09.29.10
Traumatic brain injury (TBI) has become the signature injury of the conflicts in Iraq and Afghanistan. A total of 178,876 service members were diagnosed with a traumatic brain injury between 2000 and 2010 (1). Even in peacetime, members of the military are at higher risk than their civilian counterparts for sustaining a TBI.
Many factors contribute to that increased risk, including the basic demographics of our military: young men between the ages of 18 and 24 are always at a higher risk for TBI. Wartime injuries, training exercises, and even many leisure activities – such as biking, contact sports, personal watercraft use – contribute to TBI’s posing a continuing, significant health issue for both active duty personnel and veterans. The Department of Defense (DoD) and the Veterans’ Administration (VA) are dedicated to providing men and women suffering from a TBI or other neurologic dysfunction with as many outlets for recovery as possible. The DoD and VA focus on interventions spanning from acute care to the service member’s return to duty or home. One way Walter Reed Army Medical Center (WRAMC) spans the recovery process is adding novel computer-based cognitive training as an adjunct to traditional therapy. Although some are designed for different populations, we are finding good programs that keep patients engaged with technology that appeals to and is intuitive for the younger generation most at risk for TBI. Providing patients with the opportunity to use computer-based training enhances the rehabilitative process and provides an effective means for providing a continuity of care once home. Similar to the civilian population, approximately 80 percent of military patients diagnosed with a TBI have a mild TBI or concussion; of that percentage, the majority are symptom-free within weeks to months. However, some service members’ cognitive symptoms linger. The Brain Fitness Center (BFC) was devised at WRAMC in 2009 as an adjunct to the traditional cognitive therapies offered by speech-language pathology (SLP) and occupational therapy (OT). The Brain Fitness Center uses commercially available software designed to offer cognitive exercise for service members. The BFC is conceived of as a cognitive gymnasium, providing a workout for the brain.
The BFC is independent of other therapies. It is located in the WRAMC’s Military Advanced Training Center away from other typical cognitive-rehabilitative services and requires a separate referral from our SLP and OT departments. Patients may also refer themselves. If a patient is a “walk-in,” we contact their case managers and make sure they have undergone all appropriate screens and evaluations. All active-duty service members injured in combat and complaining of cognitive dysfunction can utilize the BFC and do not need a diagnosis of TBI or neurologic disorder to participate. BFC staff work with patients, their families, and the Traumatic Brain Injury Rehabilitation team composed of speech-language pathologists, occupational and physical therapists, neuropsychologists, case managers, et al., to find engaging computer-based activities best suited for the individual service member’s rehabilitation goals and lifestyle. Participation is voluntary and dosing as well as computer-program selection is individualized. By offering yet another outlet for cognitive stimulation, we hope to vary and enhance the patient’s rehabilitation. Using software to assist with cognitive rehabilitation is nothing new. The speech and OT fields have had products to help with cognitive skills remediation for decades. However, the emerging field of “brain fitness” for the normal and normal-aging brain has exploded over the last five years, and many of its new products may help meet the needs of our patients. Brain fitness has become a billion-dollar market, fueled in part by scientific evidence of neuroplasticity (the brain’s ability to change) at any age. Many computer- and Web-based programs now provide brain exercises intended to improve overall brain health and even delay the onset of dementia. These programs, aiming to be both entertaining and stimulating, have proven popular. For example, in the four years following its 2005 release, Nintendo’s DS Brain Age game sold 17.4 million copies. The promise of profits from such sales has attracted significant venture capital to brain-fitness software companies, which has allowed them to invest in advanced computer technology, graphics and scientific manpower.
The BFC at WRAMC uses these products as a novel means of providing cognitive stimulation and examining their efficacy in our patient population. Although cognitive dysfunction associated with aging is generally different than that associated with TBI, there may be some common links, and interventions for one type of cognitive dysfunction may have applicability in others, given the apparent neuroplasticity of the brain. We know TBI patients are more likely to develop dementia and Alzheimer’s than those who have never suffered a TBI. If engaging in long-term cognitive exercise helps prevent dementia in the normal population, such programs may assist in short-term rehabilitation, and, if used long-term, could possibly help reduce or delay the onset of such long-term complications. The first program designed for the aging population to be used in the Brain Fitness Center is the Dakim Brain Fitness (DBF) system by Dakim Inc. The DBF is a touch-screen computer with over 125 different games to help “cross-train” the brain in six different cognitive domains: short-term memory, long-term memory, visuo-spatial orientation, computation, language and critical thinking. Within each of the cognitive domains, the DBF program provides five levels of challenge and self-adjusts in real-time. Because the starting level can be pre-programmed, virtually any patient, regardless of initial impairment level, can begin using the program successfully. For example, the algorithm will adjust for “SGT Bob Smith” who is strong in math but has difficulty with short-term memory. Within and across sessions, SGT Smith’s short-term memory games increase in difficulty while his math exercises remain on the same level or decrease in challenge level. As a result, every patient gets a dynamically individualized mental workout for their unique level without any preparation time from a therapist.
Many of the DBF exercises are similar to cognitive-communication therapy exercises and are based on neuropsychological tests. For example, the interactive game “Memory Mambo” asks the user to recall a sequence of numbers like the digits forward test on the Wechsler Memory Scale.
Games such as “Odd Couples”, “Picture Pairs” or “Make a Story” target short-term memory through word recall after incremental time delays. These exercises recall assessments like the Wechsler Memory Scale–III, Hopkins Verbal Learning Test-Revised, Four Unrelated Words, Benson Bedside Memory Test, and the Auditory-Verbal Learning Test. The DBF is supported by literature that indicates participating in consistent, long-term, cognitively stimulating activities can maintain brain health and helps people to feel mentally sharper (2,3). A small, unpublished study of a convenience sample of 41 seniors showed that using Dakim long-term (more than six months or 90 sessions) resulted in a statistically significant improvement in delayed recall on neuropsychological tests (4).
