Published Ahead of Print on June 27, 2018 as 10.1212/WNL.

0000000000005804
EDITORIAL

A useful communication in brain-computer

interfaces
Niels Birbaumer, PhD, and Leigh R. Hochberg, MD, PhD Correspondence

®
Prof. Birbaumer
Neurology 2018;0:1-2. doi:10.1212/WNL.0000000000005804 niels.birbaumer@
uni-tuebingen.de

An early goal for brain-computer interfaces (BCIs) is to provide people with tetraplegia and RELATED ARTICLE
severe speech impairments with a restored ability to communicate, using only brain signals to
drive a computer interface. The most extensively researched BCIs are those that use scalp-based Independent home use of
EEG recordings; over the past 30 years, these EEG-BCIs have been developed and tested with a brain-computer interface
both healthy, uninjured people and people with paralysis (e.g., due to ALS).1,2 While there have by people with
been many reports of single or a few individuals with paralysis who have used EEG-BCIs for amyotrophic lateral
communication, formal clinical trials for efficacy have been missing. sclerosis
Page 118
In this issue of Neurology®, Wolpaw et al.3 report the first prospective, multisite, pivotal clinical
trial of an EEG-BCI. The Wadsworth BCI, which consists of an EEG cap, a power-conditioned
amplifier, a laptop, and a monitor, was set up by the research team at participants’ homes. With
only occasional remote support from the researchers, participants, veterans with ALS, who
could use the technology were permitted to do so for up to 18 months. Frequency of use,
communication rate, and quality-of-life measures were assessed. The authors deserve great
credit for planning and executing this important study.

The results are, as noted in the article, “complicated.” After 42 patients provided consent, of
whom 39 met inclusion criteria, 2 withdrew consent and another 9 (25%) could not use the
EEG-BCI during screening assessments. All participants had some method of communication;
that is, none had complete locked-in syndrome (CLIS) and thus all had some method of
communication, including other assistive technologies such as eye-gaze systems. Of the
remaining 27 available participants who had devices placed in the home, only 14 completed up
to an additional month needed for patient and caregiver training. The reasons for this attrition
included losing interest, disease progression, and death. Four additional participants withdrew
from the trial (in addition to 2 deaths), leaving 8 of 39 participants using the system at study
end. For the 14 (≈33%) recruited participants (in a intention-to-treat analysis) who could use
the system at home for long enough to evaluate it (2–17 months), objective performance as
a communication system was unimpressive. The system could be used on only ≈57% of days,
the remainder being precluded by declining health, absence of caregiver, work, or travel. Of
those available days, it was used on average 2 d/wk for 1.3 h/d. And over those 1.3 hours, users
could make ≈3 selections (letters, words with word prediction, icons, etc.) per minute with
≈73% selection accuracy. To enable this 1.3 hours, caregivers needed to spend ≈30 minutes
preparing the system or placing/removing/cleaning the cap. The communication rate enabled
by this EEG-BCI was similar to that in the recent report of a fully implanted, subdural (elec-
trocorticographic) BCI used by a person with ALS and locked-in syndrome at home.4

It would be easy to conclude that this is another frustrating trial result in ALS, but there is
a silver (silver-chloride) lining. Seven of 8 participants kept the BCI at the end of the study, an
unambiguous vote by those 7 participants that the system was viewed as having either current or
future value. The system itself was nearly always in good working order, which is no small feat
for an assistive communication technology. The authors conclude, “The Wadsworth BCI home

From the Wyss Center for Bio and Neuroengineering (N.B.), Geneva, Switzerland; Faculty of Medicine (N.B.), Institute of Medical Psychology and Behavioral Neurobiology, University
of Tuebingen, Germany; School of Engineering and Carney Institute for Brain Science (L.R.H.). Brown University, Providence, RI; Center for Neurotechnology and Neurorecovery
(L.R.H.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; and VA RR&D Center for Neurorestoration and Neurotechnology (L.R.H.),
Providence Veterans Affairs Medical Center, RI.

Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the editorial.

