Single Case EMDR Congres 27032017 · 28/03/17 1 Single-Case Experimentele designs Johan Vlaeyen en Bart Michiels EMDR congres 31 Maart 2017 1. What is translaonal science? 28/03/17

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Single-Case Experimentele designs Johan Vlaeyen en Bart Michiels EMDR congres 31 Maart 2017

1.  Whatistransla-onalscience?2.  Single-caseexperimentaldesigns3.  Design&sta-s-calanalysis4.  AnIllustra-on:fearreduc-oninchronicpain

Overview

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Overview

Thelab

Theclinic

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Thelab

Theclinic

Thelab

Theclinic

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Thelab

TheclinicExperiencewithasesmentsandtreatmentsforpa-ents

ExperiencewithExperimentalcontrol

Publica-ons

Thelab

Theclinic

TRANSLATION

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…effec-vetransla-onofnewknowledge,mechanisms,andtechniquesgeneratedbyadvancesinbasicscienceresearchintonewapproachesforpreven-on,diagnosis,andtreatmentofdisease.

JAMA 2008

…ensuringthatnewtreatmentsandresearchknowledgeactuallyreachthepa-entsorpopula-onsforwhomtheyareintendedandareimplementedcorrectly.

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Basicscience Clinicalapplica-on

Transla-onalresearch

Basicscience Clinicalefficacy Clinicaleffec-veness

Popula-onhealth


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ClinicalefficacyBasicscience

T2 T3

Clinicalefficacyresearch

T1

-  Compara3veoutcomestudies-  Cost-effec3veness

T2

-Implementa3onofinterven3ons-  healthcaresystemredesign-  Treatmentfortherightpa3entontheright3me

T3

Clinicaleffec-veness

Popula-onhealth


Basicscience


€

Clinicalefficacy Clinicaleffec-veness

Popula-onhealth

T1 T2T3

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1.  Thebasisforpar-cipa-onshouldbetrustandreciprocity2.  Objec-vesaremeasurable3.  Gaincommitmentof“leadusers”4.  Engagetheworkforce

Principlesforknowledgesharing:

Trustandreciprocity:ClinicalskillsMedicalinfrastructurePar-cipants(pa-ents)

Noveltreatmentmodali-esDiagnos-cmethodsEvalua-onmethods

Transla-onalResearch&Treatment

Theclinic

ThelabSYNERGY

Theclinical lab

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Prac33onerScien3st

Descien-st-prac--onerbridgeTransla-onalResearch&Treatment

HOW?

Transla-onalresearch&Treatment

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Overview

PaulBroca1824-1880

GustavFechner1801-1887JND

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WilhelmWundt1832-1920Introspec3onPercep3onandsensa3on

HermannEbbinghaus1850-1909Learning&Memory

IvanPavlov1849-1936PhysiologyLearning

BurrhusFrederickSkinnerOperantbehavior1904-1990

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SirRonaldAylmerFisher1890-1962

Nomothe3capproach:ComesfromtheGreekwordνόμος“nomos”meaning“law”.

Assump3ons:• varianceisresultofmeasurementerror• measuringmethodsdonotinfluencethemeasurementitself• repeatableobserva-ons

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Sample-wisegeneraliza3onofknowledge

Sample

Popula-on

Nomothe3capproach:

Tradi-onalOutcomeEvalua-on:Group-basedRCT

B:ControlA:Experimental B(N=50)

A(N=50)R

Randomiza-on

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Tradi-onalOutcomeEvalua-on:Group-basedRCT

Voordelen:Uitsprakenovergemiddeldeveranderingvangrotegroepen:

MogelijkinteressantvoorpolicymakersNadelen:Erkunnengeenuitsprakengedaanwordenoverindividuen:

Nietzointeressantvoorbehandelaarsenpa-ënten

IdiographicmethodComesfromtheGreekwordιδιος“idios”meaning“own”or“private”.

