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Clinical applications: strokes, traumatic brain injuries, attention deficit disorders

Doctor and PaitentIncreasingly, we can see a variety of clinical conditions for which non-invasive, computerized cognitive training programs can play a role both as first line interventions and post diagnosis to complement existing treatments. In conditions such as stroke, traumatic brain injury, and attention deficits disorders some programs are getting traction and building practitioner networks.

Stroke / Traumatic Brain Injury

For many years, neuropsychologists have used cognitive rehabilitation to help patients suffering from strokes (cerebrovascular accident or CVA) and traumatic brain injury (TBI). Cognitive rehabilitation aims at establishing brain functional changes by (a) restructuring previously learned behaviors, and (b) establishing new cognitive patterns thanks to compensatory mechanisms. It offers retraining in the ability to think, use judgment, make decisions, as well as to rehabilitate verbal and visuo-spatial skills, memory, attention, and other functions which may suffer following CVA or TBI. Along with other tools, cognitive exercises, including computer-assisted strategies are used during the training. The development and validation of new brain training software is thus important in this area.

Two recent, comprehensive literature reviews by Cicerone (2000, 2005) on evidence based cognitive rehabilitation found out that cognitive rehabilitation provides significant benefit when compared with alternative treatments. The analysis covered 47 treatment comparisons representing 1801 patients.

NovaVision is an example of a computerized program used in the clinical field. NovaVision obtained 510(k) clearance by the FDA in April 2003 for its “Vision Restoration Therapy.” The intended use of this program is the “diagnosis and improvement of visual functions in patients with impaired vision that may have resulted from stroke, trauma, inflammation, surgical removal of brain tumors or brain surgery.” Note that NovaVision’s product had received prior clinical validation. In 1998, in Nature Medicine, Kasten and colleagues showed that vision can be improved in patients with visual-field defects thanks to the repetitive computerized stimulation of the visual field provided by NovaVision’s product.

Recent world events will soon shape the advances made in this area. Indeed, in 2007, given the high rates of Iraq War veterans with TBI (estimated at above 10 percent), Congress authorized an appropriation of close to $20m to conduct research and develop applications to diagnose and treat soldiers with TBI.

Attention deficit disorders

A Center for Disease Control report (2007) estimated that, in 2003, 4.4 million youth between four and seventeen years old lived with diagnosed Attention Deficit Hyperactivity Disorder (ADHD), and 2.5 million of them were being treated for this condition with drugs.

The view of a respected researcher in the field, Dr. Russell Barkley, is gaining ground. Dr. Barkley argues that the main deficit associated with ADHD is the failure to develop the capacity for self-regulation or self control. As a result, specific and important brain processes and functions fail to develop in an optimal way. Dr. Barkley highlights the following four problem areas: working memory, internalization of speech, sense of time, and goal directed behavior.

Following the publication in the Journal of the American Academy of Child and Adolescent Psychiatry of a double-blind controlled clinical trial that showed how working memory training improved a number of non-trained cognitive skills and alleviated behavioral symptoms in children with ADD/ADHD (Klingberg et al, 2005), a network of US clinicians are offering Cogmed’s working memory training.

According to Dr. Arthur Lavin, many school psychologists may be too quick to diagnose ADD/ADHD. This can be misleading and even counterproductive for some children. In addition, it is often the case that drugs are considered as the only potential intervention. Dr Lavin believes that “Up to a point, many kids with attention problems would benefit from educational, not medical, interventions to improve cognitive functions such as working memory.”

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