Application of the Spacing Effect to Improve Learning
and Memory for Functional Tasks in Traumatic Brain Injury:
A Pilot Study
KEY WORDS
•  activities of daily living
•  brain injuries
•  cognition disorders
•  learning
•  memory
Yael Goverover, PhD, OT, is Assistant Professor,
Department of Occupational Therapy, School of Culture,
Education, and Human Development, New York University,
35 West 4th Street, 11th Floor, New York, NY 10012, and
Kessler Medical Rehabilitation Research and Education
Center, West Orange, NJ; yg243@nyu.edu
Juan Carlos Arango-Lasprilla, PhD, is Assistant
Professor, Department of Physical Medicine and
Rehabilitation, Virginia Commonwealth University,
Richmond.
Frank G. Hillary, PhD, is Assistant Professor,
Department of Psychology, Pennsylvania State University,
University Park, and Kessler Foundation Research Center,
West Orange, NJ.
Nancy Chiaravalloti, PhD, is Director,
Neuropsychology and Neuroscience Lab, Kessler
Foundation Research Center, West Orange, NJ.
John DeLuca, PhD, ABPP, is Vice President for
Research, Kessler Foundation Research Center, West
Orange, NJ, and University of Medicine and Dentistry of
New Jersey/New Jersey Medical School, Newark.
The American Journal of Occupational Therapy
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Yael Goverover, Juan Carlos Arango-Lasprilla, Frank G. Hillary,
Nancy Chiaravalloti, John DeLuca
Research has indicated that many people with traumatic brain injury (TBI) experience learning and memory diffi-
culties because of impairments in the initial acquisition of information. We examined a strategy, the spacing effect,
known to enhance new learning in a laboratory setting in healthy control participants (HCs) and in people with TBI.
The spacing effect indicates that information is learned better when presentation trials are distributed over time
(spaced presentation) rather than consecutively (massed presentation). In this study, we examined the application
of the spacing effect in improving functional tasks. We used a within-subject design and included 10 participants
with TBI and 15 HCs. In both the TBI and the HC groups, material learned under the spaced learning condition
was recalled better than that learned under massed learning conditions. These results provide initial evidence
supporting the use of the spacing effect to improve new learning of functional tasks for people with TBI.
Goverover, Y., Arango-Lasprilla, J. C., Hillary, F. G., Chiaravalloti, N., & DeLuca, J. (2009). Application of the spacing effect
to improve learning and memory for functional tasks in traumatic brain injury: A pilot study. American Journal of
Occupational Therapy, 63, 543–548.
T
raumatic brain injury (TBI) is one of the leading causes of disability in people <35
years old (Sosin, Sniezek, & Thurman, 1996). Data have indicated that cognitive
and psychosocial impairments, rather than physical impairments alone, lead to
decreased adaptive and vocational functioning in people with TBI (Anderson, Bigler,
& Blatter, 1995; Dikmen, Machamer, Winn, & Temkin, 1995; Olver, Ponsford, &
Curran, 1996). Memory impairment is one of the most frequent cognitive symptoms
reported by patients, their family members, and clinicians after TBI (Goldstein &
Levin, 2001; Rosenthal & Ricker, 2000; van Zomeren & van den Burg, 1985), and
it has been shown to be associated with vocational instability (Drake, Gray, Yoder,
Pramuka, & Llewelly, 2000). Recent studies have demonstrated that the primary rea-
son for difficulties in new learning and memory in people with TBI is difficulty in the
initial acquisition of information rather than the retrieval of information from long-
term storage (DeLuca, Schultheis, Madigan, Christodoulou, & Averill, 2000).
Specifically, DeLuca et al. (2000) determined that when participants with TBI and
healthy control participants (HCs) reached a predetermined learning criterion, those
with TBI recalled and recognized the newly learned information at a level comparable
to that of healthy adults. However, participants with TBI required significantly more
trials to reach this learning criterion. That is, they had difficulty initially learning new
information but not in retrieving it from long-term storage. These findings suggest
that the primary memory deficit after TBI involves acquiring or learning new
information.