Assump3ons:• everyobserva-onisunique• measuringmethodscaninfluencethemeasurementitself• goalis:“dasverstehen”(understand)

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Popula-on

A

B

C

D

Event-wiseindividualiza3onofknowledgeIdiographicapproach:

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Single-CaseExperimentalDesigns:PersonalizedN=1RCT

R R

Transla-onalResearch&TreatmentSmallisbeau3ful:

Replicatedsingle-caseexperiments

Asingle-caseexperimentisanexperimentinwhichoneunitisobservedrepeatedlyduringacertainperiodof-meunderdifferentlevelsofat

leastonemanipulatedvariable

Onghena&Edgington,2005

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Overview

1. ReliableandvalidmeasurementSensi4vetochangebutrobustagainstrepeatedadministra4on

2.  Randomiza3onSta4s4calcontroloverunknownconfoundingvariablesrelatedto4me,par4cipants,se@ngetc….

Prerequisites

3.Randomiza3onTestDataarepermutedintoallsortsofdifferentorders,andtheteststa4s4coneachpermuta4on.Thedistribu4onprovidesthep-value

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Conduc-ngSingle-CaseResearch

1.  Researchques3on2.  Designofsingle-caseexperimentanddata

collec-on3.  Visualanalysisofdata4.  Sta-s-calanalysisofdataandeffectsize

es-ma-on5.  Formulateconclusions

Researchques-on

• Deviseresearchques-on&hypothesesDependentandindependentvariables

• ChoosemeasurementinstrumentsReliabilityValidity

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DeJonghetal.,2002

Researchques-on‘DoesEMDRreducefearofdentaltreatmentinpa-entswithdentalphobia?’Design:Replicatedsingle-caseABAphasedesignacross4par-cipantsInterven-on:EMDRtreatmentOutcomemeasures:

DAS(Corah,1969)DCQ(DeJongetal.,1995)SCL-90-R(Deroga-s,1977)

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1.  Researchques-on2.  Designofsingle-caseexperimentanddata

collec3on3.  Visualanalysisofdata4.  Sta-s-calanalysisofdataandeffectsize


Designofsingle-caseexperimentThingstodetermine:

Ø  TypeofdesignØ  LengthØ  Specialrequirements(e.g.,minimumphaselength)Ø  Randomiza-onØ  Teststa-s-c?

Designchoices~researchques4on

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Designofsingle-caseexperimentPhasedesigns Example:ABphasedesign

Designofsingle-caseexperimentAlterna4ondesigns

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Designofsingle-caseexperimentReplica4ondesignsExample:mul-ple-baselineacrosspar-cipantsdesign





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VisualanalysisofdataThingstoconsider(Kratochwilletal.,2010):

•  Meanleveldifferences•  Trend•  Variability•  Immedicacyoftheeffect•  Thepropor-onofoverlap•  ‘Consistencyofthedata’

⇒ Weak/medium/strongevidencefortreatmenteffect?

0 10 20 30 40

02

46

810

Measurement Times

Scor

es

A B

VisualanalysisofdataMeans

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0 10 20 30 40

02

46

810

Measurement Times

Scor

es

A B

Trended range

Visualanalysisofdata

Visualanalysisofdata

Advantages:•  Easyandflexiblemethod•  Holis-cassessment

Disadvantages•  Pronetosubjec-vity•  Interrateragreementissues•  Difficultforsmalleffects

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collec-on3.  Visualanalysisofdata4.  Sta3s3calanalysisofdataandeffectsize

es3ma3on5.  Formulateconclusions


Sta-s-calanalysisofdata:randomiza-ontests

Whysta3s3calanalysis?!

•  Cf.disadvantagesofvisualanalysis•  Detec-onofsmallbutsystema-ceffects•  Corrobora-onofresultsfromvisualanalysis

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WhatisaRandomiza3ontest?

Asta4s4caltestthatrandomizesthedataacrosstreatmentcondi4onstodetermine

thesta4s4calsignificanceofatreatmenteffect.


Characteris-csofsingle-casedata:•  Smallsamples•  Unknowndistribu-ons•  Serialdependence•  Parametricassump-onsoyenviolated!

⇒ RTshavemorevaliditythant-testsorANOVAsforthistypeofdata

WhyuseaRandomiza3ontest?

