C2005 Evidence Evaluation Template - Nov.11, 2003circ.ahajournals.org/content/suppl/2005/11/14/... · Web viewUtilizing combinations of the text search word CPR with the text words

document.doc Page 1 of 32

WORKSHEET for PROPOSED Evidence-Based GUIDELINE RECOMMENDATIONSNOTE: Save worksheet using the following filename format: Taskforce.Topic.Author.Date.Doc where Taskforce is a=ACLS, b=BLS, p=Pediatric, n=neonatal and i=Interdisciplinary. Use 2 or 3 letter abbreviation for author’s name and 30Jul03 as sample date format.Worksheet Author: David L. Rodgers, Ed.S., NREMT-P

Taskforce/Subcommittee: __BLS __ACLS __PEDS X ID __PROAD__Other:

Author’s Home Resuscitation Council: X AHA __ANZCOR __CLAR __ERC __HSFC__HSFC __RCSA ___IAHF ___Other:

Date Submitted to Subcommittee: March 15, 2004 (Resubmitted Sept. 25, 2004, Jan. 12, 2005)

STEP 1: STATE THE PROPOSAL. State if this is a proposed new guideline; revision to current guideline; or deletion of current guideline.Existing guideline, practice or training activity, or new guideline:

Audio prompts that guide action sequences and the timing of chest compressions and ventilations increase learning and retention of CPR skills and improve CPR performance (Class IIb). Page I-22, Part 3: Adult Basic Life Support – Major Guideline Changes

Step 1A: Refine the question; state the question as a positive (or negative) hypothesis. State proposed guideline recommendation as a specific, positive hypothesis. Use single sentence if possible. Include type of patients; setting (in- /out-of-hospital); specific interventions (dose, route); specific outcomes (ROSC vs. hospital discharge).

NOTE: The 2000 Guideline attempted to answer two questions with one guideline. Evidence indicates that there are separate answers to the original question posed. Therefore, the revised guideline is separated into two parts.

Hypothesis 1: Audio prompts or other forms of feedback that guide action sequences and timing of chest compressions and ventilations may aid in the early learning of CPR skills when used as a model for performance; however, overuse of audio prompts may have a detrimental effect on retention and ample practice time without audio prompting devices must be supplied.

Hypothesis 2: Audio prompts or other forms of feedback that guide action sequences and timing of chest compressions and ventilations during cardiac arrest events will aid rescuers in performing CPR skills.

Step 1B: Gather the Evidence; define your search strategy. Describe search results; describe best sources for evidence.

Initially, medical literature was searched. However, there were very few applicable returns to address Hypothesis 1. Search was expanded into education and psychology literature to obtain articles that included experimental studies, literature reviews, meta-analysis, or theory building. Search concentrated on the motor skill acquisition and retention literature. While not directly related to the provision of CPR, all relevant articles that focused on motor skill learning, particularly those that dealt specifically with timing tasks, were reviewed. The premise was created that CPR is a motor skill and information, studies, and theories relevant to motor skill learning were applicable to CPR. Note: All articles outside the medical literature are highlighted by Italics.

Utilizing combinations of the text search word CPR with the text words learning, skill, retention, feedback, education, training, KR (Knowledge of Results), KP (Knowledge of Perfromance), audio, prompts, or timing, relevant libraries and databases were searched. Additional searches of the non-medical literature on the text words learning, skill, retention, feedback, KR (Knowledge of Results), KP (Knowledge of Perfromance), audio, prompts, and timing in various combinations produced additional articles for review. Abstracts and/or articles were reviewed to determine relevance and match inclusion/exclusion criteria.

List electronic databases searched (at least AHA EndNote 7 Master library [http://ecc.heart.org/], Cochrane database for systematic reviews and Central Register of Controlled Trials [http://www.cochrane.org/], MEDLINE [http://www.ncbi.nlm.nih.gov/PubMed/ ], and Embase), and hand searches of journals, review articles, and books.

Searches completed February 2004 (updated Sept. 2004) . Databases searched: Literature search results of Guidelines 2000 worksheet; MEDLINE (PubMed); AHA EndNote 7 Master Library (April 2004 Edition); Cochrane Database for Systematic Reviews; Central Register of Controlled Trials; EMBASE; CINAHL; Academic Search Premier; ERIC; and hand searches of key articles. A late-breaking publication was included in January, 2005 Total combined unique potentially relevant returns - 245

• State major criteria you used to limit your search; state inclusion or exclusion criteria (e.g., only human studies with control group? no animal studies? N subjects > minimal number? type of methodology? peer-reviewed manuscripts only? no abstract-only studies?)

- Exclusion criteria – No abstract only studies. No editorials or letters to editor. No non-peer-reviewed articles.- Inclusion criteria – Peer-reviewed manuscripts only. Study subject had to have been CPR skills or other forms of psychomotor skills. • Number of articles/sources meeting criteria for further review:.

Regarding Hypothesis 1 – 36 Selected for inclusionRegarding Hypothesis 2 – 14 Selected for inclusion


STEP 2: ASSESS THE QUALITY OF EACH STUDYStep 2A: Determine the Level of Evidence. For each article/source from step 1, assign a level of evidence—based on study design and methodology.

Level of Evidence

Definitions(See manuscript for full details)

Level 1 Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effectsLevel 2 Randomized clinical trials with smaller or less significant treatment effectsLevel 3 Prospective, controlled, non-randomized, cohort studiesLevel 4 Historic, non-randomized, cohort or case-control studiesLevel 5 Case series: patients compiled in serial fashion, lacking a control groupLevel 6 Animal studies or mechanical model studiesLevel 7 Extrapolations from existing data collected for other purposes, theoretical analysesLevel 8 Rational conjecture (common sense); common practices accepted before evidence-based guidelines

Step 2B: Critically assess each article/source in terms of research design and methods. Was the study well executed? Suggested criteria appear in the table below. Assess design and methods and provide an overall rating. Ratings apply within each Level; a Level 1 study can be excellent or poor as a clinical trial, just as a Level 6 study could be excellent or poor as an animal study. Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study. For more detailed explanations please see attached assessment form.

Component of Study and Rating Excellent Good Fair Poor UnsatisfactoryDesign &

Methods

Highly appropriate sample or model, randomized, proper controls ANDOutstanding accuracy, precision, and data collection in its class

Highly appropriate sample or model, randomized, proper controlsOROutstanding accuracy, precision, and data collection in its class

Adequate, design, but possibly biased

ORAdequate under the circumstances

Small or clearly biased population or model

ORWeakly defensible in its class, limited data or measures

Anecdotal, no controls, off target end-points

ORNot defensible in its class, insufficient data or measures

A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpointB = Survival of event D = Intact neurological survival

Step 2C: Determine the direction of the results and the statistics: supportive? neutral? opposed?

DIRECTION of study by results & statistics: SUPPORT the proposal NEUTRAL OPPOSE the proposal

ResultsOutcome of proposed guideline superior, to a clinically important degree, to current approaches

Outcome of proposed guideline no different from current approach

Outcome of proposed guideline inferior to current approach

Step 2D: Cross-tabulate assessed studies by a) level, b) quality and c) direction (ie, supporting or neutral/ opposing); combine and summarize. Exclude the Poor and Unsatisfactory studies. Sort the Excellent, Good, and Fair quality studies by both Level and Quality of evidence, and Direction of support in the summary grids below. Use citation marker (e.g. author/ date/source). In the Neutral or Opposing grid use bold font for Opposing studies to distinguish them from merely neutral studies. Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study.


Supporting Evidence


Note: The majority of these articles represent information on skills retention from the non-medical literature and/or do not deal evaluate CPR skills. These could be considered extrapolated data. However, because many of these represented randomized controlled trials, they have been graded based on their methodology of examining motor skills. All non-medical studies and/or studies that did not evaluate CPR skills are highlighted by being shown in Italics. For clarity, medical literature studies on CPR skills retention are highlighted by Underline.

All studies represented endpoints that included varying time frames for evaluating retention.

Qua

lity

of E

vide

nce

ExcellentGoodwin (1995) Guadagnoli (2001), Pringle (2004), Schmidt (1989), Swinnen (1990), Winstein (1990), Wrisberg (1997), Wulf (1994) ,Wulf (1989,

Salmoni (1984), Winstein (1991)

Good

Anderson (1994), Anderson (2001), Butki (2003), Croce (1996), Gable (1991), Gillespie (2003),Goodwin (2001), Guadagnoli (2002), Guay (1997), Kohl (1996), Lee (1990), Liu (1997), Park (2000), Schmidt (1997), Weeks(1998), Wik,( 2001), Wulf (1993),Yao (2003)

Fair Shewokis (2000)

1 2 3 4 5 6 7 8Level of Evidence



Neutral or Opposing Evidence


Note: The majority of these articles represent information on skills retention from the non-medical literature and/or do not deal evaluate CPR skills. These could be considered extrapolated data. However, because many of these represented randomized controlled trials, they have been graded based on their methodology of examining motor skills. All non-medical studies and/or studies that did not evaluate CPR skills are highlighted by being shown in Italics. For clarity, medical literature studies on CPR skills retention are highlighted by Underline.

Negative studies indicated in BOLD.

All studies represented endpoints that included varying time frames for evaluating retention.

Qua

lity

of E

vide

nce

Excellent Wulf (1998a)

Good Watson (2001), Wulf (1998b)

Fair Turner (1994)




Supporting Evidence


NOTE: All studies are from the medical literature and deal directly with CPR skills (manikin/simulated unless otherwise specified [eg. *]).

Endpoint for all studies was skill replication during CPR events.

Qua

lity

of E

vide

nce

Excellent Boyle (2002)

Good Elding (1998),Handley (2003), Wik (2001)

Kern (1992)*

Berg (1994)*, Gruben (1990)*, Kinney (1995), Shultz (1995)

Barson (1981), Milander (1995)

Fair Perkins (2002),Wik. (2002) Thomas (1995)*


A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpointB = Survival of event D = Intact neurological survival * = studies in human arrest scenario


Neutral or Opposing EvidenceHypothesis 2: Audio prompts or other forms of feedback that guide action sequences and timing of chest compressions and ventilations during cardiac arrest events will aid rescuers in performing CPR skills.

Negative studies indicated in BOLD.

NOTE: All studies are from the medical literature and deal directly with CPR skills (manikin/simulated unless otherwise specified [eg. *]).

Endpoint for all studies was skill replication during CPR events.

Qua

lity

of E

vide

nce

Excellent

Good

Fair




STEP 3. DETERMINE THE CLASS OF RECOMMENDATION. Select from these summary definitions.CLASS CLINICAL DEFINITION REQUIRED LEVEL OF EVIDENCE

Class IDefinitely recommended. Definitive, excellent evidence provides support.

• Always acceptable, safe• Definitely useful • Proven in both efficacy & effectiveness• Must be used in the intended manner for proper clinical indications.

• One or more Level 1 studies are present (with rare exceptions) • Study results consistently positive and compelling

Class II:Acceptable and useful

• Safe, acceptable• Clinically useful• Not yet confirmed definitively

• Most evidence is positive• Level 1 studies are absent, or inconsistent, or lack power • No evidence of harm

• Class IIa : Acceptable and usefulGood evidence provides support

• Safe, acceptable• Clinically useful • Considered treatments of choice

• Generally higher levels of evidence• Results are consistently positive

• Class IIb: Acceptable and usefulFair evidence provides support

• Safe, acceptable • Clinically useful• Considered optional or alternative treatments

• Generally lower or intermediate levels of evidence• Generally, but not consistently, positive results

Class III: Not acceptable, not useful, may be harmful

• Unacceptable• Not useful clinically• May be harmful.

• No positive high level data• Some studies suggest or confirm harm.

Indeterminate• Research just getting started.• Continuing area of research• No recommendations until further research

• Minimal evidence is available• Higher studies in progress • Results inconsistent, contradictory• Results not compelling


STEP 3: DETERMINE THE CLASS OF RECOMMENDATION. State a Class of Recommendation for the Guideline Proposal. State either a) the intervention, and then the conditions under which the intervention is either Class I, Class IIA, IIB, etc.; or b) the condition, and then whether the intervention is Class I, Class IIA, IIB, etc.


Indicate if this is a __ Condition or X InterventionFinal Class of recommendation: _ X_Class IIb-Acceptable & Useful; fair evidence

A significant number of LOE 2 studies exist in the non-medical/non-CPR skill literature that demonstrated the guiding effect of prompts during motor skill acquisition. Additionally, a significant theoretical basis has been established in the motor skills literature that predicts the effect of the overuse of audio and/or video prompts on motor skill retention. However, only one applicable peer-reviewed study on CPR skill retention with the use of a prompting device has been presented in the medical literature. That study (LOE2) also supported the hypothesis. There is fair support for the hypothesis.


Indicate if this is a __ Condition or X InterventionFinal Class of recommendation: _

X_Class IIa-Acceptable & Useful; good evidence

All 13 studies (4 LOE 2, 3 LOE 3, 4 LOE 5, and 2 LOE 7) supported the hypothesis. There were no neutral or opposing studies. There is good support for the use of audio prompts or other forms of feedback that guide action sequences and timing of chest compressions and ventilations during cardiac arrest events will aid rescuers in performing CPR skills.

REVIEWER’S PERSPECTIVE AND POTENTIAL CONFLICTS OF INTEREST: Briefly summarize your professional background, clinical specialty, research training, AHA experience, or other relevant personal background that define your perspective on the guideline proposal. List any potential conflicts of interest involving consulting, compensation, or equity positions related to drugs, devices, or entities impacted by the guideline proposal. Disclose any research funding from involved companies or interest groups. State any relevant philosophical, religious, or cultural beliefs or longstanding disagreements with an individual.

Reviewer – David L. Rodgers: Education – Doctoral student in Education (Curriculum and Instruction) with Marshall University (Huntington, WV, USA); Education Specialist degree in Curriculum and Instruction; Marshall University; Master of Arts in Communication Studies (Emphasis in Organizational Communication), Marshall University; Bachelor of Science in Journalism (emphasis in News and Editorial Writing), West Virginia University (Morgantown, WV, USA). Clinical Background - National Registered Emergency Medical Technician – Paramedic. AHA Volunteer Activity – AHA ACLS Regional Faculty (WV); AHA BLS Regional Faculty (WV); AHA instructor in ACLS, BLS & PALS; member AHA Program Administration Subcommittee (2001 – 2004); member AHA Education Work Group (2004 – present); various regional level leadership positions.

Disclosure – David Rodgers is an employee of Charleston Area Medical Center Health Education and Research Institute that, in addition to being an AHA Training Center, is a distributor in the public access defibrillation market for Zoll Medical Inc. AEDPlus. Mr. Rodgers receives no compensation in the form of additional salary, bonuses, or commissions in relation to the Zoll AEDPlus distributorship.

REVIEWER’S FINAL COMMENTS AND ASSESSMENT OF BENEFIT / RISK: Summarize your final evidence integration and the rationale for the class of recommendation. Describe any mismatches between the evidence and your final Class of Recommendation. “Mismatches” refer to selection of a class of recommendation that is heavily influenced by other factors than just the evidence. For example, the evidence is strong, but implementation is difficult or expensive; evidence weak, but future definitive evidence is unlikely to be obtained. Comment on contribution of animal or mechanical model studies to your final recommendation. Are results within animal studies homogeneous? Are animal results consistent with results from human studies? What is the frequency of adverse events? What is the possibility of harm? Describe any value or utility judgments you may have made, separate from the evidence. For example, you believe evidence-supported interventions should be limited to in-hospital use because you think proper use is too difficult for pre-hospital providers. Please include relevant key figures or tables to support your assessment.


Regarding Hypothesis 1: Audio prompts or other forms of feedback that guide action sequences and timing of chest compressions and ventilations may aid in the early learning of CPR skills when used as a model for performance; however, overuse of audio prompts may have a detrimental effect on retention and ample practice time without audio prompting devices must be supplied.

Answering the worksheet hypothesis poses some difficulty as no studies have specifically addressed the use of audio prompting devices’ effect on skill acquisition and retention in CPR as it relates to compression rate. Several studies have examined parts of this issue, but none have been designed to directly measure this aspect of training. Looking at the medical literature regarding the use of audio or visual prompts for training purposes, there are relatively few studies that specifically examine this question. The only study from the medical literature to be inlcuded was Wik, Thowsen, & Steen ( 2001). Wik et al. (2001) showed that voice prompting improved several individual areas of performance in BLS skills. However, chest compression rate performance was not altered by the voice prompts owing in part to an already highly accurate baseline in both experimental groups. Nonetheless, Wik et al. demonstrated that there were not only performance improvements in some specific BLS skills with the introduction of voice prompts, but that the positive effects of voice prompts remained in a performance trial without voice prompts conducted very soon after the voice prompt trial. This was not a long-term retention test so it is difficult to transfer these results as a measure of learning.

Other studies from the medical literature have examined parts of this topic, but were excluded because they did not directly address the question posed by the hypothesis. To clarify why these studies were excluded, the following explanations are provided. Some studies have examined the use of audio prompts in guiding CPR providers through actual events (Berg et al., 1994; Kern et al., 1992; Milander et al., 1995) or simulated events (Doherty et al., 1998; Starr, 1997), but have not addressed all the points necessary to inform the worksheet hypothesis.

Handley and Handley (2003) examined the use of a voice advisory manikin that supplied concurrent, qualitative, and prescriptive voice feedback on a variety of performance parameters. Their study indicated performance improvement with voice prompts during skill acquisition trials increased some individual skills in CPR. However both control and experimental groups had chest compression rates that were within the optimal range during all phases of the study; thus, the impact on voice prompts on rate control could not be judged. This study only examined skill acquisition with and without voice prompts and did not examine delayed feedback retention capabilities.

Wik, Myklebust, et al.,(2002) also used the voice advisory manikin in an experiment that examined longer term (6 month) skill retention. While the voice advisory manikin was a key element in the training programs tested, the main intent of the study was to examine the effects of overtraining with the voice advisory manikin on skill retention. Therefore, the results – while valuable – do not provide independent support for answering the question of audio or visual prompts’ efficacy in BLS training without overtraining.

Because of the signfiicant lack of applicable studies from the medical literature that could address the issue raised in the hypothesis, the search was expanded beyond the medical literature. Studies included in this worksheet focus on motor skill learning utilizing a variety of laboratory and practical motor skills. It is hypothesized that the teaching of CPR, as a motor skill, will respond in the same manner as other motor skills. The academic literature on motor skill acquisition has many examples of well designed randomized controlled studies in addition to a well developed theoretical base for motor skills learning. Therefore, the majority of the studies included in this worksheet represent skills other than chest compressions. Because of the lack of data relating directly to the provision of chest compressions, it is not possible to answer this question without extrapolating data from other motor skills studies. To answer this question, the academic motor skill learning literature was utilized. In this literature, feedback is often referred to as Knowledge of Results (KR) or Knowledge of Performance (KP). KR and/or KP can be provided concurrently with the skill (such as using a prompting device that provides feedback or guidance to the subject) or at the conclusion of the skill task.

Details of the findings in this area of study are posted in the Citation section of this worksheet. The results are summarized in the following paragraphs.

Based on the motor skill literature two conclusions can be made. Goodwin & Meeuwsen, 1995; Guadagnoli & Kohl, 2001; Pringle, 2004; Schmidt, Young, Swinnen, & Shapiro, 1989; Swinnen, Schmidt, Nicholson, & Shapiro, 1990; Winstein & Schmidt, 1990; Wrisberg & Wulf, 1997; Wulf, Lee, & Schmidt, 1994; Wulf & Schmidt, 1989 all provide strong evidence that support these conclusions. First, some form of feedback is essential for motor skill learning. Audio or visual prompts, as a form of feedback that provides a target goal for an activity have been shown to be positive in their use as a model for learners ((refs).Second, overuse of feedback, including feedback supplied by audio or visual prompts, can lead to a dependence on feedback to guide skill performance and create an inability of the learner to independently evaluate their own skill performance. This may manifest itself as an apparent improvement in skill acquisition as demonstrated during classroom performance, but will lead to a deficit in skill reproduction during retention or transfer activities. The academic education literature refers to this as the Guidance Hypothesis, which is a well documented phenomenon. As a result, the motor skill learning literature is very clear – skill acquisition is not a reliable indicator of skill retention (Park, 2000).

