Neuropsychological Rehabilitation: An International Journal

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Neuropsychological
Rehabilitation: An International
Journal
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Rehabilitation of the central

executive component of working
memory: A re-organisation
approach applied to a single
case
a a a b
J. Duval , F. Coyette & X Seron
a
Centre de Revalidation Neuropsychologique,
Cliniques Universitaires Saint-Luc , Université
catholique de Louvain , Brussels, Belgium
b
Unité de Neurosciences Cognitives, Faculté de
Psychologie , Université catholique de Louvain ,
Louvain-la-Neuve, Belgium
Published online: 25 Jun 2008.
To cite this article: J. Duval , F. Coyette & X Seron (2008) Rehabilitation of the central
executive component of working memory: A re-organisation approach applied to a
single case, Neuropsychological Rehabilitation: An International Journal, 18:4, 430-460,
DOI: 10.1080/09602010701573950
To link to this article: http://dx.doi.org/10.1080/09602010701573950
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NEUROPSYCHOLOGICAL REHABILITATION
2008, 18 (4), 430– 460
Rehabilitation of the central executive component of

working memory: A re-organisation approach applied
to a single case
J. Duval1, F. Coyette1, and X. Seron1,2

1
Centre de Revalidation Neuropsychologique, Cliniques Universitaires
Saint-Luc, Université catholique de Louvain, Brussels, Belgium
2
Unité de Neurosciences Cognitives, Faculté de Psychologie, Université
catholique de Louvain, Louvain-la-Neuve, Belgium
This paper describes and evaluates a programme of neuropsychological rehabi-

litation which aims to improve three sub-components of the working memory
central executive: processing load, updating and dual-task monitoring, by the
acquisition of three re-organisation strategies (double coding, serial processing
and speed reduction). Our programme has two stages: cognitive rehabilitation
(graduated exercises subdivided into three sub-programmes each correspond-
ing to a sub-component) which enables the patient to acquire the three specific
strategies; and an ecological rehabilitation, including analyses of scenarios and
simulations of real-life situations, which aims to transfer the strategies learned
to everyday life. The programme also includes information meetings. It was
applied to a single case who had working memory deficits after a surgical
operation for a cerebral tumour on his left internal temporal ganglioglioma.
Multiple baseline tests were used to measure the effectiveness of the rehabilita-
tion. The programme proved to be effective for all three working memory com-
ponents; a generalisation of its effects to everyday life was observed, and the
effects were undiminished three months later.
Correspondence should be sent to Françoise Coyette, Centre de Revalidation neuropsycholo-

gique, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.
E-mail: francoise.coyette@clin.ucl.ac.be
This project was supported by a grant to Julie Duval from the Communauté française de
Belgique in association with the Ministère de l’Éducation du Québec (2004 –2005), and from
BCEI J-Armand Bombardier (2003). We are indebted to Victor for his participation. We
would also like to thank Cécile Prairial and Auriane Speth for their collaboration.
# 2008 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/neurorehab DOI:10.1080/09602010701573950
REHABILITATION OF WORKING MEMORY 431
INTRODUCTION
Working memory involves the short-term storage and manipulation of infor-
mation relevant to ongoing mental operations. This system is used for per-
forming both simple and complex mental activities such as problem
solving, language comprehension, learning, reasoning, etc. (Baddeley,
1996). The ability to maintain information active for a short time period is
essential for a large variety of activities in daily life. People with a
working memory deficit have numerous and varied problems (interference

effects in dual-task situations, difficulty in comparing propositions, loss of
information in conversations, difficulty in calculating a tip or a bill, problems
in following the thread of a movie or a book, difficulty in taking notes during a
meeting, etc.).
Several aetiologies can cause an impairment of working memory: trau-
matic brain injury, cerebrovascular accident (CVA), tumour, Alzheimer’s
disease, Parkinson’s disease, schizophrenia, etc. Therefore, working
memory deficits are frequently observed in brain-damaged subjects and
they represent a major challenge to functional recovery following brain
injury. Although theoretical research on working memory has made great
progress in the last 25 years, only a few rehabilitation programmes for
the working memory have been developed. Thus, in spite of the fact
that working memory impairment is a common cognitive deficit, and
that people affected by this deficit cannot function satisfactorily in their
daily lives, very few rehabilitation programmes currently exist. In this
paper, we present a rehabilitation programme targeting the central execu-
tive (CE) component of the working memory system and its application
to a single case.
Although different models of working memory exist (Miyake & Shah,
1999), we will use Baddeley’s model (Baddeley, 1986; 2000) as a general
framework. Actually, this is the most widely used model in neuropsychology,
and several tests have been developed to investigate its different components.
Baddeley’s model distinguishes a central executive component and three
slave sub-systems: the phonological loop, the visuo-spatial sketchpad, and
the episodic buffer. The three slave sub-systems are under the central execu-
tive’s control. The phonological loop is concerned with the temporary storage
of verbal-acoustic information. It comprises a phonological store and a
rehearsal process that serves to maintain decaying representations in the pho-
nological store (Baddeley, Lewis, & Vallar, 1984). The visuo-spatial sketch-
pad serves the function of integrating spatial, visual and possibly kinaesthetic
information into a unified representation, which may be temporarily stored
and manipulated (Baddeley, 2003; Baddeley & Lieberman, 1980). It plays
a role in the generation and manipulation of mental images (Hanley,
Young, & Pearson, 1991) and is linked with the representation and planning
432 DUVAL, COYETTE, SERON
of movements (Miyake & Shah, 1999). The episodic buffer recently intro-
duced by Baddeley (2000) is assumed to be a limited-capacity storage sub-
system, which is capable of integrating information from a variety of
sources into a multi-dimensional code. It provides a temporary interface
between the phonological loop, the visuo-spatial sketchpad and long-term
memory, and is involved in feeding information into and retrieving infor-
mation from episodic long-term memory (Baddeley, 2000).
The central executive (CE) component is an attentional control system
responsible for strategy selection, and for the control and co-ordination of
the various processes involved in short-term storage (Baddeley, Bressi,
Della Sala, Logie, & Spinnler, 1991; Collette & Van der Linden, 2002).
Baddeley (1986) suggested that the CE component could be similar to the
“supervisory attentional system” in Norman and Shallice’s model of atten-
tion. The CE component has been divided by Baddeley and Wilson (2002)
into a number of executive sub-processes (such as the capacity to co-ordinate
performance on two separate tasks, to attend selectively to one stimulus and
inhibit the disrupting effect of others, to focus and to switch attention, to acti-
vate, to hold and to manipulate representations within long-term memory). At
present, there is no consensus regarding the structure of the CE. Some recent
studies suggest the existence of a common capacity (Duncan, Emslie,
Williams, Johnson, & Freer, 1996; Duncan, Johnson, Swales, & Freer,
1997; Engle, Michael & Tuholski, 1999). On the other hand, clinical obser-
vations reveal dissociation in performance between executive tasks, which
suggests a non-unitary system (Burgess, 1997; Lehto, 1996). Recently,
Miyake et al. (2000) examined the separability of three functions (shifting,
inhibition and updating) through a confirmatory factor analysis and found
that these sub-processes are both moderately correlated and clearly
distinguishable and independent from one another.
Whatever the result of the debate regarding the internal structure of the CE,
in this paper we present a rehabilitation programme that has been adminis-
tered to a patient who had a deficit in the CE component of his working
memory. Our intervention is based on the theoretical a priori that the
central executive can be fractionated into different sub-components.
Until now, there have not been many attempts at rehabilitation focusing on
the CE component of working memory. The CE has usually been considered
as an attentional system and, as in the rehabilitation of attentional disorders,
therapists have based their attempts to rehabilitate the CE on a restoration
rationale involving repetitive and intensive exercises. The studies that have
used this restoration approach (Coyette & Van der Kaa, 1995; Vallat,
Azouvi, Hardisson, Meffert, Tessier, & Pradat-Diehl, 2005; Vallat, Pradat-
Diehl, Meffert, Ardisson, & Tessier, 2002) shared the objective of progress-
ively enhancing the capacities of the CE by gradually increasing the mental
load of the exercises.
In this way, Coyette and Van der Kaa (1995) developed a programme with
two types of exercises. In the first, the patient was trained in a variety of tasks
requiring him or her to store information and then to manipulate it. In the
second, the patient had to remember some information while, at the same
time, performing an interfering task. This programme of cognitive exercises
is accompanied by an ecological approach containing information sessions
about the use of working memory in daily-life situations as well as simu-
lations of actual daily-life and professional situations. The programme
worked relatively well for the patient (AM) who had a very selective
deficit of the CE component of working memory (Van der Linden,
Coyette, & Seron, 1992). However, the study had some shortcomings as
the baseline measurements were not specific enough, and the complexity of
the exercises was not sufficiently controlled.
More recently, Vallat et al. (2005) have discussed the rehabilitation of a
patient who had a working memory deficit with conduction aphasia. The cog-
nitive programme focused on the mental load, with eight different exercises
hierarchically organised into nine difficulty levels. The results indicated a
specific improvement in working memory, with some transfer to daily-life
situations.
Cicerone and his collaborators used a rehabilitation programme aimed at
the acquisition of new strategies to treat four patients with limitations to
their CEs (Cicerone, 2002). The objective of the programme was to
teach the patients the conscious use of strategies to improve the distri-
bution of their reduced attentional resources. Multiple strategies such as
rehearsal, verbal mediation, sharing of resources between multiple tasks,
self-monitoring of mental effort, and control of secondary emotional reac-
tions were drilled. The exercises essentially consisted of several variations
of the n-back task (where the subject has to indicate the existence of some
similarity between the last stimuli presented and the one presented “n”
steps before). The therapy also used an ecological perspective, which con-
sisted of discussions with the patients and analysis of the difficulties they
encountered in their daily lives. The programme was used with a group of
four mild trauma patients, and its results compared to a control group of
four paired control subjects. A significant improvement in working
memory and attention measures was observed in the trained group. Further-
more, their complaints diminished in comparison to the non-trained group.
This strategic approach appears very promising, but the systematic use of
only one type of exercise may constitute an obstacle to the transfer of strat-
egies to daily-life situations.
In the present research, we tried to re-organise some aspects of the func-
tioning of the CE. The origin of our programme lies in the frequent obser-
vation that some patients use ineffective strategies to overcome the
reduction in their working memory capacity. They time their mental
operations badly and tend to work too fast. Bad timing was observed in some
patients who, when asked to encode and transform some information in
memory, tried to undertake the two operations simultaneously. Such parallel
processing results in interference between the encoding and the transform-
ation stages and, as a consequence, the patients lose control of the task.
The tendency to work too fast is also observed in patients who repeated the
material frequently but too quickly and superficially. These repetitions
were resource-demanding and interfered with the subsequent processing of
the material required by the task.

