The association between awareness deficits and rehabilitation outcome following acquired brain injury

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Abstract

The relationship between awareness of deficits and rehabilitation outcome following acquired brain injury (ABI) has yet to be established. The aim of the present review was to examine empirical evidence concerning the issue of whether awareness of deficits is necessary for rehabilitation gains and provide guidelines to assist clinical decision-making. The search strategy entailed identification of longitudinal group outcome studies with individuals who had experienced ABI of varying aetiology published between 1980 and 2006 in which awareness of deficits was systematically measured from the outset of rehabilitation and examined in relation to post-intervention functional outcomes. Eligible studies were evaluated against indicators of methodological quality. The review yielded 12 empirical studies, of which four indicated that individuals with greater awareness of deficits achieve more favorable rehabilitation outcomes and six provided partial support for this association. Two studies failed to support this view. Overall, the key issues requiring consideration when forming opinions and developing interventions for individuals with awareness deficits include the following: (a) how awareness is conceptualized and determined; (b) the perceived impact of poor self-awareness and possible adverse effects of targeting awareness; (c) biopsychosocial factors underlying awareness deficits; (d) the clients' goals and expectations in the intervention; and (e) the scope, intensity and resources of the rehabilitation context. Clinical recommendations are made regarding the circumstances in which it might be optimal to target the development of awareness in the context of rehabilitation.

Introduction

There are different views concerning whether or not awareness of deficits is necessary for rehabilitation gains in the context of neurological disorder. One perspective is that individuals with impaired awareness are less likely to participate in and benefit from rehabilitation and, thus, interventions should focus on improving awareness (Robertson and Murre, 1999, Sherer et al., 1998). Other researchers emphasize that behavioral gains can occur without conscious awareness of impairments through task-specific learning and habit formation (Agnew and Morris, 1998, Schacter, 1990, Sohlberg et al., 1998). The relationship between awareness and rehabilitation outcome has received considerable attention for people with acquired brain injury (ABI) and is starting to be addressed for people with other neurological conditions, such as Alzheimer's disease (see Clare, 2004a, Clare, 2004b, Clare et al., 2005, Clare et al., 2002, Clare et al., 2004). Perspectives on this issue influence decisions about whether to target the development of awareness and about the type of intervention best suited to individuals with awareness deficits. To date, however, there has been no comprehensive review of empirical studies to investigate the relationship between awareness of deficits and rehabilitation outcome (Hart & Sherer, 2005). Greater understanding of the link between awareness of deficits and rehabilitation outcome is expected to enhance clinical decision-making concerning the need for awareness interventions and the possibility of tailoring therapeutic approaches according to individual circumstances.

Awareness deficits following neurological disorder have been observed clinically for centuries (Prigatano & Weinstein, 1996). In 1914, Babinski introduced the term “anosognosia” to refer to the apparent lack of recognition of hemiplegia following brain damage. The term “awareness deficits” is used in the present context to refer to a lack of recognition of changes to one's self and abilities following brain injury. ABI is known to result in a complex array of physical, cognitive, emotional, and behavioral changes (Pepping and Roueche, 1991, Prigatano, 1992). Awareness of deficits is purported to be a key factor influencing response to rehabilitation and shaping psychosocial adjustment.

Some studies suggest that individuals with ABI who lack awareness of their deficits are less likely to benefit from rehabilitation than individuals with accurate self-appraisal. In particular, individuals with awareness deficits may demonstrate poor motivation for therapy (Fleming et al., 1998, Lam et al., 1989), resist support or treatment recommendations (Katz, Fleming, Hartman-Maeir, Keren, & Lightbody, 2002), set unrealistic goals (Fleming, Strong, & Ashton, 1996), and develop fewer compensatory strategies (Ownsworth et al., 2000a, Ownsworth and Fleming, 2005).

Some researchers have also suggested that receptiveness to feedback or willingness to change self-perceptions and behavior is integral to successful rehabilitation outcome (Ezrachi et al., 1991, Fordyce and Roueche, 1986, Ownsworth et al., 2006). Thus, in addition to accurate self-appraisal of deficits at the outset of rehabilitation, improvement in awareness of deficits during the course of an intervention might be positively related to functional outcome.

