A Ramp to College: Intensive Cognitive-Communication Rehabilitation (ICCR) for Young Adults with Acquired Brain Injury

Presented at the 36th Annual New Hampshire Brain Injury and Stroke Conference

May 15th, 2018

Natalie Gilmore, M.S. CCC-SLP, Lindsey Foo, M.A. CCC-SLP, Swathi Kiran, Ph.D. CCC-SLP

Disclosures

• Swathi Kiran has a financial relationship with The Learning Corporation/Constant Therapy (consulting fee).

• Natalie Gilmore and Lindsey Foo have no relationships to disclose.

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After this Session You will be Able to:

1. List four principles of experience-dependent neuroplasticity

2. Identify an evidence-based approach for treating 1) attention; 2) language; 3) memory; and 4) executive function

3. State four key components of the intensive cognitive-communication rehabilitation (ICCR) program

4. Describe three outcomes of the intensive cognitive-communication rehabilitation (ICCR) program

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Agenda

Foundations of ABI and ICCR Program

1. Review acquired brain injury (ABI)

2. Discuss recovery and neuroplasticity in this population

3. State of cognitive rehabilitation and transition to college services for young adults with ABI

4. Intensive Cognitive-Communication Rehabilitation (ICCR) program

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Background: ABI - Etiology

• Acquired brain injury (ABI)A brain injury that occurs after birth that is not hereditary, congenital, degenerative, or related to birth trauma1

51 https://www.biausa.org/

Traumatic brain injury (TBI)

• Motor vehicle accidents

• Falls

• Assault

• Recreational injuries

Non-traumatic injury

• Stroke

• Brain tumor

• Infection

• Hypoxia/anoxia

Background: ABI - Pathophysiology

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TBI Stroke

Background: ABI - Long-term effects

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Executive Function

Attention

Visuospatial Skills

Memory

Communication

Anxiety

Depression

Language impairment

Impairment Domain TBI Stroke (aphasia)

Cognition

Attention

Executive Function

Memory

Language

Visuospatial Skills

Processing Speed

Psychosocial

Anxiety

Depression

Anger/Irritability

Physical

Sleep/energy level

Motor

Vision

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2Rabinowitz & Levin, 2014; 3Villard & Kiran, 2015; 4Purdy, 2002; 5Lang & Quitz, 2012; 6Kertesz & McCabe, 1975; 7Sinanovic et al. 2012; 8Seniow et al. 2009; 9Ballistone et al. 2008; 10Neto & Santos, 2012; 11Fleminger, 2008, 12Cahana-Amitay et al., 2011; 13Kauhanen et al. 2000; 14Code et al. 1999; 15Viola-Saltzman & Watson, 2012; 16Hilari et al. 2003; 17Khan et al. 2003; 18Langhorne et al. 2009; 19Greenwald et al. 2012; 20Rowe et al. 2009

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5,6

4

7

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109

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15 16

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Background: ABI - Prevalence

• 1-2 million individuals with TBI in the US annually21

• Young adults frequently-affected21

• Rise in recreation-related injuries

• 800,000 individuals with stroke yearly nationwide21

• 10-15% in working-age individuals22

• Increase in vascular risk factors

• Deficits are often chronic (i.e., >6 months post onset)2,7

• Participation in school and work is often limited due to injury severity23-28

• Reduced quality of life and increased societal burden29-32

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2Rabinowitz et al. 2014; 7Sinanović et al. 2012; 21CDC; 22Smajlovic et al. 2015; 23Matuzzi & Pfenninger, 2018; 24Graham et al. 2011; 25Todis & Glang,2008; 26Lawrence, 2010; 27Cahill et al. 2014; 28Kennedy et al. 2008; 29Ellis et al., 2012; 30Coronado et al. 2012; 31Hilari et al. 2016; 32Stochetti & Zanier2016

Background: Young adults with ABI and college

• College is a rite of passage for many young adults.

• Unfortunately, skills important for success in college are often impaired after ABI, making participation challenging33-36

• Requires high motivation and support25

• 80% of young adults with TBI report struggling with academic material28

• Provides an opportunity to improve cognition and build social skills, confidence and independence

How can we reconcile this mismatch?

