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Home / Brain training or everyday strategies: what helps most after brain injury?
by Niamh Hinkley, Assistant Psychologist at Brainkind
Acquired Brain Injury (ABI) refers to damage to the brain that occurs after birth due to a number of causes such as illness, mechanical impact on the head, or lack of oxygen to the brain. As technology evolves and becomes more readily available, so do the options for clinical intervention at our disposal in rehabilitation for those with brain injuries. We now have a range of tools to support neurorehabilitation, including digital neuropsychological assessments, smartphone apps to support the development and utilisation of compensatory strategies, and virtual reality to make interventions more engaging and intensive [1, 2]. The advancement in technology has also seen the development of a range of computerised restorative function training (CRFT) programmes aimed at improving working memory or attention [3, 4] for example, as intervention options to reduce cognitive deficits for those with ABI.
Compensatory strategy training (CST) is an intervention that involves the development of practical techniques that help people work around the difficulties associated with ABI. This is a well-established option in neurorehabilitation [5, 6]. CST focuses on improving function through the use of strategies, even if the underlying cognitive difficulties do not improve [7,8]. CRFT works on the basis that after injury the brain has some ability to reorganise itself (neuroplasticity) and aims to directly restore the affected cognitive functions through repetitive and targeted practice. Despite their differences, restorative and compensatory training approaches have the same goal; to improve the functioning and independence of those with ABI. Gerber and colleagues [9] reported that deficits in cognitive skill and a reduction in everyday functioning have a direct impact on quality of life and advocated for neurorehabilitation to focus on improving function so that quality of life is improved.
Currently, the evidence of the effectiveness of CRFT in improving functioning is mixed. While some studies suggest that improvements in working memory translate into improved everyday function [10, 11], others have found no clear advantage of CRFT over an active control condition, such as occupational therapy or standard computer games. This has led researchers to question whether the benefits seen with these programmes carry over into real-world situations and beyond the people who took part in the studies (generalisability) [12, 13]. A study by Hagovaska and colleagues [14] further supported this finding that CRFT improved the specific cognitive process targeted but did not result in improvements in functional abilities.
Given the increasing pressure on neurorehabilitation resources, it has been suggested that CRFT programmes may have an important role to play [15, 16]. However, Verhoog and colleagues [16] noted that despite the potential need for CRFT, there have been no studies directly comparing this technique with the traditional compensatory strategy training approaches, making the development of evidence-based recommendations difficult. To address this problem, Verhoog and colleagues conducted a meta-analysis of 30 studies, evaluating which approach led to improvements that translated into everyday functioning. The study compared CRFT and CST to active controls (e.g., occupational therapy or video games), as well as directly comparing the two.
In Verhoog and colleagues recent and comprehensive review, both CST and CRFT were found to improve cognitive functioning compared to active control conditions [16]. Specifically, CRFT was found to improve working memory, whereas CST was found to improve executive functioning, processing speed and working memory. However, the impact on social participation (an individual’s involvement in real-life situations and societal roles) was not greater compared to controls or when comparing one approach with the other. Interestingly, an analysis of some of the studies reviewed found more of an improvement in function after active control interventions than after CRFT.
Verhoog and colleagues found that when directly comparing the two interventions, there were no differences in outcomes. However, they caveated this by noting that this analysis only included three studies. They therefore ultimately concluded that traditional compensatory strategy training may be more effective in improving performance on a targeted activity than computerised restorative interventions, based on comparisons of each approach to the control conditions.
For clinicians, these findings highlight the potential value of compensatory strategy training in supporting people to achieve their goals, adding to an already established evidence base advocating for the use of CST in neurorehabilitation [5,6]. However, Verhoog and colleagues’ study noted that, the effectiveness of CST appeared to be dependent on the cognitive domain targeted. For example, training was found to improve executive functioning elements, such as planning and self-monitoring through the ‘Goal-Plan-Do-Check’ task, more than working memory, such as the digit span task, which asks participants to recall increasingly larger series of numbers.
An analysis of the papers included in the study found that only 16 out of the 30 (53%) investigated had low risk of bias. This means the reported benefits of the interventions may be overestimated. As such, results should be treated with caution, especially in the context of evidence-based clinical practice.
Verhoog and colleagues have consolidated a range of literature exploring CRFT and CST in one accessible paper, which is helpful in the fast-paced ever-progressing world of neurorehabilitation. However, they acknowledged that the demand on neurorehabilitation resources is increasing, and whilst CST may have out-performed CRFT compared to the control conditions, clinicians should not completely disregard CRFT. Rather, its use should be guided by a clear clinical rationale, such as targeting specific cognitive domains (like working memory), increasing engagement with therapy (e.g., for someone who finds interactive digital tasks more stimulating than paper based or functional tasks) or complementing broader rehabilitation programmes focused on functional goals.
Verhoog and colleagues proposed that future research should focus on evaluating the long-term efficacy of CST and CRFT, and on exploring factors – such as type of ABI, time since injury, or intervention format – which may influence who benefits most. The authors also noted that there are no computerised programmes based on established interventions with as strong an evidence base as CST. They therefore suggested that academics and clinicians should collaborate on the development and future research of this.
In addition, the literature does not appear to consider that many neurorehabilitation programmes, such as those offered within Brainkind, adopt a multidisciplinary approach, offering a range of techniques rather than standalone interventions. As of yet, the combined efficacy of CST, CRFT, and functional rehabilitation (i.e. physiotherapy or occupational therapy) has not been explored. But if all three approaches have been found to be successful in improving the skills and function of those with ABIs in isolation, should they not all be harnessed together in a neurorehabilitation setting?
