So much technology, so little time: factors affecting use of computer-based brain training games for cognitive rehabilitation following stroke BB Connor 1 & PJ Standen 2 1 Stroke Program, Sierra Nevada Memorial Hospital, Grass Valley, CA 2 Division of Rehabilitation and Ageing, University of Nottingham, UK ICVDRAT 2012 Laval 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

Controls R side of body Language Math Facts Controls L side of body Spatial abilities Face recognition Visual imagery

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

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 TMI Mental flexibility & processing speed

Begin (1) to this point in 64 seconds Begin (1) to End (13) in 110 seconds TMI Mental flexibility & processing speed

TMI Attention & visual spatial processing

3 minute delay30 minute delay TMI Visual 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 assessment of strengths & weaknesses Commercially available programs, like Lumosity, offer great promise and require modifications to be feasible for broader clinical populations Top down rehab is essential to bottom up success

Thank you!