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EBP Treatment: activities and ideas part 4. METACOGNITION, ATTENTION, MEMORY, LANGUAGE, VISUAL PROCESSING, COMA STIM, RTW, RTD, SPECIAL CONSIDERATIONS AND OUTCOMES RESOURCES. Case Study: William.
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EBP Treatment: activities and ideas part 4 METACOGNITION, ATTENTION, MEMORY, LANGUAGE, VISUAL PROCESSING, COMA STIM, RTW, RTD, SPECIAL CONSIDERATIONS AND OUTCOMES RESOURCES
Case Study: William • William is a 22yo male who was recently referred for a cognitive linguistic evaluation following toxic encephalopathy. Patient was recently hospitalized following mental status changes resulting in use of synthetic marijuana. The patient has very little recollection of this event, although he does remember a few days before taking the drug. The patient also does not recall the first week of his hospitalization or earlier days of rehabilitation while hospitalized. • William is a high school graduate who at the time of the accident was working at CostCo in the produce department. His job responsibilities were to discard ‘old’ fruits and vegetables when he arrived at work early in the morning, and stock fresh produce in its place. He also had to water specific produce on a watering schedule. He worked 4 days per week, 5am – 12pm. • The client is able to walk and talk and has functional communication. His biggest complaints are that he is not able to wake up in time for work, is not sleeping well, has difficulty sorting fruits from vegetables at work and following his work watering schedule. He also would like to go to college and does not want to be ‘stuck’ in this job forever. He is often late for work and his boss told him it better not happen again. He is having difficulty remembering the names of the people he works with and can’t think of the names of some produce or help customers who have questions about produce. • He is interested in designing landscaping or working in business to start his own company. William lives at home with his dad. His parents are divorced. He is not yet able to drive and needs to find productive things to do at home while his dad is working. His little brother is also home a lot and drives him crazy. He doesn’t remember feeling this way about his brother and doesn’t recall him being this annoying before the event. He is very motivated to get better. He needs to get back to work so he can save money for college. His dad wants him out of the house but is willing to help get him back to functional level and realizes he is not safe. He and William argue a lot about safety, because William thinks he is fine to drive and live alone. • William notes a PMH of ADHD. Dad reports times as a child where William would bang his head on a concrete wall because he was having trouble focusing on his school work. Mom did not accompany to this evaluation.
Case study continued • Use a treatment model grounded in attention • *Measurement of improvement at the level of everyday functioning is the most important indicator of the success or failure of attention training! Consider the WHO-ICF approach to treatment of health-related conditions • Use therapy activities that are hierarchically organized • Provide sufficient repetition • Treatment decisions should be based on client performance data • Activity facilitates generalization from the start of treatment • Be flexible in adapting the therapy format • Be explicit in training and practice (overlearning)(practice makes perfect) (Theory of Motor Learning) (impairment level) • Also train general strategies (impairment and activity level) • Change the environment (activity level practice) • Enlist support from caregivers and community (activity level practice) • Identify and anticipate barriers to success • Plan ahead for barriers and generate solutions • Promote carryover of techniques learned in everyday contexts (PARTICIPATION level practice!!!)
SLPs Role: Treatment/Management of Cognitive-Communication Disorders • Treatment focuses on rehabilitation of skills or compensation of deficits. • Goal: achieve highest level of independent function for participation in daily living, consistent with Internal Classification of Functioning (ICF) framework of the World Health Organization (WHO), 2010 • http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935337§ion=Treatment -K. Beyrer, March 2017
SLPs Role: Treatment/Management • Intervention in SLP is designed to: • (based on the WHO): • capitalize on strengths and address weaknesses related to underlying structures and functions that affect communication; • facilitate the individual's activities and participation by assisting the person in acquiring new skills and strategies; • modify contextual factors that serve as barriers and enhance facilitators of successful communication and participation, including development and use of appropriate accommodations. • http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935337§ion=Treatment -K. Beyrer, March, 2017
Current emerging evidence in SLP (for management of TBI) Treatment may include: • retraining cognitive components, focusing on functional tasks and situations • and/or "bottom-up" (training basic skills to build up to more complex processing) • and/or "top-down" (training complex skills to strengthen underlying basic skills). Ultimately, how does current research in SLP help the person return to (near) former level? -K. Beyrer, March, 2017
EBP guidelines: American Speech Language Hearing Association (ASHA) ASHA practice portal
EBP guidelines: INCOG • What is INCOG? “Traumatic brain injury results in complex cognitive sequelae. However, clinicians have difficulty implementing the available evidence. An international group of researchers and clinicians (known as INCOG) convened to develop clinical practice guidelines for cognitive rehabilitation posttraumatic brain injury.” • Attention, memory, exe function etc. via INCOG https://www.ncbi.nlm.nih.gov/pubmed/24984093 • This is helpful to clinicians and patients, because it puts the information in 1 place.
