Creating an engaging brain computer interface, electrical stimulation therapy for children with hemiparesis: a pilot study

Creating an engaging brain computer interface, electrical stimulation therapy for children with hemiparesis: a pilot study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Creating an engaging brain computer interface, electrical stimulation therapy for children with hemiparesis: a pilot study Anna Bourgeois, Meghan Maiani BScOT, Araz Minhas, Payton Shaw, and 14 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7420830/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Apr, 2026 Read the published version in Journal of NeuroEngineering and Rehabilitation → Version 1 posted 8 You are reading this latest preprint version Abstract Background : Perinatal stroke can lead to lifelong physical disabilities, where even small improvements in motor function can increase quality of life. Rapid brain development in children provides an opportunity to harness brain plasticity. Current therapies are minimally effective in part due to the boring, unengaging procedures required to achieve adequate repetitions required for therapeutic benefit. The combination of functional electrical stimulation and brain computer interface (FES/BCI) may be effective for adults with stroke-induced hemiparesis and appears feasible in children. We designed a novel FES/BCI system that uses social media to engage youth. Methods: The project was informed through engagement with youth patient partners with lived experience. Participants were fitted with a 16 channel EEG gel headset. BCI training consisted of 20 trials of attempted target movement. Successful classification was paired with FES of the target movement and allowed the participant to swipe to watch the next video as desired. Youth with perinatal stroke and hemiparesis were then recruited to trial the system. Outcomes included training accuracy, BCI performance (Cohen's Kappa), box and blocks, and qualitative interviews to characterize useability and patient experience. Results : Twelve participants (aged 10-23 years) completed three sessions. No adverse events occurred; fatigue was minimal and varied across sessions. System performance varied but most sessions had moderate or better agreement. Average FES repetitions for all sessions were 167 reps/hour [sd:55.2 range: 65-283 reps/hour] and 247 reps/hour [SD: 74.9 range:105-379 reps/hour]. Motor outcomes were variable but improved for some. Qualitative feedback suggested higher motivation and enjoyment compared with traditional therapies but also identified frustrations surrounding technical challenges and equipment comfort. Conclusion: Informed by users, simple EEG-based BCI can be integrated with FES and social media to enhance upper extremity rehabilitation in youth with hemiparesis. This pilot trial will inform the design of future clinical trials to evaluate efficacy. Clinical trial #: NCT07133347 Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Perinatal strokes are focal neurovascular brain injuries that affect 5 million people worldwide and can lead to lifelong physical disabilities. 1,2 It is the leading cause of hemiparetic cerebral palsy (HCP) which is characterized as motor dysfunction on one side of the body. 3–5 Effective therapeutic interventions can improve stroke outcomes as the young brain can adapt by creating new connections, reorganizing networks, and altering synapses. 6–9 Even modest improvements in a child’s hand function can positively impact participation and affect quality of life, which is why there is a push for therapeutic interventions during earlier developmental windows. 10 Pediatric therapeutic interventions must be family-centred with the patient’s goals at the forefront to maximize repetitions while optimizing engagement and enjoyability. 11 Motivation and attention are vital in modulating neuroplasticity, and successful task-based practice is necessary to see functional changes. 12 Partnering with patients can this by applying partner feedback directly into the design of novel interventions and embracing more engaging technologies such as social media to enhance interest, compliance, and ultimate efficacy. 13 Functional electrical stimulation (FES) stimulates muscle contraction during activity performance through low-intensity electrical currents. When applied to the affected limb, it can reduce spasticity-related symptoms and improve range of motion (ROM) and strength. 14 When a patient’s attempted movement is paired with FES, it triggers the cortical activation of sensorimotor areas, the degree of which has been associated with functional improvement. 15 In stroke rehabilitation guidelines for adults, upper extremity FES receives the highest evidence-based recommendation. 16 However, it has not been adequately studied in children, largely due to challenges with engagement, since high repetition counts are required to achieve meaningful functional gains. 17 - 18 Brain Computer Interfaces (BCI) work by converting intentional brain activity into commands that can be used to control external devices. BCIs have been recently under investigation for their role in stroke rehabilitation. 19–21 Specifically, BCI paired with FES has been explored as a novel way to drive task-related neuroplasticity to improve motor impairments over time in adults with stroke. 22 Evidence suggests BCI-FES may be effective in adult patients with stroke-induced hemiparesis. 20,22 Despite the evidence of enhanced neuroplasticity, the use of FES and BCI in children remains limited. 7 A study conducted within our group suggested that BCI-FES is feasible and well-tolerated in children with perinatal stroke; however, several children were unmotivated to continue the therapy, indicating that incorporating gamification could help sustain engagement and potentially improve BCI performance. 21 Here, we created a novel and engaging BCI-FES therapy designed for youth with the aim of increasing long-term efficacy. Methods A multi-disciplinary team of therapists, engineers, researchers, clinicians, and patient partners helped design a BCI FES therapy that is integrated with social media. The resulting application was named FlickTok, a novel BCI/FES social media therapy system. FlickTok integrates three interacting components: 1) an EEG headset, 2) the FES system, and 3) an application to coordinate the two components with social media interactions. Patient Partner Engagement We engaged three youth patient partners to design and build a BCI-FES integrated with social media to ensure research focus was on patient identified priorities. 13 Before development began, we worked with the patient partners to ensure that the system aligned with target users They helped us pilot test the system to evaluate and improve technical performance and usability. Our patient partners were also actively involved in the study design, helping to develop and conduct the qualitative interviews and supported results interpretation. Patient partner engagement methodology is found in Supplementary Figure 1. EEG A 16-channel EEG headset with gel-based g.Scarabeo electrodes and g.USB amplifier (g.tec medical engineering GmbH, Austria) was used to read and record the user’s brain activity. EEG was recorded from FC5, FC1, FCz, FC2, FC6, C5, C3, C1, Cz, C2, C4, C6, CP5, CP1, CP2, CP6 with a reference electrode placed at FPZ and a ground electrode on the participant’s earlobe. EEG was sampled at 256 Hz, with a Nyquist frequency of 128 Hz, this sampling rate is entirely sufficient to capture the EEG signals of interest which are in the Mu (~8 – 13 Hz) and Beta (~13 – 30 Hz) bands. FES The FES component was driven by a computer and stimulates the desired muscles for the execution of the target functional movement. Working with an occupational therapist (OT), we chose three functional movements to target: wrist extension, thumb abduction, and finger extension. A set of disposable “2 × 2” carbon rubber electrodes were applied to the targeted motor nerves on the forearm individualized for each participant. Electrode placement differed between participants based on individual anatomy, function, and target movement chosen. If a target movement could not be generated with FES, the participant was excluded from the study. Muscle stimulation was delivered using the Neurotrac 23 Dual Channel Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES) device with a remote switch. FES parameters differed between participants to maximize tolerability and was adapted if the participant became fatigued. FES current and voltage ranged from 8 mA to 35mA and frequency ranged from 35–40 Hz. To facilitate connecting the FES to the BCI output, we built a custom designed micro controller-based interface that connected to a USB port, enabling direct communication from the computer to control the FES stimulator. Application The FlickTok application was structured in two parts: a Python server that coordinated EEG signals built in-house using our open-source BCI software package, BCI-Essentials system. 24 The custom BCI was used to classify the EEG signal as either ‘Action’ or ‘Rest’. The second part consisted of an Electron-based user-facing application that integrated social media content and FES stimulation with the BCI. YouTube Shorts and Instagram Reels were used during both the training of the BCI and the session itself to increase participant engagement and motivation. To personalize the sessions, each participant chose a specific type of content they wanted to engage with. The social media application was displayed on a monitor and coloured icons that represented the attempted movement were integrated to improve understanding of the system. Calibration and Classification Calibration of the BCI system consisted of twenty repetitions using a 2-second on, 2-second off protocol, adapted to identify epochs of intentional “action” (on-condition) from “rest” (off-condition). Labelled 2 s epochs from calibration were used to train a Riemannian Geometry classifier without filtering, artifact rejection, or channel selection. The Riemannian Geometry approach was chosen, because it has been demonstrated as the state-of-the-art for motor imagery classification using very little data, 25 and the attempted movement task leverages the same phenomenon of event-related synchronization/desynchronization as motor imagery. First, covariance matrices were calculated for each epoch using Oracle Approximating Shrinkage (OAS) 26 , then the tangent space representation was extracted from each covariance matrix. The values of the tangent space representation of each epoch were used to train a logistic regression classifier, using 3-fold cross-validation to estimate classification accuracy. This pipeline was implemented using the PyRiemann library. 27 Following calibration, the trained classifier was then used to predict whether each 2 s non-overlapping window consisted of either action or rest. If a 2 s epoch is classified rest, nothing happened, and the video continued playing. If the window was predicted as an attempted action, an animation of the intended action played on screen, the FES stimulation was triggered, and the FlickTok application would continue to the next video. Following an action prediction, there was a 5 s pause for the action and FES stimulus to take place and for the next video to begin playing. During this pause, no windows of EEG were sent for classification. Following this 5 s period, each 2 s window of EEG was classified as action or rest. The BCI-FES-social media system set up is summarized in Figure 1. Figure 1. Successful Swipe FlickTok Flow Diagram: Participants were seated comfortably and fitted with both functional electrical stimulation (FES) and a brain-computer interface (BCI) cap. They scrolled through their chosen social media platform, resting when the screen was red. When the screen turned green, they either watched a video or attempted a movement. If the attempted movement was correctly detected by the BCI, it triggered the FES to complete the motion. If successful, the screen turned blue, and the social media content was swiped. If the BCI made an incorrect prediction (false positive) to turn on the FES and swipe the video, the FES stim would be manually turned off. On the other hand, if the BCI did not accurately predict activity when the user attempted a movement (false negative) the social media would be manually swiped by the researcher to the next video to keep the participant engage. Estimated time for each step was measure ins seconds (s). Participants Participants for the pilot trial were recruited from the Alberta Perinatal Stroke Project (APSP). 28 All participants or their guardians provided written informed consent/assent as appropriate. Inclusion criteria were: (1) Age 10-25 years (2) MRI-confirmed perinatal stroke including neonatal arterial ischemic stroke (NAIS), arterial presumed perinatal ischemic stroke (APPIS), or periventricular venous infarction (PVI) (3) Symptomatic, disabling HCP including child/parent perceived limitations in function but at least minimal upper extremity function (i.e., able to use the affected arm to lift a light object against gravity) (4) able to elicit a satisfactory physiological muscle contraction, described in the procedures below (5) a score of 3 on the Modified Ashworth Scale (MAS). 29 , 30 Exclusion criteria included: (1) severe intellectual disability (2) unstable epilepsy (3) upper limb surgery or botulinum toxin treatment within 12 months (4) severe spasticity (MAS >3) or contracture. This study was approved by the University of Calgary Research Ethics Board. Intervention Participants completed three 90-minute FlickTok sessions, each over the course of four weeks. Scheduling was primarily in the evening to accommodate participant needs. Testing took place at the Alberta Children’s Hospital in the Pediatric Brain Computer Interface Lab. During the first visit, we explained the study procedures. After motor tests and questionaries were complete, the participant spoke to a registered OT to determine the desired functional movement that would be paired with FlickTok. The therapist performed muscle responsiveness testing to ensure the FES could stimulate the proper muscles for the functional movement selected (e.g. wrist extension, thumb extension). Then the participant was fitted with the EEG cap and FES electrodes. The Flick-Tok therapy was trained, then the participant started the therapy. The Flick-Tok system was retrained if a participant’s training accuracy was below 0.4, or upon participant request if the system was not working well. Participants were able to request breaks throughout the session. Sessions two and three were conducted similarly to session one but the final thirty minutes of the third session was reserved for a qualitative interview. Motor, cognition, enjoyment, and fatigue assessments During the initial session, the assisting hand assessment (AHA) was performed to assess affected hand use during a bimanual play session, where a higher score indicates better function. 31 This was completed to characterize baseline function. All motor assessments were recorded and scored by the same individual. BCI requires sustained, focused attention, so parents were asked to complete the Behavior Rating Inventory of Executive Function (BRIEF) to give a parent report of executive and attention function. 