Practice-Based Evidence: the process for ATC rehabilitation I have no financial relationships to disclose

Don MacLennan, MA/CCC! Chief, Speech Pathology Section! Minneapolis VA Health Care System

Objectives Evolution of Cognitive Rehabilitation “We no longer find it acceptable to sit people in ! • To understand current evidence-based practice for ATC front of a computer or workbook in the belief that! • Discuss practice-based evidence as a strategy to stay such exercises will result in improved cognitive! ahead of the evidence and, more importantly, social functioning.” • Identify principles of experience-dependent plasticity Wilson & Gracey, 2009

• Illustrate how application of principles of experience-! • Collaborative Goal Setting! dependent plasticity inform instructional methods for! • Cognitive, emotional, social consequences of brain injury! providing ATC strategies to people with cognitive ! are interlinked ! impairments • Technology is playing a larger part than ever before in! helping people with cognitive deficits compensate for! • Apply above information to a case study focusing on their problems! ATC • No one model or theory is sufficient to handle all the! complexities of neurorehabilitation

ATC and Rehabilitation Staff

Survey of 81 Rehabilitation Professionals (Hart et al, 2003) 17% used AT personally / 49% used AT clinically Cost as significant barrier Lack of confidence in their ability to provide service Evidence for ATC

Survey of 147 Rehabilitation Professionals (deJoode et al, 2010) 30% used AT personally / 28% used AT clinically No longer see cost as a primary barrier BUT - implementation of AT in clinical practice has been! “delayed or even stalled” Evidence-Based Practice! The Evidence: What the Research Offers (Golper et al, 2001)

Sohlberg, Kennedy, Avery, Coelho, Turkstra, Ylvisaker & Yorkston.! (2007) Evidence-based practice for the use of external aids as a “Evidence-based practice guidelines are explicit memory compensation technique. Journal of Medical Speech- descriptions of how patients should be evaluated Language Pathology, 15, pp. xv-li. and treated. The purpose of guidelines is to improve and assure the quality of care by reducing de Joode, van Heugten, Verhey & van Boxtel. (2010) Efficacy of unacceptable variation in its provision” assistive technology for patients with cognitive deficits: a systematic review. Clinical Rehabilitation, 24, 701-714.

Literature Search: 2009-present

Sohlberg et al, 2007 21 research studies 277 participants

• majority of subjects adult males Who • most in post-acute phase of injury • varied etiologies • varied treatment settings

• written planner/memory notebook (9) • hand-held PDAs (4) What • voice organizers/recorders (3) Device • pager (3) Practice Guideline • mobile phone (1) • navigational aid (1)

• laboratory-based measures (4) • structured tasks simulating demands of everyday memory (1) Outcomes • retrospective questionnaires of everyday memory performance (6) • performance on memory tasks cued by the aid (11) • ratings of preference, satisfaction, or perception of ! benefit • frequency of use (5) • anecdotal reports of effectiveness (2)

de Joode et al, 2010 28 papers/25 studies 423 participants

• majority of subjects adult males Who • most in post-acute phase of injury • varied etiologies • varied treatment settings

• hand-held PDAs (6) What • voice recorders (4) Practice Guideline Device • NeuroPage (4) • mobile phone (4) • combination of devices (3)

• everyday tasks (14) Outcomes • laboratory-based measures (6) • performance on tests (3) • navigation (2) • interpersonal communication (1) ATC: 2009-2012

Teasdale et al, 2011 Reduced caregiver strain as measured! Class I NeuroPage 99 caregivers • • • • by Modified Caregiver Strain Index McDonald et al, 2011 • Class I • Google Calendar! • 12 adults! • Significant improvement in prospective ! with SMS texts with ABI memory tasks with SMS texts ATC 2009-2012 Dowds et al, 2011 • Class II • Paper diary vs! • 36 adults! • Significant improvement in prospective ! 2 types PDAs with TBI memory tasks with PDA

