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Section IV: Training

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General Guidelines 

(Adopted from the American Congress of Rehabilitation Medicine, general guidelines for external memory compensations)

  • Train participant and support partners on MyBRAIN assessments and interventions
  • Consider the role executive functions and memory have on the participant’s ability to learn and use the system. Formalized assessment of these skills will inform the education/training process 
  • Most participants need more cues and support early in the training process; it is important to individualize this for each participant. Gradual fading of cues and support is more effective for participants with more severe impairment. 
  • Individualize training and fading of cues

Lance comments: These were conclusions we derived from the review of literature from this spring

Note to self:  I need to review as I believe I have this represented elsewhere. 

Participant has to have significant involvement/decision/active role

  • in the selection/design (e.g. – selection of avatar, methods to complete assessments, time of day/day of week to complete assessments, choices of interventions)
  • selection of method to complete assessments 
  • training
  • ongoing utilization and implementation or reinvention; 
  • with a focus on participants priorities

Need to address/take into account 

  • impairments of awareness and memory 
  • training needs to include generalization of MyBrain usage into multiple  environments (also referred to as untrained settings)
    • generalization/utilization of assessments and self-management strategies and how that is tied to personal goals
    • design and user interface – visual, motor, auditory, etc. skills compatibility 

______________________________________________________________________________________

A person-focused goal setting, review, reflections, and planning approach

  1. Person Centered Approach
  • Learn, acknowledge, and demonstrate support of the participant’s priorities and goals 
  • Engage the participant’s elected support parties 
  • Facilitate positive control over one’s own life
  • Support the participant’s ability to make informed choices
  • Acknowledge the participant as valued member of his/her community 
  • Routinely review progress w/participant and 
  • Collaboratively adjust plan with participant and team
  1. Awareness Building 
  • Build trust by utilizing a collaborative, collegial, non-confrontational approach  
  • Demonstrate sensitivity to environment and exposure factors 
  • Support participant’s identification of, frequency of, and impact of symptoms and struggles by exploring the evidence of past and current skills together
  • Support participant’s ongoing identification of skill building and self-efficacy
  1. Principles of Motivational Interviewing 
  • Use a supportive, non-judgmental, collaborative, empathic approach 
  • With a demonstration of genuine concern and interest in participant’s experience (spirit of MI)
  • Ask permission before offering suggestions, education and information 
  • Use open ended questions
  • With affirmation of strengths and efforts toward change, and reflections, to foster a collaborative atmosphere

Lance’s comments: This might be a great component of a new section on something like “Ongoing training and utilization of MyBrain” that addresses a) need for ongoing training and strategies to promote engagement, b) team utilization of MyBrain data for individual surveillance, and c) team utilization of MyBrain for cohort of interest surveillance

New Section – Ongoing Training and Utilization of MyBrain – Addressing:

  1. The need for ongoing training and strategies to promote and sustain engagement
  2. Team utilization of MyBrain data for individual surveillance and
  3. Team utilization of MyBrain for cohort of interest surveillance

Assessment response trends and the relationship to accomplishments 

Establish routine discussion times, adding spontaneous times scheduled as needed to explore response trends and the relationship to accomplishments.

Identify a time to discuss recent scores with participant, based on:

  • Areas of concern/challenge
  • Areas of strength
  • The assessment schedule
  • Shifts in responses (improvement and/or decline) which warrant discussion
  • High and/or low risk rating within a category
  • Total risk rating score 

Pair the discussion of assessment response trends with interventions by examining:

  • interventions used, 
  • interventions not used, 
  • self-selected other interventions,
  • participant’s perceived success of interventions 

(self-selected other, MyBRAIN Now, or scheduled MyBRAIN interventions)

  • explore what the participant finds reinforcing, interesting, helpful, rewarding
  • resource needs

