10

Memory

OVERVIEW

Memory impairments are common cognitive problems associated with TBI. As such, myriad cognitive rehabilitation therapy (CRT) interventions aim to restore or compensate for memory deficits. This chapter presents descriptions for studies by method of memory strategy (e.g., internal, external, or combined). Within these sections, the controlled studies (e.g., RCTs and nonrandomized, parallel group) are divided by treatment comparator arm (e.g., no treatment, non-CRT treatment, other CRT treatment); following controlled studies, the noncontrolled studies (e.g., pre-post or single-subject, multiple baseline experiments) are described. The chapter closes with the committee’s conclusions for all memory studies reviewed, drawing out notable findings for mild or moderate-severe traumatic brain injury (TBI), as possible.

The committee reviewed 13 randomized controlled trials (RCTs) of treatments intended to improve or compensate for memory deficits. These trials varied in their intent to restore memory, show improvements in learning, or train individuals to use external or internal aids to compensate for poor memory. These trials enrolled a total of 315 study participants, with the size of the treatment group ranging from 8 to 39. The average age of participants ranged from early 20s to late 50s. Of the 13 trials, 12 enrolled participants in the chronic phase of recovery, averaging 4 to 7 years postinjury. One RCT enrolled participants who were in the subacute recovery phase, at 6 to 9 months postinjury (Watanabe et al. 1998).

The committee reviewed two nonrandomized, parallel group controlled studies of treatments intended to compensate for poor memory by training



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10 Memory OVERVIEW Memory impairments are common cognitive problems associated with TBI. As such, myriad cognitive rehabilitation therapy (CRT) interventions aim to restore or compensate for memory deficits. This chapter presents descriptions for studies by method of memory strategy (e.g., internal, exter- nal, or combined). Within these sections, the controlled studies (e.g., RCTs and nonrandomized, parallel group) are divided by treatment compara- tor arm (e.g., no treatment, non-CRT treatment, other CRT treatment); following controlled studies, the noncontrolled studies (e.g., pre-post or single-subject, multiple baseline experiments) are described. The chapter closes with the committee’s conclusions for all memory studies reviewed, drawing out notable findings for mild or moderate-severe traumatic brain injury (TBI), as possible. The committee reviewed 13 randomized controlled trials (RCTs) of treatments intended to improve or compensate for memory deficits. These trials varied in their intent to restore memory, show improvements in learn- ing, or train individuals to use external or internal aids to compensate for poor memory. These trials enrolled a total of 315 study participants, with the size of the treatment group ranging from 8 to 39. The average age of participants ranged from early 20s to late 50s. Of the 13 trials, 12 enrolled participants in the chronic phase of recovery, averaging 4 to 7 years postin- jury. One RCT enrolled participants who were in the subacute recovery phase, at 6 to 9 months postinjury (Watanabe et al. 1998). The committee reviewed two nonrandomized, parallel group controlled studies of treatments intended to compensate for poor memory by train- 175

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176 COGNITIVE REHABILITATION THERAPY FOR TBI ing the use of internal strategies. Goldstein et al. (1996) enrolled 20 par- ticipants and O’Neil-Pirozzi et al. (2010) enrolled 94 participants. In both studies participants were considered chronic, averaging 1 to more than 11 years postinjury; the average participant age ranged from the 20s to the 40s. The committee reviewed six pre-post single group design studies and six single-subject, multiple baseline (SS/MB) designs. Table 10-1 (at the end of the chapter) presents a summary of all included studies in this review. INTERNAL MEMORY STRATEGIES Internal memory strategies may include the use of visual imagery or other repetitive, drilled practices. The committee reviewed seven RCTs and two nonrandomized, parallel group studies that used internal memory strat- egies; comparator arms included no treatment (n = 3), non-CRT treatment (n = 1), and other CRT treatment (n = 5). The committee also reviewed one pre-post single group design and five single-subject multiple, baseline experiments. Table 10-2 presents all internal memory strategy studies by design, strategy and treatment comparator. Controlled Studies Comparator Arm: No Treatment Tam and Man (2004) conducted a small RCT in which 26 partici- pants were randomly assigned to four computerized learning conditions: self-paced practice, stimuli/multi-sensory feedback, personalized training contents, and visually enhanced presentation. Treatment dosage ranged be- tween 3 and 5 hours. Performance on drilled content improved significantly for all treatment groups compared to no treatment, with the feedback group showing the most gain. On a self-efficacy scale however, the feedback group demonstrated significant change after treatment, whereas others’ self- efficacy did not change. None of the groups improved significantly on the Rivermead Behavioural Test. The group that received stimuli/multi-sensory feedback appeared to improve memory for drilled content, which also may be related to their changes in self-efficacy for memory ability. It is unclear if improvement was related to the treatment, spontaneous neurological recovery, or other treatment participants were receiving at the time. With six and seven participants per group, interpretation and generalizability are limited. Also, specific time since injury was not reported, though individuals fewer than 3 months from injury were excluded. Thickpenny-Davis and Barker-Collo (2007) conducted a small RCT that included moderately and severely injured participants who were more than 1 year postinjury. The 14 participants were randomly assigned either