Another benefit of computer-based therapy is the patient’s ability to take the program home to use when not seeing a therapist or providing a seamless continuation of one aspect of care when the patient is discharged. Like Dakim, many companies offer a personal computer- or Web-based application that allows us to provide service members with the same program they have used in the Brain Fitness Center. We want patients who have been dedicated to using a program and who feel that they’re receiving a benefit from it to continue with the exercises, gleaning whatever cognitive benefits that they provide and, in serious cases, a reminder for the need for on-going therapy. Offering a variety of software options in the BFC allows patients and their supervising clinicians to find the best available match for the individual.
In the past year, 66 patients have used DBF at Walter Reed. Of those 66, 80 percent were diagnosed with a traumatic brain injury; 32 with a mild TBI, 13 with a moderate injury, five with a severe TBI and three with a penetrating brain injury. The patients without a TBI had varying diagnoses including strokes (CVA) and Post-Traumatic Stress Disorder (PTSD). On average, these patients completed 21 sessions over 14 visits before transitioning to care elsewhere. Five of the patients have completed over 100 DBF sessions. We will be doing a retrospective review of our pre and post assessments of those 66, and are also beginning to recruit for a randomized, controlled protocol comparing the use of such programs with conventional standards of care. We are measuring objective improvements in cognitive function as well as subjective self-reports of improvement in areas such as self-esteem and confidence. In addition to Dakim, we offer a Nintendo DS with Brain Age software to appropriate patients who would like to have a handheld means for brain exercises while not at the BFC. The Brain Age and Brain Age II software offer “minutes-a-day” brain stimulation. Familiar games like Sudoku are mixed in with tasks such as fast-paced calculations and (Stroop) color reading aloud. They have multi-user capability and continuously challenge the user with an "IQ" or "age" score. Patients enjoy reporting that their “brain age” has improved from a brain of a 70-year-old to a brain of a 40-year-old. In the past few months, we have also been able to offer two pieces of software from Posit Science Corp. These programs take a ‘bottom-up, top-down’ approach founded on the premise of brain plasticity. Brain Fitness Classic (for auditory processing) and Insight (for visual processing) are designed to fundamentally improve the brain’s capacity to process information efficiently. Their understanding of brain plasticity argues for intensive participation (an hour a day, five days a week is recommended) to restore brain functions rather than simply compensating for an absence of functions. These programs are hierarchically organized and adjust to the patient’s skill level so any patient can be successful as well as challenged. Randomized controlled studies have been conducted in populations with brain impairments other than TBI, the results of which indicate an improvement in processing can have a significant effect on memory and participant-reported cognitive outcomes (5). Lumosity is a web-based program that offers basic “brain games” as well as courses designed for users with specific medical conditions such as TBI, PTSD, Attention Deficit and Hyperactivity Disorder (ADHD), and cancer. The user can target specific cognitive domains for exercises, and assessments allow progress tracking in the following areas: attention, short-term memory, flexibility, spatial memory, processing speed, and working memory. The patients can pull up their user history and report back to us, and can use Lumosity on our computers in the BFC or at home. We are happy and encouraged with the use of the novel computer-based programs at the BFC. Dakim Brain Fitness has been a well-received first step and we are excited about the recent addition of Posit Science, Lumosity and Nintendo Brain Age. As Brain Fitness programs, apps and devices continue to emerge in the market, we hope the BFC at WRAMC will continue to expand to offer a wide and varied field of computer-based therapy tools. We also hope to quickly incorporate new methodologies and results as they become available over the coming years. Both patients’ end-point satisfaction forms and daily feedback documentation have proven extremely positive. Computer-based brain fitness intervention is still in its infancy. However, WRAMC's dedication to its patients drives us to examine the most innovative therapies and technologies. What these novel computer-based therapies promise is sufficient that we have invested significantly in finding what its benefits and shortcomings may be. While it's too early to tell, we are encouraged. – Katherine W. Sullivan, M.S., CCC-SLP, CBIS is a Speech-Language Pathologist and Director of the Brain Fitness Center at Walter Reed Army Medical Center. She is employed through The Defense and Veterans Brain Injury Center. She has served as a consultant to Dakim, Inc., for the past year, but has received no compensation for this article. Katie can be reach for questions at katherine.sullivan@amedd.army.mil The views expressed in this presentation are those of the authors and do not reflect the official policy of the Department of Army, Department of Defense, or U. S. Government.
References
1. http://www.dvbic.org/TBI---The-Military.aspx 2. Verghese J., Lipton R.B., Katz M.J., Hall C.B., Derby C.A., Kuslanksy G., Ambrose A., Sliwinski M., Buschke H. Leisure activities and the risk of dementia in the elderly. (2003) The New England Journal of Medicine 348:2508–2516 3. Wilson R.S., Mendes de Leon C.F., Barnes L.L., Schneider J.A., Bienias J.L., Evans D.A., Bennett D.A. Participation in cognitively stimulating activities and the risk of incident Alzheimer disease. (2002) Journal of the American Medical Association 287:742–748 4. Miller, K., Siddarth, P., O’Toole, E, Kim, Jeanne, Lea, J., Wong, J., Small G., Dakim’s Brain Fitness: A computerized cognitive training program for older adults. Poster session presented at: American Association of Geriatric Psychiatry (AAGP); 2010, March 5-8; Savannah, Georgia.
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