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J Head Trauma RehabilVol. 29, No. 5, pp. E9–E30
Copyright c© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Treatment of Unawareness of Deficitsin Patients With Acquired Brain Injury:A Systematic Review
Anne-Claire Schrijnemaekers, MSc; Sanne M. J. Smeets, MSc; Rudolf W. H. M. Ponds, PhD;Caroline M. van Heugten, PhD; Sascha Rasquin, PhD
Objective: To review and evaluate the effectiveness and methodological quality of available treatment methodsfor unawareness of deficits after acquired brain injury (ABI). Methods: Systematic literature search for treatmentstudies for unawareness of deficits after ABI. Information concerning study content and reported effectiveness wasextracted. Quality of the study reports and methods were evaluated. Results: A total of 471 articles were identified;25 met inclusion criteria. 16 were uncontrolled or single-case studies. Nine were of higher quality: 2 randomizedcontrolled trials, 5 single case experimental designs, 1 single-case design with pre- and posttreatment measurement,and 1 quasi-experimental controlled design. Overall, interventions consisted of multiple components includingeducation and multimodal feedback on performance. Five of the 9 high-quality studies reported a positive effect ofthe intervention on unawareness in patients with some knowledge of their impairments. Effect sizes ranged fromquestionable to large. Conclusion: Patients with ABI may improve their awareness of their disabilities and possiblyattain a level at which they personally experience problems when they occur. At present, because of lack of evidence,no recommendation can be made for treatment approaches for persons with severe impairment of self-awarenessin the chronic phase of ABI. We recommended developing and evaluating theory-driven interventions specificallyfocused on disentangling the components of treatment that are successful in improving awareness. High-qualityintervention studies are urgently needed using controlled designs (eg, single-case experimental designs, randomizedcontrolled trials) based on a theoretic perspective with a detailed description of the content of the intervention andsuitable outcome measures. Key words: awareness, brain injuries, intervention studies, literature review, rehabilitation
ACQUIRED BRAIN INJURY (ABI) can lead toimpairments in physical, emotional, cognitive,
and social abilities. Diminished awareness of theseimpairments—a well-known clinical problem followingABI—is seen as compromise of the ability to appraiseone’s strengths and weaknesses and the implications forlife, presently and in the future.1,2 Reported prevalence
Author Affiliations: Rehabilitation Centre Adelante, Department ofBrain Injury, Hoensbroek (Ms Schrijnemaekers and Drs Rasquin, andPonds); Adelante knowledge centre, Hoensbroek (Dr Rasquin); School forMental Health and Neuroscience (MHeNS), Department of Psychiatryand Neuropsychology, Maastricht University (Ms Smeets and Drs Pondsand van Heugten); Department of Medical Psychology, MaastrichtUniversity Medical Center (MUMC), Maastricht (Dr Ponds); andDepartment of Neuropsychology and Psychopharmacology, Faculty ofPsychology and Neuroscience, Maastricht University (Dr van Heugten),The Netherlands.
Supplemental digital content is available for this article. Direct URL citationappears in the printed text and is provided in the HTML and PDF versionsof this article on the journal’s Web site (www.headtraumarehab.com).
The authors declare no conflicts of interest.
Corresponding Author: Anne-Claire Schrijnemaekers, MSc, RehabilitationCentre Adelante, Department of Brain Injury, Zandbergsweg 111, 6432 CCHoensbroek, The Netherlands ([email protected]).
DOI: 10.1097/01.HTR.0000438117.63852.b4
ranges from 30% to 97%, depending on multiple factorsincluding the measurement instrument used, severityof injury, and amount of time since injury.1,3–9 Areasof diminished functioning about which patients maylack awareness include cognition, behavior, and inter-personal skills as well as the effects their behavior haveon others.10 Frontal lobe dysfunction has often beenlinked to impaired awareness of deficits, but currentlythere is no clinical consensus regarding the pathogenesisunderlying this phenomenon.10–12
The concept of impaired awareness can be dividedinto different types of impairment. A practical modeldefined by Crosson et al13 outlines a 3-stage hierarchi-cal model in which intellectual awareness represents theability to understand that a function is impaired or to un-derstand the complications caused by the impairment.Emergent awareness is the ability to recognize a problemwhen it is occurring, which requires the person to reacha level of intellectual awareness similar to that before in-jury. Anticipatory awareness is the ability to foresee thata problem will occur as a result of having some typeof deficit. Other models concerning impaired aware-ness of deficits after ABI also describe 3 componentsof awareness and show considerable overlap.1,14–18 In
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
E9
E10 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2014
2 models,16,17 the psychological factor of denial isprominent. Taken together, these models include cog-nitive components (basic cognitive abilities to perceive,understand, and recognize situations), higher-order cog-nitive components (self-regulation and anticipation),and a psychological component (with denial on 1 sideof the spectrum and acceptance on the other).
The implications associated with impaired awarenessof deficits include diminished motivation for treatment(as the patient may not recognize or acknowledge theneed for intervention),19 worse treatment adherence andperformance,20,21 and an unfavorable short- and long-term employment outcome.22,23 By contrast, patientswith more intact intellectual awareness achieve betterindependent living skills.24 Herein lies the challenge oftreating patients with awareness problems.
Currently, there are no well-established clinical guide-lines for treating unawareness of deficits after ABI,25 de-spite an array of studies that have evaluated differenttreatments to improve awareness of deficits. The objec-tive of this article is to review the available treatmentmethods for impaired awareness and to provide a com-prehensive summary of their effectiveness. The currentreview differs from previous reviews26–28 in that it hasno restriction on the type of brain injury, intervention,study design, and number of participants; it comprises abroad spectrum of research of interventions that aim toimprove awareness of deficits. The following questionsare addressed: (i) which interventions have been investi-gated and what are their specific characteristics and (ii)how effective were these interventions?
METHODS
Selection of articles
A systematic literature search was performed using theelectronic databases PsycINFO (1887 to October 2012),PubMed (1953 to October 2012), Embase (1989 toOctober 2012), The Cochrane Library (1890 to October2012), and PsychBITE (1940 to October 2012). Free textwords as well as index terms were combined. The searchstrategy used 3 categories: diagnosis (ABI), the specificcondition (unawareness of deficits), and intervention.The search was limited to human studies (adolescentsand adults) and articles published in peer-reviewed jour-nals. See Table, Supplemental Digital Content 1, avail-able at http://links.lww.com/JHTR/A87, for a detaileddescription of the specific search strategies used for eachdatabase.
Articles were selected if they described an interven-tion study for improving awareness of deficits in adults(16 years or older) with ABI, and if they had a studydesign with at least pre- and postintervention measure-ments. Studies published in languages other than En-glish, Dutch, German, or French were excluded. Further-
more, studies were excluded if the primary aim of theintervention was related to visuospatial or somatosen-sory neglect. Neglect is based on impaired mechanismsof visual attention and, hence, represents a specific de-marcated area that lies outside the scope of this review.
Studies were independently selected on the basis oftitle, abstract, and full text by the first 2 authors (A.C.S.and S.S.). In cases of disagreement, a third author (S.R.)made the final decision. The reference lists of the se-lected articles were examined for other potentially rele-vant studies. If appropriate, the specific study cited wastracked down and included in the review.
Data extraction
Data extraction was based on the checklist of itemsto consider from the Cochrane manual,29 together withdata extraction methods from similar reviews.30,31 Thefollowing study characteristics were extracted from thearticles: design of the study, number of patients, type ofintervention, effects on the awareness, and functionaloutcome measures. The overall effect of each interven-tion was summarized as positive (+), no effect (0), ornegative (−).32 Results were considered to be positivewhen statistically significant at the P < .05 level. If nostatistical test results were available, the interpretationof the effect was based on the interpretations made bythe authors of the study in question.
