BB Connor 1 & PJ Standen 2 1 Stroke Program, Sierra Nevada Memorial Hospital, Grass Valley, CA

1. 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, CA 2Division of Rehabilitation and Ageing, University of Nottingham, UK ICVDRAT 2012 Laval France

2. Acknowledgements 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

3. Neuroanatomy 101 • Controls R side of body • Language • Math • Facts • Controls L side of body • Spatial abilities • Face recognition • Visual imagery

4. Neuroanatomy 101 • Lack of awareness of deficits • Left inattention • Impulsivity—stimulus bound • Lack of initiation • Pathological laughing & crying • See ‘parts’ without seeing ‘whole’

5. The Problem Stroke rehabilitation takes a bottom-up approach Cognition (comprehension, judgment, reasoning) Speech & language Arm Leg

6. Brain Training Works! 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

7. Yet, so much technology…so little time 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??

8. If it’s available will they use it? 5 brave souls & their caregivers agreed to give computer based brain training a try

9. Cognitively, how were they doing? Age and education corrected percentiles

10. The task at hand 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

11. Why Lumosity Games?25,000,000 subscribers can’t be wrong Web-based brain training games that improve cognitive function by • Targeting brain functions and training that transfers to daily life • Adaptivity—level of difficulty adjusts based on individual performance • Novelty—critical for driving nervous system remodeling • Engagement—keeps brain engaged and in a “rewarded state” • Completeness—targets multiple domains of cognitive function

12. Lumosity Games Target multiple domains of cognitive function • Memory—verbal and visual • Attention • Processing speed • Mental flexibility • Problem solving

13. http://www.screencast.com/t/duVCGlQdS

14. Lost in Migration

15. Rain Drops

16. How did they do? 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

17. Facilitators of use 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”

18. Improvement in ADLs • 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”

19. One Completer! How did he do it? Nagging from • Spouse • Speech therapist • Psychotherapist

20. How did he do? 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….

21. TMI • Mental flexibility & processing speed 1 to 13 in 11 seconds 13 to 25 in 36 seconds

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

23. TMI • Attention & visual spatial processing

24. TMI • Visual spatial processing & visual memory 3 minute delay 30 minute delay

25. What did we learn?It takes a village 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

26. 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

27. Thank you!