Anh T. Nguyen, Zihua Sun, Michelle J. Johnsoncs.CE cs.LG
Motor imagery (MI) electroencephalography (EEG) decoding could support post-stroke rehabilitation, but models developed on healthy cohorts may not transfer reliably to pathological EEG. We evaluated whether Low-Rank Adaptation (LoRA) can efficiently adapt three pretrained EEG foundation models (i.e., LaBraM-base, REVE-base, and REVE-large) for binary left- versus right-hand MI decoding. Frozen-backbone head-only baselines and LoRA adaptation were evaluated using subject-wise five-fold cross-validation on the PhysioNet EEG Motor Movement/Imagery Dataset and a binary subset of the UET175 dataset comprising 30 stroke participants. On EEGMMIDB, LoRA increased accuracy to 0.822 for LaBraM-base and 0.957 for REVE-base. On UET175, all head-only models performed near chance. With LoRA, LaBraM-base remained near chance (0.499$\pm$0.009), whereas REVE-base reached 0.847$\pm$0.194 and outperformed REVE-large (0.806$\pm$0.178), indicating that increased model capacity alone did not improve stroke-domain adaptation. The strongest stroke configuration, REVE-base LoRA, was further evaluated using within-cohort leave-one-subject-out cross-validation (LOOCV), showing 0.952 mean accuracy, but subject-wise accuracy ranged from 0.586 to 1.000, revealing a small low-performing tail. Zero-shot transfer from EEGMMIDB to UET175 remained near chance (0.464$\pm$0.072). These findings show that healthy-benchmark performance does not ensure transfer to stroke EEG. Translation of EEG foundation models to pseudo-online or real-time rehabilitation BCIs should therefore include target-domain adaptation and subject-level assessment of temporal informativeness, spatial sensitivity, and physiological discriminability.
Tailoring stroke rehabilitation requires assessing how movements are organized, not merely if they succeed. Currently, this assessment is a rate-limiting bottleneck. Instruments like the Action Research Arm Test (ARAT) compress rich behavioral observations into single ordinal endpoints, discarding the movement-quality details that distinguish recovery from compensation. Automated alternatives typically chase accuracy on noisy, single-observer labels to output opaque scores - a technology-centric approach that rarely reaches clinical practice. To address this, we present xAARA: an engine designed to augment rather than replace clinical judgment. From multi-view video, xAARA returns ARAT assessments with calibrated uncertainty and explanations across task, movement-phase, and movement-quality levels. Treating clinical scoring as an ill-posed inference problem, xAARA composes 692 calibrated multimodal models via a Dynamic Bayesian Network with entropy-based gating. It qualifies results against clinical validity rules and defers low-confidence cases. In 105 stroke survivors (788 exercises), xAARA achieved 94.2% task accuracy (Cohen's kappa=0.934) and 81.3% movement-phase accuracy (kappa=0.727), reducing predictive uncertainty by 96.1% compared to single-clinician scoring. For subjective cases, it matched at least one rater 100% of the time and never returned out-of-range scores. Four independent clinicians validated the assessments and indicated willingness to adopt the system. We argue that principled uncertainty quantification and clinician-aligned explainability are the critical bridges moving automated assessment from technical demonstration to a deployable clinical tool.