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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
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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
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Neuroanatomy 101
• Controls R side of body
• Language
• Math
• Facts
• Controls L side of body
• Spatial abilities
• Face recognition
• Visual imagery
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Neuroanatomy 101
• Lack of awareness of deficits
• Left inattention
• Impulsivity—stimulus bound
• Lack of initiation
• Pathological laughing & crying
• See ‘parts’ without seeing ‘whole’
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Stroke rehabilitation takes a bottom-up approach
Cognition (comprehension, judgment, reasoning)
Speech & language
Arm
Leg
The Problem
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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!
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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
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5 brave souls & their caregivers agreed to give computer based brain training a try
If it’s available will they use it?
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Cognitively, how were they doing?
Age and education corrected percentiles
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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
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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
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Target multiple domains of cognitive function
Memory—verbal and visual
Attention
Processing speed
Mental flexibility
Problem solving
Lumosity Games
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http://www.screencast.com/t/duVCGlQdS
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Lost in Migration
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Rain Drops
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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?
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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
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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
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How did he do it?
Nagging from Spouse
Speech therapist
Psychotherapist
One Completer!
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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?
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1 to 13 in 11 seconds
13 to 25 in 36 seconds
TMIMental flexibility & processing speed
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Begin (1) to this point in 64 seconds
Begin (1) to End (13) in 110 seconds
TMIMental flexibility & processing speed
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TMIAttention & visual spatial processing
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3 minute delay 30 minute delay
TMIVisual spatial processing & visual memory
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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
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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
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Thank you!