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Summary articles Neuropsychological Rehabilitation and Treatment
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Summary Neuropsychological Rehabilitation & TreatmentEvidence-based treatment (chapter 2) – Van Heugten
A distinction can be made between effectiveness (does the treatment work, how does it work, for
whom does it work), efficacy (does it help) and efficiency (cost-benefit ratio). From a patient
perspective, efficacy is the most relevant.
1 of the key elements of good clinical practice is to make our clinical actions explicit. This is not only
important for the clinician, but also for the other members of the treatment team. Moreover, it is of
great importance to the patients and their caregivers. Evaluating individual treatments provides
information on the efficacy. Finally, it is a way of showing management and policy makers whether
your treatment is effective.
Making your clinical actions explicit will improve communication among the different parties
involved and will help multidisciplinary and interdisciplinary treatment because goals are shared and
the frame of reference is known to all. 1 of the ways to do this is by planning and evaluating the
treatment of the individual patient in a treatment plan.
An 11-step basic plan for treatment:
Evidence-based medicine (EBM) is an approach to caring for patients that involves the explicit and
judicious use of the clinical research literature combined with an understanding of pathophysiology,
clinical experience, and patient preferences to aid in clinical decision making. EBM is designed to
make treatment decisions less biased to preferences or expertise of professionals. Additionally, the
application of EBM processes helps to ensure that the most effective form of care is offered on the
basis of arguments and responsibility, as supported by scientific evidence.
1
,Applying EBM in clinical practice is done via a 5-step method:
1. Translate the clinical problem into an answerable question
2. Search efficiently for the best evidence
3. Assess the evidence in terms of methodological quality and applicability in your own clinical
situation
4. Make a decision on the basis of the evidence
5. Evaluate the quality of this process on a regular basis
The process of clinical decision-making:
Some common pitfalls in EBM are the use of habits, rules and rituals of professionals (why is the
evidence better than what I have done over the last 20 years?) and the often hierarchical structure in a
medical setting (e.g., the head of the department may lead decisions about treatment rather than the
evidence). In addition, patients have become more informed and empowered over the years, which
makes the role of the patients’ preferences more influential in decision making. 1 of the developments
along this line is shared or collaborative decision making, a process in which clinicians and patients
communicate together about the best available evidence to guide the treatment decision.
The RCT offers the best design to study the effectiveness of treatment. The reporting of RCTs can be
improved by using well-accepted checklists, such as the Consolidated Standards of Reporting Trials
(CONSORT) statement that was developed with the intention of facilitating the clear and transparent
reporting of trials.
Originally, the CONSORT statement was developed for use in pharmacological trials. In non-
pharmacological treatment studies it is not always possible to offer a sham intervention, and blinding
of patients and professionals is also difficult. As a result, these RCTs could potentially be rated as
having lower quality and therefore an alternative checklist for the report of non-pharmacological
studies was developed. Specifically, the checklist to evaluate a report of a non-pharmacological trial
(CLEAR-NPT) is a more suitable tool to critically appraise RCTs in the field of neuropsychological
rehabilitation. Items in this checklist concern:
1. Patient characteristics to help clinicians decide whether patients in the study are comparable to
patients in their own setting
2. Treatment characteristics to help clinicians decide whether the treatment is applicable to their
own setting
3. Information on treatment goals, costs and benefits to enable clinicians to anticipate the
outcomes
1 of the most efficient ways to translate this enormous amount of evidence into clinical practice is to
use evidence-based guidelines. These are often published by professional societies or governmental
organizations or teams of researchers and clinicians working together to formulate recommendations
for clinical practice.
In the field of neuropsychological rehabilitation the INCOG recommendations for the management of
cognition following traumatic brain injury can be used. An international group of researchers and
clinicians (known as INCOG) convened to develop clinical practice guidelines for cognitive
rehabilitation following traumatic brain injury. The INCOG group formulated recommendations on
five topics: post-traumatic amnesia and delirium, attention and information processing speed,
executive function and self-awareness, cognitive communication, and memory.