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25Todis & Glang, 2008; 28Kennedy et al. 2008; 33Hassanbeigi et al. 2011; 34Krumrei-Mancuso et al. 2013; 35Stadler et al.2016; 36Taraban et al. 2000;

Background: Impairment- & Functionally-based Cognitive Rehabilitation

1. Impairment-based approaches seek to strengthen cognitive-linguistic skillsat the precise level of breakdown to maximize neurological gains37,38,39

2. Functional approaches support cognitive-linguistic improvements ineveryday, personally meaningful contexts40,41,42 and compensatoryapproaches help individuals adapt to their ABI

• Gold-standard cognitive rehabilitation (CR) = combination of these twoapproaches for comprehensive treatment43

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Impairment Functional✓

37Kleim & Jones, 2008; 38Boyle, 2010; 39Sohlberg & Mateer, 1987;40Elman & Bernstein-Ellis, 1999; 41Jung Kim et al. 2000; 42Kagan, 2011;43Cicerone et al. 2019

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Background: Cognitive Rehabilitation Recommendations43

43Cicerone et al. 2019

• Attention:

• Direct attention training & metacognitive training after TBI and stroke (i.e., “thinking about thinking”)

• Language & Communication:

• Cognitive-linguistic therapy for language deficits post left hemisphere (LH) stroke (e.g., semantic treatment)

• Interventions for functional communication impairment post-TBI (e.g., pragmatics)

• Memory:

• Strategy training for mild impairments (i.e., internal or external) to improve prospective memory and performance in everyday tasks

• Executive Function:

• Metacognitive strategy training for self-monitoring and -regulation following TBI

• Problem-solving and goal management strategy training with application to everyday, functional contexts post-TBI

• Comprehensive-holistic neuropsychological rehabilitation:

• Programs targeting cognitive impairments in individual and group contexts while also addressing psychosocial aspects of the injury for individuals with TBI or stroke of all severities and at all stages of recovery

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Background: Cognitive Rehabilitation (CR) Practice Standards43

43Cicerone et al. 2019

Background: Comprehensive, contextualized CR

• With the ultimate goal of meeting “real-world” goals, comprehensive, contextualized CR44…

1) implements restorative and compensatory approaches in individual and group contexts

2) targets multiple cognitive-linguistic domains within everyday activities

3) supports management of emotional and interpersonal challenges

• Significant gains in functional outcomes like community integration and productivity43, 45-47

• Cognition has improved, yet measured less consistently and/or thoroughly

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43Cicerone et al. 2019; 44Ylvisaker et al. 2002; 45Cicerone et al. 2000; 46Cicerone et al. 2005;47Cicerone et al. 2011

Background: Experience-dependent neural plasticity37, 48-57

• Brain reorganization happens as a result of behavioral, sensory, and cognitive experiences (e.g., rehabilitation)

• Important principles of neuroplasticity

• Use it or lose it

• Use it and improve it

• Repetition

• Intensity

• Specificity

• Salience

• Age

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Photo courtesy of cognifit.com

37Kleim & Jones, 2008; 48Hamm et al. 1996; 49Warraich et al. 2001; 50Kleim, 2011; 51Bach-y-Rita, 1990; 52Kolb, 2003;53Will et al. 2004; 54Wieloch et al. 2006; 55Nudo, 2013; 56Murphy & Corbett, 2009;57Robertson & Murre, 1999

Factor TBI Stroke (aphasia)

Sex

Initial severity

Age

Injury site/extent

Education

Cognitive Status

Background: ABI - Recovery

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X

58Baum et al. 2016; 59Pedersen et al. 1995; 60Novack et al. 2001; 61Plowman et al. 2012; 62Laska et al. 2001; 63El Hachioui et al. 2013; 64Kertesz & McCabe, 1977; 65Sigurdardottir et al. 2009; 66van der Naalt et al. 1999; 67Fonseca et al. 2018; 68El Hachioui et al., 2014

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X 59

58,60 59,61,62,63,64

58,60 63,64

X59

58, 65 61

6360,65

58,60,65,66 67,68

Background: Current Continuum of Care

Emergency Department

Acute Care

Inpatient Rehab

Outpatient Care

Long term Community-based Care

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69Lorenz, L. & Katz, G., 2015

Outpatient Care;

ICAPS; TBIMS

Residential Programs;

Home Health

Day Programs

Vocational Rehab

Support Groups

Background: Rehabilitation in the Chronic Phase

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Gap in services

Where on the continuum do young adults receive the

adequate support to transition to college?

