rehabilitation improves the affected functions of patients and aims to maximize their roles 
 as members of society .
patients develop the ability to perform higher stages of functional 
 activity through repetitive and concentrated rehabilitative training , which results in the 
 improvement of the sensory , motor , and cognitive abilities1 .
activities of daily living ( adl ) are an important part of occupational performance together 
 with work , productive activity , leisure , and play , and are also an important goal of 
 rehabilitation .
should a cerebral infarction also affect the cognitive ability of a patient , 
 independent performance of basic adls , such as eating , dressing , and toileting , may be 
 disturbed2
. improvements of attention , 
 memory , visual perception , and sequencing through rehabilitation elicit improvements in 
 functional adl performance ability and in the quality of life of the patients and their 
 families .
furthermore , it has a positive effect on learning ability , shortening the duration 
 of the hospitalization period , and decreasing rates of depression , as well as other possible 
 benefits3 .
thus , it is important to 
 understand the interrelation between damage to the cognitive ability of stroke patients and 
 subsequent restriction of activity , and to identify cognitive problems affecting the 
 restoration of adls for recovery4 .
strategies for cognitive therapy are widely used to improve cognition after stroke or other 
 brain damage , but rarely for the acquisition of motor skills .
motor learning , however , is 
 required for the re - acquisition of motor skills , and cognitive factors such as memory , 
 perception , and problem solving play important roles5 .
computer assisted cognitive rehabilitation ( cacr ) training focuses 
 on similar neuropsychological processes , but utilizes computer training of attention and 
 concentration through the use of games or other programs to improve problem - solving 
 ability6 .
the task of traditional 
 cognitive therapy involves tackling the problem of lost confidence or decreased interest due 
 to increased difficulty of control , leading to failure to perform the task , whereas cacr 
 allows increased possibility of control of the different levels of task difficulty for the 
 patient7 , 8 .
more recently , cognitive rehabilitation therapies have tried various approaches including 
 neurofeedback through electroencephalogram ( eeg ) training9 , 10 .
this process provides 
 training for a certain period and is based on neural plasticity , it is based on the theory 
 that effective learning of motor control requires a certain ratio of brain waves , the 
 arousal level of patients reaches an optimum level activating the brain , therby influencing 
 many functional factors11 . to date , there is insufficient research examining the relationship between improvements in 
 adl independence and changes in brain waves of stroke patients undergoing either nfb or 
 cacr .
furthermore , despite the fact that it is important to demonstrate that rehabilitation 
 for patients with brain injury involves the use of each brain area differently , using an 
 objective evaluation like eeg12 , this has 
 seldom been attempted .
the aim of this study was to identify the most effective 
 rehabilitation method for stroke patients by comparing the effects of nfb and cacr on brain 
 waves and adls during cognitive rehabilitation .
the participants were chosen from among 48 stroke inpatients who were undergoing physical 
 and occupational therapy at an i hospital in kyeongki - do .
participant selection criteria 
 were : hemiplegic stroke patients with onset 3 months to 1  year before the study , and the 
 abilities to follow verbal instructions and to communicate .
the participants were chosen 
 from among patients with a mild cognitive deficit who scored 1823 on the mini mental state 
 examination ( mmse ) and were able to perform all the tests .
patients who had never attended 
 school or had undergone nfb or cacr within the past year were excluded from the study .
after 
 being informed about the study , all subjects agreed to participate and signed a consent 
 form .
the participants were randomly assigned to either the nfb , cacr , or control ( con ) group . 