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177 MEMORY TABLE 10-2 Internal Memory Strategies Strategy Treatment Comparator Visual No Non- Other Study Design Multiple Imagery Treatment CRT CRT Bourgeois et al. 2007 RCT X X Dirette et al. 1999 RCT X X Dou et al. 2006 RCT X X Ruff et al. 1994 RCT X X Ryan and Ruff 1988 RCT X X Tam and Man 2004 RCT X X Thickpenny-Davis and RCT X X Barker-Collo 2007 O’Neil-Pirozzi et al. Parallel X X 2010 Goldstein et al. 1996 Parallel X X Milders et al. 1998 Pre-Post X Benedict and Wechsler SS/MB X 1992 Ehlhardt et al. 2005 SS/MB X Hux et al. 2000 SS/MB X Manasse et al. 2005 SS/MB X to receive a structured memory program or to join a waitlist. The memory intervention consisted of educating participants about memory (four parts of memory: attention, encoding, storage, and retrieval), assisting partici- pants in understanding their own memory impairment and its effects, introducing and practicing strategies to aid memory and learning, and assisting participants in identifying the most appropriate and useful strate- gies for them. Strategies included didactic teaching, small group activities, discussions, problem solving and practice implementing memory strategies, errorless learning, and repetition. Postintervention, the experimental group as compared to the control group improved in many neuropsychological measures of memory (California Verbal Learning Test [CVLT]) long de- layed free recall, Wechsler Memory Scale (WMS) logical memory delayed recall, and response time on the attention test (Continuous Performance Test [CPT]). The experimental group also showed increased knowledge of memory/memory strategies, increased use of memory aids/strategies, and decreased behaviors indicative of memory impairment. Results were main- tained at follow-up with the exception of response time on the attention test

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178 COGNITIVE REHABILITATION THERAPY FOR TBI and immediate recall of narratives on the WMS. In addition to the initially small sample sizes, four of the seven participants in the waitlist control drop dropped out before providing posttreatment and follow-up measures. O’Neil-Pirozzi et al. (2010), a large nonrandomized, parallel group study, examined the effects of memory training on individuals with mild, moderate, and severe injuries. Of the 94 enrolled participants, 54 received memory intervention and 40 received no specific intervention. Memory intervention, called I-MEMS focused on memory education and teaching individuals to use internal memory strategies, particularly “semantic asso- ciation (i.e., categorization and clustering); semantic elaboration/chaining and imagery were emphasized secondarily” (O’Neil-Pirozzi et al. 2010). The memory intervention included 12 group sessions, 90 minutes each, held twice each week for 6 weeks, totaling 18 hours. Primary outcome measures were memory performance on the Hopkins Verbal Learning Test–Revised and the Rivermead Behavioural Memory Test II. Additional standardized tests of memory and executive functions were included. The treatment group demonstrated significant improvement on T-tests after treatment. Over time, these improvements went beyond changes in the control group. Regressions were used to determine if performance could be predicted after treatment (or second testing of control group). Consistent with the hypothesis, treatment predicted performance on both primary outcome measures at the second testing. Participants who received memory inter- vention improved more than those who did not. Furthermore, mild and moderately injured participants improved beyond those severely injured, even though the severely injured participants still improved beyond severely injured participants who received no treatment. At 1 month posttreatment, no significant changes were seen in memory performance. Aside from the limitation of not being completely randomized, the pre-post study design provides some evidence that the instruction of internal memory strategies has positive treatments effects when compared to no treatment, even for individuals who are at least 1 year postinjury. Comparator Arm: Non-CRT Treatment Ryan and Ruff (1988), a small RCT, enrolled 20 mildly to moderately injured participants who averaged 5 to 6 years postinjury. Participants were randomly assigned to the memory strategies arm or to the control arm. The memory strategies arm included training to use internal memory strategies such as associational tasks, chaining, rehearsal, visual imagery, and ritual- ized recall. The control group received psychosocial support and played cognitive games. Each group received 48 hours of treatment over 6 weeks. On neuropsychological measures of memory, both groups improved after treatment; however. those who were mildly injured and received strategy

