6.2 Remediation of Learning and Memory Deficits

Memory impairment is one of the most common symptoms following brain injury and it is estimated that time and cost of care would be reduced if effective medical treatments were found to improve memory (Walker et al., 1991).

When evaluating intervention strategies to improve memory performance following brain injury, the literature indicates that there are two main approaches to rehabilitation: restoration or retraining of the function and compensation. Compensation includes “training strategies or techniques that aim to circumvent any difficulty that arises as a result of the memory impairment.” Compensatory techniques include internal aids, which are “mnemonic strategies that restructure information that is to be learned.” Various interventions have focused on the remediation of memory deficits in individuals with TBI, including external compensatory aids (computers, pagers, and notebooks), individualized remediation programs, family/social support and environmental adaptations, didactic lessons and homework, training in compensatory strategies including rehearsal, organizational strategies, visual imagery, verbal labeling, and use of mnemonics, as well as implicit memory tasks.

Cicerone et al. (2000) reviewed 42 studies examining the effectiveness of various interventions to improve memory impairment following stroke and TBI (Table 6.6). It should be noted that studies were not included in our review if the population did not comprise of more than 50% brain-injured patients, or if the sample size (n) was less than 3. For this reason, only those studies dealing with moderate-to-severe brain-injured individuals are included in our review. Thirteen additional studies were added to the review in 2005 (Cicerone et al., 2005).

In an updated review by Cappa et al. (2005), strategies used to improve memory deficits without the use of electronic, external aids were judged to be “possibly effective.” Specific learning strategies (e.g. errorless learning) were found to be “probably effective” depending upon the task used, the type of memory involved and the severity of impairment.

Several studies were identified examining interventions to improve learning and memory following acquired brain injury. Studies were categorized into the following groupings: external aids used to enhance memory, internal strategies used during learning to enhance recall, and memory intervention programs consisting of a number of sessions.

6.2.1 External Aids

External aids assist memory by use of external methods of recording and accessing information. In an updated review by Cappa et al. (2005), the use of external, electronic assistive devices were assessed as “probably effective.”

Table 6.6 Remediation of Memory Deficits

Cicerone et al. (2000)
Benedict et al., 1992 Benedict et al., 1993 Berg et al., 1991 Burke et al., 1994 Cancelliere et al., 1991 Chute et al., 1988		Kirsch et al., 1987 Kirsch et al., 1992 Laatsch et al., 1983 Leng et al., 1991 Malec et al., 1983 Malec et al., 1991
Crosson et al., 1984 Evans et al., 1996 Finset et al., 1995 Fowler et al., 1972 Freeman et al., 1992 Furst et al., 1994		Malloy et al., 1984 Milders et al.,1998 Parente et al., 1983 Parente 1994 Schacter et al., 1985 Schmitter-Edgecombe et al., 1995
Gianutsos et al., 1979 Glasgow et al., 1977 Godfrey et al., 1988 Goldstein et al. ,1996 Goldstein et al., 1988 Hersh et al., 1994 Kime et al. ,1996 Kerner et al. ,1985		Squires et al.,1996 Raskin et al., 1996 Ryan et al., 1988 Sohlberg et al., 1992 Thoene et al. ,1995 Wilson 1982 Zencius et al., 1990
Cicerone et al., (2005)
Donaghy and Williams 1998 Evans et al., 2000 Hart et al., 2002 Hux et al., 2002 Kaschel et al., 2002 Ownsworth and Mcfarland 1999 Parente et al., 1999		van den Broek et al., 2000 Wade and Troy 2001 Wilson et al., 1999 Wilson et al., 2001 Wright et al., 2001 Yasuda et al., 2002
Cicerone et al., (2011)
Fish et al., 2008 Thickpenny-Davis et al., 2007 Wilson et al., 2001 Wilson et al., 2005 Tam et al., 2004 Quemada et al., 2003 Stapleton et al., 2007 Pitel et al., 2006 Ouregois et al., 2007	Melton et al., 2005 McKerracher et al., 2005 Manasse et al., 2005 Fleming et al., 2005 Campbell et al., 2007 Bergquist et al., 2008 Huildebrandt et al., 2006 Dou et al., 2006

Included are several studies which examined how external aids could be used to enhance memory following brain injury.

