Innovations in Clinical Neuropsychology
Lectures
Table of contents
Week 1 – Introduction ..............................................................................................................2
Week 2 – Visuospatial cognition: VR and serious gaming ...........................................................8
Week 3 – Memory and attention ............................................................................................. 16
Week 4 – Motor skills ............................................................................................................. 27
Week 5 – Neurotechnology .................................................................................................... 34
Week 6 – MS screener & music robots .................................................................................... 42
Week 7 – Teleneuropsychology ............................................................................................... 48
, Week 1 – Introduction
When we think about innovation, we most often think about technology. However, we should not
always take them at face value and assume that they are working.
Technology and the brain
- Brain trainings claimed that they:
o Improve performance in school/work
o Delay age-related cognitive decline
o Reduce impairment from health conditions
- The market was flooded with these brain training tools. However, we should not take
these at face value. Companies claimed that they should delay age-related cognitive
decline, but they could not provide any scientific evidence for this.
- Lumosity to pay $2 million to settle FTC deceptive advertising charges for its ‘Brain
Training’ program: As noted by Jessica Rich, director of the FTC's Bureau of Consumer
Protection, "Lumosity preyed on consumers' fears about age-related cognitive decline,
suggesting their games could stave off memory loss, dementia, and even Alzheimer's
disease. But Lumosity simply did not have the science to back up its ads.“
- Do ‘Brain Training’ programs work? “We find extensive evidence that brain-training
interventions improve performance on the trained tasks, less evidence that such
interventions improve performance on closely related tasks, and little evidence that
training enhances performance on distantly related tasks or that training improves
everyday cognitive performance.”
➔ Ongoing research and discussion (Near and far transfer effects)
- If you train a Stroop task, you will get better at a Stroop task, but not at chess or at work,
for example → near effects, no far effects
- However, these technical innovations are still very relevant for us, because they
dominate our daily life
Daily life solutions: Smart Everything
- Smartphone, smartwatch, smart fridge, smart solutions for people that lose their keys
- Everything fits in your pocket nicely and neatly, and everything is smart now
Technology development
- From passive to active to interactive
- Passive: classic input-output
- You are not just connecting to your computer, but with your
computer, you are connecting to everyone out there whenever
you want, even though you are alone on your computer.
Technology in navigation
- Then: planning with compasses and maps
- Now: Google Maps does the planning for you
Technology and education
- World maps, learning about dinosaurs by scanning the world map with your phone, and
the app shows you in which countries the dinosaurs lived
- Human body anatomy (skeleton, central nerve systems, muscles, skin, etc.)
- Interactive virtual reality: you can select what you want to learn about by gaze
- E.g., augmented reality sandbox helps conceptualize a flat 2D map as a 3D model
,Technology and sports
- By using a screen (e.g., football)
- By using virtual reality (e.g., basketball)
- Sometimes there is a solution, but there is not really a problem (like a virtual reality gym)
Technology and neuropsychology (Parson & Duffield, 2020)
- There is little technological innovations in neuropsychology if you
look at the broader field/literature: ~6% of tools were computerized
- Obsolete technologies (no new ideas)
- They did a literature search and checked the number of publications
with a specific discipline combined with a key word technology,
computer or neuroimaging
- Over the years, publications over time have exponentially grown for
neurology and neuroscience, but for neuropsychology, publications
are still very low
- This is troubling because we don’t use technology, computers, or
neuroimaging when we publish papers
- Metrisquare is a hopeful initiative. They provide digital
neuropsychological testing
Why should we innovate?
- Technical development → It is available, so let’s use it
o Often not the best reason for innovations
- Scientific motivation → More insights into cognitive function
o By using tests or digital tools, where more participants and data can be reached
- Less limitations than existing materials → More data and less susceptible to issues?
o E.g., More in line with the real-world function that you want to measure
Where can we even innovate? Categories:
- Diagnostic tools
- Treatment tools
- eHealth
- Neurotechnology
- Non-technological “innovations”
Innovations in diagnostics
- Computer-based assessment of cognition is mostly utilized in
o Military (first to develop/test it)
o Sports
➔ Why? Both military and sports have the need, since there are a lot of people who need to
be tested. They are also advanced in these things, because they have the money
(resources), and innovations are not cheap.
