the intensive cogni.ve-communica.on rehabilita.on (iccr ... · the intensive cogni.ve-communica.on...
TRANSCRIPT
The Intensive Cogni.ve-Communica.on Rehabilita.on (ICCR) Program for Young
Adults with Acquired Brain Injury
Presentedatthe46thAnnualClinicalAphasiologyConferenceJune3,2017
KatrinaRoss,M.S.CF-SLP,NatalieRoss,M.S.,NatalieGilmore,M.S.CCC-SLP,CarrieDesRoches,B.A.,andSwathiKiran,Ph.D.CCC-SLP
Cogni.ve Rehabilita.on and ABI • AcquiredBrainInjury(ABI),duetostrokeorTBI,typicallyresultsinimpairmentsof:
• Language-e.g.,speaking,listening,reading,wriSng• Cogni*on-e.g.,aTenSon,memory,execuSvefuncSoning
(Chapey,2008;Ciceroneetal.,2011;Kennedyetal.,2008;Sohlberg&Mateer,1989)
• Deficitsareo]enchronic(i.e.,>6monthspostonset;Ciceroneetal.,2011;Kennedy&Coehlo,2005)• TBIcalleda“chroniccondiSon”anda“diseaseprocess”(Corrigan&Hammond,2013;Masel&DeWiT,2010)
• YoungadultsareafrequentlyaffectedandgrowingpopulaSonwithinABI(“TBI:GettheFacts,”2017;“YoungStrokeSurvivors,”2016)
• Thisage-groupwouldtypicallybeinvolvedinhighereducaSon,butthatiso]enprecludedbyinjury
• CogniSveRehabilitaSon(CR)isatherapeuScprogramdesignedtotargetcogniSve-linguisScdeficits(Ciceroneetal.,2000)thatmaybeimpairment-based,funcSonal,oracombinaSonofthetwo
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Impairment-Based and Restora.ve CR
• Impairment-basedapproachesseektostrengthencogniSve-linguisScskillsatthepreciselevelofbreakdowntomaximizeneurologicalgains(Kleim&Jones,2008;Laatsch&Krisky,2008;Lesniak,Polanowska,Seniow,&Członkowska,2014)
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COGNITION LANGUAGE• ATenSonProcessTraining(APT;Sohlberg,McLaughlin,Pavese,
Heidrich,&Posner,2000)
• VisualscanningtrainingtoremediatehemispaSalneglect(Ciceroneetal.,2011)
• CategorizaSonProgram(CP;ConstanSnidou,Thomas,&Robinson,
2008)forproblemsolving• MulS-stepsequencetrainingforproblemsolvingand
execuSvefuncSon(Ehlhardt,etal.,2008)
• SemanScFeatureAnalysis(SFA;Boyle,2004;Wambaugh,Mauszycki,Cameron,Wright,&Nessler,2013)
• PhonologicalComponentsAnalysis(PCA;Leonard,Rochon,&Laird,2007)
• VerbNetworkStrengtheningTreatment(VNeST;Edmonds,Mammino,&Ojeda,2014)
• MelodicIntonaSonTherapy(MIT;vanderMeulen,etal.,2012)
Func.onal and Compensatory CR • FuncSonalapproachessupportcogniSve-linguisScimprovementsineveryday,personallymeaningfulcontexts(Elman&Bernstein-Ellis,1999;Johnson,Hough,King,Vos,&Jeffs,2008;Kagan,2011)
• CompensatoryapproacheshelpindividualsadapttotheirABI
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COGNITION LANGUAGE• Memorybooks,automaScelectronicreminders,and
otherexternalaids(Ciceroneetal.,2011;SIGN,2013)• MetacogniSvestrategytraining,e.g.,TimePressure
Management(Fasom,Kovacs,Eling,&Brouwer,2000),BrainBudgeSng(Mayer,Mitchinson,&Murray,2016),andTEACH-M(Ehlhardt,Sohlberg,Glang,&Albin,2004)
• Errorlesslearningtechniques(Bertens,Fasom,Boelen,&Kessels,2015)
• CaregivertrainingandenvironmentaladaptaSons(Ciceroneetal.,2011;SIGN,2013)
• AcSvity-leveltraining,e.g.pracScereadingamenu(Simmons-Mackie&Kagan,2007)
• PromoSngAphasics’CommunicaSveEffecSveness(PACE;Davis,2005)andOralReadingforLanguageinAphasia(ORLA;Cherney,2010)