For these reasons, the use of audio or visual prompting devices is useful in CPR training as a model to demonstrate CPR compression rate for learners during the early stages of training. However, all devices that provide continuous feedback or guidance should be withdrawn as early as possible during practice sessions to lessen the likelihood of learners developing a dependence on the device to guide their skill performance and allow students to develop their own intrinsic abilities of evaluating their own skills perfromance.

As an educational intervention, the use of a prompting device (either audio or visual) does not have similar end points as clinical experiments (i.e. ROSC, survival to discharge). However, within the academic education literature there are several end points that may be applied to this question. These end points can include skill acquisition as demonstrated at the conclusion of a training session, retention testing done some time later (e.g., 24 hours after acquisition, one week after acquisition, etc.), or transfer application where the skill is applied in a “real life” situation. Just as decisions regarding clinical application of guidelines prefer to utilize a long- term end point, such as one year survival, the application of educational guidelines should also consider longer term end points and not be satisfied with evaluations of skill acquisition at the completion of a course.

Regarding Hypothesis 2: Audio prompts or other forms of feedback that guide action sequences and timing of chest compressions and ventilations during cardiac arrest events will aid rescuers in performing CPR skills.

There is well documented evidence that CPR skills deteriorate significantly after initial CPR instruction (See Brennon & Braslow, 1995; Brennon & Braslow, 1998; Donnelly, Assar, et al, 2000; Dracup, Doering, et al., 1998; and Dracup, Moser, et al., 1998). Through a thorough reading of the educational literature there is clear evidence of the guiding effects of both audio and visual skill prompts. In teaching situations, aggressive (used 100% of the time) use of prompting devices guided


learners to the desired level of performance much more quickly than for learners who did not have prompting devices or had them used with less frequency. However, as that worksheet noted, the apparent acquisition of the skill was only temporary.

Nonetheless, this evidence points out the beneficial aspects of prompting devices. Utilization of a prompting device in an actual CPR situation should have the same effect on CPR rescuers as the prompting device being used 100% of the time in a training situation. To examine this effect, this worksheet reviewed situations where 100% feedback was provided to individuals through the use of a metronome or other similar timing prompt or through bandwidth feedback, a type of feedback only supplied when the provider's skill strayed beyond a point of acceptable performance such as 10% outside ideal.

The results of this worksheet indicate that there is a very strong guiding effect for both 100% guidance (Boyle, et al., 2002; Elding, et al., 1998; Kern, et al., 1992; Kinney & Tibballs, 2000; Milander, et al., 1995; Perkins, 2005; and Starr, 1997) and for bandwidth feedback (feedback that is only provided when skill performance falls outside a designated performance level) (Handley & Handley, 2003; Wik, et al., 2002; and Wik, et al., 2001) for improving chest compression and other CPR skills when applied in skill transfer activities.

However, in each of these studies, participants were oriented to the prompting device prior to its use. Given the low incidence of having a prompting device utilized in current training situations, there is some concern that the rescuer will be distracted by the prompting device. Some evidence supporting this can be related to Silfvast, Paakkonen, et al. (2002) who demonstrated that rescuers were distracted by watching the ECG waveform while CPR was in progress. Continued testing of the impact of a prompting device on students who have not been exposed to the device prior to the need to use it needs to be performed to answer this question. In the interim, if prompting devices are to be used, Basic Life Support class participants should be exposed to those devices to lessen the chances for confusion or distraction when introduced later in an actual emergency.

There is good evidence for including prompting devices into the available tools for rescuers – both professional and lay responders – to utilize during actual emergency events.

Preliminary draft/outline/bullet points of Guidelines revision: Include points you think are important for inclusion by the person assigned to write this section. Use extra pages if necessary.

Publication: Chapter: Pages:

Topic and subheading:

Reference Hypothesis 1, evidence from one LOE 2 study on CPR and 27 LOE 2 and two LOE 7 studies from the motor skills literature document improvement of either CPR or motor skill performance when feedback is administered by audio and/or video prompting devices to students in the training setting. However, the motor skills literature studies cited indicated that the guiding effect of this feedback is only temporary and may lead to a false sense of skill acquisition success.

Therefore, administration of feedback by audio and/or video prompting devices for students in a training setting should be considered provided a greater portion of CPR practice time is dedicated to skills practice without prompting devices allowing for the development of stronger intrinsic skill monitoring capabilities. (American Heart Association, Class !!b recommendation)

Reference Hypothesis 2, evidence from four LOE 2 studies in simulated arrest scenarios and supported by 10 additional studies (three LOE 3, five LOE 4 and two LOE 7; some involving simulated and some involving actual arrest scenarios) in the medical literature document improvement of CPR performance when feedback is administered by audio and/or video prompting devices to CPR providers in the cardiac arrest setting.

Therefore, administration of feedback by audio and/or video prompting devices for CPR providers in the cardiac arrest setting is recommended. (American Heart Association, Class !!a recommendation)

Attachments: Bibliography in electronic form using the Endnote Master Library. It is recommended that the bibliography be provided in annotated

format. This will include the article abstract (if available) and any notes you would like to make providing specific comments on the quality, methodology and/or conclusions of the study.


Citation List Italics in Citation Marker indicates non-medical and/or non-CPR study

Citation Marker Full Citation*Anderson (1994) Anderson, D. I., Magill, R. A., & Sekiya, H. (1994). A reconsideration of the trials-delay of knowledge of results paradigm in

motor skill learning. Research Quarterly for Exercise & Sport, 65(3), 286-290.

AB: The present research was designed to replicate and extend previous trials-delay of KR results. More specifically, the experiment sought to determine if, relative to a zero-trial delay of KR, a two-trial delay of KR would produce the detrimental effects in acquisition and the beneficial effects in retention noted in previous trials-delay KR studies. Twenty (20) subjects performed a blindfolded, rapidly executed aiming task. Subjects received KR either immediately after each trial or delayed KR (KR for trial 1 given following movement made on trial 3). The zero-trial delay KR group had a lower absolute constant error (ACE) than the two-trial delay KR group during acquisition trials. However, the two-trial delay KR group significantly outperformed the zero-trial delay KR group in two 24 hour delayed no KR retention tests (ACE for two-trial delay group 2.3 and 1.8 versus ACE for zero-trial delay of 4.7 and 5.4)

Comments: Level 2 for non-CPR setting, Good (small study), Supporting, Randomized experimental study

Subjects – 20 undergraduate university students (20 male, 20 female, all right-handed) Assignments – Assigned to either an every trial KR (feedback) group (Delay 0) or an every other trial KR group (Delay 2). Skill task – A blindfolded, rapidly executed aiming task. Procedure – 80 acquisition trials were completed. These were followed by no-KR retention testing at 10 minutes and 1 day after completion of the acquisition phase with each consisting of 20 trials. Statistical analysis – ANOVA was performed using Absolute Constant Error (CE) as the dependent variable. Results – The mean CE score for the acquisition phase indicated a significant result (p < .01) favoring the Delay 0 group. The 10-minute retention tests showed no significant difference in mean CE. The 1-day no-KR retention test showed a significant difference (p < .05) favoring the Delay 2 group. Study supports the Guidance Hypothesis. This study is significant in that it demonstrated how quickly the guidance effect wears off (less than 24 hours).

Anderson (2001) Anderson, D. I., Magill, R. A., & Sekiya, H. (2001). Motor learning as a function of KR schedule and characteristics of task-intrinsic feedback [Electronic Version]. Journal of Motor Behavior, 33(1), 59-66.AB: Forty participants (age range = 18-35 years) practiced 1 of 2 versions of an aiming task (with or without spring resistance). Knowledge of results (KR) was provided to them either immediately or after a delay of 2 trials. Immediate KR led to significantly more accurate performance during the 80 trials in acquisition but significantly less accurate performance on a 40-trial retention test given 24 hr after practice. In addition, the spring version of the task was performed significantly less accurately than the no-spring version on the 24-hr retention test. Most important, a significant interaction on the 24-hr retention test revealed that performance of the no-spring version of the task, when KR had been given after a 2-trial delay, was significantly more accurate than performance of the other 3 combinations of task version and KR schedule. The results suggest that KR dependency in motor skill learning is related to familiarity with task-intrinsic feedback in addition to the schedule on which KR is presented.

Comments: Level 2 for non-CPR setting, Good (small study groups), Supporting, Randomized experimental study

Subjects – Forty university students (ages 18- 35). Assignments – Randomized quota assignment to one of four groups with quota for equal number of males and females in each group. Groups were to receive combinations of either KR (feedback provided by a computer showing results) after every trial (no delay) or after every two-trials (delayed). An additional factor of a resistance spring was added for intrinsic feedback making for four groups (no delay, delayed, no delay/spring, delayed/spring). Skill task – An aiming task using a drawing stylus with the non-dominant hand. Procedure – 80 acquisition trials were conducted. These were followed by two 40 trial, no KR tests conducted one minute and 24 hours after the acquisition trials. Intrinsic feedback represented by the spring remained for the groups who were exposed to that form of feedback. Statistical analysis – Because a pretest indicated one group had a significantly higher degree of performance than the other three groups, an analysis of covariance was performed. For the acquisition trials this was done with a 2 x 2 x 4 (delay x intrinsic feedback x trial block) ANCOVA with repeated measures on the trial block variable. Retention data used a 2 x 2 x 2 ANCOVA. Results – Acquisition trials showed a significant (p < .05) finding favoring both every trial KR group over the other groups. One-minute retention testing showed no significance. 24-hour retention tests showed a significant (p < .05) result for the delayed KR group. The inclusion of intrinsic feedback in the form of resistance helped neither group where that was provided. Study supports the Guidance Hypothesis. This study is significant in that it demonstrated how quickly the guidance effect wears off (less than 24 hours).

Barson (1981) Barsan, W. G. (1981). Experimental design for study of cardiopulmonary resuscitation in dogs, Annals of Emergency Medicine, 10(3), 135-137.Addressed use of metronome to pace chest compressions. Did not address question regarding use of audio or video prompts in skill acquisition and retention.

AB: Many different designs for studies of various aspects of cardiopulmonary resuscitation (CPR) in dogs are described in the literature. No single technique is generally accepted. We present a systematized approach to the study of CPR in the canine model. Cardiac output, arterial blood pressure, and electrocardiogram were recorded for three different methods. The methods studied were closed chest compression, closed chest compression with an automatic gas-powered chest compressor, and open chest manual cardiac massage. Cardiac output for both types of external chest compression were less than 17% of control in all cases. With open chest cardiac massage, systemic arterial blood pressures were in the 50 mm Hg to 100 mm Hg range and cardiac output of up to 70% of control was achieved. Using a metronome to obtain compression rate and the arterial blood pressure to guide the efficacy of compression, consistent levels of cardiac output could be achieved for up to 30 minutes using open chest cardiac massage. Closed chest massage in man results in a cardiac output of 25% to 30% of normal when performed under optimal conditions. A cardiac output of 25% to 30% of control cannot be achieved in large dogs with external chest compression, and hence is not a good model to stimulate CPR in man.


Comments: Level 6, Good, Supporting

Study used a metronome to remove inconsistency of chest compression rate as a confounding variable. Berg (1994) Berg, R. A., Sanders, A. B., Milander, M., Tellez, D., Liu, P. and Beyda, D. (1994). Efficacy of audio-prompted rate

guidance in improving resuscitator performance of cardiopulmonary resuscitation on children., Academic Emergency Medicine, 1(1), 35-40.

AB: OBJECTIVE: To evaluate the effect of audio-prompted rate guidance during chest compressions on the performance of cardiopulmonary resuscitation (CPR) on children. METHODS: This 24-month prospective study occurred in the pediatric intensive care units of a university hospital and a children's hospital. Intubated children with nontraumatic cardiac arrest were eligible. After placement of an infrared capnometer between the endotracheal tube and resuscitation bag, an audiotape instructed the resuscitator to perform chest compressions at 100 per minute or 140 per minute for one minute, followed by another minute at the other rate. End-tidal carbon dioxide partial pressure (PETCO2) was recorded prior to audiotape instruction and after one minute of CPR at each rate. RESULTS: Six patients, two boys and four girls, with a mean age of 15 +/- 13 months (range 2-36 months) were studied. All had asystole or pulseless electrical activity. CPR was provided for 14 +/- 9 minutes prior to institution of the study protocol. PETCO2 at 140/min was higher than at baseline (12 +/- 7 torr verus 4 +/- 3 torr, p < 0.05). There was a trend towards higher PETCO2s at 100/min compared with baseline (11 +/- 12 torr versus 4 +/- 3 torr, p = 0.08). PETCO2s did not differ at 100/min compared with 140/min. CONCLUSIONS: In support of prior adult and animal investigations suggesting that basic CPRR is often performed poorly and at inappropriately slow rates, audio- prompted rate guidance during CPR in children resulted in higher PETCO2, suggesting improved CPR performance.


Very small group (6) in study. Device used was a prerecorded audiotape that featured audio tones at either 100 or 140 beats per minute. Rate guided CPR proved to be more effective than non-rate guided CPR based on ETCO2 levels.

Boyle (2002) Boyle, A. J., Wilson, A. M., Connelly, K., McGuigan, L., Wilson, J. and Whitbourn, R. (2002). Improvement in timing and effectiveness of external cardiac compressions with a new non-invasive device: the CPR-Ezy, Resuscitation, 54(1), 63-7.

AB: Prompt and effective cardiopulmonary resuscitation (CPR) is the first link in the chain of survival following cardiac arrest. We assessed a new device, the CPR-Ezy (Medteq Innovations Pty Ltd., Brisbane, Australia), to aid timing and effectiveness of external cardiac compressions (ECC), by 32 subjects who had prior community-based training in CPR. ECC was performed on a manikin for 4 min by all subjects without and with the device. There was a statistically significant improvement in timing of ECC. Effectiveness of compressions was also improved over the whole time period, especially so in the last minute. We conclude that the CPR-Ezy can improve timing and effectiveness of ECC, and reduce the effects of resuscitator fatigue, in community-trained subjects.

Comments: Level 3, Excellent, Supporting

Showed significant improvement in providing effective chest compressions with the use of a CPR adjunct device that provided guidance for both compression rate and force. Cohort study that had 32 participants perform four minutes of CPR on Day 1, and then another four minutes of CPR on Day 2 but with the adjunct device. Day 1 information also showed a significant drop in compression effectiveness in the last minute of the four minute trial. This drop was not present on Day 2 with the adjunct device in use. Provides strong support for using an adjunct device in the delivery of chest compressions.

Butki (2003) Butki, B. D., & Hoffman, S. J. (2003). Effects of reducing frequency of intrinsic knowledge of results on the learning of a motor skill. Perceptual & Motor Skills, 97(2).

AB: The guidance hypothesis suggests too much knowledge of results during skill acquisition can be detrimental to long-term performance. Possibly, the learner becomes dependent on augmented KR and is unable to use intrinsic feedback. This study examined this hypothesis with three groups performing a golf putting task. One group received continuous KR about ball path and final location; the other groups were deprived of specific KR on 50% or 100% of the acquisition trials. As expected, the continuous KR group performed better during acquisition, but the KR-deprived groups performed better on delayed retention trials, especially when KR was absent.

Comments: Level 2 for non-CPR setting, Good, Supporting, Randomized experimental study

Subjects – 78 undergraduate students. Assignments – Stratified random assignment (based on gender) to one of three groups: Group 1 – 50/50 group received fading KR on both ball path and final position; Group 2 – 0/50 group received no information on ball path and 50% fading KR on ball position, and Group 3 – 100% group received KR on all trials for both ball path and position. Skill task – Golf ball putting task with variations including ability to watch the ball path and/or see the final ball position. Procedure – 96 acquisition trials spread over eight blocks followed by two retention tests – one conducted immediately after acquisition phase and the other conducted 24 hours later. Retention tests included two blocks, one with KR and the other without KR. Statistical analysis – Mean error scores with ANOVA. Results – During acquisition phase, all groups improved performance, but the 100% group had reached significance (p < .05) in showing a lower mean error score in the final acquisition block. During immediate retention tests with no KR, the 100% and 50% groups had lower mean error scores than the 50/50 group. During 24-hour retention tests, the decrease in skill performance from the final acquisition trial indicated the 100% KR group lost the most skill, but this did not reach significance (p < .10). For comparison, final acquisition block versus 24-hour n-KR retention tests had the following mean error scores reported: Group 1 – 22.6 v 24.4; Group 2 – 20.1 v 24.5; and Group 3 – 22.7 v 22.3 (actually showed improvement in performance). Study lends some supports the Guidance Hypothesis.

Croce (1996) Croce, R. and Horvat, M. (1996). Augmented feedback for enhanced skill acquisition, Perceptual & Motor Skills, 82(2), 507-514


AB: Presents a study conducted on augmented feedback for enhanced skill acquisition in persons with traumatic brain injury. Previous studies conducted by A.W. Salmoni, R.A. Schmidt and C.B. Walter in 1984, and others; How individuals were measured; Absolute constant error; Variable error; Results complement proposed guidance hypothesis of Salmoni.

Comments: Level 2 for non-CPR setting, Good (atypical study group), Supporting, Randomized experimental study.

Subjects – 51 subjects (mean age 29.2) classified as having moderate disability after traumatic brain injury. Identified as having a Glasgow Outcome Scale (Jennet & Bond, 1975) Level 2 function. All were minimally two-years post trauma. Assignments – Random assignment to one of four groups: Group 1 – 0% KR, Group 2 – 100% KR, Group 3 – Summary KR (KR about each trial after 5 trials), and Group 4 – Average KR (average KR after 5 trials). Skill task – Anticipation timing test where subjects had to respond with hand movement in a coincident timing task. Procedure – 12 five-trial acquisition blocks followed by a 20 trial no-KR immediate retention test and then 24 hours later by another 20 trial no-KR retention test. Statistical analysis – Absolute constant error and variable error were measured with ANOVA with Tukey post hoc tests. Results – Group responses indicated Group 1 (0% KR) improved during acquisition phase but improvement did not maintain in either retention test; Group 2 (100% KR) improved during acquisition phase and maintained skill in immediate retention test but lost skill in long-term retention test; Group 3 (Summary KR) improved during acquisition phase and maintained skill level in both retention tests; and Group 4 (Average KR) improved during acquisition phase and maintained skill in immediate retention test but lost skill in long-term retention test. Study supports the Guidance Hypothesis while calling into question use of average KR.

Elding (1998) Elding, C., Baskett, P. and Hughes, A. (1998). The study of the effectiveness of chest compressions using the CPR-plus, Resuscitation, 36(3), 169-73.

AB: Effective cardiopulmonary resuscitation (CPR) requires a high level of skill from both healthcare professionals and the lay public. Inadequate chest compressions are a common cause of ineffective CPR. The CPR-plus is a non-invasive, hand-held, simple to use CPR adjunct designed to assist the rescuer to monitor and modify the compression technique during CPR, hopefully resulting in improved rescuer performance and more effective CPR. Forty qualified nurses were evaluated while they performed chest compressions on a training manikin. During simulated two-rescuer CPR (compression/ventilation ratio 5:1) the participants performed 150 compressions at a rate of 80-100 min. Compressions were performed with and without the CPR-plus and the results compared. The use of the CPR-plus was randomised with regard to whether the adjunct or the standard method was used first. The average number of correctly applied compressions was significantly better when the CPR-plus was used: 138.35/150 versus 110.70/150 (p = 0.0001). Improvements in techniques associated with the use of the CPR-plus also included a reduction in excessive application of pressure and incorrect hand position. The device provided reassurance of satisfactory compressions and an indication of impending fatigue in the rescuer.


Study had a small group size (original group of 40 split to make two groups for comparison). Device featured a pressure gauge to measure chest compression force and a metronome to guide rate. Study design showed group that used the adjunct device first had a higher rate of good initial CPR performance; group that used standard CPR showed improvement when adjunct device introduced.

Gable (1991) Gable, C. D., Shea, C. H., & Wright, D. L. (1991). Summary knowledge of results. Research Quarterly for Exercise and Sport, 62, 285-292.