Lemoncello et al, 2011 Television Assisted ! • 23 adults! • Class I • Significant improvement in prospective ! Prompting vs! with ABI • memory tasks with TAP! ‘typical strategies’ ! Svoboda et al, 2012

•• Class Class II II • Smartphone or ! • 10 adults! • Smartphone/PDA associated with ! PDA vs paper ! with ABI significant improvement over paper diary! diary

33 Studies

504 people Gaps in the Evidence All studies report treatment effect

Gaps: Unresearched ATC Devices There’s an App for That!!!

iTouch Tasks Schedules

iPhone Goals Smart Pens Checklists/Outlines

iPad Learning PEAT

Sustained Attention Routines Data Watches Droid Phones Gaps: Unresearched Populations Ponsford, 2012 mTBI Gaps Between What the Other compensatory strategies that might be applied Evidence Demonstrates include using mnemonic strategies...external memory aids such as a diary, daily planner and/or handheld PDF or mobile phone to assist with structuring the and! day and remembering things; using a tape recorder to tape meetings or telephone conversations to allow What Consumers Want for review of their contents...However there has been very limited controlled evaluation of interventions of this nature.

What Studies Show What People with TBI Want What Studies Show What People with TBI Want (Hart, Buchhofer, & Vaccaro, 2004) (Hart, Buchhofer, & Vaccaro, 2004)

1. Take medications 1. Track money spent (21)

Prospective Memory Prospective Memory 2. Remember appointments 2. Remember what people tell you (21)

3. Laboratory tasks ! 3. Remember things you need to do (21) Retrospective Memory (call clinic at a specific time)! (remember an artificial schedule) Learning 4. Remember therapy goals 4. Phone numbers/addresses (15)

Organization 5. Make entries into memory logs 5. Birthdays & anniversaries (14)

6. Completing real-life tasks 6. Remember shopping items (12)

7. Decreasing verbose! 7. Learn brand new things like ! conversation new procedures at work (13)

How many of you: Use ATC?

Use ATC for more than prospective memory?

Use ATC devices not yet evaluated in EBP literature?

Use app-driven ATC devices that are well-suited for customization of strategies to meet individual needs?

Use ATC with mild TBI population?

VA is Well Ahead of the Evidence Practice-Based Evidence (Horn & Gassaway, 2007) Practice-based Evidence

Embraces elements of clinical trials 1. Include a diverse population of study participants 2. Recruit from heterogeneous practice settings Clinician’s use of real-time feedback to develop, guide, and evaluate clinical services 3. Select clinically relevant interventions to compare 4. Collect data on a broad range of health outcomes

Sohlberg & Turkstra, 2011 Quality Improvement! PIE Model Program Plan! Implement! Evaluate

Practice-Based Evidence Features of Practice-Based Evidence for ATC

RCTs are important to confirm whether a new tx! Ongoing, iterative, assessment with functional, ! causes an effect - they are unlikely to discover ecologically valid measures combinations of interventions or practices that are effective and efficient in routine care Instructional methodologies that enhance acquisition, implementation, and maintenance of effective strategies Practice-based evidence provides evidence ! that will help generate new knowledge and ! bridge the gap between recommended and! Uses a variety of outcomes measures to assess improved care the effectiveness of treatment

Group Prospective Memory Challenge

Cognitive Skills Group - group of 5 (6 with me)

During the week • give everyone else in the group a prospective memory task Ongoing, Functional • at least a 24 hour interval between giving task & task completion • can only give one task per day • task must be quick, easy; not involve money; and cause no ! Assessment embarrassment Everyone in group: gives 5 tasks and receives 5 tasks

Predict performance & compare with actual performance

Appointments: 100% Identify “Real-World” Performance Targets Prospective Tasks: 70-100% More Than Prospective Memory Participant 1: Snooze Alarms Real World Target - 90%

