people with cerebral palsy.

• Practical brain–computer interface assistive technologies may need to be flexible to suit individual needs.

     

A clinical screening protocol for the RSVP Keyboard brain–computer interface

Purpose: To propose a screening protocol that identifies requisite sensory, motor, cognitive and communication skills for people with locked-in syndrome (PLIS) to use the RSVP Keyboard? brain–computer interface (BCI). Method: A multidisciplinary clinical team of seven individuals representing five disciplines identified requisite skills for the BCI RSVP Keyboard?. They chose questions and subtests from existing standardized instruments for auditory comprehension, reading and spelling, modified them to accommodate nonverbal response modalities, and developed novel tasks to screen visual perception, sustained visual attention and working memory. Questions were included about sensory skills, positioning, pain interference and medications. The result is a compilation of questions, adapted subtests and original tasks designed for this new BCI system. It was administered to 12 PLIS and 6 healthy controls. Results: Administration required 1?h or less. Yes/no choices and eye gaze were adequate response modes for PLIS. Healthy controls and 9 PLIS were 100% accurate on all tasks; 3 PLIS missed single items. Conclusions: The RSVP BCI screening protocol is a brief, repeatable technique for patients with different levels of LIS to identify the presence/absence of skills for BCI use. Widespread adoption of screening methods should be a clinical goal and will help standardize BCI implementation for research and intervention.

• Implications for Rehabilitation

• People with locked-in syndrome must have certain sensory, motor, cognitive and communication skills to successfully use a brain–computer interface (BCI) for communication.

• A screening profile would be useful in identifying potentially suitable candidates for BCI.

     

Boredom in patients with acquired brain injuries during inpatient rehabilitation: a scoping review

Abstract

Purpose: Boredom may impede engagement in inpatient rehabilitation following an acquired brain injury. This review aimed to: (1) describe the experience and (2) quantify the incidence of boredom; (3) identify measurement tools used to quantify boredom; (4) summarize factors contributing to boredom, and (5) outline evidence-based interventions shown to reduce boredom during inpatient rehabilitation.

Methods: Two researchers independently screened publications retrieved from electronic database searches. Publications presenting patient, carer or staff data relating to boredom in inpatients with acquired brain injuries were included.

Results: Two thousand four hundred and ninety-nine references were retrieved, 88 full texts were reviewed, with 24 studies included. The majority of studies reported qualitative data indicating boredom to be a common experience of patients with acquired brain injuries (n?=?14 studies +1 review). The incidence of boredom post acquired brain injury is unknown. Personal and organizational factors and the physical environment may contribute to boredom (n?=?11 studies +2 reviews). Qualitative work (n?=?9 studies) indicates that use of the creative-arts or exposure to environmental enrichment may help alleviate boredom in patients with acquired brain injuries during inpatient rehabilitation.

Conclusion: Further mixed-methods research is required to establish the incidence of and contributing factors to boredom in patients with acquired brain injuries undergoing rehabilitation. Understanding this will help inform future research aimed at improving patient engagement in inpatient rehabilitation.

• Implications for rehabilitation

• Boredom is commonly reported by hospitalised patients with ABI to negatively affect their rehabilitation yet the scope of the problem has not been measured.

• Boredom is a complex phenomenon, likely influenced by a number of personal and environmental factors that are not fully understood in this population.

• Through a better understanding of boredom, interventions may be developed to improve patient engagement in inpatient rehabilitation programs.

     

Training to use a commercial brain-computer interface as access technology: a case study

Purpose: This case study describes how an individual with spastic quadriplegic cerebral palsy was trained over a period of four weeks to use a commercial electroencephalography (EEG)-based brain-computer interface (BCI). Method: The participant spent three sessions exploring the system, and seven sessions playing a game focused on EEG feedback training of left and right arm motor imagery and a customised, training game paradigm was employed. Results: The participant showed improvement in the production of two distinct EEG patterns. The participant’s performance was influenced by motivation, fatigue and concentration. Six weeks post-training the participant could still control the BCI and used this to type a sentence using an augmentative and alternative communication application on a wirelessly linked device. Conclusions: The results from this case study highlight the importance of creating a dynamic, relevant and engaging training environment for BCIs.

