3/6/2015. Mike Studer, PT, MHS, NCS, CEEAA, CWT, CSST. Michael Studer, PT, MHS, NCS, CEEAA, CWT, CSST. Introduction, outline, goals

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1 Michael Studer, PT, MHS, NCS, CEEAA, CWT, CSST Mike Studer, PT, MHS, NCS, CEEAA, CWT, CSST Introduction, outline, goals Defining cognitive impairments, motivation, depression and associated concepts as related to rehabilitation Promoting recovery of cognition through neuroplasticity and recovery: Awareness, Attention, and Problem-solving. 1

2 Recent advances in research and evidence based practice: the psychology of rehabilitation Interventions in motivation Interventions in cognition: attention, awareness Interventions in self efficacy, autonomy and motor control Incorporating research and technological advances: cognition, self efficacy, and depression Case studies and applications by video Summary and discussion, questions Participants will be able to: Be aware of recent evidence-based advances in cognitive rehabilitation, recovery of self efficacy, motivation, and the psychological variables in rehabilitation Recognize clinical applications, functionally-relevant documentation, and measurement applications in awareness, attention, dual-task, and problem solving. 2

3 Participants will be able to: Describe available resources in psychology and executive function for clinical use in rehabilitation. Describe modalities for and interventions designed for optimal motivation, autonomy, competence, and self efficacy. Advance patient outcomes in those with cognitive impairment of attention, awareness and memory. Recent advances in research and evidence based practice: the psychology of rehabilitation Interventions in motivation Interventions in cognition: attention, awareness Interventions in self efficacy, autonomy and motor control Incorporating research and technological advances: cognition, self efficacy, and depression Case studies and applications by video Summary and discussion, questions 3

4 A relatively unique way to individualize your programs is to be aware of various personality and mental health factors, and work to overcome them when they prevent participation. We will discuss Depression and Mood Self-efficacy Optimism and Pessimism Apathy Motivation Depression and Mood Are older adults more likely to be depressed? As many as 50% of patients with a chronic illness suffer from depression. Depressive symptoms are higher in some older adults, especially chronically ill and/or institutionalized patients. Self efficacy is the belief that one has the capability to manage the demands of a challenging situation in such a way as to attain a desired outcome (Bandura, 1977). Patients who have a higher self efficacy will be more likely to fully participate in the rehabilitation process. 4

5 Optimism and pessimism are important personality characteristics that are predictive of physical and behavioral outcomes. Optimists are people who generally have a favorable outlook on life and expect that things will go their way. Pessimists generally do not have a favorable outlook on life and expect that things won t go their way. Apathy is As many as 80% of people with dementia shows signs of apathy Between 27 and 36% of community dwelling older adults are considered apathetic (as cited in Onyike et al., 2007). Motivation the reason or reasons one has for acting or behaving in a particular way the general desire or willingness of someone to do something Synonyms: 5

6 Motivation means motive, motivating force, incentive, stimulus, inspiration inducement, incitement, spur, reason.or carrot enthusiasm, drive, ambition, initiative, determination, enter prise Recent advances in research and evidence based practice: the psychology of rehabilitation The brain s mechanism for changes in cognition in response to a lesion or impairment are the same (neuroplasticity) as for motor functions. Interventions in cognition: attention, awareness 6

7 The rules have changed. We must consider the brain changeable under and condition and any time frame until proven otherwise. The brain has potential to change at any stage in life. Attention to new information stimulates neuronal branching YOU can change a patient s brain in 10 min! Survive, protect, compete, improve If there is no challenge If there is no chance If there is no expectation If there is no success There is no stimulus to continue to improve Task Complexity Jones et al., 1998 Task Difficulty Plautz, Milliken, and Nudo, 2000 Task Specificity Nudo et al., 1997 Task Intensity Sullivan et al., 2002 Van Pragg et al.,

8 the quality of being intense, specifically, extreme degree of anything Several animal studies have shown that neurorecovery and functional performance are enhanced after cortical infarction when postinjury training incorporates motor tasks of greater complexity and higher-intensity demands than training conditions that do not. (Sullivan, 2002) the majority of evidence then indicates that functional improvement through the use of CIMT is attributable to the intensity of training... (Wolf, 2007) Repetitive task practice combines elements of both intensity of practice and functional relevance. (French, 2007) 8

