Assessment of self-awareness after severe acquired brain injury: A systematic review and recommendations for a new classification of offline self-awareness.

Impairment in self-awareness (ISA) is an important obstacle in neurorehabilitation of severe acquired brain injury (ABI) patients since it can cause failure in adopting adequate compensatory strategies, or the implementation of ineffective or dangerous behaviors. Accordingly, it should be assessed as early and accurately as possible, even if, to date, no consensus exists on how best to measure SA, and on its explanatory models. The present systematic review aimed to address: (a) to which extent ISA has been assessed in studies enrolling severe ABI patients; (b) whether studies on assessment of SA after severe ABI considered any explanatory models of SA and which measures have been utilized accordingly; (c) possible gaps or criticism in the extant research on severe ABI patients; and (d) to provide a novel proposal for SA assessment/classification based on the results and discussion from the systematic review conducted in this well selected population of patients. A systematic review was carried out in the databases PubMed, Web of Science and PsycINFO; 701 studies were retrieved and finally 54 met the inclusion criteria. Our review evidenced the paucity of studies on assessment of SA in patients with severe ABI that specified the model and the level of SA. Only a few measures of SA went beyond its intellectual and declarative aspects, thus hindering an exhaustive assessment and a full comprehension of SA. Accordingly, we propose a more comprehensive classification of offline anticipatory SA, with some important implications in the neurorehabilitation field. The review demonstrated the need of measuring SA beyond its declarative level, differentiating between declarative and real anticipatory SA, as well as of assessing SA at both offline and online levels.