The Science and Clinical Application Behind the Remember pictures in order (N-back)

Working Memory (WM) plays a significant role in your daily life. We’re here to refresh your memory of the crucial role WM plays, and how it can be targeted to help with the recovery of your patients with brain injuries.

What is Working Memory?

The working memory definition is the ability to temporarily store, process, and manipulate information in your memory. It impacts language processing and cognitive tasks, including memory, executive functioning, inhibition, reasoning, and inattentive behavior.

Consider the following activities you do in your head daily, often without even thinking about them consciously:

• Calculating a restaurant tip
• Planning your daily schedule
• Determining when to leave your house to make an appointment on time
• Processing what is being said in a conversation
• Playing out the scenarios as you consider solutions to a problem
• Figuring out the price of the items in your shopping cart

In all of these daily tasks, working memory is at work.

Working Memory is Finite

There is only so much information that your brain can store at one time. After a neurological event or brain injury, an individual may not be able to hold or efficiently process as much information in working memory as before (Cicerone, 2002).

According to research, training has been shown to improve working memory capacity. Access to training can be enhanced technology. In a study amongst children with ADHD, participants used a computer in order to access more training time. Participants showed improvements in working memory as well as response inhibition and reasoning (Klingberg, et al., 2005).

Programs like Constant Therapy make it possible for individuals to practice working memory tasks more consistently and intensely, both in and outside the clinic.

Today, we focus on one of Constant Therapy’s most popular working memory tasks.

Featured Task: Remember pictures in order (N-back)

What is the Remember pictures in order (N-back) Task?

The user is shown a series of pictures that are presented rapidly. They must temporarily store and sequence this visual information in their memory to select the appropriate response.

Why is this task important?

This task targets a process of working memory called updating. Updating is when your brain holds onto information while simultaneously replacing old pieces of information with new, updated information (Klingberg, 2010).

How is it leveled?

There are 3 levels, with each level increasing the amount of information you must store in working memory.

• Level 1: Tap when the picture is the same as the previous one
• Level 2: Tap when the picture is the same as two pictures ago
• Level 3: Tap when the picture is the same as three pictures ago

How is it scored?

Scores are calculated in a formula involving the number of errors and the total number of pictures presented. There are two types of errors: 1) selecting an incorrect picture; 2) not selecting a correct picture.

The Science Behind the Task

N-Back tasks have been used in a variety of studies with different ages and diagnoses. They have been shown to improve both cognitive and language processes.

Here are examples of studies examining N-Back tasks for cognitive remediation:

“Working memory (WM) capacity predicts performance in a wide range of cognitive tasks.  Although WM capacity has been viewed as a constant trait, recent studies suggest that it can be improved by adaptive and extended training. This training is associated with changes in brain activity in frontal and parietal cortex and basal ganglia, as well as changes in dopamine receptor density. Transfer of the training effects to non-trained WM tasks is consistent with the notion of training-induced plasticity in a common neural network for WM. The observed training effects suggest that WM training could be used as a remediating intervention for individuals for whom low WM capacity is a limiting factor for academic performance or in everyday life.” – Klingberg, T. (2010). Training and plasticity of working memory. Trends in Cognitive Sciences, 317-24.

In the mild traumatic brain injury (MTBI) population, “treatment participants were more likely to exhibit clinically significant improvement on measures of attention and reduction of self-reported attentional difficulties in their daily functioning. Further analysis suggested that the principal effect of the intervention was on working memory, i.e. the ability to temporarily maintain and manipulate information during task performance, with no direct effect on processing speed. The results are consistent with a strategy training model of remediation, in which the benefits of treatment are due to participants’ improved ability to compensate for residual deficits and adopt strategies for the more effective allocation of their remaining attentional resources.” – Cicerone, K. (2002). Remediation of ‘working attention’ in mild traumatic brain injury. Brain Injury, 185-95.

Transfer Effects to Language Processes

Those who have language impairments may also present with concomitant deficits in cognition such as short-term memory and working memory.  In aphasia, WM impairments can negatively impact language processes such as lexical-semantic processing, sentence comprehension, spoken discourse, and functional communication  (Zakarias, Salis, & Wartenburger, 2017)

Studies have found that in people with aphasia, targeting working memory with tasks like Remember pictures in order (N-back) has actually transferred to improvements in other language skills.  

“Participants practiced two computerized WM tasks (n-back with pictures and n-back with spoken words) four times a week for a month, targeting two WM processes: updating WM representations and resolving interference.  All participants showed improvements on at least one measure of spoken sentence comprehension and everyday memory activities…results suggest that WM can be improved through computerized training in chronic aphasia and this can transfer to spoken sentence comprehension and functional communication in some individuals.” – Zakarias, L., Salis, C., & Wartenburger, I. (2017). Transfer effects on spoken sentence comprehension and functional communication after working memory training in stroke aphasia. Journal of Neurolinguistics, 2-17.

Whether you’re working on cognitive or language skills, working memory can be an important part of therapy.

Enjoy our tutorial video of Remember pictures in order (N-back). We would love your feedback as you incorporate these tasks into your therapy!

References:

1. Baddeley, A. (1992). Working Memory. Science, 556-59.
2. Cicerone, K. (2002). Remediation of ‘working attention’ in mild traumatic brain injury. Brain Injury, 185-95.
3. Klingberg, T. (2010). Training and plasticity of working memory. Trends in Cognitive Sciences, 317-24.
4. Klingberg, T., Fernell, E., Olesen, P., Johnson, M., Gustafsson, P., Dahlstrom, K., . . . Westerberg, H. (2005). Computerized training of working memory in children with ADHD-A randomized, controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 177-86.
5. Zakarias, L., Salis, C., & Wartenburger, I. (2017). Transfer effects on spoken sentence comprehension and functional communication after working memory training in stroke aphasia. Journal of Neurolinguistics, 2-17.