CONTRAST: Cognitive Enhancement Training for Successful Rehabilitation After Stroke (CONTRAST)

Published on: 31/10/2013

CONTRAST is a collaborative scientific project supported by the European Union for the "Cognitive Enhancement Training for Successful Rehabilitation After Stroke”.

Each year, many people are affected by stroke, which may have tremendous consequences for their future lives. After a stroke, some people are confronted with two important sources of impairment:

  1. They may experience severe cognitive problems, such as difficulties with attention, memory, language, learning, reasoning, problem solving or decision making;
  2. They may have to deal with severe motor impairment.

Both of these aspects may increase their dependence on other people, promoting feelings of lost autonomy and helplessness, and this often accelerates the development of depression. Early intervention to maintain or restore independence, which is linked to better well-being and overall management of daily life, is therefore of paramount importance.

Unfortunately, a huge gap exists between institutionalised rehabilitation and the management of stroke-injured people in their home environments. Rehabilitation efforts mostly terminate abruptly on discharge, and so do efforts to monitor any changes in motor and cognitive function, daily life activities in social integration, health parameters, such as hearth rate and blood pressure, and quality of life.

The main goals of CONTRAST are to:

  1. Bridge the gap between the institutional rehabilitation and the continuous training and monitoring of the impaired function and the health parameters at home.
  2. Provide an adaptive human-computer interface (HCI) to improve the impaired cognitive function. This is achieved by the so-called neurofeedback training. The neuronal activity of the brain is recorded with EEG (electroencephlography) and fed back to the user in real time. This allows a person to learn how to alter the EEG which then can improve cognitive functioning.

Before a neurofeedback-based rehabilitation training with patients can commence, it has to be assessed which function needs to be addressed first. A battery of neuropsychological tests and measures of affective state are applied to the patient and software now exists that allows data entering or automatic data transfer. At the end of testing an algorithm for shared decision making processes the data and suggests a sequence of training modules. This suggestion for a training schedule can be used as a basis for patient participation and shared decision making between doctors and patients.

The broader and practical application of the neurofeedback modules is supported by remote supervision, a semidry headset, and automated, reinforcing software that allow for easy setup and maintaining patient motivation.

Description of target users and groups

Health professionals involved in the treatment of people affected by a stroke, and the people themselves.

More precisely, people after stroke, possibly already in the sub-acute phase to start BNCI-neurofeedback training-based intervention as early as possible. The targeted population needs to understand instructions and thus some exclusion criteria apply at this stage of the project. General inclusion criteria are age between 18 and 70, diagnosis of stroke, and at least one communication channel must be preserved (good seeing and/or hearing). Exclusion criteria are drug treatment affecting the CNS (drugs acting on vigilance), other concomitant neurological disorders (e.g. Parkinson’s disease), severe concomitant diseases, and conditions that prevent proper bio-signal acquisition. In addition, participants need to understand the context and be able to give informed consent and a supportive person/environment is required. Dementia, psychiatric disorders, insufficient awareness, comprehension and communication ability, visuo-spatial skills, and motivation and/or cooperation are further exclusion criteria. Further, more specific inclusion and exclusion are also defined.

Doctors and paramedical staff are supposed to apply the modules after performing the neuropsychological test battery. The automated output for shared decision making should be discussed between staff and the patients. Then, paramedical staff could apply the training modules and then support the participants in the transfer to home where training could be continued remotely controlled.

To demonstrate the proof-of-principle and provide first results on efficacy of training around 30 patients after stroke are included. During in-patient rehabilitation a one-by-one training

Description of the way to implement the initiative

CONTRAST aims to implement a Chronic Care Model for post-stroke patients. The Chronic Care Model requires that Community and Health Systems contribute to well-prepared practice teams and informed active patients who are in a productive interaction allowing for shared decision making on the cognitive training which has to be continuously adapted to the individual patient to be adopted. Improved outcome is demonstrated, for example, by increased self-efficacy, which is associated with low levels of depression and feelings of helplessness.

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Figure 1. The Chronic Care Model

CONTRAST will implement the Chronic Care Model by establishing the Human-Computer-Interface (HCI). The HCI will process and integrate data that are acquired from multiple measuring sources (EEG, heart rate, social interaction) realised at the patient’s home:

  • The patient sets up a headset with electrodes, sits at home at the computer, while the doctor is in the clinic with a computer that is connected to the patient.
  • During the interactive session, the HCI sends information to the doctor. So, the patient and the doctor can interact.
  • On the basis of these data, the experts/doctors and the patient can share the decision on the training that should be conducted. Questions can be answered immediately.

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Figure 2. Implementation of feedback of physiological signals such as EEG (electroencephalogram), ECG (electrocardiogram) and for hearth rate HRV (heart rate variability) for improvement of general attention, memory and affective state.