Next steps 

  • explore participant’s satisfaction with MyBRAIN (informal and/or formal satisfaction assessment)
  • gain participant’s perspective on next steps, 
  • explore changes in the course of care, 
  • explore methods to increase engagement (as needed), 
  • discuss additional resource needs
  • report status to team and problem solve MyBRAIN, care plan adjustments, and resource alternatives, as needed
  • share team suggestions to participant, exploring participant reactions and priorities, 
  • identify time for next review, proceed with plan  

Training Methods – Training Option 1

Mild to Moderate Memory Impairment

Training Model:  Adopted from the American Congress of Rehabilitation Medicine, Cognitive Rehabilitation Manual acquisition, application, adaptation model 

Phase I – Acquisition Phase 

The goals at the acquisition stage are for the participant to:

  • Learn the purpose of MyBRAIN:
  • Learn options related to what he/she can do to monitor health and recovery (use of Kindle and other health promoting strategies)
  • Learn what he/she can do to track health concerns via MyBRAIN and interactions with the care team
  • Learn the basic functions of the Kindle – charging, storage, interface features
  • Learn how to complete MyBRAIN assessments 
  • Learn the scheduled, individualized self-management strategies designed to achieve goals and support recovery 
  • Learn how to use MyBRAIN Now interventions 

Training in this phase, for the mild to moderately impaired individuals, will require education and training followed by a series of questions and answers. Education will occur in three domains:  

  • the purpose of MyBRAIN and MyBRAIN Now, 
  • Kindle storage, features, charging, participant to device interface/functions, and 
  • features of MyBRAIN and MyBRAIN Now. 

Purpose of MyBRAIN and MyBRAIN Now

  • Q: How will using MyBRAIN help you achieve your goals

A:  Assessment answers guide the participant and care team in decisions related to treatment options, strategies, and resource needs to achieve goals. Tracking assessment scores over time will provide the participant with valuable feedback related to the effectiveness of the strategies used and help the care team determine when a new or different strategy is needed, or to recruit new resources to gain desired progress, achieve goals.

Kindle Storage – for recall and accessibility

  • Q: Where is the best place to keep the Kindle Fire and why

A: a selected same place in the home allows one to routinely, easily locate the Kindle so that one may stay up to date on assessments and allow one to initiate a self-management strategy at any time.

Kindle Fire Interface Features and Learning the Device 

  • Q: Is there a Fire Tablet User Guide?  
  • A: Yes. One can find a User Guide and Help Videos within the Tablet. Click on Settings. Scroll down, by swiping up, to the System category. Click on Help. Click on User Guide and or Help Videos.
  • Q: How does one turn on the Kindle 

A: Press the top right button

  • Q: How does one turn off the Kindle 

A: press and hold the top right button. Click OK when asked do you want to shut down your Fire?

  • Q: How do you know when the Kindle battery is getting low 

A: There are four images on the home screen. These represent the strength of the Wi Fi, the percent of energy remaining in the battery, an image of a battery, and the time.

  • Q: How does one adjust the volume on the Kindle 

A: The two top left buttons controls volume up and down

Note: if the participant reports that he/she cannot hear the Avatar’s voice, the speaker is on the back of the device. Setting the device down muffles the speaker.

  • Q: How does one get to the HOME screen 

A: After turning on the device, swipe up to go to the home screen.

  • Q: What does it mean when the screen goes blank

A: the Kindle is in sleep mode

  • Q: How does one get the Kindle out of sleep mode and re-activated 

A: Tap the button on the top right and swipe up to return to the HOME screen.

  • Q: How does one learn how to use MyBRAIN and MyBRAIN Now 

A: A care team member will teach the participant how to use the Kindle MyBRAIN for assessments and scheduled self-management strategies, and the on demand strategies via MyBRAIN NOW app.

  • Q: How does one get help with using the device and what does one do if the device isn’t working 

A: Call the care team member, at _____________, M – F, between 8:00 am and 5:00 pm for assistance.

  • Q: How does one know when and what assessments to take 

A: MyBRAIN automatically pulls up personalized assessments.

  • Q: How does one hear an assessment question a second time 

A: tap the Avatar to repeat question

  • Q: How does one initiate a self-management strategy, such as relaxation or mindfulness training 

A: Tap the MyBRAIN Now app.

