Unawareness related to brain injury is defined as the phenomenon in which a patient does not appear to be aware of impaired neurological or neuropsychological functioning which is obvious to other reasonable, attentive individuals.
Unawareness related to brain injury has considerable implications for participation in rehabilitation and functional outcome, due to limited motivation, engagement, cooperation and understanding of the purpose of rehabilitation. Despite implications, rehabilitation aimed at unawareness is a relatively unexplored field with many inconsistencies. Therefore, the present paper examines how a rehabilitation program can be designed in a way that increases awareness among individuals with acquired brain injury and consequent problems with unawareness.
Strategies to rehabilitation are examined through a research synthesis based on quantitative, qualitative and case studies to provide a united framework in terms of theoretical bases and research evidence.
The research synthesis identified a range of awareness interventions including multicontextual, psychotherapeutic, holistic, behavioral focused and group based approaches, which all seem to have a positive influence on awareness. In these approaches, some similarities can be identified such as self-regulation training, feedback, active participation, a safe environment and use of contexts and tasks that make sense to the individual. These strategies seem to be important for improving awareness, and it is therefore recommended that they are included in rehabilitation. Some of these strategies are also seen in theories that seek to explain unawareness in connection to brain injury such as the pyramid model proposed by Crosson et al. (1989) and the dynamic interactional model of cognition proposed by Toglia & Kirk (2000). Also the REF-model proposed by Mogensen and Malá (2009) seems to incorporate some of these strategies in accordance with reorganization of the brain after acquired brain injury.
The results of the research synthesis indicate that patients are able to gain awareness in connection to specific tasks and behavior without having a more abstract and general sense of awareness. This is not in accordance with the pyramid model, but instead points to the dynamic interactional model of cognition. This also leaves questions concerning transfer of knowledge from specific tasks in rehabilitation to a real-world setting; questions that are also raised by the REF-model and the dynamic interactional model of cognition.
Distinctions are made between rehabilitation approaches for unawareness due to neurocognitive and psychological factors, different degrees of difficulty, and between global and modality specific unawareness. These distinctions are factors that seem to have implications for rehabilitation, and it is therefore important that rehabilitation is adjusted to accommodate these underlying factors. This indicates the need for individually tailored strategies within rehabilitation programs in accordance with individual reactions. Rehabilitation therefore depends on careful assessment of unawareness, which should be based on considerations of underlying factors and the multifaceted phenomenon of unawareness. This means that assessment of unawareness requires multiple methods such as medical history, cognitive testing, quantitative methods, observations and the reactions of the individuals. For future research, however, this also creates methodological challenges on how to measure increased awareness achieved during rehabilitation.