32 Box and blocks assessment (BBT) on both the affected and unaffected side, was assessed as well as active and passive ROM assessments taken before and after each session to quantify motor function. After each session, the participant was asked to rank their enjoyment of the FlickTok experience against six other common childhood experiences. For sessions two and three, participants were asked to evaluate their fatigue before and after the session using a visual analog scale for fatigue; session one was considered too short to measure fatigue. 33 Qualitative Interview The qualitative, semi-structured interviews were conducted independently by a patient partner (female, 18). She was trained by an experienced qualitative researcher and had previously conducted multiple practice interviews. She had not attended any of the previous sessions and did not know the participants prior. The interview guide was developed in collaboration with two patient partners and trialed with the third patient partner. Interviews were audio-recorded and transcribed verbatim using Rev.com, an online transcription service. Interview transcripts were analyzed using NVivo 14. 34 Analysis was informed by an interpretivist paradigm, and that they were analysed using conventional content analysis. 35 Two team members independently coded all transcripts. Coders read each transcript several times to gain familiarity and met weekly to discuss trends and compare discrepancies between us eventually leading to the generation of a codebook. Our patient partner helped refine themes and codes, to ensure we captured the perspectives of the participants. Analysis: Rank ratings on the fatigue scale were converted into a change score between sessions defined as post-pre intervention, such that negative scores reflected a decrease in fatigue rating. Scores from the BRIEF were reported as global executive composite age-normed T-scores. This accounted for age-related differences in executive function development. 32 All FlickTok sessions were recorded so that repetitions could be reviewed offline for accuracy and to code movement attempts. To ensure consistency across participants, all repetition counts were scaled to a per-hour rate. Repetitions per hour were calculated by counting the number of attempts with and without assistance from FES. Repetitions without FES included the full training duration, as training did not incorporate FES-assisted repetitions. All repetitions were the sum of repetitions with and without FES. Cohen’s kappa (a quantification of agreement in attempt accuracy) was calculated by defining a true positive value (TP) as FES being triggered within 6 seconds of the participant attempting a movement and defining false positive (FP) as the FES firing without an attempted movement. A true negative (TN) was defined as 6 seconds of the FES not firing when the participant did not attempt movement – i.e. the participant did not want to trigger an FES, and the BCI did not unintentionally activate. A false negative (FN) was defined if the participant attempted a movement and Flick Tok did not trigger the FES for 6 seconds. In this case, the video was manually swiped. Six seconds was chosen as the time to determine success, as this allowed intent and initiation of movement without undue delay. Previous literature of adult studies typically use 3–4.5 s for determining successful activation following prompt by the researcher or therapist. 22 In this study, we extended this window to 6 s total, as participants were not prompted for activation and instead chose their own initiation. Paired with how the BCI resolved predictions of actions every 2 seconds, we wanted to be lenient with the possibility that the user may begin an activation at the end of a 2-second processing window, which wouldn’t then be identified until the next window at the earliest, so we added a 2-second buffer on top of the typical 3-4.5 second window from adult literature. 22 Repetitions with excessive movement/talking were removed for this calculation. Values were extracted by reviewing videos of participants during the three sessions. Cohen’s kappa Descriptive statistics were completed on Jamovi. 36 All graphs were made with Python 37 and the methodology figure was made with Canva 38 . Results Population Twelve participants were recruited to the pilot trial (50% female, 15.75 (SD:4), range 10-23 years). Population demographics are summarized in Table 1. AHA scores ranged from: 33-69 logits, BRIEF T-scores ranged from: 35-75. All participants participated in all three sessions and completed all surveys, motor tests, and the interview. Participant F did not have a complete set of BCI data because there was an application system failure during their third session, so we manually stimulated the FES when they attempted their movement. Since we were evaluating BCI performance and repetitions with the FlickTok therapy, they were removed from the repetition and BCI performance results of the third session. There were three protocol violations due to the exclusion criteria. Specifically, participant L had botulinum toxin treatment four months prior to the study however we were still able to achieve contraction, so they were included. Participant B had orthopedic surgery on her hand, but we pivoted to choosing elbow flexion as her functional movement. Participant F was not able to achieve full strength FES to reach a contraction because of tolerability. Table 1: Demographics Subject ID Sex Age Stroke Side Stroke Type Lesion location MACS level AHA (logits) BRIEF (T Score) Functional Movement A M 18 L APPIS PM1 II 33 75 Wrist extension B F 16 R APPIS DM1 II 43 42 Elbow flexion C F 14 L APPIS DM1 II 48 53 Wrist extension D F 15 R PVI II 62 39 Wrist extension E M 11 L APPIS DM1 I 52 50 Wrist extension F F 16 R PVI II 41 55 Fingers extension G M 15 L NAIS DM1 I 69 55 Index finger extension H M 10 R PVI I 53 43 Wrist Extension I F 11 R APPIS PM1 II 41 62 Fingers extension J F 20 R PVI I 59 35 Index finger and thumb extension K M 23 L NAIS DM1 63 47 Wrist extension L M 20 L APPIS PM1 34 62 Fingers extension Summary 50 % (F) 15.75 (SD:4) 50% (L) 50%: APPIS 33.3%: PVI 16.7%: NAIS 49.83 (SD:11.20) 51.5 (SD:10:33) Table note: PVI- Periventricular Venous Infarction, APPIS - Arterial Presumed Perinatal Ischemic Stroke, NAIS - Neonatal Arterial Ischemic Stroke, DM1 - distal M1 occlusion, PM1 - proximal M1 occlusion, AHA - Assisting Hand Assessment, BRIEF: Behavior Rating Inventory of Executive Function. Vascular territory and stroke type was categorized using T1-weighed MRI scans. Sessions All participants completed three sessions within a 4-week window, with the average time between sessions being 5.7 days. The sessions were entirely guided by the participants, (when/if to take breaks, when to re-train the BCI) to create a more authentic simulation of a real-world therapy experience. Participants chose content such as hockey highlights, baking videos, or funny fail clips. Each participant came in for three 90-minute sessions, but therapy time differed based on individual break and training preferences. No serious adverse events were reported across the 36 sessions. Participant I and C elected to stop the second session prematurely due to fatigue. However, both individuals resumed participation and completed the third session. When asked, participants ranked their BCI experience variably, with ‘FlickTok’ sessions being ranked similarly to long car rides and birthday parties (Figure 2) BBT affected baseline scores varied across participants (mean = 15.5, range = 0-39). Average BBT across sessions were: Session 1: pre:15.5 (SD: 11.57) post:18.3 (SD:13.3), Session 2: pre:17.8 (SD:14.5) post:17.4 (SD:13.6), Session 3: pre:17.2 (SD:13.7) post:17.8 (SD:14.8). Some participants showed improvement, while others maintained consistent performance. ROM measurements also showed substantial variability depending on the movement assessed. (Figure 3.) BCI cap and FES setup took 10-15 minutes per session. Therapy session length was the amount of time spent using social media (not training the BCI). The first session lasted an average of 14:37 minutes (minute: seconds) (SD: 5:17min, range: 8:00 -23:55 minutes), session 2 lasted an average of 30:45 minutes (SD:6:48 , range: 21:41- 45:05 minutes) and session 3 was 25:33 minutes (SD: 3:47 range: 18:21-31:09 minutes). Participants took 0-2 breaks and the BCI was trained between 1 and 4 times (mean:1.8). Average FES repetitions per hour for all sessions were 167reps/hour [SD: 55.2 range: 65-283 reps/hour] and 247reps/hour [SD: 74.9 range:105-379 reps/hour] for all repetitions. Fatigue ratings before and after each session ranged from -3 to +6. Negative fatigue values indicate their fatigue rating was reduced whereas positive fatigue values indicate their fatigue rating was increased. Repetitions and fatigue are described in Figure 4. Mean classification accuracies achieved for training were 69.3% (SD = 14.6, range = 40–97.5%) Within the 35 sessions completed, only three sessions had less than chance agreement (<0), 7 sessions had slight agreement (0.01-0.20), seven sessions had fair agreement (0.21-0.40), 13 sessions had moderate agreement (0.41-0.60), five sessions of substantial agreement (0.61- 0.80) in the Cohen’s Kappa measurement. Four participants maintained moderate to substantial agreement through the three sessions. Training accuracies and Cohen’s kappa values are displayed in Figure 6. Qualitative Interviews: Twelve interviews were completed, averaging 15 minutes per interviews. Eleven were conducted in person, and one was conducted virtually. Seven interviews were conducted one-on-one with the participant and five interviews had a parent present. Four themes were generated from analysis: Participant’s Perception of Therapy, Technology, Effects of Therapy on the Hand and Arm and Future Considerations. More information can be found in Supplementary Table 2. Participants’ Perception of Therapy: Participants generally reported a positive experience, particularly appreciating the incorporation of social media into therapy. This was largely because it involved familiar and enjoyable daily activities "I got to watch stuff or do stuff while doing it. Instead of just doing this with the motion, I could see something I wanted instead of having to just do it without having something to do." (Participant E). Flick Tok made the sessions feel less clinical: “ Time went by quick […] I wasn't feeling like I was doing therapy while I was doing it. It was just like I'm scrolling on Instagram reels.” (Participant J) While others indicated they enjoyed all their therapies. I enjoy all my therapies. They're never boring. ( Participant D ) Participants mentioned constraint inducted movement therapy (CIMT) paired with bimanual therapy camp I really enjoyed it because of how easy it is and not because with [CIMT] camps, I feel like it's a bit too, not intensive, but impractical. ( Participant L) and using FES or NMES without FlickTok application or repetitive practice. ‘A bunch of therapy is just grabbing stuff. It's useless because my hand doesn't work like that. But with the FES its different (Participant B)’ Technology. Participants had a good understanding of how the technology functioned. ‘ They connected a bunch of things to my cap […] when I did a certain action, we would flip to the next video. ’ (Participant G) Some participants felt fascinated with the technology, ‘ It was cool. Controlling the scroll.’ ( Participant B ) and others felt that the technical difficulties such as internet connectivity ‘ It was a little frustrating with it lagging’ (Participant A ) and classification errors ‘ So when I tried to move my wrist up, sometimes it didn't go’ (Participant I) . This limited their ability to control the video content ‘ It just didn't listen to my brain.’ (Participant G). Some participants found the technology difficulties frustrating, which affected how positively they perceived the therapy experience. ‘ I kind of got frustrated ‘(Participant I) Effects of Therapy on the Hand and Arm. Participants reported feeling tired, in pain, or having a tingling sensation in their hand, especially towards the end of the therapy. ‘ That day I got home really tired. I immediately went to sleep[…] my hand was sore and tired.’ (Participant D) Some participants noticed functional improvements in their hand or arm use over the course of three sessions. These included enhanced flexibility, reduced tone, and better use in everyday life: ‘ in foods class, I couldn't roll out the dough before. And then today I was able to roll out the dough perfectly. (Participant D) Some participants highlighted specific reasons they found FlickTok useful, particularly on days when their motor function was more limited. “ Sometimes… you have a bad day where your hand just [is] not working that good. So, I feel like for that it would be helpful ” (Participant J), suggesting the potential of the therapy as a supportive tool on variable function days. Future Considerations. Some participants had equipment concerns, such as discomfort and the appearance of the gel and cap, and wires. I've got a lot of hair and I don't like the gel in my hair. (Participant J) Participants highlighted the need for future improvements such as comfort and appearance. Make it look pretty. [..] Paint it pink […] Put Flowers on it. (Participant B). Another consideration was fitting therapy into daily routines, as some participants needed it to accommodate school, sports, or homework. ‘[I would use it] Maybe every day if I could, if it didn't have hockey. ’ (Participant E). Others reflected on FlickTok being more beneficial when they were younger. “ I feel like it would've been better when I was younger and actually doing physiotherapy on the regular. But now that I'm older and busy, I don't know if I'd have the time to do it” (Participant J). Participants also spoke of using FlickTok at home, and while some expressed, they would wear it for ‘ As long as I have to.’ (Participant A) others were reluctant. Discussion Our pilot trial supports the feasibility of integrating BCI with FES and social media for youth with HCP. The FES/BCI system showed good reliability and performance on par with other EEG-based BCI systems. 39,40 The methods were well tolerated by most, and many reported FES/BCI as a more enjoyable alternative to commonly used therapies such as CIMT or simple FES. Engaging patient partners with lived experience provided valuable insight to system strengths, weaknesses to be addressed, and direction for future pilot and clinical trials. Technical performance was generally good but also contributed to participant frustration and reduced enjoyment of FlickTok. Previous studies have identified that a Cohen’s kappa of at least 0.40 suggests BCI competency. 39,40 This threshold was not consistently achieved by all participants across all sessions. Some children voiced that they found it frustrating when the system did not respond when they attempted a movement. The same enhanced reward motivation of successful social media “swiping” may be countered by exaggerated frustration when it fails. It was unclear whether these failures were due to their EEG signals or an incorrect classification of the BCI software system we used. 24 The integration of BCI with FES aims to strengthen the correct brain signals associated with desired motor movements. However, children with perinatal stroke likely have altered event-related desynchronization and synchronization EEG patterns. 