Computer-based Cognitive Training 

in a Military Population

Kate Sullivan, M.S., CCC-SLP

Director, Brain Fitness Center

Defense and Veterans Brain Injury Center

Traumatic Brain Injury Service

Walter Reed National Military Medical Center

Wendy A. Law, Ph.D.

Clinical Neuropsychologist

Traumatic Brain Injury Service

Walter Reed National Military Medical Center

 

Health Services Research & Development, Cyberseminar - 27 March, 2014
Disclaimer 

The views expressed in this lecture are those of the author and do not 

necessarily reflect the official policy or position of the Department of the 

Navy, Army, or Air Force, the Department of Defense, nor the U.S. 

Government

This presentation does not 

imply any Federal/DOD endorsement

I have no relevant financial or nonfinancial relationships with the products 

described, reviewed, evaluated or compared in this presentation

Unclassified
Goals 

• Describe the need, development over time, and changing 

demographics of patients participating in a computer-based 

cognitive training center embedded in a Military Treatment 

Facility.

• Lessons learned from initial implementation and complications 

surrounding research efforts will be highlighted. 

• Controversies and efficacy concerns related to computer-based 

cognitive training will be briefly reviewed.

• Preliminary results of patients completing a minimally excepted 

intensity training experience at the BFC at Walter Reed National 

Military Medical Center will be presented. 
Poll

What is the audience’s experience with computer (software or 

web-based) brain-training programs released into the market in 

the last 10 years? 

A. No experience with recent brain-training programs on the 

market

B. Personal knowledge or experience but have not used or 

recommended the use of these programs with my patient 

population 

C. Have experience using and recommending programs with 

my patient population, but on a limited basis

D. Use and/or recommend brain-training programs on a 

regular basis for my patients
Poll 

Which of the following are professional criticisms 

regarding computer (software or web-based) braintraining programs? (select all that apply) 

A. Not theoretically-grounded 

B. Inability to reach wide-ranging patient populations

C. Too complicated for most patients

D. Professional involvement is not necessary
Identified a population:

Any OIF/OEF service member with 

subjective complaints of cognitive 

dysfunction

Determined access:

225-250 service members with the 

diagnosis of a traumatic brain injury 

(TBI)living on base at any time

Looking for novel rehabilitation approaches for our 

unique population

Walter Reed National Military Medical Center (WRNMMC) 
Looking for a novel approach – why computers?

• Growing literature in neuroplasticity

• Allows more cognitive training as an 

adjunct to functional rehab

• Therapeutic “homework” that can be 

 intensive and monitored

• Provides adaptability, intensity, and engagement 

• Maintenance once discharged with transition home with software

• Commercially available
The Brain Fitness Center

Walter Reed National Military Medical Center, est. 2008

• Contains a library of brain-training programs

• Provides adjunct cognitive rehabilitation 

services; not a stand-alone therapeutic 

approach

• Established with clinical, educational, and 

research goals

• Expanded to Fort Belvoir Community Hospital in 2012

• One completed and three current research protocols

• Continue to explore if this is the appropriate population or setting
Outcome Measures

• Initial intake, approx. every 8 weeks, and then at 

completion of BFC participation:

– Automated Neuropsychological Assessment Metrics (ANAM)

– Mayo-Portland Adaptability Inventory-4 (MPAI-4)

– Neurobehavioral Symptom Inventory (NBSI)

– Satisfaction with Life Scale (SWLS)

– Post-Traumatic Stress Disorder Checklist – Civilian Version (PCL-C)

– Headache Impact Test – 6 (HIT-6)

– Patient Satisfaction Survey – discharge only

• Daily before and after sheet at each visit to the BFC

– Pain; Restfulness; Self Esteem; Insight into progress
Programs available in the WRNMMC BFC 

