DISCLOSURES Impairments in People with Acquired Brain Injury - PDF document

3/17/2015 Summary of Evidence Based Interventions for Treatment of Cognitive DISCLOSURES Impairments in People with Acquired Brain Injury REBECCA D. EBERLE, M.A., CCC-SLP, BC-ANCDS CLINICAL ASSOCIATE PROFESSOR Rebecca D. Eberle, M.A., CCC-SLP, April 25, 2015 BC-ANCDS Has no financial or other interest to disclose Learning Objectives Evidence-Based Cognitive • Define the acquisition, application and adaptation stages Rehabilitation: Recommendations of cognitive rehabilitation  Cicerone et al, Arch Phys Med Rehab, 2000, 2005 • Write specific short-term tactical goals for cognitive and 2011 rehabilitation clearly linked to long-term strategic goals  Researchers (Cognitive Rehabilitation Task Force and the ACRM evidence-based recommendations of ACRM BI-ISIG) pursued comprehensive and • Employ a decision-tree to assist in determining the most methodical review of 370 articles (from 1971-2008) appropriate cognitive rehabilitation intervention to to derive 3 types of recommendations: implement ◦ Practice Standards • Identify the key intervention approaches for impairments ◦ Practice Guidelines of attention, memory, executive functions and social ◦ Practice Options communication, based on the literature of evidenced ◦ Did also state “Not recommended” based practices. Classification of Level of Evidence Recommendation Description – as to whether the treatment be specifically considered for persons with Cicerone et al, 2000, 2005 & 2011 combined neurocognitive impairments and disability Practice Standard Based on at least 1 well-designed class I study Class I/Ia Studies with well designed, prospective, with an adequate sample, with support from class randomized controlled trials (N = 65) II/III evidence; providing substantive evidence to support a recommendation. Class II Prospective, nonrandomized cohort studies; Practice Guideline Based on 1 or more class I studies with or clinical series with well-designed controls (N = 54) methodologic limitations, or well-designed class II that permitted between subject comparisons studies with adequate samples; providing evidence for probable effectiveness to support a of treatment conditions recommendation. Practice Option Based on class II or class III studies that directly address the effectiveness of a treatment, providing Class III Clinical series w/o concurrent controls, or evidence of possible effectiveness to support a studies with results from 1 or more single recommendation. (N = 251) cases w/ appropriate methods Cicerone et al, 2000, 2005 & 2011 Eberle ISHA 2015 1

3/17/2015 Cognitive Rehabilitation Manual (2012) Levels of Recommendation for • Based on the systematic reviews (Cicerone et Rehabilitation Strategies al., 2000, 2005, 2011) • First draft by Ed Haskins, Ph.D. • Practice Standard: “substantial evidence” • Edits, additions and revisions made by • Practice Guideline: “probable effectiveness” members of the ACRM Cognitive Rehabilitation Manual Sub-Committee. Externally-reviewed by • Practice Option: “possible effectiveness” but 24 novice to expert therapists and subsequent requires further research revisions. Reviewed by the Clinical Practice Committee of ACRM. • Final version available in April 2012 Barriers to Translation of Goals of Cognitive Rehabilitation Research into Clinical Practice • “…ameliorate injury-related deficits in order to maximize safety, daily functioning, independence • Clinical methods not often described in sufficient and quality of life” detail • Achieved in a step-wise manner with emphasis on 4 long term goal areas: • Practitioners do not have easy access to literature or • Problem orientation, awareness and goal time to read literature setting • Training programs for practitioners do not include BI • Compensation specific cognitive rehabilitation strategies • Internalization • Rehabilitation organizations have reduced training • Generalization budgets • Staff turnover results in experience drain Compensation Problem Orientation, awareness and goal setting • Providing clients with the necessary tools • Positively impacts functioning despite • Recognizing specific problem(s) that require persistent or chronic impairments intervention • Often the end goal for cognitive rehabilitation • Collaborating to establish meaningful short- and • Examples: long-term goals • External memory aids • Awareness and goal setting is a major therapeutic priority; foundation for most • External templates for decision making intervention Eberle ISHA 2015 2

