Birbaum Et Al 1999 - Spelling Device For The Paralysed

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scientific correspondence

A spelling device for the paralysed


hen Jean-Dominique Bauby suffered
W from a cortico-subcortical stroke that
led to complete paralysis with totally intact Initial Advanced
Subject A LIEBER-HERR-BIRBAUMER-

HOFFENTLICH-KOMMEN-SIE-MICH-BESUCHEN,-WENN-DIESER-
training training Copy spelling Free spelling
100 BRIEF-SIE-ERREICHT-HAT-.ICH-DANKE-IHNEN-UND-IHREM-
..
sensory and cognitive functions, he TEAM-UND-BESONDERS-FRAU-KUBLER-SEHR-HERZLICH,-DENN-
..

Correct responses (%)


SIE-ALLE-HABEN-MICH-ZUM-ABC-SCHUTZEN-GEMACHT,-DER-
described his experience in The Diving-Bell 80 .. ..
..
OFT-DIE-RICHTIGEN-BUCHSTABEN-TRIFFT.FRAU-KUBLER-IST-EINE-

and the Butterfly1 as “something like a giant MOTIVATIONSKUNSTLERIN.OHNE-SIE-WARE-DIESER-BRIEF-NICHT-


ZUSTANDE-GEKOMMEN.-ER-MUSS-GEFEIERT-WERDEN.-DAZU-
..
invisible diving-bell holds my whole body 60 MOCHTE-ICH-SIE-UND-IHR-TEAM-HERZLICH-EINLADEN-.
EINE-GELEGENHEIT-FINDET-SICH-HOFFENTLICH-BALD.
prisoner”. This horrifying condition also 40
..
MIT-BESTEN-GRUSSEN-
occurs as a consequence of a progressive IHR-HANS-PETER-SALZMANN

neurological disease, amyotrophic lateral 20


sclerosis, which involves progressive degen- 0
Figure 2 The first full message written by subject A.
eration of all the motor neurons of the 0 20 200 240 280 320 360 400 440
somatic motor system. These ‘locked-in’ Sessions responses at the 8-µV level was achieved,
patients ultimately become unable to the patients began to work with the spell-
express themselves and to communicate Initial
Subject B
Free
ing device. Subject A achieved this level
even their most basic wishes or desires, as 100
training Advanced training and copy spelling spelling after 327 sessions and subject B achieved it
they can no longer control their muscles to after 288 sessions (Fig. 1).
Correct responses (%)

activate communication devices. We have 80 For the spelling program at level 1, the
developed a new means of communication alphabet was split into two halves (letter
60
for the completely paralysed that uses slow banks) which were presented successively at
cortical potentials (SCPs) of the electro- 40 the bottom of the screen for 4.5 seconds
encephalogram to drive an electronic spell- (subject A) or 6 seconds (subject B). If the
20
ing device. subject selected the letter bank being shown
The neurophysiological basis and behav- 0 by generating a SCP, it was split into two
0 100 140 180 220 260 300 340
ioural functions of SCPs have been new halves, and so on until each of the two
Sessions
described2, and operant conditioning has letter banks had only one letter in it. When
been used to bring them under voluntary one of the two final letters was selected, it
control. We have shaped the voluntary con- Figure 1 Response accuracy of subjects using the was displayed in the top text field of the
trol of SCPs in two locked-in patients with new spelling device. Subject A began with feed- screen and then the selection began again at
amyotrophic lateral sclerosis who were able back training of SCP amplitude (initial and level 1. A ‘go back’ function, which
to learn to operate a spelling device by regu- advanced training; 71.3% correct selections, 75.0% appeared as an option when two successive
lating their brain responses. The spelling correct rejections, based on ‘go-back’ responses), letter banks had not been selected, allowed
device drives a cursor on a video screen, proceeded to copy spelling (copying of letters and the speller to go back one step to the previ-
allowing the subjects to select letters of the then words; 78.7%, 75.3%) and finally to free ous set of letter banks. If the speller was at
alphabet. Previous interfaces between spelling (self-selected letters; 66.4%, 82.9%). Sub- level 1, selecting this function erased the last
brains and computers have used different ject B began with initial training, then switched to a symbol written in the text field, so mistakes
brain responses, such as certain frequency combination of advanced training (77.5%, 68.8%) could be corrected. This procedure was
bins or event-related brain potentials3,4, but and copy spelling (77.5%, 67.6%) and finally to free chosen after extensive pilot work6 involving
these have not yet been tested with locked- spelling (86.2%, 73.7%). different types of speller.
in patients. The accuracy of responses during feed-
Both subjects suffer from advanced by a box being highlighted in either the back training, copy spelling and free
amyotrophic lateral sclerosis and have been upper (negativity) or the lower (positivity) spelling is shown in Fig. 1 for both patients
artificially respirated and fed for four years. half of the screen. Visual feedback of SCPs, over the course of 446 (subject A) and 308
Sustained voluntary control of the muscula- which was updated every 64 ms, was pro- sessions (subject B). Two types of error
ture was not possible in either patient, so vided by a ball that moved towards or away were possible: incorrect rejection was due to
they were unable to use a muscle-driven from the box, depending on the direction the SCP amplitude being too low, and
communication device. They were trained in which the SCP deviated from baseline. incorrect selection occurred when a high
to produce changes voluntarily in their SCPs The response criterion was progressively SCP was made in the presence of a wrong
lasting 2–4 seconds. Each trial consisted of a increased from 5 to 8 mV. letter or row of letters. Both subjects can
2-second baseline and a response period SCPs were extracted from the regular now write messages. The first full message
lasting 2–4 seconds, the length of which was electroencephalogram using a time con- written entirely by the brain of subject A is
adapted to suit the patient. A training day stant of 8 s and a low-pass filter of 40 Hz. shown in Fig. 2.
consisted of 6–12 sessions (depending on They were recorded from the vertex rela- Our data indicate that patients who lack
the condition of the patient), each of which tive to linked mastoids at a sampling rate muscular control can learn to control vari-
comprised about 70 to 100 trials and lasted of 256 Hz. Vertical eye movements were ations in their SCPs sufficiently accurately
about 5–10 minutes. simultaneously recorded with standard to operate an electronic spelling device.
During the response period, the subjects on-line removal of eye-movement arte- Although writing sentences is time con-
were required to produce either negativity facts2. Using an imagery strategy5, both suming — subject A took 16 hours to write
or positivity greater than a specific criterion patients were better able to produce posi- the message in Fig. 2, a rate of about 2
amplitude in random order. The baseline tivity than negativity, so training for nega- characters per minute — it is reliable and
and response periods were signalled by two tivity was soon discontinued. As soon as a precise enough to allow the patient to com-
clearly different tones, and whether positiv- stable performance of at least 75% correct municate with his or her environment.
ity or negativity was required was indicated (hitting the goal for at least 500 ms) These completely paralysed individuals
NATURE | VOL 398 | 25 MARCH 1999 | www.nature.com © 1999 Macmillan Magazines Ltd 297
scientific correspondence
now have the ability to communicate, a
15 2 —6 1
possibility that has not previously existed