• Implications for Rehabilitation

• Customising a training paradigm to suit the users’ interests can influence adherence to assistive technology training.

• Mood, fatigue, physical illness and motivation influence the usability of a brain-computer interface.

• Commercial brain-computer interfaces, which require little set up time, may be used as access technology for individuals with severe disabilities

     

Rehabilitation following cancer treatment

Abstract

Purpose: Cancer survivorship is increasing. However, life-saving treatments often leave people with physical, cognitive and emotional sequelae that contribute to activity and participation limitations. The purpose of this review is to summarize current evidence regarding rehabilitation interventions to address problems during survivorship. Method: Best evidence synthesis. The review took as its starting point a systematic review of patient needs and supportive care interventions following cancer treatment. The study team identified the needs which could be addressed by rehabilitation and suggested others not originally included. Then they built on the earlier review’s conclusions regarding effective intervention through extraction of results from subsequent systematic reviews and randomized controlled trials. Results: Evidence regarding the effectiveness of potential rehabilitation interventions was reviewed for physical functioning, fatigue, pain, sexual functioning, cognitive functioning, depression, employment, nutrition and participation. With the exception of physical rehabilitation interventions following breast cancer, this literature tends to focus on psychoeducational interventions, which have demonstrated limited effectiveness for rehabilitation outcomes. Conclusions: Most of the knowledge available regarding potential rehabilitation interventions comes from psychosocial oncology literature. While there are limitations, this literature provides an excellent starting point to examine the potential effectiveness of rehabilitation interventions within cancer survivorship programs.

• Implications for Rehabilitation

• Good evidence exists for the use of exercise/physical rehabilitation in reducing fatigue after treatment for most cancers, and improving upper extremity functioning following treatment for breast cancer.

• Preliminary evidence exists in a number of areas that may be improved by rehabilitation interventions, such as pain, sexual functioning, cognitive functioning and return to work, but further research is needed.

• No intervention studies addressing participation limitations were identified. Rehabilitation professionals are encouraged to take the lead in exploring participation limitations among cancer survivors and developing suitable interventions.

     

Motion interactive video games in home training for children with cerebral palsy: parents’ perceptions

Purpose: To explore parents’ perceptions of using low-cost motion interactive video games as home training for their children with mild/moderate cerebral palsy. Method: Semi-structured interviews were carried out with parents from 15 families after participation in an intervention where motion interactive games were used daily in home training for their child. A qualitative content analysis approach was applied. Results: The parents’ perception of the training was very positive. They expressed the view that motion interactive video games may promote positive experiences of physical training in rehabilitation, where the social aspects of gaming were especially valued. Further, the parents experienced less need to take on coaching while gaming stimulated independent training. However, there was a desire for more controlled and individualized games to better challenge the specific rehabilitative need of each child. Conclusions: Low-cost motion interactive games may provide increased motivation and social interaction to home training and promote independent training with reduced coaching efforts for the parents. In future designs of interactive games for rehabilitation purposes, it is important to preserve the motivational and social features of games while optimizing the individualized physical exercise.

Implications for Rehabilitation

• Children with neurodevelopmental disorders like cerebral palsy (CP) are in need of fun and engaging rehabilitation methods to enhance motivation and increase compliance with motor training.

• There is a rising interest among clinical professionals and parents to use motion interactive games as a rehabilitation device for these children.

• In this qualitative study parents perceived that motion interactive games can enhance motivation for practice, stimulate the child, and reduce the parental efforts related to home-based rehabilitation of children with CP.

     

The potential for non-invasive brain stimulation to improve function after amputation

Purpose: Lower limb amputee rehabilitation has traditionally focussed on restoration of gait and balance through use of prosthetic limbs and mobility aids. Despite these efforts, some amputees continue to experience difficulties with mastering prosthetic mobility. Emerging techniques in rehabilitation, such as non-invasive brain stimulation (NIBS), may be an appropriate tool to enhance prosthetic rehabilitation outcomes by promoting “normal” brain reorganisation and function. The purpose of this review is to highlight the potential of NIBS to improve functional outcomes for lower limb amputees. Methods: To demonstrate the rationale for applying NIBS to amputees, this study will first review literature regarding human motor control of gait, followed by neurophysiological reorganisation of the motor system after amputation and the relationship between brain reorganisation and gait function. We will conclude by reviewing literature demonstrating application of NIBS to lower limb muscle representations and evidence supportive of subsequent functional improvements. Results: Imaging, brain stimulation and behavioural evidence indicate that the cortex contributes to locomotion in humans. Following amputation both hemispheres reorganise with evidence suggesting brain reorganisation is related to functional outcomes in amputees. Previous studies indicate that brain stimulation techniques can be used to selectively promote neuroplasticity of lower limb cortical representations with improvements in function.

