The Berlin Bimanual Test for Stroke Survivors (BeBiT-S): Evaluating exoskeleton-assisted bimanual motor function after stroke

The Berlin Bimanual Test for Stroke Survivors (BeBiT-S): Evaluating exoskeleton-assisted bimanual motor function after stroke | 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 Method Article The Berlin Bimanual Test for Stroke Survivors (BeBiT-S): Evaluating exoskeleton-assisted bimanual motor function after stroke Mareike Vermehren, Annalisa Colucci, Cornelius Angerhöfer, Niels Peekhaus, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5661668/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Dec, 2025 Read the published version in Journal of NeuroEngineering and Rehabilitation → Version 1 posted 9 You are reading this latest preprint version Abstract Background. Brain/neural hand exoskeletons (B/NHEs) can restore motor function after severe stroke, enabling bimanual tasks critical for various activities of daily living (ADL). Yet, reliable clinical tests for assessing bimanual function compatible with B/NHEs are lacking. Here, we introduce the Berlin Bimanual Test for Stroke (BeBiT-S), comprising 10 relevant bimanual tasks, and evaluate its psychometric properties as well as sensitivity to change related to B/NHE application. Methods. 24 stroke survivors (mean age 56.5 years, 9 female) with upper-limb hemiparesis after stroke underwent the BeBiT-S assessment (baseline). Psychometric properties were evaluated via interrater reliability (ICC) and construct validity (as measured by the correlation with the Chedoke Arm and Hand Activity Inventory, CAHAI). Sensitivity to change related to B/NHE application (intervention) was assessed across 15 stroke survivors (mean age 50.3 years, 5 female). Order of conditions (baseline vs. intervention) was randomized across participants. Results. BeBiT-S showed excellent interrater reliability at baseline (ICC = 0.985, P < .001) and good reliability at the intervention condition (ICC = 0.862, P < .001). Baseline BeBiT-S strongly correlated with CAHAI-8 scores (r(22) = 0.95, P < .001), demonstrating construct validity. The BeBiT-S score improved significantly between baseline (Mdn = 38) and intervention (Mdn = 60, P < .05), evidencing the test’s sensitivity to change following the application of a B/NHE. Conclusions. The BeBiT-S is a reliable and valid test for evaluating bimanual task performance in stroke survivors, and sensitive to assess B/NHE-related improvements in bimanual task performance. Trial registration: NCT04440709, submitted June 18 th , 2020 Stroke Exoskeleton Bimanual task performance Brain-computer interface (BCI) Clinical assessment Assistive robotics Figures Figure 1 Figure 2 Figure 3 Introduction Hemiparesis, characterized by weakness or partial paralysis on one side of the body, impacts over 70% of stroke survivors,( 1 ) frequently leading to enduring disability and diminished quality of life. Thus, regaining upper-limb function is critical for increasing independence in daily life activities, and has been identified as a priority by stroke survivors, especially in long-term treatment.( 2 ) In instances of severe paralysis accompanied by complete loss or very limited residual hand function, conventional treatment approaches like constrained induced movement therapy (CIMT) or standard occupational practices often cannot be applied as they rely on residual function.( 3 ) To fill this gap in post-stroke rehabilitation, brain-computer interface (BCI)-driven exoskeletons emerged as a novel treatment option for restoring upper limb function in stroke survivors.( 4 – 7 ) By converting neural activity into control signals of robotic orthoses, such devices enable functional, user-initiated movement execution even in case of complete loss or very limited residual hand function.( 8 ) This way, BCI-based devices allow patients to use the affected limb during therapy sessions, potentially mitigating the phenomenon of “learned non-use” which refers to the tendency to avoid using the affected limb. Beyond that, recent meta-analyses confirm that repeated use of BCI-driven robotic devices can promote functional and structural plasticity triggering motor recovery.( 6 , 9 , 10 ) In recent years, technological advances resulted in the development of lightweight robotic actuators, portable and easy-to-use brain recording devices, and reliable control strategies.( 4 ) Especially brain/neural hand-exoskeletons (B/NHE) hold great promise for clinical applications beyond the laboratory setting.( 8 , 11 ) By combining brain- and other bio-signals, e.g. related to eye movements, robust and safe control paradigms for exoskeletons can be established, paving the way for their implementation as effective and impactful rehabilitative tools.( 4 , 11 , 12 ) However, there is currently no established clinical test to assess the effectiveness of such B/NHE-enabled rehabilitative approach. Such test should be designed to accommodate the use of B/NHEs while thoroughly monitoring subtle changes in upper limb functionality. Current clinical assessments lack such necessary features since they typically emphasize unilateral, repetitive movements (such as the Fugl-Meyer Assessment for upper extremity, FMA-UE) or unilateral functional tasks (like the Action Research Arm Test, ARAT, Toronto Rehabilitation Institute Hand Function Test, TRI-HFT, or Wolf Motor Function Test, WMFT). Moreover, a suitable test must also reflect the change in patients’ capability to perform ADL affected by stroke, which usually requires both upper limbs to act together in a highly coordinated and efficient way.( 13 ) Thus, arm rehabilitation strategies targeting only the weaker arm are limited in their effectiveness, suggesting to shift clinical rehabilitation towards bimanual training.( 14 ) Currently, there is only one performance-based assessment tool that evaluates bimanual hand function in ADLs after stroke, the Chedoke Arm and Hand Activity Inventory (CAHAI).( 15 ) While the CAHAI offers valuable insights into functional bimanual tasks that are important in stroke patients’ daily life, certain test items are incompatible with the use of assistive robotic devices such as B/NHEs (e.g., wringing out a wet washcloth), or are outdated (e.g., picking up a desk telephone with receiver). Additionally, the evaluation of tasks in the CAHAI focuses exclusively on the degree of independence, which is inherently biased in the use of assistive devices. A first attempt to address this gap in clinical tests has been made by Angerhöfer et al., who introduced the Berlin Bimanual Test for Tetraplegia (BeBiT-T).( 16 ) The novel assessment tool can evaluate bimanual task performance in daily life activities for tetraplegic individuals. Given the marked distinctions in motor symptoms between tetraplegia and stroke – including spasticity, residual motor function, trunk control, and weakness or partial paralysis on both sides of the body – there is a critical need to establish a similar test for stroke survivors. Here, we introduce such test which was inspired by the BeBiT-T but is specifically tailored for stroke survivors. Comprising 10 bimanual tasks directly relevant to the daily life of stroke survivors, the Berlin Bimanual Test for Stroke (BeBiT-S) is designed to seamlessly integrate with the use of modern technologies such as B/NHEs. In the following, we explain the rationale behind each item of the BeBiT-S and evaluate its reliability and validity, as well as sensitivity to B/NHE use. Methods Development of the Berlin Bimanual Test for Stroke (BeBiT-S) The development of the BeBiT-S involved a systematic three-stage process. Initially, a theoretical framework was established (Figure 1), and a pool of potential test items was generated by an interdisciplinary research team including experts in classical test theory, physicians, medical engineers, psychologists, and physical therapists. In the second stage, test items were selected based on the theoretical framework. Our criteria included coverage of various categories of ADLs, such as eating and drinking, housekeeping, dressing, and personal hygiene. Additionally, we ensured representation of all relevant grasp types essential for daily life, encompassing tripod pinch, tip pinch, power grip, spherical grip, and extension grip. In this way, the BeBiT-S aligns with the World Health Organization’s (WHO) criteria for the International Classification of Functioning, Disability and Health (ICF), considering body function, activity, and participation. Items were further selected to represent diverse bimanual actions that are affected post-stroke, following the taxonomy of Kantak et al (2017).(14) They distinguish between symmetric bimanual actions involving the use of homologous muscles, and asymmetric movements involving non-homologous muscles. Moreover, actions are distinguished in which each hand pursues an independent goal or both hands work together to accomplish a common task. In addition to these considerations, all selected test items needed to be compatible with the use of assistive exoskeletons such as B/NHEs. Moreover, items were selected for easy and quick administration as well as inexpensiveness. In the third and final stage, the selected items underwent rigorous testing on healthy participants regarding replicability, affordability, safety, representation of bimanual motor function, and compatibility with B/NHEs. The refined BeBiT-S, as presented in its final version, comprises ten bimanual tasks specifically tailored to address the needs of stroke survivors in their daily lives. The materials required for the test are readily available in most clinical and research settings around the world, making it accessible on a global scale (Table 1). The development of the BeBiT-S also involved the creation of a comprehensive scoring system to assess the primary components of bimanual function in ADLs, encompassing reaching, grasping, stabilizing, manipulating, and lifting. Scoring for the BeBiT-S relies on video recordings capturing participants’ performance of the designated tasks. An exemplary scoring sheet is provided in the appendix. Each task is assigned a score ranging from 0 to 10 points, contributing to a maximum achievable score of 100. 