Check out this website I found at journals.lww.com
Wednesday, 30 June 2010
Management of Pediatric Patients With Complex Regional Pain Syndrome
Check out this website I found at journals.lww.com
Management of Pediatric Patients With Complex Regional Pain Syndrome
Check out this website I found at journals.lww.com
Sympathetic Dysfunction in Long-term Complex Regional Pain Syndrome
Check out this website I found at journals.lww.com
Carpal Tunnel Syndrome. Part I: Effectiveness of Nonsurgical Treatments–A Systematic Review
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Tuesday, 29 June 2010
Psychometric Properties of the Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia in Patients With Shoulder Pain
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Wednesday, 23 June 2010
Charlie Rose Brain Series Episode Nine
Charlie Rose Brain Series Episode Nine
with Jeffrey Lieberman, Elyn Saks, Kay Redfield Jamison, Eric Kandel, Helen Mayberg and Stephen Warren
in Science & Health part of Charlie Rose: The Brain Series
on Tuesday, June 22, 2010 * * * * --> * * * * *
via charlierose.com
Don't get sick in July?
June is almost over. If you work in an academic medical center, as I do, that can mean only one thing.
The new interns are coming, and existing residents will soon be advancing to the next level. The joy! The excitement! The trepidation! And it's not all just the senior residents and the faculty feeling these emotions. It's the patients too. At least, it's the patients feeling the trepidation. The reason is the longstanding belief in academic medical centers, a belief that has diffused out of them and into "common wisdom," that you really, really don't want to get sick in July.
But is there any truth to this common wisdom, passed down from hoary emeritus faculty to professor to assistant professor to resident to medical student every year? Is there any truth to the belief commonly held by the public that care deteriorates in July? After all, this is something I've been taught as though it were fact ever since I first set trembling foot on the wards way back in 1986. So it must be true, right? Well, maybe. It turns out that a recent study published in the Journal of General Internal Medicine has tried once again to answer this question and come to a rather disturbing answer.
Imagine, if you will, that you want to determine whether there really is a "July effect," that quality of care really does plummet precipitously as common wisdom claims. How would you approach it? Mortality rates? That's actually fairly hard, because mortality rates fluctuate according to the time of year. For example, trauma admissions tend to spike in the summer. Well do I remember during my residency the fear of the fourth of July weekend, because it was usually the busiest trauma weekend of the year--and we had new residents to have to deal with it all. It was an attending's and senior resident's worst nightmare. In any case, if a hospital has an active trauma program it would naturally be expected that it would have more deaths during the summer regardless of resident status, quite simply because there is more trauma. Complication rates? That might also be a useful thing to look at, but that's actually not as easy as it seems either. How about comparing morbidity and mortality rates between teaching hospitals and community hospitals throughout the year and test whether mortality rates increase in academic hospitals relative to community hospitals. That won't work very well, either, mainly because there tends to be a huge difference in case mix and severity between academic institutions and community hospitals. Community hospitals tend to see more routine cases of lower severity than teaching hospitals do.
Yes, the probem in doing such studies is that it's not as straightforward as it seems. Choosing appropriate surrogate endpoints that indicate quality of care attributable to resident care is not easy. It's been tried in multiple studies, and the results have been conflicting. One reason is that existing quality metrics in medicine have not been sufficiently standardized and risk-adjusted to allow for reliable month-to-month comparisons on a large scale basis. In surgery, we are trying to develop such metrics in the form of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP), but these measures don't always apply to nonsurgical specialties and there are multiple competing measures of quality. It's true that we're getting much better at assessing quality than we used to be, but it's also true that we have a long way to go before we have a reliable, standardized, validated set of quality measures that can be applied over a large range of specialties.
That leaves investigators to pick and choose surrogates that suit their purposes, and that's exactly what the investigators of this most recent study, hailing from the University of Southern California and UCLA, have done. The surrogate that they chose is medication error-related deaths:
Inexperienced medical staff are often considered a possible source of medical errors.1-6 One way to examine the relation-ship between inexperience and medical error is to study changes in the number of medical errors in July, when thousands begin medical residencies and fellowships.1,7-11 This approach allows one to test the hypothesis that inexperienced residents are associated with increased medical errors1,8,9,11-15--the so-called "July Effect."Previous attempts to detect the July Effect have mostly failed,1,8-17 perhaps because these studies examined small,8,10-13,15-17 non-geographically representative samples,8-17 spanning a limited period,11-16 although a study of anaesthesia trainees at one Australian hospital over a 5-year period did demonstrate an increase in the rate of undesirable events in February--the first month of their academic year.1 In contrast, our study examines a large, nationwide mortality dataset spanning 28 years. Unlike many other studies,18 we focus on fatal medication errors--an indicator of important medical mistakes. We use these errors to test the "New Resident Hypothesis"--the arrival of new medical residents in July is associated with increased fatal medication errors.
