Description and Effectiveness of Environmental Approaches to Cognitive Rehabilitation for Traumatic Brain Injury: A Systematic Review of Randomised Controlled Trials.

Interventions addressing cognitive impairments after traumatic brain injury (TBI) often rely on survivors' relatively preserved capacity to learn, initiate, and consistently use rehabilitation strategies, along with the ability to apply strategies in various contexts. The cognitive functions required for such active engagement in rehabilitation are commonly impaired after TBI, consequently limiting the benefits of many existing cognitive rehabilitation approaches. Environmental approaches, which involve manipulating the environment to support cognition and function, may benefit TBI survivors, as they do not require active involvement of the user to initiate and maintain their use. Although these approaches are recommended by experts and frequently used, their effectiveness and components are largely unknown. We conducted a systematic review, searching for randomised controlled trials of adults with TBI who received environmental interventions for cognitive or related functional outcomes, compared to any control. Two reviewers independently undertook screening and data extraction following a standardised protocol. Risk of bias was assessed using Joanna Briggs Institute Critical Appraisal Instruments. Five studies were included in the review. Environmental intervention approaches included prompting (three studies) and trained communication partners (two studies), both of which demonstrated relatively strong evidence for their effectiveness. Key methodological limitations included insufficient blinding to group allocation, randomisation concealment, reliability of outcome measurement, and lack of baseline similarity between groups. Whilst environmental approaches involving prompting and trained communication partners demonstrate potential for improving the daily functioning of individuals with TBI, further research is needed.Systematic review registration number: PROSPERO CRD42024592708, registered September 2024.