20 points can be obtained for each reaching and grasping components, 10 points for stabilizing , 33 for manipulating , and 17 for lifting . In case of reaching and grasping , the maximum score is penalized if compensatory strategies are detected, such as hand-over-hand technique to reach an object or utilizing passive support of spasticity to hold an object. The scoring system categorizes object manipulation into three levels (no difficulties, slight difficulties, or great difficulties) while also considering the application of compensatory strategies, such as using both hands to manipulate a single item. No points are given if only the unaffected hand is used. Depending on the task, three or five points can be obtained for correctly manipulating an object. If applicable, two points are given for performing the task in a lifted position, when objects have no contact with any surface, including the patient’s trunk. One point is given for stabilization if the affected arm maintains a firm grip throughout the task. The BeBiT-S scoring system imposes no time constraint or limit to the number of attempts. The attempt ends when either the participant or the instructor believes that no better performance can be achieved. The best attempt is scored. Participants We recruited 24 individuals with either subacute or chronic post-stroke upper-limb hemiparesis (9 female, mean age 56.5 ± 16.8 years). Recruitment and assessment of subacute stroke survivors (n = 9, 6 months post stroke) were assessed at Charité – Universitätsmedizin Berlin, P.A.N. Zentrum Berlin-Frohnau, or at their homes. Participant characteristics are depicted in Table 2. To be eligible for the study, potential participants had to fulfill the following requirements: stroke with upper-limb hemiparesis, age ranging from 18 to 85 years, cognitive ability to understand and follow instructions, and absence of any alcohol or drug addiction, terminal medical illness, or neurological or psychiatric condition other than stroke. The study was approved by the local ethics committee at Charité – Universitätsmedizin Berlin under number EA1/106/20. All participants provided written informed consent before enrollment. Study design Participants performed the BeBiT-S without assistance (baseline) and with B/NHE support (intervention) in a within-subject study design. Conditions (baseline or intervention) were applied in random order with 8/15 participants completing the baseline condition first. In the baseline condition, the participants were seated comfortably in a chair or wheelchair in front of a desk. Each task was explained and demonstrated by the instructor. Participants were asked to perform the tasks as closely as possible to the instructor’s demonstration and were reminded of the importance of using both hands and avoiding compensatory strategies whenever possible. In the intervention condition, the BeBiT-S was repeated in the same way as in the baseline condition with participants operating a portable hand exoskeleton for assistance (Figure 2). The whole session was videotaped for scoring with a clear view of the materials throughout the task. Participants´ performance in both the baseline and intervention condition was assessed with the corresponding scoring sheet (Appendix 1). Ratings from three different raters, all experienced in evaluating stroke survivors, were obtained to assess agreement among them. To assess validity of the BeBiT-S, the CAHAI-8(17) was completed across all participants. The tasks included in the CAHAI-8 are as follows: (1) open a jar of coffee, (2) dial 911, (3) draw a line with a ruler, (4) pour a glass of water, (5) wring out a washcloth, (6) do up five buttons, (7) dry back with a towel, and (8) put toothpaste on a toothbrush. The CAHAI-8 was completed without a B/NHE. Finally, participants were asked to complete a subset of 4 domains of the Stroke Impact Scale (SIS) version 3.0 questionnaire.(18) The four domains selected were strength, ADLs, hand function, and percentage of recovery. All 24 participants were assessed with the BeBiT-S unassisted (baseline). 15 participants (5 female, 12 chronic, mean age 50.3 ± 15.8 years) repeated the BeBiT-S using a B/NHE (intervention). Reasons why the BeBiT-S was only performed unassisted (baseline) included: (1) inability to follow the B/NHE control paradigm (n = 3), (2) inability to perform horizontal eye movements (n = 1), (3) exhaustion (n = 1), (4) technical issues (n = 1), (5) exoskeleton did not fit (n = 1), (6) time constraints (n = 2). Experimental setup For the intervention, a wearable hand exoskeleton allowing firm grasping was attached to the participants paretic hand. A hybrid brain-computer interface based on electroencephalography (EEG) and electrooculography (EOG) signals allowed the participant to operate the exoskeleton (HandyRehab by Zunosaki Ltd., Hong Kong). Detection of sensori-motor rhythm (8-13 Hz) event-related desynchronization (SMR-ERD) was translated to exoskeleton closing movements, while horizontal eye movements (horizontal oculoversion, HOV) were used to control exoskeleton opening movements and to stop unintentional closing. EEG was recorded from 5 conventional recording sites according to the international 10/20 system, either F3, T3, C3, P3 and Cz to control the B/NHE on the right hand, or F4, T4, C4, P4 and Cz to control the exoskeleton on the left hand. Additionally, two electrodes were placed on the right and left outer canthus to record EOG. EEG and EOG signals were processed in real time through a custom BCI software (BeamBCI) based on the Python programming language. Signals were recorded at a sampling frequency of 250 Hz and bandpass filtered between 1 Hz and 30 Hz. Power spectral density in the mu-range was estimated using Burg’s method.(19) A surface Laplacian filter was applied to increase signal-to-noise ratio at the target electrodes C3 or C4.(8) During a short calibration session before the beginning of the measurement, participants learned to perform motor imagery or motor attempts to close the B/NHE, and maximum HOV to open the B/NHE. During the calibration, participants trained by means of visual cues on a computer screen. After the calibration, while performing the BeBiT-S tasks with the B/NHE, participants could decide when to open and close the exoskeleton in an uncued (asynchronous) paradigm. Data Analysis We assessed internal consistency and scale reliability for the baseline scores of the 10 test items by calculating Cronbach’s Alpha and corrected item-total correlations. These analyses were performed using SPSS (v. 27). Following the guideline proposed by Kline,(20) test items with item-total correlation below r = 0.3 were discarded. To quantify the level of agreement among the three raters in evaluating the BeBiT-S score, we computed the intraclass correlation coefficient (ICC) using SPSS (v. 27). The ICC was calculated separately for both baseline and intervention conditions in a Two-Way Mixed model with absolute agreement. To evaluate construct validity, we obtained CAHAI-8 scores for all participants and calculated the linear relationship between the BeBiT-S baseline scores and the CAHAI-8 scores using Pearson’s correlation coefficient. Given that the CAHAI-8 is a performance-based assessment tool for evaluating bimanual hand function in post-stroke ADLs, it seemed most appropriate for assessing construct validity of the BeBiT-S. Furthermore, we computed the linear relationship of the BeBiT-S baseline scores and four domains of the Stroke Impact Scale (strength, activities of daily living, hand function, percentage of recovery) by computing Pearson’s correlation coefficient. To evaluate the BeBiT-S’ sensitivity to assess the impact of B/NHE use, we compared baseline and intervention scores with a Wilcoxon signed rank test. Moreover, we computed five Wilcoxon signed rank tests to assess changes within each component of hand function (reaching, grasping, stabilizing, manipulating, lifting). To evaluate whether the subgroup that performed the BeBiT-S with the exoskeleton is biased (i.e., are less affected and score higher at baseline), we computed a Mann-Whitney test comparing the baseline BeBiT-S score of the subgroup of participants that also participated in the intervention and those who did not. The significance level was set at P < .05. Results Validity and Reliability The Cronbach’s alpha coefficient calculated for the 10 test items within the baseline condition yielded an α of 0.97, signifying excellent internal consistency. Furthermore, all items demonstrated item-total correlations of r ≥ 0.82, surpassing the predefined cut-off level of r > 0.3 (Table 3). Excellent interrater reliability was observed during the baseline assessment (ICC for single values: 0.985, 95% confidence interval [CI]: 0.969 to 0.993, P <.001). Additionally, the intervention condition displayed good interrater reliability (ICC for single values: 0.862, CI: 0.432 to 0.962, P < .001). A robust positive correlation was identified between BeBiT-S baseline scores (M = 48.08, SD = 32.45) and CAHAI-8 scores (M = 22.13, SD = 14.94), r(22) = 0.95, P < .001, as depicted in Figure 3A. This outcome underscores a high level of construct validity. The baseline BeBiT-S score also correlated significantly with the scores of the SIS-1 domain “strength” (r(20) = 0.53, P = .012) and SIS-7 domain “hand function” (r(20) = 0.50, P = .018), but not with domains “ADLs” (r(20) = 0.245, P = .273) and “percentage of recovery” (r(18) = 0.27, P = .911). The result of the Mann-Whitney test indicated no significant difference of the baseline BeBiT-S score between participants who participated in the intervention (Mdn = 38), and those who did not (Mdn = 18), U = 47.5, P = .245. Comparison of baseline and intervention A Wilcoxon Signed Rank test revealed an increase in BeBiT-S score from baseline (Mdn = 38) to intervention (Mdn = 60) condition, z = 2.48, P = .013, with a medium effect size (r = 0.45) (Figure 3B). This result underlines the sensitivity of the test in detecting changes in B/NHE applications. Looking at individual components, Wilcoxon Signed Rank tests indicate a significant improvement of grasping and stabilizing during B/NHE use (z = 3.11, P < .01 for grasping, z = 2.55, P < .01 for stabilizing, Figure 3C). There were also improvements in the manipulating and lifting components of the BeBiT-S score, although these were not statistically significant (z = 1.64, P = .102 for manipulating, z = 0.5, P = .619 for lifting). The reaching component displayed a marginal decline, although not statistically significant (z = 1.25, P = 0.211). Discussion The lack of reliable clinical tests for assessing bimanual hand function after stroke that are compatible with B/NHEs limits research into their clinical efficacy. Here, we addressed this critical gap and showed that the BeBiT-S is effective, reliable, and valid to assess bimanual motor function with and without B/NHEs. The central advantage of the BeBiT-S lies in its compatibility with state-of-the-art assistive technology, particularly B/NHEs, and its sensitivity to B/NHE-related motor improvements. The BeBiT-S comprises ten bimanual tasks. Test items were chosen to be inexpensive as well as quick and easy to administer. Tasks were chosen to represent bimanual actions affected after stroke, to be relevant to everyday life, to cover relevant grasp types, and finally, to be compatible with state-of-the-art (neuro-)prosthetic devices. Excellent internal consistency of the test was indicated by Cronbach’s alpha (0.97), exceeding the threshold for clinical instruments (> 0.9) as suggested by Nunally.