Log (detection limit)

Relative sensitivity
d
EAD c

EAD response (mV)


2
for such severely affected patients.

FID response (mV)


1 FID —7 0.1
b
N. Birbaumer*†, N. Ghanayim*, 10
3 4
1 —8 0.01
T. Hinterberger*, I. Iversen‡, 5 6 a
B. Kotchoubey*, A. Kübler*, —9 0.001
Absolute Relative
J. Perelmouter*, E. Taub§, H. Flor¶ 5 0 —10 0.0001
*Institute of Medical Psychology and Behavioural M. acuminata I. typographus
P. cyanea L. decemlineata
Neurobiology, University of Tübingen,
Gartenstrasse 29, 72074 Tübingen, Germany 0 —1 Figure 2 Absolute and relative sensitivities of
3 4 5 6 7 8 9 10 11
e-mail: niels.birbaumer@uni-tuebingen.de Retention time (min)
pyrophilic and non-pyrophilic insects to guaiacol.
†Department of Psychology, University of Padova, Absolute detection limits were estimated by fitting
Via Venezia 8, 35131 Padova, Italy Figure 1 Typical gas chromatograms. Two detectors logistic curves to dose–response data. The concen-
‡Department of Psychology, were used: a flame-ionization detector (FID), indicat- trations where confidence intervals (at 0.05) of aver-
University of North Florida, ing any oxidizable compound; and an electro- age control responses did not overlap with
Jacksonville, Florida 32224, USA antennographic detector (EAD), using an isolated confidence belts of fit functions were regarded as
§Department of Psychology, University of Alabama, antenna of Melanophila acuminata. The sample the limits of detection. Error bars show standard
Birmingham, Alabama 35294, USA contains volatiles released by 1 g of smouldering deviations. Letters indicate significantly differing
¶Department of Psychology, Humboldt-University, wood in 1 s, a quantity typically transported over responses (Mann–Whitney U test, P*0.05) to con-
Hausvogteiplatz 5-7, 10117 Berlin, Germany long distances. The FID response indicates quanti- centrations at detection limits. For insects infesting
1. Bauby, J.-D. The Diving-Bell and The Butterfly (Fourth Estate,
ties of the mixture’s components. The EAD res- pine trees, a-pinene was chosen as a reference
London, 1997). ponse (amplified by a factor of 100) indicates the substance for obtaining relative sensitivities, as it is
2. Birbaumer, N., Elbert, T., Canavan, A. G. M. & Rockstroh, B. electrophysiological response of the antenna to: 1, a typical constituent of host plant odour with a low
Phys. Rev. 70, 1–41 (1990).
a-pinene; 2, carene; 3, 2-methoxy-phenol (guaiacol); detection limit. (Z)-3-hexen-1-ol was chosen for the
3. Vaughan, T. M., Wolpaw, J. R. & Donchin, E. IEEE Trans.
Rehab. Eng. 4, 425–430 (1996). 4, 2-methoxy-4-methyl-phenol (4-methyl-guaiacol); 5, Colorado potato beetle (L. decemlineata) as a sensi-
4. Farwell, L. A. & Donchin, E. Electroencephalogr. Clin. 4-acetyl-guaiacol; 6, 4-formyl-guaiacol. The two tively detected constituent of its host plant odour.
Neurophysiol. 70, 510–523 (1988). peaks only in the EAD trace (retention times of 6.0
5. Roberts, L. E., Birbaumer, N., Rockstroh, B., Lutzenberger, W.
& Elbert, T. Psychophysiology 26, 392–403 (1989).
to 6.5 min) indicate substances detected by anten- to fire-damaged trees is less pronounced.
6. Perelmouter, J., Kotchoubey, B., Kübler, A., Taub, E. & nae at concentrations below the detection limit of Its sensitivity to guaiacol is slightly lower at
Birbaumer, N. Automedica (in the press). the FID: 10 ng per ml of carrier gas); presumably, 1557 pg ml11 (n411). The bark beetle
they are isomers of compound 3. Ips typographus is a pulp-feeding forest
pest without detectable attraction to fire-
of 2-methoxyphenol (guaiacol) eliciting the damaged trees, but some sensitivity to gua-
Insect antenna as a greatest response. iacols is expected because pulp also contains
Methoxylated phenols are released by guaiacol. It shows only a moderate absolute
smoke detector the incomplete combustion of lignin8 and (120565 pg ml11, n49) and relative sensi-
have been identified as atmospheric mark- tivity to this compound. The Colorado