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179 MEMORY training improved significantly more than moderately injured participants in both groups, as well as mildly injured participants in the psycho- social support group. Participants were not available for follow-up and no patient-centered measures were included. This study’s limitations include its small number of participants and data analysis by severity post hoc, even though it makes sense scientifically to examine treatment effects by injury severity. It should be noted however, that this was one of the earliest studies in memory intervention to find a severity effect. Comparator Arm: Other CRT Treatment Bourgeois et al. (2007), another modest-sized RCT, involved adults (average age 42) with persisting memory problems several years after a documented closed head injury. Participants also needed a family member willing to participate. Participant-caregiver pairs were assigned to either spaced retrieval training or a didactic control therapy that consisted of strategy education. Assignments were made using stratified pairing based on race and sex (quasi-experimental). Both interventions were delivered via telephone by clinician trainers. After initial face-to-face assessments of cognitive difficulties and social participation (Community Integration Ques- tionnaire), the trainer discussed treatment goals with the patient and care- giver, and the group selected three specific goals. The trainer then provided memory logs and asked patients and caregivers to record the frequency with which each problem occurred over the next week. The trainer called the participant the following day to make sure instructions and data collection methods were understood. The trainer then called participants four to five times weekly for 30-minute sessions. Participants in the spaced retrieval group received an instructional technique focused on selected goals. During sessions, the therapist modeled correct responses to questions related to the goals and instructed the participants not to struggle to retrieve responses, but to respond immediately. Participants in the control arm received the same total amount of therapy time in sessions that included discussion about memory strategies such as association, verbal rehearsal, imagery, and written reminders. Outcomes included goals mastered, generalization, the frequency of reported memory problems, cognitive difficulties scale, and community integration. Immediately and at 1 month posttraining, the space retrieval group (and their caregivers) reported more treatment goal mastery and use than the didactic instruction group (and their caregivers). Both groups reported some generalization to other nontargeted behaviors, but the difference between these improvements among groups was not statistically significant. There were no reported important or statistically significant improvements in quality of life between or within groups on these measures. One limitation was that data about “objective, observable

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180 COGNITIVE REHABILITATION THERAPY FOR TBI behaviors” related to selected goals was obtained from memory logs, and these data were sometimes incomplete or not turned in. Of the 51 pairs that agreed to participate, only 38 completed the study: 22 spaced retrieval training pairs and 16 didactic control pairs. Dirette et al. (1999), a small RCT, included 30 participants, the vast majority of whom had mild, moderate, or severe TBI. Injury severity was distributed equally across two treatment arms: one in which internal com- pensatory strategies (verbalization, chunking, pacing) were taught and one in which remedial computer work involving visual processing was provided. Both treatments were delivered via a computer for a total of 3 hours, in four 45-minute sessions, once per week for 4 weeks. The compensatory strate- gies came from a program called “IQ Builder,” which included “memory for numbers” and “memory for letters.” Outcomes included weekly mea- surement of working memory using the PASAT and two pre-post measures of computer-based visual processing for data entry and reading. Following treatment, both groups improved significantly on weekly and posttreatment measures, although performance did not differ by group, i.e., there was no treatment effect for learning internal compensatory strategies. Demographic variables, including injury severity and time since injury, did not account for participants’ performance either. Post hoc analyses of self-report and observations of strategy use indicated that about 80 percent of all partici- pants, regardless of which treatment they participated in, used compensa- tory strategies. Unfortunately, treatment dosage was very low; there was no description of the instruction of the strategies. Furthermore, only F statistics and p-values were presented, which limits the applicability of these results to inform future research and interpretation. Ruff et al. (1994) conducted a small RCT that involved 15 participants with severe TBI. Participants were randomized into two groups, in which the order of receiving restorative attention therapy and compensatory mem- ory therapy was counterbalanced; i.e., both groups received both kinds of therapy in a crossover design. Participants received 20 hours of therapy via a computer program called “THINKable.” Outcomes were computer scores, neuropsychological tests of attention and memory, and behavioral assessments. After intervention, the computer scores showed significant improvement in attention but no significant improvement in memory. Re- sults of the neuropsychological measures were mixed: immediate memory improved while delayed memory did not; only one attention measure im- proved. Self and other behavioral assessments of memory-based behavior did change after intervention, but only observer rating of attention-related behavior showed significant change after intervention. Thus, this study provides nonspecific, limited evidence on the efficacy of internal compensa- tory memory training (versus attention training) in that although subjective

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181 MEMORY ratings showed improved memory, improvement on computerized memory scores and neuropsychological test scores was inconsistent. Dou et al. (2006), a small RCT, involved 30 participants with TBI who were several months post neurosurgery. Exclusion criteria include a history of psychiatric problems or computer phobia. Participants were randomly assigned to three groups: computer assisted memory training, therapist as- sisted memory training, and a control group that did not receive any specific memory training. In the computer assisted training, participants were asked to identify or define the information to be learned with computerized as- sistance. This decontextualized training consisted of instruction in internal, compensatory memory strategies aimed at memory and management of typical daily activities. The computer then provided the necessary informa- tion for the participants to generate correct decisions through an errorless approach. Participants were not encouraged to engage in guesswork, to avoid mistakes, and were told to consider alternatives to and consequences of an intended action. The therapist assisted training covered the same content but converted the instruction into a picture album; therapists gave directions face to face. The 15 hours of training were delivered in 20 ses- sions occurring 6 days a week, with each session lasting about 45 minutes. Immediately after treatment, both groups improved on multiple standard- ized measures of memory (Neurobehavioural Cognitive Status Examina- tion, Rivermead Behavioural Memory Test) compared to the no-treatment group, although not on every measure. The treatment groups performed similarly in comparison to each other. Performance was the same at 1 month posttreatment. Thus, there appears to be some benefit to those at a chronic recovery stage to learning to use to internal, compensatory memory strategies; the delivery (therapist versus computer) does not appear to mat- ter. Estimates and effect sizes were not provided, so the results cannot be used to inform the design of future studies. Goldstein et al. (1996), a small nonrandomized, parallel group study, enrolled 20 participants with TBI and persistent amnesia who were pro- vided with computerized instructions on how to create stories from word lists (“The Ridiculously Imaged Story” technique). Of the 20 participants, 10 received the computerized presentation on how to make associations between names and faces, as well as additional initial coaching and in- struction about the cues the computer would provide for the list-story task. The other participants were instructed to make these associations using the original therapist delivery mode (Goldstein et al. 1988). Both groups were trained in these imagery techniques using roughly equivalent procedures. Data from 10 participants in a previous study that used thera- pist delivery were included as a comparison group. The number of words recalled from lists appeared to improve during generalization trials, though