(21) All ten test items met the predefined cut-off level of item-total correlations of r > 0.3. The high correlation coefficient (ICC) values, exceeding 0.85 in both baseline and intervention, indicate consistent and reliable scoring across different raters. Raters were only given brief instructions included on the scoring sheet (see Appendix). This underlines the robustness of the BeBiT-S and feasibility for inexperienced personnel to apply it. The highly positive correlation between baseline BeBiT-S scores and CAHAI-8 scores suggests that it effectively measures what it intends to evaluate. Moreover, the baseline BeBiT-S score also correlated with the Stroke Impact Scale (SIS) domains “strength” and “hand function”, providing additional support for the construct validity of the BeBiT-S. It is noteworthy, however, that the BeBiT-S did not correlate with SIS domains “ADLs” and “percentage of recovery” as originally anticipated. One reason for this could be the heterogeneity in chronicity in our participant group (from less than 3 months post-stroke to 27 years post-stroke), where the subjective nature of “percentage of recovery” becomes particularly apparent. In our study, the intervention condition with the assistance of a B/NHE was completed by a subgroup of 15 out of 24 total participants. To rule out a potential bias in the subgroup of participants that performed the BeBiT-S unassisted, we compared their BeBiT-S scores with that of participants that used the B/NHE. The absence of a difference suggests that lower bimanual function does not prevent B/NHE use. Looking more closely into the drop-out reasons for B/NHE use, two main reasons could be distinguished: technical and non-technical reasons. While technical reasons include issues related to the fit of the hand-exoskeleton, system failure or time constraints on the patient’s side, non-technical reasons include participant exhaustion, low motivation, or inability to follow the B/NHE control paradigm. Notably, those excluded for non-technical reasons were all within their first months after stroke (n = 5, on average 4.2 months after stroke), whereas technical reasons were more prevalent among chronic stroke survivors (3 out of 4 chronic). A notable observation was that controlling a B/NHE appeared more challenging for subacute stroke survivors compared to those in the chronic phase. This implies that incorporating B/NHE-enabled rehabilitation into sub-acute stroke cases might pose greater difficulty compared to chronic stroke scenarios. It underscores the importance of tailoring rehabilitation approaches to the specific needs and recovery stages of each individual. (22, 23) Further research is needed to refine rehabilitation protocols to enhance their effectiveness and improve patient adherence. The second main goal of our study was to demonstrate the compatibility of the BeBiT-S with novel assistive technology such as B/NHEs. This is particularly important, given the lack of such tests that are, however, necessary to evaluate efficacy of B/NHE-related rehabilitation protocols. Our investigation involved a comparison of the BeBiT-S score with and without B/NHE assistance and demonstrated an increase in BeBiT-S score from a median of 38 points without B/NHE to a median of 60 points during B/NHE use. This underscores the efficacy of the BeBiT-S in capturing and quantifying improvements in bimanual task performance facilitated by B/NHE use. While most participants demonstrated enhanced bimanual task performance with B/NHE assistance, two participants experienced a decline in bimanual task performance, however. One of them, who experienced a stroke at birth, had extensively adapted to using the impaired hand in activities of daily living, which may explain this lack of improvement. Across all participants, the grasping and stabilizing components showed significant improvements during B/NHE operation ( P < .05 for grasping and stabilizing, Figure 3C), emphasizing the positive impact of the intervention on these essential components of hand function. While the manipulating and lifting components showed improvements, statistical significance was not reached ( P = .102 for manipulating, P = .619 for lifting). The reaching component, although displaying a marginal decline, did not reach statistical significance ( P = .211). These findings align with the specific characteristics of hand-exoskeleton device employed in this study. While it can support grasping and stabilizing objects, it lacks features to support reaching and may even impede lifting, due to added weight to the hand and arm. Overall, the findings underscore that the BeBiT-S’ scoring system captures the fundamental aspects of bimanual function, encompassing reaching, grasping, manipulating, and lifting. It is crucial to acknowledge that various assistive technologies may have varying impacts on different aspects or components. It is thus important to note that during development of the BeBiT-S, deliberate efforts were made to enhance the versatility of the test towards other assistive systems or approaches. Consequently, its potential applications extend beyond a specific device class, encompassing, for instance, muscular-driven orthoses, functional electric stimulation (FES) or whole-arm exoskeletons.(24) Even application in assessment of prostheses is conceivable. Further research is needed to confirm compatibility with various assistive devices. The BeBiT-S may also be a valuable tool to assess recovery of bimanual function, e.g., triggered by repeated B/NHE training. Further research is necessary to evaluate whether the BeBiT-S is sensitive to measure improvements throughout the trajectory of such rehabilitation protocols.(4) While the psychometric evaluation of the BeBiT-S has yielded excellent results, it is important to emphasize that these findings require additional validation through larger clinical studies. Conclusions The BeBiT-S tool proves to be both reliable and valid for evaluating bimanual task performance in stroke survivors, effectively aligning with emerging assistive technologies like B/NHEs. Our study highlights this alignment and demonstrates BeBiT-S' sensitivity in detecting improvements resulting from innovative assistive interventions in stroke rehabilitation. Abbreviations B/NHE: Brain-Neural Hand Exoskeleton BeBiT-S: Berlin Bimanual Test for Stroke BCI: Brain-Computer Interface BeBiT-T: Berlin Bimanual Test for Tetraplegia CAHAI: Chedoke Arm and Hand Activity Inventory EEG: Electroencephalography EOG: Electroocculography SMR-ERD: Sensori-Motor Rhythm Event-Related Desynchronization ICC: Intraclass Correlation Coefficient SIS: Stroke Impact Scale Declarations Ethics approval The study was approved by the local ethics committee at Charité – Universitätsmedizin Berlin under number EA1/106/20. All participants provided written informed consent before enrollment. Consent for publication All participants gave their written consent. Availability of data and materials The videotapes of participants analyzed in the current study are available from the corresponding author on reasonable request. All other data generated or analyzed during this study are included in this published article and its supplementary information files. Competing interests The authors declare that they have no competing interests. Funding This research is supported in part by the European Research Council (ERC) under the project NGBMI (759370), the Federal Ministry of Research and Education (BMBF) under the projects SSMART (01DR21025A) and NEO (13GW0483C), the Korean Ministry of Science and ICT under the framework of the German-Korean Academia-Industry International Collaboration Program on Robotics and Lightweight Construction/Carbon (Grant No. P0017226), the German Research Foundation (DFG, SO932/7-1), and the Einstein Stiftung Berlin. Authors' contributions MV, AC, CA, YA and SRS conceptualized the study. VH helped with recruitment of participants. MV, AC, CA, and NP conducted the study and collected the data. MV analyzed and interpreted the data and wrote the first version of the manuscript. MV, AC, CA, NP, WSK, WKC, HK, VH, NJP and SRS provided critical feedback and revised the manuscript. Acknowledgements We extend our gratitude to Dr. Marius Nann and Yasmina Ardern for their crucial contributions to the conceptualization of the BeBiT-S. We thank Johanna Dettelbacher and Lydia Jaufmann for their assistance with recruitment, data collection, and video rating. Lastly, we want to thank all the study participants for their valuable contributions to this study. References Dobkin BH. The clinical science of neurologic rehabilitation. 2nd ed. New York: Oxford University Press; 2003. Purton J, Sim J, Hunter SM. Stroke survivors' views on their priorities for upper-limb recovery and the availability of therapy services after stroke: a longitudinal, phenomenological study. Disabil Rehabil. 2022:1-11. Kwakkel G, Veerbeek JM, van Wegen EE, Wolf SL. Constraint-induced movement therapy after stroke. Lancet Neurol. 2015;14(2):224-34. Colucci A, Vermehren M, Cavallo A, Angerhöfer C, Peekhaus N, Zollo L, et al. 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Cervera MA, Soekadar SR, Ushiba J, Millan JDR, Liu M, Birbaumer N, Garipelli G. Brain-computer interfaces for post-stroke motor rehabilitation: a meta-analysis. Ann Clin Transl Neurol. 2018;5(5):651-63. Nojima I, Sugata H, Takeuchi H, Mima T. Brain-Computer Interface Training Based on Brain Activity Can Induce Motor Recovery in Patients With Stroke: A Meta-Analysis. Neurorehabil Neural Repair. 2022;36(2):83-96. Soekadar SR, Witkowski M, Vitiello N, Birbaumer N. An EEG/EOG-based hybrid brain-neural computer interaction (BNCI) system to control an exoskeleton for the paralyzed hand. bmte. 2015;60(3):199-205. Catalan JM, Trigili E, Nann M, Blanco-Ivorra A, Lauretti C, Cordella F, et al. Hybrid brain/neural interface and autonomous vision-guided whole-arm exoskeleton control to perform activities of daily living (ADLs). J Neuroeng Rehabil. 2023;20(1):61. Bailey RR, Klaesner JW, Lang CE. Quantifying Real-World Upper-Limb Activity in Nondisabled Adults and Adults With Chronic Stroke. Neurorehabil Neural Repair. 2015;29(10):969-78. Kantak S, Jax S, Wittenberg G. Bimanual coordination: A missing piece of arm rehabilitation after stroke. Restor Neurol Neurosci. 2017;35(4):347-64. Barreca S, Gowland C, Stratford P, Huijbregts M, Griffiths J, Torresin W, et al. Development of the Chedoke Arm and Hand Activity Inventory: theoretical constructs, item generation, and selection. Topics in stroke rehabilitation. 2004;11(4):31-42. Angerhöfer C, Vermehren M, Colucci A, Nann M, Kossmehl P, Niedeggen A, et al. The Berlin Bimanual Test for Tetraplegia (BeBiTT): development, psychometric properties, and sensitivity to change in assistive hand exoskeleton application. J Neuroeng Rehabil. 2023;20(1):17. Barreca SR, Stratford PW, Masters LM, Lambert CL, Griffiths J. Comparing 2 versions of the Chedoke Arm and Hand Activity Inventory with the Action Research Arm Test. Physical Therapy. 2006;86(2):245-53. Duncan PW, Bode RK, Min Lai S, Perera S, Glycine Antagonist in Neuroprotection Americans I. Rasch analysis of a new stroke-specific outcome scale: the Stroke Impact Scale. Arch Phys Med Rehabil. 2003;84(7):950-63. Burg JP. Maximum entropy spectral analysis. Paper presented at 37th Annual International Meeting, Soc. of Explor. Geophys., Oklahoma City, Okla: Stanford University; 1967. Kline P. A handbook of test construction (psychology revivals): introduction to psychometric design: Routledge; 2015. Nunnally JC. Psychometric theory (2nd edit.). New York. 1978. Nann M, Haslacher D, Colucci A, Eskofier B, von Tscharner V, Soekadar SR. Heart rate variability predicts decline in sensorimotor rhythm control. J Neural Eng. 2021;18(4). Gallegos Ayala GI, Haslacher D, Krol LR, Soekadar SR, Zander TO. Assessment of mental workload across cognitive tasks using a passive brain-computer interface based on mean negative theta-band amplitudes. Front Neuroergon. 