View
1
Download
0
Category
Preview:
Citation preview
!
ᇡޕநൺȉமϯ൩ࣴزीჄ!)CEG231132*!
Experience Sharing
Seminar
“Cognitive and
vocational
rehabilitation for drug
rehabilitees”
! !27!Pdu!3126!
! ! !
Cognitive Rehabilitation for Vocational
Training of Primarily Ketamine Users:
A Randomized Control Trial
Qspg!Ebwje!Nbo!! ЎӀ௲!
Goal
– To investigate the efficacy and effectiveness of virtual
reality-based vocational training system (VTS) as a
cognitive intervention for enhancing vocational
outcomes in ketamine users
Objectives:
• To improve the cognitive function and vocational outcomes of
youngsters who were primarily ketamine users through vocational
training systems (VTS).
• To investigate if there was any significant differences among two
treatment groups (virtual reality-based group /VRG, tutor-
administered group/TAG) and a wait-listing control group/CG) in
terms of cognitive performance, vocational outcomes and work-
related self-efficacy, during pre-test, post-test, 3-month and 6-month
follow up.
3
Content• Goal & objectives
• Brief literature review and conceptualization
• Research questions and methodology
• Summary of key results
– Effectiveness of VR- and Tutor-based training
– Correlations between rehabilitee’s cognitive
function and work status
• Discussion & conclusions
– Experience gained
2
Literature review :
• Ketamain was the top one psychotropic drug taken by secondary students (Li, Tam & Tam, 2010; Tsui et al.,2011).
• Cognitive problems have also been documented (Amann,2009; Morgan 2006; Stewart 2001; Rowland et al., 2005)
– Cognitive impairments such as attention, memory and executive function weresuggested to slow down the progress in work rehabilitation (Liberman, 1996)
• Cognitive functioning was one of the significant predictors ofvocational outcomes (Diller, Copeland & Jansen, 2008; Hougue, 2010)
• Minimizing the effect on this cognitive factor was thus hypothesized toimprove work rehabilitation outcomes and ultimately employability
4
The impact of cognitive impairment on vocational outcome in ketamine
users
eBiz Restructure Consulting
• eBiz Strategy Consulting.
• eBiz Management Consulting
• eBiz Restructure Consulting
Literature review
• VR can be defined as “...a way for humans to visualize, manipulate,and interact with computers and extremely complex data.” (Aukstakalnis and
Blatner, 1992).
• An advanced form of computer interface that allowed the user to“interact” with and become “immersed” within a computer generatedenvironment.
• VR training in CR can be explained by– Environmental enrichment (EE; Kolb, 1999)
– Contextual learning (CL).
• EE is referred to as simulation from a complex environment
– VR offers rich and vivid visual and auditory stimulations.
– A relatively complex and stimulating environment has a better trainingeffect than an impoverished environment.
• CL refers to the learning that takes place when day-to-day problems inreal-life situations are encountered (Gordon, Cantor, Ashman and Brown, 2006).
– More effective than learning isolated cognitive skills that are not clearlyrelated to the performance of functional tasks.
5
What is Virtual Reality (VR)? How VR works?
Figure 1: Application of the virtual reality-based vocational training system (VTS) in ketamine users’ rehabilitation
to enhance cognitive functioning and vocational outcomes in people with schizophrenia
Drug users
Cognitive deficits
Drilling and
practice in a work
context
Integrated
cognitive
processes
Facilitate work skills learning and
target cognitive deficits
Relevant to
user’s personal
goal
Controllable
Stimulus and
gradable
training
Increase self-efficacy and
intrinsic motivation
Tailor made to
fit individual
needs
Interactive and
dynamic
Promote task engagement in
the training process
Improved vocational
outcome
Virtual reality-based vocational training system (VTS)
-Attention
-Memory
-Executive
function
Ecological valid
Enriched environment
Contextual learning
Improved cognitive
functioning
6
Research questions
• Did VTS enhance cognitive performance in ketamine users?
– What was its impact of VTS on cognitive performance?
• Did VTS enhance vocational outcomes in people with
schizophrenia?
– What was the impact?
• Were there any significant differences between the three groups
(virtual reality-based training group: VRG; tutor-administered
group: TAG and control group: CG)
– in terms of cognitive performance
– vocational outcomes and
– work-related self-efficacy?
