Brain injuries whether from Stroke or Trauma result in a huge burden on society. Not just from the direct medical costs but also from lost productivity and a broader impact on family. Cognitive issues are the major cause of long-lasting disability and impaired quality of life following brain injury but providing rehabilitation has been problematic - can software provide a helping hand?
In most European countries, (when it's offered) cognitive rehabilitation is provided to brain-injured patients in acute or post-acute inpatient settings. Longer term outpatient treatment is often not available due to perceived high cost and actually was once not thought to be effective in any case.
Recent reviews (Cicerone, 2011) concluded however that there is substantial evidence to support the implementation of evidence-based cognitive interventions after TBI and Stroke. The challenge remains - how can this be done despite resource limitations?
The general lack of long-term treatments has led to the recent development of a number of commercially available "web-based" training programmes which are often offered to both healthy and neurological populations. A lucrative brain training industry has sprung up which often prove attractive to users if not necessarily effective in all they claim.
A study investigating online training with healthy subjects showed some gains in task-specific activities but no transfer into positive performance gains in other, non-trained, tasks. (Owen et al 2010)
On-line training, if it could be successful, would be attractive as it offers a low-cost means of delivering long-term support at a distance - a client could work at home.
Owen and colleagues looked at a number of the web-based training approaches and found that the training dose - intensity and frequency of training were often too low. They also found that training content was not sufficiently specific and failed to leverage neuropsychological and cognitive neuroscience knowledge.
What sometimes seems to be missed is that all cognitive training programmes are not the same. RehaCom has evolved in Germany over 25 years with input from Neuropsychologists and Computer Scientists to the point where it is used by 95% of clinics. It is unique in that the cognitive training it offers is
- precisely aligned with specific cognitive deficits - more than 20 training modules
- designed to be appropriate for both acute and long term use
- training automatically adapts to the user's level of performance and can be fine tuned by the therapist - so the task presented is never too difficult nor too easy
- can be delivered face to face or via the internet for home-based training
- supports most languages (more than 20)
- self-documenting - exhaustive details of user performance are maintained
RehaCom is an intervention that is designed to contribute to the achievement of functional change in the user.
Can this be proven? Well this is very hard in a formal sense because there are so many factors that make research a challenge. We don't even know how the "dose" impacts on efficacy - but then we don't know this in other types of intervention either. Certainly clinical experience over more than 25 years shows RehaCom to be an effective enabler of cognitive rehabilitation. Of course it is not a "silver bullet" and should be consider and used as a tool that is deployed to create positive change. The interventions we have to bring about positive change are fundamentally (Cicerone 2000)
- Restitution - to reinforce, strengthen or re-establish previously learned patterns of behaviour
- Internal compensation - to establish new patterns of cognitive activity through compensatory cognitive mechanisms for impaired neurological systems
- External compensation - establishing new patterns of of activity through the use of external aids
- Adaptation - enabling patients to adapt to their disability in order to improve their overall level of functioning and quality of life.
Of course RehaCom does not impact on all the positive threads of intervention, but neither does anything else we have available.
Cicerone, KD et al 2011
Evidence based cognitive rehabilitation: updated review of the literature from 2003 through 2008.
Arch Phys med Rehabil 2011: 92: 519-30
Cicerone, KD et al 2000
Evidence based cognitive rehabilitation: recommendations for clinical practice.
Arch Phys med Rehabil 2000: 81: 1596-615
Owen, AM et al
Putting brain training to the test
Nature 2010: 465: 775-8