On Thursday, April 6th, g.tec medical engineering Spain S.L. opened its Neurotechnology Center in Barcelona, running innovative assessment and therapy systems for stroke and coma patients. The Center hosts two innovative new approaches based on Brain-Computer Interface (BCI) technology. The recoveriX GYM provides more effective stroke rehabilitation for patients in acute and chronic states, and the mindBEAGLE CENTER offers a mobile service to assess the consciousness awareness of patients with disorders of consciousness or locked-in syndrome. The mindBEAGLE Mobile Service helps physicians, neurologists or family members learn about each patient’s conscious awareness and provides communication and cognitive training for some of them.
The opening event took place at the Hotel Itaca (Barcelona) and started off with a press conference, during which Dr. Christoph Guger (CEO of g.tec) and Dr. Miguel Gallofré (Director from the Stroke Program of Catalonia, Department de Salut) introduced the new Neurotechnology Center. Dr. Jose Bové, the Austrian Consul of Barcelona, was there to congratulate g.tec for the opening of the Neurotechnology Center “using such innovative and state-of-the-art technology to enrich and improve rehabilitation and therapy”. Within the press conference, experts from g.tec explained the approaches of recoveriX and mindBEAGLE with a test subject.
Photo: Pol Pérez Sust (Generalitat de Catalunya), Robert Punkenhofer (Advantage Austria), Dr. Christoph Guger (CEO g.tec), Dr. Miguel Gallofré (Stroke Program of Catalonia), Dr. Jose Bové (Austrian Consul)
Later, a series of lectures from experts from the fields of neuroscience, stroke rehabilitation and coma assessment provided more information about BCI technology and current applications in rehabilitation and coma assessment.
Brain-Computer Interfaces (BCI) in patients with disorders of consciousness and stroke
Christoph Guger started with a general overview of different BCI applications. He described the physiological background of stroke rehabilitation based on motor imagery and different P300-based paradigms for evaluation and communication with patients who suffer from disorders of consciousness (DOC). Dr. Guger explained real use cases, such as an unresponsive patient from Italy that started to communicate with mindBEAGLE. He also presented results from a post-stroke patient who fully recovered hand movement after 21 sessions of recoveriX. These facts for the introduction of the recoveriX-GYM and the mindBEAGLE-CENTER as parts of the g.tec Neurotechnology Center in Schiedlberg, Austria and (from now on) in Barcelona as well.
BCI applications for persons with functional deficits
Dr. Felip Miralles (Director de la Unidad de Tecnología de eHealth – Eurecat) talked about the design and usability of BCI technology to improve the quality of life of people with functional impairments in his lecture. He emphasized the importance of getting a more holistic user experience to satisfy end-user needs. His lecture was mostly based on the BNCI Horizon and Back Home projects performed in close collaboration with g.tec and other European partners.
Challenges of Virtual Reality for motor rehabilitation
Dr. Sanchez-Vives (IDIBAPS) gave a lecture about one specific challenge: the use of Virtual reality (VR) in combination with BCI for physical rehabilitation. VR is a powerful tool to motivate participants to actively participate, while providing augmented feedback to instruct the subject and improve task performance. She focused her talk on the concept of “agency” that gives people a sense of control and responsibility for own actions. In her studies, she compares different BCI paradigms (Motor Imagery vs. SSVEP) to determine which gives the subject the greater feeling of control and responsibility. “I felt as if it was me controlling the virtual arm” quoted Dr. Sanchez from one of her subjects, and this is exactly the sensation she is looking for. Her conclusion is that moving a surrogate arm through motor-sensory activity in arm cortical areas leads to stronger feelings of agency.
The importance of increasing neuroplasticity of subacute stroke patients using new technologies
Dr. Esther Duarte (Cap de la Unitat Rehabilitació Neurològica – Parc de Salut Mar) talked about the importance of fostering neuroplasticity in subacute stroke by means of novel techniques. She pointed out that stroke is the first cause of disability in occidental countries. She explained that disruption and subsequent re-organization of functional connections occur both locally and remotely in relation to the stroke lesion. Further, symptom severity correlates with decreased connectivity, and recovery from symptoms correlates with the recovery of normal connectivity patterns. Functional connectivity patterns can be normalized by therapy. This underlines the potential usefulness of functional connectivity as a surrogate measure of recovery and as means of testing the effectiveness of rehabilitation strategies. Dr. Duarte remarked that, since more than 30% of stroke survivors live with some functional impairment, neurorehabilitation requires further improvement and more funding. Neurorehabilitation techniques can stimulate functional connectivity and neuroplasticity. BCI, robotics, virtual reality, constraint-induced movement therapy, functional-oriented exercises, TMS, tDCS and interactive computer games aim to remodel neuronal connections altered by stroke lesions.
