Cognitive and Behavioral Digital Health Interventions for People with Traumatic Brain Injury and Their Caregivers: A Systematic Review

Abstract

Traumatic brain injury (TBI) leads to cognitive linguistic deficits that significantly impact on quality of life and well-being. Digital health offers timely access to specialized services; however, there are few synthesized reviews in this field. This review evaluates and synthesizes reports of digital health interventions in TBI rehabilitation and caregiver education. Systematic searches of nine databases (PsycINFO, MEDLINE, CINAHL, Embase, Cochrane Library, Scopus, Web of Science Core Collection, speechBITE, and PsycBITE) were conducted from database inception to February 2022. Studies were included of interventions where the primary treatment focus (> 50%) was on improving communication, social, psychological or cognitive skills of people with TBI and/or communication partners. Data on participants, characteristics of the interventions, outcome measures and findings were collected. Risk of bias was accounted for through methodological quality assessments (PEDro-P and PEDro+, Risk of Bias in N-of-1 Trials) and intervention description. Qualitative data was analyzed using thematic synthesis. Forty-four articles met eligibility criteria: 20 randomized controlled trials, three single-case experimental designs, six non-randomized controlled trials, nine case series studies, and two case studies. Studies comprised 3666 people with TBI and 213 carers. Methodological quality was varied and intervention description was poor. Most interventions were delivered via a single digital modality (e.g., telephone), with few using a combination of modalities. Five interventions used co-design with key stakeholders. Digital health interventions for people with TBI and their caregivers are feasible and all studies reported positive outcomes; however, few included blind assessors. Improved methodological rigor, clearly described intervention characteristics and consistent outcome measurement is recommended. Further research is needed regarding multi-modal digital health interventions.

Introduction

Traumatic brain injury (TBI) refers to brain injury acquired through a traumatic incident such as a road traffic accident, sporting injury, assault or fall.^1,2 This insult to the brain, caused by an external force, initially produces a diminished or altered state of consciousness³ and in cases of severe TBI, the recovery trajectory can be protracted over a period of months or years.⁴ TBI typically affects young people (predominantly males age 18-35 years old) at the beginning of their working lives.⁵ People with TBI have been reported to have worse general health, higher incidences of depression and social isolation, and reduced labor force participation rates compared with people without TBI.⁶ Even a mild TBI can produce ongoing psychosocial problems.⁷ Those who sustain moderate and severe TBIs may face the challenge of lifelong deficits requiring intensive rehabilitation efforts and ongoing supports to facilitate community reintegration. The majority of people with severe TBI require expensive long-term care due to loss of independence, reduced work capacity and relationship breakdown.⁸

People with TBI continue to experience challenges with their cognition, behavior, social life, and emotions many years after their injury, which can negatively impact on psychosocial outcomes and quality of life.^9,10 Cognitive, behavioral and emotional difficulties are the most widely reported, persistent and detrimental consequences of TBI.^11
-13 Over the long term, injuries may compromise a range of high-level cognitive–linguistic functions¹⁴ as a result of cognitive disruptions in the frontal lobe.^4,15,16 These communication deficits are defined as “cognitive communication disorders”¹⁷ and can lead to difficulty having conversations with families, engaging in workplace interactions, reading complex information or writing for study or work.¹⁸ Caregivers experience high levels of burden and depression, as caring for people with TBI can be stressful.¹⁹ Significant sources for this stress have been identified as problems communicating with the person with TBI,^20
-22 behavioral disturbance,²³ and the level of cognitive processing difficulties of the person with TBI. Friends, caregivers, and family frequently begin avoiding the person with TBI, which impacts on their ability to maintain pre-injury relationships.^24
-26 It is therefore essential that people with TBI and their caregivers are able to access long term services. However, these are currently not readily available, especially for those in rural and remote locations.⁴

Digital health

Digital health is a healthcare model that encompasses the use of various digital modalities such as health information technology, telehealth, eHealth, telemedicine, web-based modules, and wearable devices.²⁷ The terminology and definitions pertaining to digital health continue to evolve.²⁸ These various modalities of digital health can be applied in assessment, intervention, and information-sharing processes to facilitate timely, financially sustainable, personalized, and empowered treatment management.²⁷ The growth of digital health modalities has facilitated the development of intervention programs that allow people with TBI timely and cost-effective access to specialized services, allowing them to increasingly take control of and play a more active role in their health.²⁸ Digital health rehabilitation approaches facilitate interactions between the person with TBI, their caregiver, and the clinician in meaningful environments.²⁷ People with TBI have the opportunity to apply, internalize, and practice skills and tasks within their own home during therapy sessions and receive real-time feedback from their clinician.²⁹

Digital health also supports interdisciplinary practices, which is essential in the rehabilitation process for people with TBI, which then enables universal access to cost-effective and high-quality care, particularly in rural and remote regions.³⁰ The implementation of digital health modalities into services has shown to be effective in overcoming key challenges such as the need to travel (for people with TBI, their caregivers, and clinicians) improved cost efficiencies and processes, improved clinical outcomes, and education opportunities for clinicians.³¹

Digital health interventions can be delivered synchronously or asynchronously. Synchronous interventions pertain to interventions delivered in real-time with the clinician present and providing immediate feedback and support. This can occur within the same location or context, for example in a clinic room or remotely, for example via videoconference or telephone. Asynchronous interventions do not require real-time consultation from a clinician or dedicated appointment times. These interventions are typically completed in the patient's own time and are often self-guided. Data collection can be patient or caregiver driven; however, many current technologies allow for automated data collection such as apps, computer programs or web-based interventions in which data is remotely shared with the clinician.

Whether an intervention is delivered synchronously or asynchronously can impact on the patient's engagement and efficacy of the intervention. This is illustrated in Ownsworth and colleagues' systematic review³² of telehealth platforms for people with primary brain tumors and their caregivers, where findings indicated that for interventions delivered synchronously the uptake and adherence to intervention was higher, and clinical gains in response to intervention were more likely, compared with delivered online, self-guided interventions. The timing of delivery of intervention is an important factor to consider when evaluating the efficacy and effectiveness of digital health interventions.

Current applications of digital health

Recent literature investigating telerehabilitation for people with TBI, has produced mixed results. Ownsworth and colleagues' systematic review³³ concluded that structured telephone interventions led to improvements in global functioning, post-traumatic symptoms, sleep quality and depressive symptoms. However, while the feasibility of internet-based interventions was largely supported, the efficacy could not be determined due to insufficient studies that met the review criteria. Coleman and colleagues³⁴ also found limited results in their systematic review evaluating the assessment and treatment of cognition and communication skills in adults with acquired brain injury using telepractice. They reported insufficient data on diagnostic accuracy and treatment efficacy and the heterogeneity of assessments and interventions impacted on the efficacy and evaluation of possible clinical implications of telepractice application. Studies included in the review, predominantly delivered assessment and intervention services via videoconference or telephone and other digital modalities were not explored.

Similarly, Betts and colleagues³⁵ concluded that the current evidence base is limited for understanding the effect of telerehabilitation for cognitive and psychological interventions for people with TBI. Despite limitations such as lack of standardized intervention parameters, outcome measures and small sample size, they suggest that there is some evidence that telerehabilitation may be as equally effective as other forms of care; however, uncertainty remains as to whether telerehabilitation results in better outcomes compared with usual care. These findings are echoed in a systematic review conducted by Rietdijk and colleagues,³⁶ where it was concluded that telephone-based interventions for family members of people with TBI are feasible and yield positive outcomes for both the carer and the person with TBI. Although there is limited high quality evidence of the application of diverse digital health interventions in TBI cognitive communication rehabilitation, findings from the field of aphasia communication rehabilitation indicate that there is potential for similar, TBI-specific digital programs to have positive communication and quality of life outcomes for people with TBI and their caregivers.

While digital health is a fast-emerging model of care with a broad spectrum of digital health modalities available, there is limited evidence regarding the evaluation of digital health approaches for people with TBI and their caregivers. A systematic review is required to evaluate and synthesize current literature addressing the use of a range of digital health interventions in the rehabilitation of people with TBI and the education of caregivers of people with TBI.

Aims

The aim of this systematic review is to evaluate the current literature in relation to efficacy and effectiveness of digital health cognitive and behavioral interventions for people with traumatic brain injury (TBI) and their caregivers (close others and paid caregivers). This systematic review addresses the following questions:

What are the characteristics of digital health interventions in TBI rehabilitation?

What is the efficacy and effectiveness of digital health intervention or education programs for people with TBI in improving rehabilitation outcomes?

What is the efficacy and effectiveness of digital health intervention or education programs for caregivers of people with TBI and/or the person with TBI?

Methods

A systematic search was conducted in May 2020 and repeated in February 2022 to identify studies that addressed the use of digital health intervention in rehabilitation and education for people with TBI and their caregivers. A systematic review protocol was registered for this study on PROSPERO (ID: CRD42020152218). The study method and reporting were guided by the Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) Expanded Checklist³⁷ and relevant appraisal tools as outlined below.

Risk of bias in individual studies

Randomized control trials (RCTs) are considered a gold standard of evidence in evaluating the effectiveness of healthcare interventions. However, preliminary searches indicated very few RCTs in the scope of digital health interventions. As a result, this systematic review included: 1) all quantitative designs (including RCTs, case series, and case control studies); 2) qualitative designs; and 3) mixed-methods designs. The primary reviewer (PA) evaluated the quality of included articles using an appraisal tool matched to the appropriate study design (RCTs were rated using the PEDro-P³⁸ and PEDro+³⁹ scales; single case experimental designs were rated using the Risk of Bias in N-of-1 Trials [RoBiN-T] scale).⁴⁰ Quality appraisal ratings were compared with existing ratings available on PsycBITE, where possible and the remainder of papers were rated by a second reviewer. Consensus was reached through discussion for any discrepancies between ratings.

Articles were assessed according to the National Health and Medical Research Council (NHMRC) levels of evidence (Table 1).⁴¹

Table 1.

Levels of Evidence for Questions of Treatment Benefits

Level of evidence^*	Type of study
I	Systematic review of Level II studies
II	Randomized controlled trial
III-1	A pseudorandomized controlled trial (i.e., alternate allocation or some other method)
III-2	A comparative study with concurrent controls: 1) non-randomized experimental trial; 2) cohort study; 3) case-control study; and 4) interrupted time series with a control group
III-3	A comparative study without concurrent controls: 1) historical control study; 2) two or more single arm studies; and 3) interrupted time series without a parallel control group
IV	Case series with either post-test or pre-test/post-test outcomes

Based on National Health and Medical Research Council levels of evidence.⁴¹

Inclusion and exclusion criteria

The inclusion criteria included articles that reported on all of the following: 1) digital health intervention (computer/online/web-based—i.e., any intervention delivered at a distance using technology, including telephone, websites, or videoconferencing); 2) intervention delivered to a person with TBI of any severity, and/or their caregivers (parents, partners, siblings, extended family or close friends who had taken on a caregiving role); 3) participants with TBI were adults (18 years and older); 4) in studies involving a mixed sample of conditions, at least 50% of the sample were people with a TBI and/or their caregivers; and 5) peer reviewed journal article. There were no inclusion criteria imposed on the outcomes of the intervention or on the study design.

Exclusion criteria included those publications which: 1) do not relate to TBI rehabilitation; 2) do not relate to a person with TBI and/or caregivers of a person with TBI; 3) less than 50% of participants were people with TBI or their caregivers; 4) not related to training/support for people with TBI or caregivers of a person with a TBI; 5) not delivered via digital health; 6) duplicates other results reported more fully elsewhere; 7) did not have at least an abstract available for review; 8) did not report data on outcome measures or process measures relating to the program; 9) addressed augmentative and assistive communication technology; 10) did not address cognitive or behavioral related interventions e.g., physical/gross motor therapy, upper limb intervention; and 11) only addressed assessment practices.

Search strategy

The search strategy was as follows: (traumatic brain injur* OR brain injur* OR acquired brain injur*) AND (digital health or telecommunication* OR teleconference* OR apps or ehealth OR e-health OR emedicine OR e-medicine or etherap* OR e-therap* OR (information and communication technolog*) OR multimedia messag* OR podcast* OR smartphone* OR smart phone* OR social media OR telecare OR tele-care OR telehealth OR tele-health OR telemedicine OR tele-medicine OR telerehabilitation OR tele-rehabilitation OR web-based OR web based) AND (intervention* OR treatment* OR therap* OR rehabilit*). The following search restrictions were applied: peer reviewed journal publication and population age 18 years and older. An example of the search strategy as applied in MEDLINE (Ovid, 1946-present) is shown in Table 2.

Table 2.

Search Strategy Example, Medline (OVID, 1946-present)

Key words	traumatic brain injur^* OR brain injur^* OR acquired brain injur^*	AND	digital health or telecommunication^* OR teleconference^* OR apps or ehealth OR e-health OR emedicine OR e-medicine or etherap^* OR e-therap^* OR (information and communication technolog^) OR multimedia messag^ OR podcast^* OR smartphone^* OR smart phone^* OR social media OR telecare OR tele-care OR telehealth OR tele-health OR telemedicine OR tele-medicine OR telerehabilitation OR tele-rehabilitation OR web-based OR web based OR telephone	AND	intervention^* OR treatment^* OR therap^* OR rehabilit^*
	OR
Subject headings	exp: Brain Injuries, Traumatic/

The following databases were searched using the search strategy: PsycINFO (Ovid), MEDLINE (Ovid), MEDLINE (PubMed), CINAHL (EBSCO), Embase (OVID), Cochrane Library (Wiley; including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled trials), Scopus (via Elsevier), Web of Science Core Collection, speechBITE, and PsycBITE. MeSH and keyword search terms were adapted for the specific requirements of each database. Supplemental searching included gray literature and additional papers were sourced via hand searching the reference lists of included papers and any relevant systematic reviews.^33,42

During the hand searching process it was noted that intervention studies based on telephone interventions were not sourced using the initial search strategy. A secondary search using an adjusted search strategy was performed to capture these studies. The search strategy was as follows: (traumatic brain injur* OR brain injur* OR acquired brain injur*) AND (intervention* OR therap* OR treatment* OR rehabilitat*) AND (telephone).

Study selection

Search results from each database/source were downloaded into EndNote X8 and duplicates removed. Following this, the articles were exported to Covidence, a screening and data extraction tool. The title and abstract of each article were examined against review eligibility criteria in an initial round of screening. To increase reliability, a second reviewer screened 25% of the article titles and abstracts. A total of 336 titles and abstracts were screened by the second reviewer and 88.8% reliability was achieved (Cohen's k = 0.58, 95% confidence interval = 0.475-0.702 indicative of moderate to substantial agreement).⁴³ A second reviewer also screened 51 full text articles and 96% reliability was achieved (Cohen's k = 0.91, 95% confidence interval = 0.78 to 1 indicative of an almost perfect level of agreement).⁴³ Consensus was reached for any discrepancies in ratings through discussion. Once reliability was established, a second round of screening consisted of assessing full texts of potentially relevant articles against the same eligibility criteria.

Data extraction

Data was extracted from included articles using a template containing the following fields: 1) author, year of publication; 2) study design; 3) study population and characteristics; 4) context of intervention (including dose and type of digital health tool or resource); 5) methodology; 6) outcomes assessed; 7) findings; 8) theoretical model; and 9) intervention category (psychological, cognitive, communication, education).

Quality appraisal

The RCTs were appraised using the PEDro-P³⁸ and PEDro+³⁹ scale. The PEDro+³⁹ scale is an adaptation of the PEDro-P³⁸ scale as the original scale does not address treatment fidelity or treatment replicability. These elements are essential when evaluating the rigor of behavioral treatment research. These items were added to the original scale by Cherney and colleagues³⁹ in their review of communication partner training in aphasia, to create a 12-item scale. The RoBiN-T scale⁴⁰ was used to assess methodological quality for single case experimental design studies. Ratings were used from the SpeechBITE and PsycBITE websites where available. Where no rating was available, two independent raters evaluated the papers, and any disagreements between the two ratings were resolved through discussion and 100% consensus was achieved.

Statistical analysis

Descriptive results are presented in a table format. This includes details regarding: methodology, participants, interventions, outcome measures, follow-up interventions, statistical significance, effect sizes and results. A mixed-methods synthesis included both quantitative and qualitative data analysis as per the following:

Quantitative analysis: The content of the included articles determined the nature of the comparison. Given the broad nature of the research question (i.e., interventions addressed by the included studies may vary across different digital health approaches, such as app, web-based, telephone, etc.), findings are reported in a narrative summary. Limitations within the evidence base are discussed and the possible influences of publication/small study biases are considered and presented.