In addition, we calculated effect sizes.For independent group studies (eg, RCTs),the standardized difference between means,Hedge’s g, was calculated where possible (ef-fect size = [(Meanexperimental group, postmeasurement −Meanexperimental, pre)/SDexperimental, pre] − [(Meancontrol, post
−Meancontrol, pre)/SDcontrol, pre]).33 An effect size of 0.2is considered small, 0.5 medium, and 0.8 large.34
For single-case studies (eg SCED), the percentage ofnonoverlapping data (PND)35 was used as a measure ofeffect size. For calculating the PND, the highest datapoint in the baseline phase needs to be identified. ThePND is then determined by calculating the percentageof data points during the intervention phase exceedingthis level. A PND smaller than 50% reflects minimallyeffective treatment, 50% to 70% reflects questionableeffectiveness, 70% to 90% is fairly effective and morethan 90% reflects a highly effective treatment. Althoughthe PND is often used to determine the effect of treat-ment in single-case studies, this method is sensitive tofloor/ceiling effects and lacks discrimination abilityfor highly effective treatments (eg, cannot detect slopechanges). This should be taken into account wheninterpreting the PND.
Further data extractions focused on both patient andintervention characteristics. Patient characteristics in-cluded age and sex, in- or outpatient setting, etiology
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Treatment of Unawareness of Deficits in Patients With ABI E11
of ABI, time since onset, severity of ABI, and baselinefunctioning at the beginning of treatment. The follow-ing intervention characteristics were extracted: aim(s)of intervention, content of intervention, disciplines in-volved, and duration/intensity of the intervention.
Quality assessment
Studies were divided into high- and moderate-qualitystudies following predefined criteria. Studies were con-sidered to be of high quality if they used an indepen-dent groups pre-post design (ie, patients were assignedto treatment and control groups and assessed pre- andposttreatment) or if they used single subject designswith multiple pre- and posttreatment measurements (ie,single-case experimental designs). Studies were consid-ered to be of moderate quality or less if they did notfulfill the aforesaid criteria (ie, single group pre-post de-signs or single-case designs with 1 pre- and posttreatmentmeasurement). The results of the high-quality studiesare thoroughly described. The results of the moderate-quality studies are described in summary. To accuratelyprovide a critical appraisal of the validity and applicabil-ity of the reviewed results, treatments were assessed us-ing the CONSORT 2010 checklist of information thatis to be included when reporting an RCT36 and theCONSORT Statement extension for nonpharmacologictrials.37
RESULTS
The literature search identified 471 articles that wereevaluated according to the aforesaid inclusion criteria.Ultimately, 25 articles met the full inclusion criteria andwere used for this review (see Figure 1). Reasons forexclusion included the following: the studies did notaddress awareness of deficits (eg, studies of awareness ofrisk factors for specific diseases in the normal popula-tion), the studies primarily focused on visuospatial orsomatosensory neglect, or the studies were not interven-tion studies.
Of the 25 included studies, 2 were RCTs,25,38 6were single-case experimental designs,39–44 1 was aquasi-experimental controlled trial,45 10 were uncon-trolled pre-post measurements,6,46–54 and 6 were casestudies.55–60 Nine studies fulfilled the criteria to be con-sidered high quality and are further presented in thetables. Studies of moderate quality are briefly describedin the text.
Study characteristics
High-quality studies
The study characteristics of the 9 high-qualitystudies are described in Table 1. The high-qualitystudies consisted of single-case experimental designs
Included articles based on reference in included
articles (n=2)
Systematic literature search: (n=471)
-PubMed: 135-PsychINFO: 86- EMBASE: 112
-Cochrane Library: 41-PsycBITE: 97
Potentially relevant articles (n=343)
Articles selected on abstract (n=42)
Exclusion of duplicates (n=128)
Selected articles for final review (n=25)
Exclusion based on title or abstract (n=301)
Exclusion based on full text (n=18)
No full text available (n=1)
Figure 1. Flowchart of the selection of articles.
(N = 4),39–41,43 RCTs (N = 2),25,38 a quasi-experimentalcontrolled design (N = 1),45 and single-case designs withmultiple pre- and posttreatment measurements (N =2).42,44 The number of participants in the experimentalgroups ranged from 1 to 17 with a mean of 7. Threestudies reported follow-up measurements.42–44
Awareness was measured with the Awareness Ques-tionnaire (AQ) discrepancy score (the difference inscores between the patient and an informant; N =4),38,39,42,44 the AQ patient score (N = 1),45 theself-awareness of deficit interview (SADI; N = 2),25,39
the self-regulation skills interview (SRSI; N = 3),38,42,44
the assessment of awareness of disabilities (N = 2),38,41
the Competency Rating Scale difference score (N =1),43 the difference in predicted versus actual scores ona memory test (N = 1),40 and the percentage of correctanswers on ABI questions (N = 1).43
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.headtraumarehab.com
E12 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2014T
AB
LE1
Stud
ych
arac
teri
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tho
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Treatment of Unawareness of Deficits in Patients With ABI E13T
AB
LE1
Stud
ych
arac
teri
stic
sa(C
ontin
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tho
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try
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ren
ess
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tco
me
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sco
re/C
:sco
re)
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er
Ou
tco
me
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asu
res
(E:
sco
re/C
:sco
re)
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ect
on
aw
are
ne
ss
b
(ES
)
Eff
ect
on
oth
er
ou
tco
me
s(E
S)
Ow
nsw
orth
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39
Aus
tral
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ogni
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cont
extu
alin
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n
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ge,n
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;−4.
7%
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ge,n
t
Err
orfr
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(obs
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.headtraumarehab.com
E14 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2014
TA
BLE
1St
udy
char
acte
rist
icsa
(Con
tinue
d)
Au
tho
r/s
co
un
try
N(E
/C)
Inte
rve
nti
on
De
sig
n/F
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tco
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(E:
sco
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Ou
tco
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(E:
sco
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ect
on
aw
are
ne
ss
b
(ES
)
Eff
ect
on
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er
ou
tco
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s(E
S)
No.
3:st
able
base
line,
clin
ical
lym
eani
ngfu
lch
ange
inle
velo
faw
aren
ess
betw
een
A1
and
B,c
ame
clos
eto
mai
ntai
ning
chan
ge
AD
Lab
ility
(AM
PS
)im
prov
edin
all4
part
icip
ants
.
No.
4:no
stab
leba
selin
e,cl
inic
ally
mea
ning
fulc
hang
ein
leve
lof
awar
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sbe
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nA
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the
A2
phas
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Mul
ticon
text
appr
oach
Sin
gle
subj
ect
with
base
line
(2su
bjec
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pre
(2su
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ndpo
st/1
mo
FUpr
e1=
4w
kbe
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pre2
=ju
stbe
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post
1=
imm
edia
tely
afte
rpo
st2
=4
wk
afte
r
AQ
-Dis
crep
ancy
(cha
nge
scor
es):
No.
1:8.
5,5%
chan
ge,
ntN
o.2:
−3,−
1.8%
chan
ge,n
tN
o.3:
−5,−
2.9%
chan
ge,n
tN
o.4:
−1,−
0.6%
chan
ge,n
tno
raw
scor
esre
port
edS
RS
I:A
war
enes
s:N
o.1:
pre1
10;p
re2
10;p
ost1
8;po
st2
9.5;
−4.5
%ch
ange
(pre
1-po
st2)
,nt
No.
2:pr
e110
;pre
210
;pos
t16.
5;po
st2
6;−3
6.4%
chan
ge(p
re1-
post
2),n
tN
o.3:
pre2
8;po
st1
5.5;
post
27.
5;−4
.5%
chan
ge(p
re2-
post
2),n
t
BR
IEF–
A:d
ecre
ase
of∼1
stan
dard
devi
atio
n,no
scor
esre
port
ed,n
tE
FPT:
mea
nde
crea
seof
3-5
poin
tsN
o.1:
pre1
5;pr
e24;
post
11;
post
22;
−12.
5%ch
ange
(pre
1-po
st2)
,nt
No.
2:pr
e112
;pre
210
;pos
t17;
post
26;
−24%
chan
ge(p
re1-
post
2),n
tN
o.3:
pre2
9;po
st1
3;po
st2
4;−2
0%ch
ange
(pre
2-po
st2)
,nt
No.
