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USING ASSISTIVE TECHNOLOGY TO IMPROVE

MOBILITY OUTCOMES: A COLLABORATIVE

REVIEW

KIMBERLY A. EICHHORN, MS, CCC-SLP, ATP

35TH INTERNATIONAL SEATING SYMPOSIUM

MARCH 21, 2019

DISCLOSURES

I receive salary from the Department of Veterans Affairs

Reference to/mention of particular technologies does not equal endorsement

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OBJECTIVES

Recognize concepts of systematic instruction/error control training in therapeutic

application of assistive technologies

Enhance understanding of various communication impairments and outline ways to

modify personal communication to improve patient engagement, participation, and

outcomes

Identify a plan for targeting multiple functional goals with team members as well as a

plan for generalization of trained skill(s) to functional activities

DESIGNING EFFECTIVE INSTRUCTION: PIE(SOHLBERG & TURKSTRA, 2011)

Planning

Effective

Instruction

Implementation

of Instruction

Evaluation of

Outcome

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PERSONAL CHARACTERISTICS THAT INFLUENCE

LEARNING

Cognitive-linguistic functions

Physical functions

Sensory abilities

Psychological status

Social connection

MOTOR SPEECH VS LANGUAGE DISORDERS

Motor Speech

Impairment in speech

Dysarthria versus apraxia

Dysarthria: impairment in muscular

control due to CNS or PNS damage

Apraxia: impairment in the planning and/or

programming of movements

Language

Aphasia

Impairment of language affecting :

production and/or comprehension of speech

ability to read and/or write

May affect mainly a single aspect of language use, but more commonly multiple aspects of communication are impaired.

Cognitive-Communication Impairments

Communication difficulty marked by changes to prosody, discourse, semantics, and pragmatics

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CONVERSATIONAL DISCOURSE

Conversational discourse requires

competencies of both hemispheres

Left: Basic information (e.g., word

recognition)

Right: Higher level information

(e.g., integration of parts of a

coherent whole)

Miss the point of a conversation

Be unable to stick to the point to convey own

message

Difficulty with topic maintenance

Focus on irrelevant information or be unable to

consider importance of relevant information

Verbose

SUPPORTED CONVERSATION FOR ADULTS WITH APHASIA

(SCA)™ KAGAN, 1998

Two main goals

Acknowledge the competency

of the individual with aphasia

Help reveal that individual’s

competency with simple

techniques

Speak naturally in an adult tone

Non-familiar communicators tend to SLOW

down and SHOUT

Validate and normalize the difficulty

Be honest about difficulties and frustrations.

Communication breakdowns will happen.

Don’t pretend to understand or abandon the

conversation without openly acknowledging the

breakdown.

Competency Principles

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COMMUNICATION TECHNIQUES

Getting the message TO

Use short, simple sentences

Communicate about one idea at a time;

signal topic shift

Limit distractions

Use gesture, written key word, draw

pictures

Getting the message OUT

Ask yes/no questions in a logical

sequence

Encourage writing, drawing, gesture

Write out optional multiple choice

answers

Give time to respond

COGNITIVE

PROFILE

Attention

Memory

Executive functions

Visuospatial skills

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MEMORY REVIEW: TIME DEPENDENT

Therapy is learning. Clinicians should exploit residual memory abilities

and compensate for weakness.

Long-term and short-term

Duration and capacity

Working memory – short-term store and the active process of manipulating information for storage or retrieval (Baddeley, 2013).

Often disrupted in a brain injury

Allows for complex activities such as reasoning, learning, and comprehension

Mental workspace for executive functions and metacognition

MEMORY REVIEW: CONTENT DEPENDENT

• Episodic

• Semantic

• Metamemory

• Prospective Memory

Declarative (explicit) – knowledge base of information of which we

have conscious awareness…enhanced by

conscious strategies such as elaboration, trial and error,

discovery methods. Not tied to context, so easily generalized.

• Procedural Memory

• Emotional associations

• Priming

Nondeclarative (implicit) – learn without conscious awareness;

highly context dependent, so not easily generalized unless to situations with highly similar

surface features.