To test this hypothesis of the "July effect," the investigators examined the database of computerized United States death certificates from 1979 to 2006 containing the records of 62,338,584 deaths. The authors then looked for deaths for which a medication was listed as the primary cause of death. Their results are summarized below:
One thing that irritates me about this graph is that it does something I really, really hate in a graph. It cuts off the bottom, which, because the graph doesn't go to zero, makess the differences between the values seem a whole lot larger than they really are. That "July spike" plotted on this graph is an increase in the number of deaths due to medications over expected by maybe 7%, but it looks like a whole lot more. In fairness, though, the investigators analyzed: (1) only preventable adverse effects; (2) only medication errors (rather than combining several types of medical errors like medicinal and surgical); (3) only fatal medication errors; (4) only those medication errors coded as the primary cause of death (rather than medication errors coded as primary, secondary, and/or tertiary). Still, one always have to wonder about how the denominator is calculated; i.e., how the "expected" number of deaths for each month is calculated. Basically, the investigators used a simple least-squares regression analysis to estimate the "expected" number of deaths.
If this is where the investigators had stopped, I might not have been as annoyed by this study. Sure, it's questionable whether assuming that deaths due to medication errors are strongly correlated with new, inexperienced residents. After all, if there's one thing we're starting to appreciate more and more, it's that medication errors tend to be a system problem, rather than a problem of any single practitioner or group of practitioners. But the above graph does appear to show an anomaly in July.
Unfortunately the investigators did something that always disturbs me when I see it in a paper. They faced a problem. Death certificates didn't show whether the death occurred in a teaching hospital or not. So, in order to get at whether there was a correlation between a greater "July effect" and teaching hospitals, as would be expected, they looked at county-level data for hospital deaths due to medication errors. Then they determined whether each of these counties had at least one teaching hospital and estimated the percentage of the hospitals in each county that are teaching hospitals, the rationale being the higher the proportion of teaching hospitals in a county, the larger the July effect is likely to be. This is the graph they came up with:
Holy ecological fallacy, Batman! The investigators appear to be implying that a relationship found in group level data applies to individual level data; i.e., individual hospitals. it almost reminds me of a Geier study. In any case, why didn't surgical errors increase if the "July effect" exists? Wouldn't this be expected? I mean, we surgeons are totally awesome and all, but we're only human, too. If the July effect exists, I have no reason to believe that we would be immune to it.
The existence of a "July effect" is not implausible. After all, in late June and early July every year, we flood teaching hospitals with a new crop of young, eager, freshly minted doctors. I can feel the anticipation at my own institution right now. It's a veritable yearly rite that we go through in academia. Countering the likelihood of a "July effect" is the seasonally tightened anal sphincters of attendings and senior residents that lead them to keep a tight rein on these new residents--which is as it should be. In any case, this particular study is mildly suggestive, but hardly strong evidence for the existence of the "July effect." Personally, I find the previous study on this issue that I blogged about three years ago to be far more convincing; its results suggested a much more complex interplay of factors.
In the end, I have some serious problems with this study, not the least of which is the assumption that medication errors are correlated so strongly with inexperienced residents when we now know that they are far more a systems issue than they are due to any individual physicians or groups. There are many steps in the chain from a medication order all the way down to actually administering the medication to the patient where something can go wrong, and, in fact, these days the vast majority of the effort that goes into preventing medication errors is expended on putting systems in place that catch these errors before the medication ever makes it to the patient, either through computerized ordering systems that question orders with incorrect doses or medications, systems where pharmacists and then nurses check and double check the order, and then systems where the actual medication order is checked against the medication to be given using computerized bar code scanning systems. It's really a huge stretch to conclude that fatal medication errors are a good surrogate marker for quality of care attributable to the resident staff, the pontifications and bloviations of the authors to justify their choice in the Introduction and Discussion sections of this study notwithstanding. The other problem is the pooling of county level data into a heapin' helpin' of the ecological fallacy. Is there a July effect? I don't know. It wouldn't surprise me if there were. If the July effect does exist, however, this study is pretty thin gruel to support its existence and estimate its severity.
Friday, 18 June 2010
New Clinic Location in Central London
We are very pleased to be offering Specialist Pain Physio Clinics in Central London based at a fantastic location in Temple, near the city and London Bridge. Specialist Pain Physio will be working closely with Positive Health, other Consultants & GPs, continuing to provide the highest quality care for chronic pain, persisting & recurring injuries.
See website for details or call the practice manager Susan on 07518 445493
See website for details or call the practice manager Susan on 07518 445493
The Colorful Smell of Richard Dawkins
However, I would suggest that most discussions of rearrangements of color qualia severely underestimate how much structure comes along with our color perceptions. Once one more fully appreciates the degree to which color qualia are linked to one another and to non-color qualia, it becomes much less plausible to single color qualia out as especially permutable.
Few of us, for example, would find it plausible to imagine that others might perceive music differently, e.g,. with pitch and loudness swapped, so that melody to them sounds like loudness modulations to me, and vice versa. Few of us would find it plausible to imagine that some other brain might perceive ‘up' (in one's visual field) and ‘down' as reversed. And it is not quite so compelling to imagine that one might perceive the depth of something as the timbre of an instrument, and vice versa. And so on.