Individual Studies

Table 6.6 The Use of External Aids to Enhance Memory

Author/ Year/ Country/ Study design/ PEDro and D&B Score	Methods	Outcome
Wilson et al., (2001) UK RCT D&B = 18 PEDro = 4	N=143 A randomized controlled cross-over study of subjects with memory impairments were divided into one of two treatment groups: group A (pager first) and group B (waiting list first). Patients chose their own tasks in which they wanted to be reminded. Outcomes measured included patients’ ability to successfully carry out everyday tasks.	During the last 2 weeks of the 7-week treatment period, the participants using the pager were significantly more successful in achieving target behaviours than the waiting list group (p< 0.001).
Ownsworth & McFarland (1999) Australia RCT D&B = 18 PEDro = 3	N=20 Volunteer subjects with ABI were randomized into a diary only (DS) and a diary & self-instructional training (DSIT) group intervention. The DS group participated in a 6 week “Bottom-Up” approach program that emphasized the development of functional skills using compensation based, on task,-specific learning. The DSIT group participated in a 10 week “Top-Down” approach program that emphasized the capacity for self-regulation and self-awareness using “Self Instructional Training.”	All subjects reported significantly fewer problems with memory (p<0.001) and lower levels of distress (p<0.01) during treatment phase when compared to baseline. There was a significant increase in the degree of strategy use during treatment (p<0.05) regardless of type of diary training. There were no significant differences between the DS and DSIT groups (p>0.05).
Watanabe et al., (1998) USA RCT D&B = 20 PEDro = 3	N=30 Severe TBI subjects (determined by length of PTA @ acute rehabilitation admittance) consecutively admitted to a BI inpatient unit (16 traumatic, 14 non-traumatic- without aphasia or severe visual deficits) were randomized into treatment (n=14), and control groups (n=16) to determine whether the presence of a calendar affected the score from the Temporal Orientation Test (TOT).	Presence of a calendar did not significantly affect TOT scores.
Wilson et al., (2001) UK RCT D&B = 18 PEDro = 4	N=143 A randomized controlled cross-over study of subjects with memory impairments were divided into one of two treatment groups: group A (pager first) and group B (waiting list first). Patients chose their own tasks in which they wanted to be reminded. Outcomes measured included patients’ ability to successfully carry out everyday tasks.	During the last 2 weeks of the 7-week treatment period, the participants using the pager were significantly more successful in achieving target behaviours than the waiting list group (p< 0.001).
Wilson et al., (2005) UK Sub-group analysis of Wilson et al. (2001)	N=63 TBI subjects with memory impairments were divided into one of two treatment groups: group A (pager first) and group B (waiting list first). Patients chose their own tasks in which they wanted to be reminded. Outcomes measured included patients’ ability to successfully carry out everyday tasks.	An odds ratio test revealed that 81% of the 63 patients who completed all stages of the trial were significantly more successful with the pager. This paging system helps people with memory impairments, due to TBI, document successful task achievement more efficiently than without the pager.
Bourgeois et al., (2007) USA Prospective Controlled Trial D&B=20	N=38 Individuals were quasi-randomized into either the spaced retrieval (SR) group or the didactic strategy instruction (SI) group. Daily memory logs noted areas where the participant was having difficulties and specific goals to work on were selected. 30 minute training sessions were scheduled 4 or 5 per week. Those in the SR treatment group began with a prompt question and a treatment goal. Participants were encouraged to answer the question(s) the same way each time it/they was asked. Those in the SI group common memory strategies were discussed. Participants were encouraged to identify problems and then apply a specific strategy to help deal with this problem. Contact with all participants was done over the phone.	The frequency of memory problems decreased in both groups over time. Those in the SR group showed significant improvement in goal mastery (p<0.05) compared to the SI group. This was maintained at the one month post intervention time period. Results on the Cognitive Difficulties Questionnaire (CDS) showed both groups reported having fewer difficulties following treatment. There were no significant differences between the two groups on the CIQ post treatment. Changes in community integration were not noted over time.
Schmitter-Edgecombe et al., (1995) USA Non-RCT D&B = 22	N=8 participants with severe CHI and documented memory deficits (WAIS-R-IQ>75; DRS >133; WMS-R<89) were matched and allocated to memory notebook training (treatment) and supportive therapy (control) groups for 9 weeks. Outcome measures assessed at baseline, after treatment and at 6-month follow-up included lab-based recall (Logical Memory I & 2 scales and Visual Reproduction 1 & 2 scales from the Wechsler Memory Scale – Revised), laboratory-based everyday memory tests (Rivermead Behavioural Memory Test), retrospective report of Everyday Memory Failures (EMFs) using the Everyday Memory Questionnaire (EMQ), observed EMF (EMQ assessed for 7 consecutive days), and symptom distress (Global Severity Index from the Symptom Checklist 90 – Revised).	Immediately after treatment, the notebook training group reported significantly fewer observed EMFs than the control group (p < 0.05), although this finding was no longer significant at the 6-month follow-up. There were no significant differences between groups in any of the other outcomes measures (laboratory based-recall, laboratory-based everyday memory, retrospective report of EMFs, and symptom distress indicators).
Boman et al., (2007) Sweden Pre-Post D&B=13	N=8 Participants were invited to move into one of 2 apartments for a period of 4 to 6 months. Apartments were equipped with electronic aids to daily living (EADLs). Learning how to use the EADLs was completed in the rehab clinic within 2-3 days. Once in the apartment participants were taught to use all the EADLs available to them. Training lasted 1-2 hours, 4 or 5 x per week for 3 weeks. Once all the EADLs were presented, time and attention were given to helping the individual use the ones needed in their everyday life. The Canadian Occupation Performance Measure (COPM) was used measure perceived improved function of everyday activities, the Sickness Impact Profile 136 (SIP-136) was used to measure self perceived dysfunction and the quality of life analogue scale was used to measure self perceived quality of life.	Individuals varied in the length of time (2 to 24 weeks) needed to learn how to use the EADLs. It took approximately four weeks for all to learn the very basic EADLs such as the electronic key, the photoelectric controlled water taps, etc. All felt the EADLs were very useful. Prior to beginning the study, results of the COPM indicated a lack of initiation to do what they said they would do, being on time for meetings and a decreased ability to plan things as major problems for most of the participants. During the post stage of the study, a significant improvement was noted in the self perceived ability to perform important activities and in the satisfaction with performing tasks (p<0.05). For 6 participants improvement was also seen on the SIP (p<0.05), in the following categories: body care, and psychosocial functioning. Overall occupational health and quality of life was found to have improved.
Egan et al., (2005) Australia Pre-Post D&B=15	N=7 Individuals were chosen to participate in the following study although only 6 completed it. Through the help of tutors (n=6) individuals were trained one on one to use the internet.	The majority of participants had rarely or never used the internet although most has internet access in their homes. There was a significant improvement on the post rating of moderate to total independence on the internet skills assessment scale (p<0.028). Any task that required more steps or required a greater understanding of how to use the internet showed little improvement in independence.
Burke et al., (2001) USA D&B = 17	N=5 TBI subjects with functional hearing, vision and mobility were prompted by hospital staff about appointment times and locations verbally (baseline) or using an electronic device (Patient Locater and Minder – PLAM – treatment). Measures included the number of prompts and arrival time at baseline compared to PLAM.	Average number of human prompts declined significantly (p<0.001), while the number of sessions requiring no prompting increased (p<0.005). Patients arrived on average 1.3 minutes earlier using PLAM – a 6.1 minute improvement over baseline.
Hart et al., (2002) USA Pre-Post D&B = 13	N=20 TBI subjects exhibiting significant memory impairments were involved in a comprehensive treatment program 2-5 days per week. Individualized therapy goals were assigned prospectively to intervention or non-intervention groups with “memory for therapy” goals being the primary outcome.	Recorded goals were recalled significantly better than unrecorded goals.
Wilson et al., (1997) UK Pre-Post D&B = 14	N=15 Subjects with significant, everyday memory problems due to neurological impairment from ABI completed a study of the efficacy of the NeuroPage paging system. A diary was kept in advance to identify real-life problems for each subject that served as treatment goals. Reminders for targeted problems were sent out by pager at agreed upon times; data was collected for 12 weeks.	There was a significant improvement in task completion between the baseline and treatment phase of each subject (p<0.05). Mean success at baseline was 37.08%, during treatment (85.56%) and post-treatment (74.46%).
Wright et al., (2001a) UK Pre-Post D&B = 10	N=12 Subjects with ABI via TBI (9) and subarachnoid hemorrhage (2) were provided with 2 different computer aid formats for 2 months (with a one month gap between machines). Frequency of feature use, as well as user willingness to use a specific feature were recorded.	Appointment diary was used more than any other aid. High users made more new diary entries (p<0.06) suggesting a conceptual understanding of how to use memory aids in everyday living was a prerequisite for benefiting from them.
Wright et al., (2001b) UK D&B = 10	N=12 Adult, TBI volunteers without visual or motor handicaps that would prevent the use of an electronic organizer completed a two month comparative study of Casio and HP electronic organizers (one month break between brands).	No significant correlations between any single psychometric measure and organizer entries. People accustomed to using memory aids (any type) made more use of pocket computers (p<0.07). Low frequency users were put off organizers when it had a physical keyboard (p<0.01). High frequency users used the keyboard more (p<0.07)
Fish et al., (2007) UK Case Series D&B = 12	N=20 Participants were asked to make telephone calls at specific times of the day for a 3 week period. 4 calls were made each day at which time the participant was asked to leave there name only. Times of the call were randomly selected each day but participants were given the times to call. Some telephone tasks were expected to be completed at a particular time, while others were given a time frame for completion. Participants were scored on the number of calls made in a day (0-4) and the time the call was made. Over the 3 week period on 5 randomly selected days a text message “STOP” was sent to participants. This was a cue for participants to stop and think about what needed to be done, what they were doing etc.	During the first week 15% of the participants failed to make the calls. The effect of cueing on participants had a significant impact on the number of calls made. Participants made 87.6% of calls when cued but only 71.2% of calls when they were not cued. Of note there was a positive relationship between the number of calls made (completed) and the time in which they were made (within 5 minutes of the target time).
van den Broek et al., (2000) UK Case Series D&B = 10	N=5 Outpatients of the Brain Injury Rehabilitation Centre were used to evaluate the effectiveness of the external aid, the Voice Organizer for a period of 3-weeks. This aid has a visual display presenting the current time, day and date and each device was trained to recognize the user’s voice. Messages could be dictated into the organizer and verbal reminders were repeated at specified times throughout the day.	All patients benefited from the introduction of the Voice Organizer as measured using the message-passing task and the Positive and Negative Affect Schedule (PANAS).
Manasse et al., (2005) USA Case Series D&B=10	N=5 Subjects were shown pictures of individuals they interacted with daily and asked to identify them. Traditional treatment: To assist subjects in memory recall, pictures were paired with an imagery statement. There were 9 (3 weekly over a 3 week period) one on one training sessions to assist the individuals with face name recognition. Real-world treatment: Following the third week, “real-world” treatment was begun. During the next 15 days, 2 interactions were performed each day with 2 hours separating the interactions. Researchers recorded the subjects’ spontaneous use and knowledge of the staff’s name.	Traditional treatment: results indicate that 2 of the 5 subjects mastered 6 names during treatment, 1 of the 5 mastered 3 names and 4 of the 5 mastered one of the names. Real-world treatment: During the real-world cueing condition only 2 names were consistently used by each subject. When directly asked a person’s name 4 of 5 subjects could respond correctly.
Wade & Troy (2001) UK Case Study No Score	N=5 TBI subjects (age range 18-51; chronicity: 1-15 years) with a memory impairment and for whom a memory aid was deemed appropriate were provided mobile phones for use as an external memory aid in self-initiated performance tasks using individualized diaries.	Case 1, 2, and 4 achieved 100% initial success; Case 3, 92%; and Case 5 demonstrated clear improvements when pre-aid success rates compared to post-treatment.
Zencius et al., (1991) USA Case Study No Score	N=4 Subjects (aged 23-40) with TBI from MVA suffering memory impairments underwent memory notebook training for two homework assignments per week. Success was measure by the number of assignment components prepared correctly.	Memory notebook training increased the number of homework components correctly completed from baseline for all participants (no statistics reported)

PEDro = Physiotherapy Evidence Database rating scale score (Moseley et al., 2002).
D&B = Downs and Black (1998) quality assessment scale score.

Table 6.9 Summary of the Use of External Aides to Enhance Memory

Authors	n	Intervention	Result
Ownsworth &McFarland (1999)	20	Subjects randomized to Diary Only (goal oriented strategy) and Diary and Self-Instructional Training (compensation strategy) group.	During treatment phase, DSIT group consistently made more entries (p<0.05), reported fewer memory problems (p<0.025) and made more positive ratings towards treatment efficacy.
Watanabe et al., (1998)	30	Measure the effect of having a calendar present in a patient’s room on Temporal Orientation Test Score	Presence of calendar did not significantly affect TOT score (p=0.15).
Wilson et al., (2001;2005)	143	Patients randomized to receive intervention using pager or no treatment (control)	Patients using the pager achieved a greater number of target behaviours.
Bourgeois et al., 2007	38	Individuals were randomly assigned to either the Spaced Retrieval (SR) group or the didactic strategy instruction (SI) group.	Those in the SR group reported more treatment goal mastery than those in the SI group. Significant differences were not noted on the CIQ or the CDS post treatment in either group or between groups.
Boman et al., 2007	8	Subjects resided in specially equipped apartments (equipped with either basic or advanced EADLs) for 4 to 6 months	Subjects felt the EADLS were very useful and easy to learn. Occupational performance and quality of life was found to have improved.
Egan et al., (2005)	7	Patients received individual training on how to use the internet.	The majority of those participating reached moderate to high degrees of independence on using the internet.
Schmitter-Edgecombe et al., (1995)	8	4 subjects received 9 weeks of memory notebook training, 4 received 9 weeks of supportive therapy.	Notebook training group reported significantly fewer observed everyday memory failures (EMFs) than supportive therapy group at post-treatment (p<0.05), but not at follow-up.
Burke et al., (2001)	5	Hospital staff prompting vs use of patient locator and reminder (PLAM) to direct patient to scheduled therapy sessions.	Using PLAM, need for human prompting reduced by 50%. Number of sessions requiring no prompting increased from 7 to 44%.
Hart et al., (2002)	20	Prospective, within-subject trial to test efficacy of portable voice organizer (Parrot Voice Mate III) to recall 3 therapy goals.	Recorded goals better recalled (p<0.001) than unrecorded goals in both free (p<0.005) and cued (p<0.01) conditions
Wilson et al., (1997)	15	ABA single case design measuring the effect of Neuro-Page (paging system) on individual memory targets.	Baseline: 37.08% mean success Treatment: 85.56% mean success Post-Treatment: 74.46% mean success.
Wright et al., (2001a)	12	Counter-balanced cross-over study of 2 computer organizers (HP 360LX & Casio E10). Studied attitude, usage and correlation to psychometric tests.	No correlation between usage and psychometric tests. Results suggest conceptual understanding of electronic aid use a prerequisite to treatment benefit.
Wright et al., (2001b)	12	Exploring possible correlations between psychometric measures and usage of electronic, hand-held organizers.	No significant psychometric-usage correlations made. Familiarity with any kind of memory aid resulted in significantly increased usage of electronic organizer. (p<0.07)
Fish et al., (2007)	20	Looking at the impact of text messaging on prospective memory.	The cued messages individuals received lead to a higher degree of compliance with activities or goals to be completed.
van den Broek et al., (2000)	5	5 outpatients used the external aid, Voice Organizer, for a period of 3-weeks.	All patients benefited from the introduction of the voice organizer.
Manasse et al., (2005)	5	5 patients participated in two treatment programs: traditional and real-world treatment.	Gains made in the traditional setting were not consistently seen in the functional setting.
Wade & Troy (2001])	5	Use of mobile phone diary feature to remember target tasks.	Cases 1, 2, 4 achieved 100%, Case 3 achieved 93% and Case 5 “showed significant improvement” of target tasks.
Zencius et al., (1991)	4	Use of memory notebook to improve successful achievement of target tasks (keeping appointments and completion of homework assignments).	Memory notebook training increased target achievement from baseline for all participants.

