EBP Briefs Volume 14, Issue 1: The Utilization of Internal and External Memory Strategies in Evidence-Based Practice

Volume 14, Issue 1, November 2019

EBP

briefs

A scholarly forum for guiding evidence-based

practices in speech-language pathology

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E D, MSE, SLP-CF

J W, MSE, SLP-CF

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M J. L, MHA, MSE, SLP-CF

K A. M, PD, CCC-SLP

O D U

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Cite this document as:

Davis, E., Wolff, J., Murdock, R., Lopez, M. J., & Murphy, K. A. (2019).

The utilization of internal and external memory strategies in evidence-based

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The Utilization of Internal and External Memory

Strategies in Evidence-Based Practice

iii

EBP Briefs Volume 14, Issue 1

November 2019

Structured Abstract

Clinical Question: For adult patients with cognitive linguistic impairment because of

traumatic brain injury (TBI), is the use of internal and/or external memory strategies

beneﬁcial to memory outcomes compared to alternative or no treatment?

Method: Systematic Review

Study Sources: Comprehensive EBSCOhost database search (i.e., ERIC, Academic Search

Complete, Psychology and Behavioral Sciences Collection, Education Source), speechBITE,

Cochrane Library, PubMed, PsycINFO, PsycBITE, and the ASHA PracticePortal

Search Terms: traumatic brain injury OR TBI AND intervention OR treatment OR therapy,

cognit*, memory, internal strateg* OR external strateg*

Number of Included Studies: 11

Primary Results: The use of internal and external strategies to facilitate positive memory

outcomes for TBI patients is supported. A variety of internal and external strategies have

been studied with consistent positive results.

Conclusion: Both internal and external strategies should be considered for use as

compensatory techniques for memory impairments in adults with traumatic brain injuries.

The evidence presented in this paper explores a variety of internal and external strategies,

and outcomes have revealed an overall positive effect. These strategies have important

implications for clinical decision-making for improving patient quality of life after TBI.

The Utilization of Internal and External Memory

Strategies in Evidence-Based Practice

Emily Davis, MSEd, SLP-CF

Jennifer Wolff, MSEd, SLP-CF

Rebecca Murdock, MSEd, SLP-CF

Myrelsa J. Lopez, MHA, MSEd, SLP-CF

Kimberly A. Murphy, PhD, CCC-SLP

Old Dominion University

Clinical Scenario

Betty is 6 months into her clinical fellowship year as

a medical-based speech-language pathologist providing

therapy services at a hospital outpatient clinic with an

adult patient population. Patients with ongoing primary

diagnoses of motor speech and language disorders comprise

the majority of Betty’s caseload. Betty has not had much

experience working with patients with cognitive deficits

with primary impairments in memory.

A patient named John was recently added to her

caseload. John is a 49-year-old male with a traumatic brain

injury from a motor vehicle accident 1 year ago. Of his

many symptoms, the most distressing to John and his family

are his long-term and short-term memory impairments. He

can no longer consistently remember the faces of family and

friends, and he cannot safely navigate to outside errands

because he cannot remember the directions to places he

has been many times before. Betty has explained to his

family that it is possible to use compensatory techniques

for memory to improve his quality of life. However, John

expressed to Betty he has lost confidence in his abilities and

is doubtful compensatory techniques would benefit him.

Betty is interested in identifying internal and/or

external strategies that would be a good fit for John as well

as identifying the supporting scientific evidence for their

use as compensatory techniques for memory deficits. Betty

would like to find quality research evidencing whether these

strategies have had a positive impact on memory outcomes

and whether there is evidence to support either internal or

external memory strategies as more effective. Betty tells John

that she understands his concerns, and they will discuss

whether compensatory techniques would be appropriate for

him after she reviews the research literature.

Background Information: Adults

With Traumatic Brain Injury

The American Speech-Language-Hearing Association

(ASHA) calls traumatic brain injury (TBI) “an insult to

the brain caused by an external force” (Dennis, 2009).