26,41 It is also unclear to what extent watching social media impacts EEG signals and classification. Personalized channel selection based on lesion location could improve performance and should be considered in future studies. 42 The BRIEF metric did not show an obvious association with BCI performance, as previously reported. 21 However, the integration of therapy with social media may mitigate concerns about attention in children, as they indicated that they remained engaged throughout the sessions. The optimal dosage of upper extremity therapy for children with HCP is unclear. While higher dosage is generally associated with greater motor improvement, considerable variability exists. 43 In the context of this study, the number of repetitions was not solely influenced by participant effort but also by their engagement with social media. For example, some participants preferred watching long videos, such as baking tutorials, which reduced opportunities for repeated movement. In contrast, those who engaged in frequent swiping through content completed more repetitions, thereby receiving a higher therapeutic dose. Another factor influencing dose was the participants’ ability to perform the target functional movement within the two-second prediction window. Participants with greater motor function were able to achieve more repetitions, which has been observed in previous studies 44 . Not all participants achieved the repetition or hourly dosage targets seen in pediatric CIMT and bimanual interventions. 44 In adult FES studies, dosage is typically linked to time spent in stimulation, but FlickTok introduces user choice (to swipe or not) complicating dosage. Examining modifiable variables including social media app features, reward behaviours, activation time windows and individual user preferences may identify avenues to enhance repetitions and overall system performance. Fatigue was not directly associated with the repetitions per hour but is a complicated problem that requires further investigation in children with HCP. In some cases, participants described their fatigue during therapy as debilitating, preventing them from completing sessions while others appeared unaffected. Fatigue also impacted performance on the BBT, as some participants became too fatigued to demonstrate improvement. The physiological mechanisms of this fatigue are not clear. We have previously shown that self-reported fatigue increases after 30 minutes of BCI use in school aged children, with accompanying changes in EEG power spectra, though this did not have a major effect on BCI performance. 33 Fatigue has also been linked to the unique neurophysiology of children with perinatal stroke including increased excitability of ipsilateral corticospinal projections from the contralesional hemisphere to the more affected hand. 45 Measurement and possible mitigation of fatigue using patient reported outcomes should be included in future trials of BCI-FES in youth. The possible motor improvements we observed in some participants were unexpected. Our pilot trial was not powered to determine efficacy and three sessions are presumed to be insufficient to improve function through neuroplasticity. However, some qualitative comments also highlighted possible improvements in hand function that participants experienced in everyday life. If nothing else, that some motor measures improved provides additional evidence in support of interventional safety. Our approach does not address the learned disuse of the affected hand, which is commonly observed in youth with HCP. 46 The unimanual approach employed here may only be translationally effective when combined with strategies that promote bimanual hand use. FES is supported by Grade A evidence for adult stroke rehabilitation. 16 In pediatric populations, research is limited but suggests possible efficacy for functional improvement. 47 However, due to the scarcity of studies, FES is not widely used in children. This study emphasizes the need to evaluate FES and FlickTok in long-term interventions. An important, potentially overlooked factor when evaluating a new therapy is how easily it translates into a child’s everyday life. Many of our participants shared that school, sports, and homework could get in the way of using FlickTok consistently. Other considerations include equipment comfort which needs to be at the forefront of design to ensure optimal comfort and ease of use and reduce the risk of abandonment. Even though our system was designed to be user-centered, a lot of the feedback we received suggested that it could be even better aligned with user needs, including some novel ideas we had not considered such as integrating it with an Xbox or a television. Intersubject variability was reflected in the enjoyment surveys where rankings ranged from first to sixth in preference). While some participants enjoyed all their therapies, others found most of them unengaging and preferred the FlickTok concept, validating further exploration and refinement. This study had limitations. The sample size was carefully considered for this pilot trial but limits the generalizability of the findings. We also had limited opportunity to engage with parents or caregivers, whose perspectives could provide additional valuable insight into the feasibility, usability, and potential impact in daily life. The participant driven structure of the system also posed challenges in accurately determining true positive/negative, false positive/ negative values to calculate Cohen’s Kappa. The current method of reviewing video recordings to assess BCI success was highly time-consuming and may not be sustainable in larger studies. Future work should explore more efficient and objective methods of evaluating BCI performance. Conclusions Hemiparetic cerebral palsy is a significant burden on individuals, families and healthcare systems, affecting millions worldwide. Addressing therapeutic gaps in young brains has the potential to propel the entire stroke field forward. 48 BCI can be paired with FES and social media to allow youth with hemiparesis to perform targeted movement therapy in the upper extremity. The user-centred system we designed demonstrates promising performance, tolerability, and feasibility worthy of additional design and testing informed by patient engagement. Declarations Ethics approval and consent to participate The University of Calgary and Alberta Children’s Hospital approved this study. ( REB24-0528) The study was registered at https://clinicaltrials.gov (NCT07133347). Consent for publication Not applicable. Availability of data and materials The data analyzed during the current study is not publicly available due to restrictions on sharing participant health information. Competing interests The authors declare no competing interests. Funding This study was funded by the Alberta Children’s Hospital Foundation. Authors' contributions A.B. , A.H. supported patient partner engagement. A.B. , A.M. ,P.S., I.R., G.W., N.B.,M.A., B.I.,E.S., D.C.M.,A.K.,E.K.L Created and Developed FlickTok. A.B. , M.M,B.I., ,P.S., N.B.,Z.J. H.C., A.K.,E.K.L supported methodology design. A.B. , M.M ,P.S. collected data. A.B. , M.M ,P.S., N.B., D.N, N.R., H.C., A.K.,E.K.L: Analysed Data. A.B :Wrote manuscript. A.B, A.M.,B.I.,P.S., I.R., H.C.,E.S., D.C.M.,R.M. A.H., A.K.,E.K.L: Edited manuscript. Acknowledgments We would like to acknowledge the incredible children and families who participated in this study. References Graham HK, Rosenbaum P, Paneth N, et al. Cerebral palsy. Nat Rev Dis Primers . 2016;2:15082. doi:10.1038/nrdp.2015.82 Fernández-López D, Natarajan N, Ashwal S, Vexler ZS. Mechanisms of perinatal arterial ischemic stroke. J Cereb Blood Flow Metab . 2014;34(6):921-932. doi:10.1038/jcbfm.2014.41 Cornette L, deVeber G, Govaert P. Perinatal stroke. SeminFetal Neonatal Med . 2009;14:243-244. Aisen ML, Kerkovich D, Mast J, et al. Cerebral palsy: clinical care and neurological rehabilitation. Lancet Neurol . 2011;10(9):844-852. doi:10.1016/S1474-4422(11)70176-4 Balduini W, Carloni S, Mazzoni E, Cimino M. New therapeutic strategies in perinatal stroke. CurrDrug TargetsCNSNeurolDisord . 2004;3:315-323. Hilderley AJ, Dunbar M, Andersen J, et al. Neuromodulation for Children With Hemiparesis and Perinatal Stroke: A Randomized Clinical Trial. JAMA Neurology . 2025;82(3):267-275. doi:10.1001/jamaneurol.2024.4898 Kirton A, Metzler MJ, Craig BT, et al. Perinatal stroke: mapping and modulating developmental plasticity. Nat Rev Neurol . 2021;17:415-432. doi:10.1038/s41582-021-00503-x Kolb B, Gibb R. Brain plasticity and behaviour in the developing brain. JCanAcadChild AdolescPsychiatry . 2011;20:265-276. Kirton A, deVeber G. Advances in perinatal ischemic stroke. Pediatr Neurol . 2009;40:205-214. Kirton A. Modeling developmental plasticity after perinatal stroke: defining central therapeutic targets in cerebral palsy. Pediatr Neurol . 2013;48(2):81-94. doi:10.1016/j.pediatrneurol.2012.08.001 Novak I, Honan I. Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review. Aust Occup Ther J . Published online April 10, 2019. doi:10.1111/1440-1630.12573 Novak I, Morgan C, Fahey M, et al. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep . 2020;20(2):3. doi:10.1007/s11910-020-1022-z Government of Canada CI of HR. Strategy for Patient-Oriented Research. June 18, 2018. Accessed August 25, 2024. https://cihr-irsc.gc.ca/e/41204.html Stein C, Fritsch CG, Robinson C, Sbruzzi G, Plentz RDM. Effects of Electrical Stimulation in Spastic Muscles After Stroke. Stroke . 2015;46(8):2197-2205. doi:10.1161/STROKEAHA.115.009633 Eraifej J, Clark W, France B, Desando S, Moore D. Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis. Syst Rev . 2017;6:40. doi:10.1186/s13643-017-0435-5 Adams HP Jr, del ZG, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation . 2007;115:e478-e534. Chiu HC, Ada L. Effect of functional electrical stimulation on activity in children with cerebral palsy: a systematic review. Pediatr Phys Ther . 2014;26(3):283-288. doi:10.1097/PEP.0000000000000045 Cope S, Mohn-Johnsen S. The effects of dosage time and frequency on motor outcomes in children with cerebral palsy: A systematic review. Dev Neurorehabil . Published online February 16, 2017:1-12. doi:10.1080/17518423.2017.1282053 Bates M, Sunderam S. Hand-worn devices for assessment and rehabilitation of motor function and their potential use in BCI protocols: a review. Front Hum Neurosci . 2023;17. doi:10.3389/fnhum.2023.1121481 Bai Z, Fong KNK, Zhang JJ, Chan J, Ting KH. Immediate and long-term effects of BCI-based rehabilitation of the upper extremity after stroke: a systematic review and meta-analysis. J Neuroeng Rehabil . 2020;17(1):57. doi:10.1186/s12984-020-00686-2 Jadavji Z, Metzler MJ, Kinney-Lang E, Kirton A, Zewdie E. Feasibility and Tolerability of BCI Activated Electrical Stimulation in Children with Perinatal Stroke: A Pilot Study. Neurorehabilitation and Neural Repair ..doi:10.3389/fnhum.2023.1006242 Biasiucci A, Leeb R, Iturrate I, et al. Brain-actuated functional electrical stimulation elicits lasting arm motor recovery after stroke. Nature Communications . 2018;9(1):2421. doi:10.1038/s41467-018-04673-z NeuroTrac® Rehab. TENS, Neuromuscular Electrical Stimulators, EMG and ETS Devices | Neurotrac. Accessed April 19, 2025. https://veritymedical.com/product/neurotrac-rehab/ Irvine, B., Tuladhar, A., Commaduran-Marquez, D., Gulamhusein, A., Schrag, E., Kinney-Lang, E. 2024. BCI-Essentials-Python: v0.1.3 [Software] https://github.com/kirtonBCIlab/bci-essentials-python/releases/tag/v0.1.3. Lotte F, Bougrain L, Cichocki A, et al. A review of classification algorithms for EEG-based brain–computer interfaces: a 10 year update. J Neural Eng . 2018;15(3):031005. doi:10.1088/1741-2552/aab2f2 Chen S, Shu X, Wang H, Ding L, Fu J, Jia J. The Differences Between Motor Attempt and Motor Imagery in Brain-Computer Interface Accuracy and Event-Related Desynchronization of Patients With Hemiplegia. Front Neurorobot . 2021;15:706630. doi:10.3389/fnbot.2021.706630 B Barachant, A., Barthélemy, Q., King, J.-R., Gramfort, A., Chevallier, S., Rodrigues, P. L. C., Olivetti, E., Goncharenko, V., Wagner vom Berg, G., Reguig, G., Lebeurrier, A., Bjäreholt, E., Yamamoto, M. S., Clisson, P., Corsi, M.-C. 2023. pyRiemann: v0.5 [Software]. Zenodo. https://doi.org/10.5281/zenodo.8059038 Bemister TB, Brooks BL, Kirton A. Development, reliability, and validity of the Alberta Perinatal Stroke Project Parental Outcome Measure. Pediatr Neurol . 2014;51(1):43-52. doi:10.1016/j.pediatrneurol.2014.01.052 Harb A, Kishner S. Modified Ashworth Scale. In: StatPearls . StatPearls Publishing; 2024. Accessed September 8, 2024. http://www.ncbi.nlm.nih.gov/books/NBK554572/ Garzon LC, Switzer L, Musselman KE, Fehlings D. The use of functional electrical stimulation to improve upper limb function in children with hemiplegic cerebral palsy: A feasibility study. J Rehabil Assist Technol Eng . 2018;5:2055668318768402. doi:10.1177/2055668318768402 Holmefur M. The Assisting Hand Assessment: Continued Development, Psychometrics and Longitudinal Use . Karolinska Institutet; 2009. Foss-Feig JH, de la Fontaine N, Tsatsanis K. BRIEF (Behavior Rating Inventory of Executive Functions). In: Volkmar FR, ed. Encyclopedia of Autism Spectrum Disorders . Springer; 2015:1-5. doi:10.1007/978-1-4614-6435-8_102048-1 Keough JR, Irvine B, Kelly D, et al. Fatigue in children using motor imagery and P300 brain-computer interfaces. J Neuroeng Rehabil . 2024;21(1):61. doi:10.1186/s12984-024-01349-2 NVivo: Leading Qualitative Data Analysis Software. Lumivero. Accessed May 3, 2025. https://lumivero.com/products/nvivo/ Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res . 2005;15(9):1277-1288. doi:10.1177/1049732305276687 Jamovi. The jamovi project. Published online 2021. https://www.jamovi.org Welcome to Python.org. Python.org. May 1, 2025. Accessed May 4, 2025. https://www.python.org/ Login to your Canva account. Canva. Accessed May 4, 2025. https://www.canva.com/login/ Jadavji Z, Zhang J, Paffrath B, Zewdie E, Kirton A. Can Children With Perinatal Stroke Use a Simple Brain Computer Interface? Stroke . 2021;52(7):2363-2370. doi:10.1161/STROKEAHA.120.030596 Zhang J, Jadavji Z, Zewdie E, Kirton A. Evaluating If Children Can Use Simple Brain Computer Interfaces. Front Hum Neurosci . 2019;13:24. doi:10.3389/fnhum.2019.00024 Gracies JM. Pathophysiology of spastic paresis. I: Paresis and soft tissue changes. Muscle & Nerve . 2005;31(5):535-551. doi:10.1002/mus.20284 Ma Y, Gong A, Nan W, Ding P, Wang F, Fu Y. Personalized Brain–Computer Interface and Its Applications. J Pers Med . 2022;13(1):46. doi:10.3390/jpm13010046 Eliasson AC, Krumlinde-Sundholm L, Gordon AM, et al. Guidelines for future research in constraint-induced movement therapy for children with unilateral cerebral palsy: an expert consensus. Dev Med Child Neurol . 2014;56(2):125-137. doi:10.1111/dmcn.12273 Metzler MJ, O’Grady K, Fay L, et al. Feasibility of High Repetition Upper Extremity Rehabilitation for Children with Unilateral Cerebral Palsy. Phys Occup Ther Pediatr . 