Discussion

Wade and Troy (2001) using a case study examined the use of cell phones as an effective memory aid for 5 moderately-to-severely memory impaired ABI individuals (as shown on testing and in everyday functioning as rated by a caregiver). Each phone was set up with a computerized system to send reminder messages that were specific to the individuals (e.g., upcoming appointments, to take medications, etc). The message was voice-activated by the recipient, it was preceded by the explanation that it was a recorded message and if the phone was engaged, the computer would continue to send the message until it was received (repeat at regular intervals until answered). The outcome measure was the percentage of success achieved on 4-5 items to be remembered independently over a 12-week period. Results showed improvement compared to baseline data (success ranged from 92-100% for the individuals).

Wright et al. (2001a) examined the effect of two pocket computer systems containing three memory aides: appointment diary, notebook, and a to-do-list with a group of 12 ABI participants (9 TBI, 2 ABI). The type of pocket computer was counterbalanced and participants used each one for 8 weeks. No significant difference in use was found between type of pocket computer (they differed in terms of text entry – physical keyboard or touch- screen keyboard), and the majority (83%) used the three aids. Those participants who had previously used a memory aid made significantly more diary entries compared to those who had not previously used a memory aid. Severity of injury as well as level of cognitive function was not reported in this study. In another study by Wright et al. (2001b), findings were similar (i.e. no differences between computer systems in terms of use of memory aids).

Wilson et al. (1997) evaluated the efficacy of NeuroPage, a portable paging system, in reducing everyday memory problems in 15 ABI participants (10 TBI, 5 ABI). Using an A-B-A design, results indicated that all subjects significantly benefited from using the NeuroPage system and that following 12 weeks of use, performance remained at improved levels compared to baseline for another 3 weeks. Wilson et al. (2001) conducted a randomized controlled cross-over trial with 143 memory impaired patients, many – how many having sustained a TBI. The objective for this study was to evaluate a paging system designed to improve independence in people with memory problems as well as to reduce deficits in executive function. Results demonstrated that the pager system significantly increased patients’ ability to carry out daily tasks, and successful task achievement was more efficient after the pager intervention was introduced.

Hart et al. (2002) used hand-held recorders to remind moderate-to-severely impaired patients of their therapy goals (within subject design). Six individual goals were determined and half were recorded onto a hand-held organizer with an alarm preprogrammed to review the goals 3 times a day throughout the week. The other half of the goals were not recorded but were summarized at the weekly clinical management meetings. Goals were correctly recalled when using the hand held recorder compared to when goals were reviewed. It should be noted that the study examined only if the goals could be elicited during recall (either free recall or cued) and did not examine whether the subjects actually followed through with their goals.

Burke et al. (2001) used a complex computerized tracking system (patient locater and reminder system – PLAM) to remind and direct 5 patients on an acute rehabilitation unit to their next therapy appointment. The electronic tracking system prompted patients 10 minutes in advance of their appointments and continued to do so until the patient started moving toward the therapy room. If patients were going in the wrong direction, the system would prompt them on how to get to the appointment and would offer positive reinforcement as the patient made their way to the therapy room. Using a case series design, baseline data was gathered for a week and included the number of staff prompts needed to get the person to scheduled therapy and the time the person arrived at the therapy. Once the patients were introduced to the PLAM system, data was collected for a 3-day period. Results indicated that the subjects arrived earlier to their appointments and required fewer prompts (i.e. the number of sessions that did not require prompting increased from 7% to 44%).

Using an example of cognitive teletherapy, Borugeois et al. (2007) recruited 38 individuals from two states, along with a significant other to participate in the current study. Individuals quasi-randomized into one of two groups: either the Spaced Retrieval (SR) group or the didactic strategy instruction (SI) group.

In a prospective controlled study completed by Bourgeois et al. (2007), 38 subjects, along with one significant other for each subject, were assigned to either the spaced retrieval (SR) group or the Didactic strategy instruction (SI) group. Subjects were asked to maintain a daily log where they would note all areas they were having difficulties in. Treatment goals were developed based on areas of difficulty.Those in the SR group were given prompt questions and responses for each goal selected. Answers to the prompt questions were expected to be given in exactly the same way each time. Those in the SI group received time with a therapist to discuss memory strategies. All sessions were conducted by phone for both groups. Results indicate that the frequency of memory problems decreased in both groups over time. Significant improvement in goal mastery (p<0.05) was noted in the SR group but not in the SI group. Scores on the Cognitive Difficulties Questionnaire (CDS) indicate both groups were experiencing fewer difficulties following treatment. Post treatment, scores on the community integration questionnaire (CIQ), showed no significant differences between the two groups.

Boman et al. (2007) invited 8 participants live in one of two apartments equipped with electronic aids to daily living (EADLs). Participants, one in the apartment, were given 4 or 5 sessions weekly, each lasting 1 to 2 hours on how use the EADLs. Initial COPM results indicate a lack of initiation to do what they said they would do; however, post study results indicate improvement in the self perceived ability to perform important activities and in the satisfaction with performing tasks (p<0.05). For 6 participants improvement was also seen on the Sickness Impact Profile (SIP) 136. Study results indicate occupational health and quality of life had improved. Overall the authors found that EADLs may play a role in facilitating everyday functions.

In a study conducted by Egan et al. (2005) individuals who had sustained a TBI were instructed on how to use the internet. Each participant was given one-on- one instruction in their own home. Following training, individuals showed significant improvement on their level of independence in using the internet (p<0.028). Less improvement was noted when looking at the tasks that required greater abstract understanding and required more steps to complete. Participants’ were able to complete concrete tasks using fewer steps with greater ease.

Using a memory notebook as the external memory aid, Schmitter-Edgecombe et al. (1995) assigned 8 individuals with severe closed-head-injury and memory deficits into either a notebook-training group or an interpersonal support group (control). Groups were matched on a number of demographic variables. Outcome measures included both performance on memory tests as well as observation and responses to a questionnaire on everyday memory failures. Both groups received 2, 1-hour sessions per week for 8 weeks (16 sessions). Results indicated that, on cognitive measures of memory functioning, there was no difference between groups. However, on observed everyday memory failures (questionnaire), performance improved (i.e., less failures) following treatment, although performance was not maintained at 6-month follow-up.

Zencius et al. (1991) using a case study demonstrated that notebook training enhanced recall of components of homework assignments as compared to baseline performance. However, no neuropsychological evidence of memory impairment or severity of injury was specified in the study. In an earlier study, Zencius et al. (1990b) also compared notebook strategy to other strategies and found it to be superior to other strategies.

In a randomized controlled trial, Watanabe et al. (1998) examined whether use of a calendar would enhance orientation following an acquired brain injury. Results indicated that the presence of a calendar did not enhance performance on a temporal orientation test (date and time). It is difficult to judge the outcome of this study as no scores were reported for either the control or treatment group, and it is not clear whether post-traumatic amnesia, and/or severity of injury had an impact on performance.

Ownsworth and McFarland (1999) evaluated two different training approaches in the use a diary to compensate for memory problems. They randomly assigned 20 ABI volunteers (15 TBI; 5 ABI) to either a Self-Instructional Training (SIT) approach or to a task-specific learning approach. The Diary-SIT approach trains compensation using higher cognitive skills of self-regulation and self-awareness. That is, participants where taught to question themselves with the following script (WSCT): What are you going to do? Select strategies; Try it out; Check how it’s working. By using this training approach, the researchers speculated that it provides direct, internal feedback, which can generalize to other situations involving memory. In contrast the Diary-Only approach taught subjects how to use the diary. Results indicated that those in the Diary-SIT group made consistently more diary entries, reported a reduction in everyday memory problems and made more positive ratings on treatment efficacy compared to the Diary-Only group.

In a study conducted by Fish et al. (2007), all participants (n=20) were given cell phones and asked to make calls a specific times of the day. To aid them in remembering, participants were sent text messages. Results indicate that the texting a reminder to participants resulted in significantly more calls (p<0.001) being made then when they were not sent a message.

Van den Broek et al. (2000) evaluated the effectiveness of the compensatory external aid, the Voice Organizer for five individuals following brain injury. All five participants benefited from the use of the Voice Organizer as measured by the Message-Passing Test. For four of five patients, there was no significant improvement or deterioration in positive or negative affect during the course of the study.

In a case series conducted by Manasse et al. (2005), subjects were exposed to 2 treatment measures to aid them in memory recall. The traditional treatment was designed to assist subjects with memory recall, by pairing pictures of staff with an imagery statement, while the real-world treatment consisted of name restating, phonemic cueing and visual imagery to assist subjects in remembering names. Results from the traditional treatment indicated that 2 of the 5 subjects mastered 6 names during treatment, 1 of the 5 mastered 3 names and 4 of the 5 mastered one of the names. During the cueing condition of the real world treatment sessions only 2 names were consistently used by each subject. The visual memory program was the only program where subjects consistently used both target names. When questioned directly 4 of the 5 subjects could consistently identify one or both of the target names. Because subjects did not use the names was not indicative of whether or not they knew them.

