Friday, October 25, 2013

Brain Training - The Wild West of Neuropsychology

Brain training is something neuropsychology needs to keep an eye on. There was supposed to be a brain training debate at the last conference, with FOR and AGAINST teams fighting it out in public. Because I have made noises on the topic before, I was invited to join the FOR team, and started beefing up my arguments and research in earnest. As those who went to the conference know, there was no debate. The reason? The organizers could not find enough people to stage it. Surprisingly, we could have run the FOR team, it was the AGAINST team that was missing.

I think that this is symptomatic of how the majority of neuropsychologists think about the topic: we dismiss it out of hand as pure snake oil. But it is dismissed so quickly that it is rarely investigated. So nobody was prepared to talk with authority against brain training.

I think this is both an intellectual and a strategic mistake. An intellectual mistake because we give up on the issue without knowing enough to make an informed decision. Strategic mistake because we are writing ourselves out of the biggest development of contemporary neuroscience to the detriment of the profession and, more importantly, to the detriment of our clients.

So, I am hoping to start the discussion here. I will mostly present the FOR position, and please feel free to discuss/disagree/flame me in the comments. I am planning a few posts on this, and hope to invite a couple of people to comment on the issue.
One disclaimer: I have very recently completed the Cogmed Coach course. Having read the literature and being graced with low working memory and high curiosity, I have been planning to do it for some time - and the debate speeded things up. I do not currently earn any money on this, but may do so in the future.


So, Question 1: Can intervention improve brain function?

I have a sneaking feeling that the underlying opinion in our profession is 'no, it cannot'. Or at least it was during the 2012 conference - the outlook seemed more positive this year. A lot of us believe that there is not that much that rehabilitation can do above and beyond the normal process of recovery. Not that we are doing anything to complain about our Speech Pathology colleagues offering 'ineffective' treatments, which they would be if we really believed this philosophy. However, we distrust intervention enough not to do much in the direction of cognitive rehabilitation ourselves. So what does the literature say? Here is a meta-analysis and a review.

1. Rohling, M.L., Faust, M.E., Beverly, B., Demakis, G. (2009). Effectiveness of cognitive rehabilitation following acquired brain injury: A meta-analysis re-examination of Cicerone et al.'s (2000, 2005) systematic reviews. Neuropsychology, 23(1), 20-39. Full text here.

This was a meta-analysis of 115 studies in cognitive rehabilitation. These included various treatments and techniques and did not focus on computer-based rehabilitation. Here are some of the interesting findings:

1. There was a small but statistically significant effect of rehabilitation on cognitive function. They concluded that there was a scientific base to support the assumption that cognitive rehabilitation is an effective treatment for persons with acquired brain injury.

2. Treatments for attention, visuospatial and language deficits produced significant improvements. Memory treatments and comprehensive treatments (training 'everything') failed to produce improvement.
I wonder if the lack of improvement in memory is what underlies neuropsychologists' skepticism about cognitive rehabilitation?

3. Attention training produced improvement in attention only (apart from the TBI group, in which it also improved global cognitive functioning). Visuo-spatial rehabilitation also improved performance on memory, language and comprehension measures.

My bottom line: treatments for attention, visuo-spatial function and language work, to lesser or greater degree. Don't bother rehabilitating memory - remediate instead. Generalized interventions don't work - focus on specific functions.

Cicerone, K.D. et al. (2011). Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Archives of Physical Medicine and Rehabilitation, 92, 519-530. Abstract here, try the APS databases for full text.

This is a third in a series of review articles by the same group, with the first published in 2000. Apart from a review, it provides quite a few recommendations. Among others, these include:

1. Computer-based interventions may be considered as an adjunct to clinician-guided treatment for the remediation of attention deficits and cognitive-linguistic deficits after TBI or stroke. Sole reliance on repeated exposure and practice on computer-based tasks without some involvement and intervention by a therapist is not recommended. '

2. 'Computer-based interventions intended to produce extension of damaged visual fields may be considered for people with TBI or stroke'. But: 'The use of isolated microcomputer exercises to treat left neglect after stroke does not appear effective and is not recommended.' (This appears to be based on training of focus to left hemi-field. I am not sure whether the authors considered the developments in arousal training for left neglect)

3. For memory impairment computer-based remediation is not recommended. Instead, memory strategy training, use of compensation aids, error-less learning techniques and group-based interventions are recommended.

4. For executive difficulties, no computer-based interventions are recommended.

I'm sure that there are more reviews. But this has been a long enough post (apologies).

If you want to find out more, please read Norman Doidge's The Brain That Changes Itself. It is a great read. It is a neuroscience book that reached the status of a bestseller, and if nothing else, this should make us have a look. More importantly, it is one of the great examples of scientific reporting. It talks about stuff that we did not learn at school (or uni) and talks about it well.


PS: Please comment and let the games begin.

Thursday, October 10, 2013

Which smartphone to recommend to clients

There is no doubt in my mind that a smartphone is the best available memory aid. I estimate that I keep about 60% of all my day-to-day memory on my iPhone and tablet. I would argue that a person with a moderate memory problem but an excellent smartphone use can potentially outperform the majority of their peers.

So, which smartphone? I have just read an article about a top-end Android phone (the latest Galaxy, I think), that made me salivate and wonder about switching. But on reflection, I would still not change my recommendations for phones in memory remediation.

These are:

1. If a person is already using a smartphone, of whatever ilk, do not replace it with anything else. In this case, your job should be to just point out a few extra features that they should be using.
  • One of the most important of these, especially for those of your clients that tend to lose things, is an acquisition of a special keyring that raises hell if the keys and the phone get separated (e.g.: one gets left behind in a restaurant). Which reminds me, I really must get one of those.
  • Another thing to attend to, is to make sure that a phone's data is backed up. In particular, syncing calendars is important, so that if the smartphone gets lost or damaged, the appointments don't disappear with it. I tend to sync to Google calendar, which I find very convenient. You can add appointments on a computer, your smartphone or tablet, and they propagate across devices. Also, from a computer you can request multiple reminders, in the form of texts or emails that will arrive at your smartphone. However, Google Calendar is only one of a few systems worth considering.
  • The third matter to attend to, is to make sure that your client is using all the basic memory functions of the device: the notes app, keyword searching, camera for taking pictures of relevant info, the ability to add photographs to contacts, voice recording, asking people to text you information, etc. 

2. If a person is new to smartphones, I would strongly recommend iPhone. The reasons for this are:
  • The 'closed' architecture, or inability to mess around with operating system. All apps are pre-tested by Apple, and generally work without problems. The thing does not require technical know-how to manage and is fairly resistant to messing around with software. In other words, it is relatively hard to stuff up.
  • All models of the iPhone are basically the same, with the same suite of basic apps. I have recently damaged my iPhone and had to go back to the original one I had (imported from the US before the Australian release, version 0). It still worked, and still had all the basics that I use every day. This is important if you are giving advice, recommending apps, or generally helping the person learn how to use the phone as you don't have to know the functionality of multiple systems and models (although this argument is invalid if you are an Android expert). It also means that the client can buy an older version of the iPhone, which can be very much cheaper (especially second-hand), and still enjoy the core functionality.
  • The quality of the iPhone is generally good. In contrast, I wonder what is the quality of the low-end phones on the market.
So, for me the uniformity of architecture across models and the difficulty of 'breaking' the phone (software only, if you want a physically unbreakable phone, you'll have to go to Nokia), are the most significant features.

Of course, any Android fans, and those who prefer other brands of smartphones out there, are most welcome to explain their opinion in the comments or as a guest post.