9 In a study of outcomes at 70 skilled nursing facilities, an increased intensity of physical therapy and occupational therapy resulted in increased ADL ability and decreased length of stay. (Dromerick, 2006) Optimal dosage for our patients to make functional changes? Or to make neuroplastic changes? Or both? What are we measuring? Define our DOSAGE terms in neurologic rehab, specifically the term INTENSITY. Intensity Volume DOSAGE Frequency Duration 9

10 Defined as number of repetitions provided Repetitions- COMPONENT OF VOLUME Intensity Volume DOSAGE Frequency Duration Defined in terms of number of hours of consecutive therapy. (Page, 2003) Number of repetitions Intensity within a set duration. (Dromerick, 2000, 2010) DURATION DURATION AS A COMPONENT OF VOLUME Volume DOSAGE Duration Frequency Defined as the average hours of therapy provided per day across the entire length of stay. (Jette, 2005) Intensity Volume DOSAGE Frequency Duration -DURATION AND FREQUENCY 10

11 GRADING of activity/task The effort or the load of the task being performed. (Sullivan, 2002) Step training at speeds faster than an individual s known capability over ground. Volume Intensity DOSAGE Frequency Task specific GRADING Duration High intensity works for motor control and function. CIMT: Constraint Induced Movement Therapy Forced use Task specific circuit training ExCITE: Extremity Constraint Induced HIIT: High Intensity Interval Training ASAP: Accelerated Skill Acquisition Program RESOURCES in and outside the nervous system impact participation CAPACITY CAPABILITY Nudo & Dancause (2007) 11

12 SKILL CAPACITY TASK MOTIVATION Winstein et al. JNPT (in publication). ASAP Accelerated Skill Acquisition Program If we recognize the need for intensity in recovery and we know that we cannot afford to overwhelm patients with impaired affect Then, how do we propose to structure recovery in those with affect impairment? Muscular strength Muscular endurance Cardiovascular endurance Neuroplasticity: motor, sensory, cognitive PSYCHOLOGICAL 12

13 Muscular strength Muscular endurance Cardiovascular endurance Neuroplasticity: motor, sensory, cognitive P S Y C H O L O G I C A L Are we INTENSE enough in these arenas? Muscular strength: Resistance tolerated 8-12 reps 3-4 days/week 2-3 sets Expect soreness Muscular endurance Resistance repetitions 3-4 days/week Multiple sets 13

14 Cardiovascular endurance Sustained activity, whole body as able 30 minutes 10 minutes, 3 +/day acceptable (cumulative) 4-7 days/week Are direct motor control improvements in the face of CNS lesion considered RESTORATIVE or COMPENSATORY? Are we actually restoring the same connections that were lost? Task Complexity Jones et al., 1998 Task Difficulty Plautz, Milliken, and Nudo, 2000 Task Specificity Nudo et al., 1997 Task Intensity Sullivan et al., 2002 Van Pragg et al.,

15 Motor control neuroplasticity As discussed demand and supply Task specific Repetition-based MUST be challenged and see progress RIPE a model to structure your intervention ANY patient can improve ANYTIME Central or peripheral resources Measurement priority Consider the psychological effects of seeing yourself improve Requires consistency and intensity RIPE Repetitions Intensity Promise Error 15

16 Providing frequent reality-based and challenging practice in a safe situation where the learner can make and see errors without consequence of injury or complete failure Applications to mobility, ADL, communication, Repetitions: The nervous system requires a consistent and frequent opportunity to see what changes can and should be made Exposure incentivizes the system to improve so that the same error is not repeated again Intensity: Requiring an individual to push and explore their limits of performance in the form of speed, balance, resistance, accuracy/skill, or cognition. MAY NOT require an increase in heart rate or extended practice without rest. 16

17 Promise: Task-specific practice revealing the possibility of a higher level of function than the learner currently operates. (Adjusting task difficulty enough to provide the learner with some level of success) Tasks that are too hard give no hope for improvement and no reason for change Error: Systematically grading tasks to increase difficulty in an effort to reveal a fundamental need for change. Loss of balance, need for assistance, speech fluency, missed button in dressing, etc. Tasks that are too easy do not require change and can be pandoring Tasks that are too hard will not encourage change Muscular strength Muscular endurance Cardiovascular endurance Neuroplasticity: motor, sensory, cognitive P S Y C H O L O G I C A L 17

