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Summary advanced clinical neuropsychology
Extensive summary of the master-course 'advanced clinical neuropsychology'.
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Advanced clinical neuropsychologyAdvancing the profession of clinical neuropsychology with
appropriate outcome studies and demonstrated clinical
skills (Prigatano & Morrone-Strupinsky, 2010)
Introduction
For clinical neuropsychology to flourish as a profession, two types of ‘data’ or ‘evidence’ are
needed. (1) data from ‘evidence-based’ outcome studies that demonstrate the efficacy and
the cost-effectiveness of our procedures and interventions. (2) individual practicing clinicians
demonstrating clearly to referring physicians the value of their clinical judgment in patient
care. The skills and our profession’s unique ability to add information to case
conceptualization need to be clearly taught to residents through a mentoring model so that
they can understand and communicate this information to providers.
If our profession will lose economic footing, the result will be two-fold. First, clients or patients
will be seen only on a ‘fee for service’ basis, which only some families can afford. Second,
there will be an expanding trend of neuropsychologists to do more ‘medical-legal’ work to
survive economically. → we need to evaluate what we do, how good we are at it, and what
is the value of our work.
Professional identity of neuropsychologists
Neuropsychologists have flourished because they have been able to relate their discipline to
a growing database in the neurosciences (technical knowledge). We must also be good at
taking this integrated information and presenting it in a way that helps reduce patients’
suffering and allows the referring physician to recognize that our contributions have improved
patient care.
The value of our work is ultimately judged by four individuals: the patient, a relevant family
member, the referral source, and the payor for the services we provide. Our goal is to
develop and train neuropsychologists to be scientist-practitioners who are able to blend our
science with patient and family needs and concerns.
Scope of practice of clinical neuropsychologists
Clinical neuropsychologists are actively involved in the examination and assessment of
individuals from infancy through the elderly years. Focus on trying to remediate or reverse
the effects of neuropsychological disturbances, or helping the person and family to adjust to
the permanent neuropsychological disturbances and return to a productive lifestyle. In
practice, clinical neuropsychologists must demonstrate to physicians the logic behind what
they say concerning a patient, and how their knowledge contributes to patient care → clinical
neuropsychologists must share a similar language and terminology as physicians.
Previous and continuing efforts
Advancing the profession of clinical neuropsychology requires carefully designed outcome
studies, which unequivocally demonstrate the ‘objective’ (economic and scientific) value of
our work, as well as its ‘subjective’ value to the patient, family, and physician (the degree to
which they are personally satisfied with our work and are willing to pay for it).
,Outcome research refers to research that produces some measurable change in a functional
system as a direct (or indirect) effect of a planned intervention or service. RCTs for treatment
or intervention effect, ‘cost-outcome’ studies for economic effect. Healthcare economic
studies often deal with cost-effectiveness issues. Intrinsic to cost-outcome research is the
concept of value. Value refers to the ‘worth’ of the service, and this can be measured both
objectively and subjectively. Economic value is one objective marker. The goal of
neuropsychologists is to obtain ‘fair value’ for their services (value corresponds with costs).
Future efforts
Outcome studies
Neuropsychologists should conduct outcome studies that demonstrate neuropsychological
testing/evaluations lead to practical decisions for patients (and their families).
Differential diagnostic question of neurological vs. psychiatric disorders. The economic
benefit of proper diagnosis, not to mention the subjective value for the patient, can be
staggering. Similarly, identifying patients who have epileptic vs. nonepileptic seizures could
potentially save the healthcare system several million dollars per year. Another area: when
neurosurgeons request objective information about change and neuropsychological
functioning after surgery. Neurosurgeons may also ask if abnormal findings observed on
neuroimaging are paralleled by neuropsychological impairments. Neuropsychology also
plays a role in rehabilitation (predict the time that is needed for patients to achieve certain
rehabilitation goals and educating family members in order to manage a person with known
neurological disturbances.
Neuropsychological test findings can lead to some practical decisions regarding patient care
(is patient safe to return home/work?).
Neuropsychologists need to conduct outcome studies to demonstrate that
neuropsychological testing/evaluations lead to the development of new knowledge relevant
to patient diagnosis and care.
The use of standardized neuropsychological tests helped neuropsychologists better
understand the predictable neuropsychological problems of TBI patients and what are the
important neuroanatomical correlates of these disturbances. These observations guide new
research questions.
Neuropsychologists need to conduct outcome studies to demonstrate that
neuropsychological knowledge/tests can be combined with neuroimaging to improve patient
care.
Outcome studies are needed to demonstrate that patients have less morbidity as a result of
surgeons having this knowledge and/or that they require much less speech and language
therapy following their operations.
Neuropsychologists need to conduct outcome studies to demonstrate that intervention
programs, based on neuropsychological and psychological principles, result in important
cognitive and behavioral changes for the patients, and these changes are mirrored in brain
structure and activation pattern changes.
Neuropsychologists need to conduct outcome studies to demonstrate that
neuropsychological interventions with patients not only reduce disability and improve the
quality of life of the patient, but also improve the quality of life of caregivers.
