The history of war is deeply associated with the history of brain injury—and its treatment. In ancient Greece, Hippocrates studied battlefield head injuries and taught that craniotomy could help alleviate the consequences of these terrible wounds. World War I introduced large-scale explosives to the battlefield, leading to a plague of traumatic brain injuries—which in turn led to the development of cognitive rehabilitation strategies still in use today.
Our recent wars have introduced a new kind of brain injury. An all-too-common experience is a servicemember experiencing persistent brain injury from multiple blast exposures or concussive events—the “signature injury” of the Iraq/Afghanistan wars. These initially were not viewed as having potentially life-altering consequences. Even their classification as mild Traumatic Brain Injuries (“mTBIs”) suggested they were of little consequence. But, for some people, the cognitive deficits from such blows are persistent and servicemembers exposed to multiple incidents have elevated risk of long-term consequences, including cognitive impairment.
Such cognitive impairment can be a significant hurdle for servicemembers re-entering civilian life or returning for another tour of duty. The Department of Defense knew this new kind of brain injury needed new kinds of treatments and asked (using the Congressionally Directed Medical Research Program (CDMRP)) for new treatments to be put to the test.
At Posit Science, we had developed a new type of brain training program, based on the science of brain plasticity and the discovery that intensive, adaptive, computerized training—targeting sensory speed and accuracy—can rewire the brain to improve cognitive function. This program improved cognitive performance and real-world function in older adults in numerous studies. The cognitive issues associated with mTBI looked broadly similar to those associated with aging—despite their different root causes. Could the same brain exercises designed to address cognitive impairment in older adults help servicemembers?
Such brain training had the potential to offer two significant innovations for treating cognitive impairment—a bottom-up approach to rewire the brain and computerized delivery to reach more people. Much of traditional cognitive rehabilitation is “top-down”—teaching helpful compensatory skills (like keeping a memory notebook or using a calendar). Brain-plasticity-based cognitive training is “bottom-up”—designed to improve the building blocks of cognitive function (like speed, attention, and working memory). Most traditional cognitive rehabilitation requires in-person administration. Excellent services may be available to servicemembers who can go to a VA medical center or military hospital several times a week but it’s difficult to deliver that standard of care to everyone in need. Plasticity-based brain training can be done on a computer or mobile device—anywhere. It can be remotely monitored and supervised via telehealth, significantly expanding the patient population that can be served.
With funding from the CDMRP and a multisite collaboration across leading VA medical centers and military hospitals, we could find out if this plasticity-based computerized approach worked.
The BRAVE trial enrolled participants with current cognitive impairment and a history of mTBI. Most were servicemembers and veterans. On average, participants had cognitive deficits that had persisted for seven years since their most recent mTBI. The group was randomized into a treatment group, who used the game-like brain training program, and an active control group, who used ordinary computer games.
Both groups were asked to train for the same amount—one hour per day, five days per week, for three months. People trained at home, using their own computers and internet. Clinicians provided remote coaching for both groups by phone—every week, a clinician would review a patient’s usage and provide technical support and encouragement.
We saw the brain training program significantly improved overall cognitive function—as measured by a composite of memory and executive function—as compared to the active control. In fact, the improvement in the brain training group was equivalent to moving from the middle of the pack to the top quartile of performance, while there was essentially no improvement in the active control group.
This tells us something pretty interesting: cognitive improvement, even in people with a long history of deficits from mTBI, is possible. But it’s not delivered by any kind of cognitive stimulation: it requires a specific type of training. Training with crossword puzzles and Boggle, which are cognitively demanding tasks, did not improve overall cognitive performance. But training to improve the speed and accuracy of information processing through the brain did improve cognitive performance.
The BRAVE trial is an important step forward in understanding how to help servicemembers suffering long-term consequences of mTBIs. There has been quite a lot of scientific progress in the field since the Department of Defense first recognized the problem. What’s needed now is clinical progress in the field.
I’ve visited cognitive rehabilitation clinics at VA medical centers and military hospitals. What I see over and over again is talented clinicians who are committed to helping patients but who do not have the resources (staff, space, computers) to put the evidence-based practices—validated with research grants—into practice. It’s time for the federal government to act on what has been learned from these trials to ensure that every single servicemember and veteran—regardless of location or income—has access to the best technology to treat their war injuries.
Featured image by geralt via Pixabay.