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182 COGNITIVE REHABILITATION THERAPY FOR TBI no individual trials were significantly different between computerized and the noncomputerized comparison group (from original data in Goldstein et al. 1988). After treatment, both groups recalled significantly more from examiner-provided lists when compared to pretraining, and the computer- ized group appeared to improve slightly more. On participant-provided lists, pretreatment to posttreatment recall improved significantly, though the computerized group lost its advantage. On the name-face learning task, the computerized group had a clear advantage over the original method group, both in learning trials and pre- and posttreatment comparisons; in fact, the therapist delivery group did not recall significantly more names after treatment. Authors stated that the decontextualized methods did not provide evidence of long-term use of learned strategies to improve memory, though there was no long-term follow-up. Other Study Designs Benedict and Wechsler (1992), a single-subject, multiple baseline study, examines the effects of teaching the method of loci (MOL, for word list learning) and Preview, Question, Repeat, State, and Test (PQRST, for para- graph learning). Two individuals participated in the study—one with mod- erate TBI and moderate memory impairment and the other with severe TBI and severe memory impairment. They received 27 and 34 weeks of training, respectively, in which the order of MOL and PQRST were counterbalanced. Results revealed that the moderately impaired participant’s memory for word lists benefitted from the MOL training, but the participants’ para- graph learning did not benefit from PQRST training. The severely impaired participant’s performance was highly variable throughout, resulting in little change in recall from word lists or paragraphs. Ehlhardt et al. (2005) investigated the efficacy of instructing adults with severe TBI to use recall and e-mail in a multiple-baseline-across- subjects-designed study. All five participants were many years postinjury and all demonstrated severely impaired memory and executive functions on standard neuropsychological measures. Treatment included the TEACH- M approach, which entails seven steps and learning principles of errorless learning; distributed practice and metacognitive instruction were empha- sized. Training was delivered four to five times weekly, ranging from 7 to 15 weeks (as many as required to reach criteria). Four of the five participants completed the training and three of these four participants maintained these steps at 1 month after treatment ended, and all four participants maintained implementation of of the e-mail steps when “altered interface and/or a computer game with no shared features” was added (Ehlhardt et al. 2005). Interviews revealed that all four participants who completed the training endorsed the training. Inter-rater reliability and procedural fidelity

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183 MEMORY were reportedly strong: baselines were adequate prior to the start of treat- ment; therefore within-subject experimental control was clearly established. Hux et al. (2000) examined the efficacy of internal memory strategies (mnemonics and visual imagery) to improve face-name recall in seven indi- viduals with TBI who ranged from 2 to 26 years postinjury. Participants’ memory impairment ranged from nonexistent to severe. Intervention was delivered via training sessions that occurred five times per day in one phase, one time per day in another phase, and two times per week in yet another phase using within-participant comparisons. Face-name recall improved more after the intervention was provided one time per day or two times per week as opposed to five times per day, however results were highly variable across individual participants. Authors also reported frequent participant behavior problems. Manasse et al. (2005) examined the efficacy and effectiveness of a sequential treatment approach that consisted of visual imagery for face- names, followed by real-word training that involved three cuing strate- gies: name restating, phonemic cuing, and visual imagery. There were five participants with chronic, severe TBI, ranging from more than 1 to 29.5 years postinjury. Treatment was provided in 9 sessions of visual imagery and 30 sessions of real-world intervention. All participants improved in name-face recall after intervention regardless of the kind of cuing, and four of five participants demonstrated more spontaneous use (effectiveness) of therapists’ names. Milders et al. (1998), a pre-post single group study, involved 13 adults with memory problems following closed head injuries and 13 healthy controls matched on age and level of education. Most patients had been discharged from a nearby rehabilitation center. The mean time from injury was about 4 to 5 years, and the mean length of posttraumatic amnesia (PTA) they had suffered was reported as 36 days. The healthy controls were friends or relatives of the patients. Patients were taught strategies to improve the learning of new names and the retrieval of familiar people’s names. Strategies were taught in eight, 1-hour sessions delivered one on one over a 4-month period. The importance of applying the strategies in everyday life was repeatedly stressed and homework exercises were encouraged. Pre-post assessments in both groups included the following: three target evaluation tasks that had items not presented in the training (i.e., Name Learning Test, Name-Occupation-Town Learning Test, Famous Faces Naming Test); and two memory tests assumed insensitive or unrelated to the strategies practiced during training (i.e., Digit Span Forwards and Auditory Verbal Learning Task). Performance on two of the three target tasks improved with training compared to controls, but performance on the Name Learning Test did not change in either group. Both groups had similar improvement in the two control memory tests. Limitations included