• ScriptTraining(Cherney,Kaye,&vanVuuren,2014)• ConstraintInducedLanguageTherapy(CILT;Allenetal.,2012)• ConversaSonPartnerTraining(Simmons-Mackieetal.,2010)and
environmentaladaptaSons
Comprehensive CR • Thegold-standardCRcombinestheseapproachesinordertoprovidecomprehensive,holisSc,integratedtreatment(Ciceroneetal.,2011)
• Tomaximizeoutcomes,CRshouldalsoaccountforprinciplesofneuralplasScity
(Kleim&Jones,2008):
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Impairment FuncSonal✓Intensity RepeSSon
SalienceSpecificity
✓
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• StudyofCogniSveRehabilitaSveEffecSveness(SCORE;DVBIC,2015)wasdevelopedasanoutpaSentCRprogramforindividualswithmildTBI
• Oneofthefourarmswascomprehensive
• However,SCOREislimitedinthat:• ItonlyaddressesmTBI• Onlyonearmistrulycomprehensive• Formalresultshavenotbeenpublished• Itwasnotdesignedforyoungadults
Comprehensive CR: TBI
Intensity RepeSSon
SalienceSpecificity
~ ~
~ ~
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• 16TBIModelSystemCenters(fundedbyNaSonalInsStuteonDisability,IndependentLiving,andRehabilitaSonResearch)aremedicalfaciliSesthatprovidevariouslevelsrehabilitaSon
• AllhaveoutpaSentfollow-upappointments,5havevocaSonallyfocusedoutpaSentdayprograms,and2havecommunityre-entryprograms
• TIRRMemorialHermannChallengeProgram• VocaSonallyfocusedwithacademicopSons
• However,TBIMSCentersareprimarilyfocusedonacuterehabilitaSonandareallwithinahospitalenvironment
Comprehensive CR: TBI (cont’d)
Intensity RepeSSon
SalienceSpecificity
✓
~ ~
~
Comprehensive CR: Aphasia • IntensiveComprehensiveAphasiaPrograms(ICAPs)areefficaciousandpopulartreatmentsforpeoplewithaphasia(PWA)(BabbiTetal.,2016;Rodriguezetal.,2013;Roseetal.,2014;Hooveretal.,2017;Persadetal.,2013;Winans-Mitriketal.,2014)
• However…• PWAwhoparScipateinthistypeofCRmaybeyoungerthanthegeneralstrokepopulaSon(Hooveretal.,2017;Persadetal.,2013)
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Intensity RepeSSon
SalienceSpecificity
✓ ✓
✓ ~
Review: What’s out there? Principles of Neural Plas.city
Intensity Repe..on Specificity Salience
SCORE ~ ~ ~ ~ TBIMS ✓ ~ ~ ~ ICAPs ✓ ✓ ✓ ~
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TBI Aphasia Moderate – Severe Profiles
✓ ✗ ✗
✓ ~ ✓
✗ ✓ ✓ Our Program:
“ICCR" ✓ ✓ ✓ ✓ ✓ ✓ ✓
Methods: Intensive Cogni.ve-Communica.on Rehabilita.on
• TheICCRprogramintegratesimpairment-basedandfuncSonalapproachesinasimulatedcollegesemester
• Eachdayconsistsof:• FuncSonally-basedapplicaSonofskillsandstrategytraining
• CoreandElecSveclasses(e.g.Psychology,Economics)
• GroupmetacogniSveintervenSon(e.g.aTenSonstrategies,differenttypesofmemory,etc.)
• Impairment-basedintervenSonindiscretegoalareas• IndividualSLPsessions• App-basedtherapy(i.e.ConstantTherapy)andtechnologytraining
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Dopar*cipants…
…demonstratechangesincogniSve-linguisScskillsasaresultofthisnovelintervenSonprogram?
…progresstowardpersonalandtherapeuScgoalsoverthecourseoftreatment?
…effecSvelyapplynovelskillsandstrategiesinafuncSonalenvironment?
