Neuropsychological Rehabilitation and
Treatment
Lecture 1 Evidence based treatment
Randomized controlled trials (RCT)
Principles
1. Selection of sample from a population
2. Assessment at baseline
3. Random assignment of intervention and control (blinded)
4. Following the cohort over time
5. Assessment of outcome
6. Assessment at follow up
“This treatment works!” Ask a few questions
How was success measured?
- Neuropsychological tests: Which cognitive domain? Single tests of
multivariate analysis (compound score)? Types of variables (accuary, speed,
variability of performance)?
- Behavioral observations – By whom? In which situation?
- Self and informant reports
- Indications of functioning in daily life (speeding tickets, eating disorders,
relation breakups - show indications of cognitive problems)
Training: Speed of processing (CogniPlus) – Test: Speed of processing (TMT)
Training material resembles test material, is this a problem? Yes, we train the test
material, not daily life situations.
When was success measured?
Assessment post-treatment or at follow up?
What happened between post-treatment assessment and follow up?
Follow-up and adherence to protocol
1. Choose participants who likely adhere to protocol
2. Make the intervention simple
3. Make study visits convenient and enjoyable
4. Make study measurements painless, useful and interesting
5. Encourage participants to continue in the trial
,6. Find participants who are lost to follow-up
Which data were considered?
Intention to treat Analysis of every participant according to randomized group
assigned
Per protocol Analysis of only participants who adhered to the protocol
Which approach is better? Intention to treat also considers people who were not
treated according to protocol (because of drop out, missed treatment sessions, non-
compliance, etc.).
Intention to treat likely provides a more conservative estimation of treatments
effects (tendency to underestimate the full effect of a treatment).
Which analysis was taken?
Pre-assessment, post-assessment and follow-up assessment. Interested in
difference between control group and intervention group at pre-assessment and
post-assessment.
Analysis of variance (ANOVA) Main effect time, main effect group and interaction
time x group.
Is it clinically useful?
Statistical significance and interpretation of clinical significance (difference for
people in their life).
Effective? Compared to what?
Active treatment withheld? Active treatment
comparisons
Usual care
, Pico framework
Mnemonic in evidence-base practice to frame and answer any clinical question (can
also be used more universally for scientific questions of any discipline)
P Patient, problem or population
I Intervention
C Comparison, control condition
O Outcome
Speed of information processing
Why studying processing speed?
- Adequate processing speed required for many tasks of daily living; driving,
sustaining a conversation, watching tv.
- Prerequisite for many other mental operations; attention, memory, executive
functions
- Slowed processing speeds may lead to fatigue, exhaustion, irritability,
feelings of depression etc.
Assessment
1. Behavioral observations
Rating scale of Attention and Behavior (RSAB): Clinician report scale. 5-point scale.
Items such as ‘been slow in movement’, ‘been slow to respond verbally’, ‘performed
slowly on mental tasks’
2. Self-report measures
Mental slowness questionnaire (MSQ): Self-report scale. Rated on frequency and
severity. 21 daily activities related to speed, such as ‘I have trouble following a
conversation,’ ‘I have trouble doing two things at the same time’
3. Neuropsychological tests
Symbol Digit Modalities Test (SDMT): accuracy within a limited period of time as a
measure of processing speed. Trail Making Test, part A (TMT-A) and Stroop, color
block condition: speed as a measure of processing speed.
Processing speed with acquired brain injury
Reduction in processing speed common symptom after ABI. Reduced processing
speed hampers range of ‘higher order’ cognitive tasks: focused attention, divided
attention, task switching and response inhibition.
Why does slowed down processing hamper daily life tasks?
1. Limited time mechanism: large amount of time occupied by early operations;
limited time available for later operations.
2. Simultaneity mechanism: products of early processing may be lost by the
time they are needed.
Treatment
1. Pharmacological interventions
Stimulants (methylphenidate) to improve processing speed. Clear evidence on
neuropsychological test performance. Less clear evidence on behavioral rating (on
RSAB).