Conclusions: We suggest NIBS has the potential to transform lower limb amputee rehabilitation and should be further investigated.

• Implications for Rehabilitation

• Despite extensive rehabilitation some amputees continue to experience difficulty with prosthetic mobility

• Brain reorganisation following amputation has been related to functional outcomes and may be an appropriate target for novel interventions

• Non-invasive brain stimulation is a promising tool which has potential to improve functional outcomes for lower limb amputees

     

Targeted rehabilitation reduces visual dependency and improves balance in severe traumatic brain injury: a case study

Purpose: To further understand the mechanisms underlying gait impairment following traumatic brain injury.

Case report: A 58-year-old man presented with marked unsteadiness and motion sensitivity following a severe traumatic brain injury. He underwent a 6-week inpatient rehabilitation program focused on re-weighting and subsequently re-integrating ascending interoceptive information, by gradual reduction of maladaptive visual fixation techniques. We report clinical neurological outcomes and measures of functional outcome, as well as an objective assessment of visual dependency (the rod and disk test) at baseline and after the rehabilitation.

Results: Clinically, the patient had gait unsteadiness exacerbated by visual motion. A significant reduction in visual dependency occurred with tailored multi-disciplinary rehabilitation via gradual removal of visual fixation strategies that the patient had developed to maintain balance (t-test; p?Conclusions: We highlight the importance of visual dependency in the generation of maladaptive gait strategies following brain injury. Our data suggest assessing and treating visual dependency to be an important component of gait rehabilitation after traumatic brain injury.

• Implications for rehabilitation

• Whilst gait disturbance in TBI is multifactorial, abnormal visual dependency may be important but under-recognised component of the disorder.

• Visual dependency can be easily and objectively assessed by the bedside in patients using a dynamic rod and disc test.

• Tailored rehabilitation with gradual reduction of maladaptive visual fixation can reduce visual dependency and contribute to improved gait and balance following TBI.

     

A plug-and-play brain-computer interface to operate commercial assistive technology

Abstract

Purpose: To determine if a brain-computer interface (BCI) could be used as a plug-and-play input device to operate commercial assistive technology (AT), and to quantify the performance impact of such operation. Method: Using a hardware device designed in our lab, participants (11 with amyotrophic lateral sclerosis, 22 controls) were asked to operate two devices using a BCI. Results were compared to traditional BCI operation by the same users. Performance was assessed using both accuracy and BCI utility, a throughput metric. 95% confidence bounds on performance differences were developed using a linear mixed model. Results: The observed differences in accuracy and throughput were small and not statistically significant. The confidence bounds indicate that if there is a performance impact of using a BCI to control an AT device, the impact could easily be overcome by the benefits of the AT device itself. Conclusions: BCI control of AT devices is possible, and the performance difference appears to be very small. BCI designers are encouraged to incorporate standard outputs into their design to enable future users to interface with familiar AT devices.

• Implications for Rehabilitation

• Brain-computer interface (BCI) control of assistive technology (AT) devices is possible.

• The performance impact of such control is low when BCIs are commercially available, AT providers can use a BCI as an input device to existing AT devices already in use by their clients.

     

Development and testing an online near-infrared spectroscopy brain–computer interface tailored to an individual with severe congenital motor impairments

Purpose: For non-verbal individuals, brain–computer interfaces (BCIs) are a potential means of communication. Near-infrared spectroscopy (NIRS) is a brain-monitoring modality that has been considered for BCIs. To date, limited NIRS-BCI testing has involved online classification, particularly with individuals with severe motor impairments.

Materials and methods: We tested an online NIRS-BCI developed for a non-verbal individual with severe congenital motor impairments. The binary BCI differentiated categorical verbal fluency task (VFT) performance and rest using prefrontal measurements. The participant attended five sessions, the last two of which were online with classification feedback.