participants were provided traditional rehabilitation therapy in 30-minute sessions , twice 
 weekly for 6 weeks .
after 6 weeks of intervention , a test was performed , and the results 
 were analyzed .
the general characteristics of the participants are shown in table 1table 1.general characteristics of the subjectsnfbcacrcongender ( male / female)8/69/57/9age ( years)62.2  6.263.0  5.464.0  8.8duration ( months)5.9  2.25.1  2.26.5  1.5mmse ( score)16.9  3.217.8  3.818.6 
nfb : neurofeedback training group , 
 cacr : computer assisted cognitive rehabilitation training group , con : control group , 
 mmse : mini - mental state examination .
nfb : neurofeedback training group , 
 cacr : computer assisted cognitive rehabilitation training group , con : control group , 
 mmse : mini - mental state examination nfb training used the neurocomp system ( neurocybernetics company , missouri , usa ) , and all 
 electrodes were attached to the scalp at positions determined by the standard international 
 1020 system and oscillograph records12 . 

the patients sat on a comfortable chair , and one electrode was attached at c5 or c6 , on the 
 side of scalp for mono polar training , while the other two electrodes were attached to each 
 ear .
a repeater switched the analog signal of the brainwave imported via each electrode into 
 a digital signal separated by frequency .
the monitor used for treatment showed the original 
 brain wave of the patient and that of each frequency band , and the therapist chose which 
 frequencies to compensate and restrict . controlling the threshold voltage allowed the 
 brainwaves of the patients to be conditioned .
the nfb training program of the study used the beta - smr training mode , which was performed 
 with open eyes and provided two types of compensation for feedback : acoustic and visual .
the 
 compensation brain wave was a 1215  hz smr - wave , or a 1518  hz mid - beta wave at the selected 
 location of the cerebral cortex .
the restraining brain waves were applied simultaneously a 
 0.54  hz delta - waves and 2236  hz high - beta waves10 .
the experimental training time was 30 minutes within which 10 sets 
 of 3 minute training mode periods were performed .
cacr was developed by rehacom ( hospi , seoul , korea ) for computer - based cognitive 
 rehabilitation and is used clinically13 . 

patients perform tasks while sitting , looking at a monitor , and respond using a keyboard . in 
 this study , we chose the attention , concentration , and memory programs of rehacom , running 
 the tests for 30 minutes per period according to the functional level of the patient .
the patients were 
 repeatedly informed about the electrode attachment , measuring equipment , application of the 
 analysis program , and measuring process before the test .
the brain waves were measured prior 
 to the other tests executed in this study , with the patient in a comfortable condition and 
 without any training to prevent interference from the other tests .
the brain waves were measured at a brain wave laboratory that had no windows , to maintain 
 constant light and temperature , and no noise , since brainwaves are affected by internal and 
 external environmental factors .
the patients sat on a comfortable chair , and listened to the 
 instructions and the method of the experiment with the electrodes attached to their scalp to 
 verify the normal functioning of the equipment . after a 3-minute rest period ,
the patients 
 were asked to look forward and their brain waves were measured for 3 minutes . during 
 measurement , the patients were asked not to talk or move to improve accuracy .
one hundred eighty seconds of raw data , excluding the initial and final 10-second 
 periods , of only the 450  hz frequency bandwere selected for the analysis , since the 
 0.54  hz delta wave is often corrupted by noise arising from instability of posture or 
 eye - blinking .
the raw data was transformed using the fast fourier transform , which expresses 
 the contribution by the frequency property on the frequency space , with the value calculated 
 as the amplitude of the sine raised to the 2nd power or as the absolute band power .
the 
 relative band power was calculated as the ratio of the absolute power rate of a certain 
 frequency band to the absolute band power and has a value between 0 and 1 .
relative power 
 analysis is used to identify factors leading to personal brainwave differences , such as 
 skull thickness or level of tension at the time of measuring .
the frequencied determined by 
 the relative power analysis analyzed as a relative theta wave ( 48  hz/450  hz ) , relative 
 alpha wave ( 813  hz/450  hz ) , relative beta wave ( 1320  hz/450  hz ) , and relative gamma wave 
 ( 3050  hz/450  hz ) .
the functional independence measure ( fim ) assesses three functional performances of 
 self - care , motor skill , and cognition , and consists of 18 items of basic adls which are 
 scored on a 7-point scale .
the scores range from 18 to 126 , with the lowest score reflecting 
 complete dependence , and the highest score reflecting complete independence .