ICCR Research Ques.ons
Par.cipants
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P1 P2 P3
E.ology TBI CVA TBI
Group Experimental Experimental Experimental
Age 21 29 25
Sex M M M
Educa.on (years) 12 15 10
MPO 49 70 96
WAB-R AQ 61.9 80.4 66.5
RBANS - Index 45 64 46
TBI = Trauma.c Brain Injury; CVA = Cerebrovascular Accident; MPO = months post onset; WAB-R = Western Aphasia Badery - Revised (Kertesz, 2006), AQ = Aphasia Quo.ent; RBANS = Repeatable Badery for the Assessment of Neuropsychological Status - Update (Randolph, 2012)
P4 C1
TBI CVA
Experimental Control
34 31
M F
16 14
97 59
18.8 84.6
48 76
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Methods: Assessments • StandardizedTestBaTery
• WesternAphasiaBaTery–Revised(WAB-R;Kertesz,2007)
• ScalesofCogniSveandCommunicaSveAbilityforNeurorehabilitaSon(SCCAN;Milman&Holland,2012)
• RepeatableBaTeryfortheAssessmentofNeuropsychologicalStatus-Update(RBANS;Randolph,2012)
• ChildandAdolescentScaleofParScipaSon(CASP,McDougall,Bedell,&Wright,2013)
• DiscourseComprehensionTest(DCT;Brookshire&Nicholas,1997)• GoalATainmentScaling(GAS,King,McDougall,Palisano,Gritzan,&Tucker,2000)
• PragmaScProtocol(Prumng&KiTchner,1987)
• TestofWriTenLanguage(TOWL,Hammill&Larsen,2009)
• TBI-QOL(Tulsky,2016)andNeuro-QOL(Cellaetal.,2012)• ClassroomparScipaSonmeasuresandquizzes
• SLPcogniSve-linguisScgoals(e.g.,“StudentwillalternateaTenSonamongmoderatelycomplexsSmuli,≤2errors,providedminimalcues”)
Pre-treatmentTestBaTery
Treatment(12-weeks)
Post-treatmentTestBaTery
Monday Tuesday Wednesday Thursday
10:00 Psychology Biology Psychology Biology
11:00 USHistory SLP CommunicaSons SLP USHistory SLP CommunicaSons SLP
12:00 Lunch Lunch Lunch Lunch
1:00 GroupTherapy GroupTherapy GroupTherapy GroupTherapy
2:00
Tech SLP Finance SLP
Tech SLP Finance SLP
3:00 SLP Tech SLP SLP Tech SLP
Methods: Weekly Schedule
• Coreclasseswithallstudents• Grouptherapywithallstudents• ElecSveswithonestudentpulledoutforanindividualSLPsession
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Monday
Psychology
USHistory
Lunch
GroupTherapy
Tech
SLP
• PsychologyandUSHistoryvideolecture• Coursecontent• DiscussionandcomprehensionquesSons• ResearchandstudentpresentaSons
• Grouptherapy• DiscussionofmetacogniSveprinciplesandstrategies• ApplicaSonofstrategiesinagameorfuncSonalexercise
• Techsession• App-basedtherapyorso]warepracSce(e.g.ConstantTherapy,GoogleDocs,etc.)
