A rapid realist review of clinical neuropsychology rehabilitation programmes to improve psychological wellbeing and quality of life for people with acquired brain injuries.

The review was completed rapidly to a fixed deadline. The authors say this may have made it more vulnerable to bias and limited its breadth and depth. No standard quality appraisal was used. Relevance and rigour were rated subjectively by the reviewers, and no study was excluded for being low quality. Many included studies were small. The designs include single case reports, single case series and one-arm pre-post studies, which cannot show that a programme caused the improvement. The evidence base itself is thin. Few of the original authors explain why their intervention might work, and intervention descriptions were often incomplete. After full-text screening the reviewers deliberately limited inclusion to studies where wellbeing or quality of life was the primary outcome and the programme was delivered by a psychologist, neuropsychologist or other mental health professional. Programmes delivered by families or the wider rehabilitation team were left out. Diagnoses beyond stroke and traumatic brain injury are barely represented. No included study covered meningitis or toxic or metabolic injury. Only one included study delivered its programme entirely online, so the review can say almost nothing about online delivery. Wellbeing and quality of life were measured 54 different ways across the studies, and those measures captured either negative or positive mood, so the reviewers may have missed interventions that target both. The context-mechanism-outcome links were usually the reviewers' interpretation rather than something the original authors labelled, and the logic model is the reviewers' own construction.

Funded by the UK National Institute for Health and Care Research (NIHR) Research for Patient Benefit programme, grant number 202753. No competing interests are declared. Worth knowing: the review was the first stage of a project to develop a new online, group-based neuropsychological rehabilitation programme, and the authors state the logic model will be used to refine and test that intervention, so the reviewers had a stake in producing a usable model.

Do not read the six mechanisms as a set of ingredients you can add to a programme and expect results. The review's own point is that the current evidence has not identified which specific components of neuropsychological rehabilitation lead to improvement, and much of the supporting evidence comes from single case reports, single-arm studies and small trials, with six studies rated poor for rigour and one very poor. These are hypotheses the authors intend to test, not tested components of care.