This article contains excerpt from the following text due to be published this spring:
"Optimizing Cognitive Rehabilitation: Effective Instructional Methods" by McKay Moore Sohlberg and Lyn S. Turkstra. Copyright 2011 by The Guilford Press. All rights reserved.
The increasing use of technology to help individuals compensate for cognitive impairments is one of the most notable advances in neuropsychological rehabilitation in recent years (Wilson, 2009). Cognitive aids increase the independent functioning of individuals with processing deficits by supporting the completion of functional activities in natural settings. These aids also can reduce caregiver burden and stress by helping individuals with cognitive impairment function more independently (Lopresti, 2004). A less obvious benefit is that the aids can reduce the "digital divide" for clients with cognitive impairments who often have been denied the advantages provided by technology (Sohlberg et al., 2005).
A large body of literature supports the efficacy and effectiveness of external aids for improving independence and life participation for people with cognitive impairments. A review spanning 20 years of literature on assistive technology for cognition concluded that technological solutions can help people with acquired brain injury (ABI) participate in many activities that would not otherwise be possible (Lopresti et al., 2000). A practice guidelines paper synthesized the findings from 21 studies involving a total of 270 participants; it concluded that training in the use of external aids should be a practice standard in ABI treatment (Sohlberg et al., 2007).
External aids have been called "cognitive orthoses," "cognitive prosthetics," "assistive technology" (Cole, 1999), and more recently, "assistive technology for cognition" or ATC (Lo Presti et al., 2004). Although some ATC researchers limit their definition to devices that use computer technology and are specifically designed to help people compensate for cognitive impairments, ATC refers to a range of tools that includes low-tech and mainstream devices as well as specialized technology.
Despite the rehabilitative potential of technological devices and the growing number of affordable, accessible devices, clinicians may not implement them, in part because they may be uncomfortable or inexperienced with technology (Hart et al., 2004; Sohlberg et al., 2007). Another barrier to patients' effective use of cognitive aids may be the limited systematic training they receive in using selected aids.
Clinicians treating patients with cognitive impairments can help reverse this trend—and the first step is to become familiar with the range of technology potentially useful to their patients.
Assistive Technologies for Cognition
The most important predictor of long-term success with ATC is careful selection of external aids to ensure they are well-matched to the user and the environment (Scherer et al., 2007). The assistive technology literature describes a wide variety of aids, ranging from low-tech tools designed for single-task guidance to highly technical devices that compensate for cognitive impairments across environments and task domains. Table 1 [PDF] lists sample tools categorized by complexity and target task.
Device or tool selection must be a team-based decision that includes the user's preferences and considers contextual factors likely to contribute to ultimate success. Perhaps the most comprehensive and formalized tool available for facilitating device selection is the Matching Person and Technology Assessment (MPT; Scherer et al., 2007). The commercially available MPT consists of a collection of forms designed to facilitate clinical recommendations for assistive technology. The goal is to identify a tool for a specific user and purpose in a specific environment.
Another example of a selection process is a computer questionnaire on the TechMatch website that helps clinicians and caregivers match people with cognitive impairments to computer tools. The caregiver completes a survey in collaboration with the client, and the program generates a response profile and algorithms that lead to individualized technology recommendations. A third assessment option is the Compensation Techniques Questionnaire (CTQ), a survey instrument used to collect information to establish the primary areas of need, past successes or challenges using strategies/devices, and current strategy use (Sohlberg & Turkstra, in press).
It also is important to recognize that the alignment of each client's needs and abilities with device features will change. Some critical transition points include discharge from hospital to home or from rehabilitation to community living, beginning new employment, and returning to school. Critical considerations in conducting a needs assessment include:
- Client cognitive/learning profile
- Physical abilities related to device usage
- Goal/target activities
- History of tool use
- Preferences for tools
- Client resources (e.g., financial)
- Client awareness/motivation
- Client self-determination/expectation
- Environmental supports
- Consideration of specific devices
Designing an Individualized Training Plan
The assessment leads to the selection of an assistive tool and the development of a training plan. Training patients in the use of ATC encompasses a number of goals involving teaching the mechanics of using the aid and organizing the supports and reinforcements necessary for using an aid in specific contexts. These instructional goals can be achieved by dividing the training into three phases: acquisition, mastery/generalization, and maintenance, each with different clinical procedures.
Not every client will benefit from the same training plan. For example, a client who has a significant declarative memory impairment that affects the ability to learn new information may require highly structured, errorless practice using spaced retrieval to learn how to use a device (see Sohlberg & Turkstra, in press; Wilson, 2009). In contrast, a client whose main issues are with executive functions may know how to use the device, but need prompting to use it in naturalistic contexts.
The purpose of treatment in the acquisition phase is to establish procedures and motivation for using the aid. Client buy-in is critical. A person's initial reactions, including perceptions of the device in terms of usability and effect on quality of life, predict the successful adoption of the ATC and determine long-term use (Lenker & Paquet, 2004).
For clients with significant cognitive impairments who have difficulty learning new procedures, it is important to minimize the learner's errors, move from a massed to a distributed practice schedule, and provide sufficient practice and repetition during the initial acquisition phase (Todd & Barrow, 2008; Turkstra et al., 2005).
Each session should begin with a probe to evaluate the client's recall of the steps needed to use the tool and indicate where training should begin. The session probe should be followed by a review of steps taught in previous sessions and a model of the next step identified in task analysis, chained to the previous step. Depending on the client's retention, the clinician models the two-step sequence (learned step and new step), and then has the client demonstrate the sequence. Strategies to increase client engagement should be used (e.g., prediction of performance, self-recording of performance). Data documenting performance on the practice trials will help determine how to proceed in treatment. See the sidebar at right for a summary of steps in initial acquisition training.
Mastery and Generalization Phase
The mastery and generalization phase strengthens the client's skill in using the external aid and also broadens the contexts and increases the independence with which the aid is used in the intended context (Ehlhardt et al., 2008). This training phase begins as soon as the client masters basic steps. Training will focus on increasing the client's fluency using the aid and ensuring that it is implemented in naturalistic contexts.
The best insurance against device abandonment includes (1) collaboratively selecting a device that meets the client's needs, (2) effectively training the use of the device by following the practices outlined for the first two training phases, and (3) setting up ongoing reinforcement and support for device implementation.
Additionally, scheduling follow-up visits can be very helpful to support ongoing device use. These visits facilitate any needed adjustments to the plan for using the device to adapt to changes in the client's situation, motivation, or abilities.
Technology advances of the past several years have created endless options for external aids that can help clients with cognitive impairments live more fully and independently. However, the array of choices and opportunity to adapt devices to people's individual circumstances can be overwhelming for clinicians. The process of developing goals and implementing training can be streamlined by the use of a comprehensive needs assessment to identify a tool that is well-matched to a client and his or her ecology. Following that identification, is it also important to use a systematic planning and treatment implementation that adheres to the instruction principles effective for people with cognitive impairments.