Current emerging evidence in SLPStrong evidence currently exists for these therapy principles (for TBIs and other dx): • Hearing and Balance • Telehealth • Intensive training • Sensory Stimulation • Social communication • Speech • AAC (Augmentative Alternative Communication) • Dysphagia (swallowing) • *Metacognition assessment/training • Individual and group therapy approaches • Attention • Memory • Word Retrieval • Executive Function • Computer Assisted Treatment (CAT) • Use of team approach to management • Post-acute resources -K. Beyrer, March, 2017
METACOGNITION Encouraging increased awareness of skills, deficits, techniques and strategies to improve successful outcomes!
Metacognition • According to English et al., “Students with TBI do not accurately perceive how others perceive their behavior,” following TBI. They also do not accurately perceive their own deficits and strengths, and may over/under estimate skills. • How can SLPs address this? -K. Beyrer, March, 2017
Compensatory: Patient involved in goal-setting process Patient Accountability to complete home activities/exercises (use of activity log) Metacognition summary Restorative: Pre and post-assessment surveys (both patient AND caregiver/significant other) Patient involved in goal-setting process Review goals at the beginning of each session Develop and recommend home activities which promote awareness outside of therapy Patient Accountability to complete home activities/exercises (use of activity log)
How can we measure outcomes for metacognition goals? • Single-case design (quantitative – collect data)– we already do this! We evaluate, get a baseline, monitor that over several sessions, move forward with next goal/activity • GAS – Goal Attainment Scaling – patient/caregiver is involved in setting and tracking goal progress • Capturing improvement on relevant functional tasks more effectively • Qualitative techniques --qualitative research vs. quantitative – how does the patient report that he/she is doing with goals/activities? • Examples: (next slides) • Outcomes scales • Durham Memory Index is another tool you can use! • Create your own!
A sample of surveys, questionnaires and interviews that provide self- and/or other reports of everyday activities and community participation after TBI
Measuring outcomes examples: Home program log--promotes awareness outside of tx and accountability
ATTENTION Attention is….THE building block for all cognitive linguistic functions
Compensatory: • Orienting procedures • Pacing • Key ideas log • Use of environmental supports • Reduce distractions • Avoid crowds • Manage fatigue • Mange other variables (sleep, hunger, etc.) • Avoid interruptions • Get sufficient exercise • Ask for help • Assistive technology and external aids • Phone • Written calendar or e-calendar, outlook calendar • Voice-activated messages/reminders • Task-specific, i.e. pill box reminders, key finders, watch alarms • Psychosocial support • Supportive listening • Brain injury education • Relaxation training and approaches • Suggestions/referrals for psychotherapy and grief counseling • Help patients to feel empowered and take control of their new normal • Journaling • Behavioral logs • Tracking own successes (GAS) Attention summary Restorative: Direct attention training Dual-task training
Attention Park and Ingels (2001) Attention includes • The speed at which information is processed or decisions are made; the ability to pay attention or stay focused on a task; the ability to complete more than one task at a time; and the ability to socialize, (due to attention issues); may impact the individual’s success in rehabilitation, returning to work or school and their ability to participate in other community activities.
