Interventions to improve executive functions and self-awareness in the early phase post-traumatic brain injury: A systematic review

Background: Cognitive rehabilitation guidelines addressing executive function and self-awareness impairments post-traumatic brain injury (post-TBI) involve metacognitive-strategy interventions. However, studies informing these interventions were conducted predominantly in the chronic phase, potentially limiting their applicability to earlier phases. Objective: To examine the effectiveness of cognitive interventions for improving executive function or self-awareness early post-TBI. Methods: Psycinfo, Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane, and Embase were searched for trials published from database inception to March 25, 2024. Inclusion criteria were cognitive interventions for improving executive function or self-awareness impairments post-TBI, at least level IV of evidence. Two independent reviewers screened the identified articles using Covidence software, assessed the risk of bias using Cochrane Collaboration Risk-of-Bias and Downs and Black scale, and evaluated the quality of evidence using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Conflicts were resolved by consulting with a senior reviewer. Full-text review was conducted on 527 of the 6610 identified studies, and 17 studies (957 adults post-TBI) were included (13 randomized controlled trials, 3 non-randomized experimental designs, and 1 pre–post design). Results: Individualized/group interventions focused on specific executive functions, general cognitive function, holistic programs, or self-awareness. Outcome measures included neuropsychological tests, performance-based assessments, daily function evaluations, and self-awareness measures. Positive results were evident for interventions targeting executive functions, and VR-based, metacognitive, and remedial approaches. Interventions incorporating feedback and task-performance analysis were preferable for self-awareness. Nonetheless, heterogeneity and low-quality evidence, due primarily to inconsistency and high risk of bias, limited the generalizability of findings and precluded definitive clinical recommendations. Conclusions: A significant research gap emphasizes the need to explore cognitive interventions during the early phases post-TBI. Future studies should follow standardized protocols for assessment and interventions to enhance comparability and strengthen the evidence base for cognitive rehabilitation early post-TBI.