Best Practice Instruction in Cognitive Rehabilitation

1. Best Practice Instruction in Cognitive Rehabilitation Laurie Ehlhardt, PhD, CCC/SLP Teaching Research Institute-Eugene Rik Lemoncello, MS, CCC/SLP University of Oregon September 30, 2005

2. Advanced Organizer • Part I: Background • Discuss rationale, theory & research • Part II: Practice • Evidence from E-Mail training • Video analysis • Part III: Clinical Application • Wrap-up video analysis • Concluding Remarks & Questions

3. Learning Outcomes As a result of this workshop training, participants will be able to: • Demonstrate an understanding of evidence-based practice • List one empirical study related to improved outcomes and instruction • Describe features of the TEACH-M instructional package • Apply the TEACH-M instructional package to clinical examples

4. Instruction Defined • Teaching (i.e., therapy, training, coaching, mentoring, etc.) • Sharing knowledge/skills with others • In this course… • Explicit, systematic instruction • Severe brain injury • New learning IS possible!

5. Rationale: Why focus on instruction? • Focus of rehabilitation on training/teaching • Regardless of the treatment domain, we are all instructors • Maximizes client success/goal achievement • Not all university training programs provide coursework dedicated to instruction • Have to “do more with less” • e.g., less money, treatment time, etc.

6. Why focus oninstruction? • Example: “Do more with less” • Outpatient for TBI • Average # of visits 2005: • 30-60 visits/calendar year, combining physical, occupational, and speech therapies • Minimal # of sessions with Oregon Health Plan (i.e., 1-2 per year for SLP)

7. Why focus on instruction? “…in particular [the field of cognitive rehabilitation] has neglected for over two decades the accumulated wisdom in educational psychology, special education, etc. This neglect has cost billions of dollars and yielded countless hours of largely unsuccessful intervention for people with TBI. We have an opportunity to turn this around.” • Mark Ylvisaker, personal communication, 2003

8. Why focus on instruction? • Teaching is complex • Teaching IS rocket science (Moats, 1999) • Information CAN be taught • Instructor is responsible for learning • Frame problems around what instructor can control/manipulate • *** Incorrect response is learner’s best attempt to be intelligent • More carefully taught = More easily learned

9. Rationale:Evidence-Based Practice • What is Evidence-Based Practice (EBP)? • “the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients” Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence-based medicine: What it is and what it isn’t. British Journal of Medicine, 312, 71-2. • “the integration of best research evidence with clinical expertise and client values” Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-Based Medicine: How to Practice and Teach EBM. New York: Churchill Livingstone.

10. Evidence-Based Practice • Not a new phenomenon • Think of “Efficacy” and “Accountability” • Focus on improving client outcomes • Makes us better clinicians • Remember science of rehabilitation • Clinical scientist and Research scientist • Clinical work as a marriage between art and science (Apel & Self, 2003)

11. Evidence-Based Practice • EBP is a process for decision making • Identify need for clinical information • Ask a searchable clinical question • Search for the evidence • Critically evaluate the evidence • Integrate evidence with clinical expertise and client values • Evaluate effectiveness of treatment

12. Evidence-Based Practice FREE Databases: • PubMed (MEDLINE) - Link to Full Text of: • Journal of Head Trauma Rehabilitation (1998-2005) • Brain Injury (1996-2005) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed • National Guideline Clearinghouse: http://www.guideline.gov • ASHA Website for full text journals: http://www.asha.org *See Web-Based Resources handout

13. Evidence-Based Practice • Critical Appraisal: “Is this a good study?” • Levels of Evidence: I. Well-designed Randomized Controlled Trial II.Well-designed Quasi-Experiment III. Non-Experimental Studies IV. Expert opinion • For more information: http://www.cebm.net/levels_of_evidence.asp#levels

14. Evidence-Based Practice Integrate and make a decision for your individual client Best available evidence EBP Clinician expertise Client’s values and preferences

15. Evidence-Based Practice:Insufficient Research Evidence • Focus: Provide a rationale for your decisions • Treatment should at least be theoretically grounded • Clinicians have a responsibility to track outcomes and document changes • Bottom Line: • Take data, Measure progress, and Document gains!

16. Review & Recap • Instruction defined • Rationale for instruction • Do more with less • What can we learn from the educational literature Coming up… • Types of instruction/Memory systems background • Rational decision making – EBP • Integrate research evidence with clinical expertise and client’s values

17. Instruction • Common Types of Instruction • Trial and error • Mentorship/experiential learning • Explicit, systematic instruction • Exchange of knowledge/skills from the instructor to the learner • Involves learning

18. Learning and Memory • Learning requires memory • Types of memory • Short-term memory • “Working” memory • Long-term memory • “Fact” memory • “Event” memory • “Procedural” memory

19. Types of Long-Term Memory • ”Fact-Event” memory (or “Explicit” memory): acquisition and intentional recollection of facts, concepts & events • “Procedural” memory: knowledge of procedures/skills or tasks without intentionally remembering the experience of learning (Baddeley, 1995; Brandt & Rich, 1995; Tranel & Damasio, 1995)

20. Errorless Learning (EL) • Brain injury generally does NOT affect “procedural” memory, but does affect “explicit” memory. • Impaired “explicit” memory makes it difficult to remember and correct errors. • Errors stick: “Trial and error” learning is therefore risky! Goal of EL: Avoid errors while learning something new!!!

