Recommendations for Combining Brain-Computer Interface, Motor Imagery, and Virtual Reality in Upper Limb Stroke Rehabilitation: Qualitative Participatory Design Study.

Background: The high incidence and prevalence of upper limb impairment post stroke highlights the need for advancements in rehabilitation. Brain-computer interfaces (BCIs) represent a promising technology by directly training the central nervous system. The integration of motor imagery (MI) and motor observation through virtual reality (VR) using BCIs provides valuable opportunities for rehabilitation. However, the diversity in intervention designs demonstrates the lack of guiding recommendations integrating neurorehabilitation principles for BCIs. Objective: This study aims to develop recommendations for BCI interventions using task specificity and ecological validity through simulated VR tasks for upper limb stroke survivors by gathering tacit knowledge from neurorehabilitation experts, patients' experiences, and engineers' expertise to ensure a comprehensive approach. Methods: A multiperspective qualitative study was conducted through collaborative design workshops involving stroke survivors (n=17), neurorehabilitation experts (n=13), and biomedical engineers (n=3), totaling 33 participants. This innovative approach aimed to actively engage stakeholders in developing multifaceted solutions for complex health interventions. Results: Six themes emerged from the thematic analysis: (1) importance of patient-centered approach, (2) clinical evaluation and patient selection, (3) recommendations for task design, (4) guidelines for structuring BCI intervention, (5) key factors influencing motivation, and (6) technology features. From these themes, the following recommendations (R) are established: (R1) MI-based VR-BCI interventions must be conducted through a patient-centered approach, based on individualized preferences, needs, and goals of the user, by an interdisciplinary team; (R2) selection criteria must include upper limb impairment, cognitive and communication assessment, and clinical traits, such as MI capacity, neglect, and depression must be assessed since they might influence intervention outcomes; (R3) tasks to perform should preferably be based on daily living activities, including unilateral and bilateral tasks, and a variety of tasks must be available for selection to ensure meaningfulness for the user and suitability to clinical traits; (R4) intervention must be structured by different progressing levels starting with simple, gross movements and adding complexity through additional movement features, cognitive demand, or MI difficulty; (R5) optimal levels of motivation must be sustained through task variability, gamification elements, and task demand adequacy; and (R6) multisensorial potential of MI-based VR-BCI must be effectively harnessed through the adequate adjustment of visual, haptic, and proprioceptive feedback modalities to the patient. Conclusions: Current results contribute to establishing clear guidelines on patient selection, task design, intervention structuring, motivation factors, and tailoring of sensory feedback. This framework presents a foundation for optimal implementation of VR-BCI-based interventions that associate MI and motor observation, optimizing cortical activity during the intervention, patients' engagement, and clinical outcomes. Future research should explore the application of these guidelines for validation and investigate BCIs' efficacy according to different combinations of patients' profiles, task characteristics, and technology features.