Digitalized health care services have the advantage of providing patients with access to treatment, irrespective of time and place (1–3). Web-based rehabilitation, a branch of telerehabilitation, is carried out at a patient's home over the internet. Online platforms and secure network connections also offer a new way to deliver cognitive and neuropsychological rehabilitation. The potential advantages of telerehabilitation in clinical practice are the possibility to offer services to larger population, reduce waiting times and to personalize rehabilitation but also to be cost-effectiveness (4). Still, the traditional way of carrying out neuropsychological rehabilitation is face-to-face at inpatient or outpatient clinics, but these services are regionally uneven and insufficient (5, 6).

Managing cognitive impairment in neurological disorders often requires intensive neuropsychological rehabilitation to improve cognitive functions as well as emotional and psychosocial wellbeing. A significant proportion of stroke patients show cognitive impairment despite good clinical recovery (7) and cognitive symptoms are also common after traumatic brain injury and encephalitis (8, 9). Rehabilitation for cognitive impairment has shown to be effective after brain injuries (10), and psychoeducation and compensatory strategy training (training of sets of conscious mental processes and techniques to compensate cognitive deficiencies) have been found to be the most efficient approaches for rehabilitation (11–13). Cognitive training (practice on a set of tasks designed to reflect particular cognitive functions) is also a common approach in cognitive rehabilitation, especially in online programs (14). Despite some near-transfer effect of attention and working memory training far-transfer and long-time effects of cognitive training are considered poor (15–17).

Psychoeducational framework is an established and essential approach originating from psychosocial treatment of psychiatry broadened to somatic diseases to provide support and information on the condition of patients and aims to improve functional abilities, mood, and quality of life (18, 19). Neurological patients benefit from sharing knowledge about symptoms, recovery, and symptom management (12, 20–22) and even patients with minor strokes have expressed the need for it after discharge (23). Information about stroke not only increases patients' understanding of the condition and its effects, but also enhances patients' contentment and diminishes depressive symptoms (21). Patients with mild cognitive symptoms also benefit from metacognitive and memory strategy training (11) and patients with mild traumatic brain injury cognitive strategy training was related to positive behavioral changes and better subjective and objective cognitive performance (24).

Considering the overlap and variety of the terminology in literature, in this review neuropsychological and cognitive rehabilitation is referred as broad neurocognitive rehabilitation. The interest in this study is in the neuropsychological or cognitive interventions combining psychoeducation (sharing knowledge) with cognitive strategy training (compensatory strategy training) leaving cognitive training interventions (practicing particular functions, “brain training”) outside when being the only approach of the intervention.

To date, the knowledge about structured web-based cognitive intervention programs, including psychoeducation and cognitive strategy training, is still scattered; only a few, mainly small-scale feasibility studies have been reported and deemed applicable to neurological patients (25–28). Web-based programs are also used to teach neurological patients self-management, but evidence of their effectiveness is limited (29). Web-based intervention programs have become evidence-based treatments for mood disorders (30), and have also been used for motor rehabilitation after stroke, for example (31). Yet, the effectiveness of cognitive or neuropsychological online rehabilitation programs is unclear.

The aim of this study was to systematically review the current knowledge on the effectiveness and feasibility of web-based psychoeducational interventions among adolescent and adult patients whose cognitive functions are affected by a somatic health condition.

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) (32). The review protocol (CRD42021257315) was pre-registered with the PROSPERO International Prospective Register of Systematic Reviews.

We used a PICO (population, intervention, comparison, outcome) framework to formulate the study design and search strategy. We asked: In adolescent or adult patients whose cognition is affected by a somatic health condition (P), are web-based psychoeducational interventions (I), in comparison to other interventions or no intervention at all (C), feasible and effective in improving subjective and/or objective cognitive functioning (O)? The search was targeted at adolescents or adults participating in a psychoeducational cognitive program or an intervention delivered remotely online and carried out independently by the patient. Subjective cognitive complaints, as evaluated by the patient's self-report (subjective cognitive functioning) and/or objective cognitive functions, as defined by performance in neuropsychological tests (objective cognitive functioning), were considered an outcome. We also considered data on adherence and program acceptability/feasibility.

The aim of this systematic review was to collect and evaluate the current evidence on the effectiveness and feasibility of web-based psychoeducational interventions combined with cognitive strategy training for managing cognitive impairment.

Overall, to date, the literature on digitalized cognitive or neuropsychological rehabilitation is very limited and only four studies fulfilled the inclusion criteria. Two of these studies were RCTs (38, 39), one a quasi-experimental study (37) and one a single-arm study (36). The psychoeducational content of the interventions was commonly combined with cognitive strategy training (36, 38, 39). The studies were heterogeneous in terms of age, diagnosis, and design. The diversity and heterogeneity of the interventions and populations in selected studies may hinder the comparison.

Sporadic findings in this review suggest that web-based cognitive interventions may improve self-reported subjective cognitive functioning. At 6-month follow-up, the study of stroke patients showed self-evaluated improvement in communication, memory, and meaningful activities in favor of the intervention group (37). Patients with cognitive impairment after oncological treatment showed a significant reduction in self-reported prospective memory failures post treatment and 3-month follow-up (39). The TBI adolescents self-reported recovery of functional/physical disability and executive functions parent-rated after the intervention (36). However, the study did not have a control group. Two studies indicated that some of the rehabilitation effects were maintained for longer thanks to the web-based intervention (37, 38).

On the basis of this review, the web-based interventions had no effects on objective cognitive functioning (neuropsychological test performance). However, in one study, at 9-month follow-up, fewer brain tumor participants showed cognitive impairment in the intervention group (38). The authors emphasized the uncertainty of the finding but cautiously propose that the intervention program had small beneficial effects (38).

Profound methodological problems were found in the quality of the designs of the selected studies (see Table 1). Only two studies were RCTs and only one of these was assessed as high quality. Most studies had small sample sizes and in all the studies the size of the intervention groups was under 54. In two studies, sampling was done through self-selection, which might result in biased selection—-as participants might be more motivated to take part in rehabilitation activities. Studies used self-reported outcome measures which might prone to bias to willingness to please. These might have led to an increased risk of positive findings. In addition, in some cases, information and precise descriptions of the interventions were lacking according to the Template for Intervention Description and Replication (TIDieR) checklist (41). The TIDieR checklist is recommended for use in intervention studies to describe the intervention for good reporting policy (42).

In addition to methodological issues, studies selected in this systematic review sets few notable limitations to larger scale conclusions. Due to data reported in the studies, moderation analysis and recommendations of populations benefitting from web-based interventions could not be made. There are also lack of comparison with other interventions which leaves unclear whether web-based rehabilitation programs are superior to other intervention approaches. Also, sustainability of the effects remains unclear only one study having over 6-month follow-up (27). In all, the ability to generalize from these studies remain dubious.

A few interesting studies arose that did not fulfill the inclusion criteria. A web-based program for cognitive aging of healthy adults (excluded for not having somatic condition affecting cognition) had small to moderate effects on the self-reported feeling of stability in memory functioning and locus of control over memory in an RCT study design (43). Participants also reported fewer cognitive mistakes, less worry about cognition and dementia, and better ability to cope with cognitive loads. EpilepsyJourney, a web-based program for adolescent epilepsy patients with cognitive symptoms and behavioral problems, was believed to improve executive functions and emotional and behavioral functioning in a pre-post design study (44). The program consisted of problem-solving interventions with psychoeducational modules and support from a health care professional via video (excluded for not carrying out independently). The results of these studies could be interpreted as parallel to the sporadic findings reported in this review.

In all, despite methodological flaws, the psychoeducational components of the interventions may have contributed to the increased feeling of control over subjective cognitive functioning and may have alleviated symptom-induced anxiety—the participants received reliable information about their cognition and how to manage cognitive deficits, which is believed to be effective and necessary among neurological patients (11–13, 23).

Although the evidence of the effectiveness of web-based interventions to date is scarce, in this review they were found to be a feasible approach to arranging cognitive rehabilitation, as in previous studies (26–28, 30). It seems that completion and adherence to web-based rehabilitation may be good or even excellent in patient groups with cognitive deficits. Web-based interventions were also considered to be safe, as no adverse outcomes of TBI symptoms were reported (36).

While this review followed robust methodology and a systematic search strategy to identify relevant trials, it does have limitations. We restricted our search to English language publications only, which may have excluded some relevant studies. Despite the voluminous search strategy, the search terms used might have led to the exclusion of some interesting studies due to the novelty of the field and the as-of-yet unestablished terminology related to telerehabilitation solutions. We also relied on published reports only, which may lead to publication bias.

Web-based interventions for neurological patients have several benefits. They have the potential to reach large populations and to be used widely—-accessibility and adherence is excellent and irrespective of time, and they can even be conducted at home (only a technical device with an internet connection is needed). As the aging of the population and shortage of health care resources increases, interventions carried out independently online will become more essential. Overall, the use of telerehabilitation services will increase in future healthcare, and thus we need evidence of their advantages and weaknesses. If proven to be effective, telerehabilitation services may also broaden the variety of neuropsychological interventions and have the potential to equalize regional differences, make rehabilitation more cost-effective (4), and reduce waiting times for rehabilitation services.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

OV: drafting the manuscript. OV, E-LK, AW, and HJ: writing the final version. E-LK, AW, HJ, and MH: supervision. OV and E-LK: selection of studies and quality assessment of studies. All authors: conception of the manuscript. All authors have read and approved the final version of the manuscript.