2023;4:1233722. Crea S, Nann M, Trigili E, Cordella F, Baldoni A, Badesa FJ, et al. Feasibility and safety of shared EEG/EOG and vision-guided autonomous whole-arm exoskeleton control to perform activities of daily living. Sci Rep. 2018;8(1):10823. Tables Table 1. Overview of tasks and materials included in the Berlin Bimanual Test for Stroke. Task Material ADL category Open jar Jar with screw lid, around 200g Eating and drinking Open plastic food package Zip lock bag filled with weight simulating a packet of crisps Eating and drinking Open water bottle Plastic water bottle (filled), screwed on by hand Eating and drinking Pour glass of water Plastic water bottle (filled), water glass (empty) Eating and drinking Eat with knife and fork Medium resistance putty resembling the consistency of a piece of meat, table knife, fork Eating and drinking Clean a plate Dinner plate, kitchen sponge Housekeeping Lift pot Saucepan with flat handles Housekeeping Unscrew toothpaste Toothpaste with screw lid, > 50% full Personal hygiene Apply toothpaste on toothbrush Toothpaste, toothbrush, and grip-easy rubber handles Personal hygiene Close zipper of a jacket Jacket or vest with zipper Dressing Table 2. Participant characteristics. Participant Age Gender Chronicity Stroke type Hemiparesis Location CAHAI-8 Score a BeBiT-S Score unassisted BeBiT-S Score B/NHE assisted b 01 48 m chronic n.a. right cortical/mixed 18 31 47 02 42 m subacute hemorrhagic left subcortical 47 96 96 03 40 m chronic ischemic left subcortical 19.43 60 77 04 76 m subacute hemorrhagic left subcortical 14 31 44 05 62 f chronic ischemic left cortical/mixed 9 6 - 06 71 m subacute ischemic left Cortical/mixed 8 4 - 07 60 m subacute ischemic right subcortical 47 87 78 08 84 m chronic hemorrhagic left subcortical 13 29 - 09 43 f chronic ischemic right subcortical 12 26 59 10 83 f subacute ischemic right subcortical 43 90 - 11 61 m subacute ischemic right cortical/mixed 9.33 16 - 12 41 m subacute ischemic right cortical/mixed 18 69 - 13 70 f subacute ischemic right cortical/mixed 49.33 98 - 14 73 f subacute ischemic left cortical/mixed 10 10 - 15 31 m chronic ischemic right cortical/mixed 13 38 51 16 55 m chronic ischemic right cortical/mixed 12 18 - 17 74 m chronic ischemic left n.a. 11 22 78 18 54 f chronic hemorrhagic left cortical/mixed 43 84 89 19 18 m chronic n.a. right n.a. 46 95 74 20 57 f chronic ischemic right subcortical 20 43 60 21 51 f chronic hemorrhagic right subcortical 8 4 51 22 66 f chronic ischemic right cortical/mixed 12 32 44 23 58 m chronic ischemic right cortical/mixed 32 66 70 24 47 m chronic hemorrhagic left cortical/mixed 17 27 51 Abbreviations: m = male; f = female; a Total score of the CAHAI-8 is 56, the higher the score the more assistance is necessary to complete the task. b 15 participants performed the BeBiT-S without assistance (baseline), as well as with support of a brain/neural hand exoskeleton (intervention). 9 participants took part the baseline condition only. Table 3. Internal consistency analysis Tasks Corrected item-total correlation Cronbach's alpha if item deleted Open jar 0.877 0.967 Open plastic food package 0.833 0.968 Open water bottle 0.832 0.968 Pour glass of water 0.936 0.964 Eat with knife and fork 0.820 0.969 Clean a plate 0.835 0.968 Lift a pot 0.867 0.967 Unscrew toothpaste 0.888 0.966 Apply toothpaste on toothbrush 0.867 0.967 Close zipper of a jacket 0.873 0.967 Appendix The Appendix file is not available with this version. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 08 Dec, 2025 Read the published version in Journal of NeuroEngineering and Rehabilitation → Version 1 posted Editorial decision: Revision requested 30 May, 2025 Reviews received at journal 16 Apr, 2025 Reviewers agreed at journal 16 Apr, 2025 Reviews received at journal 10 Apr, 2025 Reviewers agreed at journal 13 Mar, 2025 Reviewers invited by journal 11 Mar, 2025 Editor assigned by journal 18 Dec, 2024 Submission checks completed at journal 18 Dec, 2024 First submitted to journal 17 Dec, 2024 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. 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Soekadar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIie2RMUsDMRTHnxy0y4lritb7Cu8IVMTiZ7kg3E2C4HKDlE51Oel6fotzFIQ+CThFs0a6tMtNDjcVBBHj1UGHVEeH/CCBkPzyfy8B8Hj+KdjOIQADGLYrsmNr/EclXSv0iwLfFLm+YJMSlaeLswZG+zuhXJrXOx0ddB+XssmhP3UVZTKMS5C8dzXhh0U9j2+LDIkU8GtHDLIUeAgkKg0DFtI8QUqB7icgKnIV1iojMdPdVe+NnhLUtVXeQcwcCphWCUS1XQx2Q6IEzWfK2Ka4elE1xCVKzpQ6P9qjk7gyNkU9MF66CrtMO9jk9sWK7Ob5hY4j1GnQ5BfD/tTRvqWDX5/5A+Y8bwkWm3Y9Ho/HAx/vymEgH7UIYAAAAABJRU5ErkJggg==","orcid":"","institution":"Charité Campus Mitte (CCM), Charité – Universitätsmedizin Berlin","correspondingAuthor":true,"prefix":"","firstName":"Surjo","middleName":"R.","lastName":"Soekadar","suffix":""}],"badges":[],"createdAt":"2024-12-17 12:23:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5661668/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5661668/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12984-025-01822-6","type":"published","date":"2025-12-08T15:58:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83337477,"identity":"1bcf00a7-8370-433a-8ad7-0d2ea7b91c47","added_by":"auto","created_at":"2025-05-23 09:34:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":141650,"visible":true,"origin":"","legend":"\u003cp\u003eTheoretical background: Essential requirements for the selection of test items.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5661668/v1/68fe71f09650773c1e3eb049.png"},{"id":83337056,"identity":"e6b0b25b-f2c8-400d-b6d3-afdd848acff9","added_by":"auto","created_at":"2025-05-23 09:26:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":40124,"visible":true,"origin":"","legend":"\u003cp\u003eExperimental setup. The participant performs the BeBiT-S with the support of a hand exoskeleton on the paretic left hand. A hybrid brain-computer interface based on electroencephalography (EEG) and electrooculography (EOG) allows the participant to operate the hand exoskeleton.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5661668/v1/551e06b179f20177848d88cf.png"},{"id":83337062,"identity":"b684dd97-040b-42b5-a2ba-2e6c9ebbae6b","added_by":"auto","created_at":"2025-05-23 09:26:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":163951,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A) \u003c/strong\u003eCorrelation between Berlin Bimanual Test for Stroke (BeBiT-S) and CAHAI-8, r(22) = 0.95, \u003cem\u003eP\u003c/em\u003e \u0026lt; .001.\u003cstrong\u003e (B) \u003c/strong\u003eBeBiT-S scores across 15 participants without assistive technology and when using a brain/neural hand exoskeleton (B/NHE). A Wilcoxon Signed Rank test showed a significant increase in BeBiT-S score when participants were assisted by a B/NHE (\u003cem\u003eP\u003c/em\u003e \u0026lt; .05, r = 0.45). \u003cstrong\u003e(C)\u003c/strong\u003e Difference in BeBiT-S scores across each component of hand function. Wilcoxon Signed Rank tests indicate that scores for grasping and stabilizing components improved significantly when using a B/NHE. * \u003cem\u003eP \u003c/em\u003e\u0026lt; .05, ** \u003cem\u003eP \u003c/em\u003e\u0026lt; .01, *** \u003cem\u003eP \u003c/em\u003e\u0026lt; .001.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5661668/v1/10dda93b8b8d14cb52e9bd00.png"},{"id":98244659,"identity":"373974ff-30da-42ab-a691-8052d6b1f97b","added_by":"auto","created_at":"2025-12-15 16:14:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1146610,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5661668/v1/c20ac43a-6f23-4ce0-b179-bee225b82b1e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Berlin Bimanual Test for Stroke Survivors (BeBiT-S): Evaluating exoskeleton-assisted bimanual motor function after stroke","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHemiparesis, characterized by weakness or partial paralysis on one side of the body, impacts over 70% of stroke survivors,(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) frequently leading to enduring disability and diminished quality of life. Thus, regaining upper-limb function is critical for increasing independence in daily life activities, and has been identified as a priority by stroke survivors, especially in long-term treatment.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn instances of severe paralysis accompanied by complete loss or very limited residual hand function, conventional treatment approaches like constrained induced movement therapy (CIMT) or standard occupational practices often cannot be applied as they rely on residual function.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) To fill this gap in post-stroke rehabilitation, brain-computer interface (BCI)-driven exoskeletons emerged as a novel treatment option for restoring upper limb function in stroke survivors.(\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) By converting neural activity into control signals of robotic orthoses, such devices enable functional, user-initiated movement execution even in case of complete loss or very limited residual hand function.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) This way, BCI-based devices allow patients to use the affected limb during therapy sessions, potentially mitigating the phenomenon of \u0026ldquo;learned non-use\u0026rdquo; which refers to the tendency to avoid using the affected limb. Beyond that, recent meta-analyses confirm that repeated use of BCI-driven robotic devices can promote functional and structural plasticity triggering motor recovery.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn recent years, technological advances resulted in the development of lightweight robotic actuators, portable and easy-to-use brain recording devices, and reliable control strategies.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Especially brain/neural hand-exoskeletons (B/NHE) hold great promise for clinical applications beyond the laboratory setting.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) By combining brain- and other bio-signals, e.g. related to eye movements, robust and safe control paradigms for exoskeletons can be established, paving the way for their implementation as effective and impactful rehabilitative tools.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHowever, there is currently no established clinical test to assess the effectiveness of such B/NHE-enabled rehabilitative approach. Such test should be designed to accommodate the use of B/NHEs while thoroughly monitoring subtle changes in upper limb functionality. Current clinical assessments lack such necessary features since they typically emphasize unilateral, repetitive movements (such as the Fugl-Meyer Assessment for upper extremity, FMA-UE) or unilateral functional tasks (like the Action Research Arm Test, ARAT, Toronto Rehabilitation Institute Hand Function Test, TRI-HFT, or Wolf Motor Function Test, WMFT). Moreover, a suitable test must also reflect the change in patients\u0026rsquo; capability to perform ADL affected by stroke, which usually requires both upper limbs to act together in a highly coordinated and efficient way.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Thus, arm rehabilitation strategies targeting only the weaker arm are limited in their effectiveness, suggesting to shift clinical rehabilitation towards bimanual training.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCurrently, there is only one performance-based assessment tool that evaluates bimanual hand function in ADLs after stroke, the Chedoke Arm and Hand Activity Inventory (CAHAI).(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) While the CAHAI offers valuable insights into functional bimanual tasks that are important in stroke patients\u0026rsquo; daily life, certain test items are incompatible with the use of assistive robotic devices such as B/NHEs (e.g., wringing out a wet washcloth), or are outdated (e.g., picking up a desk telephone with receiver). Additionally, the evaluation of tasks in the CAHAI focuses exclusively on the degree of independence, which is inherently biased in the use of assistive devices.\u003c/p\u003e \u003cp\u003eA first attempt to address this gap in clinical tests has been made by Angerh\u0026ouml;fer et al., who introduced the Berlin Bimanual Test for Tetraplegia (BeBiT-T).(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) The novel assessment tool can evaluate bimanual task performance in daily life activities for tetraplegic individuals. Given the marked distinctions in motor symptoms between tetraplegia and stroke \u0026ndash; including spasticity, residual motor function, trunk control, and weakness or partial paralysis on both sides of the body \u0026ndash; there is a critical need to establish a similar test for stroke survivors. Here, we introduce such test which was inspired by the BeBiT-T but is specifically tailored for stroke survivors. Comprising 10 bimanual tasks directly relevant to the daily life of stroke survivors, the Berlin Bimanual Test for Stroke (BeBiT-S) is designed to seamlessly integrate with the use of modern technologies such as B/NHEs.