For this reason we developed an original programme aimed at alleviating
the mental load of the CE by using a triple strategy: a deeper encoding of the
material through a dual encoding strategy (using both the phonological loop
and the visual scratchpad); a serial organisation of the mental processes rather
than parallel activation; and a systematic reduction in the processing speed.
The rationale underlying these strategies is to consolidate the encoding
stages before going on to the processing of information, and to reduce the
CE mental load. We reasoned that, if the material is better encoded, then
the CE does not have to actively maintain its trace, and, as a direct conse-
quence, it leaves more resources free for the other processing steps required
by the task. Furthermore, the use of the visual scratchpad at the encoding level
may help to reduce the risk of phonological encoding error. A rehabilitation
programme conforming to such principles has already been applied with
some success to a young patient suffering from a cerebral anoxia, and
some preliminary results have been published in French (Coyette, Verreckt, &
Seron, 2003). Here we present more details of the general structure of our
rehabilitation programme, and the results of its application to another
single case.
In summary, instead of trying to re-establish the resources of the CE
through systematic restorative training exercises, we have adopted a re-
organisation rationale. Our new strategies involve a desynchronisation
between encoding and subsequent processes, and the systematic use of the
visual scratchpad sub-component of the working memory. In so doing, we
follow Emerson and Miyake’s (2003) recommendation that the slave
systems should not be considered solely as passive stores. The application
of efficient strategies ensures that more cognitive resources are available
to the central executive component to manipulate and control the various
processes involved in the processing task. Baddeley and Logie (1999) and
Logie, Della Sala, Laiacona, Chalmers, and Wynn (1996) have already
suggested that the limiting capacity of the different components of
working memory may be circumvented by the use of this type of strategy.
Our programme is also intended to promote the transfer of strategies to
daily life; the cognitive programme is therefore complemented by an eco-
logical approach.
MATERIAL AND METHOD

Cognitive rehabilitation programmes are of two types: cognitive and ecologi-
cal. Cognitive rehabilitation uses a variety of specific cognitive training tasks
to target the central executive component. Ecological rehabilitation attempts
to transfer this learning to everyday situations that involve the central
executive.
Cognitive rehabilitation is divided into three sub-programmes that address
three aspects of the functioning of working memory separately: the proces-

sing load (made up of storage and processing functions); and two sub-
processes: updating (coding incoming information and then revising the
items by replacing old information with new) and dual-task monitoring
(co-ordinating performance on two separate tasks). Ecological rehabilitation
has two stages: scenario analysis and simulations of real-life situations. Each
of these stages comprises exercises addressing the three functions (processing
load, updating and dual-task monitoring) separately. The three cognitive sub-
programmes and the two ecological stages are organised into hierarchical
levels of complexity. Progression within the programme is controlled by
responses: the patient should achieve 80% correct responses at one level
before passing to the next one.
For the cognitive programmes, we used verbal material (words, non-
words, letters) only. This material is easy to manipulate (level of concrete-
ness, length, frequency of use) to adjust the memory load, and is suitable
for the use of a double-coding strategy.
Rationale
The rationale of the programme is to teach the patient three different re-organ-
isation strategies: dual coding, serial processing and speed reduction, which
have to be used simultaneously in the different exercises.
First, the patient learns to use the dual coding strategy. When memorising
new information, the patient is asked to engage the two slave storage systems
of the working memory: the phonological loop and the visuo-spatial sketch-
pad. Concretely, when the first stimulus of a sequence is presented, the patient
has to repeat its name slowly and then to visualise it. The same technique is
used with the second stimulus, but the patient also has to repeat the first stimu-
lus. Each subsequent stimulus is learned in the same way, after which the
patient repeats the whole series.
Secondly, the patient learns the serial work strategy, used to encode all the
stimuli before treating (manipulating or transforming) them. For example, in
an alphabetical order task, each stimulus has to be encoded (i.e., named and
visualised) in turn, and the whole series has to be repeated at each stimulus
presentation before the patient is permitted to put them in alphabetic order.
For instance, when a three word series (curtain, apple and bottle) is presented
sequentially the patient must first name and visualise a curtain; then he or she
must name and visualise an apple and repeat the sequence “curtain-apple”;
then, the bottle is named and visualised and the whole series “curtain-
apple-bottle” is repeated. Only at the end of the sequence is the patient per-
mitted to put them in alphabetical order (apple-bottle-curtain). The objective
of the serial strategy is to avoid the patient being confronted with dual-task
situations.
Finally, to contribute to the success of these strategies, all the training tasks
are executed at the patient’s rate, or at a rhythm paced by the therapist, to
avoid any tendency to impulsivity which may result in superficial encoding
or too rapid repetition. With this speed reduction strategy, the emphasis is
on the quality of the performance rather than the rapidity of execution. It is
only when the patient is able to apply the strategies efficiently that the pace
of the exercises is progressively increased.
Cognitive rehabilitation programme

The strategies are taught in three different programmes related to (1) proces-
sing load, (2) updating, and (3) dual-task monitoring.
Processing load exercises (6 levels)