• IndividualSLPsession• DrillworktargeSngcogniSve-communicaSongoals• Personal,impairment-basedGASmanagement
Daily Schedule
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Results: WAB-R
-202468
101214161820
LanguageQuoSent CorScalQuoSent AphasiaQuoSent
***
P1
-202468
101214161820
LanguageQuoSent CorScalQuoSent AphasiaQuoSent
***
C1
-202468
101214161820
LanguageQuoSent CorScalQuoSent AphasiaQuoSent
*** ***
***
P3
-202468
101214161820
LanguageQuoSent CorScalQuoSent AphasiaQuoSent
P4
-202468
101214161820
LanguageQuoSent CorScalQuoSent AphasiaQuoSent
****
** ***
P2
Allgraphsshowchangescores,withpre-treatmentvaluessetat0foreachpaSent*ClinicallysignificantchangebetweenadjacentSme-points(+/-1SEM)**Clinicallysignificantchangebetweenpreandpost2(+/-1SEM)Post1Post2
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Results: SCCAN
-10-505
101520253035
**
*
*
**
*
*** *
** ***
***
C1
-20
-10
0
10
20
30
40
50
****
*
***** *
*
*
***
*
P3
-20
-10
0
10
20
30
40
50
*
***
***
*
***
***
*
***
****
P1
**
-20
-10
0
10
20
30
40
50
**
**
*
***
***
*
*
***
**
P2
**
-40
-30
-20
-10
0
10
20
30
**
*
*
P4
**
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Results: RBANS
-10-505
10152025303540
* *
P1
-40
-35
-30
-25
-20
-15
-10
-5
0
5
10
*
***
*
*
**
*
***
*
**
***
C1
-10
-5
0
5
10
15
20
25
30
35
40
*** *
***
***
****
P3
-20
-15
-10
-5
0
5
10
15
20
25
30
*
P4
-10
-5
0
5
10
15
20
25
30
35
40
***
**
*
*
**
*****
*
P2
**
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Classroom and SLP outcomes Classroomperformance• AllstudentsdemonstratedincreasedparScipaSon,acquisiSonoflearningstrategies(e.g.,requestedrepeSSon),andincreasedquizscores
SLPgoalperformance
Example of goal area at intake Example of current goal area
P1 • Selec.ve aden.on in a non-distrac.ng environment
with moderate cues • Alterna.ng aden.on in a non-distrac.ng
environment with minimal cues
P2 • 1-2 paragraph auditory comprehension • 3-4 paragraph auditory comprehension
P3 • 1-5 minute sustained aden.on • 5-10 minute sustained and selec.ve aden.on
P4 • Spoken word to picture matching with 3 items • Spoken word to picture matching with 4 items
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Discussion • InthecurrenthealthcareandCRsystems,thereremainsagapforyoungindividualswithABIwhowishtoreturntoschool
• ParScipantsinICCR:• Enrollinfull(15-week)semestersasstudentsinamodifiedclassroom• Receivetherapytosupporttheirsuccessinthatclassroom
• However…• Smallsamplesize• ControlparScipantshowedsomeclinicallysignificantgains• P4’sprofilewasthemostresistanttochange
• Overall,themajorityofourparScipantshavedemonstratedimprovedcogniSve-communicaSonskillsasaresultofICCR
• TheseresultssuggestthatICCRisworthyoffurtherinvesSgaSonasaCRprogramforyoungadultswithABI
• FuturesemesterswillconSnuetoexploreitsefficacyandthepotenSaltoscaleICCRtootherenvironmentsandpopulaSons
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Conclusions
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Thank you!
• Dean’sFundingfromSargentCollegeofHealthandRehabilitaSonSciences
• ICCRTeamatBUAphasiaResearchLaboratory• NatalieRoss,NatalieGilmore,CarrieDesRoches,&SwathiKiran
• ICCRstudents,families,andcaregivers
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Group Results P1 P2 P3 P4 P5
Pre Post1 Post2 Pre Post1 Post2 Pre Post1 Post2 Pre Post1 Post2 Pre Post
WAB-RLanguageQuoSent 56.8 61.2 61.6 73.2 83.7 81.3 72 81.2 80.6 85.3 84.6 87.1 24 24.7CorScalQuoSent 65.2 67.3 69.3 77.2 84.8 85.2 74.1 83.6 84.0 88.3 89.5 91.1 33.8 32.9AphasiaQuoSent 61.9 67.4 70.4 80.4 91.5 85.9 66.5 80.3 82.7 84.6 91.2 92 18.8 17.1
