MAKING MATB-II MEDICAL: Pilot
testing results to determine a novel
lab-based, stress-inducing task
Lauren Kennedy, PhD Candidate
Sarah Henrickson Parker, PhD
DETRIMENTAL EFFECTS OF ACUTE STRESS
DETRIMENTAL EFFECTS OF ACUTE STRESS
Excessive levels of acute stress can negatively affect key cognitive processes1
 Attention
 Working memory
 Memory retrieval
 Decision making
This response can also affect performance, especially performance relying on
these cognitive processes2-9
ACUTE STRESS IN APPLIED SETTINGS
In healthcare, we’re still in the early days in terms of addressing
acute stress management10
 Cognitive reappraisal11,12
 Mental practice13,14
Other high-risk industries have acknowledged and addressed the
negative effects of acute stress in a variety of ways
 Crew Resource Management15
 Mindfulness training16
 The Mental Gym Project17
 Cognitive-affective training18
 Biofeedback19-24
BIOFEEDBACK
25
IS BIOFEEDBACK ACTUALLY EFFECTIVE?
Evidence of effectiveness from lab-based studies22,24
Evidence of effectiveness from applied studies17,19-21,23,26,27
In all of these cases, either performance enhancement or stress reduction
are observed and reported
 In most cases, both are
GAP IN RESEARCH
Biofeedback for acute stress management in other applied industries17,19,20
Biofeedback for chronic stress management in healthcare28
Gap: Biofeedback for acute stress management in healthcare
 Impaired cognition and performance decrement can mean life or death
STRESS REDUCTION REQUIRES STRESS INDUCTION
Need to find an appropriate, reliable, and safe way to induce stress in
order to study the process of stress reduction
To achieve maximal control:
 Must be in the lab
To overcome lack of ecological validity:
 Must recruit cognitive processes representing those recruited by healthcare
practitioners
MULTI-ATTRIBUTE TASK BATTERY (MATB-II)
Designed for air craft crew
members and pilots
Purpose: to evaluate operator
performance and workload29
Reliable and appropriate for
aircraft crew-members
Goal: Adapt MATB-II into a task, with 2 distinct levels
of difficulty, that also includes the assessment of
medical knowledge
MEDICALLY-FOCUSED MULTI-TASKING GAME (MFMG)
MATB-II subtasks
 Resource management
 System monitoring
 Tracking
Medical knowledge
assessment
Four different MFMG versions
 Differed by frequency of events
within MATB-II subtasks
EXPERIMENTAL DESIGN
N = 10 medical students
Subjective measures:
 State Trait Anxiety Inventory for
Adults (STAI)
 NASA Task Load Index (NASA-TLX)
Overall performance:
 MATB-II subtasks
 Medical knowledge assessment
Objective measures:
 Electrocardiography (ECG)
ANALYSIS
Subjective measures (STAI & NASA-TLX)
 Average aggregated scores across conditions
Overall performance (MATB-II & medical knowledge assessment)
 Individual score derived from assigning equal weight to each subtask
 Average aggregated scores across conditions
Objective measures (ECG)
 Heart rate variability (HRV) components
Cognitive workload decreases as difficulty level decreases
NASA-TLX Score by Condition
100
NASA-TLX Score
90
80
70
74.3
72.2
60
61.2
63.2
MATB-C
MATB-D
50
40
30
20
10
0
MATB-A
MATB-B
MATB-II Version
Overall performance increases as difficulty level decreases
Overall Performance (including medical questions)
Overall Performance Score
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
MATB-A
MATB-B
MATB-C
MATB-II Version
MATB-D
Overall performance increases as difficulty level decreases
Overall Performance (excluding medical questions)
Overall Performance Score
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
MATB-A
MATB-B
MATB-C
MATB-II Version
MATB-D
PHYSIOLOGICAL MEASURES
Standard deviation from normal-to-normal (SDNN)
 Measure of overall variation of normal consecutive R-R intervals
Percentage of normal-to-normal 50 (pNN50)
 Measure of the fraction of normal consecutive R-R intervals that differ by more than 50 ms
Root mean square of the successive differences (RMSSD)
 Measure of beat-to-beat variability/short-term variation
SDNN value increases as difficulty level decreases
SDNN Value by Condition
Normalized SDNN Value
0.10
0.05
0.00
MATB-A
MATB-B
MATB-C
-0.05
-0.10
-0.15
MATB-II Version
MATB-D
RMSSD and pNN50 values increase as difficulty level decreases
RMSSD and pNN50 Values by Condition
Normalized RMSSD and
pNN50 Values
0.30
0.25
0.20
0.15
0.10
0.05
0.00
MATB-A
MATB-B
MATB-C
MATB-II Version
Means RMSSD
Means pNN50
MATB-D
SUMMARY/CONCLUSIONS
Subjective, performance, and physiological data converge to reveal:
 Most stressful version: highest frequency of events
 Least stressful version: lowest frequency of events
We now have 2 versions of a “medical MATB-II” (MFMG) to induce
stress in medical professional populations that represent disparate
difficulty/stress levels
HRV is a more sensitive measure of acute stress/cognitive workload
than HR alone
 This corroborates other findings30
FUTURE STEPS
Now that we can reliably induce stress in a surgical population, we can ask
more questions about stress reduction
Future work:
 Evaluating the utility of biofeedback presented at different times during a stressful task
 Evaluating the added utility of descriptive coping instructions alongside biofeedback
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ACKNOWLEDGMENTS
Sarah Henrickson Parker, PhD
Sarah Frazier, Virginia Tech
Whitney DeLong
Harrison Wade, VTC School of Medicine
Steven Crane, VTC School of Medicine
Joseph Coro, Princeton
Med students/volunteers!
[email protected]
AHRQ R18HS023465-01, PI-Parker