TBI can result from a wide variety of initiating events and

present with a wide variety of symptoms, but memory

impairment is one of the most common manifestations.

The degree of memory impairment an individual may

suffer depends on the exact manner and place in which the

brain was damaged. Short-term and long-term memory

may be affected in different ways, and in some instances it

may appear that one type of memory was left untouched

while another was critically impacted. The variability of

patient characteristics regarding severity of injury and

severity of memory impairment brings about this question:

Can internal and/or external memory strategies benefit

the majority of this patient population, and is one type of

memory strategy (i.e., internal or external) more effective

than the other?

This brief explores both internal and external strategies

practiced as memory compensation techniques. Internal

strategies involve mental manipulations that promote

retention of select stimuli (O’Neil-Pirozzi et al., 2010). They

include mnemonic devices, such as counting, repeating,

categorization, face–name associations, visualization, and

rhyming methods that “facilitate storage and retrieval”

from short- and long-term memory (Perna & Perkey,

2016). Internal strategies may target a specific task, such as

formation of an acronym to recall a regimen, or they may

be more general, such as the use of visual imagery to recall

useful information and assist with completion of functional

daily tasks (O’Neil-Pirozzi, Kennedy, & Sohlberg, 2016).

The Utilization of Internal and External Memory

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External strategies, on the other hand, reduce the cognitive

load on an individual using external aids, which may include

personal electronic planners, scrapbooks, timers, checklists,

and a wall or pocket calendar to store and reclaim short- and

long-term memories (Perna & Perkey, 2016).

Clinical Question

In Betty’s initial search for evidence, she wanted to

know if the efficacy of internal memory strategies was

greater than that of external memory strategies so that

she could determine the best type of strategy to use in her

intervention with John and future clients with similar needs.

She searched for studies that included evidence for both

strategies. It is widely accepted that using internal/external

memory strategies results in positive memory outcomes for

specific memory tasks and activities of daily living. However,

there is a lack of research comparing internal strategies to

external strategies. The existing body of evidence compares

the memory outcomes for compensatory memory strategies

(either internal or external) to memory outcomes in

control groups that received alternative treatments (such as

spaced retrieval and errorless learning) or no intervention.

Therefore, Betty changed her clinical question to reflect the

existing body of data so that she could have a foundation to

make the best clinical decision.

Betty used the PICO (population, intervention,

comparison, outcome) format to develop the following

question to guide her review of the research: Would an adult

with cognitive linguistic impairments because of traumatic

brain injury (P) benefit from the use of internal and/or

external memory strategies (I), as compared to an alternative

or no intervention (C), as shown by improvements in

memory outcomes (O)?

Search for the Evidence

Betty’s inclusion criteria required using internal/

external strategies as primary interventions, a majority

adult population with memory deficits secondary to a

traumatic brain injury diagnosis, and measurement of

memory outcomes. Additionally, articles needed to provide

an intervention and be published in peer-reviewed journals.

In following the line of her PICO question, Betty sought

out studies that focused primarily on internal and external

interventions. Subsequently, cognitive rehabilitation

studies where internal/external strategies were only part of

a bigger whole were excluded. Further exclusion criteria

applied to Betty’s search were: studies conducted or

published in a language other than English, patients with

neurodegenerative comorbidities, and studies conducted

before the year 2000 to ensure quality research standards.

Betty used these criteria when searching for relevant articles

within the following databases and resources: comprehensive

EBSCOhost database search (i.e., ERIC, Academic

Search Complete, Psychology and Behavioral Sciences

Collection, Education Source), speechBITE, Cochrane

Library, PubMed, PsycINFO, PsycBITE, and the ASHA

Practice Portal. The search terms were: traumatic brain

injury OR TBI, intervention OR treatment OR therapy,

cognit*, memory, internal strateg* OR external strateg*.

Betty read titles and abstracts to determine relevance to

her PICO question. This search returned 55 articles. Betty

also manually searched the references from two systematic

reviews that she found, but no new studies were added to

her total pool of articles. Table 1 presents the 11 studies

that met Betty’s eligibility criteria and were relevant to

her review. Two of these studies were systematic reviews,

seven were group comparison studies, and two were single

group designs. These 11 studies are further explored and

summarized in the following section.