2022;42(3):242-258. doi:10.1080/01942638.2021.2010857 Wrightson JG, Zewdie E, Kuo HC, Millet GY, Kirton A. Fatigue in children with perinatal stroke: clinical and neurophysiological associations. Developmental Medicine and Child Neurology . 2020;62(2):234-240. doi:10.1111/DMCN.14273 Basu AP, Pearse J, Kelly S, Wisher V, Kisler J. Early intervention to improve hand function in hemiplegic cerebral palsy. Front Neurol . 2014;5:281. doi:10.3389/fneur.2014.00281 Yıldızgören MT, Nakipoğlu Yüzer GF, Ekiz T, Özgirgin N. Effects of neuromuscular electrical stimulation on the wrist and finger flexor spasticity and hand functions in cerebral palsy. Pediatr Neurol . 2014;51(3):360-364. doi:10.1016/j.pediatrneurol.2014.05.009 Dukelow S, Kirton A. Enhancing Stroke Recovery Across the Life Span With Noninvasive Neurostimulation. J Clin Neurophysiol . 2020;37(2):150-163. doi:10.1097/WNP.0000000000000543 Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterials.pdf Cite Share Download PDF Status: Published Journal Publication published 24 Apr, 2026 Read the published version in Journal of NeuroEngineering and Rehabilitation → Version 1 posted Editorial decision: Revision requested 23 Nov, 2025 Reviews received at journal 03 Nov, 2025 Reviewers agreed at journal 28 Oct, 2025 Reviews received at journal 09 Oct, 2025 Reviewers agreed at journal 09 Oct, 2025 Reviewers invited by journal 29 Sep, 2025 Submission checks completed at journal 19 Sep, 2025 First submitted to journal 18 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7420830","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":527341059,"identity":"ede50160-162e-4f9f-9e91-046697ce317a","order_by":0,"name":"Anna Bourgeois","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Bourgeois","suffix":""},{"id":527341060,"identity":"8a3d0daf-8bf3-4ce3-a907-63bfbc94fa75","order_by":1,"name":"Meghan Maiani BScOT","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"prefix":"","firstName":"Meghan","middleName":"Maiani","lastName":"BScOT","suffix":""},{"id":527341062,"identity":"b60af513-61b9-45a6-8b65-8c4ba83f73de","order_by":2,"name":"Araz Minhas","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"prefix":"","firstName":"Araz","middleName":"","lastName":"Minhas","suffix":""},{"id":527341064,"identity":"74fc0f13-bd10-4f57-8054-c2b3c1d3a9e4","order_by":3,"name":"Payton Shaw","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"prefix":"","firstName":"Payton","middleName":"","lastName":"Shaw","suffix":""},{"id":527341066,"identity":"321cc154-f148-40af-b509-273855e9bbc6","order_by":4,"name":"Dejana Nikitovic","email":"","orcid":"","institution":"Alberta Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dejana","middleName":"","lastName":"Nikitovic","suffix":""},{"id":527341068,"identity":"74d4bc85-f4d3-4db2-b6b6-7c90c58d1930","order_by":5,"name":"Brian Irvine","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"","lastName":"Irvine","suffix":""},{"id":527341070,"identity":"c0335378-ba3c-46cb-94af-c9be4a1d49ac","order_by":6,"name":"Ion Robu","email":"","orcid":"","institution":"Alberta Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ion","middleName":"","lastName":"Robu","suffix":""},{"id":527341072,"identity":"436c9c31-734d-4d0d-a1b2-dc00596fdb2f","order_by":7,"name":"Nathan Brand","email":"","orcid":"","institution":"SAIT Polytechnic","correspondingAuthor":false,"prefix":"","firstName":"Nathan","middleName":"","lastName":"Brand","suffix":""},{"id":527341074,"identity":"27bf9876-f1cd-4eeb-bee1-06c88428a838","order_by":8,"name":"Zeanna Jadavji","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"prefix":"","firstName":"Zeanna","middleName":"","lastName":"Jadavji","suffix":""},{"id":527341076,"identity":"b51c5a7a-d9d5-496b-b434-ff4d75ec06e0","order_by":9,"name":"Gregory Wilding","email":"","orcid":"","institution":"Alberta Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gregory","middleName":"","lastName":"Wilding","suffix":""},{"id":527341078,"identity":"571e9738-4244-4fd8-ab90-d87d5f23ae40","order_by":10,"name":"Mateo Ambrogiano","email":"","orcid":"","institution":"SAIT Polytechnic","correspondingAuthor":false,"prefix":"","firstName":"Mateo","middleName":"","lastName":"Ambrogiano","suffix":""},{"id":527341080,"identity":"05b7251b-2e64-4269-be00-6859ee48f466","order_by":11,"name":"Emily Schrag","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"prefix":"","firstName":"Emily","middleName":"","lastName":"Schrag","suffix":""},{"id":527341082,"identity":"38f6c92b-1b77-49f3-97e8-1c5d207c8ccf","order_by":12,"name":"Alicia Hilderley","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"prefix":"","firstName":"Alicia","middleName":"","lastName":"Hilderley","suffix":""},{"id":527341083,"identity":"7bf65e16-5771-4710-93ba-57154f864885","order_by":13,"name":"Daniel Comadurán Márquez","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"Comadurán","lastName":"Márquez","suffix":""},{"id":527341084,"identity":"fd636f5d-7eab-4572-9c8e-599ea7ded56e","order_by":14,"name":"Helen L. Carlson","email":"","orcid":"","institution":"Alberta Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"L.","lastName":"Carlson","suffix":""},{"id":527341086,"identity":"0bd8fb34-5395-4f96-a792-8e87ae8088bf","order_by":15,"name":"Nicole Romanow","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"prefix":"","firstName":"Nicole","middleName":"","lastName":"Romanow","suffix":""},{"id":527341088,"identity":"be58c5e9-17c8-44f2-9270-b2fb49ed28d6","order_by":16,"name":"Adam Kirton","email":"data:image/png;base64,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","orcid":"","institution":"Alberta Children’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Adam","middleName":"","lastName":"Kirton","suffix":""},{"id":527341090,"identity":"4b551b82-0f98-42f1-890a-62072648139a","order_by":17,"name":"Eli Kinney-Lang","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"prefix":"","firstName":"Eli","middleName":"","lastName":"Kinney-Lang","suffix":""}],"badges":[],"createdAt":"2025-08-20 22:38:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7420830/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7420830/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12984-026-01990-z","type":"published","date":"2026-04-24T15:59:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":93395655,"identity":"9505822d-17a8-4c92-bd53-dbfd25078d7d","added_by":"auto","created_at":"2025-10-13 11:35:04","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1317556,"visible":true,"origin":"","legend":"","description":"","filename":"CreatinganengagingbraincomputerinterfaceEdits17Sept.docx","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/ea2c7e53cf2f3f32a11571d5.docx"},{"id":93396620,"identity":"40634b48-7755-432e-a969-15cafde10177","added_by":"auto","created_at":"2025-10-13 11:43:04","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":15830,"visible":true,"origin":"","legend":"","description":"","filename":"85e8ef446e9448578568be709b8c6ab1.json","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/53597a3f1bb6a3e548841e14.json"},{"id":93395141,"identity":"b2a88df6-263e-4287-924f-8b42d48ea271","added_by":"auto","created_at":"2025-10-13 11:27:04","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":773102,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterials.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/6fbf2a52e70f0ab576d1978b.pdf"},{"id":93395662,"identity":"1733efe1-4f9c-4e3e-854f-fec7503264d0","added_by":"auto","created_at":"2025-10-13 11:35:04","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":139707,"visible":true,"origin":"","legend":"","description":"","filename":"85e8ef446e9448578568be709b8c6ab11enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/13facf583f2e72345449fdeb.xml"},{"id":93395125,"identity":"357a438f-de77-44d7-9748-1b9f0f7163e1","added_by":"auto","created_at":"2025-10-13 11:27:04","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":234458,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/469bb15f3da1a4869ad5c992.png"},{"id":93395657,"identity":"ef6a9f02-6d93-4287-aa38-e420e4e9ee66","added_by":"auto","created_at":"2025-10-13 11:35:04","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52966,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/a29ebe5380f8f73ab3950d8e.png"},{"id":93396621,"identity":"64c4b06a-3391-415b-bffb-63192aa27eaf","added_by":"auto","created_at":"2025-10-13 11:43:04","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":686875,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/1a26508995e2ceb463c18ffa.png"},{"id":93395131,"identity":"760744dd-ff60-4893-83cf-6389c60e34a6","added_by":"auto","created_at":"2025-10-13 11:27:04","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":53634,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/34d0fe65685d25a2c0d9a24b.png"},{"id":93395663,"identity":"63cb9bd9-97d1-420e-b1ad-3714de3f33d5","added_by":"auto","created_at":"2025-10-13 11:35:04","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":166229,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/5685f128e5bde6ff2e46f799.png"},{"id":93395661,"identity":"b7425648-0732-4b11-8a93-75223e3b9d3e","added_by":"auto","created_at":"2025-10-13 11:35:04","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":44370,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/4c675cc5e2c918ad628d5851.png"},{"id":93395135,"identity":"f4aefb62-ecf4-4bae-9b9e-4b6d36e5bd0e","added_by":"auto","created_at":"2025-10-13 11:27:04","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":21353,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/3cb4647df2af84be34d1adee.png"},{"id":93395140,"identity":"a28b79ad-9574-4dd8-9ad7-06d05a958ba2","added_by":"auto","created_at":"2025-10-13 11:27:04","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":98984,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/c49d44dfd7fa020fc51bb8b2.png"},{"id":93395136,"identity":"fe7b6468-4a4a-46d5-b6c0-c4b4015e8658","added_by":"auto","created_at":"2025-10-13 11:27:04","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":15430,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/be71fe676d00188f6f25ef3e.png"},{"id":93395133,"identity":"0dddedb9-56dd-4dea-8efe-2f88021ab3bf","added_by":"auto","created_at":"2025-10-13 11:27:04","extension":"png","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":46171,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/33b73c9264d2f00eec9a6ea8.png"},{"id":93395664,"identity":"4b7e1e89-ddfd-44e9-be5d-745462d91703","added_by":"auto","created_at":"2025-10-13 11:35:05","extension":"xml","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":135261,"visible":true,"origin":"","legend":"","description":"","filename":"85e8ef446e9448578568be709b8c6ab11structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/46eb0474fef304d52cb150fa.xml"},{"id":93395142,"identity":"f137c470-c5f8-4ab5-bc22-9e6f90a71cd8","added_by":"auto","created_at":"2025-10-13 11:27:04","extension":"html","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":154315,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/476a8c3f5a3eb50f7b5a0b4d.html"},{"id":93395121,"identity":"a7cb1dc4-690b-48ed-be03-0da82338c0ce","added_by":"auto","created_at":"2025-10-13 11:27:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":234458,"visible":true,"origin":"","legend":"\u003cp\u003eSuccessful Swipe FlickTok Flow Diagram: Participants were seated comfortably and fitted with both functional electrical stimulation (FES) and a brain-computer interface (BCI) cap. They scrolled through their chosen social media platform, resting when the screen was red. When the screen turned green, they either watched a video or attempted a movement. If the attempted movement was correctly detected by the BCI, it triggered the FES to complete the motion. If successful, the screen turned blue, and the social media content was swiped. If the BCI made an incorrect prediction (false positive) to turn on the FES and swipe the video, the FES stim would be manually turned off. On the other hand, if the BCI did not accurately predict activity when the user attempted a movement (false negative) the social media would be manually swiped by the researcher to the next video to keep the participant engage. Estimated time for each step was measure ins seconds (s).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/af11a378dfc70179ebb3595d.png"},{"id":93395120,"identity":"245d7072-b48e-4de3-b674-7d59630c55b6","added_by":"auto","created_at":"2025-10-13 11:27:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":52966,"visible":true,"origin":"","legend":"\u003cp\u003eEnjoyability ratings across three sessions for all participants. The blue bars representing the FlickTok therapy. A lower ranking number indicates higher enjoyability\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/b19b4f07edd8773f97a3c210.png"},{"id":93395129,"identity":"b9e74192-84a7-4c86-9c96-0c7ad45ede70","added_by":"auto","created_at":"2025-10-13 11:27:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":686875,"visible":true,"origin":"","legend":"\u003cp\u003eMotor tests and range of motion: Line graphs display each participant’s (A) affected Box and Blocks Test scores (B) unaffected Box and Blocks Test scores, as well as (C) active range of motion measurements (D) passive range of motion measurements across the three sessions. Panel (E) shows an image illustrating wrist extension active range of motion improvement within a single session for one participant.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/20fe8904d3f1485b00a5f45b.png"},{"id":93395123,"identity":"ed4382da-d584-4de9-82ce-36939e5f63d9","added_by":"auto","created_at":"2025-10-13 11:27:04","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":53634,"visible":true,"origin":"","legend":"\u003cp\u003eAverage repetitions per hour during sessions 2 and 3 across each participant. Stacked bars represent the contribution of FES-specific repetitions (dark blue) and total repetitions (light blue). Overlaid line plots indicate changes in fatigue levels from baseline during Session 2 (solid line, circles) and Session 3 (dashed line, squares). Participants are ordered by total average repetitions per hour in descending order.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/54172fbfd294048efa6d871b.png"},{"id":93395659,"identity":"4a91a60b-d3c0-4211-b767-9109b8280853","added_by":"auto","created_at":"2025-10-13 11:35:04","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":166229,"visible":true,"origin":"","legend":"\u003cp\u003eTechnical performance of FlickTok for each participant across three sessions. The blue line represents training accuracy, while the red line indicates Cohen’s kappa. The bottom-right corner shows the average performance across all participants. Stars on graphs indicate elevated age normed T-scores on the Behavior Rating Inventory of Executive Function (BRIEF) survey.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/14b436ea9942a46757f31a3a.png"},{"id":107927845,"identity":"c0acb29b-3570-4623-8fbc-3061f96053a6","added_by":"auto","created_at":"2026-04-27 16:05:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1558905,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/34e78a87-5204-42ca-85db-27151403c5d7.pdf"},{"id":93396619,"identity":"8433342e-efb6-4ae7-b015-94945c1ca773","added_by":"auto","created_at":"2025-10-13 11:43:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":773102,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterials.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7420830/v1/4438e5f1c447f32da2172642.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Creating an engaging brain computer interface, electrical stimulation therapy for children with hemiparesis: a pilot study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePerinatal strokes are focal neurovascular brain injuries that affect 5 million people worldwide and can lead to lifelong physical disabilities.\u003csup\u003e1,2\u003c/sup\u003e It is the leading cause of hemiparetic cerebral palsy (HCP) which is characterized as motor dysfunction on one side of the body.\u003csup\u003e3\u0026ndash;5\u003c/sup\u003e Effective therapeutic interventions can improve stroke outcomes as the\u0026nbsp;young brain can adapt by\u0026nbsp;creating new connections, reorganizing networks, and altering synapses.\u003csup\u003e6\u0026ndash;9\u003c/sup\u003e Even modest improvements in a child\u0026rsquo;s hand function can positively impact participation and affect quality of life, which is why there is a push for therapeutic interventions during earlier developmental windows.\u0026nbsp;\u003csup\u003e10\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePediatric therapeutic interventions must be family-centred with the patient\u0026rsquo;s goals at the forefront to maximize repetitions while optimizing engagement and enjoyability.\u003csup\u003e11\u003c/sup\u003e Motivation and attention are vital in modulating neuroplasticity, and successful task-based practice is necessary to see functional changes.\u003csup\u003e12\u003c/sup\u003e Partnering with patients can this by\u0026nbsp;applying partner feedback directly into the design of\u0026nbsp;novel interventions and embracing more engaging technologies such as social media to enhance interest, compliance, and ultimate efficacy.\u003csup\u003e13\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunctional electrical stimulation (FES)\u0026nbsp;stimulates muscle contraction during activity performance through low-intensity electrical currents.\u0026nbsp;When applied to the affected limb, it can reduce spasticity-related symptoms and improve range of motion (ROM) and strength.\u0026nbsp;\u003csup\u003e14\u003c/sup\u003e When a patient\u0026rsquo;s attempted movement is paired with FES, it triggers the cortical activation of sensorimotor areas, the degree of which has been associated with functional improvement.\u003csup\u003e15\u003c/sup\u003e In stroke rehabilitation guidelines for adults, upper extremity FES receives the highest evidence-based recommendation.\u003csup\u003e16\u003c/sup\u003e However, it has not been adequately studied in children, largely due to challenges with engagement, since high repetition counts are required to achieve meaningful functional gains.\u003csup\u003e17\u003c/sup\u003e\u003csup\u003e-\u003c/sup\u003e\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eBrain Computer Interfaces (BCI) work by converting intentional brain activity into commands that can be used to control external devices. BCIs have been recently under investigation for their role in stroke rehabilitation.\u003csup\u003e19\u0026ndash;21\u003c/sup\u003e Specifically, BCI paired with FES has been explored as a novel way to drive task-related neuroplasticity to improve motor impairments over time in adults with stroke.\u0026nbsp;\u003csup\u003e22\u003c/sup\u003e\u0026nbsp; Evidence suggests BCI-FES may be effective in adult patients with stroke-induced hemiparesis.\u0026nbsp;\u003csup\u003e20,22\u003c/sup\u003e Despite the evidence of enhanced neuroplasticity, the use of FES and BCI in children remains limited.\u003csup\u003e7\u003c/sup\u003e A study conducted within our group suggested that BCI-FES is feasible and well-tolerated in children with perinatal stroke; however, several children were unmotivated to continue the therapy, indicating that incorporating gamification could help sustain engagement and potentially improve BCI performance.\u003csup\u003e21\u003c/sup\u003e Here, we created a novel and engaging BCI-FES therapy designed for youth with the aim of increasing long-term efficacy.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA multi-disciplinary team of therapists, engineers, researchers, clinicians, and patient partners helped design a BCI FES therapy that is integrated with social media. The resulting application was named FlickTok, a novel BCI/FES social media therapy system. FlickTok integrates three\u0026nbsp;interacting components: 1) an EEG headset, 2) the FES system, and 3) an application to coordinate the two components with social media interactions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient Partner Engagement\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe engaged three youth patient partners to design and build a BCI-FES integrated with social media to ensure research focus was on patient identified priorities.\u003csup\u003e13\u003c/sup\u003e Before development began, we worked with the patient partners to ensure that the system aligned with target users They helped us pilot test the system to evaluate and improve technical performance and usability. Our patient partners were also actively involved in the study design, helping to develop and conduct the qualitative interviews and supported results interpretation. Patient partner engagement methodology is found in Supplementary Figure 1. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEEG\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA 16-channel EEG headset with gel-based g.Scarabeo electrodes and g.USB amplifier (g.tec medical engineering GmbH, Austria) was used to read and record the user\u0026rsquo;s brain activity.\u0026nbsp;EEG was recorded from FC5, FC1, FCz, FC2, FC6, C5, C3, C1, Cz, C2, C4, C6, CP5, CP1, CP2, CP6 with a reference electrode placed at FPZ and a ground electrode on the participant\u0026rsquo;s earlobe. EEG was sampled at 256 Hz, with a Nyquist frequency of 128 Hz, this sampling rate is entirely sufficient to capture the EEG signals of interest which are in the Mu (~8 \u0026ndash; 13 Hz) and Beta (~13 \u0026ndash; 30 Hz) \u0026nbsp; bands.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFES\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe FES component was driven by a computer and stimulates the desired muscles for the execution of the target functional movement.\u0026nbsp;Working with an occupational therapist (OT), we chose three functional movements to target: wrist extension, thumb abduction, and finger extension. A set of disposable \u0026ldquo;2 \u0026times; 2\u0026rdquo; carbon rubber electrodes were applied to the targeted motor nerves on the forearm individualized for each participant. Electrode placement differed between participants based on individual anatomy, function, and target movement chosen. If a target movement could not be generated with FES, the participant was excluded from the study. Muscle stimulation was delivered using the Neurotrac\u003csup\u003e23\u003c/sup\u003e Dual Channel Transcutaneous Electrical Nerve Stimulation \u0026nbsp;(TENS) and Neuromuscular Electrical Stimulation (NMES) device with a remote switch. FES parameters differed between participants to maximize tolerability and was adapted if the participant became fatigued. \u0026nbsp;FES current and voltage ranged from 8 mA to 35mA and frequency ranged from 35\u0026ndash;40 Hz. To facilitate connecting the FES to the BCI output, we built a custom designed micro controller-based interface that connected to a USB port, enabling direct communication from the computer to control the FES stimulator.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eApplication\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe FlickTok application was structured in two parts: a Python server that coordinated EEG signals built in-house using our open-source BCI software package, \u003cem\u003eBCI-Essentials\u0026nbsp;\u003c/em\u003esystem.\u003csup\u003e24\u003c/sup\u003e The custom BCI was used to classify the EEG signal as either \u0026lsquo;Action\u0026rsquo; or \u0026lsquo;Rest\u0026rsquo;. The second part consisted of an Electron-based user-facing application that integrated social media content and FES stimulation with the BCI.\u0026nbsp;\u0026nbsp;\u003cem\u003eYouTube Shorts\u003c/em\u003e and \u003cem\u003eInstagram Reels\u003c/em\u003e were used during both the training of the BCI and the session itself to increase participant engagement and motivation.\u0026nbsp;To personalize the sessions, each participant chose a specific type of content they wanted to engage with.\u0026nbsp;The social media application was displayed on a monitor and coloured icons that represented the attempted movement\u0026nbsp;were integrated to improve understanding of the system.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCalibration and Classification\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCalibration of the BCI system consisted of twenty repetitions using a 2-second on, 2-second off protocol, adapted to identify epochs of intentional \u0026ldquo;action\u0026rdquo; (on-condition) from \u0026ldquo;rest\u0026rdquo; (off-condition). Labelled 2 s epochs from calibration were used to train a Riemannian Geometry classifier without filtering, artifact rejection, or channel selection. The Riemannian Geometry approach was chosen, because it has been demonstrated as the state-of-the-art for motor imagery classification using very little data, \u003csup\u003e25\u003c/sup\u003e and the attempted movement task leverages the same phenomenon of event-related synchronization/desynchronization as motor imagery. First, covariance matrices were calculated for each epoch using Oracle Approximating Shrinkage (OAS)\u003csup\u003e26\u003c/sup\u003e, then the tangent space representation was extracted from each covariance matrix. The values of the tangent space representation of each epoch were used to train a logistic regression classifier, using 3-fold cross-validation to estimate classification accuracy. This pipeline was implemented using the PyRiemann library.\u003csup\u003e27\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing calibration, the trained classifier was then used to predict whether each 2 s non-overlapping window consisted of either action or rest. If a 2 s epoch is classified rest, nothing happened, and the video continued playing. If the window was predicted as an attempted action, an animation of the intended action played on screen, the FES stimulation was triggered, and the FlickTok application would continue to the next video. Following an action prediction, there was a 5 s pause for the action and FES stimulus to take place and for the next video to begin playing. During this pause, no windows of EEG were sent for classification. Following this 5 s period, each 2 s window of EEG was classified as action or rest. The BCI-FES-social media system set up is summarized in Figure 1. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1.\u003c/strong\u003e Successful Swipe FlickTok Flow Diagram: Participants were seated comfortably and fitted with both functional electrical stimulation (FES) and a brain-computer interface (BCI) cap. They scrolled through their chosen social media platform, resting when the screen was red. When the screen turned green, they either watched a video or attempted a movement. If the attempted movement was correctly detected by the BCI, it triggered the FES to complete the motion. If successful, the screen turned blue, and the social media content was swiped. If the BCI made an incorrect prediction (false positive) to turn on the FES and swipe the video, the FES stim would be manually turned off. On the other hand, if the BCI did not accurately predict activity when the user attempted a movement (false negative) the social media would be manually swiped by the researcher to the next video to keep the participant engage. Estimated time for each step was measure ins seconds (s).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants for the pilot trial were recruited from the Alberta Perinatal Stroke Project (APSP).\u0026nbsp;\u003csup\u003e28\u003c/sup\u003e All participants or their guardians provided written informed consent/assent as appropriate.\u0026nbsp;Inclusion criteria were: (1) Age 10-25 years (2) MRI-confirmed\u0026nbsp;perinatal stroke including neonatal arterial ischemic stroke (NAIS), arterial presumed perinatal ischemic stroke (APPIS), or periventricular venous infarction (PVI) (3) Symptomatic, disabling HCP including child/parent perceived limitations in function but at least minimal upper extremity function (i.e., able to use the affected arm to lift a light object against gravity) (4) able to elicit a satisfactory physiological muscle contraction, described in the procedures below (5) a score of 3 on the Modified Ashworth Scale (MAS).\u003csup\u003e29\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e \u003csup\u003e30\u003c/sup\u003e Exclusion criteria included: (1) severe intellectual disability (2) unstable epilepsy (3) upper limb surgery or botulinum toxin treatment within 12 months (4) severe spasticity (MAS \u0026gt;3) or contracture. This study was approved by the University of Calgary Research Ethics Board.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIntervention\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants completed three 90-minute FlickTok sessions, each over the course of four weeks. Scheduling was primarily in the evening to accommodate participant needs. Testing took place at the Alberta Children\u0026rsquo;s Hospital in the Pediatric Brain Computer Interface Lab. During the first visit, we explained the study procedures. After motor tests and questionaries were complete, the participant spoke to a registered OT to determine the desired functional movement that would be paired with FlickTok. The therapist performed muscle responsiveness testing to ensure the FES could stimulate the proper muscles for the functional movement selected (e.g. wrist extension, thumb extension). Then the participant was fitted with the EEG cap and FES electrodes. The Flick-Tok therapy was trained, then the participant started the therapy. The Flick-Tok system was retrained if a participant\u0026rsquo;s training accuracy was below 0.4, or upon participant request if the system was not working well. Participants were able to request breaks throughout the session. Sessions two and three were conducted similarly to session one but the final thirty minutes of the third session was reserved for a qualitative interview.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMotor, cognition, enjoyment, and fatigue assessments\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDuring the initial session, the assisting hand assessment (AHA) was performed to assess affected hand use during a bimanual play session, where a higher score indicates better function.