Linguistic and Philosophical Investigations

ISSN: 1841-2394, e-ISSN: 2471-0881

Vol 23 (1), 2024
pp. 47–54

Advances in Neurofeedback and Brain-Computer Interfaces

for Speech Therapy in Stroke Survivors

Made Agus Mahendra Inggas1

1Department of Neurosurgery, Universitas Pelita Harapan, Tangerang, Indonesia
Corresponding to: Made AM Inggas ([email protected])

Abstract
Introduction
Brain-computer interfaces can potentially enhance communication skills in stroke survivors. This
literature review aims to explore the current state of neurofeedback and BCI applications in speech
rehabilitation for either ischemic or hemorrhagic stroke patients.
Methods
A systematic search until 1 August 2024 from the following electronic databases was conducted: PubMed,
Europe PMC, and SCOPUS. The search terms used included combinations of the following keywords: "Brain-
Computer Interface" or "BCI", "Neurofeedback", "Speech Rehabilitation", "Stroke Patients", "Post-Stroke
Recovery", "Communication Impairment", and "Neurorehabilitation". The outcomes of this literature
review focus on the utilization of neurofeedback and BCIs in rehabilitation and neurofeedback-based
rehabilitation.
Results
The rationale for using BCIs for speech neuroprosthesis among stroke patients lies in the ability of BCIs to
restore communication abilities, bypass damaged neural pathways, and enhance neuroplasticity. Stroke
often impairs speech and language functions, severely affecting quality of life. BCIs offer an alternative
means of communication by decoding neural signals related to speech and translating them into
synthesized speech or text. BCIs can circumvent damaged brain areas by interfacing with remaining
functional regions, promoting functional recovery and neuroplasticity.
Conclusions
This study suggests that BCIs, by decoding neural signals and translating them into synthesized speech or
text, can significantly enhance the quality of life for stroke patients. Further research is needed to refine
these technologies and integrate them into standard neurorehabilitation protocols.
Keywords: Brain-Computer Interface; Communication Impairment; Neurofeedback; Speech
Rehabilitation; Stroke Recovery.

Received: 26 April 2024 Revised: 16 June 2024 Accepted: 29 June 2024

1. Introduction
Stroke is a leading cause of long-term disability worldwide, often resulting in impairments in motor
function, cognition, and communication.[1] Traditional rehabilitation methods, while beneficial, frequently

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fall short in addressing the complex and varied needs of stroke survivors, particularly in the realm of speech
rehabilitation. Recent advancements in neurotechnology, specifically brain-computer interfaces (BCIs),
have opened new avenues for enhancing recovery outcomes in these patients.[2,3]
BCIs have emerged as a promising tool in stroke rehabilitation by translating brain activity into commands,
thereby enabling direct communication between the brain and external devices.[4] This technology can
facilitate neuroplasticity and functional recovery by bridging the gap between movement intention and
execution in paralyzed patients. For instance, BCI-guided functional electrical stimulation has been
effective in restoring muscle function in chronic stroke patients, demonstrating the potential for significant
motor improvements even long after the initial injury.[5,6] Moreover, BCIs can detect motor imagery,
offering a viable rehabilitation approach for patients with limited residual movement.
In addition to motor recovery, BCIs hold considerable promise for speech rehabilitation.[7] By leveraging
the brain's ability to adapt and reorganize, BCIs can potentially enhance communication skills in stroke
survivors. This literature review aims to explore the current state of neurofeedback and BCI applications
in speech rehabilitation for either ischemic or hemorrhagic stroke patients.