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184 COGNITIVE REHABILITATION THERAPY FOR TBI the small selected sample, an unclear history of the severity and sequelae of TBI in some patients, and narrowly focused outcome measures. EXTERNAL MEMORY STRATEGIES External memory strategies may include the use of notebook or other tool to enhance memory abilities. The committee reviewed four RCTs and no nonrandomized, parallel group studies that used external memory strate- gies; comparator arms included no treatment (n = 1), non-CRT treatment (n = 1), and other CRT treatment (n = 2). The committee also reviewed three pre-post single group designs and one single-subject, multiple baseline experiment. Table 10-3 presents all external memory strategy studies by design, strategy, and treatment comparator. Controlled Studies Bergquist et al. (2010) and Bergquist et al. (2009), a small randomized crossover study, enrolled 20 volunteers who had moderate-severe TBI and were more than 1 year postinjury. Participants with a history of ongoing TABLE 10-3 External Memory Strategies Strategy Treatment Comparator Notebook, External Diary, Cuing, Calendar, PROMpting No Non- Other Study Design Other Device(s) Treatment CRT CRT Bergquist et al. RCT X X 2009, 2010 Ownsworth and RCT X X McFarland 1999 Schmitter- RCT X X Edgecombe et al. 1995 Watanabe et al. RCT X X 1998 Bergman 2000 Pre-Post X Gentry et al. Pre-Post X 2008 Hart et al. 2002 Pre-Post X Zenicus et al. SS/MB X 1991

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185 MEMORY psychiatric symptoms were included as long as symptoms were not severe (e.g., psychotic symptoms) and did not interfere with study participation. Participants also had to have reliable access to the Internet, as the trial compared two Internet-based interventions: an active calendar treatment intervention and a control diary condition. The calendar intervention, which involved an online therapist, focused on developing calendar skills to address difficulties with memory in everyday life and strategies to improve memory functioning. Participants in the diary control condition spent an equivalent amount of time interacting with a therapist online but simply used their calendar to record day-to-day events and not as a compensatory tool. Only 14 of the 20 participants completed the study; 6 of 8 assigned to the calendar intervention, and 2 of 8 assigned to the diary. Outcome measures included self-reported measures that assessed use of compensation strategies (Compensation Techniques Questionnaire) and satisfaction (four questions—satisfaction with therapist, satisfaction with therapy received, emotional distress during therapy, and willingness to receive such therapy again), as well as measures completed by family members (Neurobehavioral Functioning Inventory [NFI] and Compensation Integration Questionnaires [CIQ]). Analytic methods were not well described, particularly regarding missing data for patients who did not complete the trial. Most participants in both groups were satisfied with the Internet-based interventions. No statistically significant differences between groups were found for the four satisfaction questions. Also, no statistically significant differences in func- tional change between groups were reported after 30 sessions (NFI, CIQ outcomes). Ownsworth and McFarland (1999) conducted a small RCT in which 20 participants with TBI who were many years postinjury were provided with a diary. Severity of brain injury was not described. Participants were randomized to either use a procedural worksheet during diary use (Di- ary and Self-Instructional Training) or to use the diary without this self- instruction (diary only), which required the use of higher cognitive skills of self-awareness and self-regulation. The diary-only participants were taught a behavioral sequence to use the diary. During the Diary and Self- Instructional Training session subjects learned how to compensate for ev- eryday memory problems using a small notebook, as an internal strategy to mediate diary use. Some instructions for daily memory checklists were given verbally over the phone (in one session), but the 4-week intervention period mainly involved self-use of diaries. At the end of the intervention period, groups did not differ in mean number of diary entries; however, the diary- plus-self-instruction group maintained their use of the diary strategy to a greater extent than the diary-only group. Using daily checklists, the diary- plus-self-instruction group self-reported these strategies as more helpful and reported less confusion on a questionnaire. Thus, support is provided for

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TABLE 10-1 Continued 202 TBI Severity Study N Level Brief Narrative Comparator Outcome Measures Findings Ownsworth 20 NR The aim of this study Y • RBMT Compared to the Diary Only and was to investigate • WMS-R (DO) group, the Diary and McFarland the remediation and No Content: Self-Instructional Training 1999 assessment of everyday Control group (DSIT) group made diary memory problems, using instructed entries more consistently, the RBMT and WMS-R to use the reported fewer memory to measure global memory diary, without problems, and made more performance in 20 treatment positive ratings associated subjects. with treatment efficacy. On the computer scores Ruff et al. 15 Severe Two groups received Y • 2+7 Selective Attn Test after intervention, there was 1994 two counterbalanced • Behavioral assessments significant improvement treatments, attention Other CRT • Continuous Performance in attention, whereas no training compared or Content: Test significant improvement for memory training, delivered Attention • Corsi Block Learning memory. On neuropsycho- via a computer-based and memory Test logical measures, the results multi-media program training, • Rey Auditory Verbal were mixed: immediate called THINKable. delivered to Learning Test memory improved while both groups in a • WAIS-R delayed memory did not; crossover design only one attention measure improved. Self- and other behavioral assessment of memory-based behavior did change after intervention, whereas only observer rating of attention-related behavior reached significance after intervention.