18 PT, OT, SLP and psych can/should be involved and attempt to intervene to remediate cognitive impairments Billable for all? Functional context separate for each Qualifications and interventions are different Are the mechanisms for cognitive recovery similar to those in sensory and motor? Pushing for more attention, challenging the brain after stroke, brain injury, MS lesion, concussion If we can demand it, can the brain supply it? INTENSITY, SPECIFICITY, DIFFICULTY, COMPLEXITY = neuroplasticity When and how to challenge attention... How can we acquire and SUSTAIN a patient s attention? 1) Interest 2) Testing 3) Challenge (patient competition)/dual tasking 4) Self monitoring expectations 5) Patient predictions 18

19 Consistent with the ICF model - Know the PERSON you are working with - Capture THEIR interest - tie to premorbid. A person s attention is only as good as their interest. Nothing captures a person s attention like the word Consider patient personality Confidence Self efficacy Competing against themselves, you, another patient or an issued challenge 19

20 Patients estimate their abilities, become invested in the outcome: Ask them to predict: How much help will you need? How much time will it take you? How many times will you lose your balance? Reinforcing learning from previous efforts Advancing patient awareness Fewer cues or logic from therapists Pre task delivery with post task review HOW will I do next time? Underestimates Overestimates Accurate Patient gains awareness of their impairment, is pleasantly surprised by their performance - benefits from this experience Therapist obtains information about patient awareness. Patient gains insight about the amount of assistance needed. Sets a more realistic goal + strives to meet the previous goal Therapist notes patient awareness is accurate for this trial. Patient is pleased with their performance 20

21 Recognize when safety is compromised: requires awareness Accommodation/habituation: handle more complex and distracting environments Systematic cueing strategy We allow patients to struggle in transfers, in ADLs, why not in problem solving? 21

22 Capture attention - meaningful tasks! Sufficient stimuli - recognizable goal/error STAY QUIET and HANDS OFF if possible Overt or subtle retention testing Follow the steps for awareness rehabilitation Value silence: Say less, mean more More active patient involvement providing feedback Introduce dual tasking at the right time Measure your results! Combine a standardized or objective measure with everyday distracters Compare performance with/without distracter Compare performance pre/post intervention The result is your functional attention cost Remember: DEMAND yields SUPPLY If you do not challenge dual-task attention, the brain will not supply it 22

23 ~70% success rate (pathway deviation, LOB, timed testing, etc.) Cognitive vs manual Random vs blocked Focus on primary vs secondary task Pre-cued for allocation of attention? Focus on adding more demands to enable the learner to make the primary task (functional mobility, swallowing or ADLs) automatic Mobility Manual Cognitive Walking Carry water Remember a fact/word during mobility Standing w/ eyes closed Pour water Read from a magazine Walking up stairs Pull things out of a bag Object recognition Walking on uneven surfaces Turn pages of a magazine Alphabet backwards Propel a w/c Dial a phone Recite a phone number Get in/out of a chair rapidly Write a note Hold a conversation, keep eye contact Walking backwards Button a shirt Count backwards by sevens Avoiding obstacles Thread a belt Think of things you need to do this month 23

24 Task Complexity Jones et al., 1998 Task Difficulty Plautz, Milliken, and Nudo, 2000 Task Specificity Nudo et al., 1997 Task Intensity Sullivan et al., 2002 Van Pragg et al., 1999 If we recognize the need for intensity in recovery and we know that we cannot afford to overwhelm patients with impaired affect Then, how do we propose to structure recovery in those with affect impairment? Adjusting dosage to consider success and tolerance for errors Translating training into PATIENT S life and activities Tracking performance objectively to baseline, compare Measuring progress > Talking potential Meaningful and VERY brief expectations in home exercise 24

25 How can you ensure that a repetition, a task is attended-to? The frontal lobes can be inhibited in depression The frontal lobes are imperative for attention Levels of processing matters (Craik & Lockhart, 1972) and is related to attention. How can we structure feedback and tasks to draw more from the patient Encouraging self-monitoring the patient as a primary point of feedback Shallow vs. Deep Processing Maintenance vs. Elaborative Rehearsal How can you help patients process information at a deeper level? Predictions Postdictions Retention testing that is announced beforehand Spaced retrieval works! See Sumowski et al., (2010) Mental imagery Put signs in the room (e.g., sternal precaution) Teaching others, group therapy Generation effect 25

26 Reversing the secondary changes of: Deconditioning (strength) Deconditioning (endurance) Sensory nonuse (visual dependence) Imbalance from fear and deconditioning Flexibility-led biomechanical impairments RESOURCES in and outside the nervous system: CAPACITY CAPABILITY Nudo & Dancause (2007) Considerations in personalizing evidence based practice Initial exam Diagnosis Prognosis Psychological Intervention Tolerance of: Intensity Errors Reexamination More success Greater challenge Accountability Adjustments Dosage Focus: impairment/function Remaining potential? 26