\u003c/p\u003e \u003cp\u003eIn the following, we explain the rationale behind each item of the BeBiT-S and evaluate its reliability and validity, as well as sensitivity to B/NHE use.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDevelopment of the Berlin Bimanual Test for Stroke (BeBiT-S)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe development of the BeBiT-S involved a systematic three-stage process. Initially, a theoretical framework was established\u0026nbsp;(Figure 1),\u0026nbsp;and a pool of potential test items was generated by an interdisciplinary research team including experts in classical test theory, physicians, medical engineers, psychologists, and physical therapists.\u0026nbsp;In the second stage, test items were selected based on the theoretical framework. Our criteria included coverage of various categories of ADLs, such as eating and drinking, housekeeping, dressing, and personal hygiene. Additionally, we ensured representation of all relevant grasp types essential for daily life, encompassing tripod pinch, tip pinch, power grip, spherical grip, and extension grip. In this way, the BeBiT-S aligns with the World Health Organization\u0026rsquo;s (WHO) criteria for the International Classification of Functioning, Disability and Health (ICF), considering body function, activity, and participation.\u0026nbsp;Items were further selected to represent diverse bimanual actions that are affected post-stroke, following the taxonomy of Kantak et al (2017).(14)\u0026nbsp;They\u0026nbsp;distinguish\u0026nbsp;between symmetric bimanual actions involving the use of homologous muscles, and asymmetric movements involving non-homologous muscles. Moreover, actions are distinguished in which\u0026nbsp;each hand pursues an independent goal or both hands work together to accomplish a common task.\u0026nbsp;In addition to these considerations, all selected test items needed to be compatible with the use of assistive exoskeletons such as B/NHEs. Moreover, items were selected for easy and quick administration as well as inexpensiveness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the third and final stage, the selected items underwent rigorous testing on healthy participants regarding replicability, affordability, safety, representation of bimanual motor function, and compatibility with B/NHEs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe refined BeBiT-S, as presented in its final version, comprises ten bimanual tasks specifically tailored to address the needs of stroke survivors in their daily lives. The materials required for the test are readily available in most clinical and research settings around the world, making it accessible on a global scale (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe development of the BeBiT-S also involved the creation of a comprehensive scoring system to assess the primary components of bimanual function in ADLs, encompassing reaching, grasping, stabilizing, manipulating, and lifting. Scoring for the BeBiT-S relies on video recordings capturing participants\u0026rsquo; performance of the designated tasks. An exemplary scoring sheet is provided in the appendix.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEach task is assigned a score ranging from 0 to 10 points, contributing to a maximum achievable score of 100. 20 points can be obtained for each \u003cem\u003ereaching\u003c/em\u003e and \u003cem\u003egrasping\u0026nbsp;\u003c/em\u003ecomponents, 10 points for \u003cem\u003estabilizing\u003c/em\u003e, 33 for \u003cem\u003emanipulating\u003c/em\u003e, and 17 for \u003cem\u003elifting\u003c/em\u003e. In case of \u003cem\u003ereaching\u003c/em\u003e and \u003cem\u003egrasping\u003c/em\u003e, the maximum score is penalized if compensatory strategies are detected, such as hand-over-hand technique to reach an object or\u0026nbsp;utilizing passive support of spasticity to hold an object.\u0026nbsp;The scoring system categorizes object \u003cem\u003emanipulation\u003c/em\u003e into three levels (no difficulties, slight difficulties, or great difficulties) while also considering the application of compensatory strategies, such as using both hands to manipulate a single item. No points are given if only the unaffected hand is used. Depending on the task, three or five points can be obtained for correctly \u003cem\u003emanipulating\u003c/em\u003e an object. If applicable, two points are given for performing the task in a lifted position, when objects have no contact with any surface, including the patient\u0026rsquo;s trunk. One point is given for \u003cem\u003estabilization\u003c/em\u003e if the affected arm maintains a firm grip throughout the task. The BeBiT-S scoring system imposes no time constraint or limit to the number of attempts. The attempt ends when either the participant or the instructor believes that no better performance can be achieved. The best attempt is scored.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe recruited 24 individuals with either subacute or chronic post-stroke upper-limb hemiparesis (9 female, mean age 56.5 \u0026plusmn; 16.8 years). Recruitment and assessment of subacute stroke survivors (n = 9, \u0026lt; 6 months post-stroke) took place at SRH Gesundheitszentrum Bad Wimpfen, Germany. Chronic stroke survivors (n = 15, \u0026gt; 6 months post stroke) were assessed at Charit\u0026eacute; \u0026ndash; Universit\u0026auml;tsmedizin Berlin, P.A.N. Zentrum Berlin-Frohnau, or at their homes. Participant characteristics are depicted in Table 2. To be eligible for the study, potential participants had to fulfill the following requirements: stroke with upper-limb hemiparesis, age ranging from 18 to 85 years, cognitive ability to understand and follow instructions, and absence of any alcohol or drug addiction, terminal medical illness, or neurological or psychiatric condition other than stroke. The study was approved by the local ethics committee at Charit\u0026eacute; \u0026ndash; Universit\u0026auml;tsmedizin Berlin under number EA1/106/20. All participants provided written informed consent before enrollment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy design\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants performed the BeBiT-S without assistance (baseline) and with B/NHE support (intervention) in a within-subject study design. Conditions (baseline or intervention) were applied in random order with 8/15 participants completing the baseline condition first. In the baseline condition, the participants were seated comfortably in a chair or wheelchair in front of a desk. Each task was explained and demonstrated by the instructor. Participants were asked to perform the tasks as closely as possible to the instructor\u0026rsquo;s demonstration and were reminded of the importance of using both hands and avoiding compensatory strategies whenever possible.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the intervention condition, the BeBiT-S was repeated in the same way as in the baseline condition with participants operating a portable hand exoskeleton for assistance (Figure 2). The whole session was videotaped for scoring with a clear view of the materials throughout the task. Participants\u0026acute; performance in both the baseline and intervention condition was assessed with the corresponding scoring sheet (Appendix 1). \u0026nbsp;Ratings from three different raters, all experienced in evaluating stroke survivors, were obtained to assess agreement among them. To assess\u0026nbsp;validity of the BeBiT-S, the CAHAI-8(17)\u0026nbsp;was completed across all participants. The tasks included in the CAHAI-8 are as follows: (1) open a jar of coffee, (2) dial 911, (3) draw a line with a ruler, (4) pour a glass of water, (5) wring out a washcloth, (6) do up five buttons, (7) dry back with a towel, and (8) put toothpaste on a toothbrush. The CAHAI-8 was completed without a B/NHE. Finally, participants were asked to complete a subset of 4 domains of the Stroke Impact Scale (SIS) version 3.0 questionnaire.(18)\u0026nbsp;The four domains selected were strength, ADLs, hand function, and percentage of recovery.\u003c/p\u003e\n\u003cp\u003eAll 24 participants were assessed with the BeBiT-S unassisted (baseline). 15 participants (5 female, 12 chronic, mean age 50.3 \u0026plusmn; 15.8 years) repeated the BeBiT-S using a B/NHE (intervention). Reasons why the BeBiT-S was only performed unassisted (baseline) included: (1) inability to follow the B/NHE control paradigm (n = 3), (2) inability to perform horizontal eye movements (n = 1), (3) exhaustion (n = 1), (4) technical issues (n = 1), (5) exoskeleton did not fit (n = 1), (6) time constraints (n = 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eExperimental setup\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor the intervention, a wearable hand exoskeleton allowing firm grasping was attached to the participants paretic hand. A hybrid brain-computer interface based on electroencephalography (EEG) and electrooculography (EOG) signals allowed the participant to operate the exoskeleton (HandyRehab by Zunosaki Ltd., Hong Kong). Detection of sensori-motor rhythm (8-13 Hz) event-related desynchronization (SMR-ERD) was translated to exoskeleton closing movements, while horizontal eye movements (horizontal oculoversion, HOV) were used to control exoskeleton opening movements and to stop unintentional closing. EEG was recorded from 5 conventional recording sites according to the international 10/20 system, either F3, T3, C3, P3 and Cz to control the B/NHE on the right hand, or F4, T4, C4, P4 and Cz to control the exoskeleton on the left hand. \u0026nbsp;Additionally, two electrodes were placed on the right and left outer canthus to record EOG. EEG and EOG signals were processed in real time through a custom BCI software (BeamBCI) based on the Python programming language. Signals were recorded at a sampling frequency of 250 Hz and bandpass filtered between 1 Hz and 30 Hz. Power spectral density in the mu-range was estimated using Burg\u0026rsquo;s method.(19) A surface Laplacian filter was applied to increase signal-to-noise ratio at the target electrodes C3 or C4.(8) During a short calibration session before the beginning of the measurement, participants learned to perform motor imagery or motor attempts to close the B/NHE, and maximum HOV to open the B/NHE. During the calibration, participants trained by means of visual cues on a computer screen. After the calibration, while performing the BeBiT-S tasks with the B/NHE, participants could decide when to open and close the exoskeleton in an uncued (asynchronous) paradigm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe assessed internal consistency and scale reliability for the baseline scores of the 10 test items by calculating Cronbach\u0026rsquo;s Alpha and corrected item-total correlations. These analyses were performed using SPSS (v. 27). Following the guideline proposed by Kline,(20) test items with item-total correlation below r \u0026nbsp;= 0.3 were discarded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo quantify the level of agreement among the three raters in evaluating the BeBiT-S score, we computed the intraclass correlation coefficient (ICC) using SPSS (v. 27). The ICC was calculated separately for both baseline and intervention conditions in a Two-Way Mixed model with absolute agreement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo evaluate construct validity, we obtained CAHAI-8 scores for all participants and calculated the linear relationship between the BeBiT-S baseline scores and the CAHAI-8 scores using Pearson\u0026rsquo;s correlation coefficient. Given that the CAHAI-8 is a performance-based assessment tool for evaluating bimanual hand function in post-stroke ADLs, it seemed most appropriate for assessing construct validity of the BeBiT-S. Furthermore, we computed the linear relationship of the BeBiT-S baseline scores and four domains of the Stroke Impact Scale (strength, activities of daily living, hand function, percentage of recovery) by computing Pearson\u0026rsquo;s correlation coefficient.