Brain Function, Learning, and Role of Feedback in Complete Paralysis

The determinants and driving forces of communication abilities in the locked-in state are poorly understood so far. Results from an experimental–clinical study on a completely paralyzed person involved in communication sessions after the implantation of a microelectrode array were retrospectively analyzed. The aim was to focus on the prerequisites and determinants for learning to control a brain–computer interface for communication in paralysis. A comparative examination of the communication results with the current literature was carried out in light of an ideomotor theory of thinking. We speculate that novel skill learning took place and that several aspects of the wording of sentences during the communication sessions reflect preserved cognitive and conscious processing. We also present some speculations on the operant learning procedure used for communication, which argues for the reformulation of the previously postulated hypothesis of the extinction of response planning and goal-directed ideas in the completely locked-in state. We highlight the importance of feedback and reinforcement in the thought–action–consequence associative chain necessary to maintain purposeful communication. Finally, we underline the necessity to consider the psychosocial context of patients and the duration of complete immobilization as determinants of the ‘extinction of thinking’ theory and to identify the actual barriers preventing communication in these patients.