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

2

Impairment-Based and Restora.ve CR

•  Impairment-basedapproachesseektostrengthencogniSve-linguisScskillsatthepreciselevelofbreakdowntomaximizeneurologicalgains(Kleim&Jones,2008;Laatsch&Krisky,2008;Lesniak,Polanowska,Seniow,&Członkowska,2014)

3

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

4

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):

5

Impairment FuncSonal✓Intensity RepeSSon

SalienceSpecificity

✓

6

•  StudyofCogniSveRehabilitaSveEffecSveness(SCORE;DVBIC,2015)wasdevelopedasanoutpaSentCRprogramforindividualswithmildTBI

•  Oneofthefourarmswascomprehensive

• However,SCOREislimitedinthat:•  ItonlyaddressesmTBI•  Onlyonearmistrulycomprehensive•  Formalresultshavenotbeenpublished•  Itwasnotdesignedforyoungadults

Comprehensive CR: TBI

Intensity RepeSSon

SalienceSpecificity

~ ~

~ ~

7

•  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)

8

Intensity RepeSSon

SalienceSpecificity

✓ ✓

✓ ~

Review: What’s out there? Principles of Neural Plas.city

Intensity Repe..on Specificity Salience

SCORE ~ ~ ~ ~ TBIMS ✓ ~ ~ ~ ICAPs ✓ ✓ ✓ ~

9

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

10

11

Dopar*cipants…

…demonstratechangesincogniSve-linguisScskillsasaresultofthisnovelintervenSonprogram?

…progresstowardpersonalandtherapeuScgoalsoverthecourseoftreatment?

…effecSvelyapplynovelskillsandstrategiesinafuncSonalenvironment?

ICCR Research Ques.ons

Par.cipants

12

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

13

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

14

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

15

16

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

17

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

**

18

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

**

19

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

20

Discussion •  InthecurrenthealthcareandCRsystems,thereremainsagapforyoungindividualswithABIwhowishtoreturntoschool

• ParScipantsinICCR:•  Enrollinfull(15-week)semestersasstudentsinamodifiedclassroom•  Receivetherapytosupporttheirsuccessinthatclassroom

• However…•  Smallsamplesize•  ControlparScipantshowedsomeclinicallysignificantgains•  P4’sprofilewasthemostresistanttochange

• Overall,themajorityofourparScipantshavedemonstratedimprovedcogniSve-communicaSonskillsasaresultofICCR

•  TheseresultssuggestthatICCRisworthyoffurtherinvesSgaSonasaCRprogramforyoungadultswithABI

•  FuturesemesterswillconSnuetoexploreitsefficacyandthepotenSaltoscaleICCRtootherenvironmentsandpopulaSons

21

Conclusions

22

Thank you!

•  Dean’sFundingfromSargentCollegeofHealthandRehabilitaSonSciences

•  ICCRTeamatBUAphasiaResearchLaboratory•  NatalieRoss,NatalieGilmore,CarrieDesRoches,&SwathiKiran

•  ICCRstudents,families,andcaregivers

23

24

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

25

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