CONTRAST’s core interventions to improve the recovery after stroke are training modules which address attention and memory. The affective state is also an important target of intervention, since depression is frequent after stroke and hampers cognitive function, and functioning in daily life. Therefore, CONTRAST will provide accurate, adaptive, individually tailored interventions to improve both cognitive function and affective state.

The CONTRAST solutions are based on sound medical and neuropsychological assessments and will help the expert and patient to work together to further develop the best training schedule.

Main results, benefits and impacts

CONTRAST will create a product that comprises three core elements:

  1. The HCI (Human-computer Interface) with cognitive training modules, and training to reduce depression.
  2. An individually tailored solution for applying these modules; this solutions can be discussed with the patient in a process of shared decision making.
  3. A test battery for measuring the training outcome at the behavioural (neuropsychological tests, activity measures, quality of life) and physiological level (heart rate variability, EEG).


The major objectives of the CONTRAST project are as follows:

Diagnosis. CONTRAST will provide an algorithm that helps the expert and patient to make sound decisions on which training modules should be used. The individually tailored interventions will be based on neuropsychological, psychological and medical assessments.

Neurofeedback-Based Training Modules. Embedded in a highly attractive and user-friendly virtual environment the patient will receive feedback about the activity in distinct brain areas measured via EEG. By making use of neurofeedback the cognitive function of interest is targeted directly in the brain. Developing an easy to use semi-dry EEG headset (comparable to headphones) will also be an objective within the CONTRAST project.

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Mood Disturbances. In addition to the improvement of cognitive functions, affective states are also important targets of the training modules. The reasoning behind is that depression is frequent in post-stroke patients and hampers executive functions, and functioning in daily life. By integrating HRV biofeedback this challenge will be addressed.

Home Support and Monitoring. In order to create a product suitable for home use CONTRAST will provide remote-control and tele-monitoring of important health and performance parameters. These features will be embedded in an HCI architecture that processes and integrates data acquired at the patient’s home from multiple sources.

Evaluation and Dissemination. The development of the product will be based on interactive feedback loops between patients, professionals and developers to ensure the best practical outcome. Also a test battery for measuring outcome at the behavioural (neuropsychological tests, activity measures, quality of life) and physiological level (heart rate variability, EEG parameters) will be composed. Additional dissemination efforts, including hosting two workshops and dissemination through publications and major events, will ensure participation of key stakeholders.

Additional challenge: As an additional challenge CONTRAST will explore the benefits of using virtual realities within the rehabilitation field.

Expected Results & Impacts

From a clinical point of view: CONTRAST’s approach to rehabilitation considers the patient as partner and fosters empowerment. The deficiency in current approaches, e.g. the huge gap between clinical and home rehabilitation, will be addressed by CONTRAST. The shared doctor-patient support system will synergise with the well-designed and user-friendly new HCI to motivate patients to remain compliant and engage with doctors, caregivers, and other key people. CONTRAST aims to increase autonomy in daily living of people after stroke, thereby improving their quality of life.

From a social point of view: Europe’s aging societies are leading to an increasing social and financial burden for young generations. Highly effective and economical approaches in rehabilitation are therefore mandatory. By potentially reducing the in-patient rehabilitation time and leading to a better cognitive and emotional outcome for the patient and the social environment, CONTRAST will reduce life time costs for people after stroke. At the same time, CONTRAST will make an effort to motivate and socially include people affected by stroke.

From a business perspective: CONTRAST clearly has the potential to surpass existing systems for neuropsychological rehabilitation. The resulting product COALA will be unique for combining neurofeedback with tele-monitoring, and being highly adaptable to the individual. It will be portable and positioned in the low-cost sector, therefore perfect for home use. In addition, CONTRAST will make an effort to ensure broad dissemination and exploitation of the product. For being highly attractive to a broad and even growing market the resulting product will presumably be easy to market.

From a scientific point of view: CONTRAST’s numerous multimodal research efforts will gain important insights in the brain mechanisms and benefits of diverse training modules (embedding EEG-signals and HRV), remote-controlled systems, and virtual realities in the context of stroke rehabilitation. The CONTRAST project might turn out to make a significant contribution to Europe’s quest for a leadership position in the rapidly growing field of BNCI (Brain/Neuronal Computer Interaction).

Return on investment

Return on investment: Not applicable / Not available

Track record of sharing

Our research results will be published in scientific journals and conferences. Further, we will conduct a workshop to inform doctors and paramedical staff about the CONTRAST achievements.

All project partners are involved in dissemination. Our industrial partners will disseminate the CONTRAST results via their dissemination channels.

Lessons learnt

  • Success of the project depends on careful patient selection
  • The COALA product MUST be easy-to-use, functional and not add any further workload on medical and paramedical staff
  • Training modules are applicable to stroke patients and first results indicate the expected improvements in cognitive performance and other indicators of success.
Scope: International