7
Research Hypotheses
• After completion of the 10-session vocational-
based cognitive training, the VRG would show
more improvements than the TAG and that
there would be no significant improvements in
the CG in the following aspects:
– Basic cognitive functions such as attention, memory and
executive functioning
– Work performance in doing sales-related tasks
– Self-efficacy score in doing sales-related tasks
– Vocational outcomes
8
Methodology
Sampling:
Inclusion criteria:
• Use of ketamine with frequency at least twice per month over 6 months withinthe last 2 years and no other illicit psychotropic drug used up to once per month within the last 2 year.
• Chinese ethnicity of both genders
• Age between 15 and 30
• Under treatment and rehabilitation following abstinence
• Negative results obtained from the rapid urinary test of Ketamine
• Able and willing to provide informed consent to participate in the study
Exclusion criteria:
• Mental retardation
• Neurological disorder
• Physical handicaps, for example blindness
• Significant medical diseases requiring regular medication
• Poly-drug group (use ketamine with other illicit psychotropic drug such as Ectascy or methamphetamine, with frequency at least twice per month over 6months within the last 2 years)
9
Simple structure of VTS
• The training module is divided into 3 levels:– Pre-trainee level, trainee level and sales level.
– Patient has to complete elementary training tasks (pre-trainee and
trainee level) under the supervision of a “manager “(computer
instructions).
– After the patient completed all the training in each level, he/she has to
pass a test before they entered the sales level which involved problem
solving tasks.
– As a salesperson, patient has to complete some preparation work (e.g.
sorting clothes and checking clothes) before the shop open and handle
requests raised by the customers
11
Instrumentation
Difference Similarities
VRG Cued stimuli or visualization
tactics were provided by the
computer program
• Received conventional skills
training
• Both VRG and TAG attended
individual training sessions, 30-45
mins per session, twice per week
for 5 weeks.
• The participants received training of
a similar content and structure but
with different delivery modes in
either VRG and TAG.
TAG -Practice tutorials guided by a
therapist
CG -No training in any sales-related
activities
10
VRVTS
Snapshot of the VR program (entrance)
Snapshot of the VR program (inner shop)
Snapshot of the VR program (store room)
Hardware of VRVTS
12
Outcome measures
- - -
Instrument Domain
Primary outcomes
The Test of Non-verbal Intelligence – Version III (TONI-III;
Brown, Sherbenou & Johnsen, 1997)
Overall cognitive
functioning
Digit Vigilance Test (DVT; Lewis, 1992) Attention
Rivermead Behavioural Memory Test (RBMT; Man and Li,
2001; Wilson et al., 1985)
Memory
Wisconsin Card Sorting Test-Computer Version 4 (WCST-
CV4; PAR)
Executive function
Employment status Open-employment to
unemployment
Secondary outcomes
On site test (self-designed checklist) Work performance
Self-efficacy score (self-designed) Self-efficacy
Cognitive and vocational outcomes before/ after training, at 3 month and 6 months follow ups16
20
Data analysis
• According Shapiro-Wilk Test of normality, the
criteria for normality was not met in most of the
dependent variables.
• Non-parametric alternative tests were used– Friedman Test (a non-parametric statistics similar to parametric
repeated measures ANOVA),
– Kruskall Wallist test (a non-parametric test to compare 2 or more
sample data) were used instead to test the differences.
– Post-hoc analysis was thus conducted by Wilcoxin Signed
Ranks Tests, instead of typical tests like the Tukey’s test.
ResultsBaseline measurement
18
Group comparisons over time
19 20
p p
- -
- -
21
Summary of findings• TONI3 (nonverbal intelligence)
– Result: No significant difference in change of TONI3 score among 3 groups, suggesting that allgroups had similar improvement across time.
– Interpretation: The change in TONI3 score was accounted by main time effect only. No groupeffect was observed. Maturation effect may account for the change. The result may alsosuggest that VRG and TAG have no additional benefit in improving intelligence.
• DVT (attention)– Result: Only VRG had significant improvement in DVT score, with large effect size
– Interpretation: The improvement in DVT score indicated significant improvement in sustainedattention. The result indicated that VRG had distinctive treatment effect in improving attention.The result may be accountable by the mode of training in VRG which more intensively requiredsustained attention.
