November 2018
Many interesting things are afoot in our research area, all on the path to changing the world very much for the better. I’d like to share a few new and exciting studies with you, they provide some new information about ongoing trials and industry updates that have come up over the past several months.
You’re receiving this newsletter because you are a former collaborator or scientific friend—or you have collaborated with me or other scientists at Posit Science—and I thought you might be interested in keeping up with ‘what’s happening’. Please let me know if you’d like to be removed from this list. We can still be friends.
A LITTLE NEWS
On remediating a brain exposed to chemotherapy
Up to a reported 90% of cancer survivors who have undergone chemotherapy self-report negative changes in attentional focus and processing speed, loosely described clinically as “chemobrain” or “chemofog”. Broad-ranging deficits recorded in standardized tests of perception, attention, cognition and executive function show that these emergent deficits may be found in the majority of treated patients.
Drs. Karen Meneses, David Vance, and colleagues from the University of Alabama in Birmingham (Breast Cancer Res Treat, 2018) tested whether BrainHQ could help. In this randomized controlled pilot study called the Speed of Processing in Middle-Aged and Older Breast Cancer Survivors (SOAR), 60 breast cancer survivors with a mean age of 55 were randomized to either 10 hours of BrainHQ’s Double Decision speed of processing training for 2 hours per week for 6-8 weeks or to treatment-as-usual. Outcome measures included subtest scores from the Useful Field of View (UFOV) assessment and NIH Toolbox Cognition Battery (Flanker, Dimensional Card Change Sorting, Picture Sequence Memory Test, Pattern Comparison Test, List Sorting Test). Assessments were taken at baseline, post-test, and at a +6 month benchmark. Participant retention was high at 96% and participants in the intervention reliably improved on most outcome measures at post-test with benefits sustained at six-months post intervention. This promising work demonstrates that a singular form of brain training that is convenient and scalable durably improves networks related to processing speed as well as executive function more generally.
We are excited to announce that this study among others (see also a wonderful integrative review by Dr. Vance) prompted the National Cancer Institute to designate BrainHQ as an evidence-based program for cancer-treated patients.
TRIALS UNDERWAY
I’ve rather arbitrarily chosen to introduce you to one of the 250+ trials using computer-delivered brain training programs that are now underway. Let me know about your projects so that we can tell other professionals in our research family about your work in future newsletters.
BrainHQ in veterans with PTSD
Post-Traumatic Stress Disorder (PTSD) is marked by poorer occupational, psychosocial, and health outcomes, lower quality of life, increased interpersonal problems, higher rates of hospitalization, and greater risks of suicide and mortality.
Drs. Laura Crocker from the VA San Diego Healthcare System and Amy Jak from UCSD are currently in the recruitment phase of the trial “Enhancement of PTSD Treatment With Computerized Executive Function Training”. In this 5-year study funded by the Department of Veterans Affairs Rehabilitation Research and Development, 110 Iraq/Afghanistan veterans with PSTD will be randomized to BrainHQ plus Cognitive Processing Therapy (CPT) or to an active control of computerized word games plus CPT for 30 min a session, 5 sessions per week for 6 weeks. The primary outcome measures are the Wisconsin Card Sorting Test, Paced Auditory Serial Addition Test (PASAT), Delis Kaplan Executive Function System (D-KEFS), and the Behavior Rating Inventory of Executive Function (BRIEF).
NEWS FROM THE FIELD
A success story for translational science
A collective goal of our field is to take the science of brain plasticity bench to bedside to enhance health outcomes in the real world. In a major step toward this goal, we are pleased to announce that we have partnered with United Healthcare to provide BrainHQ to one million users through 2019 Medicare Advantage Plans. The efforts leading up to this moment began nearly three decades ago with NIH-funded grants awarded to Dr. Karlene Ball and colleagues who invented speed training and demonstrated real benefits including reduced medical expenditures, reduced automobile accidents, decreased symptoms of depression, increased driving confidence, improved timed activities of daily living, and most notably, a reduce the risk of dementia by up 29-48% depending on training dosage. You can find all published papers from the ACTIVE trial here.