4:pr
e26;
post
12;
post
20;
−24%
chan
ge(p
re2-
post
2),n
tM
ET
erro
rs:m
ean
decr
ease
of5
poin
ts
0S
RS
Iaw
aren
ess
(PN
D10
0%),
AQ
(−)
obse
rved
+EFP
T,M
ET
BR
IEF-
A(P
ND
100%
)0
SR
SI
stra
tegy
use
(PN
D10
0%)
obse
rved
(con
tinue
s)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Treatment of Unawareness of Deficits in Patients With ABI E15
TA
BLE
1St
udy
char
acte
rist
icsa
(Con
tinue
d)
Au
tho
r/s
co
un
try
N(E
/C)
Inte
rve
nti
on
De
sig
n/F
UA
wa
ren
ess
ou
tco
me
(E:
sco
re/C
:sco
re)
Oth
er
Ou
tco
me
Me
asu
res
(E:
sco
re/C
:sco
re)
Eff
ect
on
aw
are
ne
ss
b
(ES
)
Eff
ect
on
oth
er
ou
tco
me
s(E
S)
No.
4:pr
e26;
post
12.
5;po
st2
2.5;
−31.
8%ch
ange
(pre
2-po
st2)
,nt
No.
1:pr
e110
;pre
29;
post
12;
post
23;
−54%
chan
ge(p
re1-
post
2),n
tN
o.2:
pre1
12;p
re2
11;p
ost1
7;po
st2
7;−3
8%ch
ange
(pre
1-po
st2)
,nt
No.
3:pr
e28;
post
12;
post
26;
−15%
chan
ge(p
re2-
post
2),n
tN
o.4:
pre2
7;po
st1
1;po
st2
2;−3
8%ch
ange
(pre
2-po
st2)
,nt
SR
SIS
trat
egy
beha
vior
:N
o.1:
pre1
10;p
re2
10;p
ost1
8;po
st2
9;−9
.1%
(pre
1-po
st2)
,nt
No.
2:pr
e18.
3;pr
e27.
6;po
st1
5;po
st2
4.6;
−33.
6%ch
ange
(pre
1-po
st2)
,nt
No.
3:pr
e26.
6;po
st1
4.3;
post
23.
3;−3
0%ch
ange
(pre
2-po
st2)
,nt
No.
4:pr
e27.
6;po
st1
1.3;
post
22.
3;−4
8.2%
chan
ge(p
re2-
post
2),n
tTo
glia
etal
42c
US
A1/
0M
ultic
onte
xtap
proa
chS
ingl
esu
bjec
tde
sign
with
repe
ated
pre-
post
mea
sure
s(4
wk
befo
rean
daf
ter)
SR
SIa
war
enes
spr
e110
;pre
210
;pos
t1
8;po
st2
9.5;
−4.5
%ch
ange
pre2
-pos
t2),
nt.
AQ
dif.
Sco
re:p
re1
22;
pre2
30;p
ost
124
;po
st2
45;1
2.9%
chan
ge,n
t.
SR
SIs
trat
egy
pre1
10;
pre2
10;p
ost
18;
post
29;
9.1%
chan
ge,n
t.B
RIE
Fse
lf-ra
ting
pre1
42;p
re2
45;p
ost1
47;p
ost2
48;n
t
0S
RS
Iaw
aren
ess
(PN
D10
0%),
AQ
(PN
D0%
)ob
serv
ed
+E
FPT
(PN
D10
0%),
ME
T(P
ND
100%
),B
RIE
Fin
form
ant
(PN
D0%
)
( con
tinue
s)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.headtraumarehab.com
E16 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2014
TA
BLE
1St
udy
char
acte
rist
icsa
(Con
tinue
d)
Au
tho
r/s
co
un
try
N(E
/C)
Inte
rve
nti
on
De
sig
n/F
UA
wa
ren
ess
ou
tco
me
(E:
sco
re/C
:sco
re)
Oth
er
Ou
tco
me
Me
asu
res
(E:
sco
re/C
:sco
re)
Eff
ect
on
aw
are
ne
ss
b
(ES
)
Eff
ect
on
oth
er
ou
tco
me
s(E
S)
BR
IEF
info
rman
tra
ting
pre1
61;
pre2
63;p
ost1
52;
post
256
,nt.
ME
T:pr
e12;
pre2
3;po
st1
10;p
ost2
6;30
.8%
chan
ge,n
tE
FPT:
pre1
12;
pre2
10;p
ost1
0;po
st2
6;−2
3.1%
chan
ge,n
t
0S
RS
Istr
ateg
y(P
ND
100%
)FU
:tre
ndto
war
dre
turn
toba
selin
eob
serv
ed
Zhou
etal
43
US
A3/
0N
euro
beha
vior
alre
habi
litat
ion
prog
ram
and
gam
efo
rmat
trai
ning
SC
ED
/2an
d4
wk
FUC
RS
diff
eren
cesc
ore
No.
1:ba
se32
;pha
se1
34;p
hase
221
;ph
ase3
21;−
3.9%
chan
ge(b
asel
ine-
phas
e3)
,nt
No.
2:ba
se44
;pha
se1
25;p
hase
231
;−4
.6%
chan
ge(b
asel
ine-
phas
e2),
ntN
o.3:
base
17;p
hase
119
;pha
se2
26;
phas
e327
;3.5
%ch
ange
(bas
e-ph
ase3
),nt
Kno
wle
dge
ofA
BI
resi
dual
s%
corr
ect
resp
onse
s:
CR
S(P
atie
ntfe
elin
gsof
com
pete
ncy)
No.
1:ba
se10
;ph
ase1
21;p
hase
224
;pha
se3
14;2
%ch
ange
(bas
e-ph
ase3
),nt
No.
2:ba
se24
;ph
ase1
18;p
hase
212
;6.4
%ch
ange
(bas
e-ph
ase2
),nt
No.
3:ba
se50
;ph
ase1
37;p
hase
223
;pha
se3
18;1
7%ch
ange
(bas
e-ph
ase3
),nt
0C
RS
diff
eren
cesc
ore
(PN
D50
%)
+%co
rrec
tre
spon
ses
(PN
D81
%be
havi
or;
80%
cogn
ition
;36
%ph
ysic
al)
obse
rved
0C
RS
(pat
ient
feel
ings
ofco
mpe
tenc
y)(P
ND
63%
)ob
serv
ed
No.
1:be
havi
or:b
ase
60%
;tre
atm
ent
33%
;FU
50%
,nt
cogn
ition
:bas
e16
.5%
;tre
atm
ent
54.8
%;F
U91
.5%
,nt
( con
tinue
s)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Treatment of Unawareness of Deficits in Patients With ABI E17
TA
BLE
1St
udy
char
acte
rist
icsa
(Con
tinue
d)
Au
tho
r/s
co
un
try
N(E
/C)
Inte
rve
nti
on
De
sig
n/F
UA
wa
ren
ess
ou
tco
me
(E:
sco
re/C
:sco
re)
Oth
er
Ou
tco
me
Me
asu
res
(E:
sco
re/C
:sco
re)
Eff
ect
on
aw
are
ne
ss
b
(ES
)
Eff
ect
on
oth
er
ou
tco
me
s(E
S)
Phy
sica
l:ba
se16
.4%
;tr
eatm
ent
62.4
%;F
U49
.5%
,nt
No.
2:be
havi
or:b
ase
22%
;tre
atm
ent
84.2
%;F
U84
.5%
,nt
cogn
ition
:bas
e67
.3%
;tre
atm
ent
96.3
%;F
U91
.5%
,nt
phys
ical
:bas
e60
.8%
;tr
eatm
ent
83.4
%;F
U83
%,n
tN
o.3:
beha
vior
:bas
e38
.6%
;tre
atm
ent
84.3
%;F
U91
.5%
,nt
cogn
ition
:bas
e48
.1%
;tre
atm
ent
92.3
%;F
U75
%,n
tph
ysic
al:b
ase
47.8
%;
trea
tmen
t95
.9%
;FU
91.5
%,n
t
Abb
revi
atio
ns:C
,con
trol
grou
p;E
,exp
erim
enta
lgro
up;E
S,e
ffec
tsi
ze;F
U,f
ollo
w-u
p;na
,not
appl
icab
le;n
s,no
tsi
gnifi
cant
;nt,
not
test
ed;P
ND
,per
cent
age
ofno
nove
rlapp
ing
data
;RC
T,ra
ndom
ized
cont
rolle
dtr
ial;
SC
ED
,sin
gle-
case
expe
rimen
tald
esig
n.a S
eeD
ocum
ent,
Sup
plem
enta
lDig
italC
onte
nt2,
avai
labl
eat
http
://lin
ks.lw
w.c
om/J
HTR
/A88
,for
anex
plan
atio
nof
abbr
evia
tions
and
inte
rpre
tatio
nof
outc
ome
mea
sure
s.bP
rete
stS
RS
Isco
res
orig
inal
lyw
ere
repo
rted
asra
wsc
ores
inst
ead
ofav
erag
esc
ores
.c T
his
case
stud
yw
aspa
rtof
the
larg
erca
sese
ries
stud
yof
Togl
iaet
al.44
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.headtraumarehab.com
E18 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2014
Other outcome measures focused on sustainedattention,41 executive functioning,42,44 neglect,41 motorand process skills,38 activities of daily living,25,39 level offunctional independence,25 community integration,38
feelings of competency,43 and quality of life.45 Thespecifics of the functional outcome measures appear inTable 1.
