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.

1 comment:

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