Dakim Brain Fitness

• Cross-Trainer

Posit Science - Classic

• Auditory Processing

Posit Science - Insight

• Visual Processing

Posit Science - Brainhq

• Auditory, Visual, and Executive 

Functioning

Lumosity

• Web-Based, Cross-Trainer

Cogmed 

• Working Memory

mPod

 Neuro/Biofeedback

Nintendo DS

• Brain Age, Cross-Trainer 

Mobile Applications

• Training on the go 
Considerations for Selection

Adaptability 

Intensity

Engagement

• Dynamic; self-adjusts

• Hold participants at an appropriately 

 challenging yet not a frustrating level

• Significant repetition to drive real change

• Process based to impact plasticity

• Some means of feedback and rewards 

• Entertainment value to increase compliance and 

sustainability
• 438 total patients at WRNMMC

• Diagnosis:

• 261 TBI

• 134 Other (CVA, PTSD, ADHD, Aneurysm, 

Chemofog, etc.) 

• Average age 35; 84% male

• Majority United States Army, Active Duty 

• 50% of pts seen >1 year TPO

• Pt visits per month (2013): 187 

• Average 23.4 sessions 

• Average stay 96.0 days

• 62% currently in SLP, OT or both

63% 

8% TBI Severity 

mild

moderate

severe

penetrating

17% 

12% 

BFC Patient Population 

0

BOTH SLP OT

Concomitant Therapy

20

40

60

80

100

120
Does computer-based “brain training” help?

A resource for providers: A resource for patients: 

22% 

Referrals 2013

TBI CM

SLP

Audiology

OT

Psychiatry

Neuropsych

Behavioral Health

Warrior Clinic

Neuropsch HS

Neurology

Oncology 0

50

100

150

200

250

300

WRNMMC 2012

WRNMMC 2013

FBCH 2012

FBCH 2013 18% 

14% 

13% 

12% 

7% 

4% 

4% 

4% 

1% 1% 

Patient Visits
Novel approach, as well as a novel – 

and changing - population

0

10

20

30

40

50

60

70

2007 2008 2009 2010 2011 2012 2013 2014

# of Patients

Brain Fitness Center Patient Visits

TBI DX

PSYC DX

Comorbid Patients with PSYC &

TBI DX

Neurological Origin
 Demographics 

TBI DX

26%

PSYC DX

21%

Comorbid Patients with 

PSYC & TBI DX

40%

Neurological Origin

4%

Chemobrain

2%

Physical Trauma

1%

Brain Tumor

3% Stroke

2%

Anoxic Injury

0%

Encephalitis 

1%

BFC DX % Breakdown for 2013
Brain Fitness Center Patient Satisfaction Survey

This computer program helped my recovery process: 

0 1 2 3 4 

Strongly Disagree Disagree Undecided Agree Strongly Agree 

I thought the time commitment to the program was realistic and easy to accomplish: 

0 1 2 3 4 

Strongly Disagree Disagree Undecided Agree Strongly Agree 

I found the content of the computer program to be fun and engaging: 

0 1 2 3 4 

Strongly Disagree Disagree Undecided Agree Strongly Agree 

I found the content of the computer program to be appropriately challenging: 

0 1 2 3 4 

Strongly Disagree Disagree Undecided Agree Strongly Agree 

I would like to have this computer program at home: 

0 1 2 3 4 

Strongly Disagree Disagree Undecided Agree Strongly Agree 

 I am glad I participated in this program: 

0 1 2 3 4 

Strongly Disagree Disagree Undecided Agree Strongly Agree 

I would recommend this computer program to other service members: 

0 1 2 3 4 

Strongly Disagree Disagree Undecided Agree Strongly Agree 

Access to education materials and a brain injury specialist was helpful: 

0 1 2 3 4 

Strongly Disagree Disagree Undecided Agree Strongly Agree 

I felt this computer program helped me in the following areas (circle all that apply):

Memory Concentration/Attention Math Decision Making

Real-world tasks Listening Visual tasks Vocabulary

3.1 

3.4 

3.1 

3.4 

3.1 

3.6 

3.7 

3.5 

 81 87 

 21 68 52 26 

 27 34

Results of the first 101completed surveys:

Above: Number of participants, out of 101, 

who felt the program helped in various areas.

