44.8.4. Cognitive Training
Cognitive functions such as memory and attention are often affected with a brain injury. Just as movement control can be retrained with CN-NINM training, so can cognitive abilities. Subjects report improved mental clarity, and demonstrate improved scores on memory, attention, and visuospatial tests after regular cognitive training with the PoNS device.
A cognitive training session is also 20 minutes. Individuals work at tasks that challenge their memory and attention while using the PoNS device. This can be in the form of games such as Simon, playing card games, solving puzzles, or playing challenging computer games designed specifically for cognitive training such as those found in Lumosity or Posit Science. Individuals should be provided with guidance as to the type of games that would be best for their needs. As they improve, they need to be challenged by progressing to higher levels.
44.8.5. BAT
The goal of breathing and awareness training is for the individual to develop relaxed and mindful breathing and awareness. A BAT session, also referred to as relaxation training, can have a significant positive impact on training progress. It requires 20 minutes of continuous uninterrupted PoNS use with eyes closed with attention toward relaxed muscles, breathing, and concentration.
The concept of attention to conscious breathing and relaxation helps the individual derive maximum benefit from PoNS training. Visualization and breathing are the focus points. Verbal cues are used to train the individual in how to perform a BAT session. What follows are some of the cues that we have used:
Sit unsupported (back not touching back of chair) with hands resting on thighs.
Distribute weight evenly.
Good sitting posture with head and shoulders in good alignment.
Place one hand on abdomen to feel the movement of the diaphragm.
Bring attention to the breath.
Before each breath, check in—“How am I doing?”
Slowly inhale through the nose, starting from the belly.
Feel the spine straighten and the chest expand with each inhale.
Exhale slowly through the mouth and allow spine to curl gently (flexion).
With each breath, check in with a body region.
Scan from head to feet (“body scan”).
Release tension, sensation, thoughts, judgment as you breathe.
Visualization: Pair a positive experience or outcome with inhalation and a negative experience or outcome with exhalation. Use positive memory and imagery (e.g., visualize an ice cube melting or waves at the seaside).
Breathing and awareness training is introduced in the first or second day of clinical training. During the rest of the training, individuals perform a BAT session on their own at the end of the day, approximately 1–2 hours before bedtime. BAT sometimes is used during the clinical training as an alternative to a balance, gait, or cognitive session if the individual is fatigued.
44.8.6. Continued Research
We continue to experiment to find the optimal training protocol for each type of patient population. Similar to other therapies, the final determinant of the training is the individual. The greatest success with CN-NINM training is achieved when the training is targeted to each individual according to his/her presentation, progressed appropriately so that they continue to be challenged during their training, and conducted at a level of intensity that allows for adjustment based on their level of fatigue.
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44.9. SELECTED RESULTS
44.9.1. Application to Symptoms of Acquired Brain Injury
44.9.1.1. Gait
44.9.1.1.1. Four Subject TBI Cohort Dynamic Gait Index Results
The results presented below represent the changes over a 5-day period of CN-NINM intervention in subjects with a TBI. Four female subjects (mean age: 48.3) presented with sustained and significant balance and gait deficits from moderate closed-head, nonpenetrating, concussive TBI (9–13 on Glasgow Coma Scale) at initial diagnosis. All were approximately 5 years postinjury and had previously completed rehabilitative therapy programs at their respective primary care facilities.
The results of the gait testing for four subjects that participated in the pilot study are summarized in Figure 44.5. The Dynamic Gait Index (DGI) is a clinician-scored index of eight facets of gait. Scores range from 0 (worst) to 24 (normal). A score change of 3.0 is generally considered clinically significant. The DGI scores indicate significant improvements in stability and gait that are retained for as much as 6 hours after completion of the second intervention session of the day.