In 3 of the 9 studies, the effect of the interventionon awareness was statistically significant (Hedge’s g =1.0-1.7; PND 100%).25,38,41 In 2 studies, the effects werenot statistically tested, but the authors reported a posi-tive treatment effect on awareness (PND 36%-81%).40,43
However, in these studies, the positive treatment effectsappeared to be task specific.40,43 Statistically significantimprovements on other outcome measures were seen infunctional independence (Hedge’s g = 0.5),25 activitiesof daily living (Hedge’s g = 0.8),25 and process skills(Hedge’s g = 1.0).38
Moderate-quality studies
The moderate-quality studies consisted of uncon-trolled pre-post studies (N = 10)6,46–54 and single-casedesigns (N = 6).55–60 The mean number of participantswas 22, and sample sizes ranged from 1 to 86. Aware-ness outcome was mostly determined using the SADI(N = 4)51,52,57,58 and the Patient Competency RatingScale (N = 3),6,57,58 the discrepancy between estimatedand actual task performance (N = 3),54,59,60 the AQ(N = 2),46,51 the Clinicians Rating Scale for evaluatingImpaired Self-Awareness and Denial of Disability afterbrain injury (N = 2),46,58 and the SRSI (N = 2).47,50
In 7 of the 16 moderate-quality studies, the effectof the intervention on at least 1 awareness outcomewas statistically significant (P < .05).46–48,50,51,53,54 In5 studies, there was an observed (ie, not statisticallytested) positive effect on awareness.55,57–60 However,here again these observed positive effects were relatedto task-specific improvement55,58–60 and reflectedonly in 1 study an increase in awareness of deficits.57
Positive effects on other outcomes included decreaseddepressive symptoms46 and distress,48,51 decreasedbehavioral problems,50 increased psychosocial well-being47 and psychosocial functioning,50 strategy use,47
self-regulation,50 and a more cooperative attitude toaccept assistance or participate in treatment.56,58
Patient characteristics
High-quality studies
Detailed patient characteristics of the high-qualitystudies are described in Table 2. All participants wereadults aged 20 to 76 years; the approximate mean agewas 45 years, and the majority (median 63%) were men.In 5 of the 9 high-quality studies, patients experienced a
TBI25,39,42,44,45 and in 1 study, the patients had a stroke.41
In the remaining studies, the etiology of the brain in-jury was mixed (eg, TBI, stroke, anoxia).38,40,43 Sever-ity of brain injury was mentioned in 4 studies25,38–40
and ranged from moderate to severe on the basis of theGlasgow Coma Scale, posttraumatic amnesia, or dura-tion of coma. In 7 studies, patients were in the chronicphase after injury (>6 months postinjury) at the start ofthe awareness intervention.38–40,42–45 In addition, in 7studies, patients received outpatient treatment.38–42,44,45
In the 2 studies in which patients were hospitalized, 1group was in the subacute phase25 and the other was inthe chronic phase43 after injury.
The high-quality studies differed in patients’ levelof baseline functioning prior to treatment. Cheng andMan25 reported moderate baseline Functional Indepen-dence Measure scores (experimental group score = 67;control group score = 75) and Lawton instrumentalactivities of daily living (IADL) scores (experimentalgroup score 4.4; control group score 4.6). Tham41 re-ported the baseline score on the Mini-Mental State Ex-amination (MMSE), which ranged from 22 to 27. (SeeDocument, Supplemental Digital Content 2, availableat http://links.lww.com/JHTR/A88, for the specifics ofthese scales). In the other studies, patients were inde-pendent in basic activities of daily living38 or had basicself-care skills,42,44 had difficulty managing multistepIADL,42 participated in volunteer work,39 showed globalcognitive decline,39 had severe to moderate sensory andmotor deficits,41 had a moderate level of disability,44 orshowed serious aggressive behavior.43 In 2 studies, nobaseline level of functioning was reported.40,45
Baseline levels of impaired awareness varied acrossstudies. In 2 studies, therapists recommended patientsfor awareness treatment based on clinical judgment ofevidence of impaired self-awareness.38,43 In one study,patients were included if they underestimated theirmemory deficits (incongruence between predicted mem-ory performance and actual performance),40 and in an-other study, patients had a SADI score greater than 0(mean SADI score at baseline was 5).25 Furthermore,studies reported high SRSI scores (range: 6–10),42,44 highSADI scores (8),39 and a large difference score on the AQ(range: 22–30)42 at baseline. In 2 studies, baseline levelsof awareness were not specified.41,45
Moderate-quality studies
In moderate-quality studies, patients had an approxi-mate mean age of 40 years (range: 19–70 years) and themajority (median 68%) were male. Most studies usedpatients with different types of ABI (eg, TBI, stroke, hy-poxia, infection).6,46–48,50–54,56–58,58 Three studies usedpatients with TBI,55,59,60 and 1 study included only pa-tients who had a stroke.49 Severity of brain injury was
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Treatment of Unawareness of Deficits in Patients With ABI E19T
AB
LE2
Pat
ient
char
acte
rist
icsa
Au
tho
r/s
Me
an
ag
ea
nd
ma
leN
(%)
In-
or
ou
tpa
tie
nt
Inclu
sio
n/E
xclu
sio
ncri
teri
a
Eti
olo
gy
/D
iag
no
sti
ccri
teri
aT
ime
aft
er
on
se
tS
ev
eri
tyA
BI
Ba
se
lin
efu
ncti
on
an
da
wa
ren
ess
(at
sta
rto
ftr
ea
tme
nt)
Cha
ndra
shek
aran
dB
ensh
off45
E:5
9%20
-40
y41
%40
-60
y(6
5%)
C:4
7%20
-40
y53
%40
-60
y(6
3%)
Out
patie
ntIn
cl:p
atie
nts
with
TBI
inS
outh
ern
Illin
ois
and
Mis
sour
iare
a
TBI
Chr
onic
phas
eE
:47%
1-4
y53
%5
yor
mor
eC
:21%
1-4
y79
%5
yor
mor
e
Not
spec
ified
Not
spec
ified
Che
ngan
dM
an25
E:5
4.9
(64%
)C
:58.
1(6
0%)
Inpa
tient
Incl
:App
ropr
iate
com
mun
icat
ion
abili
ties,
stab
lean
dal
ert
(GC
S=
15/1
5).
SA
DIs
core
of>
0
TBI
Reh
abili
tatio
nph
ase:
mea
nho
spita
lph
ase
5.2
wk
(E+
C).
Ave
rage
reha
bilit
atio
nst
ayE
:7.5
;C:1
0w
k
GC
SE
:10
C:1
2.6
FIM
:E:6
7;C
:75
Law
ton
IAD
L:E
:4.4
;C:4
.6S
AD
I:E
5.5;
C:5
.1
Gov
erov
eret
al38
E:3
9.5
(20%
)C
:39.
2(2
0%)
Out
patie
ntIn
cl:S
ome
evid
ence
ofse
lf-aw
aren
ess
impa
irmen
tid
entifi
edby
trea
ting
ther
apis
tE
xcl:
Aph
asia
and/
orse
vere
visu
alpr
oble
ms
orpr
imar
yps
ychi
atric
orsu
bsta
nce
abus
edi
agno
sis
AB
IE
:12.
9m
oC
:8.6
mo
GC
SE
:4.6
/15
C:3
.6/1
5
Inde
pend
ent
inba
sic
AD
LA
AD
:E:1
4.6;
C:1
6.5
SR
SI:
E:4
4.2;
C:4
4.1
AQ
-Dis
crep
ancy
:E
:11.
6;C
:13.
3
Ow
nsw
orth
etal
39N
o.1:
mal
e,36
Out
patie
ntIn
cl:S
ever
eaw
aren
ess
defic
itTB
I48
mo
GC
S:3
/15
(sev
ere)
.P
TA:a
tle
ast
6m
o
Vol
unte
erw
ork.
Glo
balc
ogni
tive
decl
ine.
SA
DI:
6A
Q-D
iscr
epan
cy:1
8R
ebm
ann
and
Han
non40
No.
1:20
,mal
eN
o.2:
21,m
ale
No.
3:25
,mal
e
Out
patie
ntIn
cl:U
nder
estim
atio
nm
emor
yde
ficit
asde
fined
byth
ein
abili
tyto
accu
rate
lypr
edic
tpe
rfor
man
ceon
the
mem
ory
task
sus
ed.
No.
1:A
VM
rupt
ure
No.
2:TB
IN
o.3:
TBI
No.
1:15
mo
No.
2:26
mo
No.
3:36
mo
Com
aN
o.1:
none
No.
2:12
wk
No.
3:7
wk
Enr
olle
din
asp
ecia
lcl
ass
for
adul
tsw
ithbr
ain
inju
ryat
aco
mm
unity
colle
ge.
Aw
aren
ess:
see
incl
usio
n ( con
tinue
s)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.headtraumarehab.com
E20 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2014T
AB
LE2
Pat
ient
char
acte
rist
icsa
(Con
tinue
d)
Au
tho
r/s
Me
an
ag
ea
nd
ma
leN
(%)
In-
or
ou
tpa
tie
nt
Inclu
sio
n/E
xclu
sio
ncri
teri
a
Eti
olo
gy
/D
iag
no
sti
ccri
teri
aT
ime
aft
er
on
se
tS
ev
eri
tyA
BI
Ba
se
lin
efu
ncti
on
an
da
wa
ren
ess
(at
sta
rto
ftr
ea
tme
nt)
Tham
etal
41N
o.1:
64,
fem
ale
No.
2:73
,fe
mal
eN
o.3:
76,
fem
ale
No.
4:58
,fe
mal
e
Out
patie
ntIn
cl:R
ight
CV
Aof
nom
ore
than
10w
kag
o,se
vere
unila
tera
lneg
lect
and
phys
ical
,ps
ycho
logi
cal,
and
inte
llect
ual
capa
citie
sth
atal
low
edac
tive
part
icip
atio
nin
asse
ssm
ent
and
trai
ning
Rig
hthe
mi-
sphe
rest
roke
<10
wk
Not
spec
ified
MM
SE
No.
1:22
No.
2:26
No.
3:24
No.
4:27
Sev
ere
sens
ory
loss
.Mod
erat
eto
seve
rehe
mip
ares
is,
visu
alfie
ldde
ficits
.A
war
enes
sle
vel
unkn
own
Togl
iaet
al44
No.
1:29
,fe
mal
eN
o.2:
27,m
ale
No.
3:47
,mal
eN
o.4:
50,
fem
ale
Out
patie
ntIn
cl:>
6m
oaf
ter
inju
ry;
inde
pend
ence
inba
sic
leve
lski
lls(F
IM);
min
imum
assi
stin
com
mun
icat
ion;
abili
tyto
atte
ndto
task
for
leas
t30
min
;com
pete
nce
topr
ovid
ein
form
edco
nsen
t;di
fficu
ltyin
man
agin
gm
ultis
tep
inst
rum
enta
lAD
L
TBI
No.
1:67
mo
No.
2:37
mo
No.
3:42
mo
No.
4:49
mo
Not
spec
ified
Mod
erat
ele
velo
fdi
sabi
lity
(Dis
abili
tyR
atin
gS
cale
).B
asic
self-
care
skill
s(F
IM)
AQ
-Dis
crep
ancy
:un
know
nS
RS
I:N
o.1:
10;
No.
2:10
;No.
3:8;
No.
4:6
Togl
iaet
al42
No.
1:29
,fe
mal
eO
utpa
tient
Incl
:>6
mo
post
-TB
I,in
depe
nden
cein
self-
care
activ
ities
,di
fficu
ltyin
man
agin
gm
ultis
tep
inst
rum
enta
lAD
L;co
mpe
tenc
eto
prov
ide
info
rmed
cons
ent
Exc
l:R
epor
tof
inte
rven
tion
ofsu
bsta
nce
abus
eor
hosp
italiz
atio
nfo
rps
ychi
atric
diso
rder
.
TBI
66m
oN
otsp
ecifi
edM
oder
ate
leve
lof
disa
bilit
y(d
isab
ility
ratin
gsc
ale)
,liv
ing
inap
artm
ent
with
24-h
aid
and
spec
ializ
edda
ypr
ogra
m.D
enia
lof
func
tiona
lor
cogn
itive
diffi
culti
es,e
xcep
tfo
rw
alki
ngan
dsp
eaki
ngcl
early
( con
tinue
s)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Treatment of Unawareness of Deficits in Patients With ABI E21T
AB
LE2
Pat
ient
char
acte
rist
icsa
(Con
tinue
d)
Au
tho
r/s
Me
an
ag
ea
nd
ma
leN
(%)
In-
or
ou
tpa
tie
nt
Inclu
sio
n/E
xclu
sio
ncri
teri
a
Eti
olo
gy
/D
iag
no
sti
ccri
teri
aT
ime
aft
er
on
se
tS
ev
eri
tyA
BI
Ba
se
lin
efu
ncti
on
an
da
wa
ren
ess
(at
sta
rto
ftr
ea
tme
nt)
Zhou
etal
43N
o.1:
30,m
ale
No.
2:32
,mal
eN
o.3:
31,m
ale
Inpa
tient
Incl
:Res
iden
tsof
the
reha
bilit
atio
npr
ogra
man
dre
com
men
ded
for
awar
enes
sin
stru
ctio
nby
clin
ical
trea
tmen
tte
am
No.
1:an
oxic
No.
2an
dN
o.3:
TBI
No.
1:24
mo
No.
2:18
mo
No.
3:12
0m
o
Not
spec
ified
Phy
sica
land
verb
alag
gres
sive
beha
vior
.C
RS
diff
eren
ce:N
o.1:
32;N
o.2:
44;
No.
3:17
Kno
wle
dge
ofA
BI
resi
dual
s%
corr
ect
resp
onse
s:se
eTa
ble
1.
Abb
revi
atio
ns:
AB
I,ac
quire
dbr
ain
inju
ry;
AV
M,
arte
riove
nous
mal
form
atio
n;C
,co
ntro
lgr
oup;
E,
expe
rimen
tal
grou
p;G
CS
,G
lasg
owC
oma
Sca
le;
PTA
,po
sttr
aum
atic
amne
sia;
TBI,
trau
mat
icbr
ain
inju
ry.
a Exp
lana
tion
ofab
brev
iatio
nsan
din
terp
reta
tion
ofou
tcom
em
easu
res
can
befo
und
inS
uppl
emen
talD
igita
lCon
tent
2,av
aila
ble
atht
tp://
links
.lww
.com
/JH
TR/A
88.
noted in 9 of the 16 studies.6,46,48,50,51,55,57–59 The major-ity of participants had a severe brain injury. Mean timepostonset varied from 8 weeks to 8 years. In 10 stud-ies, patients were in the chronic phase after injury6,46,
47,48,50–52,55,57,60; in 3 studies, patients were in the posta-cute phase and in 1 study, chronicity was mixed53; in2 studies, time since injury was not specified.54,59
Intervention characteristics
High-quality studies
The detailed characteristics of the interventions fromhigh-quality studies are described in Table 3. All in-terventions consisted of more than 1 component. Themajority used some form of psychoeducation aboutdeficits, often in combination with feedback on per-formance. Education was given by presenting declara-tive knowledge about deficits,25,39,43 experiential func-tional exercises guided by therapists,25,41,42,45 or byusing a board game with a question-answer-rewardformat.43 Feedback was given verbally,25,40 visually,40 oraudiovisually,39,41 by positive reinforcement,38,40,43,42,44
by nonconfrontational discussion between patient andresearcher about task performance,38,39,41,42 or by self-evaluation.42,44
Occupational therapy was the major discipline in-volved in the studied interventions.38,39,41,42,44 In 1study, a psychologist was involved.43 In 3 studies, thediscipline was not stated.25,40,45
Treatment duration and intensity varied across the 9studies, ranging from 3 to 12 weeks and the total numberof sessions ranging from 6 to 40 (45 minutes-2 hours).