Left: Average responses to survey questions.

0 (Strongly Disagree) to 4 (Strongly Agree)

“Program is very worthwhile. Good learning environment 

and the progressive challenge is entertaining. I would 

love a copy of the program, and I believe each unit 

should have a program similar to the BFC.” - 

Dr. Evil*

“Great program helped me in life/work environments... 

Recommend to everyone. This is good and very helpful.”

- John Smith*

“It has been a pleasure working with all of you guys in 

the Brain Fitness. I hope a lot of soldiers will take part in 

this. I benefit a lot from the Brain Fitness. Thanks again. 

Roger out.” - Harrison Ford*

* Alias chosen and used by patient during each computer session
Patient Satisfaction 

81 87

68

52

27 34

21 26

0

10

20

30

40

50

60

70

80

90

100

Number of Patients

Self-Perceived Areas of 

Improvement 

 
Benefits and Limitation of adding brain-training 

programs in a military treatment facility

Limitations

• Less Monitoring

• Perception it is “enough”

• Blanket approach?

• Pts are not home

• Pts are not stable

• Physically

• Psychologically

• Socially

• Low compliance

Benefits

• Focus on drills

• Mobile

• Low-cost 

• Patient engagement

• Independent

• Novel patients, novel 

approach

• Intro to healthy brain 

habits

• Maintenance
Clinical Challenges and Proposed Solutions

Current Clinical 

Considerations

Proposed Solution Anticipated Outcome

Less Monitoring Clinician supervision Increase in BFC-related 

therapeutic goals

Perception it is “enough” Provider education Increased awareness of

limitations of the program

 Blanket Approach Provider education on specific 

computer-based programs

Referrals based on cognitive 

complaint with 

recommendations

Patients are not home Allow flexibility but encourage 

routine and regular visits

Provide the groundwork of 

healthy brain habits

Patients are not stable Basic introductory information 

and demos; include caregivers 

Establish more educated

consumers

Low compliance, especially 

early

Offer incentives Increased long-term program 

use
A randomized, controlled pilot study looking at the effectiveness 

and feasibility of novel rehabilitation approaches for Operation 

Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) 

patients with persistent complaints of cognitive dysfunction 

following a traumatic brain injury

Principal Investigator: Louis M. French, PsyD

Site Principal Investigator (Fort Belvoir): Heechin Chae, M.D.

Co-Investigators:

• Katherine Sullivan, M.S., CCC-SLP

• Michael Pramuka, Ph.D.

• Julia Quinn, B.A.
Study Objectives

– Specific Objective (Aim) 1: Measure and compare the subject’s 

self-perception of symptoms as measured by the: 

 Mayo Portland Adaptability Index - 4 (MPAI - 4) 

 Neurobehavioral Symptom Inventory (NBSI) 

 Satisfaction with Life Survey (SWL)

– Specific Objective (Aim) 2: Measure and compare aspects of 

cognitive improvement between the two programs and control 

group using the:

 Automated Neuropsychological Metrics (ANAM)

– Specific Objective (Aim) 3: Measure and compare the subject’s 

satisfaction and compliance between the two programs and control 

group using a:

 Self-Report Form and Attendance Database 
Study Design and Methods

Patients are randomly assigned to one of three groups

35 

TBI

Dakim 

23 

non-TBI

Dakim 

174

Total 

Subjects 

35 

TBI

Posit 

35 

TBI

Control

23 

non-TBI

Posit 

23 

non-TBI

Control

Subjects assigned to treatment groups are required to complete computer 

sessions 5x/week for 6 week 

Outcome measures are administered pre-training, post-training, and at 12 

months 
Preliminary 

Findings 

Non-Published
Compliance 

Number of sessions completed and the duration of participation for each 

research participant in Groups A and B (N=26). There are two data points at 

(0,0) and (30, 8). Study design intended 30 sessions in 6 weeks.
Satisfaction 

Satisfaction Form Question

0-1

Disagree to 

Strongly 

Disagree

2

Neutral

3-4

Agree to 

Strongly 

Agree

This computer program helped my recovery process 0 3 8

I thought the time commitment to the program was 

realistic and easy to accomplish

0 0 11

I found the content of the computer program to be fun 

and engaging

1 1 9

I found the content of the computer program to be 

appropriately challenging

0 1 10

I would like to have this computer program at home 1 1 9

I am glad I participated in this program 0 0 11

I would recommend this computer program to other 

service members

0 1 10

Access to education materials and a brain injury 

specialist was helpful

0 1 10
Satisfaction 

Self-perceived areas of improvement reported by participants on the Brain 

Fitness Center Patient Satisfaction Survey (N=11).
Research Challenges and Proposed Solutions

Current Study Proposed Solution Anticipated Change in 

Eligible Subjects

Recruitment through BFC 

referrals at two study sites

Add additional study-sites 45% increase per year, per site

Eligibility is restricted to 

combat-related symptoms

Inclusion of non-combat 

related symptoms

21.9%

Eligibility restricted to service 

members with <1 TBI within 

two years of consent

Inclusion of service members 

with up to three reported TBIs 

within two years of consent

4.7%

Sessions must be completed in 

the BFC

Web-based tools 12.3%

Daily session/5x per week Flexible scheduling 11.2%

Group C (standard of care) Placebo or waitlist control 

group

5.7%

No tangible incentive Financial compensation for 

participation

Unknown
Research Challenges, Next Steps

• Explore our 

clinical patients 

with retrospective 

chart reviews; 

database 

• Redesign our next 

randomizedcontrolled study 

based on our 

lessons learned
 Retrospective Study

0

10

20

30

40

50

60

MPAI-4 Total NBSI Total SWLS Total

Symptom Self-Report Score

 

* 

* 

Caveat: Population was highly heterogeneous and procedures varied widely. 

Purpose: Determine the effectiveness of the BFC program and products 

through patient self-report questionnaires 

Method: Chart review of the first 96 

patients to participate in the BFC

Participants and Procedures: 29 

patients who completed 3 questionnaires 

of self-reported symptom change before 

and after BFC participation in an average 

of 29 (range = 3 – 137) visits

Results: Statistically significant 

reduction in symptom severity based on 

MPAI and NBSI total scores (*p<.05). 

There was no significant difference in the 

SWL score. 

*p<.05

Sullivan KW, Quinn JE, Pramuka M, Sharkey LA, French LM. Outcomes from a pilot study using computer-based 

rehabilitative tools in a military population. Studies in Health Technology and Informatics. 2012; 181: 71-7. 
Patient Visits N = 29

 Figure 1 shows the 

distribution of patient 

visits to the BFC 

 On average, patients 

completed computer 

sessions 29 times with a 

range of 3-137 visits (SD 

= 29.46, Median = 21) 

Eight patients were also using an at-home cognitive program; 

data on how often they were completing these home-based 

sessions is not available
Discussion

– The reduction in symptom severity following BFC retraining suggests that 

improvements are generalized to a broad range of domains applicable to 

everyday functioning

• The three self-report questionnaires used in this study have high face 

 validity for the Service Members

• Other factors beyond the brain-training intent of the computer 

 program(s) may play a role in real or perceived self-betterment

• Limitations of this retrospective chart review

• This review was used as justification to capture a larger sample size 

 which we are currently analyzing which may yield stronger results 
Expanding our Understanding of Computer-Based Cognitive 

Rehabilitation in the Military Population – a Longitudinal Brain 

Fitness Center Database

Study Purpose and Objectives

– Develop a database that contains demographic information, clinical data, 

self-report questionnaires and objective cognitive assessments collected 

from the WRNMMC and FBCH Brain Fitness Centers. 