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ENVIRONMENTAL CHARACTERISTICS THAT INFLUENCE

LEARNING

Setting: environment, schedule, transportation (Dishman, 1994)

Level of Distraction (Sohlberg & Mateer, 2001)

When appropriate, use environmental cues to facilitate execution of target behavior (Morris & Schultz, 1992)

Use the team: family, rehab colleagues, staff (Sohlberg & Mateer, 2001; Driver, 2006)

In session

For generalization

IMPLEMENT

Initial Acquisition

01Mastery and Generalization

02Maintenance

03

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PROGRAM

CHARACTERISTICS

THAT INFLUENCE

LEARNING

Intensity

Timing

Task Complexity

Practice

Cueing & Feedback

Maintenance & Generalization

Accountability

Use of Technology

TASK COMPLEXITY

Too difficult, may quit (Campbell, et al., 2001)

Clear instructions may augment participation (Berg, et al., 1993; Sluijs, et

al., 1991)

Dosage should take into account learner profile (Henry et al., 1998)

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PRACTICE

Motor learning and speech rehabilitation literature provides framework for

understanding practice conditions, which have relevance across rehab disciplines. (Mass, 2008; Lemoncello, 2008)

Errors

Those with moderate-severe declarative memory impairment show enhanced

learning when errors are minimized

Those with good declarative memory may have better long term retention learning

via effortful processing (Lesgold, 2001)

Critical Distinction…can one learn from their mistakes?

PRACTICE

Practice Distribution

Massed Practice: skill is practiced # times in a row in relatively small time frame

Distributed Practice: spacing of practice trials over longer period of time, spacing

intervals with unrelated events in between

Nature of the task often directs regimen

Stimulus Variability

Constant: same, specific stimulus used to elicit target behavior

Variable: wider range of context to practice the skills/behavior

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MAINTENANCE & GENERALIZATION

Clinicians are often focused on learning in the initial stages but may not systematically plan to foster retention of learning or generalization to everyday

settings.

Performance during practice is often not a good predictor of maintenance and generalization (Maas, et al.,

2008)

Maintenance effects can be enhanced by systematically altering:

Program intensity, practice regimen, cumulative review/booster sessions, use of cueing and feedback

Generalization effects can be enhanced by systematically altering:

Task complexity, practice tasks, fading cues and feedback

Greatest gains for a particular activity are seen when the training goal most closely resembles the end goal. (Burkhead, et al., 2007)

MAINTENANCE: COMBAT ABANDONMENT

StimuliTrain natural supports: people and contexts that promote ongoing use of target

PracticeCumulative review; booster sessions

Level of Engagement

Foster on-going use of metacognitive strategies

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BROAD INSTRUCTIONAL CATEGORIES

Systematic (Ehlhardt, Sohlberg, 2008)

Discovery, trial and error (Hammer, 1997; Montessori & George, 1915)

ErrorLESS EFFORTful

Systematic Instruction(including errorless learning,

spaced retrieval)

Conventional Instruction

Limited range of instructional targets (e.g., only calendar app at first)Broad range of instructional targets

(train multiple apps)

Multiple training examples Few training examples

Mastery emphasized Mastery not emphasized

Exploration discouraged Exploration encouraged

Step-by-step models, carefully faded support Whole-task models

High rates of correct, distributed practice and review per target Few practice opportunities per target

Immediate corrective feedback Feedback after task completion

Training in different environments Training primarily in clinic setting

Brush & Camp, 1998; Evans et al., 2000; Sohlberg et al., 2011; Wilson et al., 2001

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EVALUATE

Session Data

Generalization Probes: is the skill used in naturalistic environments?

Maintenance Probes: is the skill durable over time?

Impact Data: how does it improve daily functioning? Baseline vs. Post-treatment

Efficacy Data

SUMMARY OF PIE FRAMEWORK (SOHLBERG & TURKSTRA, 2011 P 83)

PLAN

(assessment

& design of

instruction)

Who?

What?

Where?

When?

Why?

How?

IMPLEMENT

Acquisition

• Varied stimuli

• Minimize errors

• Provide intensive

mass practice

• Facilitate active

engagement

Mastery

• Increase stimulus

variability

• Fade prompts

• Lengthen

distributed practice

• Incorporate

metacognitive

components

Maintenance

• Incorporate

natural supports

• Conduct

cumulative review

• Plan for follow-up

Evaluate

• Session

• Generalization

• Maintenance

• Impact

• EfficacyReevaluate if no progress

Learning Context Characteristics

Personal

Environmental

Program

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SUMMARY

Know cognitive strengths and weakness – call for back-up if you need it!