2. Methods
This literature review employs a systematic approach to identify, evaluate, and synthesize research
findings on the application of neurofeedback and BCIs in speech rehabilitation for either ischemic or
hemorrhagic stroke patients. A systematic search until 1 August 2024 from the following electronic
databases was conducted: PubMed, Europe PMC, and SCOPUS. The search terms used included
combinations of the following keywords: "Brain-Computer Interface" or "BCI", "Neurofeedback", "Speech
Rehabilitation", "Stroke Patients", "Post-Stroke Recovery", "Communication Impairment", and
"Neurorehabilitation". The outcomes of this literature review focus on the utilization of neurofeedback and
BCIs in rehabilitation and neurofeedback-based rehabilitation.
The following criteria were applied to select relevant studies: Peer-reviewed articles published in English
were included in the review. Studies focusing on the use of BCIs or neurofeedback for speech rehabilitation
in stroke patients were specifically targeted. This review also considered clinical trials, experimental
studies, and comprehensive reviews that provide empirical data or extensive analysis. Articles not available
in English were excluded. Studies focusing solely on motor rehabilitation without addressing speech
rehabilitation were not included. Additionally, publications without empirical data, such as editorials,
opinion pieces, and anecdotal reports, were excluded. Studies involving populations other than stroke
patients were also not considered.
The selection began with an initial screening of titles and abstracts to identify potentially relevant studies,
focusing on peer-reviewed publications in English that addressed the use of BCIs or neurofeedback for
speech rehabilitation in stroke patients. Following a full-text review, studies that did not meet the
established criteria were excluded. The final selection of studies was compiled for data extraction, ensuring
a comprehensive representation of the current landscape of neurofeedback and BCI applications in speech
rehabilitation for stroke patients.
Data from the selected studies were extracted using a standardized form. This form included essential
information such as the study title and authors, year of publication, study design and methodology, sample
size and characteristics, type of intervention (BCI or neurofeedback), outcome measures related to speech
rehabilitation, and key findings and conclusions.
After extracting relevant data using a standardized form, the information was organized thematically to
address the review's primary objectives, focusing on categorizing studies based on their interventions
(neurofeedback or BCI), populations (stroke patients), and outcomes related to speech rehabilitation. A
narrative synthesis was employed to summarize the findings, highlighting key trends, similarities, and
differences across studies.

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3. Results
Neurofeedback and BCIs
Neurofeedback, also known as electroencephalography (EEG) biofeedback, is a therapeutic technique that
provides real-time information on brainwave activity, enabling individuals to learn how to regulate their
brain function. This method hinges on the principle that the brain can be trained to improve its
performance through a feedback loop (figure 1).[8,9] By displaying brainwave patterns on a monitor,
individuals can modify their brain activity to achieve desired mental states, promoting self-regulation and
mental well-being. Neurofeedback is often used to treat various conditions such as ADHD, anxiety,
depression, and epilepsy.[10–12]

Figure 1. Illustration of neurofeedback.

The historical development of neurofeedback dates back to the 1960s, with significant contributions from
Dr. Joe Kamiya and Dr. Barry Sterman. Kamiya's research at the University of Chicago showed that
individuals could learn to control their alpha brainwaves, offering insights into consciousness and
brainwave activity.[13] Meanwhile, Sterman's work with cats demonstrated that neurofeedback could
reduce seizure activity, which led to its application in treating epilepsy.[13] The field advanced significantly
with the advent of computer technology and neuroscience, expanding its clinical applications throughout
the 1990s and beyond.
Current neurofeedback methods leverage various technologies to monitor and influence brain activity.
EEG-based neurofeedback, the most common approach, uses scalp electrodes to measure electrical brain
activity and provide real-time feedback, often in interactive formats like games.[14,15] Other methods
include fMRI neurofeedback, which uses brain imaging to measure activity based on blood flow, and Near-
Infrared Spectroscopy (NIRS), which monitors blood oxygenation changes in the brain. Low-Energy
Neurofeedback System (LENS) and Quantitative EEG (QEEG) also offer specialized approaches, catering to
conditions such as depression, PTSD, and more comprehensive brain mapping, respectively.[16–18]
BCIs represent a parallel technological innovation, enabling direct communication between the brain and
external devices. BCIs function by translating brain signals into commands to control computers,