Evaluating the Evidence

After Betty collected these 11 articles, she evaluated

their quality. She knew that there were rating scales she

could use to evaluate the methodological quality of the

studies and therefore the overall body of evidence. For the

systematic reviews, she chose the Evidence in Augmentative

and Alternative Communication (EVIDAAC) Systematic

Review Scale (Schlosser et al., 2008), and for the group

design studies, she chose the PEDro-P scale, which is a

version of the Physiotherapy Evidence Database (PEDro;

Maher, Sherrington, Herbert, Moseley, & Elkins, 2003)

modified by PsycBITE. Table 2 presents review criteria for

the EVIDAAC and PEDro-P scale.

The most recent review, by O’Neil-Pirozzi and

colleagues (2016), investigated the use of internal strategies

to improve memory outcomes for individuals with

traumatic brain injury. Forty-six studies were included in

the review, with a total of 1,143 participants. From the total

population, 84% of participants across studies had sustained

traumatic brain injuries. Of the studies that reported time

post-injury, time since onset was greater than 1 year for

The Utilization of Internal and External Memory

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54% of the participants. Most of the studies reported age

information, with a range of 8–86 years old. A variety of

specific and generalized internal strategies were used across

studies. The overall findings across studies suggest that

participants with brain injury benefit from internal strategy

training. O’Neil-Pirozzi et al. (2016) examined the quality

of the studies to determine the strength of the evidence.

Strength of evidence was enough to satisfy requirements for

being a Practice Guideline. The EVIDAAC rating for this

study was 11/14.

The second systematic review by Sohlberg et al. (2007)

focused on using external aids as a memory compensation

technique for individuals with brain injury. This review

examined 21 articles for key information about population

characteristics, types of interventions, outcomes, and

methodological quality. There was a total of 270 participants

across studies, the majority of whom were adult males,

with chronic post-injury memory deficits. Although there

were varied etiologies of brain injuries, the inclusion

criteria required studies to have at least one TBI subject

(with one exception). The TBI subpopulation was also the

largest across studies. The types of external aids used in

the studies varied, but the most common were memory

notebooks. This may have been because electronic devices

were too complex for persons with severe memory problems.

Outcomes of the studies collectively support using external

aids for memory compensation following TBI. The strength

of this evidence supports using external memory aids for

memory compensation following brain injury as a Practice

Guideline. The EVIDAAC rating for this study was 7/14.

A randomized controlled trial by Lannin et al. (2014)

investigated the effectiveness of using handheld computers

to improve memory in individuals who had memory

functioning impairment after an acquired brain injury. The

study’s 42 participants had the following characteristics:

older than 17, diagnosis of acquired brain injury, and

functional memory impairment. The participants were

split into an experimental group and a control group. The

experimental group was given a personal digital assistant

(PDA) with training and had to complete five training

modules within 8 weeks. The control group was trained

by an occupational therapist to use nonelectronic memory

strategies. There were significant differences between the

outcomes of the two groups. The individuals who used

the PDAs demonstrated fewer memory failures with less

frequency of forgetting per caregiver questionnaire. This

study was rated 8/10 on the PEDro-P scale.

Another randomized controlled trial (O’Neil-Pirozzi

et al., 2010) examined the effects of internal memory

rehabilitation strategies on participation within a memory

group intervention study of individuals with acute,

moderate, and severe memory impairments secondary to

traumatic brain injury. The internal memory interventions

used in the study included categorization and clustering

(e.g., semantic associations), auditory and visual imagery,

and semantic elaboration/chaining. There were 94 total

participants in the study, consisting of middle-age women

and men. Each had endured a traumatic brain injury within

the past 12 months and noted difficulty with memory after

the traumatic brain injury. After treatment, improvement

was noted in semantic associations and overall memory

functioning. The PEDro-P rating for this study was 3/10.