Various learning strategies from the cognitive psychology literature have been
shown to significantly improve the learning of new information in HC samples.
543
 However, there has been very little work in applying such
strategies to people with TBI, which could potentially result
in a significant improvement in cognitive and everyday func-
tioning. One such technique is called the spacing effect.
The spacing effect is the observation that information
presented using spaced repetitions is better remembered than
information presented via massed repetitions (Challis, 1993).
A large body of literature has documented that learning trials
spaced over time lead to better recall than massed learning
(consecutive learning trials), particularly under conditions in
which the delay between study and test is long rather than
short (Bahrick, Bahrick, Bahrick, & Bahrick, 1993; Bahrick
& Phelps, 1987; Cahill & Toppino, 1993; Dempster, 1987,
1988; Glenberg, 1976, 1977, 1979; Glenberg & Lehmann,
1980; Glover & Corkill, 1987; Hintzman, 1974; Jensen &
Freund, 1981; Melton, 1970; Rea & Modigliani, 1985;
Shaughnessy, Zimmerman, & Underwood, 1972; Toppino,
1991, 1993; Underwood, 1970; Zechmeister & Shaughnessy,
1980). Several theoretical explanations for the success of the
spacing effect exist, but these are beyond the scope of this
article (for further review, see Dempster, 1989).
To date, most of the research on the spacing effect has
been conducted with healthy people in laboratory settings
(e.g., Challis, 1993; Kahana & Howard, 2005; Janiszewski,
Noel, & Sawyer, 2003). Some researchers, however, have
examined how the spacing effect might facilitate learning of
and memory for different tasks in clinical populations who
may exhibit memory deficits, including people with amnesia
(Cermak, Verfaellie, Lanzoni, Mather, & Chase, 1996),
dementia (Camp & Foss, 1997), multiple sclerosis (Goverover,
Hillary, Chiaravalloti, Arango-Lasprilla, & DeLuca, 2008),
and TBI (Hillary et al., 2003). These studies indicated that the
spacing effect can effectively facilitate recall of newly learned
material in patients with memory impairments. However,
most of these studies examining the impact of the spacing effect
have been conducted only with laboratory-based tasks, such as
word lists. Thus, the impact of the spacing effect on everyday
activities in clinical samples remains unclear. The purpose of
this study was to determine whether spaced learning enhances
memory of functional tasks in people with TBI.
Method
Participants
Ten participants with TBI and 15 HCs without reported
neurological disabilities participated in this study. Participants
with TBI were included in the study only if positive com-
puted tomography or MRI neuroimaging results or a docu-
mented period of loss of consciousness of ≥24 hr were docu-
mented. Participants were excluded from the study if they
544
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had a history of neurological illness (aside from TBI), a his-
tory of major psychiatric illness, a history of alcohol or drug
abuse, or severe visual or motor impairment that might
interfere with study procedures. All of the participants with
TBI were ≥1 year postinjury (mean years postinjury = 8.2,
standard deviation = 6.8). The two groups did not differ
significantly with regard to age (TBI = 42.5, HC = 43.3),
gender (TBI, 54.5% men; HC, 45.5% men), and premorbid
intelligence (as measured by the Wide Range Achievement
Test 3 [WRAT–3] Reading Subtest [Wilkinson, 1993];
mean row score = 51.6 for both groups, the scaled score of
indicates above-average reading academic skills for both
groups). All recruitment and experimental procedures were
approved by the institutional review board (IRB) and Health
Insurance Portability and Accountability Act compliance
boards. Before study enrollment, all participants indicated
willingness to participate in the study by signing a consent
form approved by the IRB.
Procedure and Materials
We used a within-subject design in which all participants
were required to complete two paragraph-learning tasks
(reading a paragraph and being asked to remember it) and
two route-learning tasks (after being presented with a route
on a map, participants were asked to reproduce it on an
identical map). The paragraph-learning task involved two
different paragraphs, and the route-learning task included
two different black-and-white maps. We chose these two
tasks for this experiment to examine verbal (i.e., paragraph)
and nonverbal (i.e., map) learning and memory processes on
tasks that could be encountered during daily life.