2
,Another way of gathering best evidence is by using information from the Cochrane Collaboration,
which is a global independent network of researchers, professionals, patients, carers and people
interested in gathering high-quality information to make health decisions. Results from systematic
reviews are published in Cochrane Reviews, which can be accessed easily. For the field of
neuropsychological rehabilitation, relevant reviews are available on many topics.
Implementing a treatment or replicating a study based on an RCT is not always possible because
essential information in the reporting may be missing: (1) it may not be possible to judge the reliability
and validity of the trial findings, and (2) information concerning the treatment itself may be missing.
Single case experimental design (SCED) is used to describe studies in which 1 participant, or a series
of participants, is studied in an experimental design in which the participant(s) act as their own
control. Measurements are conducted repeatedly before the intervention (baseline phase), during the
intervention (intervention phase) and possibly during a maintenance or treatment withdrawal phase.
Confounding factors are controlled for in various ways. Many different designs are used, such as
reversal designs (ABA or ABAB designs), multiple baseline designs and alternating or parallel
treatment designs. Various names have been used to describe this type of study, including N-of-1
Trials.
The power of the SCED relates to the number of measurements, rather than the number of participants
as in group designs. The external validity of the SCED is increased when the design is replicated with
more participants. SCEDs are different from case descriptions, case reports and pre-post designs where
the design is mostly observational and outcomes are descriptive.
SCEDs are preferable when the patient population of interest shows high variability or cases are rare,
which impedes the formation of homogeneous large-scale samples that are needed to conduct well-
designed RCTs.
Over the last few years, SCEDs have gained popularity. This renewed interest may be due to the
following changes:
1. SCEDs are now ranked as level 1 evidence by the Oxford Centre for EBM
2. Tools for assessing the quality of SCEDs and guidelines for reporting the results of SCEDs are
now available
3. The methods for analyzing SCED data are improving and statistical analysis methods are
becoming more available and accepted
Economic evaluation can be defined as the comparative analysis of alternative courses of action in
terms of costs on the one hand (resource use) and consequences on the other hand (outcomes, effects).
The aim of economic evaluation studies is to describe, measure and value all relevant alternative costs
and consequences.
Different types of economic evaluation exist, such as cost-benefit analysis, cost-effectiveness analysis
and cost-utility analysis. In partial economic evaluations (e.g. cost-analyses and cost-description
studies), less evidence on the description, measurement or valuation of health-care interventions and
technologies is provided in comparison to full economic evaluations.
Economic evaluation research can be used in different areas of health care, regardless of the type of
intervention, population or disease. However, there are certain types of intervention which are of
specific interest to the field of economic evaluation research due to their potential for being cost-
effective for more than 1 population (e.g. self-management interventions).
3
,Some requirements can be formulated for all forms of evaluation, regardless of the design:
1. The level of functioning of the patient needs to be assessed at predetermined times, using the
same instruments
2. Measurements chosen to measure change in functioning should be aligned with the goals of
treatment (e.g., when the aim of treatment is return to work, it does not make sense to repeat a
neuropsychological test)
3. Group studies typically report statistical significance on the basis of mean scores of the total
group. In clinical practice mean scores are less relevant. Other forms of reporting results of
studies on effectiveness should therefore also be considered. These forms may include:
− The level of clinical relevance in addition to statistical significance by reporting, for
instance, the percentage of patients that improved x points on the primary outcome
measure
− Other parameters in which individual improvements are taken into account (e.g., the
Reliable Change Index (RCI))
− Individualized outcome measures on both a group and individual level. Goal
Attainment Scaling is a valuable tool for this purpose and has been shown to be
feasible in measuring outcome of rehabilitation after brain injury
− Client-centered outcome measures when considering outcome from a more individual
point of view
Rehabilitation of slowed information processing (chapter 13) – Fasotti
Slowness of information processing or reduced processing speed is 1 of the foremost symptoms after
acquired brain damage. Not only does slow information processing hamper several cognitive
processes like attention, memory and executive function, it also has a major impact on the life of
patients. Everyday tasks can feel overwhelming. Being no longer able to mentally keep up with the
cognitive demands of daily life tasks may in turn lead to fatigue, depressive mood, irritability and
exhaustion.