Schefft, Dulay, and Fargo (2008) compared the efficacy

and generalization effects of an external learned memory

strategy (i.e., passive participation) and a self-generated

memory strategy (active participation) in 40 adults with

average ages of 31 years and 34 years for each intervention

group. Participants had suffered a closed-head TBI between

6 weeks and 2 years earlier, with memory deficits ranging

from mild to severe. Half the participants were allocated to

the read-condition group in which they were given a pair of

words presented graphically and verbally and were told the

rule that connects the pair. These semantic rules included

synonyms, antonyms, category, association, and rhyme. The

other half of the participants were allocated to the generate-

condition group in which they were given one word, the

first letter of the second word, and the rule that connects

them. The participants were asked to generate the second

word. Both groups were then presented with the first word

of a word pair and asked to recall the second word. Analysis

of the results demonstrated significant effects on improving

recognition memory for the generate condition when

compared to the read condition. Research indicates that the

use of the generate condition in therapy can be generalized

for real-world application tasks (Schefft et al., 2008). The

PEDro-P rating for this study was 3/10.

Kaschel et al. (2002) compared the impacts of visual

imagery training versus pragmatic memory training

on memory outcomes for patients with mild memory

impairment. Twenty-one participants, with primarily closed-

head injuries and a mean age of 36.6 years, completed the

study. Participants were randomly assigned to intervention

groups receiving either the visual imagery training or the

pragmatic training. Study outcomes showed significant

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improvement in short- and long-term retention of verbal

material for the visual imagery group but no improvement

was observed in the pragmatic memory training group

outcomes. Improvements in relatives’ ratings of memory

problem occurrences were also only significant for the visual

imagery intervention group. These improvements were still

seen at the 3-month follow-up, which suggests maintenance

of functional verbal memory changes. The PEDro-P rating

for this study was 5/10.

Wilson, Emslie, Quirk, and Evans (2001) evaluated

whether using a paging system affected the ability of

subjects with memory and/or organizational problems

because of brain injury to complete everyday tasks. This

randomized control, crossover design study collected

complete data from 143 participants with memory and/

or planning/organizational problems. The largest subgroup

in the population was made up of persons with traumatic

brain injuries. Other brain injury etiologies were from

stroke, other acquired nonprogressive conditions, and

concomitant conditions. The mean age of participants was

38.57 years with an average of 4.9 years passed since brain

injury. Results indicate that using the paging system helped

84.6% of participants carry out more daily tasks. It also

suggests there is some maintenance of this improvement in

functioning for at least 7 weeks following pager use. The

PEDro-P rating for this study was 3/10.

A subsequent paper by Wilson, Emslie, Quirk, Evans,

and Watson (2005) disaggregated the data from the 2001

study to evaluate the results of the TBI subgroup. There

were 63 participants in the TBI group (mostly male), with

an age range of 8–83 years old. The average time since

injury was 5.3 years. Outcomes from the study showed

that 81% of the TBI participants had significant success

completing more target tasks when using the paging system

than at baseline.

A quasi-experimental study by Bourgeois, Lenius,

Turkstra, & Camp (2007) compared the treatment effects

of two interventions for improving memory in 38 adults

who had suffered a TBI at least 1 year before treatment

and had persistent memory problems ranging from mild

to severe. The two treatments were spaced retrieval (SR)

and didactic strategy instruction (SI), both provided via

teletherapy. Therapy sessions for the participants in the

SI group included discussions, such as written reminders,

association, verbal rehearsal, and imagery. Both treatments

resulted in fewer instances of memory problems over time;

however, there were limited generalization effects per

participant report. No significant effects on quality of life

were observed. The PEDro-P rating for this study was 2/10.

A single group research design by Perna and

Perkey (2016) examined the effects of internal memory

rehabilitation strategies on individuals with acute,

moderate, and severe memory impairments secondary to

traumatic brain injury. Internal memory strategies, such as

word associations, semantic clustering, mnemonics, and

visualization, were used during intervention activities. The

11 participants in this pilot study had endured a traumatic

brain injury within the 12 months before the start of the

study. Five weeks after treatment, significant improvement

over pretest was found in immediate free recall and delayed

free recall for word lists and story memory (immediate

recall). Each participant also reported improved memory.