3/17/2015 Internalization Generalization • The clinical process of gradually • Application of appropriate strategies for increasing the automaticity of practiced managing deficits in personally relevant strategies which facilitates independence areas of everyday functioning through the use of compensatory strategies and tools. Stages of Cognitive Rehabilitation External Versus Internal Strategies Stage of Treatment: Goals: Type of Strategies Used: 1. teach purpose and procedures of External Internal Acquisition treatment model External • Any self-generated • Those external to the 2. help patient recognize and accept procedure whose purpose deficits and benefits of treatment patient; e.g. use of 1. improve effectiveness & 1. External is to enhance conscious Application notebooks, electronic independence in compensating for control over thoughts deficits devices, cue cards… behaviors or emotions. 2. promote internalization of 2. Internal • LTG of external strategies strategies • LTG of internal strategies is 1. promote transfer of training to tasks 1. External and Internal is to enable patient to Adaptation to enable patient to become including those that are less compensate for their structured, more novel, complex, so familiar/adept with and/or distracting impairments process they can use it 2. promote generalization of skills 2. External and Internal INDEPENDENTLY by globally and without from the structured therapy setting to external assistance less structured environments such as using aids. home, community, and work Sohlberg & Mateer, 2001 Patient Progress Outcomes Treatment Planning and Goal Writing 1. Patient never develops necessary awareness Treatment planning and goal setting is a to compensate; patient learns to perform simple collaborative process. routine and action sequences procedurally Essential Ingredients: 2. Patient independent with use of external aids; • Objective measurement of progress on short- some internalization, but still needs external term tactical goals, guidance • Collaborative appraisal of progress, and 3. Patient able to internalize fully-learned strategies; can apply in specific situations or • Constructive counseling tasks. Very important to assist the patient in modifying 4. Patient generalizes learned skills to a range of goals and sustain motivation and engagement in situations and/or tasks. the therapeutic process Eberle ISHA 2015 3

3/17/2015 Writing Short-term (tactical) & Writing Short-term (tactical) & Long-term (Strategic) Goals Long-term (strategic) Goals •Writing & measuring short-term tactical goals • LT (Strategic) Goal: “improve ability to Quantification essential! The more specificity the independently compensate for memory behavioral feedback the faster behavior changes deficits using external aids” • Monitor and chart (daily, weekly, monthly) the • ST (Tactical) Goal: “patient will initiate four patient’s progress simple household tasks on a daily basis • Promote patient engagement in quantification with minimal assistance using a memory • Enhance motivation for treatment notebook” Treatment Considerations when Comprehensive Template for Designing Training Procedures Goal Writing External vs. Internal Task specific vs. Five Essential Factors Example Strategies general approaches “Patient will perform…. –Memory Mnemonics Type of Task household tasks that require – Task specific protocols scheduling (Internal) focus on procedural Complexity of Task that are simple –Procedural (External) learning for a specific task (e.g., medication) –Impairment Level Level of Cueing or Assistance with minimal assistance Needed • Mild: benefit from – General Approaches are Type of Strategy Employed to use a memory notebook both broad and aimed at an strategy overall domain (e.g., • Severe: tend to Measurement of Performance at 100% accuracy.” (e,g., speed, accuracy) memory) benefit from external Neurobehavioral and Psychosocial Is Patient Aware of Factors that Influence Process and Deficits? Yes No Outcome Can Patient Use Notebook And Use Techniques to or Electronic Device with • Patient Variables • Severity and Range of Increase Awareness Assistance? No • Values and Priorities Impairment Yes Use Task Specific Approach: Errorless • Coping skills What is patient’s level of • Emotional Reactions Learning, Spaced Retrieval, Chaining impairment? • Self-worth and self- Use both, as • Premorbid Psychiatric needed efficacy issues Severe Use External Strategies • Awareness Mild/Mod only: Provide Cueing • Family Factors and Assistance • Anosognosia • Domain-specific Continue to use External Strategy Use both, as Use Internalized with Assistance, if Needed • Brain Injury needed Strategies, as able Knowledge Eberle ISHA 2015 4