The programme comprises six levels of difficulty. The general structure of
the exercises is that the tasks require two stages of processing: first, the infor-
mation is stored, and secondly it is manipulated to achieve the goal of
the task. Progression in the programme is determined by the stimuli at the
storage level and the operation required at the manipulation level. At
the storage level, we systematically modified the length of the series (2 –6
items), the length of the stimuli (2– 6 letters or 2, 3 or 4 syllables according
to the task), and their nature (letters, words or non-words). At the manipu-
lation level, operations of progressive complexity are required: simple inver-
sion, ordering of stimuli, and item transformation. As a reminder, and to help
patients visualise the stimuli, they are invited to mentally represent the result
of the visualisation in arrays of large horizontal squares corresponding to the
number of items to be memorised.
The therapist encourages and reinforces the use of strategies. At the begin-
ning of each exercise, the therapist explains how to apply the strategies to the
particular type of exercise, and gives feedback about the performances. If an
error occurs, then the patient and the therapist try to understand its origin and,
if necessary, the strategies are explained again.
The exercises were as follows.
Level 1. Simple storage: Visual spelling task. The objective of this first step
is to familiarise the patient with the visualisation strategy. The therapist
pronounces a word orally, and the patient has to visualise it and to say
whether its letters are short (inside the two horizontal lines of writing) or
tall (going outside the two horizontal lines). For example, for the French
word “poche’’ (“pocket”), the patient has to say “tall” (for “p”), “short”
(for “o”), “short” (for “c”), “tall” (for “h”) and “short” (for “e”). The first
stimuli used are familiar words, but later non-words are presented; both are
2 – 6 letters long.
Level 2. Storage plus simple manipulation. The patient is asked to manip-
ulate the material. Two types of exercises are presented, an “inverted spelling
of orally presented word” task (“orange” ! “e”, “g”, “n”, “a”, “r”, “o”) and
an “inverted repetition of a word sequence” task (“maison, cerise, gilet”
[“house, cherry, waistcoat”] ! “gilet, cerise, maison”). For the inverted
spelling task, words of 3 –6 letters in length were used, and for the inverted
word task, sequences of 3 –6 words.
Level 3. Storage plus complex manipulation. Two types of exercise
constitute this level: An alphabetic ordering task (the patient has to repeat
a sequence of words in alphabetic order: “bonnet, abeille, poireau”
[“hat, bee, leek”] ! “abeille, bonnet, poireau”), and an anagram task
(the patient has to reconstruct a word from a scrambled series of letters:
“n-l-e-u” ! “lune” [“moon”]). The stimuli of the first task are series of
2 – 5 words and for the anagram task, series of 3– 5 letters.
Level 4. Transformation. At this level, the mental manipulation concerns
each stimulus in the sequence individually. Two exercises are used. The
first task consists of a word spelt with the “n þ 1th letter” i.e., each letter is
transformed into the next one in the alphabet (“lapin” [“rabbit”] ! “m”
“b” “q” “j” “o”). The second task is a contrary span task: A series of words
(verbs or adjectives) are presented and the subject has to produce the
sequence with the opposite meaning (e.g., “clair, prudent, beau, pauvre”
[“light, prudent, beautiful, poor”] ! “sombre, imprudent, laid, riche”
[“dark, imprudent, ugly, rich”]). As usual, the words vary in length (2– 5
letters) for the first task, and, the sequences have 2 –5 words in the second.
Updating exercises (4 levels)

Updating tasks require the subject to hold some information in memory
and to refresh some (but not all) of it as new information is presented. All
the exercises are of the n-back type. Their complexity is planned according
to three main criteria: the modality of presentation (visual or auditory); the
type of stimuli (words or letters); and the length of the n-back (1 or 2-
back). The complexity of the programme is also related to the facilitation
cues suggested to the patient.
In order to help the subject, in a first stage of the programme, the updating
process is visually simulated by a spatial array of windows and the passage of a
Figure 1. Example of visualisation tool for updating exercises. “cat” “bowl” “foot” “wheel”
strip behind these windows. On this strip, words are written down (see
Figure 1). For example, in the 1 back task, the strip moves from the right to
left behind the windows in such a way that the patient sees the two words to
be compared in the two windows. When a new word is presented, the two
words move by one position to the left and as a result the new word (to be com-
pared) appears in the right window and the word (to be forgotten) disappears
from the left window. With such an arrangement, the updating process is phys-
ically illustrated by the disappearance of the stimulus from the left window and
by the appearance of the new one in the right window. This visual tool could be
implemented by a computer programme or made by hand.
In the next stage of the programme, the subject is asked to undertake the n-
back tasks with progressive fading of the visual display. To guarantee the
internalisation of the process, the stimuli are then presented in the auditory
modality. In the final step, the subject is trained to do the n-back task by men-
tally representing a flow of stimuli (letters) moving from right to left.
Dual-task monitoring exercises (5 levels)

In the dual-task monitoring programme, the subject is trained to hold some
information in memory while at the same time undertaking a non-related task.
In this programme, the exercises are of the Brown –Peterson type: that is, first,
the material to be memorised is presented; then, the subjects have to do an
interfering task; and finally they have to recall the memorised material.
The memory task is always composed of three words which must be held
in memory for 5, 10 or 20 seconds.
The complexity of the exercises results from the manipulation of four
different parameters: the nature of the interfering task (kinetic, then
verbal), the similarities between the stimuli to be memorised (words) and
those used in the interfering task (number names, then words), the complexity
of the interfering task and the modality of the presentation of the stimuli to be
memorised (visual, then auditory). The combination of these parameters
results in a programme with five levels of increasing difficulty: visual presen-
tation of words with kinetic interference (Level 1), visual presentation of
words with repetition of numbers as auditory interference (Level 2), visual
presentation of words with mental addition of numbers (Level 3), auditory
presentation of words with mental subtraction of numbers (Level 4), and audi-
tory presentation of words with a search for synonyms as auditory interfer-
ence (Level 5).
Ecological rehabilitation programme

The ecological rehabilitation programme is composed of two stages: scenario
analysis and simulations of real-life situations. In each of these stages, exer-
cises addressing one of the three sub-processes (processing load, updating and
dual-task) are first attempted separately, and then exercises tapping several of
the sub-processes simultaneously were used.
Scenario analyses are used to help patients to become aware of the role of
working memory in real life and to identify everyday situations where the use
of the strategies could be helpful. First, the therapist presents the patient with
a set of scenarios, arranged in a hierarchical order. Patients have to solve these
daily-life problems by thinking about all their aspects, considering the advan-
tages and disadvantages of the various strategies. At this stage in the pro-
gramme they do not have to actually perform any actions. These exercises
follow these steps:
1. Setting: The patient receives a short text that describes a real-life situ-
ation involving working memory.
2. Analysis: The patient searches for the most efficient and least taxing
solution.
3. Discussion: The therapist gives some feedback and there is a discussion
between the patient and the therapist about the various possible solutions.
For example, for a scenario involving only one sub-process, in this case
updating, the patient had to read the following text: “You are in a supermarket
and you want to buy some dishwasher powder at the cheapest price you can
find. At first glance, you see a price of E3.25. You continue looking and notice
other prices: E2.99, E4.20, E3.99 and E2.79. Finally, on the last shelf you
notice another brand at a price of E2.89.” and to answer the orientation-
related question “How will you remember the name of the brand with the
lowest price and its associated price?” For the scenarios integrating the
three sub-process, the setting is a bit more complex. For example, the follow-
ing scenario involves storage, updating and processing load (calculation):
“You are due to meet some friends at a restaurant tonight. When you get
home, there is a message on your answering machine concerning this
event. You must remember the address of the restaurant, the time everyone
will arrive at the restaurant and the number of people coming as you will
be the first person to arrive and you will have to organise the seating for
the group. Here is the message: “Hi it’s Charles, I’m with Claire and Tom, we
will come tonight but John will not be there as he just called to say he has
been held up at the office. Christopher and Estelle will be there, and
they’ve asked their cousin who is visiting, to come. The restaurant is situated
. . .Wait just a moment . . . Claire told me that John left a message on her
mobile to say that he will be coming after all. The restaurant is at 374
Dorchester Avenue . . . sorry . . . no, they recently moved to the other side
of the street . . . the address is 396 Dorchester Avenue. Arrival time at the res-
taurant is 7 p.m. . . . But that may be too early . . . what do you think about
making the reservation for 7.30?”
In the second stage, the therapist invites the patient to suggest scenarios
from his or her real life which cause difficulty because they involve
working memory.
After the scenario stage, simulations of everyday situations are used to
facilitate the application of strategies to daily life. At this stage, the patient
has not only to analyse the situation, and to consider the advantages and dis-
advantages of the strategies, but also to select one of them and to perform the
related actions. These exercises have the following steps:
1. Setting: The therapist reads a short text that describes a real-life situ-
ation (e.g., the patient will have to look for books in a library, but at
this stage he or she does not know the exact titles).
2. Analysis: The patient searches for the most efficient and the least taxing
solution.
3. Instructions: The therapist gives the detailed information (e.g., the titles
of the books).
4. Action: The patient undertakes the exercise.
5. Discussion: The therapist gives some feedback and a discussion takes
place between the patient and the therapist about the activity.
Informative meetings
Our rehabilitation programme also contained informative meetings to discuss
specific topics in working memory. The first session takes place before the
cognitive rehabilitation begins, to present results from the neuropsychologi-
cal examination to the patient and to provide an interpretation of his or her
cognitive deficit. In addition the general role of working memory and its func-
tioning are explained, as well as the consequences of an impairment of this
system, and the plan for the rehabilitation programme. A 6-page leaflet con-
taining all this information is provided for the patient.
A second meeting occurs before the ecological rehabilitation to list the

