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9/11/2014
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Use of the Cognitive Rehabilitation
Manual across the Continuum of Care
Presented by Mary Ferraro, PhD, OTR/L
Susan Robinson, MA/CCC-SLP, MBA
OBJECTIVES Participants attending this presentation will:
Describe the aim and use of the Cognitive Rehabilitation Manual for interventions in the areas of: Executive Function, Memory, Attention, Hemispatial Neglect and Social Communication.
Describe the five factors of goal-writing utilized to demonstrate measurable progress in the areas of cognitive rehabilitation.
Discuss the challenges of implementing cognitive rehabilitation interventions by a variety of disciplines in diverse settings.
Evidence in Cognitive Rehabilitation
The Cognitive Rehabilitation Manual represents the work of the Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine (ACRM)
Their goal was to operationalize the published systematic reviews (2000, 2005, 2011) by Cicerone et al.
There are other sources for guidelines in this area, e.g., International Cognitive (INCOG).
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Cognitive Rehabilitation Manual
This text is NOT a substitute for clinical training and supervision in the area of cognitive interventions.
Two-day training sessions are offered to explain the structure and content of the manual.
A goal-writing framework is provided that can be used in treatment for all five cognitive areas
Classifications of recommendations
Practice Standard:
Substantial evidence
Based on at least one class I study
Practice Guideline:
Probable effectiveness
1 or more class I study w/methodological limitations
Practice Option:
Possible effectiveness but requires further research
Class II or class III studies, directly using a treatment
Cicerone et al., 2011
REMEDIATION OF ATTENTION
ACRM Practice Standard
Direct attention training and strategy (metacognitive) training during post-acute rehab after TBI.
ACRM Practice Option
Computer-based interventions as an adjunct to clinician-guided treatment. Sole reliance on repeated exposure and practice solely via computer is NOT recommended.
Cicerone et al., 2011
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REMEDIATION OF MEMORY DEFICITS
ACRM Practice Standard:
Memory strategy training recommended for mild memory impairments post TBI, including use of internalized strategies (visual imagery) and external memory compensations (notebooks).
ACRM Practice Guideline:
For those with moderate to severe impairment, only the use of external compensations (e.g., notebooks, electronic devices etc.) with direct application to functional activities are recommended.
Cicerone et al., 2011
REMEDIATION OF MEMORY DEFICITS
ACRM Practice Options:
For people with severe memory impairments after TBI, errorless learning techniques may be effective for learning specific skills or knowledge, with limited transfer to novel tasks or reduction in overall functional memory problems.
Group-based interventions may be considered for remediation of memory deficits after TBI.
Cicerone et al., 2011
ACRM Practice Standard:
Meta-cognitive strategy training (self-monitoring and self-regulation) is recommended for deficits in executive functioning after TBI, including impairments of emotional self-regulation, and as a component of interventions for deficits in attention, neglect, and memory.
Cicerone et al., 2011
REMEDIATION OF EXECUTIVE FUNCTION DEFICITS
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REMEDIATION OF EXECUTIVE FUNCTION DEFICITS
ACRM Practice Guideline:
Training in formal problem-solving strategies and their application to everyday situations and functional activities is recommended during post-acute rehabilitation after TBI.
ACRM Practice Option:
Group-based interventions may be considered for remediation of executive and problem solving deficits after TBI.
Cicerone et al., 2011
REMEDIATION OF VISUOSPATIAL AND PRAXIC DEFICITS
ACRM Practice Standards:
Visuospatial rehabilitation that includes visual scanning training is recommended for left visual neglect after right hemisphere stroke.
Specific gestural or strategy training is recommended for apraxia during acute rehabilitation for left hemisphere stroke.
ACRM Practice Guideline:
The use of isolated microcomputer exercises to treat left neglect after stroke does not appear effective and is not recommended.
Cicerone et al., 2011
REMEDIATION OF VISUOSPATIAL AND PRAXIC DEFICITS
ACRM Practice Options:
Inclusion of limb activation or electronic technologies for visual scanning training may be included in the treatment of neglect after right hemisphere stroke.
Systematic training of visuospatial deficits and visual organization skills may be considered for persons with visual perceptual deficits, without visual neglect, after right hemisphere stroke as part of acute rehabilitation.
Computer-based interventions intended to produce extension of damaged visual fields may be considered fro people with TBI or stroke.
Cicerone et al., 2011
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REMEDIATION OF LANGUAGE & COMMUNICATION DEFICITS
ACRM Practice Standards:
Cognitive-linguistic therapies are recommended during acute and post acute rehabilitation for language deficits secondary to left hemisphere stroke.
Specific interventions for functional communication deficits, including pragmatic conversational skills, are recommended for social communication skills after TBI.
Cicerone et al., 2011
REMEDIATION OF LANGUAGE & COMMUNICATION DEFICITS
ACRM Practice Guidelines:
Cognitive interventions for specific language impairments such as reading comprehension and language formulation are recommended after left hemisphere stroke or TBI.
