Integrating Other Commercially Available Programs with Fast ForWord 2/19/2014. Financial Disclosure Statements

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1 February 21-22, 2014 The Hilton El Conquistador, Tucson, AZ Financial Disclosure Statements Dr. Burns is paid as a part-time employee of Scientific Learning Corporation, producer of the Fast ForWord programs. She has no financial or nonfinancial interest or related personal interest of bias in any of the other organizations whose products or services are described, reviewed, evaluated or compared in the presentation. 2 Integrating Other Commercially Available Programs with Fast ForWord 3 1

2 Other evidence based commercially available programs Cogmed & N-Back exercises PROMPT & K-SLP Posit Science visual and social interaction options Interactive Metronome Neurofeedback Non-evidence based but used in clinical practice The Listening Program 4 Cogmed Visual Working Memory Programs Most research has been conducted by Torkel Klingberg (developer) and associates Most compelling research has been with ADHD and healthy adults One study with stroke 5 6 2

3 Training and Plasticity of Working Memory (Klingberg, 2010) Overview of 10 fmri studies using primarily computerized working memory tasks Includes data on stroke (Westerberg, H. et al., (2007) Figure 1. WM Training-related effects from neuroimaging studies. (a) Increases in frontal and parietal activity after training of WM (b) Increased activity in the caudate nucleus after training of WM tasks requiring updating (c e) Results from study by McNab et al. (c) Density of dopamine D1 receptors. (d) Regions of interest based on activation during visuospatial WM tasks versus control tasks. (e) Relation between pre- and post-training measures of dopamine D1 receptors and gain in WM capacity based on the regions of interest specified in (d). Klingberg (2010) Burns suggestions: Cogmed is a good adjunct to Fast ForWord or Reading Assistant for children who exhibit visual working memory limitations in addition to language, APD, auditory working memory, or attentional disorders Limitations still quite expensive 9 3

4 Panel recommendations 10 Prompt and K-SLP 11 Cortical Thickness of Children with CAS Fig.1a Left posterior supramarginal gyrus ROI, represented as ashaded region on a mid-surface rendering of an average brain;bchildren with idiopathic apraxia (n = 11) had thicker left posterior supramarginal gyri compared to Controls (n = 11) at baseline, t(20)= 2.84, p Mean scaled cortical thickness (±SEM), shown for each group (Color figure online) 4

5 Cortical Thickness Changes Following Prompt Fig.2a Left posterior superior temporal gyrus (Wernicke s area), represented asshaded region;b children with idiopathic apraxia (n = 9) experienced significant thinning of Wernicke s over the course of therapy, (t(8) = 2.42,p 0.05);cbaseline and follow-up scaled cortical thickness of Wernicke s area in the small subset of Controls with appropriate serial imaging (n = 3) Findings Only one significant difference was observed: children with idiopathic apraxia had significantly thicker left posterior supramarginal gyri than Controls Left posterior supramarginal gyrus thickness did not correlate with any of the baseline measures of speech performance in the clinical group In children receiving therapy for apraxia, ROI analyses revealed significant thinning in the posterior superior temporal gyrus, canonical Wernicke s area Decreasing thickness in Wernicke s over the course of therapy was not significantly correlated to change scores on any of the standardized speech measures The clinical significance of thicker left supramarginal gyri in children with idiopathic apraxia is not clear. What this research means Eight weeks of speech therapy helps children with apraxia. But since there is no control group, we have no idea whether results from PROMPT after eight weeks would be superior to any other form of speech therapy. Children with apraxia of speech (like children with ADHD) may have neuroanatomical differences from typically developing children. supports the fact that apraxia of speech in children is a neurological problem that speech therapy is useful in effecting neurological changes in the direction of normalcy however, since those changes were not correlated with improved speech the value of that finding remains an open question. Shows the value of using neuroscience research to better understand the problems we work with as SLPs and the hope for more scientific efforts at developing evidence-based methodologies. And finally, it does support the value of motor-speech based interventions for apraxia of speech in children. 5

6 Burns, M. (2011)Apraxia of Speech in Children and Adolescents: Applications of Neuroscience to Differential Diagnosis and Intervention Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders Distinguishing characteristics of Childhood Apraxia of Speech 18 6