In another single-group design, Melton and Bourgeois

(2005) explored the feasibility and efficacy of teaching

memory strategies over the telephone. They used spaced

retrieval to train participants to remember to use external

memory strategies (e.g., PDA, notebook and pen, routine

location) and to recall functional information (e.g., phone

number). The study included seven participants with an

age range of 33–56 years who presented with memory

deficits because of TBI. Memory goals were provided by

the patients and/or their families. The results indicate

that all participants attained their memory goals. Spaced

retrieval approach memory goals were 94.4% maintained,

and strategy execution on the goals trained was 77.7%

maintained. The authors concluded that spaced retrieval

intervention by phone helped facilitate the use of external

strategies. Results also revealed that 94% of goals were

maintained at the 1-month follow-up after treatment, and

the researchers concluded that phone intervention was a

viable method of therapy practice.

To assess the methodological quality of the papers

collected, Betty used the EVIDAAC for the two systematic

reviews and the PEDro-P for the seven group comparison

studies. Tables 3 and 4 show that the specific item ratings

and total scores varied across studies. Betty recognized,

however, that quality inconsistencies may be partly due

to changes in quality standards that have occurred over

time. The most frequently missed criteria on the PEDro-P

were concealment of allocation, blinding of subjects,

blinding of therapists, and using an intention-to-treat type

analysis; only one paper or no papers satisfied these criteria.

The EVIDAAC criteria that were most frequently missed

were: whether attempts to locate unpublished studies were

The Utilization of Internal and External Memory

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made, whether search terms were stated for each database,

and whether a log of rejected studies were reported or made

available to the reader. Neither paper satisfied these criteria.

Although the methodological ratings of the studies were not

consistently high, the overall strength of the evidence points

to positive clinical implications, especially considering

the findings of the systematic reviews. When collated, the

findings support using internal and external strategies as

tools to compensate for memory deficits.

e Evidence-Based Decision

Betty considered the information she collected from

the studies and the quality of the evidence. Betty’s clinical

question was: Would an adult with cognitive linguistic

impairment because of traumatic brain injury benefit from

the use of internal and/or external memory strategies, as

shown by improvements in memory outcomes? In the

studies presented, the experimental populations consisted

primarily of adults who had been diagnosed with TBI and

presented with a primary deficit of memory impairment.

The 11 studies Betty reviewed suggest positive memory

outcomes for adult patients with TBI.

At their next session, Betty shared the results of her

investigation with John and his family. She explained the

research supporting using internal and external strategies

to improve memory outcomes in activities of daily living

and how those same strategies might benefit John and his

family. John had previously expressed a lack of confidence

in the ability of compensatory techniques to meet his

daily functional needs, and Betty knew from her clinical

experience that patient buy-in is an important factor for

therapy success. She thought that if she could find situations

where John was successful in using his memory, then any

techniques he already used could be scaffolded to future

compensatory strategies. Betty asked John and his family

to describe things that were easier for him to remember

and what he did to remember the targeted information.

She listened to what worked for John and his family and

counseled them on how internal and/or external strategies

could be tailored to fit his needs. John and his family were

excited to discuss memory aids that could be built into

his routine using familiar tools, such as his cell phone and

address book.

Betty reflected on how best to integrate evidence-based

practice (i.e., external scientific evidence, clinical expertise,

and client/patient/caregiver perspectives) to create a plan of

care with John and his family. Everyone agreed that using

a combination of internal and external strategies in therapy

could help to address the memory deficits affecting his

quality of life. Betty used her clinical expertise to help John

select specific strategies that would be most beneficial to his

goals. She also used her clinical knowledge to select the best

training method to teach the selected strategies. Because

of her research, Betty felt confident in using internal and

external strategies to address John’s memory deficits. John

and his family found the research encouraging and were

motivated to begin using these strategies. Betty made further

plans to incorporate John’s use of strategies in a variety of

situations and environments to promote maintenance and

carry-over.