Treatment intensity should be considered a key factor in the rehabilitation of language skills after left hemisphere stroke.
Cicerone et al., 2011
REMEDIATION OF LANGUAGE & COMMUNICATION DEFICITS
ACRM Practice Options:
Group based interventions may be considered for remediation of language deficits after left hemisphere stroke and for social-communication deficits after TBI.
Computer-based interventions as an adjunct to clinician-guided treatment may be considered in the remediation of cognitive-linguistic deficits after left hemisphere stroke or TBI. Sole reliance on repeated exposure and practice on computer-based tasks without some involvement and intervention by a therapist is not recommended.
Cicerone et al., 2011
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COMPREHENSIVE-HOLISTIC NEUROPSYCHOLOGIC REHABILITATION
ACRM Practice Standard:
Comprehensive-holistic neuropsychological rehabilitation is recommended during post-acute rehabilitation to reduce cognitive and functional disability for persons with moderate or severe TBI.
ACRM Practice Options:
Integrated treatment of individualized cognitive and interpersonal therapies is recommended to improve functioning within the context of a comprehensive program, and to facilitate the effectiveness of specific interventions.
Group-based interventions may be considered as a part of a comprehensive neuropsychologic rehabilitation program after TBI.
Cicerone et al., 2011
Collaborative Goal Setting
It is critical to use objective measures for short-term goals and engage the patient/client
Ongoing counseling and review of progress helps to maintain patient/client participation, motivation and engagement
Does the patient/client understand the relationship between your LONG and SHORT-term goals?
Lance Trexler - CRM training, October 2012
Considerations for goal setting (STG)
Type of task
Task complexity
Level of cueing
Type of strategy
Measure of success
General guidelines
Start w/ relatively easy tasks
Individually tailored
Emphasis on feedback and discussion
Distributed practice paradigm
Be flexible!
Cognitive Rehabilitation Manual, 2012, p. 9
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Tracking progress
Quantitative measures
Accuracy
Speed
Level of cueing
Qualitative measures
Specific error patterns
Patient factors
Environmental factors
Amy Rosenbaum - CRM training, October 2012
CHALLENGES OF IMPLEMENTATION
Use of the Cognitive Rehabilitation Manual Across the Continuum of Care
Clinician’s ability to deliver cognitive interventions
Varies significantly relative to discipline, experience and setting
The terminology has different meanings for clinicians
Clinical supervision schedules vary widely, as does supervisor comfort with content
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Complexity of topic
Theory and Application to Treatment
– Selected disciplines receive coursework in the area of cognitive rehabilitation
– The literature on cognitive rehabilitation is wide ranging
– Education is initially needed at the basic level to ensure that all staff can participate
Ongoing Education
Brain Injury Center supports clinical education
Monthly inservices
Specifically targeted Hypothesis Formation, but didn’t meet need to change daily practice
Clinical Research Integration
Content experts available but must address details of documentation forms and expectations, clinical rounds guidance, and fidelity of delivered interventions
Knowledge Translation Barriers
Clinical methods may not be described in enough detail for others to replicate
Clinicians may have difficulty accessing the literature
Brain injury specific interventions may not be included in training
Staff turnover and reduced training budgets
Lance Trexler – Cognitive Rehabilitation Manual (CRM) training, October 2012
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Cognitive Rehab Manual Literature
Evidence is specific to Traumatic Brain Injury and Stroke populations
Standards, Guidelines, Options are broad
Simply distributing the Cognitive Rehabilitation Manual was not enough There are still gaps in clinicians’ ability to specify what to deliver to the patient…
Terminology Example: Selected Teaching Methods
Errorless Learning
Provide info; ask patient to recall without delay; actively discourage guessing
Spaced Retrieval
Patient/client is asked to retain info over progressively longer periods of time
Chaining
Trains sequences of steps by procedural memory; Forward and Backward types
How does staff understand and use these terms?
Cognitive Rehabilitation Manual, 2012, pp. 49-53
Next step?
We created a WORK GROUP to operationalize the manual for our setting
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PROCESS OF IMPLEMENTATION
Use of the Cognitive Rehabilitation Manual Across the Continuum of Care
Choosing First Content Area: MEMORY
Why memory? Memory deficits are ubiquitous in TBI
Wide range of difficulty seen in practice:
Post Traumatic Amnesia to Metacognitive strategy use
All services in our continuum report this problem
WHO participated?
Inpatient and Outpatient
Clubhouse
Residential
Fixed and Rotators
All Disciplines
Novice and Experienced Staff
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Meeting Schedule
Weekly work group meetings done via conference call
Inservice targeted for summer
Anticipated duration of roll-out: 3-6 months of monthly or bi-monthly inservices and meetings
Overall Plan
Identify definitions/terminology
Describe how memory works – the process
Examine discipline-specific evaluation: observation, formal vs informal assessment, hypothesis testing
Role of supervision
Translating assessment into treatment
Practical Considerations
The Work Group is comprised of 13 people
Meeting TIME was challenging due to varied sites and work schedules.
