Lifescapes System in Post-stroke Hand Recovery

Background

Stroke is a leading cause of adult long-term disability, with 30-60% of stroke survivors remaining unable to use their affected arms after discharge. While many interventional approaches have been tested - including motor imagery, robotic movement assistance, and neuromodulation - therapeutic efficacy remains limited for hand motor function. The Lifescapes system is a novel EEG-based brain-computer interface (BCI) neurofeedback system that facilitates motor imagery practice in post-stroke patients with severe hemiparesis, integrating biofeedback, neuromuscular electrical stimulation (NMES), and robot-aided sensorimotor stimulation. By triggering NMES and robotic assistance contingent on sensorimotor rhythm event-related desynchronisation (SMR-ERD) magnitude, the system enables voluntary modulation of endogenous sensorimotor activities in the ipsilesional hemisphere. A recent RCT in 40 chronic post-stroke hemiplegic patients demonstrated a significant between-group difference in Fugl-Meyer Assessment scores in favour of the Lifescapes group, supporting its potential as an adjunctive rehabilitation approach.

Study Objectives

The primary objective is to evaluate the effectiveness of Lifescapes therapy with reduced therapist supervision in improving upper-limb motor function in sub-acute and chronic stroke patients with moderate to severe upper limb paresis. The secondary objective is to evaluate the operational feasibility of Lifescapes with reduced therapist supervision in the local context. It is hypothesised that Lifescapes therapy with reduced therapist supervision is feasible in this study population and will quantitatively improve hand motor function.

Study Design

This is a single-arm, prospective study to evaluate the real-world effectiveness and feasibility of Lifescapes with reduced therapist supervision for post-stroke upper-limb rehabilitation. 32 subjects will be recruited from Alexandra Hospital (AH) and National University Hospital (NUH) over an estimated study duration of 2 years.

Participants

Inclusion criteria are: age 21-80 years; first-ever or recurrent ischemic or haemorrhagic stroke; stroke onset between 8 weeks and 5 years prior to enrolment; moderate to severe unilateral upper-limb motor impairment defined as a baseline FMA-UE score <47 and Manual Muscle Testing (MMT) of finger extensor ≤2; ability to provide informed consent and follow verbal instructions; and sufficient visual acuity to scan a full computer screen.

Exclusion criteria include: pregnant or breastfeeding women; bilateral stroke; Modified Ashworth Scale (MAS) of finger flexors >2; use of a pacemaker or other implanted stimulators; history of seizures within 90 days before enrolment; inability to record EEG due to skin status or skull deformity; sensorimotor disturbance due to causes other than stroke; and medically unstable or uncontrolled conditions that may compromise safety or the ability to complete scheduled visits.

Intervention

Eligible subjects will undergo 16 sessions of MI-BCI training with NMES and robotic movement assistance using the paralysed hand through the Lifescapes device. The intervention course must be completed within 4-8 weeks from the first to the last session, at a target frequency of 2-4 sessions per week. Therapist assistance during each Lifescapes session will be reduced progressively according to individual ability, though a therapist will remain present throughout in case assistance is needed. Each session is approximately 30 minutes.

Following each Lifescapes session, participants will complete a standardised occupational therapy programme - GRASP (Graded Repetitive Arm Supplementary Program) - supervised by a trained research staff member. All occupational tasks will be selected from the GRASP task pool and prescribed by an occupational therapist. Each GRASP session will take approximately 30 minutes.

Study Visits and Assessments

There will be up to 21 study visits over 5-6 months, comprising 16 intervention sessions and 6 rounds of assessment at the following timepoints: 2-4 weeks before the first Lifescapes session (pre-baseline), before the first session (baseline), after the 8th session (interim), after the 16th session (post), 1 month after the 16th session (1-month follow-up), and 3 months after the 16th session (3-month follow-up, optional).

Outcome Measures

Clinical outcomes assessed at each timepoint include: Upper Extremity Fugl-Meyer Assessment (FMA-UE); Action Research Arm Test (ARAT); grip and pinch strength measured by dynamometer; Modified Ashworth Scale (MAS) of the affected upper limb muscles; Motor Activity Log-14 (MAL-14); EQ-5D-5L; and corticospinal excitability measurement by TMS (optional).