Posts Tagged cognitive performance
[ARTICLE] Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE): A pilot clinical trial for chronic traumatic brain injury – Full Text
Virtual reality (VR) technology may provide an effective means to integrate cognitive and functional approaches to TBI rehabilitation. However, little is known about the effectiveness of VR rehabilitation for TBI-related cognitive deficits. In response to these clinical and research gaps, we developed Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE), an intervention designed to improve cognitive performance, driving safety, and neurobehavioral symptoms.
This pilot clinical trial was conducted to examine feasibility and preliminary efficacy of NeuroDRIVE for rehabilitation of chronic TBI.
Eleven participants who received the intervention were compared to six wait-listed participants on driving abilities, cognitive performance, and neurobehavioral symptoms.
The NeuroDRIVE intervention was associated with significant improvements in working memory and visual search/selective attention— two cognitive skills that represented a primary focus of the intervention. By comparison, no significant changes were observed in untrained cognitive areas, neurobehavioral symptoms, or driving skills.
Results suggest that immersive virtual environments can provide a valuable and engaging means to achieve some cognitive rehabilitation goals, particularly when these goals are closely matched to the VR training exercises. However, additional research is needed to augment our understanding of rehabilitation for driving skills, cognitive performance, and neurobehavioral symptoms in chronic TBI.
Each year, emergency departments treat approximately 2.5 million traumatic brain injuries (TBIs) (Langlois, Rutland-Brown, & Thomas, 2006; Marin, Weaver, Yealy, & Mannix, 2014). TBI can affect a wide range of brain systems, resulting in sensorimotor deficits (e.g., coordination, visual perception), cognitive deficits (e.g., memory, attention), emotional dysregulation (e.g., irritability, depression), and somatic symptoms (e.g., headache, fatigue) (Ponsford et al., 2014). These TBI-related impairments can have significant life consequences. Studies conducted across a wide range of neurological and psychiatric conditions show that neuropsychological abilities are strongly associated with functional skills and employment outcomes (Andelic, Stevens, Sigurdardottir, Arango-Lasprilla, & Roe, 2012; Dawson, Schwartz, Winocur, & Stuss, 2007; Drake, Gray, Yoder, Pramuka, & Llewellyn, 2000; Kalechstein, Newton, & van Gorp, 2003; Leahy & Lam, 1998; Wehman, Targett, West, & Kregel, 2005). For example, challenges in attention and concentration could result in distractibility and errors in work settings, and deficits in executive functions could lead to poor organization and problems with setting and achieving occupational goals. As many as 3.2–5.3 million people in the US are living with TBI-related disability (Selassie et al., 2008).
Rehabilitation has been shown to improve outcomes for those experiencing chronic effects of TBI (Cicerone, 2002; Cicerone et al., 2011; Cooper et al., 2017; Kennedy et al., 2008; Rohling, Faust, Beverly, & Demakis, 2009). Previously-validated rehabilitation approaches for TBI include both ‘cognitive’ and ‘functional’ approaches. ‘Cognitive’ methods of rehabilitation are focused on improving performance on individual cognitive tasks, with the hope that these gains will generalize to functional activities (Cicerone, 2002; Giles, 2010). Restorative cognitive training approaches have been shown to improve cognitive functioning across multiple conditions such as schizophrenia, traumatic brain injury, and normal aging (Ball, Edwards, & Ross, 2007; Fisher, Holland, Merzenich, & Vinogradov, 2009; Lebowitz, Dams-O’Connor, & Cantor, 2012; Lovell & Solomon, 2011; Smith et al., 2009). Some of the most promising results to date have been demonstrated for training of attention and working memory, which have been shown to correspond to changes in functional brain activity (Kim et al., 2009). Evidence suggests that the format of therapist-guided rehabilitation is able to harness some of the well-established benefits of the therapeutic relationship, and may be preferable to computer-guided training (Cooper et al., 2017). While there is some evidence indicating that benefits of cognitive remediation extend to untrained tasks, a number of studies have shown that improvements in performance on individual cognitive tasks tend to generalize very weakly, if at all, to other cognitive tasks and functional abilities (Devos et al., 2009; Owen et al., 2010). This weak transfer of training might be attributable to low levels of correspondence between the cognitive and sensorimotor demands of rehabilitation tasks and those encountered during challenging real-world situations.