Qualitative analysis: A thematic synthesis was conducted to facilitate further investigation regarding types and modes of interventions

Mixed-methods synthesis (quantitative and qualitative): Findings from the narrative synthesis and thematic synthesis were collated into a summary in response to the research questions. As per the PRISMA protocol,³⁷ the findings are presented, discussed and then conclusions drawn based on this evaluation. Additionally, implications for clinical practice and research and limitations are subsequently outlined.

Results

Study selection

Figure 1 depicts the search results and the process of exclusion of articles. A total of 2004 sources were identified from the initial search strategy in May 2020. A further 13 sources were identified using the additional search strategy and handsearching. Following removal of duplicates and application of exclusion criteria, there were a total of 40 articles that met the inclusion criteria for review. The search strategy was repeated in the February 2022 and an additional four articles met the inclusion criteria. Figure 1 was updated accordingly to give a total of 44 articles.

FIG. 1.

Study selection flow-chart.

Study design and quality appraisal

The search identified 22 RCTs (Level II), three single case experimental design studies (Level III-I; reported in Table 3),^{44

–88} six non-randomized controlled trials (non-RCTS; Level III-2), nine case series studies (Level IV), and four case studies (Level IV). All studies were published in the last 25 years. Figure 2 shows the distribution of studies at each level according to the study population.

FIG. 2.

Distribution of studies across National Health and Medical Research Council levels.

Table 3.

Description of Intervention Characteristics

Study	Title of intervention	Purpose of intervention	Asynchronous or synchronous	Who provided?	Modality	Individual or group	Location	Period of time	Total number of sessions	Frequency	Duration of session	Level of evidence
Banerjee and colleagues, 2021⁴⁴	Multi-method approach of Cognitive remediation	Improving memory activation	Synchronous	Therapist	Social media	Individual	Not specified	Not specified	Not specified	Not specified	Not specified	IV
Belanger and colleagues, 2015⁴⁵	Recovering From Head Injury: A Guide for Patients	Education for reduced post-concussion symptoms	Asynchronous	Self directed	Web-based	Individual	Participant's home	1 point in time	1	N/a	15-45 min	II
Bell and colleagues, 2005⁴⁶	Scheduled telephone intervention (STI)	Improve problem-solving, motivation for change, and information or referrals for assistance.	Both	Counselor	Telephone	Individual	Participant's home	9 months	7	2 weeks, 4 weeks and 2, 3, 5, 7, and 9 months after discharge	30-45 min	II
Bell and colleagues, 2011⁴⁷	Scheduled telephone intervention (STI)	Problem-solving treatment (PST)	Synchronous	Counselors	Telephone	Individual	Client's home	2 years	11	3 to 4 days then 2, 4, 8, and 12 weeks, and 5, 7, 9, 12, 15, 18, and 21 months postinjury	Not specified	II
Bell and colleagues, 2008⁴⁸	Scheduled telephone intervention (STI)	Symptom management and physical remobilization to minimize occurrence of chronic post-concussive symptoms.	Both	Psychologist, sociologist, or anthropologist	Telephone, written resources	Individual	Client's home	Not specified	5	within 2 days of injury and four follow-up calls at 2, 4, 8 and 12 weeks after injury	Average 8 min	II
Bell and colleagues, 2017⁴⁹	Problem Solving Treatment (PST)-based telephone therapy	Problem-solving psychological and physical symptoms	Both	Counselor	Telephone (Rx group), Mail or email (Education only)	Individual	Client's home	6 months for PST	12	Bi-weekly	30-45 min	II
Bergquist and colleagues, 2009⁵⁰	Not specified	Cognitive rehabilitation	Synchronous	Therapist	Instant messaging	Individual	remote	Not specified	30	2-3 per week	Not specified	II
Bombardier and colleagues, 2009⁵¹	Scheduled telephone intervention	Improving self reported depressive symptoms	Both	Counselors	Telephone	Individual	Remote	9 months	7	2 and 4 weeks, then 2, 3, 5, 7, 9 months post discharge	30-45 min	II
Bos and colleagues, 2017⁵²	Not specified	Improving memory and compensatory memory strategies	Synchronous	Therapist	Smartphone	Individual	In person	8 weeks including 2 weeks for training	8	weekly	1 h	IV
Bourgeois and colleagues, 2007⁵³	Spaced retrieval (SR) training via telehealth	Improving everyday memory behaviors	Synchronous	Speech pathologists (SP)	Telephone	Individual	Remote	Not specified	10-12 sessions	4-5 days per week	30 min	III-1
Brown and colleagues, 1999⁵⁴	Not specified	To provide education, skill development, counseling to rural families of a person with TBI	Both	Psychologist, neuropsychologist and social worker	Telephone	Group	On-site or participant home	9-10 weeks	9-10 sessions	weekly	1.5-2 h	III-2
Connor and Shaw, 2016⁵⁵	Lumonisity (commercial brain training game)	Improve visual attention and memory for PwTBI in the community	Asynchronous	SP	Web-based game	Group	Clinic and remote	12 weeks	24	2 times per week structured and also self directed	30-40 min	IV
Corrigan and colleagues, 2005⁵⁶	Not specified	Increasing participation in substance abuse treatment for clients with TBI	Synchronous	Psychologist	Telephone	Individual	Remote	Not specified	Not specified	Not specified	Not specified	II
Damianakis and colleagues, 2016⁵⁷	Caring for Others	Intervention and support program for TBI caregivers	Asynchronous	Master of Social Work clinician	Website and videoconferencing	group	Participants' own home	10 weeks	10	weekly	1 h	IV
Dowds and colleagues, 2011⁵⁸	Memory aid using PDA	Improving task completion efficiency	Asynchronous	Therapist	Personal digital assistant/ hand held computer	Individual	Remote	8 weeks	8 occasions	5 days per week	15 min	II
Eilam-Stock and colleagues, 2021⁵⁹	Remotely supervised - Transcranial direct current stimulation (RS-tDCS) with computer based adaptive cognitive training (aCT)	Improving cognitive performance	Synchronous	Self-directed	Computer	Individual	Remote	4 weeks	20 sessions	5 days per week	20 min	IV
Elbogen and colleagues, 2019⁶⁰	Cognitive Applications for Life Management (CALM)	Improving executive function and emotion regulation	Both	Self-directed and therapist	App “Mind Jogger” and “IQ Boost”	Individual	Remote and home visit at 0, 2 and 4 months	6 months	Unspecified	Daily self-directed tasks	Home visits 60-90 min	II
Fann and colleagues, 2015⁶¹	Cognitive behavior therapy – TBI (CBT-TBI)	Reduce depressive symptoms	Synchronous	Therapist	Telephone	Individual	Remote	12 weeks	12	Weekly	30-60 min	II
Forducey and colleagues, 2003⁶²	Neuro Developmental Treatment (via telehealth)	Improving functional status and transfer of knowledge	Synchronous	Physiotherapist	Videoconferencing	Individual	Remote	24 weeks	48	2 days per week	50-65 min	IV
Gomez and colleagues, 2013⁶³	Adaptive manuals	Improving independent task completion and efficiency	Asynchronous	Therapist and self directed	Mobile phone	Individual	Clinic (first 3 sessions) then home/remote	2 weeks	16 (including 2 baseline sessions - session 1 and 16)	daily	Not specified	IV
Hart and colleagues, 2020⁶⁴	Not specified	Improving emotional status	Asynchronous	Therapist	Mobile phone/SMS	Individual	Initial clinic session, then home/remote	8 weeks	Not specified	Daily text message	Not specified	II
Hart and Vaccaro, 2017⁶⁵	Goal intention reminding via Implementation intentions	Enhancing goal-related implementation and activity	Asynchronous	Clinician and self directed	Text message	Individual	Remote	8 weeks	Varied by Pt	Negotiated depending on Pt preference	Not specified	II
Hart and colleagues, 2002⁶⁶	Compensatory memory aid intervention	Improving recall of therapy goals and plans	Both	Case manager	Voice recorder	Individual	Onsite (post-acute TBI rehab)	7 days	2 CM sessions	3 times per day	Not specified	IV
Hwang and colleagues, 2020⁶⁷	RehaCom (adapted by authors)	Improving cognitive functioning	Synchronous	Study nurse	Computer	Individual	Remote	6 months	24	Weekly session with nurse, self practice 3 × week	45 min	II
Inge and colleagues, 2017⁶⁸	Not specified	Increasing the knowledge of evidence-based employment research	Asynchronous	Vocational rehab counselor	Email and social media	Individual	Remote	3 months	Email group: 3 emails Facebook: minimum 5 posts per work week	Email: 1 email per month, Facebook: minimum 5 posts per work week	N/A	II
Kirsch and colleagues, 2004⁶⁹	Assistive technology for cognition (modification of the cognitive environment)	Reducing utterance length	Asynchronous	Occupational therapist (OT) and SP	Personal digital assistant/ hand held computer	Individual	Day rehab program	Not specified	18 (b = 5, A = 7, B = 6)	Not specified	Not specified	III-3
Larsson and colleagues, 1995⁷⁰	Not specified	Train cognitive functions, compensate for cognitive impairments, and aid preparation for occupational training and leisure time activities	Synchronous	OT	Computer	Individual	Not specified	Case c: 12 weeks, Case D: 15 weeks	Case C: 18, Case D: 20	Not specified	1-3 h	IV
McGraw-Hunter, Faw, Davis, 2006⁷¹	Systematic instruction	Teach a cooking skill and examine skill generalization to a novel food item	Asynchronous	Clinician	Video feedback	individual	Clinic	Dependent on Pt's progress	Dependent on Pt's progress	Daily	Dependent on Pt's performance	III-3
McLaughlin and colleagues, 2013⁷²	The Brain Injury Partners	1) Improve family active listening and problem solving; 2) Find broad range of services and supports; 3) provide strategies for reducing stress	Asynchronous	Self-directed	Web-based	Individual	Participants own home	10 days	Unspecified	Unspecified	30 min	II
Ng and colleagues, 2013⁷³	Cognitive Orientation to daily Occupational Performance (CO-OP) (Polatajko and Mandich, 2004)	Promoting community integration and management of executive dysfunction	Asynchronous	OT	Videoconferencing	individual	Participant's homes via Skype	10 weeks	20	Twice weekly	1 h	IV
Powell and colleagues, 2016⁷⁴	Problem Solving Training	Improving the quality of life and emotional well-being of caregivers of persons with moderate to severe TBI.	Synchronous	Interventionist	Telephone	Individual	Participants' own home	unspecified	maximum of 10	Fortnightly	Unspecified	II
Powell and colleagues, 2019⁷⁵	ProSolv (Metacognitive strategy instruction)	Supporting generalization of trained cognitive skills into everyday environments	Both	SP, OT, Vocational counselor	Web-based app	Group and individual	Clinic and remote	8 weeks	6	Not specified	1 h	III-2
Riegler and colleagues, 2013⁷⁶	Military On-Line Problem Solving Videophone Intervention (MOPS-VI)	Improving treatment adherence and improving cognitive functioning	Asynchronous	SPs	Videoconferencing and online modules	Individual	own home or workplace	6 weeks	6	1 × per week module and 1 × per week videoconference call	60 min completion of module, 60 min for v/c call	III-2
Rietdijk and colleagues, 2019⁷⁷	TBIConneCT	Improving social communication skills	Both	SP	Videoconferencing	Individual and Group	Own home	10 weeks	10 group and 10 individual	Weekly	Group (2.5 h)Individual (45 min)	III-3
Rietdijk and colleagues, 2020⁷⁸	TBIConneCT⁷⁹	Improving social communication skills	Both	SP	Videoconferencing	Individual	Remote	10 weeks	10	Weekly	1.5 h	III-3
Salazar and colleagues, 2000⁸⁰	Not specified	Improve cognitive functioning for return to work military personnel	Synchronous	Psychiatric nurse	Telephone	Individual	Remote	8 weeks	8	Weekly	30 min	II
Schoenberg and colleagues, 2008⁸¹	Cognitive Systems Incorporated (CSI) marketed as CRI/PSS Teletherapy System	Enhancing cognitive functioning (attention, reaction time, visuospatial skills, learning and memory, and problem solving)	Asynchronous	SPs (10+ years experience)	Computer based program	Individual	F2F: in clinic, TELE: participant home	Not specified	6 F2F sessions for control group, Not specified for TELE group	Not specified	Not specified	III-2
Smith and colleagues, 2012⁸²	Ecological momentary assessment (EMA) using PDA	Improving attitudes, behaviors, and experiences in real time in subjects' natural environments.	Asynchronous	Research assistant	Personal Digital Assistant (PDA), SMS in follow up phase	Individual and group	Clinic (in Participant's own time) and as an outpatient	Not specified	Once	Daily at random times	Not specified	IV
Solana and colleagues, 2014⁸³	Intelligent Therapy Assistant as part of Guttman Neuro Personal Trainer	Improving cognitive and neuropsychological skills	Asynchronous	Neuropsychologists	Web-based	Individual	Not specified	Not specified. Data collected over a 18 month period	60 sessions	2 to 3 per week	60 min	III-2
Solana and colleagues, 2015⁸⁴	Guttmann Neuropersonal Trainer (GNPT)	Neuropsychological rehabilitation	Asynchronous	Neuropsychologists	Web-based	Individual	Institute Guttman, clinical centers, home	3 months	60 sessions	5 sessions per week	60 min	IV
Välimäki and colleagues, 2018⁸⁵	CogniFit	Improving cognitive functioning andwell-being among people with TBI	Both	Registered nurse	Web-based (gaming)	Individual	Remote (home)	8 weeks	Not specified	Daily	30 min	II
Nakase-Richardson and colleagues, 2016⁸⁶	Telephone based problem solving treatment (PST)	Improving individual problem solving in managing and understanding sleep disturbances	Asynchronous	Counselor	Telephone (Rx group), Mail or email (Education only)	Individual	Participant's homes	6 months PST	12	bi-weekly	Not specified	II
Waldron and colleagues, 2012⁸⁷	Structured training sequence	Improving compensatory skills for memory problems.	Asynchronous	Not specified	Personal Digital Assistant (PDA)	Individual (however group training in use of PDA)	Community	2 weeks	N/A	Varying the days and times of completion	N/A	IV
Wang and colleagues, 2019⁸⁸	Visual Impact Pro	Complete kitchen related sequencing tasks	Asynchronous	OT	App	Individual	Clinic/Lab	Not specified	1	Not specified	Not specified	II

The quality appraisal and distribution of results for each of the studies is shown in Figure 3. Results of quality reviews of the communication partner training studies include both a PEDro-P rating and a PEDro+. The mean PEDro-P rating for the RCTs was 5.6/10.0 (range 3/10 to 7/10) and the mean PEDro+ rating was 6.3/12.0 (range 4/12 to 9/12).

FIG. 3.

Quality appraisal scores on the PEDro-P and PEDro+ for randomised controlled trial studies. The circles represent the PEDro-P scores, which are scored out of 10. The solid line indicates the mean PEDro-P score. The triangles represent the PEDro+ scores, which are scored out 12. The dotted line indicates the mean PEDro+ score.

The mean ROBiN-T rating for internal validity was 4/14 (range 3/14 to 5/14), the mean external validity rating was 7.3/16.0 (range 4/16 to 10/16) and the total mean rating was 11.3/30.0 (range 7/30 to 14/30). The results for each study are shown in Figure 4.

FIG. 4.

Scores on the Risk of Bias in N-of-1 Trials (RoBiNT) scale for single case experimental design studies. Dotted line indicates the mean ROBiNT score.

Further detail on the quality appraisal and scores for each criterion can be found in Supplementary Table 1 for PEDro-P and PEDro+, and Supplementary Table 2 for ROBiN-T ratings.

Study characteristics

Participants

People with TBI

The description of participants is presented in Table 4. Of the 44 studies in this review, 35 studies included people with TBI resulting in a total of 3823 participants with TBI. For 11 studies, the participants had a range of conditions with at least 50% of the sample including participants with TBI and 27 studies including participants with TBI only. The number of participants in the studies ranged from 1⁶⁹ to 746 participants.⁸² There was considerable heterogeneity in sample characteristics. For studies reporting age (n = 42), the age ranged from 18 to 90 years. In those reporting severity (n = 26), 14 studies included participants with moderate to severe TBI, five studies included participants with mild TBI, four studies included participants with a range of mild to severe TBI, two studies included participants with severe TBI only and one study included a participant with moderate TBI. The remainder of the studies did not specify severity.