Attention Restorative • Direct Attention Training (attention process training) case example Gary age 33 • Gary had a TBI due to MVA. He received 10 weeks of attention process training, 3x per week for 1 hour each visit. Most difficulty was with high-level sustained attention and selective attention. Outcomes: patient reported greater success with attention-related activities, greater ease at work, and improvement in everyday tasks. Testing results also improved. • Dual Task Training Compensatory • Orienting procedures • Pacing • Key ideas log • Use of strategies • Use of environmental supports • Assistive technology and external aids • Psychosocial support
example • Task is: Completing a maze • Component: sustained attention • Other tasks to group with: Could also work on alternating/divided attention by introducing distractions or multiple mazes • Methods for scoring: 1. time the patient to complete the task WITHOUT distractions and score for time and accuracy. 2. Provide a similar maze {difficulty level} with mild distraction {therapy door open} and again time the task and check for accuracy. • Make it easier: (start from the end and work backward – this is a strategy to teach also) • Make it harder: Introduce rules (cannot backtrack)
Direct attention training • Direct attention training at least 1x per week. • How? – slowly build on various levels of attention, then add levels of distraction • Sustained attention – this skill is needed to maintain attention for a specific period of time to complete a task e.g. writing an essay, reading a book. • Selective attention – this skill enables you to attend to something without being easily distracted by background noise, or movement e.g. performing a task while music is playing. • Alternating attention – this skill allows you to switch between 2 activities and not just focus on one and forget the other e.g. cooking a meal and setting the table. • Divided attention – this skill allows you to divide your attention between 2 tasks e.g. driving and talking at the same time while also following a map, visual memory of where to go -K. Beyrer, October, 2016
Direct attention training continued • 1. Do activity (connect dots, Sudoku, mazes, etc.) ---make sure not a language task {unless you want to increase complexity, such as a word find, crossword}. Do this activity in quiet environment first to be sure client is able to complete it. • 2. Then combine with: • Background noise (door open, radio or tv on, Coffitivity app, NPR, TedTalks, etc)
Let’s try itsee provided materials packet pages 2-4 • Krazy dad maze #1 • Krazy dad maze #2 with distraction (NPR playing in background https://www.npr.org/2018/12/29/679361624/abused-wolves-and-troubled-teens-find-solace-in-each-other • Krazy dad maze #3 with distractions (NPR talk radio – listen for details) • NPR link:http://www.npr.org/sections/health-shots/2016/05/31/479750268/poll-nearly-1-in-4-americans-report-having-had-a-concussion
NPR comprehension questionsaccording to the poll… • What percentage of Americans have experienced a concussion? 25% 2. What percentage of clinically diagnosed cases report loss of consciousness (LOC)? Less than 10% 3. What fraction of concussions are identified as sports-related? 2/3 4. What percentage of households who had a child concussed via sports said they would allow their child to play that sport again? 84%
Therapy ideas for Attention types • specific therapy activities for (see provided materials packet p. 5-6) • Sustained • Selective • Alternating • Divided
Dual-task training Dual task training focuses on improving task complexity by targeting the ability to carry out two competing tasks (typically requiring equal amounts of attention) simultaneously. The tasks may involve a combination of two cognitive tasks, a cognitive and motor task, or two motor tasks (Evans, Greenfield, Wilson, & Bateman, 2009). You can also think about using cognitive and language tasks together! Example: bouncing a ball while providing verbal answers to problem solving scenarios https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5178854/ Physical and cognitive training seem to counteract age-related decline in physical and mental function. Recently, the possibility of integrating cognitive demands into physical training has attracted attention. The purpose of this study was to evaluate the effects of twelve weeks of designed physical-cognitive training on executive cognitive function and gait performance in older adults.
Attention compensatory • Use of strategies • Use of environmental supports • Assistive technology and external aids • Psychosocial support
Restorative: Memory exercises should include STM (working memory) and LTM (content and time dependent, declarative and non-declarative, as well as everyday (prospective) memory in the higher-level patient. Spaced-retrieval Errorless learning Priming Rehearsal Visual imagery training Memory practice drills Mnemonic strategy training Prospective memory training Metamemory training Memory summary Compensatory: Auditory strategies Visual strategies Keep structure Keep schedule Personal assistive devices and external memory aids: • Watch (iwatch) • Planner • Journal • Phone (sync calendars, set reminders, tell your phone to remind you to do something) Simplify information Reduce the amount of information to be remembered Check for understanding Try to help the person link information to existing information Set up distributed practice (few minutes, several times each day than for 1 set hour per day) Help individuals organize information that needs to be remembered.