– The data collected will provide the foundation for the development of 

hypothesis-driven protocols, and will ultimately advance our 

understanding of characteristics of treatment responders and nonresponders, aspects of cognitive change, and self-perceived symptom 

change following Brain Fitness Center participation.
Exploratory Study: 

Cognitive efficiency and neurobehavioral symptoms of 

Military patients seeking BFC treatment

Goals and Methods

• Determine the relationship between baseline cognitive performance on the 

Automated Neuropsychological Assessment Metric 4-TBI battery 

(ANAM) and symptom severity on the Neurobehavioral Symptom 

Inventory (NBSI) in high and low symptom endorsers overall and within 

the mTBI and NOT mTBI subgroups

• A retrospective chart review was completed for BFC participants with 

ANAM baseline data (Nov 2008 – Feb 2011)

– 97 patients had completed ANAM baseline assessments

– ANAM and NBSI summary scores were used to determine 

relationships between objective performance and subjective symptoms 

(bivariate correlation and t-test analyses)
Patient Demographics

(N=97) 

• Majority male

• Age 20 - 56 (Mean = 33, Median = 31)

• Gender (90% male)

• Primarily Active Duty

• 74% of total sample had a dx of TBI 

– 66% of TBI = mild TBI (n45, 20% comorbid PTSD) 

– 34% of TBI = moderate, severe, penetrating
NOT mTBI subsample (n=52)

• TBI not mild (moderate, severe, penetrating)

• No TBI

– Psychiatric – 33% 

• PTSD, MDD, phobia

– Other Neurologic – 33% 

• Stroke, craniotomy, encephalitis, tumor, migraine

– Physical – 33% 

• Physical trauma below neck, peripheral sensory deficits

• Unknown but not mTBI (n=3)
N=97 Total Sample

(n=45 mTBI) (n=52 NOT mTBI) 

Primary measures

 Mean/Median (range) 

NBSI Total (max 88) 

• N97 32/33 (0-74, SD18)

• n45 39/40 (0-74, SD16)

• n52 25/23 (0-63, SD17)

ANAM AVG TP STD

• N97 81/88 (41-113, SD18)

• n45 73/69 (41-103, SD19)

• n52 88/91 (48-113, SD14)

Correlations (N=97)

• NBSI Tot w/ ANAM TP (STD)

SRT1 TP STD -.511** 

SRT2 TP STD -.417** 

PRT TP STD -.378** 

CDL TP STD -.401** 

CDD TP STD -.380** 

MTH TP STD -.320* 

M2S TP STD -.356** 

ANAM AVG TP STD -

.491** 

 *p = .001

**p = .000
Correlations 

N=45 (mTBI subsample) 

• NBSI Tot w/ ANAM TP (STD)

SRT1 TP STD -

.402** 

SRT2 TP STD -

.198 

PRT TP STD -.220 

CDL TP STD -.168 

CDD TP STD -.096 

MTH TP STD -

.187 

M2S TP STD -.325* 

ANAM AVG TP STD -.276* 

**p <.01

*p <.05

N=52 (NOT mTBI subsample) 

• NBSI Tot w/ ANAM TP (STD)

SRT1 TP STD -.476** 

SRT2 TP STD -.452** 

PRT TP STD -.385** 

CDL TP STD -.423** 

CDD TP STD -.401** 

MTH TP STD -.277* 

M2S TP STD -.249* 

ANAM AVG TP STD -.538** 

**p <.01

*p <.05
Results: NBSI Median Split (Low/High) 

Total Sample N=97 (n50 L, n47 H)

• The Low symptom 

endorsement group had 

significantly more efficient 

initial simple RT performance 

efficiency and overall 

performance efficiency than 

High symptom endorsers

(t-test: *p<.01) 

0

SRT1TPstd Avg ANAM TP

STD

Low NBSI Sxs

HI NBSI Sxs

10

20

30

40

50

60

70

80

90

100
Results: NBSI Median Split 

(Low/High)

mTBI n=45 (n14 L, n31 H)