Cicerone et al. (2000) recommended that the use of memory notebooks or other external aids “may be considered for persons with moderate to severe memory impairments after TBI [and] should directly apply to functional activities, rather than as an attempt to improve memory function per se.”

Conclusions

There is Level 2 evidence supporting the use of external aids as a compensatory strategy for memory impairments.

External memory aids have been shown to be an effective compensatory strategy for memory impairments.

6.2.2 Computer-assisted training

A specific intervention for improving general cognitive functioning is computer- assisted training. The use of computer-assisted cognitive retraining has multiple potential benefits within the rehabilitation setting following brain injury. Computer retraining allows for flexibility in retraining procedures, increased individuality of therapy programs and also decreases the amount of direct time a therapist is with the patient. It also has the potential of continuing cognitive retraining within the community setting. Furthermore, as presented at the NIH Consensus Development Panel (1999) computer-assisted strategies are used to improve neuropsychological processes, including attention, memory and executive skills.

In recent years, clinicians have recommended the use of computers as an efficacious tool in cognitive rehabilitation. One study investigated the efficacy of computer-assisted rehabilitation in comparison to non-computerized methods (Tam & Man, 2004). Eight studies were identified that used computer-assisted measures for cognitive rehabilitation following brain injury.

Individual Studies

Table 6.8 The USe of Computer Assisted Training to Enhance Executive Function

Author/ Year/ Country/ Study design/ PEDro and D&B Score	Methods	Outcome
Dou et al., (2006) Hong Kong, (China) RCT PEDro = 5 D&B=18	N=37 Participants were randomized to 2 memory training programs:the computer assisted memory training group (CAMG) and the therapist administered memory training group (TAMG). Each group received 1 month memory training programs that were similar in content but delivered differently. The control group received no training. Those in the treatment groups received 20 training sessions. Sessions ran for 6 days each week and last approx 45 mins. Post treatment follow up last for one month. Sessions consisted of training a basic component memory skills, in the management of typical daily tasks utilizing/integrating the component memory skills, in customized programs and skill consolidation as well as in the generalization of those skills in practice.	Scores from the NCSE indicate that was a significant increase in the TAMG (p<0.015) and the CAMG (p<0.02) on the memory sub-test of each scale compared to the control group. When looking at the results of the scores on the RBMT test, there was only a significant difference between the CAMG and the control group (p=0.0001).
Ruff et al., (1994) USA RCT D&B = 16 PEDro = 3	N=15severe head injured subjects between 16 and 50 with GOAT entry score > 70, 6 months post-injury, and a DRS score > 100 were divided into 2 attention and memory training groups – the first (A) received attention followed by memory training, the second (B) vise versa through prototypical exercise modules with variable difficulty levels developed from the THINK-able computer program.	Analysis performed on entire sample due to group size. Attention: Computer based attention training results in significant improvement (p=0.003) Memory: Significant improvement in Memory-II (p=0.021). Gains were significant for Rey Verbal (p=0.004) and Corsi Block Learning (p=0.03) total correct; Patient and observer memory ratings (p=0.04, p<0.001). WMS-part III (p=0.004), and part IV (p=0.013). Psychometric: significant improvements in digital symbol scores (p<0.001).
Tam and Man (2004) China Non-RCT D&B = 15	N=34A study of adults with post-head injury amnesia due to closed-head injury was conducted to assess the effectiveness of computer-assisted memory retraining programmes. Participants were randomly assigned to one of four treatment groups (matched diagnostically and demographically): (1) self-paced group; (2) feedback group; (3) personalized group; and (4) the visual presentation group. Each group went through one of the four computer-assisted memory re-training strategies. Each participant was involved in 10 sessions, approximately 20-30 minutes in length. The Rivermead Behavioural Memory Test (RBMT) was used to evaluate self-efficacy.	After intervention, in any one of the four computer-assisted memory programmes, patients performed significantly better in memorizing and remembering ‘drilled content’ (p< 0.05). All four memory-training conditions showed a positive trend in the treatment group as compared to the control group although there were no statistical differences between measures.
Bergquist et al., (2009) USA Non-RCT D&B =12	N=14 Participants were placed in one of two intervention groups: an active calendar acquisition intervention group or the control diary intervention group. Throughout each intervention participants had 30 sessions with a therapist and sessions were completed via the internet using instant messaging. Participants were placed in one of the 2 groups and at the end of the 30 sessions they began “other” condition. During the calendar condition, participants were encouraged to use the on-line calendar to plan events and to remind them of these events. During the diary condition, participants were asked to use their diary to keep track of their day to day events and occurrences. The IM sessions were used to review what (work, appointments) was completed during both types of sessions.	There were no significant difference between the two sessions on memory functioning as noted on the neurobehavioral functioning inventory (NFI) (p>0.05). From time 1 to time 2, improvement was found on the compensation techniques questionnaire (CTQ): specifically the notes on calendar (p<0.02) and the use of cue cards (p<0.01). Family members also noted improvement in levels of depression (p<0.02) from time 1 to time 2. Family also felt the patient’s memories had improved.
Chen et al., (1997) USA Case-Control D&B = 15	N=40 Closed-head TBI subjects matched for diagnosis, age >= 18 years, education ≥9 years, chronicity, severity and time between testing were divided retrospectively into computer-assisted rehabilitation (CACR) and tradition therapy groups. Pre and post-treatment scores of neuropsychological tests; attention, visual-spatial ability, memory and problem solving ability measured by the WAIS-R, and WMS.	Experimental group showed significant improvement (all values p<0.004 with Bonferioni Connection): category test – trails A & B, WCST, logical memory delayed, visual reproduction immediate, VIQ, PIQ, FSIQ, information, digit span, vocabulary, PC, OA, DSYM. Comparison group made significant gains in trails B, PIQ, FSIQ, picture arrangement, block design, OA and DSYM.
Gentry et al., (2008) Canada Pre-Post D&B = 18	N=23 individuals at least one year post injury participated in the following study. Participants were each given a PDA and trained in how to use by an occupational therapist (OT).	Pre and post test assessments indicate significant improvements in satisfaction with performing everyday tasks following PDA training. Improvements were noted when looking at post training performance and post training satisfaction (p<0.001). Scores on the CHART-R self-assessment rating scale showed improvement as well. Significant improvement was seen on the scores of the cognitive independence, mobility, and occupation subsections of the test (p<0.001).
Middleton et al., (1991) USA Pre-Post D&B = 12	N=36TBI subjects, mean age 27 years, mean chronicity 3 years spent 8 weeks in a rehabilitation program that included 32 hours of computer-assisted training. Cohort divided into two groups to compare attention and memory vs reasoning and logical thinking training. Standard pre/post treatment neuro-psychological assessment.	Gains made by both groups similar through all measures. No differential effects associated with treatment group in attention and memory tests (p=0.83: WAIS-R digit span, Wechsler paired associates, Knox's Cube) or reasoning tests (p=0.79: concept formation subtest of Woodcock battery, Abstraction subtest of Shipley Scale, and block counting) .
Middleton et al., (1991) USA Pre-Post D&B = 12	N=8 A pilot study of subjects with acquired cognitive-linguistic impairments receiving electronic mail intervention. An analysis for errors and subject preference was assessed.	Types of errors observed in composing emails that were not related to the mechanics of the email or word-processing was variable across all participants in all conditions. There was considerable variation in patient preference.
Kim et al., (2000) USA Case Series D&B = 12	N=12Subjects (11 TBI and one CVA) were introduced to a supervised usage trial of a palmtop computer that included scheduling software capable of generating audible reminder cues.	Nine subjects (75%) reported that the palmtop computer had been a useful tool. Seven of these 9 patients expressed that they continued to use the computer following the completion of the study. All patients recommended that the computer continue to be used in outpatient brain injury rehabilitation.

PEDro = Physiotherapy Evidence Database rating scale score (Moseley et al., 2002).
D&B = Downs and Black (1998) quality assessment scale score.

Discussion

In a current RCT conducted by Dou et al. (2006), participants were randomized to one of two groups: the computer assisted memory training group (CAMG-treatment - group 1) or the therapist administered memory training group (TAMG-treatment - group 2) with each receiving one month memory training. Memory training was similar between the groups but they were delivered differently. The treatment groups received 20 training sessions with each running for 6 days per week and lasting approximately 45 minutes. The control group received no training. Sessions consisted of: training basic component memory skills in (1) the management of typical daily tasks utilizing/integrating the component memory skills, (2) customized programs and (3) skill consolidation as well as in the generalization of those skills in practice. Scores on the neurobehavioural cognitive status examination (NCSE) showed significant improvement in the TAMG and CAMG groups (p<0.015, p<0.02 respectively) compared to the control group. Results from the Rivermead Behavioural Memory Test (Cantonese version) showed the CAMG improved significantly compared to the control group (p<0.0001).Those in the TAMG showed no significant improvement.

Ruff et al. (1994) evaluated the effect of computer assisted rehabilitation using the THINKable computer program which is a multi-media system that focuses on memory and attention retraining. Although this study was designed as a randomized controlled cross over design, due to the small number recruited (15), the groups were analyzed together in a pre-post intervention fashion. Psychometric testing revealed modest but significant gains made for some memory and attention measures in each of the groups.

Self practice, presentation of attractive stimuli, multi-sensory feedbacks and personalized training contents were the four different forms of computer-assisted cognitive re-training programmes that Tam and Man (2004) used to evaluate people with post-head injury amnesia. Participants were randomly assigned to one of four treatment groups (matched diagnostically and demographically): (1) self-paced group, which allowed individuals to move at their own pace in a non-threatening environment; (2) feedback group, which involved immediate provision of feedback in a non-judgmental fashion; (3) personalized group, whereby the computer presented training contents showing the participant’s actual living environment and routines; and (4) the visual presentation group, which was a provision of attractive and bright presentation designed to help individuals engage in the activity. Each group went through one of the four computer-assisted memory re-training strategies. Results revealed that the patients in the experimental group showed positive improvements on all of the four memory training methods as compared to the control group. However, there were no statistically significant differences among the four training methods. Nonetheless, this study showed that computer-assisted memory retraining yield positive results for patients with memory post-head injury amnesia. Similarly, in a non-controlled study by Kim et al. (2000), all 12 patients that took part in a trial investigating the efficacy of a palmtop computer for use in daily activities, recommended that this treatment continue to be used in outpatient brain injury rehabilitation.