For each task, participants received a total of three learn-
ing trials to the task materials. In the massed condition, tasks
were presented three consecutive times; in the spaced condi-
tion, tasks were presented three times with a 5-min interval
between them. The two conditions were presented in coun-
terbalanced order.
Paragraph Learning Task. The paragraph-learning task
required participants to read aloud two short paragraphs (one
in a massed condition and one in a spaced condition, as
described earlier). Both paragraphs were taken from a news-
paper and contained 5 sentences, 84 words, and 14 elements
of information. After the three learning trials, two recall trials
were conducted at immediate recall and then again 30 min
after initial presentation. Participants were asked to repeat
the paragraph provided to them using “as close to the same
words as possible.” The dependent measures for this task
were the total number of elements recalled for each of the
immediate and delayed free-recall trials, ranging from 0 to
14. The dependent variables were the total score for the
immediate and delayed free-recall trials.
September/October 2009, Volume 63, Number 5
 Route-Learning Task. The route-learning task was To analyze performance on the spacing effect protocol,
designed to simulate the procedure of learning and recalling we analyzed performance on the paragraph and route tasks
a simple set of visual instructions when a new route is by means of a 2 (group: TBI vs. HC) × 2 (condition: massed
learned (e.g., when traveling to a new place). Each of the vs. spaced) × 2 (time: immediate vs. 30 min) repeated-
routes to be learned consisted of 13 different streets and 13 ­measures analysis of variance (ANOVA) with group as the
directional turns to be memorized. The three learning trials between-groups factor and condition and time as within-
consisted of the examiner visually presenting the route group factors.
(including the route streets and turns) using a red laser
pointer on a map. During the presentation of the route, the
examiner was positioned across a table from the participant. Results
Each presentation lasted 20 s. After three learning trials, a We analyzed cognitive functioning by using a one-way
recall trial was obtained by asking the participant to draw ANOVA to compare performance between TBI and HC
the route on another map without further presentation. An groups. These results are presented in Table 1. The TBI group
identical recall trial was performed after a 30-min delay. For took significantly longer to perform the D–KEFS Trail
every correct turn and street traced, 1 point was awarded. Making Test number–letter switching task than did the HC
The range of possible scores ranged from 0 (not remembering group (F[1,24] = 13.6, p < .01]. On the CVLT, HC partici-
anything) to 26 (accurate recollection of the route). The depen- pants recognized significantly more words than did the TBI
dent variables were the total score for immediate and delayed participants (F[1,24] = 5.5, p < .05). Additionally, participants
free-recall trials. with TBI demonstrated slower speed of processing on the
SDMT than did HC participants (F[1,24] = 4.8, p < .05).
Neuropsychological Testing
TBI can cause cognitive impairments in the areas of atten- Performance of Paragraph-Learning Task
tion (Mathias & Wheaton, 2007), information-processing Figure 1 illustrates the different scores each participant
speed (Madigan, DeLuca, Diamond, Tramontano, & group received in the different learning conditions for the
Averill, 2000), learning and memory (Deshpande, Millis, paragraph-learning task. We observed a significant interac-
Reeder, Fuerst, & Ricker, 1996), executive functions tion between time and condition (F[1, 23] = 5.9, p = .02, η2
(Macdonald, Flashman, & Saykin, 2002), and visuospatial = .20). This interaction indicates that information presented
abilities. Therefore, the battery of neuropsychological tests in a spaced manner was retained significantly better than
administered was geared toward assessing these cognitive information learned in a massed presentation after the 30-
functions. This battery consisted of the Digit Span subtest min delay and even better than recall immediately after ini-
(Wechsler Adult Intelligence Scale–Revised [WAIS–R]; tial learning. This interaction was observed in both the TBI