\u003csup\u003e31\u003c/sup\u003e This was completed to characterize baseline function. \u0026nbsp;All motor assessments were recorded and scored by the same individual. BCI requires sustained, focused attention, so parents were asked to complete the Behavior Rating Inventory of Executive Function (BRIEF) to give a parent report of executive and attention function. \u0026nbsp;\u003csup\u003e32\u003c/sup\u003e Box and blocks assessment (BBT) on both the affected and unaffected side, was assessed as well as active and passive ROM assessments taken before and after each session to quantify motor function. After each session, the participant was asked to rank their enjoyment of the FlickTok experience against six other common childhood experiences. For sessions two and three, participants were asked to evaluate their fatigue before and after the session using a visual analog scale for fatigue; session one was considered too short to measure fatigue.\u003csup\u003e33\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative Interview\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative, semi-structured interviews were conducted independently by a patient partner (female, 18). She was trained by an experienced qualitative researcher and had previously conducted multiple practice interviews. She had not attended any of the previous sessions and did not know the participants prior. The interview guide was developed in collaboration with two patient partners and trialed with the third patient partner.\u003c/p\u003e\n\u003cp\u003eInterviews were audio-recorded and transcribed verbatim using Rev.com, an online transcription service. Interview transcripts were analyzed using NVivo 14.\u003csup\u003e34\u003c/sup\u003e Analysis was informed by an interpretivist paradigm, and that they were analysed using conventional content analysis.\u003csup\u003e35\u003c/sup\u003e Two team members independently coded all transcripts. Coders read each transcript several times to gain familiarity and met weekly to discuss trends and compare discrepancies between us eventually leading to the generation of a codebook. Our patient partner helped refine themes and codes, to ensure we captured the perspectives of the participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnalysis:\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cbr\u003eRank ratings on the fatigue scale were converted into a change score between sessions defined as post-pre intervention, such that negative scores reflected a decrease in fatigue rating. Scores from the BRIEF were reported as global executive composite age-normed T-scores. This accounted for age-related differences in executive function development.\u003csup\u003e32\u003c/sup\u003e All FlickTok sessions were recorded so that repetitions could be reviewed offline for accuracy and to code movement attempts. To ensure consistency across participants, all repetition counts were scaled to a per-hour rate. Repetitions per hour were calculated by counting the number of attempts with and without assistance from FES. Repetitions without FES included the full training duration, as training did not incorporate FES-assisted repetitions. All repetitions were the sum of repetitions with and without FES. Cohen\u0026rsquo;s kappa (a quantification of agreement in attempt accuracy) was calculated by defining a true positive value (TP) as FES being triggered within 6 seconds of the participant attempting a movement and defining false positive (FP) as the FES firing without an attempted movement. \u0026nbsp;A true negative (TN) was defined as 6 seconds of the FES not firing when the participant did not attempt movement \u0026ndash; i.e. the participant did not want to trigger an FES, and the BCI did not unintentionally activate. \u0026nbsp;A false negative (FN) was defined if the participant attempted a movement and Flick Tok did not trigger the FES for 6 seconds. In this case, the video was manually swiped. Six seconds was chosen as the time to determine success, as this allowed intent and initiation of movement without undue delay. Previous literature of adult studies typically use 3\u0026ndash;4.5 s for determining successful activation following prompt by the researcher or therapist.\u003csup\u003e22\u003c/sup\u003e In this study, we extended this window to 6 s total, as participants were not prompted for activation and instead chose their own initiation. Paired with how the BCI resolved predictions of actions every 2 seconds, we wanted to be lenient with the possibility that the user may begin an activation at the end of a 2-second processing window, which wouldn\u0026rsquo;t then be identified until the next window at the earliest, so we added a 2-second buffer on top of the typical 3-4.5 second window from adult literature.\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eRepetitions with excessive movement/talking were removed for this calculation. Values were extracted by reviewing videos of participants during the three sessions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCohen\u0026rsquo;s kappa \u003cimg width=\"26\" height=\"19\" src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1760352476.png\" alt=\"image\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1760352528.png\" width=\"424\" height=\"82\"\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were completed on Jamovi.\u003csup\u003e36\u003c/sup\u003e All graphs were made with Python\u003csup\u003e37\u003c/sup\u003e and the methodology figure was made with Canva\u003csup\u003e38\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003ePopulation\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwelve participants were recruited to the pilot trial (50% female, 15.75 (SD:4), range 10-23 years). Population demographics are summarized in Table 1. AHA scores ranged from: 33-69 logits, BRIEF T-scores ranged from: 35-75. All participants participated in all three sessions and completed all surveys, motor tests, and the interview. Participant F did not have a complete set of BCI data because there was an application system failure during their third session, so we manually stimulated the FES when they attempted their movement. Since we were evaluating BCI performance and repetitions with the FlickTok therapy, they were removed from the repetition and BCI performance results of the third session. There were three protocol violations due to the exclusion criteria. Specifically, participant L had botulinum toxin treatment four months prior to the study however we were still able to achieve contraction, so they were included. Participant B had orthopedic surgery on her hand, but we pivoted to choosing elbow flexion as her functional movement. Participant F was not able to achieve full strength FES to reach a contraction because of tolerability.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Demographics \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eSubject ID\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eStroke Side \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eStroke Type\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eLesion location\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eMACS level\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eAHA\u003c/p\u003e\n \u003cp\u003e(logits)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eBRIEF (T Score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFunctional Movement\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eAPPIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003ePM1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e33\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eWrist extension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eAPPIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eDM1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eElbow flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eAPPIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eDM1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eWrist extension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003ePVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e62\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eWrist extension\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eAPPIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eDM1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eWrist extension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003ePVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFingers extension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eNAIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eDM1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eIndex finger extension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003ePVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eWrist Extension\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eAPPIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003ePM1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFingers extension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eJ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003ePVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eIndex finger and thumb extension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eNAIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eDM1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eWrist extension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eAPPIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003ePM1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e34\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFingers extension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eSummary\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e50 % (F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e15.75 (SD:4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e50% (L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e50%: APPIS\u003c/p\u003e\n \u003cp\u003e33.3%: PVI\u003c/p\u003e\n \u003cp\u003e16.7%: NAIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e49.83\u003c/p\u003e\n \u003cp\u003e(SD:11.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e51.5 (SD:10:33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable note: PVI- Periventricular Venous Infarction, APPIS - Arterial Presumed Perinatal Ischemic Stroke, NAIS - Neonatal Arterial Ischemic Stroke, DM1 - distal M1 occlusion, PM1 - proximal M1 occlusion, AHA - Assisting Hand Assessment, BRIEF: Behavior Rating Inventory of Executive Function. Vascular territory and stroke type was categorized using T1-weighed MRI scans.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSessions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll participants completed three sessions within a 4-week window, with the average time between sessions being 5.7 days. The sessions were entirely guided by the participants, (when/if to take breaks, when to re-train the BCI) to create a more authentic simulation of a real-world therapy experience. Participants chose content such as hockey highlights, baking videos, or funny fail clips. Each participant came in for three 90-minute sessions, but therapy time differed based on individual break and training preferences. No serious adverse events were reported across the 36 sessions. Participant I and C elected to stop the second session prematurely due to fatigue. However, both individuals resumed participation and completed the third session. When asked, participants ranked their BCI experience variably, with \u0026lsquo;FlickTok\u0026rsquo; sessions being ranked similarly to long car rides and birthday parties (Figure 2)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBBT affected baseline scores varied across participants (mean = 15.5, range = 0-39). Average BBT across sessions were: Session 1: pre:15.5 (SD: 11.57) post:18.3 (SD:13.3), Session 2: pre:17.8 (SD:14.5) \u0026nbsp;post:17.4 (SD:13.6), Session 3: pre:17.2 (SD:13.7) \u0026nbsp;post:17.8 (SD:14.8). Some participants showed improvement, while others maintained consistent performance. ROM measurements also showed substantial variability depending on the movement assessed. \u0026nbsp; \u0026nbsp;(Figure 3.)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBCI cap and FES setup took 10-15 minutes per session. Therapy session length was the amount of time spent using social media (not training the BCI). The first session lasted an average of 14:37 minutes (minute: seconds) (SD: 5:17min, range: 8:00 -23:55 minutes), session 2 lasted an average of 30:45 minutes (SD:6:48 , range: 21:41- 45:05 minutes) and session 3 was 25:33 minutes (SD: 3:47 range: 18:21-31:09 minutes). Participants took 0-2 breaks and the BCI was trained between 1 and 4 times (mean:1.8). Average FES repetitions per hour for all sessions were 167reps/hour [SD: 55.2 range: 65-283 reps/hour] and 247reps/hour [SD: 74.9 range:105-379 reps/hour] for all repetitions. Fatigue ratings before and after each session ranged from -3 to +6. Negative fatigue values indicate their fatigue rating was reduced whereas positive fatigue values indicate their fatigue rating was increased. Repetitions and fatigue are described in Figure 4.\u003c/p\u003e\n\u003cp\u003eMean classification accuracies achieved for training were 69.3% (SD = 14.6, range = 40\u0026ndash;97.5%) Within the 35 sessions completed, only three sessions had less than chance agreement (\u0026lt;0), 7 sessions had slight agreement (0.01-0.20), seven sessions had fair agreement (0.21-0.40), 13 sessions had moderate agreement (0.41-0.60), five sessions of substantial agreement (0.61- 0.80) in the Cohen\u0026rsquo;s Kappa measurement. Four participants maintained moderate to substantial agreement through the three sessions. Training accuracies and Cohen\u0026rsquo;s kappa values are displayed in Figure 6.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative Interviews:\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwelve interviews were completed, averaging 15 minutes per interviews. Eleven were conducted in person, and one was conducted virtually. Seven interviews were conducted one-on-one with the participant and five interviews had a parent present. Four themes were generated from analysis: Participant\u0026rsquo;s Perception of Therapy, Technology, Effects of Therapy on the Hand and Arm and Future Considerations. More information can be found in Supplementary Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipants\u0026rsquo; Perception of Therapy:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eParticipants generally reported a positive experience, particularly appreciating the incorporation of social media into therapy. This was largely because it involved familiar and enjoyable daily activities \u003cem\u003e\u0026quot;I got to watch stuff or do stuff while doing it. Instead of just doing this with the motion, I could see something I wanted instead of having to just do it without having something to do.\u0026quot;\u0026nbsp;\u003c/em\u003e(Participant E). Flick Tok made the sessions feel less clinical: \u0026ldquo;\u003cem\u003eTime went by quick [\u0026hellip;] I wasn\u0026apos;t feeling like I was doing therapy while I was doing it. It was just like I\u0026apos;m scrolling on Instagram reels.\u0026rdquo; \u0026nbsp;(Participant J)\u003c/em\u003e While others indicated they enjoyed all their therapies. \u003cem\u003eI enjoy all my therapies. They\u0026apos;re never boring. (\u003c/em\u003eParticipant D\u003cem\u003e)\u003c/em\u003e Participants mentioned constraint inducted movement therapy (CIMT) paired with bimanual therapy camp \u003cem\u003eI really enjoyed it because of how easy it is and not because with [CIMT] camps, I feel like it\u0026apos;s a bit too, not intensive, but impractical. (\u003c/em\u003eParticipant \u003cem\u003eL)\u0026nbsp;\u003c/em\u003eand using FES or NMES without FlickTok application or repetitive practice. \u0026nbsp;\u003cem\u003e\u0026lsquo;A bunch of therapy is just grabbing stuff. It\u0026apos;s useless because my hand doesn\u0026apos;t work like that. But with the FES its different (Participant B)\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTechnology.\u003c/strong\u003e Participants had a good understanding of how the technology functioned. \u0026lsquo;\u003cem\u003eThey connected a bunch of things to my cap [\u0026hellip;] when I did a certain action, we would flip to the next video.\u003c/em\u003e\u0026rsquo; (Participant G) Some participants felt fascinated with the technology, \u0026lsquo;\u003cem\u003eIt was cool. Controlling the scroll.\u0026rsquo; (\u003c/em\u003eParticipant B\u003cem\u003e)\u003c/em\u003e and others felt that the technical difficulties such as internet connectivity \u0026lsquo;\u003cem\u003eIt was a little frustrating with it lagging\u0026rsquo;\u0026nbsp;\u003c/em\u003e(Participant A\u003cem\u003e)\u0026nbsp;\u003c/em\u003eand classification errors \u0026lsquo;\u003cem\u003eSo when I tried to move my wrist up, sometimes it didn\u0026apos;t go\u0026rsquo;\u0026nbsp;\u003c/em\u003e(Participant I)\u003cem\u003e.\u0026nbsp;\u003c/em\u003eThis limited their ability to control the video content \u0026lsquo;\u003cem\u003eIt just didn\u0026apos;t listen to my brain.\u0026rsquo;\u003c/em\u003e (Participant G). Some participants found the technology difficulties frustrating, which affected how positively they perceived the therapy experience. \u0026lsquo;\u003cem\u003eI kind of got frustrated\u003c/em\u003e \u0026lsquo;(Participant I)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEffects of Therapy on the Hand and Arm.\u003c/strong\u003e Participants reported feeling tired, in pain, or having a tingling sensation in their hand, especially towards the end of the therapy. \u0026lsquo;\u003cem\u003eThat day I got home really tired. I immediately went to sleep[\u0026hellip;] my hand was sore and tired.\u0026rsquo;\u003c/em\u003e(Participant D) Some participants noticed functional improvements in their hand or arm use over the course of three sessions. These included enhanced flexibility, reduced tone, and better use in everyday life: \u0026lsquo;\u003cem\u003ein foods class, I couldn\u0026apos;t roll out the dough before. And then today I was able to roll out the dough perfectly.\u0026nbsp;\u003c/em\u003e(Participant D) Some participants highlighted specific reasons they found FlickTok useful, particularly on days when their motor function was more limited. \u0026ldquo;\u003cem\u003eSometimes\u0026hellip; you have a bad day where your hand just [is] not working that good. So, I feel like for that it would be helpful\u003c/em\u003e\u0026rdquo; (Participant J), suggesting the potential of the therapy as a supportive tool on variable function days.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFuture Considerations.\u003c/strong\u003e Some participants had equipment concerns, such as discomfort and the appearance of the gel and cap, and wires. \u003cem\u003eI\u0026apos;ve got a lot of hair and I don\u0026apos;t like the gel in my hair.\u0026nbsp;\u003c/em\u003e(Participant J) Participants highlighted the need for future improvements such as comfort and appearance. \u003cem\u003eMake it look pretty.\u0026nbsp;[..]\u0026nbsp;Paint it pink [\u0026hellip;] Put Flowers on it.\u003c/em\u003e (Participant B). \u0026nbsp;Another consideration was fitting therapy into daily routines, as some participants needed it to accommodate school, sports, or homework. \u0026lsquo;[I would use it] \u003cem\u003eMaybe every day if I could, if it didn\u0026apos;t have hockey.\u003c/em\u003e\u0026rsquo; (Participant E). Others reflected on FlickTok\u0026nbsp;being more beneficial when they were younger. \u0026ldquo;\u003cem\u003eI feel like it would\u0026apos;ve been better when I was younger and actually doing physiotherapy on the regular. But now that I\u0026apos;m older and busy, I don\u0026apos;t know if I\u0026apos;d have the time to do it\u0026rdquo;\u003c/em\u003e (Participant J). Participants also spoke of using FlickTok at home, and while some expressed, they would wear it for \u0026lsquo;\u003cem\u003eAs long as I have to.\u0026rsquo;\u003c/em\u003e (Participant A) others were reluctant.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur pilot trial supports the feasibility of integrating BCI with FES and social media for youth with HCP. The FES/BCI system showed good reliability and performance on par with other EEG-based BCI systems.\u0026nbsp;\u003csup\u003e39,40\u003c/sup\u003e The methods were well tolerated by most, and many reported FES/BCI as a more enjoyable alternative to commonly used therapies such as CIMT or simple FES. Engaging patient partners with lived experience provided valuable insight to system strengths, weaknesses to be addressed, and direction for future pilot and clinical trials.\u003c/p\u003e\n\u003cp\u003eTechnical performance was generally good but also contributed to participant frustration and reduced enjoyment of FlickTok. Previous studies have identified that a Cohen\u0026rsquo;s kappa of at least 0.40 suggests BCI competency.\u0026nbsp;\u003csup\u003e39,40\u003c/sup\u003eThis threshold was not consistently achieved by all participants across all sessions. Some children voiced that they found it frustrating when the system did not respond when they attempted a movement. The same enhanced reward motivation of successful social media \u0026ldquo;swiping\u0026rdquo; may be countered by exaggerated frustration when it fails. It was unclear whether these failures were due to their EEG signals or an incorrect classification of the\u0026nbsp;BCI software system we used.\u003csup\u003e24\u003c/sup\u003e The integration of BCI with FES aims to strengthen the correct brain signals associated with desired motor movements. However, children with perinatal stroke likely have altered event-related desynchronization and synchronization EEG patterns.\u003csup\u003e26,41\u003c/sup\u003e It is also unclear to what extent watching social media impacts EEG signals and classification. Personalized channel selection based on lesion location could improve performance and should be considered in future studies.\u003csup\u003e42\u003c/sup\u003e The BRIEF metric did not show an obvious association with BCI performance, as previously reported.\u003csup\u003e21\u003c/sup\u003e However, the integration of therapy with social media may mitigate concerns about attention in children, as they indicated that they remained engaged throughout the sessions.\u003c/p\u003e\n\u003cp\u003eThe optimal dosage of upper extremity therapy for children with HCP is unclear. While higher dosage is generally associated with greater motor improvement, considerable variability exists.\u003csup\u003e43\u003c/sup\u003e In the context of this study, the number of repetitions was not solely influenced by participant effort but also by their engagement with social media. For example, some participants preferred watching long videos, such as baking tutorials, which reduced opportunities for repeated movement. In contrast, those who engaged in frequent swiping through content completed more repetitions, thereby receiving a higher therapeutic dose. Another factor influencing dose was the participants\u0026rsquo; ability to perform the target functional movement within the two-second prediction window. Participants with greater motor function were able to achieve more repetitions, which has been observed in previous studies\u003csup\u003e44\u003c/sup\u003e. Not all participants achieved the repetition or hourly dosage targets seen in pediatric CIMT and bimanual interventions.\u0026nbsp;\u003csup\u003e44\u003c/sup\u003e In adult FES studies, dosage is typically linked to time spent in stimulation, but FlickTok introduces user choice (to swipe or not) complicating dosage. Examining modifiable variables including social media app features, reward behaviours, activation time windows and individual user preferences may identify avenues to enhance repetitions and overall system performance.\u003c/p\u003e\n\u003cp\u003eFatigue was not directly associated with the repetitions per hour but is a complicated problem that requires further investigation in children with HCP. In some cases, participants described their fatigue during therapy as debilitating, preventing them from completing sessions while others appeared unaffected. Fatigue also impacted performance on the BBT, as some participants became too fatigued to demonstrate improvement. The physiological mechanisms of this fatigue are not clear. We have previously shown that self-reported fatigue increases after 30 minutes of BCI use in school aged children, with accompanying changes in EEG power spectra, though this did not have a major effect on BCI performance.\u003csup\u003e33\u003c/sup\u003e Fatigue has also been linked to the unique neurophysiology of children with perinatal stroke including increased excitability of ipsilateral corticospinal projections from the contralesional hemisphere to the more affected hand.\u003csup\u003e45\u003c/sup\u003e Measurement and possible mitigation of fatigue using patient reported outcomes should be included in future trials of BCI-FES in youth.\u003c/p\u003e\n\u003cp\u003eThe possible motor improvements we observed in some participants were unexpected. Our pilot trial was not powered to determine efficacy and three sessions are presumed to be insufficient to improve function through neuroplasticity. However, some qualitative comments also highlighted possible improvements in hand function that participants experienced in everyday life. If nothing else, that some motor measures improved provides additional evidence in support of interventional safety. Our approach does not address the learned disuse of the affected hand, which is commonly observed in youth with HCP.\u003csup\u003e46\u003c/sup\u003e The unimanual approach employed here may only be translationally effective when combined with strategies that promote bimanual hand use. FES is supported by Grade A evidence for adult stroke rehabilitation.\u003csup\u003e16\u003c/sup\u003e In pediatric populations, research is limited but suggests possible efficacy for functional improvement.\u003csup\u003e47\u003c/sup\u003e However, due to the scarcity of studies, FES is not widely used in children. This study emphasizes the need to evaluate FES and FlickTok in long-term interventions.\u003c/p\u003e\n\u003cp\u003eAn important, potentially overlooked factor when evaluating a new therapy is how easily it translates into a child\u0026rsquo;s everyday life. Many of our participants shared that school, sports, and homework could get in the way of using FlickTok consistently. Other considerations include equipment comfort which needs to be at the forefront of design to ensure optimal comfort and ease of use and reduce the risk of abandonment. Even though our system was designed to be user-centered, a lot of the feedback we received suggested that it could be\u0026nbsp;\u003cem\u003eeven better\u003c/em\u003e aligned with user needs, including some novel ideas we had not considered such as integrating it with an Xbox or a television. Intersubject variability was reflected in the enjoyment surveys where rankings ranged from first to sixth in preference). \u0026nbsp;While some participants enjoyed all their therapies, others found most of them unengaging and preferred the FlickTok concept, validating further exploration and refinement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study had limitations. The sample size was carefully considered for this pilot trial but limits the generalizability of the findings. We also had limited opportunity to engage with parents or caregivers, whose perspectives could provide additional valuable insight into the feasibility, usability, and potential impact in daily life. The participant driven structure of the system also posed challenges in accurately determining true positive/negative, false positive/ negative values to calculate Cohen\u0026rsquo;s Kappa. The current method of reviewing video recordings to assess BCI success was highly time-consuming and may not be sustainable in larger studies. Future work should explore more efficient and objective methods of evaluating BCI performance.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eHemiparetic cerebral palsy is a significant burden on individuals, families and healthcare systems, affecting millions worldwide. Addressing therapeutic gaps in young brains has the potential to propel the entire stroke field forward.\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003eBCI can be paired with FES and social media to allow youth with hemiparesis to perform targeted movement therapy in the upper extremity. The user-centred system we designed demonstrates promising performance, tolerability, and feasibility worthy of additional design and testing informed by patient engagement.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe University of Calgary and Alberta Children\u0026rsquo;s Hospital approved this study. ( REB24-0528) The study was registered at https://clinicaltrials.gov (NCT07133347).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data analyzed during the current study is not publicly available due to restrictions on sharing participant health information.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Alberta Children\u0026rsquo;s Hospital Foundation. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA.B. , A.H. supported patient partner engagement. \u0026nbsp;A.B. , A.M. ,P.S., I.R., G.W., N.B.,M.A., B.I.,E.S., D.C.M.,A.K.,E.K.L Created and Developed FlickTok. A.B. , M.M,B.I., ,P.S., N.B.,Z.J. \u0026nbsp;H.C., A.K.,E.K.L supported methodology design. A.B. , M.M ,P.S. collected data. A.B. , M.M ,P.S., N.B., D.N, N.R., H.C., A.K.,E.K.L: Analysed Data. A.B :Wrote manuscript.\u003c/p\u003e\n\u003cp\u003eA.B, A.M.,B.I.,P.S., I.R., H.C.,E.S., D.C.M.,R.M. A.H., A.K.,E.K.L: Edited manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the incredible children and families who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGraham HK, Rosenbaum P, Paneth N, et al. Cerebral palsy. \u003cem\u003eNat Rev Dis Primers\u003c/em\u003e. 2016;2:15082. doi:10.1038/nrdp.2015.82\u003c/li\u003e\n \u003cli\u003eFern\u0026aacute;ndez-L\u0026oacute;pez D, Natarajan N, Ashwal S, Vexler ZS. Mechanisms of perinatal arterial ischemic stroke. \u003cem\u003eJ Cereb Blood Flow Metab\u003c/em\u003e. 2014;34(6):921-932. doi:10.1038/jcbfm.2014.41\u003c/li\u003e\n \u003cli\u003eCornette L, deVeber G, Govaert P. Perinatal stroke. \u003cem\u003eSeminFetal Neonatal Med\u003c/em\u003e. 2009;14:243-244.\u003c/li\u003e\n \u003cli\u003eAisen ML, Kerkovich D, Mast J, et al. Cerebral palsy: clinical care and neurological rehabilitation. \u003cem\u003eLancet Neurol\u003c/em\u003e. 2011;10(9):844-852. doi:10.1016/S1474-4422(11)70176-4\u003c/li\u003e\n \u003cli\u003eBalduini W, Carloni S, Mazzoni E, Cimino M. New therapeutic strategies in perinatal stroke. \u003cem\u003eCurrDrug TargetsCNSNeurolDisord\u003c/em\u003e. 2004;3:315-323.