Case study III
The errorless learning technique induces inflexible learning, in order to cover it up Stark et al. (2005) demonstrated that inflexible learning by errorless learning technique can overcome by providing some variance conditions in training. As a following study, Stark and his colleague (2008) compared T.E.’s memory performances among three conditions (Early variance, No variance, and Late variance) to evaluate when the introduction of variance into the training session might be most beneficial. This study was conducted two years later since previous study, thus at the time of study T.E. was 70 years old with profound amnesia. T.E. was trained 16 sessions and was tested eight test sessions on his recognition and recall performance for novel three-word sentences; a set of three-word sentences used by Stark et al. was modified due to T.E.’s previous training experience about it. In this study, T.E.’s performance on studied items and semantically related items among No variance (one version of each sentence studied), Early variance (three versions of each sentence studied from the onset), and Late variance (each of three versions of each sentence presented throughout the training) condition were compared. Overall, T.E.’s recognition and generalization performance was higher for the Late variance condition relative to other conditions, also showed greater learning and generalization following variant training than traditional errorless learning technique with no variant training that was replicated the previous finding by Stark et al.( 2005). A particular result was T.E.’s recall performance was higher for no variance condition than variance conditions. This study suggested that gradual introducing variant items into training may be the most efficient strategy for training amnesia patients to learn and generalize new semantic knowledge.

Case study IV
Articles have showed that errorless learning paradigm is one of the most effective rehabilitation techniques for individuals with memory impairments. Above studies demonstrated its effectiveness to help patients learn semantic information in experimental conditions ( Duff et al., 2002; Stark et al.,2005; Stark et al., 2008). As the other strategy for amnesic patient especially not only limited for lab situation but also for apply real word situation, Cavaco and her colleagues (2005) suggested that the using non-declarative memory capacity of amnesic patients to improve patients’ independence and successful return to work. This study reported the case study of a severe amnesia that was applied with the Mayo Brain Injury Outpatient Program (MBIOP) intervention plan. A patient is M.H. who was 43 years old with severe amnesia with an anterior communicating artery (ACoA) aneurysm damage to the orbitofrontal area including the basal forebrain. At the bagging of intervention plan, M.H. scored 91, 98, 86 on full scare IQ, verbal, and performance on the Wechsler Adult Intelligence Test III which showed lower portion of the average range of intellectual abilities. M.H. started the MBIOP and continued for 8 months. MBIOP’s rehabilitation plan was focused on community education, providing and receiving feedback from others, self-evaluation, and the sense of involvement in the rehabilitation process. M.H. was trained to use of external aids (e.g. planner, cue cards) through extensive practice, cueing and feedback. Due to M.H.’s impairment for episodic information, the quality of the notes on the external aids was focused on training, also M.H. was trained to check up and summary of tasks routinely.

As environmental support interventions, his family and employers were also educated about M.H.’s memory impairment, difficulties of awareness, and intervention techniques, structure and routine. Location of furniture on his house, cloths pattern (i.g. pockets size for external aids) were also facilitated to support his training. To successful learning of new skills, especially in the early phase of intervention, the errorless learning based on the vanishing cues paradigm was promoted. As errorless learning, during learning period, M.H. was provided with external cues to avoid errors. The main goal of MBIOP intervention was help M.H. return to work as his most important personal goal, through rehabilitation process, M.H. was able to successfully learn to perform some jobs despite his difficulties to acquire declarative information. It was evaluated as his learning of new skills was profoundly relied on non-declarative information. Couple of months later the MBIOP intervention, M.H. was able to work in a nursery garden department store with adequate performances also expressed his wish to keep doing this work. This report suggested that the usefulness of non-declarative memory capacities of amnesic patients to improve their independence in daily life and vocational rehabilitation. The MBIOP intervention demonstrated that integrated memory rehabilitation methods such as external aids, environmental supports and errorless learning based on vanishing cues to an individualized intervention plan helped an amnesic patient efficiently to return to work.

Case study V
Due to their impaired memory function, amnesic individuals are commonly handicapped to achieve positive academic, vocational, and social outcomes. Therefore, improvement of real-word abilities should be the most important goal of rehabilitation for amnesic individuals. Duff and her colleagues (2008) reported a unique care of a severe amnesic woman who retains successful life abilities with good sense of self-awareness even after the onset of amnesia. A. is a 50 years old woman who has profound anterograde amnesia after closed head injury damage to the white matter tracks in 1985. After head injury, even though A. attempted to return to work, could not successively did it due to her memory impairment. However, 14 years after her head injury and the onset of amnesia, A. had achieved a great success and independence in social relationships, marriage and nurturing kids, education, and her vocation without having any formal rehabilitation service. At the beginning of the observation of her case, she scored 130, 126, and 118 on verbal, performance, and full scale IQ on WAIS-III which are within the high average to superior range while 80 on working memory index on WAIS-III and 49 on general memory index on the Wechsler Memory Scale-III which are the low average or extremely low range. Nerupsychological assessment data indicated her profound memory impairment. Despite her severe memory impairment that prevents her consciously recalls and learning events of her daily life, she showed her great managing ability to create a quality of life even without formal rehabilitation. She successively created her own ways of routine procedure to handle of real word memory demands in daily life (e.g., driving routes for home and work, tracking progress at work place) even those are inflexible to follow (e.g., always driving from home to grocery but avoid driving to grocery on her way to home).

To achieve successful outcome in real life demands, A. has used external records such as notes on kitchen cabinets, flow charts at work, even notes of phone conversation that could cover her absence of internal knowledge for such information. With practice, some of external aids became internalized (i.e., no longer use of notes on kitchen cabinets). Elaborately developed visual routines also well supported for information that was not internalized (i.e., color-coded flow charts at work). Although her developed severe amnesia, A. successfully created her own interventions to achieve positive outcome in her daily life. It was possible due to her minimal MTL damage, longer education period, and higher intellectual abilities, however, the regularity and rigidity of her routines interventions suggested that her positive outcome in real life activities are largely depend on her non-declarative or procedural memory capacities.