Unlike color qualia, most alternative possible qualia rearrangements do not seem plausible. Why is that? Why is color the butt of nearly all the "inverted-spectra" arguments?
The difference is that these other qualia seem to be more than just mere labels that can be permuted willy nilly. Instead, these other qualia are deeply interconnected with hosts of other aspects of our perceptions. They are part of a complex structured network of qualia, and permuting just one small part of the network destroys the original shape and structure of the network - and when the network's shape and structure is radically changed, the original meanings of the perceptions (and the qualia) within it are obliterated.
The reason other qualia seem to be more than mere labels is that most of them have clear meanings and functions. We know what they're for, and how they plug in to the rest of our network of qualia. For color, on the other hand, we have historically been largely blind to what colors are for, and how they functionally integrate with the rest of our perception. In the absence of knowing how to plug colors in to the rest of our qualia, they do seem much more rearrangeable.
But we're beginning to know more about what colors are for, and as we learn more, color qualia are becoming more and more like other qualia in their non-permutability. Let's see why.
First, even before describing some of the new insights on color vision, I note that most conversations about color qualia don't seem to account for what has long been known about colors. Colors are not a set of distinct crayons with no connections to one another. Instead, colors are part of a three dimensional space of colors, a space having certain well-known features. The space is spanned by a red-green axis, a yellow-blue axis, and a black-white axis. These three axes have opponent colors at opposite ends, and these extreme ends of the axes are pure or primary (i.e., not being built via a combination of other colors). All the colors we know of are a perceptual combination of these three axes. For example, burnt orange is built from roughly equal parts yellow and red, and is on the darker side of the black-white dimension.
To perceive colors like I do requires, at a minimum, having the same color space as I do. To perceive ‘red' without having (its opposite) ‘green' also as part of one's color space is impossible, just as perceiving ‘light' would be impossible without also having ‘dark'. And to perceive orange without having both red-green and yellow-blue axes is impossible, because orange is a perceptual mix of red and yellow.
And that's just the bare beginnings of the structure of colors. Colors are not only intricately connected to one another in a space, but are linked to many other aspects of our mental life, including other sensory modalities (e.g., a "red sounding trumpet") and emotions.
In fact, in my research I have provided evidence that our primate variety color vision evolved for seeing the color changes occurring on our faces and other naked spots. Our primate color vision is peculiar in its cone sensitivities (with the M and L cones having sensitivities that are uncomfortably close), but these peculiar cone sensitivities are just right for sensing the peculiar spectral modulations hemoglobin in the skin undergoes as the blood varies in oxygenation. Also, the naked-faced and naked-rumped primates are the ones with color vision; those primates without color vision have your typical mammalian furry face.
In essence, I have argued elsewhere that our color-vision eyes are oximeters like those found in hospital rooms, giving us the power to read off the emotions, moods and health of those around us.
On this new view of the origins of color vision, color is far from an arbitrary permutable labeling system. Our three-dimensional color space is steeped with links to emotions, moods, and physiological states, as well as potentially to behaviors. For example, purple regions within color space are not merely a perceptual mix of blue and red, but are also steeped in physiological, emotional and behavioral implications - in this case perhaps of a livid male ready to punch you.
Furthermore, these associations are not arbitrary or learned. Rather, these links from color to our broader mental life are part of the very meanings of color - they are what color vision evolved for.
The entirety of these links is, I submit, what determines the qualitative feel of the colors we see. If you and I largely share the same "perceptual network," then we'll have the same qualia. And if some other animal perceives some three-dimensional color space that differs radically in how it links to the other aspects of its mental life, then it won't be like our color space. ...its perceptions will be an orange of a different color.
Mark Changizi is the author of The Vision Revolution and a professor at Rensselaer Polytechnic Institute.
18 Reader comments join the discussion here!Tags: animals, audition, bats, brain, butt, color qualia, color space, colors, ins, inverted spectrum, labels, locusts, melody, modulations, moths, music, perceptions, pitch, richard dawkins, spatial sense, spectra, timbre, visual modalities
Chronic musculoskeletal pain predicted hospitalisation due to serious medical conditions in a 10 year follow up study
Chronic musculoskeletal pain predicted hospitalisation due to serious medical conditions in a 10 year follow up study Lindgren, Hans Bergman, Stefan info:doi/10.1186/1471-2474-11-127 BMC Musculoskeletal Disorders 2010, 11:127 2010-06-18 BMC Musculoskeletal Disorders 2010-06-18 11 1 Research article 127 -->Research article
Chronic musculoskeletal pain predicted hospitalisation due to serious medical conditions in a 10 year follow up study
Hans Lindgren
and Stefan Bergman
BMC Musculoskeletal Disorders 2010, 11:127doi:10.1186/1471-2474-11-127
Published: 18 June 2010
Monday, 14 June 2010
More Trouble for Brain Training
Jun 11 2010
More Trouble for Brain Training
Brain training is the idea that training in a specific task will improve brain function for a type of skill that will then transfer more broadly to other tasks. For example, a memory task with improve your overall memory and therefore improve your performance on a different memory task. There is now a multi-million dollar industry based upon this concept.