Consistency of training is paramount for persons with cognitive impairments

Minimizing errors and fading cues can lead to durable learning in persons with cognitive impairments

Limit training targets until mastery is achieved: Chain steps together

Despite communication impairments, persons with communication disorders should be actively included in assessment, goal setting

Take your lead from the person with regards to ease of communication for THEM

Simplify the content of your messages while maintaining their dignity

REFERENCES

Baddeley, A. (2013). Essentials of human memory (Classic Edition). Psychology Press.

Berg, J., (1993). Medication compliance: a health care problem. Ann Pharmacother, 27, S4-S19.

Burkhead, L. M., Sapienza, C. M., & Rosenbek, J. C. (2007). Strength-training exercise in dysphagia rehabilitation: principles, procedures, and directions for future research. Dysphagia, 22(3), 251-265.

Brush, J. A., & Camp, C. J. (1998). A therapy technique for improving memory: Spaced retrieval. Menorah Park Center for Senior Living.

Campbell, R., Evans, M., Tucker, M., Quilty, B., Dieppe, P., & Donovan, J. L. (2001). Why don't patients do their exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee. Journal of Epidemiology & Community Health, 55(2), 132-138.

Dishman, R. K. (1994). Advances in exercise adherence. human kinetics publishers.

Driver, S. (2006). Applying physical activity motivation theories to people with brain injuries. Adapted Physical Activity Quarterly, 23(2), 148-162.

Ehlhardt, L. A., Sohlberg, M. M., Kennedy, M., Coelho, C., Ylvisaker, M., Turkstra, L., & Yorkston, K. (2008). Evidence-based practice guidelines for instructing individuals with neurogenic memory impairments: what have we learned in the past 20 years?. Neuropsychological rehabilitation, 18(3), 300-342.

Evans, J. J., Wilson, B. A., Schuri, U., Andrade, J., Baddeley, A., Bruna, O., ... & Lorenzi, L. (2000). A Comparison of''errorless''and''trial-and-error''learning methods for teaching individuals with acquired memory deficits. Neuropsychological Rehabilitation, 10(1), 67-101.

Hammer, D. (1997). Discovery learning and discovery teaching. Cognition and instruction, 15(4), 485-529.

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REFERENCES

Henry, K. D., Rosemond, C., & Eckert, L. B. (1999). Effect of number of home exercises on compliance and performance in adults over 65 years of age. Physical Therapy, 79(3), 270-277.

Kagan, A. (1998). Supported conversation for adults with aphasia: Methods and resources for training conversation partners. Aphasiology, 12(9), 816-830.

Lemoncello, R. R. (2008). A within-subjects experimental evaluation of the Television Assisted Prompting (TAP) system to maximize completion of home-delivered swallow strengthening exercises among individuals with co-occurring acquired swallowing and cognitive impairments (Doctoral dissertation, University of Oregon).

Lesgold, A. M. (2001). The nature and methods of learning by doing. American Psychologist, 56(11), 964.

Maas, E., Robin, D. A., Hula, S. N. A., Freedman, S. E., Wulf, G., Ballard, K. J., & Schmidt, R. A. (2008). Principles of motor learning in treatment of motor speech disorders. American Journal of Speech-Language Pathology.

Montessori, M. (1915). The Montessori Method: Scientific Pedagogy as Applied to Child Education. Heinemann.

Morris, L. S., & Schulz, R. M. (1992). Patient compliance—an overview. Journal of clinical pharmacy and therapeutics, 17(5), 283-295.

Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive rehabilitation: An integrative neuropsychological approach. Guilford Publications.

Sohlberg, M. M., & Turkstra, L. S. (2011). Optimizing cognitive rehabilitation: Effective instructional methods. Guilford Press.

Sluijs, E. M., Kok, G. J., & Van der Zee, J. (1993). Correlates of exercise compliance in physical therapy. Physical therapy, 73(11), 771-782.

Wilson, B. A., Emslie, H. C., Quirk, K., & Evans, J. J. (2001). Reducing everyday memory and planning problems by means of a paging system: a randomised control crossover study. Journal of Neurology, Neurosurgery & Psychiatry, 70(4), 477-482.