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Illustra-on•  Design:ABdesign(A:baseline;Btreatment)•  Observa3ons:8repeatedmeasurements•  Limita3on:minimum2observa-onsperphase

→5possibleassignments:

AABBBBBB => AAABBBBB AAAABBBB AAAAABBB AAAAAABB

Illustra-on•  Design:ABdesign(A:baseline;Btreatment)•  Observa3ons:8repeatedmeasurements•  Limita3on:minimum2observa-onsperphase

→5possibleassignments:Observa-ons:65320132 mean(A)–mean(B)

AABBBBBB 3.67 => AAABBBBB 3.07 AAAABBBB 2.50 AAAAABBB 1.20 AAAAAABB 0.33

p-value:2/5=0.4

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Effectsizecalcula-onProblem:p-valuedoesnotgiveinforma3onaboutthesizeoftheeffectSolu3on:calculateeffectsizes(ESs)Effectsizemeasure:quan-fiesthesizeofthetreatmenteffectinasinglenumber:

Standardizedmeandifferences,nonoverlapmeasures,...

EffectSizesprovidemoreinforma-onabouttreatmentefficacythanp-valuealone.Example:theNonoverlapofallPairs(NAP)…

NonoverlapofAllPairs(NAP)• Measureofeffectsize• Ordinalmeasure• Probabilis-cinterpreta-on• Chancelevel:50%• 0%(minimum)-100%(maximum)

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Soyware•  Soywarepackagesforvisualandsta-s-cal

analysisofsingle-casedataavailableinR,afreesta-s-calprogram.o  RCommanderpoint-and-clickpackageo  Future:Web-basedShinyapplica-ons





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FormulateconclusionsBaseconclusionsoninforma-onfrom:•  Visualanalysis•  Sta-s-calanalysis

Effectsizes&confidenceintervals•  Feedbackfrompar-cipant(s)=>Sta-s-calsignificance≠clinicalsignificance=>Usemul-pleinforma-onsourcestocorroborateconclusions

ReferencesDeJongh,A.,VandenOord,H.J.M.,&TenBroeke,E.(2002).Efficacyofeyemovementdesensi-za-onandreprocessinginthetreatmentofspecificphobias:Foursingle-casestudiesondentalphobia.JournalofClinicalPsychology,58(12),1489–1503.Onghena,P.&Edgington(2005).Customiza-onofPainTreatments,ClinicalJournalofPain,21(1),56–68.

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Overview

Basicscience

T2 T3



Popula-onhealth

T1 T2T3

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Basicscience



Popula-onhealth

Fromthelabtotheclinic

T1

Exposure

a. Se�ngfunc-onalgoals

b. Educateaboutparadoxofsafetyseekingbehaviors

c. Hierarchy

d. Modeling

e. Challengeexpectancieswithbehavioralexperiments

Vlaeyen et al., CJP 2002

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h�p://www.psychology.unimaas.nl/phoda-sev/

FearHierarchy

Leeuwetal..JPain2007;8(11):840-849.

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RSIPa-ent#5

012345678910

CAT FOP FOM PAIN

-

+

BAS:19days GEXP:8sessionsin29days FU:7days

VAS

DeJongetal.PAIN2012

PAIN

Fear of Movement

DataAnalysis:Illustra-oninRData:‘pain’and‘fearofmovement’ofpa-ent5Steps:•  Visualanalysis

•  Meanleveldifferences•  Trend•  Variability•  Immedicacyoftheeffect•  Thepropor-onofoverlap•  ‘Consistencyofthedata’

•  Sta-s-calanalysis•  p-value•  Effectsize(NAP)

•  Conclusion

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ComplexRegionalPainsyndrome

0123456789

10

A B C Dfear pain push the baby buggy lift a child

DeJongetalPain,2007

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Bedanktvoorjullieaandacht!!

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Single Case EMDR Congres 27032017 · 28/03/17 1 Single-Case Experimentele designs Johan Vlaeyen en Bart Michiels EMDR congres 31 Maart 2017 1. What is translaonal science? 28/03/17