JOG MY MEMORY!

1. JOG MY MEMORY! Instructional Approaches for Memory Rehabilitation NSW TBI Evidence Based Practice Group Jason Bransby Royal Rehab Michael Dunne Westmead BIU Colleen Kerr Optimal SP

2. Clinical Question • Process • Dec 2013 Survey to members. • Consensus that we needed to address an area of current clinical concern given some of the 2013 difficulties with exploring newer area of practice (emotional recognition) • Consensus to look at compensatory strategies in memory intervention in an effort to distinguish our interventions from restorative (word list retention etc) laboratory studies. • Tentative question formulated March 2014 for initial literature screening and liaison with academic leaders/multidisciplinary teams "What teaching strategies are most effective in training use of memory aides in adults and adolescents with TBI?".

3. Refining question • Discussion with Skye McDonald re clinical question and potential models of memory to guide/re-structure our question and search terminology • Discussion with Belinda Carr, Carr Rehab re her publications in the area of efficacy of compensatory memory aides. • Initial literature search – half of our group looking at range of instructional techniques and remainder looking at nature of compensatory device • Regroup April 2014 with agreement that we needed to restrict our question to focus on the nature of the instruction as this was of greatest clinical interest and relevance. • Further discussion of potential pitfalls if evidence review failed to directly contrast or adequately define techniques.

4. ASKING THE RIGHTQUESTION .... • What are the range of instructional techniques used to facilitate use of compensatory memory aides in adults and adolescents with TBI?

5. METHOD • Initial search papers loaded to shared document (Evernote) for group review/cull • 12 CAPs completed by group members and three students • CAT under preparation but we have a bottom line...

6. Clinical bottom line • A range of instructional techniques have been explored in the literature, for training use of external memory aides. These techniques include: • Errorless learning • Vanishing cues (Forward & Backward Chaining) • Self-instruction (WSTC) • “Systematic instruction” • Self-awareness training • Distributed practice • Rehearsal in meaningful environments.

7. Instructional approaches • Errorless Learning • Clinician minimises errors during teaching process • Tasks broken down into steps (e.g. entering reminder into iPhone) • Target response provided/modelled by clinician, to minimise patient errors • Best practice for patients with severe memory impairment

8. INSTRUCTIONAL APPROACHES • Forward Chaining Forward chaining: • Any complex task represents a sequence of specific behaviours or “a chain”. Completion of one step acts as a cue for the next… • Task broken down into series of components • First step trained. When mastered, second step added and trained and so on…

9. INSTRUCTIONAL APPROACHES • Backward Chaining Backward chaining/vanishing cues: • Errors initially minimised via modelling/cueing, but prompts slowly faded • May be used in combination with errorless learning • More effective for patients with mild-mod memory impairment E.g. (with visual cue) “You unlock your phone, open the calendar, then select the date” (no visual cue) “You unlock your phone, open the calendar, then select the date” “You unlock your phone, open the calendar, then….”

10. INSTRUCTIONAL APPROACHES • Spaced Retrieval (SR)/ Distributed Practice (DP) • Useful for semantic, procedural, prospective memory • More effective than massed practice/ learning SR- within trial • Target behaviour provided to patient e.g. checking phone for appointment time, and practiced until mastery achieved • Patient asked to retain information for progressively longer periods of time (e.g. immediate, 15 secs, 30 secs etc.) e.g. How will you remember your appointment tomorrow? • DP- training better spaced over time, rather than mass practice

11. INSTRUCTIONAL APPROACHES • Systematic Instruction/ Teaching “Packages” • Sohlberg (1989)- 3 stage procedure: Acquisition (basic competence with memory aid use), Application (role play simulating real life situations), Adaptation (use of device in novel situations) • Approach used in several studies with good effect compared with conventional practice

12. INSTRUCTIONAL APPROACHES • Self- Instruction • WSTC W (hat are you going to do?) S (elect a strategy) T (ry it out) C (heck if the strategy worked) • May result in better maintenance of treatment effects when training compensatory memory aids (Ownsworth & McFarland, 1999)

13. INCOG GUIDELINES 2014 • Memory #2. Environmental supports and reminders are recommended for TBI patients who have memory impairment and most especially with those who have severe memory impairment—(eg, NeuroPage, mobile/smartphones, SIRI,PDA, notebooks, whiteboards, etc). Patients with TBI and their caregivers/support staff must be trained in how to use theseexternal supports. (Adapted from EFNS,40(p672) INCOG16) • Memory #4. There are a number of key instructional practices that can promote learning for individuals with memory impairments, which include:

14. Incog guidelines 2014 • Clearly define intervention goals • Task analysis • Allow sufficient time and opportunity for practice • Use principles of distributed practice (spaced retrieval) • Teach strategies using variations in the stimuli/information being presented (eg, multiple exemplars, practical tasks) • Ecologically validity • Use teaching strategies that constrain errors

15. Implications for practice • Difficult to determine “best instructional technique” • A consistent theme in the literature is the superiority of errorless learning and systematic approaches to instruction, rather than conventional trial-and-error approaches. • Training should occur in natural contexts • These techniques may extend to a range of other cognitive and communication therapies e.g. AAC, word retrieval etc. • Given the multidisciplinary nature of TBI interventions our findings are likely to be of interest to other professional groups

16. Questions?