The treatment programs were effective in improvingawareness in 525,38,40,41,43 of the 9 high-quality studies.Therefore, they are described more thoroughly.
Goverover et al38 investigated an occupation-basedtraining protocol. Twenty patients with some evidenceof self-awareness performed IADL tasks. The patients inthe experimental group had to predict their performancebefore a task, then estimate and evaluate their perfor-mance afterward. They were stimulated to think of astrategy to improve their task performance. Participantshad learned to improve IADL activities and showed bet-ter self-regulation. The improvement in self-regulationwas significant (Hedge’s g = 1.0). Self-regulation was de-fined as having awareness, the readiness to change andformulating strategy behaviors.63 The patients in thecontrol group completed the IADL tasks without theawareness intervention. On specific awareness measures,no significant treatment effect was observed.
Tham et al41 investigated awareness in 4 women withmild to moderate cognitive disabilities and severe sen-sory loss. Patients were fewer than 10 weeks poststrokeand had intellectual awareness at baseline. The 4-weekintervention phase consisted of training purposeful and
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.headtraumarehab.com
E22 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2014
TA
BLE
3In
terv
entio
nch
arac
teri
stic
s
Au
tho
r/s
Aim
of
inte
rve
nti
on
Inte
rve
nti
on
(E/C
)D
iscip
lin
es
inv
olv
ed
Du
rati
on
/In
ten
sit
y
Cha
ndra
shek
aran
dB
ensh
off45
Tode
term
ine
ifpe
rson
sw
ithTB
Iw
hopa
rtic
ipat
ein
6w
eeks
ofth
eQ
ualit
yof
Life
and
Aw
aren
ess
Trai
ning
diff
ersi
gnifi
cant
lyfo
rmth
ose
who
dono
tpa
rtic
ipat
ein
the
way
that
(1)t
hey
perc
eive
qual
ityof
life
and
(2)t
hey
are
awar
eof
thei
rde
ficits
.
E:6
wk
Qua
lity
ofLi
fean
dA
war
enes
sTr
aini
ng(Q
LAT)
.Tra
inin
ggo
als
and
activ
ities
wer
ees
tabl
ishe
don
the
basi
sof
the
Wis
cons
inH
SS
Qua
lity-
of-L
ifeIn
vent
ory.
Aw
aren
ess
trai
ning
goal
san
dac
tiviti
esw
ere
base
don
Ow
nsw
orth
etal
’s61
wor
kboo
kon
grou
pac
tiviti
esfo
rpe
rson
sw
ithTB
I.C
:no
QLA
T,pl
ayin
gbo
ard
gam
esan
dca
rds
ina
grou
p.
Not
spec
ified
E:6
sess
ions
in6
wk.
Eac
hse
ssio
nw
as1
han
d30
min
inle
ngth
with
10-m
inbr
eak.
C:6
sess
ions
of11 / 2
hdu
ring
6w
k
Che
ngan
dM
an25
Man
agem
ent
ofim
paire
dse
lf-aw
aren
ess
E:A
war
enes
sIn
terv
entio
nP
rogr
am:
educ
atio
nto
enha
nce
obje
ctiv
ekn
owle
dge
abou
tde
ficits
;ex
perie
ntia
l,fu
nctio
nale
xerc
ises
toen
hanc
epa
tient
s’aw
aren
ess
ofch
ange
sin
thei
rab
ility
;pra
ctic
eof
self-
perf
orm
edpr
edic
tion
and
goal
-set
ting
durin
gex
perie
ntia
lfu
nctio
nale
xerc
ise;
conc
rete
and
exte
nsiv
efe
edba
ck.I
ndiv
idua
l.
Not
spec
ified
4w
k,5
da
wee
k,2
sess
ions
per
day.
C:C
onve
ntio
nalr
ehab
ilita
tion
prog
ram
:in
clud
edph
ysic
al,f
unct
iona
l,an
dco
gniti
veas
pect
sof
occu
patio
nal
ther
apy.
Ingr
oups
,par
ticip
ants
wer
etr
aine
din
activ
ities
ofda
ilyliv
ing,
trai
ning
inm
otor
func
tion
prer
equi
site
sfo
rfu
nctio
nalt
asks
,co
gniti
vetr
aini
ng(u
nstr
uctu
red
orie
ntat
ion
and
mem
ory
grou
p),a
nda
pred
isch
arge
arra
ngem
ent
grou
p.(c
ontin
ues)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Treatment of Unawareness of Deficits in Patients With ABI E23T
AB
LE3
Inte
rven
tion
char
acte
rist
ics
(Con
tinue
d)
Au
tho
r/s
Aim
of
inte
rve
nti
on
Inte
rve
nti
on
(E/C
)D
iscip
lin
es
inv
olv
ed
Du
rati
on
/In
ten
sit
y
Gov
erov
eret
al38
Alle
viat
edi
fficu
lties
rela
ted
tose
lf-aw
aren
ess
and
self-
regu
latio
nan
dto
addr
ess
func
tiona
lpe
rfor
man
ceou
tcom
es
Per
form
ance
ofon
ein
stru
men
tal
activ
ityof
daily
livin
g.E
:Prio
rto
task
,pa
rtic
ipan
tde
fined
task
goal
s;pr
edic
ted
perf
orm
ance
;ant
icip
ated
and
prep
lann
edfo
rer
rors
orob
stac
les;
chos
ea
stra
tegy
toav
oid
erro
rs;a
sses
sed
amou
ntof
assi
stan
cene
eded
.Aft
erta
skco
mpl
etio
n,pa
rtic
ipan
tes
timat
edan
dev
alua
ted
own
perf
orm
ance
,fol
low
edby
adi
scus
sion
with
the
rese
arch
er.
Aft
erw
ards
the
part
icip
ant
wro
teex
perie
nces
ina
jour
nal
Occ
upat
iona
lth
erap
y6
indi
vidu
alse
ssio
ns(4
5m
in)o
ver
3w
k
C:c
onve
ntio
nalp
ract
ice,
incl
udin
gdi
rect
corr
ectiv
efe
edba
ckfr
omth
erap
ist.
Ow
nsw
orth
etal
39To
targ
eter
ror
awar
enes
san
dse
lf-co
rrec
tion
in2
real
-life
sett
ings
:(1
)coo
king
atho
me
and
(2)
volu
ntee
rw
ork
Prio
rto
base
line
asse
ssm
ent
subj
ect
prac
tices
cook
ing
am
ealw
ithhi
sm
othe
r’s
supp
ort.
Trea
tmen
t:Fe
edba
ckab
out
the
subj
ect’
spo
stin
jury
chan
ges.
Edu
catio
nfo
rfa
mily
,fee
dbac
ken
prom
ptin
gdu
ring
the
spec
ific
perf
orm
ance
son
cook
ing
and
wor
kta
sks.
Pro
mpt
ing
acco
rdin
gto
the
prin
cipl
esof
“Pau
se,P
rom
ptan
dP
rais
e.”62
Rol
ere
vers
alte
chni
que
(obs
ervi
ngm
othe
rco
oken
give
her
feed
back
).E
xter
nalr
emin
der
(ele
ctro
nic
timer
)for
chec
king
reci
pe,
prec
ooki
ngdi
scus
sion
,and
post
cook
ing
feed
back
disc
ussi
on.
Vid
eofe
edba
ck.S
imila
rte
chni
ques
wer
eus
edin
the
volu
ntee
rta
sk.
Occ
upat
iona
lth
erap
ist
Coo
king
:16
wk:
4w
kba
selin
e,8
wk
trea
tmen
t,an
d4
wk
mai
nten
ance
and
gene
raliz
atio
nW
ork:
16w
k:12
wk
base
line,
4w
ktr
eatm
ent.
Reb
man
nan
dH
anno
n40To
test
anin
terv
entio
nfo
rre
duci
ngun
awar
enes
sof
mem
ory
defic
itsus
ing
abe
havi
oral
appr
oach
Bas
elin
eco
nditi
on:n
ofe
edba
ckdu
ring
perf
orm
ance
trea
tmen
t:(1
)vis
uala
ndve
rbal
feed
back
:pro
blem
solv
ing
appr
oach
,enc
oura
ging
subj
ects
tofin
dou
tw
hyth
eir
pred
ictio
nsdi
dno
tm
atch
thei
rpe
rfor
man
cean
d(2
)po
sitiv
ere
info
rcem
ent:
verb
alpr
aise
and
lott
ery
ticke
ts.