Middleton et al. (1991) also examined computer assisted cognitive rehabilitation by comparing two forms of retraining. Patients were assigned to either a group targeting reasoning and logical thinking or a group targeting attention and memory. Gains were made by both groups using within-group comparisons. No differences were noted in outcomes based on treatment group.

Chen et al. (1997) studied the effect of computer assisted cognitive rehabilitation versus traditional therapy methods. Within-group comparisons of pre- and post-intervention measures demonstrated significant gains on multiple psychometric tests taking into account multiple statistical comparisons. However, multivariate analysis comparing the experimental and control groups across the domains of attention, visual-spatial, memory and problem solving did not demonstrate significant differences between the groups.

Gray et al. (1992) investigated the effects of attentional retraining using a microcomputer-based intervention. Patients were stratified into closed-head-injury (CHI) or other diagnosis (17 patients diagnosed as CHI) and mild/moderate or severe injury (15 diagnosed as severe) and randomly assigned to receive either attentional retraining or recreational computing (control). Time since injury varied widely from 7 weeks to 10 years. Immediately following training, the treatment group showed marked improvement on two measures of attention in comparison to the control group, however once premorbid intelligence score and time since injury were included as covariates, this treatment effect was no longer significant. The experimental group showed continued improvement at 6-month follow-up on tests involving working memory.

In a recent study conducted by Bergquist et al. (2009), individuals were asked to participate in either an active calendar acquisition intervention or a control diary intervention program. Participants were assigned to one of the two interventions and once completed they began the second intervention. Sessions were completed on line using an instant messaging system. Improvement was noted in calendar use and using a cue card (p=0.02, p=0.01 respectively). Family members noted an improvement in mood and memory problems post intervention.

Gentry et al. (2008)conducted pre and post test assessment on a group of 23 individuals with a TBI living in the community. Due to problems with memory, all participants were found to have difficulties with every day tasks. To assist them in improving their memory a PDA was given to each individual and training was provided by an occupational therapist. Following training, participants reported improved in satisfaction with performing everyday tasks. Improvements were noted when looking at post training performance and post training satisfaction (p<0.001) and on the scores on the CHART-R self-assessment rating scale. Overall significant improvement was seen on the scores of the occupation, cognitive independence, and mobility subsections of the test (p<0.001).

Electronic mail (email) may prove useful for reducing the experience of social isolation for patients sustaining acquired cognitive-linguistic impairments (Sohlberg et al., 2003). The authors were interested in the usability and patient preference of a simplified email interface on eight brain injured patients. Patients were asked to read and reply to four prompt conditions: no prompt, idea prompt, fill-in-the-blank prompt and multiple-choice prompt. Difficulties encountered included computer usability and message composition. Results identified three categories of usability problems: lack of knowledge concerning functionality of keys for word-processing operations, poor conceptual understanding for the mouse operation and poor use of interface prompts. Results also found that there was considerable variation among patient preferences and the types of errors observed in composing emails, and that all patients legitimized the use of email interfaces as a means of reducing social isolation.

Conclusions

There is conflicting evidence supporting the use of computer assisted cognitive retraining as an adjunct to the rehabilitation program, especially regarding attentional retraining following brain injury. Although some improvement in memory was found in a few of the studies it was not found in all. General cognitive functioning did appear to benefit from computer assisted cognitive retraining; however, further study confirming these findings need to be conducted.

Computer-assisted training has been shown to have a positive effect on general cognitive functioning, but has not yet been shown to be an effective treatment for the remediation of memory and attentional deficits.

6.2.3 Virtual Reality and Cognitive Functioning

One study was identified that used an innovative approach to improving cognitive function following brain injury, using a non-immersive, virtual reality component to promote exercise and cognitive functioning.

Individual Studies

Table 6.9 Virtual Reality (VR) Exercises and Their Impact on Cognitive Functioning

Author/Year/ Country/Study design/ D&B Score

Methods

Outcome

Grealy et al., (1999)

Scotland

Non-RCT

D&B = 15

N=13 Ambulatory TBI subjects with no perceptual disabilities participated in a random allocation crossover study that used non-immersive virtual reality exercises to test attention, information processing, learning, memory, reaction and movement times. Information for 320 patients was collected and acted as the control for this study.

Intervention group (n=13) performed significantly better than control group (n=320) on digit symbol (p<0.01), verbal (p>0.01) and visual (p<0.05) learning tasks. Reaction (p<0.01) and movement (p<0.05) times improved significantly after a single VR session.

Zhang et al., (2001)

USA

Case Control

D&B = 13

N=60 VR kitchen was designed to test the skills of those who had sustained a TBI. Participants are outfitted with a VR head set, personal computer platform with a sound card, head mounted 3-dimensional glasses. To assist in completing the task the software allowed for cues and prompts in response to the user’s sequence of actions or lack of. Participants are given a task to complete. All participants performed the task 2 in 10 days.

Assessment of participants revealed the non-TBI participants performed better then those with a TBI during both test phases. Those with a TBI had difficulty processing the information presented to them, completing the assessment and working through the task in a logical way. Speed at which the task was completed from time 1 to time 2 did not significantly improve for the TBI participants, it did improve for the non-TBI participant

D&B = Downs and Black (1998) quality assessment scale score.

Discussion

Grealy et al. (1999) addressed the effects of exercise and virtual reality post brain injury. This study evaluated the impact of an exercise program, which used a stationary bicycle in conjunction with non-immersive virtual reality administered over a minimum of 4 weeks. The results demonstrated significant benefits in the experimental group pre and post intervention for learning and memory tasks. Similarly, when compared to historical controls, the experimental group fared significantly better on digit symbol as well as visual and verbal learning tasks.

In a study by Zhang et al. (2001) 60 individuals (30 of them had suffered a TBI) participated in a study which tested their skills in a virtual reality kitchen. Participants were given a task to complete (twice in ten days) and were given cues to assist in completing the task. Individuals who had sustained a TBI did not perform as well as those without a TBI. Individuals with a TBI were slower, experienced difficulty in processing information presented to them and were unable to work through the task in a logical way.

Conclusions

There is Level 2 evidence of a positive impact on visual and verbal learning post exercise intervention for brain injury survivors.

There is Level 3 evidence from one study indicating that VR programs do not enhance cognitive functioning post TBI in individuals who have sustained a TBI.

Virtual reality programs may enhance the recovery of visual and verbal learning following brain injury; however more study needs to be completed as currently there is limited evidence supporting the use of VR programs.

6.2.4 Internal Aids

The following studies examined how internal aids could be used to enhance memory following an ABI.