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prosthetics, and other technologies. These systems typically involve signal acquisition through methods
like EEG or fMRI, followed by signal processing to extract relevant features. Machine learning algorithms
then translate these features into actionable commands, which can operate various assistive
devices.[19,20] Feedback mechanisms are crucial in BCIs, helping users adapt and improve control over
time.
BCIs have diverse applications, particularly in the medical field, where they restore communication and
mobility for individuals with severe disabilities, such as those with ALS or spinal cord injuries. BCIs are also
utilized in neurorehabilitation for stroke patients. Beyond medical uses, BCIs enable individuals with
disabilities to control wheelchairs, prosthetic limbs, and communication devices, significantly enhancing
their independence and quality of life.[21–23] Additionally, BCIs are being explored for cognitive
enhancement, mental health interventions, and even immersive gaming and virtual reality experiences.
As both neurofeedback and BCI technologies evolve, they hold significant promise for future applications.
Advances in neuroscience, machine learning, and signal processing are expected to enhance their efficacy
and accessibility. However, ethical considerations, including privacy, security, and potential misuse, will be
crucial in shaping the future landscape of these technologies.[24] The continued integration of these
innovations promises to transform therapeutic practices, assistive technologies, and cognitive
enhancement, offering profound benefits across various domains.
Neurofeedback-Based Rehabilitation
Recent studies have demonstrated that neurofeedback can elicit bidirectional white matter plasticity
within 24 hours of training in healthy individuals. The technique has shown promise in both clinical and
experimental contexts, affecting reinforcement learning networks and specific cortical regions. Decoded
neurofeedback (DecNef), an advanced form of the technique, provides strong evidence for targeted neural
plasticity while refuting alternative explanations such as placebo effects.[25,26] However, challenges
remain in quantifying temporal dynamics, generalizing behavioral outcomes, designing appropriate
controls, and developing more advanced signal processing methods. Further research into the neural
mechanisms of neurofeedback could lead to more powerful tools for basic and clinical research.
In the context of neurofeedback-based rehabilitation, the mechanisms of action involve significant changes
in neural plasticity. By providing real-time feedback on brainwave activity, individuals can learn to
modulate their brain function. This modulation can lead to synaptic plasticity, the growth of new synapses,
and the strengthening of existing ones. For speech recovery, neurofeedback targets brain regions involved
in language processing and production. The left hemisphere, particularly perilesional areas and the left
superior temporal cortex, plays a crucial role.[27] The left supplementary motor area also shows
prominent compensatory activation in subacute stroke patients.[28] When these regions are severely
impaired, neurofeedback can help recruit right-hemisphere regions to support language functions,
although this strategy is generally less effective.
Several case studies and clinical trials have demonstrated the effectiveness of neurofeedback-based
rehabilitation.[29,30] For example, in patients with ADHD, neurofeedback has been shown to improve
attention and reduce hyperactivity. In stroke patients, neurofeedback has facilitated motor and speech
recovery by enhancing brain connectivity in relevant regions. The success rates of neurofeedback-based
rehabilitation vary depending on the condition being treated and the specific protocols used. Studies have
shown that neurofeedback can be particularly effective for ADHD, with success rates comparable to
medication-based treatments.[31,32]
Neurofeedback offers several advantages over traditional rehabilitation methods. It is non-invasive, drug-
free, and can be tailored to individual needs. Neurofeedback can target specific brain regions and neural
pathways, potentially leading to more precise and effective interventions. It also promotes self-regulation
and empowerment, as individuals actively participate in their own rehabilitation process.[33] However,
the need for specialized equipment and trained professionals can make it less accessible and more
expensive than traditional methods. The variability in individual responses and the need for multiple