21. How do we achieve EL? • Errorless learning works by using high amounts of correct practice. • Distributed practice (e.g., spaced retrieval) also facilitates EL. • Target skill therefore becomes “routine”, “firm”, “solid”. (Evans, et al., 2000; Wilson, Baddeley, Evans, & Shiel, 1994)

22. Direct Instruction • Direct Instruction (DI): • well-established, systematic instructional methodology • used across many different populations, particularly individuals with learning disabilities • used across many different subject areas (e.g., reading, math, social skills) • Errorless learning is a key component of DI • DI components: * See Direct Instruction Strategies handout

23. Examples:Evidence in Support of DI/Errorless Learning for Individuals with Cognitive Impairment • Wilson, et al. (1994) Errorless Learning in the Rehabilitation of Memory Impaired People; Levels 2 & 3 evidence • Evans, et al. (2000) A comparison of "errorless" and "trial and error" learning methods for teaching individuals with acquired memory deficits; Level 2 evidence • Kern, et al., (2002) Applications of Errorless Learning for Improving Work Performance in Persons with Schizophrenia; Level 1 evidence • Swanson, H., & Hoskyn, M. (1998). A synthesis of experimental intervention literature for students with learning disabilities: A meta-analysis of treatment outcomes. Review of Educational Research, 68, 277-321. Level 1 evidence

24. Research: Mozzoni & Bailey(1996)Improving training methods in brain injury rehabilitation • Research Goal: To evaluate and improve the teaching effectiveness of therapists in an in-patient rehabilitation setting • Participants: Six therapists (speech, OT, recreation, nurse, cognitive rehab.) and five patients with severe TBI (Rancho Levels 5-6) • Intervention: Daily feedback on therapists teaching skills using a checklist of specific behaviors • Outcome measure: Patient performance on Functional Independence Measure (FIM) • Level of Evidence: Level 2

25. Mozzoni & Bailey: Skills Checklist • Is the cuing clear? • Is the patient attending to the therapist? • Is the therapist using a task analysis? • Is treatment consistent between sessions? • Is therapist prompting systematically? • Is the patient practicing the skill more than once? *See Clinician’s Skills Checklist (#1) handout

26. Break • When we return… • Research evidence to support DI for training individuals with severe cognitive impairments to use adapted E-Mail • Videotape analysis of teaching examples • Practical applications of new skills!!

27. Welcome Back • Review Part I • What is instruction? • Evidence-Based practice • Research evidence to support systematic instruction for individuals with severe cognitive impairments • In this hour… • Evidence from training E-Mail • Videotape examples for practical application

28. Research:An instructional package TEACH-M Evaluation of an instructional sequence for persons with impaired memory and executive functions (Ehlhardt, Sohlberg, Glang, & Albin, 2005) Level 2 Evidence

29. TEACH-M! Task analysis: Know your content. What is the target skill? Break it into small steps. Chain steps together. Errorless learning: Keep errors to a minimum during the acquisition phase. Model target step(s) BEFORE client attempts a new skill/step. Carefully fade support. Don’t let an error sneak by! Demonstrate the correct skill/step right away and ask client to do it again. Assess performance: (initial)-assess skills before treatment; (on-going) - probe performance at the beginning of teaching session and/or before introducing a new step. Cumulative review: Regularly review previously learned skills. High rates of correct practice trials: 5 trials is not enough! 30-50 or more is like it! Metacognitive strategy training: self-evaluation of one’s own performance

30. Research Questions Is there a functional relationship between implementation of the E-Steps program and: • The percentage of e-mail steps learned, in sequence? • Are treatment effects maintained at one month following the cessation of treatment? • Do treatment effects generalize to use of a similar e-mail interface with added features (i.e., altered interface) and/or a computer game with no shared features? • How many training sessions are required to reach the criterion for mastery?

31. Methods:Materials & Task Analysis • Simple email system • Not a “live” system for this study • Hypothetical partners (e.g., counselor) Task Analysis • Click on start • Click on inbox • Click on picture • Read message/click on reply • Click on answer (yes or no) • Click on send • Click on quit

32. Methods: E-Steps program (IV) Phase 1: review - model - practice Phase 2: metacognitive strategy training (reflection-prediction using screenshots) “Which step(s) will be easy? Which step(s)will be difficult?” Phase 3: spaced retrieval (immediate recall, 30 seconds, 1 minute, 2 minutes) Phase 4: metacognitive strategy (reflection using screenshots) “Which step was easy? Which step was difficult?” Program implemented 4-5x weekly

33. MethodsDependent Variables Number of correct email steps completed in sequence (out of 7) Whole task probe - Participants asked to perform email task (“Read and respond to the new message, then quit the program when through”); stopped when unable to go any further Number of sessions to reach criterion for mastery (100% steps correct for 3 consecutive sessions)

34. Results

35. Results:Additional participant performance data • Total instruction time: 4 to 9 hours • Relatively high number of mouse activations per session (73-88 activations) when compared to the average number of minutes per session (37 minutes) • High accuracy - averaged 99% accuracy across all treatment trials/activations

36. Video Analysis: Part I See Handouts (Task Analysis Forms) (Clinician Checklists)

37. Welcome Back The continuing saga… • Video Analysis: Part 2 • Concluding remarks • Questions and Answers

38. Learning Outcomes • As a result of this workshop training, participants will be able to: • Describe process of evidence-based practice • List one empirical study related to outcomes and instruction • Describe features of TEACH-M instructional package • Apply TEACH-M instructional package to clinical examples

39. Final Thoughts “What is it about myinstruction that makes this client unable to learn?” & “Nothing succeeds like success!” Have fun and thank you!!!  ehlhardtl@wou.edu rlemonce@uoregon.edu