The problem of slow information processing is likely to be exacerbated by new developments in
modern society.
Speed of information processing refers to how quickly a person can react to incoming information.
This process consists of several operations such as encoding, understanding and manipulating
information, formulating a reaction and executing a selected response.
In the majority of studies on acquired brain injury (ABI), speed of information processing has been
measured using neuropsychological tests, such as the Symbol Digit Modalities Test (SDMT) or the
Trail Making Test (TMT). In neuropsychological tests, cognitive operations and speed of motor
reaction are not distinguished and hence are computed as 1 variable. A notable exception is the
DKEFS Trail Making Test, in which contrast conditions allow control of motor speed.
Often, speed of completion of the test and accuracy scores (e.g. errors) are interpreted as measures of
processing speed, as in the Stroop Color-Word Test or in the TMT. Alternatively, the number of items
correctly completed within a certain time limit is recorded, as in the SDMT. Moreover, in some tests,
reaction times (RTs) are measured, as in the Selective Attention Task. It is only in reaction time tasks
that decision times and motor response times have been regularly registered and described separately.
In contrast to performance on decision times, the motor response speed of patients with TBI with no
motor deficits in the preferred hand is comparable to healthy controls. Stroke patients responding with
the hand ipsilateral to their lesion have only slower movement times in cognitively demanding tasks,
but not in simple and choice reaction tasks. In a rare study investigating slowness in several separate
cognitive stages, like encoding and response selection, it was found that slowness after TBI is
generalized and does not pertain to any particular stage in cognitive processing.
4
,Speed of information processing can also be measured through behavioral observation. The Rating
Scale of Attentional Behaviour (RSAB) developed by Ponsford and Kinsella (1991) contains several
items related to slow information processing like ‘Been slow to respond verbally’, ‘Been slow in
movement’, or ‘Performed slowly on mental tasks’, which are rated by therapists on a 5-point scale
ranging from ‘Not at all’ to ‘Always’.
Winkens et al. (2009) developed the Mental Slowness Observation Test (MSOT). The final version of
this test contains 4 tasks that are commonplace for most people, amenable to accurate timing and
easily standardized. The tasks were designed to measure performance in time pressure situations such
as following a route description, sorting money and making a telephone call. 2 tasks have a
predetermined time, after which they are interrupted, whereas the time taken to perform the
assignment and the number of correct elements achieved are recorded for other tasks.
Self-report measures in which patients with ABI can indicate their own perceptions of problems with
speed of information processing in daily life, are also used. Winkens et al. (2009) developed the
Mental Slowness Questionnaire (MSQ) comprising 21 daily activities related to slow information
processing such as ‘I have trouble following a conversation’ or ‘I have trouble doing 2 things at the
same time’. Items are scored on a 5-point frequency scale and on a 3-point severity scale.
Overall, a combination of approaches can be used to assess speed of information processing in
research and clinical practice.
Some authors have demonstrated that when slowness in basic speed of information processing is
controlled for, deficits in divided attention, focused attention and task switching are no longer
apparent. This suggests that most attentional processes are dependent on adequate speed of
information processing. However, other studies have shown that deficits in the strategic control of
attention are still present after slowness of information processing has been accounted for. These
findings support the pervasive and independent influence of reduced speed of information processing
on attentional performance after TBI.
Although slowness of information processing shows a significant amount of recovery after ABI
(especially in patients with TBI after the first 6-8 months post-injury), this slowness remains a chronic
impairment for many patients.
The ratio between the reaction times of patients and those of controls is approximately 1.5, meaning
that patients react at a speed approximately 1/3 slower than healthy controls. This reaction time ratio
appears to be even slightly larger in more complex tasks than in the more straightforward choice
reaction time tasks. These findings help to understand why people with brain injury easily become
overwhelmed in daily life by the fast speed at which information is presented and events take place.
