Basic Science Research that Informs Medicine
Neuroscientist Jeremy Manning, PhD, wants to understand the causal link between exercise, mental health, and cognitive performance—his Contextual Dynamics Lab researches human memory and he has a few ideas about how the three may be connected.
Perception and attention are among the critical actions essential to thinking. If these become distorted, then the mental, social, and emotional processes that rely on them become so as well—depression, for example, can lead to short term memory loss.
“A substantial body of research demonstrates that physical exercise has beneficial effects on various aspects of mental health and cognition. These effects are mediated through specific physiological changes in the brain—different types of exercise have differential effects on both the brain and behavior,” the assistant professor of psychological and brain sciences at Dartmouth explains.
To explore links between cognitive performance and exercise, Manning first recruited runners who used fitness trackers to take online memory-related tests then mined their fitness histories for patterns to see whether going for a run prior to testing improved their memory.
One pattern did emerge—participants who exercised more in the days leading up to memory testing showed improved performance, “but we didn’t know whether the increase in exercise was causing the improvements in memory, or whether our participants who exercised more also happen to have better memories,” he says.
While similar studies looking at this connection were taking place in a lab, Manning wanted to further test his theory in an unprecedented way in the wild.
He wondered if gathering more personalized information about exercise habits could be used to inform an individual’s decision on how and when to exercise. If so, he may be able to pin down a type, level of exertion, or ideal time for exercise to positively affect remembering new information. To explore this further, Manning needed new software and easy to use app-based technology to motivate exercise and to collect custom-designed physiological and behavioral data to further his study—technical expertise his lab did not possess.
He reached out to Lorie Loeb.
Loeb’s research focuses on the intersection of user centered (UX) design, information visualization, and persuasive communication to help people change their behavior. She is deputy director for user interface design at Geisel’s Center for Technology and Behavioral Health (CTBH), a leader in enhancing the quality, pace of achievement, and impact of scientific research focused on the development, empirical testing, and implementation of digital therapeutics with partnerships throughout Dartmouth as well as nationally and globally.
She is also faculty director and a founder of Dartmouth’s Digital Applied Learning and Innovation (DALI) Lab, where undergraduate students design and build mobile applications, websites, and virtual and augmented reality while learning how to solve real-world problems.
With funding from CTBH’s Pilot Core, Manning and Loeb pulled together Dartmouth-wide experts in human memory, physiological changes associated with exercise and cognition, remote sensing technologies and software development, and data analysis/app design—a collaboration that included undergraduate and graduate students as well as faculty—to launch the pilot study.
“Focused on discovery science, the Pilot Core funds novel research projects so investigators can refine their early-stage methodology and see whether an idea has promise,” says Lisa Marsch, PhD, CTBH director, and the Andrew G. Wallace Professor in psychiatry at Geisel. “The goal is not just a published paper or a conference presentation, but rather how to scale up the learning from the pilot work to a larger initiative.”
Prior to launching larger, more complex studies, researchers often rely on pilot studies to help them pinpoint a variety of issues, including refining study questions, testing research instruments, identifying and resolving potential problems, and producing results that can help fund future studies. Major funders, such as the National Science Foundation or the National Institutes of Health, often want to see promising study data before funding larger scale projects.
“This particular pilot was so exciting because it focused on a novel and understudied area in the broader research community—understanding the physiological changes in exercise through real time data capture in natural settings from wearables, such as smart watches and smart phones, and to understand how those changes may affect mental health, cognition, and memory,” Marsch says.
“There is increased demand for remote models of care with a surge in digital therapeutics—software to prevent, treat, and manage health conditions,” she adds. “Although this is early-stage work, the promise of this, as the model and methods are refined, could be extraordinary.”
DALI Lab is experienced in developing sensors to help people exercise, to track food consumption for those struggling with eating disorders, and diagnostic tools for neurological illnesses. Based on the parameters of the pilot study, and the design specs of the memory tests given to Loeb’s team by Manning, Dartmouth students developed and built an app to communicate between an Apple watch and iPhone.
The app continually logs fitness activities and periodically asks the user to play short games, which are used to evaluate memory for distinct types of information. The goal: to provide real-time personalized information that can help the user make informed and deliberate decisions involving exercise that will enable them to improve their mental fitness alongside their physical fitness.
FitWit
“We spent a lot of time thinking about how to guide people and keep them motivated through this very complicated process,” Loeb says. “There are on and off days for exercise and numerous variables in the time between exercise, tasks, and the type of tasks—all of that needed to be part of the FitWit app design. Most of the work went into building out the iPhone application so data collected by the Apple watch could be easily accessed and parsed.”