SRT1 TP p>.10, Avg TP >.10

0

10

20

30

40

50

60

70

80

90

SRT1TPstd Avg ANAM TP

STD

Low NBSI Sxs

HI NBSI Sxs

NOT mTBI n= 52 (n36 L, n16 H)

SRT1 TP p<.01, Avg TP <.01

0

SRT1TPstd Avg ANAM TP

STD

Low NBSI Sxs

HI NBSI Sxs

10

20

30

40

50

60

70

80

90

100
Conclusion/Discussion 

• Within a Military patient population, subjectively reported neurobehavioral 

symptoms are associated with objective cognitive functioning in a general mixed 

clinical sample but are unclearly related in patients with mTBI/concussion as the 

primary diagnosis

• For mTBI patients reporting neurobehavioral symptoms, factors other than 

neurocognitive functioning play a role in symptom persistence

• Cognitive retraining outcomes related to such patient factors are unknown at this time 

and require further investigation. Patients without clear associations between 

objective performance and subjective symptoms may be less likely to benefit from 

cognitive retraining or may show improved cognitive functioning without reduced 

symptom report. 

• Limitations of this retrospective chart review

• Future directions –Examine patient factors impacting outcome (e.g., premorbid risk 

factors/vulnerabilities, performance validity)
Performance Validity and symptom 

improvement

• PRIOR FINDINGS

– BFC Retrospective study results– Significantly improved Mayo and 

NBSI scores and suggested improvement in SWL in a mixed clinical 

sample following cognitive retraining exercises

– BFC Exploratory study results– ANAM performance efficiency is 

related to NBSI symptoms in a mixed clinical sample overall and in the 

subgroup that did not have mTBI but are not clearly related in the 

mTBI subgroup. Need to consider other factors

• NEXT STEP

– BFC Descriptive study – Examine the role of performance validity on 

symptom improvement following cognitive retraining exercises
Descriptive Study: 

Performance Validity and Symptom Improvement 

following Computerized Cognitive Retraining exercises

Goals and Methods

• Examine pre/post changes in MAYO, NBSI and SWL for the mixed 

clinical patient sample overall and in each of the two subsamples (mTBI 

and NOT mTBI) in relation to valid ANAM performances at both visits

 

• Completed ANAM assessments were reviewed to identify BFC 

participants that had pre/post ANAM testing results

– 37 patients had completed two ANAM assessments (14 mTBI)

– 18 patients had completed at least 12 BFC sessions (minimum 

accepted intensity) and had valid ANAM assessments at BOTH 

(pre/post) visits (3 mTBI)
Patient Demographics

(N=37) 

• Majority male

• Age 20 - 78 (Mean = 36, Median = 32)

• Gender (86% male)

• Primarily Active Duty

• 65% of total sample had a dx of TBI 

– 63% of TBI = mild TBI (n14)

• NOT mTBI subsample (n23, 10 TBI + 13 Other 

DX)
BFC Cognitive Retraining Exposure Rates

Total Sample w/ two ANAM 

assessments 

(N37: n14 mTBI, n23 NOT mTBI)

Mean/Median (range, SD)

#Wks btw visits 

• N37 19/15 (3-76, SD14)

• n14 23/18 (6-76, SD18)

• n23 17/14 (3-41, SD11)

Total visits

• N37 20/20 (2-62, SD14)

• n14 18/17 (3-47, SD12)

• n23 22/22 (2-62, SD15)

Sample w/ minimally accepted 

intensity + performance validity 

(N18: n3 mTBI, n15 NOT mTBI)

Mean/Median (range, SD) 

#Wks btw visits 

• N18 18/14 (8-41, SD10)

• n3 23/21 (13-35, SD11)

• n15 17/14 (8-41, SD11)

Total visits

• N18 28/24 (13-62, SD15)

• n3 33/34/(17-47, SD15)

• n15 27/24 (13-62, SD13)
Symptom changes with repeat BFC visits

Total sample (n30/37) with two 

ANAM visits

0

Mayo (n30,

p.000)

NBSI Tot (n37,

p.078)