  • Q: How does one stop a program on MyBRAIN or MyBRAIN Now

A: Tap the button the top right. The screen will go black. Tap the button a second time and you return to the locked screen.  To open and go to the home screen, swipe up.

  • Q: How does one get back to the home screen after stopping a program on MyBRAIN or MyBRAIN Now 

A: Swipe up. 

  • Q: Can the screen settings be modified to make it easier for one to use 

A: accessibility settings can be modified on the Kindle. One can do this through the Settings button or with a care team member. Tap the Settings button. Scroll down the page by swiping up. Under the System category, you will see the term Accessibility. Tap Accessibility. There are a variety of options here, some of which include the opportunity to change the font size, modify screen contrast, invert the color (black screen with white letters or white screen with black letters), to receive an audio description of what is on the page, and to have closed captioning. These are just a few options. One may want to work with the care team member to select what is best. 

  • Q: Can one reduce the number of folders on the screen to reduce clutter 

A: icons can be drug into folders to reduce clutter. Determine which two apps you may want to put in one folder. Think about how the apps are related. Click and hold the app icon until it enlarges. Drag it on top of another app icon. A prompt asks for a folder title. One can also ask a care team member to assist.

  • Q: Can one re-organize the app icons on the home screen? 

A: yes, click on an app until it enlarges. Move it to a different location by keeping your finger on the screen and dragging it to the new location.

Features of MyBRAIN and MyBRAIN Now 

  • Q: Which assessments are sent to the participant and how often?

A:  Brain injury, for some individuals, is viewed as a chronic disability, affecting various systems and functions. A research-informed set of assessments has been selected by the care team to assess    common areas of concern, and to guide the care plan over time. The selected assessments will be discussed with participant, and are delivered at a minimum of one time per month. Assessments may be delivered more frequently, based on an individual’s needs. 

  • Q: How are self-management interventions determined?

A: A menu of self-management interventions can be linked to assessments. Based on the participant’s individualized needs, specific interventions are delivered on a schedule. The client and care partner/care team can discuss selected interventions and adjust as needed. 

  • Q: Is it possible to use the interventions on an as needed basis?

A: MyBRAIN Now is an app, which allows the participant to have access to and self-select from a list of interventions at any time.  

Phase II – Acquisition Phase

In the Acquisition Phase, cueing in the first month should include the following:

  • scheduled reminders to take assessments and utilize self-management strategies, 
  • rehearsal of strategically identified questions from the list above
  • responding to participant generated needs related to practical use or purpose of MyBRAIN

Discontinuation of Q & A and cueing training activities occurs when the participant demonstrates success with taking assessments and utilizing self-management strategies, on schedule, after one month.  

Phase III – Application Phase 

In this phase, the participant:

  • is able to describe how MyBRAIN assessments and interventions relate to participant’s goals  
  • demonstrates consistent use of the MyBRAIN by taking assessments and utilizing scheduled self-management strategies, on schedule, for an additional month, with minimal cueing  
  • participates in a review, with care team member, of assessment response trends and explores the relationship to accomplishments

Phase IV – Adaptation Phase 

Adaption is achieved when:

  • cueing is no longer required, assessments are completed routinely,
  • the participant participates in an ongoing review of assessment response trends and the relationship to accomplishments, and  
  • the participant engages in tailoring and/or adjusting scheduled events (assessments and self-management strategies), and spontaneously uses MyBRAIN Now, as needed.

Training Methods – Training Option 2

Methods for the Individual with Severe Memory Impairment

Training Models:  Adopted from the American Congress of Rehabilitation Medicine, Cognitive Rehabilitation Manual, Errorless Learning, Spaced Retrieval, and Chaining Techniques

Errorless Learning Technique

The Errorless Learning Technique is designed as a training paradigm, which reduces or eliminates the likelihood of errors in learning. The clinician asks a question, provides the answer, and the participant is asked to recall the statement and answer immediately. A somewhat more complex method is to provide a simple command with a conditional clause attached, indicating when the command is to be executed.  Cues are to be provided freely, as needed, with frequent repetition.  The clinician does not allow guessing or trial-and-error learning. The paradigm is set up so that the participant cannot make mistakes, or perseverate on mistakes. 