Table 4.

Description of Participants

	Authors	Year of publication	Sample	Age	TBI characteristics
1	Banerjee and colleagues	2021	1	25	Not specified
2	Belanger and colleagues	2015	Rx = 69/79, Control (no Rx) = 70/79	18-55	Mild TBI
3	Bell and colleagues	2005	Rx = 79/85, Control = 78/86 (Caregiver + TBI)	Average 36	Moderate-severe TBI
4	Bell and colleagues	2011	Rx = 169/210, Ctrl = 174/223 (caregiver and TBI)	Rx = 38 (mean), Control = 40 (mean)	Moderate-severe TBI
5	Bell and colleagues	2008	Control = 167/195, Rx = 146/171	Mean for control = 32, mean for Rx = 33	Mild
6	Bell and colleagues	2017	Rx = 142/178, Control = 157/178	20-54	Mild (self reported)
7	Bergquist and colleagues	2009	Rx group = 6/8 (calendar), Control group = 8/10 (diary)	22-61	Moderate-severe TBI
8	Bombardier and colleagues	2009	Rx = 62/85, Control = 64/86 (caregiver + TBI)	Rx = 34.5 (mean), control = 37.1 (mean)	Mild-severe TBI
9	Bos and colleagues	2017	Rx group 1 (notebook) = 2, Rx group 2 (smart phone) = 5	26-62	Moderate-severe TBI
10	Bourgeois and colleagues	2007	Rx = 22 (TBI) and 22 (caregivers), control = 16 (TBI) and 16 (caregivers)	Rx = 43 (mean for TBI), control = 40 (mean for TBI)	Not specified
11	Brown and colleagues	1999	Caregivers: Rx = 52/74, control = 39/57, pwTBI: Rx = 48, Control = 35	pwTBI: Rx = 41.8 (mean), control = 39.8 (mean)	Mild-severe TBI
12	Connor and Shaw	2016	2 (TBI) (3 total)	34-66	Moderate-severe TBI
13	Corrigan and colleagues	2005	195 (TBI)	18-74	Not specified
14	Damianakis and colleagues	2016	10 (caregivers)	Not stated	Not specified
15	Dowds and colleagues	2011	36	18-66	Not specified
16	Eilam-Stock and colleagues	2021	1	29	Moderate
17	Elbogen and colleagues	2019	Rx = 57, control = 55	Rx = 36.77 (mean), control = 36.25 (mean)	64/112 Moderate-severe
18	Fann and colleagues	2015	Rx (telephone) = 40, Rx (in-person) = 18, Control (usual care) = 42	45.8 (mean), 19.9-87.3 (range)	Mild-severe
19	Forducey and colleagues	2003	1 (TBI)	26	Severe
20	Gomez and colleagues	2013	1	39	Not specified
21	Hart and colleagues	2021	Rx (group 1) = 38, Rx (group 2) = 21	Rx (group 1) = 40.4 (mean), Rx (group 2) = 38.5 (mean)	Moderate-severe
22	Hart and Vaccaro	2017	Rx = 4/4, control = 4/4	Rx = 23.8 (mean), control = 34.3 (mean)	Moderate-severe
23	Hart and colleagues	2002	10 (TBI)	19-45	Moderate-severe
24	Hwang and colleagues	2020	Rx (CCT) = 32, Rx (TC) = 32, UC = 32	Rx (CCT) = 65.8 (mean), Rx (TC) = 65.8 (mean), UC = 68.1 (mean)	Mild-severe
25	Inge and colleagues	2017	Rx (Facebook) = 30/34, Control (e-news) = 30/33	Rx = 45.33 (mean) and control = 45.06	Not specified
26	Kirsch and colleagues	2004	1 (TBI)	Mid thirties	Moderate-severe TBI
27	Larsson and colleagues	1995	2 TBI, total = 4	P1 = 40, P2 = 40	Not specified
28	McGraw-Hunter and colleagues	2006	4 (TBI)	17-39	Not specified
29	McLaughlin and colleagues	2013	Family member of pwTBI, Control = 97, Intervention = 104	18 to over 61	Not specified
30	Ng and colleagues	2013	3 (TBI)	P1 = 47, P2 = 34, P3 = 55	Severity not specified, >10 years post-injury
31	Powell and colleagues	2016	control = 76, intervention = 77 (both caregiver and TBI survivor)	Caregiver: 19-89, TBI survivor: 16-90	Not specified
32	Powell and colleagues	2019	Usual care = 9, intervention = 14 (TBI)Single case followup = 1	20-75	Not specified
33	Riegler and colleagues	2013	Rx group 1 (MOPS-VI) = 6, Rx group 2 (standard care) = 6	23-38	Not specified
34	Rietdijk and colleagues	2019	2 TBI and 2 carers	24 years and 33 years	Severe
35	Rietdijk and colleagues	2020	Rx group (in-person) = 17, Rx group (telehealth) = 19, historical control group = 15	Rx group (in-person) = 54 (mean), Rx group (telehealth) = 42 (mean), historical control group = 36 (mean)Total age range: 19-68	Moderate-severe
36	Salazar and colleagues	2000	Rx group (hospital) = 67, Rx group (home/telephone) = 53	Rx group (hospital) = 25 (mean), Rx group (home/telephone) = 26 (mean)	Moderate-severe
37	Schoenberg and colleagues	2008	Rx group 1 (computer based) = 19, Rx group 2 (face to face) = 20	TELE: M = 27, F2F: M = 33	Moderate-severe
38	Smith and colleagues	2012	27 (TBI and/or PTSD) - not specified	Not specified	Mild
39	Solana and colleagues	2014	746 (face-to-face treatment), 141 (ITA treatment)	16-55	Not specified
40	Solana and colleagues	2015	612/887 TBI	Older than 17	Not specified
41	Välimäki and colleagues	2018	Rx group 1 (rehabilitation gaming) = 29, Rx group 2 (entertainment gaming) = 29, control (no intervention) = 32	Rx group 1 (rehabilitation gaming) = 42.14 (mean), Rx group 2 (entertainment gaming) = 40.90 (mean), control (no intervention) = 39.34 (mean)	Not specified
42	Nakase-Richardson and colleagues	2016	Rx group 1 (education only) = 178, Rx group 2 (PST) = 178	Education only = 20-53, PST = 20-54	Mild
43	Waldron and colleagues	2012	3 (TBI)	30-52	Not specified
44	Wang and colleagues	2019	16 (TBI)	Mean = 46.8	Mild-severe

TBI, traumatic brain injury; Rx, treatment; Ctrl, control; pwTBI, person/s with traumatic brain injury; CCT, computerized cognitive training; TC, tai chi; UC, usual care; MOPS-VI, Military On-Line Problem Solving Intervention; PTSD, post-traumatic stress disorder; ITA, intelligent therapy assistant; PST, problem solving treatment.

Caregivers

Across the 44 studies, two studies included only caregivers of people with TBI (n = 213) as their participants and seven studies included both people with TBI and caregivers (combined total of n = 908). Studies included a heterogeneous sample of caregivers, including parents, siblings, partners, and friends of people with TBI. For the one study⁷² that reported the age range of participants that were specifically caregivers, ages ranged from 18 to 61 years.

Interventions

The intervention characteristics are presented in Table 3.

Asynchronous or synchronous

Of the 44 studies, 20 studies evaluated interventions that were delivered asynchronously and 13 studies examined interventions that were delivered synchronously. There were 11 studies that included both an asynchronous and synchronous component to the intervention. Figure 5 depicts the delineation of synchronous and asynchronous approaches within each modality. Interventions delivered by telephone and videoconferencing were exclusively synchronous; however, intervention modalities such as mobile use, computer programs and social media demonstrated a combination of synchronous and asynchronous approaches across the studies. The use of personal digital assistants (PDA) was exclusively asynchronous.

FIG. 5.

Modalities of intervention.

Modality

From the 44 studies included in this review, there was a range of nine different digital health modalities (Fig. 5). The most frequently used modalities include telephone (n = 12), web-based (n = 8) and videoconferencing (n = 6). Four studies used a combination of two digital health modalities, with one of these studies⁸² using a PDA during the main intervention period and then text messaging during the follow-up period. Five studies compared two digital health interventions, including Inge and colleagues⁶⁸ who delivered an intervention using social media (Facebook) and email. Figure 6 demonstrates the distribution of modality types across the years of publication.

FIG. 6.

Distribution of modalities across the years of publication.

Provision of intervention

Interventions were delivered by a variety of health professionals. Five of the studies included interventions that were delivered by counselors, five by speech pathologists and three by occupational therapists. Other health professionals included: neuropsychologists (n = 2), psychologists (n = 2), nurses (n = 3), social worker (n = 1), case manager (n = 1) and vocational rehabilitation counselor. Nine studies did not specify the discipline of the therapist. Four studies implemented a multi-disciplinary approach with interventions being delivered by: 1) a psychologist, sociologist, and anthropologist⁴⁸; 2) a psychologist, neuropsychologist, and social worker⁵⁴; 3) an occupational therapist and a speech pathologist⁶⁹; and 4) a speech pathologist, an occupational therapist, and a vocational counselor.⁷⁵ Three studies^45,59,67 included interventions that were self-directed by the participants and four studies^60,63,65 included interventions that were a combination of self-directed and therapist-led components.

Individual or group

Of the 44 studies included in this review, 38 studies involved interventions delivered to individual participants. Three studies^54-55 were delivered in a group model and three studies^75,78,82 included a combination of both individual and group service delivery models.

Location

The interventions were predominantly delivered remotely (n = 27), with this including participant homes, workplaces, or other sites within the community. Four interventions were delivered synchronously using a digital modality (e.g., a computer-based program) with the clinician in person and five studies did not specify the location of service delivery. There were seven studies that were delivered involving a combination of both on-site sessions with the clinician and remote sessions (for example in the participants' homes). On-site locations included rehabilitation units, laboratories, and clinics. There was one intervention that required the participants to engage in the intervention asynchronously (self-directed content) both on-site and remotely.

Dosage

Number of sessions ranged from one session to 60 sessions, with interventions most frequently ranging in duration between six and ten sessions. Length of interventions ranged from a single session (n = 1) to 2 years (n = 1). For the interventions that were over 6 months in duration, these programs included multiple follow-up or maintenance sessions that were up to 3 months apart. The interventions were delivered mostly over 8-12 weeks. Sessions were predominantly scheduled fortnightly (n = 5), weekly (n = 5) or used a tapered approach to include follow-up and maintenance sessions (n = 4). Session duration ranged from an 8-min phone call⁴⁸ to sessions that were up to 3 h in length,⁷⁰ with 60-min sessions being the most common (n = 7) followed by 30-45 min sessions (n = 6). Total hours of intervention ranged from 40 min to 60 h. From the studies that reported the total number of sessions and the duration of each session, the mean dosage (number of sessions × duration of session) was 17.5 h.

Aims of intervention

The primary purpose of the interventions included in this review was to address cognitive rehabilitation (n = 16), with other studies focusing on education and improving knowledge about brain injury (n = 4), improving problem solving skills (n = 4), symptom management (n = 3), improving task completion and efficiency (n = 4), goal setting skills (n = 3), acquisition of new functional skills (n = 2), social communication (n = 2), improving management of mental well-being (n = 3) and compensatory strategies (n = 3). Two studies addressed cognitive-communication skills.

Theoretical models

Nine studies clearly stated the underpinning theoretical model of the included interventions. This included; cognitive behavioral theory (n = 4), Spacing Effect theory (n = 1), neuroplasticity (n = 1), Supervisory Attentional System (n = 1), mindset theory of action phases (n = 1) and Theory of Reasoned Action (n = 1).

Co-designed interventions

Five interventions^{52,66,68,72,75} involved elements of co-design. However, these studies only partially applied the co-design process to the development of intervention programs and excluded a diverse range of key stakeholders. Elements that were considered included seeking advice or consultation from clinicians,⁵² clinician-based focus groups⁶⁶ and feedback from people with TBI via interviews or focus groups.^68,75 McLaughlin and colleagues⁷² incorporated a combination of different elements, such as: 1) evidence-based interventions for caregivers of people with TBI; 2) interviews with family members of people with TBI and experienced professionals; and 3) adaptation of a text-based program.⁸⁹

Outcomes

A summary of key findings and outcomes is presented in Table 5.

Table 5.