\u003c/p\u003e\n\u003cp\u003eTo evaluate the BeBiT-S\u0026rsquo; sensitivity to assess the impact of B/NHE use, we compared baseline and intervention scores with a Wilcoxon signed rank test. Moreover, we computed five Wilcoxon signed rank tests to assess changes within each component of hand function (reaching, grasping, stabilizing, manipulating, lifting).\u003c/p\u003e\n\u003cp\u003eTo evaluate whether the subgroup that performed the BeBiT-S with the exoskeleton is biased (i.e., are less affected and score higher at baseline), we computed a Mann-Whitney test comparing the baseline BeBiT-S score of the subgroup of participants that also participated in the intervention and those who did not. The significance level was set at \u003cem\u003eP\u003c/em\u003e \u0026lt; .05.\u003c/p\u003e"},{"header":"Results ","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eValidity and Reliability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Cronbach\u0026rsquo;s alpha coefficient calculated for the 10 test items within the baseline condition yielded an \u0026alpha; of 0.97, signifying excellent internal consistency. Furthermore, all items demonstrated item-total correlations of r \u0026ge; 0.82, surpassing the predefined cut-off level of r \u0026gt; 0.3 (Table 3).\u003c/p\u003e\n\u003cp\u003eExcellent interrater reliability was observed during the baseline assessment (ICC for single values: 0.985, 95% confidence interval [CI]: 0.969 to 0.993, \u003cem\u003eP\u003c/em\u003e \u0026lt;.001). Additionally, the intervention condition displayed good interrater reliability (ICC for single values: 0.862, CI: 0.432 to 0.962, \u003cem\u003eP\u003c/em\u003e \u0026lt; .001).\u003c/p\u003e\n\u003cp\u003eA robust positive correlation was identified between BeBiT-S baseline scores (M = 48.08, SD = 32.45) and CAHAI-8 scores (M = 22.13, SD = 14.94), r(22) = 0.95, \u003cem\u003eP\u003c/em\u003e \u0026lt; .001, as depicted in Figure 3A. This outcome underscores a high level of construct validity. The baseline BeBiT-S score also correlated significantly with the scores of the SIS-1 domain \u0026ldquo;strength\u0026rdquo; (r(20) = 0.53, \u003cem\u003eP\u003c/em\u003e = .012) \u0026nbsp;and SIS-7 domain \u0026ldquo;hand function\u0026rdquo; (r(20) = 0.50, \u003cem\u003eP\u003c/em\u003e = .018), but not with domains \u0026ldquo;ADLs\u0026rdquo; (r(20) = 0.245, \u003cem\u003eP\u003c/em\u003e = .273) and \u0026ldquo;percentage of recovery\u0026rdquo; (r(18) = 0.27, \u003cem\u003eP\u003c/em\u003e = .911).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe result of the Mann-Whitney test indicated no significant difference of the baseline BeBiT-S score between participants who participated in the intervention (Mdn = 38), and those who did not (Mdn = 18), U = 47.5, \u003cem\u003eP\u003c/em\u003e = .245.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eComparison of baseline and intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA Wilcoxon Signed Rank test revealed an increase in BeBiT-S score from baseline (Mdn = 38) to intervention (Mdn = 60) condition, z = 2.48, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= .013, with a medium effect size (r = 0.45) (Figure 3B). This result underlines the sensitivity of the test in detecting changes in B/NHE applications.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLooking at individual components, Wilcoxon Signed Rank tests indicate a significant improvement of grasping and stabilizing during B/NHE use (z = 3.11, \u003cem\u003eP\u003c/em\u003e \u0026lt; .01 for grasping, z = 2.55, \u003cem\u003eP\u003c/em\u003e \u0026lt; .01 for stabilizing, Figure 3C). There were also improvements in the manipulating and lifting components of the BeBiT-S score, although these were not statistically significant (z = 1.64, \u003cem\u003eP\u003c/em\u003e = .102 for manipulating, z = 0.5, \u003cem\u003eP\u003c/em\u003e = .619 for lifting). The reaching component displayed a marginal decline, although not statistically significant (z = 1.25, \u003cem\u003eP\u003c/em\u003e = 0.211).\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003eThe lack of reliable clinical tests for assessing bimanual hand function after stroke that are compatible with B/NHEs limits research into their clinical efficacy. Here, we addressed this critical gap and showed that the BeBiT-S is effective, reliable, and valid to assess bimanual motor function with and without B/NHEs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe central advantage of the BeBiT-S lies in its compatibility with state-of-the-art assistive technology, particularly B/NHEs, and its sensitivity to B/NHE-related motor improvements. The BeBiT-S comprises ten bimanual tasks. Test items were chosen to be inexpensive as well as quick and easy to administer. Tasks were chosen to represent bimanual actions affected after stroke, to be relevant to everyday life, to cover relevant grasp types, and finally, to be compatible with state-of-the-art (neuro-)prosthetic devices. Excellent internal consistency of the test was indicated by Cronbach\u0026rsquo;s alpha (0.97), exceeding the threshold for clinical instruments (\u0026gt; 0.9) as suggested by Nunally.(21) All ten test items met the predefined cut-off level of item-total correlations of r \u0026gt; 0.3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe high correlation coefficient (ICC) values, exceeding 0.85 in both baseline and intervention, indicate consistent and reliable scoring across different raters. Raters were only given brief instructions included on the scoring sheet (see Appendix). This underlines the robustness of the BeBiT-S and feasibility for inexperienced personnel to apply it.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe highly positive correlation between baseline BeBiT-S scores and CAHAI-8 scores suggests that it effectively measures what it intends to evaluate. Moreover, the baseline BeBiT-S score also correlated with the Stroke Impact Scale (SIS) domains \u0026ldquo;strength\u0026rdquo; and \u0026ldquo;hand function\u0026rdquo;, providing additional support for the construct validity of the BeBiT-S. It is noteworthy, however, that the BeBiT-S did not correlate with SIS domains \u0026ldquo;ADLs\u0026rdquo; and \u0026ldquo;percentage of recovery\u0026rdquo; as originally anticipated. One reason for this could be the heterogeneity in chronicity in our participant group (from less than 3 months post-stroke to 27 years post-stroke), where the subjective nature of \u0026ldquo;percentage of recovery\u0026rdquo; becomes particularly apparent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, the intervention condition with the assistance of a B/NHE was completed by a subgroup of 15 out of 24 total participants. To rule out a potential bias in the subgroup of participants that performed the BeBiT-S unassisted, we compared their BeBiT-S scores with that of participants that used the B/NHE. The absence of a difference suggests that lower bimanual function does not prevent B/NHE use. Looking more closely into the drop-out reasons for B/NHE use, two main reasons could be distinguished: \u003cem\u003etechnical and non-technical reasons.\u0026nbsp;\u003c/em\u003eWhile technical reasons include issues related to the fit of the hand-exoskeleton, system failure or time constraints on the patient\u0026rsquo;s side, non-technical reasons include participant exhaustion, low motivation, or inability to follow the B/NHE control paradigm. Notably, those excluded for non-technical reasons were all within their first months after stroke (n = 5, on average 4.2 months after stroke), whereas technical reasons were more prevalent among chronic stroke survivors (3 out of 4 chronic). A notable observation was that controlling a B/NHE appeared more challenging for subacute stroke survivors compared to those in the chronic phase. This implies that incorporating B/NHE-enabled rehabilitation into sub-acute stroke cases might pose greater difficulty compared to chronic stroke scenarios. It underscores the importance of tailoring rehabilitation approaches to the specific needs and recovery stages of each individual.\u003csup\u003e(22, 23)\u003c/sup\u003e Further research is needed to refine rehabilitation protocols to enhance their effectiveness and improve patient adherence.\u003c/p\u003e\n\u003cp\u003eThe second main goal of our study was to demonstrate the compatibility of the BeBiT-S with novel assistive technology such as B/NHEs. This is particularly important, given the lack of such tests that are, however, necessary to evaluate efficacy of B/NHE-related rehabilitation protocols. Our investigation involved a comparison of the BeBiT-S score with and without B/NHE assistance and demonstrated an increase in BeBiT-S score from a median of 38 points without B/NHE to a median of 60 points during B/NHE use. This underscores the efficacy of the BeBiT-S in capturing and quantifying improvements in bimanual task performance facilitated by B/NHE use. While most participants demonstrated enhanced bimanual task performance with B/NHE assistance, two participants experienced a decline in bimanual task performance, however. One of them, who experienced a stroke at birth, had extensively adapted to using the impaired hand in activities of daily living, which may explain this lack of improvement. Across all participants, the grasping and stabilizing components showed significant improvements during B/NHE operation (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; .05 for grasping and stabilizing, Figure 3C), emphasizing the positive impact of the intervention on these essential components of hand function. While the manipulating and lifting components showed improvements, statistical significance was not reached (\u003cem\u003eP\u003c/em\u003e = .102 for manipulating, \u003cem\u003eP\u003c/em\u003e = .619 for lifting). The reaching component, although displaying a marginal decline, did not reach statistical significance (\u003cem\u003eP\u003c/em\u003e = .211). These findings align with the specific characteristics of hand-exoskeleton device employed in this study. While it can support grasping and stabilizing objects, it lacks features to support reaching and may even impede lifting, due to added weight to the hand and arm. Overall, the findings underscore that the BeBiT-S\u0026rsquo; scoring system captures the fundamental aspects of bimanual function, encompassing reaching, grasping, manipulating, and lifting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is crucial to acknowledge that various assistive technologies may have varying impacts on different aspects or components. It is thus important to note that during development of the BeBiT-S, deliberate efforts were made to enhance the versatility of the test towards other assistive systems or approaches. Consequently, its potential applications extend beyond a specific device class, encompassing, for instance, muscular-driven orthoses, functional electric stimulation (FES) or whole-arm exoskeletons.