Orientation to the Kindle Fire – sample questions

  1. “Your Kindle is the device you will be using to for 2 different types of activities – take assessments which ask how you are, and to use interventions to help you achieve your goals.”  Your Kindle Fire is used to for two different types of tasks. What are those two tasks? _____________________
  2. “Your Kindle needs to be charged and turned on to access assessments and interventions. To check the charge on your Kindle you do two things – press the button on the top right boarder of the device and check the battery symbol in the upper right hand corner on the screen. To check the charge on your Kindle battery, you do what 2 things: ________________________”
  3. “Your care team tracks the answers to your assessments to learn more about your recovery and needs. What does your care team learn from the answers to the assessments?”
  4. “Your Kindle requires access to Wi-Fi to upload your answers to the assessments. What does your Kindle require to upload your answers to the assessment questions?”________________

Orientation to MyBRAIN – sample questions

  1. “MyBRAIN is a technology interface system that has 2 primary purposes – to monitor your health and recovery, and to offer you tools to help you achieve your goals. MyBRAIN has 2 primary purposes which are ___________________ and to _________________________”.
  2. “Your Kindle has many apps on the home page. To access the MyBRAIN app, on the home page, you must do two things – swipe up on the screen and then select the MyBRAIN app on the upper left corner. What are the two steps to accessing the MyBRAIN app? _________________________”
  3. “You will interact with the MyBRAIN technology through the use of an avatar that you select. How will you interact with the MyBRAIN technology?   ___________”
  4. “A member of your care team will review how your assessment answers change over time and how this relates to your recovery. What will a care team member tell you about your answers? _________________”
  5. “Interventions will help you achieve one or more of your goals.  For example, if you have a goal to reduce depression, your MyBRAIN avatar will offer you a mindfulness exercise designed to reduce depression. What is one example of an intervention given by the avatar to help you achieve your goals?”__________________

Question: Do we want to provide a sample competency checklist for the care team member to use?

And would /should this be included in BEAM?

Spaced Retrieval Technique

The Spaced Retrieval Technique is identical to errorless learning except that the participant is asked to retain      information for progressively longer periods, e.g. immediate recall (examples in errorless learning above) is followed by 15-second delay, 30-second delay and so on. 

  1. “Your Kindle is the device you will be using for 2 different types of activities – to take assessments which ask how you are, and use interventions to help you achieve your goals.”  Your Kindle Fire is used for two different types of tasks. What are those two tasks? _____________________

Trial 1 _______       Trial 2 _______       Trial 3 _______   Total Correct_______

If a participant responds incorrectly at immediate recall, simply repeat the statement.  Once a participant is correct on trial 1, 2, or 3, proceed to short delay (e.g. 15 seconds). 

  1. 15 second delay

“I want to see if you can remember the 2 different types of activities you will be using your Kindle for, for a longer period of time. Let us try again and see if you can remember the two different types of activities after a 15-second delay.  Your Kindle is the device you will be using to for 2 different types of tasks – to take assessments which ask how you are, and use interventions to help you achieve your goals.” 

After 15 seconds, the care team member states/asks” Your Kindle Fire is used for two different types of tasks. 

What are those two tasks?” _____________________. If the participant responds incorrectly at the short delay, the care team member states “Actually the Kindle is the device you will be using to for 2 different types of tasks – to take assessments which ask how you are, and use interventions to help you achieve your goals.”

After a 2nd 15 second delay, the care team member asks the question again. 

If the participant cannot remember the two different types of tasks after the second 15-second delay, it may be appropriate to try a 5-second or 10-second delay.  Once a participant is correct on trial 1, 2, or 3 with a 15-second delay, proceed to a 30-second delay. 

Delay intervals can be adjusted based on participant performance and the density of the information to recall. 

