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It has been argued that there are various forms of awareness including intellectual, emergent and anticipatory. 91
Unfortunately, this complexity and lack of consensus means that the term is often misunderstood and
many interventions have arguably developed out of a perceived clinical need with inadequate theoretical
grounding. 92 In clinical contexts a variety of treatment approaches have been suggested, including behavioural
interventions, direct feedback, game formats, group work, structured experiments, and psychotherapy.
Despite the importance afforded this area in clinical practice, there is a very limited body of evidence
examining the effectiveness of treatment interventions, with few systematic reviews or RCTs available. A
systematic review revealed mixed findings concerning the association between awareness of deficits and
rehabilitation outcome following brain injury (four supporting studies, six with partial support and two that
did not support the association). It concluded, however, that awareness deficits represent a probable barrier to
the client’s own goals or personally valued outcomes. 93 An RCT reported that an awareness training protocol
embedded within the practice of instrumental activities of daily living significantly but selectively improved
self awareness as well as functional performance. 94 The need for a larger study with more treatment sessions
was emphasised by the authors.
There is insufficient evidence available to support recommendations relating to the rehabilitation of poor
insight or self awareness.
5.3 MEMoRy
There is evidence to support the use of compensatory approaches including memory strategy training
and electronic aids (such as NeuroPage, personal digital assistants). 95-97 There is no substantial evidence
that repetitive practice improves memory impairment. There is some evidence that cognitive approaches,
95, 98
including errorless learning, may be effective in relation to learning specific information.
D Patients with memory impairment after TBI should be trained in the use of compensatory memory
strategies with a clear focus on improving everyday functioning rather than underlying memory
impairment.
y for patients with mild-moderate memory impairment both external aids and internal strategies
(eg use of visual imagery) may be used.
y for those with severe memory impairment external compensations with a clear focus on
functional activities is recommended.
B learning techniques that reduce the likelihood of errors being made during the learning of specific
information should be considered for people with moderate-severe memory impairment.
5.4 ATTENTIoN
5 • Cognitive rehabilitation
In relation to attention, there is evidence that impairment focused training (eg computerised attention
training) may produce small beneficial effects in the post-acute phase after TBI, 97 although evidence for
generalisation of these effects is weak. 89,95,99 However, larger effects are found when interventions focus on
training-specific functional skills that make demands on attention through repetitive practice, or teaching
strategies that compensate for attention impairments in everyday tasks.
C Patients with attention impairment in the post-acute phase after TBI should be given strategy
training relating to the management of attention problems in personally relevant functional
situations.
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