• Community college• Disability services

Background: Intensive Cognitive-Communication Rehabilitation

• The ICCR program provides comprehensive, contextualized CR via a simulated college milieu

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EBP Cog Rehab Principles of Neuroplasticity Profiles

Individual & group

therapy

Contextualized learning

Intensity Repetition Specificity SalienceYoung

AgeTBI

Stroke (Aphasia)

Mod-Severe

ICCR

• Significant gains on 2/4 standardized assessments of cognitive-linguistic function as the number of ICCR semesters increased

• Significant improvements in classroom participation, individual therapy and at least one aspect of life participation and quality of life for individuals who participated in multiple semesters of the program (n=3)

Background: Efficacy of ICCR

70Gilmore et al. 2018, AJSLP

Methods: Our program

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• Functionally-basedapplication of skills and strategy training in classroom setting & 1:1

• ~6 young adults with ABI in each class

Intensive Cognitive-Communication Rehabilitation (ICCR)

• College-level courses

• Impairment-based1:1 intervention of discrete cognitive-linguistic skill areas

Methods: Treatment - Core Courses

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• Lecture (10-11am)

• Watch lecture with minimal clinician interference

• Quizzed 2x/week on content

• Lecture Review (11-12:30pm)

• Clinician-guided review of lecture information

• Allows for metacognitive strategy instruction/modeling/application

• Practice Quiz Questions (12:30-1:00pm)

• Answer practice potential quiz questions re: lecture content as a group

• Application of test-taking strategies (e.g., process of elimination)

Yale Open Courses

Course Content:https://oyc.yale.edu/; https://www.khanacademy.org/

Methods: Treatment - Metacognitive strategy instruction

Metacognition = “thinking about thinking”

Four primary strategies: • RITA

• Rehearse, Imagine, Take Time, Activate

• LEAP• Listen Actively, Eliminate

Distractions, Ask Questions, Paraphrase

• TPDR• Think, Plan, Do, Review

• STEP BACK

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Methods: Treatment – Elective

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• Discussion and project-based learning opportunities

• Target reading, writing, and problem-solving skills

• Provide metacognitive strategy instruction/application

• Quizzed 2x/week on content

https://www.khanacademy.org/

Methods: Treatment – Technology skills session

• Constant Therapy

• ICCR course website

• Text-to-speech (e.g., VoiceDream)

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Methods: Treatment - Individual

• Clinician-directed intervention• Target cognitive-linguistic goals for academic success

• Address GAS goals for increased independence

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Methods: Treatment – Facilitating the Transition

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Student Rights

Resource packet

Connect with other individuals with ABI who have returned to school or work

Disability Services

Post-Secondary Education Options

Technology

Neuropsychtesting

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Do participants…

… demonstrate improvements in cognitive-linguistic skills?

… demonstrate improvements in participation/quality of

life?

… improve in their academic performance?

… improve on individual speech-language therapy goals?

Methods - Research Questions (RQ)

As a function of intensive cognitive-communication rehabilitation (ICCR)…..

Methods: Standardized Assessments –Impairment-based measures

Non-Linguistic Cognition

Attention Memory

Visuospatial SkillsExecutive Functions

Language

Verbal Expression

Auditory Comprehension

Reading Comprehension

WrittenExpression

• Western Aphasia Battery – Revised (WAB-R)71

• Discourse Comprehension Test (DCT)72

• Test of Everyday Attention (TEA)73

• Repeatable Battery for the Assessment of Neuropsychological Status - Update (RBANS)74

• Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN)75

71Kertesz, 2007;72Brookshire & Nicholas, 1997;73Robertson, Ward, Ridgeway, & Nimmon-Smith, 1994;74Randolph, 2012;75Milman et al. 2008

Pre-treatment Test Battery

Treatment (12-weeks)

Post-treatment Test Battery

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Methods: Standardized Assessments –Participation/QOL

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• Child and Adolescent Scale of Participation (CASP)76

• Captures students’ and caregivers’ current perception of ability • Involves home, school, and community

participation

• TBI-QOL 77 and Neuro-QOL78

• Self-reported measures of health-related QOL• Anxiety, Depression, Communication, Cognitive

Function, Positive Affect

• Goal Attainment Scaling (GAS)79

• Client sets 1-2 personal goals for the semester outside of cognitive-linguistic therapy goals

Pre- and Post-ICCR

76McDougall, Bedell, & Wright, 2013; 77Tulsky, 2016; 78Gershon et al., 2012; 79Ertzgaard et al., 2011

Methods: Informal Measures –Therapy and Academic Performance

• Weekly quizzes

• Performance in individual speech therapy

• Post-program enrollment in school

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Results Fall 2016 – Spring 2019

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Participants

P1 P2 P3 P4 P5 P6 P7 P8

Etiology TBI CVA TBI TBI TBI Tumor CVA TBI

Age 21 29 25 22 25 24 30 26

Sex M M M F M F M M

Education 13 15 12 14 12 13 15 15

MPO 49 70 96 15 69 99 98 36

Language

severity (WAB-

AQ)

62 79 63 94 68 82 88 91

Cognitive

severity

(RBANS Total)

45 64 46 78 49 44 52 53

Note: 4 /12 originally enrolled participants withdrew from the program after the first semester and thus, are not represented in this table or included in the analysis.

