Abstract
Neurofeedback training of Motor imagery (MI)-related brain-states with brain-computer/brain-machine interfaces (BCI/BMI) is currently being explored as an experimental intervention prior to standard physiotherapy to improve the motor outcome of stroke rehabilitation. The use of BCI/BMI technology increases the adherence to MI training more efficiently than interventions with sham or no feedback. Moreover, pilot studies suggest that such a priming intervention before physiotherapy might-like some brain stimulation techniques-increase the responsiveness of the brain to the subsequent physiotherapy, thereby improving the general clinical outcome. However, there is little evidence up to now that these BCI/BMI-based interventions have achieved operate conditioning of specific brain states that facilitate task-specific functional gains beyond the practice of primed physiotherapy. In this context, we argue that BCI/BMI technology provides a valuable neurofeedback tool for rehabilitation but needs to aim at physiological features relevant for the targeted behavioral gain. Moreover, this therapeutic intervention has to be informed by concepts of reinforcement learning to develop its full potential. Such a refined neurofeedback approach would need to address the following issues: (1) Defining a physiological feedback target specific to the intended behavioral gain, e.g., β-band oscillations for cortico-muscular communication. This targeted brain state could well be different from the brain state optimal for the neurofeedback task, e.g., α-band oscillations for differentiating MI from rest; (2) Selecting a BCI/BMI classification and thresholding approach on the basis of learning principles, i.e., balancing challenge and reward of the neurofeedback task instead of maximizing the classification accuracy of the difficulty level device; and (3) Adjusting the difficulty level in the course of the training period to account for the cognitive load and the learning experience of the participant. Here, we propose a comprehensive neurofeedback strategy for motor restoration after stroke that addresses these aspects, and provide evidence for the feasibility of the suggested approach by demonstrating that dynamic threshold adaptation based on reinforcement learning may lead to frequency-specific operant conditioning of β-band oscillations paralleled by task-specific motor improvement; a proposal that requires investigation in a larger cohort of stroke patients.