Treatment
Lecture 1 Evidence based treatment
Randomized controlled trials (RCT)
Principles
1. Selection of sample from a population
2. Assessment at baseline
3. Random assignment of intervention and control (blinded)
4. Following the cohort over time
5. Assessment of outcome
6. Assessment at follow up
“This treatment works!” Ask a few questions
How was success measured?
- Neuropsychological tests: Which cognitive domain? Single tests of
multivariate analysis (compound score)? Types of variables (accuary, speed,
variability of performance)?
- Behavioral observations – By whom? In which situation?
- Self and informant reports
- Indications of functioning in daily life (speeding tickets, eating disorders,
relation breakups - show indications of cognitive problems)
Training: Speed of processing (CogniPlus) – Test: Speed of processing (TMT)
Training material resembles test material, is this a problem? Yes, we train the test
material, not daily life situations.
When was success measured?
Assessment post-treatment or at follow up?
What happened between post-treatment assessment and follow up?
Follow-up and adherence to protocol
1. Choose participants who likely adhere to protocol
2. Make the intervention simple
3. Make study visits convenient and enjoyable
4. Make study measurements painless, useful and interesting
5. Encourage participants to continue in the trial
,6. Find participants who are lost to follow-up
Which data were considered?
Intention to treat Analysis of every participant according to randomized group
assigned
Per protocol Analysis of only participants who adhered to the protocol
Which approach is better? Intention to treat also considers people who were not
treated according to protocol (because of drop out, missed treatment sessions, non-
compliance, etc.).
Intention to treat likely provides a more conservative estimation of treatments
effects (tendency to underestimate the full effect of a treatment).
Which analysis was taken?
Pre-assessment, post-assessment and follow-up assessment. Interested in
difference between control group and intervention group at pre-assessment and
post-assessment.
Analysis of variance (ANOVA) Main effect time, main effect group and interaction
time x group.
Is it clinically useful?
Statistical significance and interpretation of clinical significance (difference for
people in their life).
Effective? Compared to what?
Active treatment withheld? Active treatment
comparisons
Usual care
, Pico framework
Mnemonic in evidence-base practice to frame and answer any clinical question (can
also be used more universally for scientific questions of any discipline)
P Patient, problem or population
I Intervention
C Comparison, control condition
O Outcome
Speed of information processing
Why studying processing speed?
- Adequate processing speed required for many tasks of daily living; driving,
sustaining a conversation, watching tv.
- Prerequisite for many other mental operations; attention, memory, executive
functions
- Slowed processing speeds may lead to fatigue, exhaustion, irritability,
feelings of depression etc.
Assessment
1. Behavioral observations
Rating scale of Attention and Behavior (RSAB): Clinician report scale. 5-point scale.
Items such as ‘been slow in movement’, ‘been slow to respond verbally’, ‘performed
slowly on mental tasks’
2. Self-report measures
Mental slowness questionnaire (MSQ): Self-report scale. Rated on frequency and
severity. 21 daily activities related to speed, such as ‘I have trouble following a
conversation,’ ‘I have trouble doing two things at the same time’
3. Neuropsychological tests
Symbol Digit Modalities Test (SDMT): accuracy within a limited period of time as a
measure of processing speed. Trail Making Test, part A (TMT-A) and Stroop, color
block condition: speed as a measure of processing speed.
Processing speed with acquired brain injury
Reduction in processing speed common symptom after ABI. Reduced processing
speed hampers range of ‘higher order’ cognitive tasks: focused attention, divided
attention, task switching and response inhibition.
Why does slowed down processing hamper daily life tasks?
1. Limited time mechanism: large amount of time occupied by early operations;
limited time available for later operations.
2. Simultaneity mechanism: products of early processing may be lost by the
time they are needed.
Treatment
1. Pharmacological interventions
Stimulants (methylphenidate) to improve processing speed. Clear evidence on
neuropsychological test performance. Less clear evidence on behavioral rating (on
RSAB).