Wechsler, 1981) to assess attention; Symbol Digit Modalities and the HC groups. It is important to note, though, that the
Test (SDMT)–Oral Version (Smith, 1982) to assess process-
ing speed; California Verbal Learning Test (CVLT; Delis, Table 1. Neuropsychological Test Performance
Kramer, Kaplan, & Ober, 1987) to assess learning and mem- (Means ± Standard Deviations)
ory; and three subtests of the Delis–Kaplan Executive TBI HC
Domain Assessed and Test (n = 10) (n = 15) F(1, 24)
Function System (D–KEFS; Delis, Kaplan, & Kramer,
Speed of processing: SDMT   42.8 ± 13.9 56.3 ± 11.2 4.8*
2000)—the Trail Making Test, Verbal Fluency Test (Letter
Learning and memory
Fluency), and Color–Word Interference Test (Inhibition–
  CVLT—Sum of 5 trials   50.2 ± 13.8 54.8 ± 10.5 0.51
Switching)—to assess executive functions.   CVLT—Discriminability   89.8 ±   9.2 96.3 ±   3.7 5.5*
Working memory: Digit Span Total   18.6 ±   7.6 19.3 ±   3.4 0.10
Data Collection and Analysis
Executive functions
Participants were recruited by advertisements distributed at   D–KEFS Trail Making Test: 109.8 ± 42.6 64.5 ± 14.1 13.6**
local support groups and clinics. On initial phone contact,    Number–letter switching
potential participants were screened for participation on the   D–KEFS Verbal Fluency–   34.8 ± 19.3 43.2 ± 11.8 1.3
basis of the inclusion and exclusion criteria discussed earlier.    Letter Fluency

Participants were then scheduled for interview and testing.   D–KEFS Color–Word:   74.4± 18.5 58.4 ± 14.8 3.8
   inhibition and switching
The testing session lasted approximately 3 hr, in which the
Note. TBI = traumatic brain injury; HC = healthy control participants; SDMT =
neuropsychologic battery and the spacing effect protocol were Symbol Digit Modalities Test; CVLT = California Verbal Learning Test; D–KEFS
administered by Yael Goverover and Juan Carlos Arango- = Delis–Kaplan Executive Function System.
Lasprilla. All participants were paid for their participation. *p < .05. **p < .01.

The American Journal of Occupational Therapy 545

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 main effect of condition was not statistically significant (F[1,
23] = 3.4, p = .07, η2 = .15). Thus, tasks of paragraph learn-
ing (learned under the spaced condition) were recalled at a
slightly higher rate (mean [M] = 7.85) than tasks presented
in a massed condition (M = 7.1) collapsed across groups and
time. However, this difference was not significant, and the
effect size was small. Additionally, the relative difference
between the spaced versus massed conditions was equivalent
across participant groups. The interaction of participant
group (HC vs. TBI) and condition (spaced vs. massed) was
not significant and demonstrated a small effect size (F [1, 23]
= 0.1, p = .80, η2 = .003). Thus, both HC and TBI partici-
pants showed a similar pattern of learning whereby they
benefited from the spaced condition as compared with the
massed condition when learning the paragraph.
Following a Route on a Map
Performance on the route-learning task is presented in Figure
2. We observed a significant interaction between time and
condition (F[1, 23] = 7.9, p = .01, η² = .25). This interaction
demonstrates that participants in both the TBI and the HC
groups did worse in the immediate recall when they learned the
route in a spaced manner. However, after a 30-min delay, routes
on the map that were learned in the spaced condition were
remembered significantly better than the routes learned in the
massed condition. Thus, the pattern of results was reversed at
the 30-min recall. There was no significant main effect of condi-
tions (i.e., spaced and massed learning) for the map-learning
task across time and groups (space, M = 16.9; mass, M = 16.9;
condition main effect, F[1, 23] = .00, p = .98, η² = .01).
The TBI and HC groups did not differ significantly in
the mean number of items recalled. The main effect of group
was not significant (F[1, 23] = 0.34, p = .56, η² = .009).
Similar to the paragraph tasks, the interaction of participant
Figure 1. Paragraph tasks: Recall scores for spaced vs. massed
conditions.
Note. HC = healthy control participants; TBI = traumatic brain injury.
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group and condition (spaced vs. generated) was also not sig-
nificant (F[1, 23] = 0.41, p = .52, η2 = .01), suggesting that
the spaced and massed conditions affected memory abilities
to an equivalent degree in both participant groups.