Copyright © 2018 American Academy of Neurology 1

Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
 system can function reliably and usefully when operated by
patients in their homes.” For a population of people with
severe, progressive ALS, as communication rates decline to-
ward zero (CLIS), we should not underestimate the impor-
tance of a home-deployed system that provides even a low
communication throughput for a subset of patients. Particu-
larly when the risk of an intervention is relatively low or nil, as
it is for an EEG-BCI, the burden-to-benefit threshold for
useful is probably best determined by individual patients
themselves.
The current report can be further interpreted in the context of
2 other ongoing BCI efforts: the evaluation of patients with
ALS with CLIS and the communication rates enabled by
other BCIs. Using cerebral functional near-infrared technol-
ogy, 2 studies5,6 have indicated that people with CLIS due to
ALS can indicate “yes” or “no” to repeated questions, taking
about 15 seconds per response, again with ≈70% accuracy.
The apparent maintenance of consciousness in this group,
even if fluctuating, underscores the imperative to develop
robust BCIs or other communication technologies that could
be used by people with CLIS.7 At the other end of the human
BCI research spectrum are intracortical BCIs, which, while
requiring the neurosurgical placement of microelectrode re-
cording arrays, are able to thus take advantage of the enor-
mous information that can be extracted from single and small
groups of cerebral neurons. Recent studies from the Brain-
Gate consortium have demonstrated that people with ALS
and other paralyzing disorders have used intracortical BCIs to
type ≥39 correct characters per minute in their homes.8–10
However, such systems today still require the support of
a research technician and substantial, expensive equipment.
They are also a few years from the type of prospective, pivotal
clinical trial of a BCI as reported in today’s journal, in which
benefit and risk can be assessed most objectively.
With advances in recording technology and computational
neuroscience, BCIs will continue to evolve. Both noninvasive
and implanted BCIs should continue to be improved to the
point of providing objective benefit. Even if intracortical
systems enable faster and more accurate communication,
some patients will have contraindications or personal pref-
erences to avoid surgery. People with Parkinson disease make
a personalized risk/benefit assessment when considering deep
brain stimulation; the same eventually will be true for people
with paralysis selecting from a spectrum of BCI options.11
Clinicians tasked with guiding their patients about these
options will continue to rely on definitive, practical assess-
ments of device efficacy. Generating those data requires re-
search teams to pause the evolution of their BCI technology
long enough to assess it carefully and prospectively; those
2 Neurology | Volume , Number  | Month 0, 2018
Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
teams and, more important, our patients will benefit from the
valuable experience gained in this important first trial.
Author contributions
NB/LRH: Drafting/revising the manuscript.
Acknowledgment
The authors acknowledge the Wyss Center for Bio and
Neuroengineering, Geneva, Deutsche Forschungsgemein-
schaft, BMBF (German Ministry of Education and Research)
CoMiCon, and LUMINOUS-H2020-FETOPEN. The con-
tent is solely the responsibility of the authors and does not
necessarily represent the official views of the Department of
Veterans Affairs or the US government.
Study funding
No targeted funding reported.
Disclosure
N. Birbaumer has received research support from Brain
Products (Gilching, Germany); the German Research Soci-
ety, and Bundesministerium fur Bildung und Forschung.
L. Hochberg has served on the scientific advisory board of
Synchon Med, Inc and has received research support from
Rehabilitation Research and Development Service (Office of
Research and Development, Department of Veterans Affairs),
National Institute on Deafness and Other Communication
Disorders, National Institute of Child Health and Human
Development–National Center for Medical Rehabilitation
Research, and National Institute of Neurological Disorders
and Stroke. Go to Neurology.org/N for full disclosures.
References
1. Wolpaw JR, McFarland DJ, Neat GW, Forneris CA. An EEG-based brain-computer
interface for cursor control. Electroencephalogr Clin Neurophysiol 1991;78:252–259.
2. Birbaumer N, Ghanayim N, Hinterberger T, et al. A spelling device for the paralysed.
Nature 1999;398:297–298.
3. Wolpaw JR, Bedlack RS, Reda DJ, et al. Independent home use of a brain-computer
interface by people with amyotrophic lateral sclerosis. Neurology 2018;91:
e258–e267.
4. Vansteensel MJ, Pells EGM, Bleichner MG, et al. Fully implanted brain-computer
interface in a locked-in patient with ALS. N Engl J Med 2016;375:2060–2066.
5. Gallegos-Ayala G, Furdea A, Takano K, Ruf CA, Flor H, Birbaumer N. Brain com-
munication in a completely locked-in patient using bedside near-infrared spectros-
copy. Neurology 2014;82:1930–1932.
6. Chaudhary U, Xia B, Silvoni S, Cohen LG, Birbaumer N. Brain-computer
interface–based communication in the completely locked-in state. PLoS Biol 2014;
15:e1002593.
7. Hochberg LR, Cudkowicz ME. Locked in, but not out? Neurology 2014;82:
1852–1853.
8. Bacher D, Jarosiewicz B, Masse NY, et al. Neural point-and-click communication by
a person with incomplete locked-in syndrome. Neurorehabil Neural Repair 2015;29:
462–471.
9. Jarosiewicz B, Sarma AA, Bacher D, et al. Virtual typing by people with tetraplegia using
a self-calibrating intracortical brain-computer interface. Sci Transl Med 2015;7:313ra179.
10. Pandarinath C, Gilja V, Blabe CH, et al. Neural population dynamics in human motor
cortex during movements in people with ALS. Elife 2015;4:e07436.
11. Blabe CH, Gilja V, Chestek CA, Shenoy KV, Anderson KD, Henderson JM. As-
sessment of brain-machine interfaces from the perspective of people with paralysis.
J Neural Eng 2015;12:43002.
Neurology.org/N
 A useful communication in brain-computer interfaces
Niels Birbaumer and Leigh R. Hochberg
Neurology published online June 27, 2018
DOI 10.1212/WNL.0000000000005804

This information is current as of June 27, 2018

Updated Information &
Services
Subspecialty Collections
Permissions & Licensing
Reprints
including high resolution figures, can be found at:
http://n.neurology.org/content/early/2018/06/27/WNL.0000000000005
804.full
This article, along with others on similar topics, appears in the
following collection(s):
All clinical neurophysiology
http://n.neurology.org/cgi/collection/all_clinical_neurophysiology
All Neuromuscular Disease
http://n.neurology.org/cgi/collection/all_neuromuscular_disease
EEG; see Epilepsy/Seizures
http://n.neurology.org/cgi/collection/eeg_see_epilepsy-seizures
Evoked Potentials/Visual
http://n.neurology.org/cgi/collection/evoked_potentials-visual
Information about reproducing this article in parts (figures,tables) or in
its entirety can be found online at:
http://www.neurology.org/about/about_the_journal#permissions
Information about ordering reprints can be found online:
http://n.neurology.org/subscribers/advertise

Neurology ® is the official journal of the American Academy of Neurology. Published continuously since
1951, it is now a weekly with 48 issues per year. Copyright © 2018 American Academy of Neurology. All
rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.