Individual Studies

Table 6.10 The Use of Internal Aids to Enhance Memory Post ABI

Author/ Year/ Country/ Study design/ PEDro and D&B Score	Methods	Outcome
Twum and Parente (1994) USA RCT D&B = 15 PEDro = 3	N=60 Consecutively referred TBI subjects from Maryland State Dept. of Vocational Rehabilitation (mean age: 21 years) were randomized into four groups: no imagery / verbal labeling; imagery / no verbal labeling; imagery / verbal labeling and a no imagery / no verbal labeling (control). Delayed recall and trials to criterion were measured on the VerPA and VisPA tasks.	MANOVA analysis revealed an overall significant main effect of mental imagery instructions (p < 0.0001) and a main effect of verbal labeling instructions on the VisPA (p < 0.0001).
Berg et al., (1991) Netherlands RCT PEDro = 4 D&B = 13	N=39 Subjects with PTA indicative of very severe brain injury with subjective memory complaints in everyday life (no etiology or demographic data provided) & 9 months post-injury were randomly divided between a strategy, drill and practice and a re-test control group.	Both training approaches had no effect on reaction time. Patients from the strategy rehabilitation group performed significantly better at follow-up than the other groups (no p value provided).
Milders et al., (1995) Netherlands Follow-up to Berg et al. (1991)	31 of 39 subjects participated in a four year follow up of the Berg et al. (1991) RCT that compared Memory Strategy training vs. Drill and Practice vs. no treatment. Follow-up consisted of control tasks, and subjective reports.	Standardized memory sum scores at long-term are significantly lower in the three patient groups than in the normal control group (p<0.05). Drop out effect on follow-up results was significant (p<0.05). The strategy groups 1995 results were significantly lower than in 1991 (p<0.05). Drill & Practice improved significantly (p<0.05), and no training improved but not significantly. The difference between groups at the 4 yr follow-up is no longer significant (p> 0.1).
Ryan & Ruff (1988) USA RCT PEDro = 3 D&B = 18	N=20 TBI patients who had received a traditional intervention (neuropsychology-free) were divided into treatment (age: 22-60, education: 12-18 yrs, LOC: 1-42 days) and control (age 19-45; education:12-18yrs, LOC: 21-122 days) groups based on DRS score of mild (>134/144) or moderate (<= 133/144). Placebo (psychosocial issues – no structured feedback) and cognitive (attention and spatial integration exercises focused on memory retention) treatments were undertaken for 6 weeks (4 days/week, 5/5 hours/day).BVRT, WMS, CFT, TLT, SRT used to measure outcome.	MANOVA analysis of overall effect indicated both groups improved significantly over time, but not compared to each other (p<0.05). ANOVA showed no significant differences between groups on any of the outcome measures. MANOVA (2 groups x 2 severity ratings x 3 assessments) showed a significant interaction between treatment group and the level of severity over the 3 testing conditions (p < 0.001) – with mildly impaired subjects showing greater improvement over severely impaired subjects.
Tailby & Haslam (2003) Australia Non-RCT D&B = 10	N=24 TBI subjects with acquired deficits in explicit memory were divided into groups of 8 based on Verbal Memory Index (VMI) score, and matched across groups in terms of age, gender, premorbid and current intellectual functioning. Ninety-six 5-6 letter concrete nouns were used over two sessions to practice 3 learning conditions: errorful, errorless (examiner generated), and errorless (self-generated). Following the learning tasks, memory was tested explicitly and implicitly 5 and 30 minutes after study phase generating 6 scores for each learning condition at both testing times.	Cued recall performance following self-generated errorless learning was significantly better than standard errorless learning conditions (p<0.0001). Level of priming did not differ significantly between groups (p>0.05). Memory performance was significantly better following errorless learning (examiner generated) activity (p<0.0001). Mild and moderate groups performed significantly better than severe group (defined by VMI – p<0.0001).
Evans et al., (2000) Non-RCT D&B = 16	A three-phase consisting of 9 experiments was conducted to compare the effects of two internal, memory techniques: errorless learning and trial-and-error learning in both short and long delay recall conditions. Brain-injured patients were trained to use these techniques and comparisons were made (phase 1 n=18; phase 2 n=16; phase 3 n=34).	It was demonstrated that the more severely memory-impaired patients benefited to a greater extent from errorless learning than those with less severe conditions. It should be noted that this benefit may not apply when the interval between learning and recall is relatively short.
Goldstein et al., (1996) USA Non-RCT D&B = 13	N=30 Subjects with ABI who had sustained a serious closed head injury within 1 year of assessment and suffered a significant impairment of memory but with an absence of generalized dementia received computer training programs with (self-directed help software) and without (human trainer) assistance. Tasks focused on word lists (15 sessions, 2-3 times per week) and face association (10 sessions). The data for the “without” group derived from a 1988 study by same author.	Both original (p< 0.01) and computer- assisted (p< 0.001) methods were significant in word list tasks. Delayed recall of face/name tasks was found to be significant in computer assisted trials (p<0.01). The number of trials to learn lists was significant in original (p<0.01) and computer assisted (p<0.05).
Glisky & Delaney (1996) USA Case-Control D&B = 12	N=16 TBI patients (mean LOC 10 days) who experienced PTA (mean of 53 days) participated in 3 separate sessions practicing stem completion of 4-7 letter words using cued recall, free recall and recognition.	Priming effect in PTA patients was not significant from the controls (p>0.05), but was significant within the PTA group (p<0.05) – compared to those without prior exposure to word lists). Controls substantially improved their results when given explicit instructions while PTA patients performed equivalently. Control group recalled significantly more words than the PTA group (p<0.01). None of the PTA patients were able to recall any of the list items, made significantly more false alarms (p<0.01).
Milders et al., (1998) Netherlands Case-Control D&B = 17	N=26 Thirteen closed-head injury subjects (mean PTA 36 days) and 13 healthy controls matched on age and level of education participated in 8 individual 60-90 minute sessions over four months using exercises with standardized instructions that help make the new name more significant to the learner.	ANOVA (cases vs controls, baseline vs post-training were significant for group (p<0.01), evaluation moment (p<0.001), and interaction (p<0.001). At follow up, only verbal learning scores reached significance (p<0.01).
Goldstein et al., (1990) USA Case-Control D&B = 9	N=30 Sixteen subjects with closed head injuries free of aphasic disturbance demographically matched with 14 normal controls were presented with 60 target words and tested for recognition memory of words from the list using a levels of processing paradigm involving categorical, physical or acoustic features.	Recognition memory of patient group was higher for semantic processing as compared with physical and acoustic (p<0.01). Patients and controls both benefited from semantic relative to acoustic cues (p<0.05). The effect of type of response did not significantly interact with type of processing (p>0.05).
Ewert et al., (1989) USA Case-Control D&B = 9	N=32 A series of memory tests (procedural and declarative) were administered to 16 subjects with severe closed head injuries (GCS <= 8) and 16 neurologically intact control subjects. Results were compared between groups.	Mirror Reading (p<0.001), Porteus Maze (no values provided), Pursuit Rotor (both tumble speeds - p<0.001), and Declarative Memory (p<0.001) tests significantly improved once PTA phase had resolved.
Thoene and Glisky (1995) USAand Germany Pre-Post D&B = 14	N=12 TBI Subjects in a comparative, multiple intervention study in the USA and Germany. Interventions focused on learning name – face associations using a mnemonic training technique combining verbal elaboration and visual imagery, a vanishing cues method, and a video presentation. Success was measured by the number of correct name-face associations and trials necessary to achieve criterion.	The number of correct name/face associations required to achieve criterion decreased significantly (p = 0.001). Patients needed significantly fewer trials to reach criterion in the mnemonic condition than the other conditions. The number of cues needed to produce the names during training decreased rapidly across the first few sessions, then tended to asymptote at approximately one cue per name.
Malec et al., (1991) USA Pre-Post D&B = 13	N=18 Subjects with a history of closed head injuries (10 from Goldstein 1988 study) with clinical or psychometric evidence of persistent memory impairment lasting beyond PTA participated in a memory retraining intervention based on the Ridiculous Imaged Story technique using computer controlled cueing to recall forgotten words. Subjects trained over 15 sessions.	Pretraining performance on selective-reminding (p<0.001), free-recall memory tasks (p<0.001) and chronicity (p<0.05) were significant.
Zencius et al., (1990) USA Case Series D&B = 4	N=6 TBI subjects were required to extract and recall 6 pieces of job related information from the newspaper want-ads using four different memory therapies (verbal & written rehearsal, acronym formation and memory notebook training).	Baseline number of correct recalls 2.2 (mean); rehearsal – verbal: 3.0; written: 2.2; acronym formation: 3.3; memory notebook logging: 5.9 – best among the four memory therapies.

PEDro = Physiotherapy Evidence Database rating scale score (Moseley et al., 2002).
D&B = Downs and Black (1998) quality assessment scale score.

Discussion

Twum and Parente (1994) randomly assigned 60 TBI patients into one of 4 groups (one control and three mnemonic strategy groups) counterbalanced. The researches demonstrated improved performance for subjects who were taught a strategy (either verbal labeling or visual imagery) while learning paired-associations. Treatment groups showed greater efficiency in learning and greater delayed recall information.

Ryan and Ruff (1988) used mnemonic strategies, including visual imagery in a memory group and found that these strategies enhanced performance for mildly impaired subjects only (severely impaired group showed non-significant findings between control and treatment groups). Thoene and Glisky (1995) using a case series design also showed enhanced performance following the use of a mnemonic strategy (verbal elaboration and visual imagery) compared to vanishing cues and/or video presentation during paired associations.

Goldstein et al. (1996) and Malec et al. (1991)evaluated a visual-imagery technique (“Ridicuously Imaged Story” technique (RIS)) in training severely brain injured individuals to learn and recall lengthy word lists. Participants were asked to read a story where 20 words are presented in bold-face and subjects were instructed to remember the bold-face words for later recall. If subjects could not recall all the words they were provided with (1) the part of the story in which the word appeared and if that didn’t aid recall, they were then provided with (2) a category cue for the word. It should be noted that in both studies reviewed, a number of their subject pool (N=10) came from a previous study (Goldstein et al., 1988). Goldstein et al. (1996) evaluated whether there were differences between a computerized and non-computerized version of RIS and another visual imagery technique (Pictorial Imagery). Results indicated that although the computerized versions resulted in a slightly better performance on learning trials, the difference was non-significant. Malec et al. (1991) used the RIS technique to examine the predictors of memory training success and found that the “better subjects did at tasks similar to those which they were trained, the better their learning and capacity to generalize.”

By using the various visual imagery techniques to aid learning and recall, researchers have demonstrated that increasing the saliency of features encoded, results in an increase in the amount recalled. Milders et al. (1998) examined performance on a name learning task by increasing the meaningfulness of people’s names with various strategies (e.g. when learning a new name-face association try to think of an occupation or object with the same name or a famous person with a similar name etc). When subjects (13 severely TBI vs. 13 matched controls) were tested on 3 different memory tasks, results indicated a significant difference following training, more so for the control group than the TBI group. Also, learning procedures were more effective on one task (where subjects were required to learn the name-occupation-and town) compared to the other two tasks (famous-faces or name learning), which supports Malec et al. (1991) findings of generalization when tasks are similar. Goldstein et al. (1990) found that semantic processing aids recognition of to-be-recalled words compared to processing words at a more perceptual level in both closed head injury patients and control subjects (of course the degree of facilitation is reduced in the TBI group compared to controls).

Zencius et al. (1990a) examined the differential effects of various strategies on recall of information. Six TBI patients were asked to find two jobs from the help wanted column of a newspaper extracting 3 pieces of information for each job. They were asked either to learn the information for later recall using one of the following strategies: verbal rehearsal, written rehearsal, acronym formation or notebook logging. All strategies resulted in improved performance (number of information correctly recalled) with the exception of written rehearsal (performance similar to baseline). Notebook logging resulted in the best performance.

Berg et al. (1991) demonstrated that severely brain injured patients demonstrated improved effects on objective measures of memory at 4 months following training in a strategy-use group compared to a pseudo-treatment and a no treatment control group. In the strategy group, individuals were taught general cognitive principles of memory functioning and aids (i.e., internal and external strategies were taught and practiced). In contrast, the pseudo-treatment group practiced memory games and tasks with no explanation. In a 4 year follow up study Milder et al. (1995) results demonstrated that the effects at 4 months were no longer evident at 4 years (all groups were equivalent).