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sessions can also be seen as drawbacks. Additionally, while neurofeedback has shown effectiveness for
various conditions, more research is needed to establish standardized protocols and to understand the
long-term effects fully.
Comparing neurofeedback to traditional rehabilitation methods, it provides a unique approach by directly
targeting brain activity and promoting neural plasticity. Traditional methods, such as physical therapy and
speech therapy, focus on external behaviors and skills. Combining neurofeedback with these traditional
approaches could potentially enhance overall rehabilitation outcomes, providing a more comprehensive
and effective treatment strategy. Research on targeted brain regions for speech recovery in aphasia
suggests a hierarchical organization of recovery mechanisms, emphasizing the importance of integrating
various therapeutic techniques to maximize recovery. Patients with efficient, control-like network topology
show greater improvement in language recovery, highlighting the potential benefits of combining
neurofeedback with other established rehabilitation methods.[34,35]
BCI-Based Speech Neuroprosthesis for Stroke Patients
Stroke frequently leads to communication and swallowing impairments, with dysarthria, aphasia, and
dysphagia being common sequelae. Following first-ever acute ischemic stroke, the incidence rates are
approximately 42% for dysarthria, 30% for aphasia, and 44% for dysphagia, with 10% of patients
experiencing all three impairments.[36] These impairments significantly impact patients' quality of life and
functional outcomes. Speech rehabilitation plays a crucial role in managing dysarthria post-stroke. A
systematic review and meta-analysis revealed that speech therapy can significantly improve acoustic
parameters, including alternating and sequential motion rates and maximum phonation time.[37] Various
speech rehabilitation techniques have been identified to guide physicians in developing effective treatment
protocols for post-stroke dysarthria. Early assessment and intervention for these impairments in the acute
care setting are vital for optimizing long-term outcomes in stroke survivors.
BCIs have shown promising potential for stroke rehabilitation, particularly in motor recovery and speech
rehabilitation.[38] BCIs translate brain activity into commands, enabling direct communication between
the brain and external devices. These systems can promote neuroplasticity and functional recovery by
bridging the gap between movement intention and execution in paralyzed patients. BCI-guided functional
electrical stimulation has demonstrated effectiveness in restoring muscle function in chronic stroke
patients.[39,40] Additionally, BCIs can detect motor imagery, providing an alternative rehabilitation
approach for patients with limited residual movement.[41] Clinical trials have shown significant motor
improvements in chronic stroke patients using BCI-based neurorehabilitation strategies.[42] While
challenges remain, BCI technology offers a promising avenue for enhancing post-stroke rehabilitation
outcomes in motor, cognitive, and communication impairments.
The rationale for using BCIs for speech neuroprosthesis among stroke patients lies in the ability of BCIs to
restore communication abilities, bypass damaged neural pathways, and enhance neuroplasticity.[3] Stroke
often impairs speech and language functions, severely affecting quality of life. BCIs offer an alternative
means of communication by decoding neural signals related to speech and translating them into
synthesized speech or text.[43] BCIs can circumvent damaged brain areas by interfacing with remaining
functional regions, promoting functional recovery and neuroplasticity. Additionally, BCIs improve
independence by enabling control of assistive devices, thereby enhancing patients' autonomy and social
interaction. The technology’s adaptability allows for personalized solutions tailored to individual needs,
making it a promising component of stroke rehabilitation.
The primary mechanism by which BCIs aid in speech neuroprosthesis involves decoding neural signals
from specific brain regions responsible for speech production. Techniques such as EEG capture electrical
activity from the brain's surface, while intracortical electrode arrays, implanted directly into speech-
related areas, provide high-resolution neural data. These signals are processed to extract relevant features,
which advanced machine learning algorithms then translate into speech commands or text.[44] The output
can be converted into audible speech using synthesis technology or displayed as text, facilitating effective
communication.

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However, several challenges and considerations must be addressed to optimize BCI systems for speech
neuroprosthesis. Technical challenges include signal noise and artifacts, which require sophisticated
filtering and processing techniques, and the need for real-time operation, demanding fast and accurate
decoding algorithms.[45] Users may also face a learning curve and cognitive load when adapting to BCI
systems, necessitating extensive training and support. Ethical and privacy concerns, particularly with
invasive procedures and data security, must be carefully managed to ensure user safety and confidentiality.
Future directions for BCI research focus on improving non-invasive techniques, integrating advanced AI
and machine learning for better signal decoding, and developing personalized BCI systems tailored to
individual users' neural patterns and speech characteristics. Continued clinical trials are essential to
validate the efficacy and safety of BCI-based neuroprosthesis for speech.[46] As research and development
progress, BCIs are poised to play an increasingly vital role in the field of speech neuroprosthetics, offering
a transformative solution for those with severe speech impairments.

4. Conclusions
This literature review underscores the promising potential of BCIs and neurofeedback in enhancing
communication skills in stroke survivors. The studies reviewed demonstrate that BCIs can effectively
restore communication abilities, bypass damaged neural pathways, and promote neuroplasticity, thus
offering significant benefits in speech rehabilitation for both ischemic and hemorrhagic stroke patients. By
decoding neural signals related to speech and translating them into synthesized speech or text, BCIs
provide an alternative means of communication that can significantly improve the quality of life for stroke
survivors. The findings highlight the need for further research and clinical trials to optimize BCI
technologies and integrate them into standard neurorehabilitation protocols for speech recovery in stroke
patients.
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