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Utility of a brief computerized cognitive battery for people with concussion: a preliminary qualitative study

A 2019/2020 Summer Studentship research project

Using computerized formats for assessing cognitive problems after concussion has great potential to streamline assessment. However there is a lack of well validated, brief computerized measures that clinicians feel confident using with patients early after concussion. The findings of this study could benefit future concussion research and clinical practice in NZ.

Student: Clare Macleod
Supervisors: Dr Deborah Snell, Associate Professor Lois Surgenor (UOC); Dr Jonathan Williman (UOC); Professor William Levack (UOW); Prof Richard Siegert (AUT); Associate Professor Alice Theadom (AUT): Dr Noah Silverberg (UBC); Dr Jono Hackney (CDHB)
Sponsor: Canterbury Medical Research Foundation


Concussion, also known as mild traumatic brain injury (TBI) is a very common injury and a proportion of people demonstrate persisting cognitive symptoms after their injury, although these do tend to fade with time. Cognitive impairments are associated with functional outcome in many TBI studies (Silverberg et al. 2017). Given its prevalence and clinical significance, cognitive impairment is a key therapeutic target after TBI and requires sound measurement tools.

Adequate measurement of cognitive outcome after TBI requires administering a battery of tests that, at minimum, cover the domains of attention, memory, processing speed, and executive functioning. Brief, efficient, and reliable computerized cognitive assessments may be useful in clinical practice and research after mild TBI (Holdnack et al. 2017). One such tool is The National Institutes of Health (NIH) Toolbox for Assessment of Neurological and Behavioral Function (Gershon et al., 2010; Gershon et al., 2013). The NIH Toolbox (cognition) (Weintraub et al., 2013) is a computerized neuropsychological screening battery that has been recommended as a common data element for TBI research and clinical trials. The Cognition Toolbox, developed in North America, has not been used in a NZ study before and accordingly it is not known how NZ study participants and patients in clinical settings might experience the format and nature of the assessment tool.

We currently have a study underway evaluating outcomes after concussion. In order to evaluate the role of early cognitive impairment in risk for development of anxiety, negative recovery expectations and poor outcome, we included the NIH Cognition Toolbox. We would like to evaluate the utility of the Cognition Toolbox for the NZ context by reviewing how our participants have experienced this tool. One aspect of evaluating utility is to ask participants themselves how they experienced the format and nature of the measure and to consider additional factors such as time taken to complete the battery. Accordingly this proposal is for a sub-study interviewing a small number of study participants who have been assessed using the Cognition Toolbox as part of our parent study, to find out more about how they experienced the computerized format and the tasks themselves. This will help us determine if any adaptations could be required to the Cognition Toolbox for wider use in NZ, beyond our main study.


The aim of this study is to investigate the utility of the NIH Cognition Toolbox for use with people with concussion in NZ research and clinical contexts, recruiting a small number of participants from a larger study already underway at Burwood Hospital.


This is a small qualitative study. Six-10 participants will be identified from a larger pool of participants from the parent study, and invited to take part in a semi-structured individual interview to find out more about their experiences of the Cognition Toolbox. Participants will be identified on the basis of age, gender and ethnicity, in order to achieve a diverse study sample. Inclusion and exclusion criteria will be as for the parent study. Ethical approval from the University of Otago Human Ethics Committee will be sought, although the parent study already has ethical approval from HDEC and institutional/locality approvals are in place.

Interview questions and data collection

Data will be collected by semi-structured interview, recorded and then transcribed. Example interview questions include:

  1. Was there anything you particularly liked about the Cognition Toolbox, and if so what?
  2. Was there anything you didn’t like and if so what?
  3. How was the iPad format for you (e.g. easy to follow, frustrating, fun, fatiguing, difficult to see, etc)
  4. How did you find the tests themselves (e.g. easy, difficult, frustrating, good reflection of difficulties experienced after concussion, etc)
  5. How long did it take and how did you feel at the end of the assessment?

Data analyses

Data from participant interviews will be recorded, transcribed verbatim and analyzed using a general thematic approach (Braun & Clark, 2006; Thomas, 2006).

Student researcher’s component of the study

This project will be able to be completed by the student within 10 weeks. Potential participants will be identified by the First Supervisor (also the parent study lead investigator). The student will contact potential interview participants, invite them to take part and to attend an interview either in person, by zoom or by phone; conduct the interview and work with the First Supervisor and wider team on the data analyses.

This opportunity will enable the student to i) work within a research team, ii) learn about data collection and preliminary thematic analyses, iii) learn about a health condition/ intervention with significant health service delivery implications for NZ, iv) practice presenting at Department and School levels.


  • Braun V, & Clarke V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3:77-101.
  • Gershon, RC, et al. (2013). NIH Toolbox for Assessment of Neurological and Behavioral Function. Neurology, 80 (Suppl. 3).
  • Holdnack, JA et al. (2017). NIH Toolbox Cognition Tests Following Traumatic Brain Injury: Frequency of Low Scores. Rehabilitation Psychology, 62 (4), 474-484.
  • Silverberg, N et al. (2017). Developing a Cognition Endpoint for Traumatic Brain Injury Clinical Trials. Journal of Neurotrauma, 34: 363-371.
  • Thomas D. (2006). A general inductive approach for analysing qualitative evaluation data. American Journal of Evaluation, 27:237-46
  • Weintraub, S. et al. (2013). Cognition assessment using the NIH Toolbox. Neurology, 80 (Suppl. 3).

How to apply