(24) Even application in assessment of prostheses is conceivable. Further research is needed to confirm compatibility with various assistive devices. The BeBiT-S may also be a valuable tool to assess recovery of bimanual function, e.g., triggered by repeated B/NHE training. Further research is necessary to evaluate whether the BeBiT-S is sensitive to measure improvements throughout the trajectory of such rehabilitation protocols.(4) While the psychometric evaluation of the BeBiT-S has yielded excellent results, it is important to emphasize that these findings require additional validation through larger clinical studies.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe BeBiT-S tool proves to be both reliable and valid for evaluating bimanual task performance in stroke survivors, effectively aligning with emerging assistive technologies like B/NHEs. Our study highlights this alignment and demonstrates BeBiT-S\u0026apos; sensitivity in detecting improvements resulting from innovative assistive interventions in stroke rehabilitation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eB/NHE: Brain-Neural Hand Exoskeleton\u003c/p\u003e\n\u003cp\u003eBeBiT-S: Berlin Bimanual Test for Stroke\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBCI: Brain-Computer Interface\u003c/p\u003e\n\u003cp\u003eBeBiT-T: Berlin Bimanual Test for Tetraplegia\u003c/p\u003e\n\u003cp\u003eCAHAI: Chedoke Arm and Hand Activity Inventory\u003c/p\u003e\n\u003cp\u003eEEG: Electroencephalography\u003c/p\u003e\n\u003cp\u003eEOG: Electroocculography\u003c/p\u003e\n\u003cp\u003eSMR-ERD: Sensori-Motor Rhythm Event-Related Desynchronization\u003c/p\u003e\n\u003cp\u003eICC:\u0026nbsp;Intraclass Correlation Coefficient\u003c/p\u003e\n\u003cp\u003eSIS: Stroke Impact Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the local ethics committee at Charité – Universitätsmedizin Berlin under number EA1/106/20. All participants provided written informed consent before enrollment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants gave their written consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe videotapes of participants analyzed in the current study are available from the corresponding author on reasonable request. All other data generated or analyzed during this study are included in this published article and its supplementary information files.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research is supported in part by the European Research Council (ERC) under the project NGBMI (759370), the Federal Ministry of Research and Education (BMBF) under the projects SSMART (01DR21025A) and NEO (13GW0483C), the Korean Ministry of Science and ICT under the framework of the German-Korean Academia-Industry International Collaboration Program\u0026nbsp;on Robotics and Lightweight Construction/Carbon (Grant No. P0017226), the German Research Foundation (DFG, SO932/7-1), and the Einstein Stiftung Berlin.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMV, AC, CA, YA and SRS conceptualized the study. \u0026nbsp;VH helped with recruitment of participants. MV, AC, CA, and NP conducted the study and collected the data. MV analyzed and interpreted the data and wrote the first version of the manuscript. \u0026nbsp;MV, AC, CA, NP, WSK, WKC, HK, VH, NJP and SRS provided critical feedback and revised the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our gratitude to Dr. Marius Nann and Yasmina Ardern for their crucial contributions to the conceptualization of the BeBiT-S. We thank Johanna Dettelbacher and Lydia Jaufmann for their assistance with recruitment, data collection, and video rating. Lastly, we want to thank all the study participants for their valuable contributions to this study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eDobkin BH. The clinical science of neurologic rehabilitation. 2nd ed. New York: Oxford University Press; 2003.\u003c/li\u003e\n \u003cli\u003ePurton J, Sim J, Hunter SM. Stroke survivors\u0026apos; views on their priorities for upper-limb recovery and the availability of therapy services after stroke: a longitudinal, phenomenological study. Disabil Rehabil. 2022:1-11.\u003c/li\u003e\n \u003cli\u003eKwakkel G, Veerbeek JM, van Wegen EE, Wolf SL. Constraint-induced movement therapy after stroke. Lancet Neurol. 2015;14(2):224-34.\u003c/li\u003e\n \u003cli\u003eColucci A, Vermehren M, Cavallo A, Angerh\u0026ouml;fer C, Peekhaus N, Zollo L, et al. Brain-Computer Interface-Controlled Exoskeletons in Clinical Neurorehabilitation: Ready or Not? Neurorehabil Neural Repair. 2022;36(12):747-56.\u003c/li\u003e\n \u003cli\u003eAngerh\u0026ouml;fer C, Colucci A, Vermehren M, H\u0026ouml;mberg V, Soekadar SR. Post-stroke Rehabilitation of Severe Upper Limb Paresis in Germany \u0026ndash; Toward Long-Term Treatment With Brain-Computer Interfaces. Frontiers in Neurology. 2021;12(2166).\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. J Neuroeng Rehabil. 2020;17(1):57.\u003c/li\u003e\n \u003cli\u003eUshiba J, Soekadar SR. Brain-machine interfaces for rehabilitation of poststroke hemiplegia. Prog Brain Res. 2016;228:163-83.\u003c/li\u003e\n \u003cli\u003eSoekadar SR, Witkowski M, G\u0026oacute;mez C, Opisso E, Medina J, Cortese M, et al. Hybrid EEG/EOG-based brain/neural hand exoskeleton restores fully independent daily living activities after quadriplegia. Science Robotics. 2016;1(1):eaag3296.\u003c/li\u003e\n \u003cli\u003eCervera MA, Soekadar SR, Ushiba J, Millan JDR, Liu M, Birbaumer N, Garipelli G. Brain-computer interfaces for post-stroke motor rehabilitation: a meta-analysis. Ann Clin Transl Neurol. 2018;5(5):651-63.\u003c/li\u003e\n \u003cli\u003eNojima I, Sugata H, Takeuchi H, Mima T. Brain-Computer Interface Training Based on Brain Activity Can Induce Motor Recovery in Patients With Stroke: A Meta-Analysis. Neurorehabil Neural Repair. 2022;36(2):83-96.\u003c/li\u003e\n \u003cli\u003eSoekadar SR, Witkowski M, Vitiello N, Birbaumer N. An EEG/EOG-based hybrid brain-neural computer interaction (BNCI) system to control an exoskeleton for the paralyzed hand. bmte. 2015;60(3):199-205.\u003c/li\u003e\n \u003cli\u003eCatalan JM, Trigili E, Nann M, Blanco-Ivorra A, Lauretti C, Cordella F, et al. Hybrid brain/neural interface and autonomous vision-guided whole-arm exoskeleton control to perform activities of daily living (ADLs). J Neuroeng Rehabil. 2023;20(1):61.\u003c/li\u003e\n \u003cli\u003eBailey RR, Klaesner JW, Lang CE. Quantifying Real-World Upper-Limb Activity in Nondisabled Adults and Adults With Chronic Stroke. Neurorehabil Neural Repair. 2015;29(10):969-78.\u003c/li\u003e\n \u003cli\u003eKantak S, Jax S, Wittenberg G. Bimanual coordination: A missing piece of arm rehabilitation after stroke. Restor Neurol Neurosci. 2017;35(4):347-64.\u003c/li\u003e\n \u003cli\u003eBarreca S, Gowland C, Stratford P, Huijbregts M, Griffiths J, Torresin W, et al. Development of the Chedoke Arm and Hand Activity Inventory: theoretical constructs, item generation, and selection. Topics in stroke rehabilitation. 2004;11(4):31-42.\u003c/li\u003e\n \u003cli\u003eAngerh\u0026ouml;fer C, Vermehren M, Colucci A, Nann M, Kossmehl P, Niedeggen A, et al. The Berlin Bimanual Test for Tetraplegia (BeBiTT): development, psychometric properties, and sensitivity to change in assistive hand exoskeleton application. J Neuroeng Rehabil. 2023;20(1):17.\u003c/li\u003e\n \u003cli\u003eBarreca SR, Stratford PW, Masters LM, Lambert CL, Griffiths J. Comparing 2 versions of the Chedoke Arm and Hand Activity Inventory with the Action Research Arm Test. Physical Therapy. 2006;86(2):245-53.\u003c/li\u003e\n \u003cli\u003eDuncan PW, Bode RK, Min Lai S, Perera S, Glycine Antagonist in Neuroprotection Americans I. Rasch analysis of a new stroke-specific outcome scale: the Stroke Impact Scale. Arch Phys Med Rehabil. 2003;84(7):950-63.\u003c/li\u003e\n \u003cli\u003eBurg JP. Maximum entropy spectral analysis. Paper presented at 37th Annual International Meeting, Soc. of Explor. Geophys., Oklahoma City, Okla: Stanford University; 1967.\u003c/li\u003e\n \u003cli\u003eKline P. A handbook of test construction (psychology revivals): introduction to psychometric design: Routledge; 2015.\u003c/li\u003e\n \u003cli\u003eNunnally JC. Psychometric theory (2nd edit.). New York. 1978.\u003c/li\u003e\n \u003cli\u003eNann M, Haslacher D, Colucci A, Eskofier B, von Tscharner V, Soekadar SR. Heart rate variability predicts decline in sensorimotor rhythm control. J Neural Eng. 2021;18(4).\u003c/li\u003e\n \u003cli\u003eGallegos Ayala GI, Haslacher D, Krol LR, Soekadar SR, Zander TO. Assessment of mental workload across cognitive tasks using a passive brain-computer interface based on mean negative theta-band amplitudes. Front Neuroergon. 2023;4:1233722.\u003c/li\u003e\n \u003cli\u003eCrea S, Nann M, Trigili E, Cordella F, Baldoni A, Badesa FJ, et al. Feasibility and safety of shared EEG/EOG and vision-guided autonomous whole-arm exoskeleton control to perform activities of daily living. Sci Rep. 2018;8(1):10823.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Overview of tasks and materials included in the Berlin Bimanual Test for Stroke.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"616\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTask \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaterial\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eADL category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eOpen jar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eJar with screw lid, around 200g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eEating and drinking\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eOpen plastic food package\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eZip lock bag filled with weight simulating a packet of crisps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eEating and drinking\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eOpen water bottle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePlastic water bottle (filled), screwed on by hand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eEating and drinking\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003ePour glass of water\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003ePlastic water bottle (filled), water glass (empty)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eEating and drinking\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eEat with knife and fork\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eMedium resistance putty resembling the consistency of a piece of meat, table knife, fork\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eEating and drinking\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eClean a plate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eDinner plate, kitchen sponge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eHousekeeping\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eLift pot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eSaucepan with flat handles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eHousekeeping\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eUnscrew toothpaste\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eToothpaste with screw lid, \u0026gt; 50% full\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003ePersonal hygiene\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eApply toothpaste on toothbrush\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eToothpaste, toothbrush, and grip-easy rubber handles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003ePersonal hygiene\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eClose zipper of a jacket\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003eJacket or vest with zipper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eDressing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Participant characteristics.