Investigating the effects of repetition and guided relaxation on

memory retention and recall in non-brain injured participants

Student: Brittany N. Jordan

Supervisor: Prof. J. Opacka-Juffry

MSc Clinical Neuroscience

Department of Life Sciences

University of Roehampton, London

 “How important is memory? Imagine if we were without it. We wouldn’t recognize

anyone or anything familiar. We would be unable to talk, read, or write, because we

would remember nothing”

(Eysenck & Keane, 2010).

2
Acknowledgements

I would like to thank Professor Jolanta Opacka Juffry for her expert advice,

encouragement and support throughout this dissertation process. Also I would like to

thank Dr. Sarah Crawford and the staff of the Royal Hospital for Neuro-disability for

their collaboration and support.

3
Table of Contents
INTRODUCTION...........................................................................................................................8
1.1 MEMORY ARCHITECTURE.................................................................................................8
SENSORY MEMORY............................................................................................................................10
SHORT-TERM MEMORY................................................................................................................... 13
WORKING MEMORY.........................................................................................................................17
LONG-TERM MEMORY..................................................................................................................... 20
MEMORY PROCESSES.......................................................................................................................21
1.2 NEUROBIOLOGY OF MEMORY.......................................................................................22
AT THE SYNAPSE.............................................................................................................................. 25
1.3 ACQUIRED BRAIN INJURY AND MEMORY.....................................................................26
1.4 MEMORY BOOSTS..............................................................................................................29
REPETITION...................................................................................................................................... 29
RELAXATION.................................................................................................................................... 32
RATIONALE................................................................................................................................34
HYPOTHESES.............................................................................................................................35
METHODOLOGY........................................................................................................................36
ETHICS............................................................................................................................................... 36
DESIGN.............................................................................................................................................. 36
SAMPLE.............................................................................................................................................. 37
MATERIAL......................................................................................................................................... 39
PROCEDURE....................................................................................................................................... 42
PATIENT PROCEDURE.........................................................................................................................47
STATISTICAL ANALYSIS.....................................................................................................................51
RESULTS......................................................................................................................................52
DISCUSSION................................................................................................................................63
CURRENT VS PAST FINDINGS....................................................................................................66
DESIGN EVALUATION AND LIMITATIONS..........................................................................71
CONCLUSION.............................................................................................................................72
REFERENCES..............................................................................................................................73
APPENDICES...............................................................................................................................82

4
List of Tables

Table I…………………………………………………………………………………..42

Table 1………………………………………………………………………………….51

Table 2………………………………………………………………………………….58

5
List of Figures

Figure I…………………………………………………………………………………...9

Figure II………………………………………………………………………………...19

Figure III……………………………………………………..........................................46

Figure 1…………………………………………………………………………………53

Figure 2…………………………………………………………………………………54

Figure 3…………………………………………………………………………………55

Figure 4…………………………………………………………………………………57

Figure 5…………………………………………………………………………………58

Figure 6…………………………………………………………………………………60

Figure 7…………………………………………………………………………………61

Figure 8…………………………………………………………………………………62

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Abstract

The cumulative strength hypothesis posits that the repetition of an experience

strengthens the memory trace developed during the initial experience. Thus, repetition
has been assessed as a means by which memory can be enhanced. A few studies also
suggest that a period of relaxation after learning new information allows for minimal
interference thereby alleviating forgetting. The current study investigated how the
repetition of information in the encoding phase, and a period of guided relaxation after
learning new information can affect memory recall on a short term and long-term basis
in a healthy population. Additionally, data was assessed from one patient who has
suffered a hypoxic brain injury. The recall scores of two stories which have been
matched for readability were recorded at 3 different time intervals; immediately, 15
minutes and 24-hours. We found that scores from the repetition condition were better,
despite the interference period, than scores from the relaxation condition. Overall, 71%
of participants maintained ≥100% 24-hour memory retention in the repetition condition
versus 21.8% of participants in the relaxation condition. Due to these findings it is
concluded that repetition during the encoding phase enhances memory recall, but
relaxation after the encoding phase does not. It is proposed that the relaxation condition
of this study be investigated separately against a control population to assess if the
effects of guided relaxation on interference-based forgetting.

7
Introduction

Memory is the process by which information is stored in the brain and retrieved. Vital to

experience, and laying at the base of personal identity, memory is arguably one of the

most key cognitive processes as it is utilized constantly in our everyday lives. Decades

of neuropsychological research has been aimed towards elucidating the construct of

human memory. Several theories highlight the architecture of memory; how it is

structured, i.e. the stages, and also the processes of memory; what takes place during the

various stages. Further research has also aimed to highlight the neurological processes

which underpin memory and forgetting. There are several things which can affect

human memory including age, illness and injury. Amongst these is acquired brain

injury, which affects thousands of people yearly and can result in long term cognitive

deficits, inclusive of, but not limited to, memory issues. With advancements in memory

research insight has been provided into manipulations which may aid in boosting

memory recall. The present study investigates how repetition and guided relaxation may

affect memory recall.

1.1 Memory Architecture

Several theories have been put forward on how the phenomenon of memory is

constructed. Some theorists propose a multi-store approach which highlights several

different memory capacities, while some others posit a unitary-store approach which

asserts that some stores can be grouped into one single store as they function

8
interchangeably. Arguably, multi-store models are more widely accepted and highlight

three main memory capacities: sensory memory, short-term memory and long-term

memory.

Figure I: Simplified illustration of the multi-store model of memory showing memory types and

processes.

One of the most influential multi-store theories of memory was proposed by

Richard Atkinson and Richard Shiffrin in 1968. They proposed that memory is

ultimately structured into a three-store format where information passes in a linear way

from one memory capacity to the next (Atkinson & Shiffrin, 1968). As we encounter

stimuli in our daily environment this information is held in the sensory memory store.

Due to the bounty of information which passes into our sensory memory stores, if not

paid attention to the information quickly decays and is forgotten within a short time

9
frame. However, if attention is paid to selected information, this information moves to

the short-term memory store. Continued rehearsal of this information allows for it to

then enter long term memory, where it can be stored for extended periods of time & can

where it can be recalled into the short-term memory store at a later date. Thus, the

duration of which information lasts varies depending on the memory store to which it

lies. Contrary to this, unitary store models of memory are based on the notion that there

is no distinction between the short term and long term memory stores, but instead, they

assert that “short term memories consist of temporary activations of long term

memory,” thus making them both one memory store (Jonides, et al., 2008).

Sensory Memory

Stimuli from the environment are received via the sensory system (sight, hearing,

touch etc.) and assessed via the sensory memory store. This memory store is “pre-

attentive” and stimuli enters regardless of if the information is paid attention to or not

(Neisser, 1967). Information is held in the sensory memory store for very short periods

of time, ranging from 50 milliseconds to 5 seconds, after which they rapidly fade

(Atkinson & Shiffrin, 1968) (Sperling, 1960). Though the terms ‘sensory memory’ or

‘sensory store’ is used to refer to information derived from all of the senses, those from

the visual and auditory systems have been researched the most. The visual store of

sensory memory is referred to as ‘iconic memory’. In 1960, Sperling highlighted how

10
this branch of memory operates. Displaying rows of letters for 50 milliseconds, Sperling

asked participants to relay as many letters as they could remember. Typically, the

participants reported 4-5 letters, therefore, it was assumed that the limited number of

letters which participants could recall was due to the fact that the information they had

seen had faded before they could report it (Sperling, 1960). Thus, Sperling’s findings

suggested that iconic memory was fast decaying, with information lasting only about 0.5

seconds (Sperling, 1960). More recent research on visual sensory memory have been

aimed at analyzing the make-up of visual perception and how information is passed

from this memory capacity on the others. One study, investigating the capacity of the

different stages of the visual memory store via change detection tasks, found that in

iconic memory participants recalled 6.1 objects versus 4.6 objects in visual short-term

memory and 2.1 objects in visual working memory (Sligte, et al., 2010)

Öğmen and Herzog argue that the iconic memory store previously discussed in

earlier studies posit that the memory type is retinoptically encoded (encoded based on

“how the stimulus is projected onto the retina) and therefore has a limited working

capacity for when the person or stimulus is stagnant but can produce very little useful

information if either is in motion (Öğmen & Herzog, 2016). To address this, they have

recently put forward a new conceptualization of iconic memory, where they introduce a

non-retinoptic motion based aspect of visual sensory memory, which they assert is not

susceptible to ‘the masking effect” (when the introduction of a new stimulus into the

visual field reduces the visibility of another stimulus), but instead posits that the

11
incoming visual information is grouped based on common pattern of motion, where

visual groups can be updated as directional changes occur (this is based on the Gestalt

common fate grouping principle) (Öğmen & Herzog, 2016).

The memory store associated with the auditory system is referred to as ‘echoic

memory.’ Echoic memory last bit longer than iconic memory. Unlike visual stimuli

which can be repeatedly scanned, only one set of auditory stimuli can be perceived at a

given time. Thus, while the eyes can filter several stimuli present in the surrounding

environment, persons can only hear one set of sound which will resonate in their mind

until another sound is made (Clarke, 1987). Information can be held in the auditory store

for 2-4 seconds (Treisman, 1964). More recent studies highlight the weakness of

auditory sensory memory compared to that of memory from other sensory modalities

(Cohen, et al., 2009) (Bigelow & Poremba, 2014) (Gloede, et al., 2017). One study on

memory retention found that while the accuracy for echoic memory showed no

significant difference from memory derived from the other sense at short retention

intervals (1-4 seconds), the accuracy decreased substantially below was observed for the

other sense at longer retention intervals (8-32 seconds) (Bigelow & Poremba, 2014).

Another study aimed at assessing the differences in echoic vs iconic memory found that

less could be recalled form auditory condition than visual, this finding was interpreted

as a reflection of lesser memory capacity for auditory memory compared to that for

visual memory (Gloede, et al., 2017). The other type of sensory memory is referred to as

haptic memory represents the store of tactile information resulting from touch.

12
 Though not as much research studies have been conducted on the memory stores

for the sense of smell and taste as for sight and hearing, a few studies have highlighted

them (Rouby, et al., 2002) (Herz, et al., 2004) (Miranda, 2012) (Arshamian, et al., 2013)

(Chinnakkaruppan, et al., 2014). The “Proust phenomenon” is the notion of odor evoked

memories (named after author Marcel Proust who wrote about the vivid recollection of

forgotten memories which were triggered after smelling madeleine biscuits dipped in tea

(Proust, 1919)). Olfactory memory can be both implicit (does not need the conscious

recall of the encounter), or explicit (requires conscious awareness of the encounter)

(Rouby, et al., 2002) (Wilson & Stevenson, 2006). Furthermore, studies have attempted

to map the neural systems associated with olfactory memory in order to assess why they

are said to be more emotional than memories triggered by the other sensory modalities

(Herz, et al., 2004) (Arshamian, et al., 2013). Using fMRI, two separate studies found

that odor evoked memories activated the olfactory bulb, piriform cortex and other areas

associated with olfactory perception and also areas of the limbic system such as the

amygdala, which plays a key role in emotion processing, and may explain why olfactory

associated memories are more emotional (Herz, et al., 2004) (Arshamian, et al., 2013).

Short-term Memory

Short-term memory is a memory store which temporarily holds information in an

accessible state (Atkinson & Shiffrin, 1968) (Miller, 1956) (Cowan, 2008). Unitary

13
approaches to memory propose that short-term and long-term memory stores are not

distinct, but instead, “short term memories consists of temporary activations of long

term memory” (Cowan, 2008) (Jonides, et al., 2008). However, the main argument for

short-term memory as a separate memory store addresses the differences in the capacity

for information storage and the duration which that information can be stored. Memory

capacity refers to amount of information which can be held within a memory store

before it is forgotten. Miller (1956), assessing the capacity of short term memory via the

analysis of previous memory research at the time, proposed that the capacity of short

term memory is limited to “seven plus or minus two” items. Short-term memory can be

further enhanced via ‘chunking’; a process where subsets of a large set of information

are grouped together, thus making them easier to remember (e.g. breaking down

telephone numbers) (Miller, 1956).

Contrary to Miller’s assertion of seven being the magical number in short term

memory capacity, 21st century analyses of this memory store suggest that there is an

even lower limit (Cowan, 2000). Following the assessment of a variety of studies on

short term memory, including those using retrieval task and change detection tasks,

Cowan (2000) concluded that short term memory has a capacity of four, plus or minus

one item. Furthermore, data from neuroimaging research also support the notion of a

short-term memory capacity which is limited to approximately four items (Alvarez &

Cavanagh, 2004) (Todd & Marois, 2004) (Vogel & Machizawa, 2004) (Awh, et al.,

2007). One study, recording the event related potentials (ERPs) of adults doing visual

14
change detection tasks, found a plateau in signals on tasks containing over 3 and 4 items

(Vogel & Machizawa, 2004). Another study using function magnetic resonance imaging

(fMRI) found that the accuracy of the detection tasks declined as the set sized increased

with “the number of objects encoded at each set size…increasing up to set size 3 or 4

and leveled off thereafter” (Todd & Marois, 2004). Furthermore, findings from a study

conducted by Awh, et al. (2007) suggests that the capacity of this memory store is fixed

regardless of the similarities or complexities of the task at hand, and large variations

come from rehearsal techniques or other mechanism such as chunking.

Another argument provided for short-term memory being a distinct memory store

is based on memory decay. The basis of decay theories is that memories fade over time,

thereby making them less accessible for retrieval (Berman, et al., 2009). This assertion

has come under scrutiny due to contradictions in its explanation. On one hand it states

that neural traces weaken over time accounting for the loss of memory from the short

term memory store, but on the other hand, it proposes that memories in the long-term

memory store remain intact (Cowan, 2008) (Berman, et al., 2009). Studies attempting to

highlight decay mechanisms have yielded contrasting results and many are unable to

rule out alternative explanations for the loss of memories in recall tasks (Cowan, 2008)

(Jonides, et al., 2008) (Berman, et al., 2009). It has been argued that memory loss cannot

be attributed solely to time-dependent decay, but activities such as the interference,

which takes places within the time frame of the decay must also be taken into account.

15
The concepts of decay and interference are often discussed in opposition, however,

Jonides and colleagues propose a combination of the two concepts; interference-based

decay, which accounts for the loss of memories due to the interference of new stimuli

which reduces the focus on the information, and can occur as a separate process or work

in tandem with time-dependent decay (Jonides, et al., 2008).

Some research also argues that anterograde amnesia; the inability to learn new

facts prior to a particular incident, also serves as major supporting evidence for the

existence of a distinct and separate short-term memory store. Patients with anterograde

amnesia are unable to form long-term memories after the amnesia-causing incident. One

of the most famous cases of anterograde amnesia is the case of patient H.M (Henry

Molaison). Having suffered from epilepsy, in 1953 at the age of 27 H.M underwent a

bilateral medial temporal-lobe resection. H. M’s anterograde amnesia was first reported

by William Scoville (the neurosurgeon who performed the lobectomy), and Brenda

Milner in 1957 (Scoville & Milner, 1957). Scoville and Milner reported that H.M

displayed memory impairment, reverted to stories from his younger years and seemed to

be unaware that he had undergone an operation. They write, “this patient appears to

have a complete loss of memory for events subsequent to bilateral medial temporal-lobe

resection 19 months before… but early memories are seemingly normal and there is no

impairment of personality or general intelligence” (Scoville & Milner, 1957). H.M

could learn new task but could not remember ever having learned them. Writing on his

condition, Suzanne Corkin states that “H.M is able to register new information; his

16
striking disability becomes apparent when his immediate memory span is exceeded”

(Corkin, 1984). Cases of amnesia stress the notion of short-term and long-term memory

being two separate and distinct memory stores, as some patients have impairments in

long-term memory while short-term memory remains intact, and vice versa.

Working Memory

Baddeley and Hitch (1974) posit that the concept of short-term memory should be

replaced with a memory capacity which they refer to as ‘working memory’. The

differentiation between short-term memory, working memory has been long debated.

Working memory refers to an active memory store which needed for planning and task

execution where information can be stored for periods of time (Cowan, 2008) (Eriksson,

et al., 2015). Baddeley and Hitch (1974) proposed that all types of temporary memory

could not be bound in one memory store, thus, they assert that there are 4 major sub-

systems of working memory; the central executive, the phonological loop, the visuo-

spatial sketchpad and the episodic buffer. The central executive serves as the control

center, directing information to the other subsets. It directs attention to relevant

information, suppresses irrelevant information and is involved in cognitively taxing

tasks. “the phonological loop and visuo-spatial sketchpad are slave systems used by the

central executive for specific purposes” (Eysenck & Keane, 2010). The phonological

loop is a sub-system which retains verbal information via rehearsal (the ‘inner voice’;

silent repetition of information in one’s head e.g. when trying to remember a telephone

17
number). Baddeley found that the recall of words is worse if they are phonologically

similar (e.g. BAY, DAY, SAY). This is referred to as the ‘phonological similarity

effect’ (Baddeley & Hitch, 1974). Auditory information enters directly in the

phonological store, whereas visual information can be entered via rehearsal called

‘articulacy rehearsal’. This silent rehearsal prevents the decay of information. The

visuo-spatial sketchpad is responsible for the storage of visual and spatial information.

This system is involved in making mental maps and finding routes etc. In 2000

Baddeley added a new concept, the episodic buffer, to the construct of working memory

(Baddeley, 2000). Baddeley posits that the episodic buffer provides a temporary storage

of information, translating verbal, spatial and visual information to the previously

described sub-systems. Baddeley asserts that “retrieval from the episodic buffer

occurred through conscious awareness,” thus the episodic buffer relies heavily on the

central executive (Baddeley, 2012).

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Figure II: Simplified illustration of working memory as proposed by Baddeley & Hitch (1974). Image

Ref: (Eysenck & Keane, 2010)

Attention is at the core of working memory. The maintenance of object/task

information, working along with related representations available in the long term

memory store reflect the process of working memory (Baddeley & Hitch, 1974)

(Baddeley, 2000) (Cowan, 2008) (Eriksson, et al., 2015). Memories in working memory

are susceptible to interference of surrounding stimuli and must therefore be maintained

with the use of silent rehearsal (Eriksson, et al., 2015). Working memory capacity, as

with the short-term memory store, has a limited capacity for approximately four items

(Cowan, 2010). Similarly to short-term memory, working memory capacity can be

altered by utilizing chunking mechanism, but depends on how much units on

information a person can hold in active memory. Various research has been done to

assess the differences between individuals in working memory capacity. Eriksson and

19
colleagues propose that as memory capacity is predicted by cognitive measure such as

abstract reasoning and fluid intelligence, it therefore depends highly on a person’s

ability to execute complex cognitive tasks (Eriksson, et al., 2015).

Long-term Memory

Both sensory and short-term/working memory stores are characterized by limited

storage capacities, with information only lasting for short periods of times. Contrarily,

long-term memory refers to a storage of large quantities of information for unlimited

periods of time (Atkinson & Shiffrin, 1968). Long-term memory can be categorized as

explicit or implicit. Explicit memory can further be split into two subsets;

Episodic/Declarative and Semantic Memory. Episodic memory refers to the collection

of past experienced which occur in particular places and times. Episodic memory

encompasses “factual knowledge of people, places and things” (Kandel, et al., 2000).

Sematic memory on the other hand is the store of memory for general knowledge

accumulated of the course of a person’s life. The other category of long-term memory is

referred to as implicit memory. “Implicit memory is typically involved in the training

reflexive motor or perceptual skills” (Kandel, et al., 2000). Implicit memory

encompasses actions done with conscious thought into the process, such as riding a

bike. Kandel et.al., distinguishing between the two states that, “explicit memory is

highly flexible and involves the association of multiple bits and pieces of information.

20
In contrast, implicit memory is more rigid and tightly connected to the original stimulus

conditions under which the learning occurred” (Kandel, et al., 2000).

Memory Processes

The different stages of memory can be classified with different activities, these

are the processes of memory. Human memory processes include encoding (and

consolidation), maintenance, storage and retrieval. Once a stimulus is perceived

encoding allows for it to be converted into a construct, so the information can be stored.

Encoding allows for cognitive focus to be place on a particular object or task, which

renders surrounding stimuli irrelevant. Similarly, Squire et.al describe consolidation as

the “process by which a temporary, labile memory is transformed into a more stable,

long lasting form” (Squire, et al., 2015). The general assumption is that new memories

can be easily loss due to interference, Wixted highlights that “new memories are clear

but fragile, and old ones are faded but robust” (Wixted, 2005).

The maintenance of information is a process which is key to the understanding of

short-term and working memory, and refers to “how information is held in the mind for

the purpose of future action after perceptual input is gone” (Postle, 2006) (Jonides, et

al., 2008). Memory storage refers to the process of retaining information. Alterations of

neural signaling and brain tissue have been found to largely underpin a person’s ability

to store information. Finally, retrieval refers to the use of previously stored information.

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Arguably, “the key process in memory is retrieval” (Tulving, 1991). If we cannot access

the information which we have stored, then what use is it to us?

1.2 Neurobiology of Memory

Several brain areas have been highlighted as playing a key role in the physiology

of memory. Studies in amnesic patients and animal models show areas such as the

hippocampus and the amygdala as underpinning processes of memory storage and

retrieval. The hippocampus has been found to play a key role in explicit memory.

Damage to the hippocampus and surrounding areas have been shown to result in

anterograde amnesia. Scoville and Milner report “a grave loss of recent memory…

observed as a sequel to bilateral temporal-lobe resection” (Scoville & Milner, 1957).

The operations included the removal of “the prepyriform gyrus, uncus, amygdala,

hippocampus, and para-hippocampal gyrus and… and interruption of some of the white

matter leading to the temporal lobes” (Corkin, 1984). Studies in animal models also

highlight impairment in spatial memory due to hippocampal lesions. Fortin et. al report

that “hippocampal damage impairs memory for the order of a series of recently visited

spatial locations” (Fortin, et al., 2002). Thus, the findings suggest that “hippocampal

networks mediate associations between sequential event that constitute elements of an

episodic memory” (Fortin, et al., 2002). Memory impairments such as anterograde

22
amnesia, observed subsequent to hippocampal damage or removal highlight not only its

importance to memory storage but also to the encoding of memory.

The hippocampus is also key to memory consolidation. Consolidation can be

categorized into two major types; systems consolidation and synaptic consolidation.

Contrary to the typical view as memory as being stored in one place in the brain like

books in a library, memory traces are spread across the neocortex. Therefore, if one area

in the brain is damaged, persons may still be able to recall certain memories systems

consolidation refers to the process of making hippocampal dependent memories

independent via reorganization neural networks. Squire and Alvarez (1995) use

temporally-graded retrograde amnesia as support for the concept of system

consolidation. Continued activation of hippocampal dependent memories sends synaptic

messages to the memory trace in neocortical neurons, thus triggering local consolidation

in these neurons. (Dudai, 2004). Over time (weeks to years) these memories can be

activated independently of hippocampal activation (Dudai, 2004) (Squire & Alvarez,

1995). This is due to the ability for quick synaptic alteration (synaptic plasticity) in the

hippocampus, while neocortical synapses change slowly over time (Dudai, 2004).

Several studies also highlight the medial temporal lobe and prefrontal cortex as

playing key roles in memory processes, and impairments to this region have been shown

to affect the recall of recent memories as well as long-term memories. Lesions to the

medial prefrontal cortex in rats has been shown to result in difficulty recalling

associations previously made between places and rewards (Seamans, et al., 1995).

23
Similarly, Corcoran and Quirk (2007) found that the inactivation of the medial

prefrontal cortex resulted in impairments of memory recall about fear which had been

learnt days before (Corcoran & Quirk, 2007) . The prefrontal cortex has also been

shown to have a key involvement in working memory (Braver, et al., 1997) (Engle, et

al., 1999) (Kane & Engle, 2002). One study using fMRI to assess the activity in

prefrontal cortex during letter tasks found a linear relationship between cortical

activation and working memory load (Braver, et al., 1997). Similarly, activity in the

prefrontal cortex has been shown to correlate with the capacity of the working memory

stores (Kane & Engle, 2002) (Vogel & Machizawa, 2004) (Eriksson, et al., 2015).

Furthermore, studies show interactions between the hippocampus and the prefrontal

cortex support the sorting of new memories into to preexisting memory schemas

(Preston & Eichenbaum, 2013). It has been proposed that the function of the prefrontal

cortex is “to learn associations between context, locations, events, and

corresponding adaptive responses,” and therefore accounts for the pervasive presence of

prefrontal cortex activity in various memory processes (Euston, et al., 2012).

Other structures have also been shown to play key roles in memory, including the

amygdala, basal ganglia and cerebellum. Studies show that the amygdala plays a key

role in activations of emotional memory, particularly in odor-evoked memories and

memory of fear (Phelps & Anderson, 1997) (Milad & Quirk, 2002) (Herz, et al., 2004)

(Corcoran & Quirk, 2007) (Arshamian, et al., 2013).

24
At the Synapse

Learning and memory are different sides of the same coin, both associated with

synaptic alterations and neural tissue. Dudai posits that “synaptic consolidation, which

is accomplished within the first minutes to hours after learning, occurs in all memory

systems” (Dudai, 2004). Continued activity at the synapse is shown to lead to plasticity.

Synaptic plasticity is the strengthening or weakening of synapses due to an increase in

their activity (Hughes, 1958). Hebbian theory posits that “neurons that fire together wire

together” (Hebb, 1949). This synchronized system of neural activity reflects the

memory traces present in short term and long-term memory.

Two mechanisms are said to underpin synaptic plasticity. The first involves

NMDA and AMPA receptors. The opening of NMDA channels leads to depolarization

and an increase flow of Calcium (Ca2+). Strong depolarization causes the displacement

of magnesium (Mg2+) ions which block NMDA ion channels and allow more Ca2+ to

enter the cell, which is speculated to cause long term potentiation. Weaker

depolarizations allow for less Ca2+ to enter the cell, thereby leading to long term

depression (Bear, et al., 2007)

The second mechanism of synaptic plasticity depends on second messenger

cascade (as associated with G-protein coupled receptors) regulated gene transcription,

and protein alterations at the synapse (Zhong, et al., 2009). These proteins include

Ca2+/calmodulin-dependent protein kinase II (CaMKII), a protein kinase which has

been implicated as an important factor in cognitive processes such as learning and

25
memory (Yamauchi, 2005). Activation of second messenger pathways lead to an

increase of protein kinases in the dendrites of neurons. Zhong et al., highlight that

protein kinases such as CaMKII are linked to dendritic spine growth and long-term

potentiation (Zhong, et al., 2009).

The configuration of synapses, as is needed for memory storage to occur can split

into two types; short-term and long term. Short-term plasticity can include synaptic

enhancement; where synapses are strengthened for short periods of time due to

increased activity, or short-term depression. Long-term plasticity can be split into two

categories; long-term depression (LTD) and long-term potentiation (LTP). LTD is

described as any activity dependent reduction in the efficacy of neuronal synapses

(Haas, et al., 2011). On the other hand, LTP refers to a persistent increase in synaptic

strength following the high frequency stimulation of a chemical synapse (Cooke &

Bliss, 2006). LTP and synaptic consolidation are the underlying mechanisms of learning

and memory, thus, memory is said to be represented by vast systems of interrelated

synaptic networks (Hebb, 1949).

1.3 Acquired Brain Injury and Memory

Acquired brain injury (ABI) refers to damage to the brain caused by sudden

injury to internal impairments (Zinga, et al., 2003). ABI can include both traumatic

brain injuries (TBI) and non-traumatic brain injuries. Traumatic brain injury refers to

26
any incident which occurs outside of the body and results in head trauma, such as;

vehicular accidents, impacts from sports such as football, falls and construction

accidents (Zinga, et al., 2003). Non-traumatic brain injuries on the other hand, refer to

incidents of disruption of normal function within the body which results in brain

damage, such as; brain tumors, ischemia, hypoxia and strokes. Typically, ABI excludes

brain damage & impairment resulting from neurodegenerative diseases such as

Parkinson’s, Alzheimer’s Huntington’s.

Subsequent to brain injury patients are faced with a wide range of

neuropsychological symptoms, including the weakness of limbs, fatigue, difficulties

with concentration an information processing, difficulties understanding and producing

language, emotional disturbances such as depression and anxiety and impairments of

memory and learning (Brain Inury Hub, n.d.). Depending on the severity of the brain

damage sustained, patients may be paced in rehabilitative facilities for profession care.

Memory impairments are commonly reported following acquired brain injury.

Approximately 25% of person who suffer a TBI suffer some form of memory

impairment, and “more than a third of patients who have suffered a stroke show

cognitive impairments in one or more cognitive domains such as attention [and]

memory” (Cappa, et al., 2011). Partial recovery of memory function is reported in ABI

patients; however, some often remain, permanently handicapped and require some form

of aid. As memory loss and impairment can cause disruptions in normal daily

functioning, and obstruct patient’s independence post-incident, as well as affect their

27
overall quality of life, memory rehabilitation is a major focal point of cognitive

rehabilitation (Spreji, et al., 2014).

Memory rehabilitation typically adopts two main approaches, “remediation by

restoration or retraining of the function and… compensation” (Spreji, et al., 2014),

which refers to modifications or aids employed to help patients to remember more

efficiently (Cappa, et al., 2011) (Spreji, et al., 2014) (Evans, et al., 2003). Cramer posits

that restoration of brain function in the brains of stroke patients is typically spontaneous

(Cramer, 2008). Restoration of function is not aimed at salvaging the damaged brain

areas, but instead is aimed at training the healthy brain tissue to adapt. “The assumption

[is] that impaired memory will respond to mental exercise in the same manner as

muscles respond to physical exercise” (Spreji, et al., 2014). Studies on spontaneous

recovery remain few, thus, compensation techniques are typically employed in the

cognitive rehabilitation of ABI patients (Spreji, et al., 2014). These techniques include

repetitive tasks, name-face associations and the use of external memory aids (Spreji, et

al., 2014) (Evans, et al., 2003). Evans and colleagues found that “external aids such as

calendars, wall charts and notebooks were the most commonly used memory aids”

(Evans, et al., 2003). The used of compensation techniques varies depending on

variables such as age and how long has passed since the brain injury was acquired.

28
1.4 Memory boosts

Research on memory loss, brain injuries and neurodegenerative disease have

provided insight into techniques which might serve to improve memory. Studies show

that diet, exercise, and cognitive training are all ways of potentially improving memory

storage and recall. From a cognitive neuroscience standpoint, factors such as repetition,

relaxation and wakeful rest have been shown to impact memory recall. One study,

analyzing the effects of wakeful rest on forgetting via memory analysis during a foreign

language learning activity, found that participants who were allowed an 8-minute rest

period in between tasks produced better recall scores than those who were not (Mercer,

2015). Thus, it was concluded that rest in between tasks can shield new memories from

interference and help to lessen forgetting. A series of studies conducted by Dewar and

colleagues also suggest that wakeful resting boots memory in the long-term (Dewar, et

al., 2012) (Dewar, et al., 2014). The team found that participants who benefitted from a

10-minute period of wakeful rest showed significant memory enhancement after a 7-day

delay (Dewar, et al., 2012). The main argument place against wakeful rest as memory

boost is that the time of rest allows for participants to engage in silent rehearsal of the

materials they are asked to remember.

Repetition

Several studies have been conducted on the effects of repetition on memory.

Contemporarily, the general consensus on the effect of repetition on memory is split

29
between the cumulative-strength hypothesis and the multi-trace hypothesis. The

cumulative-strength hypothesis “assumes that when an experience is repeated, the

memory representation that was formed during the first experience is strengthened”

(Hintzman, 2010) (Weickelgren, 1969) (Murdock, 1982). Wickelgren (1969), testing

recognition memory of pitches by means of delayed comparison tests, found that

participants relied on the familiarity of different tones to help that correctly recall them

(Weickelgren, 1969). On the other hand, the multiple-trace hypothesis assumes that

regardless of repetition, each experience creates its own distinct memory trace

(Hintzman, 2010) (Hintzman & Block, 1971). Hintzman and Block (9171), testing the

effects of frequency on memory, found that when a single word was presented in a list

multiple times the effects of the “repetitions could be discriminated in memory”

(Hintzman & Block, 1971). Thus, it was hypothesized that each experience forms its

own unique memory trace (Hintzman & Block, 1971). Studies show that the effect of

repetition on memory is dependent on the space of time in which the repetition is

presented (Hintzman, 2010) (Gillund & Shiffrin, 1984). Hintzman (2010) posits that

“repetition can make an item seem more recent or less recent than a non-repeated item,

depending on presentation spacing” (Hintzman, 2010).

Studies have also assessed repetition’s effect memory in patients with cognitive

impairments. Weingartner et. al (1993), testing the effects of repetition on the memory

of patients with Alzheimer’s disease, major depression, alcohol amnesic disorder

(AMD) and healthy elderly persons, found that persons suffering from major depression

30
were sensitive repeated information (Weingartner, et al., 1993). In addition, participants

with AMD recalled more words that were repeated than one’s which were not, and

participants with AD were observed to be insensitive to the repetition of information

(Weingartner, et al., 1993).

While repetition is generally thought to increase the accessibility of memories,

some argue that it can lead to poor memory recall as well. An example of this is

semantic satiation. Previously termed verbal satiation, semantic satiation, a term coined

by Dr. Leon Jakobovits James, is used to describe a kind of mental fatigue experienced

following the repetition of words over a short period of time where the person perceives

the words as having lost meaning temporarily due to repetition (Jakobovits, 1962).

According to James, this comes as a result of rapid neural firing which results in

reactive inhibition in tasks following the repetition phase (Jakobovits, 1962). More

recent studies also argue against the widely accepted view of repetition being a memory

boost, positing that it may have negative effects on memory accessibility under certain

circumstances. Kuhl and Anderson (2011), studying the effects of repetition on memory,

found that while participants who actively repeated words for shorter periods of time (5-

10 seconds) performed well on recall tasks, performance was shown to decline in

participants whose rehearsal was prolonged (20-40 seconds) (Kuhl & Anderson, 2011).

This repetition-based performance decline was termed as mass repetition decrement

(Kuhl & Anderson, 2011). Another study found that the effects of repetition varied with

respect to the context of learning in which it occurred. Investigating the effects of

31
repetition on intentional learning (deliberate/ persistent) versus incidental learning

(indirect/unplanned), increased repetition caused a decline in the memory of the

repeated items in the incidental learning condition, whereas, memory increased due to

repetition in the intentional learning condition (English & Visser, 2014).

Relaxation

Relaxation training has been shown to reduce stress, thus, there is speculation on

its possible effects on cognitive function. Rezai Kargar et. al (2013), researching the

effects of relaxation training on working memory in 7th grade girls, found that

“relaxation training increase working memory capacity and its components, storage and

processing and academic achievement” (Rezai Karga, et al., 2013). Similarly, a study on

relaxation and mnemonics on memory and anxiety in the elderly found that anxiety in

the elderly affects their cognitive function, but their attention and memory could be

improved via relaxation training (Yesavage & Jacob, 1984). Another study assessing

differences in memory recall of children in yoga versus art camp found that memory

recall was improved in children form the yoga camp following meditation and

relaxation techniques (Majunath & Telles, 2004). Studies on relaxation and memory

however, remains scarce, thus, this study will add to the present available research on

relaxation and memory, utilizing guided relaxation as to eliminate any basis for

arguments of rehearsal during the rest period. In addition, as it is being carried out in

collaboration with the Royal Hospital for Neuro-disability (RHND), this study serves to

32
be of clinical relevance in the development of memory improvement techniques for

rehabilitation of memory function in patients with ABI.

33
Rationale

The present study is designed to gather information about the conditions that help

memory recall and retention in a healthy non-brain injured population, this information

may in turn have relevance for the rehabilitation of patients post-brain injury. The

manipulations focused on in this study are repetition and guided relaxation. Acting to

the basis of the cumulative hypothesis, the repetition condition in this study will yield

high recall scores during the 2nd immediate recall. The study also aims to assess the

effect of guided relaxation, the aim of which is to provoke a state of rest with minimal

silent information rehearsal by the participant. Memory recall scores will be assessed at

various time delays in order to provide a more long-term view of the effect of each

manipulation. This study will also aim to comment on the pattern of findings for at least

one patient in a current clinical study being conducted at the RHND, assessing the

effects of wakeful rest versus and interference on memory retention in patients with

moderate to severe brain injuries, using the same stories as those being used with the

non-brain injured sample.

The findings of this study could serve to as key information about the potential

benefits, or risk, of including repetition of information and/or guided relaxation

cognitive rehabilitation of patients with ABI. This study’s findings could also be of

interest to other populations such as students and healthcare personnel and could also

prove useful in the development of teaching techniques.

34
Hypotheses

H1: Initial recall scores for both stories will be similar or equal for both the repetition

and relaxation conditions in control participants.

H2: Scores from the 2nd recall for the repetition condition will be higher than Immediate

Recall scores for the relaxation condition in control participants

H3: Delayed Recall scores (i.e. absolute scores) for the repetition condition will be

higher than Delayed Recall scores for the relaxation condition.

H4: 24-hour delay scores for the repetition condition will be higher than those for the

relaxation condition.

35
Methodology
Ethics
The present research was approved as a part of a larger study being conducted at the

Royal Hospital for Neuro-disability (REC reference: 17/LO/0453). It was also approved

at the Department of Life Sciences, University of Roehampton.

Design
The current study design aims to examine the different manipulations that may influence

memory performance; in this study we focus on repetition and guided relaxation.

For each participant one of the stories will be repeated in the encoding phase, with recall

assessed after both repetitions (Immediate Recall 1 and Immediate Recall 2).

Repetition is followed by an interference delay where neuropsychological tests are

conducted before the presentation the 2nd story.

The delay after presentation of the other story will be filled with a relaxation exercise

directed by the assessor. The rationale for this paradigm is to create a ‘rest’ condition

that is equivalent for all participants. By providing the participants with instructions, it

is predicted that rehearsal of the materials will be reduced, and a state of relaxation and

rest promoted.

36
The study will also comment on a pattern of findings for a patient participant in the

patient study, using the same stories as with the non-injured population, as to improve

clinical relevance.

Sample
They were 40 participants; 25 females and 15 males.

Participants were informed of the exclusion criteria before beginning the study. The

exclusion criteria were as follows:

 Having suffered or suffering from a major head injury

 Suffering or having a history of psychiatric illnesses (e.g. schizophrenia, bipolar

disorder, major depression etc.)

 Having suffered from major neurological disorders (e.g. Parkinson’s disease,

Alzheimer’s disease etc.)

 Having a high proficiency for the English language (e.g. English as a first

language or having been taught in English at college level)

As previously stated, to enhance clinical relevance the data from one patient from the

Royal Hospital for Neuro-disability was included in the study. To preserve anonymity,

this patient will be referred to as Patient X for the purpose of this analysis.

37
 Patient X is a 39-year-old woman suffering from cerebral hypoxia which she

experienced after a cardiac arrest out of hospital. As a result of this hypoxic brain injury

she experiences difficulties with executive functions such as multitasking and set

shifting. She also has slurred speech and a myoclonic jerk syndrome; the body struggles

to coordinate muscle movements, including the movements of the mouth and

diaphragm, which can occur after hypoxic brain injury. Patient X’s highest level of

education is a bachelor’s degree.

In order to be able to participate in the study, Patient X had to meet specific criteria:

1. Not to have been diagnosed as densely amnesic, as evidence of a minimum

retention of a novel learning task was needed.

2. To have an adequate conversation level of English (comprehension and

production).

3. To be able to communicate orally or, if non-verbal, to be able to write clear

responses.

4. Not to have an uncorrected hearing impairment problem, as the auditory

impairment could interfere with the learning phase.

Additional to the above criteria, Patient X (as any other patient tested by the hospital)

had to pass a mental capacity assessment conducted by a certified Clinical Psychologist

38
to judge the patient’s ability to take decisions independently and therefore to decide to

volunteer in the study. For both legal and ethical reasons, only if the patient possessed

the mental capacity could they take part in the investigation (Mental Capacity Act,

2005).

This study is a part of a larger study being conducted at the Royal Hospital for Neuro-

disability entitled ‘Memory and learning after brain injury: a study exploring causes of

common memory problems,’ conducted by Dr. Nathan Illman and colleagues.

Material

Material used during the learning phase

Two stories which were prerecorded, to eliminate any bias of them being read by the

researcher or anyone else. The complexity of the two stories were matched using

Flesch-Kincaid readability tests; an index which assigns a numerical value to the

readability of the stories based on the sentence length and some selected words

(Kincaid, et al., 1975).

39
Story 1

“On Tuesday morning / you went to an appointment at / Willowdale/ General

Hospital/. You met with Dr. Harding /. It was to discuss your upcoming/

laparoscopic / hip operation/. You have suffered/ numbness and pain/, and trouble

sleeping / for 7 months /. The surgery is scheduled / for 11:15am / on 5th July /, and

will last around 90 minutes /. Your best friend told you / the fastest ways to travel

there are / on the number 83 bus / or to catch a train / from Eastern Street / train

station.”

Story 2

“Dr. Lee /has diagnosed you with /Robinson’s disease /. This condition /affects your

small intestine/. Symptoms can include /feeling bloated /nauseas /and tiredness /. The

treatment /is called Doxycrazalone /. You must take two / red capsules /with food

/three times a day /and do this for 8 days /. This totals 600mg a day /. If you

accidentally take more than this, /call the NHS /non-emergency phone line /. Your

follow-up appointment /is in three weeks”

Stories were played on a MacBook Air laptop.

Materials used during the Relaxation phase

Recorded sounds of the ocean were played on a MacBook Air laptop.

40
Material used during Interference

Three neuropsychological tests were administered during the interference phase.

 Spot the Word test (Wechsler, 2009). Participants were given a list of 100 pairs of

words. One word in each pair was an existing word while one was not.

Participants were asked to point out or call the word which they knew or thought

to be an existing word. One point was awarded for every word which participants

correctly identified (maximum score: 100).

 Digit Span Test (Wechsler, 2009), which has 3 parts. In the first part (Digit Span

Forward), the examiner read a sequence of numbers which participants were

required to recall in the exact order in which they were presented. In the second

part (Digit Span Backwards), participants were asked to recall the number

sequences in the reverse order. Finally, in the third part (Digit Span Sequencing),

participants were asked to recall the numbers read to the in numerical order. Each

section of the test was stopped once participants scored 0 in both trials of an item.

 Hayling test (Burgess & Shallice, 1997); a two-part assessment. In the first

section, the examiner read a series of sentences with the last words missing from

each, participants were required to give a word which would accurately complete

the sentence, as quickly as possible. In the second section, participants were

required to give a word which was completely unrelated to the sentence, also to

be done as quickly as possible. For both sections the participants’ responses, as

well as their response time, was recorded on the score sheet.

41
 Other materials used

A questionnaire was administered to each participant at the end of the study.

Questions asked for participant’s age, level of completed education, which story they

felt was easier to remember and how relaxed they felt during the relaxation phase.

(Questionnaire will be referenced in the Appendix).

An iPhone was used to contact participants via text, 24 hours after their participation

in the study.

Procedure

The study was conducted in 2 locations; a room at the Royal Hospital for Neuro-

disability and a room at the Roehampton University.

Participants were randomly selected for this study from friends and colleagues of the

examiner, strangers and employees of the Royal Hospital for Neuro-disability.

First, participants were questioned regarding the exclusion criteria. They were then

issued with a debriefing form, and a consent form which they were required to sign.

Each participant was issued with a unique code which they were to remember in case

they wished to withdraw or have their data excluded from the study. Procedure for

the patient was tweaked due to their condition (will be discussed separately).

They were 4 different counterbalances used in this study to gather the information on

the differing conditions (repetition and relaxation).

42
 Counterbalancing order Order of materials
1 Story 1 then Story 2
2 Story 2 then Story 1
3 Story 1 then Story 2
4 Story 2 then Story 1
Order of condition
Repetition then relaxation
Repetition then relaxation
Relaxation then repetition
Relaxation then repetition

Table I: table showing the counterbalances assessed in this study

For example; testing counterbalance 3.

Participants were told,

“I am going to present to you an imaginary scenario two times. I really want you

to pretend that the information you hear is about you, and therefore very important that

you remember it as it will be of future relevance. I want you to listen carefully both

times and after the second, repeat back everything you hear, using the exact same

words that were used. Ready?”

After the participant’s initial recall of the first story, they were then informed of the

relaxation/rest period and were asked to relax, guided by the examiner.

The examiner instructed them with the following,

43
 “I now need you to close your eyes, take a deep breath and relax. Tense your toes

up and release them. Tense your calves up and release them. Tense your buttocks up,

and release. Ball your hands into fists and then release. Shrug your shoulders up

and release them. Scrunch your face up and then release. Now, keeping your eyes

closed, I want you to now relax while listening to the sounds of the oceans. I will be

stepping out of the room preparing for the rest of the study.”

The sounds of the ocean were played on the laptop and the examiner left the room,

taking all records and score sheets to prevent any tampering. A timer was set for 15

minutes and after the time had elapsed, the examiner returned & stopped the ocean

sounds and instructed participants to open their eyes and asked to recall what they

could remember from the story they had heard.

Participants were then asked to listen to the second story, given the same instructions

which they had received before hearing the first story.

“I am going to present to you an imaginary scenario two times. I really want you to

pretend that the information you hear is about you, and therefore very important that

you remember it as it will be of future relevance. I want you to listen carefully both

times and after the second, repeat back everything you hear, using the exact same

words that were used. Ready?”

They were then asked to recall this story.

44
 Participants were then played the story for a second time (the repetition condition)

and again asked to recall it.

After being scored, participants were then asked to complete some

neuropsychological tests (the interference period).

The examiner would alert them to this by saying;

“Now we are going to do three neuropsychological assessments.”

Test were administered & particular instructions for each test were given before they

begun. (See Appendix for test)

Administration of these test took approximately 15 minutes (dependent on the

swiftness of the individual’s responses). After the neuropsychological tests were

completed, participants were asked to do a final recall of both stories which they had

previously heard.

Finally, participants were asked to complete a post-study questionnaire. (See

Appendix G)

Non-student participants were given a 10-pound Amazon voucher as compensation

for their time and participation.

45
 On the day after each participants study, the examiner reached out to them via a text

regarding their 24-hour delayed memory recall.

The text read;

“Good day, as a final part of the study, I would like to assess 24-hour memory

recall of the information presented during yesterday’s study. Can you tell me what

you remember from the stories presented yesterday? Thank you again for your

participation.”

Presentation of Presentaion of
Story 1 Story 2

Immediate recall
of Story 2
Immediate
recall of Story 1

2nd Presentation
of Story 2
Relaxation for
15 minutes
Immediate 2nd
recall of Story 2

Delayed recall Interference 15 Story 1 and Story 1 and

of Story 1 24Hours
minutes Story 2 recall Story 2 recall

Figure III: Schematic representation of counterbalance 3. The course of study which occurred for

counterbalance 3 including presentations, time delays and the conditions (here interference refers to

the execution of the neuropsychological tests).

46
Patient Procedure

Having met the exclusion criteria for patient participants, participants were issued

with a consent form which they were to fill out themselves or have a helper fill out

via their instructions (See Appendix D).

The participant was asked to give a rating of their tiredness and level of pain. To rate

their tiredness, they were asked;

“On a scale of 1-10, how tired are you feeling right now, where a 1 would indicate

being really sleepy as if you could fall asleep, and a 10 being the most energetic and

full of energy you can have?”

To rate their pain, they were asked;

“On a scale of 1-10, how much pain are you in right now, with 1 being no pain at all

and a 10 being extreme, unbearable pain?”

Following this, participants were informed that they were about to hear the first set of

information.

“I am going to present to you an imaginary scenario two times. I really want you to

pretend that the information you hear is about you, and therefore very important that

you remember it as it will be of future relevance. I want you to listen carefully both

times and after the second, repeat back everything you hear, using the exact same

words that were used. Ready?

47
After the story was played for the second time participants were asked to recall, with

every unit they remembered being scored on the scoresheet (See Appendix)

Participants were then informed of the REST period.

“I need to go and prepare something for the rest of the experiment so I’m going to leave

you here to rest for about 10 minutes. Just sit and close your eyes and relax during this

time but try not to fall asleep. I will be just outside in the next room, so just call if there

is anything wrong.”

All of the record forms and scoring sheets were taken from the room as to prevent

participants from tampering with them. Once out of the room a timer was set for 10

minutes. The researcher returned after 10 minutes and engaged the participant in

conversation for 5 more minutes.

When these 5 minute were up, participants were informed that they would now hear a

second set of information.

“I’m now going to present to you another imaginary scenario two times. Again, I really

want you to pretend that the information you hear is about you, and therefore very

important that you remember it as it will be of future relevance. I want you to listen

48
carefully both times and after the second, repeat back everything you hear, using the

exact same words that I use. Ready?”

After the story was played for the second time, and participant recall was scored,

participants were then entered the INTERFERENCE phase.

“I’m now going to ask you some more questions”

A timer was then set for 15 minutes. After 15 minutes participants were asked to recall

the information they had been presented with earlier.

“Please can you tell me everything you can remember from the first set of information I

played to you earlier?”

Once scored for the first story, they were asked to recall the second story.

“Please could you now tell me everything you remember from the second piece of

information I played to you?”

After scoring the researcher administered a questionnaire to end off the study.

For the 24-hour delay patient logs were checked to see the estimated number of hours

of sleep the patient had.

49
Records were checked to see if any incidents had occurred in the past 24 hours, such as

if patients had suffered a seizure, had experienced extremely disrupted sleep, had

become unwell etc.

Once the participant had been cleared for the previous incidents they were informed

about the 24-hour recall.

“I want to test your memory again for the information we learned. Please can you tell

me everything you can remember from the first piece of information I played to you

yesterday – it was about your trip to the doctor”.

Once recall was scored the participants were asked questions about the story.

“I’m now going to ask you some questions about the first piece of information that I

played you. If you don’t know the answer, just have a guess.”

A recognition questionnaire was then administered

Following this, participants were asked to recall the second story.

“Please could you now tell me everything you remember from the second piece of

information I played to you – it was about your mother’s appointment?”

A recognition questionnaire was then administered

Participants were thanked for their participation.

50
The independent variable in this study is the percentage of memory retention. The

dependent variables are the conditions; repetition and relaxation, and the time periods

surrounding memory recall; immediately, 15-30 minutes and 24 hours

Statistical Analysis

The data collected were analyzed using IBM Statistical Package for the Social

Sciences (SPSS) version 25. Memory performance was assessed based on the

number of story sections (vignettes) successfully recalled by the participants at

different time intervals (immediate recall, 15-30 minutes and 24-hour recall), and

analyzed against the two conditions (relaxation and repetition). Subsequently, to

measure how much of the immediate recall score was retained over the various time

delays, a percentage retention score was computed for each participant by dividing

the number of story units recalled after each delay by the number of story units

recalled during the immediate recall and multiplying the obtained result by 100. This

percentage retention score calculation was done both capped at 100% and uncapped

due to the clinical relevance that the scores may hold.

51
Results

This study consists of both male and female participants of ages ranging from 22 to

52 years old, all from various educational backgrounds.

Gender

Frequency Percent Valid Percent Cumulative Percent

Valid Female 25 62.5 62.5 62.5
Male 15 37.5 37.5 100.0

Total 40 100.0 100.0

Education Level

Frequency Percent Valid Percent Cumulative Percent

Valid Highschool 6 15.0 15.0 15.0
Bachelors 23 57.5 57.5 72.5

Masters 9 22.5 22.5 95.0

PhD 2 5.0 5.0 100.0

Total 40 100.0 100.0

Table 1: Frequency tables displaying the demographic information of the participants.

Females made up 62.5% of participants (25) and males made up the remaining 37.5 %
(15).

52
  

FIGURE 1. Bar graph comparing mean initial recall scores for both stories (n= 40).

Analysis show a mean initial recall score to be 13.25 and 18.30 for story 1 and 2

respectively. 44 points (representing the segments of the story remembered) is the

highest score which can be achieved for each story, only 30% of this was achieved

initially for story 1, while 41.5% was initially achieved for story 2.

53
  

FIGURE 2. Bar graph showing differences in the mean recall scores of the story 1

(Willowdale) based on the conditions. In the repetition condition (n= 20) there was a

mean recall score of 24.5 versus a mean recall score of 11.5 in the relaxation

condition (n=10).

54
  

FIGURE 3. Bar graph showing differences in the mean recall scores of the

story 2 (Dr. Lee) based on the conditions. In the re condition (n=20) there was a

mean recall score of 28.95 versus a mean recall score of 15.4 in the relaxation

condition (n=10).

55
 The two previous figures highlight a 25% increase in the recall scores from story 1

(raising from 30% to 55.7%), and a 24.5% increase in the recall scores from story 2

(raising from 41.5% to 65.8%). Mean scores for the relaxation condition were 11.5

and 15.4 for story 1 and story 2 respectively, thus highlighting a decrease in recall

scores by 3.9% for story 1 (dropping from 30% to 26.1), and 6.5% in story 2

(dropping from 41.5% to 35%) (Figure 2 and 3). Recall scores of the repetition

condition, for both story 1 and 2, were shown to be higher than those of the

relaxation condition, by 29.6% and 30.8%.

56
FIGURE 4. Bar chart showing the overall mean final recall score. Overall, the mean

final recall score was higher for story 2 than story 1, being 14.85 and 18.78. As

expected, when separated by counterbalance, in counterbalance 1 and 4 the mean final

recall scores were higher than those for story 2 (48% versus 37% in counterbalance 1

and 43% versus 31.3% in counterbalance 4). Similarly, the mean final recall scores for

story 2 were higher than those for story 1 in counterbalance 2 and 3 (39.1% versus

21.1% in counterbalance 2 and 63.1% versus 22% in counterbalance 3).

57
  
 
FIGURE 5. Line graph showing comparing the means of 24-hour recall for both stories

across each counterbalance (n= 10). For Story 1 the highest mean scores were in

counterbalance 1 (20.50) and 4 (14.43). For story 2 the highest mean scores were in

counterbalance 2 (19.63) and 3 (22.86).  There is a significant difference between the

mean 24-hour recall scores of Story 1 between CB 1 and 2 (p=0.001) and CB1 and 3

(p=0.10). No significant difference was found between the mean recall scores of Story

2.

58
 VCI (STW) Hayling Scaled DS Scaled
Mean 96 5.9 10.2
SD 9.1 0.73 2.7
FRS1-p value : r value 0.012 : 0.147 0.016 : 0.377 0.366 : 0.147
FRS2-p value : r value 0.003 : 0.463 0.003 : 0.462 0.8 : -0.41

TABLE 2. Table showing the statistical data for the neuropsychological test done

following repetition (n=40). No significant correlation was found between any of the 3

test and the final recall scores for Story 1. However, a moderate significant relationship

was found between Hayling Test scores and the Final Recall Scores for Story 2 (FRS2)

(p=0.003, r=0.462). A moderate significant relationship was also found between VCI

and the final recall scores for story 2 (p=0.003, r=0.463).

The verbal correlation index (VCI) was used to convert scores from the spot the word

(STW) test because it correlates better with word reading. In the population, you would

expect the mean VCI to be 100 with a standard deviation of 15. The current findings

show a mean of 96 and a standard deviation of 9, suggesting the sample is fairly

representative of the population. For Hayling and Digit Span Test the mean overall

scaled score for the population is 6 and 10 respectively with a standard deviation of 3

for the digit span test. The current findings show a mean of 5.9 and 10.2 with a standard

deviation score of 2.7 for digit span test, again suggesting that the sample was

representative of the population.

59
FIGURE 6. Pie chart showing participant responses on the relaxation phase. 62.5 % of

participants said they were mind wandering/daydreaming during the relaxation phase.

10% said they were thinking about the information, 7.5% said they were worrying about

something and 2.5 said they were sleeping. 17.5% choose “Other”.

60
 16

14

12

10

0
FirstRecallS1 FirstRecallS2

FIGURE 7. Bar graph showing initial recall scores from the patient participant. There

was a higher recall score for Story 2 (Dr. Lee) than story 1 (Willowdale).

61
 15

10

5
First Recall Delay Recall 24HourRecall

Story 1 Story 2

FIGURE 8. Line graph of the patient participant recall scores. The graph shows the

recall scores of the patient participant over various time intervals. Here, in story 1, a

decline can be seen from the initial recall score, however, there is an incline at the 24-

hour recall. Story 2 shows a decline at each delay recall following the initial recall.

62
Discussion

Memory, seemingly ubiquitous in nature, underpins the bases human cognitive

function and adaptation. Wood and colleagues broadly refer to the construct of memory

as “information gained from past experience that is available in the service of ongoing

and future adaptive behavior” (Wood, et al., 2011). Decades of memory-based research

studies have been aimed at developing a better understanding of the processes of

memory and the manipulations which may affect it.

The present study aimed to assess the effects of repetition and guided relaxation

on memory recall and retention in a non-brain injured population. Various studies have

yielded evidence which supports each concept as a memory boost. Here we

hypothesized that, as both stories have been matched for difficulty using the Flesch-

Kincaid readability tests, the initial recall scores for both stories should be similar/equal

across both conditions. The findings are in contrast to this however, with analysis

showing higher scores for story 2 than for story 1. This finding is interesting, firstly, and

most obviously due to the previous matchings for difficulty and readability. Secondly, a

similar study similar study conducted by Hilary Bravi, using another version of the

stories to assess the effects of interference and wakeful rest on memory recall also found

that initial recall scores for Story 1 were lower than that of other stories (Bravi, 2017).

The story was later modified and matched again for difficulty before its use in the

63
present study, however, these findings suggest that Story 1 may in fact be more difficult

than Story 2 to remember. Due to this we reject our first hypothesis.

The cumulative hypothesis as proposed by Hintzman (2000) asserts that repetition

strengthens memory representations. Following this notion, we hypothesize that the

second immediate recall scores from the repetition condition will be higher than those

from the relaxation condition. As hypothesized, recall scores for the repetition condition

for both stories were shown to be higher than those of for the for the relaxation

condition. Furthermore, the recall scores for the repetition condition were higher than

those for the relaxation regardless of the delay interval at which they were collected.

Hence, we accept the second and third hypotheses. From these findings it can be

assumed that repeated story would yield the highest final recall scores, compared to the

story presented in the relaxation condition of each counterbalance (thus, Story 1 should

yield higher final recall scores in counterbalance 1 and 4, while story 2 should yield

higher final recall scores in counterbalance 2 and 3)., as they did in this study. These

findings reiterate the prior findings which highlight that the scores from the repetition

condition are higher than those from the relaxation condition.

The question then arises as to how this information was maintained throughout

the duration of the study and be present at for a final recall after the interference of the

administered neuropsychological assessments. Jonides and colleagues, discussing how

information in short-term memory is kept safe from the interference of irrelevant

thoughts and the addition of new stimuli, argue that the maintenance of information is

64
not the same as rehearsal (Jonides, et al., 2008). This argument is opposite to those

proposed by earlier researchers who assert that it is rehearsal which maintains

information in the short-term memory store (Waugh & Norman, 165) (Craik & Watkins,

1973). Rehearsal, whether it be verbal or mental, reflects “a strategy composed of a

series of retrievals and re-encodings” of information (Jonides, et al., 2008), and in the

present study can be assumed to take place mentally during the repetition condition.

This strategy can account for the increase in memory recall scores following the second

story reading in the repetition condition and may also account for the reflection of

higher recall scores for the repetition condition at delay intervals due to the

strengthening of the initial memory encoded during the first playing of the story.

However, over time delays, most notably the longest delay period of 24-hours, what

prevents this information from becoming obsolete in the face of new incoming

stimulus? Postle (2006) posits that maintenance mechanisms in the brain prevent the

interruption of information which has been deemed important long after the subject

ceases to cognitively perceive it.

How then might this help us to understand why more information may be lost in

patients with brain injuries and cognitive deficits? In the current study, the patient data

reveals a decrease in memory recall scores in each condition at the second delay recall

interval. The answer may lie in the area of the brain which has been compromised, as

several studies highlight specific brain regions which play a role in the maintenance of

short-term memory (Braver, et al., 1997) (Corcoran & Quirk, 2007) (Kane & Engle,

65
2002) (Seamans, et al., 1995). For example, the prefrontal cortex activity has been

shown to underpin the maintenance of memory during working memory tasks, thus, the

inactivation of this brain region due to injury may lead to compromises in short-term

memory capacity and task execution (Postle, 2006).

To assess the effects of repetition and relaxation on a long-term scale we

hypothesize that 24-hour delay scores for the repetition condition would be higher than

those from the relaxation condition. As hypothesized 24-hour delay scores for the

repetition condition are higher than those of the relaxation condition. A significant

difference between mean recall scores was found for story 1, but no significant

difference was found between groups in regard to story 2. This difference was found

between counterbalance 1 and 2 (p=0.01). As expected, 24-hour recall scores for story 1

were higher than those for story 2 in counterbalance 1 and likewise higher for story 2 in

counterbalance 2 and 3. The higher scores present in the repetition condition could

arguably be attributed to the strengthening of the memory trace, thereby making the

story heard in the relaxation condition more easily forgotten. Thus, due to these

findings we accept the final hypothesis.

CURRENT VS PAST FINDINGS

The current study’s findings support the long-standing notion that repetition boost

memory recall, as previously discussed, scores from the repetition condition were higher

than those of initial and final recall for the relaxation condition, suggesting that memory

66
recall is strengthened following the repetition of information. Previous studies have

proposed that the effect of repetition on memory is based on the time frame in which the

repetition takes places in relation to the memory recall as well as the frequency of the

repetition. For the current study, repetition took place directly after initial recall and as

hypothesized, yielded increased memory recall scores. This finding is similar to Khul

and Anderson’s, who found participants remembered more words when the repetition of

the words took place for short periods of time compared to longer periods (Kuhl &

Anderson, 2011). It was assumed that the story repeated in the various counterbalances

would be listed by the participants as the easier of the 2 to remember, or that they would

say that the two stories were equal as they have been matched for difficulty. Overall, the

majority of participants said the story 2 was easier to remember, of these participants,

41% said it was due to the repetition of the of the story, as was expected. Interestingly

however, 35% said it was due their being specific details which they could visualize or

imagine. This finding is similar to Wicklegreen’s finding during his study on auditory

memory where participants recalled familiar tones easier in delayed comparison tests

(Wicklegreen 2000). While increases in memory recall directly after repetition may

seem arguably obvious, more interesting is the memory retention scores for the

repetition condition at different time intervals. Here we tested the effect of repetition on

memory at a 15-30-minute delay and a longer 24-hour delay. Percentage retention

memory recall scores calculated for the 15-30-minute delay in the repetition condition

shows an overall 72% of participants maintained over a 100% memory retention; more

67
than doubling the number of participants who maintained memory retention scores in

the relaxation condition (27%). Overall, 71% of participants maintained 100%, or more,

24-hour memory retention, more than tripling the percentage memory retention for the

relaxation condition (21.8%). In counterbalance 1, 90% of participants maintained over

100% memory retention in 24-hour delay recall; 22% of these participants doubled their

memory retention scores (200%+ memory retention) and 11% tripled their memory

retention scores from that obtained in initial recall. In counterbalance 2, 62.5% of

participants maintained over 100% memory retention for the 24-hour delay recall, 57%

in counterbalance 3 maintained over 100% memory retention, while 71% of participants

in counterbalance 4 maintained memory retention scores over 100%. These findings

support not only the notion of repetition as a memory boost, but also support the

cumulative frequency hypothesis of memory, which asserts that repeated experience

strengthens the memory representation made during the initial experience (Hintzman,

2010).

Various studies conducted on the effects of relaxation on memory have yielded

results in favor of it being a memory boost. Theories of interference posit that the

influence of new stimuli after the formation of a new memory disrupt the consolidation

of the memory thereby making it prone to being forgotten (Jonides, et al., 2008).

Following this notion, it can be assumed that by removing subjects from environments

that pose interference forgetting could be reduced. Testing such a hypothesis, one study

found that participants who were not allowed a break in between the learning of various

68
tasks showed significantly worse scores on recall tests (Mercer, 2015). Thus, it was

concluded that short periods of relaxation can shield newly formed memories from

interference and decrease forgetting (Mercer, 2015). In the present study however, the

relaxation condition was showed to have no positive effect on memory recall, and in

some cases, scores following relaxation were lower than initial scores highlighting a

loss of information.

Hudtez and colleagues found that there were increases in the mean test scores of

participants following guided imagery relaxation (Hudetz, et al., 2000). For the present

study, to reduce the chances of mental rehearsal during the break between the

presentations of information guided auditory relaxation was used incorporating sounds

of the ocean. While the scores for the relaxation condition were less than those of the

repetition condition as hypothesized, only approximately a quarter of participants

showed maintenance of 100% memory retention in the relaxation condition. Another

study conducted by Manjunath and Telles (2004), assessing spatial and verbal memory

in children of yoga and fine arts camps found a 43% increase in the spatial memory

scores of children from the yoga group, suggesting that “meditation and guided

relaxation improved delay recall scores of spatial information” (Majunath & Telles,

2004). In the present study however, findings from a non-patient population imply that

relaxation may not serve to improve verbal memory as it did spatial memory in the

aforementioned study. Similar to the findings from the non-patient participants, the

scores of the patient participant show no maintenance or increase of memory recall, for

69
the story administered in the rest condition. In addition to this, the percentage memory

retention for the rest condition showed decline at every time delay, and finally reflected

only a 64% memory retention at the 24-hour delay recall point. Interestingly however,

there was a 100% memory retention at the 24-hour delay recall point for the story from

the interference condition. Thus, the current study’s findings do not suggest that

relaxation acts as an effective memory boost. However, it must be noted that the

relaxation condition in the present was not tested against participants from a normal

condition who had no relaxation as in Mercer’s (2015) study, but instead is compared

with that of the repetition condition. Thus, is remains unclear as to if relaxation does not

boost memory recall or at least aid in preserving more information than would have

been preserved in a condition where subjects were not allowed relaxation or repetition.

Therefore, we must conclude that relaxation, compared to repetition, doesn’t aid in

boosting memory recall and retention.

70
Design Evaluation and Limitations

Though the stories used for this present study have been previously tested and

matched for difficulty, initial recall scores for both stories were not equal or similar, and

therefore do not reflect that they are of equal difficulty. Therefore, these stories should

be reevaluated again and modified if necessary. For this study the relaxation phase took

place in a quiet room, where the music was played aloud, any future attempts on testing

relaxation conditions in this was should consider providing participants with

headphones as to block out any surrounding noises which may affect the relaxation

process, such as persons passing by, as to maximize focus on the instrument guiding the

relaxation. One limitation of the current study was the absence of a control group who

were not afforded the repetition of stories and phases of relaxation. The two conditions

were not tested against a control group without either a relaxation or repetition paradigm

and it would be interesting to see a study executed using the same relaxation condition

as the current study but compared with scores from a controlled condition. This

proposed design may aid in highlighting if relaxation after memory formation allows for

the maintenance of more information. Also, an interesting comment regarding the 24-

hour delay recall is that recall scores may be impacted by the way participants were

contacted (text versus phone call), thus raising the question as to whether participants

71
remembered more or less information due to their previous recalls being verbal and the

24-hour delay recall being written.

72
Conclusion

In conclusion, the findings from this study suggest, as has long been assumed, that

repetition acts a memory boost, with analysis showing increases in memory recall in the

repletion condition across all counterbalances. On the other hand, the present findings

do not suggest that relaxation acts as an effective boost of memory recall. Compared to

the repetition condition the relaxation condition was not shown to enhance memory

recall. Assessing this relaxation condition against a control group could help to better

clarify the effects of relaxation on memory.

Overall, this study could aid in the modification of how patient information is

presented to cognitively impaired patients, as patient data shows the maintenance of

information after a 24-hour delay. It could also the development of memory

rehabilitation techniques following brain injury. In addition, the findings of the present

study could also aid in the modification of the presentation of information to students in

classroom settings who are tasked with remembering bundles of information. Adding a

repetitive style of teaching such as recapping the previous lecture before the start of

each new lecture may boost student’s recall of information.

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in a Quarter of a Century, and Perspective: Implication for Learning and Memory. Biological and
Pharmaceutical Bulletin, 28(8), pp. 1342-1354.

Yesavage, J. A. & Jacob, R., 1984. Effects of relaxation and mnemonics on memory, attention and
anxiety in the elderly. Experimental Aging Research, Volume 10, pp. 211-214.
Zhong, H. et al., 2009. Subcellular dynamics of type II PKA in neurons. Neuron, 62(3), pp. 363-374.

Zinga, D., Bennett, S., Good, D. & Kumpf, J., 2003. Educating Educators About Acquired Brain
Injury: A Prigramm Description. Journal of Developmental Disabilities, 10(1), pp. 159-163.

82
 APPENDICES

83
 APPENDIX A
Ethics for the study being conducted at the Royal Hospital for Neuro-disability

South East Coast - Surrey Research Ethics Committee

Whitefriars
Level 3, Block B
Lewins Mead
Bristol
BS1 2NT

Telephone: (020) 71048053/33

Fax:

[If the study is for HRA Approval, the user should insert the
following text box if the HRA assessment is not complete]

Please note: This is the favourable

opinion of the

REC only and does not allow you to

start your study at NHS sites in
England until you receive HRA
Approval

07 March 2017

Dr. Nathan Illman

Clinical Psychologist
Royal Hospital for Neuro-disability
Royal Hospital for Neuro-disability
West Hill
London
SW15 3SW

Dear Dr. Illman

Study title: Memory and learning after brain injury: A study exploring
causes of common memory problems.
REC reference: 17/LO/0453
IRAS project ID: 213917

The Proportionate Review Sub-committee of the South East Coast - Surrey Research Ethics
Committee reviewed the above application on 14 March 2017.

84
We plan to publish your research summary wording for the above study on the HRA website,
together with your contact details. Publication will be no earlier than three months from the date
of this favourable opinion letter. The expectation is that this information will be published for all
studies that receive an ethical opinion, but should you wish to provide a substitute contact point,
wish to make a request to defer, or require further information, please contact

85
hra.studyregistration@nhs.net outlining the reasons for your request. Under very limited
circumstances (e.g. for student research which has received an unfavorable opinion), it may be
possible to grant an exemption to the publication of the study.

Ethical opinion

On behalf of the Committee, the sub-committee gave a favourable ethical opinion of the above
research on the basis described in the application form, protocol and supporting documentation,
subject to the conditions specified below.

Conditions of the favourable opinion

The REC favourable opinion is subject to the following conditions being met prior to the start of
the study.

[If applicable, user to insert additional conditions from the minutes]

[Where additional conditions are specified by the REC:]

You should notify the REC once all conditions have been met (except for site approvals
from host organisations) and provide copies of any revised documentation with updated
version numbers. Revised documents should be submitted to the REC electronically
from IRAS. The REC will acknowledge receipt and provide a final list of the approved
documentation for the study, which you can make available to host organisations to
facilitate their permission for the study. Failure to provide the final versions to the REC
may cause delay in obtaining permissions.

[All studies]
Management permission must be obtained from each host organisation prior to the start of
the study at the site concerned.

Management permission should be sought from all NHS organisations involved in the study in
accordance with NHS research governance arrangements. Each NHS organisation must
confirm through the signing of agreements and/or other documents that it has given permission
for the research to proceed (except where explicitly specified otherwise).

Guidance on applying for HRA Approval (England)/ NHS permission for research is available
in the Integrated Research Application System, www.hra.nhs.uk or at http://www.rdforum.nhs.uk.

Where a NHS organisation’s role in the study is limited to identifying and referring potential
participants to research sites (“participant identification centre”), guidance should be sought
from the R&D office on the information it requires to give permission for this activity.

For non-NHS sites, site management permission should be obtained in accordance with
the procedures of the relevant host organisation.

Sponsors are not required to notify the Committee of management permissions from
host organisations.

Registration of Clinical Trials

86
All clinical trials (defined as the first four categories on the IRAS filter page) must be registered
on a publicly accessible database. This should be before the first participant is recruited but no
later than 6 weeks after recruitment of the first participant.

There is no requirement to separately notify the REC but you should do so at the earliest
opportunity e.g. when submitting an amendment. We will audit the registration details as part of
the annual progress reporting process.

To ensure transparency in research, we strongly recommend that all research is registered but
for non-clinical trials this is not currently mandatory.

If a sponsor wishes to request a deferral for study registration within the required timeframe,
they should contact hra.studyregistration@nhs.net. The expectation is that all clinical trials will be
registered, however, in exceptional circumstances non registration may be permissible with prior
agreement from the HRA. Guidance on where to register is provided on the HRA website.

It is the responsibility of the sponsor to ensure that all the conditions are complied with
before the start of the study or its initiation at a particular site (as applicable).

Ethical review of research sites

The favourable opinion applies to all NHS sites taking part in the study, subject to
management permission being obtained from the NHS/HSC R&D office prior to the start of the
study (see “Conditions of the favourable opinion”).

Approved documents

The documents reviewed and approved were:

Document Version Date

Evidence of Sponsor insurance or indemnity (non NHS Sponsors 1.0 29 September 2016
only) [2016 TWIMC Letter_V1.0]
GP/consultant information sheets or letters [Letter to consultant] 2 15 February 2013
IRAS Checklist XML [Checklist_24022017] 24 February 2017
Letter from sponsor [nathansponsorlet] 1 22 December 2016
Participant consent form [Consent form] 2 15 February 2017
Participant information sheet (PIS) [Participant Information Sheet] 2 15 February 2017
REC Application Form [REC_Form_24022017] 24 February 2017
Referee's report or other scientific critique report [RHN Acceptance 1 19 February 2016
letter]
Referee's report or other scientific critique report [Peer review report] 1 04 November 2016
Research protocol or project proposal [Protocol ] 4 19 December 2016
Summary CV for Chief Investigator (CI) [Chief Investigator CV] 1 09 December 2016

Membership of the Proportionate Review Sub-Committee

The members of the Sub-Committee who took part in the review are listed on the attached sheet.

87
Statement of compliance

The Committee is constituted in accordance with the Governance Arrangements for

Research Ethics Committees and complies fully with the Standard Operating Procedures for
Research Ethics Committees in the UK.

After ethical review

Reporting requirements

The attached document “After ethical review – guidance for researchers” gives detailed
guidance on reporting requirements for studies with a favourable opinion, including:

 Notifying substantial amendments

 Adding new sites and investigators
 Notification of serious breaches of the protocol
 Progress and safety reports  Notifying the end
of the study

The HRA website also provides guidance on these topics, which is updated in the light of
changes in reporting requirements or procedures.

User Feedback

The Health Research Authority is continually striving to provide a high quality service to all
applicants and sponsors. You are invited to give your view of the service you have received and the
application procedure. If you wish to make your views known please use the feedback form
available on the HRA website: http://www.hra.nhs.uk/about-the-hra/governance/quality-assurance/

HRA Training

We are pleased to welcome researchers and R&D staff at our training days – see details
at http://www.hra.nhs.uk/hra-training/

With the Committee’s best wishes for the success of this project.

17/LO/0453 Please quote this number on all correspondence

Yours sincerely

PP - Dr. Mark
Atkins Chair

Email: nrescommittee.secoast-surrey@nhs.net
 APPENDIX B
Participant consent form

PARTICIPANT CONSENT FORM

Title of Research: Investigating the effects of repetition and guided

relaxation on memory retention and recall in a non-brain injured sample.
Brief Description of Research Project, and What Participation Involves:

The research being carried is aimed at understanding how different manipulations may serve to
improve memory recall. This study may prove useful to patients with memory deficits such as
those who have suffered from a brain injury. Participants will be read 2 stories, for some the
stories will be repeated and recall scores assessed. For others there will be a period of guided
relaxation before they are asked to recall the stories.

The interview will be tape recorded and transcribed with any identifying details removed. The
transcript, or extracts from, may appear in my report and in publications arising from it. The
tapes may be heard by my supervisor and others who might be involved in examining the
report.

The data will be collected in a way that makes it fully anonymous.

No identifying details will be recorded on your questionnaire response so that your data will be
completely anonymous, and it will therefore not be possible to be linked to your consent form.

You will be asked to assign a code number to your data which only you will know, so if you wish
to withdraw your data you will be able to do this by providing the research with your code
number

Investigator Contact Details:

Brittany Jordan
Life Sciences
Kings, Whitelands College, Roehampton University
SW15 4JD
jordanb@roehampton.ac.uk
+447754790604

Consent Statement:

I agree to take part in this research, and I am aware that I am free to withdraw at any point
without giving a reason, although if I do so I understand that my data might still be used in a
collated form. I understand that the information I provide will be treated in confidence by the
investigator and that my identity will be protected in the publication of any findings, and that data
will be collected and processed in accordance with the Data Protection Act 1998 and with the
University’s Data Protection Policy.

Name ………………………………….

Signature ………………………………

Date ……………………………………

Please note: if you have a concern about any aspect of your participation or any other queries
please raise this with the investigator or the Supervisor. However, if you would like to contact an
independent party please contact the Head of Department.

Project Supervisor
Professor Jolanta Opacka-Juffry
Department of Life Sciences
University of Roehampton
Whitelands College
Holybourne Avenue, London, SW15 4JD
j.opacka-juffry@roehampton.ac.uk
+44 (0)20 8392 3563

Project Supervisor (Royal Hospital for Neuro-disability)

Dr. Sarah Crawford
Clinical Neuropsychologist
Royal Hospital for Neuro-disability
West Hill
London, SW15 3SW
scrawford@rhn.org.uk
(0)20 8780 4500 ext. 5143
 APPENDIX C

Participant Debrief Form

Participant Number: __________

PARTICIPANT DEBRIEF

Thank you very much for taking part in our study, we greatly appreciate your contribution.