0

Mayo (n15,

p.001)

NBSI Tot (n18,

p.014)

10

20

30

40

50

60

10

20

30

40

50

60

SWLTot (n31,

p.800)

pre

post

SWL Tot (n15,

p.139)

pre

post

Total Sample (n15/18) w/ minimum 

accepted intensity + performance 

validity
Symptom changes with repeat BFC visits

mTBI subsample (n13/14) 

with two ANAM visits

0

Mayo (n13,

p.225)

NBSI Tot (n14,

p.793)

0

Mayo (n17,

p.000)

NBSI Tot (n23,

p.013)

10

20

30

40

50

60

10

20

30

40

50

60

SWLTot (n13,

p.293)

pre

post

SWLTot (n18,

p.474)

pre

post

NOT mTBI subsample (n17/23) 

with two ANAM visits
Symptom changes with repeat BFC visits

mTBI subsample (n3) w/ minimum 

accepted intensity + performance 

validity

0

Mayo (n3, p.038) NBSI Tot (n3,

p.144)

0

5

Mayo (n12,

p.006)

NBSI Tot (n15,

p.065)

10

20

30

40

50

60

10

15

20

25

30

35

40

45

50

SWLTot (n3,

p.622)

pre

post

SWLTot (n12,

p.178)

pre

post

NOT mTBI subsample (n12/15) w/ 

minimum accepted intensity + 

performance validity
Preliminary Conclusions/Discussion

• Within a Military patient population seeking computerized cognitive 

retraining exercises due to subjective symptom concerns, symptom 

improvement is associated with intensity of participation (total visits) 

• Significant improvement in subjective symptoms following participation in 

such exercises is moderated by performance validity on objective cognitive 

assessments. 

• mTBI patients who endorse problematic subjective symptoms and 

consistently demonstrate valid performance on objective cognitive 

assessment may benefit from computerized cognitive retraining exercises

• Limitations

• Future directions
BRAVE Trial: Broad-spectrum Cognitive Remediation Available 

to Veterans: Effects of a Brain Plasticity-based Program in mTBI 

 

• Henry W. Mahncke, Ph.D. 

Brain Plasticity, Inc.

• Morris Bell, Ph.D., ABPP

Veterans Affairs Connecticut Health Care System

• Chad Grills, Ph.D.

Tripler Army Medical Center

• Harvey Levin, Ph.D; Mary Newsome, Ph.D.; Nick Pastorek, Ph.D.

 Michael E. DeBakey Veterans Affairs Medical Center

• William Milberg, Ph.D.; Regina McGlinchey, Ph.D.; Joseph DeGutis, Ph.D.

VA TBI Center of Excellence, Boston, MA

• Louis French, Psy.D.; Paul Pasquina, MD; Kate Sullivan, MS

Walter Reed National Military Medical Center
BRAVE Purpose and Objectives 

• This study is a multi-site, prospective, parallel arm, double-blind, 

randomized, controlled clinical trial to assess the safety and efficacy of 

plasticity-based, adaptive, computerized cognitive remediation treatment 

(CRBI) versus a computer-based control. 

– Specific Aim 1: Evaluate the effect of CRBI on generalized cognitive and 

functional performance.

– Specific Aim 2: Evaluate the endurance of effects following completion of 

CRBI use.

– Specific Aim 3: Identify specific populations of treatment responders and nonresponders 
Current Pros/Cons Regarding Computer-Based 

Cognitive Enhancement

PROS:

– Theoretically-grounded in relation to current knowledge in neuroplasticity 

– Able to reach and provide adjunctive services to patients in remote locations 

– Easy for almost all patients to utilize 

– Limited evidence for transfer effects beyond the training tasks (some domains 

better than others; e.g., attention versus language) 

CONS:

– Limited empirical support (small sample sizes, lack of controls, 

generalizability uncertain)

