http://journals.sagepub.com/doi/full/10.1177/1550059417717398?
Abstract
Motor
imagery (MI) with neurofeedback has been suggested as promising for
motor recovery after stroke. Evidence suggests that regular training
facilitates compensatory plasticity, but frequent training is difficult
to integrate into everyday life. Using a wireless electroencephalogram
(EEG) system, we implemented a frequent and efficient neurofeedback
training at the patients’ home. Aiming to overcome maladaptive changes
in cortical lateralization patterns we presented a visual feedback,
representing the degree of contralateral sensorimotor cortical activity
and the degree of sensorimotor cortex lateralization. Three stroke
patients practiced every other day, over a period of 4 weeks.
Training-related changes were evaluated on behavioral, functional, and
structural levels. All 3 patients indicated that they enjoyed the
training and were highly motivated throughout the entire training
regime. EEG activity induced by MI of the affected hand became more
lateralized over the course of training in all three patients. The
patient with a significant functional change also showed increased white
matter integrity as revealed by diffusion tensor imaging, and a
substantial clinical improvement of upper limb motor functions. Our
study provides evidence that regular, home-based practice of MI
neurofeedback has the potential to facilitate cortical reorganization
and may also increase associated improvements of upper limb motor
function in chronic stroke patients.
Introduction
A more recent development is the combination of MI training with online neurofeedback (NF). This development is closely linked to the notion that feedback in combination with high-intensity task-specific practice is essential for the facilitation of adaptive cortical reorganization.6 Accordingly, NF should help to induce adaptive neural plasticity and thereby contribute to restoring lost motor function.10 Several studies indicate that MI training in combination with NF can indeed induce positive changes at behavioral, functional, and structural levels.11-15 At least 1 study provides clear evidence that functional changes are more pronounced when MI is combined with NF as compared with MI without NF.16 Moreover, concurrent acquisition of electroencephalogram (EEG) NF and functional magnetic resonance imaging (fMRI) in healthy individuals validated systematic NF effects on cortical activation patterns.17
The effectiveness of neurorehabilitation training regimes such as MI NF is difficult to evaluate, in particular because most approaches are technically demanding, and all of them require frequent, regular practice. The latter issue is of particular importance for stroke victims, because frequent laboratory or hospital visits place a large burden on motor impaired individuals. Without experiencing immediate training effects this effort may negatively impact on a patient’s training motivation. Recently developed small and wireless EEG systems may help overcome this problem. They are portable and low in cost,18,19 perform on par with nonportable EEG systems,20 and soon, NF protocols will be available on smartphones.21
We investigated whether home-based, frequent MI EEG-based NF training is feasible. Specifically, we examined whether chronic stroke patients can stay motivated over a 4-week training period. In addition, we wanted to know whether they experience NF as helpful for MI training. We designed the MI NF protocol to facilitate stronger cortical activity in the ipsilesional than in the contralesional hemisphere in response to MI of the paretic hand. Frequent, high-intensity MI NF should result in systematic behavioral, functional, and structural improvements. To assess training effects, the home-based training was framed by detailed laboratory-based assessments of motor functions, high-density EEG, structural as well as fMRI, and by diffusion tensor imaging of the corticospinal tract (CST).
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