How individuals learn (i.e., encode) information will determine to a large extent what is later recalled. Twum and Parente (1994) demonstrated that if an active strategy (either verbal labeling for visual information or visual imagery for verbal information) is taught to individuals while learning the paired associations, learning and recall is enhanced (i.e., fewer trials needed to reach criterion during learning and improved recall following a delay).Tailby and Haslam (2003)also examined how learning can improve or limit later recall of information. They had 24 ABI subjects matched on basis of age, gender, premorbid and current intellectual status divided into 3 groups based on performance of verbal memory (mild, moderate & severe). Each group (n=8) was randomly assigned to one of 3 learning conditions: errorless learning, self-generated; errorless learning, experimenter generated; and errorful learning. Results showed that regardless of severity level, subject recalled more information in the errorless learning conditions (with self-generated superior to experimenter generated) than in the errorful learning condition.

Constantinidou and Neils (1995) examined the effects of stimulus modality on verbal learning of patients with moderate-to-severe closed head injury and a matched control group. Results indicated that when information is presented visually (with and/or without auditory presentation of names) more information is learned than when information is presented within the auditory modality alone. As expected, patients learn new information at a significantly slower rate compared to controls.

It is generally thought that while patients are experiencing post-traumatic amnesia (PTA), they are not able to learn and retain new information, and as a result, cognitive rehabilitation is usually postponed until PTA has resolved. This tends to be true if using tasks of explicit or declarative learning and recall. Two studies were reviewed that reported that PTA patients were capable of learning and retaining new information when task demands were dependent on implicit/procedural learning. Glisky and Delaney (1996) evaluated implicit memory (priming using a stem completion task) and the use of vanishing cues when learning semantic information in a small number of TBI patients (n=8 & 4) who were still experiencing PTA and a matched control group. Findings revealed that learning and recall of information (once PTA has resolved) had occurred, albeit at reduced levels compared to controls. Ewert et al. (1989)also demonstrated procedural learning and retention in a group of 16 severely closed head injured participants and matched controls.

Conclusions

There is Level 2 evidence (from several studies) that internal strategies appear to be an effective aid in improving recall performance.

There is Level 3 evidence from several case-control studies that internal strategies appear to assist in improving recall performance.

Internal strategies appear to be an effective aid in improving recall performance.

6.2.5 Memory Programs

Following an ABI or TBI one of the most persistent problems are memory deficits. Although the literature examining the efficacy of memory programs is limited, there is some support for training that stresses external memory strategies. Again the support for these programs is limited as many individuals post injury neglect their devices or simply stop using them (O'Neil-Pirozzi et al., 2010). Internal memory strategies have also met with limited success.

Individual Studies

Table 6.13 The Effect of Amantadine on Executive Functioning Following Brain Injury

Author/ Year/ Country/ Study design/ D&B Score	Methods	Outcome
Thickpenny-Davis & Barker-Collo 2007 RCT New Zealand PEDro = 5 D&B = 15	N=14 Individuals were randomly assigned to either the treatment group (memory rehab group) or the waitlist control group. Those assigned to the treatment group participated in a memory rehabilitation program. The memory group consisted of 8 learning modules, each 1 hr in length and held 2x a week for 4 weeks. Didactic teaching about memory and memory strategies, small group activities, discussions, problem solving, practice implementing memory strategies was used. Errorless learning was also used when reviewing materials.	Overall improvement was seen for the treatment group across the various time periods. When comparing pre-group results on the various memory scales, improvement was seen at time of post group testing and again at follow-up.
Ryan & Ruff (1988) USA RCT PEDro=3 D&B = 18	N=20 TBI subjects divided into treatment and control groups according to score on Dementia Rating Scale (>133 mild, <134 moderate) received either attention and spatial integration exercise (experimental) or psychosocial treatment (control) over a 6 week treatment period (4 days/week, 5/5 hours / day).	Both groups improved significantly over time (p<0.05). The experimental group did not show significantly greater improvement when compared to control group (no p value reported). MANOVA indicated that subjects with mild neuropsychological impairments benefit more from memory remediation when compared to more severely impaired patients (p<0.001).
O’Neil-Pirozzi et al., (2010) USA Non-RCT D&B = 21	N=98 Individuals were assigned to either the experimental group (n=57) or the control (wait-list group n=41).12-90 minute sessions, held 2 x weekly for 6 weeks intervention sessions were held. The intervention included memory education and emphasized internal strategy acquisition to improve memory function from encoding, storage and retrieval perspectives. Primary emphasis was placed on semantic association (categorization and clustering), followed by semantic elaboration/chaining and imagery.	Pretesting revealed a significant difference between both groups on the Hopkins verbal learning test-revised (HVLT-R) only. Individuals who had had a severe TBI performed more poorly on the HVLT-R than those with moderate injuries. Although those with a severe injury did not improve as much as those with a mild or moderate injury, they did improve more than those in the control group from week 1 to week 7. Results of the Rivermead Behavioural Memory test II revealed similar results. Overall memory performance was improved for all those in the experimental group compared to the control group.
Schefft et al., (2008) USA Non-RCT D&B=12	N=20 The authors report on 2 studies they conducted with individuals who had sustained a mild, moderate or severe BI. Study 1: Read condition: words were presented in pairs-1 pair per card, which participants were asked to read aloud. Generate condition: participants were shown one word on the card with the first letter of second word, and asked to read aloud the words as soon as they knew the second word. The first recall test was given immediately after the presentation of the 50 word pairs, followed by the recognition memory test. Free recall test had patients write down as many of the second words from each pair that could be remembered. Recognition Test: 50 items corresponding to the appropriate input list and each item was composed of 2 previously unseen distractor words and 1 target word from the learning task. Word pairs were presented in the same order at testing as they had been presented during the learning trials. Study 2: Both the read and generate conditions were identical to study 1; however, here there was no recognition test. Patients were given a cued recall trail, where each word pair association rule was provided as a cue for memory and a cued recall trail where the first word in the pair was presented. Free recall test had participants write down as many of the second words from the pair they could remember. For the cued recall with rules test they were given a sheet of paper with the title on it and one example of each rule. They were then asked to write down as many of the second words they could remember.	Study 1: self-generation encoding procedures improved recognition memory test performance, but not free recall, compared with the didactic presentation. Study 2: self generation strategy improved cued recall but not free recall compared with the didactic condition. Study results also indicated that cued recall was also important as it was found to be effective when presented with the first word of the word pair.
Sumowski et al., (2010) USA Case-Control D&B=13	N=28 Both individuals who had sustained a TBI and those who had not were enrolled in this study.Each group was presented with 48 verbal paired associated. These were divided across 3 learning conditions (massed restudy, spaced restudy and retrieval practice). During the massed restudy, paired words were presented for 6 s followed by 2 6s restudy trails. During spaced restudy, participants were shown paired words for 6 s. followed by 3 filler trails each 6 s and a 6 s restudy trails, six filler trails (6s) and another 6s restudy trail. During the retrieval practice, paired associates were presented for 6s followed 3 filler trials and a re-exposure trailed consisting of 5 s cued recall test and a 1 s feedback screen.	After a two and a half week period, results demonstrated significance between the treatment and the control group’s post-test memory scores (p=0.02) with the treatment group showing enhanced improvement beyond that of the control group.
Hillary et al., (2003) USA Case Series D&B = 13	N=20 Eighty (80) words were selected, (low-medium frequency wrods-6-11 letters long; printed in upper case on index cards). Once group of words was presented once; another group of words was not presented but appeared on the recognition sheet. There were 4 groups of 20 words, 4 separate words lists (once-presented, massed and spaced). Participants in groups of 5 were randomly assigned to each of the 4 study lists constructed for counter-balancing purposes. They were asked to ready the work and rank it from 1 to 10 on how familiar they were with it. The learning of the word list was assessed by asking patients to recall the list immediately after its presentation and then 30 minutes later with a free recall and recognition test after a 30 min delay.	Spaces words were more likely to be recalled during the immediate recall than massed words (p=.018). On the delayed recall spaced words were more likely to be correctly recalled than massed words or once presented words during delayed recall performance. On the recognition performance test, individuals were able to correctly identify spaced words over massed or once presented words. Over all individuals with a moderate to severe TBI can improve their memory by altering the manner in which learning takes place.
Evans & Wilson (1992) UK Case Series D&B = 10	N=5 Individuals suffering TBI and subsequent impairment of memory function received 2 hr weekly sessions for 11 months consisting of reflections, memory exercises, games, strategy and coping discussions with special emphasis on use of notebooks and diaries. Progress measured by third party questionnaire on use of memory aids/strategies, RBMT, and the HAD prior to start, at 7 months and at end of group intervention.	The overall use of memory aids increased significantly between pre and midpoint intervention (p < 0.05) and pre-intervention and end of study (p < 0.05). RBMT scores did not improve. HAD scores not compared.
Quemada et al., (2003) Spain Pre-Post D&B = 19	N=12 Severe TBI subjects (GCS mean 5.7, PTA > 28 days) with a memory impairment that interfered with autonomy in ADL, and scored below the 10^th percentile on both the CVLT and REY, received individualized treatment using Wilson's Structured Behavioral Memory Program in 50 minute sessions daily for 6 months. REY, CVLT, RBMT, MFE tests were measured at baseline and at the end of program.	All patients achieved meaningful functional gains. Improvements were not found using REY, RBMT or MFE measures. There were modest improvements in some scales of the CVIL.
Fleming et al., (2005) Australia Case Study No Score	N=3 Subjects were introduced to organizational strategies and various environmental modifications to minimize confusion. Each participated in an 8 week prospective memory rehab programme (1 to 2 hours per week), incorporating elements of self-awareness training and compensatory strategy training. Strategies used included post-it notes, labeling shelves, making lists of chores etc.	Following the intervention each subject responded well to the introduction of various strategies (personnel notebooks, diaries and organizers) to assist them in organizing their daily lives. Over time the number of entries into their notebooks did decrease but individuals did choice to keep using them.
Hux et al., (2000) USA Case Study No Score	N=7 Male TBI subjects displaying persistent deficits in encoding and recalling (based on 5 subsets of CAM) were presented visual stimuli (photos of staff members) in individual sessions consisting of a probing and directed training activity (mnemonics & visual imagery) in varying frequencies (5x/day, 1x/day, 2x/week).	Lower training frequencies were more effective than training 5 times per day. The higher frequency resulted in longer encoding phases, and behavioral issues in some patients. Due to individual strengths and weaknesses, there was no discernible pattern between memory deficit profile and face-name association tasks.