But as is typical, for-profit commercial claims tend to race ahead of the science. The evidence for this generalizability effect is weak at best. Those who play video games have some performance advantages over those who do not. There may be benefits to engaging in novel cognitive activities. But brain training products either do not work or have a minimal effect below the resolution of research to detect.
Now a recent study published in Nature add further evidence for lack of efficacy to brain-training products. They report:
Here we report the results of a six-week online study in which 11,430 participants trained several times each week on cognitive tasks designed to improve reasoning, memory, planning, visuospatial skills and attention. Although improvements were observed in every one of the cognitive tasks that were trained, no evidence was found for transfer effects to untrained tasks, even when those tasks were cognitively closely related.
This was an online study, so there may be some self-selection bias. But it is a fairly large study. If there were a significant effect it probably could have detected it.
One thing to note is that the subjects became better at the task at which they were training. This is universally true in such studies, even in other research areas, like stroke recovery, for example. There is a generic training effect – people become better at specific tasks at which they train. This has to be taken into consideration for any study that uses performance at baseline and after an intervention – subjects will get better at the task from training alone, even if the intervention had no effect at all. Keep an eye out for that training effect, because it can make any intervention seem to work.
But again – the question here is does training in one task create generic skills that transfer to other tasks that use those same skills? The answer appears to be no, at least not significantly. This is in line with other research.
I admit, however, that this does not entirely make sense to me – which means that the research is somehow misleading, or my concept of how the brain works is not accurate. It seems that skills should transfer. My concept, which is probably common, is that working out the brain is similar to working out a muscle. If you build muscle strength by lifting weights, that strength will transfer to other tasks, like doing pull ups. Of course, the brain is not a muscle, and cognitive ability is more complex than something as straightforward as how much force your muscles can generate. But still, this conceptual framework is compelling.
What does this research on the lack of efficacy of brain training mean, then? Assuming it is accurately reflecting underlying reality, it could mean that learning is very specific. The mechanism of memory and plasticity are such that they apply to a very narrow range of activity, not generic skills. Perhaps generic skills, like how good your memory is, are more inherent and not subject to training. But applying those base skills to a specific task is all about training. Perhaps this is the relationship between talent and skill. You are born with whatever talent you are ever going to have, but you have to learn how to apply it to fairly specific skills.
To add another dimension to this, some skills are more generally useful than others. Reading seems like a more useful skill than playing the kazoo. But this is different than the underlying cognitive substrate of learning one versus the other.
At this point the bottom line of this research is that expensive brain training products and programs are probably not worth the time and money. School systems should not invest their resources and their classroom time in such systems. Learn and teach those skills that serve some function for you themselves – they are practical or fun.
28 Responses to “More Trouble for Brain Training”
This reminds me of that study that came out back in 2007 about video games and surgeons. The study measured laproscopic skills, suturing capability, video games scores, and video game experience. They were able to find a significant correlation between gaming experience and rate of errors and speed of surgery. Specifically they showed that video game skill and past video game experience were high predictors of laproscopic skill. This seems to support the idea that there is transfer of function … and that video game playing is important for American youth …
Performance training is in-line with your perspective: specific training so those skills coupled with talent will be implicitly applied when under stress, as playing on a field with other professionals in front of vocal spectators.
I wonder if the study focused solely on memory-based or object recognition based tasks. I played a popular version of such a game on my Iphone, and most of the tasks were memorizing long sequences of symbols short-term and sorting objects quickly. If so, it makes sense.
Imagine training your brain to differentiate between different quantities of a certain object, like marbles. Assuming memory is not improvable, your only improvable skill is visually estimating marble quantity.
In a different type of exercise, like a video game, you practice skills like eye-hand-controller-screen coordination or user interface understanding, which will help you master other controllers with similar dynamics and similar user interfaces.
I am still following the video-game research – I think it’s equivocal. As much as I would love for there to be a generic benefit to playing my favorite video game, the research so far has mostly found a correlation, not proved caustion.
So surgeons who have the skills that make them good at laparoscopic surgery may also have the same skills that make them good at video games, hence they find video games fun and play them.
But I think user interface and translating hand movements to video control may be generic skills that are broadly applicable (like reading).
Perhaps we need to distinguish applicability from transferability.
The research is still sorting this out.
Maybe you need a different way of exercising or a catalyst for transfer.
Usually person would just trains their normal way of thinking. But what if those games/exercises suggest another way of thinking.
For example a game where you count birds. Usual approach would be to just estimate or count one-by-one. Eventually you’ll get faster and better but no significant improvement.
If you change your technique to counting-by-groups there is an significant improvement. (That means you group birds into 10 or more and start counting 10, 24, 37 and so on.) This teaches you a new way of thinking and maybe now it transfers to other things like adding/subtracting numbers.
