Presentation Notes (Cognitive Rehabilitation for Vocational Training of Primarily Ketamine Users: A Randomized Control Trial) Slide No. 1 Text Content Cognitive Rehabilitation for Vocational Training of Primary Ketamine Users: A Randomized Control Trial 認知康復 – 強化就業硏究計劃 (BDF120021) Experience Sharing Seminar “Cognitive and vocational rehabilitation for drug rehabilitees” Prof David Man 文偉光教授 2 16 Oct 2015 Content 3 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 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). 4 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. Literature review : The impact of cognitive impairment on vocational outcome in ketamine users Ketamine 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 were suggested to slow down the progress in work rehabilitation (Liberman, 1996) Cognitive functioning was one of the significant predictors of vocational outcomes (Diller, Copeland & Jansen, 2008; Hougue, 2010) Minimizing the effect on this cognitive factor was thus hypothesized to improve work rehabilitation outcomes and ultimately employability 1 5 Literature review: What is Virtual Reality (VR)? How VR works? 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 generated environment. 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 training effect than an impoverished environment. 6 CL refers to the learning that takes place when day-to-day problems in reallife situations are encountered (Gordon, Cantor, Ashman and Brown, 2006). – More effective than learning isolated cognitive skills that are not clearly related to the performance of functional tasks. 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 Virtual reality-based vocational training system (VTS) Ecological valid: Promote task engagement in the training process (Tailor made to fit individual needs; Interactive and dynamic) Facilitate work skills learning and target cognitive deficits (Drilling and practice in a work context; Integrated cognitive processes) Enriched environment, Contextual learning: Increase self-efficacy and intrinsic motivation (Relevant to user’s personal goal; Controllable Stimulus and gradable training) All the above factors affect drug users (with cognitive deficits: Attention, Memory, Executive Function) The VTS lead to: Improved cognitive functioning and Improved vocational outcome 7 Improved cognitive functioning also lead to improved vocational outcome 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 2 8 – vocational outcomes and – work-related self-efficacy? 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: 9 – 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 Methodology Sampling: Inclusion criteria: Use of ketamine with frequency at least twice per month over 6 months within the 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 10 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 6 months within the last 2 years) Instrumentation Group (VRG), Difference (Cued stimuli or visualization tactics were provided by the computer program), Similarities (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) Group (TAG), Difference (Practice tutorials guided by a therapist), Similarities (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) 11 Group (CG), Difference (No training in any sales-related activities), Similarities (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) 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). 3 - 12 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 VRVTS 13 Photographs of practice tutorial setting and virtual reality training system VRVTS 14 Screen captures of virtual reality training session Cognitive Rehabilitation for Vocational Training of Primarily Ketamine Users: A Randomized Control Trial 認知康復-強化就業硏究計劃 Therapist – administered training group 治療師認知訓練組 15 16 Manual 訓練內容 1 至 10 堂 每堂時間:30-45 分鐘 Content page of manual used by the therapist-administered training group Instrument Instrument for primary outcomes: The Test of Non-verbal Intelligence – Version III (TONI-III; Brown, Sherbenou & Johnsen, 1997) Domain: Overall cognitive Functioning Instrument for primary outcomes: Digit Vigilance Test (DVT; Lewis, 1992) Domain: Attention Instrument for primary outcomes: Rivermead Behavioural Memory Test (RBMT; Man and Li, 2001; Wilson et al., 1985) Domain: Memory Instrument for primary outcomes: Wisconsin Card Sorting Test-Computer Version 4 (WCSTCV4;PAR) Domain: Executive function Instrument for primary outcomes: Employment status Domain: Open-employment to unemployment Instrument for secondary outcomes: On site test (self-designed checklist) Domain: Work performance Instrument for secondary outcomes: Self-efficacy score (self-designed) Domain: Self-efficacy 17 Cognitive and vocational outcomes before/ after training, at 3-month and 6months follow-ups 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 4 18 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. Results Baseline measurement 19 Table 1: Demographic characteristics and baseline outcome measures by groups (VRG, TAG and CG) Groups comparison over time 20 21 22 Table 2: Post-intervention, 3 months follow-up, and 6 months follow-up measures of primary and secondary outcomes by groups(VRG, TAG and CG)) Table 3: Comparison of outcome measures among 3 groups Table 4: Post-hoc analysis of change in outcome measures across 4 time points Vocational status - VRG: 3-month follow-up Unemployment (100%) Sheltered workshop (0%) Supported employment (0%) Part-time employment (0%) Full-time employment (0%) VRG: 6-month follow-up Unemployment (50%) Sheltered workshop (0%) Supported employment (0%) Part-time employment (18.2%) Full-time employment (31.8%) ----TAG: 3-month follow-up Unemployment (100%) Sheltered workshop (0%) Supported employment (0%) Part-time employment (0%) Full-time employment (0%) TAG: 6-month follow-up Unemployment (83.3%) Sheltered workshop (0%) Supported employment (0%) Part-time employment (0%) Full-time employment (16.7%) ----CG: 3-month follow-up Unemployment (100%) Sheltered workshop (0%) Supported employment (0%) Part-time employment (0%) Full-time employment (0%) 23 CG: 6-month follow-up Unemployment (86.4%) Sheltered workshop (0%) Supported employment (0%) Part-time employment (0%) Full-time employment (13.6%) Summary of findings (I) 5 - 24 TONI3 (nonverbal intelligence) Result: No significant difference in change of TONI3 score among 3 groups, suggesting that all groups had similar improvement across time. - Interpretation: The change in TONI3 score was accounted by main time effect only. No group effect was observed. Maturation effect may account for the change. The result may also suggest 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 sustained attention. 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 required sustained 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 the effect 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 group effect is observed. Practice effect and maturation effect may explain the improvement in the score across the time as the WCST score continued to increase with the number of trial. The result may suggest that VRG and TAG had no additional benefit in improving executive functioning. Summary of findings (II) 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 6 months 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 sales job skills. TAG was superior in sustaining the training effect when compared with VRG. 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 months follow-ups. Post hoc test showed that TAG had a larger improvement comparing with VRG. • Interpretation: Both VRG and TAG enhanced self-efficacy but the effect did not sustain. TAG was more effective than VRG in improving participants’ self-efficacy in sales-related activities. The result may suggest that human contact and real person instruction may be more effective in enhancing self-efficacy in vocational training. All the subjects at 3-month follow up were unemployed. And there were no statistically significant difference in employment status at 6-month follow up across the three groups respectively ("2= 5.875; p=0.209) though VRG had got more open employment (VRG=31.8%) than TAG (16.7%) and CG group 6 25 (13.6%); part-time employment (VRG=18.2%; TAG= 0%; CG=0%), lower percentage in unemployment (VRG=50%; TAG=83.3%; CG=86.4%). 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. 27 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). 參加者意見 Comments from the subjects 參加者意見(電腦訓練組) 28 正面意見 學到銷售技巧及溝通技巧 學習到待客技巧及有耐性 學習到新的事物 電腦做是好的,清晰的指引,不會含糊及可重複練習 可增強初學者的信心及認知 有助提升記憶 參加者意見(電腦訓練組) 29 改善意見 電腦程式出現故障 訓練內容沉悶 電腦程式變化小,與現實場景有距離 參加者意見(導師訓練組) 30 正面意見 學到銷售技巧 了解行業運作,如認識不同種類的衣服,衣服分類的簡寫,燙衫及摺衫 學到溝通技巧及待人接物應有態度 實習方式,容易明白,投入及入腦 記憶力改善一些 參加者意見(導師訓練組) 31 改善意見 課程所設計的情境太重覆,有些悶 模擬場景不夠真實,宜放置更多貨品及對話太過有禮貌 每堂的時間宜增加,以增加時間記憶 Discussion (I) 26 1. VRG showed significant improvement in cognitive functions in respect of attention and memory across time, but not in the TAG and the CG. 32 might be due to its unique mode of training, though the VRG had to pay attention to the instructions and choices had to concentrate on multi-modal (visual and auditory) stimulus in an extended period of time. Discussion (II) 2. Improvement in overall memory performance in the VRG Due to greater spatial processing demand with virtual environment that could induce activity in posterior hippocampus and parahippocampal cortex (Rose 7 33 et al., 2005; Lee & Rudebeck, 2010). Capacity of working memory may be enhanced because of the activation of the corresponding brain regions (Lee & Rudebeck, 2010; Baumann, et. al., 2003). Discussion (III) 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. - 34 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. Discussion (IV) 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. Learning, Task achievement Intrinsic motivation, Task engagement Task meaningful, Self-efficacy, Task difficulty 35 Discussion (V) 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. 36 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. Discussion (VI) 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? 8 37 38 39 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. Thank you Q&A 9