AB: Summary knowledge of results (KR) involves delaying the presentation of KR until a predetermined number of trials has been completed. Schmidt, Young, Swinnen, and Shapiro (1989) found an optimal summary of 15 trials (compared to 1, 5, and 10) and Schmidt, Lang, and Young (1990) found an optimum length of 5trials (compared to 1, 10, and 15) for 1 and 2 kinematic degree of freedom timing tasks, respectively. Experiment 1 was designed to determine the optimal summary length for learning a simple isometric force production task. The results indicated better retention for the 16-trial summary than for 8- or 1-trial summaries. Experiment 2 was an initial attempt to determine the locus of the 16-trial summary effect. Specifically, Experiment 2 focused on the role played by both the information provided in the summary presentations and the practice per se of the first 14 trials in the 16-trial block. The results suggest KR is important to ensure response stability. However, it also appears important to restrict the subject's immediate utilization of KR. This latter requirement may potentially aid the parameterization process, resulting in a reduction in response bias


Two experiments with experiment 1 having relevance to this topic. Subjects – 18 male, 18 female upper division undergraduate students. Assignments – While not reported, it is assumed based on other works by these authors that there was random assignment to one of the three experimental groups was done. Skill task – An isometric dynamic force measurement system involving the use of both arms that transferred subject effort onto a graphic computer display indicating knowledge of results of effort. Procedure – The acquisition phase consisted of 10 blocks of 16 trails. Feedback (KR) was provided after every trial, after every eight trials, or after a block of 16 trials was completed. For the latter two groups, KR was supplied as summary KR. A single 16 trial block without KR was completed 24 hours later to test retention. Statistical analysis – MANOVA examined absolute constant and variable errors. Results – During acquisition phase, KR1 group outperformed both other groups with the lowest error rates. During retention phase, KR16 significantly outperformed KR1. There was no significance with KR when compared to either of the other groups. Study supports the Guidance Hypothesis and results are consistent with other similar studies.

Gillespie (2003) Gillespie, M. (2003). Summary versus every-trial knowledge of results for individuals with intellectual disabilities. Adapted Physical Activity Quarterly, 20(1), 46-56.

AB: The purpose of this study was to examine the effect of a summary knowledge of results (KR) feedback schedule (KR after every fifth trial) versus everytrial KR on the acquisition and retention of a golf putting task for individuals with intellectual disabilities. Thirty-two individuals with mild intellectual disabilities were randomly assigned to either a summary


or every-trial KR group. Participants performed 50 acquisition trials, 25 one-day retention trials, and 25 one-week retention trials. Participants in the every-trial KR group scored significantly better during acquisition, while the summary KR group performed significantly better for both retention intervals. Because of the absence of an acquisition block effect, results relative to learning must be viewed with caution. Findings partially support the guidance hypothesis

Comments: Level 2 for non-CPR setting, Good (atypical subjects), Supporting, Randomized experimental study

Subjects – 32 males, mean age 129 months, all with intellectual disabilities (IQ range of 55-70). Assignments – Randomized assignment to one of two groups. First group to receive KR (feedback) after every trial, second group to receive KR after every fifth trial. Skill task – Golf ball putting task aimed at placing ball a specific distance from starting point. Procedure – Included 50 skill acquisition trials and two retention trials (with no feedback) conducted one day and one week after acquisition trials. Each retention trials consisted of 25 putts. Statistical analysis – Acquisition data analyzed using a 2 (group) x 10 (trial block) analysis of variance with repeated measures on the last factor. Retention data analyzed with 2 (group) x 5 (trial block) analysis of variance with repeated measures on the last factor. Results – Acquisition trials indicated a significant (p < .05) difference with effect size calculation indicated a large effect favoring the KR after every trial group. One day retention trials indicated a significant (p < .05) difference with effect size calculation indicated a moderate effect favoring the KR after every fifth trial group. One week retention trials indicated a significant (p < .05) difference with effect size calculation indicated a large effect favoring the KR after every fifth trial group. Study provides support for the Guidance Hypothesis.

Goodwin (2001) Goodwin, J. E., Eckerson, J. M. and Voll Jr., C. A. (2001). Testing specificity and guidance hypotheses by manipulating relative frequency of KR scheduling, Perceptual & Motor Skills, 93(3), 819-824

AB: Examines the manipulation of relative frequency of knowledge of results scheduling in motor skill acquisition. Use of a shuffleboard task; Prediction of specificity hypothesis; Support for the guidance hypothesis


Subjects – 110 university students with equal number male and female.

Assignments – Random assignment to one of five groups with the constraint that each group have equal male and female ratios. Group 1 – 100% KR, Group 2 – 50% KR (every other trial), Group 3 – 50% KR (Fading KR), Group 4 – 50% KR (reverse fading), and 0% KR. Skill task – Shuffleboard with goal area vision blocked. Procedure – 60 acquisition trials followed 48 hours later by a no-KR retention trial (2 ten-trial blocks). Statistical analysis – Absolute constant error (CE) and variable error (VE) were measured. Results – During acquisition, only 0% KR condition versus all other KR conditions showed significance for CE. 100% KR ad Fading KR showed significance late in the acquisition trials for consistency (VE). During retention tests, 50% every other and fading KR groups showed significantly better performance than 100% and 0% KR groups for CE. 0% KR group showed significantly more variable performance than all other KR conditions. Study supports the Guidance Hypothesis.

Goodwin (1995) Goodwin, J. E., & Meeuwsen, H. J. (1995). Using bandwidth knowledge of results to alter relative frequencies during motor skill acquisition. Research Quarterly for Exercise & Sport, 66(2), 99-105.

AB: This investigation examined the predictions of the guidance and specificity hypotheses by manipulating different distributions of relative frequency of knowledge of results (KR) using bandwidth (BW) conditions. Subjects (n = 120) were randomly assigned to either a BW0%, BW10%, shrinking-BW, or expanding-BW condition. After 100 acquisition trials were completed, a double transfer design was employed in which the subjects were divided in half and randomly assigned to a no-KR or KR retention condition. Retention tests of 10 min and 48 hours were completed under a no-KR or KR retention condition. Results of the 48-hr retention test under the no-KR retention condition suggested that receiving high relative frequencies of KR at the end of the acquisition phase was as detrimental to motor skill learning as receiving high relative frequencies of KR throughout acquisition.

Comments: Level 2 for non-CPR setting, Excellent, Supporting, Randomized experimental study

Subjects – 120 female undergraduate students (Mean Age 20.65) Assignments – Randomly assigned to one of four groups that received bandwidth KR (KR that is applied based on the performance of the individual in the assigned task, as compared with average KR, fading KR, and summary KR). Groups would receive 0% bandwidth for each trial where there was any deviation from the target goal, 10% bandwidth for each trial where there was more than 10% deviation from the target goal, shrinking bandwidth where the initial trials provided KR when the trial was more than 20% from target goal but that percentage shrunk in subsequent trials, or expanding bandwidth KR where the initial trials provided KR for every trial that deviated from the target goal but expanded that percentage for subsequent trials. Bandwidth conditions refer to providing feedback only when the subject strays from the ideal perfromance level by a percentage or amount. Skill task – a golf ball putting task where there was a curtain hung between the subject and the target goal so that only instructor supplied KR was available. Procedure – The acquisition phase consisted on 100 trials with brief rest periods provided every 20 trials. Two retention trials were conducted; one immediately after the acquisition trials and the other conducted 48 hours after the acquisition trials. For the retention trials, each group was randomly assigned to either receive KR during the retention trials or to a no-KR retention trial. This was done to test the specificity hypothesis which states performance is best when the same conditions present for practice are present for application. Statistical analysis – ANOVA conducted examining absolute constant error. Tukey’s HSD was utilized as a post hoc test. Results – During acquisition trials, the 0% bandwidth and the shrinking bandwidth groups had significantly smaller constant error than the other groups, but this effect was only seen in block 10 of the trials. During retention testing, 10% bandwidth and expanding bandwidth had significantly smaller constant error in the no-KR retention trials. This finding supports the Guidance Hypothesis.

Gruben (1990) Gruben, K. G., Romlein, J., Halperin, H. R., & Tsitlik, J. E. (1990). System for mechanical measurements during cardiopulmonary resuscitation in humans. IEEE Trans Biomed Eng, 37(2), 204-210.

AB: Effective study of CPR requires measurement of the mechanical properties of the human chest and the resultant vascular pressures. A computer-based mobile data acquisition system was designed and built for this purpose. During


manual CPR a short cylindrical module was placed between the rescuer's hands and the patient's chest. This module, which was attached to an easily manipulated position-sensing arm, measured force and acceleration at the sternum. Three-dimensional position and orientation of the module were measured, as well as the component of the applied force which was perpendicular to the sternum. The central venous and aortic pressures were measured by high fidelity pressure transducers. All transducer signals were recorded by digital computer. Real-time feedback of sternal force and displacement, and vascular pressures was provided to the rescue team via chart recordings. An audible signal was produced as an aid in maintaining desired compression rate and duration. The system's mobility permitted rapid implementation at any hospital location. In conclusion, this system was capable of measuring, recording, and displaying multiple physical quantities during manual CPR in humans.

Comments: Level 5, Good, Supporting, Case reports

Guadagnoli (2001) Guadagnoli, M. A., & Kohl, R. M. (2001). Knowledge of results for motor learning: Relationship between error estimation and knowledge of results frequency. Journal of Motor Behavior, 33(2), 217-224.

AB: The authors of the present study investigated the apparent contradiction between early and more recent views of knowledge of results (KR), the idea that how one is engaged before receiving KR may not be independent of how one uses that KR. In a 2 x 2 factorial design, participants (N = 64) practiced a simple force-production task and (a) were required, or not required, to estimate error about their previous response and (b) were provided KR either after every response (100%) or after every 5th response (20%) during acquisition. A no-KR retention test revealed an interaction between acquisition error estimation and KR frequencies. The group that received 100% KR and was required to error estimate during acquisition performed the best during retention. The 2 groups that received 20% KR performed less well. Finally, the group that received 100% KR and was not required to error estimate during acquisition performed the poorest during retention. One general interpretation of that pattern of results is that motor learning is an increasing function of the degree to which participants use KR to test response hypotheses (J. A. Adams, 1971; R. A. Schmidt, 1975). Practicing simple responses coupled with error estimation may embody response hypotheses that can be tested with KR, thus benefiting motor learning most under a 100% KR condition. Practicing simple responses without error estimation is less likely to embody response hypothesis, however, which may increase the probability that participants will use KR to guide upcoming responses, thus attenuating motor learning under a 100% KR condition. The authors conclude, therefore, that how one is engaged before receiving KR may not be independent of how one uses KR.


Subjects – 64 undergraduate students with a mean age of 23. Assignments – Random assignment to one of two KR conditions (100% or 20%) and one of two error estimating conditions (100% or 0%). Skill task – A static force measurement system that involved having subjects strike a padded transducer with the goal of generating a specified amount of force. Procedure – In addition to the feedback frequency, some subjects were required to estimate their results prior to being supplied with KR. Subjects performed ten 15-trial blocks during the acquisition phase and one 15-trial retention test 24 hours after completion of the acquisition phase. Statistical analysis – Root mean square error was examined with a 2 x 2 ANOVA. Results – When subjects did not do error estimation, lower KR frequencies improved retention scores. When subjects did error estimation, higher KR frequency improved retention scores. It was suggested that when subjects were performing error estimation they were engaging themselves in hypothesis testing and the more frequent feedback provided a greater degree of input in helping them test hypotheses. Considering the results from the group that did not perform error estimation, this study supports the Guidance Hypothesis.

Guadagnoli (2002) Guadagnoli, M. A., Leis, B., Van Gemmert, A. W. A., & Stelmach, G. E. (2002). The relationship between knowledge of results and motor learning in Parkinsonian patients. Parkinsonism & Related Disorders, 9(2), 89-95.

AB: A simple timing movement was used to investigate augmented feedback on motor learning in Parkinson's disease (PD) patients and controls. During acquisition, participants received knowledge of results (KR) about their errors after every trial (100%) or every fifth trial (20%). Participants then performed a retention test without KR. Controls performed better on the retention test after having had 20% KR during acquisition. PDs showed superior retention with 100% KR. This suggests that the PD patients are more reliant on KR for learning motor skills; a difference that may be attributable to reduced proprioceptive acuity in PD patients.

Comments: Level 2 for non-CPR setting, Good (mixed results), Supporting, Randomized experimental study.

Mixed results that showed the control group responded to the premise of the Guidance Hypothesis (performed better in retention with 20% KR) while the experimental group of Parkinson’s Disease patients that received 100% KR outperformed Parkinson patients who received 20% KR in no-KR retention tests. Indicates that for healthy population, reduced KR frequencies are advised, but for individuals with mental processing impairments more KR may be needed.

Guay (1997) Guay, M., Salmoni, A., & Lajoie, Y. (1997). Summary knowledge of results and task processing load. Research Quarterly for Exercise & Sport, 68(2), 167-171.

AB: While summary KR refers to the number of trials performed by the participant before error information is provided, task processing load for the present experiment was operationally defined as the number of subcomponent timing goals and resulting KR required to be processed from trial to trial to execute a response successfully. Thus, the purpose of the present investigation was to determine if these two manipulations might interact to promote different levels of skill learning. Specifically, it was predicted that the optimal summary length would be less for a task with greater processing load than for a task with a relatively small load. The prediction that task processing load should interact with summary length was not supported. In keeping with the prediction of the guidance hypothesis and the summary effect, 5-trial and 10-trial summary KR groups should have been superior to the 1-trial KR group during transfer and retention. This prediction was at least partially supported, because the 10-trial summary KR group displayed the most response consistency during transfer and retention.

Comments: Level 2 for non-CPR setting, Good (small group size), Supporting, Randomized experimental study


Subjects – Sixty undergraduate students (30 male, 30 female, mean age 19.8). Assignments – 5 males and 5 females each randomly assigned to one of six experimental groups based on summary KR condition (KR after every 1, 5 or 10 trials) and task processing load (high and low determined by requiring either a total movement goal or subcomponent goals). Skill task – A timed, sequenced arm and hand movement exercise requiring participants to move a horizontal bar through a series of three specific positions each with their own target times. Procedure – 120 acquisition trials were conducted followed by an immediate 30 trial no-KR retention test and one week later with another 30 no-KR retention test. Authors described this series of tests as acquisition, transfer, and retention phases. Statistical analysis – Absolute constant error was measured as a means of determining accuracy. ANOVA conducted. Results – Conclusion made that task processing load made no difference on results. There was partial support for the Guidance Hypothesis since the every 10 trial KR group had better performance in both the transfer and retention tests.

Handley (2003) Handley, A. J. and Handley, S. A. (2003). Improving CPR performance using an audible feedback system suitable for incorporation into an automated external defibrillator, Resuscitation, 57(1), 57-62.

AB: BACKGROUND: It has been shown that a computer-based audible feedback system can improve acquisition and retention of basic life support (BLS) skills. This system is being developed to work in association with an automated external defibrillator (AED). AIM: To determine if such a feedback system is likely to improve the quality of CPR performed by trained nurses whilst using an AED. METHOD: Thirty-six general nurses performed 3 min of BLS on a manikin connected to a laptop computer running an experimental software program. After initial testing they were randomly allocated to control or 'feedback' groups. Both groups then performed a further 3 min of BLS, but those in the feedback group received audible corrective instructions from the computer when errors of technique were detected. RESULTS: The group receiving feedback were significantly better than the control group at performing inflations (P=0.004) and achieving the correct depth of chest compression (P<0.0005). CONCLUSIONS: The results suggest that if the feedback system were to be incorporated into an AED, it could lead to better performance of CPR during a resuscitation attempt.


Using a computer-based verbal response program attached to a CPR manikin, qualitative and prescriptive feedback was provided to participants according to their CPR skill performance. Study shows that automated feedback is positive in improving CPR skill performance, but the method of guidance provided requires some extrapolation since the use of a guiding device such as a metronome was not used. Additionally, the specific skill of chest compression rate did not significantly differ due to an already higher degree of accuracy in meeting the target rate. However, other areas of CPR skill did significantly improve.

Kern (1992) Kern, K. B., Sanders, A. B., Raife, J., Milander, M. M., Otto, C. W. and Ewy, G. A. (1992). A study of chest compression rates during cardiopulmonary resuscitation in humans: the importance of rate-directed chest compressions., Archives of Internal Medicine, 152(1), 145-149.

AB: A prospective, cross-over trial was performed comparing two different rates of precordial compression using end-tidal carbon dioxide as an indicator of the efficacy of cardiopulmonary resuscitation in 23 adult patients. A second purpose of this study was to determine the effect of audio-prompted, rate-directed chest compressions on the end-tidal carbon dioxide concentrations during cardiopulmonary resuscitation. Patients with cardiac arrest received external chest compressions, initially in the usual fashion without rate direction and then with rhythmic audiotones for rate direction at either 80 compressions per minute or 120 compressions per minute. Nineteen of 23 patients had higher end-tidal carbon dioxide levels at the compression rate of 120 per minute. The mean end-tidal carbon dioxide level during compressions of 120 per minute was 15.0 +/- 1.8 mm Hg, slightly but significantly higher than the mean level of 13.0 +/- 1.8 mm Hg at a compression rate of 80 per minute. However, end-tidal carbon dioxide levels increased rather dramatically when audiotones were used to guide the rate of chest compressions. Mean end-tidal carbon dioxide concentration was 8.7 +/- 1.2 mm Hg during standard cardiopulmonary resuscitation immediately before audio-prompted, rate-directed chest compression and increased to 14.0 +/- 1.3 mm Hg after the first 60 seconds of audible tones directing compressions. Using end-tidal carbon dioxide as an indicator of cardiopulmonary resuscitation efficacy, we conclude that audible rate guidance during chest compressions may improve cardiopulmonary resuscitation performance.


Relatively small group (23) in study. Device used was a prerecorded audiotape that featured audio tones at either 80 or 120 beats per minute. Rate guided CPR proved to be more effective than non-rate guided CPR based on ETCO2 levels.

Kinney (2000) Kinney, S. B. and Tibballs, J. (2000). An analysis of the efficacy of bag-valve-mask ventilation and chest compression during different compression-ventilation ratios in manikin-simulated paediatric resuscitation, Resuscitation, 43(2), 115-120.

AB: The ideal chest compression and ventilation ratio for children during performance of cardiopulmonary resuscitation (CPR) has not been determined. The efficacy of chest compression and ventilation during compression ventilation ratios of 5:1, 10:2 and 15:2 was examined. Eighteen nurses, working in pairs, were instructed to provide chest compression and bag-valve-mask ventilation for 1 min with each ratio in random on a child-sized manikin. The subjects had been previously taught paediatric CPR within the last 3 or 5 months. The efficacy of ventilation was assessed by measurement of the expired tidal volume and the number of breaths provided. The rate of chest compression was guided by a metronome set at 100/min. The efficacy of chest compressions was assessed by measurement of the rate and depth of compression. There was no significant difference in the mean tidal volume or the percentage of effective chest compressions delivered for each compression-ventilation ratio. The number of breaths delivered was greatest with the ratio of 5:1. The percentage of effective chest compressions was equal with all three methods but the number of effective chest compressions was greatest with a ratio of 5:1. This study supports the use of a compression-ventilation ratio of 5:1 during two-rescuer paediatric cardiopulmonary resuscitation.



Relatively small group (18). Study not designed to test audio guided CPR. Use of a metronome was to eliminate inconsistency of compression rate as a confounding variable in the study.

Kohl (1996) Kohl, R. M., & Guadagnoli, M. A. (1996). The scheduling of knowledge of results. Journal of Motor Behavior, 28(3), 233-240.

AB: The experiments outlined in this article were performed so that the acquisition effects of KR scheduling on no-KR retention could be determined. In Experiment 1, the group that alternated between 12 KR and 12 no-KR responses produced better retention than both the group that alternated between 6 KR and 6 no-KR responses and an all-KR group. The partial KR group that performed the best on retention also received the least number of reversals from KR to no-KR responses and from no-KR to KR responses, however. ln Experiment 2, when acquisition KR reversals were held constant for partial KR groups, groups that received either random KR scheduling or all KR produced similar and better retention than groups who received blocked KR scheduling. These results were reconciled with KR frequency experiments by proposing that memory processes invoked by KR protocols decrease from KR frequency, to reversal, to scheduling conditions.


