J Neurol (2006) 253 : 520–521DOI 10.1007/s00415-006-0014-5 SHORT COMMENTARY

Jonathan J. Evans Memory rehabilitation – should we beaiming for restoration or compensation?

A commentary on Hildebrandt et al. “Group therapyfor memory impaired patients. A partial remediationis possible.” in J Neurol (2006) 253:512–519

Memory impairment is a common consequence of neu-rological injury or disease, causes significant disabilityand is therefore a critical target for rehabilitation inter-vention. Whether cognitive rehabilitation should aim toreduce impairment or to compensate for the impair-ment is a question that has exercised the rehabilitationcommunity, but in relation to most cognitive functionsremains largely unresolved. For some disorders (e. g.unilateral neglect) there is evidence that interventionsspecifically targeted at modifying relevant cognitive sys-tems are effective [1].

However, for memory rehabilitation, there has, todate, been no substantial evidence that memory can beimproved through restitution-oriented therapies andhence compensatory approaches (e. g. use of externalmemory aids, or application of compensatory learningstrategies) are the treatment of choice [1, 2]. However,this conclusion is largely based on the absence of evi-dence rather than evidence of absence of an effect ofrestitution oriented therapies [2].

As a result of the paucity of evidence comparingrestitution-oriented and compensation approaches tomemory rehabilitation, the paper by Hildebrandt et al. iswelcome. I will argue, however, that caution is required

in drawing conclusions with regard to clinical practicefrom this study. Hildebrandt et al’s study comparedthree interventions for patients with organic memoryimpairment. One group underwent an intensiveprocess-oriented treatment (POT) with a focus on prac-tice at learning word lists (emphasising encoding strate-gies, repetition, and rehearsal). A second group receivedmemory strategy training (ST), including associationalstrategies (i. e. face-name learning), various encodingstrategies and use of external aids.A third control groupreceived a similar training to the POT group, but withlower intensity. Outcome measures were neuropsycho-logical tests of memory, attention and verbal fluency.The results showed that the low intensity treatment con-trol group did not improve significantly on any measure.Both of the high intensity treatment groups showed im-provement on a range of measures of memory function-ing, but the POT group improved on a greater number oftests including a measure of free recall and a measure ofattention. There was therefore evidence of a dose-de-pendent effect for memory rehabilitation and theprocess-oriented treatment was, overall, more effective.

Hildebrandt et al. acknowledge that their study haslimitations, particularly in terms of the outcome mea-sures used. Rehabilitation is ultimately concerned withthe ability of individuals to participate in valued activi-ties. Psychometric measures of cognition are useful, butlimited, tools for the evaluation of cognitive rehabilita-tion. Restitution-oriented treatments may be better atimproving performance on psychometric tests (whichare typically close in form to training tasks) than strat-egy training. However, compensatory strategy trainingmay be better at increasing functioning in activities ofdaily living than restitution oriented therapies. If thiswere the case, it would be reasonable to conclude thatlimited rehabilitation resources should be focused oncompensatory strategy training. Hildebrandt et al.’s pa-per helpfully highlights that this issue is not yet resolved,and requires further systematic examination.JO

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Received: 27 May 2005Accepted: 27 May 2005

Prof. Jonathan J. Evans (�)Academic CentreGartnavel Royal HospitalGlasgow, G12 0XH, UKTel.: +44-0141/211-3978E-Mail: jje2k@clinmed.gla.ac.uk

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1. Robertson IR (1999) Setting goals forrehabilitation. Curr Opin Neurol 12:703–708

2. Cicerone KD, Dahlberg C, Kalmar K,et al. (2000) Evidence based cognitiverehabilitation: recommendations forclinical practice. Arch Phys Med Rehabil81:1596–1615

References

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