Domain-specific memory intervention approaches - Teach the client a process they can perform independently Mnemonic strategy training for specific information - Mnemonic strategy training for specific information • A mnemonic is an instructional strategy designed to help students improve their memory of important information. • This technique connects new learning to prior knowledge through the use of visual and/or acoustic cues. • The basic types of mnemonic strategies rely on the use of key words, rhyming words, or acronyms. • Expanding rehearsal time (spaced retrieval methods) – next slides • Use of preserved priming (method of vanishing cues) - 1. Provide patient with enough information to make a correct response (could be combined with errorless learning) • 2. Then, parts of the information are gradually withdrawn across trials Creating a personal history (for managing Retrograde Amnesia) - Take advantage of spared non-declarative memory to help with this deficit Priming or rehearsal can be used to teach personal history events • Errorless Learning - Eliminating the opportunity for making errors when initially learning a task
Memory – Spaced Retrieval • Spaced retrieval (SR) • evidence-based memory technique • targets procedural memory to help people recall information over progressively longer intervals of time • Anyone can use this technique, but it has been proven especially effective in helping people with Alzheimer’s disease, Parkinson’s disease, traumatic brain injury, and aphasia. • It can be done anywhere with simple tools by anyone familiar with the procedure, but it is not meant to be done alone by the person with the memory impairment. • https://tactustherapy.com/spaced-retrieval-training-memory/ -K. Beyrer, October, 2016
MEMORY – CASE to illustrate SR • Mark loves soccer. He used to play the position of forward for his high school team prior to diagnosis of stage 1 glioblastoma and resulting surgery. He still enjoys going to soccer games and has grown up in Cincinnati. He has a hard time remembering the players names who play forward when he’s at the game. He wants to be able to yell their names when they score. You are teaching him those player names via spaced retrieval (with a combination mnemonic strategy)
Current Evidence: Memory – Spaced Retrieval continued • Step 1: Choose one or more functional targets or goals (eg. remembering facts such a name or room number, remembering to perform a certain action, remembering future activities). FC Cincinnati Players • Step 2: Ask a question to elicit the target response. Who are the FC Cincinnati players who play forward? (use timer for 15 seconds) • Step 3: Ask again 15 seconds later. If Mark can’t recall, give the answer and have him repeat it back. Try again in 15 seconds. If it’s still not right, spaced retrieval may not be appropriate. • Step 4: When the answer is given correctly, double the time interval (15 seconds, 30 seconds, 1 minute, 2 minutes, 4 minutes, 8 minutes, etc.) and ask the question again. Repeat this step each time the answer is correctly given. Now ask again in 30 seconds. • Step 5: If the answer is incorrect, give the right answer immediately and ask the question again at the last correct time interval. -K. Beyrer, October, 2016
Memory – LET’S TRY IT! • Spaced retrieval combined with mnemonic strategy • Word list – 30 seconds – GO! • Welshman 10 • Ameobi 9 • Konig 11 • Cicerone 7 • Haber 92
Recall list • Welshman 10 • Ameobi 9 • Konig 11 • Cicerone 7 • Haber 92 • Use mnemonic: WAKCH (INSTEAD OF WATCH) • “I love to WATCH (WAKCH) FC Cincinnati.”
Restorative • Encoding • Spaced-retrieval • Errorless learning • Priming • Rehearsal • Visual imagery training • Memory practice drills • Workingmemory • Mnemonic strategy training • Prospective memory training - PROMPT (prospective memory process training, Sohlberg) • Remember to carry out a task in a certain number of minutes • The number of minutes is increased after success • Clinician systematically increases the time • Metamemory training - Clients compare predictions with actual performance
Compensatory • Auditory memory strategies (materials packet pp. 14-15) • Chunking/grouping information, creating lists and taking notes, graphing and/or charting, identifying key concepts, linking/associations, paraphrasing, rehearsal/subvocalizing and visualization • Visual memory strategies • Acronyms/silly sentences, chunking/grouping, defining/drawing, graphing/charting, paraphrasing, identifying key concepts, copying/drawing/tracing, and visualization • Personal assistive devices • External memory aids – • Phone (sync calendars, set reminders, tell your phone to remind you to do something). use phone to your advantage! • Watch (iwatch) • Planner • Journal • Keep structure • Keep schedule
Memory Task involving working memory, combined with SR and strategies Use numbers Cicerone 7 Ameobi 9 Welshman 10 Konig 11 Haber 92 Use mnemonic • Ameobi 9 • Cicerone 7 • Haber 92 • Konig 11 • Welshman 10