Two experiments examining the scheduling of KR. Experiment 1: Subjects – 36 undergraduate students. Assignments – Random assignment to one of three groups: one would receive KR after every trial, one would receive KR after every 6 trials, and the last would receive KR after every 12 trials. Skill task – A dynamic force measurement system that involved having subjects strike a padded transducer with the goal of generating a specified amount of force. KR would be supplied via a computer readout. Procedure – Subjects participated in 5 blocks of 24 trials. This was followed up with a 12 trial no-KR retention test 24 hours after acquisition testing. Statistical analysis – ANOVA conducted on root mean square error as a measure of accuracy. Results – Acquisition trials did not reveal a significant difference in results. While overall performance of the every 12 trial KR group was better, no clear pattern was noted. This experiment lends partial support to the Guidance Hypothesis. Experiment 2: Subjects – 70 undergraduate students. Assignments: Random assignment to one of five groups with various levels of KR provided ranging from KR for every trial to KR after every 12 trials. Additionally, KR was provided either randomly or at scheduled times. Skill task – Same as Experiment 1. Procedure - Subjects participated in 6blocks of 24 trials. This was followed up with a 12 trial no-KR retention test 24 hours after acquisition testing. Statistical Analysis – ANOVA conducted on root mean square error. Results – General indication that subjects who received KR in a random fashion produced had better retention performance than subjects who received scheduled or blocked KR.

Lee (1990) Lee, T. D., White, M. A., & Carnahan, H. (1990). On the role of knowledge of results in motor learning: Exploring the guidance hypothesis. Journal of Motor Behavior, 22(2), 191-208.

AB: Explored the guidance hypothesis (GH) (J. Annett, 1969; D. H. Holding, 1965) in 3 experiments that contrasted the effects of relative frequency of guidance versus the relative frequency of knowledge of results (KR). According to the GH, it was predicted that parallel effects of the relative frequency manipulation on motor learning and performance would result under guided and KR conditions. The movement task was a reciprocal timing task that was either paced by a metronome (Exp 1) or augmented by auditory KR (Exps 2 and 3). A total of 90 undergraduates served as Ss. The results of Exps 1 and 3 reveal a number of parallel effects, thus providing support for the GH. The contrast of Exps 1 and 2 resulted in a number of dissociable effects, however. Findings are discussed in relation to the potential guiding properties of KR and their impact on motor performance and learning.

Comments: Level 2 for non-CPR setting, Good (small study groups), Supporting, Randomized experimental study. This study is important for its use of a metronome to guide performance.

Three experiments that examined the use of auditory KR being supplied by either a metronome or a continuous tone providing variable levels of sound based on subject performance.

Subjects – 30 university students. Assignments – Random assignment to one of three groups with all groups being gender balanced. One group received continuous guidance by following a metronome (Exp. 1) or 100% KR (Exps. 2 & 3) for 100 trials. One group (50%-50T) received KR on 50% of 50 trials. Last group (50%/100T) received KR on 50% of 100 trials. Statistical analysis – Absolute constant error and variable error were measured and the reviewed with ANOVA. Skill task – A hand tapping exercise between two target plates with a goal rate of 500 ms (rate of 120 taps per minute). Procedure – Acquisition phase reflected trial length as listed above. A 20 trial immediate retention test than followed. Results – Most relevant experiment was experiment 1 that used a metronome to provide continuous guidance or KR. This study showed that there was a trend for the 100% guided group to perform more accurately during acquisition trials. During retention both 50% groups outperformed the 100% group. In a cross-experiment analysis of the retention data, there was a finding that all groups had similar performance on the first retention block but during retention blocks 2, 3, and 4, both 50% groups performed significantly better than (p < .05) than the 100% group. Study supports the Guidance Hypothesis. Also introduced information that error was still present with continuous guidance from a metronome at a rate that is similar to chest compressions.

Liu (1997) Liu, J., & Wrisberg, C. A. (1997). The effect of knowledge of results delay and the subjective estimation of movement form on the acquisition and retention of a motor skill. Research Quarterly for Exercise & Sport, 68(2), 145-151.

AB: This study examined the effects of knowledge of results (KR) delay and subjective estimation of movement form on the acquisition and retention of a motor skill. During acquisition, four groups of participants performed 60 trials of a throwing accuracy task under the following conditions: (a) immediate KR, (b) delayed KR, (c) immediate KR + form estimation, and (d) delayed KR + form estimation. Retention tests of throwing accuracy and outcome error estimation in the absence of visual KR were administered 5 min and 24 hours following acquisition. Throwing accuracy was significantly higher during acquisition but significantly lower during retention for immediate KR participants than for delayed KR participants. However, participants who estimated their movement form during acquisition produced significantly higher


throwing accuracy and lower estimation error during retention than those who did not.


Subjects – 48 undergraduate students. Assignments – Random assignment to one of four groups. Groups either received immediate or delayed (13 sec) KR. Additionally, one of each of the KR timing groups were also asked to make a subjective error estimation of their performance. Skill task – A nonpreferred-hand throwing task with the target area blocked from view. Procedure – 12 blocks of 10 trials each during the acquisition phase followed by a single 10 trial immediate no-KR retention trial conducted 5 minutes after the last acquisition trial. This was followed 24 hours later by another 10 no-KR retention trial. Statistical analysis – ANOVA conducted on a scoring system used to determine performance accuracy. Results – Both immediate KR groups performed better than both delayed KR groups in the acquisition trials. In the 5-minute post acquisition retention trial, the immediate KR/No subjective error estimation group fell from best performing to worst performing. In the 24 hour retention test, both subjective error estimation groups outperformed the groups that did not conduct self analysis. Authors suggested that improved performance in the error estimation groups was due to the ability in that group to possess a more highly developed error detection capability than found in the other two groups.

Milander (1995) Milander, M. M., Hiscok, P. S., Sanders, A. B., Kern, K. B., Berg, R. A. and Ewy, G. A. (1995). Chest compression and ventilation rates during cardiopulmonary resuscitation: the effects of audible tone guidance., Academic Emergency Medicine, 2(8), 708-713.

AB: OBJECTIVES: To determine: 1) whether chest compressions during CPR are being performed according to American Heart Association (AHA) guidelines during cardiac arrest; and 2) the effect of an audio prompt to guide chest compressions on compliance with AHA guidelines and hemodynamic parameters associated with successful resuscitation. METHODS: An observational clinical report and laboratory study was conducted. A research observer responded to a convenience sample of cardiac arrests within a 300-bed hospital and counted the rate of chest compressions and ventilations during CPR. To evaluate the effect of an audio prompt on CPR, health care providers performed chest compression without guidance using a porcine cardiac arrest model for 1 minute, followed by a second minute in which audio guidance was added. Chest compression rates, arterial and venous blood pressures, end-tidal CO2 (ETCO2) levels, and coronary perfusion pressures were measured and compared for the two periods. RESULTS: Twelve in-hospital cardiac arrests were observed in the clinical part of the study. Only two of 12 patients had chest compressions performed within AHA guidelines. No patient had respirations performed within AHA guidelines. In the laboratory, 41 volunteers were tested, with 66% performing chest compressions outside the AHA standards for compression rate without audible tone guidance. With guided chest compressions, the mean (+/- SD) chest compression rate increased from 74 +/- 22 to 100 +/- 3/min (p < 0.01). End-tidal CO2 levels increased from 15 +/- 7 to 17 +/- 7 torr (p < 0.01). Coronary perfusion pressure increased minimally with audible tone-guided chest compressions. CONCLUSIONS: The majority of Basic Cardiac Life Support--certified health care professionals did not perform CPR according to AHA-recommended guidelines. The use of audible tones to guide chest compression resulted in significantly higher chest compression rates and ETCO2 levels.


Animal study that compared CPR rate accuracy with and without a metronome. Key variables included rate and clinical findings (ETCO2 and coronary perfusion pressure). Significant findings showing effectiveness of rate guided CPR.

Park (2000) Park, J.-H., Shea, C. H., & Wright, D. L. (2000). Reduced-frequency concurrent and terminal feedback: A test of the guidance hypothesis. Journal of Motor Behavior, 32(3), 287-296.

AB: In 2 experiments, the authors manipulated the frequency of concurrent feedback to discern the effects on learning. In each experiment, participants (N = 48, Experiment 1; N = 36, Experiment 2) attempted to reproduce a criterion force-production waveform (5 s in duration) presented on the computer monitor. Consistent with the guidance hypothesis, the results of Experiment 1 indicated very strong guiding effects of concurrent feedback and strong dependence on the feedback, as indicated by participants' extremely poor performance upon feedback withdrawal in retention. As predicted by the guidance hypothesis, dependence on the feedback was reduced as a result of reducing the frequency of the concurrent feedback. The results of Experiment 2 indicated that one can enhance learning by providing concurrent and terminal feedback on 1 trial, with no feedback on the subsequent trial. In that way, the strong guiding effects of concurrent feedback could be realized and the beneficial effects of terminal feedback could also be achieved.


Two experiments. Experiment 1: Subjects – 38 undergraduate students. Assignments – Random assignment to one of four groups. Skill task – Static force measurement system designed to measure pressure exerted using the arms pushing against a load cell with a specified pressure cycle over 5000 ms. Procedure – KR was supplied as either concurrent or terminal KR, or both. Groups received one of the following: 100% concurrent, 100% terminal; 50% C, 100%T; 0%C, 100%T; or 100%C, 0%T. Acquisition phase consisted of 10 blocks of 10 trials each. Retention testing was conducted 24 hours later and utilized 10 no-KR trials. Statistical analysis – ANOVA was used to analyze rot mean square error. Results – The 100% concurrent feedback groups performed significantly better than the other groups during the acquisition phase. The no-KR retention testing showed both the 0% and 50% concurrent KR groups significantly outperformed the 100% concurrent KR groups. Study supports the Guidance Hypothesis and indicates the temporary effects of both concurrent and terminal feedback on skill acquisition and learning. Experiment 2 Subjects – 36 undergraduate students. Assignments – Random assignment to one of four groups. Skill task – Same skill task as in Experiment 1. Procedure – Groups received concurrent and/or terminal feedback on the following schedule: 0%C, 100%T; 100%C, 100%T; 50%C, 50%T with both occurring on same trial; 50%C, 50%T with alternating with each trial. Acquisition phase consisted of 10 blocks of 10 trials each. Retention testing was conducted 24 hours later and utilized 10 no-KR trials. Statistical analysis – ANOVA was used to analyze rot mean square error. Statistical analysis – ANOVA was used to analyze rot mean square error. Results – There was a significant difference (p < .001) for the groups with the 100%C group outperforming the others during the acquisition trials. There was a statistically significant finding (p < .05) for the retention testing with the least error in the


50%C/50%T Same group. The 100%C/100%T group had the highest error. Study supports the Guidance Hypothesis and demonstrates the detrimental effects of concurrent feedback on retention performance.

Perkins (2005) Perkins, G. D., Augre, C., Rogers, H., Allan, M., & Thickett, D. R. (2005). CPREzy(trade mark): an evaluation during simulated cardiac arrest on a hospital bed. Resuscitation, 64(1), 103-108.

CPREzy(trade mark) is a new adjunct designed to improve the application of manual external chest compressions (ECC) during cardiopulmonary resuscitation (CPR). The aim of this study was to determine the effect of using the CPREzy(trade mark) device compared to standard CPR during the simulated resuscitation of a patient on a hospital bed. Twenty medical student volunteers were randomised using a cross over trial design to perform 3min of continuous ECC using CPREzy(trade mark) and standard CPR. There was a significant improvement in ECC depth with CPREzytrade mark compared to standard CPR 42.9 (4.4)mm versus 34.2 (7.6):mm, P = 0.001; 95% CI d.f. 4.4-12.9mm. This translated to a reduction in the percentage of shallow compressions (<38mm) with CPREzy(trade mark) 16 (23)% compared to standard CPR 59 (44)%, P = 0.003. There was a small increase in the percentage of compression regarded excessive (>51mm): CPREzy(trade mark) 6.5 (19)% versus standard CPR 0 (0.1)%. P = 0.012). There was no difference in compression rate or duty cycle between techniques. Equal numbers of participants (40% in each group) performed one of more incorrectly placed chest compression. However the total number of incorrect compressions was higher for the CPREzy(trade mark) group (26% versus 3.9% standard CPR, P < 0.001). This was due to a higher number of low compressions (26% of total compressions for CPREzy(trade mark) versus 1% for standard CPR, P < 0.001). In conclusion, CPREzy(trade mark) was associated with significant improvements in ECC performance. Further animal and clinical studies are required to validate this finding in vivo and to see if it translates to an improvement in outcome in human victims of cardiac arrest.

Comment: Level 2, Fair, Supporting. Small (20 subjects) study utilizing a manikin model. Device tested provided visual (LED light scale) prompt for compression depth and an audible tone to guide compression rate. Mixed results. Significant improvement in higher accuracy for appropriate compression depth. No difference between study groups in rate as both groups performed at the desired level. Improper compression location was higher for the device group. Also, there was a report of a higher degree of rescuer physical discomfort in using the device.

Pringle (2004) Pringle, R. K. (2004). Guidance hypothesis with verbal feedback in learning a palpation skill. Journal of Manipulitive and Physiological Therapeutics, 27(1), 36-42.

AB: OBJECTIVE: To investigate whether a force application of a novel motor skill was simple or complex and to determine the appropriate level of feedback during training. The objective was to determine the effects of various amounts of knowledge of results (KR) on learning a novel skill that is frequently taught in chiropractic for the assessment of vertebral motor unit dysfunction. METHODS: Thirty-five active subjects were taught the novel skill of spring testing to a particular force range through 9 or 10 teaching sessions over a 2-week period (a school holiday limited some to only 9 sessions). To determine the particular force range, an initial phase of the study involved a licensed and practicing clinician performing motion palpation spring testing of the thoracic spine of a prone subject. The data from a total of 47 pushes throughout the thoracic spine were recorded, and the mean force and standard deviation were calculated. The second phase of the study used the obtained mean and standard deviation for teaching the force of prone thoracic spine motion palpation to 35 active subjects by administering spring testing to 35 passive subjects. The active subjects were randomly divided into 4 groups, with each receiving a varying amount of verbal feedback to move toward the target force of their learned skill. Each passive subject was laid prone on an instrumented adjusting table. Group 1 received the least amount of feedback while learning the novel skill. Groups 2 and 3 received more frequent, intermittent feedback while learning the skill, and group 4 received constant, frequent feedback during each of the 10 teaching sessions. All subjects returned within 2 weeks for 2 retention trials to determine the efficacy of the learned skill. RESULTS: The mean force determined was 143 N with a standard deviation of 14 N. Each subject was taught spring testing within this target range. The 2 final retention trials showed group 3 to have demonstrated the most targeted retention of the learned motor skill. These subjects exhibited the closest force range to the target for the motor skill learned and fewer changes in standard deviation compared with their acquisition trials and thus the highest retention. Group 4, receiving 100% feedback, demonstrated the most accurate spring testing during the acquisition trials, but the subjects did not effectively demonstrate when compared on acquisition and retention trials. CONCLUSION: The results of this study show data to be consistent with the guidance hypothesis in learning a novel motor skill. The constant KR feedback is beneficial for learning when used to reduce error during practice but detrimental when relied upon for retention and learning. These data suggest the necessity of using motor skill development learning theory in the teaching of chiropractic.

Comments: Level 2 for non-CPR setting, Excellent, Supporting, Randomized experimental study. Significant in that this is one of the only articles from the medical literature (MEDLINE) that dealt specifically with the Guidance Hypothesis by name.

Subjects – 34 first year chiropractic students. Assignments – Random assignment to one of four groups: Group 1 received one round of verbal KR after each training session; Group 2 received 2 rounds of KR during each session; Group 3 received 4 rounds of KR during each session; and Group 4 received KR after each trial in the session. Skill task – Prone spring testing of the thoracic spine on an instrumented manipulation table capable of reporting force feedback. Procedure – 9 acquisition session consisting of 12 trials each conducted over a 2-week period. This was followed 1 to 2 weeks later with 2 no-KR retention trials. Performance was compared to a criterion template that specified proper force. Results – Group 3 had the lowest error rate in the no-KR retention sessions. Group 4, which had the most acquisition KR, had the most extreme decrease in skill application of the four groups. The author concludes this supports the Guidance Hypothesis.

Salmoni (1984) Salmoni, A. W., Schmidt, R. A., & Walter, C. B. (1984). Knowledge of results and motor learning: A review and critical appraisal. Psychological Bulletin, 95(3), 355-386.

AB: Previous analysis of knowledge of results (KR) and motor learning have generally confounded the transient performance effects as shown when KR is present and the relatively permanent (i.e. learned) effects that we argue should be evaluated on a transfer test without KR. In this review, we classify investigations according to this distinction, and a


number of new relations emerge between KR and both learning and performance. In addition to the motivational and associational roles of KR, we emphasize that it also acts as guidance, enhancing performance when it is present but degrading learning if it is given too frequently.

Comments: KEY ARTICLE – Level 7, Excellent, Supporting, Theoretical.

One of the most significant articles in the motor skills literature and the single most important article on the use of KR in motor skill learning. Presented the basis for the Guidance Hypothesis. Provides information on standardizing terminology and experimental design, defines learning, reviews performance effects of KR, discusses transfer testing designs, discusses appropriate variables, the role of KR in learning and defines and discusses relative and absolute KR. Discusses the temporal locus of KR, KR and Post-KR delay effects, KR precision, and the motivational effects of KR.

Schmidt (1997) Schmidt, R. A., & Wulf, G. (1997). Continuous concurrent feedback degrades skill learning: Implications for training and simulation. Human Factors, 39(4), 509-525.

AB: In two experiments we investigated the role of continuous visual feedback in the learning of discrete movement tasks. During practice the learner's actions either were or were not displayed on-line during the action; in both conditions the participant received kinematic feedback about errors afterward. Learning was evaluated in retention tests on the following day. We separated (a) errors in the fundamental spatial-temporal pattern controlled by the generalized motor program from (b) errors in scaling controlled by parameterization processes. During practice concurrent feedback improved parameterization but tended to decrease program stability. Based on retention tests, earlier practice with continuous feedback generally interfered with the learning of an accurate motor program and reduced the stability of time parameterization. Continuous feedback during acquisition degrades the learning of not only closed-loop processes in slower movements (as has been found in earlier studies) but also motor programs and their parameterizations in more rapid tasks. Implications for feedback in training and simulations are discussed.

Comments: KEY ARTICLE - Level 2 for non-CPR setting, Good (small study size), Supporting, Randomized experimental study

Two experiments. Experiment 1: Subjects – 30 undergraduate students. Assignments – Random assignment to one of two groups. One group received concurrent feedback while the other did not. Both groups received post-trial KR after every trial. Skill task – A four part arm/hand movement with specific time intervals and amplitude between each movement. Procedure – 90 acquisition trials were conducted on Day 1 followed by 12 trial retention testing on Day 2. Concurrent feedback was provided to one group in addition to KR at the conclusion on the movement. Statistical analysis – Root mean square error and residual root mean square error were the primary measurements. Other measures included constant error of the amplitude factor, variable error of the amplitude factor, constant error of the time factor, and variable error of the time factor. Results – During acquisition, continuous feedback generated better accuracy and stability in both amplitude and time factors, although over performances as judged by root mean square error were similar. For retention, results “indicated that concurrent feedback during practice degraded the learning of both the accuracy and stability of the motor-program representation…Thus the chief effect of concurrent feedback on motor program accuracy seemed to be a degrading influence on motor program accuracy and stability and on time parameterization stability (p. 518).” Experiment 2: Subjects – 32 undergraduate students. Assignments/Skill Task/Procedure/Statistical Analysis – Same as experiment 1 except that both group would be exposed to the movement template. Results – For acquisition trials, same effects seen with improved stability in time factors for the concurrent feedback group. In the retention trials, the concurrent feedback group again showed a degrading of performance in the movement pattern when compared to the no concurrent feedback group. Authors stated, “During practice, concurrent feedback generally facilitated performance of most of the measures of parameterization…However, in the retention tests, these trends were reversed (p. 522)."

Schmidt (1989) Schmidt, R. A., Young, D. E., Swinnen, S. P., & Shapiro, D. C. (1989). Summary knowledge of results for skill acquisition: Support for the guidance hypothesis. Journal of Experimental Psychology: Learning, Memory, and Cognition, 15(2), 352-359.

AB: Summary knowledge of results (KR) involves the presentation KR for each of a set of trials (e. g. , 10) only after the last trial in the set has been completed. Earlier, Lavery (1962) showed that, relative to providing KR after each trial, a 20-trial summary KR was detrimental to performance in a practice phase with KR present but was beneficial for a no-KR retention test. Using a relatively simple ballistic-timing task, we examined summary lengths of 1 (essentially KR after every trial). 5, 10, and 15 trials, searching for an inverted-U relationship between summary length and retention performance as predicated by a guidance hypothesis for KR. During acquisition when KR was present and being manipulated, all groups showed improvements in performance across practice, while increased summary lengths generally depressed performance. However, in a delayed no-KR retention test, there was an inverse relation between the summary length in acquisition and absolute constant error on the retention test. A guidance hypothesis is favored to explain how, relative to immediate KR, long KR summaries can provide detrimental effects in acquisition while enhancing retention performance.

Comments: KEY ARTICLE - Level 2 for non-CPR setting, Excellent, Supporting, Randomized experimental study

Subjects – 72 undergraduate students, equal male and female numbers, all subjects right-handed. Assignments – Assigned to one of four groups to receive either KR after every trial, after every five trials, after every 10 trials, or after every 15 trials. Skill task – A novel movement timing task involving movement of a slide through a specified pattern with a target completion time of 550 ms. Procedure – 90 acquisition trials were completed. These were followed by no-KR retention testing at 10 minutes and 2 days after completion of the acquisition phase with each consisting of 25 trials. Statistical analysis – An ANOVA was performed based on acquisition condition x trials blocks x gender. No differences were found between genders, thus remainder of reporting focused on groups as wholes. Tukey post hoc testing was utilized to compare groups. Results – Mean performance as measured by Absolute Constant Error during the acquisition phase favored the every 1 and every 5 KR conditions over the every 10 and every 15 KR groups at a significant level (p < .05). The immediate retention testing conducted 10 minutes after completion of the acquisition phase showed no significant difference between groups. The delayed retention testing conducted 2 days later showed a significant (p < .05) result favoring the every 10 and every 15 KR groups. In this test, the rate of error for the every KR group was twice that of


the every 15 KR group. Study supports the Guidance Hypothesis. This study is significant in that it demonstrated that the guidance effect looses it value very quickly and actually becomes a detriment in as little as two days.

Shultz (1995) Shultz, J. J., Mianulli, M. J., Gisch, T. M., Coffeen, P. R., Haidet, G. C. and Lurie, K. G. (1995). Comparison of exertion required to perform standard and active compression-decompression cardiopulmonary resuscitation, Resuscitation, 29(1), 23-31.

AB: OBJECTIVE: Active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) utilizes a hand-held suction device with a pressure gauge that enables the operator to compress as well as actively decompress the chest. This new CPR method improves hemodynamic and ventilatory parameters when compared with standard CPR. ACD-CPR is easy to perform but may be more labor intensive. The purpose of this study was to quantify and compare the work required to perform ACD and standard CPR. METHODS: Cardiopulmonary testing was performed on six basic cardiac life support- and ACD-trained St. Paul, MN fire-fighter personnel during performance of 10 min each of ACD and standard CPR on a mannequin equipped with a compression gauge. The order of CPR techniques was determined randomly with > 1 h between each study. Each CPR method was performed at 80 compressions/min (timed with a metronome), to a depth of 1.5-2 inches, and with a 50% duty cycle. RESULTS: Baseline cardiopulmonary measurements were similar at rest prior to performance of both CPR methods. During standard and ACD-CPR, respectively, rate-pressure product was 18.2 +/- 3.0 vs. 23.8 +/- 1.7 (x 1000, P < 0.01); mean oxygen consumption 15.98 +/- 2.29 vs. 20.07 +/- 2.10 ml/kg/min or 4.6 +/- 0.7 vs. 5.7 +/- 0.6 METS (P < 0.01); carbon dioxide production 1115.7 +/- 110 vs. 1459.1 +/- 176 ml/min; respiratory exchange ratio 0.88 +/- 0.04 vs. 0.92 +/- 0.04 (P = NS); and minute ventilation 35.5 +/- 5.1 vs. 45.6 +/- 9.2 l/min (P < 0.01). CONCLUSIONS: Approximately 25% more work is required to perform ACD-CPR compared with standard CPR. Both methods require subanaerobic energy expenditure and can therefore be sustained for a sufficient length of time by most individuals to optimize resuscitation efforts. Due to the slightly higher work requirement, ACD-CPR may be more difficult to perform compared with standard CPR for long periods of time, particularly by individuals unaccustomed to the workload requirement of CPR, in general.


Study used a metronome to remove inconsistency of chest compression rate as a confounding variable.

Shewokis (2000) Shewokis, P. A., Kennedy, C. Z., & Marsh, J. L. (2000). Effects of bandwidth knowledge of results on the performance and learning of a shoulder internal rotation isokinetic strength task. Isokinetics & Exercise Science, 8(3), 129-139.

AB: The purpose of this study was to examine the influence of no-error knowledge of results (KR) and relative frequency of feedback on the performance and retention of an isokinetic internal shoulder rotation exercise. Males (n = 32) who were free of any shoulder injuries, uninvolved in organized athletics, and unfamiliar with isokinetic testing; performed 90 acquisition trials over a period of three days at 70% of their peak force (PF). No sooner than 48 hours after the last acquisition session followed a 10-trial delayed retention test. Participants received error KR in either a 10% bandwidth, yoked, verbal 100% terminal KR, or visual100% concurrent KR condition. Retention results revealed that participants in the 10% bandwidth and yoked conditions performed more consistently than both the 100% KR conditions, and the bandwidth participants were found to be more accurate than their yoked counterparts. Our findings support previous research and provide empirical support for using reduced amounts of extrinsic feedback.

Comments: Level 2 for non-CPR setting, Fair (small groups in study), Supporting, Randomized experimental study

Subjects – 32 undergraduate males. Group was selected to represent a relatively homogenous group in relation size and strength. Assignments – Random assignment to one of four groups that would receive KR in different ways. First group received bandwidth KR (KR provided when results fell outside of a predetermined criteria. Second group was yoked to group one. Third group received 100% verbal KR. Fourth group received 100% concurrent visual KR. Skill task – A seated internal shoulder rotation isokinetic exercise. Procedure – Four sessions including a pre-test, two acquisition sessions, and a retention session conducted 24 hours after the last acquisition session. Each session consisted of three sets of 10 trials. Statistical analysis – The absolute constant error of maximum peak force was the measurement of interest. ANOVA was utilized. Results – Indicated qualitative KR associated with bandwidth KR proved beneficial to the ability of the learner to perform better.

Silvestri (1988) Silvestri, L. (1988). The use of knowledge of results in the acquisition and performance of motor skills. Education, 109(2), 178-183.

AB: Knowledge of results (KR) is a very effective means for educators to communicate feedback to the learner concerning performance. When presented at the right time, in the proper amount and under advantageous circumstances, errors in learning are minimized and performance is improved. Depending on the nature of the task and the readiness of the learner, KR can be a very powerful tool to enhance the learning process.

Comments: Level 7, Good, Supporting, Theory building

Article provides literature review and summary of works to date (1988) on the use of KR in teaching motor skills. Primary focus is motor skills in children. Presented arguments supporting the benefits of delayed KR.

Swinnen (1990) Swinnen, S., Schmidt, R. A., Nicholson, D. E., & Shapiro, D. C. (1990). Information feedback for skill acquisition: Instantaneous knowledge of results degrades learning. Journal of Experimental Psychology: Learning, Memory, and Cognition, 16(4), 706-716.

AB: The role of acquired error-detection capabilities in skill learning was investigated by manipulating the delay of knowledge of results (KR). Compared with delayed feedback, instantaneous KR should be detrimental to the learning of error-detection capabilities because it should tend to block spontaneous subjective evaluation of response-produced feedback. Weaker error-detection capabilities should then be evident on delayed no-KR retention tests. During acquisition, one group of subjects received KR after a delay of a few seconds while another group received KR instantaneously; then both were evaluated on several retention tests. Using a timing task with two reversals in direction (Experiment 1) and a


coincident-timing task (Experiment 2), we found that, relative to delayed feedback, instantaneous KR degraded learning as measured on delayed retention tests. Although the KR-delay interval has traditionally been considered of minor importance for skill learning, the present findings suggest that very short KR-delays interfere with learning, perhaps by degrading the acquisition of error-detection capabilities.

Comments: KEY ARTICLE - Level 2 for non-CPR setting, Excellent, Supporting, Two randomized experimental studies

Experiment 1 – Timing task with reversal in direction - Subjects – 76 undergraduate college students. Assignments – Assigned to one of three groups. First group received instantaneous KR after every trial, second group received delayed KR 8 seconds after trial completion, third group was required to estimate performance before being given KR 8 seconds after trial completion. Skill task – Timed movement task involving a novel hand/arm motion using a metal slide attached to a table. Target time for completion of the specified movement task was 1000 ms. Procedure – 90 acquisition trials were completed. These were followed by no-KR retention testing at 10 minutes and 2 days after completion of the acquisition phase with each consisting of 30 trials. Statistical analysis – ANOVA was completed measuring Absolute Constant Error (CE). Results – No significant difference in CE was found between groups at the completion of the acquisition phase or at the 10-minute no-KR retention test. The 2-day retention test showed a significant (p < .05) finding favoring the estimation group over the instantaneous KR group. The delayed KR group fell in the middle of the two and showed no significant difference with either group.

Experiment 2 – Coincident-timing task - Subjects – 40 undergraduate college students (20 male, 20 female, all right-handed). Assignments – Random assignment to one of two groups. First to receive instantaneous KR (feedback), the second to receive delayed KR 3.2 seconds after task completion. Skill task – Timed movement task involving a novel hand/arm motion using a metal slide attached to a table with the goal being completion of the movement and intercepting a moving light target at a specific coincidence point. Procedure – 90 acquisition trials were completed on two consecutive days. These were followed by no-KR retention testing at 10 minutes, 2 days, and 4 months after completion of the acquisition phase with each consisting of 30 trials. Statistical analysis – ANOVA was used to compare scores calculated from spatial error and velocity. Results – During acquisition trials, groups performed at equivalent levels at the end of Day 1. However, at the end of Day 2 of acquisition, the delayed KR group performed at a significantly higher level (p < .01). This significance was repeated in the 10-minute and 2-day no-KR retention. The 4-month no-KR retention tests showed no significant difference between groups (p > .05).

While these experiments did not specifically address the Guidance Hypothesis, it does indicate that there are better options available than instantaneous, every trial KR (feedback). This study also showed the decrease in effectiveness over time (4 months) of either method.

Thomas (1995) Thomas, S. H., Stone, C. K., Austin, P. E., March, J. A., & Brinkley, S. (1995). Utilization of a pressure-sensing monitor to improve in-flight chest compressions. Am J Emerg Med, 13(2), 155-157.

AB: Previous research at the Division of Air Medical Services at East Carolina University School of Medicine has demonstrated impairment of chest compression efficacy in the setting of an airborne BO-105 helicopter. This study was undertaken to determine whether in-flight compression efficacy could be improved with utilization of a pressure-sensing monitor providing real-time feedback during cardiopulmonary resuscitation (CPR). Ten flight nurses each performed two minutes of in-flight chest compressions on a mannequin that electronically assessed compression depth and hand placement. The session was then repeated using the pressure-sensing device. The mean proportion of correct compressions (95.7 +/- 3.2%) achieved with utilization of the pressure-sensing monitor was significantly higher (P < .01) than the corresponding proportion for the control group (33.4 +/- 12.1%). This study demonstrated that the difficulties of performing effective in-flight chest compressions are largely overcome with utilization of a pressure-sensing device providing real-time feedback on compression efficacy.

Comments: Level 3, Supporting, Fair (small study size)

Turner (1994) Turner, M. (1994). The frequency of knowledge of performance and psychomotor music memory: A pilot study. Texas Music Education Research, [Electronic Version](available at www.tmea.org/080_College/Research/Tur1994.pdf).

AB: Based on motor behavior research, the following hypotheses are proposed. It is predicted that there will be no significant difference between the acquisition error scores of subjects who receive constant KP (100%) and those who receive faded KP. It is also predicted that subjects who receive faded KP will have significantly lower error scores on a one week retention test and transfer task than subjects who receive 100% KP. The experiment included 60 fifth-grade volunteers. The experimental apparatus was a bass xylophone. Subjects were randomly assigned to one of three experimental groups: (a) 100% verbal KP, (b) faded KP, and (c) no KP. The data suggest that verbal feedback does not significantly affect learning, retention, or transfer in this experimental situation.

Comments: Level 2 for non-CPR setting, Fair, Neutral or Opposing, Randomized experimental study

Subjects – 60 fifth grade students (mean age 10 years, 10 months). Assignments – Random assignment to one of three groups” One would receive 100% KR, one would receive faded KR, one would receive no KR. Skill task – Sequential pattern of notes on a bass xylophone. Procedure – Acquisition phase consisted of 4 blocks of 20 trials. One week later a no-KR retention test was conducted with four blocks of 20 trials. This was followed by another set of four 20-trial no-KR blocks which the author referred to as transfer trials. Statistical analysis – ANOVA using three types of errors: rhythmic, melodic, and executive skill. Results – ANOVA showed no significant differences (p > .05) in any blocks for any of the error measurements. Study utilized a skill not often associated with motor program learning. One point that makes this study more relevant was the use of a metronome to assist in timing.

Watson (2001) Watson, T. A., & Radwan, H. (2001). Comparison of Three Teaching Methods for Learning Spinal Manipulation Skill: A Pilot Study. Journal of Manual & Manipulative Therapy, 9(1), 48-52.


AB: The purpose of this study was to determine the difference in how a spinal manipulation skill was acquired and retained using one of three learning methods. Twenty-three physical therapy students were divided into three groups. All received training in a spinal manipulation technique. Group 1 (n=8) was trained by an instructor, who gave delayed verbal feedback. Group 2 (n=8) received training via videotape observation. Group 3 (n=7) was trained by an instructor and given concurrent feedback. The students were than asked to train 10 minutes per day for one week, after which time they were tested. The students were then required to refrain from practice and to return one week later for retention testing. No difference was demonstrated in acquisition of the motor skill between the three teaching methods. A one way ANOVA of the difference of score (Trial 1 - Trial 2) revealed significant differences (p<.05) between groups, and post hoc Tukey follow-up revealed greater differences in the scores for Group 1 and 2 than Group 3. The three methods of teaching spinal manipulation appeared no different in acquiring skill initially. However, the concurrent feedback received by Group 3 appeared to improve retention of spinal manipulation skills.

Comments: Level 2 for non-CPR setting, Good (Small study group size), Neutral or Opposing, Randomized experimental study. Study is significant in that it is one of the few examples of Knowledge of Result testing in the medical literature.

Subjects – 23 first year physical therapy students. Assignments – Random assignment to one of three study groups. Group 1 – Instructor training with delayed qualitative feedback, Group 2 – Videotape training with no instructor feedback. Group 3- Instructor training with concurrent qualitative feedback. Skill task – A supine thoracic spine manipulation technique. Procedure – Each group received instruction in the technique according to the parameters listed above for group assignments. Subjects then were told to practice the technique for 10 minutes a day for the next week. They were then told to stop practicing for the following week. At the conclusion of that week they returned for retention testing. Statistical analysis – Retention testing was videotaped and raters applied an 18-point criteria to retention performance. Inter-tester reliability was rated 0.80. ANOVA applied to results. Results – Acquisition testing showed no differences between groups. For retention testing, concurrent feedback group showed a significantly higher degree of performance than the other two groups. Additionally, there was a significant decrease in the level of performance for Group 1 and 2 from acquisitions trials to retention trials. Group 3 did not experience this significant drop in performance. Study does not support the Guidance Hypothesis.

Weeks (1998) Weeks, D. L., & Kordus, R. N. (1998). Relative frequency of knowledge of performance and motor skill learning. Research Quarterly for Exercise & Sport, 69(3), 224-230.

AB: This study examined the effects of variations in relative frequency of knowledge of performance (KP) on acquisition, retention, and transfer for a multilimb closed sport skill. Two groups received either 100% relative frequency KP or 33% relative frequency KP while learning the soccer throw-in skill. Participants were boys between the ages of 11 and 14 years who were unfamiliar with the skill. Participants performed a 30-trial acquisition phase in which KP was provided about one of eight aspects of form. Following acquisition, five trial retention and transfer (to a target at a different distance than experienced in acquisition) tests were administered at 5 min, 24 hr, and 72 hr. Although no group differences were found for accuracy scores, the 33% group had higher form scores in acquisition and all retention and transfer tests. It was concluded that reducing the relative frequency of KP eliminated a dependency on KP to guide performance in acquisition, which was beneficial for maintaining form in conditions in which KP was absent.


Subjects: 34boys (Mean age 12.3 years). Assignments: Random assignment to two groups. One group to receive 100% KR, the other received 33% KP on form. Both groups would receive accuracy information by seeing the distance to target. Skill task: Soccer throw-in skill to a target. Procedure: 30-trial acquisition phase followed by two 5-trial no-KP tests, one at original target distance and the other at a distance 50% of target distance. These were followed by 24 hour and 72 hour retention tests conducted in the same mnner as the immediate recall tests. Statistical analysis: MANOVA and univariate ANOVA on accuracy as reported by a scoring system developed for target accuracy and form scores. Results: The 33% group had higher form scores throughout all trials, including acquisition trials. This ran counter to the Guidance Hypothesis. This was explained by “maladaptive short-term corrections.” The 100% KP group received so much KP that they tended to over/undercorrect and were not able focus on correcting single aspects of the form over a series of trials. During retention and transfer tests, the 33% KP group significantly outperformed the 100% in form score. This partially supported the Guidance Hypothesis.

Wik, et al. (2002) Wik, L., Myklebust, H., Auestad, B. H. and Steen, P. A. (2002). Retention of basic life support skills 6 months after training with an automated voice advisory manikin system without instructor involvement, Resuscitation, 52(3), 273-9.

AB: AIM: To evaluate the retention of skills 6 months after training in ventilation and chest compressions (CPR) on a manikin with computer based on-line voice advisory feedback and the possible effects of initial overtraining. METHODS: Thirty five volunteers had 20 min provisional CPR training on a manikin with computer based voice advisory feedback but without an instructor. The appropriate feedback was taken from a pre-recorded list depending on performance measured by the manikin--computer system versus set limits for ventilation and compression variables. One group in addition was randomised to receive 10 similar 3 min training sessions during 1 week in the following month (overtrained group). All ventilation and compression variables were measured without feedback before and after the initial training session, with feedback immediately thereafter, and both without and with feedback 6 months after the initial training session. RESULTS: The initial training improved all variables. Compressions with correct depth increased from a mean of 33 to 77%, and correct inflations from a mean of 9 to 58%. After 6 months, the results for the controls were not significantly different from pre-training, except for a higher of correct inflations (18%), while the overtrained group had better retention of skills including the correct compression depth (mean 61%) and inflations (mean 42%). When verbal feedback was added both the compressions and ventilations immediately improved both when tested immediately and 6 months after the initial training session. CONCLUSIONS: The computer-based voice advisory manikin (VAM) feedback system can improve immediate performance of basic life support (BLS) skills, with better long-term retention with overtraining.

Comments: Level 2, Fair, Supporting (Hypothesis 2)


Relatively small study groups (21 in control, 14 in experimental, prior to attrition). Prompting device used qualitative and prescriptive feedback to subjects on their skill performance. Did not use a timing device, only verbal feedback. The impact of overtraining was the primary focus of study. Unable to determine if audio feedback or overtraining created increase skill performance for experimental group over control. Results mixed concerning chest compression rate (one session comparing unprompted rate versus promoted rate did not reach significance due to an already high degree of skill performance level.) However, several other skills did show significant with audio prompting. Comparing session 2 to 3 (of 5 sessions) was most useful to this question. Session 4 & 5 had confounding variable of overtraining introduced.

Wik ( 2001) Wik, L., Thowsen, J. and Steen, P. A. (2001). An automated voice advisory manikin system for training in basic life support without an instructor. A novel approach to CPR training, Resuscitation, 50(2), 167-72.

AB: Twenty-four paramedic students with previous basic life support training were randomised, performing cardiopulmonary resuscitation (CPR) on a manikin for 3 min without any feedback followed by 3 min of CPR with audio feedback from the manikin after a 2-min break, or vice versa. A computer recorded information on timing, ventilation flow rates and volumes and all movements of the sternum of the manikin. The software allowed acceptable limits to be set for all ventilation and compression/release variables giving appropriate on-line audio feedback according to these settings from among approximately 40 pre-recorded messages.Students who started without feedback significantly improved after feedback in terms of the median percentage of correct inflations (from 2 to 64%), with most inflations being rapid before feedback (94%), compressions of correct depth (from 32 to 92%), and the duration of compressions in the duty cycle (from 41 to 44%). There were no problems with the median compression rate, sternal release during decompressions, or the hand position, even before feedback. There were no significant differences in any variables with and without feedback for the students who started with feedback, or between the audio feedback periods of the two groups. It is concluded that this automated voice advisory manikin system, a novel approach to basic CPR training, caused an immediate improvement in the skills performance of paramedic students.