Now a catalyst for a transfer would show how to apply this skill. For example 4*24 is same as counting 4 times group of 24 birds. So 24, 48, 72, 96.
“I admit, however, that this does not entirely make sense to me – which means that the research is somehow misleading, or my concept of how the brain works is not accurate.”
I see the problem being that these studies and products may say more about the efficacy of the training and the study designs than they do about the brain itself. If brain ‘training’ didn’t work then education in a broad sense wouldn’t work… unless we are arguing that education only works in a specific sense (which doesn’t appear to be true). I think we are not really testing for what we think we are when we design these studies, or we are attempting to say something broad about training the brain when our results may say something more narrow about a specific task.
So what does this imply for more complex training activities,such as learning a new language or learning to play a new musical instrument?
Also I recently heard that exercise has an important role in keeping the brain healthy,so has there been any research on the effects on learning during exercise?
I am confused how reading is a “generic skill.” Truly, once taught to read you can read anything, anywhere. But this is not a generic behavior, it is very specific. The things that you are reading consist of very specific stimuli, arranged in very specific patterns, and of which you have very specific training histories. If I give you a highly technical science article in a field you are unfamiliar with (no training history) sure you can read the words but they will be meaningless. I think reading is no different than walking in this respect, we don’t say walking is some sort of general behavior because you can walk at home, at the mall, and (with special equipment) on the moon. Similarly we read sci-fi, magazines, and science articles.
As for brain skill-transfer, I agree it is alluring and took a while for it to be trained out of me in grad school. It is far more likely that the brain only supports behavior that are functionally related to the environment, such things that have been already trained (either actively by someone or passively by the environment itself). If we teach a child all the math skills she will need to know, but we teach them all in a base-5 system, there is no reason to believe she will have any skills in 6+6 or 6×6. The skill to add and the skill to multiply will likely exist, but with out any history with the specific relations of those numbers no behavior will occur.
What about slowing the decay of Brain function in the elderly?
Do you know of any good studies about weather brain workouts (like countering the Stroop effect, adding large numbers or remembering word lists) have any effect on age-induced decrease in mental capacity?
Well this is depressing news. I have this dream of developing a video game or some sort of learning program that will teach critical thinking. So that once the skill is mastered narrowly in the game, it will be applied broadly in real life.
But this seems to indicate that it would be a useless attempt.
Xal – I tried to clarify this – generic in terms of applicability. It is a skill that gives you an enhanced ability to acquire more knowledge and skills. As opposed to playing the kazoo, which does not feed into much else.
We need to separate applicability from transferability.
@ ccbowers
” If brain ‘training’ didn’t work then education in a broad sense wouldn’t work… unless we are arguing that education only works in a specific sense (which doesn’t appear to be true) ”
Education doesn’t work in the sense that learning physics doesn’t help you learn english or biology. In fact, if skill transferability was a reality wouldn’t we expect students to be equally good at everything, more or less, by the time they were done? After all, all academic learning engages the same skill sets (critical thinking, structured learning, memorizing vocabulary, etc), but the majority of students do not develop equally. Even accounting for individual preference and differential levels of focus between studies, you do not generally see multi-talented individuals.
It seems to me that people are successful in things because of talents they have, such as memory or organizational ability, and not because of what they have learned in other areas of life, no matter how closely related.
What about n-back training which improves fluid intelligence outside of the game? There’s a research paper on n-back training improving fluid intelligence which acknowledges exactly what was discovered in the study referenced by Dr. Novella while showing n-back training is an exception and generally improves fluid intelligence. Here’s the abstract:
“Fluid intelligence (Gf) refers to the ability to reason and to solve
new problems independently of previously acquired knowledge.
Gf is critical for a wide variety of cognitive tasks, and it is
considered one of the most important factors in learning. Moreover,
Gf is closely related to professional and educational success,
especially in complex and demanding environments. Although
performance on tests of Gf can be improved through direct practice
on the tests themselves, there is no evidence that training on any
other regimen yields increased Gf in adults. Furthermore, there is
a long history of research into cognitive training showing that,
although performance on trained tasks can increase dramatically,
transfer of this learning to other tasks remains poor. Here, we
present evidence for transfer from training on a demanding working
memory task to measures of Gf. This transfer results even
though the trained task is entirely different from the intelligence
test itself. Furthermore, we demonstrate that the extent of gain in
intelligence critically depends on the amount of training: the more
training, the more improvement in Gf. That is, the training effect
is dosage-dependent. Thus, in contrast to many previous studies,
we conclude that it is possible to improve Gf without practicing the
testing tasks themselves, opening a wide range of applications.”Full paper: http://www.iapsych.com/articles/jaeggi2008.pdf
Free open source implementation: http://brainworkshop.sourceforge.net/“In fact, if skill transferability was a reality wouldn’t we expect students to be equally good at everything, more or less, by the time they were done?”
