Intensive training but no benefits to everyday life: computerised cognitive training

In its current form, computerised cognitive training should not be used in occupational therapy practice. The evidence of effectiveness is just not convincing. Recent years have seen incredible changes in internet connectivity and the availability of computers and hand-held devices. This makes possible different forms of computerised training that can be used easily by large groups of people. If occupational therapists had an effective computerised training task available to them it would have the potential to speed the therapeutic process, allow them to treat more people and give patients the flexibility to practise from any location. Computers make it possible to produce repetitive training over long durations that can adapt to the user’s skill level. Computerised cognitive training typically consists of daily training (often five days a week) over a period of time that is generally for a minimum of four weeks, but is often significantly more. Daily training length also varies but typically sits somewhere between 15 and 30 minutes. The benefits of repetitive training have, however, generally proved elusive. With the surge in computerised training research in the healthy and developmental populations, unsurprisingly investigations into its potential efficacy following neurological damage have begun, particularly in traumatic brain injury, stroke, and more recently in people with multiple sclerosis. [1,2] Unfortunately, results have not shown any significant improvement to daily functioning for these populations. Systematic reviews of the topic have not been encouraging. [1,3] In many cases transfer to everyday life was not even measured in studies, which in itself questions the relevance of any findings to therapeutic practice. There is a strong need to develop evidence-based interventions that specifically target the areas of functioning that people have difficulty with. [2] Occupational therapy research has been slow to develop, and especially test, such interventions in neurological conditions when compared with its psychology counterparts. Much needs to be done to address this gap. It is encouraging that humans will get progressively better at almost any non-trivial task that they practise. This is evident in the literature as elsewhere. Wellpowered and conducted studies using randomisation and active, conservative control conditions have reported some generalisation of gains. [4–6] Numerous factors are likely to be relevant to these improvements including familiarity with what is required, increased confidence through success, the development of strategies that minimise task demands, and so forth. However, if tasks are practised in the hope of spreading benefits to everyday skills this needs to be demonstrated rather than assumed. It seems, to date, that studies with fewer participants are more likely to produce extreme, and in many cases unreliable, results. When combined with positive publication biases (from authors and journals) the picture is almost inevitably rosier than from a single high-powered (hence more reliable) study. [e.g. 6] It raises important cautionary points, particularly about the likely efficacy of the multibillion-dollar ‘brain training’ software industry’s products. It is now possible for people, including those at risk from cognitive impairment through age, neurological illness, or developmental difficulty, to engage in intensive computerised cognitive training at low financial cost. From a treatment and rehabilitation point of view the results are not encouraging: there is a real risk with current programmes that people would be spending long periods in ultimately fruitless activity. It is clear that as mixed and contradictory results continue to be found in terms of differing cognitive training regimes a full identification of the methodological issues needs to happen and be targeted before it makes its way into occupational therapy practice. We are an occupation-focused and evidence-driven profession and computerised training does not comfortably fit within this framework. Unless there