Summary of Key Findings and Outcomes

Authors	Year of publication	Study design	Primary outcome measures	Procedures	Key findings/outcomes		Theoretical model	Intervention category
Authors	Year of publication	Study design	Primary outcome measures	Procedures	Significant	Non-significant	Theoretical model	Intervention category
Banerjee and colleagues	2021	Case study	1) National Institute of Mental Health and Neurosciences neuropsychological battery, 2) Beck's Depression Inventory	Therapy sessions consisted of a multi-method approach:a) Cognitive remediation (CR) using paper-pencil and computer-based tasks.b) CR via Neurologic Music Therapy [Techniques of NMT, such as the Associative Mood and Memory Training (AMMT), Music Psychosocial training and Counseling (MPC)] were also used. In addition, listening to music and dance choreography was used as a technique to help target memory and autobiographical memory deficits.c) Use of social media for memory training.d) Individual and family therapy sessions to address interpersonal factors.	Significant improvements reported on percentiles on the neurocognitive assessments of mental speed, sustained attention, verbal fluency, verbal working memory, response inhibition and verbal and visual learning and memory	No significant change for planning and set shifting assessments.	Cognitive retraining, reminiscence theory, social cognition theory, cognitive behavioral theory	Cognitive
Belanger and colleagues	2015	RCT	Neurobehavioral symptom Inventory (NSI)	Participants completed online modules relevant to education on TBI and associated symptoms, general strategies for symptom management. Links for further optional resources provided.	NSI scoresdecreased from baseline to 7 days (p < 0.001)	NSI scores 7 days to 6 months (p = 0.94)Group × time interactions for NSI for both groups	Not specified	Education
Bell and colleagues	2005	RCT	An overall composite score based on the scores on the FIM, DRS, CIQ, FSE, GOS-E, EuroQol, NFI, PQOL, SF-36, and BSI	Telephone contacts included 3 basic elements: 1) followed up previously identified concerns, 2) identify current concerns, 3) determining appropriate level of intervention	Composite score greater for telephone group compared to UC (p = 0.002)	Secondary measures	Not specified	Cognitive and education
Bell and colleagues	2011	RCT	A composite score based on FIM, DRS, the Participation with Recombined Tools-Objective, and GOS-E.	Usual care (UC) group received care in their community and follow-up from their medical and rehabilitation providers. Rx group: research care manager called the subject and caregiver based on a schedule.		Primary measure scores between groups at Years 1 or 2 (p = 0.987 regression for year 1, p = 0.983 for year 2)	Not specified	Cognitive
Bell and colleagues	2008	RCT	Post-traumatic symptom composite based on the number of new or worse post-traumatic symptoms and the number of functional areas impacted by the symptoms (Head Injury Symptom Checklist and 12 functional areas listed in Measures section)General health composite based on assessments in five areas: physical functioning (SF-12 Physical Score), satisfaction with life (PQOL), emotional well-being (PHQ-Depression, PHQ-Anxiety/Panic, PHQ-Anxiety/Other, SF-12 Mental Score), major role, and community integration	Usual care group received usual care consisting of a patient instruction handout and standard outpatient treatment. Rx group received scheduled telephone contacts over the first 3 months post injury, along with the standard patient instruction handout, a wallet card with the toll-free telephone number, and a booklet ‘‘Facts about Concussion and Brain Injury and Where to Get Help,’’ in addition to usual care.	Post-traumatic symptoms composite for Rx group compared to UC (p = 0.016)	General health composite for both groups	Not specified	Cognitive and education
Bell and colleagues	2017	RCT	Brief Symptom Inventory-18 (BSI-18) to evaluate psychological distressRivermead Post Concussion Symptoms Questionnaire (RPQ) to evaluate PCS	Rx group received PST + TAU and usual care group received education only (EO) + TAU. Both groups received 12 educational brochures describing common mTBI and post-deployment problems	BSI-18 at 6 months for PST group compared to EO group (p = 0.005)	BSI at 12 months for PST group compared to EO group (p = 0.543)RPQ at 6 months for PST group compared to EO group (p = 0.190)RPQ at 12 months for PST group compared to EO group (p = 0.453)	Not specified	Cognitive and education
Bergquist and colleagues	2009	RCT	Memory and Mood subscales of Neurobehavioral Functioning Inventory (NFI)	2 hours of initial IM training with therapist in room and out. Calendar group: Rx focused on developing calendar skills to address difficulties with memory and developing strategies to improve memory functioning in identified aspects of day-to-day life. Diary group: participants reviewed their diary since the last Rx session with the online therapist to review in detail what occurred in the intervening time.		All primary outcomes (p > 0.05) in the Calendar Condition compared to the Diary Condition	Not specified	Cognitive
Bombardier and colleagues	2009	RCT	The Brief Symptom Inventory-Depression (BSI-D) subscaleThe Short-Form-36 Mental Health Index (MHI-5)The Neurobehavioral Functioning Inventory-Depression (NFI-D)	Rx group received 7 scheduled telephone sessions over 9 months designed to elicit current concerns, provide information, and facilitate problem solving in domains relevant to TBI recovery. Usual care group received no contact until 1 year follow up by telephone.	Rx group reported less severe depressive symptoms than the control groupBSI-D (T score) p = 0.017NFI-D (SS) p = 0.002MHI-5 p = 0.009		Not specified	Psychological
Bos and colleagues	2017	Case series	1) Test of Memory Malingering (TOMM), 2) Rivermead Behavioral Memory Test–II (RBMT-II), 3) functional memory tasks	Semi-structure interviews conducted at each session. At the end of the session, two functional memory tasks were assigned to be completed prior to the next session. Participants were prompted to enter these tasks into their memory aid if they did not spontaneously do so.	6/7 participants (86%) improved ability to perform assigned functional memory tasks using smartphoneMore task completion with use of a smart-phone compared to use of memory notebook first.		Not specified	Cognitive
Bourgeois and colleagues	2007	RCT	Cognitive Difficulties Questionnaire (CDS) and Community Integration Questionnaire (CIQ)	Dyads of person with TBI and their caregiver were allocated into a SR treatment group and a didactic strategy instruction (SI) group. Participants in both groups identified three memory-related goals and were paired to receive the same total telephone contact time with the therapist.	CDS scores for SR participant at follow up (p < 0.001)CDS scores for SR caregiver at follow up (p < 0.01)	CDS scores for SR participant and caregiver for pre/post change (p > 0.05)CDS scores for SI participant and caregiver for pre/post change and at follow up (p > 0.05)CIQ for SR participant and caregiver for pre/post change and at follow up (p > 0.05)	Spacing effect theory	Cognitive
Brown and colleagues	1999	Non-RCT	Family Assessment Device (FAD), Caregiver Burden Inventory (CBI), Profile of Mood States (POMS), Questionnaires re: satisfaction	Caregiver groups attended weekly meetings and selected topics for discussion lead by a health professional. In all but 1 case the first meeting was face to face. Participants were provided with photos of other group members. They were also provided with 6 video programs and written discussion guidelines.	CBI score; TG participants reported less burden than OG (p < 0.001)POMS score; TG reported less distress than OG (p < 0.05).Both groups reported they were satisfied with the intervention	FAD comparison	Not specified	Education and psychological
Connor and Shaw	2016	Case series	1) Woodcock-Johnson III (WJ-III) subtests, 2) Barkley Functional Impairment Scale (BFIS), 3) Lumosity Brain Performance Test, 4) semi structured interviews	Participants completed metacognitive training by the speech therapist to, followed by group discussion for psychosocial support. Training took place in a group setting. Participants trained on either a computer or tablet using the Lumosity web site games for attention and memory.	Participant A performance on WJ-III (except 1 subtest) and BSIParticipant B modest improvement on all outcome measuresParticipant C modest improvement on most outcome measures	Participant A performance on WJ-III Pair cancellation and Luminosity Brain Performance TestParticipant C performance on W-J III Pair Cancellation subtest	Neuroplasticity	Cognitive
Corrigan and colleagues	2005	RCT	Percentages of participants who signed an individualized service plan (ISP) in 30 days.	Four interviewers conducted structured, brief telephone interventions targeting the timeliness of signing an individualized service plan.Participants were randomly assigned to one of four treatment conditions: (a) attention control, (b) barrier reduction, (c) motivational interview, or (d) financial incentive.	Barrier reduction group (74%) and financial incentive group (83%) were more likely to participate within 30 days compared with the motivational interview (45%) and attention control groups (45%).3-months premature termination: Attention control (15%), motivational interview (9%), barrier reduction (6%), financial incentive (4%)6 months premature termination: Attention control (47%), motivational interview (34%), barrier reduction (16%), financial incentive (21%)		Not specified	Psychological
Damianakis and colleagues	2016	Case series	Qualitative data: participant report on intervention helpfulness	Participants received technical support in accessing the password-protected website (Caring for Others) as well as negotiating website links. The CFO website included 1) a TBI Information Handbook, 2) an e-mail link with a pull-down list of group member e-mails, 3) a text-based discussion forum, and 4) a videoconferencing link for both individual and group meetings.	Participants report of improved management of emotional impact of caring for a family member with TBI.		Not specified	Education
Dowds and colleagues	2011	RCT	Rate of timely task completion	Week 1: participants were assigned a random time per workday (5 per week) to call in and additional time related personalized tasks were chosen in collaboration with the participant. Weeks 2-4: participants were randomly assigned a memory aid (paper based, POS based PDA or MOS based PDA). Weeks 5 to 8: repetition of weeks 1 to 4 with use of memory aid. Weeks 6 to 8: conducted with re-randomized assigned memory aids.	PDA device compared with paper memory aid condition: Palm OS device, IncidenceRate Ratio; p < 0.0005, CI = 1.77–2.59Microsoft Pocket PCOS device, p < 0.001, CI = 1.18-1.82.Completion rates between PDA devices:(p < 0.0005, CI = 1.26–1.70), with the Palm version producing the better scores.		Not specified	Cognitive
Elbogen and colleagues	2019	RCT	Delis-Kaplan Executive Function System (DKEFS) (Color-Word Inhibition task)Barratt Impulsiveness Scale (BIS)Dimensions of Anger Reactions (DAR)Head Injury Behavior Scale (HIBS)	Participants engaged in goal management training (GMT) with a nominated support person. Intervention group (CALM): provided with iPod touches, and designed 2 monthly goals. Mobile applications used to complete goal related actions and tasks and log usage. The control group: received psychoeducation and used mobile devices to train visual memory. Home visits at 0, 2, and 4 months	DAR: p = 0.008 (larger decrease in anger towards others over 6 months in CALM group)BIS: p = 0.016 (CALM group engaged in fewer maladaptive behaviors according to caregivers over 6 months)	DKEFS scores between groupsBIS scores between groups	Supervisory Attentional System	Cognitive
Eilam-Stock and colleagues	2021	Case study	1) Wechsler Adult Intelligence Scale, 4th Edition (WAIS-IV): Digit Span and Letter-Number Sequencing subtests, 2) Paced Auditory Serial Addition Test (PASAT), 3) Brief Test of Attention (BTA), 4) Wechsler Memory Scale, Fourth Edition (WMS-IV): Symbol Span, 5) Cogstate Brief Battery (CBB)5: Two-Back, detection and identification, one card learning, 6) Trail Making Test—Part A (TMT-A) & Part B (TMT-B), 7) Delis-Kaplan Executive Function System (D-KEFS): Verbal Fluency, 8) Symbol Digit Modalities Test (SDMT)8—oral administration, 9) Rey Auditory Verbal Learning Test (RAVLT), 10) Neurospsychological Assessment Battery (NAB), Memory Module: Story Learning, 11) Beck Depression Inventory, Second Edition (BDI-II), 12) Beck Anxiety Inventory (BAI), 13) Positive and Negative Affect Scale (PANAS), 14) Patient Reported Outcomes Measurement Information System (PROMIS): Sleep, Pain, and Fatigue ScalesRaw scores were converted to z-scores based on published normative data	Participant completed training for at home self-administrations of RS-tDCS and aCT procedures in the clinic. He was provided with a study laptop and completed the sessions at home with a study technician remotely supervising. Sessions were completed daily with 20 min of aCT (BrainHQ) during 20 min of RS-tDSC. Following 20 sessions, participant returned to the clinic for follow-up evaluation of the cognitive measures.	Change >1 SD is considered significant.DSS at follow up, z score difference = 1.33PASAT: 3 seconds at follow up, z score difference = 1.23CBB: two-back at follow up, z score difference = 1.27CBB: identification at follow up, z score difference = 1.85D-KEFS: category at follow up, z score difference = 1.67PROMIS: sleep at follow up, z score difference = 2.0	All other measures were insignificant at follow up	Not specified	Cognitive
Fann and colleagues	2015	RCT	Hamilton Depression Rating Scale (HAMD-17)Symptom Checklist-20 (SCL-20)	Telephone and in-person CBT-TBI sessions (adapted from Simon and Ludman's structured telephone care management and CBT protocol). Patients' support persons were invited to attend sessions. Workbooks were provided and follow-up summary and plans were mailed post session.	SCL-20 scores at follow up for CBT-T vs. UC (treatment effect = 0.36, 95% CI: 0.01–0.70; p = 0.043)	HAMD-17 scores at 16 weeks for CBT vs. UC group (treatment effect = 1.2, 95% CI: -1.5–4.0; p = 0.37)SCL-20 scores at 16 weeks (however favored CBT (treatment effect = 0.28, 95% CI: - 0.03–0.59; p = 0.074)	Cognitive behavioral theory	Psychological
Forducey and colleagues	2003	Case study	Clinical observations	A metro-based physiotherapist provided clinical support and mentoring to a multidisciplinary team in a rural setting providing care for a minimally conscious patient. Baseline observations were completed by the physiotherapist and neuropsychologist in person and then clinical observations were used to measure progress during intervention.	Minimal improvement in physical skills. Patient showed qualitative improvement in his alertness and basic neurocognitive skills.		Not specified	Education
Gomez and colleagues	2013	Case study	Number of tasks, number of times the therapist had to guide him, total time to complete tasks	Participant was provided with a mobile phone with a QR code application and the corresponding QR codes. QR Codes produce a set of instructions that help the participant to accomplish the activity. Instructions were presented in different modalities: graphical, text and oral.	Improved on all measures, increased independence, reduced guidance.		Not specified	Cognitive
Hart and colleagues	2021	RCT	1) Environmental Reward Observation Scale (EROS), 2) Behavioral Activation for Depression Scale (BADS)	Implementation Intention (INT) group: Initial education session with therapist to generate and prioritize list of potential activities.Motivation interventions (MOT) group: Initial education session with therapist about importance of maintaining motivation, confidence and focus. Participants selected 8-10 motivational messages from a menu.Both groups: Participants received SMS messages according to agreed schedule (at least 4-5 messages per day). Participants read each message to themselves 2 times and were instructed to reply with a paraphrase.	INT group:EROS (p = 0.017 at 4 weeks, p = 0.005 at 8 weeks)BADS (p = 0.003 at 4 weeks, p = 0.0001 at 8 weeks)MOT group:BADS (p = 0.005 at 8 weeks)	MOT group:EROS (p = 0.353 at 4 weeks, p = 0.052 at 8 weeks)BADS (p = 0.335 at 4 weeks)	Not specified	Psychological
Hart and Vaccaro	2017	RCT	1) Participation with Recombined Tools-Objective (PART-O) 2) Brief Symptom Inventory-18 (BSI-18) 3) Goal Attainment Scale	The Goal Intention (GI) condition: individualized reminder messages relevant to ongoing goals, framed as implementation intentions. Participants were given the choice to receive their messages via voice, email or text messages. Participants were asked to rehearse messages by reading them at least 3-times each time they arrived and to reply to confirm receipt of message. Goal Review (GR) group: completed a session on the importance of goals, followed by a discussion of the goals achieved and future goals. Participants were encouraged to keep working toward their goals; no specific plans for doing so were discussed.	Group × time interactions favoring the GI group were observed on PART-O community activity and social relations (F = 47.4, p = 0.002, η2 = 0.18)Qualitative results suggested overall acceptance and success of SMS reminders.	Differences between scores for BSI-18 or GAS	Mindset theory of action phases	Cognitive
Hart and colleagues	2002	Case series	The Participant's recall of recorded and unrecorded goals from the previous week's case management session. A 0- to 3-point scoring system was developed for comparison of the participants' responses to the content of each of the original goal statements.	Development of 6 patient specific goals and one to two word "key words" for each goal. Goals were randomly assigned to be recorded and not recorded. Participants were provided with a voice recorder. Participants were instructed to play the goals that had been recorded for them each time the alarm sounded. At the next session, participants were asked to recall the entire goal when provided with the key word	Recorded goals were recalled significantly better than unrecorded goals in both free (z = -2.53, p < 0.005) and cued (z = -2.66, p < 0.01) recall conditionsCued recall appeared to be superior to free recall for both recorded and unrecorded goals (p < 0.03, z = -2.37)		Not specified	Cognitive
Hwang and colleagues	2020	RCT	1) Mattis Dementia Rating Scale (MDSR), 2) Mini-Mental State Examination (MMSE), 3) modifiedTelephone Interview of Cognitive Status (TICS-M), 4) Trail Making Test (TMT).	Pamphlets that provide educational information promoting physical and mental activities were distributed to all participants.UC group: as per physician advice and recommendationsComputerized Cognitive Training (CCT) group: provided by RehaCom software. Authors adapted the program into 4-domains for cognitive training of attention, memory, speed of processing, and executive functioning. Participants completed more than 20 different therapeutic activities for activation and stimulation, with task difficulty levels for each domain automatically increasingTai Chi (TC) group: 8-form Yang-style TC exercise took place with a TC instructor. The intensity and complexity of the TC exercise increased over the intervention period.	MDSR scores at post-CCT group p < 0.05TC group p < 0.05Moderate-large effect sizeMDSR scores at follow-up (12 months)TC p < 0.05Moderate-large effect sizeMMSE at post-CCT group p < 0.05TC group p < 0.05Moderate-large effect sizeTMT-B at post -CCT group p < 0.05Moderate-large effect sizeTMT-B at follow up (12 months)CCT group p < 0.05Moderate-large effect size	MDSR scores at postUC group p > 0.05MDSR scores at follow up (12 months)CCT group & UC group p > 0.05MMSE at post-UC group p > 0.05MMSE at follow up (12 months)CCT group, TC group and UC group p > 0/05TMT-B at postTC and UC group p > 0.05TMT-B at follow up (12 months)TC and UC group p > 0.05	Not specified	Cognitive
Inge and colleagues	2017	RCT	The knowledge assessment measure contained 10 multiple choice items concerning knowledge of evidence-based employment knowledge. The measurement instrument was used at both baseline and post-intervention. The number of items correct was used as baseline and postintervention score for each participant.	Email group: received an “e-news” email at the beginning of each of the three months with content on evidence-based practices in supported employment for individuals with TBI. Facebook group: The same evidence-based information formed the foundation for the posts that were made in the secret Facebook group a minimum of five times a week during the work week.	Knowledge gain for within group between baseline and post-intervention (p = 0.0001, 95% CI [-2.58, -1.28] and had a large effect size (d) of 0.91)	Knowledge gained between groups at post-intervention.Knowledge differences at post-intervention between the Facebook group and e-News group (p = 0.542, 95% CI [-0.71-1.51].	Not specified	Education
Kirsch and colleagues	2004	SCED	Utterance frequency and total utterance time	Pt recorded his own verbal cue on a PDA, e.g., "be brief." The intervention presented the Pt with the verbal cue at 15 min intervals. This was targeted in a group environment.	Utterance frequency did not change. However, the total utterance time was reduced during B trials, attributable to the reduced frequency of lengthier utterances		Not specified	Communication
Larsson and colleagues	1995	case series	Goal Attainment Scaling	Initial assessment; included an interview with the participant and different evaluation instruments to form a basis for computer selection and supervision. Equipment was prescribed, consisting of trials or study visits to computer resource centers, purchase of computers and software and installation. Supervision was provided, which included instructions and Goal Attainment Scaling. A concluding interview was conducted.	Case C: achieved 14/15 goals, Case D: achieved 5/7 goals,		Not specified	Cognitive
McGraw-Hunter and colleagues	2006	SCED	Percentage of steps correct on the task analysis for the food to be prepared	Four individuals with TBI received instruction in cooking. They watched videotapes of themselves cooking and practiced that skill while receiving prompts and feedback. Treatment effects were evaluated by comparing performance before, during and after training and at a 2- and 4-week follow-up. Additionally, cooking performance on a novel food item was examined.	3/4 participants achieved criterion performance within 4 training sessions. Those participants also maintained skills at 2 and 4 weeksP1 maintained the treatment effects during the 2-week and 4-week follow-up sessions at 100%P2 performed 84% and 96% of the steps in the cooking task independentlyP3 independently performed 96% and 100% of the cooking steps.3 participants independently performed 92-100% of the steps in the generalization tests.P4 completed an average of 54% of the steps independently for the cooking task and 56% of the steps independently on the generalization test. Performance was 40% post video.		Not Specified	Cognitive
McLaughlin and colleagues	2013	RCT	Computer-based pretest, posttest, and follow-up measures were used to assess knowledge, skill application, behavioral intention and overall life satisfaction (The Satisfaction with Life Scale (SLS)). Program use data was collected to evaluate exposure to the BIP materials (google analytics).	Participants completed an online informed consent form and the pretest. Participants were randomly assigned to treatment or control groups and either (a) granted access to the program (treatment group) or (b) directed to the BIAUSA Web site (control group).	Pre/post change for 1) Skill application (p < 0.01, d = 1.01),2) Intentions (p < 0.01, d = 0.70), 3) Knowledge (p < 0.01, d = 0.67)Change at follow up compared to baseline for 1) Skill application (p < 0.01, d = 0.84),2) Intentions (p < 0.01, d = 0.80), 3) Knowledge (p = 0.032, d = 0.32)	Satisfaction with life (p = 0.054, d = 0.29) at follow up compared to baseline	Theory of Reasoned Action	Education and psychological
Ng and colleagues	2013	Case series	Feedback interviews (semi-structured), Canadian Occupational Performance Measure (COPM), The Dysexecutive Questionnaire (DEX), The Mayo-Portland Adaptability Inventory-4 Participation Index, The Flanagan's Quality of Life Scale (QoL)	Intervention based on intervention protocol. Client chosen goals were developed based on the problem list identified during the COPM interviews. Intervention consisted of preparation phase, acquisition phase and verification phase. A list of trained and untrained goals was generated and evaluated post intervention. New goals post-intervention were identified and then evaluated at 3-month follow up. Significant others were also involved in the sessions, with no pre-determined involvement	Participant 1MPAI-4-P for pre/post (p = 0.02, CI = 7.42) and at follow up (p = 0.51)DEX at follow up (p = 0.03, CI = 1.73)Significant other 1Pre/post MPAI-4-P (p = 0.04, CI = 1.96)Participant 2Pre/post MPAI-4-P (p = 0.05, CI = 3.97)QoL for pre/post (p = 0.02, CI = 11.33)Participant 3Pre/post for DEX (p = 0.02) and QoL (p = 0.05)Significant other 3Pre/post for MPAI-4-P (p = 0.01, CI = 0.65)	Participant 1DEX for pre/post (p = 0.08, CI = 3.46)QoL for pre/post (P = 0.22, CI = 11.98) and follow up (p = 0.35, CI = 29.19)Significant other 1Pre/post DEX (p = 0.06, CI = 1.73)Participant 2MPAI-4-P at follow up (p = 0.14, CI = 5.35)DEX for pre/post (P = 0.12, CI = 1.96) and follow up (p = 0.08, CI = 1.13)QoL at follow up (p = 0.06, CI = 10.18)Significant other 2MPAI for pre/post (p = 0.71, CI = 5.35) and follow up (p = 0.51, CI = 4.57)DEX for pre/post (p = 0.21, CI = 4.71) and follow up (p = 1.00, CI = 2.61)Participant 3Pre/post MPAI-4-P (p = 0.19, CI = NA)Significant other 3Pre/post DEX (p = 0.93, CI = 4.57)	Not specified	Cognitive
Powell and colleagues	2016	RCT	1) The Brief COPE (baseline), 2) Adapted the Bakas Caregiving Outcomes Scale, 3) structured, closed-ended interview questions, 4) PART-O (Participation Assessment with Recombined Tools–Objective), 5) caregiver knowledge and skill acquisition (structured interview and Likert scale ratings), 6) Modified Caregiver Appraisal Scale. TBI survivor measures - Disability rating scale (DRS)	Usual care group: received usual care and were not contacted by study personnel between randomization and outcome assessment. Rx group: received combined education and mentored on problem solving on topics relating to caregiving and TBI recovery and management (in addition to usual care).	Caregivers in the intervention group:Access to family and friend support (p = 0.019), access to healthcare support (p = 0.027), managing own health (p = 0.046), No. of people helping with caregiving (p = 0.015), active coping (p = 0.020), less emotional venting (p = 0.028), less use of humor (p = 0.011) in dealing with life stressors		Not specified	Cognitive
Powell and colleagues	2019	Non-RCT and case study	Outcome measures were administered online; Project-specific knowledge test, Problem Solving Questionnaire (PSQ), Problem Solving Rating Scale (PSRS), TBI Self-Efficacy Questionnaire (TBI-SE), Satisfaction with Life Scale (SWLS), System Usability Scale (SUS) (ProSolv condition only).Additional measures for follow up case: BRIEF, EMQ and structured role play	Rx group: ProSolv involved face-to-face sessions to train the participant in the use of the app, a web-based ProSolv tutorial and a ProSolv app to document problem solving steps and reminders.Usual care group: metacognitive strategy instruction without using an appFollow up single case:Participant and her coach met completed the ProSolv trainingSessions.	Single case: Improvements were noted across measures (knowledge test, PSQ, TBI-SE and SWLS). Ratings on the BRIEF varied and indicated increased difficulty in this domain by the final follow up session. The role play measure also showed a trend towards improvement, with progressively higher averages from pretest through to follow up.	All outcome measures for Rx vs. UC group	Not specified	Cognitive
Riegler and colleagues	2013	Non-RCT	Test of Memory and Learning 2nd Edition (TOMAL-2)	Usual care group: received face-to-face intervention, Rx group received: online intervention. Both treatments provided 1) education re: TBI and PTSD and 2) therapeutic cognitive intervention focused on attention and memory.	Memory improved for both groups (p < 0.001)	TOMAL-2 scores for face-to-face vs MOPS-IV groups (p = 0.55)	Not specified	Cognitive
Rietdijk and colleagues	2019	SCED	Exchange structure analysis	The program involves both the person with TBI and a regular communication partner attending sessions and completing practice tasks between sessions. Topics covered include: (1) Program introduction (2), How brain injury affects communication (3), Effective communication strategies (4), Collaboration (5), Elaboration (6), Asking questions, and (7) Further practice for improving skill and confidence.	Positive change on blinded ratings of conversation and self-reported measures for both participants.Exchange structure analysis conducted on session-by-session data did not demonstrate treatment effects due to variability during baseline.		Behavioral, cognitive and educational theory	Communication and education
Rietdijk and colleagues	2020	Non-RCT	Adapted Measure of Participation in Conversation (MPC) Reveal competence in casual conversations	Telehealth intervention group completed TBIconneCT via Skype and in-person intervention group received home-visits from the clinician, completing TBIconneCT. Activities related to core content included learning about communication processes, identifying personally relevant strategies, and practicing in conversations.	MPC reveal competence scores for Rx group vs No treatment (p = 0.04, d = 0.71)	MPC reveal competence scores for telehealth vs. In-person training (p = 0.47, d = 0.26).	Behavioral, cognitive and educational theory	Communication and education
Salazar and colleagues	2000	RCT	Actual return to work and fitness for military duty at 1 year post treatment as determined from interview, military record or both	Rx group: received a limited home rehabilitation program with weekly telephone support from psychiatric nurse. Usual care group: received intensive, standardized, in-hospital cognitive rehabilitation program.		Return to employment at 1 year between Rx and UC group (p = 0.51, 95% CI)Fitness for duty at 1 year between Rx and UC group (p = 0.43, 95% CI)	Not specified	Cognitive
Schoenberg and colleagues	2008	Non-RCT	Functional outcomes as defined by authors: independent living, independent driving, return to work or school.	Rx group: completed computer-based cognitive rehabilitation program via computers connected under the supervision of a therapist. Therapist monitored participants' progress via data received through the server, and exercises were adjusted on the basis of participant performance. Usual care group: received a minimum of six sessions of therapy.	Participants living independently, driving, and working significantly improved for both groups (p = 0.01)	Between groups difference in the proportion of participants living independently, driving, or returning to school or work at the conclusion of treatment.	Not specified	Cognitive
Smith and colleagues	2012	Case series	Authors developed a questionnaire to include a subset of 32 questions adapted from Symptom Checklist-6, the Brief COPE, and Beck Depression Inventory-II. Included other questions assessing level of pain, hassles, and uplifts, a series of questions designed to gather feedback from participants about the previous day's activities.	During the active treatment phase, EMA data were collected on a daily basis from participants via PDAs. After discharge in the follow-up phase of treatment, patients continued to participate through interactive text messaging technology (SMS) as they received and responded to check-in messages on their personal cell phones.	Initial response rate: 23%Study modified based on informal feedback due to intrusiveness of randomized EMA delivery. Instead, incorporated into daily group therapy session.1-month response rate: 92%2-month response rate: 95%3-month response rate: 91%		Not specified	Psychological
Solana and colleagues	2014	Non-RCT	1) Tasks selected 2) difficulty level of the tasks 3) improvement on cognitive capacities (neuropsychological assessment not specified, reported pre- and post-tests)	Usual care group: completed traditional manual planning procedure where therapists selected tasks and Rx group: received computerized GNPT program		All measures for between Rx and UC groups (p = 0.3484)	Not specified	Cognitive
Solana and colleagues	2015	Case series	Not specified (neuropsychological assessment)Set of validated tests used to evaluate cognitive functions (attention, memory or executive functions) prior to the treatment. Each test's item has been semantically translated onto the InternationalClassification of Functioning, Disability and Health(ICF)	Participant completed sessions on the GNPT platform, completing rehabilitation tasks in attention, memory and executive function. Performance was evaluated prior and post intervention.	67.53% of patients improved cognitive capacities after completing treatment.		Not specified	Cognitive
Välimäki and colleagues	2018	RCT	Trail Making Test (TMT)WAIS-IV subtests: (1) symbol search, (2) cancellation, and (3) coding.	Rx group completed daily exercises on a web-based digital brain training program with weekly telephone calls. Researchers had access to the participant's access to the program and progress. Frequency of training was recorded in a diary. Entertainment gaming group completed 30 min of gaming of a commercial digital game designed for the Sony PlayStation 3 console. They also received weekly phone calls from the researcher and recorded their progress and frequency of use in a diary. The no intervention group did not receive treatment.	All three groups showed improvements in test performance across 3 time points.	TMT, WAIS-IV subtests for between groups	Not specified	Cognitive and psychological
Nakase-Richardson and colleagues	2016	RCT	Pittsburgh Sleep Quality Index (PSQI)	Participants received 12 informational brochures on topics addressing common problems associated with mTBI. The EO group received a second mailing of the educational brochures on a biweekly basis. PST group received phone calls from counselors resolving participant-chosen problems from a list generated during the first or second call, using PST steps	Overall sleep quality between the PST and EO groups at 6 months (p = 0.003)PST improved sleep quality at 6 months (p = 0.001)	Overall sleep quality between groups at 12 monthsPST sleep quality at follow up	Not specified	Cognitive
Waldron and colleagues	2012	Case series	Number of tasks completed/ remembered	Participants were informed of tasks to be completed at the beginning of each week. Participants were asked to rely on their memories alone and could not record tasks externally during baseline. Intervention phase lasted two weeks: Participants were instructed to perform a similar set of experimental tasks per week, varying the days and times of completion, using the PDA device.	Pre/post scores for all participants using PDA (Z = 2.02, p < 0.05)		Not specified	Cognitive
Wang and colleagues	2019	RCT	Performance Assessment of Self-Care Skills (PASS), NASA Task Load Index (TLX), custom questionnaire was used to assess user-perceived ease-of-use and usefulness of the two prompting methods, and user stress levels	Participants completed two cooking tasks in a lab. One group used an automatic prompting method and the other group used a user-controlled prompting method. The sequence of the two prompting methods and two cooking tasks were counterbalanced.	PASS outcomes (between groups) for total amount of required assistance: p = 0.034 (significant)Self report outcomes (between groups) for ease-of-use (p = 0.016) andStress (p = 0.047)	PASS outcomes (between groups) for safety (p = 0.333), adequacy (p = 0.054), highest level of required assistance (p = 0.283)Self report outcomes (between groups) for NASA-TLX (p = 0.06) and usefulness: (p = 0.186)	Not specified	Cognitive