This study is designed to examine the effects of repetition and relaxation on memory and your
participation is extremely valuable.

All data gathered during this study will be held securely and anonymously. If you wish to
withdraw from the study, contact us with your participant number (above) and your information
will be deleted from our files.

Should you have any concern about any aspect of your participation in this study, please raise it
with the investigator in the first instance or with the Project Supervisor or Head of Department.

Investigator Project Supervisor

Brittany Jordan Professor Jolanta Opacka-Juffry

Life Sciences Department of Life Sciences

University of Roehampton University of Roehampton

Whitelands College Whitelands College
Holybourne Avenue, London, SW15 4DJ Holybourne Avenue, London, SW15 4JD
jordanb@roehampton.ac.uk j.opacka-juffry@roehampton.ac.uk

+447754790604 +44 (0)20 8392 3563

If you are a student at Roehampton University and are troubled or worried about any aspect of
the study, or issues it may have raised, you may find it helpful to contact the Student Welfare
Team who will be able to advise you on agencies that can deal with your particular concern:

Student Wellbeing Officers

Digby Stuart College Froebel College
Nicola Hallam Sophie Cutforth
nicola.hallam@roehampton.ac.uk                                           Sophie.cutforth@roehampton.ac.uk
(020 8392) 3200 (020 8392) 3304 
Location: Erasmus House 101, Digby Stuart Location: Grove House, 209

Southlands College Whitelands College

Jo Eskdale Emily Cookson
Email: j.eskdale@roehampton.ac.uk Email: emily.cookson@roehampton.ac.uk
(020 8392) 3402 (020 8392) 3502
Location: Queen's Building 149, Southlands Location: PH, G048, Whitelands

If you feel your concerns are more serious or complex you may wish to contact the
Student Medical Centre on Ext 3679, or the Health & Wellbeing service via
health&wellbeing@roehampton.ac.uk

If you are a non-student, you may find it helpful to contact your GP.
 APPENDIX D

Patient Participant Consent Form

RESEARCH CONSENT FORM

Title of Project: Memory and learning after brain injury: A study exploring causes of common
memory problems (REC ref: 17/LO/0453)
(The patient/volunteer should complete the whole of this sheet him/herself. If they are unable to write, a member of staff should complete the
form under instruction from the participant and in the presence of a witness).

Please circle the appropriate response:

Have you read the Information Sheet (Version 2; 15.02.17)? Yes No

Have you had the opportunity to ask questions and discuss the study? Yes No

Have you received satisfactory answers to all of your questions? Yes No

Have you received enough information about the study? Yes No

Whom have you spoken to? (write name)…………………………………………………………………..

Do you understand that you are free to withdraw from the study,
at any time, without having to give a reason, and without affecting
the quality of your present or future medical care or legal rights? Yes No

I understand that sections of any of my medical notes may be looked at

by responsible individuals from the Hospital or from regulatory
authorities where it is relevant to my taking part in research. I give
permission for these individuals to have access to my records. Yes No

Do you agree to take part in this study? Yes No

Your participation in this research study will be recorded in a confidential database of research
participants managed by the Research Department.

NAME OF SUBJECT: ………………………………………………………………

IN BLOCK LETTERS: ……………………………………………………………..

Signed: ………………………………………. Date: ……………………………….

If patient is unable to write, signed on their behalf by: ………………………….……

Signed: ……………………………………… Date: ………………………………

WITNESS: …………………………………………………………………………………………

Signed: ………………………………………. Date: ………………………………

NAME OF INVESTIGATOR: ……………………………………………………...

Signed: ………………………………………. Date: ……………………………….

 2-point response Score 1-point response Score
Word/phrase
Criteria Examples Criteria Examples
On Tuesday Tuesday AND morning 2 Tuesday OR morning 1 0
morning
you went to an Went to an appointment 2 Indication that you had gone I went for a meeting; I’d 1 0
appointment at somewhere been to: I went to.
Willowdale Willowdale 2 Any name beginning with W Westmead; Wellsend; 1 0
with two syllables Wendale.
General Hospital. General AND Hospital 2 Indication of a hospital or Local hospital; hospital; 1 0
medical institution medical centre; GP
surgery.
You met with Dr Doctor AND Harding or Herring; Hardy. 2 Doctor OR Harding or close Herring; Hardy. 1 0
Harding. close variant beginning with variant beginning with same
same letter. letter.
It was to discuss Discuss AND indication that Coming-up; 2 Any phrase that suggests a We had a chat about; we 1 0
your upcoming the content of this was planned; conversation was held about discussed; it was to talk
something in the future. something that the operation about; it was about.
was in the diary.
laparoscopic laparoscopic 2 Close variant of laparoscopic Laposcopic; landoscopy. 1 0
beginning with letter L and
between 4-5 syllables.
hip operation. hip AND operation 2 Operation 1 0
You have suffered I have suffered 2 Reference to there being Symptoms included; I’ve 1 0
symptoms been experiencing; I’ve
had.
numbness and Numbness AND pain 2 Numbness OR pain 1 0
pain,
and trouble Trouble AND sleeping 2 A phrase indicating sleep Difficulty; problems with; 1 0
sleeping problems haven’t been able to
sleep.
for 7 months. 7 AND months 2 Indication symptoms have Several months; a 1 0
existed for months number of months;
many months.
The surgery is Surgery AND scheduled 2 Any indication the surgery is It’s planned for; the 1 0
scheduled scheduled. operation is booked in
for; the operation will go
ahead on.
for 11.15am 11.15am 2 Indication of operation Morning of…. 1 0
being booked in for the 10am; 12.15.
morning or within an hour
+/- of 11.15
on 5th July, 5th AND July 2 5th OR July 1 0
and will last Indication of a duration of 1.5 hours; an hour 2 Indication that the operation A couple of hours. 1 0
around 90 minutes. operation AND 90 minutes, and a half. will last more than one hour
or similar.
Your best friend Best friend and indication Said; told me; 2 Friend or variant AND Mate; buddy; pal; 1 0
told you that they gave information advised me; indication that they gave neighbour; good friend.
informed me. information
Said; told me; advised
me; informed me.
the fastest ways to Fastest AND travel 2 Indication that this transport The quickest; the best 1 0
travel there are is preferable to other ways. ways.
on the Number 83 83 AND bus 2 Indication of a bus, but The number thirty- 1 0
bus number does not need to be something bus.
correct.
or to catch a train Catch AND train 2 Variant of catch Take; get; board. 1 0
from Eastern Street Eastern AND Street or close East Street; Easter 2 Eastern or similar close East Road; Western 1 0
variant beginning with same Street. variant indicating compass Avenue.
letter. direction AND street or
similar
train station. Train AND station 2 Station. 1 0
TOTAL 2 point TOTAL 1 point responses
responses (add all (add all 1s, max = 22)
2s, max = 44)
 2-point response Score 1-point response Score
Word/phrase
Criteria Examples Criteria Examples
Dr Lee Doctor AND Lee or close Words rhyming with 2 Doctor on its own as a word OR Single syllable word rhyming 1 0
variant Lee, e.g. Dee, Bee, or Lee or a close variant. with Lee, or beginning with L.
indication of the name
beginning with letter L.
has diagnosed you with diagnosed AND notion Diagnosed me; given 2 Implication that the doctor or Someone told me I’ve got; I 1 0
of it being the me a diagnosis. someone has diagnosed or was told I’m suffering from;
participant (i.e you, or conveys idea of diagnosis. I was diagnosed with.
me).
‘Robinson’s disease’. Robinson’s AND 2 Close variant of Robinson’s starting Robbins; Robson’s; sickness; 1 0
disease. with letter R; variation of the word illness; disorder; syndrome.
disease.
This condition condition 2 A close variant of condition sickness; illness; disorder; 1 0
syndrome.
affects your small Small AND intestine 2 Small OR intestine, or close variant Bowel; stomach. 1 0
intestine. of intestine.
Symptoms can include Symptoms AND include 2 Symptoms or close variants Effects. 1 0
feeling bloated, Feeling bloated 2 Close variant of bloated Bloatedness; gassy 1 0
nausea nausea 2 Conveys idea of feeling sick 1 0
and tiredness. tiredness 2 Conveys idea of tiredness Makes you sleepy; you want 1 0
to sleep; fatigue.
The treatment treatment 2 Variant of treatment or implication It can be treated with. 1 0
that the condition can be treated.
is called Doxycrazalone 2 Close variant of Doxycrazalone Doxycyclozone. 1 0
Doxycrazalone. starting with letter D, with at least
4 syllables.
You must take two take AND two 2 Implication that you need to take, 1 0
or consume something.
red capsules Red AND capsules 2 Notion of red medication Red Caps; red pills; red 1 0
tablets; red tabs.
with food with food or notion of it With a meal; along with 2 Notion of food or meal times being Before food; before eating; 1 0
being consumed at the food; at the same time involved in taking the medication. after eating.
same time as eating. as food/meals.
three times a day three AND indication Per day; every day; 2 Reference to it being taken more Several; a few. 1 0
that it is daily each day. than once each.
and do this for 8 days. Notion of treatment You need to continue 2 A reference to the treatment Keep doing this for a week; 1 0
lasting 8 days. this for 8 days; keep lasting a certain number of days. treatment last just over a
doing that for 8 days. week; do it for 9 days.
This totals 600mg a 600mg AND day 2 Reference to there being a daily The total is 600 something; 1 0
day. total dose of milligrams. that equals … grams.
If you accidentally take Accidentally AND If you overdose; if you 2 Any mention of the notion of Overdose; take more; take 1 0
more than this, notion of taking more go over that; exceed. taking too much too much; exceed stated
than stated dose dose.
call the NHS Call AND NHS 2 Notion that you have to call Call the doctor; call for help. 1 0
someone
non-emergency phone Non-emergency AND Telephone number; 2 Notion that it is not 999 or 1 0
line. close variant of phone number; service. emergency services.
line.
Your follow-up Follow-up AND 2 Notion of there being another Next appointment; follow- 1 0
appointment appointment appointment up; I have to see the doctor
again.
is in three weeks. Three AND weeks 2 Notion that the follow-up is some In a few weeks time; several 1 0
weeks in the future. weeks; 2-4 weeks time.
TOTAL 2 point TOTAL 1 point responses
responses (add all 2s, (add all 1s, max = 22)
max = 44)
 APPENDIX G
Post study questionnaire.

POST STUDY QUESTIONNAIRE

Participant Number: __________ Age: _____

Education Level (e.g. Highschool/ BSc etc.): _____________________

1. If you think about the stories, were they equally easy to remember, or
was one easier than the other?

Equal Dr. Lee Willowdale

2. If one was easier than the other, why do you think that story was
easier?

3. When we asked you to relax, how relaxed did you feel?

_____
0 1 2 3 4 5
Not relaxed Very relaxed

4. Which of the following did you do during the rest period?

a. Mind wandering/day dreaming
b. Thinking about the information we had asked you to remember
c. Worrying about something
d. Sleeping
e. Other:
The investigator would like to reach out to you following a 24hour period to
ask your thoughts on the study.
Tel: _________________________

Please be assured that this number will only be used for the purpose of this study and will be
discarded after.