27 Defining motivation, depression and associated concepts in self efficacy as related to rehabilitation Rethinking the role of psychology in neuroplasticity and recovery Recent advances in research and evidence based practice We have defined Depression and Mood Self-efficacy Optimism and Pessimism Apathy Motivation Now, we will discuss a relatively unique way to individualize your programs is to be aware of various personality and mental health factors, and work to overcome them when they prevent participation. Recall than many people with dementia shows signs of apathy Recall that apathetic individuals, who are in the normal range for cognitive ability, perform worse than non-apathetic individuals on neuropsychological tests. Why is this a problem for therapists? 27

28 Recall that older adults more likely to be depressed Recall that the rates are higher in those with a degenerative disease or chronic illness Depressive symptoms are additionally higher in institutionalized patients Depression affects a number of cognitive variables, which can affect compliance, comprehension, and ability to learn new information. Even after controlling for the effects of strokes, age, education, and Alzheimer s Disease, researchers found that depression affects episodic memory, semantic memory, short term memory, perceptual speed, and visual-spatial ability (Bennet et al., 2004). Executive functioning has a profound influence on your patients ability to benefit from treatment. Attention Inhibition Awareness 28

29 We can enhance executive functioning (Miotto et al., 2009), which should improve many patients prognoses. Moreover, cognitive rehabilitation for memory problems should primarily exercise executive functioning. Decrease depressive symptoms through pharmacological treatment. Decreasing depressive symptoms through the use of SSRIs (i.e., sertraline, nortryptyline, and fluoxetine) leads to improved memory and cognitive ability in older adults (Doraiswamy, 2003). Depression in older adults is related to a lack of initiation and perseveration or an inability to inhibit (Murphy & Alexopoulos, 2004). Alexopoulos et al., (2004) showed that perseveration is associated with a poorer prognosis for overcoming depression. Examples of perseverating in the clinic? 29

30 L Hemisphere CVA Chronic illness Painful conditions Heart disease Changes in social networks Relocation Stress Alzheimer s Disease Memory problems Cancer Parkinson s Disease Diabetes Caregiver burden Clearly depressed patients are going to have unique challenges that not only affect their motivation for therapy but also their cognitive ability. What can we do? Motivate them Overcome cognitive impairments Long Term Approaches Deal with depression Maximize cognition through behavioral interventions Assess and reassess (improves self efficacy and increased accountability) Short Term Approaches Increase attention in the moment Increase motivation to engage and fully participate in the therapeutic process 30

31 According to Motl et al., (2005) Physical activity might be one of the most important behavioral interventions for preventing depression among older adults. A 6 month walking intervention can improve mood for depressed and non-depressed older adults. And, the benefits last for up to 54 months! How do we start a walking program? Higher consumption of fish is associated with reduced depression. Intervention studies have also shown that fish oil tablets can reduce depression as much or almost as much as antidepressants. Side effects Dosage Cognitive stimulation and rehab that focuses on executive functioning can be effective in improving attention. We did a controlled clinical study that led to a 15% improvement in older adults ability to pay attention and make new memories. Daily cognitive stimulation in SNFs and rehabilitation hospitals? 31

32 Maximize motivation to fully participate in the rehabilitation process Our single best theory and approach in psychology Increase self efficacy Increase perceived outcome expectations. Or, What s in it for me? Patients who have a higher self efficacy will be more likely to fully participate in the rehabilitation process. 49% of geriatric PT patient improvement predicted by self efficacy in a study we did. Could it even predict no shows? Can we PREVENT no shows caused by reduced self efficacy? I can always manage to solve difficult problems if I try hard enough. If someone opposes me, I can find the ways and means to get what I want. It is easy for me to stick to my aims and accomplish my goals. I am confident that I could deal efficiently with unexpected events. Thanks to my resourcefulness, I know how to handle unforeseen situations. I can solve most problems if I invest the necessary effort. I can remain calm when facing difficulties because I can rely on my coping abilities. When I am confronted with a problem, I can usually find several solutions. If I am in trouble, I can usually think of a solution. I can usually handle whatever comes my way. 32