Visual cues can be used to help support recall as well. For example, the care team member can have the Kindle device question or intervention page up on the screen. It is important for the care team member to track performance over trials, paying careful attention to those circumstances, which help or hinder learning. A sample recording form is below. 

Insert information being presented: ___________________________________________________________

Delay in either seconds___ or in minutes_____ (check which applies)
Trial numberImmediate15 sec30 sec1 min2 min3 min5 min___min__min 
List facilitators and/or barriers to learning here:

The care team member indicates if the recall was correct (+) or incorrect (-) for each trial.  Obviously, the delay interval can be modified according to the participant need.  

Chaining Technique

Chaining is a technique, using a procedural memory training approach, which focuses on training each 

item or step individually and linking it to the item before and after. Each step is a cue for the next. Chaining can be used with verbal information, visual or both. A preliminary step in this training technique requires a careful task analysis of the task to be trained.  Step 1 is taught. Once learned, step 2 is introduced and the participant is asked to produce steps 1 and 2. Once learned, step 3 is linked to step 1 and 2 and so on. Learning through chaining can be accomplished by training with a forward or backward chaining method. A forward chaining method will be demonstrated in the structured example below. 

 Forward Chaining Method Example

  Participant Name:  ________________________________ Date of training: ____________________

  Task: Learning to use the MyBRAIN Avatar to answer assessment questions

  Steps involved in the task:

  1. Turning on the Kindle
  2. Adjusting the volume
  3. Swiping up to reach the home screen
  4. Selecting the MyBRAIN app
  5. Answering the questions presented by the avatar
  6. Turning off the Kindle

Instructions: Forward chaining (for a six-step task)

First:  Demonstrate all steps in the task sequence and label each step as you do.

Say: To complete MyBRAIN assessments on your Kindle, you will do 

Step 1: turn on the Kindle by pressing the button on the upper right  

Step 2: adjust the volume by using the up or down button on the upper left 

Step 3: swipe up to reach the home screen 

Step 4: select the MyBRAIN app by tapping on it

Step 5: answer the questions presented by the avatar by touching the answer on the screen which best represents your response, 

Step 6: turn off your Kindle by pressing the button on the upper right. The Kindle will present a question – click OK to turn off Kindle. 

Do:  Perform the task for the participant.

Next:  Teach step 1

Say: “When you need to complete assessments, you begin by turning your Kindle on by pressing the button on the upper right.  What should you do when you need to complete assessments?”

Do: Guide participant, as needed, through performance of step 1.

Next: Teach step 2

Say: “After you turn on your Kindle by pressing the button on the upper right, you adjust the volume by pressing the up or down button on the upper left. What should you do after you turn on the Kindle by pressing the button on the upper right?” 

Do: Guide participant, as needed, through performance of step 1 and 2 together.

Next: Teach step 3

Say: After you adjust the volume by pressing the up or down button on the upper left, you should swipe up to reach the home screen. What should you do after you adjust the volume by pressing the up or down button on the upper left?

Do: Guide participant, as needed, through performance of step 1, 2, and 3 together.

Next: Teach step 4

Say: After you swipe up to reach the home screen, you should select the MyBRAIN app by tapping on  

it. What should you do after you swipe up to reach the home screen? 

        Do: Guide the participant, as needed, through performance of step 1, 2, 3, and 4 together.

        CONTINUE with this pattern of Say and Do for steps 5 and 6.

Habit formation – Principles and Tips for the Care Team 

  • ABI sequelae disrupt previously established hierarchical and interdependent habits that underlie all efficient, adaptive living skills. 
  • One’s emotional state, attitudes and expectations constitute important variables for learning and  relearning. 
  • Emotions and attitudes can both promote and guide re-establishment of new habits, or interfere with their development.
  • Incremental movement toward desired goals requires that:
    • the person focuses on the vision of a desirable future, 
    • breaks expectancies and goals into small, progressive steps, 
    • and develops habits that facilitate persistent and stepwise, goal directed efforts.