Hypothesis 1

Comments: Level 2, Good (small study size), Supporting, Randomized experiment

Significant article supporting statement that feedback (knowledge of results) should be used early in CPR instruction. Study did not examine retention past training class. Compression rate as a variable unable to be judged since experimental groups maintained adequate compression rate throughout entire experiment. Requires extrapolation of data from other skill sets within CPR to address question.

Hypothesis 2


Relatively small study groups with 24 with random assignment to two groups. Prompting device used qualitative and prescriptive feedback to subjects on their skill performance. Did not use a timing device, only verbal feedback. Study showed several significant gains in skill with verbal feedback. However, chest compression rate could not be judged due to an already high level of skill performance in this area by both groups. Considering improvement in other skills that benefited from voice prompting, extrapolation to over all skill performance indicates usefulness of verbal guidance.

Winstein (1991) Winstein, C. J. (1991). Knowledge of results and motor learning: Implications for physical therapy. Physical Therapy, 71(2), 140-149.

AB: Relevant to this special series on movement science, a brief overview of research in the field of motor learning is provided. A distinction between learning and performance is emphasized with respect to experimental design and the evaluation of laboratory and clinical intervention techniques. Intrinsic and extrinsic feedback are defined. Basic principles of motor learning pertaining to the use of augmented feedback or knowledge of results (KR) are reviewed. Particular emphasis placed on recent research regarding the effect of selected KR variations (KR relative frequency, KR bandwidth, and KR delay) on motor performance and learning in healthy young adults. Results are discussed in terms of short-lasting learning effects. Theoretical and practical implications from this research are discussed. It is suggested that it is appropriate to use the principles obtained through laboratory experimentation as guidelines rather than as exact recommendations when applying basic research findings to clinical practice.

Comments: KEY ARTICLE - Level 7, Excellent, Supporting, Theory building

Extensive (67 references) review of the literature on KR and motor skill learning. Provides support for the Guidance Hypothesis. Details current research in motor skills learning. Implications to motor learning in physical therapy, types of feedback, learning versus performance, KR’s impact on motor learning, relative KR frequency, bandwidth KR, KR delay, and theoretical and practical implications.

Winstein (1994) Winstein, C. J., & Pohl, P. S. (1994). Effects of physical guidance and knowledge of results on motor learning: Support for the guidance hypothesis. Research Quarterly for Exercise & Sport, 65(4), 316-323.

AB: Investigates the effects of physical guidance and knowledge of results on motor learning, based on the guidance hypothesis that predicts the benefits of augmented feedback on motor learning. Forms of feedback with levels of relative frequency; Confirmation of the hypothesis.

Comments: Level 7, Good, Supporting, Theory buildingWinstein (1990) Winstein, C. J., & Schmidt, R. A. (1990). Reduced frequency of knowledge of results enhances motor skill learning.

Journal of Experimental Psychology: Learning, Memory, and Cognition, 16(4), 677-691.

AB: Relative frequency of knowledge of results (KR) is the proportion of KR presentations to the total number of practice trials. Contrary to predictions from most traditional motor learning perspectives (e. g. , Adams, 1971; Schmidt, 1975; Thorndike, 1927), recent evidence suggests that, compared with practice in 100% relative frequency conditions, practice


with lower relative frequencies may be beneficial to longer-term retention and learning, but detrimental to practice performance. Three experiments are reported in which the effects of variations in acquisition KR relative frequency were examined. Experiment 1 showed that a markedly reduced KR relative frequency during practice was as effective for learning as measured by various retention tests, compared with a 100% KR practice condition. In Experiments 2 and 3, when the scheduling of KR was manipulated so that the number of KR trials was systematically lowered across practice, a reduced average relative frequency enhanced learning as measured by a delayed no-KR retention test (Experiment 2) and a retention test in which KR was provided (Experiment 3). Results are inconsistent with predictions from an acquisition-test specificity hypothesis and conventional motor learning theories and thus suggest a revision in the principles governing the role of KR for motor learning. Empirical support is provided for the KR guidance hypothesis (Salmoni, Schmidt, & Walter, 1984) and for various encoding-retrieval operations associated with spaced retrieval practice. Possible learning strategies invoked by relative frequency and other related practice variations are discussed with respect to response consistency and the development of intrinsic error detection mechanisms.

Comments: KEY ARTICLE - Level 2 for non-CPR setting, Excellent, Supporting, Randomized experimental study

Experiment 1 - Subjects – 136 undergraduate students. Assignments – Random assignment to one of eight groups with restriction on maintaining equal male/female ratios with groups. Skill task – Goal movement task involving manipulation of a lever through four segments with a target completion time of 800 ms. Procedure – During two 99 trial acquisition sessions (separated by 24 hours), subjects were provided KR (feedback) at either 100% or 33%. The 33% group had KR provided at random intervals, so there was no way to predict when feedback would be available. A 27 trial retention test was administered 10 minutes after completion of the last acquisition trial. During retention testing, KR was provided at either 0%, 33%, 66% or 100%. Statistical analysis – ANOVA conducted of Root Mean Square of error scores. Significant ANOVA results further examined with Scheffe post hoc procedure. Results – No statistical significance in group performance for either acquisition trial (p > .05). Retention trials showed some slightly better performance with the 33% KR acquisition group, but it did not reach statistical significance. Authors comment that reduced KR did not have a detrimental effect on skill retention. Since retention testing conditions differed from acquisition phase, authors rejected specificity hypothesis that states similar acquisition and retention conditions will lead to improved performance.

Experiment 2 - Subjects – 58 undergraduate students. Assignments – Random assignment to one of two groups with restriction on maintaining equal male/female ratios with groups. Skill task – Same apparatus as used in Experiment 1. Procedure – Each group had 96 acquisition trials with either 100% KR or 50% KR. The 50% KR group had more KR supplied early and KR was withdrawn as acquisition phase neared its end. Two 12 trial no-KR retention trials were conducted, the first 5 minutes after completion of the acquisition phase, the other 24 hours later. Statistical analysis – ANOVA conducted based on root mean square of error score. Results – Contrary to expected findings, the 50% KR group significantly outperformed the 100% KR group at the conclusion of the acquisition phase (p < .05). Immediate retention testing showed no significant results. 24-hour retention testing showed significantly better performance (p. < .01) for the 50% KR group. Study supports the Guidance Hypothesis and supported the concept of “fading” KR during acquisition as a means of improving performance.

Wrisberg (1997) Wrisberg, C. A., & Wulf, G. (1997). Diminishing the effects of reduced frequency of knowledge of results on generalized motor program learning [Electronic Version]. Journal of Motor Behavior, 29(1), 17-26.

AB: Several recent studies have shown that compared with presenting knowledge of results (KR) on every practice trial, withholding KR on some practice trials enhances the learning of generalized motor programs. In this study, whether this effect may result from an uncertainty on the part of participants about when KR is to be presented was determined by examining the GMP learning of two 67% relative frequency KR groups - one that received advance information regarding the delivery of each KR (67% AKR) during practice trials and another that received no advance information (67% KR) - as well as that of a 100% KR group. The task required participants to produce 3 movement patterns that shared the same relative and absolute timing and relative amplitude but different in terms of absolute amplitude. KR was provided by displaying the root-mean-square (RMSE) score and by graphically superimposing the participant-produced pattern on that of the goal movement. The results revealed no group differences in measures of GMP development or parameterization effectiveness during practice and no-KR retention. However, during no-KR transfer with a novel abolute amplitude, the 67% KR group demonstrated a more accurate and stable GMP than the 67% AKR and 100% KR groups.


Subjects – 60 undergraduate students. Assignments – Random assignment to one of three groups. Group 1 received 100% KR, Group 2 received 67% KR, and Group 3 received 67% KR but was also told in advance which trials the KR would be supplied. Skill task – A right-arm movement task through a series of specific motions within a prescribed period of time (937 ms). There were three different patterns employed. Procedure – Three sessions: practice, delayed retention, and delayed transfer. For practice, subjects performed 30 trials of each pattern for a total of 90 trials. Trials were broken down into 15 blocks of 6 trials each. 24 hours after practice trials were completed delayed retention was conducted with a 12 trial no-KR session. Immediately following the delayed retention trials, a transfer test was conducted with a new movement pattern for 12 trials. Statistical analysis – Residual root mean square error was calculated and MANOVA was applied. Results – Practice trials and retention trials indicated no significant differences. For the transfer trials, the 67% KR group significantly outperformed the other two groups. Authors concluded that procedures that increase the certainty of KR delivery may diminish the effectiveness of skills performance.

Wulf (1994) Wulf, G., Lee, T. D., & Schmidt, R. A. (1994). Reducing knowledge of results about relative versus absolute timing: Differential effects on learning. Journal of Motor Behavior, 24, 362-369.

AB: The purpose of the present experiment was to examine further earlier suggestions that a reduced relative frequency of knowledge of reslts (KR) can enhance the learning of a generalized motor program (GMP) but at the same time degrade parameter learning, compared with giving KR after every trial. In contrast to earlier studies, here KR was given separately for relative timing and absolute timing. Subjects practiced three movement patterns that required the same relative timing but different absolute timing. KR was provided on 100% or 50% of the practice trials for the relative timing


or the absolute timing, respectively. In retention and transfer tests the groups that had had 50% KR about relative timing demonstrated more effective learning of the relative timing structure, that is, GMP learning, than the groups that had had 100% KR about relative timing. The KR frequency had not effect on parameterization during retention; yet, when transfer to a task with a novel overall duration was required, the groups given 100% KR about absolute timing were more accurate in parameterization than the groups provided with 50% KR about absolute timing. Thus, the reduced relative KR frequency enhanced GMP learning but had no beneficial effect, or even a degrading effect, on parameter learning. The differential effects of a reduced KR frequency o the learning of relative timing and absolute timing also provided additional support for the dissociation of GMP and parameterization processes.


Subjects – 72 undergraduate students. Assignments – Random assignment to one of four groups. Group 1 received 100% KR for both relative and absolute timing. Group 2 received 100% KR on relative timing and 50% KR on absolute timing. Group 3 received 50% KR on relative timing and 100% KR on absolute timing. Group 4 received 50% KR on relative timing and 50% KR on absolute timing. Skill task – A prescribed sequence of button activation that also included a set time difference between button activation. There were three different movement patterns used. Procedure – Five sessions: practice, immediate retention, immediate transfer, delayed retention, and delayed transfer. Practice consisted of 108 trials (36 of each movement pattern). Immediate retention consisted of a single 12 trial no-KR block. The immediate transfer trial included a new movement pattern with a single 12 trial block. 24 hours later, the retention and transfer trials were conducted again. Statistical analysis – Absolute error and absolute constant error was compiled for ANOVA. Results – Mixed results showing generalized motor programs enhanced with 50% KR with regard to relative timing while 50% KR with absolute timing was adversely affected.

Wulf (1989) Wulf, G., & Schmidt, R. A. (1989). The learning of generalized motor programs: Reducing the relative frequency of knowledge of results enhances memory. Journal of Experimental Psychology: Learning, Memory, and Cognition, 15(4), 748-757.

AB: In earlier studies, reducing the relative frequency of knowledge of results (KR) enhanced retention of single movements. In the experiments here we asked whether this variable also enhances memory for classes of actions governed by generalized motor programs. Acquisition conditions involved practicing three versions of a sequential timing task. All three versions had the same temporal structure (or phasing), but the overall durations were different. KR was presented on either 100% or 67% of the trials for two groups. In Experiment 1, reduced relative KR frequency, spread equally across all task versions, enhanced accuracy of the learned relative timing structure as measured on a transfer test with a novel movement duration. Experiment 2 showed that retention of a medium-duration version was more accurate for subjects who never received KR about it in acquisition, as compared with subjects who always did. The data support the view that reduced KR frequency enhances acquisition of the relative-timing structure underlying memory for a class of actions.

Comments: Level 2 for non-CPR setting, Excellent, Supporting, Randomized experimental studyWulf (1998a) Wulf, G., & Schmidt, R. A. (1998). Average KR degrades parameter learning [Electronic Version]. Journal of Motor

Behavior, 28(4), 371-381.

AB: In the present study, the effects of average knowledge of results (KR) about a set of trials on the learning of a spariotemporal movement pattern were examined. Participants (N = 85) practiced 3 movement patterns with the same relative and absolute timing and the same relative amplitudes but with varied absolute amplitudes. Five groups of participants practiced under 1 of the following 5 conditions: KR after every trial (100% KR); average KR after every 3rd trial (average); average KR after every trial about the last 3 trials (running-average); KR after every 3rd trial (33% KR); and KR after every trial, plus average KR after every 3rd trial (both). Although there were no differences between groups in the learning of the fundamental movement pattern (or generalized motor program), average feedback (average, running average) clearly degraded subjects' ability to learn to properly parameterize the actions in amplitude.

Comments: Level 2 for non-CPR setting, Excellent, Neutral or Opposing, Randomized experimental study

Subjects – 85 undergraduate students. Assignments – Random assignment to one of five groups: the 100% KR group, the average group (received average KR over last 3 trials on every 3rd trial), the running-average group (received average KR over last 3 trials on every trial), the 33% KR group, and the both group (received KR after every trial and average KR after every 3rd trial). Skill task – A right-arm movement task through a series of specific motions within a prescribed period of time (908 ms). There were three different patterns employed. Procedure – Practice trials consisted on 6 blocks of 15 trials. Followed by 12 no-KR trials for immediate retention testing and 12 no-KR trials 24 hours later for delayed retention. Statistical analysis – Several factors were reviewed but root mean square error was the primary factor for the ANOVA. Results – During practice, immediate retention and delayed retention testing, average and running average groups had significantly greater amounts of error. Shows that average KR degrades learning. Differences between 33% and 100% KR were not significant. Authors speculated that frequency of KR may have been too low to make a significant difference.

Wulf (1993) Wulf, G., Schmidt, R. A. and Deubel, H. (1993). Reduced feedback frequency enhances generalized motor program learning but not parameterization learning, Journal of Experimental Psychology: Learning, Memory, and Cognition, 19(5), 1134-1150.

AB: The purpose of the study was to examine the effects of a reduced feedback frequency on the learning of generalized motor programs and movement parameterization. Subjects practiced three movement patterns with the same relative timing and the same relative amplitude, but with varied movement time (Experiment 1) or varied movement amplitude (Experiment 2). KR was given either on 100% or 63% of the trials, with learning being assessed by retention and transfer tests. In both experiments, reduced KR frequency enhanced GMP learning but generally degraded parameter learning. These data provide converging evidence for the dissociation of the program and parameterization processes postulated in GMP theory.


Comments: Level 2 for non-CPR setting, Good (mixed results, but favored supporting), Randomized experiment

Two experiments involving a arm movement exercise to be completed in a prescribed time. Evaluated 100% KR with 63% KR. Reduced KR showed improved performance when reviewing general motor program functions in both acquisition and delayed retention phases. However, there was difficulty maintaining this advantage when requirements of target tasks changed.

Wulf (1998b) Wulf, G., & Shea, C. H. (1998). Frequent feedback enhances complex motor skill learning. Journal of Motor Behavior, 30(2), 180-192.

AB: Feedback frequency effects on the learning of a complex motor skill, the production of slalom-type movements on a ski-simulator, were examined. In Experiment 1, a movement feature that characterizes expert performance was identified. Participants (N = 8) practiced the task for 6 days. Significant changes across practice were found for movement amplitude and relative force onset. Relative force onset is considered a measure of movement efficiency; relatively late force onsets characterize expert performance. In Experiment 2, different groups of participants (N = 27) were given concurrent feedback about force onset on either 100% or 50% of the practice trials; a control group was given no feedback. The following hypothesis was tested: Contrary to previous findings concerning relatively simple tasks, for the learning of a complex task such as the one used here, a high relative feedback frequency (100%) is more beneficial for learning than a reduced feedback frequency (50%). Participants practiced the task on 2 consecutive days and performed a retention test without feedback on Day 3. The 100% feedback group demonstrated later relative force onsets than the control group in retention; the 50% feedback group showed intermediate performance. The results provide support for the notion that high feedback frequencies are beneficial for the learning of complex motor skills, at least until a certain level of expertise is achieved. That finding suggests that there may be an interaction between task difficulty and feedback frequency similar to the interaction found in the summary-KR literature.

Comments: Level 2 for non-CPR setting, Good, (small study groups), Neutral or Opposing, Randomized experimental studies

Two experiment project with Experiment 2 being the relevant experiment. Subjects – 27 students ages 18 to 31. Assignments – Random assignment to one of three groups: 100% concurrent feedback, 50% concurrent feedback, 0% concurrent feedback. Skill task – Skiing simulator measuring amplitude, frequency, and relative force onset of movements. Procedure – 10 acquisition trials on Day 1, 10 acquisition trials on Day 2, and 10 no-KR retention trials on Day 3. Statistical analysis – ANOVA Results – During acquisition, only Amplitude demonstrated a significant (p < .05) result favoring 100% KR. During retention testing, there were no significant differences in amplitude or frequency between the groups. For relative force onset, the 100% KR group had significantly better performance (p < .05). Only one of three findings found significance in both acquisition and retention testing with those results favoring 100% KR. Suggestion made that for more complex skills, higher degrees of KR need to be supplied. Study did not support the Guidance Hypothesis.

Yao (2003) Yao, W. X. (2003). Average KR schedule benefits generalized motor program learning. Perceptual & Motor Skills, 97(1), 185-191.

AB: The main purpose of this study was to examine the effects of average Knowledge of Results (KR) on generalized motor program learning and parameter learning. Two groups of participants (n=15 per group) performed 80 acquisition trials of sequential timing tasks. All participants were asked to depress sequentially four keys (2, 4, 8, and 6) on the numeric pad portion of the computer keyboard with the index finger of the right hand. The author presented average feedback on timing errors based on 5-trial blocks and compared this feedback schedule with every-trial feedback. Analysis of the delayed no feedback retention test indicated a strong advantage for the average KR compared with the every-trial condition in both generalized motor program learning and parameter learning. The current results suggest that the average KR schedule may have positive effects on generalized motor program learning and parameter learning.

Comments: Level 2 for non-CPR setting, Good (small study group size), Supporting, Randomized experimental study.

Assignments – Random assignment to two groups. One would receive feedback (KR) after every trial, the other would receive average KR given as a mean over five trials. Skill task – Numeric keypad requiring sequential keystrokes within a prescribed time frame for both for key-to-key movements and overall time with a target time of 900 ms. Procedure – Eight blocks of 10 trials represented the acquisition phase. A no-KR retention test of 10 trials was conducted 24 hours after the acquisition phase. Statistical analysis – Analysis of both relative timing error and absolute timing error were conducted. Results – At the conclusion of the acquisition phase, there was no significant difference in performance. In the no-KR retention test, both relative and absolute timing error comparisons indicated a significant (p<.001) advantage for the average KR group over the every trial KR group. Study supports the Guidance Hypothesis.

*Type the citation marker in the first field and then paste the full citation into the second field. You can copy the full citation from EndNote by selecting the citation, then copying the FORMATTED citation using the short cut, Ctrl-K. After you copy the citation, go back to this document and position the cursor in the field, then paste the citation into the document (use Ctrl-V). For each new citation press Tab to move down to start a new field.

Excluded Articles

Excluded References of Note (Studies included in GL2000 Worksheet but excluded in GL2005)

Doherty, A., Damon, S., Hein, K. and Cummins, R. O. (1998). Evaluation of CPR prompt and home learning system for teaching CPR to lay rescuers., Circulation, 98(suppl I)(I-410.

Excluded because it was only presented in Abstract format for conference presentation.


AB: Purpose: To determine whether two new CPR-training innovations can enhance instructor-led classes and improve initial training. The devices are: a) the CPR Prompt (Prompt) which is an electronic, interactive, audio device that prompts rescuers to perform the ABC steps of CPR; and b) the Home Learning System (HLS) which is comprised of a Prompt, a watch-then-practice videotape, and personal manikins. Methods: A standard design was used to evaluate training: subjects > Interventions > Initial outcomes > long-term outcomes. Adult citizens received an instructor-led AHA Heartsaver class, plus assignment to either Group A: Prompt plus HLS (N=194), Group B: Prompt alone (N=93, or Group C: control (N=93). Exit testing of CPR skills was performed at the end of the class and recorded on videotape. Using a validated skills checklist, 3 reviewers, without knowledge of group assignments, graded the videotapes using an 11-criteria CPR score. Skills graded on the CPR score: assess & cal 911; A (open airway); B (check breathing, 2 breathes, chest rises); C (check pulse, chest compressions, hand position, depth, ratios). Results: All 3 group performed equally on the CPR score: Group A = 9.8; Group B = 9.5; Group C = 9.5. Use of the Prompt (Groups A & B) was associated with equal performance on 1 of 11 criteria, better performance on 8 of 11 criteria (NS), and significantly better performance on 2 criteria - open airway (10.3 Prompt vs. 8.9 control) and check pulse (8.2 Prompt vs. 7.1 control). Conclusions: Even in instructor-led classes, the HLS appears to enhance learning via 1:1 manikin/learner ratios; uniform video-based instruction, and increased hands-on practice time. The Prompt's repeated voice messages, learned as a chant, enhanced learning by requiring the same, easily memorized approach to a complex skill, and by imposing more hands-on practice time. These innovations were uniformly popular with both instructors and learners. Though initial CPR scores were similar, long-term retention may differ in the HLS and Prompt groups (evaluation in progress). We think these approaches merit some consideration as valuable enhancements to instructor-led CPR training.

Starr, L. M. (1997). Electronic voice boosts CPR responses, Occupational Health and Safety, 66(4), 30-37.

AB: No abstract available

Excluded because it is not from a peer-reviewed journal

Very good study but not from the peer-reviewed literature and had no statistical test of significance. 67 subjects, mean age 37.1, 46 male, 31 female. All subjects received one-rescuer adult CPR training. At completion of initial training, all participants received overview of a CPR prompting device that provided a variety of voice prompts to guide rescuer through the CPR process including guiding information on chest compression rate delivery. Random assignment then made at 30 days post training to reevaluate CPR skills. One group would perform CPR without the promoting device, while subjects in the other group performed CPR with the prompting device. Results showed that ventilations and compressions with appropriate timing were performed significantly better by the prompt group (91.89% adherence to AHA guidelines for the prompt group and 20.00% adherence to guidelines for the control group. No p value listed, but results look obviously significant. Other individual skills in the CPR process all showed much higher acceptable performance rates for the prompt group

Other excluded references - (Doherty, Damon, Hein, & Cummins, 1998)

Adams, J. A. (1971). A closed-loop theory of motor learning, Journal of Motor Behavior, 3(2), 11-149.Amith, G. (1997). Revising educational requirements: challenging four hours for both basic life support and automated external defibrillators. New Horiz, 5(2), 167-

172.Assar, D., Chamberlain, D., Colquhoun, M., Donnelly, P., Handley, A. J., Leaves, S. and Kern, K. B. (2000). Randomised controlled trials of staged teaching for

basic life support. 1. Skill acquisition at bronze stage, Resuscitation, 45(1), 7-15.Assar, D., Chamberlain, D., Colquhoun, M., Donnelly, P., Handley, A. J., Leaves, S., Kern, K. B. and Mayor, S. (1998). A rationale for staged teaching of basic life

support, Resuscitation, 39(3), 137-43.Attia, R. R., Miller, E. V., & Kitz, R. J. (1975). Teaching effectiveness: evaluation of computer-assisted instruction for cardiopulmonary resuscitation. Anesth Analg,

54(3), 308-311.Bang, A., Ortgren, P. O., Herlitz, J., & Wahrborg, P. (2002). Dispatcher-assisted telephone CPR: a qualitative study exploring how dispatchers perceive their

experiences. Resuscitation, 53(2), 135-151.Barber, J. P., Luborsky, L., Gallop, R., Crits-Christoph, P., Frank, A., Weiss, R. D., et al. (2001). Therapeutic alliance as a predictor of outcome and retention in the

National Institute on Drug Abuse Collaborative Cocaine Treatment Study. J Consult Clin Psychol, 69(1), 119-124.Batcheller, A. M., Brennan, R. T., Braslow, A., Urrutia, A. and Kaye, W. (2000). Cardiopulmonary resuscitation performance of subjects over forty is better following

half-hour video self-instruction compared to traditional four-hour classroom training, Resuscitation, 43(2), 101-10.Baubin, M., Haid, C., Hamm, P. and Gilly, H. (1999). Measuring forces and frequency during active compression decompression cardiopulmonary resuscitation: a

device for training, research and real CPR, Resuscitation, 43(1), 17-24.Benedetti, C. and McCullagh, P. (1987). Post-knowledge of results delay: Effects of interpolated activity on learning and performance, Research Quarterly for

Exercise and Sport, 58(4), 375-381.Berden, H. J., Bierens, J. J., Willems, F. F., Hendrick, J. M., Pijls, N. H. and Knape, J. T. (1994). Resuscitation skills of lay public after recent training, Ann Emerg

Med, 23(5), 1003-8.Berg, R. A. (2000). Role of mouth-to-mouth rescue breathing in bystander cardiopulmonary resuscitation for asphyxial cardiac arrest. Crit Care Med, 28(11 Suppl),

N193-195.Berg, R. A., Kern, K. B., Sanders, A. B., Otto, C. W., Hilwig, R. W., & Ewy, G. A. (1993). Bystander cardiopulmonary resuscitation. Is ventilation necessary?

Circulation, 88(4 Pt 1), 1907-1915.Bernhard, W. N., Turndorf, H., Cottrell, J. E., Vea, F., & Basak, A. (1979). Impact of cardiopulmonary resuscitation training on resuscitation. Crit Care Med, 7(6),

257-262.Bilger, M. C., Giesen, B. C., Wollan, P. C. and White, R. D. (1997). Improved retention of the EMS activation component (EMSAC) in adult CPR education,

Resuscitation, 35(3), 219-24.Billi, J. E., & Membrino, G. E. (1993). Education in adult advanced cardiac life support training programs: changing the paradigm. Members of the Advanced

Cardiac Life Support Education Panel. Ann Emerg Med, 22(2 Pt 2), 475-483.Blandin, Y., Lhuisset, L. and Proteau, L. (1999). Cognitive processes underlying observational learning of motor skills, Quarterly Journal of Experimental

Psychology: Section A, 52(4), 957-979.Bossaert, L. and Van Hoeyweghen, R. (1989). Evaluation of cardiopulmonary resuscitation (CPR) techniques. The Cerebral Resuscitation Study Group,

Resuscitation, 17 Suppl(S99-109; discussion S199-206.Boyde, M., & Wotton, K. (2001). A review of nurses' performance of cardiopulmonary resuscitation at cardiac arrests. J Nurses Staff Dev, 17(5), 248-255.Boyle, A. J., Wilson, A. M., Connelly, K., McGuigan, L., Wilson, J. and Whitbourn, R. (2002). Improvement in timing and effectiveness of external cardiac

compressions with a new non-invasive device: the CPR-Ezy, Resuscitation, 54(1), 63-7.


Braslow, A., Brennan, R. T., Newman, M. M., Bircher, N. G., Batcheller, A. M. and Kaye, W. (1997). CPR training without an instructor: development and evaluation of a video self-instructional system for effective performance of cardiopulmonary resuscitation, Resuscitation, 34(3), 207-20.

Brennan, R. T. (1991). Student, instructor, and course factors predicting achievement in CPR training classes, Am J Emerg Med, 9(3), 220-4.Brennan, R. T. and Braslow, A. (1995). Skill mastery in cardiopulmonary resuscitation training classes, Am J Emerg Med, 13(5), 505-8.Brennan, R. T. and Braslow, A. (1998). Are we training the right people yet? A survey of participants in public cardiopulmonary resuscitation classes, Resuscitation,

37(1), 21-5.Brennan, R. T. and Braslow, A. (1998). Skill mastery in public CPR classes, Am J Emerg Med, 16(7), 653-7.Brisson, T. A. and Alain, C. (1997). A comparison of two references for using knowledge of performance in learning a motor task [Electronic Version], Journal of

Motor Behavior, 29(4), 339-350.Broomfield, R. (1996). A quasi-experimental research to investigate the retention of basic cardiopulmonary resuscitation skills and knowledge by qualified nurses

following a course in professional development. J Adv Nurs, 23(5), 1016-1023.Capone, P. L., Lane, J. C., Kerr, C. S., & Safar, P. (2000). Life supporting first aid (LSFA) teaching to Brazilians by television spots. Resuscitation, 47(3), 259-265.Celenza, T., Gennat, H. C., O'Brien, D., Jacobs, I. G., Lynch, D. M., & Jelinek, G. A. (2002). Community competence in cardiopulmonary resuscitation.

Resuscitation, 55(2), 157-165.Cavanagh, S. J. (1990). Educational aspects of cardiopulmonary resuscitation (CPR) training, Intensive Care Nurs, 6(1), 38-44.

Chamberlain, D., Smith, A., Colquhoun, M., Handley, A. J., Kern, K. B. and Woollard, M. (2001). Randomised controlled trials of staged teaching for basic life support: 2. Comparison of CPR performance and skill retention using either staged instruction or conventional training, Resuscitation, 50(1), 27-37.

Chamberlain, D., Smith, A., Woollard, M., Colquhoun, M., Handley, A. J., Leaves, S. and Kern, K. B. (2002). Trials of teaching methods in basic life support (3): comparison of simulated CPR performance after first training and at 6 months, with a note on the value of re-training, Resuscitation, 53(2), 179-87.

Chen, D. D. (2001). Trends in augmented feedback research and tips for the practitioner, JOPERD: The Journal of Physical Education, Recreation & Dance, 72(1), 32-36.

Chiviacowsky, S. and Wulf, G. (2002). Self-controlled feedback: Does it enhance learning because performers get feedback when they need it?, Research Quarterly for Exercise & Sport, 73(4), 408415.

Chu, K. H., May, C. R., Clark, M. J., & Breeze, K. M. (2003). CPR training in households of patients with chest pain. Resuscitation, 57(3), 257-268.Coleman, S., Dracup, K. and Moser, D. K. (1991). Comparing methods of cardiopulmonary resuscitation instruction on learning and retention, J Nurs Staff Dev,

7(2), 82-7.Cummins, R. O., Eisenberg, M. S., Bergner, L., Hallstrom, A., Hearne, T., & Murray, J. A. (1984). Automatic external defibrillation: evaluations of its role in the home

and in emergency medical services. Ann Emerg Med, 13(9 Pt 2), 798-801.Cummins, R. O., Eisenberg, M. S., Moore, J. E., Hearne, T. R., Andresen, E., Wendt, R., et al. (1985). Automatic external defibrillators: clinical, training,

psychological, and public health issues. Ann Emerg Med, 14(8), 755-760.Curry, L., & Gass, D. (1987). Effects of training in cardiopulmonary resuscitation on competence and patient outcome. Cmaj, 137(6), 491-496.Davies, N. and Gould, D. (2000). Updating cardiopulmonary resuscitation skills: a study to examine the efficacy of self-instruction on nurses' competence, J Clin

Nurs, 9(3), 400-10.Demirovic, J. (2004). Cardiopulmonary resuscitation programs revisited: results of a community study among older African Americans. Am J Geriatr Cardiol, 13(4),

182-187.Dick, W. F., Brambrink, A. M., & Kern, T. (1999). ["Topless" cardiopulmonary resuscitation? Should heart-lung resuscitation be preformed without artificial

resuscitation?]. Anaesthesist, 48(5), 290-300.Doherty, A., Damon, S., Hein, K. and Cummins, R. O. (1998). Evaluation of CPR prompt and home learning system for teaching CPR to lay rescuers., Circulation,

98(suppl I)(I-410.Doherty, A. and Cummins, R. O. (1997). Can lay citizens learn to use an automated external defibrillator during a routine AHA Heartsaver CPR class?, Circulation, Donnelly, P., Assar, D. and Lester, C. (2000). A comparison of manikin CPR performance by lay persons trained in three variations of basic life support guidelines,

Resuscitation, 45(3), 195-9.Dracup, K., Doering, L. V., Moser, D. K. and Evangelista, L. (1998). Retention and use of cardiopulmonary resuscitation skills in parents of infants at risk for

cardiopulmonary arrest, Pediatric Nursing, 24(3), 219-25; quiz 226-7.Dracup, K., Heaney, D. M., Taylor, S. E., Guzy, P. M. and Breu, C. (1989). Can family members of high-risk cardiac patients learn cardiopulmonary resuscitation?,

Arch Intern Med, 149(1), 61-4.Dracup, K., Moser, D. K., Doering, L. V. and Guzy, P. M. (1998). Comparison of cardiopulmonary resuscitation training methods for parents of infants at high risk for

cardiopulmonary arrest, Ann Emerg Med, 32(2), 170-7.Dracup, K., Moser, D. K., Guzy, P. M., Taylor, S. E. and Marsden, C. (1994). Is cardiopulmonary resuscitation training deleterious for family members of cardiac

patients?, Am J Public Health, 84(1), 116-8.Drake, E. (1995). Discharge teaching needs of parents in the NICU. Neonatal Netw, 14(1), 49-53.Edmonds, E. M. and Mueller, M. R. (1968). The effects of incidental learning and reinforcement on schemata learning and schemata transfer: Final report,

Psychonomic Science, 10(2), 75-76.Eisenburger, P., & Safar, P. (1999). Life supporting first aid training of the public--review and recommendations. Resuscitation, 41(1), 3-18.Fabius, D. B., Grissom, E. L., & Fuentes, A. (1994). Recertification in cardiopulmonary resuscitation. A comparison of two teaching methods. J Nurs Staff Dev,

10(5), 262-268.Faddy, S. C. (2002). Towards new models of cardiopulmonary resuscitation teaching: the role of practical scenario training on surf lifesavers' perceptions of

resuscitation efficacy. Resuscitation, 53(2), 159-165.Fitten, L. J., Lusky, R., & Hamann, C. (1990). Assessing treatment decision-making capacity in elderly nursing home residents. J Am Geriatr Soc, 38(10), 1097-

1104.Flint, L. S., Jr., Billi, J. E., Kelly, K., Mandel, L., Newell, L., & Stapleton, E. R. (1993). Education in adult basic life support training programs. Ann Emerg Med, 22(2

Pt 2), 468-474.Fossel, M., Kiskaddon, R. T., & Sternbach, G. L. (1983). Retention of cardiopulmonary resuscitation skills by medical students. J Med Educ, 58(7), 568-575.Franssen, V. and Vandierendonck, A. (2002). Time estimation: does the reference memory mediate the effect of knowledge of results?, Acta Psychologica, 109(3),

239-267.Frohwerk, A. (1999). Implementing the CPR: a journey. J Ahima, 70(3), 32-37; quiz 39-40.Gabrielli, A., Layon, A. J., Wenzel, V., Dorges, V., & Idris, A. H. (2002). Alternative ventilation strategies in cardiopulmonary resuscitation. Curr Opin Crit Care, 8(3),

199-211.Gass, D. A., & Curry, L. (1983). Physicians' and nurses' retention of knowledge and skill after training in cardiopulmonary resuscitation. Can Med Assoc J, 128(5),

550-551.


Gazmuri, R. J., Weil, M. H., von Planta, M., Gazmuri, R. R., Shah, D. M., & Rackow, E. C. (1991). Cardiac resuscitation by extracorporeal circulation after failure of conventional CPR. J Lab Clin Med, 118(1), 65-73.

Gombeski, W. R., Jr., Effron, D. M., Ramirez, A. G., & Moore, T. J. (1982). Impact on retention: comparison of two CPR training programs. Am J Public Health, 72(8), 849-852.

Gruben, K. G., Guerci, A. D., Halperin, H. R., Popel, A. S. and Tsitlik, J. E. (1993). Sternal force-displacement relationship during cardiopulmonary resuscitation, J Biomech Eng, 115(2), 195-201.

Hall, K. G. (1994). A further look at erroneous KR: How do learners resolve conflicts in intrinsic and extrinsic information, Research Quarterly for Exercise & Sport, 65(1), A63-A64.

Hallstrom, A. P., Cobb, L. A., Johnson, E., & Copass, M. K. (2003). Dispatcher assisted CPR: implementation and potential benefit. A 12-year study. Resuscitation, 57(2), 123-129.

Handley, A. J. (2002). Teaching hand placement for chest compression--a simpler technique. Resuscitation, 53(1), 29-36.Handley, J. A. and Handley, A. J. (1998). Four-step CPR--improving skill retention, Resuscitation, 36(1), 3-8.Hauff, S. R., Rea, T. D., Culley, L. L., Kerry, F., Becker, L., & Eisenberg, M. S. (2003). Factors impeding dispatcher-assisted telephone cardiopulmonary

resuscitation. Ann Emerg Med, 42(6), 731-737.Hodges, N. J. and Franks, I. M. (2001). Learning a coordination skill: Interactive effects of instruction and feedback, Research Quarterly for Exercise & Sport, 72(2),

132-142.Hodges, N. J. and Franks, I. M. (2002). Learning as a function of coordination bias: Building upon pre-practice behaviours, Human Movement Science, 21(2),

231258.Hodges, N. J. and Franks, I. M. (2002). Modelling coaching practice: The role of instruction and demonstration, Journal of Sports Sciences, 20(10), 793-811.Hodges, N. J. and Lee, T. D. (1999). The role of augmented information prior to learning a bimanual visual - motor coordination task: Do instructions of the

movement pattern facilitate learning relative to discovery learning? [Electronic Version], British Journal of Psychology, 90(3), 389-403.Ivens, C. J. and Marteniuk, R. G. (1997). Increased sensitivity to changes in visual feedback with practice [Electronic Version], Journal of Motor Behavior, 29(4),

326-338.Johnson, E. M. and Payne Jr., M. C. (1966). Effects of frequency of knowledge of results, Journal of Applied Psychology, 50(1), 33-34.Kaye, W., & Mancini, M. E. (1986). Retention of cardiopulmonary resuscitation skills by physicians, registered nurses, and the general public. Crit Care Med, 14(7),

620-622.Kaye, W., Mancini, M. E., Giuliano, K. K., Richards, N., Nagid, D. M., Marler, C. A., et al. (1995). Strengthening the in-hospital chain of survival with rapid

defibrillation by first responders using automated external defibrillators: training and retention issues. Ann Emerg Med, 25(2), 163-168.Kaye, W., Mancini, M. E., & Richards, N. (1995). Organizing and implementing a hospital-wide first-responder automated external defibrillation program:

strengthening the in-hospital chain of survival. Resuscitation, 30(2), 151-156.Kaye, W., Rallis, S. F., Mancini, M. E., Linhares, K. C., Angell, M. L., Donovan, D. S., et al. (1991). The problem of poor retention of cardiopulmonary resuscitation

skills may lie with the instructor, not the learner or the curriculum. Resuscitation, 21(1), 67-87.Khan, M. A. and Franks, I. M. (2000). The effect of practice on component submovements is dependent on the availability of visual feedback, Journal of Motor

Behavior, 32(3), 227-240.Kilduski, N. C. and Rice, M. S. (2003). Qualitative and quantitative knowledge of results: Effects on motor learning, American Journal of Occupational Therapy,

57(3), 329-336.Kinney, S. B. and Tibballs, J. (2000). An analysis of the efficacy of bag-valve-mask ventilation and chest compression during different compression-ventilation ratios

in manikin-simulated paediatric resuscitation, Resuscitation, 43(2), 115-120.Kiskaddon, R. T., & Sternbach, G. L. (1985). Retention of CPR skills. Am J Emerg Med, 3(5), 479.Komelasky, A. L. (1990). The effect of home nursing visits on parental anxiety and CPR knowledge retention of parents of apnea-monitored infants. J Pediatr Nurs,

5(6), 387-392.Komelasky, A. L., & Bond, B. S. (1993). The effect of two forms of learning reinforcement upon parental retention of CPR skills. Pediatr Nurs, 19(1), 96-98, 77.Kovacevic, J. (1997). [Importance of beginning prompt cardiopulmonary resuscitation as a factor in survival in emergency medical care]. Med Arh, 51(1-2 Suppl 1),

17-20.Lavery, J. J. (1962). Retention of simple motor skills as a function of type of knowledge or results, Canadian Journal of Psychology, 16(300-311.Lavery, J. J. (1964). The effect of one-trial delay in knowledge of results on acquisition and retention of a tossing skill, American Journal of Psychology, 77(437-443.Lee, T. D. and Genovese, E. D. (1989). Distribution of practice in motor skill acquisition: Different effects for discrete and continuous tasks, Research Quarterly for

Exercise and Sport, 60(1), 59-65.Lee, T. D. and Magill, R. A. (1983). Activity during the Post-KR Interval: Effects upon Performance or Learning?, Research Quarterly for Exercise and Sport, 54(4),

340-345.Lester, C. A., Weston, C. F., Donnelly, P. D., Assar, D., & Morgan, M. J. (1994). The need for wider dissemination of CPR skills: are schools the answer?

Resuscitation, 28(3), 233-237.Lewis, F. H., Kee, C. C., & Minick, M. P. (1993). Revisiting CPR knowledge and skills among registered nurses. J Contin Educ Nurs, 24(4), 174-179.Liberman, M., Golberg, N., Mulder, D., & Sampalis, J. (2000). Teaching cardiopulmonary resuscitation to CEGEP students in Quebec--a pilot project. Resuscitation,

47(3), 249-257.Lippman, L. G. and Rees, R. (1997). Consequences of error production in perceptual-motor task, Journal of General Psychology, 124(2), 133-142.Locke, E. A. (1967). Motivational effects of knowledge of results: Knowledge or goal setting?, Journal of Applied Psychology, 51(4), 324-329.Mancini, M. E., & Kaye, W. (1985). The effect of time since training on house officers' retention of cardiopulmonary resuscitation skills. Am J Emerg Med, 3(1), 31-

32.Mancini, M. E., & Kaye, W. (1990). Measuring cardiopulmonary resuscitation performance: a comparison of the Heartsaver checklist to manikin strip. Resuscitation,

19(2), 135-141.Mandel, L. P., & Cobb, L. A. (1982). Initial and long-term competency of citizens trained in CPR. Emerg Health Serv Q, 1(3), 49-63.Martin, W. J., Loomis, J. H., Jr. and Lloyd, C. W. (1983). CPR skills: achievement and retention under stringent and relaxed criteria, Am J Public Health, 73(11),

1310-2.McSwain, E. C., & Mahan, J. M. (1980). Modular teaching of cardio-pulmonary resuscitation for nursing service personnel. Resuscitation, 8(4), 257-261.McCullagh, P. and Little, W. S. (1989). A comparison of modalities in modeling, Human Performance, 2(2), 101-111.McNevin, N. and Magill, R. A. (1994). Effects of erroneous knowledge of results on transfer of anticipation timing, Research Quarterly for Exercise & Sport, 65(4),

324-329.McNevin, N. H., Shea, C. H. and Wulf, G. (2003). Increasing the distance of an external focus of attention enhances learning, Psychological Research, 67(1), 22-29.

Meischke, H., Finnegan, J. and Eisenberg, M. (1999). What can you teach about cardiopulmonary resuscitation (CPR) in 30 seconds? Evaluation of a television campaign, Eval Health Prof, 22(1), 44-59.


Mejicano, G. C., & Maki, D. G. (1998). Infections acquired during cardiopulmonary resuscitation: estimating the risk and defining strategies for prevention. Ann Intern Med, 129(10), 813-828.

Messmer, P., Meehan, R., Gilliam, N., White, S., & Donaldson, P. (1993). Teaching infant CPR to mothers of cocaine-positive infants. J Contin Educ Nurs, 24(5), 217-220.

Messmer, P. R. and Jones, S. G. (1998). Saving lives. An innovative approach for teaching CPR, Nurs Health Care Perspect, 19(3), 108-10.Miller, R. I., Johnson, R. P., Ryan, D. E. and Chilton, R. J. (1980). Cardiopulmonary resuscitation: a teaching aid, J Oral Surg, 38(7), 513-5.Miyadahira, A. M. (2001). [Motor capacities involved in the psychomotor skills of the cardiopulmonary resuscitation technique: recommendations for the teaching-

learning process]. Rev Esc Enferm USP, 35(4), 366-373.Mononen, K., Era, P., Konttinen, N. and Viitasalo, J. T. (2003). The effects of augmented kinematic feedback on motor skill learning in rifle shooting, Journal of

Sports Sciences, 21(10), 867-976.Monsieurs, K. G., Vogels, C., Bossaert, L. L., Meert, P., Manganas, A., Tsiknakis, M., et al. (2004). Learning effect of a novel interactive basic life support CD: the

JUST system. Resuscitation, 62(2), 159-165.Montgomery, W. H., Brown, D. D., Hazinski, M. F., Clawsen, J., Newell, L. D., & Flint, L. (1993). Citizen response to cardiopulmonary emergencies. Ann Emerg

Med, 22(2 Pt 2), 428-434.Moser, D. K., Dracup, K. and Doering, L. V. (1999). Effect of cardiopulmonary resuscitation training for parents of high-risk neonates on perceived anxiety, control,

and burden, Heart Lung, 28(5), 326-33.Moser, D. K., Dracup, K., Guzy, P. M., Taylor, S. E. and Breu, C. (1990). Cardiopulmonary resuscitation skills retention in family members of cardiac patients, Am J

Emerg Med, 8(6), 498-503.Moule, P. and Albarran, J. W. (2002). Automated external defibrillation as part BLS: implications for education and practice, Resuscitation, 54(3), 223-30.Moule, P. and Knight, C. (1997). Emergency, cardiac arrest! Can we teach the skills?, Nurse Educ Today, 17(2), 99-105.Muller, J. H. (1992). Shades of blue: the negotiation of limited codes by medical residents. Soc Sci Med, 34(8), 885-898.Mullie, A., Van Hoeyweghen, R. and Quets, A. (1989). Influence of time intervals on outcome of CPR. The Cerebral Resuscitation Study Group, Resuscitation, 17

Suppl(S23-33; discussion S199-206).Murphy, D. J., Burrows, D., Santilli, S., Kemp, A. W., Tenner, S., Kreling, B., et al. (1994). The influence of the probability of survival on patients' preferences

regarding cardiopulmonary resuscitation. N Engl J Med, 330(8), 545-549.Neigh, G. N., Kofler, J., Meyers, J. L., Bergdall, V., La Perle, K. M., Traystman, R. J., et al. (2004). Cardiac arrest/cardiopulmonary resuscitation increases anxiety-

like behavior and decreases social interaction. J Cereb Blood Flow Metab, 24(4), 372-382.Nelson, M., & Brown, C. G. (1984). CPR instruction: modular versus lecture course. Ann Emerg Med, 13(2), 118-121.Newell, K. M. (1977). Knowledge of results and motor learning, Exercise and Sports Sciences Reviews, 4(195-228.Nicholson, D. E. and Schmidt, R. A. (1991). Scheduling information feedback to enhance training effectiveness, Human Factors Society 35th Annual Meeting, Santa

Monica, CA.Noordergraaf, G. J., Van Gelder, J. M., Van Kesteren, R. G., Diets, R. F. and Savelkoul, T. J. (1997). Learning cardiopulmonary resuscitation skills: does the type of

mannequin make a difference?, Eur J Emerg Med, 4(4), 204-9.Nyman, J., & Sihvonen, M. (2000). Cardiopulmonary resuscitation skills in nurses and nursing students. Resuscitation, 47(2), 179-184.Ornaque, I., Gomar, C., Fernandez, C., Fabregas, N., Basora, M., & Matute, P. (1999). [Learning cardiopulmonary resuscitation using conventional external cardiac

massage or active compression-decompression in simulated cardiopulmonary resuscitation]. Rev Esp Anestesiol Reanim, 46(5), 186-190.Ornato, J. P. (1993). Hemodynamic monitoring during CPR. Ann Emerg Med, 22(2 Pt 2), 289-295.Page, S., & Meerabeau, L. (1996). Nurses' accounts of cardiopulmonary resuscitation. J Adv Nurs, 24(2), 317-325.Palese, A., Trenti, G., & Sbrojavacca, R. (2003). [Effectiveness of retraining after basic cardiopulmonary resuscitation courses: a literature review]. Assist Inferm

Ric, 22(2), 68-75.Palmisano, J. M., Akingbola, O. A., Moler, F. W., & Custer, J. R. (1994). Simulated pediatric cardiopulmonary resuscitation: initial events and response times of a

hospital arrest team. Respir Care, 39(7), 725-729.Pane, G. A., & Salness, K. A. (1987). A survey of participants in a mass CPR training course. Ann Emerg Med, 16(10), 1112-1116.Perron, A. D., Brady, W. J., & Erling, B. F. (2001). Commodio cordis: an underappreciated cause of sudden cardiac death in young patients: assessment and

management in the ED. Am J Emerg Med, 19(5), 406-409.Peterson, T., & Klauer, K. (1991). Cardiac arrest outcome in a tiered response system. Iowa Med, 81(6), 255-257.Plank, C. H., & Steinke, K. R. (1989). Effect of two teaching methods on CPR retention. J Nurs Staff Dev, 5(3), 145-147.Reeve, T. G. and Magill, R. A. (1981). The role of the components of knowledge of results information in error correction, Research Quarterly for Exercise & Sport,

52(1), 80-85.Rivera-Tovar, L. A., & Jones, R. T. (1990). Effect of elaboration on the acquisition and maintenance of cardiopulmonary resuscitation. J Pediatr Psychol, 15(1), 123-

138.Rosafio, T., Cichella, C., Vetrugno, L., Ballone, E., Orlandi, P., & Scesi, M. (2001). Chain of survival: differences in early access and early CPR between policemen

and high-school students. Resuscitation, 49(1), 25-31.Ryan, L. J. and Robey, T. B. (2002). Learning and performance effects of accurate and erroneous knowledge of results on time perception, Acta Psychologica,

111(1), 83-100.Ryden, M. B., Brand, K., Weber, E., Oh, H. L., & Gross, C. (1998). Nursing home resuscitation policies and practices for residents without DNR orders. Geriatr Nurs,

19(6), 315-319; quiz 320-311.Sanders, M. S. and Freedman, S. (1974). An effect of knowledge of results on performance with goal setting controlled, Paper presented at the 54th Annual

Convention of the Western Psychological Association, San Francisco, California.Sauer, J., Hockey, G. R. J. and Wastell, D. G. (2000). Effects of training on short- and long-term skill retention in a complex multiple-task environment, Ergonomics,

43(12), 2043-2064.Schmidt, R. A. (1975). A schema theory of discrete motor skill learning, Psychological Review, 82(225-260.

Schmidt, R. A., Lange, C. and Young, D. E. (1990). Optimizing summary knowledge of results for skill learning, Human Movement Science, 9(325-348.Seaman, J. E., Greene, B. F., & Watson-Perczel, M. (1986). A behavioral system for assessing and training cardiopulmonary resuscitation skills among emergency

medical technicians. J Appl Behav Anal, 19(2), 125-135.Seidel, J. S., Henderson, D. P., & Spencer, P. E. (1993). Education in pediatric basic and advanced life support. Ann Emerg Med, 22(2 Pt 2), 489-494.Seraj, M. A., & Naguib, M. (1990). Cardiopulmonary resuscitation skills of medical professionals. Resuscitation, 20(1), 31-39.Shaffer, L. H. (1982). Rhythm and timing in skill, Psychological Review, 89(2), 109-122.Shea, C. H., Lai, Q., Wright, D. L., Immink, M. and Black, C. (2001). Consistent and variable practice conditions: Effects on relative and absolute timing, Journal of

Motor Behavior, 33(2), 139-152.


Shea, C. H., Wright, D. L., Wulf, G. and Whitacre, C. (2000). Physical and observational practice afford unique learning opportunities, Journal of Motor Behavior, 32(1), 27-36.

Shea, C. H., Wulf, G., Park, J.-H. and Gaunt, B. (2001). Effects of an auditory model on the learning of relative and absolute timing, Journal of Motor Behavior, 33(2), 127-.

Silfvast, T., Paakkonen, H. and Gorski, J. (2002). The effect of seeing the rhythm display on performance of cardiopulmonary resuscitation, Resuscitation, 55(1), 25-9.

Simon, D. A. and Bjork, R. A. (2002). Models of performance in learning multisegment movement tasks: Consequences for acquisition, retention, and judgments of learning, Journal of Experimental Psychology: Applied, 8(4), 222-232.

Sloman, J. G., & Ross, D. L. (1977). Cardiac arrest. Aust Fam Physician, 6(4), 368, 371, 373-364, 377-369.Smith, A., Colquhoun, M., Woollard, M., Handley, A. J., Kern, K. B., & Chamberlain, D. (2004). Trials of teaching methods in basic life support (4): comparison of

simulated CPR performance at unannounced home testing after conventional or staged training. Resuscitation, 61(1), 41-47.Smith-Love, J., & Carter, C. (1999). Collaboration, problem solving, reevaluation: foundation for the Heart Center of Excellence. Prog Cardiovasc Nurs, 14(4), 143-

149.Starr, L. M. (1998). An effective CPR home learning system: A program evaluation, AAOHN J, 46(6), 289-95.Strang, H. R. (1983). The effects of knowledge of results upon reaction time performance, Journal of General Psychology, 108(1), 11-17.Stapleton, E. R. (2002). Basic life support cardiopulmonary resuscitation. Cardiol Clin, 20(1), 1-12.Sternbach, G. L., Kiskaddon, R. T., Fossel, M., & Eliastam, M. (1984). The retention of cardiopulmonary resuscitation skills. J Emerg Med, 2(1), 33-36.Sugiyama, O., Watanabe, S., Tanaka, K., Toya, M., Igarashi, S., Watanabe, K., et al. (1990). [Perinatal and postnatal study of cefpirome sulfate in rats]. J Toxicol

Sci, 15 Suppl 3, 91-107.Swor, R., Compton, S., Vining, F., Ososky Farr, L., Kokko, S., Pascual, R., et al. (2003). A randomized controlled trial of chest compression only CPR for older

adults-a pilot study. Resuscitation, 58(2), 177-185.Swinnen, S. (1990). Interpolated activities during the knowledge-of-results delay and post-knowledge-of-results interval: Effects on performance and learning,

Journal of Experimental Psychology: Learning, Memory, and Cognition, 16(4), 692-705.Todd, K. H., Braslow, A., Brennan, R. T., Lowery, D. W., Cox, R. J., Lipscomb, L. E. and Kellermann, A. L. (1998). Randomized, controlled trial of video self-

instruction versus traditional CPR training, Ann Emerg Med, 31(3), 364-9.Todd, K. H., Heron, S. L., Thompson, M., Dennis, R., O'Connor, J. and Kellermann, A. L. (1999). Simple CPR: A randomized, controlled trial of video self-

instructional cardiopulmonary resuscitation training in an African American church congregation, Ann Emerg Med, 34(6), 730-7.Tremblay, L. and Proteau, L. (2001). Specificity of practice in a ball interception task, Canadian Journal of Experimental Psychology, 55(3), 207-218.Turner, I., Turner, S., & Armstrong, V. (2002). Does the compression to ventilation ratio affect the quality of CPR: a simulation study. Resuscitation, 52(1), 55-62.Turner, S. (1987). Teaching CPR as a motor skill. J Nurs Staff Dev, 3(2), 80-81.Turner, S., Turner, I., Chapman, D., Howard, P., Champion, P., Hatfield, J., et al. (1998). A comparative study of the 1992 and 1997 recovery positions for use in the

UK. Resuscitation, 39(3), 153-160.Tweed, W. A., Wilson, E. and Isfeld, B. (1980). Retention of cardiopulmonary resuscitation skills after initial overtraining, Crit Care Med, 8(11), 651-3.Uhley, H. N., Fox, C., Levy, E., & Horne, L. (1979). Enhancement of recall of cardiopulmonary resuscitation (CPR): Use of moving-image card to review the

dynamics of CPR. Heart Lung, 8(3), 517-520.Umlauf, M. G. (1990). How to provide around-the-clock CPR certification without losing any sleep. J Contin Educ Nurs, 21(6), 248-251.Van Kerschaver, E., Delooz, H. H., & Moens, G. F. (1989). The effectiveness of repeated cardiopulmonary resuscitation training in a school population.

Resuscitation, 17(3), 211-222.van Lommel, P., van Wees, R., Meyers, V., & Elfferich, I. (2001). Near-death experience in survivors of cardiac arrest: a prospective study in the Netherlands.

Lancet, 358(9298), 2039-2045.Vanderschmidt, H., Burnap, T. K., & Thwaites, J. K. (1975). Evaluation of a cardiopulmonary resuscitation course for secondary schools. Med Care, 13(9), 763-774.Vanderschmidt, H., Burnap, T. K., & Thwaites, J. K. (1976). Evaluation of a cardiopulmonary resuscitation course for secondary schools retention study. Med Care,

14(2), 181-184.Viitasalo, J. T., Era, P., Konttinen, N., Mononen, H., Mononen, K. and Norvapalo, K. (2001). Effects of 12-week shooting training and mode of feedback on shooting

scores among novice shooters, Scandinavian Journal of Medicine & Science in Sports, 11(6), 362-368.Ward, P., Johnson, L. A., Mulligan, N. W., Ward, M. C. and Jones, D. L. (1997). Improving cardiopulmonary resuscitation skills retention: Effect of two checklists

designed to prompt correct performance, Resuscitation, 34(3), 221-5.Weaver, F. J., Ramirez, A. G., Dorfman, S. B., & Raizner, A. E. (1979). Trainees' retention of cardiopulmonary resuscitation. How quickly they forget. Jama, 241(9),

901-903.Weeks, D. and Anderson, P. (1994). Distribution of demonstration effects in skill learning, Research Quarterly for Exercise & Sport, 65(1), A67-68.Whelan, Y. (1997). Cardiac arrest: the skills of the emergency nurse practitioner. Accid Emerg Nurs, 5(2), 107-110.Wik, L., Dorph, E., Auestad, B., & Andreas Steen, P. (2003). Evaluation of a defibrillator-basic cardiopulmonary resuscitation programme for non medical personnel.

Resuscitation, 56(2), 167-172.Wilson, E., Brooks, B. and Tweed, W. A. (1983). CPR skills retention of lay basic rescuers, Ann Emerg Med, 12(8), 482-4.Wilson, J. (1994). Is CPR training based on practice that ensures reliable performance?, Occup Health Saf, 63(10), 152-6, 158.Wong, M. J., & Lenihan, K. M. (1995). Advances in cardiopulmonary resuscitation. Crit Care Nurs Clin North Am, 7(2), 227-237.Woollard, M., Whitfeild, R., Smith, A., Colquhoun, M., Newcombe, R. G., Vetteer, N., et al. (2004). Skill acquisition and retention in automated external defibrillator

(AED) use and CPR by lay responders: a prospective study. Resuscitation, 60(1), 17-28.Wright, S., Norton, C., & Kesten, K. (1989). Retention of infant CPR instruction by parents. Pediatr Nurs, 15(1), 37-41, 44.Wulf, G., Horger, M. and Shea, C. H. (1999). Benefits of blocked over serial feedback on complex motor skill learning, Journal of Motor Behavior, 99(31), 95-103.Wulf, G. and Horstmann, G. (1995). Does mental practice work like physical practice without information feedback?, Research Quarterly for Exercise & Sport, 66(2),

262-267.Wulf, G. and Schmidt, R. A. (1997). Variability of practice and implicit motor learning [Electronic Version], Journal of Experimental Psychology, 23(4), 987-1006.Wulf, G., Shea, C. H. and Whitacre, C. (1998). Physical-guidance benefits in learning a complex motor skill, Journal of Motor Behavior, 30(4), 367-380.Wulf, G. and Toole, T. (1999). Physical assistance devices in complex motor skill learning, Research Quarterly for Exercise & Sport, 70(3), 265-272.Wulf, G. and Weigelt, C. (1997). Instructions about physical principles in learning a complex motor skill: To tell or not to tell, Research Quarterly for Exercise &

Sport, 68(4), 362-367.Yakel, M. E. (1989). Retention of cardiopulmonary resuscitation skills among nursing personnel: what makes the difference? Heart Lung, 18(5), 520-525.

Documents

C2005 Evidence Evaluation Template - Nov.11, 2003circ.ahajournals.org/content/suppl/2005/11/14/... · Web viewUtilizing combinations of the text search word CPR with the text words