In contrast to methods of rehabilitation that rely upon generalization of cognitive benefits to functional outcomes, ‘functional’ methods of rehabilitation focus on improving performance on real-life activities through direct practice of those activities (Fadyl & McPherson, 2009; Giles, 2010; Vanderploeg et al., 2008). This approach requires effective targeting of specific functional tasks that are relevant to each patient and may be limited by the physical environments available within the treatment setting (e.g., a simulated home environment used to practice activities of daily living). However, the basic functional tasks that are often emphasized in functional rehabilitation (e.g., self-care, food preparation) may not be sufficiently challenging to address more subtle or ‘higher order’ cognitive and functional deficits that many mild to moderate TBI patients experience in the long-term phase of recovery (Giles, 2010).
Virtual reality (VR) technology may provide an effective means to integrate cognitive and functional approaches to TBI rehabilitation (Imhoff, Lavallière, Teasdale, & Fait, 2016; Lew, Rosen, Thomander, & Poole, 2009). The guiding concept for VR rehabilitation is to provide an immersive, engaging, and realistic environment in which to practice cognitive, sensorimotor, and functional skills. VR scenarios can simulate a wide range of real or imagined tasks and environments. While VR may not be necessary for tasks that are easily recreated in existing therapy environments, it is particularly well-suited for tasks that are challenging or dangerous to recreate within real-world treatment environments, such as driving an automobile (Imhoff et al., 2016; Lew et al., 2009).
Driving is one of the most universal, cognitively challenging, and potentially-dangerous activities of everyday life. Safe driving requires continuous synchronization of processes like reaction time, visuo-spatial skills, attention, executive function, and planning (Lundqvist, 2001; Lundqvist & Rönnberg, 2001; Spiers & Maguire, 2007). Whereas it would be obviously unsafe to place an impaired patient into many real-world driving situations, VR allows for safe assessment and rehabilitation of driving-relevant skills at the true limits of the individual’s current capabilities. Individuals with TBI are at elevated risk for motor vehicle accidents and other driving difficulties (Bivona et al., 2012; Bottari, Lamothe, Gosselin, Gélinas, & Ptito, 2012; Classen et al., 2011; Cyr et al., 2009; Formisano et al., 2005; Lundqvist & Rönnberg, 2001). Many individuals with severe TBI never return to driving (Novack, Alderson, Bush, Meythaler, & Canupp, 2000; Ponsford et al., 2014), and an estimated 63% of those with severe TBI who do return to driving are involved in motor vehicle accidents (Bivona et al., 2012). Available evidence suggests that deficits in attention and visual search may underlie these driving impairments. While most of this research has been conducted with moderate-to-severe TBI populations, these issues are not exclusive to severe forms of TBI. Individuals recovering from mild TBI have also been found to exhibit slower detection of driving hazards in simulated driving experiments (Preece, Horswill, & Geffen, 2010, 2011) and to be at increased risk for real-world motor vehicle accidents (Schneider & Gouvier, 2005).
Previous results suggest that VR driving rehabilitation can be effective for improving driving skills among those with moderate-to-severe TBI (Cox et al., 2010). However, these findings have not been replicated or validated for those with symptomatic mild TBI. Additionally, little is known about the effectiveness of VR rehabilitation programs for TBI-related cognitive deficits (Imhoff et al., 2016). In response to these clinical and research gaps, we developed an intervention known as Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE), which was designed to improve cognitive performance and overall driving safety by providing integrated training in these skills. In contrast to intervention approaches that are geared toward more severely impaired individuals, NeuroDRIVE was designed for use with a wide range of TBI patients (i.e., mild, moderate, or severe TBI) who are seeking treatment in these areas and have the capability to engage in the driving process. This pilot clinical trial examined feasibility and preliminary efficacy of NeuroDRIVE for improving VR driving performance, cognitive performance, and symptom outcomes among those with chronic TBI. Given the focus of the intervention, effects on attention and working memory were of particular interest. Additionally, we have provided the NeuroDRIVE treatment manual as a supplementary document to facilitate continued development of VR rehabilitation for those with TBI.
Are Omega-3s Important for Brain Healing?