fim scores 
 correlate well with motor skills ( r=0.77 ) and cognition ( r=0.83)14 . this study analyzed the fim total score , and the motor 
 and cognitive subtotal scores .
student s t - test was performed to examine the significance of 
 within the group differences between before and after training .
one - way anova was performed 
 to examine the significance of differences in the dependent variable among the 3 groups with 
 the scheffe method as the post - hoc test .
the brainwave and adl values before and after nfb or cacr are shown in tables 2table 2.comparison of the relative beta waves of each groupchannelnfbcacrconprepostprepostprepostfp10.07  0.030.10  0.040.08  0.060.10  0.050.07  0.040.07  0.03fp20.07  0.030.11  0.040.08  0.050.10  0.050.06  0.030.07  0.03f30.11  0.030.15  0.060.11  0.050.12  0.050.12  0.030.11  0.03f40.12  0.030.15  0.050.11  0.040.13  0.040.11  0.030.11  0.03t30.15  0.050.17  0.090.12  0.030.14  0.040.15  0.040.16  0.04t40.14  0.050.16  0.050.11  0.040.12  0.030.15  0.040.14  0.04p30.11  0.060.15  0.060.11  0.030.12  0.040.12  0.040.13  0.03p40.11  0.050.15  0.060.11  0.040.12  0.040.12  0.030.12  0.03all variables are mean  standard deviation ( sd ) .
nfb : neurofeedback training group , 
 cacr : computer assisted cognitive rehabilitation training group , con : control group , 
 fp1 : lt .
parietal , p4 : rt . parietal . * p<0.05 , 
 * * p<0.01  : comparison of nfb group and control group , p<0.05 and 3table 3.comparison of activities of daily living ( adl ) of the groupsfimnfbcacrconprepostprepostprepostmotor58.0  13.159.6  13.154.6  18.656.9  17.650.9  13.653.0  12.7cog24.4  5.225.8  4.524.5  5.325.4  5.225.8  4.126.6  4.1total82.4  17.685.5  16.279.1  21.882.3  21.076.8  16.379.6 
nfb : neurofeedback training group , 
 cacr : computer assisted cognitive rehabilitation training group , con : control group , 
 fim : functional independent measure , motor : motor subscale score , cog : cognition 
 subscale score , total : functional independent measure total score . *
the relative beta wave values showed significant differences between before 
 and after training at fp1 , fp2 , f3 , p3 , and p4 in the nfb group ( p<0.05 ) . in the parietal 
 area , in the nfb group , brain waves at f3 and p4 showed significant differences between 
 before and after training ( p<0.05 ) .
all three groups showed significant improvements in 
 motor and cognition fim subscale scores , and the fim total score ( p<0.01 ) .
however , there 
 was no significant difference aming the fim scores of the three groups .
nfb : neurofeedback training group , 
 cacr : computer assisted cognitive rehabilitation training group , con : control group , 
 fp1 : lt .
* p<0.05 , 
 * * p<0.01  : comparison of nfb group and control group , p<0.05 all variables are mean  standard deviation ( sd ) .
nfb : neurofeedback training group , 
 cacr : computer assisted cognitive rehabilitation training group , con : control group , 
 fim : functional independent measure , motor : motor subscale score , cog : cognition 
 subscale score , total : functional independent measure total score . * * p<0.01 , 
 * * * p<0.001
this study investigated relative brain wave and adl changes hemiplegic stroke patients 
 following nfb or cacr training .
attention and judgment related tasks mainly activate the 
 frontal area of the brain , and tasks requiring language and spatiotemporal information 
 mainly activate the parietal region15 . 