- Who not so much in clinical practice?
o Financial costs
o Neuropsychologists are a bit reserved when it comes to implementing
innovations
o Lack of normative data: different data for digital cognitive tests and on paper, you
cannot assume they are the same
o Concerns about utility and validity (see Miller & Barr, 2017)
➔ Digital versions of existing standardized material
,NCATs (= NeuroCognitive Assessment Tools) for military personnel with mTBI (Jones et al., 2021)
- Scoping literature review (≠systematic review)
o 33 studies included (~30,000 participants)
o Neurocognitive assessment tools: ImPACT, ANAM, DANA
- Recommendations for healthcare professionals
o Use these digital versions cautiously (not standalone); do not just blindly rely on
them and just use the digital version, since the current norm data might not be
fully established yet. You might still want to use the pen and paper version on the
side, which might also help establish norm data in the future
o Use what you “feel best fits [your/the clinician] needs and targeted populations”.
It is also about accessibility.
o Consider age and education as context; not everyone is comfortable with using
digital assessments (both the administrator and the taker of the test)
o Remain aware of forthcoming recommendations
- The authors looked for the Randolph criteria (= derived from the field of sports
diagnostics) → In order to be classified as a good tool, the tool should have:
o Test-retest reliability
o Sensitivity
o Validity
o Reliable change scores (do you get worse or better?)
o Clinical utility
Advantages of computerized NCATs
- More detailed measurements
o Time (e.g., initiation, inspection, per item)
o Drawing and writing (e.g., start, clustering, neglect); the program can
assign different colors to different time intervals. Color-coding gives you
insight into the process, which improves the diagnostics.
o You have a lot of extra data digitized and on a millisecond resolution, which you
do not have if you manually assess time.
- Tailoring to specific needs
- Ease of use (once you know how to use them)
- Reducing human error
- Mimicking everyday situations → measuring
everyday functioning
- Remote and portable testing
Disadvantages of NCATs
- Norm data not directly transferable → Validity and reliability need to be proven for every
tool, which takes considerable work and resources
- Technical requirements (you need a tablet/phone and internet)
- Training of clinicians
- Cognitive processes are possibly different for the digital environment
o Tools or processes had to be altered or added that are not necessary in the pen
and paper version. A screen captures your attention differently.
- Cybersickness (e.g., in VR)
- Novelty costs (adjustment time needed)
o E.g., transition period where you do both the digital and pen and paper versions
, - Privacy issues (data storage); usually uploaded in the cloud instead of in a service in
their practice. Other companies often have the (sensitive) data of your patients. You
don’t know what these companies do with this data; they might even sell it.
Ecological validity of VR diagnostics? (Van der Ham et al.,
2015). Experiment with 4 conditions:
- Real (locomotion) vs hybrid (locomotion + tablet)
- Real: Participants walked through a hallway. At
certain locations, there were certain landmarks
(pictures of objects) installed
- Hybrid: Participants still walked, but not through the hallway. They could see
the walls and landmarks on a tablet.
- Virtual (no locomotion) vs virtual+ (no locomotion + compass): Participants
were passively navigated through the hallway.
- Condition affects performance selectively
o Landmark and route knowledge unaffected
o Locomotion benefits survey knowledge (allocentric: making a cognitive
map of your surroundings), not route knowledge (egocentric)
o Virtual navigation left your landmark and route knowledge unaltered, but it did
change how easily participants came up with a cognitive map
- Adding a compass actually makes performance worse; it is distracting
Treatment tools
- Less developed than diagnostics
- But rapidly increasing
- They are easier, more straightforward
- Tools focus mostly on physical therapy
➔ Increased ecological validity (but see diagnostics)
- Pelosin et al. (2022): Parkinson’s patients underwent virtual treadmill
training for either 6 or 12 weeks. Motor function and executive function
(cognition) were trained. The training on the treadmill decreased the
risk and fear of falling in patients for the next weeks and months. Even
cognition improved, more for the 12 weeks than the 6 weeks. The more training you got,
the better your improvement and the longer the improvements held. However, in the 6-
month follow-up, all the improvements were not significant anymore. They were short-
to-medium-term improvements, but no long-term improvements. So you might not want
to do 1 intervention, but you might need updating and continuous treatment.
- Conclusion: It does work to a certain degree, and we can actually increase ecological
validity, similarly to what we can do in diagnostics with these tools.
Something to consider for treatment is: What are we actually going to do?