TBI, traumatic brain injury; FIM, Functional Independence Measure; DRS, Disability Rating Scale; CIQ, Communication Integration Questionnaire; FSE, Functional Status Examination; GOS-E, Glasgow Outcome Scale (Extended); NFI, Neurobehavioral Functioning Inventory; PQOL, Perceived Quality of Life Scale; SF-36, Short Form-36; BSI, Brief Symptom Inventory; PST, problem solving treatment; mTBI, mild traumatic brain injury; RCT, randomized controlled trial.

Telephone interventions

Five^47
-49,51,86 of the 10 studies investigating the effectiveness of telephone-based intervention for people with TBI reported outcomes that were better than usual care intervention, such as face-to-face interventions, for all of the aforementioned intervention aims. Regarding long-term outcomes, there was no significant difference at 12 months follow-up for most studies, although Nakase-Richardson and colleagues⁸⁶ reported better overall sleep quality for their telephone problem-solving treatment group compared with the education-only group at 6 months post-treatment. The other five studies^{46,53,56,61,81} reported improved outcomes for both the usual care intervention groups and the telephone interventions groups; however, there were no statistically significant differences in long term outcomes.

Two studies^54,75 investigated the effectiveness of telephone-based interventions for caregivers of people with TBI. Brown and colleagues⁵⁴ reported that education, skill development and counseling for rural families of a person with TBI delivered via telephone resulted in less burden and less distress in their role as caregivers than the usual care group. Powell and colleagues⁷⁵ found that intervention targeting quality of life and emotional well-being of caregivers, resulted in improvements for both the telephone intervention group and the usual care group and there was no statistically significant difference between the groups.

Computer and web-based interventions

Ten studies^{45,50,55,59,67,70,80,82
-84} investigated the use of computer and web-based interventions for people with TBI. One study⁴⁵ reported better outcomes in reducing post-concussion symptoms for people with TBI completing intervention via computer and web-based modalities compared with those receiving in person intervention. Another study⁶⁷ reported better outcomes post-intervention for participants that completed computerized cognitive treatment compared with participants that were in the Tai Chi group and usual care group. However, these cognitive improvements were not maintained at follow-up. Two studies^80,82 reported improvements for both the web-based intervention group and the in-person intervention group; however, no statistical differences were found. Four studies^55,59,70,83 did not include a usual care condition; however, they found that participants showed improvements in cognitive and neuropsychological skills compared with baseline measures. One study⁸⁴ investigated the effectiveness of three different web-based video games in improving cognitive functioning and well-being for people with TBI in comparison to usual care. There were no significant differences between all three gaming groups in improvement on the outcome measures with all groups showing improvements in test performance across three time points. Additionally, Bergquist and colleagues⁵⁰ used internet based instant messaging to investigate the effectiveness between an active condition (use of a calendar) and a control condition (use of a diary). They found that there were no significant differences between conditions for changes in functioning on any of the primary or secondary outcome measures.

One study⁷² investigated the use of a web-based program in targeting active listening and problem-solving skills in families of people with TBI and identifying relevant support services and strategies for stress reduction. There were greater improvements in skill application, intention, and knowledge related to the targeted areas at post-test for the web-based intervention group compared with the control group, which received usual care. However, at 3 months follow-up, there was no difference between the intervention group and the control group regarding knowledge acquired and satisfaction with life.

Videoconferencing interventions

Two studies^62,73 investigated the effectiveness of using videoconferencing in the provision of intervention for people with TBI without a comparison to usual care. Ng and colleagues⁷³ found that intervention delivered via videoconferencing resulted in positive changes for the participants with self-reported improvements in both trained and untrained goals. There was also a trend toward fewer symptoms of executive dysfunction and greater community integration. Forducey and colleagues⁶² found in a single case study that neuro-developmental treatment delivered via videoconferencing resulted in minimal improvement in physical skills; however, the patient showed qualitative improvement in his alertness and basic neurocognitive skills.