Strategy Outcome Strategy Outcome

Trial 1 iTouch Tasks App Predicted: 90% Trial 1 Written Notes Predicted: 80% Actual: 100% Actual: 30%

i Touch / Pocket Informant app! Predicted: 80% Trial 2 1 alarm Actual: 30%

i Touch / Pocket Informant app! Trial 3 Retrospective: 0% 2 alarms

Participant 1: Snooze Alarms Real World Target - 90% Multiple Alarms Strategy Outcome

Trial 1 Written Notes Predicted: 80% Actual: 30%

i Touch / Pocket Informant app! Predicted: 80% Trial 2 1 alarm Actual: 30%

i Touch / Pocket Informant app! Predicted: 80% Trial 3 2 alarms Actual: 50%

i Touch / “Due” app! Trial 4 continuous 1 minute snooze

Participant 1: Snooze Alarms Real World Target - 90%

Strategy Outcome

Trial 1 Written Notes Predicted: 80% Actual: 30%

i Touch / Pocket Informant app! Predicted: 80% Trial 2 Actual: 30% 1-minute ! 1 alarm

snooze ! i Touch / Pocket Informant app! Predicted: 80% alarm Trial 3 2 alarms Actual: 50%

Trial 4 i Touch / “Due” app! Predicted: 80% continuous 1 minute snooze Actual: 90% Participant 2: Organization Real World Target - 100% Paper & Pencil Organizer

Strategy Outcome Tasks Given Assigned Due Mr Yellow: Tell me where you had basic training 5/4 5/6 lunch Trial 1 iPhone 4S task list! Predicted: 70% with alarms Actual: 30% Ms Purple: Where did you buy your parrot? 5/3 5/6 0830 Mr Pink: Give me a high 5 at cognitive skills group 5/2 5/4 cog skills iPhone 4S task list ! Predicted: 50% Mr Green: Show me the book you’re reading 0830 5/5 5/7 Town Hall Trial 2 with alarms Actual: 40% Mr Red: Who is Nebraska’s quarterback? 10:00 5/6 5/8 lunch Tasks Received Assigned Due • iPhone 4S task list! Tasks Given Assig Due Trial 3 Mr Yellow: Tell me where you had basic 5/4 5/6 lunch Mr Yellow: with alarms Ms Purple: Where did you buy your 5/3 5/6 0830 parrot? Ms Purple: Mr Pink: Give me a high 5 at cognitive skills 5/2 5/4 cog • Paper & pencil ! Mr Green: Show me the book you’re 5/5 5/7 Town organizational grid Mr Red: Who is Nebraska’s quarterback? 5/6 5/8 lunch Mr Pink: Tasks Received Assig Due Mr Yellow: Mr Green: Ms Purple: Mr Pink: Mr Red: Mr Green: Mr Red:

Participant 2: Organization Real World Target - 100% Outliner + iPhone Tasks Strategy Outcome

Trial 1 iPhone 4S task list! Predicted: 70% with alarms Actual: 30%

iPhone 4S task list ! Predicted: 50% Trial 2 with alarms Actual: 40%

iPhone 4S task list! • Predicted: 50% Trial 3 with alarms • Paper & pencil ! Actual: 100% organizational grid

Trial 4 • iPhone 4S task list! • Outliner app for iPhone

Participant 2: Organization Real World Target - 100% Group Retrospective Memory Challenge

Strategy Outcome

Trial 1 iPhone 4S task list! Predicted: 70% with alarms Actual: 30% Emphasis on prospective memory in rehabilitation

iPhone 4S task list ! Predicted: 50% Spend the majority of our time thinking about the future ! Trial 2 with alarms (Giambra, 2000) Actual: 40%

iPhone 4S task list! • Predicted: 50% Trial 3 with alarms Problems with memory represent most frequent cognitive! • Paper & pencil ! Actual: 100% complaint after mod-severe brain injury (Jamora, Young, & Ruff, 2012) organizational grid

Trial 4 • iPhone 4S task list! Predicted: 90% • Outliner app for iPhone Actual: 100% Group Retrospective Memory Challenge Retrospective Memory Assessment