33 You can help patients increase their self efficacy by providing opportunities for them to succeed Show them objective measures of their success they have had. Use video to document improvement (e.g., walking) Start and end with a successful experience Use appropriate cues to facilitate success Free recall Cued recall Recognition Use appropriate cues to facilitate success Free recall - Do you remember what you were going to do when getting out of a chair? Cued recall - It had something to do with your hands and, where you place them. Recognition - Were you going to: Scoot forward Put your hands on the walker Put your hands on the arm of the chair The ability to recognize the correct answer doesn t diminish as much as the ability to recall. Make the therapy relevant to the depressed patient or resident. Work Parenting School Pets Spouse Hobbies Live independently Maintain some independence Maintain mobility Reduce pain 33

34 Grindley et al. (2008) suggested that we also need to look at whether the patient believes the therapy can help them. They found that self efficacy predicted treatment outcomes in a PT setting and adherence to treatment. Protection Motivation Theory assumes that people will be motivated to do certain behaviors if they protect them from harm. PMT also assumes we can change how people think about their situation and their belief that doing certain behaviors will reduce problems or risks. Experiences in mastering new skills and overcoming obstacles will increase self efficacy Vicarious experiences provided by successful models who are similar to oneself Stories of similar patients who have succeeded Encouragement and persuasion can also increase self efficacy a final (not a FIRST) step Optimists are people who generally have a favorable outlook on life and expect that things will go their way. Pessimists generally do not have a favorable outlook on life and expect that things won t go their way. Recall that optimism and pessimism are important personality characteristics that are predictive of physical and behavioral outcomes. 34

35 Research on coronary artery bypass surgery patients showed that optimists reached their goals quicker. For example, optimistic patients took less time before they began walking around their room Using a similar population, researchers found that low optimism patients were more likely to be re-hospitalized. Success vs. Failure Internal or external cause? Temporary or permanent trait? 35

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38 Motivation as related to rehabilitation Modified SIRROWS approach Self predictions Approximated success Task specific training International Classification of Function (ICF) 38

39 Know THIS person Reach out and touch somebody s brain Consider frequency of success rate in practice Know THIS person International Classification of Function (ICF) Reach out and touch somebody s brain Consider frequency of success rate in practice Initial exam Diagnosis Prognosis Psychological Intervention Tolerance of: Intensity Errors Reexamination More success Greater challenge Accountability Adjustments Dosage Focus: impairment/function Remaining potential? 39

40 Provide frequent and challenging practice in a safe situation where the learner can make and see the a balance of success and errors without consequence of injury or outright failure - No errors = patronizing and insufficient dosage - High rate of errors = defeatist and over dosage Reiterate the purpose and initial testing Interpret objective outcomes This score tells us that you are less likely to fall now. Demonstrate accountability This shows that we need to work more on walking speed. Relay expectations: I expect you to continue to improve your strength and walking speed. We will retest this again next month. Do you have enough time or repetitions? Are you working this patient hard enough? Is the patient working outside of therapy? Do you need to change your interventions? Are you allowing errors and self correction? What outcome areas should you target? Does this person have remaining potential? Does this person have remaining desire? 40

41 Scientist: neurophysiology, kinesiology What works? What does THIS system need? Changing the brain as you are able. Providing peripheral resources of strength, endurance, etc. as able Psychologist/counselor Frequency of errors and intensity THIS PERSON can tolerate Motivational coach: Salesperson Convince THIS PERSON that together you can maximize THEIR potential Depression Apathy Self efficacy Optimism and pessimism Motivation Ready for more?? Psychology as a tool in recovery 41

42 Demonstration of initial examination Follow up progress evaluation Prescribing home exercises: how much, why, accountability Demonstration of initial examination Follow up progress evaluation Prescribing home exercises: how much, why, establishing accountability Video Case Example Patient evaluation + discussion 42

43 P S Y C H O L O G I C A L Understand that the brain can change Understand that I can improve SEE that I have improved Know that challenge = opportunity to improve Use MEASUREMENTS to prove potential This professional believes that I can improve They are taking measures to see if I improve I want to see that I improved, not pretend I have to compete against myself! I need to work hard to show this person and myself, that I can do this! Both of us have some risk here (PT and patient) Interventions in motivation Interventions in self efficacy, autonomy and motor control Practical tools in measurement and intervention incorporating technological advances. Summary and discussion, questions 43

44 Utilizing the latest in evidence Incorporating technological advances - Motivation - Self efficacy - Caregiver training/education (503) mike@northwestrehab.com FB: NWRehab YouTube: Rehabilitation NWRA 44

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