The mechanisms by which slow information processing may hamper task execution (especially in
time-limited tasks) have been hypothesized by Salthouse (1996). He postulated 2 mechanisms
responsible for impaired performance in cognitive speed tasks:
1. Limited time mechanism: during the achievement of a cognitive task the time to perform later
operations is greatly restricted when a large amount of the available time is occupied by the
execution of early operations. This mechanism is at work in tasks with external time limits,
wherein relevant cognitive operations are achieved too slowly within the available time
2. Simultaneity mechanism: the products of early processing may be lost by the time they are
needed for later processing. In other words, when information is processed slowly, relevant
information may not be available or be impoverished or degraded by the time it is needed
5
, In general, there are 3 main approaches to treating mental slowness after brain damage:
1. Pharmacological trials: the improvement of impaired speed of information processing is
pursued by administering methylphenidate. Methylphenidate has been widely used for the
treatment of ADHD, and to improve attentional behavior and speed of information processing
after TBI. There is clear evidence of stimulants on neuropsychological test performance, but
less clear evidence on behavioral ratings
2. Remedial or restorative approach: aims at improving speed of information processing to
restore the person’s abilities to a level that approximates normal function. In terms of
theoretical sophistication and quality of evidence, the lower end of the remedial approach is
occupied by so-called brain games. The effectiveness of brain games is questionable: training
effects are often nonsignificant or small in size, there is no support of broad gains (effects
restricted to the trained function), there is limited support of long-term effects, and studies are
often methodologically flawed (e.g. poorly controlled)
− Theoretically grounded training programs are computerized programs to improve the
speed of processing of patients with brain injury, which are specifically developed to
train multiple aspects of attention (e.g. Attention Process Training (APT) and specific
attentional training programs). The training of processing speed is an important
component in most trainings because of the role of processing speed for daily life and
other cognitive operations. Several studies show significant improvements in speed of
processing. However, generalization to untrained tasks and daily functioning is not
sufficiently supported
− In summary, the sole reliance on computer-based interventions to improve speed of
information processing, even when targeted at specific attentional processes involving
speed demands, is not recommended. The main reasons are the task specificity of the
effects and the lack of evidence of generalization to daily life tasks
3. Compensatory approach: assumes that increasing speed (especially in daily life tasks) is an
unattainable aim and that it is more beneficial for patients to learn compensatory strategies to
circumvent the consequences of mental slowness. An approach to managing slow information
processing is strategy training, which entails teaching brain-injured patients metacognitive
strategies that allow them to compensate for the consequences of their mental slowness and
thereby reduce the negative consequences that this slowness produces in everyday life
− Time Pressure Management (TPM) is an example of strategy training. The framework
underlying TPM was derived from an earlier idea proposed by Michon (1979) in
traffic psychology. Traffic behavior was conceptualized as a hierarchically ordered set
of subtasks with 3 levels of time pressure:
1. Strategic level (the highest level): decisions preceding the critical action.
Risks involved at this level are minimal because decisions can usually be
made with ample time margins, with minimal amounts of internal time
pressure
2. Tactical level: anticipating critical events. At this level some time pressure
will be felt because there is a time limit wherein decisions have to be taken
3. Operational level: action taking from moment to moment. At this level,
decisions to avoid dangerous situations have to be made within very narrow
time limits and the risk of inadequate or too slow reactions is ubiquitous
− Although a compensatory approach to slow information processing like TPM is
considered beneficial for improving the performance of people with brain injury in a
large range of daily life tasks, the evidence in favor of strategic or metacognitive
approaches remains mixed. To date it has not been possible to demonstrate an
unequivocal relationship between the use of compensatory strategies and improved
performance in tasks requiring speed of information processing. Also, generalization
to other cognitive domains and other daily tasks remains to be shown
6
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