7 Implications for Existing Interventions Interventions that involve: Visual cueing and imitation have a high probability of positively shaping Broca s area Responsible for articulation, verbal fluency and grammar The mirror neuron center Auditory training components further build Wernicke s area connections as well Cross training of multiple cognitive and motor speech domains are likely more efficient at building the long fiber tracts that underlie speech and language processes Intensity (many responses per session) are more effective at driving neuroplastic change Using Posit Science Interventions Adolescents and Adults Speed of Processing exercises shown to have greatest benefit and 10 year longitudinal outcomes in healthy adults 20 Ten-Year Effects of the Advanced Cognitive Training for Independent and Vital Elderly Cognitive Training Trial on Cognition and Everyday Functioning in Older Adults George W. Rebok, et al., Journal of the American Geriatrics Society Volume 62, Issue 1, pages 16 24, January

8 Subject and Cognitive Training Design 6 metropolitan centers - included 2802 participants randomly assigned to 1 of 3 interventions a memory, a reasoning, or a speed-ofprocessing or no-contact control group. Training was conducted in small groups in ten 60- to 75-minute sessions over 5 to 6 weeks. Tasks Multifaceted memory training verbal episodic memory through instruction and practice in the use of strategy. Reasoning training ability to solve problems that contain a serial pattern. The speed-of-processing training computer-based program (Posit Science) involved learning to quickly take in increasingly more complex information based on original Fast ForWord exercises Important for tasks such as driving or everyday activities such as reading labels and following recipes in cooking. Tasks The speed-of-processing training is now available through PositScience and Fast ForWord. Although the other 2 training programs are not yet commercially available, Dr. Rebok and his colleagues have a grant from the National Institute on Aging (NIA) to develop a Web-based version of the ACTIVE memory training. 8

9 Take away for clinicians Computerized cognitive training is available now Posit Science exercises (those used in the ACTIVE trial) are available and inexpensive Working memory exercises for children and adults are available and inexpensive The training is highly evidence based for enhancing and maintaining memory and other cognitive skills Computerized memory exercises should be included as an adjunct to any and all treatment programs with children and adults who have memory issues (ASD, APD, Dyslexia, especially) Burns recommendations For adolescents or adults Fast ForWord does provide speed of processing exercises Posit Science speed of exercises might be used in combination with FFWD Literacy for adults with dyslexia, other learning disabilities, or in preparation for standardized graduate admission tests 26 Interactive Metronome Two controlled research studies provided on website Other research included non-controlled outcome studies, case studies and white papers 27 9

10 Interactive Metronome with ADHD Shaffer et al., (2001) American Journal of Occupational Therapy, 55, N=19 in experimental group, 2 control groups (Video games; regular control) Evaluated using the TOVA (Test of Variables of Attention); Child Behavior Checklist (CRS-R); and WRAT-3 (Wide Range Achievement) Control group showed significant incr. on similarities and differences, reduction of aggression, Also increases in five tests of reading and four characteristics of attention IM with TBI Nelson, L. A., MacDonald, M., Stall, C., & Pazdan, R. (2013, September 23). Effects of Interactive Metronome Therapy on Cognitive Functioning After Blast-Related Brain Injury: A Randomized Controlled Pilot Trial. Neuropsychology

11 Nelson, et al., (2013) IM Results: Significant group differences (Standard Rehab C vs. IM) were observed for indices in unadjusted analyses RBANS Attention (p.044), Immediate Memory (p.019), and Delayed Memory, with the IM group showing significantly greater With effect sizes in the medium-to-large range in the adjusted analyses for each outcome 31 Panel recommendations 32 Neurofeedback Arns, M., de Ridder, S., Strehl, U., Breteler, M., & Coenen, A. (2009). Efficacy of neurofeedback treatment in ADHD: the effects on inattention, impulsivity and hyperactivity: a meta analysis. Clinical EEG and Neuroscience, 40(3), Duric, N., Assmus, J., Gundersen, D., & Elgen, I. (2012). Neurofeedback for the treatment of children and adolescents with ADHD: a randomized and controlled clinical trial using parental reports. BMC Psychiatry, 12(1), 107. American Academy of Pediatrics report: Evidencebased Child and Adolescent Psychosocial Interventions, released November

12 Arns et al., (2009) Three randomized studies have employed a semiactive control group which can be regarded as a credible sham control providing an equal level of cognitive training and client-therapist interaction. Therefore, in line with the accepted guidelines for rating clinical efficacy, we conclude that neurofeedback treatment for ADHD can be considered "Efficacious and Specific" (Level 5) with a large Effect Size for inattention and impulsivity, and a medium Effect Size for hyperactivity. 34 Group discussion 35 12

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