Rehabilitation refers to interventions, strategies or techniques that are designed to support individuals and their families in adjusting to, managing, or compensating for deficits resulting from neurological injury or illness (Wilson, 1989). For individuals with ABI, the emphasis in rehabilitation is to maximize post-injury adjustment and functional gains through different approaches including remediation of deficits, substitution of preserved or new skills for impaired skills, adjusting goals and expectations, and modifying the environment (Dixon & Bäckman, 1999). Awareness of deficits is viewed as a mechanism for change that allows individuals to recognise the mismatch between the skills they possess, expected performance, and environmental demands (Dixon & Bäckman, 1999). Robertson and Murre (1999) proposed that individuals with deficits in awareness might be less likely to attend to stimulation and activities as part of the rehabilitation experience. Many share the view that interventions should focus on enhancing individuals' awareness of their deficits (Sherer et al., 1998, Sherer et al., 1998, Sherer et al., 1998, Toglia and Kirk, 2000). This conviction has spurred the development of a variety of awareness interventions for individuals with ABI (for a review, see Fleming and Ownsworth, in press).

Other authors emphasize, however, that functional gains can be made without explicit awareness through task-specific learning and behavioral adaptation (Agnew and Morris, 1998, Schacter, 1990). In particular, it appears that individuals with cognitive impairment can acquire skills in areas of behavioral dysfunction without an associated improvement in awareness (Medd and Tate, 2000, Sohlberg et al., 1998). Furthermore, there may be circumstances in which targeting awareness is not beneficial or is potentially harmful. It has been suggested that individuals may become distressed if confronted by their deficits too early in the adjustment process and that the effectiveness of particular approaches for enhancing awareness may depend on the extent to which an individual's awareness deficits are psychologically based and/or neurologically based (Bieman-Copland and Dywan, 2000, Langer and Padrone, 1992, Ownsworth and McFarland, 2004). Thus, understanding the link between awareness deficits and rehabilitation outcome requires consideration of other factors potentially related to awareness of deficits, such as neuro-cognitive and emotional status, which are also likely to influence rehabilitation outcomes.

In general, there has been no systematic evaluation of the literature to examine the role of awareness of deficits in achieving rehabilitation gains. Whilst this issue is relevant for a range of neurological disorders, ABI is the primary focus of this review. The main aim of this review was to examine empirical evidence concerning the relationship between awareness of deficits and rehabilitation outcome for people with ABI. Based upon the prevailing opinion in the literature, it was hypothesized that individuals with greater awareness of their deficits would achieve more favorable rehabilitation outcomes.

Section snippets

Methodology

The search strategy for relevant articles involved electronic searches in Medline and PsycINFO databases in January 2006. Keywords used in the search were a combination of the following: (a) awareness, unawareness, anosognosia, denial, insight, metacognition, and self; (b) rehabilitation, treatment, intervention, outcome, and functional gains; and (c) brain injury, head injury, and stroke. Both authors initially reviewed abstracts and articles independently and reached consensus about the

Results and discussion

A total of 12 studies met the selection criteria for inclusion in the review. A summary of the sample characteristics, assessment of awareness of deficits, rehabilitation intervention, outcome measures, and overall finding of each study in relation to the hypothesis is presented in Table 1. The present review identified four studies that supported the hypothesis that awareness of deficits is associated with rehabilitation outcome. A further six studies provided partial support whereby

Summary

The present review identified four studies that supported the hypothesis that awareness of deficits is associated with rehabilitation outcome. A further six studies provided partial support whereby significant findings were only reported for selected functional outcomes or a particular approach for measuring awareness. Two studies failed to support the hypothesis. Due to the mixed findings and methodological differences between the studies, few clear and definitive findings arise from the

Clinical issues concerning awareness deficits

Some of the key clinical issues to consider for individuals with awareness deficits include the following: (a) how awareness is conceptualized and determined; (b) the perceived impact of poor self-awareness and possible adverse effects of targeting awareness; (c) the relative influence of neuro-cognitive, psychological and socio-environmental factors underlying awareness deficits; (d) the clients' goals and expectations in the intervention compared to those of the therapists and caregivers; and

Acknowledgments

A University of Queensland Travel Award for International Collaborative Research and a National Health and Medical Research Council Public Health Fellowship jointly supported the preparation of this paper.

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