the prefrontal area of the brain is mainly involved in cognitive activities , such as direct 
 attention on new situations , and the frontoparietal area is involved in attention for space 
 and control of intentional movement16 . in this study , the relative beta wave values showed a significant difference ( p<0.05 ) 
 between before and after training at fp1 , fp2 , and f3 in the frontal area of the nfb group , 
 and between f3 of the nfb group and the control group at post - test ( p<0.05 ) . in the 
 parietal area of the nfb group ,
brain waves at f3 and p4 showed significant differences 
 ( p<0.05 ) between before and after training and a significant difference from the control 
 group at p4 post - test ( p<0.01 ) .
kim et al . evaluated patients with brain injury and normal controls after cacr cognitive 
 training using 10 comcog attention ability tasks , which activate the frontal area and 
 temporoparietal area more than the front area of the temporo - occipital area , supplementary 
 motor area , and cingulate gyrus as determined by fmri , and compared them with a control 
 group17 .
their results showed nfb 
 training improved the spatiotemporal attention of patients with brain injury .
they proposed 
 that nfb training may induce spread of brain activity to other brain areas eliciting 
 long - term improvement .
furthermore , the brain activity differed in the injured area and they 
 also suggested that further research was required in this area .
explored the effect of cognitive functions on the restoration of adls 
 1  year after discharge of stroke patients .
they reported that the patients with cognitive 
 functional impairment showed a difference in the restoration speed of adls compared to the 
 normal group , and that understanding the relationship between cognitive damage and activity 
 restraint is necessary , since it is very important to identify the cognitive problem 
 influencing adl restoration and to rectify this4 .
likewise , the improvement of the cognitive - recognition function is 
 related to adl performance in stroke patients , and cognition - recognition training of certain 
 areas appropriate to the patient s condition is necessary for independent adl performance , 
 as well as for a functional training approach in rehabilitation .
in addition to hospital 
 treatment , constant stimulation of cognitive functions by family and the surrounding 
 environment may also be a motivating factor leading to successful rehabilitation .
this study found that in terms of adl performance , as measured by the fim score , all three 
 groups showed significant improvements in motor and cognition subtotal scores , and their fim 
 total score , and that self - care showed especially significant improvement as part of the 
 motor skill area ( p<0.01 ) .
walker et al . examined the effect of intervention using qeeg 
 in patients with mild brain damage and found that 88% of patients showed an overall 
 improvement in adls , and all of them returned to their occupations15 .
kado et al . revealed that cacr therapy for brain damaged 
 patients improved adls such as activity at home , occupational performance , and driving 
 ability3 .
this seems to 
 result from the fact that nfb , cacr , and traditional rehabilitation therapy aim to be 
 performed independently from adls such as self - care , dressing , or mobility .
traditional 
 rehabilitation therapy , as well as nfb or cacr , are all considered to be able to lead to 
 improvement of cognitive function .
more rapid rehabilitation seems to be possible , and nfb 
 and cacr , which are beneficial for stroke patients with cognitive impairment , it is also 
 necessary to develop and activate nfb and cacr programs and to conduct further research on 
 the damaged brain areas in patients with cognitive impairments .
 [ purpose ] this study investigated the effects of neurofeedback ( nfb ) and 
 computer - assisted cognitive rehabilitation ( cacr ) on the relative brain wave ratios and 
 activities of daily living ( adl ) of stroke patients . [ subjects and methods ] forty - four 
 participants were randomly allocated to the nfb ( n=14 ) , cacr ( n=14 ) , or control ( con ) 
 ( n=16 ) groups . 
 two expert therapists provided the nfb , cacr , and con groups with 
 traditional rehabilitation therapy in 30-minute sessions , 5 times a week , for 6 weeks . 
 nfb 
 training was provided only to the nfb group and cacr training was provided only to the 
 cacr group . 
 the con group received traditional rehabilitation therapy only . before and 
 after 6 weeks of intervention 
 , brain wave and adl evaluations were performed , and the 
 results were analyzed . [ results ] the relative ratio of beta waves , only showed a 
 significant increase in the frontal and parietal areas of the nfb group . 
 significant 
 changes in adl were shown by all three groups after the intervention . however , there were 
 no significant differences between the nfb and cacr groups and the con group . 
 [ conclusion ] 
 our results suggest that cacr and nfb are effective at improving cognitive function and 
 adl of stroke patients . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION