So much technology, so little time:

factors affecting use of computer-based brain training games for cognitive rehabilitation following

stroke

BB Connor1 & PJ Standen2

1Stroke Program, Sierra Nevada Memorial Hospital, Grass Valley, CA2Division of Rehabilitation and Ageing, University of Nottingham, UK

ICVDRAT 2012Laval France

The stroke patients who participated —EB, JW, PP, NB, & BF

Lumos Labs and the Lumosity.com training program

Sierra Nevada Memorial Hospital Stroke Program & Out Patient NeuroRehab Speech, OT & PT

Acknowledgements

Neuroanatomy 101

• Controls R side of body

• Language

• Math

• Facts

• Controls L side of body

• Spatial abilities

• Face recognition

• Visual imagery

Neuroanatomy 101

• Lack of awareness of deficits

• Left inattention

• Impulsivity—stimulus bound

• Lack of initiation

• Pathological laughing & crying

• See ‘parts’ without seeing ‘whole’

Stroke rehabilitation takes a bottom-up approach

Cognition (comprehension, judgment, reasoning)

Speech & language

Arm

Leg

The Problem

Computer based brain training can combat cognitive decline

Training generalizes to real world function

Benefits are durable over time

Neuropsychological evaluation can identify specific strengths and weaknesses to target with training

Brain Training Works!

Stroke patients & caregivers report ADLs + outpatient therapies can consume an entire day

Fatigue & energy allocation is a constant balancing act

Therapies for walking & using the affected upper limb can be physically exhausting

What’s left over for the brain??

Yet, so much technology…so little time

5 brave souls & their caregivers agreed to give computer based brain training a try

If it’s available will they use it?

Cognitively, how were they doing?

Age and education corrected percentiles

Goal—complete 40 sessions of training Train as frequently as possible

Notice what factors interfered with training

What factors made training easier

Agree to complete semi-structured interview when training was complete

The task at hand

Web-based brain training games that improve cognitive function by

1. Targeting brain functions and training that transfers to daily life

2. Adaptivity—level of difficulty adjusts based on individual performance

3. Novelty—critical for driving nervous system remodeling

4. Engagement—keeps brain engaged and in a “rewarded state”

5. Completeness—targets multiple domains of cognitive function

Why Lumosity Games?25,000,000 subscribers can’t be wrong

Target multiple domains of cognitive function

Memory—verbal and visual

Attention

Processing speed

Mental flexibility

Problem solving

Lumosity Games

http://www.screencast.com/t/duVCGlQdS

Lost in Migration

Rain Drops

Barriers to use Physical limitations—hemiplegia, hemianopsia, color

blindness

Cognitive limitations Login process—unable to do without assistance Comprehension—understanding training & game

instructions Anosognosia—“I don’t feel I have any problems”

Time & fatigue management—ADLs, outpatient appointments

Problems with software— Unable to quit out of games that are too difficult Using keyboard 1 handed, navigating up & down arrows Navigating quickly enough with mouse

How did they do?

Short duration of training sessions (15-20 minutes)

Easy arithmetic problems—“I could do the problems!”

Game playing experience—“the more I played the easier it was to play”

Facilitators of use

Memory—remember words & names better

Problem solving—“when I see I’m making a mistake I don’t continue doing it. I develop strategies to offset my personal difficulties”

Visual scanning—“she is reading a lot better, not skipping over chapters”

Mood—“I feel quicker, sharper in my brain” “when she is down, depressed or angry & does Lumosity she feels better”

Improvement in ADLs

How did he do it?

Nagging from Spouse

Speech therapist

Psychotherapist

One Completer!

Within game improvement

Admitted to paying more attention to names and faces—a lifelong problem

Improved processing speed

Some improvement in mental flexibility

Lingering problems….

How did he do?

1 to 13 in 11 seconds

13 to 25 in 36 seconds

TMIMental flexibility & processing speed

Begin (1) to this point in 64 seconds

Begin (1) to End (13) in 110 seconds

TMIMental flexibility & processing speed

TMIAttention & visual spatial processing

3 minute delay 30 minute delay

TMIVisual spatial processing & visual memory

When left to their own devices stroke survivors

Have difficulty finding the time

Have difficulty with login

Task demands (keyboard, mouse) are challenging

Coach or trainer is needed

What did we learn?It takes a village

Prescription

• Courses prescribed based on patient needs—determined by neuropsychological evaluation

• Qualitative is as important as quantitative assessmentof strengths & weaknesses

• Commercially available programs, like Lumosity, offer great promise and require modificationsto be feasible for broader clinical populations

• Top down rehab is essential to bottom up success

Thank you!