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"665\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChronicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroke type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemiparesis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCAHAI-8 Score\u003c/strong\u003e\u003ca href=\"https://journals.sagepub.com/doi/10.1177/1545968317753682#table-fn5-1545968317753682\"\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/a\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBeBiT-S Score unassisted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBeBiT-S Score B/NHE assisted\u003c/strong\u003e\u003ca href=\"https://journals.sagepub.com/doi/10.1177/1545968317753682#table-fn5-1545968317753682\"\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/a\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;n.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ecortical/mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003esubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;hemorrhagic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003esubcortical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003esubcortical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e19.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003esubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;hemorrhagic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003esubcortical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003ef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ecortical/mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003esubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eCortical/mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003esubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003esubcortical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;hemorrhagic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003esubcortical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003ef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003esubcortical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003ef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003esubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003esubcortical\u0026nbsp;\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: 76px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003esubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ecortical/mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e9.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003esubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ecortical/mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003ef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003esubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ecortical/mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e49.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003ef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003esubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ecortical/mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ecortical/mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ecortical/mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003ef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;hemorrhagic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ecortical/mixed\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: 76px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;n.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003ef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003esubcortical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003ef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;hemorrhagic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003esubcortical\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003ef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ecortical/mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;ischemic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ecortical/mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003em\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003echronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;hemorrhagic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ecortical/mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: m = male; f = female;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Total score of the CAHAI-8 is 56, the higher the score the more assistance is necessary to complete the task.\u0026nbsp;\u003cbr\u003e\u003csup\u003eb\u003c/sup\u003e 15 participants performed the BeBiT-S without assistance (baseline), as well as with support of a brain/neural hand exoskeleton (intervention). 9 participants took part the baseline condition only.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eInternal consistency analysis\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTasks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCorrected item-total correlation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCronbach\u0026apos;s alpha if item deleted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOpen jar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.877\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.967\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOpen plastic food package\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.833\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.968\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOpen water bottle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.832\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.968\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePour glass of water\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.936\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.964\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eEat with knife and fork\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.820\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.969\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eClean a plate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.835\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.968\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eLift a pot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.867\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.967\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eUnscrew toothpaste\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.888\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.966\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eApply toothpaste on toothbrush\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.867\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.967\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eClose zipper of a jacket\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.873\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.967\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Appendix","content":"\u003cp\u003eThe Appendix file is not available with this version.\u003c/p\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":"Stroke, Exoskeleton, Bimanual task performance, Brain-computer interface (BCI), Clinical assessment, Assistive robotics ","lastPublishedDoi":"10.21203/rs.3.rs-5661668/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5661668/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground. \u003c/strong\u003eBrain/neural hand exoskeletons (B/NHEs) can restore motor function after severe stroke, enabling bimanual tasks critical for various activities of daily living (ADL). Yet, reliable clinical tests for assessing bimanual function compatible with B/NHEs are lacking. Here, we introduce the Berlin Bimanual Test for Stroke (BeBiT-S), comprising 10 relevant bimanual tasks, and evaluate its psychometric properties as well as sensitivity to change related to B/NHE application. \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods. \u003c/strong\u003e24 stroke survivors (mean age 56.5 years, 9 female) with upper-limb hemiparesis after stroke underwent the BeBiT-S assessment (baseline). Psychometric properties were evaluated via interrater reliability (ICC) and construct validity (as measured by the correlation with the Chedoke Arm and Hand Activity Inventory, CAHAI). Sensitivity to change related to B/NHE application (intervention) was assessed across 15 stroke survivors (mean age 50.3 years, 5 female). Order of conditions (baseline vs. intervention) was randomized across participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults.\u003c/strong\u003e BeBiT-S showed excellent interrater reliability at baseline (ICC = 0.985, P \u0026lt; .001) and good reliability at the intervention condition (ICC = 0.862, P \u0026lt; .001). Baseline BeBiT-S strongly correlated with CAHAI-8 scores (r(22) = 0.95, P \u0026lt; .001), demonstrating construct validity. The BeBiT-S score improved significantly between baseline (Mdn = 38) and intervention (Mdn = 60, P \u0026lt; .05), evidencing the test’s sensitivity to change following the application of a B/NHE.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions. \u003c/strong\u003eThe BeBiT-S is a reliable and valid test for evaluating bimanual task performance in stroke survivors, and sensitive to assess B/NHE-related improvements in bimanual task performance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eNCT04440709, submitted June 18\u003csup\u003eth\u003c/sup\u003e, 2020\u003c/p\u003e","manuscriptTitle":"The Berlin Bimanual Test for Stroke Survivors (BeBiT-S): Evaluating exoskeleton-assisted bimanual motor function after stroke","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-23 09:26:20","doi":"10.21203/rs.3.rs-5661668/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-30T07:38:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-16T22:18:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38332039763494802041556944186049684444","date":"2025-04-16T18:11:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-10T10:13:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201570243893508188087506847622736006256","date":"2025-03-13T09:59:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-11T09:44:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-12-18T19:22:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-12-18T19:21:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of NeuroEngineering and Rehabilitation","date":"2024-12-17T12:14:42+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":"2485b32e-2cd2-4813-b561-2c54daf0e8db","owner":[],"postedDate":"May 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:08:20+00:00","versionOfRecord":{"articleIdentity":"rs-5661668","link":"https://doi.org/10.1186/s12984-025-01822-6","journal":{"identity":"journal-of-neuroengineering-and-rehabilitation","isVorOnly":false,"title":"Journal of NeuroEngineering and Rehabilitation"},"publishedOn":"2025-12-08 15:58:56","publishedOnDateReadable":"December 8th, 2025"},"versionCreatedAt":"2025-05-23 09:26:20","video":"","vorDoi":"10.1186/s12984-025-01822-6","vorDoiUrl":"https://doi.org/10.1186/s12984-025-01822-6","workflowStages":[]},"version":"v1","identity":"rs-5661668","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5661668","identity":"rs-5661668","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}