variables (tiredness, stress, anxiety, external and internal interferences,
dual-task situation, etc.), which can negatively influence cognitive perform-
ance. We talk about the importance of setting the mind at rest before
undertaking a mental activity, ways of adapting to tiredness (taking a
rest or even a siesta, finding your own speed and your optimal
moments) and some techniques for dealing with stressful situations. We
also discuss some ways of reducing external interference (finding a quiet
place to work, telling other people that you need peace and quiet, etc.).
We present a set of guidelines for planning activities day by day and we
remind the patient of the importance of a healthy lifestyle (eating well,
getting enough sleep, etc.). The second category of advice is directed at
facilitating the patient’s conscious use of mental strategies to produce
the best-possible functioning of working memory. We introduce a range
of strategies: minimise internal interference (be disciplined, use a notebook
for divergent ideas), use the double coding and serial work strategies, set
up routines, etc.
APPLICATION OF THE PROGRAMME

This programme has been tested with a patient who has a selective deficit of
the central executive component of his working memory. We report here the
results obtained.
Case report
Victor is a 23-year-old right-handed student at an academy of music. He
comes from Lithuania and has lived in Belgium since 2002. French is his
second language, but Victor speaks it well enough to work and study in a
French environment. In June 2004, he underwent a surgical operation for a
cerebral tumour (ganglioglioma II), situated in the left and internal part of
the temporal lobe. Nine months after the operation (March 2005), Victor
came to the Neuropsychological Rehabilitation Unit of the St Luc Hospital
at Brussels. At that time, his complaints were merely about taking notes
during courses, reading, performing two tasks simultaneously, concentrating,
and memorising new information. Victor did not show psychological
problems.
A neuropsychological evaluation was done. This examination covered
mnesic (spatio-temporal orientation, verbal and visual episodic long-term
memory), language (naming, reading, writing and number processing),
constructional praxis, intellectual, attention (alertness and divided atten-
tion), executive (inhibition, flexibility, planning), and short-term memory
functions.
At neuropsychological evaluation, the patient was well oriented in time

and space. His language and communicative abilities were functional.
There was no aphasic deficit but, given that the patient had only been using
French for two years, some cultural and linguistic limitations were present
in naming (naming test score: 67/80, –3.1s; see de Partz, Bilocq, Dewilde,
Seron, & Pillon, 2001), writing (some spelling mistakes) and reading tasks
(correct but slow). Constructional praxis was preserved and scores on fluid
intelligence tasks were in the normal range (PM 38: 54/60, . 75th percentile;
Raven, 1976). The results of the episodic long-term memory tasks with
verbal (selective remembering test: mean recall ¼ 12.44, þ 0.4s ; list
learning ¼ 72.3%, 20.03s ; delayed recall ¼ 15, þ 0.7s ; Van der Linden
et al., 2004) and visual material were normal (Doors test, Part A:
12, 75th percentile; Part B: 8, ¼ 50th percentile; Baddeley, Emslie &
Nimmo-Smith, 1994). As for short-term memory, the forward span (digit
span of 6) was in the normal range, but there was a deficit on the Brown–
Peterson task (Brown– Peterson: interval of 0 sec ¼ 100%; 5 sec ¼ 61.1%,
22.3s ; 10 sec 39%, 23.4s ; 20 sec: 27.8%, 23.4s ; Meulemans, Coyette
& Van der Linden, in preparation) which suggests an impaired functioning
of the working memory central executive component. Attentional functions,
as measured by the sub-programmes of the “Test d’Evaluation de l’Attention”
(TEA), were also preserved (Zimmerman and Fimm, 1994) (index of phasic
alertness: 0.21, 95th percentile; divided attention tasks: mean RT ¼ 607 msec,
31th percentile; omissions ¼ 2, ,34th percentile). Some difficulties with the
executive functions were manifest in a tendency to a speed/accuracy trade
off. On some executive tests the patient produced responses which were
correct but too slow (Trail Making Test Part B: 128 sec, 23.2s, with 0
errors, Reitan, 1958); too lengthy reading: 81 sec, 22, 2s; naming: 55 sec,
22,2s ; times for the Stroop task, but a score in the normal range on the inter-
ference sub-task (Nehemkis & Lewinshon, 1972); Tower of London: number
of moves in the normal range but the patient was too slow on either planning
or execution on some items. This lengthening was however not general and
the patient’s score remained in the normal range on the incompatibility and
flexibility attentional tasks (TEA) and on the picture arrangement sub-test
of the Wechsler Adult Intelligence Scale (WAIS-III).
Three ecological questionnaires were administered: the “Questionnaire
d’Auto-évaluation de la Mémoire” (QAM)1 (Memory Self-Assessment)
(Van der Linden, Wyns, Coyette, Von Frenckell & Seron, 1989); the
1
The QAM contains 48 questions on the functioning of memory in daily-life situations: con-
versation, watching television, reading, personal information, people’s names and faces, etc.
this questionnaire has been standardised on 324 control subjects. For every question, the
patient has to indicate the frequency of his or her difficulties along a 6-point Likert scale,
ranging from “never” (score 1) to “always” present (score 6). The range of the total score is
thus between 48 and 288.
“Questionnaire d’Auto-évaluation de l’Attention” (QAA)2 (Attention Self-