Not
spec
ified
No.
1:8
trea
tmen
tse
ssio
nsN
o.2:
6tr
eatm
ent
sess
ions
No.
3:6
trea
tmen
tse
ssio
nsD
urat
ion
and
inte
nsity
:2se
ssio
nsa
wee
kfo
r5-
6w
k.( c
ontin
ues)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.headtraumarehab.com
E24 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2014
TA
BLE
3In
terv
entio
nch
arac
teri
stic
s(C
ontin
ued)
Au
tho
r/s
Aim
of
inte
rve
nti
on
Inte
rve
nti
on
(E/C
)D
iscip
lin
es
inv
olv
ed
Du
rati
on
/in
ten
sit
y
Tham
etal
41Im
prov
ing
awar
enes
sof
disa
bilit
ies
incl
ient
with
unila
tera
lneg
lect
Aph
ase:
occu
patio
nalt
hera
py;5
days
aw
eek
focu
sed
ontr
aini
ngin
self-
care
activ
ities
byus
ing
the
part
icip
ants
avai
labl
eab
ilitie
san
dby
adap
ting
task
sde
man
dsan
dco
ntex
ts.
Pat
ient
spa
rtic
ipat
edin
othe
rre
habi
litat
ion
serv
ices
asw
ell.
Bph
ase:
Focu
sof
occu
patio
nalt
hera
pyon
trai
ning
awar
enes
sof
abili
ties.
Ther
apis
tssu
ppor
tth
epa
tient
sto
choo
sem
otiv
atin
gtr
aini
ngta
sks;
disc
uss
and
eval
uate
perf
orm
ance
(incl
udin
gle
arni
ngco
mpe
nsat
ory
tech
niqu
es);
use
the
hom
een
viro
nmen
t(e
g,co
nfro
ntat
ion)
;vi
deo
feed
back
;usi
ngth
erap
eutic
narr
ativ
es
Occ
upat
iona
lth
erap
yA
BA
:A1
phas
e:ba
selin
eob
serv
atio
nsdu
ring
4se
ssio
nsov
er2-
wk
perio
d.1-
2h
ada
y.In
terv
entio
nph
ase
B:
4da
taco
llect
ion
sess
ions
over
4w
k,1
hto
2h
ada
y,5
days
aw
eek.
A2
FUph
ase:
2tim
esda
taco
llect
ion
afte
r5
and
9w
k
Togl
iaet
al44
Toim
prov
epr
oxim
alou
tcom
es(c
ogni
tive
stra
tegi
esan
dse
lf-re
gula
tion)
,di
stal
outc
omes
(gen
eral
awar
enes
san
dev
eryd
ayfu
nctio
n),
and
mai
nten
ance
ofga
ins
4w
kFU
Gui
ded
antic
ipat
ion
ofch
alle
nges
,gu
ided
stra
tegy
gene
ratio
n,er
ror
disc
over
yph
ase,
stra
tegy
trai
ning
/med
iatio
nph
ase,
rein
forc
emen
tof
stra
tegy
use,
sess
ion
self-
eval
uatio
n,st
ruct
ured
jour
nal
Occ
upat
iona
lth
erap
y75
-min
sess
ions
,tw
ice
per
wee
kov
er∼5
wk
Togl
iaet
al42
Toim
prov
ele
arni
ngan
dtr
ansf
erof
stra
tegy
use,
self-
mon
itorin
gsk
ills,
perf
orm
ance
infu
nctio
nalt
asks
post
inte
rven
tion,
and
awar
enes
s
See
Togl
iaet
al44
Occ
upat
iona
lth
erap
y75
-min
sess
ions
,tw
ice
per
wee
kov
er∼5
wks ( con
tinue
s)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Treatment of Unawareness of Deficits in Patients With ABI E25
TA
BLE
3In
terv
entio
nch
arac
teri
stic
s(C
ontin
ued)
Au
tho
r/s
Aim
of
inte
rve
nti
on
Inte
rve
nti
on
(E/C
)D
iscip
lin
es
inv
olv
ed
Du
rati
on
/In
ten
sit
y
Zhou
etal
43A
gam
efo
rmat
tote
ach
info
rmat
ion
abou
tA
BIt
ope
rson
sex
perie
ncin
gth
eef
fect
sof
such
inju
ries.
Six
cate
gorie
sw
ere
targ
eted
:beh
avio
r,em
otio
n,co
gniti
on,c
omm
unic
atio
n,ph
ysic
al,a
ndse
nsor
y.E
ach
cate
gory
cons
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.headtraumarehab.com
E26 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2014
meaningful daily tasks at both the rehabilitation cen-ter and the home environment. Strategy behaviors wereencouraged, followed by self-evaluation and visual andverbal feedback. Awareness of abilities improved in these4 patients (clinically meaningful change). The PND of100% indicates that the treatment was highly effective.The improvements were maintained at follow-up in 2 of3 patients.
Cheng and Man25 conducted an RCT with 22 pa-tients with moderate ABI in the postacute phase withintellectual awareness at baseline. The experimentalgroup received a 4-week Awareness Intervention Pro-gram that included enhancing objective knowledgeabout deficits, experiential functional exercises, prac-tice of self-performed prediction and goal setting, andconcrete and extensive feedback. The control group fol-lowed a conventional rehabilitation group program in-cluding training in activities of daily living, training inmotor function, and cognitive training. The result wasan improvement in the level of awareness and in func-tional activities of daily living and IADL activities for theexperimental group, but not the control group (Hedge’sg = 0.5-1.7).
The behavioral approach of Rebmann and Hannon40
was based on positive verbal (praise) and materialistic(lottery tickets) reinforcement for more accurate predic-tions of performance. Task-specific awareness improvedin all 3 participants; however, the effect of the treatmentwas questionable as indicated by a PND of 56%.
Zhou43 investigated a modified Trivial Pursuit gameformat intervention over a period of 11 weeks using pos-itive feedback in 3 aggressive men with severe TBI whohad poor awareness of deficits in the chronic phase re-covery. Participants engaged in 1-hour group sessions3 times a week (32 sessions). The topics included “be-havior and emotion,” “cognition and communication,”and “physical and sensory.” For each topic, the ques-tions concerned terminology, the effects that limitationsmight have on a person’s life, and potential compen-satory strategies. Feedback was positive when answerswere correct and informative (ie, corrective) when an-swers were incorrect. All 3 patients showed improve-ment in general knowledge of the consequences of ABI(PND 80%–81%). However, a general understanding ofthe impact of ABI may not reflect patients’ awarenessof their own deficits. There was no change observed inthe discrepancy between ratings given by patients andclinicians on a competency rating scale, indicating thatpatients’ knowledge of their own deficits did not im-prove (PND 50%).
The remaining 4 studies in the high-quality group didnot show improvement in awareness of deficits. How-ever, the 2 studies of Toglia et al42,44 are worth describ-ing briefly because of the theoretical background of theintervention.
Toglia et al42,44 outlined the importance of gener-alizing strategy use from trained to untrained tasks.Therefore, they used a multicontext approach that in-cluded systematically varying treatment activities andcontext and gradually increasing transfer distance. In9 sessions, improvements were observed in monitoringskills and strategy use (PND 100%), and these improve-ments persisted in 3 of 4 patients at follow-up in onestudy,44 but not in the other.42 General awareness ofdeficits, however, remained unchanged. Toglia et al44
and Ownsworth et al64 suggested that persons who lackunderstanding of their general deficits still are able tolearn to use and monitor a strategy across situations. Theunderlying mechanisms may include automatic learn-ing and habit formation and active and deliberate self-monitoring mechanisms.