Close relationship between future thought & Friday retrospective memory Conversational! What I Did Who I was With Topics Similar neural activity is involved for both future thinking &! ability to recall past experiences (Addis et al, 2007; Szpunar, 2010)

Brain-injured patients with poor episodic memory also show! difficulties with episodic future thinking (Hassabis & McGuire, 2007; ! Klein et al, 2002)

Retrospective Memory Assessment Retrospective Memory Assessment

12 Staff Mr Red

Baseline 7-Day Total 7-Day Total

What I Did! Conversational! What I Did! Conversational! Who I was With Who I was With (Routine Tasks) Topics (Routine Tasks) Topics

6 ! 36! 10 14 35 29 (4) (10)

Retrospective memory spanned previous six days Retrospective memory spanned previous two days

Group Retrospective Memory Challenge Journaling as Retrospective Memory Treatment

Journal Review - distributed rehearsal Each morning and evening review previous 3 days’ entries! Retrospective Memory Assessment “imagine yourself in the situations you recorded” Each entry is reviewed 6 times over a 3 day period Use journaling strategy to enhance retrospective memory Mon Tues Weds Thur Entries! Entries! Entries! Entries! 12:00 & 9:00pm 12:00 & 9:00 pm 12:00 & 9:00 pm 12:00 & 9:00 pm Review7am & 9pm! Review 7am & 9pm! Review 7am & 9pm! Repeat Retrospective Memory Assessment ! ! ! Mon! Mon - Tues Mon-Tues-Weds Journaling as Retrospective Memory Assessment Mr Green

Post-Journaling Strategy 7-Day Total Conversational! What I Did Who I was With Topics

12 items! 31 26 6 routine

Retrospective memory spanned previous 4 days

What Do We Do? ! (Gonzalez-Rothi, 2001)

Our goal as therapists is to facilitate the “reconstruction of behavioral functioning after injury or disease through Instructional Methodology ! rehabilitation.”

& Experience-Dependent! Premise: Neuroplasticity All behaviors, thoughts, emotions, and perceptual experience! arise from the brain If Rehabilitation Changes Behavior,! 10 Principles of Experience-Dependent Plasticity! It Changes the Brain! (Kleim & Jones, 2008) (Gonzalez-Rothi, 2001)

1. Use it or Lose it: Failure to drive a specific brain function can lead to Rehabilitation is potent - it can change the brain functional degradation

Plasticity: the ability of the nervous system to change structurally 2. Use it & Improve it: Training that drives a specific brain function can! lead to an enhancement of that function

Hebb (1949): Learning stems from changes in neural connections! 3. Specificity The nature of the training experience dictates the at the level of the synapse nature of the plasticity

- Can learn across the lifespan 4. Repetition Matters Induction of plasticity requires repetition

Induction of plasticity requires sufficient training ! 5. Intensity Matters intensity

10 Principles of Experience-Dependent Plasticity! (Kleim & Jones, 2008) Application of Experience-Dependent Plasticity

Different forms of plasticity occur at different 6. Time Matters: Dysphagia times during training Robbins JR, Butler SG, Daniels SK, Gross RD et al. (2008)! Swallowing and Dysphagia Rehabilitation: Translating! The training experience must be sufficiently salient to Principles of Neural Plasticity into Clinically Oriented Evidence.! 7. Salience Matters: produce plasticity JSHR, 51, S276 - S300 Aphasia Training-induced plasticity occurs more readily ! 8. Age Matters in younger brains Raymer AM, Beeson P, Holland A, Kendall D et al. (2008)! Translational Research in Aphasia: From Neuroscience to! Plasticity in response to one training experience can Neurorehabilitation.! 9. Transference enhance the acquisition of similar behaviors JSHR, 51, S259 - S300

Plasticity in response to one experience can interfere Voice 10. Interference with the acquisition of others Ramig L & Fox C. (2009) LSVT Global Certification

Principles of Neuroplasticity: ! Application to Brain