Two studies investigated the effectiveness of delivering intervention via videoconferencing for people with TBI and their caregivers. Rietdijk and colleagues⁷⁷ found that the use of videoconferencing in targeting social communication skills, showed positive change on blinded ratings of conversation and self-reported measures of conversational skills for two participants with TBI using single case experimental design. In a separate non-randomized controlled trial, Rietdijk and colleagues⁷⁸ found that participants and their caregivers who received this videoconferencing-based intervention had similar outcomes in participation in conversations compared with an in-person intervention group on most outcomes, although two secondary outcomes showed medium to large effect sizes favoring the in-person group. Studies that used videoconferencing as the intervention modality focused on participants within the moderate-severe or severe TBI population.

PDA interventions

Four studies^58,69,81,86 investigated the inclusion of a PDA in intervention programs for people with TBI. Dowds and colleagues⁵⁸ found that the use of a PDA as memory aid resulted in significantly higher task completion rates for participants in the intervention group compared with the usual care, paper memory aid group. The other three studies did not compare the outcomes of intervention to usual care; however, they did find improved outcomes for people with TBI compared with their baseline scores prior to intervention. Kirsch and colleagues⁶⁹ found that the use of a PDA to provide verbal cues for reducing utterance length resulted in no change in utterance frequency; however, total utterance time (and therefore, length) was reduced. Further, Smith and colleagues⁸² demonstrated that participants showed increased participation in intervention and improvements in attitudes, behaviors, and experiences in real time in their natural environments when messages were provided via PDA. Waldron and colleagues⁸⁷ also found that using a PDA to improve compensatory skills for memory problems resulted in a higher number of tasks completed and remembered during the 2 weeks of intervention.

Mobile and smart phone interventions

Six studies^{52,60,63
-65,88} included mobile and smart phones as a modality to deliver intervention. This included the use of text messaging,^64,65 apps^52,60,88 and adaptive manuals⁶³ on these devices. Elbogen and colleagues⁶⁰ investigated the use of an app and reported no significant change between the intervention group and the usual care group in cognitive or impulsiveness outcome measures. However, the intervention group showed a larger decrease in anger towards others and engaged in fewer maladaptive behaviors at 6 months follow-up. Two studies^52,63 did not involve a comparison to usual care; however, they did report improved outcomes for the participants compared with their baseline performance.

Hart and Vaccaro⁶⁵ compared two text messaging interventions, comparing the effectiveness between a goal intention-reminding intervention approach and a goal review intervention approach. Both groups showed improvements, with the goal intention group reporting greater participation in the community. Hart and colleagues⁶⁴ also compared two text messaging interventions, comparing the effectiveness between an intentional implementation approach and a motivational intervention approach resulting in better outcomes for the intentional implementation group. Wang and colleagues⁸⁸ investigated the effectiveness of an app-based intervention targeting completion of kitchen related sequencing tasks. Their findings showed improved performance for the group using the app compared with the usual care group. There was a statistically significant change in reducing the number of steps where participants needed external assistance.

Social media interventions

One study⁶⁸ compared the use of email and social media (Facebook) for knowledge translation in people with TBI by increasing their knowledge of employment-based practices. Both groups (email and Facebook) were reported to have gained knowledge in this area; however, there was no significant difference between groups, and no comparison to usual care. Another study⁴⁴ included the use of social media as part of a multi-method approach in improving memory activation in a single case, along with cognitive remediation and neurologic music therapy. The participant showed significant improvements on the neurocognitive outcomes as a result of this multi-method approach.

Recording device interventions

Two studies investigated the inclusion of recording devices as part of their rehabilitation approach for people with TBI. Hart and colleagues⁶⁶ found that the use of a voice recorder to recall therapy goals and plans showed that recorded goals were recalled better than unrecorded goals and appeared to be associated with better awareness or follow-through with therapy objectives. McGraw-Hunter and colleagues⁷¹ found that teaching a cooking skill via video-feedback using a digital camera resulted in increased independent completion of the task compared with baseline performance, as well as generalization of skills to a novel food item for those that maintained their skills at 2- and 4-weeks post-training.

Combination of digital health modalities

Two studies^57,76 incorporated a combination of modalities in their intervention approaches. Damianakis and colleagues⁵⁷ found that intervention and support for caregivers delivered via website and videoconferencing resulted in improvements in cohesiveness, mutual identification, empathic support, and problem-solving strategies; however, there was no comparison with usual care. Similarly, Riegler and collealgues⁷⁶ delivered intervention via videoconferencing and asynchronous online modules when targeting cognitive functioning. This resulted in increased treatment adherence for people with TBI who would otherwise disengage with the service, compared with usual care. Memory improvements were observed for both the telehealth group and the usual care group, with no significant difference between the groups.

Discussion

This systematic review aimed to investigate the characteristics of current digital health interventions and the effectiveness and efficacy of these interventions. This paper showcases the large variety of digital health interventions used in the rehabilitation of people with TBI and to provide support and education for their caregivers. Overall, the findings supported the effectiveness of digital health interventions. In those studies which compared digital health with usual care, there was evidence that digital health interventions may be as effective, and in some cases potentially more effective, than usual care. This indicates that the application of this fast-emerging model of care in TBI rehabilitation is feasible and has potential to increase accessibility to specialist services for people with TBI and their caregivers throughout their life trajectory.

Characteristics of digital health interventions in TBI rehabilitation

This paper reported on interventions across seven categories of digital health modality: telephone, computer- and web-based, videoconferencing, personal digital assistants, social media, recording devices, and mobile and smart phones. Only two studies^57,76 incorporated the use of more than one digital modality in their intervention approach. Two studies^{48, 49} included a combination of a traditional intervention modality (e.g., written resources) with a digital health intervention modality (e.g., telephone). Additionally, 10 studies used a combination of asynchronous and synchronous service delivery methods. However, despite using a combination of service delivery modes, these studies often used one digital health modality in combination with traditional face-to-face intervention. These results indicate that the effectiveness of using multiple digital health modalities has not yet been thoroughly explored and researched. Studies such as that of Riegler and colleagues⁷⁶ indicate that the use of multiple digital modalities (videoconferencing and online modules) compared with usual care can result in positive patient outcomes. This is also consistent with the findings of Damianakis and colleagues⁵⁷ where caregivers reported ease of access to services and improved outcomes in caregiver stress, self-efficacy, and coping capacity.

Advancements in technology have also facilitated improved efficiency and effectiveness for clinicians in providing interventions via digital health rather than traditional face-to-face approaches. Digital health modalities such as apps and computer and web-based interventions enable improved data collection efficiency and accuracy. Data collection is often completed by the digital program and reported to the clinician for further analysis and decision making. This improves clinical planning and accuracy for further intervention task and goal selection. However, automated data collection and decision making was integrated infrequently in the studies included in this review, with only one study, Solana and colleagues,⁸³ including algorithm technology to support clinical decision making and task selection. This enabled further tailored and individualized intervention approaches. Computerized clinical decision support is currently being explored in pharmacy and medicine,⁹⁰ with findings that electronic prescribing systems have good potential to improve medication safety. These modalities often have features that allow the clinician to document how often material is accessed. This encourages those completing the intervention to be more accountable in completing asynchronous tasks. It also facilitates the clinician to review and evaluate patterns or other ways to support the person with TBI and their caregiver in engaging with their therapy, such as the inclusion of reminders or follow-up calls or emails.

Multiple studies in this review reported improved engagement due to reduced need for travel, and ease of follow-up processes (for example, participants responding to telephone calls from clinicians). For studies that evaluated satisfaction with care, participants reported this to be high on most surveys. Most studies acknowledged that there is potential for technical issues to affect engagement and delivery of intervention. This was addressed by ensuring that participants were trained and educated in the relevant digital health modality prior to commencing intervention as well as including an investigator or clinician who was available to assist with technical issues.

Foundational work to evaluate and identify the active ingredients of interventions is vital in the development of digital health interventions in TBI, to ensure that strategies are efficacious and facilitate therapeutic improvement. The active ingredients that comprise the intervention and facilitate therapeutic improvement were rarely outlined in the included studies. Studies did report whether participants received feedback during their intervention; however, there was limited data on the frequency or type of feedback. This has substantial potential to impact fidelity, which is supported in the PEDRO+ ratings, where fidelity was rarely described in the randomized control trial studies. Additionally, studies often reported on the intervention approach; however, the theoretical underpinnings were not clearly reported or discussed in the paper. This emphasizes the importance of reporting theoretical foundations of intervention approaches as we move across modalities and embrace digital health in our practice. A clear understanding of active ingredients also further ensures that these elements are maintained and carried across into new digital modalities to confirm that therapeutic benefits are maintained. It is recommended that future intervention studies incorporate the Rehabilitation Treatment Specification System (RTSS) framework⁹¹ or the Template for Intervention Description and Replication (TIDieR) checklist and guide.⁹² An example of work in this field was undertaken by O'Rourke and colleagues,⁹³ who identified the common and distinct active elements of communication partner training interventions within the stroke, TBI, and dementia populations.

An interesting finding when investigating the intervention characteristics was that only five interventions^{52,64,68,72,75} in this paper involved elements of co-design. However, these studies only partially applied the co-design process to the development of intervention programs and excluded a diverse range of key stakeholders. There is growing evidence of the application of co-design in interventions to ensure that the needs of all stakeholders are met.^94,95 Ownsworth and colleagues⁹⁶ emphasized the importance of investigating the perceived usability and acceptability of videoconferencing for delivering rehabilitation to people with acquired brain injury (ABI) from the perspective of people with ABI, their caregivers, and service coordinators. Ownsworth and colleagues,⁹⁶ were able to identify the facilitators and barriers to videoconferencing uptake from the perspective of each user group. For example, service coordinators identified that there is a growing demand for specialist brain injury rehabilitation services, especially in rural and remote communities, pointing to a service gap that videoconferencing has the potential to address. Additionally, caregivers and people with ABI were able to identify potential barriers such as cognitive-linguistic and behavioral impairments, access to internet and technology and lack of technical support. An understanding of the factors that influence uptake of technology in healthcare is essential to facilitating user experience and supporting healthcare providers in successful implementation of digital health in their practice.

Interventions can also be further enhanced by a wider range of available ideas, a better understanding of user needs, and reduction in development costs and time. Users may also benefit by receiving a more satisfactory intervention or higher quality of service and develop an understanding of future interventions through participation in the co-design process. Mulvale and colleagues⁹⁷ propose that co-design facilitators focus on the primary principles of co-design such as achieving meaningful engagement and management of power differentials when working with vulnerable and disadvantaged populations, rather than focusing on following a set of steps. This participatory approach is significantly more empowering for the consumer. The co-design process in the development of interventions is increasingly used across healthcare, including acute, rehabilitation, and outpatient or community contexts.^98
-100

Efficacy and effectiveness of digital health intervention or education programs for people with traumatic brain injury compared with face-to-face intervention approaches

The findings of this systematic review paralleled the findings from previous systematic reviews investigating telerehabilitation in TBI,^34
-36 where interventions were primarily delivered via telephone. Interestingly, there has been an uptake in videoconference and web-based interventions in the last 5 years. This may be in response to the increased availability and accessibility of this technology for personal and vocational use.

Although there were predominantly no statistically significant differences in outcome measurement between usual care groups and intervention groups post-intervention and at follow-up, there were a few studies that reported improved maintenance of skill acquisition and/or knowledge for people with TBI during the follow-up phase.^{45,53,56,60,61} There was no significant difference between intervention and control immediately post-intervention; however, the intervention groups improved over the follow-up phase. Intervention modalities included web-based, mobile application, and telephone. With the exception of Belanger and colleagues,⁴⁵ these interventions were delivered synchronously. Elbogen and colleagues⁶⁰ also included an asynchronous component consisting of daily self-directed tasks that the person with TBI completed. Telephone and computer-based programs may be considered as a “staple” of digital health intervention modalities as they have been consistently implemented as part of rehabilitation over the last 20 years. However, this has changed to include new advances in technology, which have increased in demand due to COVID-19.

Over the last 5 years, intervention programs for people with TBI have predominantly been delivered via videoconference and web-based platforms. This is reflective of the improvements in accessibility, development, and technological literacy. These modalities in particular have shown some evidence that digital health interventions produce similar outcomes to face-to-face interventions. It is recommended that future interventions and studies continue to reflect and harness the evolving nature of technology. Additionally, videoconferencing appears to be the modality of choice when working with people with moderate-to-severe TBI. The opportunity for synchronous clinician input may influence the choice for this modality, as it may be more appropriate than self-guided digital health technologies for people with more severe injuries. From the studies that only included participants with severe TBI, videoconferencing was the only modality used in the intervention programs. It is imperative to consider the severity of brain injury when selecting digital health interventions and to also consider additional supports or adaptability required for this population to be able to effectively engage with their rehabilitation. As technology evolves, new technologies relevant to people with severe injuries can be expected, such as smart technologies and artificial intelligence technologies. For example, Project Euphonia¹⁰¹ is an initiative by the Google AI for Social Good program aiming to improve the sensitivity of automated speech recognition (ASR) technologies through collecting speech samples from people with impaired speech patterns such as dysarthria and apraxia. Ensuring accessibility to everyday technology for people with TBI is essential and needs to be acknowledged as a rehabilitation priority.

Efficacy and effectiveness of digital health interventions or education programs for caregivers of people with TBI and/or the person with TBI

Interventions and education programs for caregivers of people with TBI were delivered using three primary modalities: telephone, web-based tools, and videoconferencing. However, web-based interventions and programs delivered by videoconferencing platforms, have been more prevalent in the last 5 years. As technology evolves and accessibility and availability increases, it is vital that interventions and programs continue to advance with it.

There is limited research in caregiver specific interventions. Only two studies^57,72 investigated intervention and support programs that were designed specifically for the caregiver. Both programs demonstrated positive outcomes following the intervention, although neither demonstrated maintenance of these outcomes. The development of digital health interventions that address and support the long-term needs of carers of people with TBI is a priority for future development. There is also a lack of research in communication specific interventions for people with TBI and their caregivers. TBIConneCT^77,78 was the only conversation skills-based program in this review, with other interventions focusing on education and problem-solving treatment of post-concussive symptoms and/or emotional management. Social communication challenges are prominent at 1 year post-injury,¹⁰² and these deficits can continue into the long-term resulting in relationship difficulties at 10 years post-injury.¹⁰³ This indicates a need to provide continuing services and supports to caregivers of people with TBI as rehabilitation needs and environments change, in particular, addressing communication needs across work, leisure and relationships during different life stages. Research should focus on examining resourceful methods of sustaining contact with caregivers, such as the consideration of a combination of digital health modalities as well as a combination of asynchronous and synchronous engagement.

Limitations

There are several limitations associated with this systematic review. Firstly, half of the included papers were a Level III or Level IV study as rated using the NHMRC levels of evidence.⁴¹ While these studies indicated positive outcomes, it is essential that future research incorporate rigorous high-level studies comparing digital health interventions and modalities to usual care, other digital health interventions or modalities or control conditions. Additionally, there were only a small number of studies that directly compared a digital health intervention with an equivalent non-digital intervention, and therefore it is difficult to draw direct conclusions about relative efficacy of digital health approaches to traditional in-person care.

Secondly, this review examined evidence across a range of healthcare disciplines and intervention types, therefore, making comparisons between studies challenging due to the range of outcome measures specific to the intervention. However, the inclusion of interventions across disciplines, allows for the evaluation of current applications of digital health interventions across the board in TBI rehabilitation and assists in understanding how interventions and service delivery in this population are evolving. Additionally, examining digital health in the TBI population across disciplines, encourages researchers and clinicians to further review and develop outcome measures that are applicable in the digital health space itself, as digital health interventions may require more considerations compared with traditional outcomes. This is complemented by Curran and colleagues' recommendations¹⁰⁴ of applying hybrid designs to evaluate clinical effectiveness and implementation of intervention simultaneously to enable fast translational gains, increased effectiveness of implementation strategies and improved dissemination of useful information for decision makers. Lastly, the results here may be influenced by the publication bias towards studies with positive findings, which may skew the impression of the effectiveness of interventions.

Recommendations

The emergence of digital health in TBI interventions has improved accessibility to specialist TBI services, which has been increasingly important during recent years due to restrictions on in-person services related to the COVID-19 pandemic.¹⁰⁵ To ensure that the treatment components of existing evidence-based interventions are retained during the transition to digital health modalities, it is recommended that interventions are customized to these new environments. McLaughlin and colleagues⁷² and Rietdijk and colleagues⁷⁷ demonstrated this in the adaptation of evidenced based treatment paper manuals allowing for the maximization of opportunities offered in the digital space. The investment in customized online versions of interventions, can be furthered with the consideration of a combination of modalities (particularly videoconferencing and web-based programs) within the same intervention and introduction of bespoke training guided by artificial intelligence. This may include integrated computer algorithms that configure treatment goals and tasks based on the input from the person with brain injury, or automated clinical decision-making tools.