Authors’ Note

Emily Davis, MSEd, SLP-CF, is a communication

science and disorders graduate from Old Dominion

University. She graduated with a BS in neuroscience with a

minor in linguistics from the College of William & Mary.

Jennifer Wolff, MSEd, SLP-CF, is a communication

science and disorders graduate from Old Dominion

University. She graduated with a BA, BFA, and BS in

French, graphic design, and art education from Kansas State

University.

Rebecca Murdock, MSEd, SLP-CF, is a communication

science and disorders graduate from Old Dominion

University. She graduated with a BA in French with a minor

in linguistics from the University of Virginia.

Myrelsa J. Lopez, MSEd, is a communication science

and disorders graduate from Old Dominion University.

Kimberly A. Murphy, PhD, CCC-SLP, is an assistant

professor in the Department of Communication Disorders

and Special Education at Old Dominion University. She

teaches the graduate class on evidence-based research in

speech-language pathology where the first draft of this paper

was written.

Corresponding author:

Kimberly A. Murphy

4501 Hampton Blvd.

Old Dominion University

Norfolk, VA 23529

[email protected]

The Utilization of Internal and External Memory

Strategies in Evidence-Based Practice

EBP Briefs Volume 14, Issue 1

November 2019

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evaluate a paging system for people with traumatic

brain injury. Brain Injury, 19(11), 891–894.

doi:10.1080/02699050400002363

The Utilization of Internal and External Memory

Strategies in Evidence-Based Practice

EBP Briefs Volume 14, Issue 1

November 2019

Table 1. Summary of Articles Selected for Review

Authors

and year Title Population

Intervention

strategies

Outcomes/

Findings

Quality

ratings

Bourgeois, M.

S., Lenius, K.,

Turkstra, L., &

Camp, C.

(2007)

The effects of

cognitive teletherapy

on reported everyday

memory behaviours

of persons with

chronic traumatic

brain injury

n = 38

TBI > 1 year before

intervention

Persisting memory

problems

Spaced retrieval (SR)

vs.

Didactic strategy

instruction (SI); for

example, written and

auditory reminders and

elaboration

(external and internal

strategy)

No statistically significant

effect sizes between groups

SR subjects mastered their

goals more quickly than SI

subjects

Both groups reported

generalization to nontargeted

behaviors

PEDro-P

2/10

Kaschel, R.,

Della Sala, S.,

Cantagallo, A.,

Fahlböck, A.,

Laaksonen, R.,

& Kazen, M.

(2002)

Imagery mnemonics

for the rehabilitation

of memory: A

randomised group

controlled trial

n = 21

57% TBI

Brain injury > avg. 5

years prior

Mean age 42 years

Majority male

Mild memory

impairment

Visual imagery

mnemonic training

(internal strategy)

vs.

Pragmatic training

control group

Significant improvements

in the visual imagery group

for short- and long-term

retention of verbal material,

positive effects seen at

3-month follow-up

Relatives’ ratings of

frequency of memory

problems for the imagery

group improved but not for

the pragmatic group

Lack of changes in the

pragmatic control group

PEDro-P

5/10

Lannin, N.,

Carr, B., Allaous,

J., Mackenzie,

B., Falcon, A., &

Tate, R.

(2014)

A randomized

controlled trial of

the effectiveness of

handheld computers

for improving

everyday memory

functioning

in patients

with memory

impairments after

acquired brain injury

n = 42

Personal digital assistant

with occupational

therapy

(external strategy)

vs.

Control group trained

with nonelectronic

memory strategies with

occupational therapy

(external strategy)

Instances of functional

memory failure significantly

decreased

Significant decrease in

number of instances of client

forgetting in caregiver report

PEDro-P

8/10

Melton, A., &

Bourgeois, M.