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Ryan and 20 Mild- Memory retraining with Y • Benton Visual Retention On neuropsychological Ruff 1988 Moderate visuospatial and verbal Test (BVRT) measures of memory, both representations, using Non-CRT • Rey-Osterrieth Complex groups improved after multiple strategies: Content: Figure Test (CFT) treatment; however, those associational tasks, Psychosocial • Ruff-Light Trail who were mildly injured chaining, rehearsal, activities with no Learning Test (TLT) improved significantly more visual imagery, multiple feedback from • Selective Reminding Test than moderately injured associations, ritualized therapist • Taylor Complex Figure participants who had received recall. • Wechsler Memory strategy training, moderately Scale (WMS), Logical injured participants in the Memory Subtest psychosocial support group, or mildly injured participants in the psychosocial support group. Schmitter- 8 Severe The purpose of this Y • Everyday Memory The notebook training group Edgecombe study was to evaluate Questionnaire (EMQ) reported significantly fewer et al. 1995 the effectiveness of a Non-CRT • Global Severity Index everyday memory failures 9-week memory notebook Content: from the Symptom (EMFs) on a daily checklist treatment for patients with Supportive Checklist 90–Revised measure than the supportive known memory deficits. group therapy • Logical Memory 1 and therapy group; at follow-up, 2 scales this finding was no longer • Notebook training significant. For the lab- • RBMT based memory measures, no • Visual Reproduction 1 significant treatment effects and 2 scales were found at posttreatment • Weekly learning or follow-up. activities packets (LAPs) • WMS-R 203 continued

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TABLE 10-1 Continued 204 TBI Severity Study N Level Brief Narrative Comparator Outcome Measures Findings Y Tam and 26 NR The goal of this study • Built-up computer Though all four memory Man 2004 was to gain understanding performance records training methods showed non- No Content: of computer-assisted • RBMT statistically significant positive Unspecified; the training effects, using four results compared with the • Self-efficacy rating scale study indicated theoretically different no-treatment control, clinical treatment was memory retraining improvement was found in all not provided strategies, for the four methods, and the Feed- treatment of posttraumatic back group showed significant amnesia. improvement in self-efficacy compared to the other groups. Y Moderate- This study aimed to Thickpenny- 14 • Behavioral indicators Compared to the control, the Severe evaluate the effect of an Davis and of memory impairment experimental group improved eight-session structured No Content: Barker- checklist in many neuropsychological group format memory Waitlist control Collo 2007 • California Verbal measures of memory (CVLT rehabilitation program on Learning Test (CVLT) long delayed free recall, WMS memory function deficits. • Integrated Visual and logical memory delayed recall, Auditory Continuous and response time on the Performance Test attention test [CPT]), also (IVA-CPT) showing increased knowledge • Memory in Everyday of memory/memory strategies, Life and Use of Aids and increased self/observer (sig- Strategies Questionnaire nificant other) use of memory • “Memory quiz” (Extent aids/strategies and decreased of participants’ knowl- self/observer behaviors indica- edge about memory and tive of memory impairment. Results were maintained at memory strategies) • Visual paired associates follow-up, with the exception (VPA) of response time on the atten- • Wechsler Memory Scale tion test and immediate recall (WMS) Logical Memory of narratives on the WMS. Subtest, revised

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Watanabe et 30 NR This study compared the Y Temporal Orientation Test Results indicated that al. 1998 effect of the presence (TOT) measuring day, the presence of a wall or absence of a wall Other CRT date, month, year calendar and corresponding calendar in participants’ Content: orientation therapy had no hospital room on temporal Control received effect on orientation; only orientation. nonspecific the emergence out of PTA cognitive corresponded to orientation. rehabilitation, with no calendar in room Nonrandomized, Parallel Controlled Group O’Neil- 94 Mild, This study examined the Y • Hopkins Verbal Memory group intervention Pirozzi et al. Moderate, effects of memory training Learning Test–Revised participants showed improved 2010 Severe focused on internal No Content: (HVLT-R) memory performance strategy use for memory Control received • Rivermead Behavioral immediately postintervention impairment. no specific Memory Test II (RBMT as well as one month intervention II) postintervention. Mild and moderately injured participants improved beyond those who were severely injured, even though the severely injured participants still improved beyond severely injured participants who received no treatment. 205 continued

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TABLE 10-1 Continued 206 TBI Severity Study N Level Brief Narrative Comparator Outcome Measures Findings Goldstein et 30 NR This study replicated Y • Free recall of patient- After treatment, both groups al. 1996 earlier work that provided list recalled significantly more demonstrated the efficacy Other CRT • Number of words from examiner-provided of two methods of memory Content: recalled on a selective lists when compared training using imagery Parallel groups, reminding task to pretraining, and the mnemonics. with one • Scoring on RIS and computerized group appeared receiving (partly) FNM tasks to improve slightly more. On computerized participant-provided lists, intervention, one pretreatment to posttreatment receiving non- recall improved significantly, computerized though the computerized intervention group lost its advantage. On name-face learning task, the computerized group had a clear advantage over the original method group both in learning trials and pre- and posttreatment comparisons; the therapist delivery group did not recall significantly more names after treatment. Pre-Post Single Group Bergman 41 NR This study examined the N • Appointment Scheduling Thirty-six of the 41 2000 effect of orientation to a • Check Writing participants achieved mastery cognitive orthosis (CO); • Directory of four or more activity subjects were progressed • Journal modules and 36 demonstrated on specific tasks until they • Savings Deposit/ rapid achievement of success could perform without Withdrawal on initial assigned tasks. assistance (mastery). • Telephone Log