Results: An online classification accuracy of 63.33% was achieved using a linear discriminant classifier trained on a four-dimensional feature set. An offline, cross-validation analysis of all data yielded an optimal adjusted classification accuracy of 66.6?±?9.11%. Inconsistent functional responses, contradictory effects of feedback, participant fatigue and motion artefacts were identified as challenges to online classification specific to this participant.

Conclusions: Results suggest potential in using an NIRS-BCI controlled by the VFT in instances of severe congenital impairments. Further testing with users with severe disabilities is necessary.

• Implications for Rehabilitation

• Brain–computer interfaces (BCIs) can provide a non-motor based means of communication for individuals with severe motor impairments.

• Near-infrared spectroscopy (NIRS) is a haemodynamic-based brain-imaging modality used in BCIs.

• To date, NIRS-BCIs have not been thoroughly tested with potential target users.

• This case study shows that NIRS-BCIs may offer a means of practical communication for individuals with severe congenital impairments and continued exploration is advisable.

     

Electrode subset selection methods for an EEG-based P300 brain-computer interface

Purpose: An electroencephalography (EEG)-based P300 speller is a type of brain-computer interface (BCI) that uses EEG to allow a user to select characters without physical movement. In general, using fewer electrodes for such a system makes it easier to set up and less expensive. This study addresses the question of electrode selection for EEG-based P300 systems. Methods: Data from 13 subjects collected with a 16-electrode cap was analyzed. The optimal subsets of electrodes of sizes 1–15 were calculated for each subject and for the group as a whole. The methods of exhaustive search, forward selection, and backward elimination were then compared to each other and to these optimal subsets. Results: The results show that, while none of the methods consistently picked the best-performing electrode subsets, all methods were able to find small electrode subsets that provided acceptable accuracy both for individuals and for the whole group. The computationally intensive exhaustive search method provided no statistically significant increase in performance over the much quicker forward and backward selection methods. Conclusions: The forward and backward selection methods are preferred for electrode selection.

• Implications for Rehabilitation

• A P300 speller is a type of brain-computer interface that allows a user to select characters without physical movement.

• Using fewer electrodes reduces setup time and cost for an EEG-based P300 speller.

• We show that acceptable P300 speller performance can be achieved with as few as four electrodes.

• We compare methods of selecting electrode sets and identify fast and efficient methods for customizing electrode sets for individuals.

     

Patient perspectives on navigating the field of traumatic brain injury rehabilitation: a qualitative thematic analysis

Purpose: This study aimed to provide an understanding of the lived experience of rehabilitation in adults with traumatic brain injury (TBI) from hospital discharge up to four years post-injury.

Materials and methods: We used a qualitative explorative design with semi-structured in-depth interviews. Twenty participants with TBI were included from a level I Trauma Center in Denmark at 1–4 years post-injury. Qualitative thematic analysis was applied for data analysis.

Results: Three main themes emerged during analysis: A new life, Family involvement, and Rehabilitation impediments. These themes and their sub-themes described the patient perspective of TBI and rehabilitation post hospitalization. Participants reassessed their values and found a new life after TBI. Family caregivers negotiated rehabilitation services and helped the participant to overcome barriers to rehabilitation. Although participants were entitled to TBI rehabilitation, they had to fight for the services they were entitled to.

Conclusion: Individuals with TBI found ways of coping after injury and created a meaningful life. Barriers to TBI rehabilitation were overcome with help from family caregivers rather than health care professionals. Future studies need to find ways to ease the burden on family caregivers and pave the way for more accessible rehabilitation in this vulnerable group of patients.

• Implications for rehabilitation

• TBI rehabilitation might benefit from:

• ??Increased transparency in rehabilitation options

• ??More systematic follow-up programs

• ??Age-appropriate rehabilitation facilities

• ??Inclusion of patient and family in the planning of long-term rehabilitation

     

Non-invasive brain stimulation for the lower limb after stroke: what do we know so far and what should we be doing next?