As a member of the brain training community, you’re likely to receive questions from your patients, participants, colleagues, and friends and family who are interested in learning more about this move from United Healthcare. The motivation for this translational effort is two-fold. First, cognitive function is a top concern of Medicare Advantage Plans. If you ask someone over the age of 50 what their greatest health fear is, he or she will likely say losing their memories, losing their independence, losing the very essence of what makes them, them. Dementia is a very much a major public health concern with prevalence of this devastating condition expected to skyrocket over the next few decades. Second, policy evidence data suggests that certain forms of brain training improve cognition. For example, The National Academies of Science, Engineering, and Medicine (NASEM) published a review last year on three primary prevention factors and interventions—brain training, maintaining normal blood pressure, and exercise—that may delay, slow, or prevent cognitive decline (Preventing Cognitive Decline and Dementia: A Way Forward, 2017). More recently, the American Academy of Neurology (AAN) convened an expert panel led by Dr. Ronald Petersen at the Mayo Clinic and updated its guidelines to now list brain training and physical exercise as clinical recommendations for those with MCI (see also physician and patient tools and materials here). This is exciting news for our field. We thank you for being a contributor and for joining us in celebrating this success story for translational science.
CURRENT PERSPECTIVES
Otolaryngology’s Cobra Effect
The high prevalence of tinnitus may be a consequence of modern-day living. Environmental and artificial white noise generators are in many places—in therapy offices, in the bedrooms of those who have trouble sleeping, and most alarmingly, in the NICU where they rewire the developing infant brain. Several cognitive difficulties, especially in young children, have been linked to ongoing noise exposure.
Drs. Mouna Attarha and Michael Merzenich at Posit Science in collaboration with Dr. James Bigelow at UCSF published a review on the consequences of white noise exposure after noting widespread use of noise generators by health professionals (JAMA Otolaryngology Head & Neck Surgery, 2018).
Increasing evidence shows that the brain rewires for the worse when it is fed random information, such as white noise. The review cites several studies in which unstructured noise exposure, although effective as a short-term strategy for masking tinnitus percepts, is capable of compromising the structural and functional integrity of the central auditory pathway in the long term via changes that reduce neural inhibition, increase temporal integration times, and produce imprecise cortical representations. Two primary concerns follow from this perspective. First, because the general syndrome of disinhibition associated with hearing loss and tinnitus is recreated by exposure to non-traumatic noise, the treatment strategies employing exposure to broadband noise could lead to the worsening of symptoms over time. Second, aside from tinnitus symptoms, chronic exposure to non-traumatic noise is known to undermine important aspects of central auditory processing, such as temporal processing ability, which lead to behavioral deficits in speech comprehension and the discrimination of signals in noise. These maladaptive changes in the brain have consequences that, with time, exacerbate the tinnitus, degrade functioning of the auditory system, and compromise other important cognitive processes. A therapeutic strategy so often recommended needs to be more fully understood, including its unintended and often overlooked consequences.
It is our belief that white noise can be avoided in virtually all cases. Even for patients not seeking clinical interventions, the masking effects of noise can be accomplished with alternative sounds such as music or speech, which do not carry risks of changing the structural, chemical, and functional status of the brain in the maladaptive direction. In cases where white noise therapy is adopted as a last resort, we recommend that it be limited as much as possible in terms of exposure time and volume.
It is critical for clinics to bring the past 50 years of neuroplasticity research to bear, and to stay current with relevant scientific and clinical findings from the past as they become available in the literature. For all conditions in which white noise is recommended, we hope health professionals will be motivated to become familiar with the often unanticipated and counterintuitive effects of noise and how repeated exposure to randomly-generated information remodels the brain. We hope structured sounds will be offered as the alternative.
A shared publication database
The scientific literature in our field is scattered across many journals. We try to keep up with it, and am committed to making our efforts public. We ask you to help us keep up with this fast-moving feast! You can see our shared database of published randomized controlled trials in brain training online. It’s worth taking a look, as you might find something you weren’t aware of before that can be helpful for you. As always, please email us any papers that you know about that you find to be missing from this compendium.