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Freeman et 12 NR This study compared N Identification of key ideas There was a statistically al. 1992 the efficacy of memory in a paragraph read to the significant difference between remediation treatment, subject treatment and control post- which consisted of test memory scores that compensatory and favored the treatment group. executive training skills delivered over a 2.5-week period, with no treatment. Gentry et al. 23 Severe This study examined the N • Canadian Occupational Self-ratings of occupational 2008 efficacy of personal digital Performance Measure performance and satisfaction assistants (PDAs) as a (COPM) with occupational compensatory cognitive • Craig Handicap performance (COPM), aid, used by subjects Assessment and Rating as well as self-rating of for 8 weeks after three Technique-Revised participation (CHART-R), to six in-home training (CHART-R) showed statistically significant sessions conducted by an improvement. occupational therapist. Hart et al. 10 Moderate- This study investigated the N Number of goals (recorded Subjects recalled recorded 2002 Severe usefulness of a portable and nonrecorded) that goals more often than goals voice organizer in helping were remembered that were not recorded; people recall therapy furthermore, recorded goals goals and plans previously seemed to be correlated discussed with their case with better awareness or managers. follow-through with therapy objectives. 207 continued

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TABLE 10-1 Continued 208 TBI Severity Study N Level Brief Narrative Comparator Outcome Measures Findings Milders 26 Severe In this training study, N • Digit Span Forwards Performance on two of the et al. 1998 patients were taught • Dutch version of Rey’s three target tasks improved strategies to improve the auditory verbal learning with training compared to learning of new names and task controls but performance on the retrieval of familiar • Famous Faces Naming the Name Learning Test did people’s names. Test not change in either group. • Name Learning Test Both groups had similar • Name-Occupation-Town improvements in the two Test control memory tests. Raskin and 8 Mild, Prospective memory N • Boston Diagnostic Subjects showed improvement Sohlberg Moderate, training delivered to eight Aphasia Examination, on prospective memory 2009 Severe subjects in a within- animal naming time and tasks after 2 subjects crossover design. • Consonant Trigrams minutes, but not at the Subjects were expected to Test longer delay of 10 minutes. perform a specific task, • Controlled Oral Word On neuropsychological tested at 2 and 10 minutes, Association Test measures immediately post with and without external • PASAT treatment, subjects improved cues. In addition, half of • Randt Memory Test, in attention and executive the subjects were tested on story recall and picture functions. Generalization retrospective memory. recognition to everyday memory • Revised Attention performance also improved, Process Test as measured by a memory • RBMT questionnaire and diaries. • Trail Making Test Maintenance of prospective memory improvements was demonstrated at one year post- treatment. None of the subjects showed improvement for retrospective memory drills.

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Single Subject, Multiple Baseline Experiment Design Benedict and 2 Mild and The study examined the N Scores on word-list recall The moderately impaired Wechsler Moderate efficacy of long-term and paragraph recall participant’s memory for 1992 memory retraining in two word lists benefitted from the adults using two training MOL training, but paragraph strategies: method of loci learning did not benefit (MOL) and the PQRST from PQRST training. The verbal strategy. severely impaired participant’s performance was highly variable throughout, resulting in little change in recall form word lists or paragraphs. Ehlhardt et 4 Severe The TEACH-M program, N • Number of correct All four participants replicated al. 2005 which facilitates learning e-mail steps in sequence treatment effects immediately and retention of multi- (out of 7) posttreatment and 30 days step procedures, was • Number of correct steps thereafter; generalization administered to assess regardless of sequence and social validity data also participants’ ability to • Number of training supported the effectiveness of learn multi-step procedures sessions needed for TEACH-M. utilizing specific cognitive mastery rehabilitation principles. Hux et al. 7 NR This study examined the N • Number of faces Sessions held daily and twice 2000 efficacy of internal memory correctly identified a week were found to be strategies, specifically • Number of training more effective than those held mnemonics and visual sessions needed to five times a day. Mnemonics imagery, to improve reliably identify subset and visual imagery strategies face-name recall in seven of faces were effective for four of the subjects ranging from 2 to participants, irrespective of 26 years postinjury. session frequency. 209 continued