Cindy Shen D ’21, was one of the UX designers who adapted the psychological cognitive memory tests—spatial, vocabulary word, and foreign language memory from Manning’s earlier studies—into fun, intuitive games while maintaining experimental standards.
Inspired by Duolingo’s owl that guides users through the language-learning app, Shen created Brian the Brain, a friendly character that runs, leads users through FitWit, and monitors their progress.
FitWit’s home screen required four daily user states: a prompt to exercise for x number of minutes; a specific time waiting time between exercise and playing a game; a prompt to play a game within x number of minutes before the game expires; and congratulations for completing all required tasks.
Complicating the home screen, the study alternated between workout days and rest days. Rest days, renamed lazy days, required only two home screen states: prompts to play a game and congratulations for completing the game. For simplicity, Shen wove workout and lazy days together into one cohesive home screen with a daily task bar.
Because interruptions while playing a game could potentially undermined results, Manning asked Shen’s team to a develop a prompt advising users to report interruptions after completing a game. They created a pop-up that redirected users to a help page where Brian asked them to exercise with him again then complete a game.
Though Brian gave FitWit a fun personal touch, Shen knew keeping users motivated to precisely follow experimental procedures was a challenge—they needed something more than a fun app to commit to the project.
They needed monetary compensation.
She devised a rewards system using WitCoins that participants would earn when leveling up in a game. When users leveled up from novice to pro to wizard to royalty, so did Brian, and they tracked their progress on a profile page; at the end of the study, those who earned the most coins were automatically entered in a drawing to win cash.
DALI software engineers moved FitWit from design to functionality—customizing and building the app’s computing utilities and operating systems. Faustino Cortina D ’21, worked on the memory games and integration of the Apple watch.
“Getting the core functionality of the memory games created on Figma, a design software platform, was the most technically complex part of the project—I needed to transition from that format to a mobile format,” he says. “Fortunately, we had strict research guidelines about how the games needed to be implemented. In one game, for example, users needed to look at a picture of an object for two seconds, then a blank screen for one second, then another object for two seconds.”
Cortina also needed to ensure FitWit linked to the Apple Health app that Apple uses to keep track of smart watch activity. “If it was time to exercise or play a game, a screen reminded the user to do that. And when they went for a run, the app needed to detect that activity then display a screen directing them to a memory game.”
The Apple Health app saves all Apple watch activity that can then be viewed on other connected devices—such as an iPhone, which does not detect exercise. The stored and updated information can be viewed by both users and researchers.
“Because this project had the potential for real-world impact,” Cortina says, “it was cool to be closely involved with a research tool created by and tested on Dartmouth students.”
Scaling Up
“The main goal of our pilot project,” Manning says, “was to develop at minimum a viable product that we could use to collect data and show that our main ideas were feasible.”
Though he and his team are still parsing data, early results indicate they are ready to take the next step now that the pilot has concluded—scaling up to collect more data will move this basic science research to a level that can affect people’s lives.
Paxton Fitzpatrick D ’19 and Esme Chen D ’22 work in Manning’s lab and are busy preparing for this next phase of research.
As lab manager, Fitzpatrick is helping adapt the project to allow study participants both on and off Dartmouth’s campus to choose however they want to exercise. Whereas the pilot project was focused on collecting data from members of the Dartmouth community, Fitzpatrick is now helping to broaden the scope of the project to enable the team to test people from around the world.
Chen wrote an onboarding script introducing participants to the study—including a run through of the app—and is also mining the pilot data for new clues about how exercise affects memory. Though FitWit is still being used in this larger study, DALI students are refining the app—when new versions are pushed out, Chen tests them and provides feedback.
“Between this pilot study and a related project, led by Dr. Manning’s former postdoctoral researcher, Gina Notaro, we have amassed a rich dataset that will help guide the next steps of the project,” Chen says. “Meanwhile, we are also running a parallel project led by Dr. Manning’s graduate student, Kirsten Ziman, to link our findings to mental health. I’m excited to see where the project will go next.”
There is value in asking questions that advance our understanding of the brain. But when research is not clinical in nature, it can be difficult to see a connection between grant funding and how research affects lives. “I think this is one of those studies where it is not difficult to see that connection,” Fitzpatrick says. “Because we are conducting the research with people going about their lives in a familiar environment, doing the exercises and cognitive tasks they are used to, we are able to draw more direct and impactful conclusions than traditional lab-based studies.”
“The dream,” Manning says, “is to find exercise-based interventions for mental health and cognitive performance. If we can better understand this connection, we can provide more effective interventions and change people’s lives for the better.”