The value of new technologies for diagnosing patients with disorders of consciousness or brain damage
Dr. Sergiu Albu (Neurologist at the Guttmann Institute) gave a lecture about the relevance of new diagnostic techniques in patients with disorders of consciousness (DOC) secondary to brain injury. He emphasized the importance of such techniques as prognostic measures, and described the natural evolution of brain injuries from coma. A fast recovery occurs in 10% of the cases, while 50% remain in the Unresponsive Wakefulness Syndrome (UWS) until some progress to Minimum Consciousness State (MCS), or even to the Locked-in Syndrome (LIS). The rest of the cases typically result in death. Prognostic measures are relevant to determine the best therapy for each patient or to take other measures. Dr. Albu mentioned that some patients can regain consciousness even after 4 years of being in MCS, although this only occurs in roughly 10% of the cases. Evaluations must be systematic and repeated over time. However, a study showed that, based on the standard clinical evaluation, 43% of the cases were misdiagnosed. That is the reason why Guttmann trusts BCI-based neurotechnology and started using mindBEAGLE as a complementary evaluation tool, and (in responsive patients) to provide communication.
mindBEAGLE clinical validation in post-reanimation units
Dr. Christoph Guger (CEO of g.tec) explained the different paradigms implemented in mindBEAGLE, i.e. auditory evoked potentials, vibro-tactile P300-response based on 2 tactors, vibro-tactile P300-response based on 3 tactors, and the motor imagery paradigm. The last two paradigms allow communication and include further tests to assess command following. Dr. Guger presented data from healthy and comatose patients, includiing real cases in which mindBEAGLE allowed communication. “A patient in Poland was reclassified from UWS after he passed all P300-based mindBEAGLE tests with 100% accuracy and got 16 correct answers out of 20 questions” – Dr. Guger said.
Consciousness assessment and communication in the post-reanimation unit – mindBEAGLE experience
Dr. Frédéric Pellas (Unidad de Post-reanimación, Centre Hospitalier Universitaire (CHU) de Nîmes, France) corroborated that 43% of patients in the Unresponsive Wakefulness State (UWS) have to be reclassified at least to Minimally Consciousness State (MCS) when revised by experts. fMRI research further demonstrated that around 17% of patients in UWS can be consciously aware and able to answer yes/no questions. If that is the case, Dr. Pellas said, “we can use mindBEAGLE to try to communicate with the patient.” Dr. Pellas systematically uses mindBEAGLE to evaluate MCS and LIS patients in his post-reanimation unit. He insisted that mindBEAGLE is a complementary tool to MRI or PET evaluations for consciousness. Further, mindBEAGLE is affordable and portable.
recoveriX clinical validation in rehabilitation units
Dr. Christoph Guger again reviewed the recoveriX system. He explained that recoveriX synchronizes three rehabilitation techniques to help the brain reorganize to be able to perform movements again independently. These techniques are motor movement imagination, visual feedback through virtual reality like in the mirroring technique, and sensory feedback via functional electrical stimulation (FES). He described several real cases in the chronic, subacute and acute phases where after using recoveriX for a number of sessions the motor function was fully recovered. “Sleeping after recoveriX training seems to be really important. An acute post-stroke patient could fully recover his functional motor movement after sleeping one night and after one single recoveriX session”, Dr. Guger said. He added: “However, it’s still too soon to be sure of the extent of recovery that results from spontaneous recovery versus recoveriX”.
Methods of motor rehabilitation after brain damage – recoveriX program
Finally, Marc Sebastián (physiotherapist in the recoveriX GYM in Barcelona) presented several evidence case results with recoveriX training obtained in the recoveriX-GYMs in Austria and in Barcelona. Most of the observed effects were a reduction of spasticity while extending the wrist and the fingers, improved control of grip, better stability at wrist level and improved control of the involuntary movements. Evaluations were performed using standard scales such as 9-hole peg test, Barthel index or Fugl-Meyer assessment. Marc showed a video of a chronic patient who presented a strong spasticity, yet could extend his hand again after only 13 sessions. He also showed the case of a patient in Austria who regained motor functioning after using recoveriX and could keep her job. “She used to work as a hairdresser before the stroke, and now she works as a hairdresser again, thanks to recoveriX”, Marc said.
More than 80 decision-makers, physicians, medical doctors and physiotherapists from various hospitals and rehab centers attended the opening event. Some of the participants were very curious, and quite eager to try out recoveriX and mindBEAGLE on their own at the demonstration area. The new, advanced BCI-based technologies seemed to be very much needed and necessary to overcome therapeutic stagnation and the long, costly, exhausting, and often unsuccessful processes of physical rehabilitation. The research and development of both mindBEAGLE and recoveriX are funded under the Horizon 2020 SME program, with g.tec playing in the champion’s league of European companies.
recoveriX motor rehabilitation and mindBEAGLE assessment and communication system are now available at the recoveriX GYM and mindBEAGLE CENTER at the g.tec office in Carrer de Plom 5-7, 08038 Barcelona (phone: +34 936764579, email: firstname.lastname@example.org, office hours: Monday – Friday, 9 AM to 5 PM).