Not at all. There are other factors (interest, drive, work ethic, life circumstances, etc.) that come into play. I disagree with most of what you are saying. Talent is important for determining an aptitude for something, but there are very few things for which talent is enough. Do you really think only the most talented people always end up on top? I think the correlation is pretty weak. I would argue drive and determination is most important, assuming some talent is there.
“It seems to me that people are successful in things because of talents they have, such as memory or organizational ability, and not because of what they have learned in other areas of life, no matter how closely related.”
Its hard to separate the two sometimes because people tend to gravitate towards things for which they are more talented, but again you are downplaying the role that hard work plays. The most successful people are often the hardest working, in addition to being fairly talented.
“It seems to me that people are successful in things because of talents they have, such as memory or organizational ability, and not because of what they have learned in other areas of life, no matter how closely related.”
One major point that I didn’t mention is that you are confusing improvements in specific tasks (or even general tasks) with life successes. These are not the same thing, and may be completely dischordant for the reasons I stated before.
Steve
Out of curiosity does this support the research showing a correlation in dementia between spouses. I know it is correlational not causative. Does this enhance or dispute the preliminary findings that having a spouse with dementia increases your risk of dementia. It is difficult to draw any conclusions directly. I would think that this evidence would tend to support a hypothesis that lack of stimulus, IE: dementia in a spouse, would not be the reason for the statistical correlation. Even though it was reported as such. I have been racking my brain about that research trying to come up with a plausible origin other than statistical anomaly or environmental(Meaning lack of mental stimulation).Steve–
I can see a potential deep problem in the conclusions made in this post concerning the efficacy of “brain strength training.” As an avid video gamer in my earlier years, I realize that what I say may be a result of confirmation bias, but it makes enough logical sense that I believe it valid.
It seems intuitive that certain memory tasks use the same “brain muscles” (hippocampus, basal ganglia, etc.) and plenty of studies have demonstrated that specific types of memory can be very specifically localized within the brain. But a big thing that jumped out at me when reading this blog post was a video I saw by Richard Feyman, in which he discusses the different “ways of thinking” that people have (link: — a beautiful video!).
After watching that video and reading this post, I thought about times where a stranger in my building might ask how to get to, for example, the women’s rest room. In my head, I visualize a 3-D map of the building, and I usually have to suppress the urge to point diagonally upwards through the roof to where the actual location of the room is and say “right there.” Instead, I convert this information, based on my knowledge of the layout of the building, into a series of directions. This 3-D mapping is something I learned from playing Descent, a 3-D game in which spatial mapping involved 3-D maps. I firmly believe that this 3-D mapping was a specific skill I learned in the game and is DIRECTLY transferable to real-life scenarios. It’s not “related”–it IS the same skill, exactly. But if people didn’t follow visual maps in the same way I do–for example, updating lists of directions–then I can see how the skills might not transfer.
The problem I think is the assumption that skills learned in games are not really transferable to real life–I believe they very much are, and that some “general” skills, which can be learned, become applicable to many different circumstances. I would bet that major league pitchers would beat us in darts, that Halo players would have better aim with real rifles, that people who play computer pool would be better at real pool, that Starcraft players can better judge economic tradeoffs, and that runners can better tell how fast a car is moving–because the skills are the same.
I’ve kind of started rambling I guess, but my main point is that many skills acquired through “training” are not really specific to one thing. The skill itself might be specific in terms of how it’s described, but it’s still a skill that can be used in very large set of circumstances. I think that this study chose many skills that do not hold this feature (for example, matching windows to images that were in the window, or memorizing strings of digits), and as a result avoided using skills which can be specifically applied to different situations.
#Marshall your last point was sounded close to saying “the controls were to tight”. The suggestions you offered all had one thing in common, one common controllable factor+medley of other uncontrolled factors. For example: Halo players use a lot of spatial judging by shooting, jumping, throwing grenades and so on. You suggest they would be better at shooting rifles. There are more factors to shooting a rifle than spatial recognition and judgment. There are methods for pulling a trigger, breathing, etc.
I’m not saying this invalidates your hypothesis out of hand; I am saying those are holes in how you would control the experiment and a different question than was asked in the study. You now are testing against tons of previous experiences and potential knowledge. Yes you can tease this out through statistical methods, but this was neither the question nor hypothesis for this study.
This experiment kept it as clean as possible by having people do extremely simple tasks (like the games and products the study specifically questioning the efficacy of) and then see if it was applicable in a more general use of the specific skills the games were designed to work on (again what these products claim). This means that claims from games like Brain Age, Brain Academy and the myriad of other products spawned from their popularity (and other sources I’m sure) are not supported by this study.
To me it seems you have a problem with the scope of the experiment. You could now ask different questions such as, is there an effect from more complex or dynamic skills? Is it possible that there is an affect when you perform two different tasks that use multiple skills in the exact same manner (suggesting that the ability to link sets of skills has an effect rather than how proficient you are with the skill)? There are many things that could produce your theorized effects. This study is not one of them. The next one should be seeing if there is an effect in more complicated tasks (such as the ones you suggested) and then measuring. However if there is no effect there either, I would say that it would be a very unpromising avenue. =)
I just wonder if there is a “negative” correlation between training the brain in a particular task and improvements in other areas, I mean training your brain in task A makes you worse on task B.