Habit formation in the therapeutic milieu

  • A strong, positive and trusting therapeutic relationship is essential
  • A credible rationale is required to offer a believable treatment model and logically convincing procedure that sets prerequisite positive expectancies.
  • A credible methodology & set of procedural interventions that produces measurable successes to confirm expectations & reinforce hope & continued efforts.
  • The consistent application of rewards and reinforcements shape, highlight and increases desirable goal directed achievements.

Three primary and essential ingredients for relearning and rehabilitation are emphasized:

  1. a prescriptive rehabilitation plan, derived from a thorough task analysis, for stepwise progress toward relearning a deficient behavioral skills
  2. practice/repetition in a structured, consistent, repeated trial method conducted over many weeks to months to form habits, automatic behaviors which do not require special effort, energy, concentration, memory or cognitive demand
  3. promotion of a positive attitude through shaping of incremental expectations, reinforcement for incremental gains, adaptive reinterpretation and redirection of residual negative emotions 

Focusing on Accomplishments 

  • Focus on progress, promote hope, promote positive expectations
  • Promote persistent, goal related effort and discourage quitting, and giving up
  • Facilitate incremental expectancies
  • Promote adaptive self-assessment, comparison’s and adaptive self-reinforcement
  • Promote practice and a positive, promotional attitude

 Strategies to support positive behavior change 

  • Make good habit cues easier to see. The easier to see, the more likely one is to perform behavior. Make it obvious where the behavior is to occur. 
  • Have participant write an implementation/intention statement – a statement identifying what will be done, when, where.
  • Make the habit cue and the habit behavior attractive so that one is more motivated to do it. The more positive the meaning/emotions one assigns to the cue and the task, the more likely one is to do it.
  • Make it easy- scale down the behavioral expectation in the beginning.
  • Make is satisfying –use habit trackers, to visually measure progress, and to offer visual feedback. 
  • The more the behavior is associated with positive emotion, the more likely one is to repeat it 

      Reference: James Clear Atomic Habits

Sustaining Engagement with Technology – Review of Literature – Key Points

  • Assess satisfaction throughout the course of care and at end of care (MPT assessment) 
  • Involve caregivers in training
  • Assess the trainers self-efficacy before and after training 

The trainer’s confidence has an impact on the participant’s use of assistive technology 

  • The trainer needs to adapt initial and ongoing training to the participant’s cognitive, communication, behavioral, social, physical, and sensory needs profile, as well as participant’s priorities 
  • The training paradigm needs to consider:
  • the number and complexity of decision making points
  • reducing reliance on memory
  • the sequential presentation of information 
  • Both participants/recipients and trainers need to have access to immediate and ongoing support
  • Support should be 
  • comprehensive, 
  • accessible,
  • individualized, 
  • available through multiple routes, e.g.
    • participants – telephone call with care team member
    • team member – telephone contact with MyBRAIN expert 
    • MeMinder can be used as task guidance/tutorial (how and when to use MyBRAIN) 
    • web-based supports
    • peer mentors 
  • Participant has significant involvement in decision making
  • in the selection and design, e.g. selection of avatar, methods to complete assessments, time of day/day of week to complete assessments, choice of interventions
  • selection of method to complete assessments (avatar versus web link)
  • training methods
  • participation in ongoing utilization, implementation, or reinvention with a focus on participants priorities
  • Care team need to take into account and address:
  • impairments of awareness and memory 
  • include generalization of MyBrain usage into multiple  environments (also referred to as untrained settings)
    • the necessity of generalization/utilization of assessments and self-management strategies, and how that is tied to the participants goals
    • design and user interface – visual, motor, auditory skills compatibility 

Accommodations for Cognitive and Behavioral Impairments

Accommodating the Symptoms of TBI

https://wexnermedical.osu.edu/neurological-institute/departments-and-centers/research-centers/ohio-valley-center-for-brain-injury-prevention-and-rehabilitation/for-professionals(Add content here post LET review and guidance)

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Previous Section III: Theories Supporting the Orientation and Training Protocols
Next Section IX: Appendices
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