Assessment) (Coyette, Arno, Leclercq, Seron, Van der Linden & Grégoire,
1999); and the “Questionnaire d’Auto-évaluation de la Mémoire de Travail”
(QAMT)3 (Working Memory Self-Assessment) (Hiernaux & Demoulin,
1999). On the QAM, Victor’s global score was 137 (out of 288) and he
reported substantial difficulties (“always” or “often” experiencing a
problem) on 10 of the 48 questions he completed. His complaints concerned
different aspects of memory functioning but were mainly related to the learn-
ing of new information (new itinerary, proper names, news) or the recovery of
recent information (forgetting news, names, conversations). One complaint
also pointed to specific working-memory (WM) difficulties: “doubt about
whether something has or has not already be done”. On the whole
however, Victor’s difficulties were diverse and few were more extensive
than might be expected from a selective working-memory deficit. Victor’s
total score on the QAA was 142 (out of 330). He had considerable difficulties
on 2 items out of 55, one concerning the inhibition of irrelevant information,
and the other related to co-ordinating reading and memorising activities,
which suggests WM difficulties. On the QAMT, Victor reported major pro-
blems for 5 of the 14 items (such as “taking notes under dictation”, “doing
mental calculations” and “forgetting a phone number just after having read
it”) that typically indicate the presence of WM difficulties.
Given the difficulties Victor encountered in daily life situations that could
result from a deficit in working memory, we also administered a detailed
battery tapping different components of working memory. Storage capacity
was examined through three tests: forward digit span (Wechsler, 2000),
forward spatial span (Wechsler, 2001) and word span (Majerus at al.,
2004); mental processing load by four tests: backward digit-span (Wechsler,
2000), backward spatial span (Wechsler, 2001), letter-digit sequences
(Wechsler, 2000) and an indirect measure, the arithmetical sub-test of the
WAIS (Wechsler, 2000); updating by two tasks: the updating task from the
TEA battery (Zimmermann and Fimm, 1994) and the Paced Auditory
Serial Addition Test (PASAT) (Naegele & Mazza, 2003); and dual-task
monitoring by two tasks: the Brown – Peterson Test (Meulemans et al., in
preparation) and Baddeley’s dual-task (Baddeley, Logie, Bressi, Della
Sala, & Spinnler, 1986). The results of this examination are presented in
Table 2 later. Victor’s scores for processing load were not actually
2
The QAA is a questionnaire structured in the same way as the QAM but with the emphasis
on attentional functioning in everyday situations. The norms have been derived from 426
control subjects. The questionnaire is composed of 55 questions, using the same 6-point
likert scale as the QAM. The range of the total score is thus between 55 and 330.
3
The QAMT contains 14 questions related to the functioning of working memory. At
present, there are no norms. Again, 6-point likert scales are used, and the range of the total
score is thus 14 to 84.
pathological, but he scored poorly on the three WAIS-III verbal tasks (digit
span backward, letter-number sequencing and arithmetic, Wechsler, 2000),
although he was within the norms on the spatial task. His deficit was more
pronounced on the other two components. He scored well below the
average on the two dual-task monitoring tests (Brown– Peterson and Badde-
ley’s dual task) and he had some problems with the updating tasks: He was
below the norm for the PASAT and he made too many omissions on the
TEA updating task.
We thus decided to offer Victor our rehabilitation programme. We decided

to use the whole programme, covering the three working memory sub-
processes, despite the fact that his scores on the processing load tasks were
not pathological but merely below average. Victor’s results on these tests
were low and may have been responsible for some of his difficulties with
attention tasks and also with updating and dual-task monitoring.
Baseline measurements and time scale for the rehabilitation

programme
To evaluate the specific effects of our therapy, we took some complementary
baseline measures before, during and after the treatment. Given that our reha-
bilitation programme had two sub-parts (the cognitive and ecological parts),
we developed two different baselines to evaluate these two dimensions.
The cognitive baseline comprised three specific tasks to measure the three
working memory sub-processes: An alphabetic span for the processing load
(maximum score 8); a 2-back letter task for updating (maximum score 16);
and a variant of the Brown – Peterson task with digits for dual-task monitoring
(maximum score 54). To limit any test – retest practice effects, two different
protocols presenting the items in different orders were constructed for each
task. In addition, the tasks were exclusively made of numbers and letters so
that remembering the items was difficult and the test – retest effect was limited.
The ecological baseline comprised two evaluation sets, one containing
three scenarios and the other three simulations of real-life situations. In the
“scenario set”, one task assessed the processing load, one the updating
process, and the third dual-task monitoring. The “real-life situation set” was
similarly structured, that is one real-life situation was presented to assess
each of the three CE sub-processes. The scenarios and the simulations of
real-life situations used for the baselines were never presented to the patient
during the treatment. The scoring procedures are different according to the set.
For the scenarios baseline, the researcher evaluated the worth of the patient’s
suggestions for strategies for dealing with the situation both qualitatively and
quantitatively with the help of an analysis chart. He checked that the efficient
strategies learned through the rehabilitation programme were being applied in
different situations. Each scenario could receive a maximum score of three if
the patient explained how he would systematically apply the three learned strat-
egies: slowing down the processing speed, visualising the stimuli, and sequen-
cing the processes. Given that three different scenarios were presented the total
possible score for the scenarios’ baseline was nine. For the simulations of real-
life situations, the scoring was easy, since the task required the patient to com-
plete a precise activity. For example, in the fast-food scenario, Victor had to
buy nine different things and thus the scoring corresponded to the number of
correct things he bought. Thus the patient’s action was evaluated quantitatively
according to the number of correct responses made in each situation. The data
for these simulations was changed each time the baseline was measured to
ensure that the patient did not memorise them.
The time scale

The rehabilitation programme involved up to four sessions a week, over a six-
month period. Each session lasted about 90 minutes. The rehabilitation began
with the cognitive programme, and the ecological programme occurred later.
The cognitive programme took 19 sessions, comprising 8, 6 and 5 sessions for
processing load, updating, and dual-task monitoring respectively. The
ecological programme took 7 sessions. The various neuropsychological
evaluations, tests and baseline measurements required a total of 15 sessions.
The time scale of the training and evaluation phases is shown in Table 1.
To determine whether significant changes were generated by the treatment
the neuropsychological evaluation of memory and of related executive func-
tions was carried out four times: before beginning the rehabilitation, between
the cognitive and ecological therapies, at the end of the treatment and three
months after the end to evaluate the long-term effects of the treatment. Base-
line assessments of the working memory (cognitive and ecological) were
carried out eight times: twice before the treatment began (to evaluate the stab-
ility of the deficits), after each cognitive sub-programme and each ecological
stage, and three months after the end of the treatment. Such a design allows
the specificity, if any, of the different cognitive and ecological sub-
programmes to be evaluated. The effect of the cognitive therapies on the
ecological tasks can also be evaluated. Finally, the two information sessions
take place before the cognitive and the ecological programmes.
RESULTS
Two statistical methods were chosen to analyse the results, depending on the
presence or absence of a maximum score. For standardised tests with no
maximum scores (i.e., TEA tests, digit span, etc.) we compared Victor’s
results with the norms established with control subjects of the same age
group and the same socio-cultural background. For the tests for which a
TABLE 1
Timing of the treatment
Cognitive and
Neuropsychological ecological
and ecological Training baseline
Sessions evaluation phases measurements
Sessions 1–2 1
Session 3 1
Session 4 2
Session 5 Information session
Sessions 6–13 Cognitive training on processing load
Session 14 3
Sessions 15–20 Cognitive training on updating
Session 21 4
Sessions 22–26 Cognitive training on dual-task
monitoring
Session 27 5
Sessions 28–29 2
Session 30 Information session
Sessions 31–32 Ecological scenarios training
Session 33 6
Sessions 34–37 Ecological daily-life situations
training
Session 38 7
Sessions 39–40 3
Sessions 41–42 3 months later: 4
Sessions 43 8
maximum score (standardised or unstandardised) can be obtained, the

changes generated by the rehabilitation were evaluated by a nonparametric
chi-square test. Given that we anticipated an improvement and not a
decline, we chose to use a directional hypothesis.
The evaluation of the cognitive programme and the ecological programme
are discussed in turn.
Cognitive evaluation
In this section, we discuss the effect of the treatment on working memory and
related neuropsychological tasks first. We then comment on the evolution of
the cognitive baseline measurements.
Neuropsychological tests
The comparisons of the pre- and post-therapy neuropsychological tests
indicate that the rehabilitation was efficient for the three working memory
sub-processes (see Table 2). After the cognitive training, Victor’s
TABLE 2
Evaluation of working memory at different stages of the therapy
Tests Pre–evaluation Intermediate Post immediate Post 3 months
Storage systems
–Digit span (forward) (WAIS-III; Wechsler, 2000) 6 6 6 6
–Spatial span (forward) (Mem-III; Wechsler, 2001) 6 6 6 6
–Word span (Majerus et al., 2004):
Short word 4 5 4 4
Long word 4 5 4 4
Central executive component
Processing load:
–Digit span (backward) (WAIS-III; Wechsler, 2000) 3 (21.4 s) 6 (þ 0.8 s) 6 (þ 0.8 s) 6 (þ 0.8 s)
6 (ss ¼ 11) 5 (ss ¼ 8) 5 (ss ¼ 8) 5 (ss ¼ 10)
REHABILITATION OF WORKING MEMORY