There are three types of omega-3 fatty acids: ALA, DHA, and EPA.
ALA (alpha-linolenic acid), found in flax seeds, walnuts, and chia seeds, cannot be synthesized in the body and therefore must be consumed in the diet. DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid) are almost exclusively found in fish.
DHA and EPA have been shown to play a crucial role in brain development. They are involved in neurotransmitter synthesis and functioning. DHA is necessary for the functional maturation of the retina and visual cortex . Infants of mothers who supplemented with DHA had higher mental processing scores, hand-eye coordination, and psychomotor development .
Omega-3 supplementation has been shown to improve cognitive functioning in the mature brain as well. Studies have correlated accelerated cognitive decline and mild cognitive impairment with low tissue levels of DHA and EPA . Additionally, omega-3 consumption is associated with a decreased risk for dementia and Alzheimer’s disease .
To be completely transparent, there isn’t much research on the use of omega-3s to aid brain healing after a TBI or stroke. However, there is evidence testifying to the crucial role of omega-3s in brain development and linking DHA and EPA to improved cognitive performance. To me this evidence makes a strong case for the use of omega-3s in a brain recovery program.
Top 5 Reasons to use Omega-3’s for Brain Healing
DHA is proven essential to brain development
DHA is required for the development of the sensory, perceptual, cognitive, and motor neural systems during fetal and childhood brain growth. Specifically, DHA is vital for the neuronal formation of axons and dendritic extensions and for proper synaptic functioning. EPA’s importance for the brain’s development is unclear, but colostrum and breast milk do contain EPA. Omega-3 deficiencies during development have been linked to deficits in retinal structure, visual acuity development, and cognitive performance .
Has been shown to reduce aggression
I was pleasantly surprised by this benefit. The mechanism by which it works is unknown, but several double-blind studies have shown decreased physical aggression and impulsivity after omega-3 supplementation. DHA in particular has been shown to help prevent aggression resulting from mental stress .
Linked to improved cognitive performance
Researchers have concluded that DHA and EPA supplementation can improve higher brain functions – sense of wellbeing, reactivity, attention, cognitive performance, and mood. Additionally, omega-3s have been shown to decrease cognitive decline and lower dementia risk .
Beneficial for affective disorders
Affective disorders that respond to DHA/EPA include major depressive disorder, manic depression, schizophrenia, and borderline personality disorder. EPA seems to provide the most benefit when it comes to decreasing depression and managing mood .
EPA reverses cellular inflammation, including inflammation in the brain. The primary mediators of inflammation in the body are derived from arachidonic acid, an omega-6 fatty acid. When omega-3 consumption is increased, EPA blocks the production of these pro-inflammatory mediators .
What is the Best Source of Omega-3s?
For ALA (alpha-linolenic acid) I would suggest simply adding a daily tablespoon of ground flax seed to your diet.
DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid) are almost exclusively found in fish. While DHA and EPA can be synthesized from ALA in the body, the conversion rate is very low – it’s thought to be around 1% of the total intake of ALA.
Seaweed and microalgae are the only plant sources of DHA and EPA. However, they are found in very low concentrations. While a healthy individual may get by on a plant based omega-3 supplement, it would be very difficult consume the high quantities recommended after a brain injury.
For high doses of EPA and DHA, go with a good quality, highly purified fish oil. For more information on choosing a good quality fish oil see: Choosing the Best Fish Oil Supplement for Brain Health.
But isn’t Fish Oil a Blood Thinner?
I think Dr. Lewis addresses this concern best,
“There is a theoretical risk that high dose omega‐3s may cause bleeding or stroke. Biochemical pathways tell us this is a valid concern. However, not a single study in the scientific literature has shown this to be of any clinical significance.” 
I personally believe that the benefits of fish oil outweigh the risks. I would however recommend that you discuss it with your doctor before using high doses of fish oil, especially if you are on a prescription blood thinner. Do your own research first so that you are prepared to discuss the pros and cons with them (even doctors don’t know everything).
How much Fish Oil should You Take?
Currently there is not a set recommendation for daily intake of DHA/EPA for brain function. For healthy individuals, I have seen recommendations ranging from 0.5 grams up to 5 grams. In individuals with brain injury, most of the existing literature suggests much higher doses are needed. Here is the information that I have found relating to dosage:
Week 1 – Take 3 g of EPA + DHA 3 times a day for a total of 9 g per day.