PEDro = Physiotherapy Evidence Database rating scale score (Moseley et al. 2002).

D&B = Downs and Black (1998) quality assessment scale score.

Discussion

In a recent study by O’Neil-Pirozzi et al. (2010), individuals with a TBI participated in 12 ninety minute sessions which were held twice a week. The intervention included memory education and to improve memory function the study emphasized internal strategy acquisition. Primary emphasis was placed on semantic association followed by semantic elaboration/chaining and imagery. Results from the Hopkins Verbal Learning test indicated significant differences between the groups and those with a severe TBI performed more poorly than those with a moderate injury. Those with severe TBIs, although they performed more poorly than those with mild or moderate injuries, did perform better than those in the control group who were individuals who had sustained a severe TBI. In all memory performance was seen to improve for all in the intervention group compared to the control group.

Thick-Penny and Barker-Collo (2007) randomly assigned 14 individuals to either the treatment or control groups. Those in the treatment group participated in a memory rehabilitation program. The memory groups consisted of 8 learning modules each 60 minutes long. They ran twice a week for 4 weeks. Memory improvement and difficulties were evaluated. Overall a reduction in memory impairment was noted at the end of the 4 weeks of intervention and again at the one month follow-up time period.

Ryan and Ruff (1988) randomly assigned 20 severely brain injured individuals, matched for age, gender, education, and time since injury, to either a memory retraining group or a psychosocial group (control). Treatment lasted for 6 weeks (4 days per week, 5.5 hours per day for each group. Initially no differences were observed between groups on neuropsychological measures of memory. When groups were subdivided based on neurocognitive severity (mild vs. severe), results indicated that the mildly impaired group benefited more than the severely impaired group from memory retraining.

Sumowski et al. (2010) investigated the effects of retrieval practice (a technique that has been shown to be effective with non-TBI individuals) on those who had sustained a TBI. It has been shown with healthy individuals that retrieval practice allows for the retrieval of information shortly after it has been presented which leads to better delayed recall. Here 14 TBI and non-TBI individuals were presented with a series of paired words and divided across 3 learning conditions: massed restudy, spaced restudy and retrieval practice. Results indicate that retrieval practice was effective in improving memory in persons with a TBI.

Schefft et al. (2008) conducted two studies looking at the effect of a self generation memory encoding strategy on memory. In both studies flash cards were presented to participants with a pair of words on each. In Study 1 subjects were assigned to either the generate condition or the read condition or vise versa. In the read condition cards were presented to the subjects with a pair of words on each card, which they were asked to read aloud. In the generate condition participants were asked to look at the word presented and voice the second word that had been on the card. In Study 2, pairs of words were presented to the participants followed by a cued recall trail or a free recall trial. Results of Study 1 indicate that memory test performance improved as a result of self-generation encoding procedures. Again the results of Study 2 indicated that self generation strategy improved cued recall. It did not however improve free recall.

In a case series conduced by Hillary et al. (2003), 20 individuals with a TBI were presented with a series of words (4 groups of 20 words each). Each group was presented once (single condition), twice (massed condition) or twice with 11 words between each presentation (spaced condition). Spaced presentation led to significantly (p=0.018) greater recall and recognition of words than massed and once presented words. This result was also seen during delayed recall, and delayed recognition.

Freeman et al. (1992) conducted a matched-controlled treatment outcome study to evaluate executive and compensatory memory retraining in traumatic brain injured patients. Twelve patients were included in this study; six who received remediation treatment, which involved repeated presentation of various paragraphs, and six who received no treatment. A significant difference was found between the treatment group and the control group’s post-training measures with the experimental group improving considerably more than the control group. Results suggest that memory remediation is effective for brain-injured patients with memory impairments.

Evans and Wilson (1992) examined the effects of a memory group that met weekly for 11 months (2 hours a week for approximately 48 weeks). Family and individuals reported an increase in using memory aides and strategies at 7 months and at 11 months compared to baseline (no objective measures were given and it is unclear if beneficial). Scores on neuropsychological measures of memory did not change over time. A main drawback of this study is the researchers failure to describe the nature and content of the memory program.

Quemada et al. (2003) examined memory rehabilitation following severe TBI in 12 individuals (no controls). The program ran for 6 months (50 minute sessions 5 days a week for 5 months and then 3 days a week for one month) and followed a specified format utilizing behaviouralcompensation techniques, mnemonic strategies, environmental adaptations, external and internal aides. Results indicated little improvement in standard measures of memory functioning, although patients and family members report meaningful functional gains (self-report and observed behaviour in everyday functioning).

In a case study(n=3) conductedby Fleming et al. (2005)subjects were enrolled in an eight week memory rehabilitation program. Each attended 1 to 2 hours per week. In each session elements of self-awareness and compensatory strategy training (using post-it notes, labeling and making lists) was incorporated. Subject responded well to the introduction of various strategies (personnel notebooks, diaries and organizers) to assist them in organizing activities in their daily lives and over time the total number of entries into their notebooks decreased.

Hux et al. (2000) examined the effect of training frequency on face-name recall. Seven TBI patients with demonstrated memory impairment in a modified multiple-baseline design utilizing 3 training phases (daily sessions, twice a week session and 5 times a day) participated in the study. The phases were counterbalanced, thereby eliminating any order effect. Daily sessions as well as twice a week sessions were found to be more effective than sessions that occurred 5 times a day. Mnemonics and visual imagery strategies were effective for 4 of the 7 participants regardless of frequency of intervention sessions.

Conclusions

There is Level 2 evidence indicating that memory-retraining programs appear effective, particularly for functional recovery although performance on specific tests of memory may or may not change.

There is Level 3 evidence supporting spaced retrieval practice as an effective method of improving memory post ABI.

There is Level 3 evidence suggesting

Memory-retraining programs appear effective, particularly for functional recovery although performance on specific tests of memory may or may not change.

Although several mnemonic strategies have been used to help improve memory post ABI, retrieval practice seems to be the most effective.

Recall and recognition of words can be enhanced by using a spaced learning condition.

6.2.6 Cranial Electrotherapy Stimulation and Memory

Cranial electrotherapy stimulation (CES) is the application of less than 1 mA of electric current to the cranium. This application has been used to treat a variety of disorders, including treatment of withdrawal of patients with substance abuse (Michals et al., 1993). The effect of CES for the improvement of memory following brain injury was investigated.

Individual Studies

Table 6.12 The Effect of Cranial Electrotherapy Simulation on Memory

Author/ Year/ Country/ Study design/ D&B Score

Methods

Outcome

Michals et al., (1993)

USA

RCT

PEDro = 7

D&B = 22

A double blind, sham controlled trial was performed on 24 brain-injured patients to evaluate the effectiveness of cranial electrotherapy stimulation (CES) on post-traumatic memory impairment. After a four-week study period, memory performance was measured using subtests from the Wechsler Memory Scale-Revised, California Verbal Learning Test, and Recurring Figures Test.

Results revealed that CES stimulation in brain-injured patients did not improve memory or immediate and delayed recall compared with controls.

Repeated trial effects showed no significant differences between groups.

PEDro = Physiotherapy Evidence Database rating scale score (Moseley et al., 2002).

D&B = Downs and Black (1998) quality assessment scale score.

Discussion

Michals et al. (1993) studied cranial electrotherapy stimulation and its effect on post-traumatic memory impairment in clinical care patients with closed head injury. Patients received CES or sham CES treatments for 40 minutes daily over a period of four weeks. The group receiving CES treatment did not improve in their memory performance, nor did their immediate or delayed recall improve. Further, with retesting, both the CES and the sham CES group showed a similarly significant trend with no group performing any better than the other. These results suggest that CES stimulation in brain-injured patients does not improve memory functioning.

Conclusion

There is Level 1 evidence, from one RCT, that cranial electrotherapy stimulation did not help to improve memory and recall following brain injury.

Cranial electrotherapy stimulation was not shown to be an effective treatment to enhance memory and recall abilities following brain injury.

Summary of Learning and Memory Post ABI

Not all patients respond equally to all intervention strategies and no study in the current review indicated whether severity of memory impairment (or memory profile) interacts with a particular external memory aid. Technology has increased the availability of external aids, although some seem more feasible to use than others (e.g., cell phones or hand-held recorders). Unfortunately, the studies reviewed did not specify the length of time subjects required to master compensatory strategies nor the nature of the long-term effects, if any.

Most studies examined only tasks of word list recall and paired-associate learning suggesting that the mnemonic strategies reviewed may not generalize to other types of information (particularly real-world or functional information outside the laboratory). Errorless learning appears to be one procedure that can be used to enhance learning conditions. One study highlighted the difference between severity of impairment and ability to benefit from internal strategies.

Frequency of intervention has an impact on learning and retention, although the exact parameters of this are unclear at the present time. The optimal duration of a program is also open for speculation. No studies reviewed examined the number of sessions required for memory groups to be effective and only one study evaluated a difference in effectiveness between mild and severely impaired individuals after sessions.

Pharmacologic intervention does not appear to be effective in improving learning and memory deficits.

6.2 Remediation of Learning and Memory Deficits

6.2.1 External Aids

Individual Studies

Discussion

Conclusions

6.2.2 Computer-assisted training

Individual Studies

Discussion

Conclusions

6.2.3 Virtual Reality and Cognitive Functioning

Individual Studies

Discussion

Conclusions

6.2.4 Internal Aids

Individual Studies

Discussion

Conclusions

6.2.5 Memory Programs

Individual Studies

Discussion

Conclusions

6.2.6 Cranial Electrotherapy Stimulation and Memory

Individual Studies

Discussion

Conclusion

Summary of Learning and Memory Post ABI

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