Further, we recommend that researchers undergo a task analysis process when mapping current intervention into an online space. It is crucial to consider which treatment components can be completed synchronously or asynchronously and the inclusion of logistical mechanisms such as screensharing. When considering synchronous and asynchronous treatment components, it is imperative to also consider the impact that real-time or self-guided treatment delivery can have on user engagement and therefore, efficacy of intervention. It is also essential that future research provides a rigorous description of treatment methods and ensures that treatment materials are easily accessible to further accelerate translation of interventions into clinical practice.

The fast-evolving nature and accessibility of digital health has led to a proliferation of mobile applications (apps) available for download to personal mobile devices. Of the 44 studies included in this systematic review, only two studies^{60, 88} reported data on the use of apps, focusing on improving executive function and emotional regulation, and completion of kitchen related tasks respectively. This supported by Vaezipour and colleagues,¹⁰⁶ where the researchers used the Mobile App Rating Scale (MARS),¹⁰⁷ a validated tool for assessing the quality of health mobile apps, to review widely available apps for speech-language therapy specific to people with acquired brain injuries. Of the 70 apps that met their inclusion criteria for review, only four apps referred to published empirical studies that assessed app effectiveness. These findings indicate an evidence-practice gap and the need for clinicians to investigate whether an app is supported by evidence prior to providing recommendations and education to people with brain injury and their family members. Educating people with brain injury and caregivers on the importance of evidence-based interventions may also empower them to make informed decisions throughout their rehabilitation journey.

Since the current COVID-19 pandemic, there has been increased lobbying for virtual care to remain a part of offered clinical services.¹⁰⁸ Virtual services have improved the flexibility and availability of financial and human resources and reduced administration time, for example, as a result of electronic data collection and management.¹⁰⁹ With the transition to the digital space, it is essential that clinicians maintain the use of validated assessment tools and outcome measures in psychosocial TBI practice and research.¹¹⁰ Clinicians are also encouraged to be familiar with regulatory compliance with this new digital environment within their workplaces and services. Effective and successful clinical implementation of digital health interventions necessitates careful patient specific considerations. The severity of injury is an important consideration during clinical decision making when selecting an appropriate digital health modality and intervention.

For example, mobile apps are best considered when the person with brain injury has awareness and cognitive capacity to manage a self-guided intervention. Time post-injury and the stage of an individual's recovery can also impact on clinical decision making when ensuring unification between life goals and needs with the introduction of technology. Technology can improve everyday life and functional goals, such as engaging with family and friends, return to work and participating in education and learning. The studies included in this systematic review showcase how these goals can be targeted using a range of digital modalities, such as Salazaar and colleagues⁸⁰ using telephone-based interventions to target return to work for military personnel, or Powell and colleagues⁷⁴ targeting quality of life and emotional well-being of caregivers through a web-based program.

It is essential to note that technology, on its own, will not improve functioning, but rather it is a tool to be used as part of a holistic rehabilitation program focused on person centered goals. By choosing digital health modalities that correspond to the patient's life goals and functional needs, clinicians can support individuals with brain injury to regain necessary skills to return to their life roles. With the application of technology in rehabilitation, people with TBI and their caregivers can benefit from the capacity to monitor their own feedback and practice, as well as engage with their therapist. Metacognitive strategy instruction^111,112 can be embedded in the technology itself to encourage self-monitoring and goal setting. These findings and new understandings can inform future work in the development of forthcoming digital health interventions to ensure that the active ingredients within an intervention are maintained during the transition to digital modalities.

The current COVID-19 pandemic has illuminated the value of technology in maintaining social connection, and continuing work and education. Social media, in particular, has been an important way for people with TBI to engage with others and self-advocacy.¹¹³ However, cognitive communication and social cognition¹¹⁴ difficulties can lead to vulnerability for people with TBI in online environments due to challenges with understanding social cues, detecting humor or sarcasm, and inferencing from written communication. For people with TBI, eHealth safety can be a significant issue; however, social media specific training and education can assist in addressing this. The evidence-based¹¹⁵ online social media training program, social-ABI-lity,¹¹⁶ is a novel free self-guided web-based course aiming to increase understanding and knowledge of support people and organizations for safe and successful social media use for people with brain injury and others involved in their care such as family members, friends, support workers and health professionals. The development and use of training and education resources in digital health TBI rehabilitation is critical in ensuring safe and effective implementation of technology.

Conclusion

Overall, this review has found that digital health interventions are as effective and efficacious as traditional face-to-face interventions, and in some cases have potential to produce better outcomes for TBI rehabilitation. However, an appreciation of the active components within these interventions is limited, resulting in a lack of understanding of specific strategies and components that facilitate therapeutic improvement across modalities.

Additionally, it is imperative that further research and intervention development adopt a co-design approach to ensure that the needs of all stakeholders are met. This can then be furthered by using a hybrid research design to simultaneously evaluate clinical effectiveness and implementation of the intervention. A rapid translation of research into clinical practice is essential in the field of digital health, given the fast-evolving improvements in access to and quality of technology.

Footnotes

Acknowledgments

The authors would like to thank Sophie Brassel for her assistance with reliability ratings for this review.

Authors' Contributions

All authors contributed to the study design, data collection and analysis, decision to publish, and preparation of the manuscript.

Funding Information

This work was supported by the University of Sydney Faculty of Medicine and Health Traumatic Brain Injury Scholarship. Author RR is supported by funding from icare NSW. Author LT is supported by an Australian NHMRC Senior Research Fellowship.

Author Disclosure Statement

The authors declare the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: LT is Director of speechBITE, and EP is a speechBITE board member.

The authors acknowledge that two of the included papers in the systematic review were authored by the members of the team (RR, LT, EP, and MA) and in this case these papers were not reviewed by those authors.

Supplementary Material

Supplementary Table S1

Supplementary Table S2

References

Hyder

, Wunderlich

, Puvanachandra

, et al. The impact of traumatic brain injuries: a global perspective. NeuroRehabilitation, 2007; 22(5):341–353.

World Health Organization. Neurological Disorders: Public Health Challenges. World Health Organization; 2006.

Menon

, Schwab

, Wright

, et al. Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil, 2010; 91(11):1637–1640; doi: 10.1016/j.apmr.2010.05.017.

Maas

, Menon

, Adelson

, et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol, 2017; 16(12):987–1048; doi: 10.1016/S1474-4422(17)30371-X.

Australian Institute of Health and Welfare. Disability Prevalence and Trends. Australian Institute of Health and Welfare: Canberra, Australia; 2003.

Hawthorne

, Gruen

, Kaye

. Traumatic brain injury and long-term quality of life: findings from an Australian study. J Neurotrauma, 2009; 26(10):1623–1633; doi: 10.1089/neu.2008.0735.

Chan

, Levin

, Shum

, editors. Understanding Traumatic Brain Injury: Current Research and Future Directions. Oxford University Press: Oxford, U.K.; 2014.

Tate

RL.

Assessing support needs for people with traumatic brain injury: the care and needs scale (CANS). Brain Inj, 2004; 18(5):445–460; doi: 10.1080/02699050310001641183.

Ponsford

, Downing

, Olver

, et al. Longitudinal follow-up of patients with traumatic brain injury: outcome at two, five, and ten years post-injury. J Neurotrauma, 2014; 31(1):64–77; doi: 10.1089/neu.2013.2997.

10.

Tate

, Broe

, Cameron

, et al. Pre-injury, injury and early post-injury predictors of long-term functional and psychosocial recovery after severe traumatic brain injury. Brain Impairment, 2005; 6(2):75–89; doi: 10.1016/j.apmr.2010.11.015.

11.

Cicerone

, Langenbahn

, Braden

, et al. Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008. Arch Phys Med Rehabil, 2011; 92(4):519–530; doi: 10.1016/j.apmr.2010.11.015.

12.

Ponsford

Factors contributing to outcome following traumatic brain injury. NeuroRehabilitation, 2013; 32(4):803–815; doi: 10.3233/NRE-130904.

13.

Ruttan

, Martin

, Liu

, et al. Long-term cognitive outcome in moderate to severe traumatic brain injury: a meta-analysis examining timed and untimed tests at 1 and 4.5 or more years after injury. Arch Phys Med Rehabil, 2008; 89(12):S69–S76; doi: 10.1016/j.apmr.2008.07.007.

14.

MacDonald

, Shumway

Preferred Practice Guidelines for Cognitive-Communication Disorders. College of Speech-Language Pathologists and Audiologists of Ontario: Ontario, Canada; 2002.

15.

Bigler

ED.

The lesion(s) in traumatic brain injury: implications for clinical neuropsychology. Arch Clin Neuropsychol, 2001; 16(2):95–131.

16.

Mathias

, Beall

, Bigler

. Neuropsychological and information processing deficits following mild traumatic brain injury. J Int Neuropsychol Soc, 2004 Mar;10(2):286-297; doi: 10.1017/S1355617704102117.

17.

American Speech-Language-Hearing Association. Knowledge and skills needed by speech-language pathologists providing services to individuals with cognitive-communication disorders [Knowledge and skills]. ASHA; 2003. Available from: https://www.asha.org/policy [Last Accessed 7/27/2022].

18.

MacDonald

Introducing the model of cognitive-communication competence: a model to guide evidence-based communication interventions after brain injury. Brain Inj, 2017; 31(13-14):1760–1780; doi: 10.1080/02699052.2017.1379613.

19.

Kreutzer

, Rapport

, Marwitz

, et al. Caregivers' well-being after traumatic brain injury: a multicenter prospective investigation. Arch Phys Med Rehabil, 2009; 90(6):939–946; doi: 10.1016/j.apmr.2009.01.010.

20.

Bracy

, Douglas

. Marital dyad perceptions of injured partners' communication following severe traumatic brain injury. Brain Impairment, 2005; 6(1):1–2; doi: 10.1016/j.apmr.2009.01.010.

21.

Douglas

, Spellacy

. Correlates of depression in adults with severe traumatic brain injury and their carers. Brain Inj, 2000; 14(1):71–88; doi: 10.1080/026990500120943.

22.

Marsh

, Kersel

, Havill

, et al. Caregiver burden at 1 year following severe traumatic brain injury. Brain Inj, 1998; 12(12):1045–1059; doi: 10.1080/026990598121954.

23.

Timmer

, Jacobs

, Schonherr

, et al. The spectrum of long-term behavioral disturbances and provided care after traumatic brain injury. Front Neurol, 2020; 11:246; doi: 10.3389/fneur.2020.00246.

24.

Wallace

, Bogner

, Corrigan

, et al. Primary caregivers of persons with brain injury: life change 1 year after injury. Brain Inj, 1998; 12(6):483–493; doi: 10.1080/02699052.1998.11910751.

25.

Knight

, Devereux

, Godfrey

. Caring for a family member with a traumatic brain injury. Brain Inj, 1998; 12(6):467–481; doi: 10.1080/026990598122430.

26.

Tate

, Lulham

, Broe

, et al. Psychosocial outcome for the survivors of severe blunt head injury: the results from a consecutive series of 100 patients. J Neurol Neurosurg Psychiatry, 1989; 52(10):1128–1134; doi: 10.1136/jnnp.52.10.1128.

27.

Meskó

, Drobni

, Bényei É, et al. Digital health is a cultural transformation of traditional healthcare. mHealth, 2017; 3:38; doi: 10.2103/7/mhealth.2017.08.07.

28.

Shaw

, McGregor

, Brunner

, et al. What is eHealth (6)? Development of a conceptual model for eHealth: qualitative study with key informants. J Med Internet Res, 2017; 19(10):e8106; doi: 10.2196/jmir.8106.

29.

Defense Health Agency. DoD Clinical Recommendations: Cognitive Rehabilitation for Service Members and Veterans Following Mild to Moderate Traumatic Brain Injury [Ebook]. Silver Spring, MD; 2019. Available from: https://health.mil/Reference-Center/Publications/2020/07/30/Cognitive-Rehabilitation-for-Following-Mild-to-Moderate-TBI-Clinical-Recommendation-Full [Last accessed 8/9/2022].

30.

Tran

, Lam

, Amon

, et al. Interdisciplinary eHealth for the care of people living with traumatic brain injury: a systematic review. Brain Inj, 2017; 31(13-14):1701–1710; doi: 10.1080/02699052.2017.1387932.

31.

Bradford

, Caffery

, Smith

. Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability. Rural Remote Health, 2016; 16(4):1–23.

32.

Ownsworth

, Chan

, Jones

, et al. Use of telehealth platforms for delivering supportive care to adults with primary brain tumors and their family caregivers: a systematic review. Psychooncology, 2021; 30(1):16–26; doi: 10.1002/pon.5549.

33.

Ownsworth

, Arnautovska

, Beadle

. Efficacy of telerehabilitation for adults with traumatic brain injury: a systematic review. J Head Trauma Rehabil, 2018; 33(4):E33–E46; doi: 10.1097/HTR.0000000000000350.

34.

Coleman

, Frymark

, Franceschini

, et al. Assessment and treatment of cognition and communication skills in adults with acquired brain injury via telepractice: a systematic review. Am J Speech Lang Pathol, 2015; 24(2):295–315; doi: 10.1044/2015_AJSLP-14-0028.

35.

Betts

, Feichter

, Kleinig

, O'Connell-Debais

, et al. Telerehabilitation versus standard care for improving cognitive function and quality of life for adults with traumatic brain injury: a systematic review. Internet J Allied Health Sci Pract, 2018; 16(3):9.

36.

Rietdijk

, Togher

, Power

. Supporting family members of people with traumatic brain injury using telehealth: a systematic review. J Rehabil Med, 2012; 44(11):913; doi: 10.2340/16501977-1058.

37.

Page

, McKenzie

, Bossuyt

, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev, 2021; 10(1):89; doi: 10.1136/bmj.n71.

38.

Blobaum

Physiotherapy evidence database (PEDro). J Med Library Assoc, 2006; 94(4):477.

39.

Cherney

, Simmons-Mackie

, Raymer

, et al. Systematic review of communication partner training in aphasia: methodological quality. Int J Speech Lang Pathol, 2013; 15(5):535–545; doi: 10.3109/17549507.2013.763289.

40.

Tate

, Rosenkoetter

, Wakim

, et al. The Risk of Bias in N-of-1 Trials (RoBiNT) Scale: An Expanded Manual for the Critical Appraisal of Single-Case Reports. PsycBITE Group: St. Augustine, FL; 2015.

41.

Merlin

, Weston

, Tooher

Extending an evidence hierarchy to include topics other than treatment: revising the Australian ‘levels of evidence.’. BMC Med Res Methodol, 2009;9(1):1–8; doi: 10.1186/1471-2288-9-34.

42.

Vaezipour

, Whelan

, Wall

, et al. Acceptance of rehabilitation technology in adults with moderate to severe traumatic brain injury, their caregivers, and healthcare professionals: a systematic review. J Head Trauma Rehabil, 2019; 34(4):E67–E82; doi: 10.1097/HTR.0000000000000462.

43.

Landis

, Koch

. The measurement of observer agreement for categorical data. Biometrics, 1977:159–74.

44.

Banerjee

, Hegde

, Thippeswamy

, et al. In search of the ‘self’: Holistic rehabilitation in restoring cognition and recovering the ‘self’ following traumatic brain injury: a case report. NeuroRehabilitation, 2021; 48(2):231–242; doi: 10.3233/NRE-208017.

45.

Belanger

, Barwick

, Silva

, et al. Web-based psychoeducational intervention for postconcussion symptoms: a randomized trial. Military Med, 2015; 180(2):192–200; doi: 10.7205/MILMED-D-14-00388.

46.

Bell

, Temkin

, Esselman

, et al. The effect of a scheduled telephone intervention on outcome after moderate to severe traumatic brain injury: a randomized trial. Arch Phys Med Rehabil, 2005; 86(5):851–856; doi: 10.1016/j.apmr.2004.09.015.

47.

Bell

, Brockway

, Hart

, et al. Scheduled telephone intervention for traumatic brain injury: a multicenter randomized controlled trial. Arch Phys Med Rehabil, 2011; 92(10):1552–1560; doi: 10.1016/j.apmr.2011.05.018.

48.

Bell

, Hoffman

, Temkin

, et al. The effect of telephone counselling on reducing post-traumatic symptoms after mild traumatic brain injury: a randomised trial. J Neurol Neurosurg Psychiatry, 2008; 79(11):1275–1281; doi: 10.1136/jnnp.2007.141762.