Week 2 – Take 3 g of EPA + DHA 2 times a day for a total of 6 g per day.
Maintenance dose – Take 3 g of EPA + DHA once a day.
Dr. Lewis suggests starting at an even higher dose and maintaining it for longer if the brain injury is severe. If you explore his website a bit, you will find that he has lots of good information regarding fish oil and brain injury. I particularly liked this article: High Dose Omega-3s in Severe Brain Injury.
Dr. Sears doesn’t lay out an exact protocol, but he does recommend using 10 – 15 grams of EPA + DHA per day.
How soon should You see Results?
While I have read testimonies of people seeing almost immediate results, this seems to be the exception not the rule. You should begin to see results within 2 months, but it could take up to 3 months.
It took around 3 months for us to really start seeing improvements with my dad.
Which Supplement should You use?
Since you will be taking high doses, it is vital that you take a high quality supplement.
I have found both Nordic Naturals* and NutriGold* to be very good brands. There are many other brands available though, just make sure the one you choose is third party tested. For more information on choosing a brand read: Choosing the Best Fish Oil Supplement for Brain Health.
* Links denoted with an * are affiliate links. I will receive a small commission (at no cost to you) if you purchase something through the one of these links. For my full disclosure click here. Thank you for your support!
Public awareness of the role diet plays in brain function has been steadily increasing. This has led to significant development of new products, dietary supplements, functional foods, nutraceuticals and public health recommendations for maintaining brain function. Nutrition for Brain Health and Cognitive Performance presents a detailed and innovative scientific summary of nutrition–cognition research to provide valuable information regarding nutrition and lifestyle choices for cognitive health. Internationally recognised scholars along with the next generation of researchers have contributed chapters that present a valuable resource for health professionals, teachers, researchers and the general public.
The book critically reviews the evidence surrounding the impact of dietary patterns and nutrition on brain function and cognitive performance. It covers diverse topics such as:
- Innovative new technologies that assess brain function
- Tools for measuring mood and its relation to nutrition
- How a diet rich in fruits and vegetables coupled with low consumption of meats can prevent cognitive decline in ageing adults
- Effects of glucose, omega 3s, vitamins and minerals, nutraceuticals and flavonoids on cognitive performance
- Cognitive benefits of herbal extracts such as ginseng, ginkgo biloba and green tea
- Use of technology such as neuroimaging and noninvasive brain stimulation (NBS) to capture nutrition effects on cognition and brain function
Presenting state-of-the-art scientific evidence, challenges, and potential applications within this exciting field, the book promotes and extends the research, teaches the process of research in this area, and promotes a collaborative understanding of the field between industry and academia. It gives you a balance of rigorous scientific information and analysis on the impact of dietary patterns, nutritional components and research processes to support brain health and performance claims and knowledge.
The current book starts with an overview of the past, by providing a brief history of how transcranial electrical stimulation has been used to enhance cognition and improve health. The rest of the book discusses current knowledge in the field, and provides an excellent overview of different lines of research, such as those in animals, healthy humans, and patients. The aim of this last chapter is to discuss further directions for research in the field of transcranial electrical stimulation (tES).
Over the different chapters it becomes clear that research using tES has demonstrated improvements in different cognitive and non-cognitive functions, ranging from perception and motor movement to attention, working memory, language, and mathematical abilities. These results show that such improvements are not limited to typical populations but can also affect young adults and the elderly, and neurological and psychiatric patients. These results are indeed promising, but suffer from some limitations that have been discussed in various of these chapters, as well as elsewhere (Pascual-Leone, Horvath, & Robertson, 2012; Rothwell, 2012). Some of these limitations include low sample size, artificial tasks with reduced ecological validity, lack of consistency in the montage that led to the enhancement effects, and need for replication. I will not extend the discussion on these points, as they are rather trivial and are not limited to the current field. Instead I will discuss what I perceive as the directions in which the field of tES should, and hopefully will, go. It was difficult deciding which sections to include in this respect, and I have chosen to limit our discussion to 10 sections. I will conclude the chapter with a brief discussion of the challenges that the field is facing.