– May prevent/reduce engagement in evidence-based rehabilitation services 

focusing on compensatory training strategies

– Professional guidance is not required

– Much of the existing research has been offered by the program developers 
Poll

Which of the following are professional criticisms 

regarding computer (software or web-based) braintraining programs? (select all that apply)

A. Not theoretically-grounded 

B. Inability to reach wide-ranging patient populations

C. Too complicated for most patients

D. Professional involvement is not necessary
Acknowledgments 

Principal Investigator – Louis M. French, PsyD

Neuropsychologist; 

Supervisor – Michael Pramuka, PhD

Research Assistants – Alanna Covington

– Laura Loyola

– Angela Perta
References

Brehmer Y, Westerberg H, and Backman L. Working-memory training in younger and older adults: training gains, transfer, and 

maintenance. Frontiers in Human Neuroscience. 2012; 6(63): 1-7.

Cicerone KD, Langenbahn DM, Braden C, Malec JF, Kalmar, K, Fraas M, Felicetti T, Laatsch L, Harley JP, Berqquist T, Azulay J, 

Cantor J, & Ashman T. Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008, 

Archives of Physical Medicine and Rehabilitation, 2011; 92(4): 519-530.

Diener E, Emmons RA, Larson RJ, and Grillin S. The Satisfaction with Life Scale. Journal of Personality Assessment. 1985; 49: 

171-75. 

Jak AJ, Seelye AM, & Jurick SM. Crosswords to Computers: A Critical Review of Popular Approaches to Cognitive Enhancement. 

Neuropsychology Review, 2013; 23: 13-26.

Johnson DR, Vincent AS, Johnson AE, Gilliland K, Schlegel RE. Reliability and construct validity of the Automated 

Neuropsychological Assessment Metrics (ANAM) mood scale. Archives of Clinical Neuropsychology. 2008; 23(1): 73-85.

Katsnelson A. No gain from brain training: Computerized mental workouts don’t boost mental skills, study claims. Nature. 2010; 

464: 1111.

Malec, JF, Kragness M, Evans R, Kent A, and Lezak MD. Further psychometric evaluation and revision of the Mayo-Portland 

Adaptability Inventory in a National Sample. Journal of Head Trauma and Rehabilitation. 2003;18(6): 479-492. 

Meterko M, Baker E, Stolzmann KL, Hendricks AM, Cicerone KD, and Lew HL. Psychometric assessment of the Neurobehavioral 

Symptom Inventory-22: the structure of persistent postconcussive symptoms following deployment-related mild traumatic 

brain injury among veterans. Journal of Head Trauma and Rehabilitation. 2012; 20(1): 55-62. 

Smith GE, Housen P, Yaffe K, Ruff R, Kennison RF, Mahncke HW, Zelinski M. A cognitive training program based on principles 

of brain plasticity: results from the improvement in memory with plasticity-based adaptive cognitive training (IMPACT) 

study. Journal of the American Geriatrics Society. 2009 Apr; 57(4): 594-603.

Sullivan KW, Quinn JE, Pramuka M, Sharkey LA, French LM. Outcomes from a pilot study using computer-based rehabilitative 

tools in a military population. Studies in Health Technology and Informatics. 2012; 181: 71-77.

Willis SL, Tennstedt SL, Marsiske M, Ball K, Elias J, Koepke KM, Morris JN, Rebok GW, Unverzagt FW, Stoddard AM, Wright 

E, for the ACTIVE Study Group. Long-term effects of cognitive training on everyday functional outcomes in older adults. 

JAMA. 2006; 296: 2805–2814.
Websites 

Dakim Brain Fitness

– www.dakim.com

Posit Science

– www.brainhq.com

Lumosity 

– www.lumosity.com

Cogmed 

– www.cogmed.com

Sharpbrains 

– www.sharpbrains.com
Contacts and Questions

Kate Sullivan, M.S., CCC-SLP

Director, Brain Fitness Center 

katherine.w.sullivan.ctr@health.mil 

Wendy A. Law, Ph.D.

Clinical Neuropsychologist, WRNMMC

wendy.a.law.civ@health.mil