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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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This new online resource is based on the con­tent from the book The Sharp­Brains Guide to Brain Fit­ness (May 2009, $19.95), by Alvaro Fer­nan­dez and Dr. Elkhonon Gold­berg.

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