–Spatial span (backward) (Mem-III; Wechsler, 2001)
–Letter/number sequencing / 21 (WAIS-III; Wechsler, 2000) 9 (ss ¼ 7) 11 (ss ¼ 9) 12 (ss ¼ 9) 13 (ss ¼ 10)
– Arithmetic /22 (WAIS-III; Wechsler, 2000) 5 (ss ¼ 5) 9 (ss ¼ 7) 11 (ss ¼ 8) 13 (ss ¼ 9)
Updating:
–Updating (TEA; Zimmermann & Fimm, 1994)
RT (msec) 605 (P 42) 669 (P 27) 577 (P 50) 695 (P 24)
Omissions 5 (P 4) 0 (.P 54) 1 (.P 58) 0 (.P 54)
Errors 2 (,P 54) 2 (,P 54) 0 (.P 73) 1 (,P 76)
–PASAT (Naegele & Mazza, 2003) Score /60 43 (,P 5) 57 (.P 50) 59 (.P 75) 57 (.P 50)
Dual–task monitoring:
–Brown-Peterson (Meulemans et al., 2006)
Interval 0 sec (%) 100 (þ0.2 s) 100 (þ0.2 s) 100 (þ0.2 s) 100 (þ0.2 s)
Interval 5 sec (%) 61.11 (22.3 s) 100 (þ0.8 s) 94.44 (þ0.4 s) 100 (þ0.8 s)
Interval 10 sec (%) 38.89 (23.4 s) 72.22 (21.1 s) 100 (þ0.9 s) 83.33 (20.3 s)
Interval 20 sec (%) 27.78 (23.4 s) 83.33 (20.1 s) 83.33 (20.1 s) 83.33 (20.1 s)
–Dual-task (Baddeley et al., 1997) Score (%) 66.5 (22.7 s) 92.4 (20.3 s) 98.5 (þ0.3 s) 98.9 (þ0.3 s)
ss: scaled score; P: percentile; RT: reaction time; significant effect (p , .01)
447
performances on several tasks evaluating processing load (backward digit

span and arithmetic), updating (TEA updating task and PASAT) and dual-
task monitoring (Baddeley’s dual-task and Brown– Peterson task) improved.
Interestingly, it appeared that greatest improvement was observed at the inter-
mediate neuropsychological evaluation (that is, after the cognitive and before
the ecological training). The improvement was not generalised to all the
components of the working memory system since the storage capacity (not
rehabilited) remained poor, even at the post-therapy evaluation (long and
short word spans). Some discrete improvements were also observed in

executive functions but the only important change was in the flexibility
test, and this improvement was only present after the ecological rehabilitation
at the end of the whole rehabilitation programme. The other changes were
more subtle; interestingly there were decreases in the latency and resolution
times on the Tower of London planning test (Table 3).
Cognitive baseline measurements

Comparisons of the pre- and post-therapy neuropsychological tests show
an improvement in two of the cognitive baseline scores. Analyses of the
TABLE 3
Evaluation of the executive functions at different stages of the therapy
Post Post 3
Tests Pre-evaluation Intermediate immediate months
Attentional functions
Divided attention (TEA;
Zimmermann & Fimm, 1994)
Mean RT (msec) 607 (P 31) 650 (P 18) 576 (P 46) 561 (P 54)
Omissions 2 (,P 34) 0 (.P 62) 1 (,P 66) 1 (,P 66)
Executive functions
Flexibility (TEA; Zimmermann &
Fimm, 1994)
Mean RT (msec) 928 (P 8) 917 (P 8) 625 (P 31) 669 (P 54)
Errors 2 (,P 50) 3 (P 34) 3 (P 34) 1 (,P 62)
Tower of London (Coyette & Van der
Linden, 1993)
Latency time (out of norms /6) 4 4 2 2
Resolution time (out of norms /6) 3 2 0 0
Movements number (out of 0 0 0 0
norms /6)
Incompatibility (TEA;
Zimmermann & Fimm, 1994)
Mean RT (msec) 405 (P 45) 426 (P 26) 385 (P 58) 3333 (P 92)
Errors 4 (P 50–54) (P 84–97) 2 (P 73 –82) 1 (P 84–97)
RT: reaction time; P: percentile

specific baselines measurements during the cognitive therapy confirmed that

the different sub-programmes were specific, since several WM functions
improved markedly after the corresponding training (see Figure 2).
More specifically, after the processing load sub-programme, a significant
improvement was observed on the cognitive baseline for processing load,
x2(1) ¼ 3.3, p ¼ .03. At the same time an improvement was also observed
on the baselines for dual-task monitoring sub-process, interval of 20 sec:
x 2(1) ¼ 14.6, p , .001. No improvement was observed in the 2-back with
letters task following the updating sub-programme, but this absence of pro-
gress was due to a ceiling effect, the updating baseline task being too easy
for this patient. After the dual-task monitoring sub-programme, a significant
improvement was observed on the related Brown– Peterson number baseline
task: the score increased from 35/54 to 48/54, x 2(1) ¼ 18.8, p ¼ .002. The
improvements were so large that, before the ecological programmes even
began, the three cognitive baselines were at (processing load, updating) or
near (dual-task monitoring) their ceiling values. This means that it was not
possible to determine whether the ecological programmes had an effect on
the cognitive functions using these baseline measurement. However it is
important to note that performance on the cognitive baselines did not deterio-
rate during the application of the ecological sub-programmes. Indeed there
was a further significant improvement on the Brown– Peterson baseline test
after the training with the simulations of daily-life situations.
Self-assessment and ecological evaluation

In this section we present Victor’s results on the self-assessment question-
naires and the ecological baseline measurements.
The self-assessment
The Attention Self-Assessment (QAA) and the Memory Self-Assessment
(QAM) were only administered twice, before and after the therapy. There
was a considerable decrease in Victor’s complaints on the QAM: he did
not have substantial difficulties on any of the questions at the end of the
therapy, although there were 10 such complaints at the start (see Table 4).
On the QAA, Victor scored below the norms on only two questions at the
beginning, and by the end of the therapy, all his self-evaluations were in
the normal range. The diminution of complaints between the pre- and post-
therapy evaluations may also be measured by comparing Victor’s total
scores at the two time points. Before the therapy, he scored a total of 137/
288 for the QAM and 142/330 on the QAA; by the end of the therapy, his
scores had dropped significantly to 107/288 and 113/330, respectively.
The Working Memory Self-Assessment Scale (QAMT) was administered
at three different stages: before the cognitive therapy, midway through the
Figure 2. Evolution of the cognitive and ecological baselines at different points of the therapy.
¼ after specific intervention; ¼ significant effect.
TABLE 4
Evolution of the self-assessment questionnaires at different stages of the therapy
Post Post 3
Tests Pre-evaluation Intermediate immediate months Controls
QAM (Memory Self-Assessment):

48 questions
Total score /288 137 – 107 91 –
Substantial difficulties8 /48 10 – 0 0 –
Mean 2.85 – 2.23 1.90 2.45

(standard deviation) (1.17) – (0.83) (0.83) (0.52)
QAA (Attention Self-Assessment):
55 questions
Total score /330 142 – 113 109 –
Substantial difficulties8 /55 2 – 0 1 –
Mean 2.58 – 2.05 1.98 2.08
(standard deviation) (1.18) – (0.97) (0.91) (0.43)
QAMT (Working Memory Self-
Assessment): 14 questions
Total score /84 42 44 33 34 –
Substantial difficulties8 /14 5 4 2 1 –
Mean 3 3.14 2.36 2.43 –
(standard deviation) (1.62) (1.46) (0.93) (1.02) –

Significant decrease from previous score (p , .01); 8 responses “often” and “always”
programme (before the ecological therapy) and at the end of the programme.
On this scale there was a significant decrease in the reporting of serious
difficulties between the beginning (42) and the end (33) of the therapy.
However there was no change at the intermediate stage, when the number
of complaints (44) actually increased slightly from the start of the pro-
gramme. This suggests that it was the ecological therapy that changed the
QAMT scores.
Ecological baselines measurement