The larvae of jewel beetles of the genus ers of wood smoke. The chemical structure potato beetle, Leptinotarsa decemlineata, is a
Melanophila (Buprestidae) can develop only of the phenolic compounds in smoke is non-pyrophilic pest that is not attracted to
in the wood of trees freshly killed by fire1. To dependent on the species of tree attacked fire-damaged trees, although it exhibits
arrange this, the beetles need to approach by fire9. Because it is particularly sensitive escape behaviour in response to high con-
forest fires from as far as 50 kilometres to guaiacol derivatives, Melanophila can centrations of fire-generated volatiles. It
away1,2. They are the only buprestid beetles detect remote forest fires and might even does not show such specialized sensitivity
known to have paired thoracic pit organs3, be able to use the pattern of volatiles to (4505160 pg ml11, n424) to guaiacol
which behavioural2, ultrastructural4 and identify the species of tree. Our results derivatives. These values reflect the relative
physiological experiments5 have shown to be therefore indicate that the beetles can per- degree of specialization to fire detection.
highly sensitive infrared receptors, useful for ceive a fire-damaged P. sylvestris tree by In the same way that infrared-sensitive
detecting forest fires. It has been suggested olfactory cues. pit vipers and boid snakes use chemorecep-
that Melanophila can sense the smoke from The beetles’ antennae can detect these tors on their tongue to detect volatiles
fires6, but behavioural experiments failed to guaiacol derivatives at concentrations as low released by their prey, Melanophila beetles
show that crawling beetles approach smoke as a few parts per billion (p.p.b.) (Fig. 2). We use chemoreceptors sensitive to the speci-
sources2. We find that the antennae of jewel estimate10 that this sensitivity is sufficient for fic volatiles of burning wood. It is unclear
beetles can detect substances emitted in the beetle to detect a single pine tree 30 cm how the two sensory systems used by
smoke from burning wood. in diameter that has smouldering bark to a Melanophila to identify fire — the thoracic
We connected freshly excised antennae height of 2 m and a bark depth of 1 cm, infrared receptors and the antennal olfac-
from M. acuminata (n45) to a gas chro- releasing about 7 g of guaiacol in an hour tory receptors — act together to detect fire
matograph equipped with parallel flame under light wind conditions (0.3 m s11), and orientate the beetle towards its source.
ionization and electroantennographic detec- from a distance of more than 1 km. Understanding how the beetles detect
tors7. Volatiles generated by smouldering M. acuminata shows a high absolute fires could have applications in fire detec-
splint wood from Pinus sylvestris were col- (1.150.8 pg ml11, n414) and relative sen- tion devices11 in storehouses and public
lected on a charcoal trap, chemodesorbed by sitivity to guaiacol. For comparison, we also buildings, for example, as well as in early-
an organic solvent, and injected into the studied the sensitivity to guaiacol of three warning detection systems for forest fires.
apparatus. The resulting chromatograms other beetles. The pulp-feeding forest pest Stefan Schütz*, Bernhard Weissbecker*,
indicated that several components of these Phaenops cyanea attacks weakened trees and Hans E. Hummel*, Karl-Heinz Apel†,
volatiles were biologically active (Fig. 1). sometimes breeds in trees that have previ- Helmut Schmitz‡, Horst Bleckmann‡
Most of the volatiles perceived by the anten- ously been damaged by fire. It is closely *Justus-Liebig-Universität Giessen,
nae are phenolic compounds, derivatives related to M. acuminata, but its attraction Institut für Phytopathologie und Angewandte

298 © 1999 Macmillan Magazines Ltd NATURE | VOL 398 | 25 MARCH 1999 | www.nature.com

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