• RBMT (memory)– Result: Only VRG showed significant improvement in RBMT score immediately after and 3
month after treatment, with large effect size.
– Interpretation: The improvement in DVT score indicated significant improvement in memory.The result indicated that VRG had distinctive treatment effect in improving memory and theeffect can be maintained for 3 months.
• WCST (executive functioning)– Result: Significant improvement across all treatment groups, no significant difference in change
observed among the groups
– Interpretation: The change in WCST score was accounted by main time effect only. No groupeffect is observed. Practice effect and maturation effect may explain the improvement in thescore across the time as the WCST score continued to increase with the number of trial. Theresult may suggest that VRG and TAG had no additional benefit in improving executivefunctioning.
23
Vocational status3 month follow up
(6 month follow up)
VRG (%) TAG (%) CG (%)
Unemployment100% (50%) 100% (83.3%) 100% (86.4%%)
Sheltered workshop0% (0%) 0% (0%) 0% (0%)
Supported employment0% (0%) 0% (0%) 0% (0%)
Part-time employment0% (18.2%) 0% (0%) 0%(0%)
Full-time employment0% (31.8%) 0% (16.7%%) 0% (13.6%)
Total 100% (100%) 100% (100%) 100% (100%)22
• Onsite Test (sales-related activities)– Result: Both VRG and TAG showed significant improvement in onsite test. The
improvement was shown immediately after treatment, and at 3 months and 6months follow-ups. Post-hoc analysis showed that the improvement in TAG was significantly larger than that of VRG at 3 months and 6 months follow-ups.
• Interpretation: Both VRG and TAG showed significant effect in enhancing salesjob skills. TAG was superior in sustaining the training effect when compared withVRG. The result may suggest that job skills learned in real environment or under real person instruction may be more sustainable than virtual reality.
• Self-efficacy (sales-related activities)– Result: Both VRG and TAG showed significant improvement in Self-efficacy
immediately after treatment but the effect did not last for 3 months and 6 monthsfollow-ups. Post hoc test showed that TAG had a larger improvement comparingwith VRG.
• Interpretation: Both VRG and TAG enhanced self-efficacy but the effect did notsustain. TAG was more effective than VRG in improving participants’ self-efficacyin sales-related activities. The result may suggest that human contact and realperson instruction may be more effective in enhancing self-efficacy in vocationaltraining.
• All the subjects at 3-month follow up were unemployed. And there were nostatistically significant difference in employment status at 6-month follow upacross the three groups respectively (χ2= 5.875; p=0.209) though VRG hadgot more open employment (VRG=31.8%) than TAG (16.7%) and CG group(13.6%); part-time employment (VRG=18.2%; TAG= 0%; CG=0%), lower percentage in unemployment (VRG=50%; TAG=83.3%; CG=86.4%).
24
Relationship between cognitive
status and outcomes• The canonical correlation between cognitive
function and work status for those successful
follow ups at the 3-month and 6-month follow-
ups were 0.363 and 0.477, respectively.
• When cognitive functioning was used to predict
work status, the overall classification rates were
65.3% (at the 3-month follow-up) and 54.7% (at
the 6-month follow-up).