As can be seen in Figure 2, the scores on the two ecological baselines
improved steadily throughout the treatment. The ecological baseline scores
began to increase when the cognitive therapy was under way: the scenarios
score rose from 1 and 1.5 in pre-therapy to 6 at the end of the cognitive
therapy, and the scores on the daily-life simulation baselines went from 12
and 16 in pre-therapy to 25 at the end of the cognitive therapy. The improve-
ment continued during the ecological therapy, when the scenarios score rose
to the maximum and the daily simulation score went to 26/27 at the end of the
ecological phase.
Long-term effect of the treatment

Victor’s scores three months after the end of the therapies suggest that the
effect of the training is stable on a long-term basis. There were no significant
decreases in his performance between the end of the treatment and three
months later. This stability is evident in the neuropsychological tests
(Tables 2 and 3), the baseline measurements (Figure 2), and the self-
assessment questionnaires. After three months Victor had no substantial
difficulties on the 48 questions of the QAM (as at the end of the therapy),
and his total score had dropped to 91/288 (i.e., an even lower level than
immediately after the programme). After three months, his score on the
QAA fell below the norms on one question (all his self-evaluations were in
the normal range at the end of the therapy), but his total score was 109 com-
pared to 113 at the end of the programme. Victor’s total score on the QAMT
was stable (34 after three months compared to 33 at the end of the therapy),
and the number of items on which he had substantial difficulties fell to one
(Table 4).
DISCUSSION
We have shown that a cognitive therapy targeting some aspects of the central
executive (CE) component of the working memory (WM) system may be effi-
cacious with a patient presenting selective and moderate WM deficits. We
have also shown that the therapy was efficacious not only according to
specific neuropsychological tests evaluating the sub-components trained by
the therapy, but that its effects were transferred to related tasks with an eco-
logical dimension. The patient also reported significant progress in his daily
life, as indicated by his answers to various self-assessment questionnaires.
The programme also modified the attitude and the self-awareness of the
patient. At the beginning of the treatment, Victor was sceptical about
the re-organisation strategies being suggested. The therapist had to provide
active assistance to encourage him to use these strategies, to slow down his
coding, and to confront his errors. But, progressively, Victor started to use
all the re-organisation strategies effectively, and he began to report situations
from his everyday life where he had applied them. During the intermediate
evaluations, Victor spontaneously commented on the importance of their
use. At the end of the rehabilitation, Victor also demonstrated the importance
of the advice received in the informative meetings: he reported new ways of
adapting to his tiredness (taking a siesta when he came back from college,
finding his best times during study days), employing a technique for
dealing with stressful situations (after having received some advice from a
relaxation therapist), and new ways of reducing external interference
(turning off the computer and radio when he is studying, telling his co-tenant
about his deficit and explaining his need for a peaceful environment, etc.). He
reported that this programme enabled him to eliminate important difficulties
from his everyday life and that the experiment had restored his confidence in
his cognitive capacities.
This observation of a single case thus confirms the results obtained in
earlier research on the rehabilitation of working memory and suggests that
systematic WM training programmes may be efficacious with brain
damaged subjects (Cicerone, 2002; Coyette & Van der Kaa, 1995; Coyette
et al., 2003; Vallat et al., 2002; 2005;). The most original aspect of our
approach is the adoption of a re-organisation rationale. We followed the
general approach adopted by Cicerone that consisted of training patients
systematically to use a variety of strategies to regulate the distribution of
their reduced resources better. But, while Cicerone emphasised the use of
strategies such as repetition, verbal mediation, self-monitoring, and control
of emotional reactions, we essentially worked on the dual coding of incoming
information, sequencing of the mental operations, and speed-reduction. We
chose these aspects of WM functioning, not because we think that they are
more important than the aspects studied by Cicerone, but because we
observed that some patients (including Victor) spontaneously use an ineffec-
tive strategy to compensate for their working memory deficit, which consists
of accelerating their processing speed. This strategy is adopted by the
patients in the hope that, by accelerating their mental processes, they can
complete the task before their memory trace decays. However the result is
generally counterproductive, mainly because of their limited working
memory resources.
Our rehabilitation programme seemed to be specific in some of its effects,
since most sub-processes improved significantly after the corresponding pro-
gramme was completed. This observation supports the concept of the modu-
larity of the functions attributed to the sub-processes of the central executive
component and, more generally, to executive functions. However, we also
have observed some transfer of training, particularly between the processing
load and the dual-task sub-process. This last observation may imply the exist-
ence of some functional relationships between the different CE sub-processes
but it may also more simply indicate that our tasks are not pure. In total, these
observations point in the same directions as those of Miyake et al. (2000).
They conclude that the updating, flexibility and inhibition functions attributed
to the sub-processes of the CE are, in one way, related and, in another way,
dissociable. The relationship between the specific sub-programmes and the
targeted sub-process is, however, somewhat obscured by the fact that, for
the cognitive updating sub-programme, we were unable to observe any sig-
nificant improvement in the 2-back test with letters because it was too easy
for the patient (ceiling effect). Nonetheless, we can deduce the effectiveness
of the updating sub-process by observing the significant improvement in the
patient’s performance on the PASAT after the cognitive sub-programme, as

well as the decrease in the number of errors on the TEA updating test.
Another point suggesting some specificity in our programme is the absence
of any significant progress in functions related to the working memory that
were not directly rehabilitated. For instance, during the neuropsychological
testing after the therapy, no change was observed in the inhibition, divided-
attention, and short-term memory storage tasks. However a general atten-
tional effect of the programme, or some test– retest practice effects due to
the many exposures to the tests, cannot completely be ruled out, as some
improvements were observed on tasks not targeted by the programme. This
is true for the TEA flexibility task (where the reaction times were below
average at the pre-therapy evaluation but were normal at the post-therapy
evaluation). Although no exercises focused on the flexibility processes, it
could be that the strategies used to work on processing load, updating and
monitoring tasks had an impact on the flexibility function. In the same
way, some discrete improvements were observed on the latency and total
times on the Tower of London planning test. This might be due to the fact
that, given the increase in his processing load capacity, the patient had
more processing resources available for planning his actions.
The successive use of two therapies merits some specific comments. The
cognitive therapy, applied first, had an effect not only on the cognitive base-
lines, but also on the ecological ones. Clinically there was even some evi-
dence for specific relations between the cognitive sub-programmes and the
various ecological tasks. For example, after the processing load cognitive
sub-programme a significant improvement was observed on the scenario eval-
uating mental charge (scores increased from 0.5 to 2). After the updating cog-
nitive sub-programme an increase of 3 points was observed on the updating
scenario and a very modest improvement of 1 point on the dual-task monitor-
ing scenario. We thus come to the conclusion that, after the cognitive rehabi-
litation, there was already some transfer to real-life situations. However care
has to be taken about such an interpretation because our ecological baselines
comprised a very small number of situations – just one for each sub-
process – which clearly means that we cannot be confident about the
reliability of our measures.
Given that the performance of the patient was within the normal range at
the intermediate evaluation on the tasks evaluating the central executive com-
ponent of working memory, the utility of the ecological therapy may be ques-
tioned. We would, however, emphasise that the number of serious difficulties
recorded in the QAMT dropped mainly after the ecological therapy. The eco-
logical programme thus had its own positive effect. The beneficial effect of
the therapy for daily life activities was furthermore confirmed by the sister
of the patient who reported that the patient had made progress in many
dual tasks: after the programme he was able to do something (e.g., driving)
and to have a verbal exchange simultaneously; he was also able to interrupt an