A major source of distress of parents of children with traumatic brain injury is they do not
know what the long-term outcome will be for their child. Further, studies suggest that
neuropsychologists have much to offer in reducing the costs associated with the care of
,patients who have dementia (e.g. progressive muscle relaxation techniques lead to a
decrease in psychiatric and behavioral disturbances in AD).
Neuropsychologists need to conduct outcome studies to demonstrate the economic impact
of not receiving neuropsychological assessments and interventions in a timely fashion.
Developing the clinical and professional skills of neuropsychologists
Primary clinical skills
Capacity to review the medical and psychosocial history of a patient and identify key
variables that bear on the neuropsychological interview and the examination
procedures
Capacity to carefully interview the patient and family and briefly reveal the complexity
of the problem.
Capacity to establish a therapeutic alliance with the patient and family member.
Capacity to examine a broad range of abilities that are necessary for diagnosis, clarify
the patient’s strengths and weaknesses, and develop possible interventions.
Capacity to give verbal feedback regarding the test findings to the patient and family.
Capacity to write reports that are concise and clear, which identify the next step in the
patient’s care and provide practical suggestions.
Capacity to perform cognitive rehabilitation as a method of either compensation or
restoration of function.
Capacity to conduct psychotherapeutic interventions to help the patients struggle with
his or her personal losses.
Capacity to educate the patient, family, and physician regarding how the underlying
brain disorder impacts neuropsychological functioning
Capacity to elucidate the next step in the patient’s care.
Professional skills
Demonstrated acknowledgment of the limits of our knowledge with the capacity to
advocate for the patient given the knowledge that is available.
Demonstrated capacity to negotiate conflicts within and between professions.
Demonstrated steadfastness in learning one’s profession over several years.
Seeking out fair reimbursement for our services, but never putting economic gain
over patient needs.
Self-monitoring or out personal and professional behaviour.
Demonstrated capacity to conduct ongoing clinical research to check on the validity of
our clinical assumptions.
Final points
Summary of what we consider to be important for our field:
1. Find your professional niche: doing something that meets your professional needs
while meeting the needs of others.
2. Recognize that neuropsychologists are not ‘mini’ neurologists, psychiatrists, or
radiologists. Be both a ‘good’ clinical psychologists and a ‘good’ neuropsychologist.
3. Evaluate the concept of value in healthcare economics: strive to provide ‘good value’.
, Fatigue in multiple sclerosis: Mechanisms, evaluation and
treatment (Braley & Chevin, 2010)
Abstract
Among patients with MS, fatigue is the most commonly reported symptom, and one of the
most debilitating. However, it is poorly understood and often under-emphasized because of
its complexity and subjective nature. The aims of this review are to examine the most
commonly proposed primary and secondary mechanisms of fatigue in MS, tools for
assessment of fatigue in this setting, and available treatment approaches to a most common
and challenging problem.
MS is an inflammatory disease of the central nervous system that results in myelin
destruction and axonal degeneration in the brain and spinal cord. 80% of patients present
with a relapsing-remitting subtype. In the majority of untreated cases, relapsing-remitting MS
evolves into a secondary-progressive phase during which the subject experiences a gradual,
insidious deterioration, usually in the form of paraparesis, hemiparesis, or dementia.
Therapies available for the management of the MS disease process can decrease the
frequency of clinical relapses and new radiological lesion formation. However, none of these
therapies reverse preexisting tissue damage or control chronic symptoms, such as fatigue,
that are common to all subtypes of MS.
Fatigue is considered to be one of the main causes of impaired quality of life among MS
patients, independent of depression or disability. Fatigue is also among the most common
symptoms. Fatigue remains poorly understood and often underemphasized for several
reasons. First, fatigue is a subjective symptom without a unified definition. Second, there is
no gold standard by which to measure fatigue. Finally, fatigue in MS patients may be
multifactorial. In addition to immunologic abnormalities, MS is associated with an increased
prevalence of other conditions that contribute to fatigue, including depression and several
sleep disorders.
Primary mechanisms
The most commonly proposed primary mechanisms of fatigue in MS involve the immune
system or sequelae from central nervous system damage (proinflammatory cytokines,
endocrine influences, axonal loss, and altered patterns of cerebral activation).
Cytokine influences
There may be increased cytokines in fatigued MS patients compared to non-fatigued
patients. However, both kinds of cytokines are relatively nonspecific and may be elevated in
a variety of inflammatory conditions.
Endocrine influences
The HPA-axis and the hormone dehydroepiandrosterone (DHEA) have been studied in
multiple autoimmune diseases in which fatigue is a common symptom. Both low cortisol and
low DHEA levels have been implicated in chronic fatigue syndrome. The fact that many MS
patients report increased energy while taking corticosteroids as treatment for their neurologic
symptoms further supports a possible hormonal influence. However, because of the chronic
nature of fatigue and risks of long-term steroid use, steroids are not advocated as treatment
for fatigue.
Axonal loss and altered cerebral activation
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