iii DEDICATION I would like to dedicate this work especially to my wife and daughter, for their undaunted faith in me. v ABSTRACT Background: Cognitive rehabilitation aims to alleviate or ameliorate cognitive deficits that have resulted from traumatic brain injury (TBI). The present study developed and evaluated a computer-assisted memory rehabilitation programme, based on a postulated EE & EL model (enriched environment and errorless learning), and through the use of comprehensive cognitive training principles for persons with TBI so as to improve their impaired memory functions. The efficacy of this computer-assisted memory rehabilitation protocol was evaluated through formative and summative tests. It was hypothesized that that positive treatment effectiveness would be exhibited in the two memory rehabilitation programme respectively (i.e. computer-assisted or CAMG; and therapist-administered or TAMG) but not in a control group (CG). Methods: A prospective pretest and posttest quasi-experimental clinical design research was carried out in two phases, i.e. pilot and main study phase. A pilot study was conducted to test out the usability of the training programmes, validity and reliability of measuring instruments and related training procedures. The pilot study involving 15 subjects with TBI gave evidence of the robust content validity and applicability of the two memory training modes. In the main study, 112 subjects were screened by selection criteria from five hospitals and one rehabilitation centre to participate. There were 28 subjects who dropped out of the study due to various reasons. Eighty-four subjects were randomly assigned into the three groups CAMG (n=30), TAMG (n=24) and CG (n=30) and they had completed 1-month, 20-session training and 1-month follow up. It was shown that there were no significant pre-training differences in age, gender, post-injury period, diagnosis, sidedness of brain injury and education level among the three groups. Outcome measures included the Chinese Version of the Neurobehavioral Cognitive Status Examination (NCSE-CV; Chan et al., 1999), the Rivermead Behavioral Memory Test–Chinese Version (RBMT-CV; Neuro-Rehabilitation Working Group, 1998; You, Han & Xu, 2003), The Hong Kong List Learning Test (HKLLT; Chan & Kwok, 1999), The Memory Functioning Questionnaire (MFQ; Gilewski, Zelinski & Schaie, 1990) and a memory self-efficacy questionnaire. vi A 20-session computer-assisted memory training package using a human-computer interaction and multimedia presentation was developed for use in CAMG. This software was tailor-made for Chinese subjects with memory disorders. In TAMG training, subjects undertook the same training structure and content as that in CAMG. Instead of delivering through a computer, the training materials were delivered by therapists through a face-to- face mode and training was guided by a colour-print training manual which included all corresponding guidelines for assessment and training instructions of each session. Statistical procedures such as repeated measures analysis of variance (ANOVA) were used to test and compare overtime trend of CAMG, TAMG and CG. They were used to evaluate the positive effect and possible carryover effects of memory performance in different time spots. Both within-group and between-group comparisons were also made on the outcome measures. A correlation analysis was also conducted to explore correlations between TBI subjects’ scores in learning strategies and memory processes. Results: Subjects in CAMG had shown improvement in sub-test items of NCSE-CV, including orientation, comprehension, repetition, naming, construction, memory, judgment (P <0.05). There were similar changes in TAMG. But there was no statistically significant difference between CAMG and TAMG. Comparing with CG, both CAMG and TAMG demonstrated a significant positive effectiveness in NCSE-CV (memory). In addition, attention was the only sub-score that did not change over time and this finding was consistent across the three groups. Some sub-scores (belonging, story-immediate, story-delay, face and total score) of RBMT-CV in both CAMG and TAMG improved (P < 0.05 to P < 0.01) but not in CG. There was also no statistical significant difference in the total score of RBMT-CV between CAMG and TAMG. Significant positive changes of HKLLT sub-score related to memory process were identified in both CAMG and TAMG (P < 0.05 to P < 0.01). But CAMG demonstrated a more significant positive effectiveness (P < 0.05) than TAMG in encoding and storage (in both testing conditions of random and blocked). Concrete concept commonly correlated with the encoding and storing (random condition) in both CAMG and TAMG. Abstract vii concept correlated with storing and retrieval (random condition); and with encoding (blocked condition) in both CAMG and TAMG. In addition, semantic clustering correlated with storing (random and blocked conditions). When comparing MFQ over time and across the three groups, it was found that there were significant differences between CAMG and CG as well as between TAMG and CG (P < 0.05 to P < 0.01). After training, significant differences in memory self-efficacy questionnaire were identified in areas of memory competence, evaluation of programme, and more significantly improvement was found in TAMG than CAMG (P < 0.0001). Conclusion: The present study revealed that errorless learning is likely to be an effective method to improve memory performance and function following traumatic brain injury. This memory training mode may affect the whole memory process including encoding, storage and retrieval, and may produce a better carryover treatment effect up to a month. Significant positive correlation was found between subjects’ encoding, storage of memory process and learning strategy factors (semantic clustering, subjective organization ability, concrete and abstract concepts). Self-efficacy enhancement was found better in TAMG than CAMG. This benefit might extend to family and/or care- givers who may experience relief, reduced anxiety, and pride when subjects’ improvements in functioning, after training, can be evidenced in the daily activities of the participants. viii PUBLICATIONS ARISING FROM THE THESIS Refereed journal publication: 1. Dou, Z.L., Ou, H.L., Zheng, J.L., Man, D.W.K. and Tam, S.F. (2006). Computerized errorless learning-based memory rehabilitation for Chinese patients with brain injury: a preliminary quasi-experimental clinical design. Brain Injury, 20(3), 219-225. 2. Dou, Z.L., Ou, H.L., Man, D. W. K., Tam, S. F., and Hui-Chan, C. W. Y. (2006). The effect of errorless learning on memory process for patients with brain injury: A initial study. Neurorehabilitation & Neural Repair, 20(1), 89 3. Dou, Z.L., Ou, H.N., Man, D.W.K. and Zheng, J.L. (2005). The application of errorless learning in memory rehabilitation on memory deficit following brain injury: A preliminary quasi-experimental clinical design study. Chinese Journal of Clinical Rehabilitation, 9 (1), 84-87. 4. Dou, Z.L., Man, D. W.K, Tam, S.F and Hui-Chan, C.W.Y. (2005). Computerized memory rehabilitation programmes for persons with traumatic brain injury: New development and evaluation. Brain Injury, 19 (Suppl 1), 31. 5. Dou, Z.L., Man, D. W.K., Tam, S.F. and Chan, C.W.Y. (2004). Community-based cognitive rehabilitation service for population with traumatic brain injury in China. International Journal of Rehabilitation Research, 27(1), 81-84. 6. Dou, Z.L., Man, D.W.K. and Au, H.N. (2004). Rehabilitation of attention deficits. Chinese Journal of Rehabilitation Medicine, 19(4), 307-310. 7. Dou, Z.L., Man, D.W.K., Zhu, H., Tam, S.F., & Hui-Chan C.W.Y. (2003). Feasibility investigation of cognitive rehabilitation service after traumatic brain injury in community. Chinese Journal of Rehabilitation Medicine, 18(5), 266-268. 8. Dou, Z.L., Man, D.W.K. and Ou, H.N. (2003). Cognitive rehabilitation and theoretical foundations in persons with brain injury: Part I. Chinese Journal of Rehabilitation Medicine, 18(10), 625-626. 9. Dou, Z.L., Man, D.W.K. and Tam, S.F., (2003). The development of tele- cognitive rehabilitation. Chinese Journal of Physical Medicine and Rehabilitation, 25(9), 568-571. ix 10. Dou, Z.L., Man, D.W.K., Tam, S.F. and Hui-Chan, C.W.Y. (2003). Cognitive rehabilitation of persons with brain injury: PR China scene. Brain Injury, 17 (Suppl 1), 169-170. 11. Dou, Z.L. (2003). Tele-rehabilitation and its application in Hong Kong. Chinese Journal of Physical Medicine and Rehabilitation, 25 (12), 761-762. 12. Ou, H.N. Dou, Z.L. (2005). The application of errorless learning on memory disorders rehabilitation. Journal of Chinese Rehabilitation Medicine, 29(4), 312- 314. 13. Man, D.W.K., Dou, Z.L., Tam, S.F. and Hui-Chan C.W.Y. (2004). Efficacy of computer-assisted memory rehabilitation program for persons with traumatic brain injury: Development and evaluation. Brain Impairment, 5 (suppl), 173. Refereed journal submissions: 1. Dou, Z.L., Man, D.W.K., Tam, S.F., Ou, H.N. and Hui-Chan, C.W.Y. (2005). The effectiveness of an errorless learning- (EL) and computer-based training programme in memory rehabilitation for those with traumatic brain injury: An initial study. Neuropsychological Rehabilitation (under review). 24 pages. 2. Dou, Z.L., Ou, H.N., Man, D.W.K., Zheng J.L., Tam, S.F. and Hui-Chan, C.W.Y. (2005). The effect of errorless learning on memory process for patients with brain injury. Journal of Chinese Physical Medicine and Rehabilitation (under review). 16 pages. Refereed conference presentations: 1. Dou, Z.L., Ou, H.N., Man, D.W.K., Zheng J.L., Tam, S.F. and Hui-Chan, C.W.Y. (2005). The effect of errorless learning on memory process for patients with brain injury. 2005 International Conference on Occupational Therapy, September 16- 21, 2005. Qingdao, China. (Oral presentation, Best paper-Golden reward). 2. Dou, Z.L., Ou, H.N., Man, D.W.K., Zheng J.L., Tam, S.F.