Discussion
The results of this pilot study are consistent with earlier lit-
erature on the spacing effect (Hilary et al., 2003) and suggest
that this learning strategy can play a role in rehabilitation
even in chronic-stage post-TBI. This study’s findings sup-
port the idea that treatment focusing on improving acquisi-
tion may significantly increase recall of learned information
and extend this support to functional tasks.
This study demonstrated two primary findings. First,
results showed that the spacing effect can be successfully
applied to a functional task such as paragraph and route learn-
ing in TBI. Second, when participants acquired skills (reading
information from a newspaper or following a route on a
map), delayed recall of this information was better when the
information was originally learned under spaced conditions.
Initial performance was better, however, when the tasks were
learned in massed practice compared with spaced practice.
These results are consistent with those of previous research.
Specifically, Rohrer and Pashler (2007) concluded that the
benefits of the spacing effect generally seem to get bigger, not
smaller, when one examines longer-term retention.
In terms of long-term retention, the observed benefit of
spaced learning trials is of major importance because delayed-
recall trials are presumed to be a better reflection of recall of
what was learned (transfer test; Hall & Magill, 1995). Spaced
practice trials clearly have a significant, long-term positive
effect on learning and memory, and this effect is critical to
the conduct of clinical rehabilitation. These results have
Figure 2. Map task: Recall scores for spaced vs. massed
conditions.
Note. HC = healthy control participants; TBI = traumatic brain injury.
September/October 2009, Volume 63, Number 5
 widespread implications for instruction at many levels.
Although tradition dictates that therapists present multiple,
different sets of instructions or exercises during each therapy
session, these findings show that clients might be far better
served if material was distributed sporadically across many
therapy sessions. The findings of the long-term benefit of
learning through spaced learning trials are critical to the
rehabilitation of people with TBI who have deficits in acquir-
ing new information because it provides evidence for long-
term learning of functional information.
Clinical Implications
This pilot study provides Class II evidence for the use of
spaced learning trials in learning and memory interventions
(see Cicerone et al., 2000, 2005). Thus, it provides fair evi-
dence to support a recommendation as to whether treatment
may be effective. Because of this, the information gained
from this pilot study provides the opportunity to proceed to
the next step by designing treatment plans that are based on
individualized goals but using learning techniques that may
improve long-term retention. In sum, spaced learning trials
can be viewed both theoretically and practically as a learning
strategy that can be applied as a compensatory technique
with a variety of tasks with people with TBI.
Limitations of the Study
This study’s results should be interpreted with the following
caveats. First, the small sample studied may not be fully rep-
resentative of the population of people with TBI. Second,
severity level was not accounted for, and it is not clear how
injury severity may affect the usefulness of spacing effect
techniques. Third, this study has demonstrated the usefulness
of the encoding strategy in improving two functional activi-
ties (route learning and reading a paragraph); however, it is
not clear how useful the techniques might be when applied
to other daily tasks (e.g., vocational tasks, driving). Fourth,
although the spacing effect improved recall immediately and
at 30 min after initial presentation, it is not clear whether
these gains are maintained over a longer follow-up period.
Future Research
Replication of these results in larger, more diverse populations
of people with TBI with differing levels of cognitive impair-
ment is needed to ensure adequate generalization of the find-
ings. Further investigation of the usefulness of this technique
on tasks completed in the patient’s natural environment,
instead of in a research laboratory setting, would help to deter-
mine the spacing effect’s ecological validity. It would also be
informative to study the potential benefits of the spacing effect
on longer-term recall by including 1-week, 3-month, or 6-
month follow-ups, or all of these, in the study design.  s
The American Journal of Occupational Therapy
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Acknowledgments
This research was supported by National Multiple Sclerosis
Society Grant RG3837A1/T and by the Henry H. Kessler
Foundation and was presented in part at the annual meet-
ing of the International Neuropsychological Society,
February 2005, in St. Louis, Missouri, and at the Inter­
national Neuro­psy­chological Society Congress in Dublin,
Ireland, July 2005.
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