The review concluded that comprehensive-holistic rehabilitation programmes can be considered a treatment standard for adults with behavioural and psychosocial disorders following acquired brain injury. Limitations in reporting, a lack of significant findings from RCTs on which the authors' primary conclusion was based and uncertain study quality mean the authors' conclusions should be treated with caution.

To determine the efficacy and effectiveness of neurobehavioural rehabilitation programmes for adults with maladaptive behaviour, emotional disorders or reduced psychological functioning after moderate-to-severe acquired brain injury.

PubMed (from 1970), PsycINFO (from 1970), EMBASE (from 1980) and CINAHL (from 1982) were searched for published peer-reviewed papers up to 2008; search terms were reported. References of relevant articles were checked.

Studies that evaluated a behavioural treatment with measurable outcomes in adults (16 years and above) with acquired brain injury were eligible for inclusion. Case studies without quantitative data were excluded. Also excluded were: studies of interventions that did not concern behavioural or emotional disorders or psychological problems; studies that dealt primarily with mild or mild-to-moderate severity acquired brain injury; studies that focused on specific skills training, occupational therapy, vocational rehabilitation or job coaching; and studies that described pharmacological interventions or alternative medicine approaches. Acquired brain injury was defined as a cerebral damage that occurred after birth and was not related to congenital disorders, developmental disabilities or processes that progressively damage the brain.

Interventions included behavioural analysis, cognitive-behavioural therapy and comprehensive-holistic rehabilitation programs. Most intervention settings included residential rehabilitation services (community based rehabilitation settings were also used). Almost all participants had severe brain injury. Site of lesion was reported in less than half the studies; most of these participants had frontal lobe injuries. Most participants were described as having specified behavioural problems, predominantly externalising symptoms. The primary diagnosis in most studies was traumatic brain injury; in most cases mixed aetiologies were reported (including anoxia, subarachnoid haemorrhage, rupture of a cerebral artery aneurysm, viral encephalitis, brain tumour and acquired hydrocephalus). Chronicity, where reported, varied across studies: most individuals initiated treatment within one to four since injury (range within one month up to 36 years). Treatment duration ranged from two weeks to 10 years. The primary outcome in behavioural analysis studies was decreased intensity and frequency of specific externalising behaviours. Studies that reported cognitive-behavioural therapies or comprehensive-holistic programmes mostly considered behavioural and psychosocial changes as assessed by a variety of productivity level, standardised functional scales and customised rating scales or self-rated questionnaires.

Two reviewers independently selected studies from the retrieved full papers for inclusion in the review; any disagreements were resolved by discussion or arbitration with a third reviewer.

No formal assessment of internal validity was performed. Studies were evaluated according to an evidence grading system based on neurological management guidelines of the European Federation of Neurological Societies.

The authors did not state how data were extracted.

The authors conducted a narrative synthesis.

Sixty-three studies were included (n=1,094). Study designs were randomised controlled trials (RCTs), non-randomised controlled trials, case-control studies, case series and case reports.

Applied behaviour analysis (33 studies, two RCTs): The two RCTs found no effects of combined contingency management procedures and positive behaviour interventions on outcomes. Other studies were very small and reported conflicting results.

Cognitive-behavioural therapy (13 studies, two RCTs): The two RCTs found no effects of cognitive-behavioural therapy on outcomes. Results from uncontrolled studies of interventions that promoted internalising of self-regulation strategies through instruction of self-monitoring and integrated treatment of individualised cognitive and interpersonal therapies were largely negative or equivocal.

Comprehensive-holistic rehabilitation programs (17 studies, two RCTs): One RCT of military personnel found no significant difference between a telephone counselling programme and controls. One well-designed case series and two non-RCTs reported significant effects in favour of comprehensive-holistic rehabilitation programmes. Other studies of largely mixed aetiology were small and reported conflicting results.

Results indicated that the greatest overall improvement in psychosocial functioning was achieved by comprehensive-holistic rehabilitation programmes and can be considered a treatment standard for adults with behavioural and psychosocial disorders following acquired brain injury

The review addressed a clear question supported by defined inclusion criteria. Several relevant sources were searched. The search was restricted to published full-paper articles, which raised the possibility of publication bias. Two reviewers selected studies for inclusion from selected full papers; it was unclear whether similar methods were used to select papers at the title/abstract stage and to extract data. Use of a hierarchical model without further systematic validity assessment was not considered adequate. The authors acknowledged a number of limitations that included that very few RCTs or well-designed case-controls and non-randomised trials were found. Given the apparent heterogeneity of the included studies, a narrative synthesis was appropriate.

Limitations in reporting, the small number of studies and a lack of significant findings from RCTs on which the authors' primary conclusion was based and the lack of a formal assessment of study quality mean the authors' conclusions should be treated with caution.

Practice: The authors stated that comprehensive-holistic rehabilitation programmes can be considered a treatment standard for adults with behavioural and psychosocial disorders following acquired brain injury.

Research: The authors stated that better controlled research was needed with rigorous inclusion/exclusion criteria and greater specification of the theoretical basis, design and contents of treatments for interdisciplinary or traditional remedial interventions and for cognitive-behavioural therapy. The authors indicated that future research should consider the quality of the therapeutic relationship.

None reported.

Erratum in: Neuropsychology Review 2011; 21(2): 224.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.