Neurology is not my area but at least in computer neural networks (if they represent biological ones at all), training the network strongly on a particular input reduces the accuracy of the system for other inputs. Given the fixed number of neurons and synapses in brain, this also sounds logical to me. But again this is a very rough guess.
Do you know if there are studies showing such negative correlations?
Rikki-Tikki-Tavi, How can brain workouts reverse brain and vascular damage in the elderly? If you memorize a word list regardless of color context, or add a column of numbers quickly, its very possible you simply appear to others as an elderly idiot-savant. It still won’t help with practical daily living skills including making sensible financial or heathcare decisions. These workouts may simply be useful as a time filler for the elderly as social activities.
Marshall,
“It seems intuitive…I believe they very much are…I would bet that…”
This study converts “intuition”, “believing, and “betting” into what’s scientifically defensible. It’s not the last word (no single study can be), but it’s better then the notoriously unrelaible evidence from personal experience.
Another dubious anecdote:
I have very good 3D and map reading skills, but the only computer game I ever played is “Cosmo”. Maybe Cosmo was responsible. But maybe not.Marshall
“link: — a beautiful video!”
Thanks for that.
I spent a beautiful ten minutes listening to that video.The one about training is the fiction! ISn’t most of it a matter of executive function? The individual’s ability to systematically parse a learned skill and new situations relevant to its application? Isn’t efficiency at this a function of the skill level that IQ tests for?
@Marshall,
When transferring a physical skill out of the virtual realm, I think there is a disconnect. There was a recent article in Discover: ( http://discovermagazine.com/2010/apr/16-the-brain-athletes-are-geniuses ) about how we have to train ourselves to do a physical task well. It involves the repetitive physical action so that your brain knows exactly how to adjust your arm, your wrist, whatever.
So I think the halo player is unlikely to be a crack shot in real life, because while he has learned a great deal about the visual part of the task, he has not learned the muscular part of it.But to your point, because it involves a new skill, it would no longer be a direct transfer of learning. Unlike your 3-D map example, which is a direct transfer.
@HHC,
I am merely asking a question. I was not trying to imply an answer.>>How can…
I don’t know. That’s why I asked.
I study mechanical engineering with a focus on launch vehicles. I know nothing about neurology other than what I’ve read here.
By the way: You haven’t exactly answered my question, you just answered a straw man.
You implied that I asked about reversal of the damage, while I asked about reversal of the effects. And any way you put it, you have not stated any references. Can you give me some?Hi, I couldn’t find a contact admin link, so I am just leaving a comment. I used the search box to look something up, and my virus scanner alerted me, twice, with a Trojan virus warning.
Perhaps we need better training games. Ones that teach more general skills such as good organisation, deduction etc… rather than how many meaningless symbols you can remember after 10 seconds.
I think the distinction needs to be made between “learning a task” like the ability to memorise strings of numbers and “learning a skill” like the scientific method. It would seem that “learning a skill” IS transferable and “learning a task” is NOT transferable.
Here’s my conclusion (is this a hypothesis, or is this too strong a word?).
1. We are born – our DNA “pre-programs” a base level of (for want of a better word) “intelligence” and a tendency to be “better” at some tasks, more “driven” and/or have better concentration (obviously lots more to add here).
2. We grow up – we learn “skills” and become good at “tasks” that we repeat regularly.
3. We develop and grow our “abilities” throughout our life (my definition – the combination of DNA, skills and tasks). The development and direction of our tasks and our ability to utilise tasks is influenced by our DNA and “skills” (such as the scientific method).
4. Tasks are NOT transferable, but appropriate skills (such as the scientific method) provide the basis for tasks to be utilised cross functionally, influencing the direction and “growth” of our abilities.As a non-scientist, I am not sure if this actually makes sense or is missing the mark. Also, I have not read the original article, just Steve’s article and the 27 responses.
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How “social” is your biopsychosocial model?
It’s called the biopsychosocial model, but how much attention do we really pay to the social part of this model? While we know the medical model has its limitations (especially when we’re looking at how people respond to having health problems), in pain management I wonder whether we now have a ‘psychological’ model of pain rather than a biopsychosocial model?The first time I started pondering this was when a large purchasing body in New Zealand removed the word ‘social’ from what is called a ‘Comprehensive Pain Assessment’. This is an assessment that has medical, functional and psychosocial components – but without the social part it seems to omit some of those really important aspects of the experience of both pain and disability…
I’ve pondered this issue of ‘social’ for a long time. What does it actually mean? There doesn’t appear to be a particularly clear definition of ‘social’ in the biopsychosocial model. I returned to Engel’s (1996) work on biopsychosocial model – and this is what he said: “As the name suggests, its intent is to provide a framework within which can be conceptualized and related as natural systems all the levels of organization pertinent to health and disease, from subatomic particles through molecules, cells, tissues, organs, organ systems, the person, the family, the community, the culture, and ultimately the biosphere.” He goes on to say “processes at the cellular level are subordinate to those at the tissue or organ level, which in turn are subordinate to those at the person or community level“.