RBANS
ImmediateMemory 44 44 44 69 76 83 44 40 53 73 76 73 40 40
VisuoconstrucSonal 69 72 78 72 87 109 66 75 102 102 92 84 102 84
Language 40 44 40 82 89 82 47 74 54 85 78 54 40 40
ATenSon 43 49 40 40 40 43 53 64 53 49 40 56 43 46
DelayedMemory 44 44 52 94 85 101 40 44 44 94 83 97 40 40
IndexSum 240 253 254 357 377 418 250 297 306 403 369 364 265 250
Total 45 46 46 64 69 79 46 52 52 76 67 66 48 46
SCCAN
OralExpr. 42.1 47.4 57.9 78.9 73.7 68.4 47.4 52.6 57.9 89.5 84.2 94.7 0.0 5.3
Orient. 58.3 83.3 91.7 100.0 100.0 100.0 58.3 91.7 58.3 100.0 100.0 100.0 0.0 8.3
Memory 42.1 36.8 47.4 42.1 52.6 84.2 21.1 26.3 31.6 57.9 68.4 89.5 21.1 21.1
Speech 61.5 76.9 69.2 76.9 100.0 92.3 84.6 100.0 92.3 76.9 100.0 92.3 30.8 46.2
Reading 41.7 83.3 66.7 83.3 83.3 83.3 58.3 66.7 58.3 83.3 91.7 83.3 66.7 33.3
WriSng 57.1 57.1 57.1 57.1 57.1 57.1 85.7 71.4 85.7 57.1 71.4 57.1 42.9 42.9
ATenSon 43.8 56.3 62.5 75.0 75.0 81.3 43.8 43.8 56.3 87.5 100.0 93.8 56.3 56.3
Prob.Solv. 52.2 69.6 82.6 87.0 78.3 78.3 56.5 52.2 56.5 95.7 95.7 91.3 47.8 60.9
Total 48 61 63 71 74 79 54 59 57 78 82 84 29 31
TBIandNeuro-QOL
Anxiety 41.2 54.2 41.2 49.4 42.1
CogniSvefuncSon 43.0 43.9 32.8 47.5 46.0
CommunicaSon 45.4 20.0 57.5 40.3 19.0
Depression 68.3 45.3 38.3 70.5 36.9
PosiSveAffectandWell-being 33.7 57.8 67.8 43.1 68.0
CASP-SelfReport
Home 79.2 100.0 79.2 91.7 83.3 87.5 87.5 83.3 79.2 91.7 100.0 100.0 79.2 70.8
Neighborhood 50.0 68.8 50.0 75.0 62.5 75.0 81.3 75.0 68.8 93.8 93.8 100.0 68.8 68.8
School 0.0 75.0 80.0 0.0 85.0 85.0 0.0 75.0 75.0 0.0 0.0 0.0 0.0 65.0
AcSviSes 100.0 50.0 58.3 80.0 68.8 68.8 81.3 62.5 62.5 100.0 100.0 100.0 37.5 75.0
Total 75.0 76.3 69.4 83.3 76.3 80.3 83.9 75.0 72.4 95.0 98.3 100.0 64.3 70.0
DCT
TotalMI-L 11 17 16 15 15 17 8 13 12 20 20 20 0 11
TotalDT-L 10 10 11 12 12 14 12 10 12 18 16 19 0 11
ListeningTotal 21 27 27 27 27 31 20 23 24 38 36 39 0 22
TotalMI-R 12 13 16 18 12 16 10 9 9 12 15 18 0 9
TotalDT-R 12 11 11 15 14 13 8 9 10 14 17 15 0 9
ReadingTotal 24 24 27 33 26 29 18 18 19 26 32 33 0 18
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Classroom and SLP outcomes Classroomperformance• AllstudentsdemonstratedincreasedparScipaSon,acquisiSonoflearningstrategies(e.g.,requestedrepeSSon),andincreasedquizscores
SLPgoalperformance
Intake goals Current goals
P1 • Selec.ve aden.on in a non-distrac.ng environment with moderate cues • 3-unit working memory with ≤3 repe..ons • Concrete problem solving • 1 paragraph auditory comprehension
• Alterna.ng aden.on in a non-distrac.ng environment with minimal cues • 4-unit working memory with ≤2 repe..ons • Mixed concrete-abstract problem solving • 1-3 paragraph auditory comprehension • Reading and wri.ng
P2 • 1-2 paragraph auditory comprehension • Concrete problem solving • Organiza.on and cogni.ve flexibility in concrete, discrete scenarios
• 3-4 paragraph auditory comprehension • Abstract problem solving • Organiza.on and cogni.ve flexibility in func.onal situa.ons
P3 • 1-5 minute sustained aden.on • Basic concrete problem solving • <15 automa.c uderances per session with maximum cues
• 5-10 minute sustained and selec.ve aden.on • Minimally-moderately complex concrete problem solving • <10 automa.c, inappropriate uderances per session with minimal cues
P4 • Use total communica.on on 3 occasions to repair breakdowns given maximal cues
• Iden.fy basic familiar pictures by name from a field of 3
• Use total communica.on on 4-5 occasions to repair breakdowns given moderate cues
• Iden.fy basic familiar pictures by name from a field of 4