(2005)

Training

compensatory

memory strategies

via the telephone for

persons with TBI

n = 7

Patients were trained

to use memory aids

using spaced retrieval

techniques via telephone

(external strategy)

Memory goals were attained

and generalized after five

30-minute sessions

Not rated

O’Neil-Pirozzi

et al.

(2010)

A controlled

treatment study of

internal memory

strategies (I-MEMS)

following traumatic

brain injury

n = 94

Categorization and

clustering (e.g., semantic

associations), auditory

and visual imagery, and

semantic elaboration/

chaining

(internal strategies)

Individuals with mild and

moderate brain injuries

were the best candidates

for the internal memory

rehabilitation strategies,

with improvement noted in

semantic associations and

overall memory functioning.

PEDro-P

3/10

The Utilization of Internal and External Memory

Strategies in Evidence-Based Practice

EBP Briefs Volume 14, Issue 1

November 2019

Table 1. Summary of Articles Selected for Review (continued)

Authors

and year Title Population

Intervention

strategies

Outcomes/

Findings

Quality

ratings

O’Neil-Pirozzi,

T. M., Kennedy,

M. R. T., &

Sohlberg, M. M.

(2016)

Evidence-based

practice for the use

of internal strategies

as a memory

compensation

technique after brain

injury: A systematic

review

n = 1,143

84% - TBI

Of studies that

reported the

information:

54% had TBI >1 year

before intervention

Majority adult males

A variety of specific

and generalized internal

strategies

Literature base is supportive

of internal memory strategy

training

Uniformity of positive

reports indicate strategy

instruction should be part of

treatment considerations

Strength of evidence base =

Practice Guideline

EVIDAAC

11/14

Perna, R., &

Perkey, H.

(2016)

Internal memory

rehabilitation

strategies in the

context of post-acute

brain injury: A pilot

study

n = 13

First letter mnemonics,

practicing visualization,

semantic clustering,

completing worksheets

from Workbook of

Activities for Language

and Cognition, and

elaborative encoding

(internal strategies)

Improvement was noted in

story memory recall, the

immediate free recall, and

delayed free recall of word

lists

N/A

Schefft, B. K.,

Dulay, M. F., &

Fargo, J. D.

(2008)

The use of a self-

generation memory

encoding strategy

to improve verbal

memory and

learning in patients

with traumatic brain

injury

Study 1:

n = 20

Study 2:

n = 20

Closed head injury

6 weeks to 2 years

before intervention

Study 1 (Read

condition): presented

word pairs and rule that

connects them (e.g.,

synonym, category)

Study 2 (Generate

condition): presented

with one word, the first

letter of the second

word, and the rule that

connects them; the

subjects had to generate

second word.

Subjects were asked to

produce second word

when presented with the

first word with which it

is associated in the list

(internal strategy)

A self-generation

intervention (i.e., generate

condition) provides a

strong effect in improving

recognition memory and

cued recall test performance

compared with the passive

didactic presentation of

information (i.e., read

condition)

PEDro-P

3/10

Sohlberg et al.

(2007)

Evidence-based

practice for the

use of external

aids as a memory

compensation

technique

n = 270

TBI largest subgroup

Majority adult males

Significant memory

deficits

A variety of external aids

used across studies

Memory books: most

common

Studies support using

external aids to compensate

for memory impairments

Using external strategies =

Practice Guideline

EVIDAAC

7/14

The Utilization of Internal and External Memory

Strategies in Evidence-Based Practice

EBP Briefs Volume 14, Issue 1

November 2019

Table 1. Summary of Articles Selected for Review (continued)

Authors

and year Title Population

Intervention

strategies

Outcomes/

Findings

Quality

ratings

Wilson, B. A.,

Emslie, H. C.,

Quirk, K., &

Evans, J. J.

(2001)

Reducing everyday

memory and

planning problems

by means of a

paging system: A

randomized control

crossover study

n = 143

44% TBI (largest

subgroup)

Brain injury > avg. 4.9

years prior

Mean age 38.57 years

Age range 8–83 years

Majority male

Memory and/or

planning/organization

problems (unspecified

severity)

Simple paging system

(external aid) use*

vs.

