Exercise and virtual reality working memory training impact cognition among heavy drinking veterans with traumatic brain injury: A pilot randomized controlled trial

ABSTRACT

Working-memory (WM) underlies executive functions responsible for self-control deficits in alcohol use disorder (AUD). WM-training is a promising treatment modality for traumatic brain injury (TBI) related cognitive impairment. However, major limitations in the field of WM-training exist. To solve these problems, we combined exercise with an enriched virtual reality (VR) WM-training application, and evaluated this intervention compared to exercise-only or sham gameplay-only. Using a 6-week randomized adaptive design study, 30 veterans were instructed to complete 9 sessions of exercise-only (n = 15) or sham gameplay (n = 15) over 3 weeks, followed by a 1-week washout period. All 30 participants then completed 9 sessions of VR WM-training plus exercise. Outcomes included feasibility to enroll and retain participants, feedback on the usability, and preliminary assessment of the VR-exercise WM intervention to improve cognitive function and reduce alcohol craving (Obsessive Compulsive Drinking Scale) and use (Timeline Followback). Fifteen participants (50%) completed both phases of the study (n = 8 withdrawn due to COVID-19 restrictions). Of the 15 completers, all noted they “would recommend the intervention to friends,” but also cited “they would need technical support” to use the system independently. Common VR-related adverse effects included dizziness/motion sickness (n = 3, 20%). Exercise-only was associated with significant improvements in cognitive inhibition and reductions in alcohol craving and number of standard alcohol drinks per week during Phase 1 (all p ≤ 0.05). Cognitive improvement and reduction in craving and alcohol use were maintained from washout through completion of Phase 2. Number of calories burned during the exercise plus VR WM-training was significantly correlated with improvement in WM performance (R2 = 0.56 p = 0.05). Recruitment into an exercise plus VR WM-training intervention is feasible, but technological barriers may impact compliance. There were notable exercise-related improvements in cognitive function and reductions in alcohol use and craving. There was also an association between improvement in WM performance and physical exertion during the exercise plus VR WM-training intervention during phase 2. Although COVID-19 restrictions impacted phase 2 retention, and effects of Phase 1 were not sufficiently washed out for proper evaluation of outcome measures during phase 2, results support further examination of exercise and VR WM-training in Veterans with AUD and TBI.