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TABLE 10-1 Continued 210 TBI Severity Study N Level Brief Narrative Comparator Outcome Measures Findings Manasse et 5 Severe The study examined three N Number of names All participants improved al. 2005 cueing strategies (name mastered (name use, name in name-face recall after restating, phonemic cueing, knowledge seen in each intervention regardless of the and visual imagery) in cueing condition) kind of cuing and four of five a real-world context to participants demonstrated increase mastery and use of more spontaneous use face-name associations in (effectiveness) of therapists’ five chronic participants. names when given the same number of opportunities. Raskin and 2 NR This study was an N • Performance on Memory for future actions Sohlberg investigation of prospective criterion standard improved more after 1996 memory training using neuropsychological prospective memory training two different types of measures than after repetitive drill, intervention: prospective • Performance on although generalization to and repetitive memory prospective memory real world remembering was drill. screening test variable across participants (Perspective Memory and type of training. Both Screening, or PROMS) participants validated their • Probes of everyday preference for prospective prospective memory memory training during interviews. Zencius et al. 4 NR In this study, the usefulness N Number of homework After notebook training, 1991 of memory notebook assignment components three of the four participants training for completing completed correctly: improved in completing the homework assignments • Meeting a specified number of components to the was examined for four person at a certain place homework assignments. adults, who were also and time receiving interdisciplinary • Turning in a completed rehabilitation services. written homework assignment

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211 MEMORY REFERENCES Benedict, R. H., and F. S. Wechsler. 1992. Evaluation of memory retraining in patients with traumatic brain injury: Two single-case experimental designs. Journal of Head Trauma Rehabilitation 7(4):83–92. Berg, I. J., M. Koning-Haanstra, and B. G. Deelman. 1991. Long-term effects of memory rehabilitation: A controlled study. Neuropsychological Rehabilitation 1(2):97–111. Bergman, M. M. 2000. Successful mastery with a cognitive orthotic in people with traumatic brain injury. Applied Neuropsychology 7(2):76–82. Bergquist, T., C. Gehl, J. Mandrekar, S. Lepore, S. Hanna, A. Osten, and W. Beaulieu. 2009. The effect of Internet-based cognitive rehabilitation in persons with memory impairments after severe traumatic brain injury. Brain Injury 23(10):790–799. Bergquist, T., K. Thompson, C. Gehl, and J. M. Pineda. 2010. Satisfaction ratings after receiv- ing Internet-based cognitive rehabilitation in persons with memory impairments after severe acquired brain injury. Telemedicine and eHealth 16(4):417–423. Bourgeois, M. S., K. Lenius, L. Turkstra, and C. Camp. 2007. The effects of cognitive tele- therapy on reported everyday memory behaviours of persons with chronic traumatic brain injury. Brain Injury 21(12):1245–1257. Dirette, D. K., J. Hinojosa, and G. J. Carnevale. 1999. Comparison of remedial and compen- satory interventions for adults with acquired brain injuries. Journal of Head Trauma Rehabilitation 14(6):595–601. Dou, Z. L. D. W. K. Man, H. N. Ou, J. L. Zheng, and S. F. Tam. 2006. Computerized errorless learning-based memory rehabilitation for Chinese patients with brain injury: A prelimi- nary quasi-exerimental clincial design study. Brain Injury 20(3):219–225. Ehlhardt, L. A., M. M. Sohlberg, A. Glang, and R. Albin. 2005. TEACH-M: A pilot study evaluating an instructional sequence for persons with impaired memory and executive functions. Brain Injury 19(8):569–583. Freeman, M. R., W. Mittenberg, M. Dicowden, and M. Bat-Ami. 1992. Executive and com- pensatory memory retraining in traumatic brain injury. Brain Injury 6(1):65–70. Gentry, T., J. Wallace, C. Kvarfordt, and K. B. Lynch. 2008. Personal digital assistants as cognitive aids for individuals with severe traumatic brain injury: A community-based trial. Brain Injury 22 (1):19–24. Goldstein, G., M. McCue, S. M. Turner, C. Spanier, J. A. Malec, and C. Shelly. 1988. An efficacy study of memory training for patients with closed head injury. Clinical Neuro- psychologist (2):251–56. Goldstein, G., S. R. Beers, S. Longmore, and M. McCue. 1996. Efficacy of memory training: A technological extension and replication. Clinical Neuropsychologist 10(1):66–72. Hart, T., K. Hawkey, and J. Whyte. 2002. Use of a portable voice organizer to remember therapy goals in traumatic brain injury rehabilitation: A within-subjects trial. Journal of Head Trauma Rehabilitation 17(6):556–570. Hux, K., N. Manasse, S. Wright, and J. Snell. 2000. Effect of training frequency on face-name recall by adults with traumatic brain injury. Brain Injury 14 (10):907–920. Kaschel, R., S. Della Sala, A. Cantagallo, A. Fahlbock, R. Laaksonen, and M. Kazen. 2002. Imagery mnemonics for the rehabilitation of memory: A randomised group controlled trial. Neuropsychological Rehabilitation 12(2):127–153. Manasse, N. J., K. Hux, and J. Snell. 2005. Teaching face-name associations to survivors of traumatic brain injury: A sequential treatment approach. Brain Injury 19(8):633–641. Milders, M. V., I. J. Berg, and B. G. Deelman. 1995. Four-year follow-up of a controlled memory training study in closed head injured patients. Neuropsychological Rehabilita- tion 5(3):223–238.

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