Background: Non-invasive brain stimulation (NIBS) is promising as an adjuvant to rehabilitation of motor function after stroke. Despite numerous studies and reviews for the upper limb, NIBS targeting the lower limb and gait recovery after stroke is a newly emerging field of research. Purpose: To summarize findings from studies using NIBS to target the lower limb in stroke survivors. Methods: This narrative review describes studies of repetitive transcranial magnetic stimulation, paired associative stimulation and transcranial direct current stimulation with survivors of stroke. Results: NIBS appears capable of inducing changes in cortical excitability and lower limb function, but stimulation parameters and study designs vary considerably making it difficult to determine effectiveness. Conclusions: Future research should systematically assess differences in response with different stimulation parameters, test measures for determining who would be most likely to benefit and assess effectiveness with large samples before NIBS can be considered for use in clinical practice.

• Implications for Rehabilitation

• Stroke is a leading cause of disability, often resulting in dependency in activities of daily living and reduced quality of life.

• Non-invasive brain stimulation has received considerable interest as a potential adjuvant to rehabilitation after stroke and this review summarizes studies targeting the lower limb and gait recovery.

• Non-invasive brain stimulation can be used to modulate excitability of lower limb muscle representations and can lead to improvements in motor performance in stroke survivors.

• Non-invasive brain stimulation for gait recovery needs further investigation before translation to clinical practice is possible.

     

Problems in functioning after a mild traumatic brain injury within the ICF framework: the patient perspective using focus groups

Purpose: To describe problems in body functions, activities, and participation and the influence of environmental factors as experienced after mild traumatic brain injury (TBI), using the ICF framework. To compare our findings with the Brief and Comprehensive ICF Core Sets for TBI. Methods: Six focus-group interviews were performed with 17 participants (nine women, eight men, age ranged from 22 to 55 years) within the context of an outpatient rehabilitation programme for patients with mild TBI. The interviews were transcribed verbatim and analysed using the ICF. Results: One-hundred and eight second-level categories derived from the interview text, showing a large diversity of TBI-related problems in functioning. Problems in cognitive and emotional functions, energy and drive, and in carrying out daily routine and work, were frequently reported. All ICF categories reported with high-to-moderate frequencies were present in the Brief ICF Core Set and 84% in the Comprehensive ICF Core Set. The reported environmental factors mainly concerned aspects of health and social security systems, social network and attitudes towards the injured person. Conclusions: This study confirms the diversity of problems and the environmental factors that have an impact on post-injury functioning of patients with mild TBI.

Implications for Rehabilitation

• Disabilities related to cognitive and emotional functions, energy and drive, and carrying out daily routine and work should be addressed in rehabilitation of people with mild traumatic brain injury (TBI).

• Attention should be given to environmental facilitators and barriers for activities and participation.

• Participation in everyday life after a mild TBI, including social- and work-participation, constitutes a challenge where multidisciplinary rehabilitation efforts should be considered.

• The Brief Core Set does not attain all frequently observed categories of functioning among people with mild TBI.

     

An augmented reality system for upper-limb post-stroke motor rehabilitation: a feasibility study

Purpose: To determine the clinical feasibility of a system based on augmented reality for upper-limb (UL) motor rehabilitation of stroke participants. Method: A physiotherapist instructed the participants to accomplish tasks in augmented reality environment, where they could see themselves and their surroundings, as in a mirror. Two case studies were conducted. Participants were evaluated pre- and post-intervention. The first study evaluated the UL motor function using Fugl-Meyer scale. Data were compared using non-parametric sign tests and effect size. The second study used the gain of motion range of shoulder flexion and abduction assessed by computerized biophotogrammetry. Results: At a significance level of 5%, Fugl-Meyer scores suggested a trend for greater UL motor improvement in the augmented reality group than in the other. Moreover, effect size value 0.86 suggested high practical significance for UL motor rehabilitation using the augmented reality system. Conclusion: System provided promising results for UL motor rehabilitation, since enhancements have been observed in the shoulder range of motion and speed.

• Implications for Rehabilitation

• Gain of range of motion of flexion and abduction of the shoulder of post-stroke patients can be achieved through an augmented reality system containing exercises to promote the mental practice.

• NeuroR system provides a mental practice method combined with visual feedback for motor rehabilitation of chronic stroke patients, giving the illusion of injured upper-limb (UL) movements while the affected UL is resting. Its application is feasible and safe.