- Compensation = (training to) use of another function (compared to the one that is
affected)
o Other function reduces impairment (e.g., changing cognitive strategy)
➔ Situations can be presented in which an alternative strategy is stimulated, with
digitalized or innovative treatment for example
- Restoration = improve lost/reduced function
o E.g., memory training
➔ Relevant situations can be presented that stimulate the function use
Lectures
Table of contents
Week 1 – Introduction ..............................................................................................................2
Week 2 – Visuospatial cognition: VR and serious gaming ...........................................................8
Week 3 – Memory and attention ............................................................................................. 16
Week 4 – Motor skills ............................................................................................................. 27
Week 5 – Neurotechnology .................................................................................................... 34
Week 6 – MS screener & music robots .................................................................................... 42
Week 7 – Teleneuropsychology ............................................................................................... 48
, Week 1 – Introduction
When we think about innovation, we most often think about technology. However, we should not
always take them at face value and assume that they are working.
Technology and the brain
- Brain trainings claimed that they:
o Improve performance in school/work
o Delay age-related cognitive decline
o Reduce impairment from health conditions
- The market was flooded with these brain training tools. However, we should not take
these at face value. Companies claimed that they should delay age-related cognitive
decline, but they could not provide any scientific evidence for this.
- Lumosity to pay $2 million to settle FTC deceptive advertising charges for its ‘Brain
Training’ program: As noted by Jessica Rich, director of the FTC's Bureau of Consumer
Protection, "Lumosity preyed on consumers' fears about age-related cognitive decline,
suggesting their games could stave off memory loss, dementia, and even Alzheimer's
disease. But Lumosity simply did not have the science to back up its ads.“
- Do ‘Brain Training’ programs work? “We find extensive evidence that brain-training
interventions improve performance on the trained tasks, less evidence that such
interventions improve performance on closely related tasks, and little evidence that
training enhances performance on distantly related tasks or that training improves
everyday cognitive performance.”
➔ Ongoing research and discussion (Near and far transfer effects)
- If you train a Stroop task, you will get better at a Stroop task, but not at chess or at work,
for example → near effects, no far effects
- However, these technical innovations are still very relevant for us, because they
dominate our daily life
Daily life solutions: Smart Everything
- Smartphone, smartwatch, smart fridge, smart solutions for people that lose their keys
- Everything fits in your pocket nicely and neatly, and everything is smart now
Technology development
- From passive to active to interactive
- Passive: classic input-output
- You are not just connecting to your computer, but with your
computer, you are connecting to everyone out there whenever
you want, even though you are alone on your computer.
Technology in navigation
- Then: planning with compasses and maps
- Now: Google Maps does the planning for you
Technology and education
- World maps, learning about dinosaurs by scanning the world map with your phone, and
the app shows you in which countries the dinosaurs lived
- Human body anatomy (skeleton, central nerve systems, muscles, skin, etc.)
- Interactive virtual reality: you can select what you want to learn about by gaze
- E.g., augmented reality sandbox helps conceptualize a flat 2D map as a 3D model
,Technology and sports
- By using a screen (e.g., football)
- By using virtual reality (e.g., basketball)
- Sometimes there is a solution, but there is not really a problem (like a virtual reality gym)
Technology and neuropsychology (Parson & Duffield, 2020)
- There is little technological innovations in neuropsychology if you
look at the broader field/literature: ~6% of tools were computerized
- Obsolete technologies (no new ideas)
- They did a literature search and checked the number of publications
with a specific discipline combined with a key word technology,
computer or neuroimaging
- Over the years, publications over time have exponentially grown for
neurology and neuroscience, but for neuropsychology, publications
are still very low
- This is troubling because we don’t use technology, computers, or
neuroimaging when we publish papers
- Metrisquare is a hopeful initiative. They provide digital
neuropsychological testing
Why should we innovate?
- Technical development → It is available, so let’s use it
o Often not the best reason for innovations
- Scientific motivation → More insights into cognitive function
o By using tests or digital tools, where more participants and data can be reached
- Less limitations than existing materials → More data and less susceptible to issues?
o E.g., More in line with the real-world function that you want to measure
Where can we even innovate? Categories:
- Diagnostic tools
- Treatment tools
- eHealth
- Neurotechnology
- Non-technological “innovations”
Innovations in diagnostics
- Computer-based assessment of cognition is mostly utilized in
o Military (first to develop/test it)
o Sports
➔ Why? Both military and sports have the need, since there are a lot of people who need to
be tested. They are also advanced in these things, because they have the money
(resources), and innovations are not cheap.
