JOG MY MEMORY!Instructional Approaches for Memory

Rehabilitation

NSW TBI Evidence Based Practice GroupJason Bransby Royal Rehab

Michael Dunne Westmead BIUColleen Kerr Optimal SP

CLINICAL QUESTION Process

Dec 2013 Survey to members.

Consensus that we needed to address an area of current clinical concern given some of the 2013 difficulties with exploring newer area of practice (emotional recognition)

Consensus to look at compensatory strategies in memory intervention in an effort to distinguish our interventions from restorative (word list retention etc) laboratory studies.

Tentative question formulated March 2014 for initial literature screening and liaison with academic leaders/multidisciplinary teams

"What teaching strategies are most effective in training use of memory aides in adults and adolescents with TBI?".

REFINING QUESTION Discussion with Skye McDonald re clinical question and

potential models of memory to guide/re-structure our question and search terminology

Discussion with Belinda Carr, Carr Rehab re her publications in the area of efficacy of compensatory memory aides.

Initial literature search – half of our group looking at range of instructional techniques and remainder looking at nature of compensatory device

Regroup April 2014 with agreement that we needed to restrict our question to focus on the nature of the instruction as this was of greatest clinical interest and relevance.

Further discussion of potential pitfalls if evidence review failed to directly contrast or adequately define techniques.

ASKING THE RIGHTQUESTION ....

What are the range of instructional techniques used to facilitate use of compensatory memory aides in adults and adolescents with TBI?

METHOD Initial search papers

loaded to shared document (Evernote) for group review/cull

12 CAPs completed by group members and three students

CAT under preparation but we have a bottom line...

CLINICAL BOTTOM LINE A range of instructional techniques have been explored in the

literature, for training use of external memory aides. These techniques include: Errorless learning

Vanishing cues (Forward & Backward Chaining)

Self-instruction (WSTC)

“Systematic instruction”

Self-awareness training

Distributed practice

Rehearsal in meaningful environments.

INSTRUCTIONAL APPROACHES

Errorless Learning

Clinician minimises errors during teaching process Tasks broken down into steps (e.g. entering reminder

into iPhone) Target response provided/modelled by clinician, to

minimise patient errors Best practice for patients with severe memory

impairment

INSTRUCTIONAL APPROACHES Forward Chaining

Forward chaining: Any complex task represents a sequence of specific

behaviours or “a chain”. Completion of one step acts as a cue for the next…

Task broken down into series of components First step trained. When mastered, second step added and

trained and so on…

INSTRUCTIONAL APPROACHES Backward Chaining

Backward chaining/vanishing cues: Errors initially minimised via modelling/cueing, but prompts

slowly faded May be used in combination with errorless learning More effective for patients with mild-mod memory impairment

E.g. (with visual cue) “You unlock your phone, open the calendar, then select

the date” (no visual cue) “You unlock your phone, open the calendar, then select

the date” “You unlock your phone, open the calendar, then….”

INSTRUCTIONAL APPROACHES Spaced Retrieval (SR)/ Distributed Practice (DP)

Useful for semantic, procedural, prospective memory More effective than massed practice/ learning

SR- within trial Target behaviour provided to patient e.g. checking phone

for appointment time, and practiced until mastery achieved Patient asked to retain information for progressively longer

periods of time (e.g. immediate, 15 secs, 30 secs etc.) e.g. How will you remember your appointment tomorrow?

DP- training better spaced over time, rather than mass practice

INSTRUCTIONAL APPROACHES Systematic Instruction/ Teaching “Packages”

Sohlberg (1989)- 3 stage procedure:

Acquisition (basic competence with memory aid use), Application (role play simulating real life situations), Adaptation (use of device in novel situations)

Approach used in several studies with good effect compared with conventional practice

INSTRUCTIONAL APPROACHES Self- Instruction

WSTC W (hat are you going to do?)

S (elect a strategy) T (ry it out)C (heck if the strategy worked)

May result in better maintenance of treatment effects when training compensatory memory aids (Ownsworth & McFarland, 1999)

INCOG GUIDELINES 2014 Memory #2. Environmental supports and reminders

are recommended for TBI patients who have memory impairment and most especially with those who have severe memory impairment—(eg, NeuroPage, mobile/smartphones, SIRI,PDA, notebooks, whiteboards, etc). Patients with TBI and their caregivers/support staff must be trained in how to use theseexternal supports. (Adapted from EFNS,40(p672) INCOG16)

Memory #4. There are a number of key instructional practices that can promote learning for individuals with memory impairments, which include:

INCOG GUIDELINES 2014 Clearly define intervention goals Task analysis Allow sufficient time and opportunity for practice Use principles of distributed practice (spaced retrieval) Teach strategies using variations in the stimuli/information being

presented (eg, multiple exemplars, practical tasks) Ecologically validity Use teaching strategies that constrain

errors

IMPLICATIONS FOR PRACTICE Difficult to determine “best instructional technique” A consistent theme in the literature is the

superiority of errorless learning and systematic approaches to instruction, rather than conventional trial-and-error approaches.

Training should occur in natural contexts These techniques may extend to a range of other

cognitive and communication therapies e.g. AAC, word retrieval etc.

Given the multidisciplinary nature of TBI interventions our findings are likely to be of interest to other professional groups

QUESTIONS?