• This system can be used to improve UL rehabilitation, an additional treatment past the traditional period of the stroke patient hospitalization and rehabilitation

     

BNCI systems as a potential assistive technology: ethical issues and participatory research in the BrainAble project

Abstract

Purpose: This paper highlights aspects related to current research and thinking about ethical issues in relation to Brain Computer Interface (BCI) and Brain-Neuronal Computer Interfaces (BNCI) research through the experience of one particular project, BrainAble, which is exploring and developing the potential of these technologies to enable people with complex disabilities to control computers. It describes how ethical practice has been developed both within the multidisciplinary research team and with participants. Results: The paper presents findings in which participants shared their views of the project prototypes, of the potential of BCI/BNCI systems as an assistive technology, and of their other possible applications. This draws attention to the importance of ethical practice in projects where high expectations of technologies, and representations of “ideal types” of disabled users may reinforce stereotypes or drown out participant “voices”. Conclusions: Ethical frameworks for research and development in emergent areas such as BCI/BNCI systems should be based on broad notions of a “duty of care” while being sufficiently flexible that researchers can adapt project procedures according to participant needs. They need to be frequently revisited, not only in the light of experience, but also to ensure they reflect new research findings and ever more complex and powerful technologies.

• Implications for Rehabilitation

• BCI/BNCI systems are not similar to existing switch-controlled or eye gaze systems. Users and those supporting them need to have their expectations carefully managed.

• BCI/BNCI are emergent technologies and side effects of long term use are not well understood: this demands an ongoing concern to ensure duty of care and maintenance of a “watching brief” regarding ethical issues.

• Practitioners need to be particularly careful when introducing BCI/BNCI systems to be sensitive to the meanings that are attached to them and how they may convey prognosis.

     

Initial constructs for patient-centered outcome measures to evaluate brain–computer interfaces

Purpose: The authors describe preliminary work toward the creation of patient-centered outcome (PCO) measures to evaluate brain–computer interface (BCI) as an assistive technology (AT) for individuals with severe speech and physical impairments (SSPI). Method: In Phase 1, 591 items from 15 existing measures were mapped to the International Classification of Functioning, Disability and Health (ICF). In Phase 2, qualitative interviews were conducted with eight people with SSPI and seven caregivers. Resulting text data were coded in an iterative analysis. Results: Most items (79%) were mapped to the ICF environmental domain; over half (53%) were mapped to more than one domain. The ICF framework was well suited for mapping items related to body functions and structures, but less so for items in other areas, including personal factors. Two constructs emerged from qualitative data: quality of life (QOL) and AT. Component domains and themes were identified for each. Conclusions: Preliminary constructs, domains and themes were generated for future PCO measures relevant to BCI. Existing instruments are sufficient for initial items but do not adequately match the values of people with SSPI and their caregivers. Field methods for interviewing people with SSPI were successful, and support the inclusion of these individuals in PCO research.

• Implications for Rehabilitation

• Adapted interview methods allow people with severe speech and physical impairments to participate in patient-centered outcomes research.

• Patient-centered outcome measures are needed to evaluate the clinical implementation of brain–computer interface as an assistive technology.

     

Assessment of spasticity after stroke using clinical measures: a systematic review

Abstract

Purpose: To identify and appraise the literature on clinical measures of spasticity that has been investigated in people after stroke. Methods: The literature search involved four databases (PubMed, CINAHL, Embase and The Cochrane Library) up to February 2014. The selected studies included those that aimed to measure spasticity using a clinical assessment tool among adult patients post-stroke. Two independent raters reviewed the included articles using a critical appraisal scale and a structured data extraction form. Results: A total of 40 studies examining 15 spasticity assessment tools in patients post-stroke were reviewed. None of the reviewed measurement tools demonstrated satisfactory results for all psychometric properties evaluated, and the majority lacked evidence concerning validity and absolute reliability. Conclusion: This systematic review found limited evidence to support the use of most of clinical measures of spasticity for people post-stroke. Future research examining the application and psychometric properties of these measures is warranted.

• Implications for Rehabilitation

• There is a need for objective clinical tools for measuring spasticity that are clinically feasible and easily interpreted by clinicians.

• This review identified various clinical measures of spasticity that have been investigated in people after stroke.

• Insufficient evidence of psychometric properties precludes recommending one tool over the others.

• Future research should focus on investigating the psychometric properties of clinical measures of spasticity.