Time periods of not

using the paging system

(time periods 1 and 3

for Group A and time

periods 1 and 2 for

Group B)

*Neuropage

84.6% of all participants

were significantly more

successful at achieving target

tasks when using the pager

than in baseline

Postpager data for Group

A participants (who were

significantly more successful

using the pagers) showed

they were still significantly

better than at baseline (7

weeks after returning the

pagers)

PEDro-P

3/10

Wilson, B. A.,

Emslie, H.

C., Quirk, K.,

Evans, J., &

Watson, P.

(2005)

A randomized

control trial to

evaluate a paging

system for people

with traumatic brain

injury

n = 63

TBI participants from

Wilson et al. (2001)

study

TBI > avg. 5.3 years

prior

Age range 8–65

Majority male

Memory and/or

planning/organization

problems (unspecified

severity)

Simple paging system

(external aid) use*

vs.

Time periods of not

using the paging system

(time periods 1 and 3

for Group A and time

periods 1 and 2 for

Group B)

81% of the TBI subgroup

were significantly more

successful at achieving target

tasks when using the pager

than in baseline

Postpager data for Group

A participants (who were

significantly more successful

using the pagers) showed

they were still significantly

better than at baseline (7

weeks after returning the

pagers)

PEDro-P

3/10

The Utilization of Internal and External Memory

Strategies in Evidence-Based Practice

EBP Briefs Volume 14, Issue 1

November 2019

Table 2. Review Criteria for PEDro-P and EVIDAAC Scales

PEDro-P criteria EVIDAAC criteria

Eligibility criteria presented

Subjects randomly allocated to groups

Allocation concealment

Groups similar at baseline

Subjects were blinded

Therapists were blinded

Assessors were blinded

Measures of one key outcome obtained from > 85% of subjects

initially allocated to groups

At least one key outcome measured by “intention-to-treat”

Results of between-intervention group statistical comparisons were

reported for at least one key outcome

Point measures and measures of variability provided for at least

one key outcome

Focused question presented

Search methods predefined

Multiple sources consulted

Unpublished studies located

Databases carefully selected

Search terms stated and appropriate

Inclusion/exclusion criteria predefined

Inclusion/exclusion criteria appropriate

Log of rejected studies available

Reliable study inclusion

Coding categories predefined

Data extracted reliably

Quality criteria predefined and appropriate

What constitutes effective treatment predefined and

operationalized

Note. PEDro-P = Physiotherapy Evidence Database, adapted by PsycBITE; EVIDAAC = Evidence in Alternative and Augmentative Communication.

Table 3. PEDro-P Ratings of Group Comparison Studies

Study

Criteria (✓ = criterion met)

Total for

criteria (2–11)1 2 3 4 5 6 7 8 9 10 11

Bourgeois et al. (2007)

✓ ✓ ✓

2/10

Kaschel et al. (2002)

✓ ✓ ✓ ✓ ✓ ✓

5/10

Lannin et al. (2014)

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

8/10

O’Neil- Pirozzi et al. (2010)

✓ ✓ ✓

3/10

Schefft et al. (2008)

✓ ✓ ✓ ✓

3/10

Wilson et al. (2001)

✓ ✓ ✓ ✓

3/10

Wilson et al. (2005)

✓ ✓ ✓ ✓

3/10

Note. PEDro-P = Physiotherapy Evidence Database, adapted by PsycBITE.

Table 4. EVIDAAC Ratings of Systematic Reviews

Study

Criteria (✓ = criterion met)

Score

total1 2 3 4 5 6 7 8 9 10 11 12 13 14

O’Neil-Pirozzi, T. M.,

Kennedy, M. R. T.,

& Sohlberg, M. M. (2016)

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

11/14

Sohlberg et al. (2007)

✓ ✓ ✓ ✓ ✓ ✓ ✓

7/14

Note. EVIDAAC = Evidence in Alternative and Augmentative Communication.