Scheduled meetings 2x/month and utilized conference calling/webinars to keep all informed
Assignments
Necessary to identify specific methods of implementation of these concepts
We relied on supervisors to create assignments in their respective areas to monitor with their staff
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First six months Where we started:
explain the process of utilizing the ACRM guidelines to educate staff on using evidence-based treatment to address memory deficits
Created slides on memory skills that could be used by ALL sites
However, other needs became apparent and we stepped back and addressed evaluation needs
Where we are now:
Discuss process of educating and training staff on how to incorporate hypothesis testing into evaluation and treatment
Outcome
Creation of staff education materials that are applicable to ALL brain injury programs
Slides were reviewed by group with the understanding that all supervisors could convey this common information to their staff. It is assumed that supervisors will augment the slides with details and examples in their discipline or point in the continuum.
Implementation Plan
Framework for evaluation and for supervision
First round of lectures provided by our neuropsychologists with the intent to identify qualified staff who can teach content to others
Extensive schedule of presentations in order to reach nurses on all shifts, residential staff etc.
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Assignments Follow-up managed by direct supervisors
Supervisors could augment slides to help instruct staff on assignment completion
Expected review of hypothesis generation and testing assignments: in supervision and in clinical documentation
Expected review of assignments on memory interventions (documentation of memory goals, description of treatment interventions, consistency across team for patient when applicable)
EXAMPLES OF SLIDES ON HYPOTHESIS TESTING AND MEMORY PROCESSES
Use of the Cognitive Rehabilitation Manual Across the Continuum of Care
• Diagnosis, impairments, abilities
• Consider the referral question
• Is the patient an active, engaged learner?
• Is the patient aware of their deficits?
Patient capacities
• Context and demands of observed actions TASK ANALYSIS
• How did the set up influence performance?
• How did the environment drive performance?
Environment and task set up
• Consider visual and verbal presentations of information
• Was a model and/or demonstrationsoffered?
• How did I present info and was one method more effective than another?
Therapist cues and behavior
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•What do I know about this patient’s diagnosis & capacities?
•How did I present data, ask questions?
•How did the environment and task contribute? •Task analysis of the activity
Gather data
• Task analysis of the activity
• What made the performance hard for the patient?
• What helped the performance?
Develop hypotheses • How are therapist actions
affecting the patient or their performance?
• Is this a reliable effect?
• Does this give me info on how the patient learns?
Intervene to address deficit
Back to DATA
Gathering
Consider…What are the possible reasons for the behavior/action?
Hypothesis: what is a
likely cause?
What behaviors did I see?
What went wrong?
What went right?
Consider brain function and
injury
Did performance change…due to environment, therapist etc.?
Info from task analysis
Acquisition Storage Retrieval
Memory PROCESS
Acquisition Storage Retrieval
Taking in Information
Encoding
Recording it, Filing it
Consolidation
Accessing information when needed
Retrieval
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Organization of Long-term Memory Systems
Declarative
Conscious recall of objects, information and events
Episodic
Autobiographical experiences
Semantic
Knowledge
Non-Declarative
Nonconscious performance of knowledge or skills
Priming
Cued recall of a previously learned response
Procedural
“skill memory”
Cognitive Rehabilitation Manual , 2012, p. 12
Is Patient aware of deficits?
Can patient use an external strategy? Use techniques to increase awareness
What is Patient’s level of impairment?
Use task specific approach: errorless learning, spaced retrieval, chaining
Use external strategies only; provide cueing and assistance
Mild Moderate
Severe
Use internalized strategies, as able
Continue to use external strategy with assistance, if needed
Yes No
Yes No
Use both, as needed
Use both, as needed
Decision Tree for Treatment Planning
Cognitive Rehabilitation Manual , 2012, p. 12
Primary References
• Cicerone, K., Langenbahn, D., Braden, C., Malec, J., Kalmar, K., Fraas, M., . . . Ashman, T. (2011). Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Archives of Physical Medicine and Rehabilitation, 92(519)
• Haskins, E. C., Cicerone, K., Dams-O'Connor, K., Eberle, R., Langenbahn, D., Shapiro-Rosenbaum, A., & Trexler, L. E. (Eds.). (2012). Cognitive rehabilitation manual: Translating evidence-based recommendations into practice. Reston, Virginia: ACRM Publishing.
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Related Readings • Dijkers, M.P., Murphy, S.L., & Krellman, J. (2012).
Evidence-based Practice for rehabilitation professionals: Concepts and controversies. Archives of Physical Medicine and Rehabilitation, 93 (S164-S176).
• Journal of Head Trauma Rehabilitation, July-August 2014 Issue on: Optimizing Cognitive Rehabilitation (INCOG Guidelines).
• Sohlberg, M. M., & Mateer, C. (2001). Cognitive rehabilitation: An integrative neuropsychological approach. New York: The Guilford Press.
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