49.

Bell

, Fann

, Brockway

, et al. Telephone problem solving for service members with mild traumatic brain injury: a randomized, clinical trial. J Neurotrauma, 2017; 34(2):313–321; doi: 10.1089/neu.2016.4444.

50.

Bergquist

, Gehl

, Mandrekar

, et al. The effect of internet-based cognitive rehabilitation in persons with memory impairments after severe traumatic brain injury. Brain Inj, 2009; 23(10):790–799; doi: 10.1080/02699050903196688.

51.

Bombardier

, Bell

, Temkin

, et al. The efficacy of a scheduled telephone intervention for ameliorating depressive symptoms during the first year after traumatic brain injury. J Head Trauma Rehabil, 2009; 24(4):230–238; doi: 10.1097/HTR.0b013e3181ad65f0.

52.

Bos

, Babbage

, Leathem

. Efficacy of memory aids after traumatic brain injury: a single case series. NeuroRehabilitation, 2017; 41(2):463–481; doi: 10.3233/NRE-151528.

53.

Bourgeois

, Lenius

, Turkstra

, et al. The effects of cognitive teletherapy on reported everyday memory behaviours of persons with chronic traumatic brain injury. Brain Inj, 2007; 21(12):1245–1257; doi: 10.1080/02699050701727452.

54.

Brown

, Pain

, Berwald

, et al. Distance education and caregiver support groups: comparison of traditional and telephone groups. J Head Trauma Rehabil, 1999; 14(3):257–268; doi: 10.1097/00001199-199906000-00006.

55.

Connor

, Shaw

. Case study series using brain-training games to treat attention and memory following brain injury. J Pain Manag, 2016; 9(3):217–216.

56.

Corrigan

, Bogner

, Lamb-Hart

, et al. Increasing substance abuse treatment compliance for persons with traumatic brain injury. Psychol Addict Behav, 2005; 19(2):131–139; doi: 10.1037/0893-164X.19.2.131.

57.

Damianakis

, Tough

, Marziali

, et al. Therapy online: a web-based video support group for family caregivers of survivors with traumatic brain injury. J Head Trauma Rehabil, 2016; 31(4):E12–E20; doi: 10.1097/HTR.0000000000000178.

58.

Dowds

, Lee

, Sheer

, et al. Electronic reminding technology following traumatic brain injury: effects on timely task completion. J Head Trauma Rehabil, 2011; 26(5):339–347; doi: 10.1097/HTR.0b013e3181f2bf1d.

59.

Eilam-Stock

, George

, Charvet

. Cognitive telerehabilitation with transcranial direct current stimulation improves cognitive and emotional functioning following a traumatic brain injury: a case study. Arch Clin Neuropsychol, 2021; 36(3):442–453; doi: 10.1093/arclin/acaa059.

60.

Elbogen

, Dennis

, Van Voorhees

, et al. Cognitive rehabilitation with mobile technology and social support for veterans with TBI and PTSD: a randomized clinical trial. J Head Trauma Rehabil, 2019; 34(1):1; doi: 10.1097/HTR.0000000000000435.

61.

Fann

, Bombardier

, Vannoy

, et al. Telephone and in-person cognitive behavioral therapy for major depression after traumatic brain injury: a randomized controlled trial. J Neurotrauma, 2015; 32(1):45–57; doi: 10.1089/neu.2014.3423.

62.

Forducey

, Ruwe

, Dawson

, et al. Using telerehabilitation to promote TBI recovery and transfer of knowledge. NeuroRehabilitation, 2003; 18(2):103–111.

63.

Gómez

, Montoro

, Haya

, et al. Adaptive manuals as assistive technology to support and train people with acquired brain injury in their daily life activities. Pers Ubiquitous Comput, 2013; 17(6):1117–1126; doi: 10.1186/s12984-018-0477-5.

64.

Hart

, Vaccaro

, Collier

, et al. Promoting mental health in traumatic brain injury using single-session Behavioural Activation and SMS messaging: a randomized controlled trial. Neuropsychol Rehabil, 2020; 30(8):1523–1542; doi: 10.1080/09602011.2019.1592761.

65.

Hart

, Vaccaro

. Goal intention reminding in traumatic brain injury: a feasibility study using implementation intentions and text messaging. Brain Inj, 2017; 31(3):297–303; doi: 10.1080/02699052.2016.1251612.

66.

Hart

, Hawkey

, Whyte

. Use of a portable voice organizer to remember therapy goals in traumatic brain injury rehabilitation: a within-subjects trial. J Head Trauma Rehabil, 2002; 17(6):556–570; doi: 10.1097/00001199-200212000-00007.

67.

Hwang

, Chen

, Wei

, et al. Effects of computerized cognitive training and tai chi on cognitive performance in older adults with traumatic brain injury. J Head Trauma Rehabil, 2020; 35(3):187–197.

68.

Inge

, Graham

, McLaughlin

, et al. Evaluating the effectiveness of Facebook to impact the knowledge of evidence-based employment practices by individuals with traumatic brain injury: a knowledge translation random control study. Work, 2017; 58(1):73–81; doi: 10.1097/HTR.0000000000000533.

69.

Kirsch

, Shenton

, Spirl

, et al. An assistive-technology intervention for verbose speech after traumatic brain injury: a single case study. J Head Trauma Rehabil, 2004; 19(5):366–377; doi: 10.1097/00001199-200409000-00002.

70.

Larsson

, Nyström

, Vikström

, et al. Computer-assisted cognitive rehabilitation for adults with traumatic brain damage: four case studies. Occup Ther Int, 1995; 2(3):166–189.

71.

McGraw-Hunter

, Faw

, Davis

. The use of video self-modelling and feedback to teach cooking skills to individuals with traumatic brain injury: a pilot study. Brain Inj, 2006; 20(10):1061–1068; doi: 10.1080/02699050600912163.

72.

McLaughlin

, Glang

, Beaver

, et al. Web-based training in family advocacy. J Head Trauma Rehabil, 2013; 28(5):341; doi: 10.1097/HTR.0b013e31824e1d43.

73.

, Polatajko

, Marziali

, et al. Telerehabilitation for addressing executive dysfunction after traumatic brain injury. Brain Inj, 2013; 27(5):548–564; doi: 10.3109/02699052.2013.766927.

74.

Powell

, Fraser

, Brockway

, et al. A telehealth approach to caregiver self-management following traumatic brain injury: a randomized controlled trial. J Head Trauma Rehabil, 2016; 31(3):180–190; doi: 10.1097/HTR.0000000000000167.

75.

Powell

, Wild

, Glang

, et al. The development and evaluation of a web-based programme to support problem-solving skills following brain injury. Disabil Rehabil Assist Technol, 2019; 14(1):21–32; doi: 10.1080/17483107.2017.1389999.

76.

Riegler

, Neils-Strunjas

, Boyce

, et al. Cognitive intervention results in web-based videophone treatment adherence and improved cognitive scores. Med Sci Monit, 2013; 19:269; doi: 10.1265/9/MSM.883885.

77.

Rietdijk

, Power

, Brunner

, et al. A single case experimental design study on improving social communication skills after traumatic brain injury using communication partner telehealth training. Brain Inj, 2019; 33(1):94–104; doi: 10.1080/02699052.2018.1531313.

78.

Rietdijk

, Power

, Attard

, et al. Improved conversation outcomes after social communication skills training for people with traumatic brain injury and their communication partners: a clinical trial investigating in-person and telehealth delivery. J Speech Lang Hear Res, 2020; 63(2):615–632; doi: 10.1044/2019_JSLHR-19-00076.

79.

Rietdijk

, Power

, Brunner

, et al. Reliability of videoconferencing administration of a communication questionnaire to people with traumatic brain injury and their close others. J Head Trauma Rehabil, 2017; 32(6):E38–E44; doi: 10.1097/HTR.0000000000000282.

80.

Salazar

, Warden

, Schwab

, et al. Cognitive rehabilitation for traumatic brain injury: a randomized trial. JAMA, 2000; 283(23):3075–3081; doi: 10.1001/jama.283.23.3075.

81.

Schoenberg

, Ruwe

, Dawson

, et al. Comparison of functional outcomes and treatment cost between a computer-based cognitive rehabilitation teletherapy program and a face-to-face rehabilitation program. Prof Psychol Res Pract, 2008; 39(2):169.

82.

Smith

, Harms

, Burres

, et al. Enhancing behavioral health treatment and crisis management through mobile ecological momentary assessment and SMS messaging. Health Inform J, 2012; 18(4):294–308; doi: 10.1177/1460458212445349.

83.

Solana

, Cáceres

, García-Molina

, et al. Intelligent Therapy Assistant (ITA) for cognitive rehabilitation in patients with acquired brain injury. BMC Med Inform Decis Mak, 2014; 14(1):1–3; doi: 10.1186/1472-6947-14-58.

84.

Solana

, Cáceres

, García-Molina

, et al. Improving brain injury cognitive rehabilitation by personalized telerehabilitation services: Guttmann neuropersonal trainer. IEEE J Biomed Health Inform, 2014; 19(1):124–131; doi: 10.1109/JBHI.2014.2354537.

85.

Välimäki

, Mishina

, Kaakinen

, et al. Digital gaming for improving the functioning of people with traumatic brain injury: randomized clinical feasibility study. J Med Internet Res, 2018; 20(3):e77; doi: 10.2196/jmir.7618.

86.

Nakase-Richardson

, Vuletic

, Bell

, et al. Telephone problem-solving treatment improves sleep quality in service members with combat-related mild traumatic brain injury: results from a randomized clinical trial. J Head Trauma Rehabil, 2016; 31(2):147–157; doi: 10.1097/HTR.0000000000000221.

87.

Waldron

, Grimson

, Carton

, et al. Effectiveness of an unmodified personal digital assistant as a compensatory strategy for prospective memory failures in adults with an ABI. Irish J Psychol, 2012; 33(1):29–42.

88.

Wang

, Mahajan

, Toto

, et al. The feasibility of an automatic prompting system in assisting people with traumatic brain injury in cooking tasks. Disabil Rehabil Assist Technol, 2019; 14(8):817–825; doi: 10.1080/17483107.2018.1499144.

89.

Hood

, Glang

, Lash

, Todis

Family Advocacy Skills Training: A Handbook for Family Advocates. Teaching Research: Eugene OR; 2001.

90.

Baysari

, Raban

. The safety of computerised prescribing in hospitals. Aust Prescr, 2019; 42(4):136.

91.

Hart

, Dijkers

, Whyte

, et al. A theory-driven system for the specification of rehabilitation treatments. Arch Phys Med Rehabil, 2019; 100(1):172–180; doi: 10.1016/j.apmr.2018.09.109.

92.

Hoffmann

, Glasziou

, Boutron

, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ 2014;348; doi: 10.1136/bmj.g1687.

93.

O'Rourke

, Power

, O'Halloran

, et al. Common and distinct components of communication partner training programmes in stroke, traumatic brain injury and dementia. Int J Lang Commun Disord, 2018; 53(6):1150–1168; doi: 10.1111/1460-6984.12428.

94.

Steen

, Manschot

, De Koning

Benefits of co-design in service design projects. Int J Design 2011;5(2).

95.

Donetto

, Pierri

, Tsianakas

, et al. Experience-based co-design and healthcare improvement: realizing participatory design in the public sector. Design J, 2015; 18(2):227–248.

96.

Ownsworth

, Theodoros

, Cahill

, et al. Perceived usability and acceptability of videoconferencing for delivering community-based rehabilitation to individuals with acquired brain injury: a qualitative investigation. J Int Neuropsychol Soc, 2020; 26(1):47–57; doi: 10.1017/S135561771900078X.

97.

Mulvale

, Moll

, Miatello

, et al. Codesigning health and other public services with vulnerable and disadvantaged populations: insights from an international collaboration. Health Expect, 2019; 22(3):284–297; doi: 10.1111/hex.12864.

98.

Hjelmfors

, Strömberg

, Friedrichsen

, et al. Using co-design to develop an intervention to improve communication about the heart failure trajectory and end-of-life care. BMC Palliat Care, 2018; 17(1):1–10; doi: 10.1186/s12904-018-0340-2.

99.

Morris

, Ruddock

, Gallacher

, et al. Developing a patient safety guide for primary care: a co-design approach involving patients, carers and clinicians. Health Expect, 2021; 24(1):42–52; doi: 10.1111/hex.13143.

100.

Thabrew

, Fleming

, Hetrick

, et al. Co-design of eHealth interventions with children and young people. Front Psychiatry, 2018; 9:481; doi: 10.3389/fpsyt.2018.00481.

101.

MacDonald

, Jiang

, Cattiau

, et al. Disordered speech data collection: Lessons learned at 1 million utterances from project euphonia. Available from: https://www.isca-speech.org/archive/pdfs/interspeech_2021/macdonald21_interspeech.pdf [Last accessed 7/27/2022].

102.

Elbourn

, Kenny

, Power

, et al. Discourse recovery after severe traumatic brain injury: Exploring the first year. Brain Inj, 2019 Jan 28;33(2):143–159; doi: 10.1080/02699052.2018.1539246.

103.

Ponsford

, Downing

, Olver

, et al. Longitudinal follow-up of patients with traumatic brain injury: outcome at two, five, and ten years post-injury. J Neurotrauma, 2014; 31(1):64–77; doi: 10.1089/neu.2013.2997.

104.

Curran

, Bauer

, Mittman

, et al. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care, 2012; 50(3):217; doi: 10.1097/MLR.0b013e3182408812.

105.

Agency for Clinical Innovation. Virtual care in practice. Telehealth Network, State of New South Wales (NSW Agency for Clinical Innovation); 2021. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0006/573270/Virtual-Care-in-Practice.pdf [Last accessed 8/9/2022].

106.

Vaezipour

, Campbell

, Theodoros

, et al. Mobile apps for speech-language therapy in adults with communication disorders: review of content and quality. JMIR mHealth and uHealth, 2020; 8(10):e18858; doi: 10.2196/18858.

107.

Stoyanov

, Hides

, Kavanagh

, et al. Mobile app rating scale: a new tool for assessing the quality of health mobile apps. JMIR Mhealth Uhealth, 2015; 3(1):e3422; doi: 10.2196/mhealth.3422.

108.

Malec

, Salisbury

, Anders

, et al. Response to the COVID-19 pandemic among posthospital brain injury rehabilitation providers. Arch Phys Medic Rehabil, 2021; 102(3):549–555; doi: 10.1016/j.apmr.2020.10.137.

109.

Taylor

, Caffery

, Gesesew

, et al. How Australian health care services adapted to telehealth during the COVID-19 pandemic: a survey of telehealth professionals. Front Public Health, 2021; 9:648009; doi: 10.3389/fpubh.2021.648009.

110.

Honan

, McDonald

, Tate

, et al. Outcome instruments in moderate-to-severe adult traumatic brain injury: recommendations for use in psychosocial research. Neuropsychol Rehabil, 2019; 29(6):896–916; doi: 10.1080/09602011.2017.1339616.

111.

Tate

, Kennedy

, Ponsford

, et al. INCOG recommendations for management of cognition following traumatic brain injury, part III: executive function and self-awareness. J Head Trauma Rehabil, 2014; 29(4):338–352; doi: 10.1097/HTR.0000000000000068.

112.

Togher

, Wiseman-Hakes

, Douglas

, et al. INCOG recommendations for management of cognition following traumatic brain injury, part IV: cognitive communication. J Head Trauma Rehabil, 2014; 29(4):353–368; doi: 10.1097/HTR.0000000000000071.

113.

Brunner

, Hemsley

, Dann

, et al. Hashtag# TBI: a content and network data analysis of tweets about traumatic brain injury. Brain Inj, 2018; 32(1):49–63; doi: 10.1080/02699052.2017.1403047.

114.

McDonald

Impairments in social cognition following severe traumatic brain injury. J Int Neuropsychol Soc, 2013; 19(3):231–246; doi: 10.1017/S1355617712001506.

115.

Brunner

, Hemsley

, Togher

, et al. Social media and people with traumatic brain injury: a metasynthesis of research informing a framework for rehabilitation clinical practice, policy, and training. Am J Speech Lang Pathol, 2021; 30(1):19–33; doi: 10.1044/2020_AJSLP-20-00211.

116.

The University of Sydney Acquired Brain Injury Communication Lab. Social-ABI-lity. ABI Communication Lab; 2022. Available from: https://abi-communication-lab.sydney.edu.au/courses/social-abi-lity [Last accessed 7/27/2022].

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