⍫≈侭シ夳(暣儎妻䶜䳬)
㬋朊シ夳:
� ⬠⇘扟ⓖ㈨ⶏ⍲㹅忂㈨ⶏ
� ⬠佺 ⇘⼭⭊㈨ ⶏ⍲㚱侸 ⿏
� ⬠佺 ⇘㕘䘬 ḳ䈑 ġ
� 暣儎 䶜佺㗗 ⤥䘬 ,㘘䘬㊯⺽ ,ᶵ㚫 ⏓䱲 ⍲⎗慵墯䶜佺 ġ
� ⎗⡆⻢ ⇅⬠侭䘬 ᾉ⽫⍲娵䞍
� 㚱 ≑㍸ ⋯姀ㅞ
⍫≈侭シ夳Comments from the subjects
⍫≈侭シ夳(暣儎妻䶜䳬)
㓡┬シ夳:
�暣儎䦳⺷ ↢䎦㓭晄
�妻䶜ℏ⭡㰱ぞ
�暣儎䦳⺷嬲 ⊾⮷炻冯䎦 ⮎⟜㘗㚱嶅暊
⍫≈侭シ夳(⮶ⷓ妻䶜䳬)
㬋朊シ夳:
�⬠⇘扟ⓖ㈨ⶏ
�Ḯ妋埴㤕忳 ἄ炻 ⤪娵嬀 ƫ ⎴䧖栆䘬堋㚵炻堋㚵 ↮栆䘬䯉
⮓炻䆁堓⍲㐢堓
�⬠⇘㹅忂㈨ⶏ⍲⼭Ṣ㍍䈑ㅱ㚱ン⹎
�⮎佺㕡⺷,⭡㖻㖶䘥炻㈽ℍ⍲ℍ儎ġ
�姀ㅞ ≃㓡 ┬ᶨṃ
⍫≈侭シ夳(⮶ⷓ妻䶜䳬)
㓡┬シ夳:
�婚䦳姕妰䘬ね⠫⣒慵央,㚱ṃぞ
�㧉㒔 ⟜㘗 ƫ ⣈䛇 ⮎炻 ⭄㓦伖㚜 ⣂屐 ⑩⍲⮵娙 ⣒忶㚱䥖尴
�㭷➪䘬㗪攻⭄⡆≈炻ẍ⡆≈㗪攻姀ㅞ
2. Improvement in overall memory Discussionperformance in the VRG
1. VRG showed significant improvement in • due to greater spatial processing demand with
cognitive functions in respect of attention and virtual environment that could induce activity in
memory across time, but not in the TAG and the posterior hippocampus and parahippocampal
CG. cortex (Rose et al., 2005; Lee & Rudebeck, 2010).
• capacity of working memory may be enhanced– might be due to its unique mode of training, though
the VRG because of the activation of the corresponding
brain regions (Lee & Rudebeck, 2010; Baumann, et. al., 2003).– had to pay attention to the instructions and choices
– had to concentrate on multi-modal (visual andauditory) stimulus in an extended period of time
31 32
3. Both the VRG and the TAG showed significant
improvement in on-site vocational skills test
compared to that of the CG,
– They had a similar effect on the difference of learning
vocational skills in sales-related activities across time.
• Improvement in self-efficacy in the TAG was
greater than that of the VRG.
– could be related to greater skills competency and skill
generalization perceived by participants in the TAG
compared to that in the VRG.
33
5. Generalizability
of the study
• The subjects were required to complete a work
performance test in a boutique. They had to
perform tasks that were very similar to those that
they performed in the training scenarios.
• It was assumed that any improvements in work
performance would be mainly due to the transfer
effects of VR training or tutor training.
• Both the VRG and TAG showed significant
improvements in the on-site tests compared to the
CG, these results indicate that both treatment
groups showed good generalization effects.
35
4. Suitability of applying
VR in ketamine users
Highly relevant to the ketamine users’ perspective
� When people valued the tasks as being meaningful
and useful for reaching their future goals, they were
more intrinsically motivated to learn and possibly
benefit more from the learning task (Expectancy-value
theory, Choi et al, 2010, Fishbein and Ajzen, 1975)
� Learning, achievement performance and task
engagement to perceptions of self-efficacy and task
value were linked (Eccles and Wigfield, 2002).
� Perceptions of self-competency (self-efficacy), task
difficulty and the relative value of a task to an individual
can affect a person’s choice of whether or not to
engage in a learning activity or task.
Task
meaningful
Self
efficacy
Task
difficulty
Intrinsic
motivation
Task
engagement
LearningTask
achievement
34
6. Use of mixed mode of training?
– Effectiveness of virtual-reality based mixed
with tutor administered
7. Use of mobile technology in training
modes ?
– Apps
– Smart phone, tablet PC version
– “Work stations” incorporating cognitive training
8. Knowledge and technology transfer to
service sectors?
Conclusion
Conclusions
1. The use of VR technology in cognitive
remediation showed initial promising results to
improve the cognitive function, self-efficacy
and work skills for ketamine users
2. Potential use by service provider to ketamine
users
37
~ Thank you~
38
Recommended