1. Cognitive Rehabilitation for Everyone – Embedding Enhanced Learning Techniques in Practice
Dr Viki Teggart, Clinical Neuropsychologist
GMMH NHS Foundation Trust
Dr Natalie Arran, Clinical Psychologist specialising in Neuropsychology
Salford Royal NHS Foundation Trust

2. What is Rehabilitation?
Rehabilitation is a process whereby people who have sustained insults to the brain are helped to achieve their optimum physical, emotional, psychological and vocational well being (McLellan, 1991)
The focus of treatment is on improving aspects of everyday life; rehabilitation therefore needs to involve personally meaningful themes, activities, settings, and interactions (Ylvisaker & Feeney, 2000)
What is Rehabilitation?

3. Ingredients for Effective Rehabilitation Winson, Wilson & Bateman, 2017
Therapeutic milieu
Meaningful goals
Shared understanding
Psychological interventions
Compensatory strategies and retraining
Families and caregivers

4. Rehabilitation and Learning
Effective rehabilitation involves:
Learning by the patient
Teaching by the professional
Smits et al, 2010

5. What kinds of things do people need to learn or relearn after a stroke?

6. Some Examples of Things to Learn
KNOWLEDGE
MOVEMENT
COMMUNICATION
FUNCTION
What a stroke is
Bed mobility
How to find words
How to scan
The effects of the stroke
How to transfer (using aids)
Using a communication book
How to swallow
Potential risks
How to walk (using aids)
Using gestures
Using new equipment
Options for future support
Balance
How to thicken drinks

7. Cognitive Deficits and Learning
Ability to learn can be affected by deficits in:
Processing speed
Attention
Comprehension
Memory
Self monitoring
Self awareness

8. Your turn….
Think of a person you are working with and a specific skill you are working on with them.
What are you trying to help your patient learn?
What cognitive difficulties does your patient have that might affect learning?
Write your answers down on the worksheet

9. Adapting Teaching Styles
Ideally we would acquire a detailed assessment of cognitive functioning and gain an understanding of learning style / needs of each patient…
But it is not always practical, possible or necessary…
So we should assume that most patients will benefit from enhanced learning and embed enhanced learning in all teaching activities

10. Systematic Instruction (Ehlhardt, Sohlberg et al 2008)
People with learning challenges benefit most from:
Explicit modelling
Minimisation of errors during initial acquisition
Strategies to promote learner engagement
Guided practice
Systematic Instruction (Ehlhardt, Sohlberg et al 2008)

11. The person learns new skills by imitating another person who performs the behavior or action to be learned
Explicit Modelling
Show, don’t tell or
Show and tell

12. Explicit Modelling Example – Object to Picture Matching
Place picture on table in front of client and name it
Pick up object and name it
Place object on top of picture and name both

13. Your turn…. Back to the client you are working with…
How have you used explicit modelling so far?
Can you think of any other ways to include modelling?
Write your answer down on the worksheet

14. Minimisation of Errors - Errorless Learning
Break down information into small chunks
Provide sufficient models before client is asked to perform
Encourage avoidance of guessing
Immediately correct errors
Carefully fade prompts
"to reduce substantially, if not eliminate, errors during the acquisition phase of learning" (Baddeley & Wilson, 1994)
Minimisation of Errors - Errorless Learning

15. Errorless Learning for Teaching Information
Break down information into small chunks
What does the person need to know?
Provide sufficient models before client is asked to perform
Tell rather than ask
Make sure information is given in a consistent way
Errorless Learning for Teaching Information

16. Errorless Learning for Teaching Information
Encourage avoidance of guessing
- “If not sure, it’s okay to say don’t know”
Immediately correct errors
- “that’s not quite right, I said ….”
Carefully fade prompts
- don’t go too fast when removing help
Errorless Learning for Teaching Information

17. An Errorless Learning Orientation Script
Example orientation programme
This is an errorless learning programme. We will be providing X with orientation information without asking him to recall or guess the answers for a few weeks to help his learning. During this time, please avoid asking X questions about what happened to him.

18. An Errorless Learning Orientation Script
Please update the orientation date board in X’s room everyday.
When doing formal orientation work with X, please give information one sentence at a time. If using this information to answer questions at other times, pick the appropriate sentences to use

19. An Errorless Learning Orientation Script
Date
“Today’s date is ……” Also show X this written on the board
Place
“You are in X Hospital in X,
“You have been here (insert number) weeks”

20. An Errorless Learning Orientation Script
 Situation
“You are here because you have had a stroke”
“A stroke is an illness that affects your brain”

21. An Errorless Learning Orientation Script
 Insert key difficulties as appropriate for example:
“At the moment, your legs aren’t strong enough to hold you up” (point to or touch legs).
“Also your left arm doesn’t move very easily” (point to or touch left arm).
“You are finding it difficult to remember things that have happened recently. You might feel confused about what is going on.”

22. An Errorless Learning Orientation Script
“Your wife / husband / children know you are here and visit you very often”
“We are working with you everyday to try and get you home safely as soon as possible”
Repeat information as necessary.

23. Minimisation of Errors - Chaining
“Each new step is individually taught and linked sequentially to the previous step. The learner moves on to a new step as soon as the current step is mastered.” Sohlberg, Ehlhardt, & Kennedy (2005)
Conduct a task analysis to identify the key stages
List the specific actions required at each stage
Teach each stage action or step individually
Carefully fade prompts
Minimisation of Errors - Chaining

24. Chaining Task Analysis – Sit to Stand
Shuffle bottom to edge of chair
Lean weight forward
Put feet back
Put hand on arms of chair
Put weight through legs
Move forwards and up

25. Errorless Learning and Chaining Combined - Grooming
Open wash bag and place comb, toothbrush, toothpaste and paper towel on the sink.
Stand in front of the mirror and hold on to the grab rail saying ‘ stand in front of the mirror and hold on to the grab rail’
Take brush from sink and brush hair, say ‘brush your hair’.
Place the brush back in the wash bag.
Sit on a perching stool in front of the sink. Say, ‘sit in front of the sink and brush your teeth’

26. Your turn…. Back to the client you are working with…
How can you break down the task you are teaching into small steps?
How could you incorporate errorless learning into the task?
Write your answer down on the worksheet

27. Promoting Learner Engagement
“encouraging active processing during training increases learning” Sohlberg & Turkstra (2011)
Promoting Learner Engagement
Get the client to be active in the learning process
Encourage self generated learning and elaboration
Make learning meaningful and fun

28. Promoting Learner Engagement
Ask client to describe the learned task in their own words
Use visual imagery or video feedback
Develop mnemonic strategies - rhymes, songs, stories
Link tasks to meaningful goals or valued activities

29. Increasing independence when practising a task whilst still receiving enough support to Minimise errors and maintain consistency
Develop a between session practice plan
Model approach to other staff
Involve family
Provide sufficient written / visual prompts or reminders
Guided Practice

30. Guided practice
Write a plan for all staff to follow consistently and model to others
Set reminders for practice or use calendars / notes / stickers
Write steps down
Draw pictures
Make video for people to watch between sessions
Involve family / carers

31. Your turn…. Back to the client you are working with…
What techniques could you introduce to promote engagement in learning the task
How can you support guided practice within and between sessions?
Write your answers down on the worksheet

32. Thank you for your attention and participation