\u003c/li\u003e\n \u003cli\u003eHilderley AJ, Dunbar M, Andersen J, et al. Neuromodulation for Children With Hemiparesis and Perinatal Stroke: A Randomized Clinical Trial. \u003cem\u003eJAMA Neurology\u003c/em\u003e. 2025;82(3):267-275. doi:10.1001/jamaneurol.2024.4898\u003c/li\u003e\n \u003cli\u003eKirton A, Metzler MJ, Craig BT, et al. Perinatal stroke: mapping and modulating developmental plasticity. \u003cem\u003eNat Rev Neurol\u003c/em\u003e. 2021;17:415-432. doi:10.1038/s41582-021-00503-x\u003c/li\u003e\n \u003cli\u003eKolb B, Gibb R. Brain plasticity and behaviour in the developing brain. \u003cem\u003eJCanAcadChild AdolescPsychiatry\u003c/em\u003e. 2011;20:265-276.\u003c/li\u003e\n \u003cli\u003eKirton A, deVeber G. Advances in perinatal ischemic stroke. \u003cem\u003ePediatr Neurol\u003c/em\u003e. 2009;40:205-214.\u003c/li\u003e\n \u003cli\u003eKirton A. Modeling developmental plasticity after perinatal stroke: defining central therapeutic targets in cerebral palsy. \u003cem\u003ePediatr Neurol\u003c/em\u003e. 2013;48(2):81-94. doi:10.1016/j.pediatrneurol.2012.08.001\u003c/li\u003e\n \u003cli\u003eNovak I, Honan I. Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review. \u003cem\u003eAust Occup Ther J\u003c/em\u003e. Published online April 10, 2019. doi:10.1111/1440-1630.12573\u003c/li\u003e\n \u003cli\u003eNovak I, Morgan C, Fahey M, et al. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. \u003cem\u003eCurr Neurol Neurosci Rep\u003c/em\u003e. 2020;20(2):3. doi:10.1007/s11910-020-1022-z\u003c/li\u003e\n \u003cli\u003eGovernment of Canada CI of HR. Strategy for Patient-Oriented Research. June 18, 2018. Accessed August 25, 2024. https://cihr-irsc.gc.ca/e/41204.html\u003c/li\u003e\n \u003cli\u003eStein C, Fritsch CG, Robinson C, Sbruzzi G, Plentz RDM. Effects of Electrical Stimulation in Spastic Muscles After Stroke. \u003cem\u003eStroke\u003c/em\u003e. 2015;46(8):2197-2205. doi:10.1161/STROKEAHA.115.009633\u003c/li\u003e\n \u003cli\u003eEraifej J, Clark W, France B, Desando S, Moore D. Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis. \u003cem\u003eSyst Rev\u003c/em\u003e. 2017;6:40. doi:10.1186/s13643-017-0435-5\u003c/li\u003e\n \u003cli\u003eAdams HP Jr, del ZG, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. \u003cem\u003eCirculation\u003c/em\u003e. 2007;115:e478-e534.\u003c/li\u003e\n \u003cli\u003eChiu HC, Ada L. Effect of functional electrical stimulation on activity in children with cerebral palsy: a systematic review. \u003cem\u003ePediatr Phys Ther\u003c/em\u003e. 2014;26(3):283-288. doi:10.1097/PEP.0000000000000045\u003c/li\u003e\n \u003cli\u003eCope S, Mohn-Johnsen S. The effects of dosage time and frequency on motor outcomes in children with cerebral palsy: A systematic review. \u003cem\u003eDev Neurorehabil\u003c/em\u003e. Published online February 16, 2017:1-12. doi:10.1080/17518423.2017.1282053\u003c/li\u003e\n \u003cli\u003eBates M, Sunderam S. Hand-worn devices for assessment and rehabilitation of motor function and their potential use in BCI protocols: a review. \u003cem\u003eFront Hum Neurosci\u003c/em\u003e. 2023;17. doi:10.3389/fnhum.2023.1121481\u003c/li\u003e\n \u003cli\u003eBai Z, Fong KNK, Zhang JJ, Chan J, Ting KH. Immediate and long-term effects of BCI-based rehabilitation of the upper extremity after stroke: a systematic review and meta-analysis. \u003cem\u003eJ Neuroeng Rehabil\u003c/em\u003e. 2020;17(1):57. doi:10.1186/s12984-020-00686-2\u003c/li\u003e\n \u003cli\u003eJadavji Z, Metzler MJ, Kinney-Lang E, Kirton A, Zewdie E. Feasibility and Tolerability of BCI Activated Electrical Stimulation in Children with Perinatal Stroke: A Pilot Study. \u003cem\u003eNeurorehabilitation and Neural Repair\u003c/em\u003e..doi:10.3389/fnhum.2023.1006242\u003c/li\u003e\n \u003cli\u003eBiasiucci A, Leeb R, Iturrate I, et al. Brain-actuated functional electrical stimulation elicits lasting arm motor recovery after stroke. \u003cem\u003eNature Communications\u003c/em\u003e. 2018;9(1):2421. doi:10.1038/s41467-018-04673-z\u003c/li\u003e\n \u003cli\u003eNeuroTrac\u0026reg; Rehab. TENS, Neuromuscular Electrical Stimulators, EMG and ETS Devices | Neurotrac. Accessed April 19, 2025. https://veritymedical.com/product/neurotrac-rehab/\u003c/li\u003e\n \u003cli\u003eIrvine, B., Tuladhar, A., Commaduran-Marquez, D., Gulamhusein, A., Schrag, E., Kinney-Lang, E. 2024. \u003cem\u003eBCI-Essentials-Python: v0.1.3\u003c/em\u003e [Software] https://github.com/kirtonBCIlab/bci-essentials-python/releases/tag/v0.1.3.\u003c/li\u003e\n \u003cli\u003eLotte F, Bougrain L, Cichocki A, et al. A review of classification algorithms for EEG-based brain\u0026ndash;computer interfaces: a 10 year update. \u003cem\u003eJ Neural Eng\u003c/em\u003e. 2018;15(3):031005. doi:10.1088/1741-2552/aab2f2\u003c/li\u003e\n \u003cli\u003eChen S, Shu X, Wang H, Ding L, Fu J, Jia J. The Differences Between Motor Attempt and Motor Imagery in Brain-Computer Interface Accuracy and Event-Related Desynchronization of Patients With Hemiplegia. \u003cem\u003eFront Neurorobot\u003c/em\u003e. 2021;15:706630. doi:10.3389/fnbot.2021.706630\u003c/li\u003e\n \u003cli\u003eB Barachant, A., Barth\u0026eacute;lemy, Q., King, J.-R., Gramfort, A., Chevallier, S., Rodrigues, P. L. C., Olivetti, E., Goncharenko, V., Wagner vom Berg, G., Reguig, G., Lebeurrier, A., Bj\u0026auml;reholt, E., Yamamoto, M. S., Clisson, P., Corsi, M.-C. 2023. \u003cem\u003epyRiemann: v0.5\u003c/em\u003e [Software]. Zenodo. https://doi.org/10.5281/zenodo.8059038\u003c/li\u003e\n \u003cli\u003eBemister TB, Brooks BL, Kirton A. Development, reliability, and validity of the Alberta Perinatal Stroke Project Parental Outcome Measure. \u003cem\u003ePediatr Neurol\u003c/em\u003e. 2014;51(1):43-52. doi:10.1016/j.pediatrneurol.2014.01.052\u003c/li\u003e\n \u003cli\u003eHarb A, Kishner S. Modified Ashworth Scale. In: \u003cem\u003eStatPearls\u003c/em\u003e. StatPearls Publishing; 2024. Accessed September 8, 2024. http://www.ncbi.nlm.nih.gov/books/NBK554572/\u003c/li\u003e\n \u003cli\u003eGarzon LC, Switzer L, Musselman KE, Fehlings D. The use of functional electrical stimulation to improve upper limb function in children with hemiplegic cerebral palsy: A feasibility study. \u003cem\u003eJ Rehabil Assist Technol Eng\u003c/em\u003e. 2018;5:2055668318768402. doi:10.1177/2055668318768402\u003c/li\u003e\n \u003cli\u003eHolmefur M. \u003cem\u003eThe Assisting Hand Assessment: Continued Development, Psychometrics and Longitudinal Use\u003c/em\u003e. Karolinska Institutet; 2009.\u003c/li\u003e\n \u003cli\u003eFoss-Feig JH, de la Fontaine N, Tsatsanis K. BRIEF (Behavior Rating Inventory of Executive Functions). In: Volkmar FR, ed. \u003cem\u003eEncyclopedia of Autism Spectrum Disorders\u003c/em\u003e. Springer; 2015:1-5. doi:10.1007/978-1-4614-6435-8_102048-1\u003c/li\u003e\n \u003cli\u003eKeough JR, Irvine B, Kelly D, et al. Fatigue in children using motor imagery and P300 brain-computer interfaces. \u003cem\u003eJ Neuroeng Rehabil\u003c/em\u003e. 2024;21(1):61. doi:10.1186/s12984-024-01349-2\u003c/li\u003e\n \u003cli\u003eNVivo: Leading Qualitative Data Analysis Software. Lumivero. Accessed May 3, 2025. https://lumivero.com/products/nvivo/\u003c/li\u003e\n \u003cli\u003eHsieh HF, Shannon SE. Three approaches to qualitative content analysis. \u003cem\u003eQual Health Res\u003c/em\u003e. 2005;15(9):1277-1288. doi:10.1177/1049732305276687\u003c/li\u003e\n \u003cli\u003eJamovi. The jamovi project. Published online 2021. https://www.jamovi.org\u003c/li\u003e\n \u003cli\u003eWelcome to Python.org. Python.org. May 1, 2025. Accessed May 4, 2025. https://www.python.org/\u003c/li\u003e\n \u003cli\u003eLogin to your Canva account. Canva. Accessed May 4, 2025. https://www.canva.com/login/\u003c/li\u003e\n \u003cli\u003eJadavji Z, Zhang J, Paffrath B, Zewdie E, Kirton A. Can Children With Perinatal Stroke Use a Simple Brain Computer Interface? \u003cem\u003eStroke\u003c/em\u003e. 2021;52(7):2363-2370. doi:10.1161/STROKEAHA.120.030596\u003c/li\u003e\n \u003cli\u003eZhang J, Jadavji Z, Zewdie E, Kirton A. Evaluating If Children Can Use Simple Brain Computer Interfaces. \u003cem\u003eFront Hum Neurosci\u003c/em\u003e. 2019;13:24. doi:10.3389/fnhum.2019.00024\u003c/li\u003e\n \u003cli\u003eGracies JM. Pathophysiology of spastic paresis. I: Paresis and soft tissue changes. \u003cem\u003eMuscle \u0026amp; Nerve\u003c/em\u003e. 2005;31(5):535-551. doi:10.1002/mus.20284\u003c/li\u003e\n \u003cli\u003eMa Y, Gong A, Nan W, Ding P, Wang F, Fu Y. Personalized Brain\u0026ndash;Computer Interface and Its Applications. \u003cem\u003eJ Pers Med\u003c/em\u003e. 2022;13(1):46. doi:10.3390/jpm13010046\u003c/li\u003e\n \u003cli\u003eEliasson AC, Krumlinde-Sundholm L, Gordon AM, et al. Guidelines for future research in constraint-induced movement therapy for children with unilateral cerebral palsy: an expert consensus. \u003cem\u003eDev Med Child Neurol\u003c/em\u003e. 2014;56(2):125-137. doi:10.1111/dmcn.12273\u003c/li\u003e\n \u003cli\u003eMetzler MJ, O\u0026rsquo;Grady K, Fay L, et al. Feasibility of High Repetition Upper Extremity Rehabilitation for Children with Unilateral Cerebral Palsy. \u003cem\u003ePhys Occup Ther Pediatr\u003c/em\u003e. 2022;42(3):242-258. doi:10.1080/01942638.2021.2010857\u003c/li\u003e\n \u003cli\u003eWrightson JG, Zewdie E, Kuo HC, Millet GY, Kirton A. Fatigue in children with perinatal stroke: clinical and neurophysiological associations. \u003cem\u003eDevelopmental Medicine and Child Neurology\u003c/em\u003e. 2020;62(2):234-240. doi:10.1111/DMCN.14273\u003c/li\u003e\n \u003cli\u003eBasu AP, Pearse J, Kelly S, Wisher V, Kisler J. Early intervention to improve hand function in hemiplegic cerebral palsy. \u003cem\u003eFront Neurol\u003c/em\u003e. 2014;5:281. doi:10.3389/fneur.2014.00281\u003c/li\u003e\n \u003cli\u003eYıldızg\u0026ouml;ren MT, Nakipoğlu Y\u0026uuml;zer GF, Ekiz T, \u0026Ouml;zgirgin N. Effects of neuromuscular electrical stimulation on the wrist and finger flexor spasticity and hand functions in cerebral palsy. \u003cem\u003ePediatr Neurol\u003c/em\u003e. 2014;51(3):360-364. doi:10.1016/j.pediatrneurol.2014.05.009\u003c/li\u003e\n \u003cli\u003eDukelow S, Kirton A. Enhancing Stroke Recovery Across the Life Span With Noninvasive Neurostimulation. \u003cem\u003eJ Clin Neurophysiol\u003c/em\u003e. 2020;37(2):150-163. doi:10.1097/WNP.0000000000000543\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-neuroengineering-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jner","sideBox":"Learn more about [Journal of NeuroEngineering and Rehabilitation](http://jneuroengrehab.biomedcentral.com/)","snPcode":"12984","submissionUrl":"https://submission.nature.com/new-submission/12984/3","title":"Journal of NeuroEngineering and Rehabilitation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7420830/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7420830/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground : \u003c/strong\u003ePerinatal stroke can lead to lifelong physical disabilities, where even small improvements in motor function can increase quality of life. Rapid brain development in children provides an opportunity to harness brain plasticity. Current therapies are minimally effective in part due to the boring, unengaging procedures required to achieve adequate repetitions required for therapeutic benefit. The combination of functional electrical stimulation and brain computer interface (FES/BCI) may be effective for adults with stroke-induced hemiparesis and appears feasible in children. We designed a novel FES/BCI system that uses social media to engage youth.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe project was informed through engagement with youth patient partners with lived experience. Participants were fitted with a 16 channel EEG gel headset. BCI training consisted of 20 trials of attempted target movement. Successful classification was paired with FES of the target movement and allowed the participant to swipe to watch the next video as desired. Youth with perinatal stroke and hemiparesis were then recruited to trial the system. Outcomes included training accuracy, BCI performance (Cohen's Kappa), box and blocks, and qualitative interviews to characterize useability and patient experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Twelve participants (aged 10-23 years) completed three sessions. No adverse events occurred; fatigue was minimal and varied across sessions. System performance varied but most sessions had moderate or better agreement. Average FES repetitions for all sessions were 167 reps/hour [sd:55.2 range: 65-283 reps/hour] and 247 reps/hour [SD: 74.9 range:105-379 reps/hour]. Motor outcomes were variable but improved for some. Qualitative feedback suggested higher motivation and enjoyment compared with traditional therapies but also identified frustrations surrounding technical challenges and equipment comfort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eInformed by users, simple EEG-based BCI can be integrated with FES and social media to enhance upper extremity rehabilitation in youth with hemiparesis. This pilot trial will inform the design of future clinical trials to evaluate efficacy.\u003c/p\u003e\n\u003cp\u003eClinical trial #:\u003cstrong\u003e NCT07133347\u003c/strong\u003e\u003c/p\u003e","manuscriptTitle":"Creating an engaging brain computer interface, electrical stimulation therapy for children with hemiparesis: a pilot study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-13 11:26:59","doi":"10.21203/rs.3.rs-7420830/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-23T22:35:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-04T03:01:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64794532295906003857288147512965813883","date":"2025-10-29T01:20:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-09T23:57:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66877113059243720918754153501431663981","date":"2025-10-09T23:02:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-29T21:31:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-19T07:47:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of NeuroEngineering and Rehabilitation","date":"2025-09-18T04:25:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-neuroengineering-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jner","sideBox":"Learn more about [Journal of NeuroEngineering and Rehabilitation](http://jneuroengrehab.biomedcentral.com/)","snPcode":"12984","submissionUrl":"https://submission.nature.com/new-submission/12984/3","title":"Journal of NeuroEngineering and Rehabilitation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"723bc599-01c5-4ac9-a6ff-6bb94788fcc0","owner":[],"postedDate":"October 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:03:28+00:00","versionOfRecord":{"articleIdentity":"rs-7420830","link":"https://doi.org/10.1186/s12984-026-01990-z","journal":{"identity":"journal-of-neuroengineering-and-rehabilitation","isVorOnly":false,"title":"Journal of NeuroEngineering and Rehabilitation"},"publishedOn":"2026-04-24 15:59:00","publishedOnDateReadable":"April 24th, 2026"},"versionCreatedAt":"2025-10-13 11:26:59","video":"","vorDoi":"10.1186/s12984-026-01990-z","vorDoiUrl":"https://doi.org/10.1186/s12984-026-01990-z","workflowStages":[]},"version":"v1","identity":"rs-7420830","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7420830","identity":"rs-7420830","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}