Moderate-quality studies
The types of interventions in the moderate-qualitystudies are similar to those of the high-quality stud-ies. They were diverse as well and consisted ofmultiple components, such as the therapeutic re-lationship (N = 3),55,57,58 education and feedback(N = 9),6,46,47,51,54,56–58,60 coping and problem-solving(N = 2),47,53 and social skills training (N = 1).50
The interventions of the moderate-quality studies weremostly carried out by a multidisciplinary team (N =5).6,47,48,52,60 Other disciplines involved were psychol-ogy (N = 3),46,50,53 occupational therapy (N = 3),57–59
and neurology (N = 1).51 In 4 studies, the type of ther-apy was not clearly specified.49,54–56 The intensity of theinterventions varied between studies from 1 session to56 sessions, with an average duration of 14 weeks andan average of 4 days a week therapy. Three interven-tions used group therapy.6,47,50 The other interventionsconsisted of individual training.
Quality assessment
Although the CONSORT Statement is primarily in-tended to address RCTs, an effort was made by theauthors to review non-RCT studies of higher quality aswell as the validity and applicability of their results.
The quality of the 9 high-quality studies is presentedin Table 4. In general, the quality of the report wasmoderate. No study scored more than 50% on thechecklist. Positive aspects were accurate reporting inthe abstract, introduction, and discussion. The methodsections, however, were of lower quality. The descrip-tion of intervention methods was mostly in globalterms, without specific discussion of the similaritiesand differences between interventions. Furthermore,descriptions of the procedure for tailoring interventionsto individual participants and details of how therapist
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Treatment of Unawareness of Deficits in Patients With ABI E27T
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adherence to the protocol was assessed or enhancedwere often not indicated.
DISCUSSION
This systematic literature search of the available treat-ment methods for unawareness of deficits in people withbrain injury yielded 25 studies for inclusion. Nine stud-ies with controlled or single case experimental designswere considered to be high quality and were investi-gated thoroughly. Interventions were performed mostlyin people with traumatic brain damage who were inthe chronic phase and had moderate to severe levels ofinjury.
Conceptual and methodological differences made itdifficult to compare studies. As noted in previous re-views, researchers used different interventions to addressimpaired self-awareness.27 The majority of the treat-ments included a combination of psychoeducation andfeedback.
Three interventions (2 RCTs and 1 SCED) showedpromising results with multimodal training andfeedback.25,38,41 These studies utilized patients in thepostacute phase of rehabilitation with intellectual aware-ness at baseline. It remains unclear which aspects of thetreatment were effective, but the interventions in thesestudies shared some elements that might have led toimprovements in awareness. These were training func-tional skills in real life settings, guided experience, mul-timodal feedback, and dialogue between therapist andpatient, which could best be described as Socratic rea-soning. The last of these comports with the view thatmotivational interviewing might be a useful techniqueto improve awareness of deficits.65
Furthermore, 2 studies40,42 investigated awareness in-terventions in an artificial training situation. In patientswith ABI exhibiting severe lack of awareness, a single taskor game was practiced, and performance was rewardedon the basis of the principles of operant conditioning.These interventions led to task-specific improvementsin awareness.
The studies that did show a positive effect of interven-tion on awareness included patients with at least someintellectual awareness. To date, there is no convincingevidence that people with unawareness in the chronicphase post-ABI may progress to some level of intellec-tual awareness. It remains unclear whether awareness ofdeficits can be improved in patients with very poor intel-lectual awareness who are in the chronic phase after in-jury when spontaneous recovery is unlikely. Moreover, aprerequisite for intellectual awareness is the basic cogni-tive ability of patients to remember and integrate past ex-periences to draw conclusions about the commonalitiesbetween their pre- and postinjury experiences. Thus, sig-nificant deficits in abstract reasoning or memory during
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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E28 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2014
the chronic phase of recovery might underlie enduringlimitations in intellectual awareness.15
There are still many questions to be answered. Toformulate general guidelines for the developmentof an awareness intervention, several points needfurther attention. First, many studies lack a theoreticalperspective. Although some studies acknowledgeand hypothesize 2 or 3 components underlying theconcept of awareness, they do not specifically report atwhich component of awareness their intervention andoutcome measures are aimed. Defining these factors isnecessary to frame the results in a theoretical perspectiveto verify and refine the existing theories. Second, thereare several good quality measurement instruments toassess awareness.66 However, these measurements donot encompass all 3 components of awareness. This isimportant to consider when evaluating the impact ofawareness interventions. Third, the concepts “learning”and “changing awareness” seem to be used inter-changeably. It remains unclear whether a task-specificimprovement is the result of increased awareness orsimply learning a task. Only when an improvement canbe generalized to other nontrained tasks or daily func-tioning, one can speak of an improvement in awareness.
Before reaching a consensus on how to treat unaware-ness of deficits, we should agree on an underlying theoryand standardize measures of awareness to promote ac-curate determination of treatment effects. The next stepis to take into account patients’ basic and higher-ordercognitive deficits that may affect awareness and, thus,determine the patients’ current ability to be aware oftheir problems.15 Another conceptual issue to addressis the fact that the reviewed studies did not distinguishbetween impaired self-awareness and denial of disabil-ity, that is, the psychological component of awareness.These concepts are not mutually exclusive, but likelyrequire different treatment approaches.58,67
In general, the quality of the study reports was mod-erate. Often, the description of the intervention was notclearly stated or was explained only in general terms. Itwas never reported how therapist adherence to the treat-ment protocol was assessed or enhanced. In addition, itwas not always clear what the important outcome mea-sures were and how they were used in the analysis. Theseresults are in line with those of a previously publishedsystematic review concerning the content of evidence-based cognitive rehabilitation, which emphasized thelack of information provided in studies about the actualcontent of treatment.68
This review differs from previous reviews in that itused less stringent restrictions on included studies ofmethods to improve awareness of deficits, resulting in abroad spectrum of research. However, this approach hasits limitations. The heterogeneity of the studied samplesin terms of injury severity, brain injury etiology, time
since injury, and the small sample sizes of several stud-ies limit the generalizability of the results and the prac-tical applicability of the conclusions. Also, we utilizedauthors’ conclusions in interpreting the effects of stud-ies that lack statistical test results, and these conclusionsmay be too optimistic or even erroneous. However, forsome studies, the calculated PNDs, despite its limita-tions, provided a better basis for interpretation of theresults.
Unawareness of deficits in patients with ABI is a well-known clinical problem that hinders the rehabilitationprocess. To tackle this problem, a practical and evidence-based protocol to improve awareness is necessary; how-ever, such a protocol is not yet available. We adviseclinicians to consider the improvement of awareness asa primary treatment goal and not as merely a byproductof rehabilitation. In other words, if a patient undergoescognitive rehabilitation but is unaware of his or her cog-nitive deficits, one main objective of cognitive rehabil-itation should be to increase awareness of the patient’sproblems. Furthermore, future studies should considerthe use of the CONSORT Statement36,37 to improvemethodological quality reporting.
On the basis of this review, we can propose sometentative guidelines regarding treatment of patients withimpaired self-awareness. A general approach to improveawareness includes training functional skills in multi-ple, preferably real life, settings with feedback usingguided experience in a Socratic dialogue. Furthermore,to choose which intervention is most appropriate for aspecific patient, it is helpful to determine a cognitiveprofile of strengths and weaknesses, because cognitionis an important component of awareness of deficits.13
It is also worthwhile to determine on which learninglevel the intervention should focus. For example, if theintervention is aimed at improving a specific task, thetraining could be based on procedural and explicit learn-ing. If the goal is improving ability, the intervention ismore complex. In this case, generalization across tasksis necessary, and it requires the meta-cognitive abilityto reflect upon oneself, which is an important aspect ofawareness.
Although we realize that the aforementioned consid-erations will be challenging in both research and clinicalsettings, they represent a necessary step to move forwardto increase understanding and improve the efficacy ofinterventions aimed at awareness of deficits.
CONCLUSION
Our systematic review showed that impaired aware-ness after ABI could be improved in patients withsome degree of intellectual awareness through a com-bination of education and multimodal feedback re-lated to performance. However, there still is a need
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Treatment of Unawareness of Deficits in Patients With ABI E29
for high-quality intervention studies with controlled de-signs (ie, SCED, RCT) based on a theoretic perspec-tive with a detailed description of the content of theintervention and suitable outcome measures. Future re-search should focus on identifying the components thatcontribute to improved awareness in people with ABI,
preferably using a sound methodology and theoreticalperspective. Instead of considering improved awarenessas the residual byproduct of rehabilitation, cliniciansshould specifically focus on awareness and test their ef-forts to improve awareness with single-case experimentaldesigns.
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