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RQ 1: Demonstrate significant gains in cognitive-linguistic skills?

Significance key: * = p < .05, ** = p < .01, *** = p < .001

p = .07, N.S.

** ***

*** p = .14, N.S.

Summary: Yes, Young adults with chronic ABI show significant gains

in language and cognitive function over time!

34Significance key: * = p < .05, ** = p < .01, *** = p < .001

RQ 1: What LANGUAGE skills are improving?

** * **

Summary: Young adults with chronic ABI are significantly

improving in speech production, word retrieval and writing.

35Significance key: * = p < .05, ** = p < .01, *** = p < .001

RQ 1: What COGNITIVE skills are improving?

** *** *

**

Summary: Young adults with chronic ABI are significantly

improving in attention, memory and visuospatial/constructional

skills.

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RQ 2: Demonstrate improvements in participation?

*

*

*

Summary: Yes, Young adults with chronic ABI significantly improve in their

participation, specifically in the community and school contexts

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RQ 2: Demonstrate improvements in quality of life?

Does not provide T-

score

*

Summary: ICCR students with TBI demonstrated significantly decreased depression over the

course of multiple semesters of ICCR.

RQ 2: Demonstrate improvements in participation/quality of life?

Experimental P1 P2 P4 P8

Etiology TBI CVA TBI TBI

# of semesters 6 3 3 3

Current Setting School School School School

Status after ICCR

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Summary: All four students who graduated from ICCR have moved on to

post-secondary education.

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RQ 3: Improve in their academic performance ?

Summary:

Participants accuracy on quizzes

significantly improved across the semester.

Week: β = .02, SE = .01, t(df=223) = 2.07, p < .05Semester*Week: β = -.01, SE = .004, t(df=223) = -1.37, N.S.

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RQ 4: Improve in their individual speech therapy?

Goal Pre-treatment Post-Treatment

P4

1Edit writing samples and

identify 80% of errors given <5 cues to detect/correct errors

Identified 50% of errorsGoal met -

Identified 80% of errors

2 Create a plan and timeline to apply to college

No plan in place

Goal met -

Developed and organized Google document with task list and deadlines to apply to college

Summary: Students were working on more complex goals and/or with less clinician support

by the end of the ICCR semester. They also progressed on personal goals (e.g., navigating

campus), showing increased independence.

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Discussion

• Cumulative benefit of academically-focused intensive rehabilitation program• Significant improvements in language (e.g., word retrieval) and cognitive function (e.g.,

attention)

• Significant gains in neighborhood, community and school participation

• Significantly less depression reported by students with TBI

• Gains in academic performance• Quiz scores significantly increased over the course of the semester

• Ramp to college success• All ICCR students that have graduated the program have successfully enrolled in post-

secondary education (e.g., community college, 4-year university)

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Discussion

Why these results?

ICCR provided…

• Intensive• Repetitive• Specific• Salient

training on multiple cognitive-linguistic domains in a contextualized environment

Outpatient Care

Residential Programs;

Home Health

Day Programs

Vocational Rehab

Support Groups

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Conclusion

• Future work will• Involve larger, more diverse participant sample

• Investigate predictors of treatment response/candidacy

• Examine effects of ICCR on specific cognitive-linguistic domains and the neuroplasticity supporting those gains

GAP INSERVICESICCR

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Thank you!• Dean’s Funding from Sargent College of Health and Rehabilitation Sciences

• Current ICCR Team at BU Aphasia Research Laboratory• Natalie Gilmore, Lindsey Foo, Maria Dekhtyar & Swathi Kiran

• MS students: Mallory Wallace, Megan Byrne, Kristin Kwan, Victoria Francesca, Kara Sheftic• Undergrad students: Cat Perreira, Mallory Haratz, Nika Egringos

• ICCR students, families, and caregivers

• Past lab members and MS students

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Questions ???

ACTIVELY recruiting participants !

aphasiaresearchlaboratory@gmail.com

617-353-2706

Supplemental slides

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References

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