- Who not so much in clinical practice?
o Financial costs
o Neuropsychologists are a bit reserved when it comes to implementing
innovations
o Lack of normative data: different data for digital cognitive tests and on paper, you
cannot assume they are the same
o Concerns about utility and validity (see Miller & Barr, 2017)
➔ Digital versions of existing standardized material
,NCATs (= NeuroCognitive Assessment Tools) for military personnel with mTBI (Jones et al., 2021)
- Scoping literature review (≠systematic review)
o 33 studies included (~30,000 participants)
o Neurocognitive assessment tools: ImPACT, ANAM, DANA
- Recommendations for healthcare professionals
o Use these digital versions cautiously (not standalone); do not just blindly rely on
them and just use the digital version, since the current norm data might not be
fully established yet. You might still want to use the pen and paper version on the
side, which might also help establish norm data in the future
o Use what you “feel best fits [your/the clinician] needs and targeted populations”.
It is also about accessibility.
o Consider age and education as context; not everyone is comfortable with using
digital assessments (both the administrator and the taker of the test)
o Remain aware of forthcoming recommendations
- The authors looked for the Randolph criteria (= derived from the field of sports
diagnostics) → In order to be classified as a good tool, the tool should have:
o Test-retest reliability
o Sensitivity
o Validity
o Reliable change scores (do you get worse or better?)
o Clinical utility
Advantages of computerized NCATs
- More detailed measurements
o Time (e.g., initiation, inspection, per item)
o Drawing and writing (e.g., start, clustering, neglect); the program can
assign different colors to different time intervals. Color-coding gives you
insight into the process, which improves the diagnostics.
o You have a lot of extra data digitized and on a millisecond resolution, which you
do not have if you manually assess time.
- Tailoring to specific needs
- Ease of use (once you know how to use them)
- Reducing human error
- Mimicking everyday situations → measuring
everyday functioning
- Remote and portable testing
Disadvantages of NCATs
- Norm data not directly transferable → Validity and reliability need to be proven for every
tool, which takes considerable work and resources
- Technical requirements (you need a tablet/phone and internet)
- Training of clinicians
- Cognitive processes are possibly different for the digital environment
o Tools or processes had to be altered or added that are not necessary in the pen
and paper version. A screen captures your attention differently.
- Cybersickness (e.g., in VR)
- Novelty costs (adjustment time needed)
o E.g., transition period where you do both the digital and pen and paper versions
, - Privacy issues (data storage); usually uploaded in the cloud instead of in a service in
their practice. Other companies often have the (sensitive) data of your patients. You
don’t know what these companies do with this data; they might even sell it.
Ecological validity of VR diagnostics? (Van der Ham et al.,
2015). Experiment with 4 conditions:
- Real (locomotion) vs hybrid (locomotion + tablet)
- Real: Participants walked through a hallway. At
certain locations, there were certain landmarks
(pictures of objects) installed
- Hybrid: Participants still walked, but not through the hallway. They could see
the walls and landmarks on a tablet.
- Virtual (no locomotion) vs virtual+ (no locomotion + compass): Participants
were passively navigated through the hallway.
- Condition affects performance selectively
o Landmark and route knowledge unaffected
o Locomotion benefits survey knowledge (allocentric: making a cognitive
map of your surroundings), not route knowledge (egocentric)
o Virtual navigation left your landmark and route knowledge unaltered, but it did
change how easily participants came up with a cognitive map
- Adding a compass actually makes performance worse; it is distracting
Treatment tools
- Less developed than diagnostics
- But rapidly increasing
- They are easier, more straightforward
- Tools focus mostly on physical therapy
➔ Increased ecological validity (but see diagnostics)
- Pelosin et al. (2022): Parkinson’s patients underwent virtual treadmill
training for either 6 or 12 weeks. Motor function and executive function
(cognition) were trained. The training on the treadmill decreased the
risk and fear of falling in patients for the next weeks and months. Even
cognition improved, more for the 12 weeks than the 6 weeks. The more training you got,
the better your improvement and the longer the improvements held. However, in the 6-
month follow-up, all the improvements were not significant anymore. They were short-
to-medium-term improvements, but no long-term improvements. So you might not want
to do 1 intervention, but you might need updating and continuous treatment.
- Conclusion: It does work to a certain degree, and we can actually increase ecological
validity, similarly to what we can do in diagnostics with these tools.
Something to consider for treatment is: What are we actually going to do?
- Compensation = (training to) use of another function (compared to the one that is
affected)
o Other function reduces impairment (e.g., changing cognitive strategy)
➔ Situations can be presented in which an alternative strategy is stimulated, with
digitalized or innovative treatment for example
- Restoration = improve lost/reduced function
o E.g., memory training
➔ Relevant situations can be presented that stimulate the function use
