Brain–Computer Interface–Based Communication in the Completely Locked-In State

Despite partial success, communication has remained impossible for persons suffering from complete motor paralysis but intact cognitive and emotional processing, a state called com- plete locked-in state (CLIS). Based on a motor learning theoretical context and on the failure of neuroelectric brain–computer interface (BCI) communication attempts in CLIS, we here report BCI communication using functional near-infrared spectroscopy (fNIRS) and an implicit attentional processing procedure. Four patients suffering from advanced amyotro- phic lateral sclerosis (ALS)—two of them in permanent CLIS and two entering the CLIS with- out reliable means of communication—learned to answer personal questions with known answers and open questions all requiring a “yes” or “no” thought using frontocentral oxygen- ation changes measured with fNIRS. Three patients completed more than 46 sessions spread over several weeks, and one patient (patient W) completed 20 sessions. Online fNIRS classification of personal questions with known answers and open questions using linear support vector machine (SVM) resulted in an above-chance-level correct response rate over 70%. Electroencephalographic oscillations and electrooculographic signals did not exceed the chance-level threshold for correct communication despite occasional differences between the physiological signals representing a “yes” or “no” response. However, electro- encephalogram (EEG) changes in the theta-frequency band correlated with inferior commu- nication performance, probably because of decreased vigilance and attention. If replicated with ALS patients in CLIS, these positive results could indicate the first step towards aboli- tion of complete locked-in states, at least for ALS.