Engel shows great compassion towards the people who seek help from the medical profession. He points out that the biomedical model is disease-oriented rather than patient-oriented, and that psychosocial is often thought to be “problems primarily of concern to the psychiatrist or the social worker.” By contrast, he states “For the patient the ultimate criteria [for wellness] are psychosocial, even when the complaint is physical. Patients’ criteria have to do with how one feels, how one functions, how one relates; with the ability to love, to work, to struggle, to seek options and to make choices. The physician, in contrast, while ostensibly attentive to such concerns, nonetheless is wont to consider such criteria as merely subjective… Even the organization of health care delivery is predicated on the assumption that the doctor, that is, the laboratory, is right and the patient is wrong.”
I couldn’t agree more when it comes to the way in which pain is conceived, especially pain where “the cause” can’t be found!
Engel’s vision was that “general competency for all health professionals would derive from their shared understanding that all three levels, biological, psychological and social, must be taken into account in every health care task.” Not the ascendency of any one of the three.
What does the “social” consist of? This diagram might help:
How often do you assess or report on roles and the changes that have occurred in a family as a result of the person you’re seeing having difficulty with their pain? How often is their economic stress acknowledged? Their communication patterns identified? What about the influence of the community – things like unemployment, the ways in which the Government or insurers fund various treatments or even income replacement/benefits, the actions of case managers, other health care providers, the effect of various policies on the individual?
Do we see these aspects of health as even relevant for health care?
My clinical focus has been on return to work for people who have persistent pain. Sadly I’ve found that it’s often not even touched on in assessment or management – and if the person has lost a job, or feels they can’t return to work, the aim is not on how to help them feel more confident, but instead, on how quickly they can be pushed through a system that can ‘determine’ the kind of work they are physically fit for – as if physical fitness or capacity is the major determinant of return to work.
A more recent paper than Engel’s excellent theoretical one discusses the way in which members of chronic pain centres discuss their work. Harding and colleagues have published several papers from a qualitative study of people and clinicians in chronic pain centres. This paper refers to a study of 25 clinicians drawn from seven pain centres across the UK.
In the study, there was a very strong belief by all team members in the biopsychosocial model. They talked about it often, believed they were delivering a biopsychosocial model and backed each other up with regard to the importance of a biopsychosocial model. But – you knew there would be one! – did they use the entire model? In the assessment of Harding and colleagues, no. The majority of interventions were biomedical or psychological – the social got left behind.
One of their concluding comments is “pain clinic practitioners we interviewed readily embraced cognitive/behavioural based management strategies but reported relatively little if any consideration of the impact social factors played in managing chronic pain for patients failing to respond to interventions or for whom interventions were deemed appropriate.”
What would ‘consideration of the impact [of] social factors’ look like?
Well, recognising that most people with chronic pain will continue needing to interact with health care providers, I think learning how to be health literate – that is, learning what to ask about treatments, how to respond to suggestions, how to effectively and assertively interact with health professionals would be a good start.I think it would be great if body language and those ‘illness behaviours’ or ‘pain behaviours’ that health providers notice were identified to the individual, and each person helped to review how much those behaviours influence how they are seen in the community. Even little things like the Mobility sticker on the car!
Communication skills, like assertiveness, would be useful. So would acknowledging changing roles and how the family adapt to the person coping with pain – and perhaps bringing some of those ‘invisible’ changes out into discussion, so families and individuals can decide what changes to hold onto, and those they want to review.
Looking at the impact of various labels, like ‘invalid’s benefit’ or ‘sickness benefit’, ‘disabled’ or ‘beneficiary’ or ‘compensation claimant’. And discussing the impact of systems that people interact with when they have chronic pain – like government agencies, or insurance agencies and the legal system.
The problem with doing this is – we start to step along a slightly more political path than we have traditionally had in healthcare. Once the effect of various systems is made clear, we can be sure that not everyone will like being made aware of this! Most notably, systems like insurance don’t tend to like having their systems critiqued – even when the critique is based on evidence. I’m not sure whether this is something we can ignore, though.
So – back to my original question: how “social” is your biopsychosocial model?Engel, G. (1979). The biopsychosocial model and the education of health professionals General Hospital Psychiatry, 1 (2), 156-165 DOI: 10.1016/0163-8343(79)90062-8
Harding G, Campbell J, Parsons S, Rahman A, & Underwood M (2010). British pain clinic practitioners’ recognition and use of the bio-psychosocial pain management model for patients when physical interventions are ineffective or inappropriate: results of a qualitative study. BMC musculoskeletal disorders, 11 PMID: 20298540Possibly related posts: (automatically generated)
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