activity and then return and continue it normally. In addition he was described
as more efficient at reading (he retained the content better, read more quickly,
and was able to read in a noisy environment). She indicated also that Victor
was in general less tired and when obliged to do so he was able to accelerate
the rhythm of his activities. All these changes suggest that the central execu-
tive of his working memory was more efficient. However two difficulties
remained: Victor continued to get tired if he was involved in an activity for
any length of time, and his thoughts continued to wander when he was
reading. Although the design we adopted does not permit us to isolate the
specific role of the information meetings, it is our conviction that such meet-
ings combined with scenario analyses and daily life exercises helped the
patient to identify the situations in which executive and working memory
functions are required, and thus represent a critical aspect of our therapy
(at least as far as its transfer to daily life is concerned).
Although our therapy seems promising, we should mention some of its
limitations. Firstly, we used only two pre-therapy baseline tests, while it
would be better to use three or more. This criticism is partially answered
by noting that the two pre-therapy baselines were stable and that the
therapy began 10.5 months after the brain operation (and thus after the
period in which a large spontaneous recovery was likely to occur). In
addition, we should emphasise that the whole pre-therapy examination,
including the neuropsychological tests, the questionnaires and the baselines
measurement, took a period of six weeks. Given that our patient was a
young student requiring immediate assistance, there were clinical and
ethical reasons not to delay the beginning of the treatment further.
Second, although in general one therapist applied the programme and the
results were recorded and analysed by another, we did not use “blind evalu-
ation” by a “neutral” tester and this may raise some difficulties, especially
with respect to the scoring procedures applied to the scenario analyses and
real-life situations. However, there were in fact no problems with the real-
life baseline situations, the scoring being of an “all or nothing” type related
to the actual performance of the patient. As for scenario analyses, the risk of
subjectivity was greater here. In most cases, the scenarios were scored indepen-
dently by two therapists, and the rare rating discrepancies were resolved
through discussion. This procedure probably reduced the element of subjectiv-
ity in comparison with a rating by a single examiner. However, we have to
acknowledge that both the therapists were actively involved in the therapeutic
project and thus were not completely protected against a Rosenthal effect.
Third, although we took care to vary the content of the scenarios and the
daily-life simulations systematically at each presentation, we cannot ignore
the possibility that the many repetitions of these tasks may have, in itself, con-
stituted a kind of training, and that what our ecological baselines revealed was
mainly a learning effect. It is certainly true that the total score on the ecologi-
cal evaluations improved regularly at each measurement. However our cog-
nitive exercises in themselves prepared the patient to face daily-life
situations. During the exercises in the cognitive part of the therapy, the
patient was trained to slow down his mental activity, to proceed sequentially
and to visualise the information. These three procedures were regularly
repeated to the patient: “Please slow down”, “Don’t forget to visualise the
material”, and so forth. Apart from its direct training effect, the cognitive
therapy thus had a metacognitive dimension, since it helped the patient to

be conscious of the three strategies and emphasised the need to use them in
some specific contexts. It is thus not surprising that, when the patient was
asked how he would handle a situation in the scenario analysis baselines,
he said that he would use the procedures he had just learned.
Fourth, at the level of its global structure, our rehabilitation programme
consisted of a mixture of three approaches: the cognitive exercises, the eco-
logical exercises and the information meetings with the patient. As is usual
with therapies combining different approaches, the question arises of which
part of the programme was most efficient and even whether some parts
were unnecessary for the success of the rehabilitation. In the future, it
would be pertinent to try to disentangle the effect of each of the sub-parts
of the programme, either by only applying one or by systematically
varying the order of their administration. However we should emphasise
that, at least with the explicit training procedures we adopted, there are
some technical reasons for beginning the treatment with the cognitive exer-
cises and not the ecological ones: it is easier to explain to the patient how
to process the stimuli in the sort of simplified working memory task we
used in the cognitive programme. In our cognitive exercises the level of com-
plexity and the rate of presentation of the stimuli are completely under the
control of the researcher, who can thus orient the attention of the patient
towards the stimuli, and assist the patient to separate the encoding phase
and the manipulation phase and to sequence these two processes. In the cog-
nitive phase, the therapist can apply a general rule of learning that is to begin
with simple situations and then to progressively increase the level of the dif-
ficulty of the exercises for the three sub-processes (updating, dual-task moni-
toring and processing load). The scenario analysis and the daily-life situations
are much more complex in their structures and in the variety of the interven-
ing cognitive processes. It is thus our conviction that the cognitive pro-
gramme must precede the ecological one and we think that Victor was
progressively able to identify daily situations in which he had to update
some information in working memory because he had been helped to identify
these executive processes and to control them in simpler and well circum-
scribed situations. Whether the whole programme could be split into two sep-
arate parts, the cognitive applied first and then the ecological, is questionable.
It is probably more effective to work in a more dynamic way, that is to do

some cognitive exercises on one sub-process and then to present the ecologi-
cal approach on the same sub-process. With such a design, the expertise that
the patient acquires after the cognitive sub-programme can immediately be
trained in ecological situations, and this would probably improve the transfer
of learning to daily life contexts.
Last but not least, our programme has so far only been applied to one
patient who had only a moderate CE disorder. It remains to be seen
whether the programme can benefit patients with more severe WM deficits.
CONCLUSIONS
The results obtained from this programme suggest that a rehabilitation pro-
gramme based on re-organisation of the strategies of the central executive com-
ponent can be effective. In this sense, the results support the idea that the
subsystems of the working memory should be considered as active systems
of the central executive component. They also support the idea of specific cog-
nitive training for each sub-processes for which there is a deficit, as well as eco-
logical exercises used to transfer these strategies to daily life.
It is our belief that this programme constitutes a promising method of reha-
bilitation. It is innovative because it targets three different sub-processes of
the central executive component specifically in suggesting re-organisation
strategies, developing ecological aspects of the evaluation and rehabilitation,
and in proposing a multifactor intervention (cognitive exercises, ecological
exercises, and life counselling to help the patient to develop an awareness
of the role of the central executive component in everyday life).
We believe that this programme provides an effective method of rehabili-
tating the central executive component. We believe that it can be an effective
tool that can easily be applied in a clinical context. If anyone wants to use this
programme in a clinic, we suggest doing both the cognitive and the ecological
rehabilitation for each sub-process, before moving on to the next sub-process.
It is our belief that this approach would be more meaningful for the patient,
who would immediately appreciate the purpose of the cognitive exercises in
real-life situations. This would probably increase the patient’s motivation.
We did not use this procedure because we wanted to be able to evaluate
the contributions of the cognitive and ecological tasks separately. Neverthe-
less we would recommend it in a clinical situation.
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Manuscript received December 2006

Revised manuscript received July 2007
First published online February 2008

Neuropsychological Rehabilitation: An International Journal

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On: 26 November 2014, At: 11:01

Rehabilitation of the central

To link to this article: http://dx.doi.org/10.1080/09602010701573950

PLEASE SCROLL DOWN FOR ARTICLE

Rehabilitation of the central executive component of

J. Duval1, F. Coyette1, and X. Seron1,2

This paper describes and evaluates a programme of neuropsychological rehabi-

Correspondence should be sent to Françoise Coyette, Centre de Revalidation neuropsycholo-

working memory deficit have numerous and varied problems (interference

the material required by the task.

MATERIAL AND METHOD

three aspects of the functioning of working memory separately: the proces-

Cognitive rehabilitation programme

Processing load exercises (6 levels)

Updating exercises (4 levels)

Dual-task monitoring exercises (5 levels)

Ecological rehabilitation programme

A second meeting occurs before the ecological rehabilitation to list the

APPLICATION OF THE PROGRAMME

At neuropsychological evaluation, the patient was well oriented in time

“Questionnaire d’Auto-évaluation de l’Attention” (QAA)2 (Attention Self-

We thus decided to offer Victor our rehabilitation programme. We decided

Baseline measurements and time scale for the rehabilitation

The time scale

maximum score (standardised or unstandardised) can be obtained, the

Tests Pre–evaluation Intermediate Post immediate Post 3 months

REHABILITATION OF WORKING MEMORY

performances on several tasks evaluating processing load (backward digit

short word spans). Some discrete improvements were also observed in

Cognitive baseline measurements

RT: reaction time; P: percentile

specific baselines measurements during the cognitive therapy confirmed that

Self-assessment and ecological evaluation

QAM (Memory Self-Assessment):

Mean 2.85 – 2.23 1.90 2.45

Ecological baselines measurement

Long-term effect of the treatment

patient’s performance on the PASAT after the cognitive sub-programme, as

and to have a verbal exchange simultaneously; he was also able to interrupt an

therapy thus had a metacognitive dimension, since it helped the patient to

It is probably more effective to work in a more dynamic way, that is to do

Baddeley, A. D. (1986). Working memory. Oxford: Clarendon Press.

Manuscript received December 2006

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